Breastfeeding is a fundamental component of child survival, growth, and development, and is universally recognized as the optimal method of infant feeding. Exclusive breastfeeding (EBF), defined as feeding infants only breast milk for the first six months of life without any additional food or drink, plays a crucial role in reducing infant morbidity and mortality. It provides complete nutrition, enhances immunity, and protects infants from common childhood illnesses such as diarrhoea and respiratory infections [1]. In addition, breastfeeding offers multiple benefits to the mother, including reduced risk of postpartum hemorrhage, faster uterine involution, and long-term protection against breast and ovarian cancers [2].

Globally, despite strong recommendations, the prevalence of exclusive breastfeeding remains suboptimal. Various socio-cultural, economic, and healthcare-related factors influence breastfeeding practices. In low- and middle-income countries, inappropriate feeding practices contribute significantly to infant morbidity and mortality [3]. In India, although awareness regarding breastfeeding has improved over the years, gaps still exist between knowledge and actual practice, especially in rural and socioeconomically disadvantaged populations [4].

Knowledge regarding breastfeeding among mothers is a key determinant influencing infant feeding practices. Studies have shown that mothers who are well informed about the benefits of exclusive breastfeeding are more likely to initiate and continue appropriate feeding practices [5]. Awareness regarding early initiation of breastfeeding, importance of colostrum, avoidance of prelacteal feeds, and duration of exclusive breastfeeding significantly impacts infant health outcomes. However, misconceptions such as the need for supplementary feeds, influence of maternal illness, and cultural beliefs often hinder optimal practices [6].

Attitude towards breastfeeding is another important factor that shapes maternal behavior. Positive maternal attitudes, including the belief that breastfeeding is beneficial, convenient, and sufficient for infant nutrition, are associated with higher rates of exclusive breastfeeding [7]. On the other hand, negative perceptions, social stigma related to public breastfeeding, and concerns regarding work-related constraints may lead to early discontinuation or mixed feeding practices [8].

In addition to knowledge and attitude, actual breastfeeding practices are influenced by multiple factors such as maternal education, socioeconomic status, parity, mode of delivery, and support from healthcare professionals and family members. Early initiation of breastfeeding within the first hour of birth, correct positioning and attachment, and continued feeding during illness are essential components of good breastfeeding practices [9]. However, studies have consistently reported that even when knowledge and attitude are adequate, practices may still be suboptimal due to lack of support, guidance, or cultural influences.

Several studies have highlighted the gap between knowledge and practice, emphasizing the need for continuous education and reinforcement through healthcare systems. Antenatal counseling, postnatal support, and community-based interventions play a critical role in promoting optimal breastfeeding practices. Healthcare professionals are often the primary source of information for mothers, and their guidance significantly influences maternal behavior and adherence to recommended practices [10].

Given the importance of exclusive breastfeeding and the factors influencing its adoption, assessing the knowledge, attitude, and practice (KAP) among postnatal mothers becomes essential for identifying gaps and planning targeted interventions. Therefore, the present study aims to evaluate the knowledge, attitude, and practice towards exclusive breastfeeding among postnatal mothers attending a tertiary care hospital, thereby providing insights into existing practices and areas requiring improvement.

The present study aims to assess the knowledge, attitude, and practice regarding exclusive breastfeeding among postnatal mothers attending a tertiary care hospital. The specific objectives include evaluating the level of knowledge about exclusive breastfeeding, assessing maternal attitudes towards breastfeeding practices, and determining the extent of adherence to recommended breastfeeding practices, along with identifying associated sociodemographic factors influencing these domains. Despite widespread awareness programs, a gap often exists between knowledge and actual practice of exclusive breastfeeding, which may adversely affect infant health outcomes; hence, this study is justified to identify these gaps and provide evidence-based insights for strengthening counseling and educational interventions. The findings of this study are expected to help in designing targeted health education strategies, improving breastfeeding practices, enhancing maternal and child health outcomes, and contributing to policy formulation and program implementation aimed at promoting exclusive breastfeeding at both community and institutional levels.

MATERIALS AND METHODOLOGY

This study was conducted as a hospital-based observational cross-sectional study at a tertiary care hospital affiliated with a medical college. The study was carried out over a period from April 2023 to July 2024. A total of 335 postnatal mothers were included in the study based on predefined inclusion and exclusion criteria.

Postnatal mothers of infants aged 1 to 6 months attending the pediatric (well-baby clinic), immunization clinic, or obstetrics department were included. Mothers of babies with severe congenital malformations, history of prolonged NICU stay of more than 7 days, preterm babies (<37 weeks), and conditions where breastfeeding was contraindicated were excluded.

The sample size was calculated using the formula n = (Z² × p × (1−p)) / L², where Z = 1.96 at 95% confidence interval, p = 68%, and allowable error (L) = 5%, yielding a minimum sample size of 335. Participants were enrolled using purposive sampling.

Data were collected using a predesigned and prevalidated proforma that included sociodemographic details such as maternal age, education, occupation, socioeconomic status, residence, gravida, mode and place of delivery, birth order, and infant characteristics. A structured questionnaire was used to assess knowledge, attitude, and practice (KAP) regarding exclusive breastfeeding. The questionnaire was administered in the local vernacular language for better comprehension.

The knowledge domain consisted of 12 questions with true/false responses, each correct answer scoring one mark (range 0–12). Scores <4 were considered poor, 4–8 average, and >8 good knowledge. The attitude domain included 10 questions assessing positive or negative perceptions, and the practice domain included 14 questions evaluating breastfeeding practices. Wherever applicable, practices were verified by direct observation.

Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC) of the concerned institution prior to commencement of the study. All participants were provided with a participant information sheet in their native language, and written informed consent was obtained. Confidentiality and privacy were maintained throughout the study.

Data collection was carried out after obtaining IEC approval. Eligible participants were enrolled purposively, and data were recorded using the structured proforma.

Data entry and analysis were performed using Epi Info (CDC) version 7. Continuous variables were expressed as mean ± standard deviation, and categorical variables were presented as proportions and percentages. A p-value of <0.05 was considered statistically significant.

RESULT

A total of 335 postnatal mothers were included in this study. The majority of mothers belonged to the age group of 26–30 years (47.8%), followed by 20–25 years (36.4%), while mothers below 19 years constituted the smallest proportion (3.6%). Most participants were homemakers (69.6%), and a large proportion had primary level education (45.4%), with only 13.1% educated up to graduation and above. Socioeconomically, the majority of mothers belonged to Class III (45.4%) and Class IV (34.3). Most participants were from urban areas (73.7%). More than half of the mothers were multigravida (56.1%), and most deliveries were normal vaginal deliveries (62.7%), with nearly all deliveries occurring in hospitals (98.2%). First-born children constituted the largest group (43.9%), and female babies slightly outnumbered males (54.3%).

In the knowledge domain, overall awareness regarding exclusive breastfeeding was high, with most mothers demonstrating correct knowledge regarding key aspects such as early initiation of breastfeeding (95.2%), importance of colostrum (89.0%), its role in immunity (91.6%), and protection against illness (98.8%). Knowledge regarding continuation of breastfeeding up to two years (92.5%) and avoidance of bottle feeding (87.2%) was also good. Overall, 86.0% of mothers had good knowledge scores, while 14.0% had average knowledge, and none had poor knowledge.

Regarding attitude, a predominantly positive attitude towards exclusive breastfeeding was observed among the participants. A large proportion of mothers believed that exclusive breastfeeding is beneficial (95.2%) and sufficient for the first six months (87.5%). Most mothers agreed that breastfeeding is more convenient (87.8%), easily digestible (86.0%), and results in healthier babies (91.3%). Additionally, 78.8% believed that breastfeeding is feasible for working mothers, and 77.0% supported breastfeeding in public. Overall, 93.1% of mothers demonstrated a positive attitude, while only 6.9% had a negative attitude.

In the practice domain, breastfeeding practices were generally satisfactory but slightly lower compared to knowledge and attitude levels. Most mothers (84.8%) provided colostrum and avoided prelacteal feeds. Exclusive breastfeeding was practiced by 80.0% of mothers, and early initiation within the first hour of birth was observed in 86.9% of cases. Proper positioning and attachment were practiced by approximately 87–88% of mothers. However, 20.0% of mothers reported giving top feeds, and 13.7% introduced complementary feeding before six months. Breastfeeding during infant illness (96.1%) and maternal illness (91.0%) was widely practiced. Overall, 59.7% of mothers demonstrated good practice, 39.7% had average practice, and only 0.6% had poor practice.

In summary, the study revealed that while knowledge (86.0%) and attitude (93.1%) towards exclusive breastfeeding were high among postnatal mothers, actual practices were comparatively lower, with good practice observed in 59.7% of participants. This highlights a gap between knowledge and implementation, emphasizing the need for continued reinforcement of breastfeeding practices through effective counseling and support systems.

Table 1: Demographic Characteristics of Study Participants (n = 335)

Table 2: Clinical Profile and Breastfeeding Practices (n = 335)

Table 3: Knowledge Domain Regarding Exclusive Breastfeeding (n = 335)

Table 4: Attitude Domain Regarding Exclusive Breastfeeding (n = 335)

Table 5: Practice Domain Regarding Exclusive Breastfeeding (n = 335)

Figure 1: KAP Domain wise Score

DISCUSSION

The present study assessed the knowledge, attitude, and practice (KAP) regarding exclusive breastfeeding among postnatal mothers and demonstrated that while knowledge (86.0%) and attitude (93.1%) were high, actual practices (59.7% good practice) were comparatively lower. This gap between awareness and implementation has been consistently highlighted in previous studies and reflects the influence of sociocultural, behavioral, and health system–related factors on breastfeeding practices.

With respect to sociodemographic characteristics, the majority of mothers in this study belonged to the age group of 20–30 years, which is consistent with findings reported by Nabi S (2020) [11], Sabo A (2018) [12], and Manjapallikkunnel SR (2021) [13], where most participants were within the reproductive age group. This age distribution indicates that breastfeeding practices are predominantly influenced during the most active reproductive years, emphasizing the need for targeted education in this age group. Similarly, the predominance of homemakers (69.6%) observed in this study aligns with findings by Nabi S (2020) [11] and Manjapallikkunnel SR (2021) [13], where a majority of participants were not formally employed, suggesting that occupation may influence breastfeeding behavior but does not necessarily ensure optimal practices.

In terms of educational status, although most mothers had primary or secondary education, only a small proportion had higher education. Comparable findings were reported by Sabo A (2018) [12] and Kumar R (2019) [14], where educational status varied widely but did not always translate into better breastfeeding practices. This suggests that formal education alone may not be sufficient to improve breastfeeding outcomes unless accompanied by specific health education interventions.

The knowledge domain in the present study revealed that a high proportion of mothers were aware of key aspects of exclusive breastfeeding, including early initiation (95.2%), importance of colostrum (89.0%), and its role in immunity (91.6%). Similar findings were reported by Nabi S (2020) [11], where 87.4% of mothers understood exclusive breastfeeding, and by Kumar R (2019) [14], where 88.9% correctly identified the recommended duration of exclusive breastfeeding. However, certain gaps were observed, particularly regarding the role of breastfeeding in family planning, where knowledge was comparatively lower. This finding is consistent with previous studies where awareness of lactational amenorrhea as a contraceptive method was limited [11,14].

Attitude towards exclusive breastfeeding was found to be highly positive in this study, with over 93% of mothers demonstrating a favorable attitude. Most participants believed that breastfeeding is beneficial, convenient, and results in healthier infants. These findings are comparable to those reported by Kumar R (2019) [14], where 85.8% of mothers preferred exclusive breastfeeding, and by Manjapallikkunnel SR (2021) [13], where positive perceptions regarding breastfeeding benefits and maternal-infant bonding were widely observed. However, a proportion of mothers expressed concerns regarding public breastfeeding and feasibility among working mothers, which is consistent with findings reported in earlier studies [12,13].

Despite high knowledge and positive attitudes, actual breastfeeding practices were comparatively lower, with only 59.7% demonstrating good practice. Although 80.0% of mothers practiced exclusive breastfeeding and 86.9% initiated breastfeeding within the first hour, a notable proportion still reported practices such as top feeding (20.0%) and early introduction of complementary feeds (13.7%). Similar discrepancies between knowledge and practice have been reported by Sabo A (2018) [12], where only 26.8% of mothers practiced exclusive breastfeeding despite moderate awareness, and by Manjapallikkunnel SR (2021) [13], where exclusive breastfeeding rates were around 55.4%. Kumar R (2019) [14] also reported suboptimal early initiation rates compared to knowledge levels, highlighting the persistent gap between awareness and implementation.

The role of healthcare professionals in promoting breastfeeding practices was evident in the present study, where all mothers (100%) reported receiving guidance from medical personnel. This finding underscores the importance of institutional support in improving breastfeeding outcomes. Previous studies have similarly emphasized that counseling during antenatal and postnatal periods significantly enhances breastfeeding practices and compliance [14].

Overall, the findings of the present study are in agreement with existing literature, demonstrating that while knowledge and attitude towards exclusive breastfeeding are generally high, translation into optimal practices remains a challenge. Factors such as cultural beliefs, family influence, maternal confidence, and practical constraints continue to affect breastfeeding behavior.

In conclusion, the study highlights the need for continuous reinforcement of breastfeeding education, focusing not only on improving knowledge but also on translating this knowledge into practice through effective counseling, family involvement, and supportive healthcare policies. Strengthening these aspects can significantly improve exclusive breastfeeding rates and contribute to better maternal and child health outcomes.

CONCLUSION

The present study demonstrates that postnatal mothers had high levels of knowledge (86.0%) and a predominantly positive attitude (93.1%) towards exclusive breastfeeding; however, actual practices were comparatively lower (59.7% good practice). While most mothers were aware of the importance of early initiation, colostrum feeding, and exclusive breastfeeding for six months, a notable proportion still practiced mixed feeding and early introduction of complementary feeds. This indicates a clear gap between knowledge and implementation, which may be influenced by sociocultural factors, family practices, and practical challenges. Intrahospital counseling and guidance from healthcare professionals played a significant role in improving awareness, but sustained behavioral change remains a challenge. Overall, the study highlights that improving breastfeeding outcomes requires not only increasing awareness but also strengthening practical support systems to ensure effective implementation of recommended practices.

LIMITATIONS

• The study was conducted in a single tertiary care hospital, which may limit the generalizability of the findings to the broader community.
• The use of a cross-sectional study design restricts the ability to establish causal relationships between variables.
• Data on practices were partly self-reported, which may introduce recall bias or social desirability bias.
• The study included only mothers attending healthcare facilities, thereby excluding mothers who do not access institutional services, potentially affecting representativeness.
• Certain influencing factors such as cultural beliefs, family dynamics, and workplace policies were not explored in depth.

RECOMMENDATIONS

• Strengthen antenatal and postnatal counseling programs focusing on practical aspects of breastfeeding, including positioning, attachment, and exclusive breastfeeding duration.
• Implement community-based awareness programs to bridge the gap between knowledge and practice, especially in rural and underserved areas.
• Encourage family involvement, particularly educating elder family members, to reduce cultural barriers and promote supportive environments for breastfeeding.
• Enhance training of healthcare professionals to provide consistent and evidence-based breastfeeding guidance.
• Develop workplace policies and support systems such as maternity leave and breastfeeding-friendly environments to support working mothers.
• Conduct multicentric and longitudinal studies to better understand long-term breastfeeding practices and influencing factors.
• Promote behavior change communication strategies rather than only knowledge-based interventions to improve actual breastfeeding practices.

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