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A qualitative study on perceptions of first time mothers about breastfeeding

Twenty two percent of neonatal deaths could be prevented, if all newborns are put to the breast within the first hour of birth. Exclusive breastfeeding (EBF) includes initiating breastfeeding of the newborn as early as possible after birth and continuing it till 6 months of age without supplementary bottle feeding but permitting the infant to receive ORS and other medications whenever required. It is an essential element for the satisfactory growth and development of infants. Breast milk is highly nutritious and provides excellent energy to the infants. It is also a rich source of protein, iron, vitamin A, and a variety of bioactive components like IgA, lactoferrin, K-caesin, cytokines, growth factors and glutathione peroxides which have anti-infective, antioxidant and growth promoting properties.


INTRODUCTION
Timely initiation of breastfeeding is defined as putting the newborn to the breast as early as possible after birth. It is the easiest, cost effective and most successful intervention and also the most effective life-saving method for the health of the newborn. 1,2 Twenty two percent of neonatal deaths could be prevented, if all newborns are put to the breast within the first hour of birth. 3 Exclusive breastfeeding (EBF) includes initiating breastfeeding of the newborn as early as possible after birth and continuing it till 6 months of age without supplementary bottle feeding but permitting the infant to receive ORS and other medications whenever required. It is an essential element for the satisfactory growth and development of infants. Breast milk is highly nutritious and provides excellent energy to the infants. It is also a rich source of protein, iron, vitamin A, and a variety of bioactive components like IgA, lactoferrin, K-caesin, cytokines, growth factors and glutathione peroxides which have anti-infective, antioxidant and growth promoting properties. 4 to contract for the expulsion of the placenta and reducing the risk of postpartum bleeding and infection. 6 Other long-term benefits include decreased risk of breast and ovarian cancers and hip fractures. 7 In spite of profound beneficial effects of breast milk breastfeeding rates in India are abnormally low. Only 21% urban and 35% rural mothers begin breastfeeding within one hour of birth. Exclusive breast feeding after discharge from hospital is low (urban 38%; rural 57%). Non-exclusive breastfeeding was practiced by 52% of urban and 50% rural mothers during hospital stay due to perceived insufficiency of milk.
Cultural practice influence 45% rural mothers about breastfeeding. Perceived insufficiency of milk (36%-47%) in the first 3.5 months and baby (37-62%) aged between 3.5 months to 6 months are considered dissatisfied by the mother. 8 Qualitative studies conducted in western countries conclude that lack of time and access to quality resources, lack of family support and discomfort with feeding in front of public negatively impact the initiation and duration of breastfeeding.
Another qualitative study conducted in Canada found that religious belief was the strongest influencing factor for the decision of breastfeeding. Mothers in the study also commented about lack of support in the work environment, and breastfeeding in public places being a problem due to environmental barriers such as lack of private rooms. [9][10][11] Williamson et al, studied eight British first time mothers who pointed out the discrepancy between new mother's experience of struggling to breastfeeding and social portrayal of breastfeeding as natural and synonymous with good mothering. 12 New mothers tend to self-blame for being unable to breastfeed their babies successfully.
All eight mothers also experienced severe breastfeeding related pain and were confused about whether the amount of pain was to be expected or signaled something wrong. 12 In another qualitative study on breastfeeding, Lee et al, reported that first time mothers generally had a positive perception of breastfeeding and followed WHO guidelines on initiation of breastfeeding. Less than half of the mothers in the study breastfed for 6 months; the main reason for non-continuation of breastfeeding being maternal employment and perceived inadequacy of milk supply. 13 There is lack of qualitative data regarding breastfeeding practices in India. Therefore, we have planned to assess the perceptions of mothers on breastfeeding in this middle part of Bengal and to understand the reasons behind non-continuation of breastfeeding among the first-time mothers. It will help the health care providers to ascertain the real scenario of breastfeeding practices and to help them to ideate and organize their efforts.

METHODS
The study was conducted in the pediatric department of Burdwan Medical College Burdwan West Bengal. This study was one of the qualitative descriptive types involving in depth interviews of 21 first time mothers with breastfed babies who attended outpatient department of Pediatrics at Burdwan Medical College, Burdwan, West Bengal. All the interviews of the mothers of breastfed babies were conducted in a convenient place after taking consent by the first author. A female nurse was present all the time during the interview process. An interview guide was prepared by the authors after thorough literature review. All the mothers were interviewed face to face and detailed notes were taken during the interview process and briefing of the summary of the interview process was done after completion of each interview.

Inclusion criteria
• mothers who had non-complicated normal vaginal delivery (spontaneous delivery of full term baby) • delivered a healthy baby without any medical conditions and initiated breastfeeding as early as possible while in the hospital

Exclusion criteria
• mothers who underwent caesarean section • could not breastfed the baby for medical reasons • not given consent for in depth interviews.
Qualitative data was obtained by the in-depth face to face interviews of 21 mothers and each of the interview lasted for 10 to 16 minutes. All the interviews were conducted in Bengali language which is the native tongue of the participants. Non-participants were not allowed to remain while conducting the interviews. Thorough handwritten notes were taken while conducting the interviews. Interviews were translated and typed into English. Transcript analysis was performed manually by both the authors.
Descriptive codes of the text information were done and then categories are formed by merging similar codes together. All the questions used during the interviews were open ended.
Before beginning of the study formal approval was taken from the institutional ethical committee of the institution. The script was written by the second author and reviewed by the first author and finalized for publication. The consolidated criteria for reporting qualitative research guidelines were followed.

RESULTS
Authors have included 21 first time mothers who have delivered a single normal healthy baby at hospital. They belong to 21-29 years of age-group of which 9 mothers reside at the rural areas and 12 mothers at the urban areas.
Regarding educational status 6 mothers have completed primary level of education, 8 mothers have completed secondary level of education, 5 mothers have higher secondary level of education and the remaining two are graduates. Among the total 21 babies, 11 babies are male, and 10 babies are female. The results of the in-depth interviews of the first-time mothers could be divided into seven categories and each of which is further divided into several codes.
The categories given here and codes in parenthesis. Reaction of mother (feeling pain, nipple bite, refusal of breastfeeding and feeling good), inadequate breast milk (baby crying, belly not full, disease of mother, taking medicine and amount of colostrum), breast milk causing ailments of the baby (diarrhea, cough, irritability, low growth and contamination), erroneous idea about breastfeeding (aya, neighbors, quack and television), lack of time (in service mother, shop owner and daily worker), lack of privacy (private room, travelling and one room), and breast milk is best for my baby (growth and development, less disease, playful and economic).

DISCUSSION
In the present study the qualitative data analysis related to breastfeeding could be classified into seven categories, viz., reaction of mother, inadequate breast milk, breast milk causing ailments of the baby, erroneous idea about breastfeeding, lack of time, lack of privacy and breast milk is best for my baby.
The category "reaction of mother" includes four codes, viz., feeling pain (I am feeling pain during breastfeeding), nipple bite (I am always afraid of nipple bite by the baby during breastfeeding), refusal of breastfeeding (My baby becomes irritated when I put him in my breast and he refuses breastfeeding) and feeling good (I am feeling well during breastfeeding and it gives me pleasure).
The category "inadequate breast milk" could be further classified into five codes, viz., baby crying (Baby is crying more during breastfeeding), belly not full (Belly of the baby is not full after breastfeeding), disease of mother (I was suffering from cough and cold -breast milk was not sufficient), taking medicine (I am taking medicine for hyperacidity, this will cause harm to my baby), and amount of colostrum (Very little amount of colostrum, so I have added water with it).
The category " breast milk causing ailments of the baby " includes five codes viz., diarrhea (My baby is suffering from diarrhea after taking breast milk), cough (My baby is suffering from cough and cold very often), irritability (My baby is very much irritable), low growth (Growth of my baby is not proper) and contamination (Infection of my nipple will affect my baby).
The category "erroneous idea about breastfeeding" consists of six codes which are aya (My attendant (aya) told me, "artificial milk is better for growth of my baby"), neighbor (My neighbor said, "Artificial milk is more nutritious for baby"), quack (The quack who treated me for fever said, "Artificial milk is best for the health of the baby), television (I have seen in the television, "For better development of brain artificial milk is better"), disfigurement (Breast feeding causes loss of figure, I will be ugly looking), and status (Buying costly artificial milk for the baby gives a pleasure to father).
The category "lack of time " includes three codes viz., in service mother (I am a school teacher, during school hours, I have to use artificial milk for my baby after his four months of age), daily worker (I have to work most of the days, less time to feed my baby), and shop owner (We have a tea-shop, I work there daylong, no time during my work to feed my baby. The category "lack of privacy " has three codes viz., private room (No private room in my school to breastfeed my baby, travelling (During long travelling in a crowded bus, breast feeding creates problems), and one room (We have only one room in our family, my father in law resides in the same room with us).
The category "breast milk is best for my baby " consists of three codes viz., growth and development (The growth and development of my baby is proper due to breastfeed), less diseases (My baby is very well, he is healthy, no disease), playful (My baby is playing the whole day, he only takes breastmilk), and economic (No extra money is required for buying costly artificial milk for my baby).
In a qualitative study conducted in Singapore, the authors explored first time mother's experience of about breastfeeding and identified four themes viz., challenges and support for breastfeeding, low degree support in the workplace, unease at breastfeeding in front of others and emotional and psychological aspects. 14 These themes are mostly identical with the categories of present study.
Themes like low degree support in the workplace, and unease at breastfeeding in front of others are almost similar with the categories 'lack of time' and 'lack of privacy' mentioned in present study. My neighbor said, "Artificial milk is more nutritious for baby"

Quack
The quack who treated me for fever said, "Artificial milk is best for the health of the baby " Television I have seen in the television, "For better development of brain artificial milk is better" Disfigurement Breast feeding causes loss of figure, I will be ugly looking In another qualitative study on breastfeeding experiences of sixteen first time mothers in Vientiane, Lee et al, the authors found that a few mothers have exclusively breastfed their babies for the first six months and most of them stopped breastfeeding at less than 20 months. 13 The mothers who have stopped exclusive breastfeeding mentioned the reason for stopping it as challenges in work situation, insufficient milk, compressed nipple, baby being old enough to eat any food and the baby's decision (reluctance). In present study the category "inadequate breast milk" is classified into five codes, viz., baby crying, belly not full, disease of mother, taking medicine, and amount of colostrum which more or less fits with the findings. Oomen et al in his study has found 55% usage of formula feeds by the mothers and showed that perceived insufficiency of breast milk was the main reason behind discontinuation of breastfeeding. 8 A study from Hyderabad, India, indicates that majority of mothers (67.5%) had favorable attitude towards breastfeeding. Top feeds were started by 48.6% mothers before completion of 6 months of the child. 15 The principal reasons were aggressive promotion of baby foods by commercial companies and lack of appropriate support structures at the places of work and community, whereas, in this study first time mothers acquired the erroneous idea about breastfeeding from the aya, neighbors, quack and television. They have also a misconception about disfigurement of the female body coupled with fathers' over-eagerness to buy expensive artificial milk as a sign of high economic status.
One study from south India found the reasons for stopping breastfeeding as no breast milk (37%), baby didn't drink (13%), mother became pregnant (3%), baby became sick (1%) and mother became sick (3%). They have also reported that 73% mothers were fully satisfied with breastfeeding. 16 In present study most of the mothers' perception is that "breast milk is best for her baby". The attitude is very encouraging for the health care personnel who stress the need for breastfeeding.

CONCLUSION
In this present study we have applied qualitative in-depth interview approach and found out different reasons of non-continuation of breastfeeding among the first-time mothers of this area. Though they have to face challenges regarding continuation of breastfeeding and have acquired some erroneous ideas about breastfeeding from multiple sources the fact remains that breastfeeding is undoubtedly best for the babies and their mothers.