Socio-Demographical Factors That Influence Breastfeeding Practices And Initiation In Women Attending Karbala Teaching Hospital For Children

Background

: For healthy growth and development, all mothers can breastfeed provided they have accurate information, and the support of their family, the health care system and society at large. Objective: To identify the impact of socio- demographical factors that influenced the initiation and practice of breastfeeding amongst women attending Karbala teaching hospital for children. Methods: A cross-sectional study in which Semi-structured questionnaires were administered to 516 mothers in Karbala teaching hospital of children. Who had infant age <6 months. Infant feeding intentions, feeding practices at birth and during 1st six months. The data were collected in 2015-2016. Sample size was calculated by special formula, identifying the first mother arrived and to get the rest of the required sample size, systematic sampling method was used.Statistical analysis: was done using statistical package for social science (SPSS) program version 21.

Chi square test was used for analysis of qualitative variables, while analysis of variance (Anova, F) test was used for analysis of quantitative variables. A probability (P value) of less than 0.05 considered statistically significant. Results: This study included a total of 516 mothers of children aged less than 6 months were included in the study, of the 516 participants mothers included in the analysis ,from them 308(59.7%) chose breastfeeding and 79(15.9) chose bottle feeding and the rest who were 129(25%) chose mixed feeding for their infants with p. value <0.001, 72% (173 out of 240) who chose breastfeeding were advised by their mother and mother in law 43.6%, 52% of those who chose bottle feeding because they thought they had not enough milk.

the social support, crowding index. Conclusions: Appropriate practice of breast feeding is still influenced by factors such as the health care system, the social support, mother's education, and cultural attitudes, type of labour, admission to the NICU, fluids offered to the babies after birth, employment status and workplace Policies and Barriers, previous feeding methods and pre-delivery woman's intention. Maternal mothers, mothers in law and pediatricians had the lion`s share in influencing breastfeeding practices. Keywords: breastfeeding, labour, lactation, lifestyles, public health.

Introduction

According to the recommendation of the WHO It is very important to start exclusive breastfeeding within the first hour of birth and continuing for at least six months to promote optimal growth and development ^[1] globally About 44% of infants 0–6 months old are exclusively breastfed ^[2]. Several programs and Polices to promote breast feeding. Start with educational programs, hospital breast feeding practices together with family and social support , the importance of breastfeeding in the prevention the risk of the infectious illness such as lowered risk of pneumonia, gastrointestinal infection, urinary tract infection and otitis media in the infant are explained by many Clinicians and the mothers are advised to adhere to the guidelines of proper breast feeding including the duration or the exclusivity which is necessary to get protection from the diseases ^[3].

Training staff who offer breastfeeding counseling to the new mothers about lactation: timing, positioning of the infant on the breast, correct nipple latch and care and to get optimal breastfeeding practices and early discover the problems that might associated with improper breast-feeding technique, a follow up visits may be taken within 24-48 hour after discharging from the hospital ^[4]. Baby in the post-partum early days, gets a thick yellow colored milk is synthesized by the mammary glands of the mother is called (colostrum which is rich in secretory IgA, lactoferrin, leukocytes which protect the infant from bacteria and viruses it is also rich in protein, fat soluble vitamins, sodium, chloride, magnesium.

potassium and calcium. Lipid and carbohydrate are present but in lower concentrations ^[5]. Colostrum helps the newborn to pass meconium and prevent jaundice and because the uterus contracts as the baby suckle the mother will have less blood loss ^[6]. Breastfeeding can lower a mother's risk of type 2 diabetes ^[7], high blood pressure, risk of cardiovascular disease, breast and ovarian, osteoporosis, and arthritis. It may also help the mother to recover more quickly from childbirth ^[8] composition of the Breast milk is a dynamic, and influenced by several maternal factors during the first four postpartum months such as, nutritional status, parity, frequency and heaviness of menstrual cycle. smoking, physical activity, Maternal BMI, and environmental factors, adequate intake of micro and macro nutrients is essential for infant development and health ^[9,10].

Most common problems of the breast feeding Nipple pain: as a result of poor infant positioning and wrong latch, mothers complain of painful / sore nipple, it considered the most common complication associated with baby oral candidiasis and mother nipple candidiasis that should be treated ^[11]. Engorgement: poor feeding technique and incomplete empty of the milk, due to Infants refusal of sucking the milk leading to a physiological fullness of the breast. It is called Engorgement of the breast ^[12]. Mastitis: breast infection can occur in lactating and nonlactating women is the most common lactating women. The incidence globally is 2% to 33% worldwide. Usually unilateral, characterized by warmth, tenderness, edema, erythema, and may be associated with general symptoms ^[13].

Inadequate breast milk: the complaint of “insufficient milk” due to multifactorial determinants classified into psychologic, physiological breastfeeding behavior maternal factors, and including, fatigability, stress, breast radiation therapy and certain medical or surgical condition of the breast, smoking and some medications, pregnancy make the production of the milk not enough. Other factors related the baby such as ineffective suckling, baby illness or ankyloglossia ^[14]. Jaundice: Breast milk jaundice which is expected to occur in the first or second week of life week due to the abnormal accumulation of bilirubin which is not contraindication of breast feeding, and usually spontaneously resolves even without stopping breastfeeding ^[15]. Factors that may affect the Initiation and practice of Breast Feeding Timing of feeding initiation: Early initiation of breast feeding by putting the baby at the breast within the first hour of childbirth is considered the cornerstone of ideal breast feeding.

The separation between mothers and infants occurs in hospitals specially after cesarean section delivery, in addition, that mothers had more stressful experiences with breastfeeding than mothers who had normal delivery. prolonged separation after birth or C-section delivery can make breastfeeding more difficult to be established ^[16]. Premature babies .Neonatal care unit support: Support is obtained by Neonatal care unit where the preterm infants , who has immature sucking skill and sucking-swallowingbreathing coordination, start with enteral and oral feeding of the mother’s milk on the first day after birth as soon as possible , skin-to-skin contact with her baby and pumping of the breast milk, presence of the parents in the NICU, and the use of bottle-feeding should be restricted.

or as soon as possible after birth. The support is not same in all units ^[17]. Occupation, Education and Economic status of the mother; Lactating employee mothers who work many hours per day they can’t manage exclusive six-month breast feeding. Because of many factors related such as early return to work, full-time working, inflexible work schedule lack of privacy, not being cooperated by other workers, all these factors and others may lead to impairment both the initiation and duration of the breastfeeding practices ^[18]. The opinions about the relation between breast feeding and the socioeconomic status of the mothers are contrary; some studies have shown that the low rate of exclusive breastfeeding was found among high socio-economic status mothers.

in contrast to other studies found that mothers with high income had high breastfeeding rate ^[19]. Some studies found that the mother’s education level positively affects exclusive breastfeeding practice, higher educational level of the mothers associated with higher breastfeeding practice ^[20], in contrast to other study reported that lower maternal education is related to increase in breastfeeding practices ^[21]. Highly educated women may be more likely to understand the benefits of breastfeeding practice as recommended when compared with less educated one. Parity and Birth weight of the baby: Several studies have reported that multiparous mothers, are more likely to initiate breastfeeding and mothers with prior breastfeeding experience have a longer breastfeeding duration compared with primiparous mothers ^[22].

There is a strong belief that breast milk substitute is very important to increase the weight of low-birth-weight infant When maternal breast milk is not sufficient ^[23]. The practice of discarding the foremilk which is mostly water combined with other nutrients and feeding low birth weight and premature infants predominantly hindmilk which is highly fatty has been shown to increase weight gain ^[24]. Maternal age, Previous experience with breast feeding: Breastfeeding initiation and longer breastfeeding duration are more likely in Multiparas. Mothers who are familial with breastfeeding are more confident about it and usually successful at breastfeeding ^[25]. Older maternal age is associated with exclusive breastfeeding and longer duration of breastfeeding ^[26], prenatally planning for breastfeeding and Family support.

The Prenatal Planning for breastfeeding is a reflection of the knowledge, attitude, women’s awareness of the importance of exclusive breastfeeding and increase the confidence in their ability to have successful continue breastfeeding. breastfeeding support must be given as part of routine health service provision ^[27] women who had support from her husband, family and her friends are likely to have longer breastfeeding duration ^[28]. Socio-demographic variables: There is a difference in the Prevalence of breast-feeding from one country to another and from one society to another, the prevalence of breast feeding was higher among Arab and Islamic communities due to cultural and religious believes ^[29]. Breast Milk Substitute Marketing: A major public health concernisunregulatedbreastmilksubstitutes(BMS)marketing because it influences negatively the mothers' decisions on infant feeding practices and encourages formula consumption and therefore decrease breastfeeding practice ^[30] Objectives To identify the impact of socio- demographical factors that influenced the initiation and practice of breastfeeding amongst women attending Karbala teaching hospital for children.

Methods

This is a cross sectional clinical based study targeting of 516 mothers who had been attending Karbala Teaching Hospital for Children. The data were collected over six months from July to December 2016, by a semi – structured questionnaire composed of 42 questions, delivered directly through faceto-face interview which last for 10-15 mints for each. After obtaining the informed verbal consent of the 516 qualified mothers who included in the study. The data collected by the researcher and other medical staff. Inclusion criteria: the newborn and infant have to be ≤6 month of age, the respondent has to be the infant`s mother, neonates with congenital anomalies interfering with breast feeding were not included in the study.

The questionnaire included the following determinants: Personal information ", demographic data" family level of education, their economic status which based on their house size compared with the number of the resident in it, rented or owned or displaced who lives in camps. Also, the occupational status of both parents which help in categorization of economic status and regarding the choice of feeding which the employed mother takes. The residence if urban or rural and if it was affecting the choice of feeding , Baby gender and gestational age. Mode of delivery, Birth weight of the baby. Neonatal care unit admission and it`s duration, and if they let the mother be with her baby during admission ^[31].

Hospital policy and health-care staff sport regarding breast feeding practice. The family support, Mother choice of feeding her baby. Time of administration of bottle if the choice was bottle fed. Introduction of liquid and food. Source of the knowledge of the mother about baby feeding practices. Mother`s intention of feeding, the main reason behind choosing bottle feeding. The privacy of feeding practices. Work institutions policy regarding employed nursing mothers and their babies, day care, lactation rooms and labor breaks. Sample size was calculated using equation 1. Where, n sample size, Z2 = 1.96 (confidence interval). The standard normal deviate usually set at 1.96 or simply 2.00 which correspond to 95% confidence level.

p=The proportion of target population (0.5=50%). q = 1-p (1-0.5), d =0.05 or 0.0. Therefore: n =384, 10% for none respondents, 384x10/100=38.4.Therefore,thesamplesizewas384+38=422. Identifying the first mother arrived and to get the rest of the required sample size, systematic sampling method was used. Statistical analysis: was done using statistical package for social science (SPSS) program version 21. Qualitative data were expressed as numbers (N), and percentages (%), while quantitative variables were expresses as N, minimum (Min.), maximum (Max.), mean and standard deviation (SD). Chi square test was used for analysis of qualitative variables, while analysis of variance (Anova, F) test was used for analysis of quantitative variables. A probability (P value) of less than 0.05 considered statistically significant.

Ethical approval for this study was obtained from the Karbala Directorate of Health. Informed consent was obtained from all participants who were informed about the research prior to collection of data. All data were saved in a password computer for research purpose only.

Results

A total of 516 mothers of infant aged less than 6 months were included in the study with response rate of 100%, 308(59.7%) of them declared to have breastfed breastfeeding, 79(15.9%) bottles feeding and 129 (25%) mixed feeding for their infants as shown in Figure 1. Figure 1. type of feeding that had been chosen by the participant mothers. Among the participants mothers 90(17.4%),107 (20.7%),103(20 %) of them were illiterates, read and write and primary education respectively. the rest of had either secondary or higher education. 80.2% of the mothers were housewives and 19.8% of them were employed. More breastfeeding practice was found in housewives and low educational level mothers.

74.7% of the women lived in rural area declared to have breastfed in front of 56.1% of the women from urban area. (p. value = 0.001). 56.8% of participants infants were male but gender not affecting the choice of breast feeding (p=0.115). 66.3% of the mothers were from low socioeconomic class and 61.0% with crowding index of <3 in one room. (p=0.146). 457 (88.6%) women given birth after 9 months of gestation and 62.6 % of them had breast feeding, those born bellow 9 months gestational age only 59(11.4%) and there were no significant results as (p-value= 0.120) . 294 (57%) had vaginal deliveries, (68.0%) was assisted by episiotomy and 222 (43%) delivered by C/S these results were significantly affecting the type of infant feeding in the 1st sixth months of life as (p-value= 0.001), Table 1.

Table 1. Maternal characteristics according to the type of feeding. Variables Categories Total Type of feeding P value Breastfed Bottle Mixed 100% 59.7% 15.3% 25.0% Mother Education Illiterate 90 17.4% 76.7% 10.0% 13.3% < 0.001 Read & write 107 20.7% 58.8% 23.4% 17.8% Primary 103 20% 55.3% 16.5% 28.2% Secondary 111 21.5% 54.1% 19.8% 26.1% Higher 105 20.3% 56.2% 5.7% 38.1% Mother Job Housewife 414 80.2% 59.7% 17.4% 22.9% 0.009 Employee 102 19.8% 59.8% 6.9% 33.3% Residence Urban 417 80.8% 56.1% 15.6% 28.3% 0.001 Rural 99 19.2% 74.7% 14.1% 11.1% Economic status Weak 342 66.3% 61.1% 18.4% 20.5% 0.146 Intermediate 165 32% 54.5% 9.7% 35.8% Good 9 1.7% 100.0% 0.0% 0.0% Crowding index (person /room) < 3 315 61% 57.8% 11.1% 11.1% 0.007 ≥ 3 201 39% 62.7% 21.9% 15.4% Child Gender Male 293 56.8% 59.4% 13.0% 27.6% 0.115 Female 223 43.2% 60.1% 18.4% 21.5% Duration of Pregnancy /month 7.0 16 3.1% 75.0% 0.0% 25.0% 0.120 8.0 43 8.3% 23.3% 46.5% 30.2% 9.0 457 88.6% 62.6% 12.9% 24.5% Type of labor NVD 294 57% 71.1% 8.8% 20.1% < 0.001 C/S 222 43% 44.6% 23.9% 31.5% NVD + Episiotomy No 94 32% 64.9% 9.6% 25.5% 0.346 Yes 200 68% 72.9% 8.4% 18.7% The average age of participant's mothers was 26 years.

mean of duration of marriage for those who breastfeed, mixed feeding was 7.01, 5.04 years respectively. Age of participants infants ranged from 2-180 days with an average age of 95 days, mean age of those who breastfed were 93 days (p. value=0.482). Infants birth weight ranges from 0.8-5.0 kg (mean=2.84 kg). Duration of admission were ranged from1 hour-30 days, out of 218 who were admitted to the NICU 98 (44.9%),50 (22.9%) and 70 (32.11%) had breastfeeding, bottle feeding and mixed feeding respectively. This table show the significant relation between type of feeding practice with the duration of marriage and duration of infant stay in prematurity Unit. Table 2. Relationship Between Feeding Methods and Maternal Age, Marriage Duration, Infant Characteristics, and NICU Admission.

Variable Type of feeding N Mean SD P value Age of mother / year Range (15- 45) Breast feeding 308 26.61 6.01 0.356 Bottle 79 27.10 6.94 Mixed 129 25.90 6.05 Total 516 26.51 6.17 Duration of marriage / year Range (1- 26) Breast feeding 308 7.01 4.71 < 0.001 Bottle 79 7.68 5.61 Mixed 129 5.04 3.50 Total 516 6.62 4.68 Age of child / days Range (2- 180) Breast feeding 308 93.37 55.92 0.482 Bottle 79 99.66 58.71 Mixed 129 99.55 59.97 Total 516 95.88 57.35 Infant birth weight / Kg Range (0.8- 5) Breast feeding 308 2.85 0.56 0.497 Bottle 79 2.76 0.75 Mixed 129 2.85 0.67 Total 516 2.84 0.62 Duration of stay in Prematurity Unit / hr Breast feeding 98 114.67 293.62 0.001 Bottle 50 314.86 583.11 Mixed 70 70.03 150.25 Total 218 146.25 362.45 About (60.3%) of the mothers initiated their babies breast feeding with in <2 hours after labor, and (71.4%) of them continue with breast feeding, while only (36.9%) of women who fed their babies after 24 hours chose breast feeding (p.

value =<0.001). Among total infants participated in the study 218 (42.2%) were admitted to the NICU, 46.3% of them chose BF and 69.5% of those who were not admitted to the NICU chose BF ,(p value= < 0.001). (59.1%) of the mothers were fed their babies previously with breast milk, from them 73.7% continue with breast feeding, only 20 (31.7 %) out of 63 who previously feed their babies with bottle chose breastfeeding for their current infants (p. value=<0.001). 109 (21.13%) (primi gravida) had no previous experience with any type of infant feeding and not included in the comparison. Participants mothers who did not offer liquids to their infant soon after birth were 325 (63%), about two thirds of them had chosen breast feeding (p.

value =<0.001), in front of (48.7%) of respondents who did introduced liquids to their infant soon after birth continue on breastfeeding and higher percentage chose mixed feeding 63 (33.0%) with (p. value=<0.001). about 90% Women who delivered their babies at hospital which encouraged breast feeding, (60.3%) of them chose BF (p .value=0.694). 73% of the mothers took their decision about the way of feeding after delivery (74.7%) of them who breastfeed their baby and (14.6%) were intend to introduce mixed feeding decided prenatally (p. value<0.001). (86.8%) had special place for feeding their infants (p. value>0.05). Table 3. Table 3. Variables related to the sampled mothers in relation to the type of feeding.

Variables Categories Total 100% Type of feeding P value Breastfed 59.7% Bottle 15.3% Mixed 25.0% Initiation of breast feeding < 2 hrs 311 60.3% 71.4% 11.9% 16.7% < 0.001 2-23 hrs 121 23.4% 45.5% 15.7% 38.8% ≥ 24 84 16.3% 36.9% 27.4% 35.7% Admission to neonatal unit No 298 57.8% 69.5% 9.7% 20.8% < 0.001 Yes 218 42.2% 46.3% 22.9% 30.7% Previous feeding methods Breastfed 305 59.1% 73.7% 10.4% 15.7% < 0.001 Bottle 63 12.2% 31.7% 45% 23.8% Mixed 39 7.6% 10.3% 26% 64.1% Non 109 21.13% 0 0 0 Fluids offered to infant after birth No 325 63% 66.2% 13.5% 20.3% < 0.001 Yes 191 37% 48.7% 18.3% 33.0% Policy of hospital No 55 10.7% 54.5% 18.2% 27.3% 0.694 Yes 461 89.3% 60.3% 15.0% 24.7% Who advise about feeding Mother 240 46.5% 72.1% 12.1% 15.8% < 0.001 Mother in law 55 10.7% 78.2% 5.5% 16.4% Friend 25 4.8% 36.0% 52.0% 12.0% Nurse 31 6% 35.5% 38.7% 25.8% Doctor 165 32% 43.6% 13.3% 43.0% When you decide how to fed Before Delivery 376 73% 74.7% 10.6% 14.6% < 0.001 After Delivery 140 27% 19.3% 27.9% 52.9% Special place for feeding No 68 13.2% 66.2% 26.5% 7.4% > 0.05 Yes 448 86.8% 58.7% 13.6% 27.7% Figure 2 shows mostly the maternal grandmothers 240 (46.5%), followed by doctors 165 (32%).

However, 72.1 %, 78.2 % ,36%, 35.5 % and 43.6 % of the mothers who received advice about way of feeding from their mothers, mothers in law, friends, nurses and their doctor chose breastfeeding respectively with (p. value<0.001). Figure 2. the person who helps mothers to choose the feeding type. Regarding causes behind choosing bottle feeding, 52% were claimed that they had not enough milk, 22% because of C/S, 14% due to baby illness, and 9% to maintain body figure, and 3% due to mother illness, as showed in figure 3. Figure 3. Main causes for choosing formula.

Discussion

Various psychological, social, emotional, and environmental factors impact whether an infant is breastfed, bottle fed or mixed. Approximately 60% of the respondents chose breastfeeding as a feeding method for their babies, 40% chose bottle feeding or both. nearly equal to the result of study in conducted in Poland ^[32] and differ from other study in K.S.A where only 28% practiced exclusive breastfeeding for the first six months. In Iran 27.7 % at 6th month and 56.8% at 4th month infants ^[33]. Age of the mother plays no significant role with EBF in contrast to other study found that maternal age significantly associated with EBF practice ^[34] while other studies found that young mothers have lower breastfeeding self-efficacy than older mothers ^[35].

The difference may be due to mothers age were approximately in the same range regarding all types of feeding. significant relation between type of feeding practice with the duration of marriage and that may be due to longer duration of marriage may associate with multiparty and more feeding experience, same result found by Shamima Akter et al ^[36]. In the current study about half of primigravida mothers chose bottle feeding and mixed feeding, the higher risk of terminating breastfeeding in mothers with first-born babies might result from that younger age-group had no breastfeeding experience ^[37,38] Regarding mother's education: there were a strong correlation between mother`s education and type of feeding and about three quarters of illiterates mothers conducted in the study chose breastfeeding, and this was the highest percentage among all, while highly educated mothers which chose mixed feeding, and that because educated mother tend to be employed and has no time for breastfeeding, in the agreement with studies in Saudi Arabia and the United Arab Emirates ^[39], and not similar to results from various south Asia or Africa countries where breastfeeding practice was more among mothers who completed secondary or higher education than among mothers with low educational levels ^[40].

May be due to that educated mothers have adequate knowledge gained from mass media or reading about importance of breast-feeding practices to their offspring health ^[41]. Regarding mother`s job a about one third of employed mothers had a mixed feeding, working for a long time had a negative impact on breastfeeding duration. this finding is consistent with other study found that shorter breastfeeding duration associated with early returning to work and working more than 34hrs per week ^[42]. Several studies in different parts of the world reported low rates of exclusive breastfeeding among working mothers ^[43]. This study showed that more than half of the women who had their private place of feeding chose breastfeeding feeding practices, lack such facilities at the workplace can hinder their ability to breastfeed exclusively.

In Iraq employed mothers who had nursery rooms in their work place are more likely to choose mixed feeding, while others had maternal leave. Mothers from rural area and low socioeconomic status had higher rates of exclusive breastfeeding than those from urban area, same finding was found by other study ^[44] and in contrast to other study in which middle income mothers had a less breastfeeding practice compared high income mothers ^[38]. Among the regional countries, a study from Iran reports that mothers from middle SES were more likely to breastfeed their babies ^[45]. The current study revealed that the culture of the Karbala is still supportive to breast-feeding since people especially the aged grandmothers provide a culture that encourages breast-feeding.

Most of the mothers who received advice about way of feeding from their mothers and mothers in law chose breastfeeding. Half of the mothers who advised by their friends chose bottle feeding. These findings are similar to those from a study done in Turkey ^[46]. mothers spend a lot of weeks postpartum in their parents' house and may be ordered to breastfeed their babies by older family members and influenced by cultural and religious beliefs. Nurses had little influence choose bottle feeding. Efforts to improve early initiation and exclusive breast-feeding should betakenbystaffsinpublicandprivatehospitalsandtosupport the baby-friendly hospital. Early initiation of breastfeeding is associated positively with increase rate of breastfeeding practice. More than two thirds of those who initiated feeding in 1st 2 hours chose breastfeeding, same results by other studies ^[47,48].

In the current study mothers who hadn't introduce prelacteal fluids, about two thirds of them breastfed their babies, the type and duration of prelacteal feeding had significant negative influence on milk production and it is a significant risk factor for shorter BF duration ^[49] to improve BF outcomes Effective interventions are needed in order to prevent the introduction of unnecessary milkbased prelacteal fluids ^[48], in this study three quarters of women who intend to breastfeed their babies prenatally breastfed their babies early. other study found that predelivery woman's intention is considered strong predictors of breastfeeding ^[50]. Out of those giving artificial formula the main reason behind this practice was not enough milk followed by C/S delivery, baby illness, mother illness and lastly to maintain body figure, doctors’ advice ^[51] and occupation ^[52], other study found that mothers with lower levels of education more likely to practice bottle-feeding ^[5].

Mothers who experienced birth complications like caesarean deliveries, fetal distress, were each associated with a shorter breastfeeding duration, and therefore mothers who had delivered their babies by vaginal delivery are more likely to breastfeed, episiotomy had no influence on feeding type or initiation, higher percentages of neonates that fed during the first day of their lives were belonged to those who delivered by C/S, unfortunately they chose either mixed or bottle feeding. Similar results in other studies ^[53,54]. Mothers who experienced complications were more likely to discontinue breastfeeding for reasons of post operative pain, delayed milk production, due to physiological and psychological stress, ability of holding the baby ^[55]. Our study also shows the effect of neonatal intensive care unit (NICU) admission on the choice of feeding, more than two thirds of those not admitted had breastfeeding in front of more than half who were admitted had mixed feeding and bottle feeding, and also duration of stay in NICU had negative impact on breast feeding practice.

Furthermore, our study shows that infant birth weight and age have no significant influence on breastfeeding. But a newborn with low birth weight or premature tend to stay longer in NICU and may fed by NG tube and therefore inversely correlated with breastfeeding duration. same finding by other studies ^[56-58] may be due to the stress and anxiety of the mother and separation of the mother and her neonate; the, which may result in depressive disorder ^[55]. Women with previous breastfeeding experience are more likely to intend to breastfeed than those who never had any experience, in consistent with other study ^[59].

Conclusions

• Many of the mothers have a basic instinct and positive attitudes towards breast feeding. • Appropriate practice of breast feeding is still influenced by factors such as the health care system, the social support, mother's education, and cultural attitudes. Maternal age, type of labor, admission to the NICU, fluids offered to the babies after birth, employment status and workplace Policies and Barriers, previous feeding methods and crowding index • Maternal mothers and mothers in law, doctors (pediatricians) had the lion`s share in influencing breastfeeding practices. • Initiation of breastfeeding is a strong predictor for the duration of breastfeeding Recommendations • In terms of early initiation during the first hour, implementing the baby-friendly hospital initiatives, and implementing of the international code of marketing of breast milk substitute are strongly recommended.

• Encouragement of doctors specially the pediatricians to attend lectures and conferences about advantages of breastfeeding and to enhance their positive attitude towards breastfeeding practices. • Also, it is recommended that mothers begin infant feeding education as soon as they get pregnant, so that they can make well informed decisions on how to feed their babies. Acknowledgment Authors are grateful to all the women who participated in the study and for Karbala Directorate of Health for its approval to perform the study in the pediatric hospital. Funding This research was funded by the University of Al- Ameed. Conflicts of Interest No conflict of interest.

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