1. Faculty of Social Sciences, Central Department of Home Science, Tribhuvan University, Nepal.

*             Correspondence: neeti2020k@gmail.com

Keywords: knowledge, attitude, practice, exclusive breastfeeding, breastfeeding mothers

1. INTRODUCTION

Breast milk is optimal baby nourishment. Breast milk contains antibacterial agents and bioavailable nutrients that are essential for infants’ healthy growth and development and protection against gastrointestinal, respiratory, and ear infections [1]. It changes daily and throughout lactation. EBF is breastfeeding an infant exclusively for the first six months. EBF is a kid’s first vaccine and has the greatest potential to reduce child mortality [2]. EBF is essential for child survival and health [3]. Breastfeeding helps achieve global nutrition, health, survival, economic growth, and environmental sustainability goals. WHO and UNICEF suggest breastfeeding within one hour after delivery, exclusively for six months, and with safe and appropriate supplemental foods for two years or more. 38% of 0–6-month-olds worldwide were exclusively breastfed in 2012 [4]. This rose to 40% in 2016. The global EBF objective for 2025 is 50%. After agreeing on the 2025 targets, WHO and UNICEF formed the Global Breastfeeding Collective with high 2030 aim [5]. Some resource-poor countries breastfeed longer than high-income countries. Between 2012 and 2030, the global rate of NEBF (Non Exclusive Breastfeeding) would drop from 62% to 33%, or 67%, by the end of 18 years [6]. Achieving 70% EBF by 2030 is possible. World Breastfeeding Week, held from 1 to 7 August, promotes breastfeeding and improves baby health. Newborns who started breastfeeding 2–23 hours after birth have a 41% higher risk of dying in the first 28 days than those who started within an hour [7]. Global data demonstrates that breastfeeding within 24 hours of birth followed by EBF reduces infant mortality by 45%. Suboptimal breastfeeding habits, particularly NEBF, cause 11.6% of under-5 fatalities, or 804000 in 2011. Despite a recent drop, Nepal’s undernourished child rate remains high. The Government of Nepal promotes breast feeding within one hour of delivery, avoids pre-lacteal feeding, and promotes EBF for the first six months to meet WHO standards [8].  Nepal signed the SDGs. Breastfeeding is a social norm and universal practice in most cultures, but it is also a learned behavior subject to socioeconomic, educational, and cultural influences [9]. Breastfeeding intent increased with mother education. One of the biggest influences on EBF is maternal education. In health promotion, self-efficacy is crucial because good behavior requires motivation and persistence beyond awareness of the advantages [10]. This can help health care practitioners anticipate breastfeeding time and EBF success to identify mothers at risk of early breastfeeding cease [11]. Mothers require breastfeeding assistance and encouragement. Having family, peer, and partner support for breastfeeding increased breastfeeding intent. Perceived personal and professional support affects breastfeeding [12]. Nepalese moms still follow detrimental cultural behaviors such pre-lacteal meals, late breastfeeding, and refusing EBF. The Nepal Demographic Health Survey (NDHS) found that EBF among children under 6 months increased from 53% in 2006 to 70% in 2011, but declined to 66% in 2016 [13]. According to NDHS 2016, 6% of children got breast milk with non-milk liquids, 10% with other milk, and 12% with complementary foods. Recent urbanization, infant formula marketing, and maternal employment outside the house have reduced breastfeeding globally [14]. The breastfeeding practices in Nepal vary by province and community. However, children in rural areas practice EBF for 4.5 months, compared to 3.9 months in urban areas, and Province 1 has the lowest length (3.3 months) and Province 6 the greatest (5.4 months) [15]. Most Nepalese breastfeeding indices are low. Positive maternal knowledge and attitude about nursing increased breastfeeding intent and success. A mother must have information, motivation, support, and a happy breastfeeding experience to breastfeed [16]. Although societal, cultural, and religious beliefs influence breast feeding, maternal baby feeding attitude is a greater independent predictor [17]. Mothers with favorable attitudes on breastfeeding are more likely to breastfeed longer and succeed. However, negative attitudes of women concerning nursing are a huge impediment. Several research have examined breastfeeding knowledge, attitude, practice, social support, and self-efficacy worldwide, but few have examined Nepalese moms [18]. No Nepalese EBSSS studies examined breastfeeding knowledge, attitudes, self-efficacy, and social support, which may differ from other studies. Thus, this study used the EBSSS to assess EBF knowledge, attitude, self-efficacy, and social support among breastfeeding moms in Kathmandu, Nepal.

2. MATERIALS & METHODS

A cross-sectional research design was used in the study, cross-sectional study is a type of research design in which data are collected from many different individuals at a single point in time. In cross-sectional research, we observe variables without influencing them. The study was conducted in Norvic International Hospital which was purposively selected according to researcher’s convenience. It is one of the leading corporate N=150 bedded super-specialty hospital located in Thapathali. Private hospital was selected as there is an assumptions that most of the respondents are employed/well educated and are likely to breastfeed. Also, most of them have high concern for body image in relation to exclusive breastfeeding. The study population for the study were breastfeeding mothers having children who were 0-24 months of age and were selected by using non-probability purposive sampling technique falling under inclusion criteria.

n = Z2 × PQ/d2

Where:

 n = represents the desired sample size

Z = the normal standard deviate, whose value at 95.0 % confidence level is 1.96

 P = current EBF prevalence rate  0.66 (MOHP, New ERA, ICF& DHS Program 2017)

Q = 1-P = 0.34

d = the set margin of error 0.05.

Thus, minimum sample size n = 344.822 or n = 345. A five percent increase was applied to the figure in order to account for the possibility of non-respondents or inaccuracies in the recording. Consequently, the total number of samples comprised 362. We used a questionnaire that we devised ourselves to collect socio-demographic information as well as information about the mothers’ breastfeeding practices. The Exclusive Breastfeeding Social Support was also used to evaluate the mothers’ knowledge and attitudes on breastfeeding. This evaluation was conducted by the Iowac social support of breastfeeding. It consists of a Likert scale with three points: a) not helping at all or a great deal less than you would like, b) helping a little less than you would like, and c) helping as much as you would like. Out of the sixteen items, we separated them into three categories: instrumental factors, emotional factors, and informational aspects. “Did Task” was one of the three elements that made up the Instrumental factor. These items reflected the tangible support that the participants had received. One example of an item that reflected emotional support was “Showed Concern.” The Emotional factor consisted of seven components. There were six items that made up the informative factor, and they were capable of capturing informational support that was advantageous. The overall score can range anywhere from 16 to 48, with higher scores indicating lower levels of social support. The individuals that participated were recognized, and they gave their informed consent in writing. In addition to receiving a briefing, the participants were responsible for self-administering the structured questions. There was a collection of completed questionnaires on the same day. Numeric values were assigned to each and every variable that was supplied. Before two separate entries were made into the computer, the data were double-checked for any errors. For the purpose of data analysis, they utilized SPSS software. In order to provide a description of demographic data, knowledge, attitudes, and practices, descriptive statistics were utilized. These statistics included the mean, standard deviations, minimum, maximum, frequency, and percentage numbers. The Chi-square test is a statistical method that involves comparing groups based on demographic factors in order to determine the significance of knowledge, attitudes, practice, self-efficacy, and social support. Statistics were judged to be significant when the ‘p’ value was less than 0.05.

3. RESULTS & DISCUSSIONS

3.1 Socio-demographic Information of the Respondents

Among the total number of 362 respondents, more than half 202 (55.8%) were >25 years old. Regarding the educational status of respondents more than half 196 (54.1%) were SLC passed and above education. Majority of respondents i.e. 310 (85.9%) were Hindu. More than half i.e. 216 (59.7%) had ≥6 months old babies. More than half i.e. 211 (58.3%) earned Rs. <30,000 monthly About 14 (3.9%) participants had home delivery. Near to two third i.e238 (65.7%) respondents had normal deliveries and more than one third i.e. 124 (34.3%) had undergone caesarean section. The one forth respondents, i.e. 91 (25.1%) didn’t receive antenatal breastfeeding education. About 203 (56.1%) participants were primipara. The majority of respondents 317 (87.6%) were unemployed. About near to two third of respondents 224 (61.9%) started breastfeeding within 1 hour of delivery. Among all respondents 8 (2.2%) didn’t feed the colostrum. All 362 (100%) participants didn’t give the pre-lacteal feeding to their baby, nearly two third of participants 232 (64.1%) did exclusive breastfeeding for 6 months. The Chi-square test for independence indicated significant association between religion and IIFAS, X2 = 20.168a, p-value = <0.001, Cramer’s V = 0.24. The association between age of mother, education, age of baby, income, place of delivery, type of delivery, antenatal breastfeeding education, parity, occupation, initiation of breast feeding, Colostrum feeding and IIFAS score were not significant. Chi-square test for independence indicated that the association between religion and BSES-SF score was significant X2 = 6.909 a, p-value = 0.009, phi = -0.14. The association between antenatal breastfeeding education and BSES-SF score was significant X2 = 9.009 a, p-value = 0.003, phi = -0.16. The association between initiation of breast feeding and BSES-SF score was significant X2 =4.910a, p-value =0.027, phi = -0.12. The association between Colostrum feeding and BSES-SF score was significant X2 =13.56a, p-value =<0.001, phi = -0.19. The association between age of mother, education, age of baby, income, place of delivery, type of delivery, parity, occupation and BSES-SF score were not significant. Chi-square test for independence indicated that the association between educational status and EBSSS score was significant X2 = 17.556a, p-value = <0.001, phi = 0.22. The association between income and EBSSS score was significant X2 = 5.125a, p-value = 0.024, phi = 0.12. The association between place of delivery and EBSSS score was significant X2 = 34.941a, p-value = <0.001, phi = 0.31.The association between type of delivery and EBSSS score was significant X2 = 4.304a, p-value = 0.04, phi = 0.11. The association between Colostrum feeding and EBSSS score was significant X2 =24.366a, p-value = <0.001, phi = -0.26. The association between age of mother, religion, age of baby, antenatal breastfeeding education, parity, occupation, initiation of breast feeding and EBSSS score were not significant.

3.2 Factors influencing on IIFAS

Additionally, ordinal regression was utilized in order to investigate the statistically significant variable (faith) that was found in the Chi-square test. We used ordinal regression to determine the extent to which respondents’ religious beliefs influenced their likelihood of expressing a favorable attitude about formula feeding, a neutral attitude toward nursing, or a positive attitude for breastfeeding. There was a statistically significant difference between the two models (x2 = 11.089, p-value = 0.001), which indicates that the final model provides a considerable improvement over a model that merely includes the baseline intercept. When compared to simply making educated guesses based on the marginal probabilities for the result categories, this indicates that the model provides a more accurate prediction. The value of the Pearson’s chi-square test for the goodness of fit was 2.299, and the significance level was 0.129. Since this value is greater than 0.05, it indicates that the model is successful. In terms of the variance in knowledge and attitude regarding breastfeeding, the model as a whole explained between 3% (Cox & Snell R Square) and 8.9% (Nagelkerke R Square). Three hundred and three percent was the predicted response category for a good attitude toward nursing. According to the data presented in the table that follows, religion was the only factor that contributed statistically meaningful information to the model. Taking into account all of the other components in the model, the odds ratio for religion was 6.081 (95% confidence interval = 2.230, 16.578), which suggested that respondents who identified as Hindu were over six times more likely to report having a good attitude towards breastfeeding than those who identified as belonging to other religions.

 Table 01: Factors influencing on IIFAS

Characteristics		B	S. E	Wald	df	Adjusted OR (95% C.I.)	p-value
Religion
Hindu		1.805	.5117	12.443	1	6.081 (2.230, 16.578)	< .001*
Other		0a				1

Note: a = Set to zero because this parameter is redundant

* = p-value < 0.05

IIFAS = Iowa Infant Feeding and Attitude Scale

3.3 Factors influencing on EBSSS

The Chi-square test was used to further investigate statistically significant variables, such as education, income, place of delivery, kind of delivery, and colonoscopy feeding. Binary logistic regression was then used to further investigate these variables. For the purpose of determining the influence of a variety of characteristics on the chance that respondents would report having a low or high level of social support for exclusive breastfeeding, direct logistic regression was carried out. A statistically significant x2 value of 39.29 and a p-value of less than 0.001 indicate that the whole model, which encompassed all predictors, was able to differentiate between respondents who reported poor social support and those who reported high social support. Given that the Chi-square value for the Hosmer-Lemeshow Test is 0.039 and the significance level is 0.843, it may be concluded that the model is supported because this value is more than 0.05. At the same time as it properly identified 90.3% of the cases, the model as a whole explained between 10.3 (Cox & Snell R Square) and 21.3 (Nagelkerke R Square) of the variance in social support for exclusive breastfeeding. Education, place of delivery, and colostrum feeding were the only three of the independent factors that offered a unique contribution to the model that was statistically significant, as seen in the table that follows.Colostrum feeding was the most significant predictor of reporting a high level of social support, with an odds ratio of 11.831 (95% confidence interval = 2.289, 61.144). This indicates that respondents who followed the Colostrum feeding protocol were over 11 times more likely to report high levels of social support compared to those who did not follow the Colostrum feeding protocol, even after taking into account all of the other factors being considered in the model. After adjusting for all of the other characteristics in the model, the odds ratio for location of delivery was 7.362 (95% confidence interval = 2.208, 24.542). This suggested that respondents who had given their babies in an institution were almost seven times more likely to report having a high level of social support than those who delivered their babies at home. In terms of the education of the mother, the odd ratio of 3.618 (95% confidence interval = 1.535, 8.530) suggested that respondents who had completed their secondary school education or above were more than three times more likely to report having high social support than those who were illiterate or had completed less than their secondary school education.

Table 02: Factors influencing on EBSSS

Characteristics	B	S.E.	Wald	df	Adjusted OR (95% C.I.)	p-value
Education
Illiterate and < SLC					1.000
SLC pass and above	1.286	0.438	8.637	1	3.618 (1.535, 8.530)	0.003*
Place of delivery
Home delivery					1.000
Health institution	1.996	0.614	10.556	1	7.362 (2.208, 24.542)	0.001*
Colostrum feeding
No					1.000
Yes	2.471	0.838	8.693	1	11.831 (2.289, 61.144)	0.003*
Constant	-2.520	0.980	6.612	1	0.80	0.010

Note: * = p-value < 0.05

EBSSS = Exclusive Breast Feeding Social Support Scale

3.4 Factors influencing on Exclusive Breastfeeding Practice

Statistically significant variables in Chi-square test were further examined using binary logistic regression. Direct logistic regression was performed to access the impact of number of factors on the likelihood that respondents would report that they did Exclusive Breastfeeding for less than six month or complete six month. The full model containing all predictors were statistically significant x2 = 15.552, p-value <0.001, indicating that the model was able to distinguish between respondents who did Exclusive Breastfeeding for less than six month or complete six month. The Chi-square value for Hosmer-Lemeshow Test was 0.068 with a significance level of 0.967, this value is larger than 0.05, therefore indicating support for the model. The model as a whole explained between 0.042 (Cox & Snell R Square) and 0.058 (Nagelkerke R Square) of the variance in social support for Exclusive Breastfeeding, and correctly classified 66.3% of cases. As shown in the table below, two independent variables (age of mother and occupation) made a unique statistically significant contribution to the model. The odd ratio of 1.689 (95% C.I. = 1.079, 2.644) for age of mother, this indicated that respondents who ≤ 25 years old were over 1 times more likely to report completed Exclusive Breastfeeding for six month than who were > 25 years old. The odds ratio of 2.668 (95% C.I =1.404, 5.069) for occupation, this indicated that respondents who unemployed were over 2 times more likely to report completed Exclusive Breastfeeding for six month than who were employed.

Table 03: Factors influencing on Exclusive Breastfeeding Practice

Characteristics	B	S.E.	Wald	Df	Adjusted OR (95% C.I.)	p-value
Age of mother
> 25					1.000
≤ 25	0.524	0.229	5.256	1	1.689 (1.079, 2.644)	0.022*
Occupation
Employed					1.000
Unemployed	0.981	0.327	8.982	1	2.668 (1.404, 5.069)	0.003*
Constant	-0.492	0.314	2.454	1	0.611	0.117

Note: * = p-value < 0.05

3.5 Correlations between IIFAS, BSES-SF, EBSSS and EBF Practice

Due to the fact that the data were non-parametric and categorical, the Spearman’s (rho) correlations coefficient was utilized in order to investigate the relationship between knowledge and attitude regarding breast feeding (as measured by IIFAS), breastfeeding self-efficacy (as measured by BSES-SF), exclusive breast feeding social support (as measured by EBSSS), and exclusive breastfeeding practice. According to the results of the study, there was a weakly negative association between breastfeeding self-efficacy and knowledge and attitude regarding breastfeeding (rho = -0.02). The respondents’ level of nursing self-efficacy decreases in proportion to the amount of breastfeeding knowledge and attitude they possess. The coefficients of determination for the link between breastfeeding knowledge and attitude, exclusive breastfeeding social support, and exclusive breastfeeding behavior were 0.011 and 0.079, respectively. This relationship was weakly favorable. There is a correlation between the respondents’ level of knowledge and attitude on breastfeeding and the amount of social support and exclusive breastfeeding practice that they actually engage in. The coefficient of determination (rho) for the connection between breastfeeding self-efficacy and exclusive breastfeeding social support and exclusive breastfeeding practice was 0.007, and the coefficient of determination (rho) was 0.112*. When individuals have a higher level of self-efficacy regarding breastfeeding, they are more likely to get social support for exclusive breastfeeding and to practice exclusive breastfeeding. The correlation coefficient (rho) between exclusive breastfeeding social support and exclusive breastfeeding behavior was -0.06, indicating a weakly negative association between the two. The respondents’ exclusive breastfeeding habit decreases in proportion to the amount of social support they receive for exclusive breastfeeding.

Table 04: Spearman’s (rho) correlations coefficient between IIFAS, BSES-SF, EBSSS and EBF Practice

	Variables	Knowledge & attitude	Self-efficacy	Social support	EBF practice
1	IIFAS	­-	-0.02	0.011	0.079
2	BSES-SF		–	0.07	0.122*
3	EBSSS			–	-0.06
4	EBF practice				–

Note:- * = Correlation is significant at the 0.05 level (2-tailed)

IIFAS = Iowa Infant Feeding Attitudes Scale

BSES-SF = Breastfeeding Self-efficacy Scale Short Form

EBSSS = Exclusive Breastfeeding Social Support Scale

EBF = Exclusive Breastfeeding

3.6 Discussions

To our best knowledge, this was the first study that examined social support of breastfeeding among breastfeeding mothers using an internationally standardized tool (EBSSS) in Nepal. The present study demonstrated that mothers had high social support for breastfeeding. In Chi-square test, the association between educational status, income, place of delivery, type of delivery, Colostrum feeding and EBSSS score were statistically significant [19]. But Education, place of delivery and Colostrum feeding were statistically significant in binary logistic regression. However, the statistically significant association not found between EBSSS score and age of mother, religion, age of baby, antenatal breastfeeding education, parity, occupation, initiation of breastfeeding [20].  A study defined social support as “an exchange of resources between two individuals perceived by the provider or the recipient to be intended to enhance the wellbeing of the recipient [21]. Breastfeeding Support Scale is to measure various types of support that breastfeeding mothers receive, the theoretical framework of the instrument is based on the Theory of Social Support, which emphasizes that the usefulness of social support is dependent on the recipient’s perception. It is divided into three domains: emotional, instrumental, and informational breastfeeding support. Higher scores indicate more social support. Mothers need support and encouragement for breastfeeding [22]. Breastfeeding intent was associated with having family, peer and partner support for breastfeeding. In present study 89.8% mothers had high social support. But the study done in Cyprus shows that overall social support was moderate. In present study the odds ratio of 7.362 (95% C.I = 2.208, 24.542) for place of delivery, this indicated that respondents who had institutional delivery were over 7 times more likely to report high social support than those who delivered in home [23]. In Nepal especially in joint family, usually the mothers doesn’t have the decision making power/role and they are affected by the decision making from partner, other family members and relatives, so that the mothers who had high social support were more likely to delivered at health institution [24]. So the breast feeding also affected by the advice from family members or relatives. In present study the odd ratio of 3.618 (95% C.I = 1.535, 8.530) for education of mother, this indicated that respondents who had SLC passed and above education were over 3 times more likely to report high social support for breastfeeding than who had illiterate and less than SLC pass. Efforts to encourage EBF need to address social support for mothers, especially those with lower education [25]. Social supports for mothers mostly come from their parents or family and their husbands; these supports tend to be positive but relatively low due to inadequate information about EBF from those closest to the mothers Indonesia, Cyprus [26]. So that there is need to give much information’s about breastfeeding to fathers, other family members and relatives.  Emotional, appraisal, and informational support were perceived as effective support for breastfeeding initiation and duration [27]. In present study there is no significant association between social support and EBF practice. However the study done in Canada shows that women with high social support significantly increased probability of EBF for 6 months. Study done in Malaysia indicated that EBF for six months and support from spouse was significantly related (OR:2.39, 95% CI:1.01–5.65) [28]. The study done in North Florida results that mothers had got most support from baby’s fathers but felt they needed more support from the fathers. Study done in South Korea indicated that mothers receiving informational, emotional support from mothers, mothers-in-law, friends and other relatives influenced their infant-feeding decision [29]. Study done in Turkey shows that considering the relationship between social support and breastfeeding self-efficacy, breastfeeding practice can be promoted by sensitizing family and society to support breastfeeding women. Partners, family members and relatives were a strong source of support for married mothers, and tended to have input on breastfeeding duration. Systematic review indicated that women who have strong desire to breastfeed for longer period of time, confident in their ability to breastfeed and well supported by their own family demonstrated positive and prolong breastfeeding behaviors [30]. African American mothers reported that they received informational and emotional support from healthcare providers and peers, strangers, Family members. A qualitative study take place in Brazil emphasized the importance of knowing, encourage and enhance the presence of social support network for breastfeeding, who has recently given birth, in order to enable their participation and collaboration in membership and maintenance of EBF practice [31]. The interaction between the professionals, the breast-feeding mother and her family is important, as it leads to more efficacious actions for the promotion of breast-feeding. So that future efforts for breastfeeding should take a several approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers [32].

4. CONCLUSIONS

The present study concluded that knowledge, attitude, self-efficacy and social support of breastfeeding were very high. However, the EBF practice was not very high as knowledge, attitude, self-efficacy and social support. So that there is gap between actual and desired EBF practice. It is important to assess the gap between knowledge, attitude, self-efficacy, social support and EBF practice. About near to two third of respondents started breastfeeding within 1 hour of delivery, 2.2% didn’t feed Colostrum and one forth didn’t receive antenatal breastfeeding education. Mothers who delivered baby at home were less likely to report social support than who delivered baby at health institution. Also, mothers who were employed were less likely to practice EBF compared with unemployed. Hence, steps should be taken such as provision of private rooms, refrigerators, and flexible time, for working mothers to breastfeed. It is speculated that providing facilities in work place could increase the rate of breastfeeding. Thus, it is important to provide education on importance of early initiation of breastfeeding, colostrum feeding, and institutional delivery and EBF practice to mothers, fathers and other family members during antenatal visit, postnatal visit and immunization clinics. Strengthening the public health education campaigns to promote effective EBF practice by addressing particularly mother’s occupational needs and effective EBF practices. There is a need to focus on providing social support (emotional, tangible, informational, and encouragement) to mothers.

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