INTRODUCTION

Breastfeeding (BF) is widely recognised to be the optimal way to nourish and nurture infants. Even with the addition of comple-mentary foods in the second half of the first year, BF continues to be of nutritional, immunological, and psychological signifycance well into the second year and beyond (Cadwell 2002). The Innocenti Declaration on Protection, Promotion and Support of Breastfeeding 1990 recognised that BF was a unique process with manifold advantages (WHO/UNICEF 1990).

In order to achieve global goal for optimal maternal and child health and nutrition, the Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by the World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) to ensure that all maternity facilities, whether free standing or in a hospital, became centres of BF support. A maternity facility could be designated 'baby-friendly' when it did not accept free or low-cost breast milk substitutes, feeding bottles or teats, and had implemented 10 specific steps to support successful breastfeeding (UNICEF website).

The Ministry of Health of Malaysia had been exemplary in its pursuit of the BFHI accreditation.In March 1998, Malaysia was recognised by WHO as the only third world country, after Sweden and Oman, to have successfully accredited all its government hospitals as Baby-Friendly Hospitals. As of July 2005, 117 hospitals in Malaysia were accredited as Baby-Friendly Hospitals (UNICEF 2005a). Despite all these effort, the State of the World’s Children 2005 (UNICEF 2005b) reported that only 29% of babies in Malaysia were exclusively breastfed for the first 6 months from 1996-2005.

OBJECTIVE

The general objective of this study was to assess the knowledge and attitude towards breastfeeding among our pregnant mothers. The prevalence of those who plan to breastfeed and the main source of information about BF were determined.

METHODS

This study was conducted in Selayang Hospital, which was a tertiary referral centre with 960 inpatient beds and 20 clinical disciplines located in the Gombak District of Selangor. It was a Baby-Friendly hospital supporting breastfeeding. The Obstetric and Gynaecology Department took over full obstetric and antenatal coverage including networking of the Northern Zone of Selangor. In 2006, the total number of deliveries in the hospital was 10,790 cases.

This was a cross-sectional study using structured questionnaires to interview pregnant mothers attending the antenatal clinic from 1/3/07 to 31/3/07.Universal sampling method was used. All pregnant mothers who were present for the antenatal sessions within the study period were recruited.

Using a structured anonymous question-naire, the sampled pregnant mothers who had given verbal consent to participate in the study were interviewed. The question-naire encompassed demo-graphic data, knowledge and attitude towards breast-feeding, and main source of information.  Respondents who answered at least 70% of the questions correctly were perceived as having high level of knowledge. Those who answered at least 70% of the questions correctly regarding attitude were regarded as having positive attitude towards BF.

The questionnaires were pre-tested in a different group of antenatal patients prior to the actual study. Analysis of the collected data was done by using SPSS version 12.0.

RESULTS

A total of 288 pregnant mothers attended the antenatal clinics during the study period. Seventy were excluded from the study as 42 of them refused to be interviewed, 27 left the clinic before being interviewed and one of them being a foreigner had language barrier. The remaining 218 were successfully recruited making the response rate of 75.69%, which was within acceptable percentage.

The respondents’ age ranged between 16 – 46 years (mean age of 30.4 years, SD of 5.3 years). The majority of respondents were multigravida (72.9%), being Malay (61.5%) and were married (99.5%). Most of them were housewives (45.4%), attaining at least secondary educational level (85.3%). Only 29.4% of respondents had total household income of less than RM 2,000 per month. Table 1 shows the demographic data of the respondents.

Almost all (96.8%) intended to breast-feed their newborns, the rest were either had no intent or was undecided.

Majority of the pregnant mothers (74.8%) scored high marks in breast-feeding knowledge with total score of more than 70%. Most of them (95.9%) knew that breast milk was the best infant food. Almost all of the respondents agreed that breast milk was good for infant’s resistance towards disease (96.3%), and BF increased bonding between mother and infant (97.2%). Breast milk was mentioned as easy and economical for their infant by 93.1% of the respondents. Most mothers (82.1%) knew that BF helped them in childbirth recovery. Breast milk was recog-nised as a well-balanced nourishing food for infant, and good for avoiding infant allergy by 97.2% and 83.9% of respon-dents respectively. Mothers knew that breast milk helped infant teeth develop-ment (64.2%) and filled up the stomach more easily (73.9%). Majority of the respondents (71.6%) agreed that BF helped to reduce maternal weight. Many mothers (45.4%) thought they should stop BF when infant and/ or mother was sick. Most of them (63.3%) would give clear fluids to the newborn even in exclusive BF to prevent dehydration. Colostrum was known to be good for their infants by 82.6% of respondents. The majority of mothers (81.2%) knew the correct age of weaning. The responses to knowledge of BF are shown in Table 2.

Most mothers (34.9%) gathered BF information from the mass media e.g. television programs, Internet, magazine, newspaper and etc; followed by antenatal class organised by midwives and nurses in the hospitals and health care centres (32.1%). They also gained knowledge from other mothers with BF experience (27.5%) and other personnel (5.5%) e.g. nurses or doctors in clinics or hospitals. Figure 1 summarises the main source of information about BF.

When assessing their attitude, 183 (83.9%) mothers responded positively towards BF. Most of them (86.2%) considered BF as being easier than feeding with infant formula. Most mothers (92.2%) denied BF had negative effect on marital relationship. Majority of respon-dents (91.7%) did not think that BF would make it difficult in taking care of their family. Only 56.9% of the mothers believed they could breastfeed their babies with modesty anywhere. The commencement of BF straight after delivery was known to be important by 98.6%. Many respondents (68.3%) agreed with the banning of the usage of bottles and teats in any hospital unless prescribed by doctor. Overall, 84.9% of the respondents believed that the community encouraged BF rather than infant formula feeding. Many of them (83.0%) would not stop BF when there was discouragement from their husband. The responses of attitude toward BF are shown in Table 3.

DISCUSSION

This study showed that most mothers were knowledgeable and supportive towards BF. The overall prevalence of those who intended to breastfeed their babies was high at 96.8%. Though the respondents were pregnant mothers who had not started BF, their early decision would pose a positive bearing after childbirth. A study by Hoyer et al had shown that the time of decision to breastfeed was important for the length of BF (Hoyer & Pokorn 1998). In her study, 77.3% of mothers decided to breastfeed before they went into labour. By making an early choice, mothers made better intellectual and physical preparation. Relevant information could be attained and the decision made after talking with family members. In this study, the ‘almost-all’ prevalence of intention to breastfeed was consistent with the respondents’ high level of knowledge and positive attitudes towards BF.

The antenatal decision of wanting to breastfeed may not reflect the actual prevalence of BF. Even if a mother was to breastfeed, the commitment of whether it was partial or exclusive and the length of BF was yet to be determined. A study in the neighborhood capital of Bangkok showed that 95% of mothers breastfed their infants up to 3 months, but the prevalence of exclusive BF was relatively low at 62.4% (Li et al.1999). We have no local data on the prevalence of BF among post-partum mothers at 3 months, but it was reported that only 29% of babies in Malaysia were exclusively breastfed for the first 6 months (UNICEF 2005b).   The theoretical declining prevalence of BF practice from antenatal to third and sixth months post-partum was an area for further research. The initiation and successful practice of BF may be affected by various factors including the social, psychological, environmental and practical barrier. Each country with its own policy, race, culture and religion could have different perception on infant feeding. In Northern Ireland, the main barriers to BF were incompatible social norms, making it difficult for mothers to breastfeed successfully (Stewart-Knox et al. 2003).

Out of 218 respondents, 163 (74.8%) were knowledgeable about breastfeeding with total score of more than 70%. They knew that colostrum and breast milk was the best food, good for resistance against disease and allergy, filling up stomach easily, helpful in teeth development and maternal recovery after birth, increased bonding, was easy and economical. A study in Vietnam showed that mothers were less aware of the advantages of BF in helping the mother to recover from childbirth and that it helped infant’s teeth development (Li et al. 2002).

In this study the respondents had two main wrong perception i.e. discontinuation of BF when baby and/or mother was sick and clear fluid was unnecessarily administrated in exclusively breast-fed infants. These misconceptions could be influenced by social and cultural beliefs. Public education or breastfeeding cam-paigns should therefore address these misconceived issues appropriately.

A high percentage of respondents (83.90%) showed positive attitude towards BF i.e. being easier than infant formula, had no negative effect on marital relationship or family care, would com-mence breastfeeding straight after delivery, agreeable to the banning of bottles and teats in hospital and they would not stop breastfeeding even if the husband discou-raged them. This was an encouraging finding among urban mothers-to-be. A study in Baghdad among medical profes-sionals showed that only 76.8% of general practitioners, 70.1% of resident doctors and 68.8% of medical students had a positive attitude towards BF (Al-Nassaj et al 2004).

Although the attitude towards breast-feeding was generally positive, only 56.9% of respondent thought it was appropriate for a mother to breastfeed her baby with modesty anywhere. This was probably due to our social environment, cultural and religious sensitivity. The respondents may believe that self-embarrassment, inade-quate public facilities in providing privacy while BF and difficulty when mothers were working outside home, were barriers towards BF anywhere. This practical issue should be addressed when promoting BF.  Antenatal education about the practice of breastfeeding, milk expression and storage may encourage mothers to continue BF anywhere even in the work place.

This study showed the strength of mass media in disseminating information in urban society. About one third of mothers (34.9%) gathered BF information from television programs, magazine, newspaper and Internet establishing that BF infor-mation could be effective via public education through the mass media. Another one third of the respondents stated the main source of BF information was from antenatal class organised by midwives and nurses in the hospitals and health care centres (32.1%). Comparing to the Bangkok study, there was much room for improvement as 73.3% of the mothers had already taken courses on breast-feeding and childcare prenatal or post-partum (Li et al.1999). Both antenatal and postnatal education program were influential in achieving successful BF (Hoyer & Horvet 2000).

CONCLUSION

Most mothers were knowledgeable and had positive attitudes towards BF. The misconception and negative attitudes had been identified and should be addressed appropriately by the NGO and Ministry of Health. Mass media and antenatal class were the main source of information and should be used to promote BF.