Knowledge , Attitudes on Infant Feeding Among Pregnant Mothers in The Gaza Strip , Palestine

Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs. The study aimed to assess knowledge, attitudes and key Breast Feeding (BF) promotion and counselling indicators among pregnant mothers in the Gaza Strip. Cross-sectional study among250 pregnant mothers in primary health care centers in the Gaza Strip. The results could be utilized to promote breastfeeding. The results indicated that less than fifty percent (48.4%) of pregnant mothers received BF counselling. Most of there spondents (88%) knew that breast milk was the best infant food. Almost all of the respondents agreed that complementary feeding should be introduced to the baby after 6 months of age (94.8%), and they also knew that Exclusive Breastfeeding extended through 6 months of age (87.2%). When assessing pregnant mothers attitude, 144 (57.6%) of pregnant mothers believed that their families will support them to breastfed. The majority of respondents (98%) will start breastfeeding directly after delivery and 96% of them will avoid milk formula and other liquids after delivery at the hospital. More than ninety percent (90.8%) of the respondents believe that complementary feeding should be started after six months of age. Mothers’ knowledge about breastfeeding needs to be increased, especially in some aspects of breastfeeding such as Colostrum use, the age of weaning, optimum duration of breastfeeding episode and formula milk. The misconception and negative attitudes had been identified and should be addressed. Health system should include all mothers into educational in-terventional programs.


Introduction
Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs [1].Breastfeeding is associated with a reduced risk of otitis media, gastroenteritis, respiratory illness, sudden infant death syndrome, necrotizing enterocolitis, obesity, and hypertension [1].
In order to achieve global goals for optimal maternal and child health and optimum breastfeeding and nutrition, the Baby-Friendly Hospital Initiative (BFHI) was launched in 1991 by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) to ensure that all maternity facilities, whether free standing or in a hospital, became centers of BF support.A maternity facility could be designated 'baby-friendly' when it did not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and had implemented 10 specific steps to support successful breastfeeding [2].One of the ten steps of successful breastfeeding are to inform all pregnant women about the benefits and management of breastfeeding.
Studies on pregnant mothers regarding breastfeeding shown that the time of the decision to breastfeed was important for the length of BF, by making an early choice, mothers made better intellectual and physical preparation [3,4] Indeed, the knowledge of mothers about breastfeeding is also very important.During the pregnancy, a mother should get ready to breastfeed her baby and this is a critical time to acquire information and to increase knowledge about breastfeeding.Authorities, physicians, and other sections of the health care department are responsible for providing information for pregnant mothers about all aspects of breastfeeding and preparing them to make a decision about the most important event during the first two years of a child life.The purpose of this study was to assess knowledge attitudes of pregnant mothers about breastfeeding.

Methods
The study was a cross-sectional study using structured questionnaires to interview pregnant mothers attending the antenatal clinic from 1st of September 2016 to end of September 2016.The 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 questionnaire, the sampled pregnant mothers who had given verbal consent to participate in the study were interviewed.The questionnaire encompassed sociodemographic data, knowledge and attitude towards breastfeeding and key breastfeeding and counselling indicators in the PHC.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 version22.

Results
Table 1 shows the characteristics of the samples studied of pregnant women attending Primary Health Care (PHC) Gaza Strip/ Palestine.Complete response was obtained from 250 (98.9%) of respondents.The majority of the study participants did not attend university education (77.2%).Regarding the age of the pregnant mothers, only 8.8 of them were less than 20 years old.The majority of respondents were multigravida (80%) and 62% of them from Gaza City governorate as shown as in table 1. Table 2 shows the key breastfeeding BF promotion and counselling indicators in the primary health care PHC/antenatal units.The results indicated that less than fifty percent (48.4%) of pregnant mothers received BF counselling.17.4% of them, received individual counselling and health educators were the principalcounsellors for pregnant mothers with a percentage of 57.8%.Table 3 shows the pregnant mothers knowledge about breastfeeding.Most of their spondents (88%) knew that breast milk was the best infant food.Almost all of the respondents agreed that complementary feeding should be introduced to the baby after When assessing their attitude, 144(57.6%) of pregnant mothers believed that their families will support them to breastfeed.Most of them (84%) considered BF as being difficult than feeding with infant formula.The majority of respondents (98%) will start breastfeeding directly after delivery and 96% of them will avoid milk formula and other liquids after delivery at the hospital.More than ninety percent (90.8%) of the respondents believe that CF should be started after six months of age.The responses of attitudes toward BF are shown in table 4.

Items N %
Starting Breastfeeding directly after delivery 245 98 Family will support you to breastfed your baby 144 57.6 Breastfeeding is difficult than infant formula 210 84 You will avoid eating liquids and formula at hospital after delivery 240 96 Starting complementary feeding after six months 227 90.8 Formula milk is the first food that should be introduced to the baby 115 46 Table 4: Attitudes of Infant Feeding Among the Respondents.

Discussion
This study showed that most mothers were knowledgeable towards benefits of BF but they had weak to moderate knowledge towards other information of BF.The overall prevalence of those who intended to breastfeed their babies was high at 98%.The antenatal decision of wanting to breastfeed may not reflect the actual prevalence of BF or EBF.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.Palestinian studies of mother's attitudes towards BF who reported that only 38% in 2008, 26.8% in 2011,39% in 2014, and 24.4% in 2015 of Palestinian mothers practicing EBF [6-9], the increasing in 2014 the continue decreasing, this lead directly to artificial milk that donate from the non-governmental organization after the war 2014.This result reflects the gap between the knowledge attitudes and practices of Palestinian mothers towards EBF.The wide gap might reflect many determinants such as the early introduction of breast milk substitutes/violation, lack of mother's support from the family members, improper feeding practices like attachment and positioning lead to baby hungry.A study in Bangkok showed that 95% of mothers breastfed their infants up to 3 months, but the prevalence of exclusive BF was relatively low [10].
Out of 250 respondents, 220 (88%) knew that breastfeeding is the best food for infants.In the Gaza Strip, many of the mothers have a good knowledge towards breastfeeding but appropriate practices are still influenced by factors such as health care system and social factors.Good knowledge and positive attitudes towards on time introduction of complementary feeding to the babies.In this study, more than ninety percent of pregnant women thought six months were the appropriate age to start giving complementary foods.Findings from the survey of breastfeeding in Gaza Strip [11], which identified that more than half of the infants 55% received CF between the age of 3 to 5 months.
Good knowledge but the lack of good practices about the recommended age for introduction of complementary food.Palestinian mothers in Gaza indicated that baby crying because of feeling hungry is the main cause for early introduction of complementary foods, this could probably due to the incomplete duration of breastfeeding episodes, lack of knowledge regarding steps of attachment and positioning [6].Breastfeeding can be a learned skill for mothers and babies and may take time and patience and it's also crucial to avoid early weaning [12].Therefore, future interventions in Gaza Strip regarding infant feeding procedure should be started, beginning in the antenatal period.
Close to half of the respondents indicated that formula milk is the first food that mothers should start to feed their babies.At six months old, breast milk is still the most important food but the time has come to add solid foods.Extra iron is needed at six months.The baby needs iron-rich foods twice every day.Solid foods also provide a variety of nutrients, flavours, and textures for the baby.The findings of this study showed that more than forty percent of pregnant indicated that feeding babies should be scheduled while only 58% knew that babies should be breastfed on demand.Low prevalence of on-demand breastfeeding was also reported by El-kariri&Kanoa in 2007 [6].
On-demand breastfeeding comes with WHO recommendations which emphasize demand feeding [13].Ondemand breastfeeding and frequent feedings (including nighttime feedings) help to establish and maintain an adequate milk supply [14].Other benefits of on demand feeding include more milk you will produce, increases the quality fat content in your milk.(less colic, vomiting and diarrhoea), promotes further bonding between mum and baby, decrease stress in mum and baby, so the more you breastfeed the less stressful, and will help baby get rid of jaundice quicker.The use of colostrum and avoidance of pre-lacteal foods are cornerstones in early infant nutrition and may be pre-requisites for the establishment of future exclusive breastfeeding.In this study, only 44% of pregnant women reported that colostrum is good for their babies' and only less than forty percent of the respondents (38.4%) knew that breastfeeding episode lasts for 25-20 minute.
Most experts recommend feeding newborns for 10-20 minutes at each breast.At the beginning of the feeding, it may take up to several minutes for your milk to "let-down."In the first part of the feeding, the "foremilk" is higher volume, watery, and higher in protein.In the last part of the feeding, which generally occurs around 10-15 minutes, the "hindmilk" is lower in volume but higher in fat-this is important for your baby's nutrition and is also thought to provide your baby with the signal to finish nursing on that breast.Allowing your baby enough time on each breast helps ensure that he finishes the hindmilk and also that he empties your breast to prevent painful engorgement, plugged milk ducts, or infection.In the current study, 47% of pregnant mothers did not know the suitable age to start weaning.According to the WHO/ UNICEF recommendations, breastfeeding should be continued to two years old Thus, there is a need for extensive efforts to encourage mothers to continue breastfeeding until the age of two years.Low level of knowledge among pregnant regarding colostrum's benefits, duration of BF episode and age of weaning were matched with [15] that recommended public health education campaign to promote BF practices [15].Delayed breastfeeding initiation, colostrum deprivation, supplementary feeding of breast milk substitutes, early introduction of complementary feeding, and incorrect weaning from breast milk are commonly found practices in communities around the world [16][17][18][19][20]. Limited communications with Health Care Providers (HCP) and lack of support for dealing with breastfeeding difficulties were reported among Palestinian pregnant mothers in the Gaza Strip.According to the study result, it was found that less than fifty percent (48.4%) of pregnant women received counselling sessions during the antenatal visit.Only (13.2%) of pregnant women mentioned receiving breastfeeding information from the doctors as compared to 57.8% of the respondents received breastfeeding information from health educators.Findings of limited communication with HCP in the Gaza Strip were matched with [21] that reported most mothers during pregnancy were not fully aware of the breastfeeding recommendations and nutritional value of breast milk.
The health benefits of breastfeeding and recommended breastfeeding duration should be emphasized in education programs when encouraging mothers to comply with the WHO breastfeeding guidelines.Specific concerns about breastfeeding and breastfeeding difficulties encountered by mothers should be addressed by health providers in a more supportive manner.In this study, the respondents had two main wrong perceptions i.e. breastfeeding is difficult than infant formula and formula milk is the first food that should be introduced to the baby.These misconceptions could be influenced by social, cultural beliefs and introduction of breast milk substitutes/violation.Public education or breastfeeding campaigns should, therefore, address these misconceived issues appropriately.
More than ninety percent of pregnant mothers showed positive attitudes towards BF i.e. starting BF directly after delivery, avoidance of infant formula and liquids at the hospital after delivery and starting CF after six months of age.The culture of the Gaza Strip is very supportive to breastfeeding especially after delivery and Palestinian mothers aware of BF and EBF benefits for their babies.Although the attitudes towards breastfeeding was generally positive, 84%of respondent thought that BF is difficult than formula milk.This was probably due to our social environment that sometimes is not supportive for BF especially husbands and grandmothers, in addition, bad and unhealthy practices towards BF of many mothers like positioning and attachment and duration of each episode and easy of formula milk preparation especially at night.
In the present study, more than forty percent (42.4%) of the respondents believe that family and social environment are not supportive for BF.Antenatal education that provides pregnant with knowledge and the best practice of breastfeeding may encourage mothers to continue BF after delivery and will increase EBF rate in the Palestinian community.

Conclusion
In spite of, most mothers were knowledgeable and had positive attitudes towards BF but still, a significant number of them had average to moderate knowledge about breastfeeding.Mothers' knowledge about breastfeeding needs to be increased, especially in some aspects of breastfeeding such as Colostrum's use, the age of weaning, optimum duration of breastfeeding episode and formula milk.The misconception and negative attitudes had been identified and should be addressed.Health system should include all mothers into educational interventional programs.

Table 1 :
Characteristics of the samples studied of pregnant women attending Primary Health Care (PHC) Gaza Strip/Palestine.

Table 2 :
Key Breast Feeding (BF) promotion and counselling indicators in primary health care centers/ Antenatal care units.

Table 3 :
months of age (94.8%), and Exclusive Breastfeeding extended for 6 months of age (87.2%).Colostrum was known to be good for their infants by only 44% of respondents.Approximately half of mothers (53%) knew the correct age of weaning.Close to half of the respondents (48%) indicated that formula milk is the first food that should be started with the baby after six months of age.Pregnant Mother's Knowledge about Breastfeeding.