Medical Journal

Published by

Faculty of Medical Sciences,
University of Sri Jayewardenepura,
Nugegoda,
Sri Lanka.

Original Articles

Anxiety related to exclusive breastfeeding and its associated factors among mothers immediately after delivery in Colombo South Teaching Hospital, Sri Lanka

Dissanayake D M C H B1*, Ranasinghe R H G B S1, De Silva K M M1, Nimsara T T N1, Gunasinghe D A1, Jayawardane M A M M2, Prathapan S3

1Faculty of Medical Sciences, University of Sri Jayewardenepura
2Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri Jayewardenepura
3Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura
*chamod.himsara99@gmail.com

Abstract

Background: Exclusive breastfeeding for six months is recommended by WHO. However only one third of mothers who start breastfeeding continue it for 6 months. Anxiety related to breastfeeding is an important factor that contribute to early cessation which is often ignored.

Objective: To determine the anxiety related to exclusive breastfeeding and its associated factors among postpartum mothers immediately after delivery in Colombo South Teaching Hospital, Sri Lanka.

Methods: A cross-sectional analytical study was carried out among 120 postpartum mothers (less than one day), above the age of 20 years admitted to the Professorial unit postnatal ward of CSTH. Systematic random sampling was carried out to recruit the participants. Data was collected using a pre-tested interviewer administered questionnaire. Anxiety related to exclusive breastfeeding was assessed by a questionnaire developed based on the Li’s self-rating feeding anxiety scale. This tool was modified and translated to Sinhala. Data was analysed using SPSS software version 25. P<0.05 was considered statistically significant.

Results: Out of the 120 participants, 49.2% (n=59) participants were aged between 26-34 years. 29.2% (n=35) were between 20-25 years and 21.4% (n=26) were 35 or above. The majority of the participants were Sinhalese (85.8%, n=103). Majority of the mothers were found to have anxiety related to EBF (52.5%, n=63). Knowledge about exclusive breastfeeding (p=0.03), having children less than 3 years of age (p=0.001), type of delivery (p=0.02) and social media influence (p=0.000) showed a statistically significant association with anxiety related to EBF. Other factors did not show any significant association with anxiety related to EBF.

Conclusions: Majority of the participants had anxiety related to EBF. Knowledge about EBF, having children less than 3 years of age, type of delivery and social media influence showed a statistically significant association with anxiety related to EBF. Hence effective programs should be carried out in the relevant institutions to educate postpartum mothers about anxiety related to exclusive breastfeeding and possible methods to overcome it.

Keywords: Anxiety, Exclusive breastfeeding, Postpartum, Infant feeding, Knowledge

Introduction

The World Health Organization (WHO) defines exclusive breastfeeding (EBF) as when ‘an infant receives only breast milk, no other liquids or solids are given – not even water, with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines’ (1). The current recommendation regarding breastfeeding is that the infant should be exclusively breastfed during their first 6 months(1). Breast milk consists of an ideal mixture of protein, fat, carbohydrates, vitamins, minerals, and trace elements which are easily digestible than infant formula and are pre-requisite to the health and survival of the baby. In addition, as breastmilk contains maternal antibodies, breastfeeding protects the baby against infections and chronic diseases as a result of the passive immunity gained from the maternal antibodies. The risk of Asthma, Obesity, Otitis media, Allergies, Diarrheal etc. are comparatively low in infants who are exclusively breastfed.

Breastfeeding lowers the risk of maternal and ovarian cancer. Studies have revealed breastfeeding has a natural contraceptive effect during the first 6 months due to the reduction of Gonadotropin Releasing hormone (GnRH), Luteinizing hormone (LH) and Follicle Stimulating hormone (FSH) release (2).

Skin to skin contact during breastfeeding which promotes powerful release of oxytocin develops a more affectionate maternal infant bonding and makes them both feel closer to each other. According to the American Psychological Association “Anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure”(3). Anxiety disorders differ from anxiety. For a person to be diagnosed with an anxiety disorder, “The fear or anxiety must: 1) Be out of proportion to the situation or age-inappropriate 2) Hinder ability to function normally”

Since mothers are very anxious about doing their best for their children, it is possible for exclusive breastfeeding mothers to develop anxiety and even go into anxiety disorders which would affect both the mother and the baby. This study is designed to determine the anxiety related to EBF of mothers immediately after delivery and factors associated with that. This information can be used to come up with methods to reduce the anxiety related to EBF of postpartum mothers which can help reduce early cessation of EBF.

Methodology

A cross sectional analytical study was conducted in the Professorial unit post-natal ward of Colombo South Teaching Hospital (CSTH). Less than one day postpartum mothers aged 20 years and over admitted to the Professorial unit postnatal ward of CSTH were chosen as the study population. Mothers having fluency in Sinhala or English language who were not diagnosed with any psychological illness before and or during antenatal period and admitted to the Professorial unit postnatal ward of CSTH were included in the study and mothers who experienced spontaneous abortions, mothers who experienced still births, mothers diagnosed with pre pregnant anxiety and depression, mothers of infants with congenital defects that interfere breastfeeding (e.g.: cleft lip, cleft palate etc.), mothers of neonates admitted to the neonatal ICU, mothers who have hearing and/or visual impairment ,teenage pregnancies were excluded from the study. (Teenage pregnancies were excluded because teenage pregnancies have another level of anxiety due to other related problems. The anxiety related to exclusive breastfeeding will not be correctly reflected in teenage pregnancies). With a non-response rate of 4% final sample size calculated was 125. This study was performed using systemic random sampling technique. Every other mother with a skip interval of 2, who were admitted to the Professorial unit post-natal ward considering the inclusion and exclusion criteria, were considered in the study until sample size was achieved.

Data collection was done using an interviewer administered questionnaire that met the objectives of the study The study instrument comprised of 3 sections.

Section 1 consist of sociodemographic factors, home environment, work related, factors related to infant, social and cultural, obstetric history whereas Section 2 consisted of questions to assess the knowledge about exclusive breastfeeding. The knowledge was assessed as it has a direct impact on anxiety related to exclusive breastfeeding. There were 15 questions consisting of 14 multiple choice questions and one short answer question.  2 marks were given for correct answer and minus 1 for wrong answer. If the participant didn’t know the answer, no marks were given. This section carried a maximum score of 30 and a minimum score of 0. This knowledge questionnaire was developed after a literature review, which was then looked into by supervisors, who are experts in this field. Therefore, the questionnaire has been looked into, specially into content validity. The median knowledge of the sample was 21. The level of knowledge of the study sample was divided into two classes with regard to the median knowledge score of the sample. Good knowledge ≥ 21 and poor knowledge < 21. Section 3 was dedicated to postpartum anxiety related to exclusive breastfeeding which was assessed by a questionnaire developed based on the Li’s self-rating feeding anxiety scale. This tool was modified and translated to Sinhala. The modified version had been judgmentally validated through face and content validity, by the supervisors, who are experts in this field. This consisted of 23 questions which describe mothers’ emotions during exclusive breastfeeding. Mothers were told to select the most appropriate answer based on their real feeling. There were no correct or wrong answer for these questions. The mean and median score for anxiety related to EBF of the sample was 44. Anxiety related to EBF of the study sample was divided into two classes with regard to the mean anxiety score of the sample. Anxiety ≥ 44 and no anxiety <44. A separate room was used for data collection to protect the patient’s privacy and maintain confidentiality. Informed written consent was taken from the participants. The collected data was analysed using the version 25.0 of Statistical Package for Social Sciences Software (SPSS). Frequency tables were used to review the descriptive data and Chi square test was used to determine the association of factors with anxiety related to EBF.

Ethical clearance for the study was obtained from the Ethics review committees of Faculty of Medical Sciences, University of Sri Jayewardenepura ad Colombo South Teaching Hospital.

Results

This research was conducted in order to determine the anxiety related to exclusive breastfeeding (EBF) and factors associated with anxiety related to exclusive breastfeeding among mothers immediately after delivery in Colombo South Teaching Hospital, Sri Lanka. The total sample size was 120 with a 4% of non-response. The sample included 3 age groups. Out of 120 respondents, 35 (29.2%) and 59 (49.2%) were between ages 20-25 years and equal to or above 35 years respectively. 59 (49.2%) of the respondents were between 26-34 years and it included the majority.103 (85.8%) respondents were Sinhala while only 12 (10%) were Muslim.49 (40.8%) individuals had a monthly income between Rs.35 000 – Rs. 49 999. There were only 11 (9.2%) respondents had a monthly income above Rs. 100 000.Most of the respondents were unemployed (n=92, 76.7%). The highest education level of the sample was graduate (n=21, 17.5%). Only 1 (0.8%) respondent had their highest education level as primary education.

Among the 120 mothers, 17(14.2%) mothers worked in private sector and only 9 (7.5%) worked in government sector. From the sample, 94 mothers (78.3%) did not require a maternity leave because either they were unemployed or self-employed. Out of the 26(21.7%) mothers who required maternity leave only 15 mothers had a maternity leave more than or equal to 6 months. Among 120 mothers only 7(5.8%) mothers worked less than 6 hours.12(10.0%) mothers worked 6 to 8 hours. Majority 67(55.8%) were from core families while 53(44.2%) mothers were from extended families.46(38.3%) mothers had children less than 3 years of age at their house other than the baby they are breastfeeding. A core family is a family consisting of the parents and children without other relations. 95 mothers (79.2%) had a baby with a normal birth weight. Majority of the mothers (n=69, 57.5%) had responded saying that their baby did not cry excessively during breastfeeding. Among the 120 babies, 42.5% (n=51) have cried during breastfeeding and 57.5% (n=69) have not cried during breastfeeding. Among the 120 mothers, majority (n=87 ,72.5%) had a sleep of less than 6 hours during night. From the sample only 34 (28.3%) mothers had the thought of breast milk insufficiency. Among the 120 mothers, majority (n=61, 50.8%) had a previous experience in breastfeeding. 65 (54.2%) mothers responded that their currently breastfeeding baby was delivered by normal vaginal delivery. Majority (n=47, 39.2%) of the mothers didn’t feel uncomfortable to breastfeed Infront of other family members. Out of the 120 respondents only 56 (46.7%) mothers were influenced by social media. Among the participants, 45.8% (55) had a good knowledge about exclusive breastfeeding, while 54.2% (65) had a poor knowledge about exclusive breastfeeding. 63 (52.5%) mothers had anxiety related to exclusive breastfeeding while 57 mothers (47.5%) mothers had no anxiety related to exclusive breastfeeding.

Table 1: Association of anxiety with sociodemographic factors

There was a statistically significant difference between those who were not occupied in mothers who had and didn’t have anxiety related to exclusive breastfeeding (p=0.022).

Table 2: Association of anxiety with home related factors

Among the mothers who had anxiety related to EBF, 57.1% (n=36)) mothers had children less than 3 years of age in addition to the currently breastfeeding baby, whereas among those who did not have anxiety related to EBF, majority (71.9%, n=41) did not have children less than 3 years of age in addition to the currently breastfeeding baby.

There is a statistically significant difference in anxiety related to EBF between mothers who had and did not have children less than 3 years of age (p=0.001).

Table 3: Association of anxiety with obstetric related factors

Among the mothers who had anxiety related to exclusive breastfeeding 55.6% (35) mothers had caesarean section while 64.9% (33) of the mothers didn’t have anxiety related to exclusive breastfeeding had a normal vaginal delivery. This observed difference in proportions was statistically significant (p=0.02).

Table 4.: Association of anxiety with social and cultural factors

More than two thirds of the mothers who did not have anxiety related to EBF (72.9% n=43) did not have a social media influence whereas among the mothers who had anxiety related to EBF 52.5% (n=32) of mothers had anxiety related to EBF. There was a statistically significant difference in anxiety between the mothers who did and did not have social media influence (p=0.000).

Table 5: Association of anxiety with knowledge about EBF

Among the mothers who had anxiety related to exclusive breastfeeding 63.5% (40) mothers had a poor knowledge about exclusive breastfeeding while 56.1% (32) of the mothers who didn’t have anxiety related to exclusive breastfeeding had a good knowledge about exclusive breastfeeding. There was a statistically significant difference between mothers with anxiety and mothers with and without a good knowledge about exclusive breastfeeding (p=0.03).

Discussion

Pregnancy and lactation are important periods of life for women during which there physiological and psychological status undergo significant changes. Sun J et al. in their study performed in the year 2020, states that post-natal anxiety and depression are most common mental health problems in women (4).

Among the factors that cause early cessation of EBF, one of the most important yet a factor that has paid less attention is anxiety related to EBF. Given the fact that postpartum anxiety related to EBF has been noted as having significant side effects just as postpartum depression, less attention has been given to anxiety related to EBF and also it has been found that there is an inverse relationship between anxiety and breastfeeding(5). To the best of our knowledge, with this being the first study performed in Sri Lanka in order to determine anxiety related to EBF and its associated factors in less than one day postpartum mothers, we intend that information from this study can be used to reduce the cascade of negative impacts of anxiety related to EBF on both infant and mother and provide a good statistical base for further research studies conducted in this subject in Sri Lanka.

CSTH caters for all ethnicities and religions from all over the Colombo district and because of this there’s high external validity. As this is a cross sectional analytical study design, the study contains multiple variables at the time of data snapshot and information from this study can be used for further research studies thus maximizing the value of collected data. Participants were selected using systematic random sampling with a skip interval of one thus ensuring that the selection bias was minimal. Usage of systematic random sampling ensured that members of the sample were selected without any favouritism and therefore reducing the possibility of selection bias thus improving external validity.      

Data collection was done via an interviewer administered questionnaire that met the objectives of the study. As less than one day postpartum mothers would be giving most of their time for their new-born baby, a self-administered questionnaire wouldn’t have been feasible. By using an interviewer administered questionnaire, it was made sure the questionnaire was not a disturbance to them so that the collected data is reliable and also reducing information bias.

Anxiety related to exclusive breastfeeding

Among the 125 mothers, 52.5% mothers had anxiety related to exclusive breastfeeding.

Mother-Infant Cohort Study (MICS) of China conducted in Beijing, Taiyuan of Shanxi, Jinan of Shandong, Changsha of Hunan, Shiyan of Hubei, Chongqing, and Chengdu of Sichuan from June 2015 to December 2018 was done among volunteer mothers less than 3 months postpartum from local childcare clinics. This study which assessed anxiety using the “Li’s self- rating feeding anxiety scale (SFAS) revealed that there was a prevalence of feeding anxiety of 61.4% among the participants (4). The findings of this study correlate with the results of our study where the majority of mothers had anxiety related to EBF. The study done in China was a cohort and advantages of a cohort study include consideration of seasonal and other variation over a long period and less subjection to selection bias. So, the study finding of a cohort study correlating with the findings of our study which is a cross sectional analytical study, supports the validity of our results furthermore.

An analytical, longitudinal and prospective study done among 186 postpartum women (60 days postpartum) in Basic Health Unit (BHU) of Sao Paulo, Brazil from October 2018 to July 2019 revealed that 66.2% of the population experienced low level of state anxiety. For assessing anxiety “State-Trait Anxiety Inventory (STAI)” was used in this study and STAI categorization includes low level anxiety, medium level anxiety and high anxiety levels. The findings of this study being contradictory to our findings can be explained by the fact that the scale we used was chosen after an extensive review of literature as it was specific to assess anxiety related to breastfeeding unlike STAI which is more focused on general anxiety.

Factors associated with anxiety related to EBF

Factors associated with anxiety related to EBF were categorized into several groups which included sociodemographic factors, home and work-related factors, factors related to infant, maternal factors, social and cultural factors, obstetric history and knowledge about EBF.

The associated obstetric factors we assessed included previous breastfeeding experience and type of delivery. Sun J et al. in their cohort study in China states that there is a statistically significant association between type of delivery and feeding anxiety in postpartum mothers(4). Similarly, in our study, the difference in anxiety between mothers who had undergone caesarean delivery and normal vaginal delivery went hand in hand with the conclusion derived by the above quoted study as it was found to be statistically significant in our study as well. Among the mothers who had anxiety related to EBF, the majority had undergone caesarean delivery. When taking previous breastfeeding experience into consideration, in our study, it was found that there was no statistically significant difference between mothers who did and didn’t have previous breastfeeding experience. In the interim Zanardo et al. portrayed a dissimilar opinion as their study states that there is a statistically significance difference in anxiety between mothers who did and didn’t have previous breastfeeding experience (6). The study done by Zanardo et al. states that they lacking information on which to base a sample size calculation and that there was a potential for misclassification of breast-feeding status because impaired lactation at discharge and early weaning were determined only at the defined assessment intervals, irrespective of the reasons given for stopping breast-feeding. These factors could have contributed to the differences in two studies.

Among the home related factors we assessed, having children less than 3 years of age was found to have a statistically significant association with anxiety related to EBF. The results revealed that among the mothers who had anxiety related to EBF, 57.1% of mothers had children less than 3 years of age. This observation could be attributed to the fact that most of the children less than 3 years of age would be also getting breastfed hence the mother might be facing the problem of breastfeeding two children.

A cohort study done in Calgary, Alberta by Kehler H et al. (6) in 2009 stated that association between failure to exclusively breastfeed and younger maternal age was statistically significant. In contrary, our study observed that there was no statistically significant association between maternal age and anxiety related to EBF. The different social backgrounds in two countries would have led to the difference.

Hence maternal knowledge about exclusive breastfeeding is a modifiable associated factor, our research also intended to find whether there was any association between maternal knowledge and postpartum anxiety related to EBF. It was found that there was a statistically significant difference in anxiety between mothers who had and didn’t have a good knowledge about EBF. Having a poor knowledge about EBF was associated with having anxiety (63.5% p=0.03).

In the current developing society, informative videos are freely available in social media such as YouTube and Facebook and the accuracy and the validity of this information is highly doubtful. Therefore, it was targeted to see whether the information gained from social media had any influence on anxiety related to EBF. It was found that there was a statistically significant difference in anxiety between mothers who had and didn’t have social media influence. It showed that social media influence led to higher anxiety levels (52,5% p=0.00). Hence, it’s important to guide mothers when it comes to social media.

Assarian et al. (7) states that there was a significant association between maternal occupation and breastfeeding success. It was also noteworthy in our study as it was found that there was a statistically significant difference in anxiety between mothers who were and were not occupied. The former study being a case control study and the results going hand in hand with our study, adds more to the external validity of our study.

Limitations

The questionnaire was available in Sinhala and English formats. Despite Tamil respondents answering the questionnaire in the English format, a more comprehensive approach would have been possible if Tamil translation was used. This was not possible as we did not have any members in our research group who were fluent in Tamil. The interviewer administered questionnaire we used was a bit lengthy as it consisted of 3 sections. This could have led to reduced attention of mothers when answering the questions. Due to the social and cultural background in Sri Lanka, several of the mothers gave answers reluctantly for questions related to family support and social and cultural factors. This could have affected the results if the study.

Conclusions

This study on anxiety related to exclusive breastfeeding and its associated factors among mothers immediately after delivery in Colombo South Teaching Hospital Sri Lanka, showed that the majority of mothers (52.5%) has anxiety related to exclusive breastfeeding. When taking knowledge about exclusive breastfeeding into consideration, majority of the mothers (54.2%) had a poor knowledge about EBF. Knowledge about exclusive breastfeeding was found to have a statistically significant association with anxiety related to exclusive breastfeeding. Among the mothers who had anxiety related to EBF, majority had a poor knowledge (63.55, p=0.03). So poor knowledge about EBF was associated with higher anxiety levels. Type of delivery showed a statistically significant association with anxiety related to EBF where out of the mothers who had anxiety related to EBF, 55.65% of mothers had their current breastfeeding child delivered by caesarean section. Presence of children less than 3 years of age at home was found to be a contributory factor towards anxiety related to breastfeeding. Out of the mothers who had anxiety related to EBF, 57.1% had children less than 3 years of age reflecting the fact that having 2 or more children in the breastfeeding age led to higher anxiety levels. It was observed that the widely used social media had an impact on maternal anxiety level related to EBF.  Among the mothers who had anxiety related to EBF, majority of mothers were found to have had social media influence (52.5% p=0.00). No statistically significant association was seen between anxiety related to EBF and age, ethnicity, monthly income, education level, family type, employment sector, birth weight of the child, crying of the child, sleep time of the mother, thought of breastmilk insufficiency, previous breastfeeding experience and feeding in front of family members or strangers.

Recommendations

Effective programs should be carried out in the responsible healthcare institutions with the target of educating postpartum mothers about anxiety related to exclusive breastfeeding and possible methods to overcome it. This will be of great importance as it will contribute to reduce the cascade of negative impacts of anxiety related to EBF on both infant and mother. Among the factors that were identified as contributory factors for anxiety related to EBF in less than one day postpartum mothers, knowledge about EBF is a significant factor. Hence carrying out efficacious series of measures to improve the knowledge about EBF among postpartum mothers will provide a great contribution to the task of reducing anxiety related to EBF. Mothers should be given proper guidance in selecting accurate social media content when gaining knowledge and experience from social media. We recommend that further research should be carried out in Sri Lanka as well as internationally to determine anxiety related to EBF as research focusing on anxiety related to EBF are sparse. It is also recommended that when carrying out further research, they should focus on evaluating anxiety related to EBF in several time intervals during the six months of EBF.

Conflict of interest

All authors declare that there is no conflict of interest.

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