|Year : 2012 | Volume
| Issue : 2 | Page : 54-58
Breastfeeding practices among lactating mothers: Problems and prospects in a cross-sectional study
Jeetender Singh, DG Vishakantamurthy, PM Charan
Department of Community Health, JSS College of Nursing, Saraswathipuram, Mysore, Karnataka, India
|Date of Web Publication||27-Sep-2012|
Department of Community Health, JSS College of Nursing, Saraswathipuram, Mysore - 570 009, Karnataka
Source of Support: None, Conflict of Interest: None
Context : Breastfeeding practices play an important role in reducing child mortality and morbidity. This study was aimed to describe the breastfeeding practices prevalent in Mysore city. Objectives: The primary objective of this study was to describe and explain the factors influencing breastfeeding practices in Mysore city, and the secondary objective was to compare the breastfeeding practices of lactating mothers attending well baby clinic (A clinic run by pediatric specialist in good hospitals) with their selected personal variables. Settings and Design: The study was conducted at selected hospitals of Mysore city from January 2009 to June 2009 for the period of six months. Materials and Methods: Lactating mothers having at least a single infant attending well baby clinic at selected hospitals were included in the study and data was collected using the pre-tested questionnaire on breastfeeding practices. Results: Our study shows 74.29% of the mothers initiated breastfeeding, more than 50% used pre-lacteal feeds, 36% had discarded the colostrum and the majority of mothers had followed hygienic practices while feeding their child. Conclusions: This study emphasizes the need for breastfeeding intervention programs especially for the mother during antenatal and postnatal check-ups and practices like discarding the colostrum and early/late weaning are still widely prevalent and need to be addressed.
Keywords: Breastfeeding practices, colostrum, lactating mothers, weaning
|How to cite this article:|
Singh J, Vishakantamurthy D G, Charan P M. Breastfeeding practices among lactating mothers: Problems and prospects in a cross-sectional study. Int J Health Allied Sci 2012;1:54-8
|How to cite this URL:|
Singh J, Vishakantamurthy D G, Charan P M. Breastfeeding practices among lactating mothers: Problems and prospects in a cross-sectional study. Int J Health Allied Sci [serial online] 2012 [cited 2020 Jan 25];1:54-8. Available from: http://www.ijhas.in/text.asp?2012/1/2/54/101663
| Introduction|| |
The first year of life is crucial in laying the foundation of good health. At this time certain specific biological and psychological needs must be met to ensure the survival and healthy development of the child into a future adult. Breastfeeding is the ideal method suited for the psychological and physiological needs of the infant. Early initiation of breastfeeding is extremely important for establishing successful lactation as well as for providing colostrum to the baby.
Medical and public health experts advocate breastfeeding as the best method of feeding young infants for a wide variety of reasons. It is evident that even the most sophisticated and carefully adapted formulae can never replicate human milk, as human milk has anti-infective properties, and is a 'live' fluid which cannot be mimicked in an artificial formula. An adequate supply of human breast milk is known to satisfy virtually all the nutritional needs of an infant at least for the first six months of life. It is easily digestible and facilitates skin to skin contact and physical warmth between mother and child, which further strengthens the emotional bond between them. 
The newborn baby is very active during the first half an hour. If the baby is kept with the mother and made to breastfeed, the infant learns sucking very fast. In caesarean deliveries newborn infants can be started with breastfeeding within 4-6 h which helps for early secretion of breast milk and better milk flow. In India, more than 11 lakh babies die during the first month of life, and another 5 lakh during 2 to 12 months of age. Neonatal mortality accounts for almost 40% of all under-five deaths and for nearly 60% of infant deaths. Around 80-90% of mothers believe that the first milk which is watery and light yellowish in color and is a secretion collected over nine months will be harmful to the neonate.  Hence they squeeze the first milk and discard it and initiate breastfeeding only after two to three days. The researcher understood the various misconceptions and myths associated with the initiation of breastfeeding and reasons for delayed initiation and suggested that the necessary strategy to explore the problems pertaining to breastfeeding practices can be undertaken among mothers attending well baby clinic.
| Materials and Methods|| |
This cross-sectional study was conducted at selected hospitals of Mysore city from January 2009 to June 2009, a period of six months, after institutional ethical committee approval. Each day, on an average 10-20 mothers visited the hospitals. Lactating mothers who came to attend well baby clinic at selected hospitals were included in the study. Verbal and written consent was obtained from the participants. Those who were not willing to participate were excluded. A pre-tested questionnaire was used to interview all mothers attending well baby clinic. Following non-probability convenience sampling method the researcher could get 280 mothers in the set duration over a period of six months.
The pre-tested questionnaire included various factors that had a potential effect on the initiation and duration of breastfeeding practices [Table 1]. The questionnaire included socio-economic and demographic data, details on the initiation and duration of breastfeeding, details on artificial feeding and weaning practices, and newborn care practices. A pre-test run was done to validate the questionnaire. The structured practice interview schedule had two sections: Section a included the questions related to socio-demographic variables; Section b contained nine items on breastfeeding practices.
|Table 1: Pre-tested questionnaire included various factors that had a potential effect on the initiation and duration of breastfeeding practices|
Click here to view
Statistical analysis used
Data analysis was done according to descriptive statistics. The frequency and percentage of various responses were obtained and results are given in percentages. Microsoft Excel was used to compute the data.
| Results|| |
In our study, the majority of the lactating mothers were between the ages of 21 and 25 years (60%), and 26 and 36 years (30%). About 52% of the mothers were illiterate and belonged to a low to medium socio-economic class (55%). A majority of the mothers were primigravidae (65%) and the age at marriage was between 15 and 20 years (69%). The majority of the mothers were housewives (69%) and mothers who were employed were 22%.
[Table 1] shows that maximum 208 (74%) of mothers initiated breastfeeding within 6 h and at least 05 (1.7%) had initiated it in 25-72 hrs. With regards to duration of breastfeeding the majority 225 (80%) of the mothers had breastfed their baby for more than six months and significantly 55 (19.6%) mothers had breastfed their child for less than six months. When enquiring about the frequency of breastfeeding it was found that only 118 (42%) mothers complied with breastfeeding every second hourly. The majority 124 (44%) of mothers were breastfeeding their baby every 4 h, a few 36 (12%) mothers had breastfed their babies as per elderly advice, and the remaining 2% had other frequencies for breastfeeding. It justifies the influence of a mother-in-law on various aspects of breastfeeding. Interestingly, it was observed that a significant 36% of mothers had discarded the colostrum considering it as harmful to the baby's health and also difficult for digestion by the baby. On enquiring about pre-lacteal feeds it was found that 47% mothers were giving only breast milk and still there were two popular methods being practiced by the mothers in study are honey (23%) and ghutti (10%) (baljanma ghutti). Many of the mothers were using plain sugar water and artificial milk also as a substitute. Regarding burping the baby it was observed that a significant number (23.97%) of mothers were not aware about the significance of burping. A comfortable position for the mother and baby promotes psychological wellbeing and proper bonding. It was found in our study that most of the mothers preferred the sitting and lying position. Cleaning the whole breast tissue and wiping the baby mouth each time after feeding helps mother in preventing acute respiratory diseases and diarrheal diseases. It was found in our study that significantly 42.5% of mothers were not wiping baby's mouth. And also it was observed that most of the mothers were not cleaning the breast or nipples after feeding the infant.
| Discussion|| |
In this study the average time for initiating breastfeeding or rooming in was found to be 6 h which suggests that breastfeeding was initiated at the right time and women had a very positive attitude towards initiation of breastfeeding. Breastfeeding should be initiated within 30 min of delivery. A delay in initiation will lead to a delay in the development of oxytocin reflexes, which are very important for the contraction of the uterus and the breast milk reflex. Other studies conducted also show similar trends. It was found that mothers who initiated breastfeeding quite late and introduced 'top' milk during the first few days postpartum, could not breastfeed for long. The major reason cited for this was lack of interest in the baby to feed. This is because the top feed which is high-calorie may satiate the baby's appetite and prevent it from wanting to feed at the breast Another important observation was that once the baby was fed with a bottle and a teat, which is a relatively easy exercise for the baby, it is less likely to return to the mother's breast because it finds it more easy to suck milk from the bottle than from the mother's breast. 
Certain social customs prevalent among the lower income groups were also found to be responsible for the delay in initiating breastfeeding. For example, the belief that taking food soon after delivery leads to infection led to mothers being deprived of a regular diet for three days after the delivery. Further, the baby was not even put to the breast as they believed that since the mother was fasting, she would not lactate. This unscientific practice led to weakness and susceptibility to infection. Infants in many cases were deprived of colostrum. Almost more than one-third of the infants in this study were not given colostrum and discarding of the colostrum is still practiced widely. This was more so in the case of poor families. As the elders in such families are largely illiterate, they consider colostrum as something indigestible and not good. Moreover, the mothers are also unaware of the benefits of colostrum. Interestingly, in some of communities, it is customary to express it out (squeeze out manually) and throw it at a wall or a tree; it is believed that if it is thrown on the ground people may step on it, and this would lead to drying up of the mother's milk. 
On the other hand, a good number of mothers fed colostrum to their infants on the advice of the doctors and health workers in the hospital [Table 1]. Some of the educated mothers had learned about its value by reading books and magazines. Around 63% (178) mothers from the middle and upper income group were aware that colostrum is rich in vitamins, minerals, and immunoglobulins provide immunity against infections.
Pre-lacteal feeds should not be given but still the majority of mothers give either Ghutti, honey or just plain sugar water. Discarding the colostrum and feeding the child with Ghutti, sugar water, or honey makes the child vulnerable to infections. Other studies have also found similar practices in the community and it is largely influenced by the relatives, especially the mother-in-law. Pre-lacteal feed is harmful not only for baby but also for the mother. This interferes with establishment of breastfeeding. Pre-lacteal feed given to a newborn will satisfy the hunger and baby will not suckle at the breast and the baby will not be benefitted by breast milk. Suckling of breast by a newborn is also necessary for milk production in the mother hence the practice of pre-lacteal feed along with supplementary feed will ultimately make the mother's breast empty and top milk will be the only option left. Risk of infection is another major drawback of pre-lacteal feed.  Methods of practicing pre-lacteal feed are highly unhygienic. People use their fingers, spoon, metal ring and cotton bud to give these feeds which can be a source of infection. Honey needs a special mention here as it is found to be a source of Clostridium botulinum, an organism which can cause a disease infantile botulism in newborn. According to latest researches honey should not be used in infants below one year of age.
One of the most common reasons voiced by women throughout the world for the early termination of lactation and the early introduction of milk supplements and weaning foods is insufficient breast milk, called the 'insufficient milk syndrome' (IMS) by Gussler and Briesemeister,  which threatens the well-being of infants. The insufficient milk syndrome has been related to changing patterns of maternal roles and infant care, and the complexities of modem life. Gussler and Briesemeister  ascribe it to what they call "non-biologic breastfeeding" and focus on the lack of "constant contact" between the mother and the infant in modern urban settings. They theorize that physical distance, barriers such as clothing, strollers and cribs, minimize intimate contact between the nursing dyads, and the pattern of scheduled, widely spaced feeding propels the mother and infant down the pathway to insufficient milk. Greiner et al. recognized the complex sociocultural and psychological aspects of the insufficient milk syndrome but state that the decreased suckling stimulus to the nipples as a result of supplemental feeds is the most "parsimonious" explanation for insufficient milk.  It would appear then that the insufficient milk syndrome is associated with psychological factors, inappropriate hospital practices, and infant characteristics rather than with a biological inability to produce an adequate milk supply. 
The majority of the mothers were doing exclusive breastfeeding, but still a section of mothers was not doing this as they complained of insufficient milk. The influence of the mother-in-law and self-assumption about lack of milk for the baby are cited as major reasons for early weaning and late weaning. Other studies have also found similar influences of the mother-in-law and neighbors regarding exclusive breastfeeding. A new baby needs to nurse at least 8-12 times in 24 h. To breastfeed successfully, it's important to nurse whenever the baby is hungry. Usually this works out to a feeding every 1½-3 h (timed from the start of one feed to the start of the next). In our study it was found that most of the mothers maintained that crucial time gap between each fed. Cleaning of breast after feeding helps the mother in preventing several infections which are potentially harmful to the baby too. The majority of the mothers in the study were following good hygienic practices.
A minor change in the breastfeeding schedule occurs and mothers become nervous and frustrated thinking that they are unable to produce adequate milk for the growing child. This doubt and the consequent psychological pressure forces them to resort to bottle feeding. Prospects of the recent research related to the clinical aspects of breast milk and the psychological implications of breastfeeding for child development have given a new impetus to the practice. Moreover, breastfeeding is being adopted as an expression of self-fulfillment. 
Positive thinking by the mother who feels confident of producing enough milk for the baby can extend the period of breastfeeding. Although the rate of decline in breastfeeding practices in India is not alarming, it is necessary to check the declining trend, particularly in urban areas through various methods in light of the experiences of other countries. A more practical way to encourage breastfeeding is to form voluntary organizations, associations and groups as done in many countries worldwide.  The oldest 'La Leche League International Inc.' founded in 1956 in the US, is the biggest breastfeeding women's group and has published a manual, "The womanly art of breastfeeding". Besides the US there is the 'Nursing Mothers' Association' in Australia, 'Independent Working Groups on Breastfeeding' in West Germany, 'Malaysian Breastfeeding Advisory Association in Malaysia, 'Susu Mamas' in Papua New Guinea, Singapore's Breastfeeding Mothers' 'Group' in Singapore, TIBS-'The Informative Breastfeeding Service' in Trinidad, 'The Nutritional Child Trust' in the United Kingdom and many more are working successfully throughout the world. The members of these groups work through group discussions, and telephone and letter counseling. They have libraries which lend literature, films and slides free of charge. Specially trained members of the associations give antenatal and postnatal talks to mothers at hospitals and at childbirth educational classes. Printed materials, posters and newsletters on the advantages of breastfeeding and how to assist mothers should be produced. 
| Conclusion|| |
This study emphasizes the need for breastfeeding intervention programs, especially for the mother during antenatal and postnatal check-ups. The information regarding the advantages and duration of breastfeeding needs to be provided for the community as a whole. Undesirable cultural practices such as giving pre-lacteal feeds, early/late initiation of breastfeeding after birth, discarding the colostrum, delay in introduction of weaning foods and avoiding exclusive breastfeeding are still prevalent among the mothers. Practices such as discarding the colostrum and early/late weaning should be discouraged. The maternal knowledge about breast feeding was just satisfactory and there was a significant gap between actual and desired practices. Hence it justifies the need for strengthening community-based health education programs and other continuous Information Education Communication (IEC) activities. It is also recommended to have qualitative research on psychological issues among young mothers to bridge the gap between knowledge and practice.
Limitations/Strengths of the study
The following limitations are applicable to this study. The centers were designated 'baby-friendly' and this may have affected the reliability of the responses given by the mothers, with a possibility of exclusive breast feeding (EBF) practice being overestimated. There was also the possibility that an infant had received some other type of feeding from someone else without the mother's knowledge. Furthermore, some infants may have shifted from one feeding pattern to another, and then returned to the previous one. Researchers felt the need of having a case study method in future, which would give in-depth information regarding hidden facts. Comparative case analysis from rural and urban settings would be really helpful.
| References|| |
|1.||Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al. Evidence for protection against infant deaths from infectious diseases in Brazil. Lancet 1987;2:319-22. |
|2.||Chandrashekar S, Chakladar BK, Rao RS. Infant feeding-knowledge and attitudes in a rural area of Karnataka. Indian J Pediatr 1995;62:707-12. |
|3.||Benakappa DG, Raju M, Shivananda, Benakappa AD. Breastfeeding practices in rural Karnataka (India) with special reference to lactation failure. Acta Paediatr Jpn 1989;31:391-8. |
|4.||Chandrashekhar TS, Joshi HS, Binu V, Shankar PR, Rana MS, Ramachandran U. Breast-feeding initiation and determinants of exclusive breast-feeding: A questionnaire survey in an urban population of western Nepal. Public Health Nutr 2007;10:192-7. |
|5.||World Health Organisation, UNICEF, Ten steps to promote successful breastfeeding Mother and Child Health Division. Geneva: 1989. Available from: http://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf accessed on 15th of April 2012 at 14.30 hours. |
|6.||Gussler JD, Briesemeister LH. The insufficient milk syndrome: A biocultural explanation. Med Anthropol 1980;4:145-56. |
|7.||Griener TP, Sterik VA, Latham MC. The Insufficient Milk Syndrome: An alternative explanation. Med Anthropol 1981;5:233-9. |
|8.||Tully, Julia, Dewey, Kathryn G. Private fears and global loss: A crosscultural study of insufficient milk syndrome. Med Anthropol 1985;9:225-30. |
|9.||Iarukov A, Nin'o A, Iarukova N, Doicheva E, Kolev D. The early breast feeding of newborn infants. Akush Ginekol (Sofiia) 1992;31:13-5. |
|10.||Reddy S. Breastfeeding - Practices, problems and prospects. J Fam Welfare 1995;41:43-51. |
|11.||Agarwal S, Srivastava K, Sethi V. Maternal and new-born care practices among the urban poor in Indore, India: Gaps, reasons and possible program options. New Delhi: Urban Health Resource Center; 2007. |