The findings below are from an Exploratory Research in Tamil Nadu.
Breastfeeding of infants is an accepted global policy priority for reducing the infant mortality rate and the recommendation to exclusively breastfeed until around six month of age has been adopted by many countries including India. The evidence regarding the benefits of exclusive breastfeeding for both the mother and baby is very compelling and convincing. We have demonstrated this in our previous blog.
As per recent statistics, Tamil Nadu's exclusive breastfeeding rate stands at 52.2%; this is lesser than the national average. Literature indicates that persistent under-nutrition among children can be associated with inadequate feeding practices. Hence improving the current state of exclusive breastfeeding will require an understanding of the barriers within a social construct.
Last year we undertook an exploratory study to identify the extent of mixed feeding/supplementation and the socio cultural barriers to the successful practice of exclusive breastfeeding among nursing mother in the State of Tamil Nadu. Focused group discussions and key informant interviews were conducted with nursing and mothers of infants, Village Heath Nurses and Medical Officers in Thiruvanamalli and Tirupattur. This blog summarizes some of key observations from the field survey.
One of the positive that was observed during the study was the high level of awareness of breast feeding and its benefits. Paradoxically, the study revealed that a significant proportion of women did not practice exclusive breastfeeding. Common deviations from the practice of exclusive breastfeeding included the inclusion of water, (gripe water), velakenai (castor oil) and other food supplements prior to six months of age and the deviation starts as early as the first day of the delivery.
"We know the importance of mothers' milk and that we have to feed our child only with breast milk till the age of 6 months. Doctors in the PHC and akka (Village health nurse) have talked to us about it. However it is our tradition to first feed the child sugar water as soon as they born. This is so that my baby will have a sweet smile" - Participant
The key factors identified during the course of the research that influences women's decision to mix feed their babies include
1) Pressure from elders and other family members to supplement feed: Elders in the village, mother-in-laws and grandmothers are the an important source of support for new mothers and it was observed that the experiences and views of breastfeeding mothers were often complemented with the of the elders in their family and village (especially in a rural/ semi urban setting)
"My mother in law suggested that I give my child castor oil as it helps with their bowel movement. I have been doing this from the age of 3 months. I wasn't sure at the beginning whether I should do it and was going to speak to akka (village health nurse) about it. However my mother in law insisted that I give it to my baby as it is a common practice and I didn't want to defy her. This would create tension in the family. But my baby is fine. So I guess it is ok" - Mother of an Infant
2) Perception that babies are underweight as mother's milk is not sufficient: A number of participants in the survey indicated the fear of infants growing weaker if their diet relied solely on breast milk; this encouraged the discontinuation of exclusive breastfeeding. Semi solid food, water and other nutritional supplements are often introduced from the age of three months. Specific constraints that explain this included poor maternal health, perceived milk insufficiency and pressure from family members.
3) Perception that health and food intake of the mother has a negative impact on the infant's wellbeing: It is perceived by the participants that the dietary intake of mothers during the lactating period will have detrimental impact on the well being of the infant. As a common remedy babies were given gripe water (also prescribed by doctors), castor oil, vasambu (sweet flag) as traditional cure for indigestion.
The mismatch between breastfeeding awareness and the practice of exclusive breastfeeding highlights the presence of conflict revolving around intentions, expectations, and social pressures to practice exclusive breastfeeding. Scaling up of exclusive breastfeeding among mothers will hence require concentrated efforts at the macro, meso and micro level. Strategies must include education and counselling of nursing mothers and others significant family members (grandmothers, mother-in-laws and husbands) in the process of encouraging exclusive breastfeeding.