"Everybody breastfeeds if they have milk": factors that shape exclusive breastfeeding practices in informal settlements of Mumbai, India

Beyond Public Health and Private Choice: Breastfeeding, Embodiment and Public Health Ethics

The key objective of this paper is to emphasize the importance of acknowledging breastfeeding as an embodied social practice within interventions related to breastfeeding and lactation and illustrate how this recognition holds implications for public health ethics debates. Recent scholarship has shown that breastfeeding and lactation support interventions undermine women's autonomy. However, substantial discourse is required to determine how to align with public health goals while also recognizing the embodied experiences of breastfeeding and lactating individuals. Presently, interventions in this realm predominantly revolve around health-related messaging and the promotion of individual behaviors, often neglecting the systemic and structural factors that influence choices and practices. I closely examine breastfeeding interventions in India, in particular Mothers' Absolute Affection health promotion program, along with breastfeeding narratives. I argue that for such interventions to evolve, they must acknowledge the intrinsic embodied social nature of breastfeeding during their design and implementation. Furthermore, it is important to emphasize that achieving equity and justice objectives necessitates moving beyond the confines of both conventional public health frameworks and frameworks solely centered on private choices. Instead, a more encompassing approach that embraces the concept of embodiment should be adopted.

Breastfeeding challenges and the impact of social support in Iranian Muslim mothers: A cross-sectional study

Breast milk is the perfect food during infancy. Adequate support from family and health systems can be helpful to continue breastfeeding. This study aimed to determine the status of breastfeeding challenges and its relationship with social support and socio-demographic factors. In this correlational-descriptive study, 348 breastfeeding mothers were recruited using cluster random sampling from health care centers in Tabriz, Iran in 2022. Socio-demographic, breastfeeding challenges and social support questionnaires were used for data collection. Data were analyzed for descriptive and inferential statistics (Pearson correlation tests, independent t-test, one-way ANOVA and general linear model) using SPSS version 16. Difficulty in completing household tasks and breastfeeding at the same time (32.5 percent) was the most common challenge reported by mothers. There was an inverse and significant correlation between perceived social support and experiencing challenges (r = -0.199؛ p = .001). Based on the adjusted general linear model, with increasing social support, the score of breastfeeding challenges decreased (B = -0.165; 95 percent CI: -0.07-0.25, p < .001). Considering the relationship between perceived social support and the challenges experienced during breastfeeding, it can be concluded that adequate support from family along with training and guidance from health care providers can lead women to have better breastfeeding experiences and overcome breastfeeding problems.

Barriers in exclusive breastfeeding encountered by mothers in urban slum area of a metropolitan city

Background

Breastfeeding is considered the most important source of nutrients for the baby. But owing to ignorance, lack of education, and cultural norms, exclusive breastfeeding (EBF) is not done by majority of the mothers. Hence, this study is carried out to determine various barriers faced by the mothers that influenced their decision on EBF.

Methods

A descriptive qualitative study was conducted among the mothers whose children were less than 1 year of age visiting a well-baby clinic and Immunisation OPD of Urban Health Centre catering to the Urban Slum of Malvani in the Metropolitan city of Mumbai. In-depth interviews (IDIs) were done with 17 participants from August to November 2022. Thematic analysis was conducted on the qualitative data obtained.

Results

Four major themes were generated from the transcripts. They are -barriers and concerns faced by mothers to exclusively breastfeed, enablers/motivators, sources of knowledge regarding EBF, and breastfeeding practices. Various barriers faced by mothers were gaps in knowledge, maternal Illness, religious reasons, inadequate milk production, bias toward top feeds, lack of autonomy to take decisions, and cultural norms, while positive family support, good knowledge about breastfeeding, and a supportive home environment motivated mothers to exclusively breastfeed their infants. Sources of knowledge were identified to be doctors and health care workers, mothers/mothers-in-law, sisters, friends, and social media.

Conclusions

There are various challenges as well as motivators identified for EBF. Barriers, such as gaps in knowledge, and the negative influence of social media can be improved upon by health education. Therefore, it is crucial to teach expectant mothers as well as families about breastfeeding. Additionally, we advise stepping up public health education initiatives to support breastfeeding.

Determinants of Infant Young Child Feeding Among Mothers of Malnourished Children in South Punjab, Pakistan: A Qualitative Study

Inadequate feeding is one of the most critical underlying determinants of child malnutrition. In this study, we explore infant young child feeding (IYCF) and deconstruct breastfeeding barriers in mothers of severely malnourished children in one of the most marginalized districts of Punjab province of Pakistan. Using purposive sampling, 20 lactating mothers are recruited for open-ended semi-structured interviews. Results reveal that barriers to immediate and exclusive breastfeeding include the introduction of pre-lacteal, butter, and cow or formula milk by mothers and grandmothers. Birthing difficulties and ritualizing prelacteal to transfer religion and culture cause the delay of early initiation of breastmilk. The colostrum is also discarded based on its weird physical look. Moreover, household circumstances, limited diet, extra workload, and mental stress associated with marital relationships are other significant barriers. Mothers perceive their breastmilk as thin, impotent, and of bad quality and often complain against breastmilk insufficiency due to general weakness. Furthermore, poor mothers reduce breastfeeding when the fertility burden is high, especially if a female baby is in their womb. Alternatively, outer milk is recommended but washing bottles with detergents often becomes frequent. In conclusion, immediacy, exclusivity, frequency, and duration of breastfeeding are circumscribed owing to multiple social, cultural, and economic causes. Therefore, a holistic approach combining cultural and structural causes might be more relevant for successful IYCF practices in marginalized communities of Pakistan.

Positive deviance in health and medical research on individual level outcomes - a review of methodology

BACKGROUND

Positive deviance as a methodology is increasing in application yet there is high variability in how this approach is applied in health services research.

METHODS

We conducted a scoping review of the literature for positive deviance applied to health outcomes informed by PRISMA-ScR. We searched the literature from 1945 to 2020, including articles on positive deviance or positive outliers, and restricted to examining individual rather than organizational outcomes. We analyzed the methodology applied including the process of identifying deviants, the use of control groups, and the degree of community engagement.

RESULTS

Our initial search identified 1140 manuscripts; we included 104 papers describing 98 studies, 11 topical and one miscellaneous category. Most studies used objective measures of health or survey-based responses to identify deviants from a sub-set of the population at risk. The use of controls was less common in some topics (hospital infections), whereas controls were universally applied in other topics (malnutrition). The degree of community engagement varied widely.

CONCLUSIONS

Positive deviance would benefit from improvements in reporting and standardized approaches to defining deviance. Studies could be improved through clarified definitions of deviance/risk, explicit descriptions of community engagement, and more consistent use of controls.

Breastfeeding practices among Syrian refugees in Turkey

Background

We evaluated (a) opinion of Syrian and Turkish healthcare workers (HCWs), and perceptions and attitudes of Syrian refugee mothers, pregnant women, fathers and grandmothers on age-appropriate breastfeeding, (b) the effect of cultural characteristics, migration and pandemics on Syrian’s infant nutrition, and (c) the suggestions of HCWs and Syrian family members to improve breastfeeding practices in the Syrian refugee society in a qualitative study.

Methods

The qualitative study consisting of structured focus group discussions (FGDs) was held in four provinces in Turkey where Syrian refugees live intensely in September and October 2020. Seven different types of online FGDs were held with Turkish HCWs working in maternity hospitals, Syrian HCWs working in Refugee Health Centers (RHCs), Syrian pregnant women, mothers, fathers, and grandmothers. In total, we carried out 46 FGDs with 335 individuals. Thematic analysis of the transcripts in a deductive-inductive fashion was carried out with MAXQDA 11.

Results

Most Syrian HCWs did not get any training on breastfeeding counseling. The short duration of breastfeeding in Syrian refugees was seen to be related to the cultural characteristics, and migration. Some cultural characteristics can be summarized as “believing that breastfeeding harms mother’s health”, “adolescent marriages”, “wanting to have as many children as possible”, “giving anise to infants and not breastfeeding at night”, “prelacteal feeding”, “believing that milk is not enough”, “over controlling mother–child interaction by grandmothers, which limits the interaction”, “short pregnancy intervals”, and “not using modern family planning techniques”. We found out that migration increased the tendency for adolescent pregnancies, deepened the poverty, and decreased family social support. We did not observe any change in breastfeeding practices during pandemics.

Conclusions

Breastfeeding counseling programs should be designed in consideration of cultural characteristics of Syrian HCWs and family members. Continuing health education programs for family members with socially appropriate interventions to prevent adolescent marriages are important.

Qualitative, longitudinal exploration of coping strategies and factors facilitating infant and young child feeding practices among mothers in rural Rwanda

Background

Mothers in low-income countries face many challenges to appropriately feed their children in the first year such as poverty, food insecurity and high workloads. However, even in the lowest income families there are mothers who succeed to feed their children according to the recommendations. In this paper, we explored the coping strategies that facilitate appropriate breastfeeding and complementary feeding practices among rural Rwandan mothers from birth to one year of a child’s life.

Methods

This qualitative longitudinal study recruited a purposive sample of 17 mothers who followed the infant and young child feeding recommendations (IYCF). They were selected from a larger study of 36 mothers. In-depth interviews were conducted with mothers of the total group (36 mothers) within the first week, at 4^th, 6^th, 9^th and 12^th months postpartum. Interviews were audio-recorded, transcribed verbatim and analyzed thematically.

Results

Coping strategies included improving mothers’ own diet for adequate breastmilk production, prioritizing child feeding over livelihood chores, livelihood diversification and mothers’ anticipatory behaviors such as preparing child’s food in advance. Some of those coping strategies were shifting overtime depending on the development of the children. Personal factors such as breastfeeding self-efficacy, religious beliefs and perceived benefits of breastfeeding were among the facilitating factors. Additionally, social support that mothers received from family members, other mothers in the community, Community Health Workers (CHWs) and health professionals played an important role.

Conclusion

In challenging contextual conditions, mothers manage to follow the recommended breastfeeding and complementary feeding practices through the interplay of active coping strategies, feeling to be in control and social support. Nutrition promotion interventions that aim to improve IYCF should consider strengthening mothers’ capability in gaining greater control of their IYCF practices and the factors facilitating their appropriate IYCF practices.

Life course learning experiences and infant feeding practices in rural Rwanda

Most studies about infant and young child feeding (IYCF) practices are often perceived as an individual choice depending on mothers' or caregivers' knowledge or attitudes and are focused on mothers' failure rather than successes in adequately feeding their children. However, the role of life course experiences in IYCF is less investigated. Applying a Salutogenic Model of Health, this study on 14 mothers looks at women's life course learning experiences shaping appropriate IYCF practices during the first year of child's life in a rural district of Rwanda. Transcripts from in‐depth interviews were analysed using thematic analysis. Results indicate that positive social interaction with parents or grandmothers during childhood such as sharing meals, parental role models for dietary choices and cooking skills gained by participating in household food preparation played a role in shaping appropriate IYCF practices. Negative experiences during childhood also had a positive influence on IYCF practices for some participants by converting life course constraints into learning opportunities. Motherhood increased mothers' sense of responsibility over their children's health and nutrition. Moreover, mothers' participation in community cooking classes and role modelling approach were strong avenues that enabled their learning through positive interactions and encouragement. Nutrition promotion interventions should consider tailoring nutrition advice to the complexity of mothers' life course experiences by creating opportunities for positive learning experiences of appropriate IYCF practices.

Reasons for the Early Introduction of Complementary Feeding to HIV-Exposed Infants in the Eastern Cape, South Africa: An Exploratory Qualitative Study

Exclusive breastfeeding has many health benefits for the baby and the mother. This study explored the reasons for the early introduction of supplementary feeding before six months, and the issues faced by parturient women in practicing exclusive breast feeding (EBF) for their HIV-exposed infants in the Eastern Cape, South Africa. Narratives from 319 parturient women with HIV (aged 18 years and above) were collected at three hospitals in the Eastern Cape through semi-structured interviews over a period of five months. Qualitative data were analysed using thematic content analysis. The maternal perception of HIV transmission from breast milk influenced the decision for the immediate introduction of formula feeding. Breast sores, lumps, surgery and perceived insufficiency of milk influenced the decision of mothers to initiate formula feeding within the first two months. However, mothers who initiated complementary feeding after two months were driven by factors common among newborns (refusal of breast milk, baby crying inconsolably and fear of losing weight) and social factors (economic or financial hardships and work-related challenges). Additionally, advice from family members weighed heavily in the decision to switch to complementary feeding, contrary to the healthcare providers' recommendations. Early complementary feeding for HIV-exposed infants is influenced by maternal perceptions of breast milk transmission, breast and infant factors and socio-economic and cultural practices in the region. Thus, behavioural interventions tailored towards promoting exclusive breastfeeding practices in this population, starting from the pre-natal and continuing during the post-partum period, should also target the immediate family members. National policy should focus on creating an EBF-friendly environment at the workplace for women.

Determinants of suboptimal breastfeeding in Haryana - An analysis of national family health survey-4 data

Background

Infant and child feeding practices are a prevalent challenge in Haryana.

Objectives

The present study aimed to determine factors associated with non-initiation of breastfeeding within 1 h of birth, no exclusive breastfeeding (EBF) and no continued breastfeeding in Haryana.

Methods

National Family Health Survey-4 data for the state of Haryana was used for analysis. The outcomes were non-initiation of breastfeeding within 1 h of birth, no EBF, and no continued breastfeeding. Independent variables were categorized as sociodemographic, maternal, and child level factors. Each category of factors was added step-by-step to the logistic regression model for multivariable analysis.

Results

Delayed initiation of breastfeeding was higher among poorer wealth quintiles. Home deliveries (adjusted odds ratio [AOR] = 1.90, 95% confidence interval [CI]-1.27-2.84), cesarean section (AOR = 2.22, 95% CI-1.46-3.40), body mass index (BMI) >25 kg/m² (AOR = 1.62, 95% CI-1.13-2.33), and not receiving postnatal check-up (AOR 1.36, 95% CI-1.40-1.78) increases likelihood of delayed initiation of breastfeeding beyond 1 h of birth. Increased risk of non-EBF was associated with no postnatal check-ups and BMI >25 kg/m2. Risk of discontinuation of breastfeeding was significantly high with birth interval of <2 years (AOR = 1.52, 95% CI-1.08-2.14) and if babies did not receive postnatal check-up (AOR = 1.54, 95% CI-1.04-2.27).

Conclusion

The study highlighted need for focused approach to counsel overweight/obese mothers, cesarean section, and home delivered mothers. Community awareness, adequate birth spacing, and postnatal visits are vital for improving exclusive and continued breastfeeding practices. Communities and health-care providers should provide adequate support to mothers for breastfeeding during the antenatal and postnatal periods.

Uptake of Skilled Maternal Healthcare in Ethiopia: A Positive Deviance Approach

Risk factor approaches are often used when implementing programs aimed at enforcing advantageous health care behaviors. A less frequently-used strategy is to identify and capitalize on those who, despite risk factors, exhibit positive behaviors. The aim of our study was to identify positive deviant (PD) mothers for the uptake of skilled maternal services and to explore their characteristics. Data for the study came from two waves of the Ethiopian Demographic and Health Surveys conducted in 2011 and in 2016. PD mothers were defined as those reporting no formal education but with adequate use of antenatal care (ANC) and/or institutional delivery services. Two-level multilevel regression analysis was used to analyze the data. Factors associated with PD for the use of ANC services were: partner's education status, involvement in household decision making, exposure to media, and distance to the health facility. Factors associated with PD for health facility delivery were: partner's education, woman's employment status, ANC visit during index pregnancy, exposure to media, and perceived challenge to reach health facility. Rural-urban and time-related differences were also identified. The positive deviance approach provides a means for local policy makers and program managers to identify factors facilitating improved health behaviour and ultimately better health outcomes while acknowledging adverse risk profiles.