Knowledge and Awareness among mothers regarding exclusive breastfeeding in holy Karbala city / Iraq CURRENT STATUS: POSTED

Background: World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) “Exclusive breastfeeding (EBF)” is explained as “the infant receives only breast milk, no other liquids or solids. Its recommended for the first 6 months of life, and then complementary feeding should be started. EBF helps to reduce child morbidity and mortality from several diseases such as diarrhea, respiratory and /or ear infections and other infectious diseases, shielding lactation women from breast and ovarian cancer. In addition to offers societal economic and environmental benefits, The objective of this study was to assess the knowledge and awareness of exclusive breast feeding among mothers with a child < 2 years of age. Methods : A descriptive cross-sectional study was carried out in Health Directorate of Holy Karbala city. The study consist of (487) mothers how attendant to six Primary Health Care center (PHC). The collected data was done by direct interview with mothers and using a questionnaire form that designed based on the study objectives according to WHO criteria. Data were analyzed by SPSS, descriptive statistics included numbers (N) and percentage (%), and the inferential statistical test was done by using Chi-Square test , P-value was equal or less than 0.05 considered as statistically significant to find for any association between the results variables. Result : A total of 487 participants were included in the study, the rate of response was 92.7%. The highest percentage (66.3%) of study sample were full in the age group (21-30) years, and more than three quarters were lived in urban area. Nearly half of the study sample 47% had primary education and 60% those housewives, and the main source of information being family and friends (84.4%). As an overall assessment, 61.8% of the study sample had good knowledge and awareness about exclusive Breastfeeding, with highly significant differences to education level ,occupation residence of the mother. Conclusion: Over half of the subjects had good knowledge and awareness of exclusive Breastfeeding. And, on the other hand, there was a very significant difference between education level, occupation and mother's residence with a level of knowledge. Background:

3 Breast milk has the full nutritional requirements for health advancement that a baby needs.
Additionally, it is safe and contains antibodies that help protect infants and boost immunity (1) .
Consequently, breastfeeding contributes to reduced infant morbidity and mortality due to diarrhea, respiratory or ear infections and other infectious diseases (2−4) , and for mothers, breast and ovarian cancer risk is reduced (5) . In addition, breastfeeding offers societal economic and environmental benefits (6) . WHO recommends that children be exclusively breastfed for the first six months of life to achieve optimum growth, development, and health. Children should then obtain complementary foods that are nutritionally adequate and healthy when continuing to the breast for up to two years or more (1) . According to WHO and UNICEF "exclusive breastfeeding" is explained as "the 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". Its recommended for the first 6 months of life, and then complementary feeding should be started. Whereas, breastfeeding should continue for 2 years age or beyond (7,8) .
The aim of this study was to assess the knowledge and awareness towards exclusive breast feeding among mothers had a child aged < 2 years and find out any association between mothers and knowledge and awareness and some demographic characteristics.

Methods:
We obtained the ethical and administrative approval on study from the research ethics committee in Karbala Health Directorate. After that, a verbal consent was taken from each mother prior to interview. A cross-sectional study was conducted to achieve the aim of the study. A total of 487 mothers of infants aged (1-24 months) was selected by simple random sampling and direct interviewed during the Period of the study with a response rate of 92.7%. The sample consist of, the mothers who attended six of primary health care (PHC) from Karbala City. Data collected by direct interview with mothers and using a questionnaire form that designed based on the study objectives.
The collected data were analyzed by SPSS. The descriptive statistics included numbers (N) and percentage (%) and the inferential statistical test was done by Chi-Square test, P-value was equal or less than 0.05 considered as statistically significant used to test for any relationship between variables with the results.

Results:
Table (1) displayed mother age distribution, the highest percentage (66.3%) was in the age group (21-30) years. Regard to the distribution the type of delivery, this table shows that (80%) of the study sample was vaginal delivery; on the other hand, the distribution of residence, education level and the occupation of the respondents, the majority of readings were (76%), (47%) and (63%) in the urban area, primary school and housewife respectively. As in the field of the knowledge domain, table 2 showed (94%) of mother answered correctly about definition of (EBF), concerning the time of initiation the breastfeeding (92%) of study sample had correct answer, while over (80%) of the participates answered correctly about EBF can be reduce diarrheal, respiratory diseases, decrease hemorrhagic after delivery and helps mothers to get back to their weight before pregnancy quicker. (78.9%), (67.1) and (41.7%) of studied sample answered correctly about exclusive breastfeeding prevent pregnancy for at least one year after delivery, colostrum is the first vaccine for newborn and reduce incidence of ( breast and ovarian cancer for mothers), respectively. According to the relationship of knowledge among lactating mothers and the demographic characteristic, not significant with the age of mother (P.value > 0.05), while the association was found to be statistically significant for each of (Type of delivery, Residence, Education level of mother and Mothers occupation) (P.value < 0.05) as shown in table (3). Discussion: It is very important for all members of the community to understand the importance of EBF for every mother and her baby, for that we assess the knowledge and awareness towards exclusive breast feeding among mothers had a child aged < 2 years in Karbala city.
Regarding the distribution the type of delivery, more than three quarters of the sample 79.3% had vaginal delivery " Normal delivery " that similar to AL-Abedi, N. et al in AL-Najaf City 74% (10) , on the other hands regarding residency, education level and occupation of the participates, most of the results 76%, 47%, and 63% were from urban area, had primary school and housewife, respectively, that also agreed with AL-Abedi, N. et al (2016) and Joshi, S. in Navi Mumbai, Where they recorded their results as 28.7%, 30% and 94%, 70% for primary school and housewife (10,11) .
Concerning to knowledge of mother about exclusive breastfeeding, table 2 showed that differences of answered as correctly about the questions, 94% of mothers answered correctly about the definition breast milk and 92% having good awareness towards initiation of exclusive breastfeeding this was similar to other reported study in Navi Mumbai (11) and Sana'a City (2018) by Dallak, A. et al (12) .
This table also indicates that more than three-quarters of participants were fully aware of exclusive breastfeeding through, decrease hemorrhagic after delivery, helps mothers return to their prepregnancy weight and prevent pregnancy for at least one year after delivery. While there was defect ( incorrect answers 58.3%) of study sample knowledge towards reducing the death rate from the breast and ovarian cancer. As overall assessment, figure (2) reveal 61.8% of the objects had good knowledge, its agreement with the study done by AL-Abedi, N. et al 71% (2016) and Mbada, et al., (2013) " they reported that overall assessment was good " (13) .
Result in (Table 3) refers to an important relationship between mother's awareness and occupational status that is could be due to, housewives are more committed to breastfeeding than female stated that a non-significant difference among mother's occupations and the knowledge level (14), (15), (16) .
For the educational level, there was a highly significant relationship with EBF, its match with the study done by Al-Hially (17) , (2010), who reported that there is a significant relationship between mother's education and awareness for breastfeeding, this might be that the " educated mother has better knowledge about breastfeeding more than an uneducated mother".
Mentions that there was a significant correlation between knowledge and delivery type, this can be because natural births are more likely to produce breast milk than cesareans, this result was similar to AL-Abedi, N. et al (10) . On the other hand, there was a non-significant relationship with Age groups, its disagree with AL-Azzawi, etal.,(2010), who stated that was a significant indicator between age of the mother and knowledge about EBF (18) .
Finally, figure (2) reveals the source of information of the study sample about EBF, the study indicates that the highest percentage 84.4% of participates in this study were received education about exclusive breastfeeding was from family and friends, " Since the majority of participated mothers had primary education, these low educational levels make them incapable to understand and comprehend the educational information in pamphlets, posters, and advanced media. So, they need to be educated about breastfeeding directly from family, friends or health workers, this means that the family plays an important role in successful breastfeeding", its approved with the result do it by Dallak, etal.,(2016), who reported that " the majority of the study sample educated by family and friends for exclusive breastfeeding" (12) .

Conclusions:
There is an urgent necessity to provide accurate prenatal education that focuses on methods and long-term benefits for breastfeeding because mothers don't have inadequate awareness of exclusive breastfeeding from where (initiation, colostrum benefits, and breast and ovarian cancer incidence reduction). The study found a highly significant relationship between mother's knowledge and that residence, education level and occupation.

Recommendation:
In spite of good mother Knowledge toward of EBF, but health education programs for breastfeeding promotion should be well planned and address the factors which reinforce and enable breastfeeding and health team members should be properly trained in breastfeeding essentials and communication skills with the mothers especially in this critical period (child aged < 2 years ) in Karbala city.  Figure 2 Distribution the sources of information of study sample.