A Study of Breastfeeding Practices in Urban and Rural Settings in Goa

Introduction

Breastfeeding is the natural way to provide infants with the nutrients they need for growth and development. Efforts to increase the rates and duration of breastfeeding are hampered by the inappropriate and unethical marketing of breast-milk substitutes.¹ Early initiation of breastfeeding lowers the risk of anaemia and postpartum haemorrhage in mothers. Breastfeeding practices vary across different regions and communities.²

All the nutrients required by infants in the first six months of life are present in the breastmilk, including carbohydrates, proteins, vitamins, minerals and water. It also contains bioactive factors that support the infant’s immature immune system, providing protection against infections, as well as components that aid in the digestion and absorption of nutrients.³

The provision of food or fluids in addition to breast milk, excluding drugs, vitamins, and minerals to infants before the age of six months is defined as non exclusive breastfeeding (NEBF).4 Despite the benefits of breastfeeding for both the mother and the child, less than half of infants under six months of age are exclusively breastfed.¹

In recent times, rapid urbanization and the resulting changes in behaviour and lifestyle have affected the practices and patterns of breastfeeding.^5,6 The gap between urban and rural areas in terms of breastfeeding practices has been an important topic of discussion over the years.^7,8 According to the National Family Health Survey (NFHS-5), despite the numerous advantages of breastfeeding, only 59.6% of the children under six months of age in urban settings and 65.1% in rural settings were exclusively breastfed.⁹ In Goa, despite the awareness regarding the benefits of exclusive breastfeeding, its prevalence remains at 61.4%.⁹

This study attempted to explore the knowledge, attitudes and practices of mothers towards breastfeeding, in order to provide informed recommendations for enhancing exclusive breastfeeding practices in the region.

Aims and Objectives

1. To assess the levels of knowledge, attitudes, and feeding practices among mothers of children aged six months to two years attending urban and rural health centres.
2. To identify the factors associated with non-exclusive breastfeeding.

Materials and Methods

A descriptive study was conducted to assess the knowledge, attitudes and feeding practices concerning breastfeeding in urban and rural areas of Goa. The study participants were mothers with children aged between six months and two years. Systematic random sampling method was used to select the study participants. An equal number of participants were enrolled from both urban and rural settings. The study was conducted at the immunization clinic of the Urban Health Centre in Santa Cruz and the Rural Health and Training Centre (RHTC) in Mandur. These are the field practice areas of the Department of Community Medicine, Goa Medical College. Data were collected over a six-month period, from January 2019 to June 2019.

Sample size

The sample size was calculated using the formula

N = z²pq/d²

Absolute error = 8%

Prevalence (p)= 60.9% (based on NFHS 4 result)

Confidence interval (z) = 95%

Sample size= 142 (rounded to 150).

A total of 75 participants were enrolled from the urban area and 75 from the rural area. Data were collected using a pretested questionnaire. The IOWA Infant Feeding Attitude Scale (IIFAS) was used to assess the attitudes of mothers towards breastfeeding. Total IIFAS sore ranges from 17 to 85, with higher scores reflecting more positive attitudes on breastfeeding. Total score is categorized into three: (1) Positive to breastfeeding (70 85), (2) Neutral (49-69), (3) Positive to formula feeding (17-48).

Results

The present study was conducted among 150 mothers with children aged between six months and two years who visited the Immunization clinics at the Rural Health and Training Centre, Mandur, Goa, and the Urban Health and Training Centre, Santa Cruz, Goa.

A total of 75 mothers were selected from the urban site and 75 from the rural site as per the protocol.

Table 1 presents the sociodemographic characteristics of the study participants. The majority mothers (35.5%, n=53) were in the age group of 25-29 years. Out of the total 150 mothers, 40% (n=60) had completed education up to the secondary level. Similarly, the majority of fathers (49.3%, n=74) were also educated up to the secondary level.

It was observed that majority of the mothers (75.3%, n=113) were housewives. Out of the 37 mothers who worked during pregnancy, maternity leave was availed by 14.7% (n=22) while 8.7% (n=13) were not granted any leave. Two mothers reported having to quit their jobs due to the denial of maternity leave.

Among the study participants, 38% (n=57) belonged to socioeconomic class II, 24.7% (n=37) to class III, 17.3% (n=26) to class IV, 13.3% (n=20) to class I and 6.7% (n=10) to class V, as per the modified BG Prasad classification.

In terms of family type, 69.3% (n=104) of participants belonged to nuclear families, 28.7% (n=43) to joint families and 2% (n=3) belonged to three-generation families.

In the present study, 46.7% (n=70) of the babies were male and 53.3% (n=80) were female. About 85.3% (n=128) babies were born at 37 weeks of gestation, while 6.7% (n=10) were born at 36 weeks. Regarding birth weight, 56.6% babies (n=85) weighed >2.5 kg, 26.7% (n=40) weighed 2.5 kg and 16.7% (n=25) had a birth weight <2.5 kg (low birth weight).

It was noted that 58% (n=87) of the babies were delivered by vaginal delivery, while 42% (n=63) were delivered by Caesarean section. In this study, all the deliveries were institutional; deliveries conducted in government hospital accounted for 63.3% (n=95), while the rest 36.7% (55) were in private hospitals.

Regarding knowledge about benefits of breastfeeding, 33.3% (n=50) of mothers responded that breastmilk is the ideal food for baby, and 36.7% (n=55) agreed that it provides immunity from infections. However, 9.3% (n=14) mothers were not aware about the benefits of breastfeeding.

When asked about their source of information on breastfeeding, 46.7% (n=70) reported receiving information from hospital staff, 27.3% (n=41) received information from doctors, 21.3% from relatives, 2.7% (n=4) through television and 2% (n=3) from their previous experience with breastfeeding.

In our study, majority of the study participants, 78.7% (n=118) were aware of the benefits of colostrum, while 21.3% (n=32) were unaware.

 It was found that 91.3% (n=137) of the babies were fed colostrum, while 8.7% (n=13) were not. It was observed that 78% (n=117) of the mothers did not give prelacteal feeds to their babies, while 22% (n=33) reported giving prelacteal feeds. In terms of time taken for the initiation of breastfeeding post-delivery, it was noted that 55.3% (n=83) mothers-initiated breastfeeding within half an hour after delivery, 26.7% (n=40) initiated within one hour and 18% (n=27) initiated after one hour. It was reported that 72% (n=108) of the mothers exclusively breastfed their babies, while 28% (n=42) practiced non exclusive breastfeeding.

Table 4 presents the relationship of exclusive breastfeeding and various factors. In this study, the pattern of breastfeeding was found to be uniform across different religions. It was observed that 84.3% (n=59) of male babies were exclusively breastfed for six months, as compared to 80% (n=64) of female babies. Among mothers who had a normal vaginal delivery, 81.6% (n=71) exclusively breastfed their babies for six months.

A statistically significant association was observed between exclusive breastfeeding for six months and socioeconomic status. Nearly equal proportions of exclusive breastfeeding were noted in socioeconomic classes II and class IV, while the highest proportion of children who were not exclusively breastfed for six months belonged to class V (χ2=27.21, df=4, P-value= <0.001*).

In this study, 80% (n=60) of mothers in the urban area exclusively breastfed their babies for six months, while 87% (n=65) of mothers in the rural population reported exclusively breastfeeding for the same duration, indicating a higher rate of exclusive breastfeeding in the rural population compared to the urban population.

In this study, overall the majority of the participants (72%, n=108) exclusively breastfed for a duration of six months (Figure 1). Majority of mothers (96.7%, n=145) opined that family support is important during breastfeeding, while 3.3% (n=5) thought otherwise. About 81.3% (122) of the mothers reported lack of provisions for breastfeeding in public places. Regarding perceptions of the impact of inadequate leave on breastfeeding practices, among 35 working mothers, 77.1% (n=27) felt that inadequate leave had an adverse effect on breastfeeding, while 22.9% (n=8) believed it did not have an effect.

In this study, the most common reason reported for non exclusive breastfeeding was insufficient milk production (10%, n=15), followed by the perception that the baby was not gaining weight (5.3%, n=8), illness of the baby (5.3%, n=8), illness of the mother (4%, n=6), and other reason (3.4%,n=5) respectively.

In our study, the mean attitude score measured using the IOWA Infant Feeding Attitude Scale was 62.1, indicating a neutral attitude towards breastfeeding that warrants attention.

Discussion

This study was conducted in both urban and rural settings in Goa among 150 mothers to assess the knowledge, attitudes and practices regarding breastfeeding.

Exclusive breastfeeding practices in the community plays a crucial role in a child’s growth and development. In this study, 72% mothers exclusively breastfed their babies for six months. This was found to be higher than the prevalence of exclusive breastfeeding reported by the NFHS-5 (61.4%).

The rate of exclusive breastfeeding for six months was higher in the rural population (87.3%) compared to the urban population (80.0%). Similar findings were reported by Ghosh et al., who observed that both exclusive and continued breastfeeding rates were higher among rural populations.¹⁰ Several factors may contribute to this discrepancy, such as the cultural and traditional practices in rural areas may place a stronger emphasis on breastfeeding, whereas, urban mothers might face greater social pressures and diverse influences that may lead to early introduction of formula or other foods.¹¹

Regarding knowledge about breastfeeding, 9.3% (n=14) of mothers in this study could not identify any benefits of breastfeeding. Meanwhile, 33.3% (n=50) recognized it as the ideal food for the baby, and 36.7% (n=55) acknowledged its role in protection against infections. Additionally, 80% (n=122) of the mothers agreed that breastfed babies are healthier than those fed with formula. Our findings are similar to those reported by Rudrappa et al., and Pramodha MS et al., where 80% of the mothers agreed that breastfeeding was beneficial for their babies.^12,13 Divyarani DC et al., in their study also reported that 100% of the mothers were aware of the benefits of breastmilk.¹⁴

The overall attitude of the participants was neither strongly in favour of breastfeeding nor of formula feeding. The mean IIFAS (IOWA Infant Feeding Attitude Scale) score was 62.1, indicating a neutral attitude towards breastfeeding.

This highlights the need for enhanced education and awareness initiatives to positively influence mother’s attitudes and promote exclusive breastfeeding practices in the region.

The attitude of the mother towards breastfeeding is known to influence the infant feeding choices. A study conducted in Taiwan indicated that prenatal breastfeeding education interventions positively influenced the breastfeeding attitudes.¹⁵

Early breastfeeding practices determine the successful establishment and duration of breastfeeding. It is recommended that newborns be put to the breast immediately or within the first hour after birth.

In this study, 82% of mothers initiated breastfeeding within the first hour of birth, which is notably higher than the 61.6% reported in Goa by the NFHS-5. This difference may be attributed to the fact that majority of deliveries in our study population were normal vaginal births. Early initiation of breastfeeding plays an important role in reducing neonatal mortality and also increases the probability of continuation of exclusive breastfeeding in the later months.¹⁶ Studies have also found that delayed initiation of breastfeeding can increase the risk of neonatal deaths by three times.¹⁷

During the first few days after delivery, colostrum serves as an important source of nutrition and should be fed to the baby while awaiting the onset of regular milk production. The practice of giving prelacteal feed before initiating breastfeeding deprives the infant of essential nutrients and increases the risk of infections.¹⁸

In this study, 22% of mothers reported giving prelacteal feeds. Similar findings were observed in a study conducted in Bihar, where 26% of children received prelacteal feeds, and in Karnataka, where 31.25% of mothers reported the same practice.^{13, 19} However, our f indings differ from those of a study by Divyarani DC et al., in which a higher proportion of children (42.4%) had received prelacteal feeds.¹⁴ This shows that the social customs and misconceptions pertaining to prelacteal feeding are still prevalent in India. This can interfere with early breastfeeding, reducing the newborn's intake of essential nutrients and antibodies.

WHO universally recommends colostrum as the ideal food for the newborn. In this study, 78.7% (n=118) of mothers had knowledge about colostrum, while 91.3% reported feeding colostrum to their babies. This indicates that despite 21.3% lacking knowledge, a large majority still practiced colostrum feeding, which is an encouraging finding. Similar results were reported by Boralingiah et al., where 97.2% of mothers fed colostrum to their babies.²⁰

In this study, the most common reason reported for non exclusively breastfeeding their babies was insufficient milk production (10%). In a study conducted by Pooja J. Mise et al., lactation failure was reported as the major reason for early weaning.²¹ Baghel et al., reported the perception of insufficient milk production by the mother to satisfy the baby’s hunger as the main reason for non-exclusive breastfeeding.²² Studies in the past also identified certain cultural beliefs, social and family pressures as the reasons for failure of exclusive breastfeeding.²³

In this study, 10.7% of the mothers were found to be exclusively breastfeeding beyond six months. It is important to educate mothers that breast milk alone is not sufficient to meet the nutritional needs of a child beyond six months. Mothers must also be educated about the timely introduction of complementary feeds.

It was observed that 81.3% of mothers felt there was inadequate provision for breastfeeding in public places, and 77.14% of working mothers reported that insufficient maternity leave negatively affected breastfeeding. The added stress of balancing work and breastfeeding may contribute to non-exclusive breastfeeding and early weaning. Therefore, it is important to provide workplace support for breastfeeding mothers. Interventions in the workplace such as dedicated lactation spaces, breastmilk expression breaks, and organizational policies can help prolong breastfeeding and delay the introduction of breastmilk substitutes.²⁴

Recommendations

Immunization clinics provide a valuable opportunity to assess breastfeeding practices and offer support to mothers. Such efforts could include educational programs, support groups, and public health campaigns, designed to enhance the perception and practices of breastfeeding, thereby promoting positive attitudes. A thorough prenatal breastfeeding education intervention taking the family into consideration could prove beneficial in addressing this issue. Also, consideration should be given to providing privacy to nursing mothers in both working and public places.

Conclusion

The study found that while most mothers had good knowledge of breastfeeding, their attitudes remained neutral, indicating a gap that could hinder optimal breastfeeding practices. Prelacteal feeding practices, driven by cultural beliefs, were still prevalent and may delay initiation of breastfeeding. Exclusive breastfeeding rates were higher in rural areas compared to urban, highlighting the need for specific urban interventions to address the unique socio-environmental and occupational barriers faced by urban mothers, in particular the lack of breastfeeding-friendly public spaces and inadequate maternity leave, especially for working mothers.

Source of Fund

None

Ethical Permission

Taken

Conflict of interest

None