Based on the identified themes two questions emerged to guide the presentation of results. First, how are the different feeding methods, EBF and ERF understood and accepted? Second, what are men's and women's responsibilities related to infant feeding?
How is breastfeeding understood?
Initiation of breastfeeding
The attitudes towards initiation of breastfeeding in general, and colostrum in particular, varied. Some of the men were aware of the value of colostrum and recognised it was good and nutritious for the newborns. Others held the view that it was necessary to discard the first milk. One reason mentioned for squeezing it out, was to avoid 'blocking' of the breasts. More commonly reported was the belief that colostrum could 'cause diarrhoea,' 'contained dirt' and was 'bad' for the baby.
But, even if the intention to start breastfeeding immediately after delivery was there, 'delayed milk' or 'lack of milk' and other difficulties were reported by men and women as main reasons for delayed initiation. The women had experienced stomach pain, loss of blood, delivery of placenta, exhaustion, stitching and even collapse and unconsciousness as factors delaying initiation of breastfeeding. Furthermore, a sleeping or sick newborn baby was reported as obvious reasons to delay breastfeeding, the baby not being capable of suckling.
Ideas about the importance of a clean body in general and clean breasts in particular could contribute to delays. Bathing mother and baby and washing of breasts were mentioned in all female groups as an important task to do before breastfeeding could start. This practice was also observed by men.
'I first have to bathe the baby then myself before I begin breastfeeding.' (Urban FGD Namatala, woman)
Skilled attendants during delivery also involved washing and wrapping prior to breastfeeding.
'The midwife first stitched me; I bathed and then put the baby on the breast.
'The midwife had to weigh and wrap the baby, and I also had to recover since I bled a lot.' (Urban FGD Namatala, women)
In exceptional situations where it was hard to explain why breastfeeding was not established as expected, some of the women mentioned supernatural forces like spirits, curses and bewitching.
'I heard that there are some spirits that stop the baby from breastfeeding, so they must please them first by offering sacrifices and give a name before the breastfeeding starts.' (Rural FGD Nakaloke, woman)
Name giving as a ritual prior to breastfeeding could involve drops of pre-lacteals like water or local brew. Both rural and urban female groups referred to this tradition.
'Some people believe that an elder has to give a name to the child before the mother breastfeeds. He puts his fingers in water, and then puts it in the baby's mouth before the mother breastfeeds.' (Rural FGD Namanyonyi, woman)
One female group also raised the issue of sexual taboos. The breasts of a nursing mother should not be sucked as part of a sexual act, lest it may harm the infant:
'If a husband suckled the breasts of the mother, the baby she gives birth to is not supposed to breastfeed or else the baby dies.' (Rural FGD Bufumbo, women)
Pre-lacteal feeding was perceived as common and closely linked to perceived lack of milk and delayed initiation of breastfeeding. Men mentioned 'warm water' or 'diluted fresh cow's milk' as pre-lacteals. Warm water should help with 'unblocking' the baby's throat before other feeds could be given. The women mentioned 'plain water,' 'glucose water,' 'sugar and/or salt and water' and 'Gripe water' as pre-lacteals. A few women specified that they boiled the water.
One reported influence from her own relative:
'My mother stopped me from giving breast milk unless I first gave sugar water.' (Rural FGD Nakaloke, woman)
The mothers also gave pre-lacteals because the 'baby was crying,' 'born hungry,' 'needed energy quickly,' 'that the breast milk was too light' and they had 'pain' and were 'exhausted.' Breast milk given first was also believed to be bad among some women.
'Milk brings worms in the stomach therefore I first give glucose water.' (Rural FGD Nakaloke, woman)
The importance of breastfeeding: the only way to feed an infant
Breastfeeding had a central position in the local infant feeding culture. Men described breastfeeding in general as 'the only way to feed' an infant and regarded breastfeeding entirely as a mother's duty. This view about breastfeeding was rooted in traditions.
'It is their tradition that their grand parents took on, so they too have taken it up, the mothers have to breastfeed as well as feed just like the grand parents did.' (Rural FGD Bufumbo, man)
But even if the men took breastfeeding for granted, they also argued for the developmental assets of breastfeeding: 'physical growth,' 'intellectual' and 'psychological development' were mentioned in the male groups as important reasons for the child to receive breast milk. In addition, a few mentioned it contained the 'necessary nutrients' for the baby and was a 'source for energy' for the babies who 'have no teeth for chewing' and stomachs which 'are not ready.' The preferred time to stop breastfeeding was between one and two years according to the men, or later if the child wanted, but depended most on when the mother conceived again.
'It depends on the time the mother takes to conceive, this is the time the children are weaned off to give way for another one.' (Rural FGD Bufumbo, man)
Ideas about exclusive breastfeeding
Although the men strongly argued that breastfeeding was a condition for child survival, they were generally unfamiliar with the idea that an infant should be breastfed exclusively for the first six months. They complained that they did not have access to infant feeding teachings and hence, 'had learnt nothing' about it. Even if a few men did describe EBF as 'the only way' and 'the easiest way' in the first couple of weeks after birth, there was a general agreement among the men that breast milk was insufficient food for the baby.
'Breast milk alone cannot give the baby sufficient energy - that's why other foods are introduced as soon as possible.' (Urban FGD Namatala, man)
The women by contrast had been taught about EBF in antenatal clinics. They were familiar with the recommendation to breastfeed exclusively for six months, and they were aware of the immunological and nutritional values of breast milk in general and EBF in particular. Nevertheless, the women also expressed a general scepticism to the concept of exclusive breastfeeding and were worried that they did 'not have enough' or had 'no milk.'
They were confused and uncertain about the recommendation to give 'nothing, but breast milk' for six months and did not understand the rationality behind it. The following quote grasps some of the frustration related to it:
'I want to know why they refuse us to give other feeds during the first six months'. (Rural FGD Nakaloke, woman)
The barriers to EBF were multi-faceted. In addition to the concern about insufficiency, some women expressed that EBF could be harmful and could cause sickness of various kinds in the baby like 'wide stomachs' and 'worms'. In this context breast milk supplements were described as beneficial and would make the baby 'more healthy,' 'immune,' and 'fatter' and would help 'to avoid worms.'
More important was the experience that EBF was very time-consuming and difficult to practice for a mother who also had other commitments in the household or outside. A woman's chores in and around the house including cooking, cleaning, collecting water and firewood as well as taking care of the children and elders were described as so demanding that it made EBF difficult:
'I have a lot of work at home so I have no time to breastfeed exclusively.'(Urban FGD Namatala, woman)
Women described working outside the home and being employed as virtually impossible to combine with exclusive breastfeeding:
'Some working mothers have no option but to introduce other feeds.' (Rural FGD Namanyonyi, woman)
Quite a few of the participants were still in school and said they had no time to breastfeed or at least could not breastfeed exclusively. The mother also needed to be relieved from the stress of a crying baby.
'The baby has to get satisfied so that he does not cry' (Urban FGD Namatala, woman)
The vulnerability involved in depending on breast milk only was expressed through the concern that' the baby should get used to other feeds'. In addition, giving supplements to breast milk was seen as a way to solve practical challenges so the women could earn money. Some of the urban men were bottle-feeding their infants during the discussion because their wives were studying or working. The rural men assigned too early introduction of supplementary foods to the 'working class women' contrasting with the 'rural women' who did it later. On the other hand, in the rural context, availability of cow's milk could in itself be a reason to introduce supplements. 'I have a cow' was mentioned by a few men and women as a reason to give cow's milk.
Most importantly, men and women were concerned about breast milk not being sufficient and EBF as not feasible in their particular poverty-ridden environment. Sickness and hunger were held as major reasons for poor milk production and hence for giving other foods:
'Sickness like malaria and breast problems like breast engorgement which are very common here do not allow the mothers to breastfeed exclusively.' (Urban FGD Namatala, man)
The exhaustion following HIV/AIDS was mentioned as a reason to introduce other foods early and thus practicing mixed feeding:
'Sickness like HIV/AIDS stops some mothers from breastfeeding exclusively.' (Urban FGD Namatala, woman)
The women explicitly linked their perceived low breast milk production to poor food intake saying that 'because mothers feed poorly they don't get enough milk' (Rural FGD Nakaloke, woman). Poverty and hunger were major concerns:
'Poverty makes me fail to buy food and so I don't eat a balanced diet which limits the milk for the baby' (Rural FGD Nakaloke, woman)
In a context where the men were seen as the main providers, women tended to hold men responsible for the scarcity of food and hence for their poor milk production:
'Husbands do not provide enough; most times they only provide millet bread, so there is no milk in the breast.' (Rural FGD Namanyonyi, woman)
These views were to some extent supported by the men who saw it as their obligation to contribute with extra food for the postnatal breastfeeding woman. Both men and women stressed that neglect; lack of food and care during the important period of breastfeeding, could cause emotional problems that again could affect breastfeeding negatively.
'Emotions cause less milk, especially if the husband is not looking after the mother well.' (Rural FGD Bufumbo, woman)
The link between poverty and poor ability to practice EBF was not unanimously held. While women said they were too poor to practice EBF because it demanded good food, men tended to associate EBF with poverty and lack of ability to buy complementary food.
'Exclusive breastfeeding exists because of financial constraints - one's income may be too low to attain other foods. (Rural FGD Nakaloke, man)
How is non-breastfeeding understood and accepted?
The possibility of a mother not breastfeeding her newborn was received with surprise and disdain. Some women mentioned the possibility that the milk could turn 'bad' with sickness like swollen breasts, cancer, HIV/AIDS and malaria, but in general avoidance of breastfeeding was an unexpected behaviour. A non-breastfeeding mother was looked upon with suspicion. Her reasons would commonly not be taken seriously:
'Some just pretend to be sick and they refuse to breastfeed.'(Rural FGD Nakaloke, woman)
Women in all groups were concerned that some women would prioritize their own appearance over the health of the child:
'Others want to remain young and want breasts to remain firm.'(Rural FGD Namanyonyi, woman)
Men and women shared the understanding that avoidance of breastfeeding would severely harm the baby. As one man put it:
'Such a mother will be taken as one who does not understand because she will be denying the baby a chance to grow well.' (Rural FGD Namanyonyi, man)
Denying an infant breast milk was associated with the death of the child and the mother would be held responsible. A mixture of feelings including moral judgement and disgust were seen among men and women alike. One of the men said that such a woman 'would be taken as a murderer' (Rural FGD Namanyonyi, man). The women used words like: 'difficult,' 'not serious,' 'irresponsible,' 'not ready for her baby,' 'abnormal,' 'mentally disturbed,' 'bad hearted' and 'wants her baby to die' about non-breastfeeding mothers. A strong social judgment was observed. A mother who did not breastfeed did not deserve the status of a mother. As one woman expressed it: 'She is not supposed to be among mothers' (Urban FGD Namatala, woman)
Apart from the acute survival issue involved in not breastfeeding an infant, the women were concerned about the emotional aspects of breastfeeding. Some felt sorry for mothers who did not breastfeed.
'I feel sorry for her because she does not know the importance of breastfeeding.' (Rural FGD Nakaloke, woman)
Even more, they were worried about the bonding between mother and infant.
'It's a sad moment because there is loss of love and intimacy between the mother and the baby.' (Urban FGD Namatala, woman)
A decision not to breastfeed on the part of the mother was perceived as an action that would require intervention on the part of the father. Unless a mother had a good reason to abstain from breastfeeding, like psychological or psychiatric conditions or lack of breast milk, the sanctions, according to the men could be rather tough.
'I would force her to breastfeed unless she has a genuine reason like serious mental illnesses.' (Urban FGD Namatala, man)
Some men said they would first just ask why. Others would 'plead her because it looks so bad.' If they were the father of the child some would try and find immediate solutions like feeding the baby with an alternative feed. Porridge with margarine, cow's milk, warm water and wet nursing were suggested. None of the men imagined they would sustain this for a long period of time, neither economically nor practically. Others would seek assistance from relatives or health workers. Physical force was mentioned by a few. One man said: he 'can even beat her.' (Rural FGD Bufumbo, man)
In all groups men said they would rely on the elected administrative person in the village (local chairman, LC) or some other person with administrative or judicial responsibilities.
'Such a mother will be taken either to probation offices, LCs [local chairman], or police immediately.' (Rural FGD Bufumbo, man)
Some expressed that a non-breastfeeding decision on the part of the mother would result in divorce.
'I would report her to the LCs [local chairman] and she will cease being my wife.' (Urban FGD Namatala, man)
In general, not breastfeeding an infant was seen as a serious neglect of maternal responsibility and was sanctioned accordingly.