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Impact of antenatal counselling on knowledge, attitude and practice regarding breastfeeding.


Early initiation of breastfeeding and sustaining exclusive breastfeeding for the first six months of life are important steps in ensuring a healthy baby and happy mother pair. Breastfeeding, though a reflexive and instinctive process, many times requires preparedness on the part of the mother and also the family. Lack of knowledge regarding the benefits of the breast milk coupled with untimely and inappropriate weaning practices results in malnutrition and its attendant risks. Several studies from India and other countries with high under five mortality rates revealed the rates of initiation of breastfeeding and continuation of breastfeeding to be far less than satisfactory. The present study attempts to explore the knowledge, attitude and practice of the expecting mothers and to assess the impact of antenatal counselling on the perception and practice of expectant mothers regarding breastfeeding.


Expectant mothers admitted in antenatal wards and mothers in the labour rooms and postnatal wards willing to breastfeed their babies are included in the study.

It is a single centre cross sectional questionnaire based study carried out from October 2012 to September 2014; 600 women admitted in Gandhi Hospital for delivery are recruited in the study. These women were divided into two groups--Group A and Group B. Group A consisted of 300 women who were interviewed after delivery with a pre-set questionnaire containing questions pertaining to knowledge, attitude and practice of breastfeeding. Group B contained 300 women who were given brief structured lactation counselling before delivery in the antenatal wards and labour room. Counselling was done by women who were appointed as support staff in our Sick New-born Care Unit (SNCU). The support staff was given basic training on ideal breastfeeding practices as per IYCF guidelines by the paediatricians working in SNCU. Group B mothers were interviewed after delivery using the same set of questionnaire. The investigators carried out the interview for both groups. Fourteen mothers from Group B were excluded from the study due to sickness either in the baby or the mother. The data from the interview of the two groups were analysed and compared using open Epi Info statistical method.


Group A consisted of 300 women who did not receive any structured lactation counselling. Group B consisted of 286 women who were counselled by a trained counsellor before delivery. Both the groups were interviewed after delivery by the investigator using the questionnaire.

Among Group A 47% of deliveries were normal vaginal deliveries and 53% were delivered by LSCS. In Group B, 54% were Normal Vaginal Deliveries (NVD) and 46% were LSCS. Group A contained 41% primi and 59% multigravida mothers. Group B contained 44% primi and 56% multigravida mothers. In Group A, 44% and in Group B 51% were literate.

Early initiation of breastfeeding was done by 67% of mothers in Group A and in Group B by 88% of mothers. In Group A 69% of mothers delivered by NVD and 58% of mothers delivered by LSCS initiated early feeding, whereas in Group B 87% of mothers delivered by NVD and 89% of mothers delivered by LSCS initiated early breastfeeding. Among the literate mothers, 75% from Group A and 94% from Group B initiated early breastfeeding, whereas in illiterate women 31% from Group A and 41% from Group B initiated early breastfeeding; 22% from Group A and 3.5% from Group B discarded colostrum; 38% from Group A and only 14% from Group B gave prelacteal feeds (Table 1).

From Group A 55% of mothers and from Group B 90% of mothers felt exclusive breastfeeding up to six months is a good practice; 71% from Group A and 89% from Group B wished to continue breastfeeding for two years and beyond; 42% from Group A and 14% from Group B felt that formula feeding makes their babies healthier and heavier; 5% from Group B and 35% from Group A felt they should not feed their babies when they are sick.


Breastfeeding plays a crucial role by providing safe and complete nutrition to an infant. Immediate breastfeeding within the first hour followed by early exclusive breastfeeding improves the health and survival status of new-borns. Early initiation of breastfeeding was shown to reduce neonatal mortality by 22% irrespective of the duration of exclusive breastfeeding. (1) In the developing countries, non-breastfed infants are six times more likely to die of infections during first two months of life than breastfed infants. (2) According to WHO, 53% of diarrhoea and 55% of pneumonia deaths are due to faulty feeding practices during the first six months of life. (3) The Bellagio Child Survival Study Group estimated that breastfeeding could prevent 13% of all deaths of children aged less than five years (About 1.3 million lives per year). (4)

Though India has been a breastfeeding nation and almost every mother is willing to breastfeed her baby, there appears to be a wide discrepancy in what is ideal and what is in practice. There are several factors responsible for this scenario. Poor knowledge of optimal breastfeeding practices and insufficient support from healthcare providers are important reasons for suboptimal breastfeeding. (5) Lack of support from family and the need to resume work with no maternal entitlements and facilities like creche at the work place often lead to early discontinuation of breastfeeding.

According to NFS3, only 25% of the twenty six million children born every year are put to breast in the first hour. A little over 25% get excusive breastfeeding for the first six months. (6) The recent Rapid Survey on Childhood 2013-2014 shows some improvement in these indicators. About 44 percent of babies are put to breast in the first hour after birth and 65% of babies are exclusively breastfed till five months. (7) World Breastfeeding Trends Initiative (WBTi) is a global initiative tool which tracks, assesses and monitors national policies and programmes promoting IYCF practices in order to support women for breastfeeding. As per WBTi, India status report 2015, India is faring poorly with a score of 78 out of 150. (8) There has been a very modest improvement over the last decade. In comparison, its neighbour Bangladesh is doing much better with a score of 123/150.P) This suggests that India has still a long way to go to reach its goals.

The present study shows that a remarkable difference in the perceptions and practices of mothers can be brought by specific antenatal interventions. It is a well-known fact that delivery by LSCS is associated with a greater delay in initiation of breastfeeding and the longer the delay the more chances for prelacteal feeds further hampering the chances of establishing successful lactation. In our study, a 31% increase in initiation of breastfeeding was noted in the counselled group. Though discarding colostrum is not as common as before, it is still prevalent. (10) in the misbelief that the colostrum is impure or it cannot be digested by the baby. Such practices keep the child at the risk of receiving prelacteal feeds for a considerable duration again compromising with successful lactation. In our study, only 3.5% of the intervention group discarded colostrum compared to 22% in the other group. Prelacteal feeds were given in 14% of the intervention group, whereas 38% mothers from the other group resorted to prelacteal feeds. The prelacteal feeds varied from diluted cow milk, formula milk, honey, sugar water to fruit juice. Manas Pratim Roy et al in their study on determinants of prelacteal feeding suggested that age of the mother, social status and place of delivery influenced the practice of prelacteal feeds. (10)

From Group A, only 55% of mothers knew that exclusive breastfeeding should be done up to 6 months. Almost 90% mothers from counselled group are aware of the recommendations on exclusive breastfeeding. Regarding the question of how long breastfeeding to be continued, 71% mothers from Group A and 89% from Group B responded that breastfeeding is to be given for a minimum of 2 years and can be continued beyond. Five percent of mothers from Group B and 35% from Group A felt that breastfeeding should be stopped in case of maternal fever or other illnesses. There is a general impression among the mothers that formula fed babies are heavier and so look healthy. In our study, antenatal counselling seems to have modified this perception in the mothers to a significant extent. Only 14% from the counselled group felt that formula feeds are superior to mother's feeds, whereas 42% of mothers from the other group felt the same.

The present study reflects the general attitude of the mothers towards breastfeeding. It also establishes that a favourable change can be brought about in the knowledge and therefore the attitudes and practice of breastfeeding in the mothers. According to Mattar et al, where breastfeeding practices are suboptimal, simple one-encounter antenatal education and individual counselling may improve breastfeeding practice up to 3 months after delivery. (11) Educating the mothers on breastfeeding and clarifying any misconceptions among expectant mothers will improve breastfeeding. Many times simple problems like soreness of breast, improper latching, mother's apprehension about the adequacy of milk production if unaddressed result in premature weaning. Such problems can be addressed during postnatal visits by the health workers. Studies show that prenatal counselling had greater impacts on breastfeeding rates at 4-6 weeks, while combined prenatal and postnatal promotion were important for breastfeeding rates at 6 months. (12) Aamer Imdad et al, in their systematic review stated 'that there is a greater increase in breastfeeding rate with promotion interventions in developing countries compared to developed countries. The reason could be that the baseline level of awareness and education among women of developing countries is less compared to those of developed nations. Besides, fewer mothers in developed countries would be receptive to breastfeeding promotion because of other factors like early employment, more ready availability of formula milk and a different social milieu.' (12)

Though our study shows a highly favourable outcome from the antenatal intervention, it is likely that the choice of many of the mothers may be modified by the elderly persons in the family (13) when faced with any lactation difficulty. In order to sustain the positive influences derived from antenatal counselling, family members should be involved in the counselling both before and after the delivery. Periodic visits by the health worker during postnatal period and assurance of the mother that help is at hand whenever it is required builds up the confidence of the mother and paves way for successful lactation. (10)

The positive changes brought about by antenatal and postnatal counselling of the mothers can be reinforced by creating awareness of optimal infant feeding practices on a large scale in the society. Experience from the Linkages project in Madagascar and Bolivia showed that concerted efforts from all the stake holders can bring a positive change in the society's attitude towards breastfeeding. (14)

India is one of the fifteen countries with highest under five mortality rates. The Global Action Plan for prevention of Pneumonia and Diarrhoea (GAPPD) recommends exclusive breastfeeding for first six months as an important intervention that protects from deaths due to diarrhoea and pneumonia. (15) With all the strategies and plans in place, India is still struggling to attain the goals related to breastfeeding. Apart from lack of knowledge regarding the benefits of breastfeeding, several other reasons are implicated. Inadequate baby friendly hospitals, inadequate outreach services, untrained and unmotivated medical and paramedical staff and aggressive promotion by baby food industries influencing the feeding choice are among the most important reasons. (5) A study done on 144 pregnant women revealed that only 21% received information about the benefits of breastfeeding during antenatal visits. (16) As per RSOC, only 63% of mothers received at least three antenatal check-ups and only 51% of the mothers get visited by the primary care workers within one week of discharge from institutions. (7) It is imperative that to improve breastfeeding rates the outreach services must be strengthened, especially in semi-urban and rural areas with special focus on educating the mothers on importance of breastfeeding.

The present study establishes that there is a need for antenatal counselling of every pregnant women in order to make them well prepared for breastfeeding of their babies. It also establishes that this can be accomplished by training persons even with minimal educational qualification.


Based on the results of our study, we recommend that designated lactation counsellors should be employed in every health care facility providing obstetric services in the country.


(1.) Edmond KM, Zandoh C, Quigley MA, et al. Delayed breastfeeding initiation increases risk of neonatal mortality. Paediatrics 2006;117(3):380-6.

(2.) Victoria C, Barros A. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet (British Ed) 2000;355(9202):451-5.

(3.) Lauer JA, Betran AP, Barros AJ, et al. Deaths and years of life lost due to suboptimal breast-feeding among children in the developing world: a global ecological risk assessment. Public Health Nutr 2006;9(6):673-85.

(4.) Jones G, Steketee RW, Black RE, et al. Bellagio child survival study group how many child deaths can we prevent this year? Lancet 2003;362:67-71.

(5.) Bansal CP. Breastfeeding-why are we still failing? Indian Paediatr 2013;50(11):993-4.

(6.) National family health survey-3 national report, vol 1:275-80. India _volume_I_corrected_17oct08.pdf.

(7.) Rapid survey on children-2013-2014. India status report ministry of women and child development, GOI.

(8.) Vandana Prasad, Arun Gupta. 4th assessment of India's policies and programmes on infant and young child feeding 2015 IBFAN Asia/BPNI 2015;p 10. ports/report/WBTi-India-Report-2015.pdf

(9.) World breastfeeding trends initiative assessment report Bangladesh 2015. IBFAN Asia/BPNI 2015;p 9. ports/report/WBTi-Bangladesh-Report-2015.pdf

(10.) Roy MP, Mohan U, Singh SK, et al. Determinants of prelacteal feeding in rural northern India. International Journal of Preventive Medicine 2014;5(5):658-63.

(11.) Mattar CN, Chong YS, Chan YS, et al. Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial. Obstet Gynaecol 2007; 109(1):73-80.

(12.) Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health 2011;11(Suppl 3):S24. doi: 10.1186/1471-2458-11-S3S24.

(13.) Susin LR, Giugliani ER, Kummer SC. Influnce of grandmothers on breastfeeding practices. Rev saude publica 2005;39(2):141-7.

(14.) Baker EJ, Sanei LC, Franklin N. Early initiation of and exclusive breastfeeding in large-scale community-based programmes in Bolivia and Madagascar. Journal of Health, Population, and Nutrition 2006;24(4):530-9.

(15.) The integrated global action plan for the prevention and control of pneumonia and diarrhoea (GAPPD). WHO/Unicef table 1 2015;p 15.

(16.) Dhandapany G, Bethou A, Arunagirinathan A, et al. Antenatal counselling on breastfeeding-is it adequate? A descriptive study from Pondicherry, India. International Breastfeeding Journal 2008;3:5. doi: 10.1186/17464358-3-5.

M. Ratna Manjula [1], N. S. Suresh [2], B. Kannaiah [3], C. Nirmala [4]

[1] Associate Professor, Department of Paediatrics, ACSR Government Medical College, Nellore, Andhra Pradesh.

[2] Assistant Professor, Department of Paediatrics, Gandhi Medical College, Secunderabad, Telangana.

[3] Senior Resident, Department of Paediatrics, Gandhi Medical College, Secunderabad, Telangana.

[4] Associate Professor, Department of Paediatrics, ACSR Government Medical College, Nellore, Andhra Pradesh.

Financial or Other, Competing Interest: None. Submission 28-04-2016, Peer Review 10-05-2016, Acceptance 13-05-2016, Published 30-05-2016.

Corresponding Author:

N. S. Suresh, #204, Lalitha Towers, New Sastry Nagar, Erragadda, Hyderabad-500018.

E-mail: drnss21

DOI: 10.14260/jemds/2016/631
Table 1: Showing Results of Interview of Groups A and B

     Parameter         Group A     Group B     p value   [chi square]
                       (N=300)     (N=286)                  value
                       No. (%)     No. (%)

Early initiation of    201 (67)    252 (88)    0.0001       36.22

Feeding colostrum      234 (78)   276 (96.5)   0.0001       44.41

Prelacteal feeds       114 (38)    41 (14)      0.001        8.64

Awareness of           164 (55)    258 (90)    0.0001       91.78

Awareness regarding    213 (71)    254 (89)    0.0001        28.7
maximum duration of

Assumption of          126 (46)    40 (14)     0.0001       125.6
formula fed being
healthier and

Perception that        106 (35)     15 (5)     0.0001        80.8
breastfeeding to be
avoided during
maternal illness
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Author:Manjula, M. Ratna; Suresh, N.S.; Kannaiah, B.; Nirmala, C.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:May 30, 2016
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