Abstract
Aim : To study the impact of baby friendly hospitals on the knowledge, attitude and practice of breast feeding.

Material and Methods : A prospective cross sectional study was conducted in a 1416 bedded tertiary baby friendly hospital at Mumbai. 150 post natal women with live births were randomly evaluated by questionnaire method, upto third post or fourth post partum day.

Results : In mothers with a normal delivery breast feeding was initiated within half an hour in 8.6% patients and in 78% it was started within half to two hours. While in those with caesarean section breast feeding was initiated within 6 to 24 hours in 74% patients. Majority of the patients practised exclusive breast feeding. Main lactation problems were that of inadequate lactation and inadequate suckling.

Conclusion : The present study shows that most mothers did follow the modern concept of lactation management. These reassuring trends may be attributed to the outcome of regular training on breast feeding imparted to medical and paramedical personnel.

Introduction
The more we know about human breast milk the more we discover about its value in human nutrition and development. The best of formula feeds are not even close to the benefits offered by human breast milk to the growing infant. However, with the advent of modern technologies, urbanization and changing lifestyles the prevalence and duration of breast feeding is on a decline.1 In developing nations like India, abandonment of breast feeding is a significant factor in the death of around 3000 to 4000 infants everyday from diarrhoea and respiratory infections. It is a known fact that though most women want to do the best for their children, they lack information on the benefits of breast feeding, encouragement before and after delivery and an opportunity to integrate breast feeding into their modern lives. Baby friendly hospitals have bridged this gap. This study attempts to evaluate the impact of a baby friendly hospital on knowledge, attitude and practice of breast feeding.

Material and Methods

A prospective cross sectional study was conducted in a 1416 bedded tertiary baby friendly municipal hospital, at Mumbai. Training programmes on breast feeding are regularly conducted in the institute by trained personnel from the obstetrics and neonatology departments for the resident doctors and paramedicals. Besides being a baby friendly hospital, there is a human milk bank to pool and store colostrum, preterm milk and mature milk separately.

In the present study, 150 postnatal women with live births were randomly selected from six obstetric units in the hospital and evaluated by questionnaire method upto the third or fourth post partum day. Data collection was done by four doctors trained in lactation management workshops. Bias was reduced to the minimum by providing sufficient time for the interview and assuring confidentiality of the data provided.

The primary objectives were

1. To assess the level of knowledge about breast milk and evaluate attitudes towards breast feeding.
2. To identify the common sources of information which effectively propagate breast feeding.
3. To determine existing breast feeding practices during the post partum period in a baby friendly environment.
4. To correlate the influence of obstetric anaesthesia and analgesia on breast feeding.

Secondary objectives were

1. To evaluate problems in breast feeding practices in a baby friendly hospital.
2. To identify areas for intervention for a successful lactation programme.

Observation and Analysis
Demographic evaluation showed that the age of the patients in the study group ranged from 18-32 years. 15.3% of patients in the study had not received formal education. 12% were graduates and only one patient was a post graduate. In the study 86.6% of patients belonged to low socioeconomic strata and 86% of patients were housewives.

Majority of the patients were multigravidae and this helped to evaluate their previous experience of breast feeding. 102 (68%) patients were antenatally registered while 48 (32%) patients were unregistered and received no antenatal care.

Tables 1,2 classify the events in labour which have a direct influence on the initiation and practice of breast feeding. High risk neonates in the study group were managed in special care units. Hence in these cases breast feeding could not be started immediately and they were advised to express breast milk to maintain lactation. Expressed milk was stored in the human milk bank in hospital premises.The initiation of breast feeding is as shown in Table 3. In mothers with a normal delivery, breast feeding was initiated within half an hour in only 8.6%, between half to two hours in 78% and 2-6 hours in 4.8%. It was delayed to more than 24 hours in 4.8% of mothers who had a vaginal delivery. The main reason for delay was mothers being high risk and being retained in the labour ward for postpartum monitoring. In contrast in patients who underwent caesarean section, breast feeding was initiated in less than 6 hours in only 13% of mothers and upto 24 hours in 74%. In 13% of caesarean sections done under general anaesthesia, breast feeding was initiated after 24 hours. 87% of mothers with regional anaesthesia had initiated breast feeding within 6 – 24 hours.

Table 4 shows 85% women had fed colostrums in the present pregnancy and a vast majority of 81% practised exclusive breast feeding. Table 5 outlines the main lactation problems encountered. 8% had engorged breasts and all were helped by nursing staff to express milk by hand or breast pumps and prevent further complications. 10.6% women had inadequate lactation. They had received advice to increase the frequency of breast feeds and use galactagogues. They expressed satisfaction about the advise and treatment they had received. An overwhelming 88% mothers expressed strong desire to breast feed for about 6 months as can be seen in Table 6. Various social, environmental, domestic and occupational factors influence the duration of breast feeding.

Evaluation about the source of information (Table 7) revealed that exclusive breast feeding was initiated and promoted by medical professionals or by paramedical personnel in 71%. On the other hand senior family members especially from joint families provided the main source of knowledge to 27% of women in the study group. A small group of 2.6% favoured media channels like television or newspapers as the main source of information.

Discussion
The present study in a tertiary institute shows that most mothers did follow the modern concepts of lactation management. These reassuring trends may be attributed to the outcome of regular training on breast feeding imparted to medical and paramedical personnel in the institute where the study was conducted.

The present study also provides an insight into recognizing problems of breast feeding despite a baby friendly environment. Though breast feeding upto 6 months is nearly universal, most women do not practice exclusive breast feeding. In the present series, 81% practised exclusive breast feeding in the hospital. 85% women had fed colostrum in the current pregnancy. The remaining were unable to feed colostrum since their babies were admitted in special care units. Only 54% of multiparous women had fed colostrums in their previous pregnancy. When questioned, the most common belief was that colostrums was ‘stale’ or old milk and hence needed to be discarded. However, it was reassuring that this misconception was corrected in current pregnancy. Though educated mothers had established lactation and fed colostrums, majority had continued breast feeding only upto 6-7 months due to constraints of time and work. An initial good start could have paved the way for maintenance of effective breast feeding. A study conducted in Chennai showed that heavy domestic work started in a month of delivery.² the 'triple burden' on women including housekeeping, child rearing and economic contribution. The achievement of exclusive or predominant breast feeding would therefore be difficult when the mother and child are separated for a long period because of women’s work. Hence, every effort should be made to reduce the time the mother has to be away from the baby for the first few months after birth.³

Prelacteals or bottle feeds were not practised in the study group. However, 47% of parous women had given prelacteal feeds in their previous pregnancy – mainly honey or water and were unaware that it was an undesirable practice. The average duration of breast feeding was 6-7 months. Almost 27% of women had delayed weaning till 12 – 18 months and were not aware that breast milk was inadequate to meet the childs nutritional requirement at that age. 12% were unaware that an additional contraceptive was required during lactation. There were two cases of conception during lactational amenorrhoea, resulting in unplanned pregnancies.

Caesarean section affects the initiation of breast feeding – lack of professional support, post operative discomfort and inadequate rooming in result in poor rates of breast feeding in first few hours after birth.4,5 Family members and medical personnel should help the post caesarean mother to overcome her limited mobility.^6,7

Training of health workers is essential for self motivation and motivating mothers for early initiation of breast feeding. Frequent shifting of resident doctors or nurses disturbs the schedule, and hence should be avoided. Workshops on lactation management imparting at least 18 hours of training, go a long way for a successful breast feeding programme.
In the present study only 22% women had undergone antenatal breast examination. The importance of breast examination atleast once during antenatal period in rectification of anomalies like retracted nipples and other lactational problems should be emphasized.⁸

Conclusion
The baby friendly hospital initiative has focused on hospitals because they are pinnacles of learning for medical practitioners. Appropriate practices can set an example for various health care providers.

Global guidelines on promotion of breast feeding have also been implemented by the UNICEF and WHO, over a decade since 1992. However, at an individual level, promotion of breast feeding still remains a subtle art. It could best begin antenatally by the obstetrician imparting suggestions blended with accurate information during a crucial period when women are most receptive to health advice.

Child birth and breast feeding are unique experiences for woman. They can only be cherished and nurtured by obstetricians, neonatologists and paramedical personnel, the baby friendly way !

References

1. Fernandez A. Pediatr. Clinics of India 1980; 25(4):18.
2. Rama Narayan. At what cost? Womens multiple roles and the management of breast feeding. Research report no. 2, MS Swaninathan Research Foundation, Chennai.
3. Grenier T. Breast Feeding and maternal employment. Another perspective. J Human Lact 1193; 9.p
4. Perez Escamilla R, Maules Radovan I, Dewey K. Am J of Public Health 1196;86;832.
5. Walker M. J Human Lact 1997;13:131.
6. WHO / UNICEF, Breast feeding counseling, A training course, Geneva : WHO, 1993.
7. Crowell MK, Hill P, Humenide SS. J Nurse / Midwif 1994;39:150.
8. Anand RK, Surekha PR, Nigam GK, Dalal M. Report submitted to UNICEF Country Regional Office for South Central Asia, New Delhi 1989.