Abstract
Background:
Breastfeeding provides optimal nutrition and immune protection for newborns; however, in India and other low- and middleincome countries, only about half of infants are breastfed within the first hour of birth, making initiation and continuation challenging. This study assessed the effectiveness of a skill-based group education module on breastfeeding among primiparous women in the third trimester in establishing successful breastfeeding.
Materials and Methods:
A quasirandomized controlled trial was conducted from December 2023 to May 2024 in the inpatient and outpatient departments of AIIMS Rishikesh and SPS Hospital. Primiparous women in the third trimester were allocated day-wise to either the intervention or control group. The intervention group received a validated skill-based breastfeeding education session supplemented with WhatsApp support and routine antenatal care (ANC), while the control group received routine ANC alone. Data on breastfeeding knowledge, attitude, early initiation of breastfeeding (EIBF), breastfeeding self-efficacy (BFSEF), and challenges were collected before and after the intervention.
Results:
The intervention group demonstrated a significant improvement in knowledge scores, increasing from a prepartum mean of 3.12 (SD (standard deviation) =0.87) to 7.93 (SD = 0.25) postdelivery, with a mean difference of 4.81 (SD = 0.90). Although the proportion of EIBF was higher in the intervention group, the difference was not statistically significant after adjustment for baseline knowledge. The overall mean breastfeeding success score was higher in the intervention group (16.13, SD = 1.15) compared with the control group (15.35, SD = 1.15). BFSEF was also significantly higher in the intervention group (45.36, SD = 3.98) than in the control group (40.71, SD = 4.05).
Conclusions:
Skill-based breastfeeding education significantly improved maternal knowledge, components of successful breastfeeding, and selfefficacy. Although EIBF rates did not differ significantly, the intervention enhanced preparedness and confidence among firsttime mothers.
Trail Registration:
CTRI/2024/02/063346 (Clinical trial registry of India registered on February 29, 2024. First patient recruited on March 29, 2024).
Keywords: Breastfeeding, prenatal education, self-efficacy, successful breastfeeding
BACKGROUND
Breast milk is widely recognized as the best nutrition for newborns, supporting infant health and development. Breastfeeding is key preventive strategy in primary care for improving child survival rates.[1] Early initiation of breastfeeding (EIBF) within the first hour reduces neonatal infection mortality and benefits both mother and child.[2,3] The World Health Organisation (WHO) aims for at least 70% exclusive breastfeeding (EBF) nationally by 2030, but only a few countries (Burundi, Lesotho, Rwanda) are likely to reach this across all districts, while some others may fall short by then.[2] Global EBF rates remain under 50%, with notable disparities between regions.
India’s EBF rate stands at 63.7%, with significant regional differences: Arunachal Pradesh and Kerala report rates above 80%, while Rajasthan, Bihar, and MP are as low as 23–30%. The National Family Health Survey-5 (NFHS-5) found only 41.4% of infants begin breastfeeding within one hour of birth, indicating a need for targeted interventions.[4]
Primiparous mothers often encounter multiple barriers to successful breastfeeding. A common challenge is that many mothers stop breastfeeding early due to concerns about low milk supply, although true physiological insufficiency is uncommon. Physical issues, such as nipple pain, mastitis, and cracked nipples, make breastfeeding challenging. Knowledge gaps and misconceptions about milk sufficiency cause self-doubt for new mothers. Delayed lactation, often seen in first-time mothers after stressful labor or cesarean delivery, further complicates breastfeeding initiation.[5,6,7] Latching problems cause discomfort and hinder effective milk transfer for both mother and baby.
Additionally, psychosocial factors, such as limited family or healthcare support, societal stigma, and premature return to work, present significant obstacles to continued breastfeeding. Addressing these issues necessitates a comprehensive strategy that includes enhanced education on breastfeeding practices, timely medical interventions, and robust social support networks to assist new mothers.
First-time mothers are particularly vulnerable to challenges in establishing breastfeeding, given their limited experience and knowledge, as well as the added pressures from societal expectations and often restricted access to healthcare services.[7] Evidence suggests that antenatal, skill-based breastfeeding education and support can increase breastfeeding self-efficacy (BFSEF) and the likelihood of EIBF.[8,9,10] Our intervention was designed with a strong emphasis on skill-based education and enhancing “self-efficacy,” drawing on principles from social cognitive theory.[11,12] Furthermore, we posit that group-based interventions, when paired with peer support and digital tools such as WhatsApp, can effectively offer emotional support, decrease feelings of isolation, and promote better breastfeeding practices.[13,14,15] Despite the increasing interest in these strategies, there remains a paucity of research evaluating their effectiveness specifically for primiparous women in India.
This study evaluates a skill-based group education module on breastfeeding for first-time mothers in the third trimester in Uttarakhand, India. The primary objective is to compare the rates of early initiation and successful establishment of breastfeeding between intervention and control groups. Secondary objectives include assessing differences in knowledge, attitude, self-efficacy, and identifying challenges encountered during breastfeeding in both groups.
MATERIALS AND METHODS
A quasirandomized controlled trial was conducted from December 2023 to May 2024 in the outpatient ANC at OBYGN department of AIIMS Rishikesh and SPS hospital. Both the study sites were under Baby Friendly Hospital Initiative practice. The study employed a day-wise allocation strategy, in which participants attending ANC on their preassigned days were randomly allocated to either the intervention or control arm. The trial was prospectively registered with Clinical Trials Registry of India (CTRI/2024/02/06334), and reporting adhered to the TREND (Transparent Reporting of Evaluation with Nonrandomized Designs) guidelines [Supplementary File Table 1].
Primiparous pregnant participants in their third trimester come to OPD for their routine ANC visits. Eligibility criteria required participants residing within the surrounding geographical area, access to a mobile phone with internet services, and be likely to undergo an uncomplicated vaginal delivery. Women presenting with high-risk pregnancies or breastfeeding contraindications were excluded. Exclusions included maternal infectious diseases with high transmission risk (such as active TB, uncontrolled HIV, or HIV-I/II infection), maternal exposure to harmful medications (chemotherapy or radioactive isotopes), severe substance abuse, conditions affecting milk production or infant metabolism (such as maternal galactosemia), active herpes simplex lesions, and cases of early neonatal death.
A total sample size of 120 participants was determined using the formula for difference in proportions, with an assumed power of 80% and a significance level of 5%, aimed at detecting an increase in EIBF from 41.8% (NFHS-5) to 65%.[4] This calculation resulted in 51 participants per group, which was increased to 60 per group to accommodate potential attrition. For feasibility and to minimize allocation bias, a quasi-random day-wise allocation strategy was implemented from each hospital. Consecutive sampling was performed, and all primiparous females attending ANC from November 2023 to February 2024 were recruited accordingly. For instance, participants were enrolled in the intervention arm at one hospital on Monday, and recruitment for the same arm continued at another hospital on Tuesday. A similar pattern was followed for the control arm, with this day-by-day recruitment strategy consistently maintained throughout the study period.
The intervention consisted of a structured, skill-based breastfeeding education module developed using guidelines from internal and national authorities, including WHO, United nation Child fund, Infant and Young Child Feeding practices, and Mother Absolute Affection program. The development process emphasized accuracy, cultural relevance, and practical usability. A multidisciplinary expert panel reviewed the module to ensure content validity, including specialists from community medicine and obstetrics who assessed alignment with evidence-based breastfeeding practices. The language was reviewed by academic language experts to ensure clarity and readability for participants from varied educational backgrounds. Face validation with a subset of eligible antenatal women confirmed that the module was understandable, practical, and acceptable for use in routine antenatal care (ANC). Expert feedback also led to the inclusion of additional audiovisual material and an emphasis on participant demonstrations to ensure skill reinforcement. The final module included group teaching, hands-on practice of techniques such as positioning and attachment, practical troubleshooting, and counselling on early initiation and continuation of breastfeeding. Participants also received a picture booklet in their preferred language to enhance recall and support at home [Supplementary File].
The intervention group received 1-hour face-to-face skill-based group education (4–8 in each group), access to audio-visual aids, and routine ANC during their visit to OPD in the respective hospitals, supplemented by a WhatsApp support group for further help and assistance in Hindi from the investigator. D.D. took sessions with the help of a validated module [Supplementary File Tables 2 and 3]. In contrast, the control group received only routine ANC during their visit to OPD. The participants were followed up immediately after the birth of their child (within 24–72 hours), once or twice, depending on the mother’s condition.
Table 2.
Breakdown of the 1-hour face-to-face skill-based breastfeeding educational intervention module for primiparous mothers validation process (Editable format)
| Time Duration | Content | |
|---|---|---|
| 5 minutes: | • Introduction & briefing about the session and to know about their knowledge and experience about breastfeeding. | |
| 10 minutes: | • Benefits of breastfeeding for baby and mother. • Common challenges faced in breastfeeding. • Addressing common myths about breastfeeding. |
|
| 30 minutes: | • Breastfeeding techniques. • Demonstrate the proper technique for breastfeeding using baby dolls or models. • Discuss the importance of a proper latch and positioning. • Explain how to recognize when the baby is getting enough milk. • Demonstrate the use of a breast pump and how to store breast milk. |
|
| 15 minutes: | • Feedback about the session. • Question and answer session. |
|
| Follow-ups: | • Weekly tailored messages via WhatsApp were send to provide additional information and support. • Consultation for individual assistance or clarification was available if needed |
Table 3.
Details of education session
| Topic | Details | |
|---|---|---|
| Benefits of breastfeeding | - For the Child: Provides optimal nutrition, supports immune system, promotes cognitive and physical development. - For the mother: Reduces risk of breast and ovarian cancer, aids in postpartum recovery, promotes emotional bonding. |
|
| Proper latching and positioning techniques | - Steps for proper latching: 1. Ensure the baby’s mouth covers the areola, not just the nipple. 2. Position the baby tummy-to-tummy with the mother. 3. Use a comfortable breastfeeding position (e.g., cradle, football hold). - Tips: Avoid pain by ensuring a deep latch; seek support if unsure. |
|
| Common challenges and solutions | - Sore nipples: Check latch, use lanolin cream, or allow nipples to air-dry. - Low milk supply: Increase feeding frequency, stay hydrated, and consider lactation support. - Infant feeding difficulties: Work with a lactation consultant, ensure correct positioning, or address potential tongue-tie. |
|
| Milk expression and storage | - Expression: Use a manual or electric pump, or hand express. - Storage guidelines: 1. Store milk in clean, BPA-free containers. 2. Keep at room temperature (≤4 hours), refrigerate (≤4 days), or freeze (≤6 months). - Thawing: Use warm water; avoid microwaving to preserve nutrients. |
|
| Maintaining a healthy breastfeeding relationship | - Sustain practices: Nurse on demand, ensure good nutrition and hydration for the mother. - Overcoming challenges: Seek help from support groups or lactation consultants. - Weaning: Gradual transition to avoid discomfort or emotional stress for both mother and child. |
Participants were assessed promptly following the birth of their child (within 24 to 72 hours), with follow-up conducted once or twice as appropriate based on the mother’s condition.
Participant blinding was not possible because the intervention included education, hands-on demonstrations, audiovisual support, and a WhatsApp group. Instead, outcome assessors (NJ) and data analysts (MK) were blinded to participant allocation to minimize measurement bias and ensure objectivity in evaluating breastfeeding practices and self-efficacy scores.
Data collection used a structured questionnaire assessing sociodemographic details, breastfeeding knowledge and attitude (pre–postintervention for the intervention arm, and routine ANC assessment for the control arm), components of successful breastfeeding, and self-efficacy. The knowledge questionnaire consisted of expert-validated items, with each question scored as correct (1), partially correct (0.5), or incorrect (0), with a maximum score of 8. Attitude toward breastfeeding was assessed using three prevalidated Likert scale questionnaire ranging from strongly agree (5) to strongly disagree (1), with higher scores indicating favorable attitudes. Components for successful breastfeeding were used to measure participants’ initiation of breastfeeding (see Supplementary File).[14,15] Observations were direct, except for the EIBF question, which was confirmed by the duty nurse, mother, and hospital record. For measuring self-efficacy, Dennis BFSEF scale was used. It is a 14-item, 5-point Likert measure of breastfeeding confidence; higher scores indicate more self-efficacy, while lower scores suggest a need for support.[16,17,18]
Data quality was ensured by trained investigators who directly observed components of successful breastfeeding, and the long-duration follow-up helped establish rapport, improving the accuracy of responses.
Data was analyzed using IBM SPSS Statistics version 25 following an intention-to-treat approach. Missing data were imputed using the last observation carried forward method. Baseline and endline assessments of knowledge and attitude were compared between the groups. Successful breastfeeding and self-efficacy scores were assessed at endline. Furthermore, to account for baseline disparities and time-based trends, a difference-in-differences (DiD) approach was employed for knowledge and attitude scores, complemented by analysis of covariance (ANCOVA) for postdelivery outcomes.
RESULTS
The study began with 160 potential participants screened for eligibility. Of these, 120 met the criteria and were evenly divided into two groups: 60 in the control group and 60 in the intervention group. During the initial recruitment phase, the control group lost 10 participants to follow-up, thus experiencing attrition, losing 16.5% of its participants. An intention-to-treat approach was used, and missing data were imputed with the last carry-forward value to compensate for the loss to follow-up if seen in any arm. The intervention group had no loss to follow-up throughout the study. The final analysis included data from 60 participants in each group. The study examined outcomes related to knowledge, attitude, successful breastfeeding components, and BFSEF scores [Figure 1].
Figure 1.
TREND compliant diagram showing the flow of participants in the study. Note: loss to follow-up—7 (delivered in private hospital), 2 (shifted to their villages), 1 (delivered at home). TREND = Transparent Reporting of Evaluation with Nonrandomized Designs
Table 1 shows baseline characteristics of 120 participants with a mean age of the study population of 24.8 (3.27) and 24.8 (3.9) for intervention and control groups. Most of the population was Hindu, and most had nuclear families (97%) compared to the control group (3%). All of them in the intervention group lived with their husband except one. Ninety percent of participants were from urban areas. Approximately 94% of both groups belong to classes 1 and 2. No significant difference was found between the baseline demographics of the two groups. The median gestational week for participants in the intervention group at the time of recruitment was 36 weeks, while the median for the control group was 37 weeks. All the participants underwent an expected vaginal delivery at the time of birth.
Table 1.
Demographic characteristics and gestational age during recruitment
| Category | Intervention n (%) n=60 (100%) | Control n (%) n=60 (100%) | Chi-square (P) | |||
|---|---|---|---|---|---|---|
| Mean age (SD) years 95% CI | 24.8 (3.27) (23.97 to 25.63) | 24.8 (3.9) (23.81 to 25.79) | t=0, P=1 | |||
|
Education | ||||||
| Illiterate | Less than 5 (5%) | 5 (8.3%) | 1.08, df=2, 0.24 | |||
| Up to secondary | 5 (8.3%) | 7 (11.67%) | ||||
| Up to higher secondary | 10 (16.66%) | 6 (10%) | ||||
| Graduate and PG | 42 (70%) | 42 (70%) | ||||
|
Residence | ||||||
| Urban | 54 (90%) | 55 (91.66%) | 0.05, df=1, 0.82 | |||
| Rural | 6 (10%) | 5 (8.3%) | ||||
|
Per capita income (Modified BG Prasad scale, January 2024) | ||||||
| Class 1 (>Rs. 9,138) | 44 (73.33%) | 51 (85%) | 2.83, df=1, 0.58 | |||
| Class 2 (Rs. 4,569–Rs. 9137) | 13 (21.66%) | 5 (8.33%) | ||||
| Class 3 (Rs. 2,741–Rs. 4,568) | 03 (5%) | 3 (5%) | ||||
| Class 4 (Rs. 1,371–Rs. 2,740) | 0 | 1 (1.66%) | ||||
| Gestational age (median) | 36 weeks | 37 weeks | U statistic: 381 P=0.3 | |||
SD=Standard deviation
Table 2 presents the pretest knowledge scores on breastfeeding practices for the intervention and control groups. The findings show that both groups initially had a limited understanding of colostrum and its significance. The intervention group had a higher percentage of participants who were aware of the importance of starting breastfeeding within the first hour of delivery, the recommended breastfeeding duration (66.7%), and the frequency of breastfeeding (75%). The average pretest knowledge score was notably higher in the intervention group (3.12, SD (standard deviation) = 0.87) compared to the control group (2.07, SD = 0.46), with a P value of less than 0.001, indicating that the intervention group had some preexisting knowledge.
Table 2.
Pre- and posttest knowledge and attitudes of study participants
| Questions | Answers | Before | After | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||||
| Intervention group n=60 (%) | Control group n=60 (%) | Intervention group n=60 (%) | Control group n=60 (%) | |||||||
| When to initiate BF | List all the correct answers* Within 1 hr of delivery |
08 (13.3%) | 0 | 56 (93.3%) | 16 (26.7%) | |||||
| List all partially correct$ | ||||||||||
| When the baby is born | 12 (20%) | 01 (1.7%) | 0 | 0 | ||||||
| After delivery | 0 | 14 (23.3%) | 0 | 44 (73.3%) | ||||||
| Colostrum to be given | List all the correct answers* Yes |
0 | 0 | 60 (100%) | 55 (91.6%) | |||||
| How long to BF* | List all the correct answers* Up to 2 years of age |
0 | 0 | 60 (100%) | 15 (25%) | |||||
| List all partially correct$ | ||||||||||
| Up to 1 yr of age | 0 | 0 | 0 | 14 (23.3%) | ||||||
| Till the baby wants | 45 (75%) | 54 (90%) | 0 | 16 (26.7%) | ||||||
| How frequently should be fed for 6 months* | List all the correct answers* On-demand feeding |
0 | 0 | 44 (73.3%) | 13 (21.7%) | |||||
| List all partially correct$ | ||||||||||
| In 2–3 hrs. | 0 | 0 | 16 (26.7%) | 11 (18.3%) | ||||||
| When the baby cries | 45 (75%) | 54 (90%) | 0 | 20 (33.3%) | ||||||
| What all to give in 6 months | List all the correct answers* Breastmilk |
60 (100%) | 60 (100%) | 60 (100%) | 60 (100%) | |||||
| Two benefits for baby* | List all the correct answers* | |||||||||
| Growth and immunity | 20 (33.3%) | 03 (5%) | 33 (55%) | 25 (41.7%) | ||||||
| Cheap | 15 (25%) | 02 (3.3%) | 0 | 14 (23.3%) | ||||||
| Easy to digest and immunity | 0 | 0 | 05 (8.33%) | 0 | ||||||
| Easy to digest and growth | 0 | 0 | 08 (13.3%) | 11 (18.3%) | ||||||
| One benefit for mother | List all correct answers* | |||||||||
| Don’t know | 60 (100%) | 60 (100%) | 0 | 0 | ||||||
| Bonds with baby | 0 | 0 | 14 (23.3%) | 14 (23.3%) | ||||||
| Prevents cancer | 0 | 0 | 33 (55%) | 0 | ||||||
| Prevents depression | 0 | 0 | 02 (3.3%) | 0 | ||||||
| Lactational amenorrhea | 0 | 0 | 07 (11.7%) | 0 | ||||||
| Cheap | 0 | 0 | 0 | 09 (15%) | ||||||
| Convenient | 0 | 0 | 0 | 10 (16.7%) | ||||||
| Total knowledge mean (SD) | 3.12 (0.87) | 2.07 (0.46) | 7.93 (0.25) | 5.62 (0.72) | ||||||
| Unpaired t-test | 8. 27, <0.001 | 23.34, <0.001 | ||||||||
| Total attitude mean (SD) | 12 (0) | 12 (0) | 13.7 (0.46) | 12 (0) | ||||||
| Unpaired t-test | 0 | 1.7 (0.46) | ||||||||
*Correct answers, $partially correct answers. BF=Breastfeeding
The intervention group’s postintervention knowledge about breastfeeding mean scores showed a significantly better understanding of breastfeeding initiation within one hour of delivery (93.3% vs. 26.6% in the control group). The intervention group had a greater awareness of breastfeeding up to two years (100% vs. 25% in the control group) and the concept of on-demand feeding (73.3% vs. 21.6%). Both groups supported EBF for the first six months. Both groups ensured that all infants received colostrum. Additionally, the intervention group emphasized the benefits of breastfeeding, such as improved growth, immunity, and nutritional value for infants, as well as enhanced bonding and reduced cancer risk for mothers. The difference in mean knowledge scores between the two groups was statistically significant (P < 0.05).
Both arms showed a favorable attitude toward breastfeeding even before any intervention. However, there was a slight increase in attitude scores of the intervention arm from 12 to 13.7 (0.46) compared to the control arm, which remained the same.
The mean change in knowledge score in the intervention group (4.81) was greater than in the control group (3.56). Participants in the intervention group demonstrated a greater shift toward positive attitudes, i.e., from scoring 13–15 with a mean score of 13.7 (0.46) compared to those in the control group, i.e., scoring 10–12 with a mean score of 12 (0). The DiD analysis revealed that the intervention group achieved a significantly higher gain in knowledge compared to the control group (DiD = 1.25; 95% CI (confidence interval): 0.94 to 1.56) [Table 3].
Table 3.
Change in knowledge and attitude score pre- and postintervention
| Before Mean (SD), 95% CI | After Mean (SD), 95% CI | Mean change Mean (SD), 95% CI | P | DiD Mean (95% CI, P) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Knowledge score | Intervention group | 3.12 (0.87), 2.9–3.34 | 7.93 (0.25), 7.87–7.99 | 4.81 (0.90), 4.58–5.04 | <0.001 | 1.25 (0.94–1.56, <0.001) | ||||||
| Control group | 2.06 (0.46), 1.94–2.28 | 5.62 (0.72), 5.44–5.82 | 3.56 (0.85), 3.34–3.78 | |||||||||
| Attitude score | Intervention group | 12 (0) | 13.7 (0.46), 13.58–13.82 | 1.7 (0.46), 1.58–1.82 | <0.001 | 1.7 [1.58–1.82, <0.001) | ||||||
| Control group | 12 (0) | 12 (0) | 0 | |||||||||
CI=Confidence interval; DiD=Difference-in-differences; SD=Standard deviation
Figure 2 shows that 56.7% of the intervention group successfully initiated breastfeeding within an hour, and every participant attempted breastfeeding within an hour. In comparison, 1.7% of the control group did not initiate breastfeeding.
Figure 2.
Graphical representation of the proportion of participants achieving components of successful BF. BF = Breastfeeding
There was no significant difference in mean scores in key areas such as early initiation (2.56; 2.44–2.68 vs 2.4; 2.27–2.53), good latch (2.31; 2.18– 2.44 vs 2.11; 1.97– 2.25), and on-demand feeding (2.85; 2.76–2.94 vs 2.75; 2.64–2.86) between two groups. The difference in proper positioning score was significant (2.4; 2.28–2.52 vs 2.08; 2.01–2.15, P < 0.001). Both groups equally avoided artificial teats and prelacteals. The overall mean of the successful breastfeeding score was significantly higher in the intervention group (16.13; 15.84–16.42) than in the control group (15.35,15.06–15.64), with a P value of 0.0004. Additionally, 10 participants in the intervention group and 3 in the control group achieved the maximum score of 18, reflecting comprehensive adherence to successful breastfeeding practices.
The scores for BFSEF, evaluated using the Dennis scale, were significantly higher in the intervention group than in the control group across various dimensions [Table 4]. For instance, the intervention group had a mean score of 3.43 (SD = 0.69) for “Getting enough milk,” compared to 3.08 (SD = 0.74) in the control group, with a P value of 0.01. Other aspects, such as managing breastfeeding challenges, responding to the baby’s crying, and feeling comfortable breastfeeding around family members, also showed significant improvements in the intervention group. The overall mean BFSEF score was 45.36 (SD = 3.98) in the intervention group, significantly higher than the 40.71 (SD = 4.05) observed in the control group, with a P value of less than 0.001. One of the situations showcased that more than 80% of the mothers were not confident about breastfeeding their babies in front of their family members. These data underscore the effectiveness of the intervention.
Table 4.
BFSEF (Dennis scale score) after delivery, all the sentences start with “I think I can…”
| BFSEF (Dennis scale score) | Intervention mean (SD) | Control mean (SD) | Significance test | |||
|---|---|---|---|---|---|---|
| 1. Determine that baby is getting enough milk (1–5) | 3.43 (0.69) | 3.08 (0.74) | 2.67, P=0.01 | |||
| 2. Successfully cope with BF like have with other challenging tasks (1–5) | 3.25 (0.60) | 2.96 (0.51) | 2.85, P=0.01 | |||
| 3. BF without using formula as supplement (1–5) | 3.51 (0.53) | 3.43 (0.56) | 0.80, P=0.84 | |||
| 4. Ensure that baby is properly latched (1–5) | 3.18 (0.59) | 2.78 (0.52) | 3.93, P<0.01 | |||
| 5. Manage BF situation to satisfaction (1–5) | 3.31 (0.50) | 3.08 (0.61) | 2.25, P=0.04 | |||
| 6. Manage to BF even if baby is crying (1–5) | 3.43 (0.64) | 3.15 (0.65) | 2.37, P=0.03 | |||
| 7. Keep wanting to BF (1–5) | 3.36 (0.48) | 3.28 (0.45) | 0.94, P=0.69 | |||
| 8. Comfortably BF with my family members present (1–5) | 2.36 (0.51) | 1.93 (0.31) | 5.58, P<0.01 | |||
| 9. Satisfied with my breastfeeding experience (1–5) | 3.33 (0.50) | 2.73 (0.57) | 6.12, P<0.01 | |||
| 10. Deal with the fact that breastfeeding can be time-consuming (1–5) | 3.21 (0.41) | 3.21 (0.41) | 0.00, P=1.00 | |||
| 11. Finish feeding my baby on one breast before switching to the other breast (1–5) | 2.98 (0.43) | 2.33 (0.50) | 7.63, P<0.01 | |||
| 12. Continue to BF my baby for every feeding (1–5) | 3.50 (0.53) | 3.20 (0.48) | 3.24, P=0.00 | |||
| 13. Manage to keep up with baby’s BF demands (1–5) | 3.50 (0.53) | 3.21 (0.49) | 3.11, P=0.00 | |||
| 14. Can tell when baby is finished BF (1–5) | 2.96 (0.48) | 2.30 (0.53) | 7.14, P<0.01 | |||
| Total (14–70) | 45.36 (3.98) | 40.71 (4.05) | 6.34, P<0.01 |
BF=Breastfeeding; BFSEF=Breastfeeding self-efficacy; SD=Standard deviation
Adjustment at baseline
The pretest knowledge was adjusted using ANCOVA, which revealed a significant difference in BFSEF and components of successful breastfeeding between the two arms. BFSEF had an adjusted score of F = 18.25, R² = 0.27 (P < 0.001) and an adjusted score of F = 7.79, R² = 0.11 (P = 0.006) for components of successful breastfeeding. However, no difference was seen in the early initiation of the BF score. Postintervention knowledge score difference was once again significant with F = 211 (P < 0.001).
Challenges and solutions
Common challenges included sore nipples, exhaustion, inappropriate milk production, knowledge gaps, lack of confidence, and improper feeding techniques, which were some of the issues observed. Potential probable solutions were given to the participants in both arms, for example, taking breaks, understanding the baby’s cues, and ensuring proper latching, and storage of milk.
DISCUSSION
This study aimed to assess the effectiveness of a skill-based group education intervention along with a WhatsApp support group for primiparous mothers who were going to experience breastfeeding for the first time in Uttarakhand, India.
In the study of 120 primiparous mothers equally allocated to each group, we observed a significant increase in the BF knowledge mean score of the intervention group from 3.12 (0.87) to 7.93 (0.25) compared to the control group. The intervention group also had higher total mean scores for components of successful BF (16.13, SD = 1.149 vs. 15.35, SD = 1.147, P = 0.0004) and self-efficacy scores (45.36, SD = 3.98 vs. 40.71, SD = 4.05) taken postdelivery (within three days, i.e., 24–72 hrs).
The current study focused on primiparous mothers experiencing breastfeeding for the first time. This targeted approach was used to help address the unique challenges of primipara by providing these mothers with a hands-on experience and equipping them with a structured skill-based intervention module. The combination of face-to-face skill-based educational sessions and ongoing support via WhatsApp with hands-on practice provides a robust learning and skill development framework, fostering a sense of community and connectivity or comfort among the participants. We directly observed the outcome (successful BF score) and confirmed with the nursing officer.
While the intervention group started with higher baseline knowledge, the DiD analysis confirms that the rate of improvement was significantly higher in the intervention arm (3.12 to 7.93), suggesting the module’s effectiveness independent of initial scores. Similar findings were also found in RCTs assessing distance education programs via Telegram,[16] BF educational kit interventions,[17] and essential newborn care-based BF support.[18] Our study observed that practical hands-on skill-based training allowed participants to gain more knowledge and confidence in BF. Poor positioning and attachment were significantly associated with the absence of breastfeeding counselling in other study as well.[17]
A higher self-efficacy score suggests greater confidence and competency in the intervention arm. Although there was a notable knowledge gap before the intervention, both groups demonstrated a positive attitude toward breastfeeding practices. We ensured that the observed improvements in postintervention outcomes were not confounded by any baseline disparities. For example, higher confidence and success in breastfeeding demonstrated by mothers in the intervention arm can be attributed to the educational module and associated support, rather than to preexisting differences in knowledge or attitudes. Similar findings were reported in training curriculum and mHealth-supported peer counselling programs,[19] tech-based interventions via WhatsApp and Zoom,[20] cluster RCT,[21] and quasiexperimental studies.[22] Likewise, evidence shows that structured interventions improve breastfeeding success rates.[18]
Comparable quality improvement initiatives conducted in secondary-level hospitals across northern India have also reported notable increases in EIBF rates.[23]
No significant improvement was seen in EIBF rates in the intervention group, with 56.7% of participants successfully initiating breastfeeding within one hour and 43.3% attempting but encountering challenges; these outcomes surpass the NFHS 5 figures yet remain below the WHO target of ≥70%. This discrepancy may be attributed to ongoing maternal concerns regarding milk sufficiency, persistent difficulties with breastfeeding technique, postpartum anxiety or lack of confidence, and various social or familial influences. In this study, nearly all participants engaged in breastfeeding within the first hour; however, emphasis was placed on the successful establishment of breastfeeding within that time frame as a key outcome. Similar patterns have been observed in studies from Ethiopia,[24,25] Karnataka,[26] global systematic analyses,[27] and extensive state-level cross-sectional research.[28]
The development and evaluation of the effectiveness of a skill-based breastfeeding education intervention module package for primiparous mothers represents a significant step toward addressing the challenges faced by first-time mothers in establishing successful breastfeeding. The intervention was designed to provide comprehensive, skill-based guidance, addressing both theoretical and practical aspects of breastfeeding, especially for those about to deliver. Mothers showcased increased confidence in their breastfeeding ability and a better understanding of managing potential challenges. Practical demonstrations were highlighted as useful by providing a visual, skill-based, hands-on learning experience, complementing theoretical knowledge. Supporting studies have shown similar positive outcomes.[20,21,22,23]
Sociodemographic and contextual determinants of EBF have also been highlighted, with maternal age, birth order, paternal education, religion, and counselling associated.[29] Several challenges were also seen during the study, such as one of the mothers in the intervention arm had a baby with a cleft lip, thus making it difficult for the baby to latch to the breast. Another case was where the baby was admitted to the NICU due to an infection. Still, neither mother opted for artificial teats and chose one of the methods learned during the educational session on expressing milk and fulfilling on-demand feedings. Control arm faced challenges regarding knowledge, nipple soreness, milk production, and the unavailability of proper storage and feeding methods.
Additional research also identifies barriers to optimal BF, including cultural, educational, organisational and work-related challenges.[30] Large-scale cross-sectional surveys in India also confirm knowledge and attitude gaps.[31] Evidence from RCTs on prenatal interventions further supports reduced nipple soreness and improved maternal experience.[32]
Limitations
Studies have some limitations. Firstly, selection bias may have influenced the results, as motivated participants were more likely to enroll if they had mobile and internet access. While our sample’s demographic profile largely reflects the characteristics of primiparous women attending ANC in similar semiurban settings in Uttarakhand, India, it may not fully represent all primiparous mothers across diverse socioeconomic strata or remote rural areas in India. Secondly, a 16.5% loss to follow-up early in the control group may have skewed the findings. Thirdly, we could not observe EIBF within one hour of delivery, so we mainly depended on the nursing officer on duty, information provided by the mother and the patient’s hospital record. Fourth, the study focused on immediate postpartum outcomes; long-term follow-up for maintenance of breastfeeding is recommended. The success of this educational model may depend on the availability of trained personnel capable of delivering such skill-based sessions and access to digital platforms like WhatsApp.
CONCLUSION
This quasirandomized controlled trial demonstrates that a structured, skill-based group education module delivered during the third trimester significantly improves breastfeeding knowledge, components of successful breastfeeding, and BFSEF among primiparous mothers compared with routine ANC alone. Mothers who received the intervention showed a substantially greater gain in knowledge scores and higher overall breastfeeding success and self-efficacy scores in the immediate postpartum period.
Although a higher proportion of mothers in the intervention group achieved EIBF compared to the control group, this difference did not reach statistical significance after adjustment for baseline knowledge. Nevertheless, nearly all mothers in the intervention arm attempted breastfeeding within the first hour, indicating improved preparedness and confidence surrounding breastfeeding initiation.
The intervention’s emphasis on hands-on skill development, practical demonstrations, and continued digital support through WhatsApp appears to have played a critical role in enhancing maternal confidence, particularly in areas such as positioning, attachment, coping with breastfeeding challenges, and breastfeeding in the presence of family members. These findings suggest that improvements in breastfeeding outcomes extend beyond knowledge acquisition to include behavioral skills and selfefficacy, which are essential for successful breastfeeding establishment.
Overall, integrating skill-based breastfeeding education into routine ANC—particularly when supported by group learning and digital followup—offers a feasible and effective strategy to support firsttime mothers. Implementing such interventions through trained paramedical staff in antenatal clinic settings may strengthen breastfeeding practices and maternal confidence in similar low-resource and semiurban settings. Further studies with longer followup are warranted to assess the sustainability of these effects on exclusive and continued breastfeeding.
Ethics declaration
Ethical approval and consent to participate
The Institutional Ethics Committee approved the study, AIIMS Rishikesh (AIIMS/IEC/23/500 dated 8/12/23). The study was designed in compliance with the Declaration of Helsinki and ICMR ethical guidelines for biomedical research. All participants gave their signed informed consent.
Author contributions
M.K. conceptualized the study, M.K., D, and NJ conducted the study intervention, collected the data, analyzed the data, and wrote the main manuscript text. L.C. and S.S. contributed to the study design. All authors reviewed and approved the final manuscript.
Conflicts of interest
There are no conflicts of interest.
SUPPLEMENTARY FILES
TREND (Supplementary File Table 1)
Title and abstract.
| Item | Description of the item—as specified by Des Jarlais et al. (2004) | Page number, line | ||
|---|---|---|---|---|
| 1 Title and abstract | Information on how unit were allocated to interventions | 1, 13 | ||
| Structured abstract recommended | 1 | |||
| Information on target population or study sample | 1, 13 |
Introduction.
| Item | Description of the item | Page number, line | ||
|---|---|---|---|---|
| 2 Background | Scientific background and explanation of rationale | 2 | ||
| Theories used in designing behavioral interventions | 2, 70–72 |
Method.
| Item | Description of the item | Page number, line | ||
|---|---|---|---|---|
| 3 Participants | Eligibility criteria for participants, including criteria at different levels in recruitment/sampling plan (e.g., cities, clinics, subjects) | 3, 92 | ||
| Method of recruitment (e.g., referral, self-selection), including the sampling method if a systematic sampling plan was implemented | 4, 102–112 | |||
| Recruitment setting | 2, 107–111 | |||
| Settings and locations where the data were collected | 2, 107–111 | |||
| 4 Interventions | Details of the interventions intended for each study condition and how and when they were actually administered, specifically including | 4, 131–143 | ||
| Content: what was presented? Delivery method: how was the content presented? Unit of delivery: how were the subjects grouped during delivery Setting: where was the intervention delivered Deliverer: who delivered the intervention? |
4, Supplementary File | |||
| Exposure quantity and duration: how many sessions or episodes or events were intended to be delivered? How long were they intended to last? Time span to deliver the intervention to each unit? |
4, Supplementary File | |||
| Activities to increase compliance or adherence (e.g., incentives) | 4 | |||
| 5 Objectives | Specific objectives and hypotheses | 2, 76 | ||
| 6 Outcomes | Clearly defined primary and secondary outcome measures | 4,145 | ||
| Methods used to collect data and any methods used to enhance the quality of measurements | 4, 145 | |||
| Information on validated instruments such as psychometric and biometric properties | 4, 145–163 | |||
| 7. Sample size | How sample size was determined and, when applicable, explanation of any interim analyses and stopping rules | 3, 102 | ||
| 8 Assignment method | Unit of assignment (the unit being assigned to study condition, e.g., individual, group, community) | Result tables | ||
| Method used to assign units to study conditions, including details of any restriction (e.g., blocking, stratification, minimization) | 3, 108 | |||
| Inclusion of aspects employed to help minimize potential bias induced due to nonrandomization (e.g., matching) | 3, 120–130 Statistical analysis -page 5 DiD and ANCOVA |
|||
| 9. Blinding | Whether or not participants, those administering the interventions, and those assessing the outcomes were blinded to study condition assignment; if so, statement regarding how the blinding was accomplished and how it was assessed. | 4,141 | ||
| 10 Unit of analysis | Description of the smallest unit analyzed to assess intervention effects (e.g., individual, group, or community) | Tables | ||
| If the unit of analysis differs from the unit of assignment, the analytical method used to account for this (e.g., adjusting the standard error estimates by the design effect or using multilevel analysis) | NA | |||
| 11 Statistical analysis | Statistical methods used to compare study groups for primary methods outcome(s), including complex methods of correlated data | 4, 160 | ||
| Statistical methods used for additional analyses, such as subgroup analyses and adjusted analysis | 4, 160 | |||
| Methods for imputing missing data, if used | 4, 160 | |||
| Statistical software or programs used | 4, 160 |
ANCOVA=Analysis of covariance
Results.
| Item | Description of the item | Page number, line | ||
|---|---|---|---|---|
| 12 Participant flow [often include a diagram] | Enrolment: the number of participants screened for eligibility, eligible or not eligible, declined to be enrolled, and enrolled in the study Assignment: the number of participants assigned to a study condition Allocation and intervention exposure: the number of participants assigned to each study condition and the number of participants who received each intervention |
Figure 1 | ||
| Follow-up: the number of participants who completed the follow-up or did not complete the follow-up (i.e., lost to follow-up), by study condition | Figure 1 | |||
| Analysis: the number of participants included in or excluded from the main analysis, by study condition | Figure 1 | |||
| Description of protocol deviations from study as planned, along with reasons | Figure 1 | |||
| 13 Recruitment | Dates defining the periods of recruitment and follow-up | 3 | ||
| 14 Baseline data | Baseline demographic and clinical characteristics of participants in each study condition | Table 1 | ||
| Baseline characteristics for each study condition relevant to specific disease prevention research | Tables 2–4 | |||
| Baseline comparisons of those lost to follow-up and those retained, overall and by study condition | Tables 2–4 | |||
| Comparison between study population at baseline and target population of interest | Table 3 | |||
| 15 Baseline equivalence | Data on study group equivalence at baseline and statistical methods used to control for baseline differences | Table 1 | ||
| 16 Numbers analyzed | Number of participants (denominator) included in each analysis for each study condition, particularly when the denominators change for different outcomes; statement of the results in absolute numbers when feasible | All tables | ||
| Indication of whether the analysis strategy was “intention to treat” or, if not, description of how noncompliers were treated in the analyses | • NA. | |||
| 17 Outcomes and estimation | For each primary and secondary outcome, a summary of results for each estimation study condition, and the estimated effect size and a confidence interval to indicate the precision | • Tables 2–4, | ||
| Inclusion of null and negative findings | • NA | |||
| Inclusion of results from testing prespecified causal pathways through which the intervention was intended to operate, if any | • NA | |||
| 18 Ancillary analyses | Summary of other analyses performed, including subgroup or restricted analyses, indicating which are prespecified or exploratory | 12, 214 | ||
| 19 Adverse events | Summary of all important adverse events or unintended effects in each study condition (including summary measures, effect size estimates, and confidence intervals) | 12, 323 |
Discussion.
| Item | Description of the item | Page number, line | ||
|---|---|---|---|---|
| 20 Interpretation | Interpretation of the results, taking into account study hypotheses, sources of potential bias, imprecision of measures, multiplicative analyses, and other limitations or weaknesses of the study | Page 12–13 | ||
| Discussion of results taking into account the mechanism by which the intervention was intended to work (causal pathways) or alternative mechanisms or explanations | Page 12–13 | |||
| Discussion of the success of and barriers to implementing the intervention, fidelity of implementation | 12–13 | |||
| Discussion of research, programmatic, or policy implications | 14, 416 | |||
| 21 Generalizability | Generalizability (external validity) of the trial findings, taking into account the study population, the characteristics of the intervention, length of follow-up, incentives, compliance rates, specific sites/settings involved in the study, and other contextual issues | 14, 416 | ||
| 22 Overall evidence | General interpretation of the results in the context of current evidence and current theory | 14, 416 |
Educational material
Picture 1.
Dummy baby, breast model and a manual
Audio video aid from IIT BOMBAY:
https://youtu.be/tGs0T2yPhHo?si=hUjeLhMk8R1HIUAP (Breastfeed baccha hone ke 1 ghanty mai hi karvana hai Aaye jaane kyu hai ye zaruri)
https://youtu.be/h2×oVKLu-u4?si=Hd6lWmxBU--xODmJ (Bacche ko duudh pilane ka sahi tareeka)
https://youtu.be/uhZwVnGOvW4?si=nUE36WoTRuJfrfty (Maa ka duudh hi sbse acha aahar hai Aye jaane kyu)
Table 4.
Scoring for successful breastfeeding
| Components of successful breastfeeding | Poor (1) | Moderate (2) | Good (3) | |||
|---|---|---|---|---|---|---|
| 1. Early initiation within 1 hour | Not tried at all | Tried but was of little success | Successful | |||
| 2. Good latch | Too sleepy or reluctant, no LATCH achieved | Repeat attempts, hold nipple in mouth, stimulate suck. | Grasps breast, tongue down, lips flanged, rhythmic sucking. | |||
| 3. Proper position (Baby well supported, tucked against mother’s body, lying on side/untwisted neck, nose-nipple, mother’s handling of the baby is confident.) | No or few elements achieved. | Achieving some elements. | Achieving all elements | |||
| 4. Giving no artificial teats | Yes | – | None | |||
| 5. No prelacteals | Yes | – | No | |||
| 6. On demand feeding | Not at all | Sometimes | Yes/many times |
Funding Statement
Nil.
REFERENCES
- 1.Kumari J, Jain S. Breastfeeding as a primary care preventive strategy towards improved child survival. Prev Med Res Rev. 2024;1:287–92. [Google Scholar]
- 2.Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475–90. doi: 10.1016/S0140-6736(15)01024-7. [DOI] [PubMed] [Google Scholar]
- 3.Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi: 10.1016/S0140-6736(15)01044-2. [DOI] [PubMed] [Google Scholar]
- 4.National Family Health Survey (NFHS-5), India Fact Sheet 2019-21. Mumbai: IIPS; International Institute for Population Sciences (IIPS) and ICF. [Google Scholar]
- 5.National Family Health Survey (NFHS-5), Uttarakhand State Fact Sheet 2019-21. Mumbai: IIPS; International Institute for Population Sciences (IIPS) and ICF. [Google Scholar]
- 6.UNICEF. New York: United Nations Children’s Fund; The State of the World’s Children 2021. [Google Scholar]
- 7.WHO & UNICEF. Geneva: World Health Organization; 2019. Global breastfeeding scorecard, 2019: Increasing commitment to breastfeeding through funding and improved policies and programmes. [Google Scholar]
- 8.Ministry of Health and Family Welfare (MoHFW), Government of India. New Delhi: MoHFW; 2016. Infant and Young Child Feeding Guidelines. [Google Scholar]
- 9.MoHFW. New Delhi: Government of India; 2017. Operational Guidelines on Lactation Management Centres in Public Health Facilities. [Google Scholar]
- 10.MoHFW. New Delhi: Ministry of Health and Family Welfare, Government of India; National Health Policy 2017. [Google Scholar]
- 11.WHO. Geneva: World Health Organization; 2018. Ten Steps to Successful Breastfeeding. [Google Scholar]
- 12.WHO. Geneva: World Health Organization; Implementation guidance: Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative 2018. [PubMed] [Google Scholar]
- 13.WHO. Geneva: World Health Organization; 2003. Global Strategy for Infant and Young Child Feeding. [Google Scholar]
- 14.WHO. Geneva: World Health Organization; World Health Assembly Resolutions on Infant and Young Child Feeding. [Google Scholar]
- 15.WHO. Geneva: World Health Organization; 1981. International Code of Marketing of Breast-milk Substitutes. [Google Scholar]
- 16.Taheri Z, Bakouei F, Delavar MA, Faramarzi M, Bakhtiari A, Amiri FN. Effectiveness of distance education program on mothers’ empowerment in exclusive breastfeeding: A randomized clinical trial. J Educ Health Promot. 2022. [doi: 10.4103/jehp.jehp_1614_21]. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9942160/. [Last accessed on 2024 May 27] [DOI] [PMC free article] [PubMed]
- 17.Souza EF, Pina-Oliveira AA, Shimo AK. Effect of a breastfeeding educational intervention: A randomized controlled trial. Rev Lat Am Enfermagem. 2020;28:e3335. doi: 10.1590/1518-8345.3081.3335. [doi: 10.1590/1518-8345.3081.3335]. Available from: https://pubmed.ncbi.nlm.nih.gov/33027400/. [Last accessed on 2025 May 27] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Glory H, Malarvizhi G, Myvizhi JER. Impact of essential newborn care guidelines in establishment of effective breastfeeding among primi postnatal mothers. Asian J Nurs Educ Res. 2015;5:113–7. [doi: 10.5958/2349-2996.2015.00024.5]. Available from: https://indianjournals.com/article/ajner-5-1-024. [Last accessed on 2024 May 27] [Google Scholar]
- 19.Bellad RM, Mahantshetti NS, Charantimath US, Ma T, Washio Y, Short VL, et al. A training curriculum for an mHealth supported peer counseling program to promote exclusive breastfeeding in rural India. Int Breastfeed J. 2023. p. 18. [doi: 10.1186/s13006-023-00546-4]. Available from: https://pubmed.ncbi.nlm.nih.gov/36658581/. [Last accessed on 2025 May 27] [DOI] [PMC free article] [PubMed]
- 20.Ozturk CS, Demir K. The effect of mandala activity and technology-based breastfeeding program on breastfeeding self-efficacy and mother-infant attachment of primiparous women: A randomized controlled study. J Med Syst. 2023;47:45. doi: 10.1007/s10916-023-01942-3. [doi: 10.1007/s10916-023-01942-3]. Available from: https://pubmed.ncbi.nlm.nih.gov/37004692/. [Last accessed on 2025 Aug 25] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Pilus FM, Ahmad N, Zulkefli NA, Shukri NH. Effect of face-to-face and WhatsApp communication of a theory-based health education intervention on breastfeeding self-efficacy (SeBF intervention): Cluster randomized controlled field trial. JMIR Form Res. 2022;6:e31996. doi: 10.2196/31996. [doi: 10.2196/31996]. Available from: https://pubmed.ncbi.nlm.nih.gov/36103244/. [Last accessed on 2025 May 23] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Gupta A, Dadhich JP, Faridi MM. Breastfeeding and complementary feeding as a public health intervention for child survival in India. Indian J Pediatr. 2010;77:413–8. doi: 10.1007/s12098-010-0049-6. [doi: 10.1007/s12098-010-0049-6]. Available from: https://pubmed.ncbi.nlm.nih.gov/20458639/. [Last accessed on 2025 May 24] [DOI] [PubMed] [Google Scholar]
- 23.Kaur R, Kant S, Goel AD, Bhatia H, Murry L. A quality improvement intervention to improve early initiation of breastfeeding among newborns delivered at a secondary level hospital in northern India. Med J Armed Forces India. 2021;77:230–6. doi: 10.1016/j.mjafi.2021.01.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nancy S, Sindhuri R, Arunagirinathan A, Dongre AR. Breastfeeding positioning and attachment among postnatal mothers: a mixed methods study in a tertiary care hospital in Puducherry, South India. J Family Med Prim Care. 2022. p. 11. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8971882/. [Last accessed on 2025 May 25] [DOI] [PMC free article] [PubMed]
- 25.Abdulahi M, Fretheim A, Argaw A, Magnus JH. Breastfeeding education and support to improve early initiation and exclusive breastfeeding practices and infant growth: a cluster randomized controlled trial from a rural Ethiopian setting. Nutrients. 2021;13:1204. doi: 10.3390/nu13041204. [doi: 10.3390/nu13041204]. Available from: https://pubmed.ncbi.nlm.nih.gov/33917366/. [Last accessed on 2025 May 25] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Renuka M, Shabadia N, Kulkarni P, Kumar DS, Anup G, Murthy MR. Effectiveness of educational intervention on breastfeeding among primi pregnant women: A longitudinal study. Clin Epidemiol Glob Health. 2020;8:89–93. [doi: 10.1016/j.cegh.2019.06.006]. Available from: https://cegh.net/article/S2213-3984(20)30128-7/fulltext. [Last accessed on 2025 May 28] [Google Scholar]
- 27.Haroon S, Das JK, Salam RA, Imdad A, Bhutta ZA. Breastfeeding promotion interventions and breastfeeding practices: A systematic review. BMC Public Health. 2013;13(Suppl 3):S20. doi: 10.1186/1471-2458-13-S3-S20. [doi: 10.1186/1471-2458-13-S3-S20]. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3847366/. [Last accessed on 2025 May 27] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Young MF, et al. State-level variations in breastfeeding initiation and duration in India: A cross-sectional analysis. BMJ Global Health. 2020;5:e002460. [Google Scholar]
- 29.Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK. Infant Feeding Study Group. Effect of community-based promotion of exclusive breastfeeding on diarrhoeal illness and growth: A cluster randomised controlled trial. Lancet. 2003;361(9367):1418–23. doi: 10.1016/S0140-6736(03)13134-0. [doi: 10.1016/S0140-6736(03)13134-0]. Available from: https://pubmed.ncbi.nlm.nih.gov/12727395/. [Last accessed on 2025 May 27] [DOI] [PubMed] [Google Scholar]
- 30.Alghamdi R, Albloushi M, Alzahrani E, Aldawsari A, Alyousef S. Nursing education challenges from Saudi nurse educators’ and leaders’ perspectives: A qualitative descriptive study. Int J Nurs Educ Scholarsh. 2019. p. 16. [doi: 10.1515/ijnes-2018-0027]. Available from: https://pubmed.ncbi.nlm.nih.gov/30798324/. [Last accessed on 2025 June 20] [DOI] [PubMed]
- 31.Sultania P, Agrawal NR, Rani A, Dharel D, Charles R, Dudani R. Breastfeeding knowledge and behavior among women visiting a tertiary care center in India: A cross-sectional survey. Ann Glob Health. 2019;85:64. doi: 10.5334/aogh.2093. [doi: 10.5334/aogh.2099]. Available from: https://annalsofglobalhealth.org/articles/10.5334/aogh.2093. [Last accessed on 2025 Aug 20] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Zhao Y, Lin Q, Wang J, Bao J. Effects of prenatal individualized mixed management on breastfeeding and maternal health at three days postpartum: A randomized controlled trial. Early Hum Dev. 2020;141:104944. doi: 10.1016/j.earlhumdev.2019.104944. [doi: 10.1016/j.earlhumdev.2019.104944]. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0378378219301471?via%3Dihub. [Last accessed on 2025 Aug 20] [DOI] [PubMed] [Google Scholar]
REFERENCE
- Des Jarlais D. C., Lyles C., Crepaz N., the Trend Group Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND statement. American Journal of Public Health. 2004;94:361–366. doi: 10.2105/ajph.94.3.361. For more information, visit: http://www.cdc.gov/trendstatement. [DOI] [PMC free article] [PubMed] [Google Scholar]