January 2000, Volume 50, Issue 1

Original Article

Decline in Breast Feeding, Who is to be blamed?!! A Study of Knowledge, Attitude and Practice of Breast Feeding amongst Nurses

Shahida Rasheed  ( Baqai Medical University, Karachi. )
Lubna A. Baig  ( Baqai Medical University, Karachi. )
Irfanullah Siddiqui  ( Baqai Medical University, Karachi. )


Objectives: Breast-feeding is on the decline. Very often the first introduction to bottle-feeding is facilitated in the maternity units. This reduces the chances for the mother to breast feed successfully. The objective of the study was to evaluate the knowledge, attitude and practices of breast-feeding amongst the nurses working in the maternity units.
Subjects: Nurses working in the maternity units of North Naziniabad, Karachi.
Design/Methodology: A cross-sectional study was conducted in the nrnternity units of North Nazimahad,Karachi. The Nurses were interviewed through a structured questionnaire.
Results: Out of 110 nurses working in the units, interviews of 70 nurses were obtained.The survey reveals that out of 70 nurses only 16 were qualified. The result shows that the nurses know little about successful lactation management and their role in the promotion and support of breast-feeding. There was a significant difference (P<0.00) between qualified and non-qualified nurses as regards management of different aspects of breast-feeding.
Conclusion: There is a huge gap between what is desired and what is available.lntensive training programs should be organized to enhance nursing activities for the required services in order to promote and support breast-feeding (JPMA 50:8, 2000).


Prevention is a complex notion, but its definition is relatively simple: anticipatory action taken to reduce the possibility of an event or condition occurring or developing, or to minimize the damage that may result from the event or condition if it does occur. In the coming years health management would be relying heavily on prevention. Amongst the various strategies, Breast-Feeding needs special mention, as it is most cost effective and beneficial1.
Breast-feeding has declined in the recent decades throughout much of the developing world, including Pakistan2-4. The failure to breast-feed, early cessation and less than optimal breast-feeding practices all have a negative impact on child and family health and well-being5. Pakistan has high infant mortality rate (95 per 1000 live births6. The major contributors are diarrhoea, acute respiratory infections, low birth weight and malnutrition7.
Breast-feeding is prevalent in this part of the world, but because of a naive level of following of the western culture and media, women, specially from the low socio­economic strata are also giving it up gradually. If breast-feeding alone is followed and taken up by the health authorities as a weapon to fight against contributing factors8, it would bring in immense benefit9. Promotion of breast-feeding could be done by utilizing a number of strategies and opportunities10, particularly by educating the expectant mothers throughout pregnancy and at the time of delivery.
The proportions of births taking place at health facilities is high in the urban areas of Sindh11. Among all the professionals engaged in health work, nurses merit particular mention. In maternity units, it is the nurses who are in direct contact with the mother and child than the doctor and can influence breast-feeding practices. Recommendations forwarded by an Invitational Asian Regional Lactation Management Workshop says that the nurses’ role on the multidisciplinary team needs to be strengthened. Mechanism by which their skills and confidence levels can be enhanced should be explored and implemented12.
The aim of this study was to assess the knowledge attitude and beliefs of the nurses regarding lactation management in the maternity units of a middle income community of Karachi.
A cross-sectional survey was conducted amongst “nurses” working in 17 maternity units of North Nazimabad which is a middle income locality of Central District of Karachi. From a total of 110 nurses working in the maternity units, 70 nurses were included in this study as the rest of them were either having night duties or were not on duty at the time of survey. All the nurses were interviewed through a structured questionnaire which included the knowledge, attitude and beliefs regarding breast-feeding.
The data was entered on Dbase 3 and analyzed through the SPSS statistical package. The results were obtained using percentages and frequencies.


Out of the 70 “nurses” who were interviewed, 16 (23%) were qualfied i.e., they possessed the degree of nursing from a recognized institute. Their age ranged from 18 to 50 years, their level of education ranged from the 8th grade to 12th, salary range was from Rs.800 - 3000 with working hours of 6 to 24. Their average years of experience was 6 years. When enquired about the time of initiation of “top-feed” (i.e., any milk besides breast-milk), 41(58.55%) recommended from the very first day, while 20 (28.57%) said that it should not be given at all. There was a significanta difference in the knowledge of qualified versus non-qualified for giving colostrum (p<0.001), exclusive breast-feeding (p

Table 2 illustrates the commonly occurring condition for which the nurses were able to advise correctly. There was a significant difference in the knowledge of qualified versus non-qualified for advising mothers for continuing lactation if the child has diarrhoea (p<0.00 1) and mother has a flat nipple (p<0.026).
Regarding their beliefs out of the 70 nurses interviewed, 39 (55.6%) believed that breast-feeding had adverse effect on the figure of the mother (Table 4). Only 38 (54.28%) were aware of the existence of breast-feeding technique while 32 (45.72%) were unaware and took it as a natural phenomenon in which no technique is involved (Table 3).

Three important and common causes of lactation failure were cited and the nurses were asked to identify whether they were true or false. None of the nurses could comprehend that all the three statements: improper latching-on, mother if not willing to breast-feed and if breast-feeding is initiated late, were true. The nurses when asked to recommend a brand of milk suitable for a newborn all of them came up with one or another name as they thought it was healthy.
When asked from nurses, it was noted that 65% of the mothers do enquire about breast-feeding from the nurses. When the nurses were asked about their commitment to preach breast-feeding, majority of the non-qualified nurses (68.5%, n54) thought that it is the duty of of the doctor to advise for breast-feeding with a significant difference (p<0.007), between qualified and non-qualified nurses as can be seen in Figure.


Internationally the ratio of doctors and paramedics is 1:4, while in Pakistan it is the opposite i,e., for every 4 doctors there is only 1 paramedical staff The ratio for a nurse against population is 1:5200. Due to this dearth many health facilities have fallen back upon engaging nurses who are non-qualfied especially so in the maternity units which are managed privately. The outcome of the survey is shocking as nurses in general lack enthusiasm and there is hardly any motivation to actively take part in improving the knowledge.
It seems that nurses do not think breast-feeding promotion activities as their assignment. Interesting aspect of this dilemma is that the doctors think that it is the duty of the nurse and due to the lack of concern of key health providers13, the sufferer are the women and their children. There has to be an open dialogue between the nurses and doctors for delegation of this all important job.
The nurses lack ability to advise mothers during commonly occurring conditions14 which compel them to undertake bottle-feeding. Practice of this partial or whole bottle-feeding adds to a lot of economical and nutritional problems. The nurses do not seem to realize the disadvantages of bottle-feeding. The mis-beliefs regarding breast-feeding are deep rooted which has a detrimental effect upon their attitudes and practices. It is imperative that the techniques of lactation management15 should be updated for qualified and non-qualified nurses presently working in the maternity units. Training in lactation management should be mandatory for nurses working in a maternity unit. Education of the nurses should amply cover the rectification of their beliefs and practices. The short courses can concentrate upon dealing with first hand information to the nurses about the time of initiation of breast-feeding, the advantages of exclusive breast-feeding, advantages of room ing-in16, disadvantages of bottlefeeding, the techniques and management of lactation and its complication. Regular monitoring cells should be formed by the Government to evaluate the practices in different areas. Nurses can be an asset in the work of promotion, protection and support of breast-feeding, provided they are adequately motivated. A policy for breast-feeding was developed by the National Steering Committee on Breast-feeding, based upon WHO/UNICEF guidelines10 to expedite the achievement of their objectives. The incentive of enlisting themselves as “Baby Friendly” upon completion and implementation of their policies was given to all hospitals/maternity units. Presently intense training in lactation management is going on in the study area and hopefully has improved the situation, however such studies must be repeated to assess the effect of this Baby Friendly Initiative.


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