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Year : 2014  |  Volume : 58  |  Issue : 4  |  Page : 270-273  

Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India

1 College of Nursing, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pediatrics, WHO Collaborating Centre for Training and Research in Newborn Care and ICMR Centre for Advanced Research in Newborn Health, Newborn Health Knowledge Centre, Division of Neonatology, New Delhi, India

Date of Web Publication5-Dec-2014

Correspondence Address:
Kamlesh K Sharma
College of Nursing, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.146292

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In spite of the countless benefits of breastfeeding, prevalence of exclusive breastfeeding (EBF) has been far from optimal in the developing world. Breastfeeding problems at or after 4 weeks has been reported as one among the constraints to EBF. The study aimed to determine the breastfeeding problems in the 1 st postnatal week, their predictors and impact on EBF rate at 6 months. Under a prospective cohort design, 400 mother-newborn dyads were assessed for breastfeeding problems before discharge and at 60 ± 12 h of discharge. Nearly 89% of the mother-newborn dyads had one or more BF problems before discharge. Major concern was difficulty in positioning and attaching the infant to the breast (88.5%), followed by breast and nipple problems (30.3%). BF problems continued to persist even after discharge in a significant proportion of the mothers (72.5%). The only independent predictor of BF problems in the 1 st week was the caesarean section (odds ratio: 1.9, 95% confidence interval: 1.3-3.2, P < 0.05). There was a marked improvement in the EBF status (69.5%) at 6 months, and BF problems did not predict EBF failure at 6 months.

Keywords: Breastfeeding problems, exclusive breastfeeding rate, predictors

How to cite this article:
Suresh S, Sharma KK, Saksena M, Thukral A, Agarwal R, Vatsa M. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Indian J Public Health 2014;58:270-3

How to cite this URL:
Suresh S, Sharma KK, Saksena M, Thukral A, Agarwal R, Vatsa M. Predictors of breastfeeding problems in the first postnatal week and its effect on exclusive breastfeeding rate at six months: experience in a tertiary care centre in Northern India. Indian J Public Health [serial online] 2014 [cited 2023 Mar 22];58:270-3. Available from:

Exclusive breastfeeding (EBF) till 6 months is a key determinant for the optimum growth and prevention of common childhood illnesses. [1] World Health Organization recommends EBF for the first 6 months with the introduction of appropriate complementary foods and continued breastfeeding thereafter. [2] In spite of the countless benefits, the prevalence of EBF has been far from optimal. EBF rate rarely exceeds 40% in most regions of the developing world. In India, according to the National Family Health Survey-3 (NFHS-3, 2005-2006), EBF rate at 6 months was only 46.4%. [3] Several studies focusing on the constraints to EBF concluded that; breastfeeding problems, delivery by caesarean section, perceived or real breast milk insufficiency, inadequate weight gain of the infant, resumption of official work by the mother, and cultural practices are the factors influencing mothers' decision for continuation of breastfeeding. [4],[5],[6],[7]

We hypothesized that breastfeeding problems are major contributors for breastfeeding failure. Since the current trend is early discharge of mother-newborn dyads from the hospital after delivery, often breastfeeding issues are not addressed properly and may lead to low EBF rates. To the best of our knowledge, there is a paucity of data from developing countries on this issue. This study aimed to determine the breastfeeding problems in the 1 st postnatal week, their predictors and impact on EBF rate at 6 months.

A prospective cohort design was adopted, and 400 mother-newborn dyads were included in the study. Minimum required sample size was calculated using formula n = z [2] pq/d [2] (where, n = the required sample size; p = the prevalence of breastfeeding problems from a previous study that is, 30%; q = 1 − p and d = error [precision] i.e., 5%). Thus, the calculated sample size was, n = 323. The study was conducted in the postnatal ward and follow-up clinic of a tertiary care hospital from June to November 2011.

Neonates who delivered at or after 34 weeks of gestation with mothers willing to participate were enrolled irrespective of the mode of delivery. Exclusion criteria were any contraindication to breastfeeding (HIV infection and treatment with anticancer drugs), multiple gestations, acutely ill mothers, ˃72 h of hospital stay, neonates with chromosomal/congenital anomalies and newborns admitted in. Neonatal Intensive Care Units for 24 h or more. As per the hospital policy, mother-newborn dyads are discharged at 48-72 h of delivery if they fulfill the discharge criteria, irrespective of the mode of delivery. Postnatal mothers benefit from routine lactation counseling by the medical and nursing staffs in the units in addition to the intense counseling by the dedicated lactation counselors who visit all the mothers within 6 h of delivery to assist them in practicing proper feeding techniques. Subsequently they visit the mothers at least every 12 hourly until discharge, for ongoing support and help to resolve their breastfeeding problems. All mother-newborn dyads are called for follow-up visit at 60 ± 12 h of discharge to assess the infant's general health, the degree of jaundice, breastfeeding issues and to identify any new problems.

Data were collected by the principal investigator, using a pretested proforma which contained the prespecified diagnostic criteria for each breastfeeding problem (poor positioning and attachment, retracted or flat nipple, sore or cracked nipple, breast engorgement, breast abscess and mastitis). Assessment of the breastfeeding problems was done once prior to discharge and then during follow-up at 60 ± 12 h of discharge. According to the severity of the problems, advice was given to the parents regarding the need for readmission to the hospital, subsequent follow-up visits or home care. At 6 months, all the enrolled mothers were contacted telephonically to enquire about the breastfeeding status of their newborns. The reasons for non-EBF were also collected.

Data were entered in MS Access and analyzed by STATA 11.1 version. Chi-squared and logistic regression analysis was performed to find the relationships between variables. P ˃ 0.05 was considered as significant. Informed written consent was obtained from all respondents after a full explanation of the nature, purpose and procedures used for the study. Ethical approval was obtained from the institute ethics committee.

Of the 980 mother-newborn dyads screened, 500 were excluded as per exclusion criteria. Among the 480 mother-infant pairs included in the final study; 80 did not report for follow-up as we could not contact them as their phone numbers were wrong or changed during study period. Most of the mothers were between 20 and 30 years of age (80.5%), primiparous (66%), delivered vaginally (63.3%) and not with associated illness (63%). Majority of the newborns were term (85.5%), and weighed ≥2500 g (76.7%) [Table 1].
Table 1: Baseline variables (n = 400)

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Breastfeeding problems were present in 88.5% of mother-newborn dyads before discharge. Major problems were poor positioning and attachment (88.5%), followed by breast and nipple problems (30.3%). Breastfeeding issues were noted in 72.5% of the mother-newborn dyads during follow-up. Most commonly identified breastfeeding problems were poor positioning and attachment (70.3%), sore or cracked nipple (17.8%) followed by retracted or flat nipple (15%) and breast engorgement (13%) [Table 2].
Table 2: Breastfeeding problems before discharge and during follow-up (n = 400)

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Major factors associated with occurrence of breastfeeding problems were multiparity (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.1-2.8), lack of previous experience of breastfeeding (OR: 1.8, 95% CI: 1.1-2.8) and cesarean delivery (OR: 2.0, 95% CI: 1.3-3.3). However, the only independent risk factor for breastfeeding problems in multivariate analysis was caesarean delivery (Adjusted OR: 1.9 95% CI: 1.2-3.2). EBF rate at 6 months was 69.5%. Major reasons given by the mothers (n = 112) for discontinuation of breastfeeding were concern of poor weight gain in baby (28.6%), advice from elders at home (27.7%) and perception of breast milk insufficiency (25%). Few mothers reported reasons like breastfeeding problems (8%), baby reused to suck or had sucking difficulty (7.1%) and baby remains hungry after feeding (3.6%) as a reason for non-EBF. Breastfeeding failure at 6 months was independent of maternal age, socioeconomic status, maternal education, parity, maternal illness, previous breastfeeding experience, infant's weight, gender, gestational age and breastfeeding problems. The only factor which was significantly associated with breastfeeding failure at 6 months was nursery stay (<24 h) after birth (Adjusted OR: 2.16, 95% CI: 1.1-4.24); this was however insignificant on multivariate analysis.

There is a high prevalence of breastfeeding problems in mother-newborn dyads delivering after 34 weeks of gestation. An interesting observation was the persistence of these problems at the end of 1 st week (poor positioning and attachment −70.8%) and increase in some reported problems (Sore or cracked nipple from 10.5% to 17.8% and breast engorgement 4.8-13%) after discharge. The possible rationale for a high prevalence of breastfeeding problems in the present study compared with previous researches (23.1-76.9%) could be prospective detection of these problems while most other studies have been retrospective. [4],[8],[9],[10],[11] These studies were done later than 3 days after delivery in community settings, in the absence of lactation counseling, and there was no follow-up visit after the same. Mothers in the present study reported an increase in the incidence of some breastfeeding problems at the follow-up visit. This reinforces the requirement of focused lactation counseling and support for this subgroup of mothers. Mothers delivered by cesarean section were more likely to report breastfeeding problems compared with those delivered vaginally. Other studies also have shown similar results. [6],[8] Breastfeeding status at 6 months showed a marked improvement from 46.4% (NFHS III, 2005-2006) to 69.5% in our setting. [3] This could be attributed to the support of a lactation team both during the hospital stay and at the time of the follow-up visit.

In contrast to our hypothesis and previous study findings, we found that breastfeeding failure at 6 months is independent of maternal age, socioeconomic status, maternal education, parity, maternal illness, previous breastfeeding experience, infant's weight, gender, gestational age and breastfeeding problems. Previous studies have reported multiple predictors of EBF failure at 6 months. [4],[5],[6],[7] We tried to justify this inconsistent finding by the influence of recently initiated intense lactation counseling for all postnatal mothers following childbirth and reinforcement of the same during early follow-up visit in our setting, which was absent in other studies. The effect of the same intervention was reflected in the markedly improved EBF rates at 6 months as contrast to the previous study from the same setting. [12]

This study looked at the breastfeeding problems among the mother-newborn dyads during the hospital stay and at follow-up and their impact on the EBF rate at 6 months. To our knowledge, this is the first Indian study which assessed the impact of breastfeeding problems on the EBF rate. However, in the present study, assessment of breastfeeding problems was done only in a single follow-up visit that might have led to the omission of later problems. Secondly, this study was done in a single center which is a referral center in North India, so the findings may not be generalizable to an area with poor lactation support and counseling.

   References Top

National guideline on of infant and young child feeding. Ministry of human resource development, Department of wmen and child development (Food and Nutrition Board) Government of India; 2004. Available from: [Last accessed on 2012 Sep 29].  Back to cited text no. 1
Kramer M, Kakuma R. The Optimal Duration of Exclusive Breastfeeding - A Systematic Review. WHO/NHD/01.08. Geneva: World Health Organization; 2002.  Back to cited text no. 2
NFHS-3 2005-2006. Available from: 3%20Data/VOL1/India_volume_I_corrected_17oct08.pdf. [Last accessed on 2012 Jan 05].  Back to cited text no. 3
Duong DV, Binns CW, Lee AH. Breast-feeding initiation and exclusive breast-feeding in rural Vietnam. Public Health Nutr 2004;7:795-9.  Back to cited text no. 4
Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003;112:108-15.  Back to cited text no. 5
Schluter PJ, Carter S, Percival T. Exclusive and any breast-feeding rates of Pacific infants in Auckland: Data from the Pacific Islands Families First Two Years of Life Study. Public Health Nutr 2006;9:692-9.  Back to cited text no. 6
Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607-19.  Back to cited text no. 7
Raju J. A survey to assess breastfeeding problems in mother-newborn dyads during first three postnatal days. New Delhi: College of Nursing, All India Institute of Medical Sciences; 2011. [Unpublished Masters' dissertation].  Back to cited text no. 8
Jain S, Parmar VR, Singla M, Azad C. Problems of breast feeding from birth till discharge - experience in a medical college in Chandigarh. Indian J Public Health 2009;53:264.  Back to cited text no. 9
Mallikarjuna HB, Banapurmath CR, Banapurmath S, Kesaree N. Breastfeeding problems in first six months of life in Rural Karnataka. Indian Pediatr 2002;39:861-4.  Back to cited text no. 10
Dongre AR, Deshmukh PR, Rawool AP, Garg BS. Where and how breastfeeding promotion initiatives should focus its attention? A study from rural wardha. Indian J Community Med 2010;35:226-9.  Back to cited text no. 11
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Oommen A, Vatsa M, Paul VK, Aggarwal R. Breastfeeding practices of urban and rural mothers. Indian Pediatr 2009;46:891-4.  Back to cited text no. 12


  [Table 1], [Table 2]

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