European Journal of Cardiovascular Medicine

Breastfeeding is universally acknowledged as the optimal method of infant feeding, providing complete nutrition and immunological protection essential for the growth and development of infants.[1] The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend early initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months of life, and continued breastfeeding along with appropriate complementary feeding up to two years of age or beyond. [2] Adherence to these recommendations has been shown to significantly reduce infant morbidity and mortality, particularly from infectious diseases such as diarrhea and respiratory infections, while also contributing to improved cognitive development and long-term health outcomes. [3]

In addition to its benefits for infants, breastfeeding confers substantial advantages to mothers, including enhanced uterine involution, reduced postpartum hemorrhage, and long-term protection against breast and ovarian cancers. [4] Breastfeeding also promotes maternal–infant bonding and offers economic benefits by reducing household expenditure on infant formula and healthcare costs. [5] Despite these well-established advantages, optimal breastfeeding practices remain suboptimal in many developing countries, including India, where cultural beliefs, social norms, and health system-related factors continue to influence maternal feeding behaviors. [6]

India has made considerable progress in promoting breastfeeding through national initiatives such as the Infant and Young Child Feeding (IYCF) guidelines and integration of breastfeeding counseling into antenatal and postnatal care services. [7] However, data from national surveys indicate persistent gaps between recommended practices and actual breastfeeding behaviors. [8] Delayed initiation of breastfeeding, discarding of colostrum, administration of prelacteal feeds, and early cessation of exclusive breastfeeding continue to be reported across various regions, highlighting the need for sustained and context-specific interventions. [9]

Maternal knowledge and attitude play a crucial role in shaping breastfeeding practices. Studies conducted in different parts of India and other low- and middle-income countries have demonstrated that although many mothers possess basic knowledge about the benefits of breastfeeding, this knowledge does not always translate into appropriate practices. [10] Factors such as maternal age, education, socioeconomic status, parity, family structure, and exposure to antenatal counseling have been shown to significantly influence breastfeeding knowledge and behavior. [11] Misconceptions regarding breast milk insufficiency and infant feeding during illness further contribute to suboptimal practices. [12]

Healthcare providers, particularly doctors and nurses, are pivotal in influencing maternal decisions related to breastfeeding. [13] Counseling during antenatal visits, immediate postnatal support, and reinforcement of correct breastfeeding techniques have been shown to improve both initiation and continuation of breastfeeding. [14] Nevertheless, several studies have reported inadequate or inconsistent breastfeeding counseling during routine maternal healthcare encounters, resulting in missed opportunities to address maternal concerns and correct prevailing myths and misconceptions. [5]

Given the continued prevalence of suboptimal breastfeeding practices and the observed gap between knowledge and practice, it is essential to periodically assess breastfeeding-related knowledge, attitudes, and practices among postnatal mothers in healthcare settings. Understanding these factors and their socio-demographic determinants can help identify key areas for intervention. The present study was therefore undertaken to assess the knowledge, attitude, and breastfeeding practices among postnatal mothers attending a tertiary care hospital and to examine the association between socio-demographic factors and breastfeeding knowledge, with a particular focus on identifying the knowledge–practice gap.

Objectives

• To assess the knowledge, attitude, and breastfeeding practices among postnatal mothers in a tertiary care hospital in Tamil Nadu
• To determine the association between socio-demographic factors and breastfeeding knowledge and to identify the knowledge–practice gap among postnatal mothers.

Study Design and Setting This study was a hospital-based cross-sectional analytical study conducted in the postnatal wards of a tertiary care teaching hospital in South India. The hospital caters to a predominantly urban and peri-urban population and provides comprehensive antenatal, intrapartum, and postnatal care services. Study Population The study population comprised postnatal mothers admitted in the postnatal wards of the tertiary care hospital during the study period. Mothers were recruited after delivery and prior to discharge from the hospital. Study Duration The study was conducted over a period of six months. Inclusion and Exclusion Criteria Inclusion criteria: Postnatal mothers who had delivered a live newborn and were willing to participate in the study were included. Mothers who were clinically stable at the time of interview and able to provide informed consent were eligible for inclusion. Exclusion criteria: Mothers with severe postpartum complications, critically ill mothers, mothers whose newborns required intensive care, and mothers with medical conditions contraindicating breastfeeding were excluded from the study. Mothers who were unwilling to participate were also excluded. Sample Size and Sampling Technique 200 postnatal mothers were included in the study. The sample size was calculated using the single population proportion formula for a cross-sectional study: n = (Z2 × p × q) / d2, where Z is the standard normal deviate at 95% confidence (Z = 1.96), p is the expected prevalence of the key indicator from a previous study, q = 1 − p, and d is the absolute precision. Based on Chinnasami et al. (2016) [1], the proportion of mothers who initiated breastfeeding within one hour was p = 0.345; hence q = 0.655. With an absolute precision of d = 0.07, the required sample size was n = (1.962 × 0.345 × 0.655) / (0.072) = 178.0. After adding 10% to account for non-response/incomplete data, the final sample size was rounded up to 200 postnatal mothers. Study Procedure Data were collected using a pre-designed, structured, and pre-tested questionnaire developed after an extensive review of relevant literature. The questionnaire included sections on socio-demographic characteristics, obstetric details, knowledge regarding breastfeeding, attitudes towards breastfeeding, and breastfeeding practices. Face-to-face interviews were conducted by trained investigators in the local language to ensure clarity and completeness of responses. Privacy was maintained during interviews, and each interview lasted approximately 15–20 minutes. Operational Definitions •Adequate knowledge: Mothers who correctly answered ≥60% of the knowledge-related questions on breastfeeding. •Inadequate knowledge: Mothers who correctly answered <60% of the knowledge-related questions. •Early initiation of breastfeeding: Initiation of breastfeeding within one hour of birth. •Exclusive breastfeeding: Feeding the infant only breast milk, without any additional food or liquids, for the first six months of life, except for oral rehydration solution or medications. •Prelacteal feeding: Administration of any food or liquid other than breast milk before initiation of breastfeeding. •Appropriate breastfeeding practice: Practice consistent with WHO recommendations regarding breastfeeding. Statistical Analysis Data were entered into Microsoft Excel and analyzed using the Statistical Package for Social Sciences (SPSS) version 26.0. Descriptive statistics such as frequencies and percentages were used to summarize socio-demographic characteristics, knowledge, attitude, and practices related to breastfeeding. Associations between socio-demographic variables and breastfeeding knowledge were assessed using the chi-square test. A p value of less than 0.05 was considered statistically significant. Ethical Consideration Ethical approval for the study was obtained from the Institutional Ethics Committee prior to the commencement of the study. Informed written consent was obtained from all participants after explaining the purpose and procedures of the study. Confidentiality and anonymity of the participants were ensured throughout the study, and participation was entirely voluntary, with the option to withdraw at any point without any consequences to their medical care.

Socio-demographic and obstetric characteristics of the study participants are presented in Table 1. Among the 200 postnatal mothers included in the study, the majority were aged 20–29 years (59%), followed by those aged 30–39 years (28%), while 9% were below 20 years and only 4% were aged 40 years or above. Nearly half of the mothers were illiterate (47%), and only 10% had attained higher education. Most participants were homemakers (82%) and belonged to middle (46%) or lower (41%) socioeconomic status. A greater proportion of mothers lived in nuclear families (64%). With regard to obstetric profile, 62% were multiparous and 38% were primiparous. Vaginal delivery was reported by 67% of mothers, and 33% had undergone cesarean section. The majority of deliveries occurred in government hospitals (71%). Less than half of the mothers (43%) reported having received antenatal counseling on breastfeeding, while 57% had not received any such counseling.

Table 1. Socio-Demographic and Obstetric Profile of Postnatal Mothers (N = 200)

Table 2 summarizes the knowledge of postnatal mothers regarding breastfeeding practices. A high proportion of mothers had correct knowledge regarding early initiation of breastfeeding within one hour of birth (80%) and the importance of colostrum feeding (75%). Most mothers were aware that prelacteal feeds should not be given (89.5%) and that exclusive breastfeeding should be continued for the first six months of life (72%). Knowledge regarding continued breastfeeding up to two years was reported by 63% of mothers. However, knowledge gaps were evident in certain domains; less than half of the mothers had correct knowledge regarding demand feeding (44%) and the use of expressed breast milk (49%). Only 52% of mothers knew that breastfeeding should be continued during infant illness, and 66% were aware that breast milk alone is sufficient for the first six months of life. Overall, while knowledge regarding key breastfeeding practices was satisfactory in several areas, notable deficiencies persisted in specific aspects of optimal breastfeeding behavior.

Breastfeeding practices among the postnatal mothers are depicted in Table 3. Only 34.5% of mothers initiated breastfeeding within one hour of delivery, while a majority (65.5%) initiated breastfeeding after one hour. Colostrum feeding was practiced by 75% of the mothers, whereas 25% reported discarding colostrum. Pre-lacteal feeding was given by 10.5% of mothers, while the remaining 89.5% did not practice pre-lacteal feeding. Exclusive breastfeeding for the first six months was practiced by 72% of mothers, whereas 28% did not adhere to exclusive breastfeeding recommendations. Top feeding was reported by 23.5% of mothers, with cow’s milk being the most commonly used top feed (66%), followed by formula milk (34%). Slightly more than half of the mothers (52%) continued breastfeeding during episodes of infant illness, while 48% discontinued breastfeeding. Among those who discontinued breastfeeding during illness, the most common reason cited was perceived insufficient breast milk (64.6%), followed by infant illness (21.9%) and maternal illness (13.5%).

Table 2. Knowledge of Postnatal Mothers Regarding Breastfeeding (N = 200)

Table 3. Breastfeeding Practices Among Postnatal Mothers (N = 200)

Table 4 presents the attitude of postnatal mothers toward breastfeeding. A majority of mothers agreed that breast milk is the best food for the newborn (71.5%) and that colostrum is healthy for the baby (75%). More than four-fifths of the mothers (81%) believed that breastfeeding strengthens mother–child bonding, and 64% perceived breastfeeding as beneficial for the mother’s health. Breastfeeding was considered economical compared to formula feeding by 61% of the respondents. Only 22% of mothers felt that breastfeeding negatively affects the marital relationship, while the remaining 78% disagreed or were unsure. Perceived insufficient breast milk was acknowledged as a common problem by 59% of mothers. Doctors were identified as the most trusted source of breastfeeding advice by a large majority of participants (87.5%). Furthermore, 63% of mothers agreed that breastfeeding should be continued up to two years of age. Overall, the findings indicate a generally positive attitude toward breastfeeding, despite the presence of certain concerns and misconceptions.

Table 4. Attitude of Postnatal Mothers Towards Breastfeeding (N = 200)

Table 5 depicts the association between selected socio-demographic factors and knowledge of breastfeeding among postnatal mothers. Maternal age showed a statistically significant association with breastfeeding knowledge, with a higher proportion of mothers aged ≥25 years having adequate knowledge compared to those aged <25 years (68.5% vs. 52.2%; p = 0.041). Educational status was strongly associated with knowledge levels, as mothers with secondary education and above demonstrated significantly better knowledge than those who were illiterate or had only primary education (82.2% vs. 43.7%; p = 0.001). Socioeconomic status also exhibited a significant association, with mothers belonging to middle and upper socioeconomic classes showing higher adequate knowledge compared to those from lower socioeconomic class (71.2% vs. 46.3%; p = 0.002). Parity was found to be significantly related to breastfeeding knowledge, with multiparous mothers having a greater proportion of adequate knowledge compared to primiparous mothers (66.1% vs. 52.6%; p = 0.036). Antenatal counseling on breastfeeding emerged as one of the strongest determinants of knowledge; mothers who had received antenatal counseling demonstrated significantly higher adequate knowledge compared to those who had not received such counseling (83.7% vs. 43.9%; p = 0.001). Overall, age, educational status, socioeconomic status, parity, and receipt of antenatal counseling were significant predictors of breastfeeding knowledge among postnatal mothers.

Table 5. Association Between Socio-Demographic Factors and Knowledge of Breastfeeding Among Postnatal Mothers (N = 200)

*- statistically significant

Table 6 compares breastfeeding knowledge with actual practices among postnatal mothers. Although a high proportion of mothers had adequate knowledge regarding early initiation of breastfeeding within one hour of birth (80%), only 34.5% practiced early initiation, resulting in a substantial knowledge–practice gap of 45.5%. Knowledge and practice were concordant for several indicators, including colostrum feeding, avoidance of prelacteal feeds, exclusive breastfeeding for the first six months, and continuation of breastfeeding during infant illness, where the proportions of mothers with adequate knowledge closely matched those who reported appropriate practices.

In contrast, discrepancies were observed in specific domains such as demand feeding and continuation of breastfeeding up to two years. While 44% of mothers had adequate knowledge regarding demand feeding, only 28% practiced it, reflecting a knowledge–practice gap of 16%. Similarly, although 63% of mothers were aware that breastfeeding should be continued up to two years of age, only 47% practiced continued breastfeeding, again demonstrating a gap of 16%. Overall, the findings highlight that despite satisfactory knowledge in several key aspects of breastfeeding, translation of knowledge into practice remains suboptimal in certain critical areas, particularly early initiation and sustained breastfeeding behaviors.

Table 6. Comparison Between Knowledge and Practice of Breastfeeding Among Postnatal Mothers (N = 200)

The socio-demographic and obstetric profile of postnatal mothers in the present study revealed that the majority belonged to the 20–29-year age group, were homemakers, had low to middle socioeconomic status, and a substantial proportion were illiterate. These findings are comparable to observations by Chinnasami et al. and Sultania et al., who reported similar age distribution, high proportion of homemakers, and low educational status among postnatal mothers in tertiary care settings [1,3]. Rudrappa et al. also documented that most mothers were young, homemakers, and belonged to nuclear families [8]. The low proportion of mothers receiving antenatal counseling on breastfeeding in the present study is consistent with findings from Ekambaram et al., who highlighted inadequate breastfeeding counseling during routine antenatal care [2]. These similarities suggest persistent socio-demographic vulnerabilities influencing breastfeeding outcomes in institutional settings.

Assessment of breastfeeding knowledge showed that most mothers were aware of early initiation of breastfeeding, colostrum feeding, avoidance of prelacteal feeds, and exclusive breastfeeding for six months, while notable knowledge gaps existed regarding demand feeding, expressed breast milk, and breastfeeding during infant illness. Comparable patterns were observed by Chinnasami et al., who reported good overall knowledge with deficiencies in specific domains such as demand feeding [1]. Ekambaram et al. similarly noted inadequate knowledge regarding expressed breast milk and breastfeeding during illness [2]. Ghure et al. and Doshi et al. reported satisfactory overall knowledge among mothers but emphasized the need for targeted education in specific areas [6,7]. These findings indicate that while general breastfeeding awareness is improving, comprehensive understanding of optimal practices remains incomplete.

Breastfeeding practices observed in the present study revealed that early initiation of breastfeeding within one hour was practiced by only one-third of mothers, despite higher levels of knowledge. This finding aligns with reports by Chinnasami et al. and Sultania et al., who documented low rates of early initiation despite good awareness [1,3]. Ekambaram et al. also reported suboptimal breastfeeding practices related to initiation and continuation [2]. Although exclusive breastfeeding rates in the present study were relatively higher, consistent with findings by Ghure et al. and Ambike et al. [7,10], continued challenges such as top feeding and discontinuation during infant illness persist. These results highlight the persistent gap between recommended practices and actual maternal behavior.

The attitudinal assessment indicated that most mothers held positive attitudes toward breastfeeding, recognizing its benefits for infants and mothers, as well as its economic advantage. Similar positive attitudes were reported by Kamath et al., who found that mothers largely perceived breastfeeding as healthy and beneficial [5]. Ghure et al. also reported favorable attitudes among primigravida mothers, with healthcare providers being a major source of information [7]. However, concerns regarding perceived insufficient breast milk were common, echoing findings from Sultania et al. and Karim et al., where such perceptions influenced breastfeeding behavior [3,4]. These findings suggest that although attitudes are generally positive, specific misconceptions continue to influence practices adversely.

Analysis of factors associated with breastfeeding knowledge demonstrated that maternal age, education, socioeconomic status, parity, and antenatal counseling were significantly associated with adequate knowledge. These findings are consistent with Ekambaram et al., who reported higher knowledge scores among older, better-educated mothers and those receiving antenatal care from tertiary centers [2]. Ambike et al. similarly found education and parity to be significant determinants of breastfeeding knowledge [10]. Karim et al. also observed a significant association between educational status and breastfeeding knowledge and practices [4]. The strong association between antenatal counseling and knowledge in the present study underscores the critical role of structured breastfeeding education during antenatal care.

The comparison between breastfeeding knowledge and practices revealed a pronounced knowledge–practice gap, particularly for early initiation of breastfeeding and continued breastfeeding up to two years. This gap has been consistently documented in earlier studies. Chinnasami et al. reported a large discrepancy between knowledge of early initiation and actual practice [1]. Sultania et al. and Rudrappa et al. also highlighted similar gaps, attributing them to cultural practices, delivery-related factors, and inadequate postnatal support [3,8]. Paudel et al. reported even wider gaps in a different cultural context, emphasizing the influence of systemic and sociocultural barriers [9]. These findings reinforce the need for interventions that move beyond knowledge dissemination to address behavioral, institutional, and cultural determinants of breastfeeding practices.

Limitations

The cross-sectional design of the study limits causal inferences between socio-demographic factors and breastfeeding knowledge or practices. Additionally, breastfeeding practices were self-reported by mothers, which may be subject to recall bias and social desirability bias.

The present study demonstrates that although postnatal mothers possess satisfactory knowledge and generally positive attitudes toward breastfeeding, optimal breastfeeding practices remain suboptimal, particularly with respect to early initiation of breastfeeding, demand feeding, and continuation of breastfeeding beyond infancy. A significant knowledge–practice gap was identified, indicating that awareness alone does not consistently translate into appropriate breastfeeding behavior. Maternal education, socioeconomic status, parity, and receipt of antenatal counseling were found to be important determinants of breastfeeding knowledge, underscoring the influence of both individual and health system factors on breastfeeding outcomes. Strengthening breastfeeding promotion requires focused and sustained interventions beyond information dissemination. Structured and comprehensive breastfeeding counseling should be integrated into routine antenatal and postnatal care, with special emphasis on early initiation, demand feeding, and continuation of breastfeeding during infant illness. Targeted counseling for younger, less educated, and primiparous mothers is essential. Capacity building of healthcare providers, particularly doctors and nursing staff, along with reinforcement through community-based education and mass media, is recommended to bridge the knowledge–practice gap and promote optimal breastfeeding practices.