Table 1 indicates that the sample size included 12 mothers of infants aged between 8–24 months. Out of 12 mothers, four mothers exclusively breastfed their children for first six months, our mothers complementarily breast fed their children and four mother never breastfed their children. The mother’s age ranged from18-30 years. Four mothers each had primary and secondary education, while two mothers each had completed graduation and post-graduation. 10 mothers were homemakers and two mothers were working. Regarding gender of the child 7 were males and five females.
Figure 1 indicates the ecological frame determining the breastfeeding practices. The transcripts of the case studies indicated that the eco system involving infants, mother, husband, family and health care system determined the breastfeeding practices of mother.
Themes developed
Based on the transcripts five themes were developed ( Fig 2).
Theme I -Promoters vs Barriers
Seven subthemes were developed under the theme-I.
a) Mother’s and child’s health
The quote from mothers illustrates child’s illness can be a promoter or barrier for breastfeeding
You know, my son was born prematurely……He weighed 1,800 gm, as he was born 1 month early. He was so tiny, I was afraid to hold him. He could not suck well. But within two days, the baby was ill. He had jaundice……again was admitted to hospital for five days for jaundice treatment. I was not able to feed properly as a result milk production decreased. I had to feed cow’s milk at one month.
Another Mother quoted
I was very weak after delivery. My hemoglobin was very low. I used get fatigued very easily…..So, I had to feed top milk…
b) Cultural beliefs and attitudes (Feeding prelacteal feeds)
A mother who fed exclusively for six months quoted
My family members as a cultural practice insisted on giving honey. …Also my baby was very lean and not plump …….so, I always used to get worried. So my family members said to give gutti, so that he will gain weight…. But I always used to consults my doctor and took his advise. He said baby is fine. ..advised me not to feed any prelacteal feeds upto six months.
The quote of a mother who complementarily breastfed Illustrates
When elders came to see the baby for the first time after delivery, they give little honey. Also I have given gutti (Badam and cashew rubbed in milk) after 1month ... it makes the baby healthy and helps to gain weight. ….I have also fed with gripe water (laughs) …..Everybody gives it….. Even elders in the family advised….. Because it keeps the baby calm and baby sleeps well.
c) Physical feeding difficulties
Quote of a mother who fed bottle fed
I had a complicated delivery. My baby was delivered pulling out by hand….. the doctor’s say the nerve on one side is damaged….you know….was kept in ICU for 17 days. Though I had surplus milk I could not breast feed ……Slowly the milk production stopped because the stress. Later I was given tablets for milk production. But the baby got adjusted to formula. He refused breastmilk ……….though I made him suck milk. …so fed formula for 6 months
d) Roles and responsibilities
Quote of a Mother who practiced complementary feeding
You see this is my third delivery.….. My mother said this is not our responsibility. It is your in-laws responsibility…… The first two deliveries was at my Mother’s place. So, I was relaxed I could breast feed properly. But now….with three children, husband in private company, I had to take responsibility after 8 days after delivery. It was really… very difficult to feed properly.
e) Family/husband’s support
Quote of exclusively breast fed mother
My husband especially is very supportive… I only sometimes get involved in household work, he tells me to stop all work and first feed him. My mother and my husband tell me to first feed breast milk and then do other things.
f) Support of health personal
Another mother says
I had caesarean…. I was tired. My family members said milk will not be produced for three days. But my doctor advised me to feed immediately… she supported me and helped in initiating breastfeeding.
A second mother said
The doctors in local PHC counseled me on benefits of breastfeeding… She gave me a book called Safe Motherhood which motivated me to practice exclusive BF for six months.
Theme II-Idealism vs. Realism
Four subthemes were developed under the theme-II.
a) Portraying breastfeeding as natural phenomena
Illustration by a mother’s quote who practiced complementary breastfeeding and fed prelacteal feeds
Nobody told me… No doctor or Asha worker… I did not ask anybody….. But everybody knows that one should breast feed the baby. It is natural.
Another Mother said
My daughter is 15 months old she is the first baby… I am pregnant again…. 8th month running…….. smiles…… I was not told anything in the hospital and nobody suggested or guided me about breastfeeding. My mother-in-law says it is natural to feed and tells to feed now also. She says…… when the second baby is born……. first baby automatically stops feeding. ……… She insists me to feed now also.
b) Conflicting advice
Quote from a mother
I delivered the baby at local PHC in village. The baby coughed….. so they sent me to the main hospital……. They said the baby has respiratory infection and was kept in ICU…which was in first floor…. you know I was in ground floor. I don’t know what they fed the baby for three days. They did not allow me to breast feed. My parents argued…. with doctors and made me feed breast milk. So, the nurses said if anything happened, they are not responsible…. But I fed baby later and she recovered.
c) Promotion of Formula and other infant feeds
A mother who stopped breastfeeding within one month says,
My baby had jaundice, weighed 1800gm and was kept in ICU. The doctors and nurses fed him with formula in ICU. They said baby is at risk. If I feed, it is at our risk……So, I did not breast feed when he was in ICU.
Another mother said
I gave him gutti for 3 months. This is because it helps in baby’s growth. He will be health and there will be weight gain……you see (showed the gutti bottle of a popular brand) it is written here, it can be given from birth……
d) Judgemental Attitude of health Personnel
Illustration by a mother’s quote
They kept my baby in ICU, I became frantic, I had…normal delivery……My family and myself we were not knowing what was happening…….for two hours nothing was said… then they said you go to district hospital… for three days nobody is telling what is happening……not even I was allowed to breast feed…
A quote by another mother
This is my third child. She had a running nose. Suddenly she started vomiting at mid night. I went to hospital……my baby was admitted for 21 days. I did not know what treatment was given…They fed formula milk in ICU. I insisted on breastfeeding. The nurses in the hospital rudely told, this is your third child, you should have experience……
Theme III-Idealism vs Realism
The three subthemes developed under the theme-III are as follows.
a) Mother’s knowledge and attitude about breastfeeding
An exclusively fed mother said,
Breast milk is the only complete food for the baby, provides all nutrients, immunity……I have read……breast fed children will be intelligent. And specially for mother, our pregnancy weight will be reduced, avoids breast knots and Cancer…….Oh…specially avoids conceiving.
Quote from a mother practicing complementary breastfeeding
I don’t know much about the benefits ………I know it is the best food for babies.
A mother who did not breast feed all her three children said,
It’s ok if you cannot feed. I fed formula for 3-5months and the cow’s milk. There is no problem in formula. I don’t think it makes difference in development…
b) Ignorance about feeding mode, feeding schedule
A quote of an educated mother illustrates
Sometimes due to back ache… I used to feed only from one breast. So I had breast knots. Also I had more milk……my family members told me to squeeze milk and throw away. ….But my doctor advised that only breastfeeding from both the breasts is the only curative thing for all my problems.
Another mother said
I fed the baby the baby every 2-3 hours ……during night I did not feed much…may be once…
c) Knowledge and myths about foods to be consumed during pregnancy and lactation
A mother quoted
I was advised by my mother and mother-in-law to consume methy and other green leafy vegetables citrus fruits ………My family members said not to take Papaya, Jackfruit, Jamun fruit……I know nothing happens (smiles). But still I did not want to take chance. So I avoided. It was said that these foods cause heat and lead to miscarriage.
After delivery I was given Alvi (garden cress seeds), dry fruits laddu, sajjaka, soft rice, vermicelli. These food were given to give me strength and increase lactation. I was told to avoid hard rotis, brinjal, spices. Since I had a male baby, all my family members insisted not to drink more water. It is believed that it create problem during urination… But I consumed lot of water as advised by my doctor.
Another mother said
I was encouraged to take good fruits, vegetables, milk. But I did not take papaya, sesame, pumpkin, cluster beans, bengal gram and such thing which causes heat. They say it leads to miscarriage
I was encouraged to take Alvi (garden cress seeds), methy seeds chutney, methy bhaji, dry fruit mixture immediately afterdelivery. I had caesarian, so I was not allowed to take green chillies and spices for 3 months. Also I did not take any acidic fruits…mmm…specially citrus fruits
Theme IV. A sense of satisfaction vs guilt
The two subthemes developed under the theme-IV are as follows.
a)An experience of breast fed mother
It helps in developing attachment and a kind of emotional bond with the baby…The emotions I experience when I held baby to my breast ……I don’t know how to express ……a special connection is established. I can feel in me that my baby feels secure and relaxed.
b)An experience of never breast fed mother
Oh!! It is the main essence of motherhood. I had that deprivation of motherhood. But what can I do…… I have to accept the situation and ……I had to feed with formula because it is my child’s life……But I really …really feel bad sometimes.
Theme V Normal development vs. developmental delay
The two subthemes developed under the theme-IV are as follows.
A quote from exclusively breast fed mother for six months and still feeding at 15 months
Smiles with sheer happiness……. At 7 months of age she told abba (father) and by 10 months she and started walking. She is very fast in all developmental milestones she is active, very calm and everybody in the family and neighborhood likes her. Now a she speaks everything…… And since ours is a joint family she sits with her elder siblings and tries to write and do what they do while studying.
A quote from formula fed mother
My son he is going to be one year old in two days…He has just started moving front by crawling. If we hold him he steps. He doesn’t speak anything………I can feel the difference…I have two daughters elder to him……I could feed them with breast milk ……my daughter’s were very fast. By this time…… they had started walking and also they talked at an early age…… I feel my son is bit slow compared to them. His growth is also slow and is little weak. He also responds less.
Qualitative analysis of present study thus shows that the support of husband, family and health personnel were the promoters of breastfeeding and the barriers were the cultural beliefs , roles and responsibilities of mothers , physical feeding difficulties like caesarean delivery , no or less than two antenatal visits , illness in infants and mothers. Titaley et al. (2014) and Meedya et al. (2010) also found that increased odds of delayed initiation of breastfeeding included caesarean-section deliveries and deliveries in government-owned facility and mothers with obstetric complication at childbirth.
The concept that breastfeeding is a natural phenomena and it is universal was endorsed by the study. Knowledge about breastfeeding, conflicting advice by health personnel and elders in the family, judgemental attitude of health personnel and promotion of formula and other prelacteal feeds by popular brands were also the determinants of breastfeeding practices in mothers.Similar results were found by Arya et al. (2015) where more than 50 per cent mothers had initiated breastfeeding within one hour and feeding prelacteal feeds was not uncommon.
Mothers’ knowledge regarding successful feeding practices had positive influence on initiation, exclusive breastfeeding and duration of breastfeeding. Myths and ignorance had negative influence on breastfeeding practices. The present study is consistent with results of Garg et al. (2016) and Mekuria et al. (2015) who also reported that the lactating mothers in who had good knowledge about breastfeeding practices practised successful breast feeding practices.
The results also indicate that the mothers who had breast fed their infants had a sense of deep satisfaction and felt that it increased the bonding, between the mother and child. The feeling that breastfeeding is the essence of motherhood was universal among mothers. However, the mothers who were not able to feed for various reasons felt a sense of guilt.
The experience of mothers with respect to the developmental progress indicated that most of the exclusively breast fed mothers perceived that their children had normal development or they felt they were ahead compared to the other children of the same age group. However, complementarily fed and never breast fed mothers perceived the development of their children as a bit slow compared to their counterparts and also with the elder siblings in the family. Der et al. (2006) also observed that one standard deviation advantage in maternal IQ more than doubled the odds of breastfeeding.
Thus the qualitative study clearly projects that most common factors for improper breastfeeding practices, prelacteal feeding, delayed initiation of breastfeeding continues to be family customs and cultural practices .This highlights the need that all the family members, particularly the elderly females and husbands to be included in awareness and training programs. Training of health workers and volunteers should focus on counseling rather than just giving messages.