Introduction
The first two years of life constitute a critical period for nutrition, immune development and neurodevelopment. The World Health Organization (WHO) and United Nations Children’s Fund recommend initiation of breastfeeding within the first hour after birth, exclusive breastfeeding for the first six months, introduction of safe and nutritionally adequate complementary foods at six months, and continued breastfeeding up to two years of age or beyond [1].
Optimal breastfeeding has immediate and long-term benefits for children and mothers. Breastfeeding protects against common childhood infections and is associated with lower infant and child mortality, while also contributing to healthier growth and development [2][3]. These benefits depend not only on whether breastfeeding occurs but also on how early it is initiated, whether it remains exclusive during the first six months, and whether complementary foods are introduced at an appropriate age.
India has made progress in several infant and young child feeding indicators, but substantial gaps remain. The National Family Health Survey-5 reported that 41.8% of children were breastfed within one hour of birth and 63.7% of infants younger than six months were exclusively breastfed; complementary feeding among age-eligible infants remained suboptimal [4]. National analyses have shown that breastfeeding and complementary-feeding behaviours vary according to maternal education, household wealth, place and mode of delivery, antenatal care, region and exposure to counselling [5][8].
Rural communities may face additional barriers related to traditional beliefs, low maternal literacy, limited decision-making autonomy and unequal access to counselling. A community study from rural North India documented low awareness regarding the benefits of exclusive breastfeeding and early introduction of complementary foods among a substantial proportion of mothers [9]. Earlier work from rural Agra found that only 21.9% of mothers initiated complementary feeding at the appropriate age and that maternal literacy was significantly associated with feeding timing [10]. Studies from other parts of Uttar Pradesh have similarly demonstrated that complementary-feeding indicators are associated with maternal literacy and household living standards [11].
Most surveys evaluate reported practices, whereas fewer studies examine the gap between what mothers perceive as appropriate and what they actually practice. In addition, infant sex and whether a pregnancy was wanted may influence household investment and caregiving, but these factors are not consistently examined together with maternal literacy and socioeconomic status. The present analysis therefore focused on maternal perception and practice regarding breastfeeding initiation and complementary-feeding initiation, while also examining awareness of exclusive breastfeeding as a selected feeding indicator under the sociodemographic analysis.
Aim and Objectives
Aim
To assess maternal perceptions and reported practices regarding the timing of breastfeeding initiation and complementary-feeding initiation and to examine their associations with selected maternal and infant characteristics among mothers residing in rural Agra district.
Objectives
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To assess maternal perception and reported practice regarding the timing of initiation of breastfeeding.
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To assess maternal perception and reported practice regarding the timing of initiation of complementary feeding.
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To determine the association of maternal literacy status, socioeconomic status, pregnancy wantedness and infant sex with breastfeeding-initiation timing, awareness of exclusive breastfeeding and complementary-feeding timing.
Materials and Methods
Study design and setting
This was a community-based cross-sectional study conducted during 2005-2006 in rural areas of Agra district, Uttar Pradesh, India. The field area comprised villages in Achnera Community Development Block.
Study population
The study population comprised mothers having children younger than one year who were residing in the selected villages during the study period. Mothers who provided written informed consent were interviewed. No additional exclusion criteria were specified in the supplied source document.
Sample size
The minimum calculated sample was 200. To compensate for non-response, 220 mothers were included.
Statistical analysis
Categorical variables were summarised as frequencies and percentages. Associations between feeding indicators and maternal or infant characteristics were examined using contingency-table analysis. The supplied source document stated that SPSS was used for analysis. During manuscript reconstruction, displayed aggregate counts were independently checked using Pearson chi-square tests; Monte Carlo conditional tests were used for sparse R x C tables and two-sided Fisher exact tests for 2 x 2 tables. A p-value below 0.05 was considered statistically significant. Because the original row-level dataset was not available, all recalculated inferential results are provisional and must be verified before journal submission.
Results
A total of 220 mothers were included. Most mothers were illiterate (177; 80.5%), and only eight (3.6%) had education above high school. Ninety-eight households (44.5%) belonged to the low socioeconomic group, 100 (45.5%) to the medium group and 22 (10.0%) to the high group. There were 126 male infants (57.3%) and 94 female infants (42.7%). The pregnancy was reported as wanted for 190 infants (86.4%) and unwanted for 30 (13.6%).
In the supplied breastfeeding-initiation tables, perception counts summed to 179, whereas practice counts summed to 220. The source document did not explain the 41-count discrepancy, and this must be resolved using the raw dataset. Based on the displayed counts, 62/179 mothers (34.6%) perceived initiation within six hours as appropriate, while 51/220 (23.2%) reported initiating breastfeeding within six hours. Both perception and practice varied by maternal literacy (both p<0.001). Socioeconomic status was not associated with perception (p=0.182) or practice (p=0.112).
Only 19/220 mothers (8.6%) were classified as aware of exclusive breastfeeding in the source tables. Awareness increased from 3.9% among illiterate mothers to 87.5% among mothers educated above high school and from 3.1% in the low socioeconomic group to 40.9% in the high group (both p<0.001). Awareness was not associated with infant sex (p=0.342) or pregnancy wantedness (p=0.303). The exact questionnaire item used to define awareness should be confirmed before submission.
Regarding complementary feeding, 136/220 mothers (61.8%) perceived that initiation should occur at more than six months. Among the 123 infants who had started complementary feeding, 62 (50.4%) were reported to have started at more than six months, 56 (45.5%) at 4-6 months and five (4.1%) before four months. Maternal literacy was associated with both perception (p=0.026) and reported practice (p=0.040). Socioeconomic status was not associated with perception (p=0.508); its association with practice was borderline (p=0.050) and should not be interpreted as definitive. Infant sex was not associated with timing (p=0.807). Pregnancy wantedness was associated with timing (p<0.001): initiation before four months occurred in 18.2% of pregnancies reported as unwanted compared with 1.0% of wanted pregnancies. Because the categories do not isolate initiation exactly at six months, these findings describe timing distributions rather than adherence to the current WHO timely-introduction indicator.
| Maternal literacy | Perception <6 h n (%) | Perception 6-24 h n (%) | Perception >24 h n (%) | Practice <6 h n (%) | Practice 6-24 h n (%) | Practice >24 h n (%) |
| Illiterate (P n=136; Pr n=177) | 35 (25.7) | 61 (44.9) | 40 (29.4) | 33 (18.6) | 72 (40.6) | 72 (40.6) |
| Up to primary (P n=16; Pr n=16) | 6 (37.5) | 7 (43.8) | 3 (27.3) | 3 (18.8) | 10 (62.5) | 3 (15.8) |
| Up to high school (P n=19; Pr n=19) | 13 (68.4) | 5 (26.3) | 1 (5.9) | 9 (47.4) | 9 (47.3) | 1 (5.9) |
| Above high school (P n=8; Pr n=8) | 8 (100.0) | 0 (0.0) | 0 (0.0) | 6 (75.0) | 1 (12.5) | 1 (12.5) |
| Total (P n=179; Pr n=220) | 62 (34.6) | 73 (40.8) | 44 (24.5) | 51 (23.2) | 92 (41.8) | 77 (35.0) |
P = perception; Pr = practice. Monte Carlo conditional p-values: literacy versus perception p<0.001; literacy versus practice p<0.001. The displayed perception counts total 179 rather than 220; verify whether 41 values were missing or whether the source table contains an error.
| Socioeconomic status | Perception <6 h n (%) | Perception 6-24 h n (%) | Perception >24 h n (%) | Practice <6 h n (%) | Practice 6-24 h n (%) | Practice >24 h n (%) |
| Low (P n=66; Pr n=98) | 23 (34.8) | 26 (39.4) | 17 (25.8) | 21 (21.4) | 42 (42.9) | 35 (35.7) |
| Medium (P n=91; Pr n=100) | 28 (30.8) | 37 (40.7) | 26 (28.6) | 20 (20.0) | 42 (42.0) | 38 (38.0) |
| High (P n=22; Pr n=22) | 11 (50.0) | 10 (45.5) | 1 (4.5) | 10 (45.5) | 8 (36.4) | 4 (18.2) |
| Total (P n=179; Pr n=220) | 62 (34.6) | 73 (40.7) | 44 (24.5) | 51 (23.2) | 92 (41.8) | 77 (35.0) |
P = perception; Pr = practice. Monte Carlo conditional p-values: socioeconomic status versus perception p=0.182; socioeconomic status versus practice p=0.112. The displayed perception counts total 179 rather than 220. These values differ from the p<0.05 statement in the supplied source table and require raw-data confirmation.
| Factor | Category | EBF aware n (%) | Not aware n (%) | Total | p-value |
| Maternal literacy | Illiterate | 7 (3.95) | 170 (96.0) | 177 | <0.001 |
| Up to primary | 0 (0.0) | 16 (100.0) | 16 | ||
| Up to high school | 5 (26.3) | 14 (73.7) | 19 | ||
| Above high school | 7 (87.5) | 1 (12.5) | 8 | ||
| Total | 19 (8.6) | 201 (91.4) | 220 |
| Factor | Category | EBF aware n (%) | Not aware n (%) | Total | p-value |
| Socioeconomic status | Low | 3 (3.1) | 95 (96.9) | 98 | <0.001 |
| Medium | 7 (7.0) | 93 (93.93) | 100 | ||
| High | 9 (36.4) | 13 (63.6) | 22 | ||
| Total | 19 (8.6) | 201 (91.4) | 220 |
EBF = exclusive breastfeeding. Monte Carlo conditional p-values were used because several expected cell counts were small. The exact questionnaire definition of EBF awareness must be confirmed.
| Infant characteristic | Category | EBF aware n (%) | Not aware n (%) | Total | p-value |
| Infant sex | Female | 6 (6.4) | 88 (93.6) | 94 | 0.342 |
| Male | 13 (10.3) | 113 (89.6) | 126 | ||
| Pregnancy wantedness | Wanted | 15 (7.9) | 175 (92.1) | 190 | 0.303 |
| Unwanted | 4 (13.3) | 26 (86.7) | 30 | ||
| Total | 19 (8.6) | 201 (91.4) | 220 |
Two-sided Fisher exact tests were used for the 2 × 2 comparisons.
| Maternal literacy | Perception < 4 months n (%) | Perception 4-6 months n (%) | Perception > 6 months n (%) | Practice <4 months n (%) | Practice 4-6 months n (%) | Practice > 6 months n (%) |
| Illiterate (P n=177; Pr n=102) | 9 (5.1) | 69 (39.0) | 99 (55.9) | 3 (2.9) | 51 (50.0) | 48 (47.5) |
| Up to primary (P n=16; Pr n=9) | 0 (0.0) | 4 (25.0) | 12 (75.0) | 0 (0.0) | 3 (33.3) | 6 (66.7) |
| Up to high school (P n=19; Pr n=8) | 0 (0.0) | 2 (10.5) | 17 (89.4) | 2 (25.0) | 1 (12.5) | 5 (62.5) |
| Above high school (P n=8; Pr n=4) | 0 (0.0) | 0 (0.0) | 8 (100.0) | 0 (0.0) | 1 (25.0) | 3 (75.0) |
| Total (P n=220; Pr n=123) | 9 (4.9) | 75 (34.1) | 136 (61.8) | 5 (4.1) | 56 (45.5) | 62 (50.4) |
P = perception; Pr = practice. Monte Carlo conditional p-values: literacy versus perception p=0.026; literacy versus practice p=0.040. The categories describe timing and do not isolate initiation exactly at 6 months.
| Socioeconomicstatus | Perception <4 months n (%) | Perception 4-6 months n (%) | Perception >6 months n (%) | Practice <4 months n (%) | Practice 4-6 months n (%) | Practice >6 months n (%) |
| Low (P n=98; Pr n=61) | 6 (6.1) | 36 (36.7) | 56 (57.1) | 3 (4.9) | 32 (52.5) | 26 (42.6) |
| Medium (P n=100; Pr n=49) | 2 (2.0) | 33 (33.0) | 65 (65.0) | 0 (0.0) | 20 (40.8) | 29 (59.1) |
| High (P n=22; Pr n=13) | 1 (4.5) | 6 (27.3) | 15 (68.2) | 2 (25.0) | 4 (30.8) | 7 (53.8) |
| Total (P n=220; Pr n=123) | 9 (4.9) | 75 (34.1) | 136 (61.8) | 5 (4.1) | 56 (45.5) | 62 (50.4) |
Monte Carlo conditional p-values: socioeconomic status versus perception p=0.508; socioeconomic status versus practice p=0.050. Practice was assessed only among 123 infants who had initiated complementary feeding. The borderline p-value requires confirmation from the individual-level dataset.
| Infant characteristic | Category | <4 months n (%) | 4-6 months n (%) | >6 months n (%) | Total | p-value |
| Infant sex | Female | 2 (4.8) | 20 (40.8) | 27 (55.1) | 49 | 0.807 |
| Male | 3 (4.5) | 36 (48.6) | 35 (47.3) | 74 | ||
| Pregnancy wantedness | Wanted | 1 (1.0) | 44 (43.6) | 56 (55.4) | 101 | <0.001 |
| Unwanted | 4 (18.2) | 12 (54.5) | 6 (27.3) | 22 | ||
| Total | 5 (4.1) | 56 (45.5) | 62 (50.4) | 123 |
Monte Carlo conditional p-values were used because of sparse cells. Only infants who had initiated complementary feeding were included. The categories do not identify initiation exactly at 6 months.
Discussion
This community-based study identified clear differences between maternal perceptions and reported feeding practices. Breastfeeding initiation within six hours was perceived as appropriate by about one-third of mothers but was reported by fewer than one-quarter. Exclusive-breastfeeding awareness, as defined in the source tables, was very limited. Complementary-feeding timing varied by maternal literacy, and pregnancy wantedness was associated with the distribution of initiation ages. Infant sex was not associated with the selected indicators. These results must be interpreted in light of important denominator and category limitations in the source data.
Because the field data were collected in 2005-2006, these findings represent historical rural practices rather than current prevalence. More recent national evidence from NFHS-5 (2019-2021) reported that 41.8% of children were breastfed within one hour of birth and 63.7% of infants younger than six months were exclusively breastfed [4]. Direct numerical comparison is limited because the present study grouped breastfeeding initiation at six hours and measured exclusive-breastfeeding awareness rather than actual exclusive feeding. Nevertheless, the later national estimates and the newer Indian studies cited in this manuscript suggest improvement in some feeding indicators since 2005-2006, while delayed initiation, suboptimal complementary feeding and sociodemographic inequalities remain important [5][8][12][14]. The historical value of this dataset is therefore to document earlier community practices and permit cautious contextual comparison with subsequent evidence.
The reported prevalence of breastfeeding initiation within six hours was 23.2%. Direct comparison with current national indicators is not possible because WHO and contemporary surveys define early initiation as breastfeeding within one hour [1][4]. Mahmood et al. reported that 78.8% of mothers in a rural North Indian sample initiated breastfeeding within 24 hours, but that broader threshold also limits comparison [9]. Khan et al. found initiation within one hour in 33.7% of mother-infant pairs and identified caesarean delivery, lack of prenatal advice, prelacteal feeding and maternal illness as barriers [14]. In the present tables, maternal literacy was strongly associated with timing, whereas socioeconomic status was not significant after recalculation from the displayed counts. The apparent literacy gradient supports the importance of understandable antenatal and immediate postnatal counselling, but the unexplained reduction of the perception denominator from 220 to 179 must be resolved before the estimate is published.
Only 8.6% of mothers were classified as aware of exclusive breastfeeding. This variable reflects awareness or perception rather than verified exclusive-breastfeeding practice and must not be presented as an exclusive-breastfeeding prevalence estimate. Mahmood et al. similarly identified substantial gaps in knowledge of the benefits of exclusive breastfeeding in rural North India [9]. National analyses have shown that breastfeeding outcomes vary with maternal education, household socioeconomic position, health-service use and region [6][8][13]. In the present study, awareness increased markedly with literacy and socioeconomic status but was not associated with infant sex or pregnancy wantedness. However, interpretation remains dependent on confirming the exact wording and scoring of the original questionnaire item.
The complementary-feeding findings require especially cautious interpretation. WHO recommends introduction of complementary foods at six months, and the standard population indicator assesses receipt of solid, semisolid or soft foods among infants aged 6-8 months [1]. The source dataset instead used the categories before 4 months, 4-6 months and more than 6 months. Consequently, the 50.4% reported in the more-than-six-month category cannot be labelled 'timely' or 'appropriate'; it may represent delayed introduction. Likewise, the 4-6-month category combines potentially early introduction with introduction at six months. Earlier studies from Agra, Aligarh and Pune used different operational definitions and are therefore useful for contextualising associated factors, but their prevalence estimates should not be directly compared with the present categories [10][12].
Maternal literacy was associated with the distribution of both perceived and reported complementary-feeding timing. More educated mothers were more frequently represented in the more-than-six-month category. Because that category is not equivalent to the WHO-recommended timing, this association should be described as a relationship with timing rather than evidence of more appropriate practice. Socioeconomic status was not associated with perception, and the practice result was borderline. Education may influence comprehension of counselling and the ability to negotiate family advice, but causal mechanisms cannot be inferred from this cross-sectional analysis. Future analysis should reclassify individual records using an exact age in completed months and current WHO indicators.
Infant sex was not associated with exclusive-breastfeeding awareness or complementary-feeding timing, providing no evidence of sex-based differences for these selected indicators in this sample. Pregnancy wantedness was associated with complementary-feeding timing, driven in part by a substantially higher proportion of initiation before four months among pregnancies reported as unwanted (18.2% versus 1.0%). At the same time, a larger proportion of wanted pregnancies fell in the more-than-six-month category, which may indicate delayed initiation. Therefore, the finding should not be simplified as better feeding among wanted children. Residual confounding by maternal age, parity, family support, workload, access to services and other social factors is possible, and the association should be explored prospectively.
Limitations
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The cross-sectional design permits identification of associations but cannot establish causal relationships.
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Feeding practices were based on maternal report and may be affected by recall or social-desirability bias.
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The displayed breastfeeding-initiation perception counts totalled 179 rather than 220. It is not known from the source tables whether 41 responses were missing or whether a tabulation error occurred.
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Exclusive breastfeeding was represented by an awareness/perception variable; actual exclusive-breastfeeding practice was not measured in the selected tables, and the exact questionnaire definition remains to be confirmed.
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Complementary-feeding practice was assessed only among 123 infants who had initiated complementary feeding, resulting in small subgroup counts.
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The study-specific categories do not match current WHO indicators. Breastfeeding initiation was grouped at six hours rather than one hour, and complementary feeding was grouped as <4, 4-6 and >6 months, which does not isolate introduction exactly at six months.
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Several cells were sparse, and p-values were recalculated from aggregate tables because the supplied source tables contained inconsistent degrees of freedom, test statistics and significance statements. All inferential results must be confirmed using the original individual-level dataset.
Conclusion
Maternal perceptions and reported practices during 2005-2006 showed important gaps in this rural Agra population. Fewer than one-quarter of mothers reported breastfeeding initiation within six hours, and exclusive-breastfeeding awareness was low. Maternal literacy was consistently associated with breastfeeding-initiation timing, exclusive-breastfeeding awareness and complementary-feeding timing, whereas infant sex was not. Pregnancy wantedness was associated with complementary-feeding timing, particularly a higher frequency of initiation before four months among pregnancies reported as unwanted. More recent Indian evidence cited in this manuscript suggests progress in some indicators, although delayed practices and sociodemographic inequalities persist. Because definitions and study populations differ, these historical-to-current comparisons should be interpreted contextually rather than as direct trend estimates. Before submission, the breastfeeding denominator discrepancy, the definition of exclusive-breastfeeding awareness and all statistical results should be verified from the original dataset.
Declarations
Conflicts of Interest
The authors declare that there is no conflict of Interest
Funding
No funding was received for this research from any Govt or Non Govt organization.
Acknowledgements
The authors wish to express their sincere gratitude to the Head of Department, Neurology, for granting permission to conduct this study.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request and subject to institutional approval.
Authors' Contribution Statement
All authors have read and agreed to the published version of the manuscript:
Conceptualization: Dr. Sonal Kumar, Dr. Shikha Mittal; Methodology: Dr. Shikha Mittal, Dr. DN Bharadwaj; Validation: Dr. Sonal Kumar, Dr. S. K. Misra; Formal Analysis: Dr. Sunil Kumar Dahiya; Investigation: Dr. Sonal Kumar, Dr. S. K. Misra; Resources: Dr. Sonal Kumar; Data Curation: Dr. Sonal Kumar; Writing (Original Draft): Dr. Sunil Kumar Dahiya; Writing (Review and Editing): Dr Jitender Kumar Jakhar, Dr. Sunil Kumar Dahiya.
Corresponding Author: Dr. Sunil Kumar Dahiya