CHAPTER I THE PROBLEM AND ITS BACKGROUND Introduction The nurse has become fully aware that breastfeeding, one of the major issues in child care today, is generally considered the best milk for infants. How, breastfeeding mothers have decreased so much that the campaign for breastfeeding as a key element is increasingly implemented here in the Philippines by the Department of Health and worldwide by the World Health Organization (WHO) to contribute to the achievement of health for all by the year 2000 through Primary Health Care.
The breastfeeding program embarked by the Department of Health is actively implemented all over the country, from north to south. Researches now and then are being done by Filipino pediatricians, public health workers, nutritionist and nurses and other interested researchers. these studies have motivated planners and implementers alike to focus their attention to the status of the breastfeeding program, particularly on the degree of compliance or acceptance of the program among Filipino families and clientele.
Considering that the public awareness of the advantages of breastfeeding is very high while its degree of compliance is low, the nurse researcher specifically desires to investigate possible reasons behind this current situation which negates the goal of Executive Order (E.
O. ) No. 51 or the Local Milk code. Conceptual Framework Breastfeeding as applied in human nutrition is a process of feeding a newborn milk directly from the breast of the mother whose milk provides all the nutrients a human baby needs including substances that promote growth and help fight infection.
Breastfeeding among humans has certain important advantages which are the following: a) provision of significant protective components against chronic diseases such as allergies and asthma; b.
anti-infection components against meningitis, diarrhea, ear infections and pneumonia; c. reduction of maternal risk of developing ovarian cancer, pre-menopausal breast cancer, osteoporosis and hip fractures in later life; d. development of mother-infant bonding; e. evelopment of maternal nurturing behaviors; and, f. development of trust of the infant. Any breastfeeding program aims for the attainment of a realization of the aforementioned benefits. The assessment of the success of the breastfeeding program after delivery is based on the attainment of these benefits for both the mother and the child. Department of Health’s Breastfeeding Program implements due to the following factors: 1. poor orientation of nurses to their roles in the Breastfeeding (BF) program, . incompetence of nurses as health educators on breastfeeding caused by lack of content, ineffective strategies, lack of planning and poor evaluation and follow-up by nurses; 3. lack of cooperation of clients due to family’s lack of support to breastfeeding, clients’ low awareness level, negative influence of mass media, absence or lack of administrative support of the BF program, and absence or lack of community linkage as well as support of the BF program and professional nurses.
All the above factors brought about the failure of the BF program resulting to the low level of child health status. They are various positive factors that bring about the high degree of compliance to the Department of Health Breastfeeding program. These are the following: 1. high level nurses’ awareness of their roles in the Breastfeeding (BF) program, 2. nurses’ competence as health educators on BF program evidenced by the adequacy of content, effective strategies, good planning, good evaluation and follow-up of health education activities by nurses, . full cooperation of clients as evidenced by their full support to the BF program, high level of awareness, and positive mass media influence, 4. adequate and strong administrative support to the BF program, and, 5. strong community linkage / support to the BF program and professional nurses. The success of the Breast Feeding Program will surely be assured if all the above factors are present. The end goal of high level wellness / status of children will eventually be attained through breastfeeding.
The ultimate goals of the Breastfeeding program which are the positive outcomes of the high degree of clients’ compliance, which are closer mother-child bonding / healthy babies / children / families and eventually, a strong, healthy community. Figure 1, show the interrelationship of how this study is being conducted. In Input – it presents the variable needed to be utilized to assess the breast feeding program of mother after delivery as implemented by selected non uniformed police and police officer nurses in Philippine National Police general Hospital.
The following questions going to investigate as: (1) Demographic profile of the respondents in terms of: category, age, gender, civil status, religion, ethnic origin, educational attainment and length of service in the hospital, (2) At what is the extent is the degree of breastfeeding compliance with regards to: rooming in procedure, feeding technique, mini banking, information, education, communication, training and prohibition observed? (3) How did nurses rate the factors influencing the degree of compliance of clients in this program in terms of the following: personnel and administrative supports, (4) What are the activities of the nurses with regards to breast feeding policy, and (5) Is there a significant difference between the breast feeding compliance and its implementations as implemented by non uniformed police and police officer nurses of the Philippine National Police General Hospital.
Throughput in the next box presents the description of the respondents in terms of demographic profile, survey questionnaire, statistical treatment, presentation and its analysis that makes all data gathered interpreted. Output, the last box also shown the projecting outcomes as to improve the present practice of the non uniformed and uniformed police officer nurses in the Philippine National Police General Hospital Input Throughput Output Figure 1 Paradigm of the Study
Statement of the Problem This research aims to assess the implementation of breast feeding program as implemented by the non uniformed police and uniformed police officer ob gyne and nursery nurses in Philippine National Police General Hospital. Specifically it sought to answer the following: 1. What if the profile of respondents in terms of: category, age, gender, civil status, religion, ethnic origin, educational attainment, and length of hospital experiences? 2. At what extent is the degree of breast feeding compliance with regard to: rooming in procedure, eeding technique, mini-milk banking, information, education, communication training, and prohibition observed? 3. How did nurses rate the factors influencing the degree of compliance of clients in this program in terms of the following: 3. 1personnel, 3. 2Administrative supports, and 4. What are the activities of nurses in breast feeding program? 5. Is there a significant difference between the breast feeding compliance as implemented by non uniformed police and uniformed police officer nurses of Philippine National Police General Hospital?
Hypothesis There is no significant difference between the breast feeding compliance as implemented by non uniform police and uniformed police officer nurses of Philippine National Police General Hospital. Scope of the Study The study will attempt to investigate the degree of compliance to the Breastfeeding Program after delivery of admitted clientele in Philippine National Police General Hospital as evaluated by the non uniformed police and uniformed police officer nurses based on the requirements and standards of the Department of Health (DOH).
Based on the established degree of compliance, the researchers will further delve into finding out specific factors that contribute to the present situation being observed. The investigation of factors related o compliance to the program will then be followed by an analysis by the researcher to find what particular factors favor or not favor compliance. The nursing aspect of the program will be particularly further observed. The professional nurses’ role in the program of the Department of Health (DOH) will be given much attention among the various factors to be considered in the study.
The researcher will utilize a pre-tested checklist evaluative tool specifically prepared and based on the standard requirements of the DOH Breastfeeding Program. Limitation of the Study The respondents will be a ten (10) non uniformed and ten (10) uniformed officer ob gyne and neonatal intensive care unit nurses from Philippine National Police General Hospital, recognized by the Department of Health (DOH) as baby-friendly. These respondent nurses in all levels must be particularly assigned in obstetrical departments of this hospital.
The checklist forms will be properly administered to ensure high retrieval percentage. Significance of the Study The findings of this study will be highly significant to the following: 1. The supervisors of these staff nurses who will provide continuing education on breastfeeding. 2. The nursing service administrators who will give more emphasis on breastfeeding program in their planning of nursing services to be provided in their respective hospitals. 3. The nursing educators, all levels, to strengthen their content and strategies in teaching breastfeeding as a nursing intervention to nursing students. . The health program planners and implementers to always base their services on results of the studies on breastfeeding by nurse practitioner. 5. The general public who will appreciate more the role of professional nurses in the success of the Breastfeeding Program. Definition of terms To provide more clarity and effect common understanding the following terms are defined: Baby-Friendly Hospital. Refers to any health institution where there is an environment created to increase the infant’s chances of survival like rooming-in and breastfeeding measures.
Breastfeeding. Is a natural process and the best process of providing nutrition after birth p to six (6) months when the baby sucks or feeds straight from the mother’s lactating breasts aided by the mother’s let-down reflect (LDR) which results in milk supply for the baby. Breastmilk. Is the human milk secretion normally produced by a lactating mother found to be rich in defense factors, hypoallergenic and convenient to use for infant nutrition. Breastmilk Substitutes.
Means any food being marketed or otherwise represented as a partial or total replacement for breastmilk, whether or not suitable for that purpose. Clientele. Refers to lactating mothers who are confined in five (5) Metro Manila hospitals under study. Compliance. Means the degree of voluntary acceptance and use of the breastfeeding technology by intended post-partum and nursing clientele who are partners in health care and involve themselves in decision-making as active participants in health care of themselves and their newborns. Degree of Compliance of Breast Feeding.
Refers to the client compliance of the breast feeding as implemented by the non uniformed police nurses and uniformed police officer nurses in Philippine National Police General Hospital in reference with the Executive Order 51 known as Local Milk Code. Department of Health (DOH). Refers to the Department of Health which by virtue of Executive Order E. O. 119 of 1987 is charged with the responsibility of protecting the health of all Filipinos through prevention of diseases, promotion of health and longevity, treatment of illnesses as well as rehabilitation through its health, environmental and related services and program.
Expressed Breastmilk (EBM). Refers to milk expressed from a lactating mother, either mammally or with the aid of a breastfeeding. Health Care System. Means governmental, non-governmental or private institutions engaged directly or indirectly in health care for mothers, infants and pregnant mothers, including those in private practice. Low Birth Weight (LBW). Refers to babies with birth weight of less than 2,500 grams. Milk Code. Refers to the international and/or local milk code as in: a.
International Milk Code by the World Health Organization of 1981 – deliberated upon by member nations, supporting breastfeeding from birth to six (6) months of life before breastmilk substitutes are served. b. Executive Order (E. O. 51) – the local milk code signed in 1988 by President Corazon C. Aquino entitled “Adopting a National Code of Marketing of Breastmilk Substitutes. Breastfeed supplements and Related Products Penalizing Violations thereof, and for other purposes.
Primary Health Care. Refers to the currently applied health as well as global development strategy described as accessible, available, essentials at a cost that the country can afford to provide and maintain in order to attain the global goal of health for all in Year 2000. Rooming-in. Refers to the practice of placing the newborn in the same room with the mother right after delivery up to discharge to facilitate mother-infant bonding and to initiate breastfeeding. Rooming-in Plan.
The system where the baby in his crib remains at the mother’s bedside for the greater part in a day and both mother and baby are treated as one unit. As an excellent educational approach, it affords both psychological and physical advantages for both as well as the father right after birth. Specifically the breastfeed baby because of proximity will avail of prompt provision of milk (breastmilk), influencing positive temperament of the child and fostering more satisfying mother-child relationship and stronger family unit. Very Low Birth Weight (VLBW).
Refers to infants with birth weight of less than 1,500 grams. CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES Introduction This chapter discusses related studies and reading both from local and foreign literature which directly provide basis for this study. It will serve as a rich source of informative facts for the researcher to utilize in the various parts of the study. Foreign Literature As early as 1980 at the thirty-third World Health Assembly “infant and young child feeding” was extensively reviewed and discussed by the delegates.
Based on these wholesome discussions, the World Health Director-General per request of the delegates prepared” as International Code of Marketing of breastmilk substitutes in close consultation with member states and with other parties concerned. The International Code supports breastfeeding from birth to six (6) months of the infant’s life and after which complementary foods or breast milk substitutes can be served. These foods are also called weaning foods. The international code major purpose is to attribute to improved infant and child nutrition and health. It was considered during the WHO deliberations that the Code’s implementation by the member states must be closely monitored according to WHO’s constitutional procedures and for the assembly to take any measures for the code’s effective application. Member states were then mandated to make full use of their organization – at global, regional and country levels by requesting its technical support in preparation of national legislation, regulation or other appropriate measures and in the monitoring of the application of the code.
The Philippines’ answer to the above international code of marketing of breastmilk substitutes is the Executive Order (EO), 51 sign by President Corazon C. Aquino. This local milk code is being vigorously implemented at the community level through the integration of the Breastfeeding Program in the various Maternal and Child Health Program of the Department of Health. Steve (2002), Chicago (USA) study of 83 children revealed that breastfed children were both physically and mentally superior to those who were bottle-fed.
The interpretation here is based in favor of the infant stimulation than that of the nutritional value. Hill (2001) pointed out “that LBW and VLBW infants present a special challenge for the nursing staff in establishing and maintaining optimal breastfeeding experience”. Factors important for the promotion of lactation, such as early mother-infant contact, on-demand feedings and early initiation of breastfeeding may be difficult to implement in the care of LBW and VLBW infants. These infants often portray poor sucking behaviors, which play a significant role in milk transfer and subsequently the production of milk. o initiate and sustain lactation, mothers of LBW and VLBW infants must often mechanically express their milk for several days or weeks before the infant can suckle at breast, recommend pumping at least 8 times in 24 hours if feeding at breast cannot occur. Ingales ( 2000) based on his study reported that breastfeeding of course, has an ancient biologic basis and is still the most universally recommended way of providing an infant with nourishment. A mother should carefully consider the advantages of breastfeeding when deciding how she will feed her infant.
A father who is supportive of breastfeeding will influence the mother’s success. Therefore, he should also be given information regarding the advantages of breastfeeding. She states that: “Putting the baby to breast contributes to the mother’s well-being in that the stimulation of the infant’s nursing causes the recently emptied uterus to contract and helps in the return of this organ to its proper size and position, a process called involution. A further benefit is the relaxing effect that prolactin, the milk-producing hormone. has on the mother”.
Many investigators believed that the baby receives certain immune factors through the breastmilk that help protect the baby against diseases to which the mother may have been previously exposed. It is agreed that as a general rule breast-fed babies have fewer respiratory tract infections and alimentary tract disturbances. Certainly, when environmental hygiene is poor, breastfeeding is preferred over the great possibility of contaminated artificially prepared feeding because breastmilk is normally sterile. The observation that cow’s milk was first designed for calves, whereas mother’s milk is specifically designed for babies, is indisputable. he curd of human milk is softer than that of cow’s milk and is easier for a baby to digest. Breastfed babies have fewer allergy problems. No prolonged preparation time is necessary, and in the long run, successful nursing is less expensive. Obesity is seen less often in children who have been breastfed. If the mother nurses her baby, the return of menstruation may be delayed until several weeks after weaning, but nursing is no guarantee that pregnancy will not occur. However, the nursing mother may experience such a sense of closeness to her baby, fulfillment, and motherliness that this becomes the primary reason she continues to nurse.
Olds (2001) discussed that it is important to teach the mother comfortable positions for feeding her infant and to coach the parents in their responses to their newborn’s cues as needed. Before feeding, the mother should be made as comfortable as possible. Preparations may include voiding, washing her hands, and assuming a position of comfort. Rooming-in offers spontaneous, frequent encounters for the family and provides opportunities to practice handling skills, thereby increasing confidence in care after discharge. It also encourages feeding in response to cues from the baby, rather than feeding by a fixed schedule.
The best preparation for maintaining lactation after return to work is frequent, unlimited breastfeeding and enjoying the baby. Rosdahi (2000) reported that because it is so widely recognized that breastfeeding is the best nutrition for human infants, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have launched a Baby-Friendly Hospital initiative. This initiative suggests ten steps that, if adapted by all hospitals, would create an atmosphere conducive to breastfeeding success as follows: Establish a written policy supporting breastfeeding that is routinely communicated to all health care personnel. – Educate all health care staff in skills necessary to implement this policy. – Inform all pregnant women about the benefits and management of breastfeeding. – Help women initiate breastfeeding within half and an hour of birth. – Show mothers how to breastfeed and how to maintain lactation even if they should be separated from the infant. – Give newborn infants no food or drink other than breastmilk unless medically indicated. – Practice rooming-in (i. e. allow mothers and infants to remain together) 24 hours a day. – Encourage breastfeeding on demand. – Give no pacifiers to breastfeeding infants. – Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from delivery center or hospital. Breastmilk provides numerous health benefits to both the mother and infant: a) breastfeeding may serve as a protective function in preventing breast cancer, b) the release of oxytoxin from the posterior pituitary aids uterine involution; and, c) successful breastfeeding can have an empowering effect because it is a skill only women can master.
Breastmilk contains secretors immunoglobulin A (IgA), which binds large molecules of foreign protein, including viruses and bacteria, and keeps them from being absorbed through the gastrointestinal tract of the infant. Pilliteri (2006) discussed: as the average post-partal hospital stay ranges for only 1 to 2 days, a mother has very little time to become acquainted with her newborn before going home. If the infant says in the room with her (rooming-in) rather than in a central nursery, she can become better acquainted with her child and begin to feel more confident in her ability to care for him or her after discharge.
She revealed that: “Not only does rooming-in allow mother-child and father-child relationships to develop rapidly, but a couple also tends to retain anticipatory guidance and instructions in newborn care better because a nurse demonstrated bathing, feeding, changing and so forth on the child. ” Sizer (2001) revealed that as the time of childbirth nears, a woman must decide whether she will feed her baby with breastmilk or formula. Before she makes her choice, she should be aware of the things about breastfeeding. She discussed why breastmilk is good for babies: Breastmilk is tailor-made to meet the nutrient needs of the human infant, its carbohydrate is lactose, and its fat provides a generous portion of the essential omega, fatty acid, linoleic acid and its products. In addition, a mother who consumes food in omega-3 fatty acids will pass these beneficial nutrients on to her child through breastmilk”. The protein of breastmilk is especially digestible and useful to infant growth. Breastmilk contains fat-digesting enzymes that help ensure efficient absorption by the infant.
Breastmilk also conveys information to the infants about its environment by way of antibodies, whole proteins, and other constituents. According to Florence Murphy, Breast Feeding Your New Baby (January 6, 2006). Breastfeeding is Natural. Babies need to eat often, every 90 minutes to two hours. Feed your baby when she begins to show signs of hunger, such as rooting or sucking on her lips, fingers or fist. Try to feed her before she cries. Feeding your baby often won’t spoil her. It will help you learn to become more aware of your baby’s needs. Don’t limit feeding times.
Babies need different amounts of food at different times of the day, just as grown people do. Breastfeeding is natural, but it takes a little time for babies and mothers to learn what works best for them. You may have sore nipples when you first start breastfeeding. The pain can be reduced if your baby is held properly when attached to the breast. Jernstorm, H. says “Breast-feeding and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers mutation carriers. “J National Cancer Institutes 2004, have shown that women who breastfeed have lower risks of developing breast cancer.
Recently, data from 47 studies in 30 countries was re-examined. The group concluded that the incidence of breast cancer in developed countries could be reduced by more than half if women had the number of births and lifetime duration of breastfeeding that have been common in developing countries until recently. According to the analysis, breastfeeding could account for almost two-thirds of this estimated reduction in breast cancer incidence. According to Young, T. K. et al. Type two Diabetes Mellitus in Children, Arch Pediatric Adolescence Medical Book 2002.
There are many studies linking development of insulin dependent Type one diabetes (formerly referred to as “juvenile diabetes”) to lack of breastfeeding. The result of a study from Finland suggest that the introduction of dairy products at an early age, and high milk consumption during childhood increase the level of cow’s milk antibodies in the children’s systems. This factor is associated with an increased risk of insulin dependent diabetes. Now a new study has indicated that breastfeeding in infancy may help reduce the risk of Type two diabetes.
This sort of diabetes was formerly referred to as “adult onset” diabetes, but has been mysteriously occurring in more and more youngsters. According to Beltran “Ecological Study of Effect of breastfeeding on infant mortality in Lantin America. “ Br Med J 2001, Numerous studies have shown that diarrheal infections are much more common in formula-fed babies. This is true throughout the world, despite a common misconception that only people living in areas with contaminated water need be concerned with this issue.
Such infections are more likely to be fatal in developing nations, but all formula –fed infants are at greater risk that their breastfed peers. According to Oddy, WH (2003), “Brest feeding and respiratory morbidity in infancy: a birth cohort study” Archives of Disease in childhood 2003, Breastfeeding effectively protects nursling from amny life-threatening respiratory infections including those caused by rotaviruses. Studies have shown breastfed babies are less than half likely to be hospitalized with pneumonia or bronchitis, and have one-fifth the number of lower respiratory tract infections compared to formula-fed infants.
According to the meta-analysis of studies from developed countries, the risk of severe respiratory tract illness resulting in hospitalization is more than tripled among infants who are not breastfed, compared with those who are exclusively breastfed for four months. According to Updegrove, K “Necrotizing Enteroclolitis. The evidence for use of milk in prevention and treatment. ” J Hum Lact 2004, This disease occurs most commonly in premature or sick newborns. In NEC the lining of the intestinal wall dies and sloughs off.
Premature infants fed their own mother’s milk or banked human milk are one sixth to one tenth as likely to develop NEC. One of the Australian study estimated that 83% of NEC cases may be attributed to lack of breastfeeding. The article of Martin RM “Does Breast-Feeding in Infancy Lower Blood Pressure in Childhood? ”. American Journal of Epidemiology 2005, a 2004 study of 4763 British children showed that 7. 5 years later, those who were breastfed as infant had lower blood pressure compared with those who were never breastfed. In another new study from the U. K. a small but important reduction in adult diastolic blood pressure is associated with having been breastfed as an infant. Foreign Studies Marandi (2000) conducted a study about the reasons for early weaning among mothers in Tehran. He interviewed 900 mothers using a systematic randomized sampling method. a total of 15 percent of the mothers were illiterate, 93 percent were housewives and 97 percent had given birth in hospitals. Only 39 percent of the newborns benefited from rooming-in facilities in hospital, and 68 percent were bottlefed while still in hospital.
In 3. 1 percent of cases the mother had not breastfed her newborn at all. Of those who had breastfed their infant, 38 percent used only their own milk, whereas 62 percent used a combination of breastmilk and infant formula. The median duration of breastfeeding was 16 months (mean, 14 months). a total of 74 percent of mothers who used supplementary formula and 39 percent of those who had completely stopped breastfeeding blamed milk insufficiency, although 67 percent of these mothers had reached this conclusion only because their infants cried or were irritable.
The study revealed that the following factors had their negative influence on the duration of breastfeeding use of supplementary formula and of estrogen-containing contraceptives; fathers with high incomes; and mothers with a high educational level. In contrast, the mother’s religious motive to breastfeed and her insistence on breastfeeding had a positive impact. Unfortunately, 21 percent of the mothers started using supplementary formula during the first month postpartum and two-thirds before the end of the fourth month. Every month that bottle feeding was started prematurely shortened the duration of breastfeeding by 20 days.
On the average breastfeeding was initiated 42. 5 hours postpartum and for more than 70 percent of mothers who breastfed, 20 hours or more after delivery. According to Jenny Sigler of Pregnancy and Parenting Writer of Breastfeeding: Seven Things You Might Not Know (2006). Breastfeeding is the perfect for the growing baby, full of nutrients, antibodies, and a perfect balance of fat and calories. Nursing can also be a rewarding and healthy experience from mom too. Here are seven other facts that you may not have heard about breastfeeding, including its benefits, complications, and protective laws:
Fact # 1: Breastfeeding may reduce your risk of developing breast cancer. Fact # 2: Your breast size has nothing to do with the amount of milk you can produce. Fact #3: Nursing mothers are protected by United States Laws. Fact #4: Breastfeeding can be difficult, even with the best intentions. Fact #5: Your baby can smell the unique sent of your breast milk. Fact #6: Your breasts will be ultra sensitive and responsive. Fact #7: The inability to produce enough milk for your baby is rare. According to The Breastfeeding Book, Copyright 2000, M. Sears, R. N. and Wm.
Sears, Nursing mothers often joke about falling asleep on the job. The sleep inducing qualities of nursing a baby are remarkable. Infact, some new mothers have to be careful to hold a nursing baby in such away that they will not drop the child when they inevitably nod off. Nursing in bed is a great solution. Even pumping at work can be a great way to calm down and get refocused during a stressful day. All this relaxation is caused by the hormone oxytocin, which is released each time a mother breastfeeds. It decreases blood pressure and calms the mother.
Interestingly, one study found that there were far fewer incidences of domestic violence and sexual abuse in breastfeeding families. According to A. A. P. Breastfeeding Policy Statement: Breastfeeding and the Use of Human Milk Pediatrics Vol. 115 No,2 February 2005, “Human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding. Exclusive breastfeeding is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.
In addition, human milk-fed premature infants receive significant benefits with respect to host protection and improved developmental outcomes compared with formula-fed premature infants. Pediatricians and parents should be aware that exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life and provides continuing protection against diarrhea and respiratory tract infection.
Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child. Martinez (2001) conducted a study on breastfeeding among the urban-poor in southern Brazil which revealed that breastfeeding practices over the first 6 months of life among a cohort of urban poor infants in southern Brazil indicated that the median duration of breastfeeding was 18 weeks, and at 6 months 41 percent of the infants were still being breastfed.
The duration of breastfeeding was significantly associated with the following: the infant’s sex, mother’s color, type of first fed, timing of the first breastfed, breastfeeding regimen and frequency of breastfeeding at 1 month, and the use of hormonal contraceptives by the mother. Dissatisfaction with their infant’s growth rate was the most frequent reason given by mothers for supplementing the diets of infants who were exclusively breastfed in the first 3 months of life. also, the mother’s perception that their milk output was inadequate was the most frequent reason expressed for stopping breastfeeding in the first 4 months.
The role sof health services and family support in providing favorable conditions for increasing the duration of breastfeeding in the study population are discussed, as well as the possibility of bias being introduced into studies of the relationship between infant feeding and growth by the effect of the infant’s rate of growth on the mother’s decision to continue breastfeeding. Cousens (2000) findings revealed that either prolonged breastfeeding may offer substantial protection against clinical malnutrition in the study population or malnutrition leads mothers to stop breastfeeding.
These results are inconsistent with those of a number of workers who have reported that prolonged breastfeeding is associated with an increased risk of malnutrition. This inconsistency might have arisen because of differences in the definition of malnutrition used or because of variations in the quantity and quality of weaning foods available in different settings. They found no evidence to support the hypothesis that prolonged breastfeeding may be detrimental to children. Local Literature
Breastfeeding researches done by Filipino health workers especially pediatricians reveal certain findings about acceptance or compliance of mothers in the breastfeeding program. One study by Dr. Hyglia Beyer in Celestino Gallares Memorial Hospital 2003, revealed that the initiation of breastfeeding by itself does not assure continuance of good breastfeeding practices and that hospital based efforts may need to be complimented with community based initiative where nurses can help a lot to sustain desirable feeding practice. According to the study of Dr.
Gloria Baens-Ramirez, et. al. (2000), early education on advantages of breast milk versus commercial milk is contributory to improved degree of compliance. “Kangaroo Care at PCMC” by Dr. Ramirez and Company (2001) further revealed that those who practice Kangaroo Care feel more confident in handling tiny premature babies at home since parental participation was maximized early in the management of newborns. This technique according to the study encourages parents to breastfeed their babies for longer period of time. In another study presented by Dr.
Cristina Vince-Cruz (2002), cultures of milk samples show that bacterial growths were higher in milk formulas (artificial or commercial) compared to breast milk by 48 hours incubation. “Alay Gatas Community Project” presented by Dr. Ramirez in August 3, 2001 Convention of Breastfeeding in the Department of Health, Convention Hall was conceived and being implemented in cooperation with selected barangays with the primary purpose of “raising the community consciousness regarding the nursing mother’s important role in promoting the children’s health and nutrition, ultimately shaping the nations future”.
According to Department of Health (DOH), on June 2001, World Health Organization and United Children Emergency Fund jointly launched a global effort known as Baby-Friendly Hospital Initiative (BFHI) to accelerate the promotion and protection of breastfeeding. The BFHI is a major initiative to transform maternity facilities and hospitals, worldwide, into supportive environments where women will find more guidance and encouragement to initiate breastfeeding successfully.
BFHI aims to protect the lives and futures of millions of infants by making breastfeeding a universally supported practice in maternity facilities and hospitals around the world. The minimum criteria for any maternity care facility to be recognized as baby-friendly by international WHO/UNICEF standards is implementation of all Ten Steps to Successful Breastfeeding. In the Philippines, the Department of Health (DOH) has launched an aggressive BFHI programme targeting all regional hospitals and medical centers and provincial hospitals in priority provinces to become baby-friendly by 1992 and still mitigating at year 2000.
To fully implement the BFHI programmed, the DOH has create an Advisory Committee and a Task Force for the BFHI. The Secretary of Health chairs the Advisory Committee and the members include DOH undersecretaries for Hospitals and Facility Services and for Public Health Services, the UNICEF Representative, the WHO Country Representative and representatives from the Philippine Hospital Association, the Philippine Pediatric Society and the Philippine Obstetrical and Gynecological Society.
The current problem of the Philippines in the breastfeeding program is the fact that more and more Filipino mothers are not breastfeeding early enough nor long enough to meet the needs of their infant for good health. Lots of child health problems like diarrhea and pneumonia, allergies, malnutrition and other risks of intellectual, psychological and emotional nature have been observed. According to Dr. Elvira SN.
Barrios, (DOH, 2000), a major concern in the Philippines are hospital obstetricians’ and pediatricians’ practices that undermine successful breastfeeding like giving of “prelacteals” of sugared water and non-rooming-in of mother and baby. The Milk Code or E. O. 51 known as Philippine Code of Marketing of Breast Milk Substitutes (DOH, 1988), is the solution to the aforementioned problems. The code aims to contribute to the provision of safe and adequate nutrition of infants by protection and promotion of breastfeeding and ensuring the use of breast milk substitutes and supplements when necessary.
The code also calls for intensifying of dissemination of information on breastfeeding and proper nutrition as well as the regulation of advertising, marketing and distribution of breast milk substitutes and other related products including bottles and tests. Reported studies by Dr. Perla D. Santos-Ocampo (2000), reveals that for a period of twenty (20) years rural group of mothers showed more consistency and had generally higher percentages. Urbanization caused the decline in breastfeeding and duration was shorter among the educated and working women.
Angara, author of the Rooming in and Breastfeeding Act 1992. He said studies have shown that mother’s milk contains specific nutrients and antibodies which protect babies from illnesses. The 2003 National Demographic and Health Survey indicated that 13 percent of the infants were never breastfed, making the Philippines the lowest country with breastfeeding rate among 56 countries that have conducted a DHS in the past 10 years. It also showed that 39 percent of infants used infant formula milk in their first 12 month of life.
During the orientation seminar on infant and young child feeding strategy held recently at the Manila Hotel, President Macapagal-Arroyo instructed the Department of Health to implement the rooming in and breastfeeding act in coordination with local government units to build breastfeeding support mechanisms in communities. Local Studies Garcia et. al. (2000) found out in their study that among children less than four months only 4. 3 percent were given breast milk exclusively. At the time of the interview, 173 of the mothers had stopped breastfeeding altogether.
Focus group discussions among mothers who practiced exclusive breastfeeding showed that the mothers were advised by the attending physician/obstetrician and were convinced about the importance of exclusive breastfeeding. On the other hand, mothers who did not practice exclusive breastfeeding believed that water is essential to a child who is breastfeed, in addition, mothers who stopped breastfeeding or who gave other milk in addition to breastmilk believed that their milk was inadequate to meet the child’s needs.
The results of the study showed that: Initiation of breastfeeding by itself does not assure continuance of good breastfeeding practices and that hospital-based efforts may need to be complimented with community- based initiatives to sustain desirable feeding practices. Agapito, et. al. (2001) found out in their study that an infant feeding intervention project to promote breastfeeding and improved weaning practices among low-income mothers in Muntinlupa was designed.
Baseline studies were conducted to document and quantify the problems of malnutrition and poor infant feeding practices and to document the determinants thereof especially at the household level. Monthly proportions showed the decline of exclusive breastfeeding without milk or liquids from 34. 7 percent at 1 month to 14 percent at 4 months. 40% were still breastfeeding at 12 months.
Multivariate analysis showed that infant with the following characteristics would spend less time exclusively breastfeeding during the first 4 months of life: 1) infants given artificial milk during the first 48 hours; 2) infants who had a diarrhea episode during the first 4 months; 3) infants who had a working mother (such as for mothers doing informal work and for mothers doing formal work; 4) born outside a government facility (such as for those born at home and for those born in other medical facilities; and, 5) born in households with more time exclusively breastfed.
The duration of breastfeeding was determined by the kind of mild feeding during the first 48 hours (infants given artificial milk at this time ran a risk of stopping breastfeeding much earlier compared to those who did not receive artificial milk), the maternal work status, (if the infant’s mother worked in the formal sector, her risk of stopping breastfeeding was 1. 9 times higher compared to those whose mother was not working and the infant’s birth rank (the risk of stopping breastfeeding increases 1. 1 times for every increase in birth rank). Lapid, et. l (2002), this study, showed that growth failure and subsequent protein-energy malnutrition (PEM) in young children constitute a significant public health problem in many developing countries including the Philippines. almost all studies documenting growth retardation in deprived communities indicate that it begins in the first two or three years of life. In many developing countries, the period when growth faltering is almost pronounced coincides with the weaning process – a time when the nourishment of the infant progressively transfers from breastmilk as the sole source of nourishment to the usual family diet.
Cross-cultural studies of infant feeding document wide cultural variation in practices and beliefs. Breastfeeding was frequently mentioned, but, if the mother was sick or tired, breastmilk was avoided because mothers believed their children would “suck” their illness or tiredness. Giving branded or commercial milk formula like Bonna and Bear Brand was positively perceived by mothers. Baldago and Barlie (2000) revelied in their study that an alarming decline in the prevalence and duration of breastfeeding in the Philippines has been noted, particularly in urban areas.
This has been attributed to difficulties caused by lack of support from close relatives, delivering the baby in a hospital and the pressures of modern urban life. A study aimed to obtain a reliable and objective picture of current infant-feeding practices, with special reference to breastfeeding, in various parts of the world was conducted by world Health Organization. Data was collected by national investigators from families living in economically advantaged urban area, urban-poor areas and rural areas with a traditional way of life.
If showed a large proportion of mothers and five times higher than Swedish mothers. The proportion among the urban-poor mother is also higher than either Hungary or Sweden. Breastfeeding is facilitated and sustained by the rooming-in policy which has been found beneficial because it provides the breastfeeding problems and allowed less work for the ward staff as it enables them to care for both mother and baby in one setting. The same setting also allowed health teachings, especially to first time mothers, how to properly breastfeed and care for the newborns.
Gonzales (2002) reported that for mother and child, every healthy love affair eventually grows while the fetus is still in the womb but breastfeeding fosters more and loving relationship between mother and baby. It brings to mother a unique and intimate contact with her child, its way of looking, its smell and is response all evoke maternal behavior and reinforce her developing feelings of motherhood. As the baby grows, breastfeeding proves rewarding and deeply satisfying for the mothers. It is quite simply but certainly, breastfeeding is now an endangered practice around the world.
Babies are being born into unfriendly environments, victims of widespread poverty, rapid urbanization and relentless marketing of breastmilk substitutes. Baby-Friendly Hospital “rooms-in” newborn babies with their mothers immediately after birth to make sure that breastfeeding and mother-child bonding are immediately established. Rooming-in provides immediate contact between the mother and newborn. After the first feeding of the baby, the mother is brought to the ward while the newborn is washed, after which the baby is brought to her mother. This rooming-in insures that the mother will be able to breastfeed.
This rooming-in policy insures that the mother will be able to breastfeed. Really there is no substitute for a mother’s milk. Tacio (2001) reported “Human milk, according to the United Nations health agency, is more than a simple collection of nutrines. ” It explains: “Mother’s milk is a living substance of great biological complexity that not only provides unique protection against disease, but also stimulates the baby’s own immune system”. But despite the benefits derived from breastfeeding, the practice keeps on declining in many countries.
UNICEF reports that breastfeeding is now an endangered practice – not only in developed countries but in developing countries as well. He revealed that if only all mothers breastfed their newborns, the world would save some US $16 billion annually. This is the amount mothers spend to feed babies with infant formulas. annual expenditures for the importation of breastmilk substitutes is estimated at US #29 million each in Thailand, the Philippines, Columbia and Ethiopia, $50 million in Nigeria and $70 million in Brazil.
In February, 1992, the first found assessment of hospitals was conducted by the DOH and UNICEF using the global BFHI Hospital Assessment Criteria. Last June 10-120, 1992, the second round assessment was conducted and results shown eighteen hospitals baby-friendly and three hospitals to be given certificates of commitment. Leyba (2000) conducted a study on the implementation of breastfeeding in rural and urban areas revealed that breastfeeding implementation is declining nowadays since it has only an average percentage of 34. 16 percent both in rural and urban areas. It did not even each the 50 percent or more. Breastfeeding method assumed greatest importance among the depressed rural families since they cannot afford much to buy those marketed formula milk and they still believe on the traditional practices. Urban poor families implement more the bottlefeeding and the combine method since they need to work for a source of living. rural communities highly implement breastfeeding while urban communities prefer the bottlefeeding or combine method.
Modernization and urbanization affect the progress in breastfeeding implementation. Most educated mothers implement the partial breastfeeding and bottlefeeding because they want to participate most actively in the modernization process and are most anxious to identify themselves with modern lifestyle. WVI’s Dr. Ram (http:www/medoserver. com/may2000/devcore. html) mentioned several reasons why breastfeeding is on decline around the world. He cites: – Intensive and aggressive promotion of artificial feeding by the formula industry; Ill-formation among health-care workers; – Women’s lack of self-confidence and lack of information about breastfeeding; – Emergence of feeding bottles as a status symbol; and – Giving out of free samples of infant formula to hospitals and maternities. As presented in the International Herald Tribune – Asia Pacific by Carlos Conde (July 17, 2007), in the Philippines, the proportion of babies who were exclusively fed on breast milk in their first six months dropped from 20 percent in 1998 to 16 percent in 2003. Throughout Southeast Asia, only 61 ercent of women breast-fed their babies up to four months and 35 percent to six months, according to the World Health Organization, or WHO. Other health officials are concerned that, while infant mortality rates remain high, the benefits of breast milk, such as enhanced immunity for the child, are being lost. To encourage breastfeeding, the Philippine government enacted a Milk code in 1986 that regulates the marketing formula. The code bans advertisements and other promotional activities for formula intended for babies up to 2 year old.
Last year, the Philippine Department of Health, concerned about the steady decline in breast-feeding and arguing that formula companies had been violating marketing regulations, revised the code, extending the promotion ban to milk substitutes fro children up to 2 years old Synthesis of the Study According to the Department of Health (DOH), the World Health Organization and the United Children Emergency Fund jointly launched global efforts known as Baby-Friendly Hospital Initiative (BFHI) to accelerate the promotion and protection of breastfeeding.
The BFHI is a major initiative to transform maternity facilities and hospitals, worldwide, into supportive environments where women will find more guidance and encouragement to initiate breastfeeding successfully. The minimum criteria for any maternity care facility to be recognized as baby-friendly by international WHO/UNICEF standards is implementation of all Ten Steps to Successful Breastfeeding.
In the Philippines, the Department of Health (DOH) has launched an aggressive BFHI programme targeting all regional hospitals and medical centers and provincial hospitals in priority provinces to become baby-friendly. Breastfeeding is facilitated and sustained by the rooming-in policy which has been found beneficial because it provides the early identification of breast feeding problems and allowed less work for the ward staff as it enables them to care for both mother and baby in one setting.
The same setting also allowed health teachings, especially to first time mothers how to properly breastfeed and care for the newborns. Rooming-in offers spontaneous, frequent encounters for the family and provides opportunities to practice handling skills, thereby increasing confidence in care after discharge. It also encourages feeding in response to cues from baby, rather than feeding by a fixed schedule. Rooming-in provides immediate contact between the mother and newborn.
Baby-Friendly Hospitals “room-in” new born babies with their mothers immediately after birth to make sure that breastfeeding and mother-child bonding are immediately established. After the first feeding of the baby, the mother is brought to the ward while the newborn is washed, after which the baby is brought to her mother. The average post-partal hospital stays ranges for only 1 to 2 days, Pilliteri discusses that a mother has very little time to become acquainted with her newborn before going home.
If the infant stays in the room with her (rooming-in) rather than in a central nursery, she can become better acquainted with her child and begin to feel more confident in her ability to care for him or her after discharge. She revealed that not only does rooming-in allow mother-child and father-child relationships to develop rapidly, but a couple also tends to retain anticipatory guidance and instructions in newborn care better because a nurse demonstrated bathing, feeding, changing and so forth on the child. Rosdahi reports ten steps suggested by the BFHI aiming to create an atmosphere conducive to breastfeeding success.
It is as follows: (1) establish a written policy supporting breastfeeding that is routinely communicated to all health care personnel; (2) educate all health care staff in skills necessary to implement this policy; (3) inform all pregnant women about the benefits and management of breast feeding; (4) help women initiate breastfeeding within half and an hour of birth; (5) show mothers how to breastfeed and how to maintain lactation even if they should be separated from the infant; (6) give newborn infants no food or drink other than breast milk unless medically indicated; (7) practice rooming-in (i. . allow mothers and infants to remain together) 24 hours a day; (8) encourage breast feeding on demand; (9) give no pacifiers to breastfeeding infants; (10) foster the establishment of breastfeeding support groups and refer mothers to them on discharge from delivery center or hospital. Therefore the need to evaluate nurses in the Philippine National Police General Hospital whether they are non uniformed police nurses or uniformed police officer nurses in compliance with breastfeeding program of government is hereby significant. CHAPTER III RESEARCH METHODOLOGY
This chapter deals with methods utilized, the data-gathering tools for data collection, the subjects of the study and the statistical treatment of data collected. Research Design The researcher utilized the descriptive-normative survey define as to describe the degree of breastfeeding program being implemented in the particular obstetrical departments of the selected government hospital. The specially prepared and pre-tested checklist was utilized to gather data to determine the factors that influence the increase and decrease in compliance to the Breastfeeding Program through the direct supervision by professional nurses in all levels.
Locale and Population The research respondents in assessing the breast feeding after delivery as implemented by the non uniformed police and uniformed police officer nurses of Philippine National Police General Hospital, are ten (10) non uniformed police and ten (10) uniformed police officer ob gyne and neonatal care unit nurses assign in the obstetrical ward randomly selected from Philippine National Police General Hospital in Camp Rafael Crame, Quezon City. Validation of Questionnaire An adviser was also consulted and follows the advised mentioned by the expert.
The prepared checklist administered to the three (3) non uniformed and three (3) uniformed police officer nurses assigned previously in the obstetrical wards. After finding the needed improvement the final questionnaire was submitted to the adviser for final checking. The respondents of the trial survey was not included in the tabulation of data. Data Gathering After making and improving the questionnaire, a letter of request from the researcher with the permission of the adviser presented in the nursing service of Philippine National Police General Hospital for approval.
The researcher conducts a survey to the required respondents and retrieved it after. Instrument Used The researcher collected data from the list of nurses from nursing office who were assigned on the particular area, followed by randomly selecting the non uniformed and uniformed nurses as respondents, then answering the questions by utilizing a carefully formulated checklist based on the Department of Health’s Standards of the Breastfeeding Program. Statistical Treatment of Data Descriptive statistics was employed in treating the data gathered by the researcher.
The relative frequency and percentage that a specific data represents were computed to achieve the most accurate interpretation of the data. For the purpose of interpreting the mean results on perceptions and effects the reference table below was used: Five Point Rating Scale WEIGHT MEAN RANGEVERBAL INTERPRETATION 54. 20 – 5. 00Highest Compliance 43. 40 – 4. 19Very High Compliance 32. 60 – 3. 39Moderate Compliance 21. 80 – 2. 59Low Compliance 11. 00 – 1. 79Zero Compliance The following are the formula used in this study: 1. Percentage. In computing for the percentage, the researcher will use the formula: here: P = representing the percentage F = representing the frequency N = representing the total number of respondents 2. Weighted Mean. This will be used to evaluate for the mean perception. Weighted Mean = where: x ¬- number of cases in consideration W – the assigned weights ? – the symbol which indicates summation operation 3. T-test. This will be used to test for a significant ………. t = where: X1 = means of 1st group X2 = means of 2nd group n1 = Number of sample of 1st group n2 = Number of sample of 2nd group s1 = Standard deviation of 1st group s2 = Standard deviation of 2nd group . Chapter 4
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA This chapter presents the data collected, including analysis and interpretation. 1. Demographic Profile of the Respondents Table1 Profile of the Respondents PROFILENON-UNIFORMED NURSESPNP NURSES AgeFrequency%Frequency% 46-Above22000 41-4522000 36-40440220 31-35110770 34-3000110 21-251100 0 Gender Male11000 Female99010100 Civil Status Single330330 Married770770 Widow00 0 0 Religion RC880880 INC220220 Born Again00 00 Jehovah’s Witness00 0 0 Educational Attainment BS in Nursing550660 With 18 units MAN110110 With 30 units MAN110 0 0 MAN330330 Doctorate Degree00
Length of Service More than 9 years660550 7 – 9110220 4 – 6220110 1 – 3110110 Less than 1 year00110 Ethnic Origin Luzon990880 Visayas00110 Mindanao110110 Table 1 shows the different demographic profile (age, gender, civil status, educational attainment, length of service and ethnic origin) of the two groups of respondents which are the non uniform personnel (civilian nurses) and uniform police officer nurses in Philippine National Police General Hospital. When the non uniform personnel respondents are grouped according to age, the age bracket 36-40 has the most number of frequencies with four (4) or 40%.
Age brackets 46 and above and 41-45 both has an equal number of frequency which is two (2) or 20%. Also age brackets 31-35 and 21-25 has also the same number of frequency which is one (1) or 10%. For the PNP nurses, majority or 70% of the respondents are ages 31-35, 20% are ages 36-40 while there is only one respondent whose age belong to the 34-30 age bracket. About ninety percent or nine (9) out of the ten (10) non-uniform police are female, while all the respondents in the PNP nurses are female. It can be noted that majority of the respondents in this study are female.
In terms of civil status, both the non-uniform police and PNP nurses have the same number of single and married respondents which are three (3) and seven (7) respectively. When grouped according to religion, both the non-uniform police and PNP nurses have also the same number of Roman Catholic and Iglesia ni Cristo respondents which are two (2) and eight (8) respectively. In terms of educational attainment, 50% of the non-uniform police have a bachelor degree in Nursing. 30% have already finished their Masters Degree while there is one respondent each for the categories with 18 units MAN and with 30 units MAN. For the PNP nurses. 0% have bachelor degree in Nursing while there are three (3) or 30% have already finished their Master Degree. When grouped according to length of service, majority or 60% of the respondents from the non-uniform police have more than 9 years of service, 20% belong to the 4-6 bracket and both 10% for the 7-9 and 1-3 years of service. Half or 50% of PNP nurses have more than 9 years of service, 20% belong to the 7-9 bracket and 10% belong to the 4-6, 1-3 and less than a year bracket. It can be noted that majority of the respondents, both from the non-uniform police and the PNP nurses, are from Luzon having a 90% and 80% respectively. . Degree of Compliance to the Breast Feeding Program (BFP) Table 2 Degree of Compliance to the Breast Feeding Program (BFP) In Terms of Rooming-in Procedure Breast Feeding Program Rooming in ProcedureNon-uniform PolicePNP Nurses WMVIWMVI All well babies shall be breastfed immediately after 2nd stage of labor4. 50Highest Compliance3. 90Very High Compliance All born vaginally without complication roomed in 1 hour after delivery(except when sick)4. 80Highest Compliance4. 30Very High Compliance All born by Cesarean Section without complications roomed in within 4-6 hours after delivery4. 70Highest Compliance3. 0Very High Compliance All roomed in babies breastfed for complicated births rooming-in as soon as medical condition allow. 4. 40Highest Compliance4. 30Highest Compliance AVERAGE WEIGHTED MEAN4. 60Highest Compliance4. 08Very High Compliance Table 2 reveals the degree of compliance to the breast feeding program (BFP) in terms of rooming-in procedure. It can be noted that the Non-uniform police have the highest compliance in all the aspect in this category. To name a few, they roomed in 1 hour after all born vaginally without complication after delivery (except when sick), with a weighted mean of 4. 80 the highest in this category.
They also have the highest compliance in the practice that all born by cesarean section without complications must be roomed in within 4-6 hours after delivery. The PNP nurse have highest compliance in breastfeeding all roomed in babies for complicated births rooming-in as soon as medical condition allow with weighted mean of 4. 30. They also have a very high compliance in the practice that all born by cesarean section without complications must be roomed in within 4-6 hours after delivery. Table 3 Degree of Compliance to the Breast Feeding Program (BFP) In Terms of Feeding Technique Breast Feeding Program
Feeding Technique for Low Birth Weight (LBW) Sick NeonatesNon-uniform PolicePNP Nurses WMVIWMVI 1. ) Pre-terms (22-36 weeks) tube feed immediately with colostrums3. 50Very High Compliance3. 70Very High Compliance 2. ) Asphyxiated infants cannot be fed 24-26 hours and with other complications 2. 1) feed colostrums by tube3. 40Very High Compliance3. 80Very High Compliance 2. 2) oral feeding instituted after critical period3. 70Very High Compliance3. 70Very High Compliance 3. ) Hyperbilirubinemia 3. 1) continue expressed breast milk (EBM) by tube or breastfed at NICU4. 40Highest Compliance4. 10Very High Compliance 3. ) discourage formula supplements4. 40Highest Compliance4. 50Highest Compliance 4. ) Acute illness as fever, URI, diarrhea 4. 1) continue breastfeeding4. 40Highest Compliance4. 00Very High Compliance 4. 2) breastfeeding during maternal illness/certain maternal conditions3. 10Moderate Compliance3. 40Very High Compliance 5. ) Common breast problems- breast engorgement/sore nipples 5. 1) continue frequent breastfeeding round the clock3. 50Very High Compliance3. 50Very High Compliance 5. 2) mothers with mild to moderate medical problems as in diabetes/malaria/heart disease and other3. 00Moderate Compliance3. 40Very High Compliance 5. ) give EBM by cup for mothers who have several illnesses like eclampsia3. 10Moderate Compliance3. 50Very High Compliance 5. 4) select drugs/other medications not contraindicate in breastfeeding. 4. 10Very High Compliance4. 40Highest Compliance AVERAGE WEIGHTED MEAN3. 69Very High Compliance3. 82Very High Compliance Table 3 shows the degree of compliance to the brea