Knowledge and Practice of Mother regarding Exclusive Breastfeeding Having Infant at a Tertiary Level Hospital , Kathmandu

Introduction: Promotion of exclusive breastfeeding is a cost effective intervention to reduce infant mortality in developing countries. The objective of this study was to identify knowledge and practice of mothers regarding exclusive breastfeeding. Material and Methods: This was a descriptive exploratory study carried out in the immunization clinic of tertiary level hospital in Kathmandu. A total of 323 mothers who came for immunization of six months to one year were selected as the sample for the study by using non-probability purposive sampling technique. Semi structured interview questionnaire was used to collect the data both on knowledge and practice of exclusive breastfeeding, from 13th July to 8th September 2014. Results: Study findings revealed that 84.5 % of the respondents were aware of the correct meaning of exclusive breastfeeding and 49.5 % of the respondents practiced exclusively breastfeeding to their children up to 6 months. There was statistically significant association of respondent’s level of knowledge regarding exclusive breast feeding with their educational status (p = 0.034, OR = 1.7, 95% CI = 1.03-2.66) and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3). Likewise, a significant association was seen between respondent’s level of practice regarding EBF and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3). Conclusion: Study concludes that only about half of the mothers tended to have adequate knowledge regarding exclusive breast feeding. However, practice of exclusive breastfeeding for up to six months tended to be low so there should be efforts on encouraging and counseling for exclusive breast-feeding up to six months in hospital, community and immunization clinic.


Introduction
B reast milk is the natural fi rst food for babies.It provides all the nutrients required by the infant for the fi rst six months of life and it con nues to provide up to half or more of a child's nutri onal needs during the second half of the fi rst year, and up to one-third during the second year of life 1 .Exclusive breas eeding is one of the most cost eff ec ve interven ons to reduce infant mortality.It is es mated that more than one out of every 10 infant-deaths (13%) could be saved by promo ng exclusive breas eeding 2 .For almost all infants, breas eeding remains the simplest, healthiest and least expensive method of feeding.Despite strong evidence in support of exclusive breast feeding (EBF) for the fi rst six months of life; its prevalence has remained low worldwide 3 .Globally less than 40% of infants under six months of age are exclusively breas ed.Adequate breas eeding support for mothers and families could save many young lives 4 .
Breas eeding helps to prevent hypothermia and hypoglycemia in newborn babies, which are the commonest causes of early neonatal deaths especially among low birth weight and premature babies.During the late neonatal period, most deaths in developing countries occur due to infec ons such as sepsis, acute respiratory tract infec on, meningi s and diarrhea.Feeding colostrums and exclusive breas eeding protects against such deaths 5 .
According to Nepal Demographic and Health Survey Report 6 , Forty-one percent of children under fi ve years of age are stunted, and 11 percent are wasted and 29 percent are under weight.Promo ng exclusive breas eeding up to six months of age to 88% by the end of 2015 and controlling protein energy malnutri on (PEM) are the major strategies of government of Nepal 7 .Therefore, protec ng and promo ng breas eeding has been one of the important priori es of public health in Nepal.
In the condi ons that normally exist in developing countries, exclusively breas ed children are six mes more likely to survive in the early months than nonbreas ed children.Exclusively breas ed infants are six mes less likely to die from diarrhea and 2.4 mes less likely to die from acute respiratory infec on in fi rst six months of life 8 .
The aim of this study was conducted to iden fy knowledge and prac ce of exclusive breas eeding (EBF) among the mothers having infants.

Material and Methods
This descrip ve exploratory study was carried out a er ge ng proposal approved by Ins tu onal Review Board of the Ins tute of Medicine, Kathmandu and the Research Division of Tribhuvan University.Kir pur Kathmandu.Permission to conduct the study in the immuniza on clinic was taken from the Tribhuvan University Teaching Hospital Director by submi ng a wri en request le er of the Research Division, A semi-structured interview schedule developed for the study was pretested among 30 mothers (10% of the es mated sample size) in the immuniza on clinic of Kan Children's Hospital.Study sample consisted of total 323 who a ended the immuniza on clinic for the immuniza on of their infants aged between 6 months to 12 months and who met the inclusion criteria.Data was collected by trained data collectors from July 13 to September 8, 2014.
The data were edited, classifi ed, coded and entered into Sta s cal Package for Social Science (SPSS) version 21.00.The data was analyzed by using descrip ve sta s cs such as frequency, percentage and inferen al sta s cal such as Chi-square test, odds ra o and Pearson's correla on.

Results
Table 1 reveals that the mean age of 323 respondents was 26.55(±3.8).Likewise, Hindus comprised 92% of the respondents and 60.4% of the respondents belonged to Brahmin/ Chhetri ethnicity.In terms of educa on, majority (68.1%) of the respondents had higher secondary level educa on.However, majority (74.3%) of the respondents were housewives.Almost all (98.5%) of the respondents had hospital delivery with vaginal delivery as 62.5% (Table 2).Table 3 depicts knowledge of respondents and reveals that 84.5% of the responded were aware about meaning of EBF, 79.6 % of the respondents were aware of ini a on of breas eeding as within one hour to a child a er birth.Likewise almost all (99.1%) respondents were aware that colostrums should be fed to the baby.Only 48.0% of the respondents gave EBF on demand.Table 4 reveals that three-forth (75.5 %) of the respondents gave breas eeding to their children within one hour and 79.9% of the respondents correctly avoided giving pre-lacteal feeding to the baby.Only 54.8 % of the respondents gave breas eeding to their infant on demand during the early months a er delivery and 49.5 % of the respondents prac ced EBF up to 6 months.Knowledge responses were scored and level of knowledge regarding EBF was categorized as high and low on the basis of median knowledge score percentage of 65.6.Knowledge score percentage of 65.6 and above was categorized as high level of knowledge and knowledge score percentage of below this was categorized as low level of knowledge.More than half (53.3%) of the respondents had high level of knowledge regarding exclusive breast feeding.
Similarly, level of prac ce was also categorized as high and low on the basis of median prac ce score percentage that was 60.Prac ce score percentage of 60 and above was categorized as high level of prac ce and prac ce score percentage of below 60 was categorized as low level of prac ce.More than half (59.4%) of the respondents had high level of prac ce regarding exclusive breast feeding (not shown in the table).Table 5 reveals that there was a signifi cant associa on between respondent's level of knowledge regarding EBF and educa onal status (p = 0.034, OR = 1.7, 95% CI = 1.03-2.66).High level of knowledge regarding EBF was found among the respondents with educa onal status of above SLC (47.3%) than respondents with educa onal status of up to SLC (44.7%).Table 6 indicates that a signifi cant associa on was seen between respondent's level of prac ce regarding EBF and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3).High level of prac ce regarding EBF was seen more among the respondents with vaginal delivery (65.3%) than respondents with caesarian delivery (49.6%).Table 7 shows there was week but signifi cant correla on between knowledge and prac ce scores.

Discussion
Regarding socio-demographic characteris cs of the mothers of infants a ending the immuniza on clinic, the mean age was 26.55(±3.8.).Hindus comprised of 92% of the respondents and 60.4% of the respondents belonged to Brahmin/Chhetri caste.More than 68.1% of the respondents had higher secondary level of educa on and 74.3% of the respondents were housewives.Almost all (98.5%) of the respondents had hospital delivery and 62.5% of the respondents had vaginal delivery.
Regarding knowledge on ini a on of breast feeding, 79.6% were aware of the ini a on of breas eeding within one hour of baby's birth.In contrast to study fi ndings of Shrestha, Bha arai, Silwal, 2013 9 reported that 48% of the postnatal mother were aware of ini a on of breas eeding.In the same away prac ce regarding ini a on of breas eeding, 75.5 % of the respondent's breas ed their children within one hour.Similar study fi nding of Ulak,Chandyo, Mellander, Shrestha and Strand 2012 10 , shows that 57% of the respondents were ini ated breas eeding within one hour of delivery.NDHS 6 data showed that 45% mothers ini ated breas eeding within 1 hour of childbirth.Concerning colostrums feeding almost all (99.1%) mothers were aware that colostrums should be fed to the baby.The study done by Joshi, Barako and Lamsal, 2012 11 that 74% of the responded was aware about colostrums from various sources.
Regarding pre-lacteal feeding, 79.9% of the respondents correctly avoided giving pre-lacteal feeding to their babies.This fi nding is similar to that of Khanal, Adhikari, Sauer, and Zhao 2013 12 where 73.5% of mothers reported of not giving prelacteal feeding to their newborn infants.Similar study done by Chaudhary, Shah and Raja 2011 13 that 33% of the mothers gave the pre-lacteal feed to their babies.
More than half (54.8 %) of the respondents in this study had reported of giving breas eeding to their infants "on demand" during the ini al months.This fi nding is lower than that of the fi nding of study done by Chudasama, Patel, and Kavishwar, 2007 14 as in their study it is reported that 80% women breas ed their children "On demand".
In this study most (84.5%)mothers knew the correct meaning of EBF.This fi nding is similar to the fi ndings of Afrosea, Banua, Ahmeda, and Khanoma 15 as in their study the overall level of knowledge regarding breas eeding among female garment workers is poor (88%).Whereas Oche, Umar, Ahmed 3 reported that only 31% of the mothers in their study had adequate knowledge of EBF.In the same way, Timilsina 16 also reported that only 16.7 percent mothers had fair knowledge regarding the breast feeding.
Regarding prac ce of EBF, 49.5% of the respondents in this study prac ced EBF up to 6 months as recommended by world health organiza on.According to Adhikari, Subedi, 2013 17 showed that 34% of the responded prac ced EBF upto six months.
Another study done at Kan Children's Nepal Hospital by Chapagain, 2013 18 reported that 33% of the mothers were prac ced exclusive breas eeding.In contrast to this, the study fi nding of NDHS (2011) 6 revealed that 70% of children less than six months age were exclusively breas ed.
In this study, there was no signifi cant associa on between respondent's level of knowledge regarding EBF with selected variables like, age, religion, ethnicity, occupa on, and type of delivery.This fi nding is in accordance with that of Afrosea, Banua, Ahmeda, and Khanoma 15 as in their study also no signifi cant associa on was found between the knowledge score of breas eeding with remaining socio-demographic variables like age, marital status.
But there was a signifi cant associa on between respondent's level of knowledge regarding exclusive breast feeding and educa onal status (p = 0.034, OR = 1.7, 95% CI = 1.03-2.66).High level of knowledge regarding EBF was found among the respondents with educa onal status of above SLC (47.3%) than respondents with educa onal status of up to SLC (44.7%).Educa on was signifi cantly (p<0.001)associated with a higher total knowledge score of breas eeding.Women with secondary level of educa on had a signifi cantly higher (p<0.001)level of total knowledge score than other categories (illiterate, primary and higher secondary) of educa on.Further the fi nding is supported by that of Timilsina, 2014 16 .But this fi nding is in opposite from that of Chudasama, Patel, Kavishwar, 2007 14 as they reported that median dura on of EBF was found more (7 months) for illiterate women than for literate (6 months).
Similarly, there was no signifi cant associa on between respondent's level of prac ce regarding exclusive breast feeding with selected variables like, age, religion, ethnicity, occupa on, educa onal status and type of delivery but there was signifi cant associa on between respondent's level of prac ce regarding EBF and type of delivery (p = 0.005, OR = 1.9, 95% CI = 1.2-3).High level of prac ce regarding EBF was seen more among the respondents with vaginal delivery (65.3%) than respondents with caesarian delivery (49.6%).This fi nding is supported by the study conducted by Onah et al., 2014 19 as their study also revealed that mothers who delivered through caesarean sec on were 0.38 mes less likely to exclusively breas eed their newborn (OR= 0.38, 95% CI= 0.18, 0.84) compared to those who delivered vaginally.Similar fi nding reported by Zia, Rajieh, Mothhareh & Ahmed, 2008 20 where it was shown that the rate of EBF was signifi cantly lower in the mothers delivered by caesarean sec on than who delivered vaginally ( 13.4% vs 41.8%).

Conclusion
On the basis of the study fi ndings, it is concluded that only about half of the mothers tended to have adequate knowledge as well as prac ce regarding exclusive breast feeding.The rela onship between the knowledge and prac ce EBF seemed to be low.The level of knowledge regarding exclusive breast feeding tended to be higher among the mothers with higher educa on status.Similarly, the level of prac ce regarding exclusive breas eeding tended to be higher among the mothers who had delivered vaginally.

Table 2 :
Place and Type of Delivery of the Last Childbirth among the Respondents (n= 323)

Table 3 :
Knowledge Regarding EBF among the Respondents *Mul ple responses

Table 5 :
Associa on between Respondent's Level of Knowledge regarding EBF and Selected Variables (n=323)

Table 6 :
Associa on between Respondent's Level of Prac ce Regarding EBF and Selected Variables (n=323)

Table 7 :
Rela onship between Knowledge and Prac ce of the Respondents about EBF (n=323) a Pearson's Correla on