A Community Based study on Breast Feeding Practices . in Gampaha District ‘

Objective: To determine the prevalence of exclusive breast feeding, the predominant breast feeding rate and the bottle feeding rate, and to identify the factors influencing exclusive breast feedingin the Gampaha district. Methodology: A sample of 1075 mothers, each with a child aged less than 365 days was identified from two randomly selected Medical Officer of Health areas, Information related to birth and feeding practices were obtained using an interviewer-administered structured questionnaire. Mothers’ knowledge on breastfeeding was also assessed. Results: Initiation of breast feeding was universal, with an exclusive breast feeding rate (EBF)of 63.7%. Logistic regression analysis identified that ‘mother working outside the home’, delivery being not a normal delivery, not receiving antenatal education and poor knowledge on EBF were negatively associated with EBF. Conclusions: Even though an improvement in the EBF rate is seen over the past years, thereis a need to strengthen antenatal and post-natal practices to encourage EBF and to develop innovative strategies to promote EBF among working women.


Introduction
Breast milk provides the best possible nutrition for the child's physical and mental development. Studies have continued to demonstrate the reduction of mortality and morbidity associated with breast-feeding (1,2). Even though the importance of breast-feeding has been well documented, exclusive breast-feeding is a relatively newentity. Studies have shownthatall beneficial effects of breast-feeding are enhanced by ensuring the practice of exclusive breastfeeding (EBF) during thefirst 4 -6 monthsof life (3).
Reports from Sri Lanka in the 1980s and 1990s indicate that even though initiation of breastfeeding has been almost universal, introduction of formula milks early in infancy has been a frequent occurrence (4,5). In view of the emphasis placed on EBFas a factor promoting child health, this study was carried out to determine the prevalence of exclusive breastfeeding, predominant breast-feeding rate and bottle-feeding rate, and to identify factors influencing EBF.

Methodology
A community based cross-sectional descriptive study design was used to study the breast feeding practices in the Gampaha district, one of the three districts in the Western Province of Sri Lanka, with a population of approximately 1,400,000.
Twooutof the 14 health areas in the district were randomly selected. All mothers resident in the selected areas whohad a child less than 365 days of age on the day of the study, were identified using the Birth and Immunization Register maintained by the Public Health Midwife as the sampling frame. A total of 1075 mothers were thus identified. Mothers of infants who had congenital abnormalities or wereill at the timeofthe study, were excluded, An interviewer administered structured questionnaire was used to collect information related to the birth of the child, feeding during the first few hours after birth, hospital practices related to infant feeding, reasons for starting other fluids, antenatal and postnatal support for exclusive breast-feeding and the current feeding history. The questionnaire included a 24-hour recall of food/fluids given to the infant. All interviews were conducted during a home visit and the respondent was the mother. A questionnaire was used to assess the level of knowledge of the mother on breast-feeding. The score developed, was used to assess the level of knowledge.
Ten pre -intern medical officers were trained as interviewers. Data collection of all study units from one health area was carried out within a period of approximately 2 weeks.
A multivariate analysis u s i n g a logistic regression model was applied to identify the factors associated with exclusive breast-feeding.

Results
Of the 1075 infants, 51.7 % were males and 48.3% females. 95.1% were singleton deliveries while 4.9%were twin deliveries. The majority, 79.6%, were normaldeliveries and 15% were ' indicating that breast-feedingis universal in the study area, The EBF rate was 62.9% with the predominant breast-feeding rate being 75.8%. Predominant breast-feeding rate was higher than the EBF rate,indicating that some mothers gave other fluids and food items during first four months. (Table 1) Study of the EBFrate by age (in months) shows that this rate was lowest during thefirst month (54.3%), increased to 71% during the second month and then declined to 63.3% and 58.7% during the third and the fourth month respectively ( Table 2). Of the infants in the first month oflife, 43% were given the ayurvedic preparation referred to as 'Ratha kalke' and/or other fluids such as coriander water, tea and water. According to the WHO (5), an infant if given any medication in addition to breast milk could be considered as being exclusively breastfed. Assuming that 'Ratha kalke' medication, exclusive breast-feeding rate during the first month increases to 65.2%. Comparison of EBF  Table 3. The variables shown to have a significant negative influence on EBF were: poor knowledge on exclusive breastfeeding, delivery other than normal vaginal delivery, not receiving antenatal education on breast feeding and the mother working outside the home.
Out of 348 mothers who introduced artificial milk, 48 (13.5 %) did so before the infant completed 4 months of age. Among the reasons for introduction of artificial milks were: not enough milk (60.9%), advised by medical personnel (50.2%) and advised by field level health personnel (33 %). Elders influenced the decision in 29.3% of the mothers. The majority of mothers gave more than one answer (Table 5). Of the entire group, 40 (3.7%) mothers had iscissis completely stopped breast-feeding at the time of the study, among whom 0.74% of mothers had done so before the infant completed 6 months of age. The majority (75%) of the mothers did so as, they believed that they did not have enough milk. Other common reasons given were: poor suckling by baby (42.5%), refusal by the infant (35%), and having to go back to work (12.5%). Many mothers gave more than one reason( Table  4). The working mothers did not commonly practice giving expressed breast milk. Only 20% of the working mothers had routinely given expressed breast milk.  4 Some mothers gave more than one reason Being a cross sectional study, each age group included a different birth cohort of children. The study ofvariationsin the EBF rates by the age of the child was clearly seen with a relatively lower Volume 7,2002 EBFrates in the group with of 0-1 month old children (65.2%) with 71% the second month and 63% during the 3rd month, Study findings indicated that 32 -35 % of the infants have been given either water or glucose water during the first month oflife and the percentage given other fluids declined to about 5 -15% during the second month. The findings of DHS, 2000 (7) which included a sample from seven provinces of Sri Lanka,shows a higher EBF rate of 83.9% during the first month oflife and a decline as the child grows older (The EBFrate of 65% among infants 2~3 months),the pattern being different from that observed in the presentstudy.
Eventhoughthe available information does not permit a clear explanation for the differences between the findings ofthepresent study carried out in 1999 and DHS, 2000,these differences could be due to variations in the sample characteristics and/or dueto true variationsin the EBF rate among the two groups,specially during thefirst month.
It is possible that in selected population groups, other factors could influence suci changes in EBFpractice. For example, Sorenson et al (8) in their study in theplantation sector in Sri Lanka reported an EBF rate of 73% during the first month, which showed a marked decline to 23% during the second month. Thelikely explanation for this difference is that the women in the plantations are a predominantly working population and the change in the EBF practices was related to the mother having to 'return to work', A study carried out in 12 out of the 24 districts in Sri Lanka in theearly '80s, identified employment of women outside the home as a factor that influenced early introduction of artificial milk (4). It is worth noting that even after nearly two decades of highlighting the influence of work on breast-feeding and after adopting changes to the Maternity Benefits Ordinance (9), employment of the mother still continues to be an important factor which has a negative influenceon breast feeding practices in Sri Lanka. This indicates the need for innovative approaches to be developed to enable workingwomen to continue breast-feeding such as promoting the use of expressed breast milk.
The practice of exclusive breast-feeding was positively associated with having received educational inputs on breast-feeding during the antenatal period and a satisfactory level of knowledge of the mother on exclusive breast-Journalofthe College of Community Physicians of Sri Lanka feeding. Similar findings have been reported in other studies (10,11). It is reported that in Sri Lanka, almost 98% of pregnant women receive antenatal care (6). Thus, paying more attention to improving educational activities on exclusive breast-feeding aimed at pregnant women during the antenatal period is an important strategy that could be considered to be feasible and effective in promoting exclusive breast-feeding practices.
Mothers who have had a normal delivery, practiced exclusive breast feeding more than mothers whodelivered other wise e.g. caesarian section, a forceps delivery or a vacuum extraction, Perez-Escamilla (12) identified delivery by caesarian section as a risk factor for not initiating breast-feeding, and for breast feeding for less than one month. Paying emphasis on proper managementof mothers with complicated deliveries could promote EBF.
The reasons given for discontinuation of exclusive breast-feeding such as 'not enough milk' (75%), child refusal (35%) and poor suckling by baby (42.5%) are very similar to those documented in other studies from Sri Lanka (4,7).
'Thebottle-feeding rate was 44.4% in the study area. Only 3.7% of the mothers stopped breastfeeding before the age of 1 year, while 32.9% of the infants received artificial "indicating that most mothers practised mixed feeding. The commonest reason for introduction of artificial milk was the assumption that they do not have enough milk. .
The findingsof the study highlight the need for strengthening the existing maternal health services by providing additional training of the relevant personnel, which will enable them to promote EBF,through improved communication strategies.