Factors Associated with Maternal Infant Feeding Attitudes in Mumbai,India

Abstract

Dear Editor:

Maternal infant feeding attitudes play a major role in determining a mother's decision to either breastfeed or formula feed.¹ We conducted this questionnaire-based cross-sectional study (May 2009–September 2010) to measure maternal attitudes and identify factors favoring either formula feeding or breastfeeding. The first consecutive 238 mothers currently having an infant child more than 6 months but less than 1 year of age and who were willing to participate were included. Mothers of infant twins and those who were known to have a psychiatric illness or to be human immunodeficiency virus–seropositive were excluded from the study.

After providing informed consent, each mother completed the Iowa Infant Feeding Attitude Scale (IIFAS).² Each mother had to indicate the extent to which she agreed with each of the 17 questions on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” The total attitude scores range from 17 (indicating “overall” attitudes favoring formula feeding) to a high of 85 (indicating “overall” attitudes favoring breastfeeding).²

Ten demographic factors of each mother (age, level of education, work status, oral contraceptive use, tobacco/alcohol use, family type, religion, socioeconomic status, type of residence, and marital relationship in conflict), seven demographic factors of each infant (gender, birth order, gestation, birth weight, type of delivery, place of delivery, and past hospitalization for illness), and 17 infant feeding practices–related factors (Table 1) were noted. Maternal total IIFAS mean (±SD) scores were computed. Bivariate analysis followed by multiple regression analysis was carried out for determining statistical significance of these variables. For multivariate analysis, each IIFAS total score was dichotomized into “poor” score outcome (score of ≤[mean−1 SD]) or “good” score outcome (score of >[mean−1 SD]) and used as “dependent variables” in the three models.

Table 1.

Description of Infant Feeding Practices–Related Variables

Variable, category	n	%	P value^a
Antenatal clinic visits			0.926
1–2	18	7.56
≥3	211	88.66
0	9	3.78
First suckled within (hours of birth)			0.403
<1	53	22.27
1–<4	103	43.28
4–<24	39	16.39
24–<72	23	9.66
≥72	20	8.40
Prelacteal feeds given			0.453
Yes	81	34.03
No	157	65.97
Colostrum given			0.442
Yes	208	87.39
No	30	12.61
Postlacteal feeds given			0.205
Yes	50	21.01
No	188	78.99
Breastfeeding decision taken			0.931
During pregnancy	231	97.06
Postdelivery	7	2.94
Pacifier used			0.150
Yes	100	42.02
No	138	57.98
Family support for breastfeeding			0.996
Yes	235	98.74
No	3	1.26
Privacy for breastfeeding			0.999
Yes	236	99.16
No	2	0.84
Breastfeeding advice received from			0.024
Relative/friend	55	23.11
Radio/television/print media	3	1.26
Doctor/health worker	94	39.49
More than one source	55	23.11
Nobody	31	13.03
Well-baby clinic visits			0.891
1–2	25	10.50
≥3	202	84.88
0	11	4.62
Co-sleeping with baby			0.352
Yes	231	97.06
No	7	2.94
Having relative/friend who is breastfeeding			0.082
Yes	106	44.54
No	132	55.46
History of bottle feeding			0.644
Yes	118	49.58
No	120	50.42
Complementary feeding started at (months)			0.652
<1	15	6.30
1–<4	51	21.43
4–6	84	35.29
>6	88	36.98
Complementary feeding decided by			0.001
Mother	118	49.58
Mother and father	13	5.46
Relative/friend	9	3.78
Doctor/health worker	98	41.18
Past history of successfully breastfeeding child			0.017
Yes	155	65.13
No	16	6.72

P value obtained by multivariate logistic regression. A value of P<0.05 was significant (by two-tailed test).

The mean age of mothers was 24.9 years (SD 3.9; range, 18.0–42.0). The majority of the mothers belonged to the lower socioeconomic strata of society (217, 91.18%) and were poorly educated (219, 92.02%). Their total IIFAS mean±SD scores were 67.13±4.90 (range, 51.0–78.0; median, 68.0). which indicated that they had infant feeding attitudes that were “overall” favoring breastfeeding. Sixty-six (27.7%) mothers had started complementary feeding before their infant was 4 months old. Only 83 (34.9%) mothers had exclusively breastfed their babies for a period of 4–6 months. Multivariate analysis revealed that none of the maternal or infant demographic factors was associated with attitudes favoring either formula feeding or breastfeeding. However, three infant feeding practices–related factors (viz., “mother receiving advice related to breastfeeding from more than one source,” “doctor or health worker deciding to start complementary feeding,” and “mother not successfully breastfeeding in the past”) were independently associated with maternal attitudes favoring formula feeding (P=0.024, odds ratio=0.10, 95% confidence interval 0.01–0.75; P=0.001, odds ratio=0.09, 95% confidence interval 0.02–0.40; and P=0.017, odds ratio=5.61, 95% confidence interval 1.37–23.02, respectively; Table 1). None of the 17 infant feeding practices–related variables was associated with attitudes favoring breastfeeding.

To the best of our knowledge, this is the first Asian study that has measured and analyzed maternal infant feeding attitudes. Moore and Coty³ and Flaherman et al.⁴ in the United States conducted focus group discussions with mothers in the postpartum period and found that receiving advice related to breastfeeding from more than one source was confusing and a major source of frustration for several participants. Sittlington et al.⁵ in Northern Ireland and McCann et al.⁶ in the United States have also reported that mothers who had not successfully breastfed in the past tended to have attitudes favoring formula feeding.

The National Family Health Survey-3 for India has reported that the exclusive breastfeeding rate at 6 months is still only 30%.⁷ The results of the present study are being used to improve maternal attitudes toward breastfeeding in our setting. First, pregnant women attending antenatal clinics and mothers attending well-baby clinics are being counseled that not only is breastmilk the most complete form of nutrition for infants up to 6 months of age, but it also has unparalleled long-term immunological, anti-allergic, developmental, and psychological benefits.⁸ Second, mothers who have not successfully breastfed in the past are receiving additional attention. Third, certified “lactation consultants” are now attending the postnatal wards and well-baby clinics to impart “uniform and practical advice” to mothers to solve issues related to lactation difficulties. Fourth, in-service training programs on breastfeeding and lactation management are being held for all resident doctors, nurses, and nurse aides to ensure that they do not give any wrong advice. We are hopeful that these measures will eventually result in improved exclusive breastfeeding rates.

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