Knowledge and attitude regarding breastfeeding among antenatal mothers

Abstract

Breastfeeding knowledge and attitude are absolutely necessary for antenatal mothers. This study aimed to assess antenatal mothers’ breastfeeding knowledge and attitudes and their association with sociodemographic characteristics. This cross-sectional study was done among antenatal mothers using semi-structured interviewer-administered questionnaire. Twenty-four knowledge-related questions scored one mark for each correct response and zero for incorrect. Scores achieved between 17-24, 9-16, and 0-8 were grouped as adequate, average, and inadequate knowledge, respectively. For assessing attitude, on the Iowa Infant Feeding Attitudes Scale, 17 questions were graded on a 5-point Likert scale ranging from 1 to 5. Scores achieved between 70-85, 49-69, and 17-48 were grouped as positive about breastfeeding, neutral, and positive about formula feeding, respectively. Descriptive statistics and chi-square tests were used to analyze data. The p-value = 0.040). Breastfeeding knowledge was inadequate in more than one-third of the expectant women which signifies the importance of scaling up the counseling about the advantages and management of breastfeeding.

INTRODUCTION

Breastfeeding is feeding an infant or young child from the mother’s breast milk, providing them with the nutrients they require for healthy growth and development [1]. According to recommendations given by the World Health Organization (WHO), infants should be breastfed exclusively for their first 6 months of life in order to experience the best possible growth, development, and health [2]. Following that to meet their changing nutritional needs, infants should be fed nutritionally adequate and safe complementary foods while continuing to breastfeed for up to 2 years or longer [2]. The term “exclusive breastfeeding” (EBF) refers to the infant receiving only breast milk. Except for oral rehydration solution or drops/syrups of vitamins, minerals, or medicines, no other liquids or solids - not even water - are given [2]. Breastfeeding has long been recognized for its benefits to both mother and baby [3]. Despite strong evidence supporting EBF during the first 6 months of life, its prevalence has remained low globally [4].

Breastfeeding appears to be influenced by social, cultural, and economic factors in India. The Breastfeeding Promotion Network of India was founded in 1991 to protect, promote, and support breastfeeding [5]. To reinforce breastfeeding promotion, in 2016, the Mothers’ Absolute Affection Program was launched at the national level in India, attempting to focus on promoting breastfeeding and ongoing efforts through the health system to achieve higher breastfeeding rates [6]. According to NFHS-5 data (2019-2021), 63.7% of children under the age of 6 months are exclusively breastfed and 41.8 % are breastfed within 1 hour of birth [7]. The WHO and United Nations International Children’s Emergency Fund emphasized the significance of breastfeeding in relation to each sustainable development goal in a joint message for 2016 World Breastfeeding Week (WBW) and further highlighted its central role in eliminating child malnutrition in 2021 WBW message [8,9].

Mothers’ knowledge and attitudes about breastfeeding influence their decision to breastfeed as some mothers are unaware of its benefits and importance, leading to a decline in breastfeeding practices [10,11]. Positive maternal attitudes toward breastfeeding are associated with longer breastfeeding duration and a higher likelihood of success while negative attitudes toward breastfeeding are regarded as a significant barrier to initiating and maintaining breastfeeding [12,13].

Breastfeeding knowledge and attitude are essential for expectant mothers, and the antenatal period is critical for acquiring this information to prepare them to breastfeed their babies. This kind of research has not been explored in this region of Eastern Uttar Pradesh in India as no published research has been found, so it is pivotal to study it. This study aimed not only to assess the knowledge and attitude of antenatal mothers regarding breastfeeding but also the association of sociodemographic characteristics affecting them.

MATERIALS AND METHODS

study setting

This descriptive cross-sectional study was conducted among antenatal mothers visiting the Department of Obstetrics and Gynaecology at the Hind Institute of Medical Science, Barabanki, Uttar Pradesh over 9 months from August 2021 to April 2022. The study used a semi-structured questionnaire to focus on knowledge and attitudes regarding breastfeeding among antenatal mothers. The nature and objectives of the study were explained to the participants in a language that they could clearly understand.

• Inclusion criteria: All those antenatal women registered in the antenatal outpatient department (OPD) register in the Department of Obstetrics and Gynaecology.

• Exclusion criteria: Those antenatal mothers who had an absolute or relative contraindication to breastfeeding, such as human immunodeficiency virus infection, active untreated tuberculosis, or mothers who were taking antimetabolites or other chemotherapeutic agents.

Study sampling

Using the online OpenEpi software, a sample size of 296 was calculated using the Crude birth rate of Barabanki district as 26/1000 population from the Annual health survey data, with a confidence interval of 95% and a margin of error of 5% [14,15]. The actual study was conducted on 311 participants. Simple random sampling to eliminate the selection bias was done from the inclusion list of antenatal women registered in the antenatal OPD register in the Department of Obstetrics and Gynaecology.

Measurements

There were three sections in the questionnaire which are as follows:

1. Section 1: It had ten questions on the sociodemographic characteristics which included their age in years, livelihood, socioeconomic status, occupation, type of family, religion, education, parity, the primary source of breastfeeding information, and whether received breastfeeding instructions in the antenatal care.

2. Section 2: It included 24 questions about breastfeeding knowledge based on a literature review and previous experiences and has been validated by experts from the nursing and obstetrics department. To ensure the validity of the breastfeeding knowledge questionnaire, pilot testing was conducted on 30 antenatal mothers which concluded that the main study was feasible without modifying the protocol. Cronbach’s alpha was calculated to be 0.814, indicating that the questionnaire was reliable. Both positively and negatively worded statements about breastfeeding were included, and the scores were reversed for the negative statements. Each question on knowledge was given a score of one mark for each correct response and zero marks for an incorrect response. The maximum score that can be achieved by participants in this section was 24, while the minimum score was zero. Participants were categorized into adequate, average, and inadequate knowledge if they scored between 17 and 24, 9 and 16, and 0 and 8, respectively.

3. Section 3: It consisted of 17 questions to assess mothers’ attitudes toward breastfeeding using the Iowa Infant Feeding Attitudes Scale (IIFAS) which is a valid and reliable measure (Cronbach’s alpha score 0.85) [16]. All questions were graded on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Nine questions were negatively worded questions (i.e., 1, 2, 4, 6, 8, 10, 11, 14, and 17). The overall IIFAS score ranged from 17 to 85, with higher scores indicating more favorable attitudes toward breastfeeding. Total scores were divided into three groups: those who were positive about breastfeeding (70–85), those who were neutral (49–69), and those who were positive about formula feeding (17–48).

Data collection and analysis

After obtaining informed consent to participate, data was collected by a female interviewer using a structured questionnaire. Following the completion of the questionnaire, the antenatal mothers were educated on breastfeeding facts. Furthermore, all of their questions were satisfactorily answered. SPSS software version 20 for Windows (IBM, Armonk, NY, USA) was used to analyze the data. Descriptive statistics were computed to measure sociodemographic characteristics, the level of knowledge, and attitude toward breastfeeding. The chi-square test was used to assess the association of sociodemographic characteristics with knowledge and attitude toward breastfeeding among antenatal mothers. The p-value < 0.05 was considered significant. Multinomial logistic regression was used to assess the independent predictors of breastfeeding knowledge and attitude scores.

RESULTS

A total of 311 antenatal mothers participated in the study. The mean age of mothers was 26.74 (±4.54) years. The sociodemographic parameters of the antenatal mothers are represented in Table 1.

Table 1.

Sociodemographic parameters of the antenatal mothers (n = 311).

Sociodemographic parameters		Frequency	Percentage
Age (years)	<20	22	7.1
	20–25	90	29
	26–30	141	45.3
	31–35	52	16.7
	>35	6	1.9
Livelihood	Rural	186	59.8
	Urban	125	40.2
Socioeconomic status	Upper class	11	3.6
	Upper middle class	48	15.4
	Lower middle class	98	31.5
	Upper lower class	79	25.4
	Lower class	75	24.1
Occupation	Unemployed	142	45.7
	Employed	169	54.3
Family	Nuclear	203	65.3
	Joint	108	34.7
Religion	Hindu	191	61.4
	Muslim	82	26.4
	Sikh	16	5.1
	Christian	12	3.9
	Others	10	3.2
Education	Illiterate	12	3.9
	Primary school	69	22.1
	High School	84	27
	Intermediate	102	32.8
	Graduate	32	10.3
	Post-graduate and above	12	3.9
Parity	Primipara	199	64
	Multipara	112	36
The primary source of breastfeeding information	Relatives and Family	211	67.8
	Health care provider	45	14.5
	Internet	31	10
	Mass media	24	7.7
Breastfeeding instructions in the antenatal care	Yes	35	11.3
	No	276	88.7

The adequate, average, and inadequate scores for knowledge-related questions were reported in 73 (23.5%), 129 (41.5%), and 109 (35%), respectively. The mean knowledge score was 13.02 (±4.40). The responses to the knowledge and attitude-related questions are represented in Figure 1.

Figure 1.

Knowledge regarding breastfeeding among antenatal mothers (n = 311).

For responses to attitude-related questions, the scores for those who were positive about breastfeeding (70–85), those who were neutral (49–69), and those who were positive about formula feeding (17–48) were reported in 78 (25.1%), 117 (37.6%), and 116 (37.3%), respectively. The mean attitude score was 54.12 (±14.64). The responses to attitude-related questions are represented in Figure 2.

Figure 2.

Attitude regarding breastfeeding among antenatal mothers (n = 311).

The association between different sociodemographic factors with knowledge and attitude is represented in Table 2. A significant association was found between knowledge and attitude scores (p-value = 0.040).

Table 2.

Association of knowledge and attitude regarding breastfeeding with sociodemographic characteristics (n = 311).

Sociodemographic parameters	Knowledge		Attitude
	chi-square test value (X2)	p-value*	chi-square test value (X2)	p-value*
Age (years)	85.527	<0.0001	15.965	0.043
Livelihood	43.285	<0.0001	16.239	<0.0001
Socioeconomic status	6.876	0.550	8.016	0.432
Occupation	1.220	0.543	0.542	0.763
Family	10.488	0.005	5.485	0.064
Religion	13.238	0.104	4.126	0.846
Education	50.048	<0.0001	77.566	<0.0001
Parity	64.357	<0.0001	12.386	0.002
The primary source of breastfeeding information	15.178	0.019	5.981	0.425
Breastfeeding instructions in the antenatal care	15.614	<0.0001	30.001	<0.0001
p-value < 0.05.

*significant p-value < 0.05.

The predictors of breastfeeding knowledge and attitude using multinominal logistic regression (n = 311) are represented in Tables 3 and 4, respectively.

Table 3.

Predictors of breastfeeding knowledge using multinominal logistic regression (n = 311).

Variable		B	Standard error	Significance*	Exp(B)	95% confidence interval for Exp(B)
						Lower bound	Upper bound
Age (years)	<20	REF
	20–25	-0.085	0.373	0.819	0.918	0.442	1.907
	26–30	0.779	0.356	0.028	2.180	1.086	4.377
	31–35	2.000	0.417	0.000	7.388	3.265	16.720
	>35	2.496	0.846	0.003	12.138	2.314	63.656
Livelihood	Rural	REF
	Urban	1.074	0.174	0.000	2.928	2.083	4.115
Socioeconomic status	Upper class	REF
	Upper middle class	0.145	0.441	0.742	1.156	0.487	2.741
	Lower middle class	-0.378	0.420	0.368	0.685	0.301	1.562
	Upper lower class	-0.198	0.424	0.640	0.820	0.357	1.883
	Lower class	-0.233	0.426	0.585	0.792	0.344	1.826
Occupation	Unemployed	REF
	Employed	-0.078	0.151	0.605	0.925	0.689	1.243
Family	Nuclear	REF
	Joint	-0.367	0.162	0.023	0.693	0.505	0.951
Religion	Hindu	REF
	Muslim	0.555	0.179	0.002	1.742	1.227	2.472
	Sikh	0.362	0.345	0.294	1.437	0.730	2.825
	Christian	-0.085	0.407	0.835	0.919	0.414	2.041
	Others	-0.180	0.451	0.690	0.835	0.345	2.021
Education	Illiterate	REF
	Primary school	0.030	0.449	0.947	1.030	0.427	2.485
	High school	-0.050	0.444	0.911	0.952	0.398	2.273
	Intermediate	0.687	0.438	0.117	1.987	0.843	4.685
	Graduate	1.161	0.488	0.017	3.192	1.226	8.310
	Post-graduate and above	2.119	0.683	0.002	8.321	2.181	31.751
Parity	Primipara	REF
	Multipara	1.172	0.181	0.000	3.228	2.265	4.601
The primary source of breastfeeding information	Relatives and family	REF
	health care provider	0.723	0.226	0.001	2.061	1.324	3.208
	Internet	0.271	0.255	0.289	1.311	0.795	2.163
	Mass media	-0.120	0.295	0.683	0.887	0.498	1.580
Breastfeeding instructions in the antenatal care	Yes	REF
	No	-0.938	0.257	0.000	0.391	0.236	0.648

*Significant p-value<0.05 (indicated as bold values).

Table 4.

Predictors of breastfeeding attitude using multinominal logistic regression (n = 311).

Variable		B	tandard error	Significance*	Exp(B)	95% confidence interval for Exp(B)
						Lower bound	Upper bound
Age (years)	<20	REF
	20–25	0.910	0.374	0.015	2.483	1.193	5.168
	26–30	1.048	0.365	0.004	2.851	1.393	5.835
	31–35	0.875	0.392	0.025	2.399	1.113	5.171
	>35	1.698	0.661	0.010	5.465	1.497	19.944
Livelihood	Rural	REF
	Urban	0.404	0.150	0.007	1.498	1.116	2.012
Socioeconomic status	Upper class	REF
	Upper middle class	0.838	0.504	0.097	2.313	0.860	6.217
	Lower middle class	0.671	0.487	0.168	1.957	0.754	5.083
	Upper lower class	0.988	0.491	0.044	2.686	1.025	7.034
	Lower class	0.878	0.492	0.074	2.406	0.917	6.314
Occupation	Unemployed	REF
	Employed	0.078	.146	0.595	1.081	0.812	1.439
Family	Nuclear	REF
	Joint	-0.352	.157	0.025	0.703	0.517	0.956
Religion	Hindu	REF
	Muslim	0.095	0.169	0.575	1.099	0.789	1.531
	Sikh	-0.201	0.343	0.557	0.818	0.418	1.601
	Christian	-0.350	0.403	0.385	0.704	0.319	1.553
	Others	0.376	0.416	0.366	1.456	0.645	3.288
Education	Illiterate	REF
	Primary school	0.053	0.455	0.907	1.055	0.432	2.572
	High School	0.193	0.447	0.666	1.213	0.505	2.915
	Intermediate	0.718	0.442	0.104	2.051	0.863	4.875
	Graduate	1.583	0.501	0.002	4.868	1.822	13.008
	Post-graduate and above	2.911	0.841	0.001	18.375	3.531	95.608
Parity	Primipara	REF
	Multipara	0.455	0.154	0.003	1.575	1.165	2.130
The primary source of breastfeeding information	Relatives and family	REF
	health care provider	0.289	0.210	0.169	1.335	0.884	2.015
	Internet	0.059	0.246	0.810	1.061	0.654	1.720
	Mass media	-0.427	0.297	0.151	0.653	0.365	1.168
Breastfeeding instructions in the antenatal care	Yes	REF
	No	-1.083	0.260	0.000	0.339	0.203	0.564

*Significant p-value<0.05 (indicated as bold values).

DISCUSSION

Breastfeeding has considerable lifelong benefits for the newborn and mother [17]. Mother’s milk is the nectar of nature for the offspring which is essential not only for the body but also for the soul, it is not only nutrition but also emotion, it is not only a medium of protection but also growth and development, and in a sense the complete source of somatic and psychological well-being of the mother-infant dyad [18]. EBF should be systematically started, encouraged, and maintained for the first 6 months followed by continued breastfeeding until 2 years of age [19,20].

In the present study, most of the mothers were in the age group 26–30 years (45.3%), and the mean age of mothers was 26.74 (±4.54). Likewise, Girish et al. [21] reported a mean age of 27.3 years, but most of the mothers were below 25 years in their study. Most of the mothers were living in rural areas (59.8%), middle and lower socioeconomic status (96.4%), and employed (65.3%) in our study. Most of the mothers belonged to the Hindu religion (61.4%), lived in nuclear families (65.3%), were literate (96.1%,), and primipara (64%) in this study. This was comparable to a study by Mohapatra and Roy [22], which reported that most of the mothers were from the Hindu religion (81.2%), lived in nuclear families (70.8%), and were literate (76%) but most of them were multipara (56%) [22]. In the present study, the primary sources of breastfeeding information were mostly relatives and family (67.8%) and most of them had not received instructions in antenatal care before (88.7%). Similarly, Mohapatra and Roy [22] reported that most of the participants had received information from their mothers (36.4%) and doctors (32.4%).

A study by Randhawa et al. [23] clearly mentioned that numerous sociodemographic variables, including rural and urban households, cultural, and socioeconomic characteristics, psychological status, religious values, and literacy particularly low levels of maternal education and employment influence breastfeeding practices, which also vary across various areas and provinces [23].

The majority of antenatal mothers breastfeeding knowledge was average (41.5%) or inadequate (35%), while attitudes of most of them were neutral toward breastfeeding (37.6%), or positive about formula feeding (37.3%) in the present study. This was in accordance with a study by Kumar et al. [24], which concluded that knowledge and attitude about breastfeeding were lacking in most antenatal mothers.

In the present study, higher age of antenatal mothers, urban residence, higher education of mothers, multiparity, and those who received breastfeeding instructions in antenatal care were associated with adequate knowledge and a positive attitude toward breastfeeding. Correspondingly, Tabassum [25] found that higher age of mothers and multiparity was associated with adequate knowledge of breastfeeding. Similarly, Chen et al. [26] found positive attitudes toward breastfeeding in older-age mothers [26]. Accordingly, Kurian et al. [27] found adequate knowledge among older age mothers, with a high level of education, multiparity, and those who received breastfeeding instructions in antenatal care ( Likewise, Charafeddine et al. [28] reported positive attitudes toward breastfeeding in mothers with higher education. Accordingly, Abdulahi et al. [29] reported that breastfeeding attitudes were observed to be higher in women who had at least four antenatal care visits than in those who had none. A study by Karnawat et al. [30] found higher knowledge scores in urban mothers, while higher attitude scores were reported in rural mothers. It is likely that previous breastfeeding experience explains the association of multiparity and older age with a positive attitude as breastfeeding is a learned behavior. High levels of maternal education are linked to a positive attitude toward breastfeeding because these women are more aware of the advantages of breastfeeding.

In the present study, mothers living in nuclear families had adequate knowledge of breastfeeding which was comparable to a study by Mohapatra and Roy [22] which reported that mothers living in the nuclear family showed a highly significant association with breastfeeding awareness. Antenatal mothers whose primary source of breastfeeding information was a health care provider had adequate knowledge of breastfeeding in the present study which was akin to a study by Piro and Ahmed [31] which reported that those antenatal mothers who received breastfeeding educational sessions from health care providers had a higher level of knowledge and attitude toward breastfeeding.

It was disheartening to note that 89% of mothers did not receive breastfeeding education during their antenatal visits. It was strongly associated with inadequate knowledge and attitudes of the expectant mothers. This may be due to the fact that obstetricians are over-burdened in routine antenatal care activities and discussions about the current medical status of the pregnant woman, and thus, the future breastfeeding education becomes side-lined. This highlights the importance of having dedicated social workers, dieticians, or lactation counselors who have a primary job to appraise the pregnant woman about her nutrition during pregnancy and lactation and also educate them about the benefits and management of breastfeeding.

It was noticed in a study by Sisodia et al. [32] that if antenatal women mothers are counseled by a lactation counselor for the benefits of breastfeeding it could have a great impact on early and sustained breastfeeding.

There was no significant association noted for socioeconomic status, occupation, and religion with knowledge and attitudes regarding breastfeeding. Similarly, Charafeddine et al. [28] reported that there was no significant association between employment, religion, and monthly income with the breastfeeding attitude of mothers.

A significant association was found between knowledge and attitude scores in the present study indicating that mothers with adequate knowledge had positive attitudes toward breastfeeding. This was in accordance with a study by Kurian et al. [27] which found a strong correlation between the knowledge and attitudes of mothers regarding breastfeeding.

Strengths and limitations

The study’s main strength was that the antenatal mothers were educated and counseled about breastfeeding facts after completing the questionnaire, and all of their queries were satisfactorily addressed. However, the present study had some limitations, including the fact that it was cross-sectional in nature and had a small sample size, which may make it challenging to generalize the results. Other limitations include the potential for recall bias, as certain information depends on participant memory, and the potential for social desirability and reporting biases among expectant mothers when face-to-face interviews are used to gather self-reported data on sensitive breastfeeding-related topics. Despite these shortcomings, the results of this study will be useful in the future for policymakers and health professionals in developing separate antenatal counseling sessions for pregnant mothers so as to improve postnatal breastfeeding practices. Future research should prioritize using larger sample sizes and qualitative methods like focus group interviews.

CONCLUSION

The present study concluded that lower age of mothers, rural residences, lower education of mothers, primiparity, and those who did not receive breastfeeding instructions were associated with inadequate knowledge of breastfeeding and a positive attitude toward formula feeding. Mothers living in joint families had inadequate knowledge of breastfeeding while those who had received information from a healthcare provider had adequate knowledge regarding breastfeeding. In the population under study, antenatal breastfeeding counseling is insufficient and needs to be improved. During antenatal appointments, it should be a top priority to educate all expectant women about the advantages and management of breastfeeding so as to improve their knowledge and attitudes towards breastfeeding.

CONFLICTS OF INTEREST

None.

FUNDING

None.

ETHICS APPROVAL

Institutional Ethics Committee permission was received via IEC/IRB letter No. HIMS/IRB/2021-22/3396 dated 20.08.2021 and data confidentiality was maintained throughout the study. Written informed consent from mothers was obtained for participation.