Background
Methods
Study design
Study site
Data collection
Method | Respondent type | Number of participants |
---|---|---|
IDIs | Ex-RMG workers, current RMG workers and RMG workers currently on maternity leave | 8 |
FGDs | Current RMG workers, RMG workers currently on maternity leave and caregivers | 25 (4 FGDs) |
KIIs | Welfare officer and line supervisor of RMG factory | 2 |
Sample and participants
Ethical consideration
Data analysis
Results
Characteristics of the participants
Characteristics | IDI with mothers (n = 8) | FGD with mothers (n = 19) | FGD with caregivers (n = 6) |
---|---|---|---|
Age group | |||
21–25 | 5 | 9 | 0 |
26+ | 3 | 10 | 6 |
Years of schooling | |||
0–5 | 5 | 10 | 5 |
6+ | 3 | 9 | 1 |
Husband’s profession | |||
Service | 4 | 12 | – |
Day Labor | 4 | 7 | – |
Mother’s job experience (years) | |||
1–5 | 3 | 7 | – |
6–10 | 4 | 7 | – |
11+ | 1 | 5 | – |
Household income (USD) | |||
100–150 | 3 | 7 | – |
151–200 | 4 | 5 | – |
200+ | 1 | 7 | – |
Child’s age | |||
≤ 6 months | 5 | 15 | – |
6+ months | 3 | 4 | – |
Alternative caregiver (Relation to child) | |||
Grandmother | 0 | 0 | 4 |
Other relatives | 0 | 0 | 2 |
Breastfeeding knowledge and experience
Exclusive breastfeeding
All participants knew that one should feed breast milk only for at least the first 6 months. As one mother said:Did you not hear that there is no substitute (for breast milk) … It is true. Breast milk has no bhejal (contaminant). [IDI 4_currently working mother]
All the participants mentioned learning about breastfeeding for 6 months from their educated and experienced relatives and neighbors and from health professionals. Despite widespread knowledge of the need for breastfeeding during the first 6 months of life, when mothers were asked if other foods could be given during this time, some talked about the need to give infants water and sugar water to quench thirst. Though, many mothers thought that, ideally, complementary foods should be introduced only after six months.Feeding breast milk [up to six months] is good. Mother’s milk is nutritious. Other foods are not the same as breast milk. We are aware now . . . We learnt from TV. [FGD 2_mother on maternity leave]
Early introduction of complementary foods
Breast milk inadequacy led to early introduction of complementary foods early in a few cases:The rule is to feed (breast milk) for six months but I can’ t. . . I have to work so I feed (formula). [FGD 1_currently working mother]
A few mothers knew that introducing complementary foods increased the risk of diarrhoea for infants and complained that their infants were often sick. They also expressed concern about the safety of the ingredients in formula:Breast milk is the best but when (the) baby does not get it she cries (with hunger) and then other foods are needed. [FGD 3_currently working mother]
Most mothers who were concerned about introducing formula also talked about the risk associated with the accessories used to feed formula. They were aware that unclean bottles could cause disease:Read the ingredients (on formula container). In 100g of formula . . . one fourth (of the weight of the formula) is medicine. In a 400g container there is four times more medicine . . . Isn’t it too much? How can an infant tolerate (this amount of medicine)? [IDI 4_currently working mother]
All mothers spoke about the inconvenience of making complementary foods and maintaining the accessories given that they resided in rented rooms with communal kitchens shared with 20–30 people. Often they had to wait for their turn to cook while their babies cried. As one caregiver explained:Bottles have germs. After a feed if the bottle is left for even two minutes, germs accumulate . . . Later if the bottle is used for another feed (without washing) . . . she (the infant) can become sick. [FGD 1_currently working mother]
The baby starts crying if we are late (in feeding); this is natural . . . We sometimes can’t tolerate (the crying) . . . What can I do, we have to share the kitchen . . . I have to wait (my turn) . . . The baby suffers. [FGD 4_caregiver]
This is an extra cost . . . It gets costlier everyday . . . Before I had money left over (from my salary) after expenses. Now I have no money left. Sometimes I have to borrow. [FGD 3_currently working mother]
Structural barriers impeding breastfeeding
Preparation for joining the workforce
I have started feeding my child Lactogen-1. I feed a little (of the formula) every day. When I join work I have to start feeding (formula) more often as I will be in the (factory) the whole day. I will breastfeed when I come home in the evening. [FGD 1_currently working mother]
Limited facilities at work
In factories where there was space and privacy for breastfeeding a few mothers who lived nearby made arrangements for caregivers to bring their infants during breaks. As one working mother said:They (supervisors) would allow me to breastfeed. But I cannot do it (at work). There is no place covered by (a) curtain in our factory where I can (breastfeed). If I want to breastfeed I have to do it at the gate (of the factory). Is it possible? . . . (There is) no privacy. [FGD 3_currently working mother]
Despite the availability of breastfeeding breaks, a few mothers had doubts about being able to avail these breaks regularly:There are some who have caregivers (at home) . . . They bring the baby to (the) office (for breastfeeding). I tell my line supervisor, “My child is here; let me go downstairs (to breastfeed).” He says, “No problem. It’s your work you have to finish.” They don’t have any problem. Mothers can breastfeed at the crèche or the doctor’s room. [IDI 4_currently working mother]
The factory management, however, disagreed and claimed that they had rules allowing breastfeeding breaks twice a day for infants who were brought to the factory during a mother’s break time.If I tell my boss that I need to go (to breastfeed) then he will allow me to go for one, two or three days. Will he allow this everyday? No, this will hamper their work. [IDI 1_currently working mother]
Some people keep their babies in the office . . . they have the facility. Mothers come every 2-3 hours and breastfeed. Two caregivers look after the babies (in the crèche). [IDI 4_currently working mother]
Workload and inadequate breaks
As many of the RMG factory tasks were performed in an assembly line, if 1 person took a break the entire line had to stop. Some factories seemed to have a mechanism to replace mothers during their breaks; others did not. When mothers’ lactation breaks affected production, it put their jobs in jeopardy. One RMG worker explained:I don’t get any break (at work). No one can replace me . . . I have to continuously run the machine. There is a break (at lunch) when I can breastfeed but sometimes I can go home and sometimes I can’t. I often reach home late after doing overtime so the whole day I can’t breastfeed. [FGD 3_currently working mother]
Participants who managed to go home at lunch time found that an hour’s break was inadequate for them to travel home, eat lunch, breastfeed and return to work on time. And the longer the commute, the more difficult the schedule became.When there is (a) heavy workload if I go (for a break), you and others in the line have to wait (for me to come back). We work in a schedule and there is no scope (for) wasting time. They don’t allow me 10 minutes to breastfeed. I am in trouble (at work if I try to breastfeed). [FGD 3_currently working mother]
Support at home
My neighbor next door (an elderly woman) looks after my child. I wish someone could bring my baby to work. I could have breastfed her at work. There is no one who can bring her. [IDI 4_currently working mother]
Consequences of not being able to breastfeed adequately
Discomfort
Mothers explained the effects of breast engorgement on the quality of breast milk and on their own health:I face difficulty (at work). Mostly my breast feels heavy, they ache a lot . . . Milk comes out and wet(s) my clothes. I have to go the toilet to press and throw out (breast milk). Work piles up (because of the breaks) and I am under pressure. [IDI 1_currently working mother]
Beyond the physical discomfort a few mothers also felt guilty when work prevented them from breastfeeding. A grandmother talked about her daughter’s situation:I know that breast milk becomes poisonous and curdles (if not fed frequently). Elders say that (milk) can cause stomach problems (for the infant). (A) mother’s breast hurts, becomes hard, engorged. She has high fever . . . many things happen. Sometimes she has to take time off. [FGD 1_currently working mother]
It is not my preference (to feed formula) . . . My daughter’s milk flows out . . . She needs to throw it out 3-4 times. She cries everyday (in despair). It is our fate that we can’t feed (breast milk) to our baby. [FG 4_caregiver]
Quitting work
Only a mother knows when a child is hungry … Grandmothers don’t understand … That’s why I left (the job). [IDI 2_ex-working mother]
From the factory perspective, the loss of trained workers was a serious problem. The RMG factory welfare officers clearly understood the struggles that mothers face but prioritized the factories’ perspective and the implications of staff resignations on business:There is no place (a crèche) for kids at work. I could not keep him (with me). He is only two months old, he needs breast milk. If I work I will have to keep him at home and feed him formula . . . During the day I won’t be able to breastfeed. I want to breastfeed him . . . I don’t want to go back to work. [IDI 4_ex-working mother]
Mothers struggle to breastfeed and struggle to get reliable caregivers to take care (of the kids). Almost 50% of our workers resign shortly after maternity leave. This is very bad (for business) . . . When an experienced operator leaves, we may replace her but production is hampered. We recruit temporary workers in anticipation (of her return) . . . when mothers come back (from maternity leave) and suddenly resign. . . her resignation hampers production. [KII 1_welfare officer]
Women’s perception and experience of using expressed breast milk
Of the 3 mothers who had expressed breast milk only 1 was able to continue the practice. The other 2 were prevented by advice from coworkers and lack of breast milk. In the words of those 2 lactating mothers:(A) doctor (from their rural area) said “if you press the breast milk out, you can keep it in a ceramic bowl and leave it (to feed) . . . You can use for 8 hours no problem.” [FGD 4_caregiver]
I tried (to express) . . . Nothing comes out. I don’t have enough (milk). I tried 2-3 days before joining (work) . . . then I stopped trying. [IDI 4_currently working mother]
When we discussed the use of expressed breast milk, mothers and caregivers expressed concerns about feeding expressed breast milk. More than a third of the participants (12 out of 33) were concerned about how long the milk remained safe and were uncomfortable about the appearance of the milk. Some participants (8 out of 33) were concerned about how the expressed milk would affect the health of the child. A grandmother said:I left breast milk for the baby for some time. Some women (at work) said “don’t leave milk like that. The baby will catch a cold.” After that I stopped (expressing). [FGD2_currently working mother]
The milk looked reddish . . . There was (a) layer on it . . . Maybe from what she (the mother) ate. It looked bad so I threw it out. She (the mother) expressed a few more times and left (the milk) but I was not comfortable (feeding it) . . . Milk left out (for a long time) might be harmful (for the baby). [FGD 4_ other caregiver]
Discussion
Areas of interest | Constraints/ barriers | Facilitators | Opportunities for intervention |
---|---|---|---|
Perceptions of breastfeeding | -Working mothers introduced formula in preparation for joining work | - All mothers prized breast milk over formula -Care givers were supportive of breastfeeding -All female RMG workers received a maternity benefit package and leave | -At the factory level policies supportive of breastfeeding should be enforced - Counseling and a supportive environment (breast pump, space, breaks) should be provided by the factories as a part of their maternity package |
Perceptions of expressed breast milk | - Concerns of longevity and safety of the expressed milk -Not a social norm | - Mothers prized breast milk -Mothers and caregivers understood the disadvantages of formula | - It is important to ensure the safety of the expressed breast milk - Mothers can be trained and counseled to express and use breast milk -Caregivers should be trained about the use of expressed milk |
Sources of information | -Mothers are receiving negative information about expressed breast milk from their social network and/or media | - A few doctors are promoting expressed breast milk | -There is a need for developing behavior change communication (BCC) strategies to increase the cultural acceptability of expressed breast milk at work and in the community -Key people in social network such as mothers, mothers-in-law, husbands should be targeted for counseling -BCCs should address beliefs about expressed breast milk |
Work environment | - Heavy workload and limited break time - No privacy for breastfeeding - Inadequate crèche facilities -Unsupportive supervisory chain | -Factory policy for providing breastfeeding breaks -Most factories had a day care facility -Management is concerned about high employee dropout rates | -Create space in the existing crèche for breast milk expression -Create a program for breast milk expression with the time constraints in mind -Train existing crèche workers to counsel and train mothers -Motivate the factory management to invest in the program - Constantly motivate the supervisors to ensure that mothers can utilize breaks |