Maternal Knowledge and Attitude toward Exclusive Breast Milk Feeding (BMF) in the First 6 Months of Infant Life in Mashhad

Authors

1 Midwifery MSc; Faculty Member of Midwhfery Department, Sabzevar University of Medical Sciences, Sabzevar, Iran.

2 Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

3 Department of Pediatrics, North Khorasan University of Medical Sciences, Bojnurd, Iran.

4 Students Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Abstract

Introduction:
Breast milk is a complete food for growing children until 6 months of age, and mothers, as the most important child health care, play a decisive role in their growth. So promoting  their attitude toward the benefits of breastfeeding ensures guarantee child health in the future. This study aimed to assess maternal knowledge and attitude of Mashhad toward exclusive BMF in the first 6 months of infant life.
 
Materials and Methods:
This cross-sectional descriptive-analytic study was conducted on 126 mothers who referring to Mashhad health-care centers for monitoring their 6-24 month year old infants. They completed questionnaire. Participants were selected by cluster and simple random sampling. Data were analyzed by descriptive- analytic tests and using SPSS 11.5.
 
Results:
Mean score of maternal attitude toward exclusive BMF was 14.32±5.28 (out of 28) and maternal knowledge score toward advantages of breast milk was 19.59±4.80 (out of 28). The incidence of exclusive BMF in the first 6 months of life study was 73.8%. Child growth was as follows: excellent growth (5.6%) and good growth (42.1%). ANOVA showed a significant difference between parents' education and maternal attitude towards exclusive BMF; whatever higher education of parents, more positive maternal attitude towards exclusive BMF (P<0.05). There was a significant direct relationship between knowledge and attitude (Spearman test, P-value= 0.000& r= 0.4).
 
Conclusion:
Maternal attitude towards exclusive BMF was moderate. It is essential to plan for mothers by officials in order to promote breast-feeding in the first 6 months of baby's life to enhance positive maternal attitude in this regard.

Keywords


Introduction

Quran as the main pillar of Islamic Sciences and felicity book of two House, has said the issue of breastfeeding within some verse, such as surah Baqara, verse 233 "and mothers should breastfeed their children for two complete years." Verses of Quran pay attention to breast milk issue directly are as follow: 1. Verse 15 of Sura Ahqaf 2. Verse 14 of Sura Luqman 3. Verse 23 of Sura Nisa , this verse is in relation to Kinship foster 4. Verse 6 of Sura Divorce 5. Verse 2 of Sura Hajj 6. Verse 7 of Sura Stories 7. Verse 12 of Sura Stories (1).

Breast milk is one of the healthiest methods of feeding infant and has obvious advantages for mothers and children. This milk contains nutrients which provide the best nutritional combination for the child at least up to 6 months. Breast milk feeding (BMF) reduces the risk of infectious diseases, diabetes, cancers, asthma and fat children, further more it also contains economical advantages (2). Epidemiological studies have shown the effect of human milk on reducing neonatal mortality caused by acute and chronic diseases (3,4). Breast milk provides all infant's nutritional requirements in the first 6 months of life and has a very important role in keeping children healthy (5) and early supplemental nutrition can have a negative influence on infant growth (5-7).

Experts believe that exclusive BMF in the first 6 months of life, has an important role in health and reducing children mortality (8,9) and besides to reducing neonatal mortality can prevent from childhood diseases (10-12). Breast milk has a special importance, since it contains known and unknown materials especially essential fatty acids for brain growth and nerves development (13). WHO and UNICEF emphasize on keeping exclusive BMF in the first 6 months of life (11,14-16).

Experts believe that children are the most valuable wealth of humanity and the most vulnerable age group, yet. Several studies have shown that several factors cause disorder in children growth which their commonest are non-organic factors (17). Some non-organic factors which can cause infant growth retardation include: lack of maternal knowledge and consequently improper behaviors to child and infant nutrition with regard to time, quantity, quality and methods of supplemental nutrition (18). Some experts believe that maternal familiarity to nutritional requirements of children may provide a correct nutritional plan for them (19). However, there is a close relationship between malnutrition and poverty, main reason of malnutrition in many societies is not lack of food at home, but it is some other factors like cultural poverty, loss of health instruments and services, lack of knowledge in preventing infections and incorrect use of foods at time of children growth (20). Genetic factors play an important role in physical growth of children, but importance of proper and correct nutrition is not deniable (21).

In performed assessments by attendants in relation to promoting BMF, exclusive BMF patterns in the first 6 months of life in different places of the world are different. In china, 80% of infants in the first 4-6 months receive exclusive BMF (22). Generally, exclusive BMF range 1% to 90 % in different places of the world (23). Exclusive BMF incidence up to 6th month has been 35.1% in Uganda, 51.6% in Ghana and 27.3% in Saudi Arabia (24-26). Exclusive BMF has been reported in the Middle East 28% in 2000- 2006, Pakistan 16%, Iraq 25%, Saudi Arabia 31%, Egypt 38% and in Iran 44% (27). Factors such as: economic- social factors, demographic, cultural, obstetrical and neonatal ones have been known effective in posing early exclusive BMF. These factors are varied in different societies (25, 28). In American (2000), 35% children had exclusive BMF, while it increased to 50% in 2010 (29-30). While according to Demographic Health  Survey (DHS) (2000) and Integrated Monitoring Evaluation System Survey (IMESS) (2004) in Iran, exclusive BMF up to 6th month has been reported 44% and 27%, respectively (31).

In several studies, controversial results have been reported on related factors to exclusive BMF. Some factors were assessed such as: infant gender, age, education degree, maternal occupation and parity, antenatal education and initial time of BMF postpartum (6-7,25-28,32). In some of the studies, there was no relationship between infant gender and exclusive BMF (6-7). In recent years, many attempts in health system of Iran   have been done to promote exclusive BMF. With regard to the importance of exclusive BMF promotion and determining its related factors and also existence of controversial studies' finding in this sense, this study aimed to assess maternal knowledge and attitude of Mashhad toward exclusive BMF in the first 6 months of infant life.

 

Materials and Methods

This cross-sectional descriptive-analytic study was conducted on mothers who referring to Mashhad health-care centers for monitoring their 6-24 month year old infants. Sample size calculated 126 persons by using past studies in similar communities with considering α=0.05% and d= 0.03%. Participants were selected by cluster and simple random sampling in the way that initially Mashhad city was divided into 3 clusters (health-care center number 1, 2 and 3), then 3 centers out of total Health – care Centers in each cluster were selected randomly (totally 9 health-care centers) by a cluster sampling method and then aimed sample was selected randomly in each health-care center. The researchers referred to maternal child care and vaccination units of health-care centers after coordination with the center’s manager, introduced the research for the participants and obtained their informed consents. Then they obtained required data by completed questionnaires and child's records. Research tool was a researcher-made questionnaire which was confirmed by content validity and internal consistency (Cranbach's alpha (α=0.81) reliability. The questionnaire consists of demographic information and 20 questions relating to maternal knowledge and attitude toward exclusive BMF. Data were coded and analyzed by descriptive and analytic [one-way analysis of variance (ANOVA), t-test] statistics and confidence coefficient 95% by SPSS-11.5. P < 0.05 was considered significant.

 

Results

126 mothers who qualified the inclusion criteria were assessed. Participants' mean age was 29.60±5.84 years (range from 19- 42 yr). Family income was good (35.7%) and very good (4%). Majority of mothers were house worker (73%) and 61.95 of fathers were self employment. Majority of mothers had academic education (40.5%) which their fathers' education was primary (6.3%) and junior high school (37.5%) (Table 1). Child growth was as follows: excellent growth (5.6%) and good growth (42.1%). 

 

Table 1: Frequency of Demographic Variables in Mothers Referring to Mashhad Health- Care Centers

Variables

Frequency

Percent

Child growth status

Excellent

Good

Moderate

Poor

Total

 

7

53

54

12

126

 

5/6

42/1

42/9

9/5

100

 

 

 

Maternal occupation

House worker

Self employment

Employee

Total

 

92

9

25

126

 

73

7/1

19/8

100

 

 

 

Maternal education

Primary

Junior high school

High school

Academic

Total

 

7

37

31

51

126

 

5/6

29/4

24/6

40/5

100

 

 

 

Family income

Low

Moderate

good

Very good

 

11

65

45

5

 

8/7

51/6

35/7

4

Total

126

100

Mean score of maternal attitude toward exclusive BMF was 14.32±5.28 (out of 28) and maternal knowledge score toward advantages of breast milk was 19.59±4.80 (out of 28) (Table 2).

 

Table 2: Mean of Maternal Knowledge and Attitude about Exclusive BMF.

Variable

Mean

S.D

Total

Attitude

14.317

5.280

28

Knowledge

19.593

4.804

28

 

There was a significant direct relationship between knowledge and attitude (Spearman test, P-value= 0.000, r= 0.4). Whatever higher score of maternal knowledge, more positive attitude towards exclusive BMF (Table 3).

 

Table3: Association between Maternal Knowledge with Attitude on Exclusive BMF

Variable

Statistical tests

Attitude

Maternal knowledge

Pearson coefficient

0.425

P-value

0.000

 

92% of mothers agreed with breast feeding in different times of night and day. 52.4% of them believed that supplemental food is necessary besides to breast milk in the first 6 months of life. 88.1% of mothers had agreement on immunized breast milk (Table 4).

Spearman test showed no significant relationship between attitude and maternal age. On the other hand, there was a significant direct relationship between maternal knowledge toward breast milk and its advantages with maternal age; whatever


older maternal age, higher score of knowledge about breast milk and exclusive BMF in the first 6 months of life (Table 5).

 

Table 4: Maternal Attitude about some Factors Influencing Exclusive BMF

Attitude                              

                             Statistics

N

Percent

 

Breast feeding at night is necessary

 

Totally agree

agree

no comment

disagree

Total

58

58

7

3

126

46

46

5/6

2/4

100

Supplemental nutrition is necessary beside to BMF

Totally agree

agree

no comment

disagree

Total

11

55

17

25

18

126

8/7

43/5

13/5

19/8

14/3

100

BMF enhances infant immunization

Totally agree

agree

no comment

disagree

Total

55

56

15

0

126

43/7

44/4

11/9

0

100

Weight gaining is indicator of enough breast feeding

Totally agree

agree

no comment

disagree

Total

42

66

15

3

126

33/3

52/4

119

2/4

100

 

Table 5: Association between Maternal Age with their Knowledge and Attitude towards Exclusive BMF

Variable

  Statistical tests

Attitude

Knowledge

Maternal knowledge

Pearson coefficient

0.425

 

0.425

P-value

0.000

 

0.000

 

ANOVA showed a significant difference between parents' education and maternal attitude towards exclusive BMF; whatever higher education of parents, more positive maternal attitude towards exclusive BMF (P<0.05) (Table 6).

 

 

Table 6: Mean Comparison of Maternal Attitude towards Exclusive BMF based on Parental Education

 Attitude

Statistics

N

Mean

SD

DF

F

 

Pvalue

 

Maternal education

Primary

Junior high school

High school

Academic

Total

7

37

31

51

126

1/019

4/151

3/179

5/170

2/057

1/215

2/088

2/011

3

5/926

0/001

 

 

 

 

 

 

 

 

 

Father’s education

 

Primary

Junior high school

High school

Academic

Total

36

38

44

8

126

5/152

0/738

4/414

2/875

2/017

1/200

2/008

1/984

3

2/919

0/037

 

ANOVA had not shown a significant difference between maternal location, birth sequence, family income, parents' occupation and maternal attitude towards exclusive BMF (P>0.05).

 

Discussion
  In the present, the incidence of exclusive BMF in the first 6 months of life study was 73.8%; which was in accordance with obtained results in China (22), but it is higher than national mean of exclusive BMF (31) and American (29- 30), Uganda and Ghana (24- 26), Egypt, Iraq, Saudi Arabia (27) and Pakistan (16); the reason of this finding may be due to being religious of Mashhad and people's belief which they should breast feed their infants for 2 whole years. In 2 recent decades, we have been observed promotion of breast feeding following achievement of scientific societies to global and new recognition toward value, importance and role of breast milk in providing child survival and health. Near monthly we observe publishing new information about being unique of breast milk in keeping and promoting desired health, growth and development of children and even its effects on adulthood in infants who breast fed and thus is emphasized on breast milk advantages for infant, mother and the community. But more than 14 centuries, important notes about breast milk have been mentioned as recommendations and trainings   in Islamic trainings with the most comprehensive, beautiful and the strongest motivations. Having knowledge about these recommendations and correct use of them follow the most effective motivations of promoting infant nutrition with breast milk.

According to the present study, maternal knowledge about exclusive BMF was moderate which was in accordance with Mosaffa Hamami study (33). The present study showed that there was a significant difference between parents' education and maternal attitude towards exclusive BMF.  Alaie et l showed that spouses (24%) and sister and mother-in-law (44%) and Kinsfolk or friends and medical staff (32%) were encouraging (34). In England, spouse support and accepting breastfeeding behavior were important factors in initiating and continuing breast feeding (35). Sweet also showed that spouses’ support and their suitable attitudes towards breastfeeding have been effective in continuing breastfeeding preterm neonates (36). Gill showed that the other family members play role in successful breastfeeding (37). Pisacane stated that educating the fathers about the importance of BMF and eliminating the problems and barriers associated with increasing exclusive BMF at the first 6 months of life (38). Scott also showed that there was a significant and positive relationship between continuing BMF and knowledge, attitude and father support (39).

In the present study there was a significant relationship between maternal age and her knowledge about exclusive BM; so that older mothers had more knowledge about exclusive BMF. The reason can be due to having more children. Ertem also showed a significant relationship between age and exclusive BMF (40).

According to the present study there was no significant relationship between maternal location and her attitude about exclusive BMF. These findings are in accordance with Mir Mirahmadizadeh (41). One study in Canada showed a significant difference between duration of exclusive BMF in two groups of urban and rural children (42).

The present study showed a significant relationship between parents’ education degree with exclusive BMF, which was in accordance with Savage’s findings (43). The findings showed mothers who were university educated had more positive towards exclusive BMF.

 

Conclusion

Exclusive BMF in the present study was higher than national mean of exclusive BMF and American, African countries like Uganda and Ghana and some countries Middle East region. On one hand, maternal attitude towards exclusive BMF was moderate. Since there is a significant relationship between knowledge and attitude, we conclude that offering continuous educations to the mothers about breast milk advantages and informing them more about exclusive BMF in the first 6 months of infant life, can promote positive maternal attitude in this regard.

 

Acknowledgment

The researchers appreciate the cooperation of technical Vice Chancellery of province health care center, dear Dr. Gholam Hasan Khodaei, and all staff of Mashhad health care centers and dear participating mothers.

 

1.  Holy Qur'an.

2.  UNICEF/WHO Baby-Friendly Hospital Initiative Revised, Updated and Expanded for Integrated Care 2009 WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland www. unicef. org/nutrition /files/BFHI_2009_s3.1&2.pdf.

3.  Horta BL, Bahl R, Martines JC, Victora CG: Evidence on the long-term effects of breastfeeding. Systematic reviews and meta-analysis. Geneva: World Health Organization 2007.

4.  Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, Eidelman AI,American Academy of Pediatrics Section on Breastfeeding: Breastfeeding and the use of human milk. Pediatrics 2005, 115: 496-506.

5. Walker A. Breast milk as the gold standard for protective nutrients. J Pediatr. 2010; 156 (2Suppl):S3-7. Review.

6. Imani M, Mohamadi M, Rakhshani F. Prevalence and factors associated with exclusive breastfeeding inZahedan .Faiz 2003; 26(7):26-33.

7. Abedzadeh M, Saberi F, Sadat Z. Quality of nutrition and factors related to it in 4/5 month old babies of Kashan .Faiz 2005;        3: 59-64.

8. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS:How many child deaths can we prevent this year? Lancet 2003, 362:65-71.

9. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality: Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet2000, 355(9202):451-5.

10. Scott JA, Landers MC, Hughes RM, Binns CW: Factors associated with breastfeeding at discharge and duration of breastfeeding. J Paediatr Child Health 2001, 37(3):254-61.

11. WHO: The optimal duration of exclusive breastfeeding.Geneva 2001.

12. Breastfeeding trends and updated national health objectives for exclusive breastfeeding United States, birth years 2000-2004. MMWR Morb Mortal Wkly Rep 2007, 56(30):760-3.

13. Innis SM: Perinatal biochemistry and physiology of longchain polyunsaturated fatty acids. J Pediatr 2003, 143(4Suppl):S1-8.

14. WHO: Report of the expert consultation on the optimal duration of exclusive breastfeeding World Health Organization; 2001.

15. American Academy of Pediatrics (AAP). Work Group on Breastfeeding. Breastfeeding and the use of human milk.Pediatrics. 1997; 100(6): 1035–9.

16. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Geneva, World Health Organization, 2001 (WHO/NHD/01. 08;WHO/ FCH/01.23).

17. Golkari Hamid, Khatami Reza. Study of developmental disorders (FTT and short stature). Tehran: Ayandesazan, 1999, Pages 5-7.

18. Seddighi P, Ghafarpur M, Jazayeri A. Effect of weaning foods, infant growth and development in Eslamshahr city. Medical Journal (Journal of Medicine, Shahid Beheshti University of Medical Sciences); 21 years, 1997, P. 14-25.

19. Razavieh V,Pourabdolahi P,Nikkhah S. Knowledge and attitudes of mothers  about feeding  infant with breastfeeding applied and supplementary foods. Journal of Urmia University of Medical Sciences, No. 2, Summer 2001, Pages 120-9.

20. Nakhshab M,Basiri H. Prevalence of malnutrition and its risk factors in children under 2 years of Sari 2000. Journal of Mazandaran University of Medical Sciences, Year XII, No. 34, Spring 2002, Pages: 47-56.

21. Kusha A. Nutritional status of children under 1 year of Hospital Medicine Branch Community in 1991-1993 years. Journal of Zanjan University of Medical Sciences, No. 20, 1995, Pages: 5-10.

22. Xu F, Qiu L, Binns CW, Liu X. Breastfeeding in China: a review. Int Breastfeed J. 2009, 16:4-6.

23. United Nations Children’s Fund (UNICEF): Progress for Children: A Child Survival Report Card 2004 [http://www. unicef.org/ publications/ files/29652L01Eng.pdf].

24. Ssenyonga R, Muwonge R, Nankya I. Towards a better understanding of exclusive breastfeeding in the era of HIV/AIDS: a study of prevalence and factors associated with exclusive breastfeeding from birth, in Rakai,Uganda. J Trop Pediatr 2004 ;50(6):348-53.

25. Aidam BA, Pérez-Escamilla R, Lartey A, Aidam J. Factors associated with exclusive breastfeeding in Accra,Ghana. Eur J Clin Nutr 2005; 59(6): 789-96.

26. Ogbeide DO, Siddiqui S, Al Khalifa IM, Karim A. Breast feeding in a Saudi Arabian community. Profile of parents and influencing factors. Saudi Med J 2004; 25(5): 580-4.

27. The state of the world’s children. 2008, [Child survival] New York: UNICEF; 2007.

28. Santo LC, de Oliveira LD, Giugliani ER. Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Birth 2007; 34(3):212-9.

29. US. Department of Health and Human Services. Chapter 16. Maternal, Infant, and Child Health. Healthy People 2010 (2nd Ed.): With Understanding and Improving Health and Objectives for Improving Health. Vol 26.Washington, DC: US. Governmental Printing Office; 2000.

30. Ryan AS, Zhou W, Acosta A. Breastfeeding continues to increase into the new millennium. Pediatrics. 2002;110(6): 1103–9.

31. The Ministry of Health IR of Iran, Breastfeeding office  ttp://www.bfps.ir/ (i5emlr 45w1kdeg45tov0ysem)/Persian/Home.aspx].

32. Venancio SI, Monteiro CA. Individual and contextual determinants of exclusive breast-
feeding in S?o Paulo,Brazil: a multilevel analysis. Public Health Nutr 2006; 9(1): 40-6.

33. Mosaffa H. Survey of the knowledge and attitude of mothers during one year after delivery about breast-feeding.Journal of Guilan University of Medical Sciences 2004; 13(51): 23-31.

34. Alaie N, Faghihzadeh S. Relationship of Mother Factors with Mothers’ Attitude about Breast Feeding. Daneshvar Medicine April- May 2008; 15(74): 31-40.

35. Bertini G, Perugi S, Dani C, Pezzati M, Tronchin M, Rubaltelli FF. Maternal education and the incidence and duration of breast feeding: a prospective study J Pediatr Gastroenterol Nutr 2003; 37(4): 447-52.

36. Sweet L, Darbyshire P. Fathers and breast feeding very-low-birthweight preterm babies Midwifery 2009; 25(5):540-53.

37. Gill SL, Reifsnider E, Lucke JF. Effects of support on the initiation and duration of breastfeeding. West J Nurs Res. 2007 Oct;29 (6): 708-23.

38. Pisacane A, Continisio GI, Aldinucci M, D'Amora S, Continisio P. A controlled trial of the father's role in breastfeeding promotion. Pediatrics. 2005 Oct;116(4):e494-8.

39. Scott JA, Binns CW, Oddy WH, Graham KI. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics. 2006; 117(4): e646.

40. Ertem IO, Votto N, Leventhal JM. The timing and predictors of the early termination of breastfeeding. Pediatrics. 2001 Mar; 107(3):         543-8.

41. Mirahmadizadeh A, Zare P, Moradi F, Sayadi M, Hesami E, Moghadami M. Exclusive breast-feeding weaning pattern and its determinant factors in Fars province in 2010.. 3. 2012; 19 (99) :11-22.

42. Duration of Exclusive Breastfeeding in Canada: Key Statistics and Graphics (2007-2008). http://www.hcsc. gc.ca/fnan/surveill/ nutrition/commun/prenatal/duration-dureeeng. php (Access at 4th Aug 2011)

43. Savage King, F. Helping breast fed mothers. Translated by Dehghani P. IUMS publications, Tehran. 1999.p 44.