Barriers to exclusive breast feeding, the missing links: a cross sectional study from Puducherry, India

INTRODUCTION

Breast milk, the first natural food for a new-born, provides all the energy and essential nutrients an infant requires for the first six months of life, half of the nutritive requirement for the next six months and thereon one-third of the requirement till two years of age, responsible for the infant’s proper physiological growth and development.^1-3 ‘Exclusive Breastfeeding’ (EBF) implies that nothing else is to be given to the baby except breast milk during the first six months of life.³ The WHO recommends exclusive breastfeeding for all new-born during the first six months of life.⁴

Breast-feeding, besides providing nutrition, energy, adequate sensory and cognitive development also protects the child from various infections and chronic diseases like obesity, type1/2 diabetes, leukemia and Sudden Infant Death Syndrome.⁵ The United Nations Children's Fund (UNICEF) estimates that exclusive breastfeeding in the first six months of life can reduce under-five mortality rates in developing countries by13%.⁶ In India, 15% out of 24 lakh child deaths can be reduced by enhancing breastfeeding practices.^1,2,7

Besides benefits to the baby, the breastfeeding mother also has a substantially low risk of postpartum haemorrhage, ovarian and breast cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction and various metabolic syndromes.^1,5,7,8 However, as per the NHFS - 4 survey (2015-2016), only 54.9% of babies are exclusively breast-fed in India, and 45.5% in Puducherry.⁹ Cultural, social and religious factors in our country such as extra lacteal feeding, use of foods soon after child- birth like sugar water or honey are prevalent, which have a negative impact on the feeding practises.^10-12 Poor feeding practices and socio-demographic characteristics are reported as major reason for poor health outcomes in developing countries.^10-12

There are a number of organisations all over the world that work towards the promotion of breast-feeding. In 1991, Breast-Feeding Promotion Network of India (BPNI) was formed to protect, promote and support breastfeeding.¹²

This study aims to assess the socio-demographic characteristics and hindering factors that may be associated with the promotion of exclusive breast-feeding.

METHODS

This was a cross sectional hospital based study conducted in the Out Patient Department (OPD) of the Department of Paediatrics of a tertiary care hospital in Puducherry with approval from the Institutional Ethics Committee.

A sample size of 115 participants calculated, based on a previous study by Ranjana et al, with 95% confidence interval using the formula 4PQ/d².¹³ A p value of <0.05 considered as statistically significant. Purposive sampling was the method used to collect data.

Inclusion criteria

The inclusion criteria considered for this study included all women of childbearing age attending the OPD, having children of the age group of 6 months to 2 year, who were born as term gestation with a birth weight of >2.5 kilograms, and volunteered to take part.

Exclusion criteria

Mothers whose children were born as Pre terms (gestational age <37weeks), low birth weight babies (birth weight <2.5kg) and babies with congenital heart defects, were excluded from the study sampling.

Written informed consent was obtained from the study participants who volunteered, after explaining in detail the purpose of the study and their right to withdraw from the study at any time maintaining their confidentiality.

Data collection was carried out using a self-developed questionnaire with inputs from previous studies.^11-15 with two sections. Section-A was based on the socio-demographic characteristics of the participants which included age of the mother, residence, education, employment status of the mother, type of family, socio economic status, birth order of the child, mode of delivery and spacing between births. Section-B included questions regarding antenatal counselling given during pregnancy, post- natal counselling after birth, the people involved in counselling, whether breast feeding was initiated after birth along with the day of initiation, number of times the baby is breast fed in a day, total duration of exclusive breast feeding.

The use of pre-lacteal feeds like sugar, honey etc., awareness on the significance of colostrum, knowledge on proper/ effective breast feeding techniques, reasons for defaulting from exclusive breast feeding, type of extra lacteal feeds given, from whom the advice was taken, and the mothers feedback on such practices were also sought. The answers to the above questions were noted in the written prescribed proforma.

Data analysis

The data collected was subjected to appropriate analysis using the SPSS software version 19.0 for Windows. (SPSS Inc, Chicago, IL, USA).

RESULTS

Of the total 115 post-natal mothers interviewed in the study from the age of 18 years to 40 years, the majority of the mothers belonged to the age group between 20-25 years (n =53/ 115, 46.1%). The study population consisted of 94% literate mothers (n=108/115), of which college graduates and high/ secondary school graduates (n= 96/115, 88%) formed the majority. However only 24% (n= 28/115) among all the mothers had a part time or fulltime job.

Among the total study population, 41% (n= 49/115) had a single child, the remaining mothers multiparous (n= 66/115, 59%), of which around two-third (n=48/66) stated they had a gap of 2-3 years between deliveries. All the mothers (n= 115) reported to have had institutional deliveries with assistance given by a trained staff nurse or doctor at the time of delivery. Only 40% (n=45) of post-natal mothers had their delivery by caesarean section. Regarding the sex of the child, two –thirds (n=72/115) of the mothers had male babies, the remaining one third (n= 43/115) being females. Around 83% (n= 95/115) of the mothers had uneventful antenatal, natal and post-natal periods (Table 1).

*p value <0.05 - significant

The total percentage of mothers in the above study group who practiced exclusive breast-feeding for six months was only 44.3% (n=51/115). Correlating this value, with socio demographic factors such as maternal age (<25yrs />25yrs), education of the mother (literate/ illiterate), occupation (unoccupied/ occupied), birth order(one /more than one), spacing between births (<2yrs/ ≥2yrs), caesarean section (no/ yes) and sex of the baby (male/female) through multiple logistic regression analysis, a significant negative association with shorter duration between spacing of births and caesarean deliveries (p value <0.05) was observed (Table 2).

Regarding breast feeding awareness and practices, three-fourth (n= 86/115)) of the mothers claimed to have received antenatal counselling on breastfeeding, of which 50% (n=58/86) was by a heath care professional (doctor or nurse). Even though all the mothers had their deliveries in a health care facility, 6% (n=7/115) of the mothers stated that they had not received post-natal counselling at all on exclusive breastfeeding. The mothers who received postnatal counselling were mostly from a health care professional alone or associated with a family member (mother/husband) (n= 103/108, 90%). Most of the mothers (n= 98/115, 88%) claimed to have initiated breast-feeding on the first day, though many could not recall whether it was in the first hour. Less than half of the mothers counselled (n=47/108) stated that they were informed the importance of initiation within the first hour and knowledge on colostrum (Table 1).

The major barriers against EBF in this study were poor maternal secretions (n= 29/64, 45.3%), inverted/sore nipple (n= 15/64, 23.3%) while 13% (n= 8/64), chose that they were prejudiced to adding formula/extra lacteal feeds early for their baby’s better growth (Figure 1). Among working mothers, 42.9% (n=12/28) attributed their jobs as the cause for early weaning. Only one- sixth of the mothers counselled (20/108, 19%) stated they were taught/ trained about proper breast-feeding techniques (Figure 2).

Almost two-thirds of the mothers (n = 38/64) disclosed that their parents/ in-laws/ husbands’ were responsible for them having to start extra-lacteal feeds, 16% (n= 10/64) revealed that their health care professional was also supportive of starting extra-lacteal feeds earlier than 6 months, while 26% (n= 16/64) said it was their own decision (Figure 3). However, 55% of these mothers (n= 36/64) revealed that they felt such extra lacteal feeds had not helped their baby, as they did not observe weight gain they expected (n = 20/36, 56.6%), in addition to frequent episodes of diarrhea (n= 11/35, 30%) or repeated episodes of falling ill (n= 5/36, 13.4%).

DISCUSSION

As per the National Health and Family Survey 4 (NHFS 4, 2015-2016), the children exclusively breast-fed in India is 54.9%, whereas in Tamil Nadu and Puducherry it is 48.3% and 45.5% respectively.⁹ This study also observed a prevalence of 44.3%, which is in concordance to the above statistical data. Similarly, the percentage of institutional births in our study was 100% and caesarean sections 40% as against 99.9% institutional births and 33.6% caesarean sections documented for Puducherry in the NFHS 4.⁹

In a study by Radhakrishnan et al, from Tamil Nadu, the prevalence of EBF was 34%.¹¹ A study in Puducherry on Health Care Professionals by Renitha et al, showed a prevalence of 58% to EBF.¹⁴ Studies from other parts of India showed the prevalence of EBF to range 37% in Gujarat, 37.7% in rural North India, 46.5% in Uttar Pradesh to 63.5% in Delhi and 63.7% in Hubli respectively.^15-19

In relation to the socio-demographic factors assessed, a significant negative association was found between caesarean sections shorter duration of spacing between subsequent childbirth (<2yrs). Studies by Senthilvel et al, and Radhakrishnan et al, also showed a similar association with caesarean section deliveries.^20,11 Three - fourth (74.8%) of the mothers in the study recalled they were counselled during their antenatal period. This was almost similar to the results obtained by Dhandapany et al, (78-87%) on antenatal mothers in Puducherry.²¹

All the mothers in the study had deliveries at a health care facility and 86% of the mothers stated they initiated breast-feeding soon after birth (first day), though only one third could exactly recall the initiation was within one hour. The increase in the number of institutional deliveries may have a positive influence on early initiation of breast- feeding by the mothers as seen with similar trends in other studies.^22-25 In addition, 6% mothers mentioned not receiving post-natal counselling on EBF. Of those counselled, less than half (43.5%) only were aware of the importance of early initiation and colostrum. In another study also conducted in Puducherry, only 56% of the mothers knew that colostrum needs to be given which is also low compared to others studies in India where the importance of colostrum was known to 75- 90% of the mothers.^26-28

Poor maternal secretions (45.3%), inverted/ sore nipples (23.3%) were the major difficulties faced by mothers against EBF. These findings are similar to those reported by Parmar et al, Aggarwal et al, Parekh et al, and Mallikarjun et al.^29-32 In the studies by Palanivel et al, in Tamil Nadu and Kashif et al, in Uttar Pradesh, the above reasons attributed to 20-30% of the total barriers.^33,17

A population of the mothers (13%) started early weaning, as they were prejudiced that it was required for their baby’s better growth. Studies by Ratnayke et al, Li et al, and Kashif et al, had similar observations.^34,35,17 Almost half of the working mothers in the study population attributed their jobs as the barrier to EBF. Observations by Renitha et al, and Ratnayke et al, also stated mothers had difficulty in breast feeding while working owing to job timings, inability to express breast feeds or no proper facility to breast-feed at work.^14,35

Ratnayke et al, observed that over 50% of the mothers were advised to start other feeds early by their family members and 12% by a health care worker on the same.³⁵ The present study too showed the family was influential for 60% mothers and health care professional in 13%. However, the mothers who were not satisfied with having given extra-lacteal feeds were dissatisfied for not achieving the expected weight gain in addition to frequent respiratory/diarrheal diseases. Statistical significance with the incidence of the above diseases sans EBF has been reported in several studies.^11,36,37

CONCLUSION

The prevalence of exclusive breast-feeding is still low despite having a fairly literate study group. Although there were no gross significant association with socio-demographic factors, lacunae have been identified. Antenatal breastfeeding counselling combined with a good post-natal lactation support especially for the initiation of breastfeeding in caesarean section mothers, proper breastfeeding techniques and facilities to continue exclusive breastfeeding in working mothers may overcome the major barriers. A more objective counselling especially in the post-natal period to mothers and their care givers may also facilitate exclusive breastfeeding to a great extent.

ACKNOWLEDGEMENTS

Authors would like to acknowledge all the mothers who participated in the study and gave their valuable responses.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

REFERENCES

1. 1. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta‐analysis. Acta Paediatrica. 2015;104(S467):96-113.
2. 2. Gupta A, Arora V. The State of World’s Breastfeeding -Tracking Implementation of the Global Strategy for Infant and Young Child Feeding. International Baby Food Action Network (IBFAN), Asia Pacific. South Asia report. Feb 2007.
3. 3. WHO (world health organization) Breastfeeding. Available at: http://www.who.int/maternal_child_adolescent/topics/child/nutrition/breastfeeding/en/. Accessed 26 December 2019.
4. 4. Infant and young child nutrition: Global strategy on infant and young child feeding. Available at: http://apps.who.int/gb/archive/pdf_files/WHA55/ea5515.pdf. Accessed 01 January 2020.
5. 5. Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health. 2011;11(3):24.
6. 6. United Nations Children's Fund (UNICEF): Progress for Children: A Child Survival Report Card 2004. Available at: https://www.unicef.org/progressforchildren/2004v1/ Accessed 29 December 2019.
7. 7. Najem B. Breast Feeding Problems in Primipara Mothers in Early Postnatal Period. Iraq J Commu Med. 2011;24(3):192-5.
8. 8. CheZem J, Friesen C, Boettcher J. Breastfeeding knowledge, breastfeeding confidence and infant feeding plans: Effects on actual feeding practice. J Obstetr Gynecol Neonat Nurs. 2003;32(1):42-7.
9. 9. National Family Health Survey, India. Key indicators for India from NFHS-4;2015. Available at: http://www.nfhsindia.org/pdf/India.pdf. Accessed 30 December 2019
10. 10. Bandyopadhyay M. Impact of ritual pollution on lactation and breastfeeding practices in rural West Bengal, India. Inter Breastfeeding J. 2009;4(1):2.
11. 11. Radhakrishnan S, Balamuruga SS. Prevalence of exclusive breastfeeding practices among rural women in Tamil Nadu. Inter J Health Allied Sci. 2012;1(2):64.
12. 12. Malhotra P, Malik S, Virk N. Prospective study to assess knowledge, attitude and breast-feeding practices of post-natal mothers in Punjab, India. Inter J Contem Pediatr. 2017;5(1):139-43.
13. 13. Tiwari R, Mahajan PC, Lahariya C. The determinants of exclusive breastfeeding in urban slums: a community based study. J Tropic Pediatr. 2008;55(1):49-54.
14. 14. Renitha R, Babu TA, Kumar M, Srinivasan S. Breast feeding practices among health care professionals in a tertiary care hospital from South India. Indian J Public Health. 2012;56:149-51.
15. 15. Chudasama RK, Patel PC, Kavishwar AB. Determinants of exclusive breastfeeding in south Gujarat region of India. J Clin Med Res. 2009; 1:102-8.
16. 16. Ahmad S, Yadav M, Shukla NK, Shukla M, Soni S, Patni KN. Assessment of breastfeeding practices in a rural area of North India. Ind J Basic Applied Med Res. 2016 Mar;5:40-7.
17. 17. Kashif M, Mirza S, Pandey A, Shukla KM, Mishra P. Study of breast feeding practices, problems and factors affecting exclusive breastfeeding in Barabanki District of Uttar Pradesh-A Hospital Based Study. Ind J Prevent Social Med. 2018;49(2):73-83.
18. 18. Aggarwal A, Verma S, Faridi MM. Complementary feeding—reasons for inappropriateness in timing, quantity and consistency. Indian J Pediatr. 2008 Jan 1;75(1):49-53.
19. 19. Pooja JM, Aditya JM, Sangamesh JM, Margol S. Study of breastfeeding practices and problems among postnatal mothers: a hospital based study. Int J Reprod Contracept Obstet Gynecol. 2017;6(8):3343-6.
20. 20. Senthilvel V, Sumathi S, Singh Z, Jayanthi V. A study of breastfeeding practices among non-working women in rural area of Puducherry. Ind J Maternal Child Health. 2011;13(3):12.
21. 21. Dhandapany G, Bethou A, Arunagirinathan A, Ananthakrishnan S. Antenatal counseling on breastfeeding–is it adequate? A descriptive study from Pondicherry, India. Inter Breastfeeding J. 2008;3(1):5.
22. 22. Prasad KN, Ahamed N. Community based study on initiation of breast feeding and determining factors in rural area of Pondicherry. Int J Contemp Pediatr. 2015;2:208-12.
23. 23. Adhikari M, Khanal V, Karkee R, Gavidia T. Factors associated with early initiation of breastfeeding among Nepalese mothers: further analysis of Nepal Demographic and Health Survey, 2011. Inter Breastfeeding J. 2014 Dec;9(1):21.
24. 24. Patel A, Banerjee A, Kaletwad A. Factors associated with prelacteal feeding and timely initiation of breastfeeding in hospital-delivered infants in India. J Human Lactation. 2013 Nov;29(4):572-8.
25. 25. Sandor M, Dalal K. Influencing factors on time of breastfeeding initiation among a national representative sample of women in India. Health. 2013;5:2169-80.
26. 26. Ekambaram M, Bhat VB, Ahamed MA. Knowledge, attitude and practice of breastfeeding among postnatal mothers. Curr Pediatr Res. 2010;14(2):119-24.
27. 27. Subbiah N. A Study to assess the Knowledge, Attitude, Practice and Problems of Postnatal Mothers regarding Breastfeeding. Nursing J Ind. 2003;94(8):177-9.
28. 28. Tiwari V, Singh A. Knowledge, attitude and practice regarding breastfeeding in an urban area of Fazidabad district (U.P). Indian J Prev Soc Med. 2007;38(1):18-22.
29. 29. Parmar VR, Salaria M, Poddar B, Singh K, Ghotra H, Sucharu. Knowledge, attitudes and practices regarding breast feeding at Chandigarh. Indian J Public Health. 2000;44:131-3.
30. 30. Agarwal A, Arora S, Patwari AK. Breastfeeding among urban women of low-socioeconomic status: Factors influencing introduction of supplemental feeds before four months of age. Indian J Pediatr 1998;35:269-73.
31. 31. Parekh C, Bavdekar SB, Shaharao V. Study of infant feeding practices: Factors associated with faulty feeding. J Trop Pediatr. 2004;50:306-8.
32. 32. Mallikarjun HB, Banapurmath CR, Shobha B, Kesari N. Breastfeeding problems in first 6 months of life in rural Karnataka. Indian Pediatr. 2002;39:861-4.
33. 33. Rajan BP, Sindhu S. Awareness and Difficulties Encountered By The Postnatal Mothers During Breast Feeding. Nat J Res Commu Med. 2016;5(4):262-7.
34. 34. Ratnayake HE, Rowel D. Prevalence of exclusive breastfeeding and barriers for its continuation up to six months in Kandy district, Sri Lanka. Inter Breastfeeding J. 2018;13(1):36.
35. 35. Li R, Fein SB, Chen J, Grummer-Strawn LM. Why Mothers Stop Breastfeeding: Mothers’ Self-reported Reasons for Stopping During the First Year. Pediatr. 2008;122:69-76.
36. 36. Sur D, Mondal SK, Gupta DN, Ghosh S, Manna B, Sengupta PG. Impact of breast feeding on weight gain and incidence of diarrhea among low birth weight infants of an urban slum of Calcutta. Indian Pediatr. 2001;38:381-4.
37. 37. Mihrshahi S, Oddy WH, Peat JK. Association between infant feeding patterns and diarrhoeal and respiratory illness: A cohort study in Chittagong, Bangladesh. Int Breastfeed J. 2008;3:23-8.