“ AN EFFECTIVENESS OF STRUCTURED TEACHING PROGRAME ON

KNOWLEDGE REGARDING IDENTIFICATION OF BREASTFEEDING RELATED

PROBLEMS AND ITS MANAGEMENT AMONG POSTNATAL MOTHERS IN
SELECTED HOSPITAL, BANGALORE”
PERFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

BY

Ms. OINAM PUSHPA DEVI

1ST YEAR M.Sc. NURSING

OBSTETRICAL AND GYNAECOLOGICAL NURSING

THE YEAR 2023-2024,

UNDER THE GUIDANCE OF

Mrs. KOKILA

HOD DEPT. OBESTERICAL AND GYNAECOLOGICAL NURSING

SPURTHY COLLEGE OF NURSING, CHANDAPURA,

ANEKAL ROAD, MARSUR,

KARNATAKA-562106
 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE OINAM PUSHPA DEVI

AND ADDRESS 1st YEAR Msc.NURSING
SPRUTHY COLLEGE OF NURSING,
BANGALORE

2. NAME OF THE INSTITUTION SPRUTHY COLLEGE OF NURSING,

BANGALORE

3. COURSE OF THE STUDY AND 1st YEAR M.Sc. NURSING,

SUBJECT OBSTETRICAL AND
GYNAECOLOGICAL NURSING

4. DATE OF ADMISSION 12/09/2022

5. TITLE OF THE STUDY “AN EFFECTIVENESS OF STRUCTURED

TEACHING PROGRAME ON
KNOWLEDGE REGARDING
IDENTIFICATION OF BREASTFEEDING
RELATED PROBLEMS AND ITS
MANAGEMENT AMONG POSTNATAL
MOTHERS IN SELECTED HOSPITAL,
BANGALORE”
6. BRIEF RESUME OF INTENDED WORK

6.1 INTRODUCTION
“Breastfeeding is a mother’s gift to herself, her baby, and the earth”

Breastfeeding is essential for the health and development of children. It is also important
for the health of the mothers. 1 Breast milk is a perfectly balanced source of nutrition and
contains a variety of nutrients and immunological factors that cannot be replicated. 2 Exclusive
breastfeeding up to first 6 month of life and after 6 months breastfeeding along with
complementary food till 2 years of age and beyond provides various health benefits to both
mother and child. It also protects the child from various acute and chronic diseases. Breastfed
infants are 6 to 10 times less likely to die than infants who are breastfed.3
Breast milk is widely acknowledged as the most complete from of nutrition for infants with
a range of benefits for infants health, growth, immunity and development. Breast milk is a
unique nutritional source that cannot adequately be replaced by any other food, including infant
formula. Although pollutants can accumulate in breast milk, it remains superior to infant formula
from the perspective of the overall health of both mother and child.4

While, being a natural act, breastfeeding is a learned behavior. The key to successful
breastfeeding is likely to be information, education and communication (IEC) strategies aimed at
promoting proper breastfeeding technique.5 for promoting and supporting the breastfeeding,
breastfeeding promotion network of India was started in 1991. In 2005 integrated management
of neonatal and childhood illness (IMNCI) was started under national health mission.
The IMNCI strategy recommended a systematic assessment of breastfeeding and emphasized in
the counseling of the mother on the proper positioning and the attachment of the infant to the
breast to facilitate effective suckling. An effective sucking technique is considered important to
establish breastfeeding, to ensure milk transfer, and to prevent breastfeeding problems. Good
positioning and attachment of the baby during breastfeeding may result in effective sucking
which facilitates milk production and milk release.6

Breastfeeding is the closest thing the world has to a magic bullet for child survival. In
developing countries, optimal breastfeeding – starting within one hour of birth, exclusive
breastfeeding (no additional foods or liquids, including water) for the first 6 months of life, and
continued breastfeeding until age 2 or longer – has the potential to prevent more than 800,000
deaths in children under age 5 and 20,000 deaths in women every year. 7

The crucial time for good nutrition of a baby is between the inception of pregnancy of a
woman and the second birthday of a child, which is usually referred to as the ‘critical
window’ .The best food for a child’s growth and development during this critical window is
breast milk. All of the vitamins, minerals, enzymes and antibodies needed by a child to grow and
thrive are provided by breast milk.8 Exclusively breastfed children are less susceptible to diarrhea
and pneumonia and are 14 times more likely to survive than non-breastfed children. 10 Putting the
newborn to the breast to nurse is now considered “normative” in the United States with 75% of
women doing so.10

Despite the advantages of breastfeeding, many women choose not to breastfeed for a
variety of reasons. Others initiate breastfeeding but stop due to problems that arise. Several
common problems that may arise during early breastfeeding period such as ;breast engorgement,
plugged milk duct, breast infection and insufficient milk supply, which originate from conditions
that lead the mother to inadequate empty of the breasts. Incorrect technique, not frequent
breastfeeding and breastfeeding on scheduled times, pacifiers and food suppliers are important
risk factors that can predispose to lactation problems. The adequate management of those
conditions is fundamental, as if not treated they frequently lead to early weaning.11

The correction of positioning and attachment is associated with fewer breastfeeding

problems.12 Antenatal counseling as well as support in the postpartum period by the maternity
nurse helps in establishing good lactation and ensure the reduction or prevention of breast and
nipple problems.13

Breastfeeding has been recognized by the American academy of pediatrics as the optimal
source of nutrition for infants. It has many benefits for both infant and mother. Exclusive
breastfeeding has the single largest potential impact on child mortality of any preventive
intervention.14

World Health Organization (WHO) recommends breastfeeding as a main source of food for
babies for the first six months, and encourages mothers to consider breastfeeding as the only
feeding source. Between six months and two years old, it is recommended that mothers could use
other supplemental sources (such as water, other liquids, or solid baby food) to feed their babies
along with breastfeeding.15 In addition to Bear, Mayer, Ryan and Up Hoff (2015) mentioned poor
positioning; insufficient milk resulted to damaged nipple, or disorganized the breast, fussiness at
the breast accompanied by fever, lethargy, cough, stunted growth and dehydration.16

Several such studies have reported the high prevalence of post-natal breast problem and the
major cause of it to be the lack of knowledge of mothers and their ignorance regarding the same.
Even the postnatal mothers have been ignorant of the various methods of managing the postnatal
breast problems. (Anjali Pushkar,2016) found in his study that only nominal number of postnatal
mothers had adequate knowledge on postnatal breast problems and their management which
indicated that there was still lack of adequate knowledge.17

Thus, health education programs are required to enhance the knowledge regarding
postnatal breast problems, proper breast feeding techniques and breast care to create awareness
among post natal mothers as well as antenatal mothers which may further help to reduce breast
problems in postnatal period. Awareness regarding management of postnatal breast problems can
be planned to improve knowledge among nursing students, staffs and other health personnel so
it can help to improve knowledge among community people through these health personnel.17

The effective breastfeeding is depending upon correct positioning of mother and baby and

attachment of baby to mother’s breast.18 Correct positioning and attachment of the baby during
breastfeeding may result in effective suckling which intern facilitates milk production and
release thereby increasing the duration of breastfeeding.20

Similarly, incorrect breast feeding technique may result in lactation failure musculoskeletal pain
generalized myalgia, breast pain, cracked nipples and nipple trauma. 19After the delivery, there
is an opportunity to demonstrate, educate and support the mothers about the correct
positioning and the attachment of the baby to the breast. It is observed that most of the
breastfeeding difficulties can be avoided if good attachment and positioning. This can be
achieved at the first and early feed.20
It was found that the number of published studies addressing the proper positioning
and attachment of the babies of breastfeeding is relatively scarce in Chhattisgarh.
Hence, the present study was undertaken with the objective to assess the improvement in
breastfeeding technique (positioning and attachment) after intervention among mothers-early
neonates units admitted in postnatal ward immediately after delivery in a tertiary level health
care institute.
Dutta.DC, (2004) was publishers the rate of growth of the infants during the first 6 months
of life is greater and then any other period of life. Its weight is doubled by the age of 5 months
and tripled by the end of one year. Keeping this in mind, the baby should be nursed adequate
which allows easy digestion and absorption. The advantage of breast-feeding is ideal
composition for easy digestion with low osmatic load. Fat is digested better when emulsified and
the globules are smaller. Protein, rich in lactalbumin and lacto globulin but less casein, is easily
digestible. Carbohydrate contains principally lactose which stimulates the growth of micro-
organisms; helps to produce organic acids necessary for synthesis of vitamin B. The mineral
contents like potassium, calcium, sodium and chloride are such as to make it a low osmotic load
so that less
Burden falls on the functionally immature kidneys protection against infection and
deficiency state. It contains vitamin D which protects the baby against rickets. It contains-
Lactoferrin, lysozyme, lactoperoxidase, complements and leukocytes hat hinder the growth of
E.coli and thereby prevents gastroenteritis. Its lysozyme content protects against infection and
interferon is an antiviral substance. Long chain W-3 fatty acids that is important for neurological
development of the baby. It confers passive immunity to the baby as the milk contains protective
antibodies. Secretary antibody IgA exerts it protective action by preventing contact to epithelial
cell surfaces, thus preventing gastrointestinal infections.21
Additional advantages are; it has laxative action. No danger of allergy, psychologist
benefit by establishing healthy mother and child relationship. Chance of conception is less during
lactation period. It helps involution of the uterus. Lessens the incidence of sore buttocks, gastro-
intestinal infection and atopic eczema. The incidence of scurvy and rickets is significantly
reduced.
Dutta was publisher’s difficulties in breast feeding and the management; At times, breast
feeding poses some problems and if it is not promptly detected and rectified, it may lead to
adverse consequences. The causes may be classified as those: Due to mother, Due to infant. Due
to mother: Reluctance or dislike to breast feeding careful listening and intelligent counseling can
solve the problem. Infant’s attachments to breast when poor, it leads to quick shallow sucks
instead of slow and deep. Areola remains outside the lips. This causes nipple pain. Skilled
support from health can provider can improve the technique of breast feeding. Prelacteal feeds
inhibit lactation process and should be avoided. Anxiety and stress, previous history of failed
lactation or elderly Primipara the mother fails during feeding a delay.
Milk secretion is inadequate unrestricted feeding, well positioned infant, practical and
emotional support to mother all are important. Dopamine antagonist (metoclopramide) may be
useful. Breast aliments such as engorgement of breast, cracked nipple, depressed nipple and
mastitis needs treatment. Due to infant; Low birth weight baby- the baby is too small or feeble to
suck. Temporary illness such as respiratory tract infection, nasal obstruction due to congestion,
lethargy, due to jaundice and oral thrush. All these conditions lead to imperfect sucking and
managed appropriately. Over- distension of the stomach with swallowed air-The problem can be
overcome by breaking the wind of the baby several times during feeding. Congenital
malformation such as cleft palate needs surgical correction. Feeding difficulties due to nipple
abnormalities: Long nipples may cause poor feeding due to improper latch on to the nipple
without the areola. Mother is to help the baby to draw the areola also. Short nipples usually cause
no problem. Mother is reassured. Inverted and flat nipples attachment to the breasts is possible
and babies are able to feed adequately. In difficult cases, lactation is initiated by expression.
Baby is then attached to breast as breast tissue become soft and protractile gradually.21
Breastfeeding is the feeding of an infant or young child with breast milk directly from
female human breasts (i.e., via lactation) rather than using infant formula. Babies have a sucking
reflex that enables them to suck and swallow milk. Experts recommend that children be breastfed
within one hour of birth, exclusively breastfed for the first six months, and then breastfed until
age two with age-appropriate, nutritionally adequate and safe complementary foods. The
American Academy of Pediatrics recommends for the U.S. that after 6 months of exclusive
breastfeeding, babies should continue to breastfeed "for a year and for as long as is mutually
desired by the mother and baby.21
WHO (2015) this year World Breastfeeding Week (WBW) theme, 'BREASTFEEDING
SUPPORT: CLOSE TO MOTHERS’ highlights Breastfeeding Peer Counseling. Even when
mothers are able to get off to a good start, all too often in the weeks or months after delivery
there is a sharp decline in breastfeeding rates, and practices, particularly exclusive breastfeeding.
The period when mothers do not visit a healthcare facility is the time when a community support
system for mothers is essential. Continued support to sustain breastfeeding can be provided in a
variety of ways. Traditionally, support is provided by the family. As for society change,
however, in particular with urbanization, support for mothers from a wider circle is needed,
whether it is provided by trained health workers, lactation consultants, community leaders,
friend’s mothers, and/or from father/partner.15

6.2 NEED FOR STUDY

“Breastfeeding is not easy, but the bond it creates is unbreakable”

Feeding breast milk to a new born is often accompanied by challenges. These challenges
can be difficult to deal with, especially when combined with the normal anxieties of mothers
about promoting health of a newborn.

Breast feeding is most important thing for all the mothers and newborn babies. It is unique
experience to be cherished. All the neonates are absolutely dependent on their mother’s milk for
survival. In fact by the end of the 19th century, virtually 100% non breast fed babies were
doomed to die because of infection. The rapid introduction of bottle feeding has been associated
with huge increase of infant malnutrition during the 20th century.21

It is highly observed that primigravida mothers usually have many doubts and fears about
proper breast feeding and they have huge concerns about the optimum care that has to be given
to their newborn babies. For this, they need to be adequately educated and helped in preventing
further breast feeding problems.

A cross-sectional study was conducted among 30,000 American women on common

breastfeeding difficulties. The study revealed that 32% of women did not start breast feeding,
14% breastfeed for more than four weeks. The study showed that the common reasons for
stopping breastfeeding were sore or cracked nipples, not producing enough milk or the baby had
difficulties in taking breast milk. The study concluded that there was a lack of awareness among
the mothers regarding prevention of breastfeeding problems and there was a need for extensive
support for breastfeeding mothers, especially in early weeks, when women have the most
difficulties in establishing breastfeeding.22

Preidt Robert, (2013) were concluded Low breast-feeding rates may be linked to as many as
5,000 cases of breast cancer, nearly 54,000 cases of high blood pressure and almost 14,000 heart
attacks among American women each year. But some experts question the study's methodology
and maintain that more research is needed before drawing conclusions about lags in breast-
feeding and women's health. The researchers, who used a simulated model to arrive at their
conclusions, said the costs of premature death caused by illnesses related to low breast-feeding
rates are $17.4 billion a year. The study, published online June 6 in the journal Obstetrics &
Gynecology, defines premature death as death before age 70, or more than 10 years before the
average U.S. woman is expected to die. Only about 25% of U.S. women follow medical
recommendations to breast-feed each child for at least one year, the researchers said. This low
rate also is associated with $734 million more in direct medical costs for women and $126
million more in indirect costs each year, they said.9

United State (2013) Were stated national progress has been made in keeping mothers and
babies together throughout the hospital and birth centre stay: from 2007 to 2011 the percent of
facilities with at least 90% of infants receiving skin-to-skin contact after vaginal birth increased
from 40.8% to 54.4%, and the percent of facilities with at least 90% of mothers and babies
staying together in the same room throughout the stay increased from 30.8% to 37.1%. In 2011,
states in the West had a majority of facilities with most infants rooming-in, while many states in
the Midwest and south had less than one-quarter of facilities reporting most infants were
rooming-in with their mothers.10

Kvist, L. J, (2013) was stated the reported incidence of lactational mastitis varies greatly;
the single highest reported incidence in the scientific literature is 33%. The purpose of this study
was to collect data regarding incidence and experiences of lactational mastitis from women
attending a meeting of lactation specialists and to compare findings in a similar population
reported in 1990 by Riordan and Nichols.22

Qi, Y, et.al. (2013)Was observed about 62% and 15% of mothers reported pump-related
problems and injuries, respectively. The most commonly reported problem was that the pump
did not extract enough milk and the most commonly reported injury was sore nipples. Using a
battery-operated pump and intending to breastfeed less than 12 months were associated with
higher risks of pump-related problems and injury. Learning from a friend to use the pump was
associated with lower risk of pump-related problems, and using a manual pump and renting a
pump were associated with a higher risk of problems.24

Edmunds, J.et.al, (2011) was told In Australia, initial exclusive breastfeeding rates are
80%, reducing to 14% at 6 months. One factor that 12 contribute to early breastfeeding cessation
is infant tongue-tie, a congenital abnormality occurring in 2.8-10.7% of infants, in which a
thickened, tightened or shortened frenulum is present. Tongue-tie is linked to breastfeeding
difficulties, speech and dental problems. It may prevent the baby from taking enough breast
tissue into its mouth to form a teat and the mother may experience painful, bleeding nipples and
frequent feeding with poor infant weight gain; these problems may contribute to early
breastfeeding cessation.32

Xu, F. Qiu, L. et.al, (2009) was observed Breastfeeding rates in China fell during the 1970s
when the use of breast milk substitutes became widespread, and reached the lowest point in the
1980s. As a result many efforts were introduced to promote breastfeeding. The breastfeeding rate
in China started to increase in the 1990s, and since the mid-1990s 'any breastfeeding' rates in the
majority of cities and provinces, including minority areas, have been above 80% at four months.
But most cities and provinces did not reach the national target of 'exclusive breastfeeding' of
80%.33

Xu, F. Qiu, L. et.al,.(2009) told the target set in the National Program of Action for Child
Development in China in the 1990s was breastfeeding of 80% by 2000 (province based) and
promoting 'exclusive breastfeeding' to four or six months. The target was explained in many
academic papers as 'exclusive breastfeeding' rate at four months of 80% by 2000 [6-8]. A new
target set in the National Program of Action for Child Development in China in from 2001 to
2010 is a breastfeeding rate of 85% (province or municipality based) and timely13 introduction
of complementary food. However the type of breastfeeding is not specifically defined and the
timeframe is not mentioned in the document.33

Dhandapany, G. et.al (2008) was conducted in 1980, supported by the World Health
Organization (WHO) which included a total of 3845 mothers recruited from the city and suburbs.
The data from this study showed the 'any breastfeeding' rate had declined to 24.8% in the city
and 77.0% in the suburbs for 0–6 month old babies. This study was technically supported by
(WHO) and used the period prevalence method of recording breastfeeding rates recommended
by WHO. In the following years further surveys revealed similar trends in other regions of the
country. In 1983 a national cross-sectional survey of 111,348 infants aged 0–6 months found that
the 'any breastfeeding' rate was 49.3% in the city and 75.1% in rural areas. The decline in
breastfeeding rates was a challenge for China as she sought to achieve the goals set at the
International Child Survival Conference in 1990 which were endorsed by the Chinese Premier.34

Melli, M.S, et.al (2007) was says sore nipples are a common complaint among
breastfeeding women and one reason why some women decide to stop breastfeeding. The
incidence ranges from 11 to 96%. Preparation for breastfeeding happens naturally in pregnancy,
and the presence of 'epidermal growth factor' in breast milk has potential therapeutic benefits by
promoting the growth and repair of skin cells.41

Abbott Laboratories, (2001) Healthy People 2010 goals state that 75% of women will
breastfeed at birth, 50% will continue for 6 months, and 25% will breastfeed for 1 year
(Department of Health and Human Service 2000). Although the United States has seen a gradual
resurgence in breastfeeding initiation and continuance rates, the goals of Healthy People 2010
have yet to be attained. After a low of 26.5% in 1970, breastfeeding initiation rates climbed to
58% in 1985, only to decline gradually to 51.5% in 1990. Since then, breastfeeding rates have
steadily increased to 68.4% in 2000. Likewise, the number of infants still breastfeeding at 6
months has increased from 14.1% in 1970 to 31.4% in 2000. By age 1 year, only 17.6% of
infants are still breastfed.

Lowdermilk, P, (2004)Breastfeeding rates have increased across all demographic groups,

although the most significant increases are seen among 14 women who have historically been
less likely to breastfeed. These individuals are typically young (younger than 25 years), lower
income ,African-American, primipara, with grade school education or less, employed full time
outside the home, residing in the South Atlantic region of the United States, mothers of low-
birth-weight infants, and enrolled in the WIC program (Ryan, 1997) . The characteristics of
women most likely to breastfeed have remained consistent over the years. These women are
white, older than 30 years, college educated, with higher incomes, not employed outside the
home or working only part-time, residents of western states, and not participating in the WIC
program.33

Taveras, E.M,.(2003) Was says breastfeeding rates fall short of goals set in Healthy People
2010 and other national recommendations. The current, national breastfeeding continuation rate
of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this
study was to evaluate associations between breastfeeding discontinuation at 2 and 12 weeks
postpartum and clinician support, maternal physical and mental health status, workplace issues,
and other factors amenable to intervention.27

6.3 REVIEW OF LITERATURE

Literature of review refers to the activities involved in identifying and searching for
information on a topic and developing an understanding of the knowledge on the selected topic.

Vries De IA et.al., (2019) conducted the retrospective study prevalence of feeding disorders
in children with cleft palate only among children. Feeding difficulties were reported in 67 %
(n=60) of all cases. NG feeding was given in 32 % (n=28) of all children. Forty-nine children (54
%) have associated malformations. There is no significant relation for gender, gestational age,
and birth weight as risk factors for feeding difficulties, NG feeding, and failure of breastfeeding.
The severity of the cleft is significantly related to the prevalence of AssD/S. After palateplasty,
feeding difficulties improved in 79 % of the CPO children. This study concluded that our results
clearly indicate that children with CPO are at high risk of developing feeding difficulties (67 %);
NG feeding is often necessary (32 %). Second, our results also indicate that the more severe the
cleft, the more likely the chance for AssD/S.22

Gagandeep et.al, (2018) conducted a quasi-experimental design study to efficacy of

Cabbage Leaves in relief of breast engorgement among 60 post natal mothers (30 in
experimental and control group). Analysis was done using both descriptive and inferential
statistics. Mean score of breast consistency in experimental group had a decrease of 1.90 while
mean score in control group had decrease of only 0.80 (p<.001). Similarly in breast tenderness
86.20% subjects in experimental group had no tenderness at day 3 compared subjects in control
groups.This study concluded that application of cabbage leaves were effective in reducing breast
engorgement.25
 PoonamSharma, (2017) conducted the exploratory study to assess knowledge of post natal
mothers regarding breast engorgement among 100 post natal mothers. Findings revealed that
majority of postnatal mothers (52%) had average knowledge regarding breast engorgement.
Mean percentage of knowledge score was highest in symptoms (64.16%) and lowest in area of
factors leading to breast engorgement (42.62). Education variable was found to be associated
with knowledge of postnatal mothers none of the other variables were found significantly related
with the knowledge of postnatal mothers. This study concluded that majority of postnatal
mothers had average knowledge regarding breast engorgement.26

Svensson.KE. et.al.,(2016) conducted a randomized trial to effects of mother-infant skin-

to-skin contact on severe latch-on problems in older infants among 103 postnatal mothers infant
pairs with severe latch-on problems 1-16 weeks postpartum were randomly assigned and
analyzed. (75% experimental group, vs. 86% control group). Experimental group infants, who
latched on, had a significantly shorter median time from start of intervention to regular latching
on than control infants, 2.0 weeks (Q1 = 1.0, Q3 = 3.7) vs. 4.7 weeks (Q1 = 2.0, Q3 = 8.0), (p-
value = 0.020)", latched-on within 3 weeks compared to 33% in the control infants (Fisher Exact
test p-value = 0.0001). Mothers in the experimental group (n = 53) had a more positive
breastfeeding experience according to the Breastfeeding Emotional Scale during the intervention
than mothers in the control group (n = 50) (p-value = 0.022). This study concluded that skin-to-
skin contact during breastfeeding seems to immediately enhance maternal positive feelings and
shorten the time it takes to resolve severe latch-on problems in the infants who started to latch.27

Khan M.H, Khalique.N,(2015) conducted a pre designed an d pre tested semi structured
questionnaire study to knowledge of breast feeding related problems and its management at
home among 200 pregnant mothers. Pregnant women (83%) were in the age group of (15-30)
years and rest 17% in the age group of 31-45 years. Mostly pregnant women (90%) Hindu
community, 75% of pregnant women were illiterate. Education of husbands of pregnant women
was also low i.e. 54% illiterate. Majority of the families (64.5 %) were nuclear. 99% pregnant
women were housewives. Majority of mothers (72.5%) had correct knowledge that continuing
breastfeeding relieved breast engorgement. Breast engorgement was relieved by local warm
water packs applied on breast of lactating mothers i.e. (58.5%). 39% mothers had correct
knowledge that breast engorgement was relieved by express breast milk. No significant
differences (p-value>0.05) were found between two groups regarding correct knowledge about
management of breastfeeding related problems at home in study group. P-value was calculated
using chi-square test and difference was accepted significant at more than 95% (p-value
<0.05).This study that concluded is positive thinking by the mother who feels confident of
producing enough milk for the baby can extend the period of breastfeeding.28

Linda.KJ. (2013) conducted a retrospective questionnaire study re-examination of old

truths; replication of a study to measure the incidence of lactational mastitis in breast feeding
women’s. As in the earlier research, respondent in the study reported a 33% occurrence of
lactational mastitis. This cannot however, be considered as the incidence of mastitis. Incomplete
emptying of the breast was the factor most frequently cited as the cause of mastitis. This study
concluded that well designed studies in different global locations are needed before any
conclusions can been drawn about the range of incidences of mastitis.29

Philip, Divya, (2013) conducted a quasi-experimental study to assess the effectiveness of

structured teaching programme on knowledge of primi gravida mothers regarding breast feeding
problems among 60 primi gravida mothers. In the present study, 90% of the primi gravida
mothers had inadequate knowledge on breastfeeding problems before the implementation of
structured teaching programme. But after the implementation of structured teaching programme
16.7% of them had moderately adequate knowledge and 83.3% of them had adequate knowledge
The mean pre-test scores was 42.33% and the mean post-test scores of 80.54% which was
significant at (P-value of 0.001) level which showed significant increase in knowledge of primi
gravida mothers and thus it proves the effectiveness of the structured teaching programme.

Ystrom E, (2012) conducted a longitudinal cohort study to breast feeding cessation and
symptoms of anxiety and depression among 42225 women in the Norwegian mother and child.
First pre partum levels of anxiety and depression were related to breast feeding cessation (β 0.24;
95%Cl 0.21-0.28), and breast feeding cessation was predictive of an increase in postpartum
anxiety and depression (β 0.11; 95%Cl 0.09-0.14).Second, pre partum anxiety and depression (β
0.04; 95%Cl0.01-0.06).This study concluded that is breast feeding cessation is a risk factors for
increased anxiety and depression.30

Thompson F J., (2010) conducted the multicentre cohort study women's breastfeeding
experiences following a significant primary postpartum hemorrhage among 206 postnatal
mothers. Among women with a significant PPH, 63% fully breastfed their babies from birth,
whereas 85% said they had hoped to do so (p < 0.001). Only 52% of mothers who intended to
either fully or partially breastfeed were able to give their baby the opportunity to suckle within
an hour of the birth. Delays were longer in women with greater estimated blood loss and women
with the longest delays in breastfeeding were less likely to initiate full breastfeeding. 70% of
women with PPH of < 2000 ml were fully breastfeeding in the first postpartum week, whereas
less than 50% of those with blood loss ≥ 3000 ml were able to do so. Overall, 58% of women
with significant PPH were fully breastfeeding at two and 45% at four months postpartum. This
study concluded that a significant PPH, women with greater blood loss are less likely to initiate
and sustain full breastfeeding and this may be related, in part, to delays in initial contact with
their baby as a consequence of the PPH. In particular, enabling the opportunity for the new born
to suckle as soon as is practicable should be encouraged.31

Holleman AC, Nee J, Knaap SF., (2011) conducted the study chiropractic management of
breast-feeding difficulties. Following history and examination, the infant received gentle
chiropractic manipulation based on clinical findings. Immediate improvement and complete
resolution of the nursing problems were observed after 3 treatments over 14 days. This study
concluded that the results of this case suggest that neuro musculoskeletal dysfunction may
influence the ability of an infant to suckle successfully and that intervention via chiropractic
adjustments may result in improving the infant's ability to suckle efficiently.32

Chakrabarti K, Basu S., (2011) conducted a study to management of flat or inverted

nipples with simple rubber bands among 19 mothers with flat, inverted, or otherwise deformed
nipples. 63% of mothers could achieve latching at the breast with good attachment within 3 days,
and all did by the end of the month, as nipples no longer remained a problem. The insufficiency
of milk was gradually taken care of by frequent suckling with time. No complications like pain
or slipping of the band were reported. This study concluded that simple method may be a good
bedside solution for flat/retracted nipples.37

Chiu JY, (2010) conducted a randomized controlled trial study to effects of Gua -Sha
therapy on breast engorgement among 54 postnatal mothers. Results 31 showed no statistical
differences between the two groups at baseline. Body temperature, breast temperature, breast
engorgement, pain levels, and discomforting levels were statistically different between the two
groups at 5 and 30 min after intervention (p < .001). The results of generalized estimating
equation analysis indicated that, with the exception of body temperature, all variables remained
more significant (p < .0001) to improving engorgement symptoms in the experimental group
than those in the control group, after taking related variables into account. This study concluded
that by using Gua-Sha therapy, nurses can handle breast engorgement problems more effectively
in primary care and hence help patients both physically and psychologically.38

Matos Ortiz., (2008) conducted a Pre-test, post-test, and an objective structured clinical
examination (OSCE) study management of lactation and breastfeeding among 11 residents in
their first year of training. Residents who participated in the educational intervention did better
than controls in the practical and written tests, and showed improvement in their knowledge
about breastfeeding management. This study concluded that has shown the need to improve
residents' knowledge in breastfeeding management, practices, and confidence when educating
breastfeeding mothers. A structured breastfeeding curriculum during the residency is
recommended.30

Scott .A J., (2008) conducted the longitudinal study occurrence of lactational mastitis and
medical management among 420 postnatal mothers. In total, 74 women (18%) experienced at
least one episode of mastitis. More than one half of initial episodes (53%) occurred within the
first four weeks postpartum. One in ten women (6/57) were inappropriately advised to either stop
breastfeeding from the affected breast or to discontinue breastfeeding altogether. This study
concluded that approximately one in six women is likely to experience one or more episodes of
mastitis whilst breastfeeding. A small but clinically important proportion of women continue to
receive inappropriate management advice from health professionals which, if followed, could
lead them to unnecessarily deprive their infants prematurely of the known nutritional and
immunological benefits of breast milk.39
 Linda.KJ., et.al (2008) conducted the descriptive study the role of bacteria in lactation
mastitis and some considerations of the use of antibiotic treatment among 192 women with
mastitis (referred to as cases) and 466 breast milk donors (referred to as controls). Five main
bacterial species were found in both cases and controls: coagulase negative staphylococci (CNS),
viridians streptococci, Staphylococcus aureus (S. aureus), Group B streptococci (GBS) and
Enterococcus faecal is. More women with mastitis had S. aureus and GBS in their breast milk
than those without symptoms, although 31% of healthy women harboure S.aureus and 10% had
GBS. There were no significant correlations between bacterial counts and the symptoms of
mastitis as measured on scales. There were no differences in bacterial counts between those
prescribed and not prescribed antibiotics or those with and without breast abscess. GBS in breast
milk was associated with increased health care contacts (p = 0.02). Women with ≥ 107 cfu/L
CNS or viridians streptococci in their breast milk had increased odds for damaged nipples (p =
0.003). This study concluded that many healthy breastfeeding women have potentially
pathogenic bacteria in their breast milk. Increasing bacterial counts did not affect the clinical
manifestation of mastitis; thus bacterial counts in breast milk may be of limited value in the
decision to treat with antibiotics as results from bacterial culture of breast milk may be difficult
to interpret.40

MelliManizhehSayyah.,(2007) conducted a study to effect of peppermint water on

prevention of nipple cracks in lactating primi parous mothers among 196 primi parous breast
feeding women. Women who were randomized to receive peppermint water were less likely to
experience nipple and areola cracks (9%) compared to women using EBM (27%P<0.01)a
cracked nipple than women who did not use peppermint water (relative risk3.6,95%Cl:2.9,4.3).
Nipple pain in the peppermint water group was lower than the expressed breast milk group (or
5.6; 95%, Cl: 2.2, 14.6; p<0.005).This study conclude that is suggests that peppermint water is
effective in the prevention of nipple pain and damage. Further studies are needed to assess the
usefulness of peppermint water in conjunction with correct breast feeding techniques.35

Haider R, (2000) conducted the prospective study neonatal diarrhoea in a diarrhoea

treatment centre in Bangladesh: clinical presentation, breastfeeding management and outcome
among 244 their mean (SD) age was 18 (6.2) days, and 33 body weight and length were 2.18
(0.52) kg and 47.5 (3.2) cm, respectively. More neonates had some dehydration than severe
dehydration (78% vs. 11%), with mean (SD) serum bicarbonate values 9.6 (5.1) mml /1. V.
cholera was isolated from 25 (12%), Shigella spp. from 8 (3%), and Salmonella spp. from 3 (1%)
of the patients who had rectal swab cultures. Mean (SD) hospital stay was 3.6 (2.1) days, during
which the majority (80%) recovered fully, but 29 (13%) left earlier. Eleven (4%) of the neonates
had to be referred elsewhere for treatment of other problems and 7 (3%) died. None of the
neonates were exclusively breastfed on admission.18

Excluding mothers of adopted neonates, breastfeeding counseling enabled 64% of the mothers to
convert to exclusive breastfeeding during the hospital stay. This study concluded that Most of the
neonates admitted with diarrhoea were small and underweight, and had poor feeding practices.
6.4 PROBLEM STATEMENT

“An effectiveness of structured teaching programme on knowledge regarding identification

of breast feeding problems and its managements among postnatal mothers in selected
hospital at Bangalore”.

6.5 OBJECTIVES OF THE STUDY

The objectives of the study are,

1. To assess the pre- test knowledge score regarding breast feeding related problems and its
management among postnatal mothers.
2. To assess the effectiveness of structured teaching programme on knowledge of postnatal
mothers of breast feeding related problems and its and management among postnatal
mothers
3. To find the association between pre-test knowledge score regarding breast feeding related
problems and its management with their selected demographic variables.

6.6 OPERATIONAL DEFINITIONS:

1. EFFECTIVENESS:

In this study the effectiveness refers to the extent to which structured teaching
programme will achieve the desired effect in imparting knowledge regarding feeding related
problems and management in terms of differences between pre-test and post-test score assessed
by structured knowledge questionnaire.

2. STRUCTURED TEACHING PROGRAMME:

In this study structured teaching programme refers to a planned teaching materials

developed to improve the knowledge regarding breastfeeding related problems and its
management among postnatal mothers.

3. KNOWLEDGE:

In this study knowledge refers to the information regarding breast feeding related
problems and its management among postnatal mothers as measured by structured knowledge
questionnaire.

4. BREAST FEEDING RELATED PROBLEMS AND ITS MANAGEMENT:

In this study it refers to the difficulty and inability in breast feeding as expressed by
mothers or observed by the investigator which may include flat and inverted nipple, sore and
cracked nipple, breast engorgement, blocked ducts, mastitis and breast abscess, leakage and not
having enough milk.
 5. POSTNATAL MOTHERS:

In this study postnatal mother refers to who have undergone delivery process and are
admitted in selected hospital at Bangalore.

6.7 ASSUMPTIONS:

The study assumes that:

1. Structured teaching programme provides opportunity for learning and better

understanding about breast feeding problems and management.
2. Structured teaching programme is an effective method for improving the knowledge level
of mothers.
3. Postnatal mothers may have inadequate knowledge regarding breast feeding problems
and management.

6.8 LIMITATIONS:

The study is limited to:

1. Postnatal mothers in selected hospital at Bangalore.

2. Sample size was small and hence generalization of findings is limited.
3. Postnatal mothers who are in 1-3 days of postnatal.

6.9 HYPOTHESES:

H1-Knowledge of the postnatal mothers regarding the breast feeding related problems and its
management will be a significantly improved after structured teaching programme.

H2- There is a significant association of the postnatal mother’s knowledge with selected
demographic variables.

7. PROJECTED OUTCOME OF THE STUDY:

The postnatal mothers will get good knowledge regarding breast feeding.

7.1 MATERIAL AND METHODS OF THE STUDY:

7.2 SOURCES OF DATA:-

The data will be collected from 60 postnatal mothers who fulfill inclusion criteria.

7.3 RESEARCH DESIGN:-

 The research design for the study will be pre-experimental, design that is one group pre- test
and post-test design.

7.4 SETTING OF THE STUDY:-

The study is conducted in post natal wards of Motherhood Hospital at Bangalore.

7.5 STUDY POPULATION:-

The population for the study in post-natal mothers who have undergone normal vaginal
delivery and (LSCS) mothers.

7.6 VARIABLES OF THE STUDY:-

I. INDEPENDENT VARIABLES:

In this study, the independent variables are the structured teaching programme on breast
feeding problems and its management among postnatal mothers.

II. DEPENDENT VARIABLES:

In this study, the dependent variables improve the knowledge regarding breast feeding
problems and its management among post-natal mothers.

8. METHOD OF DATA COLLECTION:

8.1 SAMPLING PROCEDURE:-

To accomplish the objectives of the study, non-probability sampling that purposive

sampling will be used in the study.

8.2 SAMPLE SIZE:-

In this present study the sample consists of 60 postnatal mothers in selected hospital at
Bangalore.

8.3 SAMPLING TECHNIQUE:-

Sample size, Sampling technique

8.4 CRITERIA FOR SELECTION OF SAMPLES:-

The sample was selected based on the following inclusion and exclusion criteria.

A. INCLUSION CRITERIA FOR SAMPLING:-

The study includes,

1. Postnatal mothers who are willing to participate in the study

2. Postnatal mothers who understand Kannada.

B. EXCLUSION CRITERIA FOR SAMPLING:-

The study excludes,

1. Postnatal mothers who are having medical illness.

2. Postnatal mothers who are puerperal complication.

3. Not willing participates in the study.

8.5 TOOLS FOR DATA COLLECTION:-

The research study consists of two sections.

Section A

It consist of demographic variables such as sample no, age, education, occupation, religion, type
of family, income. Obstetrical variables which type of delivery, type of feeding, number of
children, obstetrical score, food habits.

Section B

The knowledge questionnaires consist 35 questions of multiple choice items among which
correct answer was given score “1” and wrong answer was given score “0”. The probable

maximum score is “35”, probable minimum score was is “0”.

Section C
It comprised of questionnaire, regarding knowledge on breast feeding related problems and its
management. It consist of 35 multiple choice questions.

Part I: Questions related to knowledge on breast feeding (included 10 questions)

Part II: Questions related to knowledge on breast feeding problems and its management
(included 25 questions)

Section D

It comprised structured teaching programme on breast feeding related problems and its
management.

8.6 DATA COLLECTION METHOD:-

After obtaining formal administrative approval from the concerning authorities and informed
consent from the samples the investigator personally collects the demographic data. After which
data will be collected in the following three phases;

PHASE-1:- Pre-test will be conducted to assess the knowledge regarding breastfeeding in

selected hospital among postnatal mothers.

PHASE-2:- Structure teaching programme regarding breastfeeding in selected hospital will be

administered to the postnatal mothers on the same day.

PHASE-3:- After a period of one-week to assess the post-test level of knowledge regarding

Duration of data collection is 4 to 6 weeks.

8.7DATA ANALYSIS:

The data collected will be analyzed by using descriptive and inferential statistics.

i. DESCRIPTIVE STATISTICS:
 Frequency, percentage distribution will be used to analyzed the demographic variables.
 Mean and standard deviation will be used to assess the knowledge regarding
breastfeeding among postnatal mothers.
ii. INFERENTIAL STATISTICS:
 Paired‘t’ test will be used to analyze difference between the pre-test and post-test
knowledge regarding breastfeeding among postnatal mothers.
 Chi-square test will be used to analyze the association between pre-test knowledge
regarding breastfeeding among postnatal mothers will their selected demographic
variables.
 PART – A

TOOL

DEMOGRAPHIC VARIABLES

Instructions: Please answer the following questions in the order and put tick in to the specific
responses

1. Sample no:

2. Age

a. 18-22 years
b. 23-27 years
c. 28-32 years
d. 32and above.

3. Education

a. Illiterate
b. Primary school
c. High school
d. Graduate and above.

4. Occupation

a. Home maker
b. Coolie
c. Private employee
d. Government employee
e. Business.

5. Religion

a. Hindu
b. Christian
 c. Muslim

6. Type of family

a. Nuclear
b. Joint

7. Family income

a. >3,000
b. 3,001-5,000
c. 5,001-8,000
d. 8,001-10,000
e. Above – 10,000

OBSTETRICALVARIABLES:

1. Type of delivery

a. Normal vaginal delivery

b. LSCS
c. Instruments delivery

2. Type of feeding

a. Breast feeding
b. Cow milk

3. Obstetrical score

a. Gravida: 1 2 3 Above 3
b. Para: 1 2 3 Above 3
c. Live birth: 1 2 3 Above 3
d. Abortion: 1 2 3 Above 3
e. Still birth: 1 2 3 Above 3

4. Food habits
 a. Non- vegetarian
b. Vegetarian.

SECTION C: ASSESSMENT OF KNOWLEDGE ON BREASTFEEDING

PART I: Question related to knowledge on breast feeding.

Instructions: Please answer the following questions in the order and put tick in to the specific
responses

1. Which of the following milk is good for new born?

a. Cow’s milk / Buffalo milk

b. Mothers milk
c. Artificial milk (lactogen).

2. What are colostrums?

a. Milk secreted within 3 days birth

b. Milk secreted in 3 weeks after birth
c. Milk secreted in 1 week after birth.

3. Why colostrums important for baby?

a. It is secreted more
b. It protects against microorganism
c. It is sweet in taste.

4. What are the compositions of breast milk?

a. Breast milk contains low carbohydrate

b. Breast milk contains protein
c. Breast milk contains adequate nutrients.

5. What are the benefits of feeding to mothers?

a. It contracts the uterus

b. It increases pain
 c. It decreases the hormone oxytocin.

6. What are the benefits of breast feeding to milk?

a. It helps to suppress the immune system

b. It helps for optimal growth and development
c. It helps to reduce the weight.

7. What is exclusive breast feeding?

a. Providing fluids along with breast milk

b. Providing sugar water with breast milk
c. Providing only breast milk

8. Exclusive breast feeding to be given for?

a. 3 months
b. 6 months
c. 4 months.

9. What is the interval for giving breast feeding?

a. 2 to 3 hours or when the child cries

b. Based on mother convenience
c. Morning after noon evening and night.

10. Why to clean the breast before and after breast feeding?

a. To prevent infection
b. Increases secretion of milk
c. It comforts the mothers.

PART II: Questions related to knowledge on breast feeding problems and its management.

11. Effective sucking is favored by?

a. Flat nipple
 b. Protruded nipple
c. Dimpled nipple.

12. What is flat nipple?

a. Non protruded nipple

b. Nipple is drawn backwards
c. Crack across the nipple.

13. What is the management of flat nipple?

a. Application of emollient and pulling out the nipple

b. Application of warmth to the nipple
c. Putting the baby on sucking at the earliest.

14. What type of device is used for flat nipple?

a. Nipple shield
b. Application of oil
c. Breast massage.

15. The meaning of inverted nipple is?

a. Nipple drawn backwards

b. Swelling in the nipple
c. Crack in the nipple.

16. What is the management of the inverted nipple?

a. Massaging the nipple

b. Using syringe and drawing out
c. Application of oil to the nipple.

17. Sore nipple means?

a. Crack across the nipple.

b. Pus discharge from the nipple.
 c. Redness in the nipple.

18. Which of the following is not a cause for sore nipple?

a. Improper positioning during breast feeding.

b. Sudden removal of the baby from the breast.
c. Increased frequency of feeding.

19. The main symptom of sore nipple?

a. Hardness of the nipple

b. Redness, edema and pain in the nipple
c. Tenderness in the nipple.

20. What is the management?

a. Reduce pressure on sore areas

b. Applying ice packs
c. Proper detachment of baby from breast.

21. Engorgement of the breast is called?

a. Continuous leakage of milk from breast

b. Abnormally small breast
c. Swelling and over fullness of the breast.

22. The main symptoms of breast engorgement is?

a. Tenderness and fullness of the breast

b. Redness and blisters on the breast
c. Infection in the breast

23. What is the management of breast engorgement?

a. Adequate rest
b. Hot compress
c. Application of oil and massage
24. What is mastitis?

a. Pus formation in the breast

b. Breast engorgement
c. Blockage to the ducts and infection

25. Important symptoms of mastitis?

a. High grade fever and pain in the breast

b. Softness of the breast
c. Fluid formation in the breast.

26. A common cause of mastitis is?

a. Incomplete emptying of the breast

b. Poor hygiene
c. Sudden removal of baby from the breast.

27. Which of the following is important in the management of mastitis?

a. Proper consultation with physician

b. Discontinuing breast feeding
c. Applying warm water to the affected area.

28. What is breast abscess?

a. Pus formation in the breast

b. Infection
c. Formation of blocked ducts.

29. What is the management of breast abscess?

a. Breast massage
b. Incision and drainage
c. Breast pump

30. What is nipple thrush?

 a. Crack in the nipple
b. Swelling in the nipple
c. Infection occurs in the nipple.

31. The important symptom of nipple thrush is?

a. Itching and burning sensation in the nipple

b. Discharge of pus form the nipple
c. Crack in the nipple.

32. What is milk leakage from the breast?

a. Leaking of fluid from the breast

b. Leaking of milk from breast
c. Leaking of pus from the breast.

33. What is the cause for milk leakage?

a. Blocked ducts
b. Inverted nipple
c. Long intervals between feeds.

34. Which of the following measure is useful in stopping leakage?

a. Demand feeding
b. Massaging the breast
c. Using breast feeding

35. Improper breast feeding leads to the following effects in the breast?

a. Tumors formation
b. Improving in health
c. Maintaining beauty.
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