DISSERTATION PROPOSAL

“A STUDY TO ASSESS THE EFFECTIVENESS OF INFORMATION BOOKLET ON KNOWLEDGE

AND PRACTICES OF EXPRESSED BREAST MILK AMONG POSTNATAL WORKING MOTHERS IN

SELECTED HOSPITALS OF TUMKUR CITY”

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

OBSTETRICS AND GYNECOLOGICAL NUSING

SUBMITTED BY

MS ASAWARI BHALCHANDRA GAIKWADFIRST YEAR MSC NURSING

BHARATHI COLLEGE OF NURSINGTUMKUR - 01

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE, KARNATAKA

2011 -2012

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE, KARNATAKA

Performa for registration of subjects for dissertation

1 Name of the candidate and address Ms Asawari Bhalchandra Gaikwad.Bharathi College; Girls Hostel Tumkur.

2 Name of the institution Bharathi College Of Nursing4th Cross, K R Extn, TUMKUR-572101

3 Course of the study and subject First Year M.Sc. Nursing 2010-12Obstetrics and Gynaecological

4 Date of admission to course 01-10-2010

5 Title of the topic

“A study to assess the effectiveness of information booklet on knowledge and practices of expressed breast milk among postnatal working mothers in selected hospitals of Tumkur City”.

  

6. Brief resume of the intended work.

Introduction

God has created a very beautiful universe. He created many things in it. The human life is the most

beautiful gift of god to universe. The physiological mechanisms are nicely arranged for the different

stages of life. There is not a single stage that could become harmful to the body. The continuity of the

life on earth is maintained by a birth of new human being. And for that, he has created a very beautiful

and precious thing that is “MOTHER”. 1

The importance of breast milk has been accepted since the time of Hippocrates who has stated

that one’s own milk is beneficial.2

Human milk is unquestionably the best source of nutrition for neonates or infants by the virtue

of uniqueness of its biological composition. 3

One of the ancient physicians from India in his SAMHITA while describing the importance of

qualities of breast milk said “One just cannot compare even water of seven seas, with mother’s milk

which is nothing but water ensuring optimum growth, nutrition and healthy life of hundred years.”4

From the immemorial time breast feeding has been the only method of feeding in our country. It is

accepted by all Indian mothers and also mothers of tropical countries.

In India it is a common practice to send pregnant women to her mother’s place for her first

delivery. Here she gets advices from her mother, grandmother and her friends, regarding breast feeding

and rearing of the child. Both of them are considered to be vulnerable group. During this time mother

and child are in close contact with each other the mother can give full attention to the child to meet with

its daily needs. There is more skin to skin contact during this period, which helps in creating maternal

and child bond. In the olden times whenever mother was not in a position to feed her baby, the practice

of wet nursing was used (wet nursing is nursing another women’s baby).

Since 1800 B.C, regulations on practice of wet nursing were laid down. In 18 th century wet

nursing was widely practiced by mothers of nobility who refused to be feed their babies to guard their

beauty and figure. In later half of the 18th century law controlling wet nursing was introduced where the

wet nurses were registered and had to be disease free and were not permitted to nurse more than two

infants at a time.

In India from Royal families mostly women were reluctant to feed their babies and hence they

use to deploy wet nurses to feed them rather than depending upon either milk of cow or buffalo. 5

“Later half of the 20th century was marked by an upsurge towards universal breast feeding

polices hospital were readjusting the prenatal care to encourage and enhance breast feeding. Therefore

breast feeding is once again returning to its proper position.

“The consequences of artificial feed and bottle feed had caused more awareness amongst the

women that breast milk is the best.”

Dedicated members of the health care system have been successful in conveying the message

persistently in the latter 20th century. Though the breast milk is the best; there are many babies who are

not fortunate enough to get it. Expressed breast milk was suggested as substitute for breast milk.

This necessitated the storage of milk for longer time and making it more widely acceptable and usable.

Doctors and nurses became more concerned in developing this concept and human milk bank was

established in India. 6

Considering the nutritional importance of breast milk with built up in host defence mechanism

which is lacking in artificial formula and recent research demonstrating the metabolic and anti-infective

significance of human milk in premature and sick babies the idea of manual expression of breast milk

came into existence to feed the infants who are deprived of the breast milk due to various reasons. 7

“Mother of high risk babies run the problems of lactation failure as then babies is not able to

suck the breast. This could be prevented by regular expression of breast milk storing and utilization of

milk.

Milk banks are in existence for more than a century in developed countries for safe guard to the sick,

premature or for postnatal working mother’s infants. The use expressed breast milk for those infant had

made considerable impact on morbidity and mortality of infant. 7

In India first human breast milk bank was established in November 1989 at Sion Hospital,

Mumbai. 8

When we trust the makers of baby formula more than we do our own ability to nourish our

babies, we lose a chance to claim the aspect of our power as women. Thinking that baby formula is as

good as breast milk believes that thirty years of technology is superior to three million years old

nature’s evolution. Countless women have regained trust in their bodies through nursing their children,

even if they were not sure first that they could do it. It is an act of female power, and I think of it as

feminism in its purest form. 9

--- Christine Northrup

Background of the study

In today’s world around 75% of women are working in urban area, out of which 58% are working

mothers. In Indian, the maternity benefit is given for 90 days paid leave in Government setting but in

private sectors the mother have to return back to work after one and half month or two months. Also as

per W.H.O rule exclusive breast feeding should be given at least for 6 months. As the mother return

back to work the babies does not get proper feed’s thus she can express and store the breast feeds and

many a times it gets spoiled and baby may became sick thus it is important to know regarding proper

expression and storage of breast milk, at proper temperature.

Mother’s milk is best for an infant. Many scientific studies and researches have proved that

there is no substitute for breast milk. Babies who are breast fed have 30% less chances or at risk for

illness than the bottle fed babies. 10

The first year of life is crucial in laying the foundation for good health. At these times certain

specific biological and psychological needs must be met to ensure the survival and healthy

development of the child into a future adult. Breast feeding is the ideal method initiated for

physiological and psychological need of infant. During antenatal period, the mother and foetus are

physically linked and the mother feeds her baby completely through her placenta. After birth, breast

feeding creates a unique bond between the mother and her baby. When mother’s breast gives adequate

warmth, affection, security, food and protection for her baby. 11

Customs, tradition, superstition, myths and ignorance sometimes deprives the child from getting

this benefit. To educate mothers about the importance of exclusive breast feeding is one of the

important aspect of Reproductive child health.

Breast feeding is a natural process that seems to have been adversely affected by the

modernization of society. Though it is now widely accepted that breast milk is best for the baby, it is

also a well known fact that exclusive breast feeding rates in early infancy are still too low. The number

of studies have shown that deficit in the knowledge of practices regarding exclusive breast feeding

amongst postnatal women’s and lack of adequate information given to mothers are the major factors

responsible for the low rates of exclusive breast feeding. Maternal education, race and socioeconomic

factors are also known to influence breast feeding knowledge and practices. 12

Breast feeding promotion network of India, (BPNI) says, the infant aged ( 0- 5 months) who

are not breast feed have seven fold and fivefold increased risk of death from diarrhoea compared to the

infants who are exclusively breast feed. To reduce the infant mortality rate and improvement in the

health status and development of infants and young children, breast feeding is very important.

Breast milk has its socioeconomic psychological, biological and immunological aspects. Human milk is

known to be an ideal, the safe and complete food for infants made available at a suitable temperature,

helps to promote normal development of an infant. It is known to enhance the child immunity and the

additional cost of milk. 13

Exclusive breast feeding is the best source in order to prevent malnutrition in the newborn and

infants, if exclusively breast fed; it fulfills all the nutritional requirements of the baby. As breast milk

contains 70% of water thus oral water is also not required for first six months of life. Mother’s milk is

especially adapted for the baby’s need, with extra proteins and minerals.’ COLOSTRUM’ is

particularly valuable as it contains an immune factor which protects them against infection. Growth

factors help the baby’s gut to mature and also contain factors responsible for development of baby.

Breast milk is beneficial nutritionally, immunologically, psychologically as its economic value is

high.14

World Health Organization (WHO) and UNICEF, says that breast feeding should be initiated

for all babies immediately after birth. Most infant should receive only breast milk till six month of age.

The recent researches related to clinical aspects of breast feeding for child’s development have given a

new impetus to the practice.

Moreover breast feeding is being adopted as an expression of self fulfillment.

In 1980’s the importance of breast feeding has been so widely realized that the World Health

Organization conducted a study on “Breast feeding” in nine countries.15

From 1st – 7th August, “Breast Feeding Week” is celebrated every year. The first “World Breast Feeding

Week” was based on the theme of the baby friendly hospital initiative (BFHI)” Which was launched on

1ST August 1992.The aim of BFHI is to encourage all institutions and hospitals to provide maternity

services and to practice 10 steps for the successful breast feeding. This joint statement was suggested

by WHO/ UNICEF.

According to World Health Organization (WHO) report , it was found that decline in breast

feeding is due to modernization, urbanization, industrialization , working mothers, change in family

structure and change in attitude.

In today’s world around 75% of women are working in urban area, out of which 58% are

working mothers. In India, the maternity paid leave is given for 6 months in government organization

but in private sectors the mother has to return back to work after the 45 to 90 days period. Also as per

the World Health Organization (WHO) exclusive breast feeding should be given up to six months. As

mother return back to work the infants does not get proper feeds thus she can express and stores the

breast milk. But many a time it gets spoilt and the baby may fall sick thus it is important to have proper

knowledge regarding expressed breast milk and its storage at proper temperature. 16

6.1. Need of the study

Journal of Human Lactation, First published on November 12, 2009, a cohort study, Conducted in Perth

(Australia), the expression of breast milk allows a mother to be away intermittently from her infant

while continuing to breastfeed. The study to investigate between expression of breast milk and breast

feeding duration. Result: A total of 587 mother, or 55% of those eligible, participated in the study. Of

these 93% were breastfeeding at discharge but after six month they discontinue as they started on their

work.

According to WHO and UNICEF, exclusive breastfeeding for 6 months is the single most

effective child survival intervention which reduces the under five children death about 16% in India. 17

India has more than 400 million children. 2.5 million Children die in India every year,

accounting for one in five deaths in the world, with girls being 50 percent more likely to die. One out of

16 children die before they attain one year of age, and one out of 11 die before they attain five years of

age. India accounts for 35 per cent of the developing world’s low birth weight babies and 40per cent of

child malnutrition in developing countries, one of the highest levels in the world. Although India’s

neonatal mortality rate declined in the 1990s from 69 per 1000 live births in 1980 to 53 per 1000 live

births in 1990, it remained static, dropping only four points from 48 to 44 per 1000 live births between

1995 and 2000.18

On an average, 57 infants out of 1000 live births die each year in India, with Uttar Pradesh (73),

Chhattisgarh (71) and Madhya Pradesh (70) registering the highest deaths. The better performing states

are Kerala and Goa with an Infant mortality rate (IMR) of about 15.”Breastfeeding promotion” alone

contributes to 11.6% reduction in Infant mortality rate if coverage of promotion is 99%, and can avert

21.9 million DALY’s (Disability Adjusted Life Years) at 3 years.19

The new Lancet series reiterates that 77% (1.06 million) child deaths attributable to suboptimal

breastfeeding are due to non exclusive breast feeding during 0-6 months of life. Predominant breast

feeding (breastfeeding + water) increases the risk of child mortality 1.48 times as compared to

exclusive breastfeeding. Partial breast feeding (breast milk + other milk or food) increases the child

mortality 2.8 times as compared to exclusive breast feeding. The relative risk for prevalence of diarrhea

is 3 times higher and for pneumonia 12.5 times higher for partial breast feeding as compared to

exclusive breast feeding. The National average is close to 46.4%, with Haryana being lowest at

16.9%.Clearly, exclusive breast feeding for a period of six months is not a practice among more than 20

million infants of the 26 -27 million born each year.19

According Dr. Arun Gupta, National coordinator of Breastfeeding Promotion Network of India

(BPNI)stated that the rate of early initiation of breastfeeding is a mere 24.5% Nationally, ranging

between 3.7% in Bihar to 66.4% in Mizoram.

Breast feeding is rewarding experience for both mother and baby. Breastfeeding is natural but it is not

naturally known to many mothers. Breast feeding is a learned skill that both mother and baby need to

practice many times before both fully know and understand the process. The key for successful

exclusive breastfeeding is support from health care professionals. They play important role in

encouraging the exclusive breast feeding practices. Research indicates that many women lack the

knowledge of breast feeding .Thus an art of exclusively breast feeding is getting lost from our society

due to the changing scenario, as both men and women both are walking shoulder to shoulder. If Both

the parents are working thus the baby is looked after by the maid or the grandparents and mother does

not get maternity leave for six months they have to return back to work after two or three months in

private sectors thus the baby does not get proper feed and bottle feeds are given .

Breast feeding is the fundamental right of the child .Feeding practices vary from place to place and

person to person.

Human milk is superior to all substitutes and that expressed breast milk may be suitable feeding

alternative for infants whose mothers are unable to breast feed their own baby.

Hence the investigator was encouraged to undertake the study that could help the postnatal working

mothers who are intended to work, and would be away from their baby for a period of 6 to 8 hours, in

the selected hospitals of the city.

Thus there is a gap in knowledge regarding expression and storage breast milk in postnatal mother thus

this information booklet will helps them express and store breast milk to feed the baby during working

hours.

6.2. Review of literature

Polit and Beck. (2008) defines review of literature “review of published and unpublished research and

non research literature is an integral component of any scientific research. It involves a systematic

identification, location scrutiny and summary of written material that contain information regarding a

research problem.” 22

According to Boswell, Cannon S. (2007) “Review of literature is a written, analytical summary of

research findings on a topic of interest. It is a comprehensive compilation of what is known about the

phenomenon. The purpose of review of literature to assess the evidence regarding the research topic by

identifying and synthesizing studies that examine the subjects of interest”.24

In view of the present study the related literature review has been made and described under following

headings. Review related to:

1. Exclusive breast feeding.

2. Factors affecting breast feeding practices.

3. Expressed breast milk.

4. Breast milk banking.

5. View of lactating mother about the donation and use of expressed breast milk.

6. Effect of information booklet.

Review related to exclusive breast feeding.

Breast milk is the best feed for the baby till the baby is of six months old. Exclusive breast feeding

can save many lives by preventing malnutrition and infections. It is very essential to impart this

knowledge to mothers. Many researches had been conducted which highlights the importance of

Exclusive breast feeding.

Dr. Kushwaha K P (2010) a head of the department of Paediatrics, BRD Medical college,

Gorakhpur, stated that “It is sad, but true that only 46.4% of mothers do exclusive breast feeding.

The rest other 53.6% do not even realize the great harm they are doing to their child, society and

country “He stated that though it is said repeatedly that exclusively breast feeding is a natural

instinct of all mothers the truth is that it is a technique that must be taught to a women.25

The above article states that one to one breastfeeding counseling is the most critical intervention to

improve exclusive breastfeeding rates. During first six months of life.

Kaur Balwinder (Published 2011) a comparative study was conducted to assess the knowledge,

attitude and practices of mothers regarding breastfeeding in a selected urban and rural community

in Ludhiana, Punjab. The sample size was 100, out of which 50 were from urban and 50 from rural

area. The study findings revealed that rural mothers had more positive attitude regarding breast

feeding irrespective of knowledge regarding breast feeding. Also according to age and education of

the mothers rural mothers with increasing age had more knowledge, positive attitude and better

practices regarding breastfeeding whereas practices of urban mothers with more education were

also better. Similarly the findings of source of information indicated that books were more effective

in increasing breastfeeding practices among both urban and rural mothers whereas books where the

source of information regarding breastfeeding in urban mothers and media exposure in rural

mothers with regular antenatal checkups had effect on knowledge of mothers regarding

breastfeeding whereas among rural mothers regular antenatal checkups had not shown any effect on

the knowledge of mother regarding breast feeding.26

Thus the above study finding interprets that socioeconomic strata, age education influence breast

feeding knowledge and practices.

Diane L.S, Ph.D.RN (2010) conducted a study at Children’s hospital of Philadelphia on very sick

babies admitted in neonatal intensive care unit (NICU).His study findings revealed that sickest

babies can benefit from exclusive breast feeding. Many of these highly vulnerable newborns

immediately experience a paradoxical situation. Their mother’s milk helps to reduce the infection

rates and provided easily digestible nutritious food and also reduces the infant’s stay in the NICU.27

Dr.Mathur, Dr. Kushwaha (1994) conducted the study on,’Growth patterns in breast fed babies

during first six months of life’. The study consisted of 126 normal newborn in urban slum areas those

were given exclusive breast feeding till six months. Then their development like height, weight, head

and chest circumference was measured and compared with ICMR standards. The study findings

revealed that growth pattern was normal and average with ICMR standards. Thus it can be concluded

that exclusive breast feeding should be promoted as one of the most important measure for child health

promotion.28

Dr.Chaturvedi SK (1996) conducted the study to prove that breast milk helps the newborn to avoid

diseases. He concluded that “there is scientific evidence that mother’s milk may induce an infant’s

immune system to mature more quickly than it would when the child is feed artificially. Also certain

hormone in milk and smaller protein act to close up leaky mucosal lining of the newborn, making it

relatively impermeable to pathogens.29

Emmanuel G Prof. (2010) conducted a study in Greece on newborns. She stated that babies are

helped to fight against infections by composition of breast milk. For this study she tracked 926 infants

for a period of 12 months, and recorded any common infections these babies had during first year of

life. All newborns were routinely vaccinated and had an access to a high standard of healthcare.

Overall 91 of the infants were exclusively breastfeed for full six months. These infants had

significantly fewer common infections during first year of life than their peers who were either

partially breastfed or not breastfed at all.30

Donovan S. Prof. (2010) conducted a study and identified group of genes present in breast milk

contribute to more efficient immune system. Thus gene present in breast milk involved in the cell’s

response to oxygen deprivation. Lack of oxygen is a factor in the development of necrotizing

enterocolitis (NEC), a kind of gangrene of the intestine that can be fated in premature babies.NEC is

leading cause of disease and death in neonatal intensive care unit, with a reported 2,500 cases occurring

annually in the United States and a mortality rate of 26%.The intestinal tract of newborn undergoes

marked changes in response to feeding. Thus the bioactive components in breast milk are important in

this response.

Thus we can conclude that breast milk contains immune protective components that make a breast fed

infants risk lower for all king of illness.31

Fairbrother Nichole, PhD and Stanger-Ross Ilana. (2009) a study was conducted to assessed

knowledge, attitudes, and intentions regarding infant feeding practices among Canadian female

university undergraduates (N = 285). Participants completed a survey of knowledge, attitudes, and

intentions with respect to infant-feeding practices. Two versions of the survey were randomly

distributed to participants: one containing a photograph of a woman breastfeeding her infant (n = 131)

and the other containing a photograph of the same women bottle-feeding her infant (n = 154). Findings

indicated that the majority of the sample had been breastfed (84%) and intended to breastfeed their own

offspring (97%). The intention to breastfeed future offspring was predicted by knowledge, attitudes, and

perceptions of social norms. Participants reported more positive attitudes toward visual depictions of

breastfeeding compared with bottle-feeding but less positive views of breastfeeding in public compared

with bottle-feeding in public. Participants also significantly underestimated the health benefits and

optimal duration of breastfeeding. The findings highlight gaps in knowledge that may contribute to

premature cessation of breastfeeding among Canadian women and suggest the need for breastfeeding

education. 32

Review related to factors affecting breast feeding practices.

The World Health Organization & China Ministry of Health (2010) mentioned that only 29% of

mothers exclusively breastfed their babies for six months, while more than half of the mothers failed to

do so. Insufficient breast milk & having no time to continue exclusively breast feeding after returning

to work were cited as two major reasons were mothers are unable to exclusively breast feed their babies

up to six months.33

Archives of Disease’s in Childhood (2010) mentioned the study was con01ducted in UK, which

included 18,050 infants, applies to both full time and part time care, and all strata of society. The aim of

this study was to find out if childcare arrangement and socioeconomic factors had any impact on

breastfeeding rates. The study findings revealed that, babies in formal child care nursery, crèche,

registered childcare centers were found 15% less likely to breast feed.34

Journal of Pediatrics and Neonatology (2009) conducted a study at well baby clinic. To estimate the

probabilities of various factors at various time intervals for duration of exclusive breastfeeding. In this

study 277 mothers was analyzed .The major findings of the study revealed that the duration of

exclusive breast feeding was shorter in urban educated women from high income group. Thus it

conclude that children born in high economic status families had higher risk of stopping exclusive

breast feeding compared to those in low economic status families.35

Britton C. (2006) mentioned that there is extensive evidence on short term and long term health

benefits of breast feeding for infants and mothers. In 2003 World Health Organization recommended

that, whatever possible, infants should be fed exclusively on breast milk till first six months of life. But

it was seen in some high income countries, many mothers stop breast feeding before they want to and

this causes disappointment for the mothers and more health problems for the infants. The review found

34 studies, 14 countries, including almost 30,000 women. Both professional and lay support together

revealed the initiation and continuation of breast feeding was not high. Further research is needed to

identify the aspects of support that are the most effective.36

Dr.Bartick M. (2008) conducted a study in Australia on 5,000 infants and found that just 14% were

breastfed till six months down from 80% at birth and 56% at three months old. Thus the Australian

Breastfeeding Association national president Margaret Grove said “I think women are made to feel

embarrassed by breastfeeding and people sometimes feel a bit squeamish about it.”Also the study

findings revealed that rates of breast feeding dropped if women returned to work within three months of

delivery.37

Hill. Pamela D.Ph.D, RN. (2007) conducted a study on increasing the rates of both imitation of

breastfeeding and duration of breastfeeding in United States. In hospital breast feeding rates are 64%

and duration rate is 29%.These percentage fall short of the Healthy People 2010 goal for breastfeeding ,

which states that we should increase the proportion of mothers who initiate breastfeeding to at least

75% and increase the proportion of mothers who continue to breastfeed until six months to at least

50%.Factors influencing breast feeding such as socioeconomic status, mothers attitude towards breast

feeding and work place environment were examined.38

Malliarjuna. Kesaree.(2002) conducted the study on breast feeding problem in first six months of life

in rural Karnataka.420 mother infant pairs were enrolled from villages out of these 338 were practicing

exclusive breast feeding, 82 had started on top feeds and 7 mothers had completely stopped breast

feeding. It was found that in rural community there were too many problems regarding breast feeding

especially in first week of neonatal period. Thus it was concluded that one month of life determines the

success or failure of breast feeding. In order to cope with the common problems of breast feeding,

health workers and trainers need to be educated and trained.39

The above studies reveals that the rate of exclusive breast feeding is dropped due to change in scenario,

attitude, working status of the mother, with the complaints of mother that inadequate breast milk,

engorged breast, cracked nipple etc are the factors affecting excusive breast feeding practices.

Review related to expressed breast milk.

Journal of Human Lactation (November 12, 2009) conducted a study in Perth (Australia); the

expression of breast milk allows a mother to be away intermittently from her infant while continuing to

breastfeed. Total 587 mothers were taken out of which 93% of mothers though after returning to work

by the means of expressed breast milk were exclusively breastfeeding till six months. And rest 7%

discontinued by gave reason of less breast milk.40

Thus after providing proper knowledge about expressed breast milk, working mothers can exclusively

breast their babies.

Wendelin.MD, MS.Lange Linda DrPH, RN (2004) conducted a study to assess the barriers for

breastfeeding women working fulltime outside the home. She stated that most of the mothers spend one

hour or less in expressing breast milk when infants are 3 – 6 months old. Also mothers of younger

infants were no more likely to work few days per week as they use to feel embarrassed to express breast

milk at work place.41

Thus, the above study findings reveal that supportive environment needs to be provided for lactating

mothers employment at workplace.

Rajashri. (2009) mentioned that, The New South Wales Police Force has made an Aussie women work

overtime for every minute which she had spent in expressing breast milk for her baby. According to the

complaint documents observed by Daily telegraph, she was even denied to use of accumulated leave

and her requests for hours that suited her child care needs were rejected. She was also told to record the

time spent in expressing milk at work on her timesheet, and was refused a private room and had to feed

her baby using either an unlockable and unclean interview room, where she was continuously

interrupted by police officers, or a toilet cubicle. Eventually she had no choice but to express milk in

her car in the car park, but because of her "great embarrassment" she drove home and fed the baby.

When she returned she was made to work for the time she had been gone. 42

Thompson Nancy. (1997) conducted a study to determine if pre expression breast cleansing reduced

the bacterial count in expressed breast milk. The study involved the collection of 178 breast milk

samples (89 matched samples); 38 matched samples were from mothers of term infants and 51 matched

samples were from mothers of preterm infants. One half of the samples were collected following breast

cleansing with Phisoderm and tap water. The other halves were collected following breast cleansing

with tap water only. Hand and equipment washing with Phisoderm and tap water preceded all sample

collections. Storage containers were sterile. Samples were cultured for pathogenic and nonpathogenic

bacteria and examined at 24 and 48 hours. Breast cleansing with Phisoderm and water was not more

effective than water alone at reducing nonpathogenic bacteria or eliminating pathogenic bacteria.

Mothers of preterm infants had higher levels of both nonpathogenic and pathogenic bacteria than

mothers of full-term infants. The most common form of bacterial contamination was coagulase-

negative Staphylococcus epidermidis. This particular bacteria is found in higher levels in the stools of

breast fed infants than formula fed infants and it also the most common contaminant found in the blood

of preterm infants who develop sepsis. The findings of this study reveal that chemical interventions

may not be effective at rendering breast milk free from pathogenic bacteria. More research is needed to

determine the optimal cleansing protocol to achieve bacterial decontamination of breast milk or to

determine the clinically acceptable level of contamination based on the effect on infant.43

International Breast Feeding Journal (2006): a cohort study was conducted to investigate the

association between expression of breast milk and breastfeeding duration. The mothers were recruited

from two public maternity hospitals in Perth, Australia between mid-September 2002 and mid-July

2003. While in hospital, participating mothers completed a questionnaire that included questions on

how they were feeding their newborn. Telephone interviews conducted at regular periods monitored

changes in infant feeding practices, including expression of breast milk. A total of 587 mothers, or 55%

of those eligible, participated in the study. Of these 93.5% were breastfeeding at discharge from

hospital. Mothers who expressed breast milk (at one or more time periods) were less likely to

discontinue any breastfeeding before than those who had never expressed milk.

Thus study found that mothers who express breast milk are more likely to breastfeed to six months (any

breastfeeding). While further research is required in different cultures to confirm these results, the

appropriate use of expressed breast milk may be a means to help mothers to achieve six months of full

breastfeeding while giving more lifestyle options.44

Sanchez Cristina (2009) conducted a study to confirm that the composition of breast milk changes

quite markedly throughout the day. She says that breast milk contain ingredients, such as nucleotides,

which perform a very important role in regulating babies sleep. She looked for three nucleotides in

breast milk( adenosine , guanosine & uridine)In this study she collected samples from 30 mothers over

a period for 24 hours, daily 6 to 8 samples. And high nucleotides concentration were found in night

time samples (8pm to 8 am).45

It is the contradictory study related to storage of expressed breast milk for more than 24 hours

Review related to breast milk banking.

Dr.Mondkar. (2006) mentioned that the human milk center at India in Mumbai city has been providing

mother’s milk to newborn babies. The human milk bank at Sion hospital caters to newborn and

premature babies whose mothers do not lactate. The deprivation of breast milk, which contains a right

balance of nutrients and is the most easily digestible food for babies, could lead to lower IQ levels and

weaker immune systems, apart from other deficiencies. However, the Sion hospital milk bank,

authorities claims could be the first in Asia, fulfills this requirement. There are at least 8,000 babies

born here every year. In that 20 to 35% of these cases direct breast feeding becomes impossible and

thus human milk bank is a support system available.

Thousands of babies, many of them teenagers now, will be thanking the Sion hospital milk bank for

those first drops of life and health.46

The Cochrane Library (January 2010) conducted a study to determine the effect of banked preterm

milk compared with banked term milk regarding growth and development outcome in very low birth

weight infant (weighing less than 1500 gm) The study revealed there is no randomized trials that

compare preterm banked milk to promote growth and development in very low birth weight infant.47

Review related to view of lactating mother about the donation and use of expressed breast milk.

Dash Manjubala (2010) mentioned that Human milk is superior to all substitutes and that banked

human milk may be suitable feeding alternative for infants whose mothers are either unable or

unwilling to provide their own milk. Banked milk also can contribute to the health of the infants who

receive the donated milk. According to World Health Organization and UNICEF, exclusive breast

feeding for six months is the most effective child survival intervention which reduces the under five

children deaths about 16% in India. So mothers who lose their newborns should be encouraged to

consider donating milk as they can help another sick baby with their discarded milk.

As there is lack of literature regarding breast milk donation, health care professionals are seldom

exposed to the phenomenon of milk banking. Donor milk banking is defined as the collection,

screening, processing and distribution of human milk from volunteer breast feeding mother.

Also women and families may find it an instrumental part of the grieving process. It also gives an

oppournity to a nurse midwives who care for women and infant during pregnancy and neonatal period

should be prepared to discuss milk banking with mothers.

We should helped that more families will decide to participate in human milk banking in the future.

Nurses could play an essential role in making this happen.48

Woo, Katie BSN, RN; Spatz, Diane PhD, RNC (2004) endorses that human milk is species specific

and the optimal nutrition for infants, and that banked human milk is a suitable alternative. After the

death of an infant, breast milk often is disposed of without consideration of donation because the public

and healthcare providers are unaware of human milk banks. . It is imperative that healthcare providers

become educated regarding human milk banking because of the increase in informal sharing of breast

milk via the Internet. Breast milk that has not been screened and treated has the risk of transmitting

infections such as hepatitis and HIV. Healthcare providers should be familiar with the selection criteria

for suitable donors and how to approach families when the death of an infant is imminent. Human milk

banks are able to provide human milk to adopted, preterm, or ill infants whose mothers are unable to

provide their own milk.49

Rojjanasrirat, Wilaiporn PhD, RNC, IBCLC, conducted a study to describe the breastfeeding

experiences of women who returned to work after childbirth.

The study findings revealed that the women expressed a need for support such as an accepting

environment, spatial issues, modeling, and time allowance. They needed to maintain a positive attitude

so they could commit to and accomplish their breastfeeding goals. The women developed strategic

plans to help prevent breastfeeding problems as well as continue breastfeeding successfully. Finally,

they described psychological distress as a conflict between the demands of work and the breastfeeding

process. Associated feelings included guilt, stress, or having to sacrifice for breast feeding.50

Review related to effect of information booklet.

Learning is the addition of new knowledge and experience interpreted in the light of past knowledge

and experience. To impart knowledge, several methods are used. Training is one of them. Cost of

training is rising, at the same time the need of training is increasing. One way of lowering the cost of

training is to deliver it as self instruction. It allows a person to take knowledge at his or her own pace

and whenever possible. For revision to instructions, at any future times, it can be made immediately

available. For these reasons, the use of self instruction is increasing. It can be in the form of

information booklets, cassettes, compact discs etc.

Rawal (2000) developed an information booklet on the care of low birth weight infants for mothers

whose babies were admitted in NICU. She found out its increasing acceptability and utility of the

booklet among mothers, as it provided significant knowledge. 51

Bhaduri (2004) developed a criteria rating scale for developing and evaluating information booklet for

cancer for college students. The information booklet was found to be effective in increasing the

knowledge of college students in all content areas. 52

Sieght (2001), educational psychologist, has much to say about the use of embedded performance

support tools and their relationship to the effectiveness and acceptability of the practice in web based

instruction. He suggests that people learn from self instruction module. 53

Sivagam (2004) used structured teaching factors contributing to safe motherhood, as an educational

method for adolescent girls. The method was found to be effective to improve the knowledge of

adolescent girls. 54

Verma (2003) conducted a study on the impact of patient information booklet on treatment decision a

randomized trial among women with heavy menstruation. A randomized control trial was done on 363

and 206 sample of cohort with menorrhagia and it was found out that additional information led to an

increase in specific treatment decisions and changed the distribution of used treatments without

increasing the number of surgical procedures. The study suggests that well informed women adopting

an active role may gain more from newly introduced treatments. This shows that information booklet is

helpful in maintaining the compliance. 55

Mrs. Neelima Pandit (2004).conducted a study on imparting knowledge to adolescents was thought to

be a hard task, but educating the adolescents with the help of information booklet was found to be

effective means, this was proved .On the effectiveness of information booklet on knowledge about

antenatal health among adolescent girls from selected junior colleges in Tumkur city, and the result

revealed that there was a significant increase in the knowledge of the adolescent girls.56

In WHO (1972) technical report series have stated the positive implication of individual and small

group learning system in medical education. Self instruction material like information booklet is very

effective for imparting knowledge among groups. 57

The above stated studies show that information booklet was very handy and useful.

From the above stated studies it is evident that how important it is to provide education and

training to the young females to break the ignorance, misconceptions about health and health related

issues. Resources should be made available for postnatal working mothers regarding expressed breast

milk.

Statement of the problem

“A study to assess the effectiveness of information booklet on knowledge and practices of expressed

breast milk among postnatal working mothers in selected hospitals of Tumkur City”.

6.3. Objectives of the study

1. To assess the knowledge of postnatal working mothers regarding expressed breast milk.

2. To identify the practices regarding expressed breast milk among postnatal working mothers

before administration of information booklet.

3. To compare the knowledge and practices regarding expressed breast milk among postnatal

working mothers after providing information booklet.

4. To associate the demographic variables with the knowledge and practice of expressed breast

milk among postnatal working mothers.

6.4. Hypothesis

H1: There may be a significant difference in the knowledge and practices regarding expressed breast

milk after providing the information booklet

H2: There will be significant difference in the post test score on expressed breast milk than pretest

score among the postnatal working mothers.

6.5. Assumptions

The study assumes that, there will be an increase in the knowledge and practices regarding expressed

breast milk after providing the information booklet.

6.6. Operational definitions terms and variables

Assess

(According to Oxford Dictionary): Assess refers to estimate size or quality.

In this research study: Assess is to gather information about knowledge and practice regarding storage

and expression of breast milk.

Effectiveness

(According to Oxford Dictionary): Effectiveness refers to producing of intended effect.

In this research study: Effectiveness refers to change in knowledge level regarding expression and

storage of breast milk.

Expressed

(According to Oxford Dictionary): Expressed refers to squeeze out.

In this research study: Expressed refers to squeezing of breast milk.

Postnatal working mothers

(According to Oxford Dictionary): Postnatal working mothers refer to working mothers after the

delivery.

In this research study : ): Postnatal working mothers who is working in some setting or institution for 6

to 10 hours and babies will be away from them during this period.

6.7. Limitations

This study is limited to postnatal working mothers who are working in some setting or institution for 6

to 10 hours and babies will be away from them during this period.

Inclusion Criteria:

1. Postnatal working mothers admitted in selected hospitals of the city intended to work after 45 to 90

days of delivery and their baby will be away from them for 6 to 8 hours.

2. Those who understand English and Kanadda.

Exclusion Criteria:

1. Those who are from medical profession.

2. Those who doesn’t understand Kanadda or English.

Scope of the study

This study will bring awareness in the working postnatal mothers about expressed breast milk and

its storage.

Ultimately findings of this study may open avenue for the further studies.

Findings can be further used for research by the investigator.

Ethical aspects

1. The study proposal was sanctioned by the ethical committee of the college.

2. Permission obtained from the concerned authority of selected hospitals of the city.

3. Study was explained to participant and informed consent was taken from the participant.

4. Confidentiality of information maintained by utilizing code numbers for sample.

7. Material and methods

7.1. Sources of data: Postnatal working mothers admitted in selected hospitals of Tumkur city intended

to work after 45 to 90 days of delivery and their baby will be away from them for 6 to 8 hours.

Research design: Pre experimental one group pre-test and one group post-test design

Setting: selected area, Tumkur

Population: the population comprises of all the: Postnatal working mothers from a selected areas of

Tumkur, who intended to work after maternity leave (45 to 90 days)

Research approach: -

The present study was aimed at determining the effectiveness of information booklet on

knowledge and practices of expressed breast milk among postnatal working mothers in selected

hospitals of the city.

The research methodology adopted for the study was an evaluative approach. A quasi experimental

consisting of one group pretest, posttest design was selected by the investigator. The study was divided

into three phases.

Phase – I: Pretest i.e. assessing existing knowledge and practice of postnatal working mothers.

Phase – II: Providing information booklet on expressed breast milk.

Phase – III: Posttest i.e. assessing knowledge and practice of postnatal working mothers regarding

expressed breast milk on fifth day after providing information booklet.

The purpose of the evaluative research is to measure the effect of a programmed against the goal it sets

out, which contributes to subsequent decision making about the programmed and improving future

programming.

Here the investigator identifies, describes and evaluate the effectiveness of information booklet on

expressed breast milk by using self structured questionnaire and observation checklist.

7.2. Method of collection of data

    A structured questionnaire will be used for data collection. The study will be conducted after

obtaining permission from the concerned authority    

Sampling procedure: purposive sampling – is a non probability sampling technique 

Sample size: 30 Postnatal working mothers

Sampling technique: Non probability, purposive sampling technique.

Research methodology

Development of tool: The self structure questionnaire includes two parts:

Part-I: Includes demographic data.

Part –II: Includes structured questionnaire.

A) Knowledge regarding expressed breast milk.

B) Practices regarding expression of breast milk.

Data analysis: A descriptive and inferential statistics will be used.

The collected data will be coded, tabulated and analyzed by using descriptive statistics (mean,

percentage and standard deviation) and inferential statistics. Significant difference between pre test and

post test reading was tested by using paired t test; association of knowledge and practice with

demographic variables was done by one way ANOVA test.60

7.3. Does the study require any investigation or intervention to be conducted on client/ patient or other

human or animal?

NO, the study does not require any investigation or intervention to be conducted on client/ patient or

other human or animal.

7.4. Has ethical clearance been obtained from your institution?

YES, ethical clearance has been obtained from the institution.

Approval is taken from research committee of college.

Confidentiality and anonymity of subject will be maintained.

A written permission from institutional authority is obtained.

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75

9 Signature of the candidate Ms Asawari Bhalchandra Gaikwad.

10 Remark of the guide

Prof. Jayanthi. CPrincipal Bharathi College of Nursing,Tumkur

11

Name and designationGuideSignatureAddress

Prof. Jayanthi. CPrincipal Bharathi college of Nursing,11th Cross. S. S. Puram, Tumkur.

12

Name and designationCo-guideSignatureAddress

13Head of the departmentNameSignature of HOD

14

Remarks of principalNameRemarksSignature