Prevalence, knowledge, attitudes and factors associated with exclusive breastfeeding among mothers in Dhaka, Bangladesh: A cross-sectional study

INTRODUCTION Exclusive breastfeeding is balanced nutrition for growth and development of the infant, prevents stunting as well as protects from infectious and chronic diseases and has also potential to reduce infant mortality. Thus, the study aimed to assess maternal knowledge, attitudes and other factors associated with exclusive breastfeeding practices. METHODS A cross-sectional study was conducted among 385 mothers of children aged ≤12 months in Mother and Child Hospital in Dhaka city, Bangladesh, from June to December 2019 using a structured questionnaire. Data were collected by face-to-face interview from hospital’s outdoors, following simple random sampling process from hospital register list. Chi-squared test and multiple logistic regression models were used to explore the association. RESULTS The prevalence of exclusive breastfeeding was 63.4% for mothers with children aged ≤12 months. Good knowledge (p<0.001) and positive attitude (p<0.01) on breastfeeding were significantly associated with exclusive breastfeeding practices. Housewife (AOR=5.84; 95% CI: 2.42–14.13), literate (AOR=7.16; 95% CI: 1.3–39.36), family monthly income ≥15000 BDT (AOR=5.41; 95% CI: 1.78–16.47), normal delivery (AOR=13.58; 95% CI: 5.29–35.48) and hospital delivery (AOR=3.38; 95% CI: 1.24–9.23) mothers were more likely to follow exclusive breastfeeding practices compared to their counterparts. Moreover, joint family (AOR=0.27; 95% CI: 0.12–0.62) and divorced (AOR=0.12; 95% CI: 0.03–0.58,) mothers had less likelihood of exclusive breastfeeding practices than their counterparts. CONCLUSIONS Good knowledge, positive attitude and some sociodemographic factors were significant with exclusive breastfeeding which are needed to improve for promoting exclusive breastfeeding practices and reducing infant mortality and morbidity. INTRODUCTION Exclusive breastfeeding (EBF) is considered an effective way to provide balanced nutrition, better growth, development of the infant, prevent stunting as well as protect from infectious and chronic diseases1. Simultaneously, it decreases infant morbidity and mortality due to common illnesses2 such as diarrhea or pneumonia etc. The WHO (World Health Organization) and UNICEF (United Nations Children’s Emergency Fund) recommended exclusive breastfeeding for the first six months of age and giving no other food or drink to the infant, not even a single drop of water in this period3. Globally, the exclusive breastfeeding rate is only 41% of infants under six months of age4. The collective target for the global rate in 2030 is 70% for exclusive breastfeeding5. Exclusive breastfeeding rate is comparatively high in Eastern and Southern Africa (55%), South Asia (54%) and lower in the Middle East (30%) and North Africa (29%)6. Moreover, the prevalence of exclusive breastfeeding among South Asian countries was: 54.9% in India, 1.4% in China, 65.2% in Nepal, 37.7% in Pakistan, and 82.3% in Sri Lanka (WHO 2018). In Bangladesh, the prevalence of exclusive breastfeeding was about 55% in children under six months of age7. This lower Research Paper| Population Medicine Popul. Med. 2021;3(September):23 https://doi.org/10.18332/popmed/140132 2 exclusive breastfeeding rate needs proper intervention to promote exclusive breastfeeding to achieve the targets of SDG-3 (Sustainable Development Goals) by reducing infant mortality and morbidity (minimize the neonatal mortality <12 and under-5 mortality to <25) by 20308. Worldwide, exclusive breastfeeding is considered an effective intervention for preventing infant morbidity and mortality and can prevent 1.4 million deaths among children every year2. So, neonatal and infant mortality can be reduced by increasing exclusive breastfeeding practices9. Several factors are impeding the continuation of exclusive breastfeeding practice among lactating mothers in the world, including: 1) Geographical factors such as living area, place of delivery10; 2) Socioeconomic factors such as the education of mother11, occupation of the mother12; and 3) Health-related and individual factors such as mother’s age, mode of delivery, the gender of the child, cultural practices, support and guidance provided by health staff or doctor, etc.8 In addition, Bangladeshi mothers face several factors that hamper them from continuing exclusive breastfeeding practices resulting in increased infant and maternal morbidity and mortality rates. Previous studies report that health facilities and delivery (hospital vs home, normal vs caesarian delivery, etc.) are associated3 with the prevalence of exclusive breastfeeding practices8. However, few studies have been conducted on risk factors associated12 with the prevalence of exclusive breastfeeding practices as well as household, environmental, and cultural factors. No studies have been conducted in Bangladesh on associations among knowledge, attitudes, and some sociodemographic factors with exclusive breastfeeding practices. As a result, there is an urgent need to evaluate knowledge, attitude, and associated sociodemographic factors with exclusive breastfeeding practice. The findings of this study will be useful to governments/NGOs (Non-Governmental Organizations) to improve policy that focuses on resources and interventions to promote exclusive breastfeeding practices that help to achieve SDG-3 (Sustainable Development Goals) and reduce infant morbidity and mortality rates. Therefore, this study has been designed to evaluate maternal knowledge, attitude and factors associated with exclusive breastfeeding among mothers who had a child aged <12 months. METHODS Description of the study area This study was conducted in the district of Dhaka at the Mother and Child Hospital. Dhaka has a population of about 12 million. Mothers from all socioeconomic status attend this hospital due to the availability of maternal and child healthcare services. Therefore, this hospital was considered as being representative of the study population. Study design and study population This cross-sectional study was conducted among mothers who came to the hospital from July to December 2019. A total of 385 mothers were interviewed for the study who came to the hospital’s outpatient department to get treatment related to mother and child. The inclusion criteria were women who had children aged ≤12 months. Exclusion criteria were: the medical condition of the mother; medications which interrupted breastfeeding; and mothers who were diagnosed with severe congenital malformations; and those who had >12 months old children. These conditions were verified by using a health card which was monitored by the duty doctor at the hospital. Sample size estimation and procedure The minimum required sample size was calculated by using a single population proportion formula no = Z2 p q /d2; 5% margin of error, 95% confidence intervals, and estimated to practice EBF 65% of the national rate13. This yielded a sample size of 385 with 10% non-response rate. The mothers were randomly selected from the healthcare register of the hospital and interviewed when they waited for healthcare services. If the selected mother was not interested in the study she was excluded. Data collection Research assistants were recruited and trained for the fieldwork of the study and collection of data by reviewing the questionnaire through teamwork with a researcher. Structured questionnaires were used to collect data. A random sampling approach was adopted to collect information like knowledge, attitude, and some sociodemographic factors through face-to-face interviews. Questionnaire The questionnaire involved some general information questions like sociodemographic information including name, age, education level, occupation, living area, economic status, religion, place, and types delivery, etc. To ascertain maternal knowledge on exclusive breastfeeding, a set of questions was developed. Knowledge on exclusive breastfeeding was measured by asking the mother 10 questions such as benefits of exclusive breastfeeding and colostrum, approach of handling breastfeeding during pregnant condition of mother and infant with diarrhea disease, and other questions about advantages of breastfeeding both for infant and mother etc. Each correct answer was given a score of 1, while a wrong answer was given a score of 0 . The total knowledge score was then calculated and graded on a scale based on standards carried out in previous research, as follows: Good (≥7), medium (4–6) and poor (≤3)14. In the same way, attitude toward breastfeeding was assessed using a series of questions such as exclusive breastfeeding is beneficial for infant and mother, baby can survive without water up to 6 months of age, formula milk is unsuitable for baby and not a better choice for working mothers, and breast milk is more easily digested than formula milk. If the mother agreed with this opinion she was Research Paper| Population Medicine Popul. Med. 2021;3(September):23 https://doi.org/10.18332/popmed/140132 3 given a score of one and 0 if she disagreed or was neutral with the opinion. The total score was then calculated and the attitude was graded as: positive (≥7), moderate (4–6) or poor (≤3)14. Statistical analysis Statistical analyses were performed using IBM SPSS (version 23). Means and standard deviation (SD) were used for numerical data, whereas percentages were used for categorical data. Chi-squared test was used to assess the association of knowledge and attitude on breastfeeding with exclusive breastfeeding practices. Multiple logistic regression analyses were done to assess sociodemographic factors on exclusive breastfeeding practices. The model fitness was tested using Hosmer and Lemeshow test. The adjusted odds ratio (AOR) was calculated to evaluate the strength of the association of sociodemographic factors with exclusive breastfeeding practices at 95% CI for the significance test. A value of p<0.05 was considered statistically significant. RESULTS Table 1 sh