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Barriers to exclusive breast feeding, the missing links: a cross sectional study from Puducherry, India

Background: Breast milk, the first natural food for a new-born, provides all the energy and essential nutrients an infant requires for the first 6 months of life. The NHFS -4 survey shows only 45.5% of children are exclusively breastfed (EBF) in Puducherry. This study aims at assessing the socio-demographic characteristics associated with exclusive breastfeeding in a tertiary hospital in Puducherry and identify the barriers in the promotion of exclusive breastfeeding. Methods: Community-based cross-sectional study at a tertiary hospital in Puducherry. Sample size: 115 mothers of 6 months to 2-year-old children, born term gestation with a birth weight of >2.5 kg, attending the Paediatric OPD. Questionnaire-based study comprising of socio-demographic and parameters pertaining to exclusive breast-feeding. Results: Only 44.3% of the mothers have exclusively breastfed in the first 6 months. Shorter duration of spacing between births and caesarean section had significant negative association with exclusive breast-feeding. Most of the mothers received postnatal counselling on breast-feeding (94%) of which 58% were by health care personnel. Despite that, only a sixth (19%) of them were well versed with proper breastfeeding techniques. Poor secretion (45.3%), sore/inverted nipple (23.5%) amounted to the most common of the barriers. Among working mothers, 42.9% attributed their jobs as the cause for early weaning. Conclusions: The prevalence of exclusive breastfeeding is still low even among a literate study group. There were no significant association with socio-demographic factors found, but lacunae were identified. A more objective postnatal counselling to mothers involving their caregivers may improve the current scenario.

Infant Death Syndrome. 5 The United Nations Children's Fund (UNICEF) estimates that exclusive breastfeeding in the first six months of life can reduce under-five mortality rates in developing countries by13%. 6 In India, 15% out of 24 lakh child deaths can be reduced by enhancing breastfeeding practices. 1,2,7 Besides benefits to the baby, the breastfeeding mother also has a substantially low risk of postpartum haemorrhage, ovarian and breast cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction and various metabolic syndromes. 1,5,7,8 However, as per the NHFS -4 survey (2015-2016), only 54.9% of babies are exclusively breast-fed in India, and 45.5% in Puducherry. 9 Cultural, social and religious factors in our country such as extra lacteal feeding, use of foods soon after child-birth like sugar water or honey are prevalent, which have a negative impact on the feeding practises. [10][11][12] Poor feeding practices and sociodemographic characteristics are reported as major reason for poor health outcomes in developing countries. [10][11][12] There are a number of organisations all over the world that work towards the promotion of breast-feeding. In 1991, Breast-Feeding Promotion Network of India (BPNI) was formed to protect, promote and support breastfeeding. 12 This study aims to assess the socio-demographic characteristics and hindering factors that may be associated with the promotion of exclusive breastfeeding.

METHODS
This was a cross sectional hospital based study conducted in the Out Patient Department (OPD) of the Department of Paediatrics of a tertiary care hospital in Puducherry with approval from the Institutional Ethics Committee.
A sample size of 115 participants calculated, based on a previous study by Ranjana et al, with 95% confidence interval using the formula 4PQ/d 2 . 13 A p value of <0.05 considered as statistically significant. Purposive sampling was the method used to collect data.

Inclusion criteria
The inclusion criteria considered for this study included all women of childbearing age attending the OPD, having children of the age group of 6 months to 2 year, who were born as term gestation with a birth weight of >2.5 kilograms, and volunteered to take part.

Exclusion criteria
Mothers whose children were born as Pre terms (gestational age <37weeks), low birth weight babies (birth weight <2.5kg) and babies with congenital heart defects, were excluded from the study sampling.
Written informed consent was obtained from the study participants who volunteered, after explaining in detail the purpose of the study and their right to withdraw from the study at any time maintaining their confidentiality.
Data collection was carried out using a self-developed questionnaire with inputs from previous studies. [11][12][13][14][15] with two sections. Section-A was based on the sociodemographic characteristics of the participants which included age of the mother, residence, education, employment status of the mother, type of family, socio economic status, birth order of the child, mode of delivery and spacing between births. Section-B included questions regarding antenatal counselling given during pregnancy, post-natal counselling after birth, the people involved in counselling, whether breast feeding was initiated after birth along with the day of initiation, number of times the baby is breast fed in a day, total duration of exclusive breast feeding.
The use of pre-lacteal feeds like sugar, honey etc., awareness on the significance of colostrum, knowledge on proper/ effective breast feeding techniques, reasons for defaulting from exclusive breast feeding, type of extra lacteal feeds given, from whom the advice was taken, and the mothers feedback on such practices were also sought. The answers to the above questions were noted in the written prescribed proforma.

Data analysis
The data collected was subjected to appropriate analysis using the SPSS software version 19.0 for Windows. (SPSS Inc, Chicago, IL, USA).

RESULTS
Of the total 115 post-natal mothers interviewed in the study from the age of 18 years to 40 years, the majority of the mothers belonged to the age group between 20-25 years (n =53/ 115, 46.1%). The study population consisted of 94% literate mothers (n=108/115), of which college graduates and high/ secondary school graduates (n= 96/115, 88%) formed the majority. However only 24% (n= 28/115) among all the mothers had a part time or fulltime job. Among the total study population, 41% (n= 49/115) had a single child, the remaining mothers multiparous (n= 66/115, 59%), of which around two-third (n=48/66) stated they had a gap of 2-3 years between deliveries. All the mothers (n= 115) reported to have had institutional deliveries with assistance given by a trained staff nurse or doctor at the time of delivery. Only 40% (n=45) of postnatal mothers had their delivery by caesarean section. Regarding the sex of the child, two -thirds (n=72/115) of the mothers had male babies, the remaining one third (n= 43/115) being females. Around 83% (n= 95/115) of the mothers had uneventful antenatal, natal and post-natal periods (Table 1).  The total percentage of mothers in the above study group who practiced exclusive breast-feeding for six months was only 44.3% (n=51/115). Correlating this value, with socio demographic factors such as maternal age (<25yrs />25yrs), education of the mother (literate/ illiterate), occupation (unoccupied/ occupied), birth order(one /more than one), spacing between births (<2yrs/ ≥2yrs), caesarean section (no/ yes) and sex of the baby (male/female) through multiple logistic regression analysis, a significant negative association with shorter duration between spacing of births and caesarean deliveries (p value <0.05) was observed ( Table 2).
Regarding breast feeding awareness and practices, threefourth (n= 86/115)) of the mothers claimed to have received antenatal counselling on breastfeeding, of which 50% (n=58/86) was by a heath care professional (doctor or nurse). Even though all the mothers had their deliveries in a health care facility, 6% (n=7/115) of the mothers stated that they had not received post-natal counselling at all on exclusive breastfeeding. The mothers who received postnatal counselling were mostly from a health care professional alone or associated with a family member (mother/husband) (n= 103/108, 90%). Most of the mothers (n= 98/115, 88%) claimed to have initiated breast-feeding on the first day, though many could not recall whether it was in the first hour. Less than half of the mothers counselled (n=47/108) stated that they were informed the importance of initiation within the first hour and knowledge on colostrum (Table 1).  The major barriers against EBF in this study were poor maternal secretions (n= 29/64, 45.3%), inverted/sore nipple (n= 15/64, 23.3%) while 13% (n= 8/64), chose that they were prejudiced to adding formula/extra lacteal feeds early for their baby's better growth (Figure 1). Among working mothers, 42.9% (n=12/28) attributed their jobs as the cause for early weaning. Only one-sixth of the mothers counselled (20/108, 19%) stated they were taught/ trained about proper breast-feeding techniques ( Figure 2).
Almost two-thirds of the mothers (n = 38/64) disclosed that their parents/ in-laws/ husbands' were responsible for them having to start extra-lacteal feeds, 16% (n= 10/64) revealed that their health care professional was also supportive of starting extra-lacteal feeds earlier than 6 months, while 26% (n= 16/64) said it was their own decision ( Figure 3). However, 55% of these mothers (n= 36/64) revealed that they felt such extra lacteal feeds had not helped their baby, as they did not observe weight gain they expected (n = 20/36, 56.6%), in addition to frequent episodes of diarrhea (n= 11/35, 30%) or repeated episodes of falling ill (n= 5/36, 13.4%).
Figure 3: People who recommended Extra Lacteal feeding to the mothers.

DISCUSSION
As per the National Health and Family Survey 4 (NHFS 4, 2015-2016), the children exclusively breast-fed in India is 54.9%, whereas in Tamil Nadu and Puducherry it is 48.3% and 45.5% respectively. 9 This study also observed a prevalence of 44.3%, which is in concordance to the above statistical data. Similarly, the percentage of institutional births in our study was 100% and caesarean sections 40% as against 99.9% institutional births and 33.6% caesarean sections documented for Puducherry in the NFHS 4. 9 In a study by Radhakrishnan et al, from Tamil Nadu, the prevalence of EBF was 34%. 11 A study in Puducherry on Health Care Professionals by Renitha et al, showed a prevalence of 58% to EBF. 14 Studies from other parts of India showed the prevalence of EBF to range 37% in Gujarat, 37.7% in rural North India, 46.5% in Uttar Pradesh to 63.5% in Delhi and 63.7% in Hubli respectively. [15][16][17][18][19] In relation to the socio-demographic factors assessed, a significant negative association was found between caesarean sections shorter duration of spacing between subsequent childbirth (<2yrs initiation of breast-feeding by the mothers as seen with similar trends in other studies. [22][23][24][25] In addition, 6% mothers mentioned not receiving post-natal counselling on EBF. Of those counselled, less than half (43.5%) only were aware of the importance of early initiation and colostrum. In another study also conducted in Puducherry, only 56% of the mothers knew that colostrum needs to be given which is also low compared to others studies in India where the importance of colostrum was known to 75-90% of the mothers. [26][27][28] Poor maternal secretions (45.3%), inverted/ sore nipples (23.3%) were the major difficulties faced by mothers against EBF. These findings are similar to those reported by Parmar 34,35,17 Almost half of the working mothers in the study population attributed their jobs as the barrier to EBF. Observations by Renitha et al, and Ratnayke et al, also stated mothers had difficulty in breast feeding while working owing to job timings, inability to express breast feeds or no proper facility to breast-feed at work. 14,35 Ratnayke et al, observed that over 50% of the mothers were advised to start other feeds early by their family members and 12% by a health care worker on the same. 35 The present study too showed the family was influential for 60% mothers and health care professional in 13%. However, the mothers who were not satisfied with having given extra-lacteal feeds were dissatisfied for not achieving the expected weight gain in addition to frequent respiratory/diarrheal diseases. Statistical significance with the incidence of the above diseases sans EBF has been reported in several studies. 11,36,37

CONCLUSION
The prevalence of exclusive breast-feeding is still low despite having a fairly literate study group. Although there were no gross significant association with sociodemographic factors, lacunae have been identified. Antenatal breastfeeding counselling combined with a good post-natal lactation support especially for the initiation of breastfeeding in caesarean section mothers, proper breastfeeding techniques and facilities to continue exclusive breastfeeding in working mothers may overcome the major barriers. A more objective counselling especially in the post-natal period to mothers and their care givers may also facilitate exclusive breastfeeding to a great extent.