“Breastfeeding is the most precious gift a mother can give her infant. When there is illness or malnutrition, it may be a lifesaving gift; when there is poverty, it may be the only gift.” – Ruth Lawrence, M.D.
1.1 Background of research
Exclusive breastfeeding starts from a new born to the age of six months. It is an ideal and incomparable to any infant formulas created for them recently. As it has been known that breastfeed contains the perfect food for a newborn which has immunization to diseases, easy to digest and at the perfect temperature to be fed to infants. Breast milk is the natural first food for babies which provides all the energy and nutrient that the infant needs for the first months of life.
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The first breastfeed milk is known as the colostrums which can only be found in breast milk that contains all best nutrients for the new born babies. Colostrums contain antibodies that protect the baby from bacteria and viruses in the early age. It helps to increase the baby’s intelligence and growth and strengthen the close bond between mother and the baby ( Gartner et al. 1997). It strongly proven that breastfeed is the best food for a baby that no other food has the same nutrients values.
Pregnant mothers should have the knowledge and awareness of the benefits of breastfeeding to newborn infants. This study is to find out how much the awareness and knowledge of 30 pregnant women in the antenatal and postnatal wards through questionnaires. They should be aware of the benefits of breast milk to infants and to their own health.
Many women make infant feeding decisions before delivery and before any contact with healthcare professionals. Although health promotions campaigns are influential in educating women about breastfeeding, they often do not dissuade women from formula feeding once the decisions has been made. Antenatal preparations of pregnant women for breastfeeding rises awareness of the importance of breastfeeding, empower them with practical knowledge and skill in breastfeeding techniques, and prepare them for possible difficulties.
Though many campaigns and seminars were done nationally to educate the public, yet the rate of exclusive breastfeeding is still to the unsatisfactory level. The rate of exclusive breastfeeding in Malaysia has been decreased from 92% ( in 1950’s) to 78% (in 1970’s) but there was a slight of increment in the early year of 1975( Da Vanzo, 1991) although for only less than 10%. Report done by the World Alliance for Breastfeeding Action (WABA, 2005) , showed that millions of babies fell sick every year as they were not breastfeed. The World Health Organization (WHO, 2002) estimated that more than 1.5 million babies died yearly may be avoided if the babies were given exclusive breastfeed, from birth to six months and continuously until the age of two years old.
Malaysia has been doing a lot of promotions and activities lately to give the knowledge and importance of exclusive breastfeeding through activities such as World breastfeed week and Baby friendly Hospital.
1.1 Problem of statement
Breast feeding have multiple benefit to the mother and child but there are still postnatal mother that are not confident and not interest to breast feed their baby. This problem might be due to lack of knowledge on information sources regarding breastfeeding. This research is done to elevate the knowledge between antenatal and postnatal mothers in this hospital.
Breastfeeding offers irrefutable and long-lasting health benefits for both mother and baby, which are supported by a comprehensive scientific research. Many research and evidence base has been conducted and proven that the benefits of breastfeeding are undeniable.
Ministry of Health has set and implements various strategy in promoting exclusive breastfeeding. One of the strategy is the ‘Baby Friendly Hospital Initiative’ on 1993.The aim is neither than to develop an environment that support mother to breastfeed their baby, create a policy that control exclusive breastfeeding. On Mac 1998, Malaysia had been announced as the 3rd country in the world which all the government hospital has been given the ‘Baby Friendly Hospital’ status.
Over time, the percentages of births to subgroups with higher rates of breastfeeding–particularly Malays and more highly educated women–have increased. However, there is also evidence of changes in rates of breastfeeding within these subgroups. Many Malaysian infants have a total duration of breastfeeding (including with supplementation) considerably shorter than WHO recommended six months of exclusive breastfeeding.
The national breastfeeding policy has been revised in 2006, according to WHO all mothers are encouraged to breastfeed their babies exclusively from birth until 6 months of age and thereafter to continue until their child is 2 years old. Complementary foods should introduce when the baby is 6 month old.’
The postnatal mothers have a higher level of exclusive breastfeeding knowledge compared to the antenatal mothers.
1.3 Significance Of Study
The benefits of breast milk is undeniable, manufacturer are trying to create a milk that are at least having similar benefits and nutritional value as the breast milk, yet no strong research study has been conducted to prove it.
Not all the properties of breast milk are understood, but its nutrient content is relatively stable. Breast milk is made from the nutrients in the mother’s bloodstream and bodily stores. Some studies estimate that a woman who breastfeeds her infant exclusively uses 400 – 600 extra calories a day in producing milk. The composition of breast milk depends on how long the baby nurses.
“Research shows that the milk and energy content of breast milk actually decreases after the first year. Breast milk adapts to a toddler’s developing system, providing exactly the right amount of nutrition at exactly the right time. In fact, research shows that between the ages of 12 and 24 months, 448 milliliters of a mother’s milk provide these percentages of the following minimum daily requirements:
Energy 29% Folate 76% Protein 43% Vitamin B12 94% Calcium 36% Vitamin C 60%10 Vitamin A 75% .
1.4 Research Objective
1.4.1 General Objective
The aim of this study is to identify all antenatal and postnatal mothers have the confidence and knowledge to exclusive breastfeeding.
1.4.2 Specific Objectives
184.108.40.206 To examine the knowledge of antenatal and postnatal mothers towards exclusive breastfeeding
220.127.116.11 To educate antenatal and postnatal mothers with exclusive breastfeeding knowledge and understandings.
1.5 Significant of Project
1.5.1 The importance of this study is to find out the difference knowledge level between antenatal and postnatal mothers on exclusive breastfeeding.
1.5.2 This study needs to assess the knowledge level of the antenatal and postnatal mothers after informations, campaign and educations given by health care staff and to show the teaching techniques by them are effective.
1.5.3. The is to esure that it will increase the knowledge and improvements to induviduals involvements in exclusive breastfeeding
1.6 Scope of Project
1.6.1 The study sample is limited to antenatal mothers who was come for screening in labour room from 30 January to 30 Mac 2011 and postnatal mothers discharge from integrated ward.
1.6.2 Antenatal mother who was not delivered baby from 30 January to 30 Mac 2011
Assessment is a process that follows a continuous cycle of improvement based upon measurable goals, involving data collection, organization and interpretation leading to planning and integration.
Knowledge is the awareness and understanding of facts, truths or information gained in the form of experience or learning. Knowledge is an appreciation of the possession of interconnected details.
1.7.3 Exclusive breastfeeding
Exclusive breastfeeding defined as no food or liquid other than breast milk , not even water, is given to the infant from birth until six months of age.
1.7.4 Antenatal mother
Occurring or present before birth; during pregnancy
1.7.5 Postnatal mother
post meaning “after” and natalis meaning “of birth”- is the period beginning immediately after the birth of a child and extending for about six weeks.
Although the health benefits of breastfeeding are acknowledged widely, opinions and recommendations are divided on the optimal duration of exclusive breastfeeding. We systematically reviewed available evidence concerning the effects on child health, growth, and development and on maternal health of exclusive breastfeeding for 6 months vs. exclusive breastfeeding for 3-4 months followed by mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) to 6 months. Two independent literature searches were conducted, together comprising the following databases: MEDLINE (as of 1966), Index Medicus (prior to 1966), CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE-Medicine, EMBASE-Psychology, Econlit, Index Medicus for the WHO Eastern Mediterranean Region, African Index Medicus, Lilacs (Latin American and Carribean literature), EBM Reviews-Best Evidence, the Cochrane Database of Systematic Reviews, and the Cochrane Controlled Trials Register quoted by Kramer MS , Kakumar R.( Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Quebec, Canada)
Mothers often are uninformed about the health benefits of any amount of breastfeeding, their ability to continue breastfeeding while employed, and the convenience and cost differential of breastfeeding as compared to formula feeding. “Although there is a tendency in the literature to stress the time-intensive nature of breastfeeding, in fact it may require less time and attention than bottle-feeding” (Barber-Madden, 1990).
First, the promotion of breastfeeding without practical help and knowledge which led to many frustrated, unsuccessful breastfeeding attempts with subsequent backlash.
Second, a much shorter hospital stay which does not provide adequate time for mother’s milk to come in or for appropriate education and support. In Australia in 1993, a country which is known for its support of breastfeeding, the average hospital stay for vaginal delivery was still 5 to 7 days, and for C-section, 7 to 10 days. Australia also has the foresight to send home health visitors once the mother is discharged to offer further assistance and support.
Third, the continued increase of women in the workplace, many times by necessity and not by choice, has influenced the incidence and duration of breastfeeding. A non supportive work environment makes breastfeeding difficult at best.
Finally, the decline of breastfeeding has been assisted by the ambivalence of some health care professionals. This ambivalence is based on the lack of familiarity with current breastfeeding research, reliance on formula company nutritional information, and the very well meaning issue of not wanting to push breastfeeding because it might make the Mom who chooses artificial feeding feel guilty.
“Despite these initiatives, only 14.5 per cent babies were exclusively breastfed below six months in 2006,” . “In addition, only 19.3 per cent babies were exclusively breastfed below four months.” Jaafar,2008
Compared with the findings of the National Health and Morbidity Survey 2 (1996), there was a significant decline of 9.7 % in the prevalence of exclusive breastfeeding below four months and a concurrent rise in the prevalence of babies who were predominantly breastfed but given additional water.
Analysis of the breastfeeding pattern showed generally that exclusive breastfeeding rates were high in the first two months but dropped rapidly after the age of two to three months .It was also found after the age of two months, more than half of the breastfed babies were supplemented with infant formula and given other foods like commercial baby foods or home-cooked baby food while 20 percent of breastfed infants were supplemented with plain water.Few factors that contribute to early discontinuation of breastfeeding as follow :
2.1 Cultural Beliefs And Myths Of Breast Feeding
The cultural beliefs, myths and ignorance have to be blame for the country’s poor breastfeeding performance.
The myths that breastfed babies need water in addition to breast milk are wide spread in the country. Lack of knowledge and skill of mothers on when to start complementary food and how to maintain breastfeeding are other prohibitive factors,” Complementary food, including water, should ONLY be introduced after the age of six months
2.2 Lacks Of Benefit And Facility
Other factors according to Jaafar ( 2008 ) are the lack of benefits and facilities to promote and facilitate breastfeeding practices amongst women who also make up some half of the country’s working population. These include the absence of longer maternity leave, the lack of flexible working hours and missing childcare centers at work places.
Breastfeeding patterns in Malaysia suggest that inadequate maternity leave may in fact be denying babies their right to mother’s milk, and one of the reasons why only 1 in 7 infants were exclusively breastfed for the first six months of life in 2006. (Nadchatram ( 2008 )
According to Ministry of Health analysis of national breastfeeding data, exclusive breastfeeding rates in the country were high in the first two months but dropped rapidly after two or three months, roughly the period when maternity leave ends and working mothers return to paid employment.
In Malaysia, women are entitled to 8 weeks (60 days) paid maternity leave, 6 weeks short of the recommended 14 weeks by the International Labour Organisation’s Maternity Protection Convention 2000 (No. 183). Malaysia is not a signatory of the Convention.
2.4 Not Enough Milk
Hussain (2003) has revealed that other factor for early discontinuation of exclusive breast feeding is not enough milk .In his study,54% of the sample express that this is one of the reason. The reason for not having enough milk might be highly influenced by the mother’s emotional and psychological well-being.
Low levels of stress, healthy nutrition, plenty of fluid intake, emotional support and nipple stimulation through baby’s sucking are all important contributors to breastfeeding success. However, living circumstances often don’t allow perfect breastfeeding conditions: another child in the family, the death of a loved one, money worries etc. all add to an increase in stress levels.
Other factors such as breast surgery can contribute to low amounts of breast milk. It has also been found that more women who gave birth by caesarean section
Encountered breastfeeding problems, this may have various reasons such as the initial separation between mother and baby or the physical pain as a result of the surgery which ultimately affects the mother’s ability to enjoy the breastfeeding experience.
Chen ( 2006 ),conclude in his research that breastfeeding-friendly policies can significantly affect breastfeeding behaviors. However, an unfavorable working environment, especially for fab workers, can make it difficult to implement breastfeeding measures. With health professionals emphasizing that the importance of breastfeeding for infant health, and as only females can perform lactation, it is vital that women’s work “productive role” and family “reproductive role” be respected and accommodated by society.
The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life. The length of maternity leave is positively associated with the duration of breastfeeding The International Labour Organization (ILO) recommends a period of maternity leave of not less than 14 week. However, the typical maternity leave in many Asian and Middle Eastern countries falls below these levels, only offering less than 12 weeks paid leave. In Taiwan, most companies provide only eight weeks of maternity leave.
A national survey in 2005 showed that the rate of exclusive breastfeeding in Taiwan at one month postpartum was only 22.3%, and dropped to 16.7% at three month. To bring Taiwan in line with WHO guidelines, effective worksite strategies needed to be implemented to encourage new mothers to breastfeed in the workplace.
2.5 Levels of Influence and the Breastfeeding Decision
2.5.1 Health Professionals’ Roles
Multiple studies indicate that health professionals’ support of breastfeeding is important in increasing breastfeeding rates (Lawrence, 1993, Winikoff & Baer, 1980; Winikoff, Laukaran, Myers, & Stone, 1986, 1987). Health professionals have made important promotion contributions, yet many health professionals who provide care to pregnant women and infants do not demonstrate explicit support of breastfeeding; nor do they have adequate knowledge about breastfeeding. In an American Academy of Pediatrician’s study, only 65 percent of pediatricians recommended exclusive breastfeeding for the first month and only 37 percent recommended breastfeeding continue for the first year (Schanler, O’Connor, & Lawrence, 1999).
Many women do not initiate breastfeeding because they know they will be returning to full-time employment that will entail separation from the baby. Perhaps they believe that they will not be able to continue breastfeeding once they return to work, and they adopt an attitude of “Why start something I will not be able to continue?” (Fein & Roe, 1998). Furthermore, women who return to full-time work wean their infants earlier than other women. It has been found, however, that expecting to work part-time following the birth of a baby did not affect initiation of breastfeeding. Part-time work of four or fewer hours a day did not affect duration of breastfeeding. Part-time work for more than four hours per day affected duration of breastfeeding less than full-time work (Fein & Roe, 1998).
Because of economic necessity and the need for other benefits such as health insurance, many women cannot afford to work less than fulltime. When possible, however, delaying separation from the infant and reducing the amount of time mother and infant are separated during the infant’s first six months increases the likelihood that breastfeeding will be successful (Stuart-Macadam & Dettwyler, 1995).
In a qualitative study carried out by MacLaughlin and Strelnick (1984), many women suggested it would be helpful to receive breast-feeding information about combining breast-feeding with working and to have open discussions of the topic with other mothers. A survey of 567 women who breastfed while employed outside the home showed that the most significant difficulty was “role overload,” a result of the multiple demands to which they were responding. This aspect does not differ markedly from what is found for non-breastfeeding, working mothers (Auerbach & Guss, 1984).
About 60 per cent from 451 mothers who stopped breastfeeding, did so during the first postnatal month and another 20 per cent during the 2nd and 3rd month after the babies’ birth. The mother’s age, education or parity, did not affect the rate of breastfeeding.
Low birth weight, especially birth weight less than 2 kg, was a risk factor for early termination of breastfeeding. Caesarean delivery and hospitalization of the infant during the neonatal period was also associated with a higher rate of bottle feeding compared with newborns who had been delivered normally, discharged early, and nursed at home.
Although breastfeeding rates are high, the finding that the majority of mothers who give up breastfeeding do so in the early weeks, calls for better support to all mothers by committed health personnel during the period when breastfeeding is being established, and for extra assistance to women whose infants are hospitalized or have a low birth weight (Shiva , 2003 )
2.6 Advantages of breast milk to babies
Breast milk is best for newborn baby, and the benefits of breastfeeding extend well beyond basic nutrition. In addition to containing all the vitamins and nutrients baby needs in the first six months of life, breast milk is packed with disease-fighting substances that protect baby from illness.
American Academy of Pediatrics recommends exclusive breastfeeding for the first six months (although any amount of breastfeeding is beneficial). And scientific studies have shown that breastfeeding is good for mothers health, too. Numerous studies from around the world have shown that stomach viruses, lower respiratory illnesses, ear infections, and meningitis occur less often in breastfed babies and are less severe when they do happen. Exclusive breastfeeding (meaning no solid food, formula, or water) for at least six months seems to offer the most protection.
A study by the National Institute of Environmental Health Sciences showed that children who are breastfed have a 20 percent lower risk of dying between the ages of 28 days and 1 year than children who weren’t breastfed, with longer breastfeeding associated with lower risk.
The main immune factor at work here is a substance called secretor immunoglobulin A (IgA) that’s present in large amounts in colostrums, the first milk mother’s body produces for the baby. (Secretors IgA is present in lower concentrations in mature breast milk.) The substance guards against invading germs by forming a protective layer on the mucous membranes in the baby’s intestines, nose, and throat.
2.7 Advantages to breastfeed mothers
A study of more than 33,000 Danish women who had given birth between 1999 and 2002 evaluated the effect of breastfeeding on maternal weight at 6 and 18 months postpartum compared to reported pre pregnancy weight. The authors calculated that a Danish woman with normal or obese pre pregnancy weight who gained 11-12 kg during the pregnancy and exclusively breastfed her infant for 6 months would be back to her pre pregnancy weight by then. At 18 months postpartum, women who exclusively breastfed for 6 months and continued breastfeeding until their infant was 12 months of age had the lowest probability of retaining 5 or more kg of weight no matter how much weight they gained during the pregnancy (Baker, 2008)
2.8 Conceptual framework
The research conceptual framework will be carried out as shown in the flow chart below.
HOSPITAL TUANKU AMPUAN NAJIHAH
In this chapter the researcher will discuss the main aspect of the research methodology in detail. There are five aspects that consist of the research design, population, sampling and methods, study instruments, collection of data and limitation of study.
3.1 Study design
The study uses a descriptive and quantitative method. The researcher will distributes the questionnaires to the respondents as the main instrument to collect data for the study. The collection and the analysis of data is done in two weeks.
3.2 Population and sample
The population is all antenatal mothers who will be come for screening in the labour room from 30 January to 30 Mac 2011 and postnatal mothers discharge from integrated ward in Hospital Tuanku Ampuan Najihah.
3.3 Study subject
All 15 antenatal mothers who will come for screening in integrated ward from 30 January to 30 Mac 2011 and 15 postnatal mothers discharge from labour room during the study period.
3.4 Sample size calculation
The sample size will be calculated so that the study has the capability to detect clinically importance difference as statistically significant. The sample size also will be calculated to estimate effect with stated precision. Only 30 cases will be selected as the sample.
3.5 Study participants
3.5.1 Inclusion criteria
All antenatal mothers who are conceiving their second child and above that warded from 30 January to 30 Mac 2011 and postnatal mothers discharge from integrated ward.
3.5.2 Exclusion criteria
All antenatal mothers who are conceiving their first baby from 30 January to 30 Mac 2011 was not included in this study.
3.6 Data collection procedures
3.6.1 This study will be using questionnaires that will be given to the
antenatal and postnatal mothers before and after the campaign.
3.6.2 Permission to carry out the study will be obtained from the Hospital Director and the Chief Matron. An inform consent will also being obtained from the respondents
( Appendix II / Lampiran II).
3.6.3 Self Administered Questionnaire (SAQ)
Self Administered Questionnaire will be used to determine the medical personal knowledge as shown in Appendix III / Lampiran III.
3.7 Sampling methodology
Sampling refers to ‘the process of selecting a portion of the population to represent the entire population’ (Polit & Hungler, 1999). In this study only 30 participants will be selected among the antenatal and postnatal mothers in HTAN from January till March in the year of study. The study was done with pilot test 10 antenatal and postnatal mother and the cronbach’s alpha= 0.732
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3.7.1 Statistical analysis
The result of this study was based on the responses from 30 of the antenatal and postnatal mothers. The independent variables identified namely were designation. The data was analyzed and presented in percentage.
3.7.2 Research tools
Data was collected by using structured questionnaire. See Appendix III and Appendix IV.
3.8 Expected results
Antenatal mothers have the knowledge and understanding of the importance in exclusive breastfeeding.
Antenatal mothers will be making decisions on exclusive breastfeeding before delivery.
In this chapter the collected data is analysed from the questionnaires given to the respondents. The demographic factors usually tested as it is often used as the inference study as it is easy to get and easily analysed the effect (Jack Fiorito et el 2007) . The first part is a demographic data about the respondents for example race, age , education level and their exclusive breastfeeding knowledge.
4.1 Characteristics of demographic respondents
Table 1 : Ethnic :- Antenatal mothers
Post natal mothers
Number of respondents
Number of respondents
Referring to the table above, majority of the respondents are from the Malay ethnic which gives 73.3% for the antenatal mothers while the postnatal respondents gives 86.7%. The second higher percentage of ethnic comes from the Indians that give 20 %for the antenatal mothers and the postnatal mothers contributes 13.3 %.
The least is the Chinese that gives only 6.7% that is only one respondent for the antenatal but none for the postnatal mothers.. As usual majority of the respondents are the Malays as most of them preferred to give birth in government hospitals comparing to the Chinese who prefer going to the private hospitals.
Table 2 : Age of the respondents
Number of respondents
for both ante and postnatal mothers
20 -25 years old
26 – 30 years old
31 – 35 years old
36 – 40 years old
The age range for this study is done to get a better view to the majority of the ante and postnatal mothers involved. As shown in the table above the age range between 26 to 30 years of the antenatal and postnatal mothers gives the majority which contributes 40.0 %. The least comes from the age range of 36 to 40 years that gives only 10% which only 3 respondents involved.
Table 3 ; Education Level
Number of respondents
As shown in the above table, the majority of the educational level comes from the secondary school level which contributes 56.7 % from all the respondents. This shows that this group of respondents have the great trust in the government hospital so does the college/ university level respondents that gives 33.3% of all.
Table 4 : Occupation
Number of respondents
Referring to the above table, the housewife is the majority respondents in this study that carries 56.7% which is more than half of the respondents involved. The government servants contributes 16.7% while the self employed and the private sectors employees give the same percentage of 13.3% each.
Table 5. : Exclusive breastfeeding prior knowledge
Number Of respondents
Referring to Table 5, 83.3% of the respondents have the prior knowledge of exclusive breastfeeding which means that they had the experience and knowledge to breastfeeding. Five respondents, contributing 16.7% had no knowledge of exclusive breastfeeding.
Table 6 : Number of child
Number of child
(conceiving/ give birth)
Number of respondents
As shown in the table above , 12 respondents conceiving or giving birth to their second child that gives 40% of the study. 36.7% conceive or give birth to their third child, 10% or 3 respondents conceive or give birth to their 4th child and 6.6% contributed by respondents who conceive or give birth to their 5th and 6th child.
Knowledge on exclusive breastfeeding
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