Introduction

Quran as the main pillar of Islamic Sciences and felicity book of two House, has said the issue of breastfeeding within some verse, such as surah Baqara, verse 233 "and mothers should breastfeed their children for two complete years." Verses of Quran pay attention to breast milk issue directly are as follow: 1. Verse 15 of Sura Ahqaf 2. Verse 14 of Sura Luqman 3. Verse 23 of Sura Nisa , this verse is in relation to Kinship foster 4. Verse 6 of Sura Divorce 5. Verse 2 of Sura Hajj 6. Verse 7 of Sura Stories 7. Verse 12 of Sura Stories (1).

Breast milk is one of the healthiest methods of feeding infant and has obvious advantages for mothers and children. This milk contains nutrients which provide the best nutritional combination for the child at least up to 6 months. Breast milk feeding (BMF) reduces the risk of infectious diseases, diabetes, cancers, asthma and fat children, further more it also contains economical advantages (2). Epidemiological studies have shown the effect of human milk on reducing neonatal mortality caused by acute and chronic diseases (3,4). Breast milk provides all infant's nutritional requirements in the first 6 months of life and has a very important role in keeping children healthy (5) and early supplemental nutrition can have a negative influence on infant growth (5-7).

Experts believe that exclusive BMF in the first 6 months of life, has an important role in health and reducing children mortality (8,9) and besides to reducing neonatal mortality can prevent from childhood diseases (10-12). Breast milk has a special importance, since it contains known and unknown materials especially essential fatty acids for brain growth and nerves development (13). WHO and UNICEF emphasize on keeping exclusive BMF in the first 6 months of life (11,14-16).

Experts believe that children are the most valuable wealth of humanity and the most vulnerable age group, yet. Several studies have shown that several factors cause disorder in children growth which their commonest are non-organic factors (17). Some non-organic factors which can cause infant growth retardation include: lack of maternal knowledge and consequently improper behaviors to child and infant nutrition with regard to time, quantity, quality and methods of supplemental nutrition (18). Some experts believe that maternal familiarity to nutritional requirements of children may provide a correct nutritional plan for them (19). However, there is a close relationship between malnutrition and poverty, main reason of malnutrition in many societies is not lack of food at home, but it is some other factors like cultural poverty, loss of health instruments and services, lack of knowledge in preventing infections and incorrect use of foods at time of children growth (20). Genetic factors play an important role in physical growth of children, but importance of proper and correct nutrition is not deniable (21).

In performed assessments by attendants in relation to promoting BMF, exclusive BMF patterns in the first 6 months of life in different places of the world are different. In china, 80% of infants in the first 4-6 months receive exclusive BMF (22). Generally, exclusive BMF range 1% to 90 % in different places of the world (23). Exclusive BMF incidence up to 6^th month has been 35.1% in Uganda, 51.6% in Ghana and 27.3% in Saudi Arabia (24-26). Exclusive BMF has been reported in the Middle East 28% in 2000- 2006, Pakistan 16%, Iraq 25%, Saudi Arabia 31%, Egypt 38% and in Iran 44% (27). Factors such as: economic- social factors, demographic, cultural, obstetrical and neonatal ones have been known effective in posing early exclusive BMF. These factors are varied in different societies (25, 28). In American (2000), 35% children had exclusive BMF, while it increased to 50% in 2010 (29-30). While according to Demographic Health  Survey (DHS) (2000) and Integrated Monitoring Evaluation System Survey (IMESS) (2004) in Iran, exclusive BMF up to 6^th month has been reported 44% and 27%, respectively (31).

In several studies, controversial results have been reported on related factors to exclusive BMF. Some factors were assessed such as: infant gender, age, education degree, maternal occupation and parity, antenatal education and initial time of BMF postpartum (6-7,25-28,32). In some of the studies, there was no relationship between infant gender and exclusive BMF (6-7). In recent years, many attempts in health system of Iran   have been done to promote exclusive BMF. With regard to the importance of exclusive BMF promotion and determining its related factors and also existence of controversial studies' finding in this sense, this study aimed to assess maternal knowledge and attitude of Mashhad toward exclusive BMF in the first 6 months of infant life.

Materials and Methods

This cross-sectional descriptive-analytic study was conducted on mothers who referring to Mashhad health-care centers for monitoring their 6-24 month year old infants. Sample size calculated 126 persons by using past studies in similar communities with considering α=0.05% and d= 0.03%. Participants were selected by cluster and simple random sampling in the way that initially Mashhad city was divided into 3 clusters (health-care center number 1, 2 and 3), then 3 centers out of total Health – care Centers in each cluster were selected randomly (totally 9 health-care centers) by a cluster sampling method and then aimed sample was selected randomly in each health-care center. The researchers referred to maternal child care and vaccination units of health-care centers after coordination with the center’s manager, introduced the research for the participants and obtained their informed consents. Then they obtained required data by completed questionnaires and child's records. Research tool was a researcher-made questionnaire which was confirmed by content validity and internal consistency (Cranbach's alpha (α=0.81) reliability. The questionnaire consists of demographic information and 20 questions relating to maternal knowledge and attitude toward exclusive BMF. Data were coded and analyzed by descriptive and analytic [one-way analysis of variance (ANOVA), t-test] statistics and confidence coefficient 95% by SPSS-11.5. P < 0.05 was considered significant.

Results

126 mothers who qualified the inclusion criteria were assessed. Participants' mean age was 29.60±5.84 years (range from 19- 42 yr). Family income was good (35.7%) and very good (4%). Majority of mothers were house worker (73%) and 61.95 of fathers were self employment. Majority of mothers had academic education (40.5%) which their fathers' education was primary (6.3%) and junior high school (37.5%) (Table 1). Child growth was as follows: excellent growth (5.6%) and good growth (42.1%). 

Table 1: Frequency of Demographic Variables in Mothers Referring to Mashhad Health- Care Centers

Mean score of maternal attitude toward exclusive BMF was 14.32±5.28 (out of 28) and maternal knowledge score toward advantages of breast milk was 19.59±4.80 (out of 28) (Table 2).

Table 2: Mean of Maternal Knowledge and Attitude about Exclusive BMF.

There was a significant direct relationship between knowledge and attitude (Spearman test, P-value= 0.000, r= 0.4). Whatever higher score of maternal knowledge, more positive attitude towards exclusive BMF (Table 3).

Table3: Association between Maternal Knowledge with Attitude on Exclusive BMF

92% of mothers agreed with breast feeding in different times of night and day. 52.4% of them believed that supplemental food is necessary besides to breast milk in the first 6 months of life. 88.1% of mothers had agreement on immunized breast milk (Table 4).

Spearman test showed no significant relationship between attitude and maternal age. On the other hand, there was a significant direct relationship between maternal knowledge toward breast milk and its advantages with maternal age; whatever

older maternal age, higher score of knowledge about breast milk and exclusive BMF in the first 6 months of life (Table 5).

Table 4: Maternal Attitude about some Factors Influencing Exclusive BMF

Table 5: Association between Maternal Age with their Knowledge and Attitude towards Exclusive BMF

ANOVA showed a significant difference between parents' education and maternal attitude towards exclusive BMF; whatever higher education of parents, more positive maternal attitude towards exclusive BMF (P<0.05) (Table 6).

Table 6: Mean Comparison of Maternal Attitude towards Exclusive BMF based on Parental Education