Breast Feeding Knowledge and Practices among Primiparous Women with Caesarean Section: Impact on Breast Engorgement in Upper Egypt

Background: The benefits of breast milk are greatly enhanced if breastfeeding starts within one hour after birth. Hunan milk contains a host of dynamic and unique feeding properties. Breast engorgement is one of the most common minor discomforts confronting nursing women after delivery, especially Primiparous. The aim of the study was to investigate the breastfeeding knowledge and practices among primiparous women with a cesarean section and its impact on breast engorgement in Upper Egypt. The study was conducted in the postnatal unit of Beni-Suef University Hospital. The study design was a descriptive study. The type of sample was a simple random sample. The study comprised 90 Primiparous cesarean section mothers; suffer from breast engorgement. Tools of Data Collection were interview questionnaire sheet, knowledge assessment sheet, observational checklist, and engorgement assessment scale. The study revealed that the studied women’s knowledge and technique of breastfeeding were not adequate among the whole study sample. Breast engorgement was more prevalent among the younger, less educated, housewives, low social class’s women and those who were rural dwellers. Recommendation: Providing the mother with guidance and support on positioning and latching and modification of hospital practices are effective in reducing breast problems.


Introduction
Breast milk is the natural and optimal food for the newborn infant. It is superior to any alternative form of infant formula and is uniquely designed to meet the nutritional needs of the infant. The benefits are greatly enhanced if breastfeeding starts within one hour after birth. Early breastfeeding allows the baby to enjoy the benefits of Colostrum and prevent many infant feeding problems. Hunan milk contains a host of dynamic and unique feeding properties. Studies have demonstrated that the health benefits of breast milk are associated with how long an infant receive it and whether breast milk is given exclusively or supplemented with other feedings (Jane et al., 2002;Abd-Allah et al., 2017).
The advantages of breastfeeding are more than just the advantages of feeding a baby on breast milk.
Breastfeeding protects a mother's health in several ways and can benefit the whole family, and society (Oddy, 2002). Education of mother about breastfeeding will increase the like-hood of successful breastfeeding experience. Breastfeeding is not instinctive, it is learned. It is a natural process, but takes "Know-How". Ideally, each breastfeeding mother should have a breastfeeding evaluation to determine any knowledge deficit and acknowledge. For breastfeeding, teaching topics include comfortable position, appropriate techniques, feeding frequency, the letdown reflex, care of breast, and length of feeding (Davidson et al., 2008;Abd-Allah et al., 2017).
Breast engorgement is considered among the most significant problems encountered in the 1st week of motherhood (Blck et al., 2007). Breast engorgement is stated as enlarged and filling of the breasts with milk. Lactation literature refers to engorgement as the physiologic condition characterized by the painful swelling of the breasts associated with sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema during the first two weeks following birth. Engorgement is a normal physiologic process with a progression of events, not a result of trauma or injury to tissues (Walker, 2010;Hassan, 2011).
Breast engorgement is one of the most common minor discomforts confronting nursing women after delivery, especially Primiparous. As a result of increased blood supply to the breast, it causes swelling of the tissue surrounding the milk ducts. The duct may be pinched shut so that the milk does not flow (Wilson & Lowdermilk, 2006;and Riordan & Hoover, 2005). The breasts are firm, tinder, swollen & hot and they are throbbing. The skin is taut, shiny, or transparent and low-grade fever. The tenderness & swelling may extend into the axilla. The areola is firm and the nipple may flatten, and the areola is too hard to grasp, making it difficult for a newborn to latch on (Wilson & Lowdermilk, 2006;Mohrbacher et al., 1997).
Some degree of breast engorgement is normal. Minimal or no engorgement in the first week postpartum has been associated with insufficient milk, early supplementation, and a higher percentage of breastfeeding decline in the early weeks. Women with mild to moderate hypoplastic breasts with a wide intramammary space (>1 inch) and a tubular shape are at particular risk for producing less than 50 % of 37 Published by SCHOLINK INC. Assess the women with breast engorgement among a group of breastfeeding women delivered the caesarian section.

Research Questions
1) What is the Knowledge adequacy regarding breastfeeding among primiparous women with cesarean section in Upper Egypt?
2) What is the competence of breast-feeding practices among primiparous women with cesarean section in Upper Egypt?
3) What is the prevalence and degrees of severity of breast engorgement among a group of breastfeeding women delivered the caesarian section? 4) Is breast engorgement among a group of breastfeeding women delivered the caesarian section will be affected by women's knowledge and practices of breastfeeding? Total study subjects of 90 primiparous parturient women who delivered by caesarian section and suffer from breast engorgement for a period of 6 months were included in the study from the previously mentioned setting with the following criteria; Free from medical disease which interferes with breastfeeding (infectious disease as active pulmonary tuberculosis), Initiate breastfeeding, Her baby is normal.

Tools of Data Collection:
Three tools were used to collect the necessary data about the study subjects as the following: Tool (1): A specialized designed structured interview schedule was developed based on the review of currently related literature and used by the researcher to collect the necessary data about the study subjects. It comprised of two main parts:

Part (A): A structured interview questioner:
1) Included the general characteristics of the study subjects such as name, age, residence, address, phone number, educational level, type of family, family income, occupation.
2) Antenatal assessment sheet to assess antenatal care during the last pregnancy.

Part (B): Knowledge assessment sheet:
1) It included questions related to women's Knowledge regarding breastfeeding. www.scholink.org/ojs/index.php/csm Communication, Society and Media Vol. 3, No. 2, 2020 38 Published by SCHOLINK INC. 2) Also, included questions related to women's Knowledge regarding breast engorgement concerning its definition, causes, signs & symptoms, complications as well as practices for its management.
Scoring System for women's Knowledge: Puerperal women's Knowledge about breast feeding and breast engorgement. The answers to the questions were divided into two categories; these were a correct and incorrect answer.
The correct answers were predetermined according to literature and the questions were coded accordingly. Each knowledge question was given a score and the total score for knowledge regarding breastfeeding and breast engorgement was obtained for each study subject. The possible range for the score was from zero to 100 for Knowledge regarding breastfeeding, while it was from zero to 30 regarding breast engorgement. Women's total score of knowledge was classified as follows:  If ≥ 75 % correct answer = Good Score.
Tool (2): Breastfeeding assessment: It comprised of two main parts:

Part (A): Observational checklist:
It contains items related to proper breastfeeding technique as the initiation of breastfeeding, the technique used in breastfeeding, duration of breastfeeding, unilateral or bilateral breastfeeding, rooming-in, method of nipple withdrawal, and the number of breastfeeding per day.

Part (B): Breast Feeding Assessment:
During the birthing unit stay, the researcher, carefully, monitor the progress of the breastfeeding pair. A systematic assessment of several breastfeeding episodes provides the opportunity to teach the new mother about lactation and the breastfeeding process, provide anticipatory guidance, and evaluate the need of follow up care after discharge. Criteria for evaluating a breastfeeding session include maternal & infant cues, latch on, position, and let down, nipple condition, infant response, and maternal response.
The literature provides a previous tool to guide the assessment and documentation of breastfeeding efforts (Orshan, 2008 (3): Total (T) = redness + pain + edema + pyrexia.
The degree of breast engorgement was estimated according to the following:  Sever breast engorgement if T ≥ 12 .

Operational Design
The study to be completed was passed through different phases as follows: Preparatory phase then the pilot study and the field work.

2.2.1Preparatory Phase
Tools development:-The tools of data collection were developed by the researcher after extensive review of recent and related literature.

Ethical Considerations:
 The researcher took consent from women included participating in the study.
 The researcher tools didn't embarrass of modesty and didn't cause any harm or pain for the participant women.
 The researcher tools didn't cause any physical, psychological and social risk.
 The participant has the right to withdraw at any time.

Pilot Study
A pilot study was carried out on 10% of women (18 cases) who were excluded from the sample to ascertain their clarity, estimated time, efficiency and applicability and the necessary changes were undertaken.

Field Work (Procedure):
The researcher selects lactating cesarean women who fulfilled the criteria. The researcher explained the purpose of the study to every woman, and then her consent to participate in the study was obtained. Each interview was conducted individually and in total privacy to assure that information to be obtained will be confidential and will be used only for research purpose.
Six days per week specified for data collection until the study sample completed for 6 months starting from January till June 2010. Women attended to the postnatal ward were interviewed. The average number of the interviewee was 1-3 per day and the time taken for each sheet to complete was 50-60 minutes, depending upon the response of interviewee.
The study proceeds as the following: A. The whole primiparous cesarean women were interviewed by the researcher during the first 12 hours after delivery to find out the general characteristics of the sample and assess their knowledge about breastfeeding and breast engorgement. Also, the condition of their breasts was assessed during the initial interview according to the pre-designed checklist which is used in Newton's Scale. This assessment was considered as the base-line measurement of chest circumference.
B. The whole sample (90 lactating women) that was suffered from breast engorgement. They were interviewed by the researcher in the 3rd postnatal day to identify their current signs, symptoms and complain (base-line data of the participants).

Administrative Design
Official permission to conduct the study was obtained from responsible authorities after an explanation of the purpose of the study.

Statistical Design
The data collected were computerized, revised, categorized, tabulated, analyzed, and presented in descriptive and associated statistical form using the statistical software SPSS. The necessary tables were then prepared and statistical formulas were used. The following statistical measures were used: A. Descriptive measures included percentages, arithmetic mean (x-), and standard deviation (SD).

B. Statistical tests included:
1) Chi-square (X2) test for analysis of qualitative variables.
2) r test for analysis of correlation association.

C.
Graphical presentation included Column-chart diagrams.

D.
The level of significance selected for this study was P equal to or less than 0.05. Considering the type of family, it was observed that 51.1% of studied subjects had extended family.

Result
Concerning to family income, it was observed from the same table that 57.8% of the studied women didn't have enough family income.
As shown in Table 2; 70.0% & 17.8% of the studied women did not have nor had less than 4 visits for follow-up during their last pregnancy. No one of them performed breast preparation during their pregnancy. Moreover, a sizable proportion of the subject (92.2%) did not receive any information about breastfeeding and breast care and problems associated with breastfeeding during antenatal follow-up visits.
It was found in Table 3    It is observed in Table 5 that only 3.3% of the studied women initiated breastfeeding in the first postpartum day, immediately after recovery from delivery. Furthermore, all babies for subjects (100%) took prelacted feeds as glucose or sweetened water. Fortuity, all of the subjects in our setting reported the practice rooming-in for breastfeeding. When the method of nipple withdrawal was checked among the mothers, the result was that the majority and similar proportion of them (75.6%) usually pull the nipple out from the infant's mouth. It was observed that moderate engorgement scored the highest percentage (45.6%) for the studied group.  Table 6 illustrates a strong significant negative correlation association was found between the degree of breast engorgement and the age (r = -0.75) & age of marriage (r = -0.75) for the studied women. The percent of women who were able to read & write, or had basic education (2.5 ± 0.65) had got a high level of engorgement. The same table illustrates that the level of breast engorgement increased in urban areas (2.3 ± 0.7) compared to rural ones (1.82 ± 0.65). Also, a strong significant negative correlation association was found between the degree of breast engorgement and family income for both the study and control sample, respectively, r = -0.87. Table 7 illustrates a strong significant negative correlation association between the degree of breast engorgement and the numbers of antenatal visits for the studied sample, r = -0.74. In addition, Strong significant negative correlation association was found between the degree of breast engorgement and their knowledge about breast engorgement, r = -0.86. Table 8 illustrates that the degree of engorgement increased with delaying initiation breast (r = + 0.75).
I addition, introducing nipple only into infant's mouth during feeding (r = + 0.82), and unilateral lactation (+ 0.76) had a higher degree of engorgement.

Discussion
Breast engorgement during the early puerperium is one of the most common causes of morbidity affecting functions and experience of early motherhood (Jelovesk, 2006). Breast engorgement is a physiological condition that is characterized by painful swelling of the breasts as a result of a sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema during the first two weeks following childbirth. This condition is caused by insufficient breastfeeding and/or obstruction in the milk ducts. Breast pain during breastfeeding is a common problem. The occurrence of such condition faced by the mother adds to her apprehension and anxiety may lead to other severe breastfeeding problems for mother with consequent discontinuation of breastfeeding or addition of supplements of animal milk/ commercial infant formula. Besides, negligence of breast engorgement may lead to certain serious complication such as mastitis and breast abscess (Fraser et al., 2004;Hanretty et al., 2003).
The present study was conducted to investigate the breastfeeding knowledge and practices among primiparous women with a cesarean section and its impact on breast engorgement in Upper Egypt.
The results of the study reveal that the socio-demographic and general characteristics of the subjects correlate, as expected, with the middle class of Egyptian society. Where the mean age of the participants was 23.25 ± 5.75 years, and the mean age of marriage was 21.62 ± 6.25 years old, and two fifths (40.0%) of them had secondary or technical education, most of them were housewives and more than one half of them were rural dwellers and live within extended families as usual for rural communities. Besides, most of them had unsatisfied income. Analyzing these data may help to understand and/or justify the prevalence of forthcoming results of the present study.
Concerning the utilization of antenatal care (ANC) services, WHO (1997) reported that, in developed countries, 97% of women received antenatal care as compared to 65% or less in developing countries.
The lack of an established convention for quantitative measurement of adequacy of ANC utilization and the paucity of research data addressing the comparability of available indices continued to hinder the ability of researchers and policymakers to conclude from ANC literature (Stewart & Hunts, 2004;Alexander & Kotelchuck, 1996).
In Egypt, the literature review developed by Nour (2007) also stressed the importance of follow up during pregnancy, and mentioned that pregnant women should visit the health care center according to the following schedule; the first or initial visit should be made as early as possible, the once every month through the first six months, then once each two weeks through the seventh and eighth months and every week during the ninth month until delivery. However, the expectant mother should attend the antenatal clinic if there is any abnormal variation (Farg, 2020;Hassan et al., 2020 "b").
Some traditional and cultural practices not only had prevented a large number of women from utilizing the maternity services but also had harmful effects on them, thus detracting from the value of ANC (Nylander & Adekunle, 1990). Although all literature had emphasized the importance of ANC, further analysis of the results of the present study indicated that only a minority of the studied subjects had utilized antenatal care services in their pregnancy. Yet, the majority of them didn't visit antenatal clinics or less than 4 times. A similar finding was reported in a study carried out in Egypt by Salem (2004). This study aimed to assess the pattern of utilization of antenatal care in Tanta. Another research in Egypt carried out by  who investigates the traditional practices among pregnant women to overcome their common minor discomforts during pregnancy in rural areas. A third work done by Ahmed (2004) added that the most of women ignored the importance of antenatal follow up, and thus had lack of antenatal follow-up visits Hassan et al., 2016;Hassan et al., 2020 "b" ;Sheha et al., 2020).
Regarding the relationship between utilization of ANC services by studied subjects in their last pregnancy and their degrees of breast engorgement, it was observed a significant strongly negative correlation between the number of antenatal visits done by mothers and their degrees of breast engorgement. All literature emphasizes the importance of antenatal education for pregnant women to avoid or decrease the incidence of complications during pregnancy, labor and the postpartum period.
During the antenatal period, the maternity nurse should provide the necessary information to a pregnant woman about pregnancy, delivery, and postpartum care. The most important information that should be given to women during the third trimester of pregnancy includes information about puerperium; breastfeeding technique and breast care for lactating mothers (Symonds & Symonds, 1998;Churchill, 1995;Sheha E., et al., 2018;Hassan et al., 2015;Farg and Hassan, 2019).
The results of the present study reveal an unacceptable finding where the majority of women did not receive any knowledge about breast care and breastfeeding problems. This may reflect the deficiencies in health institutions regarding their role in health education. Also, this is probably because the interest of antenatal clinic focuses mainly on serious cases and neglects health teaching about such subjects for pregnant woman, especially primiparae.
On investigation of women's knowledge about breastfeeding practices, the results of the present study revealed an overall lack of knowledge concerning the different variables that were studied. This is probably because primiparous usually lack knowledge and experience. Moreover, more than half of the samples were rural citizens with limited educational background & inadequate income. The finding of the present study is supported by (Sallem & Mahzuz, 1998;Reghab, 1996) who mentioned that women with poor knowledge are vulnerable to reproductive health problems because of lack of information and access to health services. The information helps women to understand how their bodies work, dispel myths and correct inaccuracies.
More elaborate analysis of the knowledge components related to the baby's benefits of breastfeeding shows that 17.7% of the studied group mentioned correctly and complete answer. As regard value of breastfeeding for mother, only 10.0% of the studied group stated a correct and complete answer. Also, only 4.4% of them mentioned correct and complete answer regarding society's value of breastfeeding.
This shows that not all of them were fully aware of the benefits of breastfeeding. Grant (1992) reported that breastfeeding saves lives, breast milk is ideal reflect food for infants, prevents diarrhea, confer immunity, helping to space births, lower the mother's risk of breast and ovarian cancer and reduces chances of fetal post-partum hemorrhage, promote bounding. Many authors stated that women were choosing breastfeeding, not because of cultures influences, but because of knowledge on the benefits for both the mothers and the infant (Nikodem, 2006;Singh et al., 2003;Ip et al., 2008).
The American College of Obstetricians and Gynecologists (ACOG, 2007) encourages health professionals to support women in attempts to establish and continue breastfeeding. The American Academy of Pediatrics (AAP, 2005) recommends that infants are breastfed for at least the first 6 months of life. Obstetricians have unique access to women as they prepare for childbearing. During the months preceding birth, physicians may be able to influence breastfeeding practices by educating and encouraging patients (Wambach et al., 2005).
Concerning the constitutions of colostrum and its value, more than one quarter (28.9%) of the studied group responded completely correct acknowledging about colostrum. The colostrum meets the newborn's total requirements for the first days and it is very rich in protective factors, rich in calories, contains more protein and vitamin A than mature milk, very rich in immunoglobulin as well as immune factors protecting against many bacteria and viruses and acts as laxative (UNICEF/WHO, 1993).
Most nursing and midwifery texts reported that breastfeeding technique should be corrected, with an improved attachment of the newborn to the breast, otherwise may develop and breast become more firm, painful and hot, and fever is usually present "engorgement" (Burroughs et al., 2002). The results of the present study reveal that no one of the studied group had correct and complete knowledge about the steps of breastfeeding. Moreover, the majority of them did not have correct and complete knowledge about positions of breastfeeding. Ministry of Health (2000) and Smith & Farces (2000) reported the improper positioning of the neonate on the nipple also usually causes sore nipple.
Correcting the baby's position on the breast is the most important tactic for prevention and relief of sore nipples.
Literature emphasized the importance of a mother to know infant hunger and satiety cues (Davidson et al., 2008, Leifer, 2003AAP, 2005). The results of the present study illustrated that the majority of women did not have correct and complete knowledge regarding infant hunger cues. Moreover, no one of them had correct and complete knowledge of infant satiety cues. Again this is probably because all of the participants were primiparous with limited educational background.
The present study indicates that women lacked basic knowledge regarding breast engorgement.

Concerning women's knowledge about causes and signs & symptoms of breast engorgement after birth,
the result of the present study revealed that the majority of women in the studied group were unaware of the causes and complications of breast engorgement. This finding may attribute to the fact that all of the participants were primiparous who usually lack knowledge and experience in motherhood crafts.
This assumption has been supported by many literature reviews since they indicate that breast engorgement is one of the most common minor discomforts confronting nursing women after birth either because the lack of knowledge or because they were not properly prepared during antenatal period or early postpartum period. Moreover, this is probably because many of them were from rural areas that do not usually have good access to care and information (Friel & Hodson, 1991).
Concerning breastfeeding knowledge, findings of the present study revealed many prevalent misconception and wrong believes among the sample. The majority of the studied women had unsatisfactory scores. This means that the sample does not know enough about breastfeeding. This is evident from the very poor knowledge demonstrated by mothers. On the other hand, although about one-fifth of women had a university education, yet, this did not have an impact on their breastfeeding knowledge and practices. Baumslag (1989)

Another important part of knowledge is the women's sources of information about breastfeeding and its
problems. The results of the present study showed that Traditional Birth Attendance (TBAs) was the first sources of knowledge, followed by mothers and/or mother-in-law, friends and/or neighbors and the least sources were the professional sources (doctor, nurses) and mass media. This was not amazing since all the studied subjects were from Upper Egypt and almost of them lived in rural areas, were housewives, had large and extended families, were married before the age of 20 years old and had not enough family income. So, they tended to consult older experienced women as well as friends and relatives. Also, this result may reflect how much peers and friends can affect or form one's knowledge regarding important health issues and/or practices such as breastfeeding. It is well known that receiving information from wrong sources is just as bad as ignorance (WHO, 1997). Isabirye (1990) stated that a support group for breastfeeding mothers can provide valuable information and suggestions for breastfeeding. The mothers, commitment to breastfeeding and the support from her partner, family, and friends greatly increase the chances of success. May (1990) mentioned that a recent study of Mexican and Mexican-American women found that only significant interpersonal influence on feeding decision was that the husband and/or partner. If the grandmother is an important family figure, she also should be included in teaching. In this way, important people who may significantly affect the course of breastfeeding can gain information and confidence. This may subsequently lead to more available support for nursing mothers.
Traditional Birth Attendance (TBAs) is considered a community leader and a trustful person for most women, especially in rural areas. They seek her advice in all matters related to reproduction, sexuality, family planning, and even marital problems. Abd-el-Twab et al. (2000) in Raedat Ryfyate Project was activated and intended to train them to help them to provide helpful and sound care to their client as well as to equip them by the necessary and correct scientific knowledge regarding all related aspects of care. Also, a study in the United Kingdom by Liburd (1998) revealed that midwives had been identified as the highest sources of information.
On the other hand, it was striking to find out that health professionals (doctors, nurses) had the least rank as a source of knowledge to the participants in this study which explains the low level and unsatisfactory score of knowledge about breastfeeding and breast engorgement. Needless to say, those health professionals are the most important resource person within the reproductive health team. Kharboush (1992) reported that physicians and nurses were the most trustable source of breastfeeding information to mothers in Damanhour. In Ismailia, similar findings were obtained. They are qualified to provide women with the necessary knowledge and guidance that help them to accept the post-partum period with its physical and psychological changes as normal and non-pathologic events and to maintain healthy practices during this period to fulfill important objectives such as prevention of infection. Therefore, health education for women during maternity cycle is considered an important component of maternity care within all maternal and child health centers as well as rural health units.
However, the role of mass media in different health issues especially reproductive health matters should always be highlighted stressed and activated (Mohamed et al., 2020;Gamel et al., 2019).
Mass media is a very beneficial and effective way to disseminate correct awareness among the population at large and specific or targeted sectors of the community in particular. It plays a major role in shaping the development of the future generation. This important and key role should be used to provide the correct and the most needed information about pregnancy, childbirth, and postpartum care and to improve the level of awareness among people in the community. Health education campaigns are also effective channels for promoting the use of health care services and can contribute to healthy behaviors that prevent illness and improve the quality of life and decrease the cost of illness. Such health education campaigns should pay special attention to peer groups since they have a great impact on the dissemination of knowledge (Bonner, 2001).
The second important part of the study deals with breastfeeding practices among breastfeeding mothers.
In general, many researches indicate that the incidence of breast engorgement was not influenced by the duration, frequency, and technique of breastfeeding. Other interventions, such as providing the mother with guidance and support on positioning and latching, and modification of hospital practices may be more effective in reducing breast problems. Therefore, postnatal education is vital for new  (Pavan & Davanzo, 1999;Duffy, 1997).
According to the results of the present study, it was observed that breastfeeding practices were worse than breastfeeding knowledge in both groups. Breastfeeding is recognized to be important for both mothers and baby. Effective breastfeeding is influenced by many factors which include antenatal care practices, the time of the first feed, positioning, timing and duration, supplements for babies and mothers and support for breastfeeding mothers. All of these factors can affect the establishment and maintenance of breastfeeding. Many of the above-mentioned breastfeeding problems that confront women trying to breastfeed their babies are avoidable through access to accurate information.
Appropriate and practical help and support, when they need it, are effective (Neifert, 1999).
Early initiation is important; WHO (2001) emphasized it within the first half an hour after delivery. The establishment and maintenance of breastfeeding should be one of the major goals of good postpartum care. It is recommended that the baby is given to the mother to hold immediately after birth, to improve skin-to-skin contact and for the baby to start suckling as soon as he shows signs of readiness-normally within 1/2 -1 hour after birth. Spontaneous suckling may not occur until 45 minutes to 2 hours after birth, but skin-to-skin contact can start earlier. Numerous studies have demonstrated that a period of early mother-infant contact postpartum is effective in increasing the incidence and/or duration of breastfeeding.
Initiation rates for breastfeeding remain high in most developing countries and may not be decreasing as fast as has been feared (Savage, 1990). The present study indicated that the majority of mothers started breastfeeding after the first day. This is because women delivered by cesarean section usually postpone the initiation of breastfeeding as they have pain which interferes or limit them from the process. This is serious because all literature and researchers, AL-Hussein (1992), Alexandria (1991), and Ismailia (1993), emphasized the importance of early initiation of lactation within 50-60 minutes after delivery to prevent the occurrence of breastfeeding problems.
The initiation and establishment of breastfeeding immediately following birth are crucial to increase breastfeeding. However, Wahba (1991) reported that almost all mothers initiated breastfeeding on the third day after delivery. Agency for international development (1990) stated that delayed initiation of breastfeeding is a common practice in both urban and rural areas worldwide. In urban hospitals, breastfeeding initiation is often delayed several hours after delivery, during that time glucose, water or infant formula may be given. There is a great need for health care providers to know more about the early initiation of breastfeeding.
It was observed from the study that, the degree of breast engorgement was higher among women who delayed initiation of breastfeeding than those who had initiated earlier. Furthermore, a significant strong positive correlation was observed between women's initiation of breastfeeding and their degree of breast engorgement. This result is in line with Yamauchi (1992) who mentioned that early initiation of breastfeeding reduces the occurrence of sore-cracked nipples and breastfeeding problems. Moreover, Newton and Newton (1951) reported that, mother's experience less severe form of engorgement with early feeding. Also, the results of the studies of Artola and Jimenez (1990) and Essawy and Ahmed (1998) revealed that most mothers who initiated breastfeeding early eventually protected themselves from breastfeeding problems. Ultimately, they continued lactation for up to one year of their infant's age compared to those who initiated breastfeeding at later times and thus continued breastfeeding for only 5-9 months of their infant's age.
Concerning hospital practices, the present study showed that many negative hospital practices regarding breastfeeding were prevalent in our Egyptian public hospitals. One of the most common prevalent errors in hospital practices is the use of prelacted feeds. Glucose has been reported by previous studies as being common prelacted feeds (Mishriky & Barrima, 1993). In the present study, the findings reveal that all babies for subjects took prelacted feeds as glucose or sweetened water. Kharboush (1992) found that the most frequently using decoction includes sweetened water and glucose. To compare with health care providers practices EL-Sahwi et al. (1991) reported that the majority of physicians in their sample were using sugar and water as the prelacted feeds given to babies. Brady (1990) indicated that prelacted feeds are physiologically unnecessary for either the nutrition or the hydration of normal babies because a healthy baby does not need extra fluid or foods before breastfeeding is established, and it may harmful because it will interfere with appetite and desire of the baby to suckle. Babies who have had their appetite satisfied with an artificial feed may lose interest in trying to breastfeed. Consequently, they may delay the onset of lactation. Prelacted feeds may also introduce infection because the baby is not protected by the anti-infective factors which are concentrated in the colostrum (UNICEF UK, 1999).
Another important part of breastfeeding practices is managing the system of feeding properly.
On-demand feeding program facilitates each baby's rhythm and may be less traumatic to the mother's nipples while not causing excessive weight gain (Nikodem, 2006;Davidson et al., 2008). Demand feeding is critical for the establishment of good breast milk supply. This has been called responsive feeding, or breast on request. May (1990) indicated that rigid feeding schedules, substitutions of other liquids of breast milk, and delaying feeding will gradually decrease the supply of milk.
Regarding the frequency and duration of breastfeeding, times/day, the finding of this study revealed that, more than one third (35.6%) of the study sample breastfeed their infants less than 3 times/day, and about one half (48.9%) of them feed their infants less than 10 minutes/day. This disappointing observation is serious because all literature reviews emphasized the importance of nursing "on-demand". Newborns need to nurse frequently at least every two hours, and not on any strict schedule, this will stimulate the mother's breast to produce plenty of milk. Later, the baby can settle into a more predictable routine. However, because breast milk is more easily digested than the formula, breast-fed babies often eat more frequently than bottle-fed babies (Aarts, 2004;Nikodem, 2006). Baunmslag (1989) reported that most research findings showed higher rates and longer duration of breastfeeding in rural areas. Kharboush (1992), Henagel (1989) and Okhasha (2000) supported the same findings. In brief, most infants born at term feed 8-10 times a day for approximately 20 minutes (Eglash et al., 2008;Komar, et al., 2007;Kramer et al., 2001).
It was observed that the degree of breast engorgement was less among women who breastfed 8-12 times/day. A strongly negative correlation was observed between the frequency of breastfeeding and degree breast engorgement. This result is not incongruence with Newton & Newton (1951) who stated that, mother's experience less severe form of engorgement with frequent, self-demand feeding and unlimited suckling times. Short frequent feeds were shown to increase engorgement in a study performed by , probably because abbreviated feeds (as short as two minutes) did not allow sufficient drainage of the breast as preventing milk accumulation.
Hospital practices such as rooming-in have been shown to improve breastfeeding success. However, it has been a common practice in many hospitals to separate mothers and babies and put the babies in a nursery, to allow the mothers to rest and to be observed. No advantages have been proven and outbreaks of infection in nurseries are associated with these practices. The results of this study illustrated that all of the subjects in our setting reported the practice rooming-in. This result is in accordance with all literature which focuses on room-in (Komara, et al., 2007;Ford & Simpson, 2008;Pillitteri, 2003). Furthermore, Shiau (1997) demonstrated significantly less engorgement on day three in mothers who participate in the skin to skincare of their full-term babies rather than standard nursery care. Fortunately, most of our general & public hospitals, especially in rural areas are not equipped by available separate room for newborn babies. Rooming-in practices varied from one place to another.
Another study reported that the majority of mothers 89.35% and babies were rooming in confirmed by Kharbouch (1992) in Damanhour. Rooming-in has several important advantages. It facilitated bounding, permits breastfeeding on demand and allows for closer contact with other family members. Restricted mother-infant contact after delivery results in significantly more frequent discontinuation of breastfeeding at 1-3 months (pediatric advisor, 2009). It is also in line with Salhan (2007) who mentioned that more Prolactin is produced at night, so breastfeeding at night is especially helpful for keeping up milk supply.
Breastfeeding is not supposed to hurt. Poor positioning and latch-on are the most common causes of breast problems in the early weeks of nursing. Sometimes only a minor adjustment of positioning and latch-on are all that is needed. Correct position of the baby during breastfeeding plays a crucial role in www.scholink.org/ojs/index.php/csm Communication, Society and Media Vol. 3, No. 2, 2020 66 Published by SCHOLINK INC. both the prevention of sore nipples and the successful establishment of breastfeeding. Professionals must understand the underlying mechanisms of suckling and acquire the skill and experience to help a mother to position her baby correctly before they can be a real value to the mother (Hahn, 2006;Kramer et al., 2001). A proper latch-on is crucial to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who do not know what a proper latch-on is. The trick of breastfeeding is getting the baby to latch-on well. A baby, who latches-on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch baby will not get much milk. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods and may lead to engorgement of breasts, which become heavier, firmer inconsistency, thus aggravating the pain (Newman, 2006;Kramer et al., 2001).
Unfortunately, the results of the present study reveal that almost all of the subjects introduce the nipple only into the infant's mouth during breastfeeding. This result completely contradicts the literature review which emphasizes that correct positioning of the nipple is essential to prevent sore nipples: the whole areola should be well into the mouth, above the tongue, so that the gums can perform the essential driving action. A proper latch is a key to easy breastfeeding (ILCA, 2000). Shea (1998) attributed to lack of knowledge of the basic skills concerning breastfeeding in some cultures to decades of public bottle feeding. The International Lactation Consultant Association (ILCA 2000) recommends that to prevent problems, women need sensitive and skilled assistance in learning to breastfeed, and follow up care should continue until their infants are breastfed effectively. It was observed from the study that, the degree of breast engorgement was higher among women who introduced nipple only to their baby during breastfeeding than those who introduced both nipple and areola. A significant strong positive correlation was observed between breast engorgement degree and part of the breast which introduced to baby's mouth. This comes in agreement with Righard and Alade (1992) who mentioned that, mother's experience less form of engorgement with babies who demonstrate correct sucking technique.
Looking into the technique of breastfeeding, the finding of the present study showed that most of the mothers did not know about alternating both breasts during each feeding. Around two-thirds of them use only one side to breastfeed their infant (unilateral). This means that mothers need to be aware of the importance and technique of breastfeeding. Similar results were drawn out from Damanhour (1992) study. Leifer (2003) and Davidson et al. (2008) indicated that both breasts should be used in each feed so that they could receive adequate stimulation. The mother should start on the breast that she ended with during the last feed. It was observed from the study that, the degree of breast engorgement was higher among women who introduced only one breast to their baby during breastfeeding than those who introduced both breasts. Furthermore, a significant strong positive correlation was observed www.scholink.org/ojs/index.php/csm Communication, Society and Media Vol. 3, No. 2, 2020 67 Published by SCHOLINK INC. between breast engorgement degree and breastfeeding practices (unilateral or bilateral). This result is in conceding with Livingstone (1996) who stated that milk stasis magnified if infants consume less milk, if less milk is pumped, as result, it may place a mother at high risk of engorgement.
When the method of nipple withdrawal was checked out among the subjects, the results revealed that the majority of women stated that they usually pull the nipple out of the infant's mouth. This result is incongruent with the literature review which indicates that the baby should be removed from the nipple either by pressing on his chin or by inserting a finger between his lips and the breast, so gradually releasing the vacuum. Roughly Pulling out the nipple from the baby's mouth especially before the end of a feed, would lead to nipple damage and crack (Nikodem, 2006;Davidson et al., 2008;Leifer, 2003).
A strongly positive correlation was found between breast engorgement degree and the method of nipple withdrawal from the infant's mouth after feeding.
Concerning the preparations for breastfeeding, Bobak (1993) stated that most women are motivated by the sixth or seventh month of pregnancy during ANC to learn about breast preparation and breastfeeding. Fikry (1980) reported that nurses should educate mothers about the importance of antenatal breast care and motivate them to do so. It is important to guide them to adopt the correct technique of breastfeeding. During the last two months of pregnancy, women should be taught that the nipples and areola should be washed, dried, and anointed each day. The same routine may be continued after the baby starts suckling (Ziemer & Pigeon, 1995). Kenner (1996) does not recommend nipple preparation technique for mothers with a history of preterm labor. Preparation should be done in the third trimester.
Every postpartum woman needs to care for her breasts and keep them clean. The breasts should be washed at the beginning of the shower each day. Women who are breastfeeding use no soap on the nipples, to prevent drying and cracking. The woman can use disposable pads in her bra to absorb the excess moisture. These should be changed frequently to prevent infection (Mustafa, 2005). Keeping the nipples clean between feeding helps prevent tissue damage, and wearing a good bra provides necessary support as the breast size increase (WHO, 1999). Results of the present study illustrated that all and the majority of the studied sample had no idea either about breast preparation or breast care during pregnancy. It was not amazing as most of the subjects never visited antenatal clinics or follow up on their pregnancy. Also, their main source of information was TBAs. Kenner (1996), Bobak (1993), and UNICEF (1993) mentioned that usually, the breasts require no care other than daily cleaning with clear water. The mother should avoid using soap on her nipples because of its drying effect. Advise the mother to leave a drop of milk at the end of feed on the nipple. It was observed from the study that, the degree of breast engorgement was higher among women who didn't perform general and breast hygiene before feeding. A significant strong positive correlation was observed between breast engorgement degree and non-performance of general and breast hygiene before feeding. The present study clearly illustrates that all women suffer signs and symptoms (redness, pain, edema, and pyrexia) of breast engorgement. The results of the present study illustrate the degrees of breast engorgement. Studies have shown that 20%-85% of breastfeeding women experienced moderate and severe breast engorgement. The degree of engorgement usually lessens with each child. First-time mothers often suffer more from engorgement than women who are nursing their second or third child, because the time it takes for the mature milk to "come in" seems to shorten with each child.
When the relationship between certain characteristics of puerperal women and the degree of breast engorgement was investigated, it was revealed that younger women were less likely to develop high degree breast engorgement than older ones. Furthermore, a strongly negative correlation was observed between women's degree of breast engorgement and their age. This may be due to the fact that older primiparae are more likely to be concerned about their babies, thus they followed instructions more accurately and breastfed their babies appropriately. Lactational failure, however, leads to the absence of suckling and failure of ejection which may lead to engorgement and stasis of milk .
It was also evident from the results that better-educated women had less breast engorgement degree, while women with limited educational background had more breast engorgement degree. A strongly negative correlation was observed between women's degree of breast engorgement and their education.
This was expected since educated women are more likely to have better access to the community health care services and source of information that help in early detection and proper management of minor discomforts during puerperium. These results were in line with Hassan (2000). It was also mentioned that women who had been educated were open-minded to new ideas (Biennial report, 1996). In addition, this finding went hand with El-Sherbeni (1998) who emphasized on the importance of education in the prevention and control of maternity health problems. Moreover, education should be a mean that enables women to gain access to knowledge. The more educated women received a better contribution to their empowerment. Education of women could also improve the health of the entire family. Women with more education should also be able to control many events in their lives. Thereby, access to education had to be a fundamental human right and a prerequisite to social, cultural and economic well-being (Rowley, 1992;Gamel et al., 2020).
The results of the present study also revealed a strong positive correlation women's degree of breast engorgement and their occupation. It was no wonder to find housewives and rural women are less likely to develop a higher degree of breast engorgement. This was expected since housewives and rural citizens accept their role as lactating mothers and practice it accurately as they are guided. This is opposite to urban working ones who prepare themselves in the wrong way for employment. Salhan (2007), reported that to help the mothers to maintain breastfeeding while working, the nurse should www.scholink.org/ojs/index.php/csm emphasize to the mother that she must establish a good milk supply, plan how and where she will pump the breast at work as well as planning baby feeding during the mother's working time.
Regarding age at marriage of the studied subjects, the results of the present study presented that about two-thirds of the studied group married at age less than 20 years. Furthermore, a strongly negative correlation was noticed between women's age at marriage and women's degree of breast engorgement.
It was not surprising to find that younger women tend to have a higher degree of breast engorgement than older ones. This might be due to the fact that day by day life enhances women's experience and improves their knowledge. This result was considered by Ghulam (1979) who stated that early marriage could have a negative effect on the mother's education, and also her understanding of how to relieve the minor discomforts during pregnancy. This result was supported by the other researches which indicated the fact that early marriage and pregnancy had hindered women to finish their education and to get a good job and had become financially dependent on their family. Therefore, teen mothers were more likely to live in poverty than women who were in delayed childbearing age (PBWRC, 2000;Smith & Maurer, 2000). Moreover delaying age at marriage was a key to improving women's status and maybe a way of increasing their leverages in the decision-making the process (Ibrahim, Mensch, El Gibaly, 1998).
The results of the present study had also revealed a strongly negative correlation between women's degree of breast engorgement and their family income. Degree of breast engorgement was more prevalent among poor women as most women were likely lived in large and extended families. This increased family size might reduce the per capita income and amount of care the mother gained especially during her puerperium. This would affect badly on the mother's health and her health practices. This was in accordance with Abrams & Gordon (1961) and William (1967). Moreover, poverty, type, and size of the family might increase the burden on women caring for many persons and striving hard for a living (WHO, 1995). These results were supported by the Fourth world conference (1995) which denoted that statistics about women and poverty were all too familiar, where women were the majority of 1.3 billion people living in extreme poverty. Those poor women were more likely to live in crowded houses.

Conclusion
Based on the findings revealed by the present study, it can be concluded: The studied women's knowledge about breastfeeding was not adequate among the whole study sample.
Moreover, a sizable proportion of them lacked the basic knowledge regarding breast engorgement; they also lacked the experience in relation to the proper technique of breastfeeding, duration and number of feeding times/day. Their main sources of information were their family, friends, TBAs whereas the least sources of information were physician, nurse and mass media which explain the low level of knowledge. The degrees of severity of breast engorgement was higher with younger, less educated, working, urban, lower social classes women and those who had limited visits to antenatal clinic, who had limited knowledge about breast engorgement than others and, those who had an improper technique of breastfeeding.

Recommendations
In light of the results of the present study, the following recommendations are suggested: 1) Counseling as a practice and technique is vital and significant relevance in allowing the health professionals to have the opportunity of carrying out not only educational but also assistance actions in the common illnesses at the beginning of breastfeeding. Hence, The nurse should focus on prevention of breast engorgement by providing counseling to the mother about starting breastfeeding as soon as possible after the birth, to give the baby time to learn to breastfeed before the breasts become full and firm, avoid early use of bottles, once the milk comes in, and breastfeed at least eight times in 24 hours to prevent over fullness.
2) Small, informal group health education classes, delivered in the antenatal period, to provide women with accurate information about the importance of breastfeeding for the mother and baby, early initiation and proper technique of breastfeeding, and how to prevent the problem that may arise during the breastfeeding process.
3) Providing the mother with guidance and support on positioning and latching, and modification of hospital practices are effective in reducing breast problems. 4) Prevention is a key element in reducing breast engorgement potentially among nursing mothers. So, mothers should learn about preventive measures for breast engorgement. 5) Correct the negative hospital practices regarding prelacted feeds, especially with C.S delivery, which are prevalent in our Egyptian public hospitals.
6) Traditional birth attendants already form a considerable part of the basic core of primary health workers for the majority of the rural population in many developing countries. Therefore they should be trained and prepared in the field of health education to carry out effective health practices.