DISSERTATION PROPOSAL

“A STUDY TO ASSESS THE EFFECTIVENESS OF VIDEO ASSISSTED TEACHING

ON KNOWLEDGE AND PRACTICES OF EXPRESSED BREAST MILK AMONG

POSTNATAL WORKING MOTHERS IN SELECTED HOSPITALS OF HYDERABAD.

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

OBSTETRICS AND GYNECOLOGICAL NURSING

SUBMITTED BY
MRS. ANKITA MANNA
FIRST YEAR MSC NURSING
ESHWARI BAI MEMORIAL COLLEGE OF NURSING
HYDERABAD

DR. KALOJI NARAYANA RAO UNIVERSITY OF HEALTH SCIENCES,

WARANGAL
 DR. KALOJI NARAYANA RAO UNIVERSITY OF HEALTH SCIENCES,
WARANGAL

Performa for registration of subject for dissertation

Mrs. Ankita Manna

1 Name of the candidate
First Year M.Sc. Nursing

Eshwari Bai Memorial College of Nursing,

H.No. 10-1-5/C
2 Name of the institution Road No.4,West Maredpally, Secunderabad -26
Telangana

First Year M.Sc. Nursing 2019-21

3 Course of the study and subject
Obstetrics and Gynaecological

4 Date of admission to course 01-11-2019

“A study to assess the effectiveness of video

assisted aids on knowledge and practices of
5 Title of the topic expressed breast milk among postnatal working
mothers in selected hospitals of Hyderabad,
Telangana”.

6. Brief resume of the intended work.

Introduction
“A healthy baby is a parents’ dream
-and it can be a employer’s dream too.”
(Penny Vant Esteris, 1988)
The importance of breast milk has been accepted since the time of Hippocrates who has
stated that one’s own milk is beneficial. Human milk is unquestionably the best source of
nutrition for neonates or infants by the virtue of uniqueness of its biological composition.
One of the ancient physicians from India in his SAMHITA while describing the
importance of qualities of breast milk said “One just cannot compare even water of seven
seas, with mother’s milk which is nothing but water ensuring optimum growth, nutrition and
healthy life of hundred years.”
From the immemorial time breast feeding has been the only method of feeding in our
country. It is accepted by all Indian mothers and also mothers of tropical countries.
In India it is a common practice to send pregnant women to her mother’s place for her
first delivery. Here she gets advices from her mother, grandmother and her friends, regarding
breast feeding and rearing of the child. Both of them are considered to be vulnerable group.
During this time mother and child are in close contact with each other the mother can give
full attention to the child to meet with its daily needs. There is more skin to skin contact
during this period, which helps in creating maternal and child bond. In the olden times
whenever mother was not in a position to feed her baby, the practice of wet nursing was used
(wet nursing is nursing another women’s baby).
In India from Royal families mostly women were reluctant to feed their babies and
hence they use to deploy wet nurses to feed them rather than depending upon either milk of
cow or buffalo. 5
“The consequences of artificial feed and bottle feed had caused more awareness
amongst the women that breast milk is the best.”
Dedicated members of the health care system have been successful in conveying the message
persistently in the latter 20th century. Though the breast milk is the best; there are many
babies who are not fortunate enough to get it. Expressed breast milk was suggested as
substitute for breast milk.
This necessitated the storage of milk for longer time and making it more widely acceptable
and usable. Doctors and nurses became more concerned in developing this concept and
human milk bank was established in India.
 Considering the nutritional importance of breast milk with built up in host defence
mechanism which is lacking in artificial formula and recent research demonstrating the
metabolic and anti-infective significance of human milk in premature and sick babies the idea
of manual expression of breast milk came into existence to feed the infants who are deprived
of the breast milk due to various reasons.
“Mother of high risk babies run the problems of lactation failure as then babies is not
able to suck the breast. This could be prevented by regular expression of breast milk storing
and utilization of milk.
Milk banks are in existence for more than a century in developed countries for safe guard to
the sick, premature or for postnatal working mother’s infants. The use expressed breast milk
for those infant had made considerable impact on morbidity and mortality of infant.
In India first human breast milk bank was established in November 1989 at Sion
Hospital, Mumbai.
When we trust the makers of baby formula more than we do our own ability to
nourish our babies, we lose a chance to claim the aspect of our power as women. Thinking
that baby formula is as good as breast milk believes that thirty years of technology is superior
to three million years old nature’s evolution. Countless women have regained trust in their
bodies through nursing their children, even if they were not sure first that they could do it. It
is an act of female power, and I think of it as feminism in its purest form. 9
--- Christine Northrup
6.1. Need for the study
Breast milk is the best gift a mother can give her baby. The nutrients which are needed for the
baby like carbohydrate, protein, fat, minerals and vitamins are available in simple form in the
breast milk. Breast feeding is not only the best, but a must for the baby. Human milk is
decidedly superior to other milks. It is remarkably adopted to the requirement of the infant
and provided the best start in life. Breast milk is always available at the proper temperature
and requires no preparation time. Breast milk is the ideal food made for baby. Breast milk
contains a number of protective substances including antibodies, disease resistant factors and
provides protection against infection. Human milk promotes faster development and
maturation. There is evidence to suggest that breastfed babies are less likely to develop
obesity, hypertension, diabetes mellitus and atherosclerosis in later life. Breast fed babies
have better visual development, cognition and IQ score later in life. Infants who breast fed
are less prone to anaemia or vitamin deficiencies. Breast feeding stimulates release of
protective substances in mother’s blood which protects mothers from breast cancer, ovarian
cancer, hip fractures and rheumatic arthritis. A great asset in India is that an average Indian
mother, although poor in nutritional status, has a remarkable ability to breast feed her infant
for prolonged periods, sometimes extending to nearly two years.

Today, a large number of women are going for work to support their family financially.
Women comprise half of the Indian population and account for nearly one-third of the total
work force. The total number of women employed in the organized sector for India as a
whole is 4.42 million. Out of this 41% is accounted for by South India. According to
Registrar General Of India, the work participation rate of women increased from 19.67 % in
1981 to 25.68% in 2001 and became 35.7% in 2008. Increasing number of mothers are
returning to work during the first year of their infant's life. In urban India, women have
impressive number in the work force. As an example, at software industry 30% of the work
force is female. In rural India, agriculture and allied industrial sectors employ as much as
89.5% of the total female labour. In overall farm production, women’s average contribution is
estimated at 55% to 66% of the total labour. According to 1991 world bank report, women
accounted for 94% of total employment in dairy production in India, women constitute 51%
of the total employed in forest-based small scale enterprises.

In India, 50% of women who are employed during their pregnancy return to work
by the time their children are two or three months old. 13 Factors such as weaning in
preparation to return to work, maternal fatigue, difficulty in juggling the demands of work
and breast feeding, may also contribute to shorter duration of breast feeding after returning to
work.11A recent survey conducted on middle class mothers on breast feeding duration and
employment at India showed that the usual duration of breast feeding is significantly shorter
for working mothers, which is 16 weeks on average compared with the 25 weeks for non-
working mothers.

Breastfeeding is the common problem that working mothers face every day.
Feeding the baby with the breast milk may not be possible for the working mothers during
their working hours. Maternal employment has been cited as the major reason for the decline
in breast feeding, as they don’t have 6 months of maternity leave in most working places.
According to a poll by the National Women’s Health Resources, the data shows that the
factors that breastfeeding working mothers face is dependent on factors like their age and
type of job they have. If a mother works in retail, the rate of breastfeeding is lower than those
engaged in an office environment. High levels of stress and fatigue also account for the
decrease in breastfeeding or durations of breastfeeding in working mothers. Other reasons
include difficulty storing and transporting milk, low supply of milk and physical exhaustion.
In India, most of the mothers are unaware of expression and storage of breast milk which
leads to inadequate provision of mother’s milk to the baby resulting in decreased health status
of the child as the mother returns to work.

Women who desired to continue to breast feed when they return to work may face
difficulties, especially if their work sites lack a supportive environment and their work duties
and schedule lack flexibility. Workplace policies and practices are also another cause. Lack of
support and knowledge regarding management of breastfeeding while employed, a non-
supportive work environment, and problems of expressing breast milk are frequently given as
reasons that working women wean early. Believing that expressing breast milk was not
feasible, having negative feelings related to expressing breast milk, and doubting the safety
and hygiene of expressed breast milk also preventing the working women from expressing
their breast milk. The lack of facilities at the workplace also makes expressing breast milk not
feasible for them. The lack of knowledge and poor attitude of employers regarding the
benefits of exclusive breastfeeding for their employees and the company is another reason.

The most prominent problem for working mothers concerns their children. 20.In the
modern urban setting, it is complicated by the increasing tendency of women to work in
situations where they are separated from their infants and depend on the formulated feed.
According to WHO/UNICEF document, at least one million deaths per year from diarrhoea
and infections are absolutely preventable through breast feeding.

Premature cessation of exclusive breast feeding and introduction of formula feed

unnecessarily exposes children to the risk of infection and malnutrition. About 1.4 million
deaths of child aged below two year are due to the sub optimal breast feeding practices. 20%
of the neonatal death can be prevented by enacting exclusive breast feeding. 21 The data
suggest that infant mortality rates in developing countries are 5-10 times higher among
children who have not been breast fed or who have been breast fed for less than 6 months.

In case of mothers who work at far off places, they go for formula feeding when
they are not at home. But studies have suggested that formula feeds are not good for the baby
in the long run. Most of the paediatricians do not recommend formula as they lack all the
immunological back up which is generally present in the breast milk. 16 Healthy People 2010,
the American Academy Paediatrics, and the Department of Health and Human Services
Office on Women's Health all address the importance of supporting breastfeeding mothers
who return to the work force. They recommend providing appropriate facilities and adequate
time for manual expression in the workplace.

As working women is a mother, her major concern is to keep her baby in the best of
his health and she can overcome this situation by feeding the baby with expressed breast
milk. If a mother has to breastfeed her infant successfully during the period of separation, she
must learn the art of breast milk expression and storage. Feeding the baby fresh or stored
breast milk gives the baby the best food to help to grow and be healthy. Therefore mothers
require an adequate knowledge regarding the expression and storage of breast milk.

Mothers who return to work is constantly under the stress as to how to manage
breast-feeding and employment. Believing that expressing breast milk was not feasible,
having negative feelings related to expressing breast milk, and doubting the safety and
hygiene of expressed breast milk preventing them from expressing their breast milk. These,
together with other issues, had influenced to add infant formula to their infants feeding.
Usually these mothers wean earlier and their infants are at the risk of infections. Therefore
mothers require an education regarding the expression and storage of breast milk Along with
this, the various difficulties faced by the employed mothers to continue breast-feeding
initiated the investigator to undertake a study in order to enable the breast-feeding mothers to
make a successful transition to the work place. Therefore the researcher felt the need to assess
the knowledge and attitude and give education regarding techniques of expressing and storing
breast milk among working women with the help of an information booklet.

6.2. Review of literature

Polit and Beck. (2008) defines review of literature “review of published and unpublished
research and non research literature is an integral component of any scientific research. It
involves a systematic identification, location scrutiny and summary of written material that
contain information regarding a research problem.”
According to Boswell, Cannon S. (2007) “Review of literature is a written, analytical
summary of research findings on a topic of interest. It is a comprehensive compilation of
what is known about the phenomenon. The purpose of review of literature to assess the
evidence regarding the research topic by identifying and synthesizing studies that examine
the subjects of interest”.
In view of the present study the related literature review has been made and described under
following headings. Review related to:
1. Exclusive breast feeding.
2. Studies related to breast feeding practices.
3. Expressed breast milk.
4. Breast milk banking.
5. Studies related to breast feeding practices among working mothers
1.Review related to exclusive breast feeding.
Breast milk is the best feed for the baby till the baby is of six months old. Exclusive
breast feeding can save many lives by preventing malnutrition and infections. It is very
essential to impart this knowledge to mothers. Many researches had been conducted which
highlights the importance of Exclusive breast feeding.
Kaur Balwinder (Published 2011) a comparative study was conducted to assess the
knowledge, attitude and practices of mothers regarding breastfeeding in a selected urban and
rural community in Ludhiana, Punjab. The sample size was 100, out of which 50 were from
urban and 50 from rural area. The study findings revealed that rural mothers had more
positive attitude regarding breast feeding irrespective of knowledge regarding breast feeding.
Also according to age and education of the mothers rural mothers with increasing age had
more knowledge, positive attitude and better practices regarding breastfeeding whereas
practices of urban mothers with more education were also better. Similarly the findings of
source of information indicated that books were more effective in increasing breastfeeding
practices among both urban and rural mothers whereas books where the source of
information regarding breastfeeding in urban mothers and media exposure in rural mothers
with regular antenatal checkups had effect on knowledge of mothers regarding breastfeeding
whereas among rural mothers regular antenatal checkups had not shown any effect on the
knowledge of mother regarding breast feeding.
Thus the above study finding interprets that socioeconomic strata, age education influence
breast feeding knowledge and practices.
2. Review related to breast feeding practices:

Mahesh Kumar Mummadi( 2013) A cross sectional study was conducted during May to
October 2013 in the urban slums of Hyderabad Outskirts. Out of four slums two were
randomly selected for the study. The questionnaire was administered to the mothers who had
children less than 3 years of age. A total of 112 mothers participated in the study. Of them
97.3% breast fed their children and 2.7% did not. Breast feeding was initiated within an hour
among 50.89%. Pre-lacteal feeds given in 23.21%. Of them 34.6% gave buffalo milk, 30.8%
gave honey, 19.2% gave sugar water and 15.4% gave infant formula. 83.03% received breast
milk within 24 hrs. 54% practiced Exclusive breastfeeding. 33.1% reported having used
bottle feeding, 10.7% reported having used a pacifier, of them 19.2% had low milk secretion,
3.85% were busy, 61.54% used it to stop the baby crying. Conclusions: Breast feeding
practices were adequate with initiation within one hour was fine which needs to be increased
by promoting importance of breast feeding. Practice of pre- lacteal feeds was high. There is a
marked difference between exclusively breastfed percentage in different parts of India.
3. Review related to expressed breast milk.
Journal of Human Lactation (November 12, 2009) conducted a study in Perth (Australia);
the expression of breast milk allows a mother to be away intermittently from her infant while
continuing to breastfeed. Total 587 mothers were taken out of which 93% of mothers though
after returning to work by the means of expressed breast milk were exclusively breastfeeding
till six months. And rest 7% discontinued by gave reason of less breast milk.
Thus after providing proper knowledge about expressed breast milk, working mothers can
exclusively breast their babies.
4. Review related to breast milk banking.
The Cochrane Library (January 2010) conducted a study to determine the effect of banked
preterm milk compared with banked term milk regarding growth and development outcome
in very low birth weight infant (weighing less than 1500 gm) The study revealed there is no
randomized trials that compare preterm banked milk to promote growth and development in
very low birth weight infant.
5. Review related to breast feeding practices of working women:
A descriptive study was conducted in Karnataka on Knowledge and practice of employed
mothers about breast feeding. A structured interview schedule to determine the knowledge
and attitude and semi-structured interview schedule to determine the practice. The purposive
sampling technique was used to select 60 mothers, working in selected colleges. Analysis
showed that 73% of mothers had knowledge on benefits of breastfeeding. 46.66% of the
sample knew that, the working mother can continue breastfeeding by giving expressed breast
milk to her baby. Only 24% of mothers had knowledge on expression and storage of breast
milk whereas only 1.66% of the subjects had knowledge that expressed breast milk can be
stored at room temperature for a period of six to eight hours. 60% of the mothers expressed
that feeding with expressed breast milk is harmful for the health of the baby. The study
concluded that there is a lack of knowledge in the areas of expression and storage of breast
milk.
Statement of the problem
“A study to assess the effectiveness of information booklet on knowledge and practices of
expressed breast milk among postnatal working mothers in selected hospitals of Hyderabad,
Telangana’’.

Objectives of the study

1. To assess the knowledge of postnatal working mothers regarding expressed breast
milk.
2. To identify the practices regarding expressed breast milk among postnatal working
mothers before administration of information booklet.
3. To compare the knowledge and practices regarding expressed breast milk among
postnatal working mothers after providing information booklet.
4. To associate the demographic variables with the knowledge and practice of expressed
breast milk among postnatal working mothers.
Hypothesis
5. H1: There may be a significant difference in the knowledge and practices regarding
expressed breast milk after providing the information booklet
6. H2: There will be significant difference in the post test score on expressed breast milk
than pre-test score among the postnatal working mothers.
Assumptions
The study assumes that, there will be an increase in the knowledge and practices regarding
expressed breast milk after providing the information booklet.
Operational definitions terms and variables
Assess
In this research study: Assess is to gather information about knowledge and practice
regarding storage and expression of breast milk.
Effectiveness
In this study, effectiveness refers to the extent to which information given in the booklet will

enhance the knowledge of working women regarding techniques of expressing and storing

breast milk which is measured by the difference between pre test and post test scores.

Information booklet :

In this study, information booklet refers to the content which narrates about the techniques of
expressing and storing of breast milk.

Knowledge:

In this study, knowledge refers to the correct responses given by the working women to the
items on techniques of expressing breast milk as measured by the structured knowledge
questionnaire.

Practice:

In this study, practice refers to the customary, habitual, or expected procedure of the mothers
regarding expressed breast milk.

Expressed
In this research study: Expressed refers to squeezing of breast milk.
Postnatal working mothers
According to researcher Postnatal working mothers refer to working mothers after the
delivery in some setting or institution for 6 to 10 hours and babies will be away from them
during this period.

Limitations
This study is limited to postnatal working mothers who are working in some setting or
institution for 6 to 10 hours and babies will be away from them during this period.
Inclusion Criteria:
1. Postnatal working mothers admitted in selected hospitals of the city intended to work
after 45 to 90 days of delivery and their baby will be away from them for 6 to 8 hours.
2. Those who understand English.
Exclusion Criteria:
1. Those who are from medical profession.
2. Those who doesn’t understand English.

Scope of the study

 This study will bring awareness in the working postnatal mothers about expressed breast
milk and its storage.
 Ultimately findings of this study may open avenue for the further studies.
 Findings can be further used for research by the investigator.

Ethical aspects
1. The study proposal was sanctioned by the ethical committee of the college.
2. Permission obtained from the concerned authority of selected hospitals of the city.
3. Study was explained to participant and informed consent was taken from the
participant.
4. Confidentiality of information maintained by utilizing code numbers for sample.

Material and methods

Sources of data: Postnatal working mothers admitted in selected hospitals of Hyderabad
intended to work after 45 to 90 days of delivery and their baby will be away from them for 6
to 8 hours.
Research design: Pre experimental one group pre-test and one group post-test design
Setting: selected area, Hyderabad
Population: the population comprises of all the: Postnatal working mothers from a selected
areas of Hyderabad, who intended to work after maternity leave (45 to 90 days)
Research approach: - The present study was aimed at determining the effectiveness of
information booklet on knowledge and practices of expressed breast milk among postnatal
working mothers in selected hospitals of the city.
The research methodology adopted for the study was an evaluative approach. A quasi
experimental consisting of one group pretest, posttest design was selected by the investigator.
The study was divided into three phases.
Phase – I:Pre-test i.e. assessing existing knowledge and practice of postnatal working
mothers.
Phase – II: Providing information booklet on expressed breast milk.
Phase – III: Post-test i.e. assessing knowledge and practice of postnatal working mothers
regarding expressed breast milk on fifth day after providing information booklet.
The purpose of the evaluative research is to measure the effect of a programmed against the
goal it sets out, which contributes to subsequent decision making about the programmed and
improving future programming.
Here the investigator identifies, describes and evaluate the effectiveness of information
booklet on expressed breast milk by using self structured questionnaire and observation
checklist.

Method of collection of data

A structured questionnaire will be used for data collection. The study will be conducted after
obtaining permission from the concerned authority
Sampling procedure: purposive sampling – is a non probability sampling technique
Sample size: 30 Postnatal working mothers
Sampling technique: Non probability, purposive sampling technique.

Research methodology
Development of tool: The self structure questionnaire includes two parts:
Part-I: Includes demographic data.
Part –II: Includes structured questionnaire.
A) Knowledge regarding expressed breast milk.
B) Practices regarding expression of breast milk.
Data analysis: A descriptive and inferential statistics will be used.
The collected data will be coded, tabulated and analyzed by using descriptive statistics
(mean, percentage and standard deviation) and inferential statistics. Significant difference
between pre test and post test reading was tested by using paired t test; association of
knowledge and practice with demographic variables was done by one way ANOVA test.60
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