Rajiv Gandhi University of Health Science, Bangalore, Karnataka Synopsis Proforma For

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCE, BANGALORE, KARNATAKASYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

NAME OF THE INSTITUTION

TITLE OF THE TOPIC

STATEMENT OF THE PROBLEM

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

Though lactation is a normal physiological process, it makes considerable demands on the mother.1 The nutritional status of the woman during adolescence, pregnancy and lactation has a direct impact on maternal and child health in the puerperium. Selected interventions and dietary advice can affect a woman’s nutritional status, whether or not she is breastfeeding.2

In many developing countries, the nutritional status of large segments of the population, especially of women, is inadequate. Undernutrition of women can be attributed to discrimination in terms of food allocation, to the heavy burden of physical labour, and to reproduction (McGuire & Popkin 1989). In a survey of the literature Prentice et al (1994) found that during lactation the volume of milk production was not affected by maternal under nutrition. However, some studies showed a weak, but significant correlation between maternal BMI and milk fat.2

Maternal undernutrition was reflected in the composition of breast milk which had a reduced fat content (Van Steenbergen et al 1994). It is clear that, women need an increased caloric intake throughout the period of lactation. Women’s intake should be increased to cover the energy cost of lactation: by about 10% if the woman is not physically active, but 20% or more if she is moderately or very active. Virtually all dietary restrictions should be avoided. Micronutrient malnutrition is the term commonly used when referring to deficiency of micronutrients (vitamins or minerals). The three main vitamin or mineral nutritional deficiencies of public health significance in the lactating period are:

• iodine deficiency disorders (IDD)
• vitamin A deficiency
• iron deficiency anaemia.

The main causes of micronutrient malnutrition are inadequate intake of foods providing these micronutrients and their impaired absorption or utilization 2

Nutritional advice and supplementation of pregnant and lactating women is a subject of special importance for those countries and regions with a high prevalence of malnutrition. Under these conditions nutritional advice and supplementation of women with proteins and energy is useful for the woman and probably for her infant. 3

6.2. NEED FOR STUDY

The knowledge of an individual is found to have a close correlation with the practice of the individual. Several misconceptions, ignorance and inadequate knowledge in relation to the self care are prevalent among mothers.

Human milk is a symphony of nutrients that varies between mothers and changes with lactation duration or even time of day. In studies of lactation during famine conditions, malnourished mothers were able to produce sufficient breast milk and support normal growth in their infants. In several instances, maternal nutrition stores suffered, asthe breast milk quantity and quality remained adequate.4

For lactation, the dietary reference intake is 550 calories higher than guidelines in the first six months and another 400 calories from 7 – 12 months.5 The recommendation of 2,700 calories per day during the first 6 month is based on energy needed for milk production, energy mobilized from fat stores, and estimated metabolic rate. In addition, there is an extra requirement of proteins, Thiamine, Riboflavin and Nicotinic acid.1

Lactating mother’s nutritional requirements should meet her own daily needs, provide enough nutrients for growing infant and furnish the energy for the mechanics of milk production. Diet of lactating mothers and their nutritional status affects to certain extend the quality and quantity of milk production.2

In poor Indian communities the nursing mother takes only rice supplementation with little pulse and vegetables. Milk is used in tea or coffee. Despite a faulty and insufficient diet, the quality of breast milk does not suffer. It keeps up the quality by withdrawing nutrients from mothers own bone, blood and muscle for the formation of milk. Continuous withdrawal of nutrients from the maternal body leads to Osteomalacia and other health problems2

The recommended dietary allowances of many expert committees have set out the extra energy requirements necessary to support lactation on the basis of efficiency of 80 per cent for human milk production. The metabolic efficiency of milk synthesis can be derived from the measurements of resting energy expenditure. The results of study in lactating women, as well as a review of human studies on energy expenditure during lactation performed in different countries, suggest an efficiency of human milk synthesis greater than the value currently used by expert committees. It propose that an average figure of 95 per cent would be more appropriate to calculate the energy cost of human lactation.3

Studies on the Dietary and Nutritional status of nursing mothers in India showed that the mean body weight of nursing mothers of low socio economic group was found to be about 40 – 42 kg. serial body weight changes recorded in 14 mothers throughout the period of lactation showed that while some of the mothers did not show any change, many lost weight to the extend of 2 to 7 kg in a period of one year of lactation. 1

A longitudinal study conducted in china on postnatal iron status among 47 women showed that 27.7 % were anemic and that study concluded that post natal recovery of iron status is more related to the dietary factors than the physiological factors.6 A study conducted in Bangalore by Piers LS, Diggavi SN etal on Changes in energy expenditure, anthropometry and energy intake during pregnancy and lactation also recommended the extra energy intake during the lactation. 7

A study was done on “Malnutrition and iron deficiency in lactating women” to determine the iron deficiency status and malnutrition. Six urban slums were included and one thousand and seventeen lactating women were enrolled in the study. The result shows an overall prevalence of iron deficiency anaemia (IDA) and protein energy malnutrition in the slum communities was 22.3% and 27.1% respectively. The mean age of mothers (28.4 +/- 6.12 years) indicates that prevalence of malnutrition and iron deficiency anaemia was higher among younger mothers than among older mothers. The prevalence of malnutrition was positively correlated with the serum ferritin concentration status, of the mothers. The study concluded that malnutrition and iron deficiency anemia are major health problems and therefore, an appropriate nutrition intervention package to improve the nutrition situation of the communities is recommended.8

Similarly several studies reported the deficiency status of the lactating mother with and without effect on the baby. During the clinical posting, the investigator found many lactating mothers, who came as patients and also as bystanders of the patients, as anemic and malnourished. The communication with these mothers made it to recognize about the poor knowledge regarding the diet. It was felt by the investigator that the lack of knowledge was more in the mothers, who belong to the low economic status, low education and those belonging to the rural areas of Hassan. So the investigator felt the need for taking this study with an intention to assess clearly about their knowledge level and to give information about the diet and thereby to help them to regain the good health.

6.3. STATEMENT OF THE PROBLEM

A study to evaluate the effectiveness of structured teaching programme regarding diet during lactation on knowledge among lactating mothers in selected rural areas at Hassan.

6.4 OBJECTIVES OF THE STUDY

1. To assess the pre test and post test knowledge regarding diet during lactation among lactating mothers in experimental and control group.

2. To evaluate the effectiveness of structured teaching programme regarding diet during lactation in terms of significant increase in knowledge in experimental group when compared with the control group.

3. To find out the association between the post test knowledge scores with demographic variables of lactating mothers of experimental group.

6.5 HYPOTHESIS:

H1. The knowledge scores of lactating mothers in experimental group will be significantly higher than that of lactating mothers in control group.

6.6 ASSUMPTIONS

The lactating mothers are willing to express their knowledge regarding diet during lactation.

Structured knowledge interview schedule regarding diet during lactation can assess the level of knowledge of lactating mothers effectively.

Structured Teaching Programme is an accepted strategy to increase the level of knowledge of lactating mothers.

6.7. OPERATIONAL DEFINITIONS

Evaluate:-

Evaluate refers to the process of valuing the effectiveness of structured teaching programme regarding the diet during lactation.

Effectiveness:-

Effectiveness refers to the significant increase in the post test knowledge score among lactating mothers in experimental group, when compared with the increase in

post- test knowledge scores of lactating mothers in control group.

Structured Teaching Programme:-

Structured Teaching Programme refers to a teaching programme regarding the diet during lactation for 45 minutes, Conducted by investigator by using lecture- cum discussion method with the help of AV aids.

Lactation period:-

Lactation period refers to the period during which the infant is nourished from the breast.

Knowledge:-

Knowledge refers to the number of correct response of lactating mothers to the knowledge questions of structured interview schedule.

Lactating Mothers:-

The mothers who have given birth to their babies within the last three months and are breastfeeding their babies and fulfilled the inclusion and exclusion criteria.

Rural area:-

Rural area is a place [Shanthigrama, Doddegenigere] where it does not have

much facility and away from the city.

6.8 CRITERIA FOR SELECTION OF SAMPLE:-

Inclusion criteria:-

The study will include lactating mothers, who

1. are residing at the selected rural areas of Hassan.

2. had spontaneous vaginal delivery within the last three month period.

3. are willing to participate in the study

4. can understand Kannada.

Exclusion criteria:-

The study will not include those who

1. are not available during study period.

2. had given birth within the last three month period.

69. LIMITATION

1. The sample size is limited to 60

2. The study is limited to selected rural areas of Hassan

3. Prescribed data collection period is 4 – 6 weeks

6.10 SIGNIFICANCE OF THE STUDY

The study implies the importance of Structured Teaching Programme regarding knowledge of lactating mothers regarding lactation. Increase in knowledge and practice help the lactating mothers to practice in their life and can help to improve the health of the mother as well as the baby and also help to prevent the problems like malnutrition, anaemia etc.

6.11. CONCEPTUAL FRAME WORK OF THE STUDY:-

The study is based on “Wiedenbachs Helping Art theory” by Ernestine Wiedenbach.

6.12. REVIEW OF LITERATURE

A study was conducted on “Concurrent micronutrient deficiency in lactating women and their infants” in Indonesia. A cross sectional survey was used and 155 lactating mothers and their infants were assessed. The result of the study showed that vitamin A deficiency was found in 54 % of the infants and 18 % of the mothers and more that 50% of the mothers and infants were anemic and 17% of the infants and 25% of the mothers were zinc deficient. This study concluded that the micronutrient status of lactating mothers and that of their infant were closely related and the breast milk was the key connecting factor.9

A study was conducted on “Traditional food consumption and nutritional status of mothers” in rural Andhra Pradesh, SouthIndia. A cross sectional study design was used and the anthropometric measurements, clinical eye examination, and socio-cultural questionnaire were used. The aim is to identify the prevalence of malnutrition. 220 mothers were selected from 37 villages and the result showed that 58% of the mothers are chronic energy deficient and the illiterate mothers were more likely to have chronic energy deficient than the literate. It also showed that vitamin A deficiency is also a predominant problem.10

A study was done on “postpartum thiamine deficiency in a Karen displaced population”. Women were enrolled prospectively at 30 week of gestation and were followed up weekly until delivery and at 3 months postpartum. The result showed that at 3 month postpartum, thiamine deficiency was found in 57.7% (15/26 of mothers, 26.9% (7/26) of who had severe deficiency. The study concluded that this situation can be improved by educating lactating women to reduce their consumption of thiaminase containing food and by implementing an effective thiamine supplementation programme.11

A cross sectional study was conducted on “Iodine nutrition in pregnancy and lactation” on 100 lactating women from Taleghani hospital. The result showed that the mean urinary iodine concentration in lactating women was 250 micro g l-1, and 16% of women had a urinary iodine concentration < 100 micro g l-1. Grade 1 goitre was present in 8% of lactating women, and another 8% had grade 2 goitre.This study concluded that special attention to iodine intake during lactation is needed. The currently recommended intake of iodine through universal salt iodization may not be adequate for the pregnant and lactating women, and supplementation during pregnancy and lactation should be further considered in light of the latest recommendations. 12

A study was done on “Nutritional and medical status of lactating women and there infants” in Nepal. 26 lactating women and their 2-6-month-old infants. Analysis of 24-hour duplicate diet composites indicated that the mothers were consuming approximately 2100 kcal energy/d. The diets contained approximately 62 g protein (11.6% of the calories), 392 g carbohydrate (73.3% of the calories), and 20.9% g fat (8.6% of the calories) and a mean of 24 g neutral detergent fiber. Although anthropometric measurements indicated that the mothers had mild protein malnutrition and inadequate energy reserves, their infants exhibited low-normal weight and length for age. The mothers showed evidence of multiple infections and possible nutrient deficiencies.13

A placebo controlled trial was conducted to identify the“Effect of papaya and carrots on the vitamin Astatus” of lactating women with 2- to 12-months-old infants. The women were randomly assigned to three supplementation groups and a placebo group, and received 6 mg of beta-carotene capsules, 650 g puréed papaya, 100 g grated carrots or a placebo, daily for 60 d. All groups were given a meal containing 10 g of vegetable oil daily. Serum retinol, relative dose response, serum ferritin, hemoglobin and C-reactive protein were measured before and after the supplementation period. Mean serum retinol increased significantly after supplementation in the beta-carotene group (P < 0.001), the papaya group (P < 0.001) and the carrot group (P < 0.001), but not in the placebo group. The study concludes that puréed papaya and grated carrots can improve the vitamin A and iron nutritive of lactating women. These findings reinforce the importance of plant food-based approaches in the control of vitamin A deficiency in low income countries.14

A study was conducted on “Energy expenditure and food intake in lactating women”. Total energy expenditures and intakes were simultaneously assessed in 18 lactating women (10 months postpartum) and compared to 6 similarly-sized nonlactating, nonpregnant but multiparious women living in the same rural village. . Energy intakes were estimated by the 24-hour recall method for each of 4 consecutive

days. Energy expenditures were determined for 2 days. The result showed that Most of the lactating women had been losing weight progressively during the past 6 months. Over the 10-week period prior to our measurements, the mean weight loss was more than 10 times greater in the lactating group (-369 g/month) (P 0.01) than in the nonlactating group (-35 g/month).15

A study was conducted on “Energy requirement during pregnancy and lactation”. The subjects of the study were healthy lactating women and the energy requirement during lactation were derived from rates of milk production, energy density of human milk and energy mobilization from tissues. The result of the study showed that the energy cost of lactation was 2.62 MJ day, energy density of milk of 2.8 kJ g, and energy efficiency of 0.08. This study concluded that the energy intake of pregnant women and lactating women should be updated based on recently available data.16

A study was done on “maternal dietary antigen avoidance during pregnancy and lactation” for preventing or treating a topic disease in child. The data were extracted from published reports and a quasi randomized design was used. The result showed that the evidence from 4 trials involving 334 participants does not suggest a protective effect of maternal dietary antigen avoidance during pregnancy and lactation on the incidence of atopic eczema during first 18 months of life. One cross over trial involving 17 lactating mothers of infants with established atopic eczema concluded that the maternal dietary antigen avoidance is not associated with significant reduction in eczema severity.17

7. MATERIALS AND METHODS OF THE STUDY

7.1 Sources of data:-

The data will be collected from the lactating mothers of selected rural areas of Hassan.

7.2 Research design:-

A quasi- experimental approach which includes manipulation, control and no randomization.

Key:-

O1- Pretest knowledge of lactating mothers.

X- Structured Teaching Programme regarding knowledge on lactating diet.

O2- Post test regarding knowledge on lactating diet.

7.3 METHODS OF DATA COLLECTION

Data collection is planned through structured interview schedule regarding knowledge on lactating diet.