Knowledge, Attitude, and Practices Regarding Early Startof Breastfeeding Among Pregnant, Lactating Womenand Healthcare Workers in El-Minia University Hospital

Salem A. Sallam,1 Gihan M. Babrs,1 Refaat R. Sadek,2 and Amna M. Mostafa1

Abstract

Background: Breastfeeding within the first hour of life is a potential mechanism for health promotion and isconsidered to be an indicator of excellence of breastfeeding. This study was conducted to evaluate the knowl-edge, attitude, and practice regarding early breastfeeding initiation within the first hour of life in both thePediatrics and Gynecology and Obstetrics Departments of Minia University Hospital, Minia, Egypt.Subjects and Methods: A study was conducted on four groups of participants from both the Pediatrics andGynecology and Obstetrics Departments of Minia University Hospital, each of them consisting of 30 individuals,using a questionnaire to assess the knowledge, attitude, and practice regarding early breastfeeding initiation foreach group.Results: Sixty percent of women delivered by spontaneous vaginal delivery and 16.7% of those delivered bycesarean section initiated breastfeeding within 30 minutes to 1 hour after birth. Forty percent of lactating womendelivered by spontaneous vaginal delivery, 83.3% of lactating women delivered by cesarean section, and 36.7%of healthcare workers used prelacteal feed instead of early breastfeeding initiation. The most important factorsaffecting the breastfeeding initiation were maternal illness followed by immediate skin-to-skin contact.Conclusions: Although the majority of women participating in this study exhibited knowledge about earlybreastfeeding initiation, actual application of this practice was clearly deficient. In order to improve the rates ofbreastfeeding initiation within the first hour of life we should enhance vaginal delivery and prenatal classes andimplement Baby-Friendly Hospital Initiative policies in both the Pediatrics and Gynecology and ObstetricsDepartments of Minia University Hospital.

Introduction

The World Health Organization and UNICEF re-commended that breastfeeding be initiated within 30minutes to an hour of birth because early initiation stimulatesbreastmilk production, increases uterine activity, and maythus reduce the risk of heavy bleeding and infection. It alsofosters motherchild bonding and increases the duration ofbreastfeeding.13

Despite the inclusion of breastfeeding within 30 minutes to1 hour of birth in international child feeding recommenda-tions,4 much of the focus of breastfeeding advocacy and re-search has been on exclusive breastfeeding rather than anearly initiation The recent finding that early initiation couldsubstantially reduce neonatal mortality5,6 should result inmore comprehensive efforts to increase the number of infantsbreastfed within 30 minutes to 1 hour of birth.

The present study was designed to evaluate knowledge,attitude, and practice regarding early start of breastfeeding inboth the Pediatrics and Gynecology and Obstetrics Depart-ments of Minia University Hospital, Minia, Egypt.

Subjects and Methods

The present study, done between April and June 2011, wasconducted on four groups of participants from both thePediatrics and Gynecology and Obstetrics Departments ofMinia University Hospital, with each group consisting of 30individuals.

The study population was grouped as follows: antenatalgroup, including 30 women receiving antenatal care (Group I);vaginal delivery group, including 30 women shortly afternormal labor (Group II); cesarean section group, including 30women shortly after cesarean section (Group III); and health

1Pediatrics Department, Children and Obstetrics and Gynecology Hospital, Faculty of Medicine, Minia University, Minia, Egypt.2Community Medicine Department, Faculty of Medicine, Minia University, Minia, Egypt.

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workers, including 30 women from our healthcare workers(15 nurses, 15 doctors), some of them from the PediatricsDepartment and the rest from the Gynecology and ObstetricsDepartment (Group IV).

Knowledge, attitude, and practice regarding early start ofbreastfeeding and use of prelacteal fluid were evaluated.

Sample size

The sample of the present study was 120 mothers attend-ing, delivered, or working in Minia University Hospital whowere selected by systematic random sampling.

Data were collected with the help of an interview sched-ule of knowledge, attitude, and practice questionnaireswhere the answers were filled by the investigator herself afteran oral interviewwith the participants fromApril 2011 to June2011. Approximately four subjects were interviewed perday (12 per week), with about 30 minutes spent with eachparticipant.

Ethical consideration

The investigator personally introduced herself to the par-ticipants and explained the purpose of the study and ascer-tained their willingness to participate. The respondents wereassured anonymity and confidentiality of the informationthey provided.

Criteria of data collection

The following criteria were set for selection of the sample.Inclusion criteria were as follows: (1) pregnant women whoattended the antenatal clinic of the Gynecology andObstetricsDepartment of Minia University Hospital during the datacollection period and were willing to participate in the study;(2) lactating women delivered in the maternity ward of theGynecology and Obstetrics Department of Minia UniversityHospital during the period of data collection and who werewilling to participate in the study; and (3) female healthcareworkers in both the Pediatrics and Gynecology andObstetricsDepartments of Minia University Hospital during the datacollection period.Mothers whowere not willing to participatein the study and not available during the period of data col-lection were excluded.

Description of the tool

Section I included items related to socioeconomic and de-mographic criteria of the participants.

Section II consisted of five items regarding Groups IIII butsix items regarding Group IV; these items related to knowl-edge on early breastfeeding initiation. The total score possiblewas 11 in Groups IIII but 12 in Group IV.

Section III consisted of four items regarding Groups IIIIbut six items regarding Group IV. These items identified theattitude of participants toward early start of breastfeeding.This section used a 3-point Likert scale to assess attitude asstrongly agree, agree, or dont agree. The total score possiblewas 8 in Groups IIII but 12 in Group IV.

Section IV consisted of four items regarding Group I, 7 inGroups II and III, but five items regarding Group IV. Theseitems assessed practice related to early breastfeeding. Thetotal score possible was 7 in Group I, 12 in Groups II and III,but 7 in Group IV.

In each section answers were scored in a range from 0 forwrong answers to 2 for correct ones.

Statistical analysis of data

The data obtained were entered after editing, coding, andgrouping, tabulated, and transferred to a computer file. Thedata were analyzed according to the objective of the study byusing the SPSS version 137 Windows program (SPSS, Inc.,Chicago, IL), in which descriptive and inferential statisticshad been done.

The v2 test, Fishers exact, t test, analysis of variance, andpost hoc tests were used to find out the association betweenknowledge, attitude, and practice with selected variables. Avalue of p< 0.05 was significant, and p< 0.01 was highly sig-nificant.

Results

Sixty percent of women who initiated breastfeeding within1 hour after labor were delivered by spontaneous vaginaldelivery, while 50% of women delivered by cesarean sectioninitiated breastfeedingwithin 26 hours after delivery (Table 1).Of women delivered by cesarean section, 83.3% used pre-lacteal feed in comparison with 40% of women deliveredby spontaneous vaginal delivery (Fig. 1); this difference wasstatistically significant.

There was a significant difference regarding practice andtotal score betweenwomen delivered by spontaneous vaginaldelivery (Group I) and those delivered by cesarean section(Group II) ( p = 0.02 and p = 0.04, respectively), but no signifi-cant statistical difference regarding knowledge and attitude(Fig. 2).

The practice and total scores of nurses working in the Pe-diatrics Department were higher compared with nursesworking in theGynecology andObstetricsDepartment (Table 2),and this difference was statistically significant ( p= 0.005).

Table 3 shows a statistically significant difference betweenGroup I (pregnant women attending for antenatal care) andGroup III (lactating women delivered by cesarean section)regarding knowledge score ( p = 0.0001). Also, the differencebetween Group I and Group IV (healthcare workers), thatbetweenGroup II (lactatingwomen delivered by spontaneousvaginal delivery) and Group IV, and that between Group IIIand Group IV regarding knowledge and attitude score werestatistically significant.

Table 4 shows that the most important factors affectingthe start of breastfeeding were maternal illness, followed byearly skin-to-skin contact (as 86.7% of women delivered

Table 1. Breastfeeding Initiation TimeAccording to Delivery Type

n (%) for delivery typeBreastfeeding timeafter delivery SVD (n = 30) CS (n = 30)

Within 1 hour 18 (60%) 5 (16.7%)26 hours 10 (33.3%) 15 (50%)After 24 hours 2 (6.7%) 10 (33.3%)

By v2 test, v2 = 13.6, p = 0.001.CS, cesarean section; SVD, spontaneous vaginal delivery.

EARLY START OF BREASTFEEDING 313

spontaneously had early skin-to-skin contact, and 60% of thesame group initiated breastfeeding within 1 hour, whereas40% of women delivered by cesarean section had skin-to-skincontact with their babies, and as a result only 16.7% of themhad early initiation of breastfeeding).

Discussion

Initiating breastfeeding within 1 hour of birth was one ofthe 10 Steps to Successful Breastfeeding on which the Baby-Friendly Hospital Initiative was based and launched in 1992.Step 4 was Help mothers initiate breastfeeding within onehalf-hour of birth. Its explanation, as provided by the WorldHealth Organization,8 is as follows:

Mothers in the maternity ward who have had normal vaginaldeliveries should confirm that within a half-hour of birth theywere given their babies to hold with skin contact, for at least 30

minutes, and offered help by a staff member to initiatebreastfeeding.... At least 50% of mothers who have had cae-sarean deliveries should confirm that within a half-hour ofbeing able to respond, they were given their babies to holdwith skin contact.

In the present study it was found that 90% of pregnantwomen, 83.3% of the mothers delivered by vaginal delivery,and 93.3% of mothers delivered by cesarean section wereaware of the importance of colostrum and breastfeeding.These findings were consistent with previous studies911 inwhich 76.7% of the mothers were aware of the importance ofcolostrum and breastfeeding.

Community strategies to promote the early initiation ofbreastfeeding should target not only mothers but also thosewho influence behavior such as grandmothers and other fe-male relatives. In the present study 36.7% of pregnant womenattending for antenatal care, 40% of women delivered byvaginal delivery, and 43.3% of those delivered by cesareansection received information about the early start of breast-feeding from their relatives. This consistent with a studyconducted by Tawiah-Agyemong et al.,3 which reported thatgrandmothers and other female relatives were importantinfluences as to advice to first-time mothers, because breast-feeding behaviors are learned from them and because theseinfluencers often had control over the baby in the first fewhours of life.

In the present study we found that 60% of those deliveredby vaginal delivery initiated breastfeeding within an hourafter delivery (World Health Organization rate of good).12

Table 2. Comparison Between Nurses Workingin the Pediatrics and Gynecology

and Obstetrics Departments

Mean SD for nurses working in the

ScorePediatric

DepartmentGynecology and

Obstetrics Department t p value

Knowledge 5.5 1 4.5 1.2 1.6 0.4Attitude 8 1.3 7 1 1.8 0.5Practice 6.4 1.7 3.5 2.9 3.3 0.005Total 25.7 2.7 20 3.9 3.3 0.005

FIG. 2. Comparison between Groups II and III regardingknowledge, attitude, and practice score.

Table 3. Multiple Comparisons Amongthe Four Groups

p value

Attitude score Knowledge score

Group I versusGroup II 0.002 0.6Group III 0.0001 0.03Group IV 0.0001 0.0001

Group II versusGroup III 0.358 0.1Group IV 0.0001 0.0001

Group III versusGroup IV 0.0001 0.0001

Significance was calculated by post hoc test.

FIG. 1. Use of prelacteal feed according to delivery type.

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This was consistent with the result obtained by Orun et al.,5

who demonstrated that the percentage of breastfeeding ini-tiation in women delivered by vaginal delivery was 51.2% inthe first hour but 81.4% in the second hour after delivery. Incontrast, a study conducted by Boccolini et al.13 in Rio deJaneiro between 1999 and 2001 found that only 22.4% of ba-bies born through vaginal delivery were breastfed within thefirst hour after birth.

In the present study we found that one of the major factorsfor delaying the first breastfeed was delivery by cesareansection: only 16.7% of the mothers delivered by cesareansection initiated breastfeeding within 30 minutes to an hourafter recovery from anesthesia, whereas 50% started tobreastfeed their babies after 26 hours from delivery. This isnear to the results obtained by Orun et al.,5 who reported thatthe percentage of breastfeeding initiation in women deliveredby cesarean section was 18.9% in the first hour but 64% in thesecond hour after delivery. Several studies had confirmed thatcesarean section is a significant barrier that inhibits breast-feeding within the first hour of life.13,14

In the present study we found a significant associationbetween skin-to-skin contact and early breastfeeding initia-tion, and this is in agreement with a study conducted byMikiel-Kostyra et al.,15 who stated that the first breastfeedingwithin 2 hours was significantly associated with skin-to-skincontact.

As expected, in the present study preterm newborns wereless often breastfedwithin the first hour of life than those bornat full term. This is consistent with a study in Japan conductedby Nakao et al.16 and another in Massachusetts conducted byMerewood et al.17 They reported that premature newbornswere less likely to receive maternal milk.16,17 This result maybe explained by coincident common problems, such as limitedoral-motor skills, hypoglycemia, maternal adaptation tohaving a small infant, and delayed lactogenesis in prematureinfants.18

According to the literature to date, several studies haveinvestigated maternal age, educational level, and employ-ment status for their impact on breastfeeding behavior.1923

However, none of these factors was shown to influence earlybreastfeeding initiation in our study. Similarly, Orun et al.5

revealed that there was no influence of maternal age, educa-tional level, and work status on early breastfeeding initiation.

In the present study it was found that healthcare workers atMinia University Hospital had good knowledge about im-portance of early breastfeeding initiation, as 96.7% wereaware of the benefits of colostrum and 93.3% of them had apositive attitude regarding early breastfeeding initiation be-

ing right for each baby. This was in consistent with a studyconducted by Tawiah-Agyemong et al.,3 which demonstratedthat despite the problem reported around the disseminationof breastfeeding information and materials and the focus ofpolicy on exclusive breastfeeding, health workers knowledgeof the importance of early initiation was high.

Although Minia University Hospital was designated as aBaby-Friendly Hospital in the past, nowadays the Baby-Friendly Hospital Initiative policies are not actually activated,as 100% of healthcare workers in both the Pediatrics andGynecology and Obstetrics Departments had a negative atti-tude about the role and encouragement of the Hospital re-garding early initiation of breastfeeding. The most commonreasons for this problem were attributed to a lack of com-munication between the Pediatrics and Gynecology and Ob-stetrics Departments and regular training programs aboutearly breastfeeding initiation in the Hospital.

Conclusions and Recommendations

Although knowledge about early breastfeeding initiationwas expressed by the majority of mothers participating in thisstudy, actual application of this practice was clearly deficient.

In our study, the most important prenatal and postnatalfactors associated with delayed breastfeeding initiation weredetermined to be maternal anemia, maternal illness duringpregnancy, cesarean section delivery, and premature birth.Therefore, effective antenatal care to prevent and appropri-ately treat maternal anemia and illness and decrease cesareansection deliveries and premature birth will contribute to earlybreastfeeding initiation.

This study shows that there is a need for activatingthe Baby-Friendly Hospital Initiative policies in both thePediatrics and Gynecology and Obstetrics Departments ofMinia University Hospital and to ensure that all healthcareworkers present at deliveries are skilled in supportingmothers in breastfeeding initiation and they have the mate-rials they need.

In addition, we recommend the need to ensure sustain-ability of Baby-Friendly practices by periodic assessment andreassessments and by installation of monitoring systems in-side the Hospital for checking and improving the Baby-Friendly policies. Finally, empowering parents and families todemand for their rights to Baby- and Mother-Friendly prac-tices is core to changing hospital practices.

Acknowledgments

We would like to acknowledge all mothers who agreed toparticipate in our study and gave us their times and efforts tounderstand and answer our questions.

Disclosure Statement

No competing financial interests exist.

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Table 4. Multiple Regression Analysis of FactorsAffecting the Start of Breastfeeding

Factors affecting the start of breastfeeding b t p

Maternal illness 0.5 4.2 0.0001Early skin-to-skin contact 0.4 3.8 0.0001Baby gender 0.19 1.6 0.1Parity 0.05 0.5 0.7Gestational age at birth 0.03 0.3 0.8

Dependent variable is the start of breastfeeding.R2 = 0.6.

EARLY START OF BREASTFEEDING 315

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Address correspondence to:Gihan M. Babrs, MDPediatrics Department

Children and Obstetrics and Gynecology HospitalFaculty of MedicineMinia UniversityP.O. Box 61111

Minia, 61111, Egypt

E-mail: gihanbabrs@hotmail.com

316 SALLAM ET AL.