Breastfeeding Knowledge and Practices Among Rural Women of Punjab,India: A Community-Based Study

Abstract

Objectives:

Irrespective of the fact that breastfeeding in India is almost universal, psychosocial and cultural barriers still exists to early breastfeeding. The exact reasons for this delay are not clearly known. Hence we conducted this study to assess breastfeeding knowledge and practices and the factors influencing them among women in rural Punjab, India.

Methodology:

We interviewed 1,000 women in a community-based analytical cross-sectional study that was carried out in 20 villages of the District of Amritsar, Punjab, India, in 2005–2006 by standard cluster sampling. Time at initiation of breastfeeding and variables like understanding about the importance of colostrum, nutrition during lactation, and motivation by health workers were assessed. Statistical analysis was done by percentages compared with the χ² test.

Results:

Two hundred twenty-five respondents (23.8%) started breastfeeding their babies on the first day of birth, but in terms of early breastfeeding only 128 (13.5%) respondents put their babies on the breast within 4 hours of birth. Of the 1,000 respondents, 356 (35.6%) of the respondents were unaware of the importance of colostrum, 733 (77.6%) were not given advice on benefits of breastfeeding/weaning, and 306 (33.5%) of respondents had not increased their diet during lactation.

Conclusions:

Early breastfeeding knowledge and practices were suboptimal among the mothers in rural Punjab. Health education on breastfeeding and nutrition remains the dark area. Research and public health efforts like one-to-one “breastfeeding counseling and health education on nutrition” to the mother by health workers should be promoted.

Introduction

From time immemorial breastmilk has been considered to be the most suitable food for infants. Breastmilk was the sole food for infants, suitable for their survival and growth. It protects babies against various diseases like diarrhea, pneumonia, and allergies and boosts their immunological response.¹ No substitutes, supplements, or even water was required for infants who were totally breastfed. With breastmilk being the best food for the infant and the young child, breastfeeding had been recognized as a human right. The International Convention on the Rights of the Child adopted by the United Nations General Assembly in 1989 also recognized breastfeeding as one of a child's right. In 1983, the Government of India adopted the National Code for Protection and Promotion of Breastfeeding. In 1990, the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, the Convention on the Rights of Child, and the Declaration of the World Summit for Children, to which India was a signatory, called attention to the importance of breastfeeding.² In February 1991, major international organizations set up a World Alliance for Breastfeeding Action with the common goal to protect, promote, and support breastfeeding; furthermore, August 1–7 was declared as the annual Global Breastfeeding Week. In 1992, the Indian Parliament passed the Infant Milk Substitutes, Feeding Bottles and Infant Food (Regulation of Production, Supply and Distribution) Act.²

In developing countries like India, the exclusive breastfeeding rate was found to be 51%.³ The proportion of ever-breastfeed children in India was 95%.⁴ In rural areas of India breastfeeding was initiated only after 3–6 days because colostrum was considered as pus. In certain families, the “pundit” (priest) declared some auspicious occasion between days 3 and 4 for the initiation of breastfeeding. Breastfeeding promotion alone contributed to a 11.6% reduction in infant mortality rate if coverage of promotion was 99% and could avert 21.9 million disability-adjusted life years at 3 years.⁵ A recent study from Ghana found that 22% of deaths among newborns were prevented if all newborns started breastfeeding within 1 hour of birth, irrespective of whether they were exclusively breastfed later or not; further analysis by the researchers now suggested this figure could be 31% for developing countries.⁶ Correct counseling had the potential of increasing exclusive breastfeeding substantially during the first 6 months. The relative risk for prevalence of diarrhea was three times higher and for pneumonia was 2.5 times higher for partial breastfeeding compared to exclusive breastfeeding. Recent epidemiological evidence suggested that beginning breastfeeding within the first hour would have additional benefit with regard to mortality even in exclusively breastfed infants. The Lancet series reaffirmed the recommendation to begin breastfeeding immediately after delivery.⁵ India could save 250,000 babies annually by just one action, i.e., if all mothers could begin breastfeeding within 1 hour of birth.⁶

Subjects and Methods

To assess the breastfeeding knowledge and practices in rural areas of Punjab, India, we conducted an analytical cross-sectional study in the Verka block of the District of Amritsar of Punjab, India, during the period 2005–2006. The total study period was 13 months, from November 3, 2005 to December 19, 2006. In mid-2005, the population of the Verka block was 219,555. Out of 94 villages, a total of 20 were selected by the standard cluster sampling technique.⁷ In these 20 clusters, there was a Primary Health Centre in three villages, a Subsidiary Health Centre in six villages, and a Sub-Centre in four villages. No government health center was available in seven villages.

Study subjects

The date of the visit was planned in consultation with the medical officer/multipurpose health worker, male/female, of the village. Then, on the preappointed date, the help of members of local elected bodies (Panchayati Raj Institution) was obtained as their support made the respondents more receptive and thus helped in the smooth conduct of the study. Selection of houses was done through systemic random sampling. If no female was present in the selected house at the time of visit, then the next house was taken into consideration. Thus in each cluster, 50 women were interviewed, each from a separate household. In multiple-female households, only one female respondent from that household was interviewed.

A total of 1,000 women (50 females each from 20 villages) were interviewed, out of which 945 had had a child.

Study tools and technique

The respondents were informed about the purpose of the study. They were assured about confidentiality, and written consent was obtained. The responses were recorded on a proforma evolved and pretested for the study. These proformas were based on the "Primary Health Care Management Advancement Programme" modules of Aga Khan Foundation.⁸ The questions were semi-open-ended and were asked in the local vernacular language. The help of medical interns, who were posted at that time in the Department of Community Medicine, Government Medical College, was used for interviewing the respondents. Permission was obtained from the head of the Department involved. A total of 15 interns were trained for the study, each in a batch of three, because of rotation of their duties during the internship program. Each batch of three interns was specially briefed about the study, and every question in proforma was explained to them. Before field visits, they were trained for 2 days by the principal investigators for conducting interviews. After that, they were accompanied to the field area where mock interviews were demonstrated to them. Then, in the field they conducted the interviews themselves under the principal investigators' observation. They were retrained once in a month for 1 day. Each intern interviewed four women in a single visit. Thus each cluster was covered (for 50 interviews) in about four visits.

Authenticity of the data was ascertained by the principal investigator by cross-checking some of the interviewed houses. Any problem/query faced in the field was discussed and rectified on the spot. Interns were always compulsorily accompanied and supervised by one of the principal investigators in the field during every visit. Uniformity of data collection was maintained strictly during the whole study. Because each interviewer had his or her identity card and also because of the support of local health staff/local elected officials, there was not a single case of non-response. Finally, compilation, analysis, and interpretation of data were done by the principal investigators.

Exclusion criteria

Out of 1,000 women studied, 46 were either unmarried or had never been pregnant, and nine were pregnant for the first time, so they were excluded from the study, giving a total sample size of 945 respondents.

Statistical analysis

Data collected were compiled into a computer-based Excel (Microsoft, Redmond, WA) sheet for easy comparison, reference, and analysis. The χ² test, proportions, and percentages were applied wherever relevant. A value of p < 0.05 was considered significant.

Ethical clearance

Ethical clearance was taken from the ethical committee of the sponsoring institution, i.e., Government Medical College, Amritsar, Punjab, India, with the assurance that confidentiality would be maintained and the information thus obtained would not be used for any other purpose except for academic purposes. Hence there was no conflict on ethical issues. No financial help/grant of any kind were taken from any agency/sector.

Results

The demographic profile of the 1,000 respondents showed that most of them, i.e., 423 (42.3%) were in the age group of 26–35 years; 200 (20.0%), 242 (24.2%), 90 (9.0%), and 45 (4.5%) were in the age group of 18–25 years, 36–45 years, 46–55 years, and 55 years and above, respectively. Regarding education, 223 (22.3%), 113 (11.3%), 230 (23.0%), and 24 (24.0%) of the respondents were educated up to primary, middle, higher secondary, and graduates and above, respectively, while 410 (41.0%) were illiterate.

Table 1 gives the time of initiation of breastfeeding. A total of 128 (13.5%) respondents stated that they put their babies on the breast within 4 hours of birth, and 225 (23.8%) started breastfeeding their babies on the first day of birth. Overall (n = 945), 914 (96.7%) children were breastfed, and 31 (3.3%) children were not breastfed by their mothers.

Table 1.

Breastfeeding Initiation by Respondents After Childbirth (n = 945)

Breastfeeding initiation time	Number (percentage)
1–4 hours	128 (13.5%)
5–24 hours	97 (10.3%)
After 1 day	205 (21.7%)
After 2 days	239 (25.3%)
After 3 days	155 (16.4%)
No breastfeeding	31 (3.3%)
Total	945 (100.0%)

As shown in Table 2, nearly one-fourth, i.e., 34 (22.2%), of the respondents in the age group 18–25 years initiated breastfeeding on day 1 compared to six (13.6%) in the age group 55 years and above (total n = 945). On the other hand, breastfeeding initiated after 2 days of the baby's birth was observed in 22 (50.0%) of the age group 55 years and above compared to 47 (30.7%) of the age group 18–25 years (p < 0.025).

Table 2.

Breastfeeding Initiation by Respondent's Age Group (n = 945)

	Time of initiation of breastfeeding
Age (years)	Day 1	After 1 day	After 2 days	After 3 days	No breastfeeding	Total
18–25	34 (22.2%)	32 (20.9%)	47 (30.7%)	32 (20.9%)	8 (5.2%)	153 (100.0%)
26–35	105 (25.1%)	93 (22.2%)	142 (33.9%)	62 (14.8%)	16 (3.8%)	418 (100.0%)
36–45	58 (24.1%)	57 (23.6%)	87 (36.1%)	36 (14.9%)	3 (1.2%)	241 (100.0%)
46–55	22 (24.7%)	19 (21.3%)	31 (34.8%)	17 (19.1%)	—	89 (100.0%)
55 and above	6 (13.6%)	4 (9.1%)	22 (50.0%)	8 (18.2%)	4 (9.1%)	44 (100.0%)
Total	225	205	329	155	31	945

χ² = 25.986; df = 12; p < 0.025 (significant difference).

Table 3 summarizes that two-fifths, i.e., 82 (40.0%), of the higher secondary educated respondents started breastfeeding on day 1 compared to 54 (13.5%) of those who were illiterate (total n = 945) (p < 0.001).

Table 3.

Breastfeeding Initiation by Respondent's Educational Level (n = 945)

	Time of initiation of breastfeeding
Educational status	Day 1	After 1 day	After 2 days	After 3 days	No breastfeeding	Total
Illiterate	54 (13.5%)	70 (17.5%)	182 (45.5%)	84 (21.0%)	10 (2.5%)	400 (100.0%)
Primary	56 (26.5%)	54 (25.6%)	62 (29.4%)	30 (14.2%)	9 (4.3%)	211 (100.0%)
Middle	26 (24.1%)	28 (25.9%)	31 (28.7%)	20 (18.5%)	3 (2.8%)	108 (100.0%)
Higher secondary	82 (40.0%)	45 (21.9%)	50 (24.4%)	19 (9.3%)	9 (4.4%)	205 (100.0%)
Graduate and above	7 (33.3%)	8 (38.1%)	4 (19.0%)	2 (9.5%)	—	21 (100.0%)
Total	225	205	329	155	31	945

χ² = 90.01; df = 12; p < 0.001 (significant difference).

As summarized in Table 4, 644 (64.4%) respondents were aware of the importance of colostrum (total n = 1,000); 142 (71.0 %) in the age group 18–25 years knew about the importance of colostrum compared to 140 (57.8%) in the age groups 36–45 years and above. The younger age group was observed to be more aware regarding the importance of colostrum than the older age group (p < 0.001).

Table 4.

Knowledge Regarding Importance of Colostrum by Respondent's Age Group (n = 1,000)

	Knowledge regarding importance of colostrum
Age (years)	Yes	No	Total
18–25	142 (71.0%)	58 (29.0%)	200 (100.0%)
26–35	287 (67.8%)	136 (32.2%)	423 (100.0%)
36–45	140 (57.8%)	102 (42.2%)	242 (100.0%)
46–55	56 (62.2%)	34 (37.8%)	90 (100.0%)
55 and above	19 (42.2%)	26 (57.8%)	45 (100.0%)
Total	644	356	1,000

χ² = 20.36; df = 4; p < 0.001 (significant difference).

Table 5 shows that 165 (71.7%) higher secondary and 22 (91.7%) graduates and above respondents knew about the importance of colostrum compared to 244 (59.5%) of those who were illiterate (total n = 1,000) (p < 0.005).

Table 5.

Knowledge Regarding Importance of Colostrum by Respondent's Educational Level (n = 1,000)

	Knowledge regarding importance of colostrum
Educational status	Yes	No	Total
Illiterate	244 (59.5%)	166 (40.5%)	410 (100.0%)
Primary	143 (64.1%)	80 (35.9%)	223 (100.0%)
Middle	70 (61.9%)	43 (38.1%)	113 (100.0%)
Higher secondary	165 (71.7%)	65 (28.3%)	230 (100.0%)
Graduate and above	22 (91.7%)	2 (8.3%)	24 (100.0%)
Total	644	356	1,000

χ² = 17.76; df = 4; p < 0.005 (significant difference).

Out of 945 respondents, only 212 (22.4%) were advised by the multipurpose health worker about the benefits of breastfeeding and proper weaning after delivery (Table 6). Out of 914 respondents who breastfed their child, only 608 (66.5%) of respondents had increased their diet during lactation (Table 7).

Table 6.

Imparting of Health Education Regarding Breastfeeding/Weaning by Health Workers (n = 945)

Health education imparted	Number (percentage)
Yes	212 (22.4%)
No	733 (77.6%)
Total	945 (100.0%)

Table 7.

Respondents Who Increased Diet During Lactation (n = 914)

Increased diet during lactation	Number (percentage)
Yes	608 (66.5%)
No	306 (33.5%)
Total	914 (100.0%)

Discussion

It was observed in the present study that 225 (23.8%) respondents started breastfeeding their babies on the first day of birth. According to the National Family Health Survey-III, in India, 23.4% of children were breastfed within 1 hour, whereas in Punjab, it was 10.3% (the rural figure was 7.3%).^9,10 In addition, only 45% were put to the breast within the first day of life.¹¹ According to a study by Khan et al.,¹² only two (1.0%) infants were put to the breast within 6 hours and 177 (88.5%) at 48 hours after birth.

We observed that 34 (22.2%) respondents in the age group 18–25 years initiated breastfeeding on day 1. Approximately one-third of the respondents in the all other age groups breastfed their babies for the first time only after 2 days of birth. This could be explained by the fact that there was a belief among the older villagers that the breastfeeding should be delayed for first 2 days of birth and then it should be initiated on day 3 only after “watching the stars,” which were considered auspicious for the health of the baby. Another important factor for delayed breastfeeding was the consideration by families that it was auspicious if the child was breastfeed for the first time in the presence of a particular relative, the “Bua” (aunt of the child); as she took time to reach the family, initiation of breastfeeding got delayed. Higher education had an impact upon early breastfeeding practices. We observed this co-relation to be significant (p < 0.001). According to the National Family Health Survey-III, in Punjab, 37.9% of those who were illiterate and 51% with a high school education and above started breastfeeding within 1 day.¹¹

In the present study, 356 (35.6%) of the respondents were unaware of the importance of colostrum. However, knowledge regarding the importance of colostrum was more in the younger age group, and it increased with an increase in education level (p < 0.005). The role of education and awareness created by mass media could be attributed to these findings. However, their practice largely depended upon the decision of their mother/mother-in-law and elderly family members. We observed a big “knowledge, attitude and practice” gap as far as early breastfeeding was concerned. This issue needs due importance for promotion of breastfeeding. The 55 respondents who were excluded from study because of being unmarried/not having a child were included in Tables 4 and 5, thus making the sample size 1,000. They were included because in today's world of print and electronic media, with comparative more access to health services and with more enrollment of females in school, it was assumed that they might have knowledge about breastfeeding that could turned into practice later on.

In our observations, only 212 (22.4%) respondents were advised by the multipurpose health worker about the benefits of breastfeeding and proper weaning after delivery. According to a study by Agarwal et al.,¹³ none of the mothers was advised regarding weaning practices in the rural area. According to the National Family Health Survey-II, in Punjab, during the visits to the health center by the respondents, only 0.1% of respondents were advised about breastfeeding.¹⁴

In the present study, among those respondents who breastfed their child, only 608 (66.5%) of respondents had increased their diet during lactation. According to a study by Panda,¹⁵ more food was consumed during pregnancy by 31.3% of women. According to the study by Agarwal et al.,¹³ appropriate postnatal counseling on diet was given to 31.9% of women in a rural area.

Strengths, weaknesses, opportunities, and threats analysis

This study had some strengths and limitations. The strength was that the investigators were able to reach to a large sample of women for door-to-door interviews. However, an important limitation of the study was that many factors like economic status, caste, and education of the husband, which influences breastfeeding practices, were not included in the study. Also, the responses of the 45 (4.5%) respondents who were 55 and above years of age were indicative of their own breastfeeding practices and also their current attitude towards breastfeeding. These women generally gave advice to their married daughters/daughter-in-laws to adopt their breastfeeding attitudes and practices. Even so, this was a limitation of the present study as the knowledge and practices of this group (>55 years) must have changed with time.

Conclusions and Recommendations

Irrespective of the observation that the vast majority of women breastfed their babies, breastfeeding within the first few hours of birth was practiced only by a small fraction of the respondents. This could be attributed to the prevalent psychosocial and cultural belief of the villagers. Health education aspect was often neglected by the healthcare delivery system. The “Baby-Friendly Hospital Initiative,” created and promoted by the World Health Organization and UNICEF, had proved highly successful in promoting breastfeeding, but it still needs more efforts to expand it.¹⁶ The 10 steps to promote breastfeeding should be displayed and practiced at all those places where institutional deliveries take place. The multipurpose health workers-female and newly appointed field health workers, i.e., accredited social health activists, should be given proper training regarding breastfeeding promotion. One-to-one “breastfeeding counseling and health education on nutrition” to the mother by these workers requires constant motivation and sincere efforts. The traditional “dais,” who conducts deliveries, must be taken into confidence as they were very close to families and could influence their decisions, including that of breastfeeding. The reproductive life cycle curriculum must be given its due during higher secondary schooling with proper consideration for local sensitivity and cultural practices. The role of celebrities, particularly women, from various walks of life such as sports, movies, corporate, politics, art, science, etc., for spreading the message through print and electronic media could be explored as in the case of the polio eradication program and other health programs. Laws prohibiting promotion of infant food like the one in India, i.e., the Infant Milk Substitutes, Feeding Bottles and Infant food (Regulation of Production, Supply and Distribution) Act, 1992, should be implemented strictly, particularly with the help of nongovernmental organizations.¹⁶ The incentives to local village bodies, i.e., Panchayati Raj Institutions, should be linked to the indicators of maternal and child health services including early and exclusive breastfeeding to ensure real “community participation.”

Footnotes

Acknowledgments

We acknowledge the support of Panchayati Raj Institution members, medical officers, and multipurpose health workers (male and female) of the villages during this study. We also acknowledge the people in the villages who cooperated with us and gave us all the required information. We thank all the medical interns of the Government Medical College, Amritsar, Punjab, India, who helped in conducting the interviews in the field.

Disclosure Statement

No competing financial interests exist.

References

Benefits for Infants. Advantages of Breastfeeding. www.breastfeeding.com/all_about/all_about_more.html. 2009 November 13.

Breastfeeding in India. Report of National Symposium. National Institute of Public Cooperation and Child Development: New Delhi, 1993; 1.

Putting Babies Before Business. The Progress of Nations. United Nations Children Fund: New York, 1997; 20.

Breastfeeding Patterns in the Developing World with Selected Maternal and Child Health Indicators. Population Reference Bureau: Washington, DC, 1999.

Breastfeeding Promotion Network of India [Internet]

India lags behind in infant mortality, Lancet shows the way forward [press brief ], May 2008. www.breastfeeding.com/all_about/all_about_more.html. 2009 November 13.

Srivastava

. Breastfeeding: the First Hour Saves One Million Babies! World Breastfeeding Week 2007, August 2–4. Breastfeeding Promotion Network of India, Delhi, 2007. www.bpni.org/WBW/2007/UNICEF-India-Health.html. 2009 November 13.

Mahajan

. Cluster sampling. Methods in Bio-Statistics, 6^th. Jaypee Brothers Medical Publishers: Delhi, 1997; 100.

Reynolds

. Rapid service quality assessment check list. Primary Health Care Management Advancement Program, Assessing Community Health Needs and CoverageUser's Guide, Module 2USA, Canada, and Geneva: Aga Khan Foundation, 1993; 89–99.

Central Bureau of Health Intelligence. National Health Profile 2006. Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India: New Delhi, 2006pp. 25,90–112.

10.

Government of India. Fact sheet—Punjab (provisional data) National Family Health Survey (NFHS-3) 2005–06. International Institute for Population Sciences: Mumbai, India/Ministry of Health and Family Welfare, Government of India, New Delhi,2007. www.nfhsindia.org/pdf/Punjab.pdf. 2009 November 13.

11.

National Family Health Survey (NFHS-3) 2005–06. International Institute for Population Sciences, Ministry of Health and Family Welfare, Government of India, Mumbai, India. 2008. www.nfhsindia.org/NFHS3%20Data/Punjab_report.pdf. 2009 November 13.

12.

Khan

, Hasan

, Sinha

. Breast feeding practices in a rural area of District Aligarh. Indian J Community Health, 1994; 7:21.

13.

Agarwal

, Idris

, Mohan

. Quality of reproductive health care at primary care level. Indian J Community Med, 2001; 26:119–126.

14.

Government of India. Maternal and reproductive health. National Family Health Survey (NFHS-II), 1998–99, Punjab. International Institute for Population Sciences: Mumbai, India/ORC MACRO, Calverton, MD,2001; 160–205.

15.

Panda

. Brief report of PVOH-II Project of OMRAH, Cuttack, Orissa. Indian J Community Health, 1997; 3:82–6.

16.

Park

. Preventive medicine in obstetrics, paediatrics and geriatrics. Textbook of Preventive and Social Medicine, 19^th. Jabalpur (India): Banarsidas Bhanot Publishers, 2007; 444.