Exploring parental perceptions and knowledge regarding breastfeeding practices in Rajanpur, Punjab Province, Pakistan

The study was based on a qualitative research design. Data were collected through 12 focus-group discussions (FGDs) with mothers and fathers of children aged under two years in both rural and urban settings in Rajanpur District of Punjab Province, Pakistan. Rajanpur is situated in southern Punjab and has three Tehsils (administrative divisions) and 44 union councils (local government bodies). It has one of the poorest socio-economic indicators related to maternal and child health among all the districts of Punjab Province [14]. Rajanpur was selected as our study setting due to our interest in understanding the contextual factors behind child mortality and poor maternal and child health. Despite the traditional socio-economic environment, people are not practising exclusive and optimal breastfeeding, which can overcome deficiencies in child nutrition. Although about 98% of mothers breastfeed their children, very few of them (14%) initiate timely breastfeeding or practise exclusive breastfeeding [14]. Figure 1 presents the summary of union council and participant selection for the FGDs.

A purposive sampling technique was used to select mothers who had children aged under two years and were currently breastfeeding or trying to breastfeed their child. The sample was restricted in terms of the child’s age in order to minimise recall bias. Mothers who had a child with a severe illness or feeding problems (such as cleft lip or palate) were not included in the study. The data were collected from six union councils (two union councils from each Tehsil). In total, 12 FGDs were conducted with 38 mothers and 40 fathers (six in each category, out of which three were in urban and three in rural areas). The participants did not belong to the same families and were not couples. There were six or seven participants in each FGD. Table 1 presents an overview of the profile characteristics of participants recruited for FGDs.

All the participants were recruited with the help of lady health workers (LHWs). LHWs are female community health workers who live in the same community where they work. Each LHW is responsible for an average of 1000 people. LHWs register the population of their service area and act as liaison between the community and health facilities. They provide antenatal care, vaccinations for children under two and health-education information on hygiene and sanitation. For the recruitment of study participants, we contacted LHWs because they knew all the families in their localities. They went door to door in their localities and explained the study objectives to mothers and fathers and invited them to participate in the FGDs. LHWs provided a list of people who had agreed to participate to the researchers. The researchers contacted the fathers and mothers who had expressed an interest in participating in the study and arranged a time and venue for the meeting according to their convenience.

The study was conducted in 2013 over a four-month period in a community setting. Eleven FGDs were conducted at LHWs’ offices, and one FGD with fathers was arranged at the house of one of the participants. The six FGDs with mothers were arranged for 10:00 am because the mothers were relatively free at that time while their older children were at school. All of the six FGDs with fathers were organised on Sundays (as this is their day off and fathers could spare enough time for the meeting). The participants were served tea and refreshments before the interview to create a friendly environment. The FGDs with mothers and fathers were conducted by female and male interviewers respectively, usually in the participants’ national language (Urdu). The interviewers were experienced in qualitative interviewing and were trained in the FGD guide before going into the field. In some cases, when participants were not comfortable with Urdu, interviews were conducted in their local language (i.e. Siraiki or Punjabi). The local LHWs were also present during the FGDs to facilitate the sessions as they had good rapport with all the participants, being members of the same community. Moreover, the presence of LHWs did not influence the content discussed in the sessions because they acted as moderators and translated certain parts of messages for researchers and participants if required. Each FGD lasted for between 90 and 120 min.

Before the start of the FGDs, all participants were informed about their voluntary participation, the confidentiality of recorded data and anonymity. Written informed consent was provided by all participants. For those participants who could not read and write, the interviewer read the consent form aloud and took their thumb impression instead of a signature. All the FGDs were audio recorded with the permission of the participants; notes were also taken during the discussions. After each discussion, the researchers discussed the topics with each other and with the LHWs to clarify the concepts and their meanings.

The study used an FGD guide to collect data from mothers and fathers. The guide was developed on the basis of an extensive review of the literature on the topic and consisted mainly of deductive themes. Also, we held informal discussions with lactating mothers and with fathers, as well as other stakeholders such as mothers-in-law, doctors, midwives, LHWs and elders in the community to incorporate contextual elements into the FGD guide. The guide was pilot tested with a group of five breastfeeding mothers before the commencement of the FGDs. The guide consisted of topics such as: the first feed given to the child after birth, the use of and misconceptions about colostrum, the timing and frequency of breastfeeding, the benefits of breastfeeding for both child and mother, perceptions about partner support, and problems related to breastfeeding. Ethical clearance for the study protocols was obtained from the Institutional Review Board, University of the Punjab, Pakistan. Throughout the research process, we assured the confidentiality and anonymity of data. The data transcripts were shredded after use in data analysis.

A thematic content analysis was performed manually to analyse the data. All audio-recorded FGDs were transcribed verbatim in Urdu. The transcripts were then translated into English. Both deductive and inductive reasoning were applied in the data analysis [25]. The transcripts were read several times by the authors. A cross-check of the translations was performed to address the possibility of detracting from the contextual meaning of response statements. The field notes taken by the researchers during FGDs were also considered in order to aid the data analysis. Firstly, the initial codes were highlighted, first independently and then in joint sessions involving all the authors. A listing of all the codes was prepared. Response statements referring to the same theme were extracted and written out separately. In the second stage, the groupings of common themes/codes referring to broader categories were identified. Afterwards, thematic categories were coded to reveal the patterns and interplay of categories. The researchers moved back and forth in the transcribed data and searched for similar occurrences or repeating ideas about the same phenomenon. The refining process continued until all the instances of contradictions and similarities had been explained. Finally, the findings were presented as theoretical constructs to explain the phenomenon being studied [26]. To maintain the credibility of the responses, all the authors discussed the findings. Multiple researchers performed thematic content analysis and the initial findings were shared with the LHWs and participants to obtain their comments on whether the research findings and interpretations reflected the meanings intended and related to their personal experiences. This allowed the participants to provide corrections for errors as well as clarifications.

The data analysis revealed that most of the participating mothers and fathers practised feeding a child with ghurati. This refers to the first food in the form of sweet things given to the newborn from the hands of some elderly and pious person in the family immediately after birth. This is done with the understanding that the child will grow up with the qualities of the person who gave the first food. These things might be honey, sugar or Arq [extract of rose flower], which are called ghurati in their native language. Almost all the respondents strongly believed in ghurati as it has a cultural and ritual significance. Some of the respondents considered it a religious obligation, so the act was religiously sanctified, and the validity of the action was rarely questioned. The cleanliness of the hands giving this food was not considered at all in this context.

About half of the mothers (16 of 38) and fathers (20 of 40) believed that breast milk produced during the last month of pregnancy and soon after delivery (colostrum) is not suitable for a small baby. They perceived colostrum as “too heavy” [in direct translation from local language] for the newborn and believed that it cannot be digested by the infant’s fragile digestive system. Some mothers viewed colostrum as “decayed material” containing germs and other impurities. They believed that it became decayed due to its long stay in the breast during pregnancy. Therefore, discarding colostrum to clean the breast was considered a necessary and wise step.

Since the colostrum was perceived as not good for the baby, goat’s or sheep’s milk was given for the first two or three days. Mothers considered goat’s milk to be very light and easily digestible as it is relatively “thin and light” compared to the milk of a buffalo or cow. Sometimes Sonf [a locally produced herb which is perceived to have a good effect on digestion] was also boiled with goat’s milk and the extract was given to the baby. There was a belief among mothers that during the process of birthing, babies can ingest various smelly and dirty fluids. Thus, it is considered necessary to give goat’s milk to clean and drain that fluid out of the stomach. In order to clean the abdomen of the baby, Arqs [rose water] is exclusively given to newborns for one or two days for “cleaning purposes” and then after two days breast milk is started. Mothers reported that this behaviour is usually followed by most mothers as it has been practised for generations.

In addition, there is a cultural belief among mothers that milk comes three days after birth. One mother who recently gave birth to her fourth child and lives in a rural area, stated:

“When a woman delivers a child, she is in great pain; she cannot eat properly, and her body is dirty. In such a state, how could she feed her child? There may be no milk and even if there is some, it may not be healthy for the newborn. .. So it is advisable to wait for some time before feeding.” (G2, P4, M22).

Some male participants said that they were not aware of any specific benefits of breastfeeding for a mother, but they were sure that it is a healthy activity. Almost all the mothers perceived breastfeeding as a natural activity having many benefits without any harm.

A farmer with no formal schooling stated: “It is the command of Allah; so why think about any benefit? Order is order.” (G1, P6, F32).

Overall, the discussion demonstrated several benefits, as realised by both mothers and fathers. These included the fact that breast milk is readily available round the clock, and it was considered cost-effective and to have the required nutrients to strengthen an infant. However, not a single participant reported anything about improving mothers’ dietary nutrients during lactation. There was much concern about making an infant fat, which implied that the fatness was considered to be healthy and powerful. The benefits of breastfeeding were seen by participants as being more important and advantageous for labouring-class families, who did not own a refrigerator or sophisticated heating appliances in the kitchen. A female farm worker reported that:

“Labouring-class mothers are too busy in their household and farm work and they don’t have time to properly sterilise the bottle: they don’t have fridges or other facilities. Formula milk is, therefore, not feasible for them… We earn our living with great difficulty and can only feed our child with breast milk.” (G3, P4, M28).

There was a general perception among the participants that, after discarding colostrum for a few days, the breast milk becomes healthy and easily digestible for the newborn. Mothers agreed that breastfeeding increases the intimacy between a mother and her baby and that it has a positive health impact for both the baby and the mother. Furthermore, they reported that the risk of cystic formations in the breast and many other ailments had been reduced. Some male participants were of the view that poor families could not afford to buy infant formula and other alternatives so they relied on breastfeeding for their infants. They believed that if a mother was not producing milk due to weakness or health complications, a child might grow up with deficiencies and weak immunity. In addition, breastfeeding was perceived to be a natural birth prevention mechanism. Despite enumerating many benefits of breastfeeding for mothers, some of the participants believed that these benefits could only be “materialised” if the mother got proper food and was healthy.

“If the mother is weak [referring to anaemia], living in a poor and unhealthy environment and has no access to nutritious food, she will get less benefit from breastfeeding. Rather, breastfeeding will drain her energy and make her dhaancha [referring to her body structure turning into skin and bones].” (G1, P2, M36).

Invariably, all the participants considered breastfeeding extremely beneficial for the health and growth of a newborn. Some of the respondents believed that “it is a sin if the baby is deprived of breast milk”. The respondents attached some cultural notions of power/strength to breast milk. Most of the participants mentioned that breast milk provides “preventive energy” for babies; if the baby has proper breastfeeding, “hundreds of diseases and ailments can be warded off”.

One father mentioned that breast milk contains some “special and lasting power… the impact and power of breast milk lasts for 40 years.” (G6, P3, F34) Another one stated:

“Breastfeeding is good for an infant. Medical knowledge has not yet discovered and counted the benefits of this natural gift [referring to breast milk] to the infant. Our forefathers used to be healthy and powerful because they got proper breastfeeding. There was no concept of diabetes, blood pressure or ulcers because the children were exclusively breastfed then…” (G4, P1, F41).

Some of the mothers and fathers believed that breast milk transmitted behavioural traits from mother to baby. However, linking breast milk with a mother’s religiosity and piety is a tricky proposition. The misbehaviour of a child in later stages of life are blamed on the breast milk and poor attitudes of the mother. These arguments were supported by religion:

“If a noble and God-fearing mother breastfeeds, it will make the baby noble and God fearing as well.” (G4, P2, F48).

“Breast milk has an impact on the behaviour of an infant. If the mother is deviant, sinful or of ‘loose character’ she may not be allowed to breastfeed. In such cases, cow’s milk is better.” (G3, P5, M36).

“Breastfeeding is a command of Allah. His commands are always beneficial and good for the health and well-being of mankind… The training of a child begins with breastfeeding.” (G2, P1, M29).

Participants were asked: why do some mothers prefer bottle-feeding instead of breast milk? The main reason stated was that mother’s milk was not available in sufficient quantity or that some mothers did not have any milk at all. It was rarely reported that a healthy mother opted to bottle-feed her child. The mothers who had undergone caesarean section also reported not breastfeeding. Nevertheless, they could not explain any relationship between caesarean section and non-production of breast milk. One mother, who had herself undergone the experience of caesarean section, said: “After the operation, the doctor prescribed strong medicine [referring to antibiotics], which dried up the milk.” Another woman believed that the food produced by excessive use of fertilisers and pesticides may cause an insufficiency or total absence of breast milk. Some mothers reported that, in the case of delivery in a private hospital, doctors prescribed and encouraged the use of expensive infant formula after a caesarean operation.

“After a caesarean operation, the mother cannot feed, as the baby is kept in a nursery. How can the mother feed the baby? The lady doctor prescribes some imported formula milk. So the baby is started feeding with bottle milk and then it gradually gets used to bottle feeding. Almost all the babies born through caesarean are bottle-fed.” (G2, P2, M32).

Negative connotations were implied for formula feeding. Mothers as well as fathers believed that rich people and fashionable women choose to formula feed their babies.

“Formula milk is dekhawa [snobbery] and a show of wealth and modernity: wealthy people buy expensive milk to show their wealth.” (G5, P4, F43).

We found contradictory opinions about the effects of breastfeeding on mothers’ bodies. Some women believed that breastfeeding practices could improve the feminine shape of the female body. However, others perceived that the practice de-shapes the female body. These mothers avoided breastfeeding because they believed that it would make their bodies lose shape. They further reported that some “modern women” who took more care of their health perceived that breastfeeding would weaken their bodies and would have a negative impact on their fitness. The respondents believed that mostly educated, middle-class families think in this way.

Some people were concerned about the poor quality of milk, which made the baby ill. Upon such suspicions about the quality of their milk, breastfeeding was stopped by mothers. Some people believed that in certain circumstances, due to the mother’s ailments or unknown reasons, the mother’s milk becomes poisonous; it makes the baby ill and pale [referring to anaemia], and breastfeeding should be stopped immediately. The local culture had a technique to “empirically verify” the quality of milk. One mother stated: “Sometimes the mother’s milk is poisonous. In such cases, the mother’s milk is extracted and is given to small insects. If the insect dies, it is construed that the milk is poisonous.” (G2, P7, M37) There were also other reasons that discouraged exclusive breastfeeding. Some participants stated that some mothers start infant formula as supplementary food and others use it to increase the weight of the baby. One mother said: “Mother’s milk is thin, so the baby remains thin and weak. If you want to increase the weight of the baby, you may give bottle milk.” (G6, P1, M35).

Some participants underlined certain medical conditions when breastfeeding is to be avoided. One of the male participants reported: “When the mother is suffering from tuberculosis or any other malignant disease, she should avoid breastfeeding. Because, the local culture believes, the disease could be transmitted to the baby through the breast milk.” (G3, P4, F36) A female participant shared: “If the mother is ‘too weak’ she ought to stop breastfeeding. It could be harmful to the health of the mother as well as the baby. Milk from a mother who is too weak may not be beneficial for her baby.” (G2, P5, M23) Nevertheless, other participants disagreed with this idea.

The data analysis revealed that mothers do not practise exclusive breastfeeding, which has positive health implications for both child and maternal health. Cultural practices were preventing mothers from doing so. The lack of health literacy and guidance about healthy breastfeeding were contributing to the poor health of children. The majority of mothers and fathers were unable to comprehend what exclusive breastfeeding was about. Irrespective of the fact that an infant needs only the mother’s milk during the first six months, people preferred alternative ways to feed their baby, which were mainly backed by non-scientific sources. Both mothers and fathers believed that keeping a child on mother’s milk for six months would not make the baby fat. The strength needed to crawl was associated with the semi-liquid feed given from the fourth month.

We found a common perception about the duration and frequency of breastfeeding. It was believed that the mother should breastfeed the baby as long as possible. Nevertheless, they had no clear idea about the desirable duration of breastfeeding. The women reported having breastfed for between seven months and four years. It was also reported that the duration of breastfeeding depended on factors such as: 1) the occurrence of the next pregnancy; 2) the quantity of milk produced; and 3) the quality of milk. While discussing the duration of breastfeeding, some of the male participants made reference to the Holy Quran, which stipulates a duration of two and a half years. In the light of this Quranic reference, some male participants considered it sinful not to breastfeed a baby. They considered breast milk an “inalienable right of the baby” and very important for his/her proper growth and development.

“Breastfeeding duration is not in the hands of mothers; it depends on the next pregnancy. So, it should be given until the next pregnancy or as long as milk comes.” (G3, P5, F29).

One male participant, who taught at a local high school, stated: “A lactating mother must keep a balance in her food intake to provide healthy milk for her child. She must not eat ‘too hot’ or ‘too cold’ food.” (G3, P2, F45) In the words of one mother-in-law stated by a mother [said in informal conversation]: “A mother must not keep eating ‘like a goat’; rather she should be careful and responsible.” (G1, P5, M39).

Various problems related to breastfeeding were discussed. The most commonly reported problem was tears on the nipples, which caused a lot of pain to the mother. One mother shared: “Due to tears on my nipple, it was virtually impossible for me to breastfeed my baby.” (G4, P2, M23) Some of the women reported the problem of breast abscesses and said that severe pain in the breast was an obstacle to breastfeeding. Most of these problems were treated with home remedies and spiritual treatments. About half of the female participants reported the problem of producing insufficient breast milk for the child. A majority of these women said that this was due to the lack of a proper diet eaten by the mother. Some women stated that, due to their extensive engagement in household and farm activities, they could not feed their babies frequently enough, and this infrequent suckling led to a reduced production of milk.

Some of the mothers considered lactational amenorrhea harmful to the health of the mother. While explaining the ill effects, one mother explained:

“If mahwari [referring to the menstrual cycle] is stopped, that means decayed and “bad” blood is being accumulated within the body. Definitely this would have dangerous consequences for the health of women. Sometimes it causes a constant headache or weakening eyesight, or it may cause general decay of the whole body.” (G3, P1, M34).

However, a majority of the mothers disagreed with this comment and thought that missing cycles has no ill effects on the body. One mother shared: “Missing menstrual cycles is good in two ways: First, it prevents the next pregnancy and, second, it prevents the wastage of blood.” (G1, P3, M25).

There was a complex normative system regulating inter-spousal communication in the local culture. Cultural norms usually encouraged the involvement of husbands in issues related to reproductive health. When male participants were asked about their communication with their wives in matters relating to reproductive health, at the outset, the response was negative. A majority of the female participants reported that their husbands were not at all concerned with lactation and pregnancy-related things and “they ought not to be.”

One mother said: “No one would appreciate it if a man takes an interest in women-related issues, they [men] may not have proper knowledge and may offer bad advice.” (G4, P1, M29).

Another female participant explained: “The responsibility of the husband is to earn and provide necessary household things for the wife; this is enough, it is better to mind his own business.” (G6, P2, M32).

Mostly the female participants believed that a woman should first consult her mother-in-law and other elderly wise women and she may also inform her husband if there is something serious. One woman in her mid-thirties reported: “Informing the husband about women-related problems may be good but it is useless. Men in villages have no information or training about women’s health problems.” (G5, P2, M36) Some of the female participants highlighted the issue of discrimination against female babies. One mother of three girls and one son shared:

“My husband never took any interest in breastfeeding-related issues when I had female babies. He never cared about my diet during lactation. But recently, I gave birth to a baby boy. Now he takes a lot of interest and asks me about my diet.” (G5, P4, M38).

Participants employed different information-seeking mechanisms in rural and urban areas. The rural respondents were mostly illiterate or semi-literate and their main source of information was their elders and relatively more informed neighbours. “People discuss things with trusted people and then make decisions accordingly”, observed an illiterate female respondent. However, in urban areas the literacy rates were high and people received information from written material, the mass media – especially TV debates – and advertisements, healthcare staff and educated friends.

Participants were asked about their information-seeking and dissemination mechanisms. A majority of female (30 of 38) and male (32 of 40) participants reported interpersonal communication as the most effective way to seek and share information. It was also pointed out that group discussions were important for providing information. Participants stated that advertisements on television and the radio also provided information, but that such one-way information is usually ignored by end-users. Some of the female participants suggested that illustration-based, easy-to-understand leaflets and pamphlets could be useful to improve and update their level of information.

A major strength of this study was the comparatively large design with 12 FGDs. In addition, the combination of a deductive and inductive approach in data analysis has led to a comprehensive assessment of topics related to parental perceptions and knowledge regarding breastfeeding practices. As for any qualitative study design, the findings may not be generalisable. However, we expect that the results provide a good picture for similar populations. Interviews were conducted by trained interviewers. Nevertheless, the use of different languages may also influence the results. In addition, it has to be noted that the focus-group discussants may have provided socially desirable answers.