Knowledge and Attitude Evaluation of Mothers Regarding Exclusive Breastfeeding Referring to Health Care Centers View PDF

Breastfeeding is a basic human activity, vital to infant and maternal health and of immense economic value to households and societies. Exclusive breastfeeding is the single most effective intervention for child survival [1,2]. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that every infant should be exclusively breastfed for the first six months of life, with breastfeeding continuing for up to two years of age or longer [3]. Hence, breastfeeding is an important public health strategy for improving infant, child and maternal morbidity and mortality, and helping to control health care costs. Breastfeeding is associated with a reduced risk of otitis media, gastroenteritis, respiratory illness, sudden infant death syndrome, necrotizing enter colitis, obesity, and hypertension [4]. Many factors that may influence breastfeeding include race, maternal age, maternal employment, level of education of parents, socio-economic status, insufficient milk supply, infant health problems, maternal obesity, smoking, parity, method of delivery, maternal interest and other related factors [5]. Only 35% of worldwide infants were exclusively breastfed for even the first six months of life and the recommendations in developing countries were still low [6].

Exclusive breastfeeding is uncommon and breastfeeding practices in Iran are varying considerably and suboptimal. The exclusively breastfed infants in 1998 were 28% and increased to 55.6% in 2000 and a decrease in 2005 (27.1%) [7] And it was 31.17% in 2011 [8] and 53% in 2013 [9]. Exclusive breastfeeding during the first year of a child’s life ensures the provision of certain biological and psychological needs and therefore increases the probability of survival during this critical stage of development [10,11]. Consequently, mothers are encouraged to breastfeed exclusively in the first six months of a child’s life. Breastfeeding has declined worldwide in recent years as results of urbanization, maternal employment; mothers felt that breast milk was inadequate. Inadequate knowledge, attitude along with inappropriate practice, of breastfeeding may lead to undesirable consequences. Many researches are done about mother’s knowledge and attitude concerning exclusive breastfeeding in many areas in Iran, but no research is done around this topic, in southeastern Iran. Hence, we decided to assess breastfeeding knowledge, attitude among mothers referring to Health Care Centers in Zabol. Findings from this study could be used in developing appropriate intervention strategies to promote optimal infant feed.

A descriptive cross-sectional study of 268 mothers with baby less than 2 years' age was conducted in Zabol, in Sistan & Baluchestan Province, Iran. The sample selected among pregnant women that whom referred at the Health Care Centers for routine babies' checkup. Sample size was determined by help of a statistician based on the previous data derived on knowledge score [12], by using formula,

with 5% marginal error and 95% CI. Finally, 270 pregnant women selected through randomized cluster stratified sampling method. Inclusion criteria involved all mothers with baby less than 2 years' age visiting the Health Care Centers, Zabol. Exclusion criteria included, conditions where breastfeeding is contraindicated like galactosemia, mother suffering from cancer, active tuberculosis, psychoses. The study approved by Ethics Committee of Zabol University of Medical Sciences, Iran, in 2016. A written informed consent was taken from eligible participants.

Data collected by structured questionnaire and interview. Data were including demographic characteristics of mothers, their knowledge and attitude toward exclusive breastfeeding.

A structured questionnaire used to assess demographic data, knowledge and attitudes towards exclusive breastfeeding among Participants. The questionnaire was containing three sections as follow:

Section A: The demographic form elicited information on participants’ background: age, type of delivery, occupation, education level, Type of baby milk feed, the source of information regarding breastfeeding.

Section B: This part of questionnaire was developed by the researchers based on the review of literature and past experiences. This section included 33 multiple-choice questions about knowledge. Each item in the knowledge section of the questionnaire had 3 possible responses, namely True, False, and not sure. One mark was awarded for every correct response, zero otherwise. Hence, the total number of marks in the knowledge section ranged from 0 to 33. Total score of awareness varied from zero to 33. Scoring of knowledge were as follow; the total score of 11 and less considered as weak awareness, between 11 and 22 as moderate and more than 22 as good awareness.

section C: Third part contained 16 questions related to attitude items to determine level of agreement to each question. A 5-option Likert scale from strongly disagrees to strongly agree was applied to all questions. It is mentionable that some of the questions were negatively worded. Total scores were grouped into three groups (1) score of 30 and less considered as weak attitude, (2) between 30 to 60 as moderate and (3) greater than 60 as good attitudes.

Questionnaire was validated by nutrition experts in Department of Nutrition in Zabol University of Medical Sciences. Reliability of used questionnaire was evaluated by a pilot study on 10% of study population. Analysis of data that gathering by pilot study showed, the questionnaire was reliable with Cronbach’s alpha coefficient of 91% and 87 for knowledge and attitude respectively. Finally data analyzed by SPSS ver.18. Continuous variables were expressed as mean ± SD, qualitative data were presented as frequency (percent). One-way ANOVA and post hoc-Tukey test, Student independent sample t test and Pearson correlation were used to determine relationship between variables. A P-value of

The results of current study demonstrated that, the mean age of mothers was 27.33 ± 6.13 with ranged from 16 to 46 years, 64. 6% of children used breastfeeding and 39.5% of them had exclusive breastfeeding till 4 months a?er birth and 28% had exclusive breastfeeding till end of 6 months.

The educational levels of 50.4% were secondary and high school, 32.5% had university education and 1.9% of them were illiterate. The most of families had two children (37.7%) and a low percent (0.7%) had five children. The mode of delivery of 75.4% of mothers was vaginal, while 24.6% were delivered through a Caesarian Section (CS)and 37.7% of them had twice pregnancy experience. Most of the participants (74.3%) were housewives. As depicted in the Table, 64.6% of infants used breastmilk and a low percent of them merely used formula (1.9%). The results demonstrated that the highest lactation period (29.5%) was for children between 6-12 months and the lowest (2.2%) was for children who consumed milk for more than 24 months. Majority of participants mentioned, the breastmilk is inadequate for their child (28.4). The main sources of mothers’ knowledge reading breastfeeding were Health Care Centers personnel's (Table 1).

Table 1: The mothers' demographic characteristics and relationship with their knowledge and attitude regarding exclusive breastfeeding.

The results showed that 9.7% of the subjects had poor knowledge, 59.7% of them had a moderate awareness and 30.6% had a good knowledge about breastfeeding. Moreover 41.8% had a moderate attitude and 58.2% had a good attitude towards breastfeeding (Table 2).

Table 2: Distribution of di??erent levels of knowledge and attitude in participant toward exclusive breastfeeding.

Analysis of data showed there was no statistical significant between mothers’ knowledge and attitude regarding breastfeeding with their type of delivery, occupation, type of feeding, the cause of using formula (P>0.05). A significant association found between mothers’ knowledge and attitude concerning breastfeeding with duration of lactation (P<0.05). A significant association found between mothers’ knowledge and their education levels (p=0.014), based on post hoc -Tukey test, the knowledge of mothers’ with university education level was higher than others (P<0.05), while there wasn't significant association between mothers' attitude with their education levels (P>0.05). Analysis of data by post hoc-Tukey test demonstrated that the knowledge of that mothers’ hadn’t breastfeed to their baby's was significantly lower than others, while the attitude of mothers’ that had 18 to 24 months' duration of lactation was higher than others. There was not significant association between mothers’ knowledge and the sources of information regarding breastfeeding (P>0.05). Association between attitude with the source of information regarding breastfeeding was statistically significant (P = 0.018), based on post hoc-Tukey test mothers believed that, the health care center personnel were the main source of information about breastfeeding (Table 1). According to Pearson correlation, no significant relationship was found between knowledge with attitude and age of mothers? in the 1st pregnancy, (P>0.05), but there was a significant positive relationship with between knowledge and age (r = 0.28, P<0.05) and the time of initiating of supplementary food (r = 0.166, P-value?0.05) (Table 3). No significant relationship observed between attitude with knowledge and age, age of mothers? in the 1st pregnancy and the time of initiating of supplementary food (P>0.05) (Table 3).

Table 3: Correlation between knowledge and attitude with age, age of mothers? in the 1st pregnancy, the time of initiating of supplementary food.

The results showed that 9.7% of the subjects had poor knowledge, 59.7% of them had a moderate awareness and 30.6% had a good knowledge about exclusive breastfeeding.

Mothers’ knowledge concerning breastfeeding demonstrated that, the highest correct response (92.2%) were regarding after delivery is the best time to initial the breastfeed”, 91.4% for “neonate need breastfeeding throughout the night”, 88.1% for “there is a relationship between the mental and psychological status of mother and secretion of her milk”, 84% for “the best time to initiate the supplementary food, is the end of the 6th month”, 81.7% for “breastfeeding enhance immune system of baby against the illness” and 80.2% for “lactation has not complication for health of mother”, 79.1 for “It is possible to keep the mother's milk in the refrigerator”, 78.7% for “First milk is low, but it will be increased by lactate”, 70.9 for “Colostrum's consumption has eff?ect on health of neonates”, also for “Breastfeeding couldn't fully meet the child’s need, if supplementary food not be started at suitable time, thus, it would lead baby to the malnutrition ”and for “the nutritional status of mother has not effect on nutrients contents of her milk” and 70.5 % for “Long separation of mother and her neonate's is a main reason for deteriorating (failing) of breastfeeding” and 69% for “Night lactation is eff?ectiveness to increase the mother’s milk” and 64.2% for “Glass containers are the first choice and hard plastic transparent containers are the second choice to save mother’s milk” and 63.1% for both answers “Mother’s milk is compulsory for feeding of immature neonate” and “it's necessary to wash the breast before breastfeeding” (Table 4).

Table 4: Knowledge of participants towards exclusive breastfeeding.

Mothers’ attitude towards breastfeeding showed in Table 5. As clear, about 91% of the mothers were strongly agree that “breastfeeding is a cause of deformity of the mothers’ breast”, followed by 68.7% the item “breastfeeding increase mother infant bonding”, then a slightly lower with percentage of 63.1 for item of “breastfed babies are healthier than formula fed babies”. Followed by 59%, the item of “mothers whom, formula fed their baby miss one of the great joys of motherhood”. After that the item of “breastfeeding is more convenient than formula feeding” with percentage of 57.1% and it’s followed by 54.1%for the item of “breast milk is cheaper and save money than formula” and finally item of “breastmilk is more easily digested than formula” (52.2%) (Table 5).

Exclusive breastfeeding is the single most effective intervention for child survival. According to the Millennium Development Goals, exclusive breastfeeding for six months is considered as one of the most effective interventions [13]. The results of current study demonstrated that, 64.6% of children used breastfeeding that was lower than Poormand et al. [9] results that was 78%. Also 39.5% of participants demonstrated had exclusive breastfeeding till 4 months after birth, and 28% had exclusive breastfeeding till end of 6 months while in Poormand et al. [9] findings, it was higher than current results (53%). Findings showed 9.7% of the subjects had low level of knowledge, 59.7% of them had a moderate level and 30.6% had high level of knowledge about breastfeeding, while Dallak et al. [14] showed the highest percent of mother's knowledge regarding breastfeeding was in moderate level, that was slightly lower than current results (59.7% vs. 47.3%) and they demonstrated that, 30.2% of participants had low level of knowledge that was higher than current results(30.2 vs. 9.7) , while 22.5% of the mothers had high level of knowledge that was lower than current findings (22.5 vs. 30.6). As mention above, the study shows that 30.6% of mothers had good knowledge towards exclusive breastfeeding which is lower than studies conducted in Gondar, Ethiopia (69.8%); Abha city, Saudi Arabia (55.3%) [15]; Calabar, Nigeria (80%) [16]; Bedele town in Ethiopia (87.3%) [17]; Hyderabad, Telangana, India (72.8%) [18]. Knowledge towards exclusive breastfeeding in current research is higher than studies conducted in Hamadan, Iran, that was 3% [19]. These differences may be related to variations in sampling technique, sociocultural and economic status participants, and healthcare delivery systems.

In the current study, the knowledge of initiation of breast feeding after birth is 92.2% which is higher than that from a study conducted in Gondar, Ethiopia that was 70%; study conducted in Mizan, Aman town of Ethiopia that was 73.3% [20]; a study conducted in Odisha which was 52.78% [21] and Tanzania which was 58.8% [22]. The above dissimilarities may be due to the differences of sample sizes. Knowledge of respondents on colostrum in this study is 70.9% (having good knowledge). This is higher than the previous study which was 54.7%.

In this study based on the attitudinal score 58.2% had a good attitude towards exclusive breastfeeding. The finding is lower than reports done in Gondar Ethiopia (76%); Rwanda, Kigali, which was 71.1% and in Jima town in Ethiopia that was 73.9% [23]; Mizan Aman town, which is 89.5% in Ethiopia [20]. The disagreement among these study results might be attributed to the dissimilarities due to the differences of study settings and may be due to methodological difference.

The mother's attitude level toward breastfeeding indicated that, 41.8% had a moderate level of attitude and 58.2% had a high attitude towards breastfeeding. While in Dallak et al. [14] study, the majority (86.1%) of the participated mothers had neutral attitude toward breastfeeding and 12.8% of mothers had positive attitude to breastfeeding and only 1.1% of the mothers had positive attitude toward formula feeding. Aghababai et al. [19] study showed, just 3% of participants had good level of knowledge about breastfeeding and an increase observed in their knowledge of them a?er education (55.5%). Naseem et al. [18] in their study demonstrated that, Majority of mothers received antenatal counselling regarding benefits and management of breast feeding. Their results showed that, the mothers had good knowledge; attitude and practices were still prevalent in the community which needs to be addressed.

According the current results, there is a need for programmers, which support and encourage breastfeeding at a primary level, focusing more on younger women, less well educated and those from lower socioeconomic class. So, it is suggestible that, serious practical steps have to be put in place in order to rectify resolve such a public health concern. Intensive education about breast feeding starting early in high school, during antenatal visits and through social media channels are important to provide sufficient awareness knowledge to young and expecting mothers. Other important aspects include serious support to new mothers at the postnatal wards with education and psychological support. Longer maternity leave might give working mothers more time to spend with her young infant and might encourage continuation of the already started breast feeding.

Authors would like to thank all mothers, who participated in this study and without them this study would not have been accomplished. This study was extracted from B.Sc. Project, No: zbmu. 1. REC.1395.46. School of Health, Zabol University of Medical Sciences, Zabol, Iran.

This work supported financiall\ by Student Research Committee, Deputy Research and Technology, Zabol University of Medical mSciences, Zabol, Iran

This study was approved by the Ethics Committee of Zabol University of Medical Sciences

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