Original Article

Knowledge & Practices of Breastfeeding in Working and Non-working Mothers

Muhammad Hashir Iqbal, Namra Noukhaiz, Saadia Shahzad

ABSTRACT
Objective: To assess knowledge and practices of mothers towards breastfeeding and identify the association of
socio demographic factors with knowledge and breastfeeding practices among mothers.
Methodology: A descriptive cross-sectional study conducted in outdoor departments of Pediatrics & Gynecology
in a tertiary level hospital in Lahore. The study population was mothers having children ≤5 years of age. Study
variables included socio-demographic factors, knowledge & practice factors. The calculated sample size was 362
and a purposive sampling technique was applied. The data collection instrument was a self-developed
questionnaire. The data analysis plan was: descriptive statistics, frequency trends, and Chi-square test of
significance application.
Results: Demographic profile showed 75.5% of mothers were housewives and 24.3% working mothers; 42%
were living in a nuclear family, 58% in an extended family. Knowledge level revealed that 36.5% knew
breastfeeding (BF) should be done up to 2 years; 75.5% knew that it should be given on demand; 91% knew that
colostrum should be given to the newborn. Practice level assessment showed 44.5% had initiated BF immediately
after birth; 79.9% had given colostrum; and 34.9% had done BF > one year. Significant association <0.05 was
found between socio-demographic factors (status of mother, type of family, total family income, mode of
delivery) and knowledge and practice variables.
Conclusion: There is an important role of an extended family system that could act as a support pillar to enhance
the practice of breastfeeding practices among mothers. Furthermore, at home mothers and lower socio economic
class also play an important role as contributing factors in continuation of BF >6 months.

KEYWORDS: Breastfeeding, initiation, knowledge, newborn, practice.

INTRODUCTION
Breastfeeding behaviors are mostly dependent upon hour after birth of the newborn and then continue with
the specific cultural norms and perceptions of the exclusive breastfeeding for next six months;
mothers that actually guide them towards duration and specifically, in low economic and developing
frequency of breastfeeding to the infant. 1 Breast milk countries.5The WHO also advocates that breastfeeding
prevents malnutrition in the newborn and boosts up its is to be continued along with complementary feeding
immunity.3Timely and early initiation of breastfeeding up to the age of two years or beyond.5 However, many
by the mothers play an important role in control of unhealthy breastfeeding practices are seen in
infections and mortality in infants.4 The World Health developing countries like Pakistan; where infant and
Organization (WHO) and United Nations Children’s child mortality rates are high and infection rate among
Fund (UNICEF) have strongly recommended all infants is high.6 Various researchers have identified
nursing mothers to initiate breastfeeding within first multiple influencing factors that affect the early
initiation and duration of breastfeeding among
mothers; like their age, education level, income,
Muhammad Hashir Iqbal marital status, and professional career, information
MBBS Student
Shalamar Medical and Dental College, LHR
from media and literature, and family support.7 It so
Namra Noukhaiz happens that with an increase in the age of the child,
MBBS Student practices of breastfeeding by the mothers’ decline.
Shalamar Medical and Dental College, LHR The first two hours after birth is labeled as the
Dr.Saadia Shahzad, MBBS, MPhil sensitive period and is the optimum time to start
Associates Professor
Shalamar Medical and Dental College, LHR breastfeeding to the child, and unfortunately, only
29% of the newborn get breastfeed during this time.9
Correspondence: With this scenario in mind, the current study was
Dr. Saadia Shahzad planned to assess breastfeeding knowledge and
Email: [email protected]
practices among working and non-working mothers in

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 KAP Study Breastfeeding

a lower socio-economic community. Current study RESULTS

results will also guide us towards the planning of an
effective exclusive breast feeding (EBF) promotion Total Data of 362 respondents was collected. We
drive in the said locality to improve the situation obtained hundred percent response rate which was
further and to raise awareness among the community entered on SPSS 20 and analyzed. The mean age of
about the significance of EBF and its impact upon the mothers was 28 years±4.95 with a range of 16-42
health of child and mother both. We aimed to assess years. We found that 356(98.3%) of mothers had ≤3
the knowledge and practice level of mothers towards children and only 6(1.7%) mothers had > three
breastfeeding and identify the association of socio children.
demographic factors with knowledge and
breastfeeding practices among mothers. Table 1: Knowledge level of mothers regarding
breastfeeding in their last born (N=362)

METHODOLOGY Variable Response N (%)

Should mother’s milk be
Yes 328 (90.6%)
It was a descriptive cross-sectional study conducted given to child immediately
No 34 (9.4%)
in the outdoor departments of Pediatrics and after birth
Gynecology in a tertiary level hospital situated in a Should colostrum be given to Yes 325 (91.1%)
the child No 36 (9.9%)
lower socio-economic category area of Lahore during For how long breastfeed 38 (10.5%)
June 2018 to Dec 2018. IRB approval was taken from should be given Up to 4 months 103
the organization (letter no: SMDC/ IRB/ 01-03/083) Up to 6 months (28.45%)
Study universe was married females of reproductive Up to 1 year 89 (24.58%)
Up to 2 years 132
age group visiting the selected hospital outdoor
(36.46%)
departments for health care. The study population was How many times should 1-4 times 28 (7.7%)
mothers having children ≤5 years of age. Study mother’s milk be given to 5-8 times 60 (16.6%)
variables included: socio-demographic variables and the child in a day On-demand 274 (75.7%)
variables for knowledge and practice regarding When should you start solid At 4 months
85 (23.5%)
breastfeeding, in their last, birth. Inclusion criteria food for a child At 6 months
255 (70.4%)
were: willingness of the respondent and mothers 8 months-1
22 (6.1%)
year
having children ≤5 years of age. Whereas exclusion
After weaning should
criteria were: mothers having children above the listed mother’s milk be given to a Yes 348 (96.1%)
age and mothers who had participated in research of a child No 14 (3.9%)
similar kind. The sample size was calculated upon Should mother’s milk be Yes 331 (91.4%)
Open Epi software using the prevalence of exclusive given to child during illness No 31 (8.6%)
breastfeeding of 38%, CI of 95%, and 5% margin of
Does mother’s milk
error.9 The calculated sample size was 362. Purposive strengthens immunity in a Yes 355 (98.1%)
sampling technique was applied to select our study child No 7 (1.9%)
sample and respondents were recruited for the study Does breastfeeding reduces
after due written informed consent. Data collection the risk of breast cancer in Yes 255 (70.4%)
tool was the interview method and the data collection mother No 107(29.6%)
instrument was self-developed questionnaire related to Do you know the benefits of Yes 314 (86.7%)
breastfeeding, in the last born child. Questions breastfeeding No 48 (13.3%)
included in the questionnaire were selected after a
detailed reading of the relevant material upon Results showed that 274(75.7%) mothers were
breastfeeding by the World Health Organization housewives and 88(24.3%) were working mothers
(WHO). (majorities are teachers, few had their own small
Data was collected by the female team members on business, and only one or two are doctors). The
account of the sensitive nature of the questions and present study found that 152(42%) mothers were
cultural limitations. living in nuclear family type and 210(58%) in
Statistical Analysis: The data analysis plan was extended family type. According to the results,
developed as a descriptive statistics calculation, 198(54.7%) mothers had their last born through
frequency trends in knowledge and practice sections, cesserian section and 164(45.3%) through normal
and Chi-square test of significance was applied. vaginal delivery (NVD).

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Table 2: Practice level in mothers regarding breastfeeding Table 4: Association between variables and duration of
in their last born (N=362) Breast-Feeding practices ≤6 &>6 months
Variable Response N (%) Variable Chi
What did you give your last Pre lacteals 141 (39%) Duration of
square P-value
born child immediately after Colostrum 181 (50%) Breastfeeding
value
birth Water 6 (1.6%) Status of
Top feed 34 (9.4%) ≤6 months >6 months
mother
When did you give Immediately 141 (44.5%) House wife 115 159 4.052 0.045*
breastfeed after birth After one day 136 (37.6%) Working 26 61
After two days 65 (18%) Mode of
Did you give colostrum to Yes 289 (79.9%) ≤6 months >6 months
delivery
your child No 72 (19.1%) C-section 64 128 5.713 0.022*
Did not NVD 75 89
28 (7.7%)
breastfeed Type of
For how long did you <4 months 6 (1.6%) family ≤6 months >6 months
breastfeed your baby 4-6 months 37 (10.2%)
6-12 months 165 (45.5%) Nuclear 71 81 6.636 0.012**
>12 months 126 (34.9%) Extended 70 140
How many times do you 1-4 times 30 (8.3%) Total family
≤6 months >6 months
breastfeed your child in a 5-8 times 63 (17.4%) income
day On-demand 268 (73.5%) <25000 55 67
In case of a child’s upset Yes 325 (89.8%) 25000-50000 60 80
10.712 0.013**
stomach do you continue to No 37 (10.2%) 50001-85000 16 37
breastfeed >85000 10 37
Did you choose to breastfeed Yes 206 (56.9%) NVD= Normal vaginal delivery, P-value ≤ 0.05 is significant
to reduce the risk of breast No 156 (43.1%)
cancer
Did you practice Yes 322 (89%)
DISCUSSION
breastfeeding after weaning No 40 (11%)
Did you give top feed to last Yes 252 (69.6%) As per WHO recommendation, initiation of
born No 110 (30.4%) breastfeeding to the infant should be within the first
P-value ≤0.05 is significant sixty minutes’ after birth. The initial start with
colostrum is a rich source of antibodies and nutrients.
Table 3: Associations of demographic variables and Present study patterns of socio-demographic
knowledge of initiation of breastfeeding soon after birth
Variable Should mother’s milk Chi- P- characteristics are supported by the findings of
be given to baby square value Pakistan Demographic and Health Survey (PDHS)
instantly after birth value 2017-18 which states: 49% of women had no
Status of mother Yes No
Housewife 254 20
education, 17% had primary level, 9% had middle
Working
73 14 5.984 .020* level, 12% had secondary level, and 13% had
Type of family Yes No
education up-till higher level. This survey also found
Nuclear 144 8 5.249 .028*
that the general current employment rate in women is
Extended 17%. Specific current employment rate for various age
184 26
Total family income Yes No groups was 96% among women of age 15-44 years;
<25000 114 8 with more involvement of urban women in
25000-50000
50001-85000 119 21 11.197 .011** professional/ technical/ managerial jobs 25% and 43%
>85000 48 5 in skilled manual work. Furthermore, the survey
47 0 reported that 58.3% women were from the lowest-
P-value <0.05 is significant middle wealth quintile and only 41.9% from fourth-
highest quintile. Survey reported that 15.3% women
Educational level of mothers showed: 36% mothers
had 1-2 children and 15.1% had 3-4 children.10
had education up to matric, forty five percent had
Another study conducted in Pakistan found that only
Intermediate-Graduate level, and nineteen percent had
10% of the respondent women were employed in
Postgraduate level education.
regular jobs; the pattern of educational level of
In our study it is found that the Total family income
mothers; and household monthly income trends in this
of the respondents revealed: Thirty four percent had
study are also similar to our study findings.11
<25000/ month, Fifty three percent had 25001-85000/
Demographic profile in our study is also consistent
month, and only thirteen percent had >85000/ month.
with another study conducted in a rural area in India,

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 KAP Study Breastfeeding

upon 250 respondents from different religious early initiation of breastfeeding soon after birth,16 and
backgrounds.12 then some had done so after one day some after two
In our study the knowledge level of women days; majority had breastfed their last born for 4-12
regarding breastfeeding is highly satisfactory upon all months and >12 months; majority had done on-
the key aspects. The good knowledge level of the demand breastfeeding, had continued breastfeeding
respondents regarding all the important aspects of BF after weaning; majority knew that breastfeeding
is the strength of our study and findings are consistent prevents from breast cancer, and majority practiced
with another study conducted in Pakistan that found: continuation of breastfeeding during an episode of
89% mothers knew about the importance of BF, 42% illness of the child. These findings are supported by
of mothers did not add any substitute for breast milk. the national level survey of Pakistan that found:
11
Still our findings upon the knowledge level of almost all last born children less than two year of age
women regarding some aspects of BF are much higher were breastfed, with 20% of the children breastfed in
than this past study that found: 36% women did not the first hour after birth and 56% are breastfed within
have any idea about early initiation of BF to the a day of birth. 10 Our findings are also similar to a past
newborn, and 44% had no idea about the importance Indian study that investigated the knowledge, attitude,
of giving colostrum to the newborn.11 In another study and practices of mothers regarding breastfeeding.12
conducted in a rural area in India KAP of mothers These findings are also consistent with the findings of
(belonging to diverse religions) was assessed breastfeeding practices investigated in a study
regarding BF, and authors of this study found similar conducted in Lahore, Pakistan that reported similar
trends of knowledge level of mothers regarding trends of breastfeeding practices as in our study.13 In
importance of BF, initiation of BF, giving colostrum the present study breastfeeding practice rate in 4-6
to the newborn, and about importance/ otherwise of months’ infants is again lower than some past studies
prelecteals.12 Our findings are also supported by that found breastfeeding rate for four months’ duration
another study conducted in Pakistan that showed as: 20.9% 16; 31% 14; and 49%.15 Results also showed
similar trends of knowledge level in mothers a highly significant association of family income with
regarding the different significant aspects of knowledge of immediate onset of breastfeeding after
breastfeeding. 13 Present study findings upon birth; with a greater proportion of mothers in the
knowledge level regarding breastfeeding among category of <25000 and up to 50000 per month. A
women are strongly supported and are similar to the significant association was found with the status of
findings of few other comparative studies that show mothers with a large number in the category of
the same pattern as; 66% mothers in India and 99% housewives as compared to working mothers. We also
mothers in Sri Lanka responded that breastfeeding had significant association with the type of family
strengthens the immunity of the child.14,15 The with the majority of mothers in the category of the
findings of our respondents upon knowledge level are extended family system. Logically these findings can
also consistent with the Jordanian study that found a be explained by the fact that most of the families in
similar pattern among the study subjects stating that this socio-economic group are living in an extended
majority of mothers answered correctly about the family system in our culture. Hence, there is the
nutritional benefits of breast milk, a little more than possibility of the impact of lower socioeconomic
half of the mothers knew whether breastfeeding status, greater social pressure on the mother as well as
should be stopped or not when baby is sick, and the age-old inherited knowledge of the elders
majority knew that breastfeeding protects against regarding early initiation of breastfeeding can also
breast and ovarian cancers.16 Our study also found that play a role in it. Recent national level survey in
mothers were in the practice of giving pre-lacteals to Pakistan found that median duration for any
the last born; that included pure honey. This finding is breastfeeding decreases with household wealth, from
similar and supported by another study conducted in 22.3 months in the lowest quartile to 12.3 months in
India that had a similar finding.14 Practice level the highest quartile.10 This same survey found that
regarding BF among our study participants has shown children of illiterate mothers had a median duration of
remarkable results in all the important areas: majority 21 months as compared to 12.3 months among the
mothers knew that colostrum had to be given to the children with highly educated mothers.10 Though, in
newborn immediately after birth and they had done so our study we could not find significant association of
in their last born; near about half of the respondents mother’s education level with breastfeeding. Present
had initiated BF soon after birth which is far less than study found a significant association of demographic
a previous study that found higher rate (72.4%) of factors: status of mother (working/ housewife), type of

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 Saadia Shahzad et al

family (nuclear/ extended), total family income, and 4. Mullany L.C, Katz J, Li Y.M, Khatry S.K, LeClerq S.C,
type of delivery (normal/ C-section); with duration of Darmstadt G.L, Tielsch J.M. breastfeeding patterns, time
breastfeeding practices. In all these significant to initiation, and mortality risk among newborns in
associations a greater proportion of mothers was Southern Nepal. J Nutr 2008; 138: 599-603.
found in the group of housewives, from households 5. WHO & UNICEF. Global strategy for infant and young
with lower household income groups, and mothers child feeding. Geneva: World Health Organization: New
who had NVD. Whereas, there is not much difference York: United Nations Children’s Fund; 2003.
in the distribution ratio between the two family types. 6. Amini M, Salarki N, Eshrati B, Djazayery A. Poor
Possible logical explanation for this finding of our breastfeeding as a probable cause of childhood
study can be that housewives mothers from lower malnutrition: exploring mothers and care giver’s views on
income households are more inclined towards breastfeeding via a qualitative study in Damavand, Iran.
breastfeeding the infant for longer duration on account Razavi Int J Med 2013; 1(1): 30-4.
of the affordability issue. 7. Arora S, McJunkin C, Wehrer J, Kuhn P. Major factors
Limitations: It was a hospital-based survey with a influencing breastfeeding rates: Mother’s perception of
non-representative sample; so results cannot be father’s attitude and milk supply. Pediatrics 2000; 106:
generalized. E67.
8. Li R, Darling N, Maurice E, Barker L, Grummer-Strawn
CONCLUSION L.M. Breastfeeding rates in the United States by
characteristics of the child, mother, or family: the 2002
The present study findings also show that there is an National Immunization Survey. Pediatrics 2005; 115: 31-
important role of an extended family system in 7.
enhancing the satisfactory knowledge level of mothers 9. National Institute of Population Studies (NIPS) Pakistan
regarding breastfeeding. At home mothers and lower and Macro International Inc. Pakistan Demographic and
socio economic status has also shown to have a major Health Survey 2012-2013, Islamabad, Pakistan. National
contribution towards BF > 6 months’ duration. Institute of Population Studies and Macro International
Recommendations: Results of the study warrant that Inc.2009.
another more precisely planned study should be 10. National Institute of Population Studies Islamabad
conducted in this area with a representative sample Pakistan. Pakistan Demographic and Health Survey 2017-
and breastfeeding practices should be studied in detail 18.
along with the influencing factors. Still, in the light of 11. Zeb J, Mustajab M, Zeeshan M, Ullah S, Qasim S, M,
the present study results, health education programs/ Khalil M Z. nursing mothers’ knowledge, attitude and
sessions can be planned for mothers coming to this practice towards breast feeding. Pak J of Med and
hospital; regarding improvement in their breastfeeding Dentistry 2017; 6(4): 39-43.
practices and enhancing the motivation level of 12. Kumar S, Jha SK, Singh A, Rawat CMS, Awasthi S, Bano
mothers for optimal breastfeeding practices. M, Surana A. Knowledge, attitude, and practices (KAP)
regarding breastfeeding: a community based cross
Funding Source: None sectional study from rural Uttrakhand. Health J 2015;
6(2): 17-22.
Conflicts of Interest: None 13. Zakria M, Afzal M, Hussain M, Gillani SA. Assess
knowledge, attitude, and practices of mothers regarding
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 KAP Study Breastfeeding

Author’s Contribution:

M. Hashir Iqbal: Concept, literature search, data collection, analysis, first draft write- up.
Namra Noukhaiz: Literature search, data collection, second draft write up.
Dr. Saadia Shahzad: Study concept and design, analysis, final review, overall supervision.

All authors are equally accountable for research work and integrity.

Received: 09 July 2020,

Revised received: 08 Oct 2020,
Accepted: 27 Oct 2020

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