Background
Methods
Study design, participants and setting
Conceptual framework and research paradigm
Qualitative and quantitative study components
In-depth interviews (IDI)
Surveys
Analysis
Qualitative analysis
Quantitative analysis
Outcomes
Independent variables
Statistical analysis
Bias
Results
In-depth interview results
Framework level | Theme | Quotation |
---|---|---|
Workplace drivers | 1) Responsive implementation of policies | Actually, I was lucky that the hospital understood me because I felt that 3 months were not enough. I was lucky that my… colleagues understood me, and I was allowed to extend my leave. It helped, I returned to work after passing the difficult period. When I came to work, it was good that my colleagues understand and let me have time for pumping. These things are necessary because it may be difficult if some colleagues don’t understand.TH1 |
2) Organizational support | For me I just have one funny idea– it would be nice to have a clinic for mothers who are breastfeeding because every mother who is breastfeeding has different challenges– it is not all the same. It would be great for mothers to have a training course. So for the mothers who are determined to breastfeed their children but face challenges they could receive advice and support.TH2 | |
3) Arr-nar/kreng-jai (“not wanting to impose”) | I would say [maternity leave should be] 6 months, but I feel that it is too long and feel bad for our colleagues. 5 months and a half will do, just a little bit longer.TH1 | |
4) Organizational leadership | Working here it feels like a family, looking after each other.CBO1 | |
HCW personal outcomes | 5) Breast milk production | You need to be very consistent with pumping milk because if not consistent, you will not produce as much milk as you need, and since you don’t have a baby to directly breastfeed to stimulate your breast milk production, your production will gradually go down… especially when you don’t have your baby nearby to directly breastfeed. When our baby is directly breastfeeding it induces the release of oxytocin which causes more milk to be produced. If there is no stimulation, and the brain is not triggered, eventually there will be no milk production.TH2 |
6) Mother-infant Bonding | After delivery the mother’s hormones can contribute to stress for the mother. Some patients will have depression from the hormones. When we let our child breastfeed we feel warmth in our heart, it will heal the heart. I also experienced quite often the feeling that I just suddenly want to cry– it is the hormonal effect. When I pick up my child and breastfeed that feeling disappears.TH2 | |
HCW professional outcomes | 7) Improved care for breastfeeding mothers | I can counsel better after I have babies. When I was single, I am not quite good at that. After breastfeeding my two babies, we can share our experiences. We can tell them how to hold the baby.CBO1 They ask me about herbal supplements and ways to increase milk production. I tell them that banana blossoms, ginger tea, and Kaeng Liang (Thai spicy mixed vegetable soup) can stimulate milk production, but also tell them that they can take some medicines to stimulate milk production… I had experienced the same problem. I had a low milk production when I had my first baby.… I sympathize with them because I was there before, so I want to help them. And I’m glad to help.TH1 |
Contextual factors | 8) Family Support | I would give this suggestion: find one person who can take care of the baby well. A husband who is not using [alcohol or drugs], who loves babies and can take care of them well. When it is time for breastfeeding, he will give the baby to you to breastfeed. When the baby is finished breast feeding, he will take the baby back. For the baby, breastfeeding is important. If breastfeeding is regular and on time, your baby will grow beautiful…CBO2 |
9) Culture and traditions | I live close to a Burman community in my area. They are also very experienced about breastfeeding…. The hilltribe women [breastfeed] more than 2 years. So I can see even 2–3 years they can still breastfeed their children. [For hospital staff] I don’t really know how long because I didn’t ask them. But for some people around 6 and a half months.TH2 We disagree whether we should feed the baby with water following milk for the first 6 months. I don’t think so, but my babysitter, grandma, says it’s a must…TH1 | |
10) Meta: Proximity and peace/ Separation and stress | I worried that people will not look after my baby really well. I worry that mosquitos would bite my baby while he was sleeping. Sometimes, I would bring a hammock and let him sleep here [at the clinic]. I felt more peace of mind when I did that.CBO2 That’s why this year if they don’t transfer me [to the city where my children live], I will resign… If I take care of my kids by myself, I feel more peace of mind.TH2 |
Workplace policies
Responsive implementation of policies
The leaders helped me to move to another department so I am okay now. I really appreciate that. [Laughing] They understand me and look out for mothers who are like me… It is really good for us how our organization helps us… They look after us and think for mother and baby.CBO1.
There was no rule for when to start night shift after delivery, so we got some complaints from our staff… We called a meeting to decide when breastfeeding mothers should start night shift. We agreed on 5 months.CBO2.
[HR] came and held a meeting and said, “Staff cannot bring children to the clinic at all.” Aaack. I felt very sad…. What can I do? I want to breastfeed… I said, (whispering) “Doctor, I will go back to breastfeed.” If the doctor allows, I would go back by bicycle quick quick quick and back again… I had to do that for 2 months. I couldn’t do that any longer… What could I do? Her grandmother came. If the baby was hungry she brought her to me and I gave breastfeeding in the back of the room.CBO2.
I could take only 3 months’ leave. Actually I wanted to take leave for 6 months. They told me I could take 6 months’ leave according to the new policy, but my supervisor did not allow me to take leave. My supervisor said there were not enough people.TH2.
Organizational support
Yes, the hospital supports breastfeeding a lot. They want the children to get breastmilk… The first few days after I delivered this baby, I didn’t have any breastmilk. The first day, not even one drop of milk came out. It was a challenge for me because my husband started to feel sorry for the child and he wanted to go buy formula for the child. But because I am staff in the hospital the seniors wanted me to be a good example for the other people so I tried. So on the third day I even went to ask for medications to increase the milk production.TH2.
The Health Promotion Unit organized trainings on how to feed with breastmilk. I would like to participate when I have the opportunity. There were experiences from the experienced mothers shared to new mothers. We learned from them how to cope with problems.TH1.
Workplace environment
Not wanting to impose: arr-nar/kreng-jai
[At 6 months] I didn’t try to express breast milk anymore. For the past 4 months I felt I had imposed on my colleagues. Now my baby is 6 months and he can eat. I can give formula. Since the baby was little I disturbed my colleagues. I feel I imposed on my colleagues. My colleagues might complain. I feel I took advantage of my colleagues. I don’t want to impose on my colleagues.CBO2.On busy days I feel kreng-jai and try to finish as much as I can, and then I ask my colleagues if I can finish the rest after I come back. I planned to pump every 3 h but sometimes I couldn’t. I would feel engorgement but it was relieved when I could pump. And when I came home and my baby nursed, it was much better.TH2.
HCW personal breastfeeding outcomes
Breastmilk production
I could only pump 3 times a day, lunch time, evening time, and night time. Yes, so the milk starts to decrease… I think if I took 6 months of leave and my child always directly breastfeed, I might have milk.TH2.Sometimes there is just not enough breast milk.CBO2.
For my friends in the village who don’t go to work, they just easily breast feed, just fine. But for my working friends, I think it will be a bit worse, they will all be a bit sad.CBO2.
HCW professional outcomes
Improved care for breastfeeding mothers
It is helpful because I have a child so I can relate more in detail to them, and I can use my experience to talk to them, compared with someone who doesn’t have children. Those who don’t have children will use whatever they have learned and seen, but since I have a child and I have experience raising a child, I use my experience in addition to what I have learned. And I think it helps a lot.TH2.
Contextual factors
Proximity and peace of mind
In the beginning there were the challenges I mentioned before. But I was able to adjust to it… and my home is near my work. In the beginning I forgot the pumping equipment often so I would need to drive home to get it, but my house was not very far from work. It is around 5–6 min if I drive fast.TH2.
If we could have a room it would be more comfortable to bring a nanny. But now we have to use the corner here and there to do it. There is no designated place… a nursing room would be very helpful for us, it would be enough. I do not need anything special. A normal fan would be nice. A room with windows to get sunlight and some fresh air.CBO2.
I had a problem because there was no one to watch my baby. There was nothing I could do, I had to send my daughter to my mother-in-law. My baby was just 6 months old, I felt so sorry for her… I wanted to keep her with me longer, but there was nobody to take care of her… If her own mother can care for her, her mother will feel more at ease. But I cannot– I have to leave her.CBO2.
Survey results
Characteristic | Overall | CBO1 (hi/hi)* | CBO2 (hi/lo) | TH1 (lo/hi) | TH2 (lo/lo) | ||
---|---|---|---|---|---|---|---|
No children | 114/311 (37) | 25/74 (34) | 40/89 (45) | 19/75 (25) | 30/73 (41) | ||
Mothers | 169/311 (54) | 37/74 (50) | 34/89 (38) | 56/75 (75) | 42/73 (58) | ||
Fathers | 28/311 (9) | 12/74 (16) | 15/89 (17) | 0/75 (0) | 1/73 (1) | ||
Were breastfed themselves | no/don’t know | 17/309 (5) | 0/74 (0) | 2/89 (2) | 6/73 (8) | 9/73 (12) | |
yes | 292/309 (95) | 74/74 (100) | 87/89 (98) | 67/73 (92) | 64/73 (88) | ||
Years working | 10 [5.5–15.6] (0-39.4) | 10 [6.25-13] (1–30) | 20 [7.7–25.6] (1-39.4) | ||||
Formal training | 132/312 (42) | 1/75 (1) | 4/89 (4) | 64/75 (85) | 63/73 (86) | ||
Completed high school | 244/312 (78) | 49/75 (65) | 56/89 (63) | 71/75 (95) | 68.73 (93) | ||
Patient exposure > 10/3mo | 199/312 (64) | 38/75 (51) | 65/89 (73) | 44/75 (59) | 52/73 (71) | ||
BF attitudes (quartiles from least favorable to most favorable) | 1 | 83/311 (27) | 32/75 (43) | 30/89 (34) | 12/74 (16) | 9/73 (12) | |
2 | 76/311 (24) | 19/75 (25) | 26/89 (29) | 17/74 (23) | 14/73 (19) | ||
3 | 78/311 (25) | 14/75 (19) | 24/89 (27) | 19/74 (26) | 21/73 (29) | ||
4 | 74/311 (24) | 10/75 (13) | 9/89 (10) | 26/74 (35) | 29/73 (40) | ||
High Confidence (4–5) | 138/287 (48) | 38/74 (51) | 38/84 (45) | 29/58 (50) | 33/71 (46) | ||
Knowledge score: mean % correct (sd) | 34.7 (15.5) | 32.5 (12.9) | 28.8 (9.9) | 49.9 (20.1) | 31.9 (10.9) | ||
Correct advice | 143/288 (50) | 39/73 (53) | 29/84 (35) | 27/59 (46) | 48/72 (67) |
WHO recommended breastfeeding practices
Characteristic | Overall | CBO1 (hi/hi)* | CBO2 (hi/lo) | TH1 (lo/hi) | TH2 (lo/lo) | ||
---|---|---|---|---|---|---|---|
Mother/ infant dyad | Age of mother at delivery† | 18–27 | 39/131 (30) | 11/33 (33) | 7/24 (29) | 8/39 (21) | 13/35 (37) |
28–43 | 92/131 (70) | 22/33 (67) | 17/24 (71) | 31/39 (79) | 22/35 (63) | ||
Baby rejected breast after bottle | 39/131 (30) | 10/33 (30) | 8/24 (33) | 11/39 (28) | 10/35 (29) | ||
Set goals for breastfeeding duration | 89/131 (68) | 28/33 (85) | 19/24 (79) | 23/39 (59) | 19/35 (54) | ||
Positive BF experience | 120/131 (92) | 31/33 (94) | 24/24 (100) | 36/39 (92) | 29/35 (83) | ||
Cesarean birth | 50/131 (38) | 9/33 (27) | 8/24 (33) | 14/39 (36) | 19/35 (54) | ||
Hospital birth (vs. clinic or home)* | 100/131 (76) | 13/33 (39) | 13/24 (54) | 39/39 (100) | 35/35 (100) | ||
Stopped BF because not enough milk | 40/131 (31) | 3/33 (9) | 2/24 (8) | 19/39 (49) | 16/35 (46) | ||
Stopped BF because of work | 29/131 (22) | 4/33 (12) | 10/24 (42) | 9/39 (23) | 6/35 (17) | ||
Worksite | WBSS n = 152 | 41.4 (7.0) | 39.5 (6.2) | 35.4 (5.6) | 42.8 (6.3) | 45.8 (6.0) | |
WBSS-SF | 24.9 (5.4) | 24.0 (4.3) | 20.6 (4.1) | 25.2 (5.8) | 28.6 (4.3) | ||
Maternity leave (ML) (months) | |||||||
Felt ML was adequate | 90/130 (69) | 26/33 (79) | 14/24 (58) | 28/38 (74) | 22/35 (63) | ||
Had night duty | 65/130 (50) | 13/33 (39) | 15/24 (63) | 19/38 (50) | 18/35 (51) | ||
Used Day care n = 153 | 48/131 (37) | 27/33 (82) | 13/24 (54) | 1/39 (3) | 7/35 (20) | ||
Expressed breastmilk at work | 88/131 (67) | 24/33 (73) | 14/24 (58) | 27/39 (69) | 23/35 (66) | ||
Breastfeeding is common at work | 96/131 (73) | 27/33 (82) | 14/24 (58) | 24/39 (79) | 24/35 (69) | ||
Baby close, can visit during work | 84/130 (65) | 29/33 (88) | 17/24 (71) | 14/38 (37) | 24/35 (69) | ||
Baby sent to distant relatives | 22/130 (17) | 1/33 (3) | 3/24 (13) | 13/38 (34) | 5/35 (14) | ||
Year of Birth | 1990–2009 | 33/131 (25) | 3/33 (9) | 2/24 (8) | 14/39 (36) | 14/35 (40) | |
2010–2015 | 36/131 (27) | 12/33 (36) | 7/24 (29) | 12/39 (31) | 5/35 (14) | ||
2016–2017 | 27/131 (21) | 6/33 (18) | 8/24 (33) | 5/39 (13) | 8/35 (23) | ||
2018–2021 | 35/131 (27) | 12/33 (36) | 7/24 (29) | 8/39 (21) | 8/35 (23) | ||
WHO goals | Exclusive breastfeeding 6 months | 69/130 (53) | 25/33 (76) | 13/24 (54) | 21/38 (55) | 10/35 (29) | |
Total breastfeeding ≥ 2 years | 40/130 (31) | 19/33 (58) | 8/24 (33) | 9/38 (24) | 4/35 (11) | ||
Both | 27/129 (21) | 15/33 (45) | 5/24 (26) | 5/37 (14) | 2/35 (6) |
Exclusive BF to 6 months (N = 130) | Breastfeeding to 2 years (N = 130) | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
univariable | Multivariable* | univariable | Multivariable** | |||||||
Characteristic | proportion (%) | p | aOR (95%CI) | p | proportion (%) | p | aOR (95%CI) | p | ||
Work site | Low BF prevalence, low support (TH2) | 10/35 (29) | ref | - | 4/35 (11) | ref | - | - | ||
Low BF prevalence, high support (TH1) | 21/38 (55) | 0.023 | 6.3 (1.8–21.6) | 0.003 | 9/38 (24) | 0.180 | 3.7 (0.9–15.0) | 0.068 | ||
High BF prevalence, low support (CBO2) | 13/24 (54) | 0.051 | 2.7 (0.6–13.1) | 0.182 | 8/24 (33) | 0.048 | 3.6 (0.8–16.3) | 0.094 | ||
High BF prevalence, high support (CBO1) | 25/33 (76) | < 0.001 | 7.3 (1.8–29.1) | 0.005 | 19/33 (58) | < 0.001 | 6.3 (1.6–24.6) | 0.008 | ||
Reason for stopping breastfeeding | not enough milk | 19/39 (49) | 0.704 | 1.5 (0.5–4.6) | 0.472 | 5/40 (13) | 0.004 | 0.2 (0.1–0.7) | 0.012 | |
work | 12/29 (41) | 0.142 | 0.8 (0.3–2.5) | 0.715 | 5/29 (17) | 0.011 | 0.3 (0.1–0.9) | 0.028 | ||
other/still BF | 38/62 (61) | ref | 30/61 (49) | ref | ||||||
Expressed breastmilk at work | no | 16/43 (37) | ref | 9/42 (21) | ref | |||||
yes | 53/87 (61) | 0.013 | 1.6 (0.6–4.3) | 0.359 | 31/88 (35) | 0.124 | 1.6 (0.5–4.4) | 0.404 | ||
Used Day care# | no | 36/82 (44) | ref | 17/82 (21) | ref | |||||
yes | 33/48 (69) | 0.045 | 23/48 (48) | 0.061 | ||||||
Mother/ infant dyad | Age at delivery† | < 28 years | 26/39 (66) | 0.024 | 3.5 (1.2–9.6) | 0.018 | 6/24 (25) | 0.666 | ||
≥ 28 years | 43/91 (47) | ref | 34/106 (32) | ref | ||||||
Place of birth# | clinic/home | 22/31 (71) | ref | 18/31 (58) | ref | |||||
hospital | 47/99 (47) | 0.242 | 22/99 (22) | 0.018 | ||||||
Set a goal | no | 11/41 (27) | ref | 9/41 (22) | ref | |||||
yes | 58/89 (65) | < 0.001 | 4.4 (1.7–11.5) | 0.002 | 31/89 (35) | 0.492 | ||||
Finished High school | no | 20/27 (74) | 0.031 | 3.0 (0.8–10.5) | 0.089 | 12/27 (44) | 0.457 | |||
yes | 49/103 (48) | ref | 28/103 (27) | ref | ||||||
Baby rejected the breast after bottle | no | 53/91 (58) | ref | 30/91 (33) | ref | |||||
yes | 16/39 (41) | 0.056 | 0.4 (0.2–1.1) | 0.071 | 10/39 (26) | 0.350 |
Reasons for breastfeeding cessation: work and low milk production
Insufficient breastmilk | Difficult to breastfeed and work | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Univariable (clustered) | Multivariable* | Univariable (clustered) | Multivariable | |||||||
Characteristic | proportion (%) | p | aOR (95%CI) | p | proportion (%) | p | aOR (95%CI) | p | ||
Work Site | Low BF prevalence, low support (TH2) | 16/35 (46) | ref | 9/39 (23) | ref | |||||
Low BF prevalence, high support (TH1) | 10/39 (49) | 0.796 | 1.3 (0.5–3.8) | 0.610 | 6/33 (18) | 0.611 | 1.1 (0.3–4.2) | 0.935 | ||
High BF prevalence, low support (CBO2) | 2/24 (8) | 0.006 | 0.2 (0.0-0.9) | 0.040 | 10/24 (42) | 0.057 | 3.1 (0.7–14.9) | 0.148 | ||
High BF prevalence, high support (CBO1) | 3/33 (9) | 0.002 | 0.1 (0.0-0.5) | 0.005 | 4/33 (12) | 0.495 | 0.7 (0.1–3.7) | 0.699 | ||
WBSS-SF | below mean | 17/80 (21) | ref | 21/79 (27) | ref | |||||
above mean | 23/51 (45) | 0.083 | 1.9 (0.8–4.8) | 0.172 | 8/50 (16) | 0.117 | 0.6 (0.2-2.0) | 0.432 | ||
Maternity leave† | < 3 months | 4/27 (15) | ref | 9/26 (35) | ref | |||||
≥ 3 months | 36/103 (35) | 0.396 | 20/103 (19) | 0.102 | ||||||
Felt maternity leave was long enough | no | 14/40 (35) | ref | 12/38 (32) | ref | |||||
yes | 25/90 (28) | 0.539 | 17/90 (19) | 0.079 | 0.3 (0.1–1.1) | 0.063 | ||||
Expressed breastmilk at work | no | 14/43 (33) | ref | 15/41 (37) | ref | |||||
yes | 26/88 (30) | 0.497 | 14/88 (16) | 0.035 | 0.7 (0.3-2.0) | 0.509 | ||||
Distance from child | far | 17/46 (37) | ref | 16/46 (33) | ref | |||||
daycare/close# | 22/84 (26) | 0.421 | 14/82 (17) | 0.053 | 0.3 (0.1–0.8) | 0.024 | ||||
Mother-infant dyad | Birth order of the last child | 1 | 15/44 (34) | ref | 6/42 (14) | ref | ||||
2 | 22/70 (31) | 0.915 | 0.7 (0.2–2.8) | 0.426 | 17/70 (24) | 0.172 | 3.0 (0.8–11.5) | 0.111 | ||
≥ 3 | 3/17 (18) | 0.159 | 0.3 (0.1–1.6) | 0.161 | 6/17 (35) | 0.148 | 8.3 (1.4–48.8) | 0.020 | ||
Breast rejection | no | 27/92 (29) | ref | 16/90 (18) | ref | |||||
yes | 13/39 (33) | 0.408 | 13/39 (33) | 0.181 | 2.6 (0.9–7.4) | 0.082 | ||||
Experience of breastfeeding | positive | 34/120 (28) | ref | 28/119 (24) | ref | |||||
neg/neutral | 6/8 (75) | 0.005 | 9.2 (1.2–71.9) | 0.034 | 1/8 (13) | 0.266 | ||||
Year of birth | Before 2018 | 30/96 (31) | ref | 26/94 (28) | ref | |||||
2018–2021 | 10/35 (29) | 0.533 | 3/35 (9) | 0.021 | 0.2 (0.0-0.8) | 0.027 |
Caring for breastfeeding patients
Confidence caring for breastfeeding dyads* n = 281 | Breastfeeding advice consistent with WHO** n = 281 | ||||||||
---|---|---|---|---|---|---|---|---|---|
Characteristic | proportion (%) | p | aOR (95%CI) | p | proportion (%) | p | aOR (95%CI) | p | |
Met both WHO goals | no | 108/235 (46) | 113/236 (48) | ref | |||||
yes | 21/30 (70) | 0.016 | 2.6 (1.1–6.4) | 0.033 | 17/30 (57) | 0.243 | 1.5 (0.7–3.4) | 0.299 | |
Low BF prevalence, low support (TH2) | 31/61 (51) | ref | ref | 45/68 (66) | ref | ||||
Low BF prevalence, high support (TH1) | 38/82 (46) | 0.742 | 1.2 (0.6–2.8) | 0.605 | 27/59 (46) | 0.022 | 0.4 (0.2–0.8) | 0.009 | |
High BF prevalence, low support (CBO2) | 32/68 (47) | 0.930 | 1.4 (0.6–3.1) | 0.382 | 29/82 (35) | < 0.001 | 0.5 (0.2–1.5) | 0.207 | |
High BF prevalence, high support (CBO1) | 29/58 (50) | 0.670 | 2.1 (0.9–4.9) | 0.088 | 32/61 (52) | 0.114 | 1.5 (0.5–4.6) | 0.517 | |
Age (years)# | < 30 | 29/72 (39) | ref | 34/73 (47) | 0.625 | ||||
≥ 30 | 102/197 (52) | 0.062 | 1.9 (1.1–3.6) | 0.032 | 99/197 (50) | ref | |||
Occupation | Nurse or MW | 76/124 (61) | < 0.001 | 2.6 (1.5–4.7) | 0.001 | 67/125 (54) | 0.241 | ||
Other | 54/145 (37) | ref | 66/145 (46) | ref | |||||
Training | informal | 72/155 (46) | 65/155 (42) | ref | |||||
formal | 58/114 (51) | 0.473 | 68/115 (59) | 0.037 | 2.1 (0.8–5.5) | 0.139 | |||
Number of BF patients in the past 3 months | ≤ 10 | 25/72 (35) | ref | 26/72 (36) | ref | ref | |||
> 10 | 105/197 (53) | 0.008 | 1.6 (0.9–2.9) | 0.145 | 107/198 (54) | 0.006 | 2.1 (1.2–3.7) | 0.014 | |
Number of patients with breastfeeding problems in the past 3 months | 0 | 11/55 (20) | ref | 25/55 (45) | ref | ||||
≥ 1 | 119/214 (56) | < 0.001 | 3.3 (1.6–6.5) | 0.001 | 108/205 (50) | 0.621 | |||
Breastfeeding attitude quartile (1 is the least positive, 4 is the most positive) | 1 | 27/66 (41) | ref | ref | 20/66 (30) | ref | |||
2 | 29/72 (40) | 0.940 | 0.8 (0.4–1.6) | 0.506 | 35/72 (49) | 0.029 | 2.3 (1.2–4.7) | 0.025 | |
3 | 32/66 (48) | 0.382 | 1.3 (0.6–2.7) | 0.520 | 36/66 (55) | 0.006 | 3.4 (1.6–7.1) | 0.001 | |
4 | 42/64 (66) | 0.005 | 1.8 (0.7–4.2) | 0.193 | 42/65 (65) | 0.001 | 2.6 (1.2-6.0) | 0.021 |