Breastfeeding Experiences of Women- The Essence of Womanhood: A Qualitative Study


 Qualitative Research for the Social Sciences uses a conversational writing style that draws readers into the excitement of the research process. It provides insights into behaviours, moods and interactions which would have been difficult to measure using traditional survey techniques. “Narrative Analysis” is a qualitative approach which emphasises on power of spoken word. This approach was used because of its tremendous initiative appeal and is the best approach to “restory” the breastfeeding experience of the woman –the essence of womanhood. The study participants included four mothers who breast fed their children exclusively for six months, four mothers who complementarily breast fed for first six months and four mothers who never breast fed the babies from Dharwad district of Northern Karnataka. A total of 12 mothers in the year 2017-18 were selected by purposive sampling method. The participants consent was taken for their participation in lengthy, in depth interview and to audio record their interview by assuring confidentiality. Analytical procedures like data reduction, coding and thematic development were done based on repeated readings of transcript. Based on this, five themes like Barriers vs Promoters, idealism vs realism, Knowledge vs Ignorance, Sense of Satisfaction vs Guilt and Normal Development vs Developmental delay were framed. Peer debriefing, member checking and triangulation were used as strategies of rigor. The results of qualitative analysis revealed that the support of husband, family and health personnel were the promoters and cultural beliefs, responsibilities of mothers,illness in infants and mothers were barriers of breast feeding. Conflicting advice by health personnel and elders in the family, and promotion of formula and other prelacteal feeds by popular brands were also the negative determinants of breastfeeding practices in mothers.The feeling that breastfeeding is the essence of motherhood was universal among mothers. Exclusively breastfed mothers perceived that their children had normal development while complementarily and never breastfed mothers perceived the delay in development of their children.


Introduction
Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; although breastfeeding is a universal phenomenon in India, it is usually started after 3-4 days and the practice of feeding prelacteal feeds like honey, sugar water, gutti(a prelacteal feed prepared by rubbing almonds and other herbs), water, etc is common. It can be observed that breastfeeding is culturally well accepted but inadequately practiced, partly due to ignorance. Lack of knowledge, prevailing misconceptions and cultural taboos signi cantly contribute to undesirable breastfeeding practices such as delayed initiation and discarding of colostrum. According to the NFHS-4 report the exclusive breastfeeding rates in India are 54.90per cent and in Karnataka is 54.20per cent (Anon., 2014). Improvements in breastfeeding rates are critical to the attainment of the Millennium Development Goals Studies involving mere logical and statistical procedures cannot provide a complete insight in understanding such phenomena. Hence, qualitative research, a process of naturalistic inquiry that seeks in-depth understanding of social phenomena within their natural setting and focuses on the "why" rather than the "what" of social phenomena and relies on the direct experiences of human beings as meaning making agents in their everyday lives was used. Qualitative Research for the Social Sciences uses a conversational writing style that draws readers into the excitement of the research process. It provides insights into behaviours, moods and interactions which would have been di cult to measure using traditional survey techniques.
In this context a qualitative study was conducted in which case studies based on Narrative Analysis Approach were conducted, with emphasis on the following objectives.
1. To know the socio-cultural perspectives of women on breast feeding experiences and practices.
2. To identify factors responsible for successful breast feeding practices.
3. To explore the developmental outcomes of breastfed and non-breast fed infants.

Population and Sample
The study participants included a total of 12 mothers by purposive sampling method. Among them, four mothers who breast fed their children exclusively for six months, four mothers who complementarily breast fed for rst six months and four mothers who never breast fed the babies from urban and rural area of Dharwad district were selected. The participants consent was taken for their participation for lengthy, in depth interview and also to audio record their interview by assuring con dentiality. The study was approved by University ethical Committee.

Tools Used for data Collection
The data was collected by in depth interviews which were recorded. An interview guide with open ended questions was framed. However, the guide had some must ask questions, but the researcher was open to information and was led by promising leads and played the role of good listener and remained neutral as a method of rigor to avoid researcher's bias and did not ask any leading questions.
Research Design "Narrative Analysis", a qualitative approach which emphasises on power of spoken word was adopted. Narrative methods can be considered "real world measures" that are appropriate when "real life problems" are investigated. In a basic linear approach, they encompass the study of the experiences of single individual embracing stories of the life and exploring the learned signi cance of those individual experiences. This approach helps to analyse the stories people create, engaging in an inquiry of asking a given question of the narrative 'texts' for a given purpose. It helps to understand how people are representing themselves, or their experiences, to themselves and to others. This approach was used for the study because of its tremendous initiative appeal and is the best approach to "restory" the breastfeeding experience of the woman -the essence of womanhood.

Qualitative data analysis
The narrative analysis approach to elicit stories from the participants talk was adopted by following the below procedure.
Individual narratives /Interview transcripts were made.
The recorded interview was played 2-3 times to write a detailed transcript.
The most commonly used analytical procedures like coding and thematic analysis was done based on repeated readings of transcript.
Open codes and themes as well as in vivo codes emerged directly from participants words were identi ed from the transcript to nd similarities as well as dissimilarities among the cases.
Peer debrie ng and member checking were used as strategies of rigor. Table 1 indicates that the sample size included 12 mothers of infants aged between 8-24 months. Out of 12 mothers, four mothers exclusively breastfed their children for rst six months, our mothers complementarily breast fed their children and four mother never breastfed their children. The mother's age ranged from18-30 years. Four mothers each had primary and secondary education, while two mothers each had completed graduation and post-graduation. 10 mothers were homemakers and two mothers were working. Regarding gender of the child 7 were males and ve females. Figure 1 indicates the ecological frame determining the breastfeeding practices. The transcripts of the case studies indicated that the eco system involving infants, mother, husband, family and health care system determined the breastfeeding practices of mother.

Themes developed
Based on the transcripts ve themes were developed ( Fig 2).

Theme I -Promoters vs Barriers
Seven subthemes were developed under the theme-I.

a) Mother's and child's health
The quote from mothers illustrates child's illness can be a promoter or barrier for breastfeeding You know, my son was born prematurely……He weighed 1,800 gm, as he was born 1 month early. He was so tiny, I was afraid to hold him. He could not suck well. But within two days, the baby was ill. He had jaundice……again was admitted to hospital for ve days for jaundice treatment. I was not able to feed properly as a result milk production decreased. I had to feed cow's milk at one month.
Another Mother quoted I was very weak after delivery. My hemoglobin was very low. I used get fatigued very easily…..So, I had to feed top milk… b) Cultural beliefs and attitudes (Feeding prelacteal feeds) A mother who fed exclusively for six months quoted My family members as a cultural practice insisted on giving honey. …Also my baby was very lean and not plump …….so, I always used to get worried. So my family members said to give gutti, so that he will gain weight…. But I always used to consults my doctor and took his advise. He said baby is ne. ..advised me not to feed any prelacteal feeds upto six months.

The quote of a mother who complementarily breastfed Illustrates
When elders came to see the baby for the rst time after delivery, they give little honey. Also I have given gutti (Badam and cashew rubbed in milk) after 1month ... it makes the baby healthy and helps to gain weight. ….I have also fed with gripe water (laughs) …..Everybody gives it….. Even elders in the family advised….. Because it keeps the baby calm and baby sleeps well. c) Physical feeding di culties Quote of a mother who fed bottle fed I had a complicated delivery. My baby was delivered pulling out by hand….. the doctor's say the nerve on one side is damaged….you know….was kept in ICU for 17 days. Though I had surplus milk I could not breast feed ……Slowly the milk production stopped because the stress. Later I was given tablets for milk production. But the baby got adjusted to formula. He refused breastmilk ……….though I made him suck milk. …so fed formula for 6 months d) Roles and responsibilities Quote of a Mother who practiced complementary feeding You see this is my third delivery.….. My mother said this is not our responsibility. It is your in-laws responsibility…… The rst two deliveries was at my Mother's place. So, I was relaxed I could breast feed properly. But now….with three children, husband in private company, I had to take responsibility after 8 days after delivery. It was really… very di cult to feed properly. e) Family/husband's support Quote of exclusively breast fed mother My husband especially is very supportive… I only sometimes get involved in household work, he tells me to stop all work and rst feed him. My mother and my husband tell me to rst feed breast milk and then do other things. f) Support of health personal Another mother says I had caesarean…. I was tired. My family members said milk will not be produced for three days. But my doctor advised me to feed immediately… she supported me and helped in initiating breastfeeding.

Another Mother said
My daughter is 15 months old she is the rst baby… I am pregnant again…. 8 th month running…….. smiles…… I was not told anything in the hospital and nobody suggested or guided me about breastfeeding. My mother-in-law says it is natural to feed and tells to feed now also. She says…… when the second baby is born……. rst baby automatically stops feeding. ……… She insists me to feed now also. b) Con icting advice Quote from a mother I delivered the baby at local PHC in village. The baby coughed….. so they sent me to the main hospital……. They said the baby has respiratory infection and was kept in ICU…which was in rst oor…. you know I was in ground oor. I don't know what they fed the baby for three days. They did not allow me to breast feed. My parents argued…. with doctors and made me feed breast milk. So, the nurses said if anything happened, they are not responsible…. But I fed baby later and she recovered. c) Promotion of Formula and other infant feeds A mother who stopped breastfeeding within one month says, My baby had jaundice, weighed 1800gm and was kept in ICU. The doctors and nurses fed him with formula in ICU. They said baby is at risk. If I feed, it is at our risk……So, I did not breast feed when he was in ICU.
Another mother said I gave him gutti for 3 months. This is because it helps in baby's growth. He will be health and there will be weight gain……you see (showed the gutti bottle of a popular brand) it is written here, it can be given from birth…… d) Judgemental Attitude of health Personnel Illustration by a mother's quote They kept my baby in ICU, I became frantic, I had…normal delivery……My family and myself we were not knowing what was happening…….for two hours nothing was said… then they said you go to district hospital… for three days nobody is telling what is happening……not even I was allowed to breast feed… A quote by another mother This is my third child. She had a running nose. Suddenly she started vomiting at mid night. I went to hospital……my baby was admitted for 21 days. I did not know what treatment was given…They fed formula milk in ICU. I insisted on breastfeeding. The nurses in the hospital rudely told, this is your third child, you should have experience…… Theme III-Idealism vs Realism The three subthemes developed under the theme-III are as follows. a) Mother's knowledge and attitude about breastfeeding An exclusively fed mother said, Breast milk is the only complete food for the baby, provides all nutrients, immunity……I have read……breast fed children will be intelligent. And specially for mother, our pregnancy weight will be reduced, avoids breast knots and Cancer…….Oh…specially avoids conceiving.
Quote from a mother practicing complementary breastfeeding I don't know much about the bene ts ………I know it is the best food for babies.
A mother who did not breast feed all her three children said, It's ok if you cannot feed. I fed formula for 3-5months and the cow's milk. There is no problem in formula. I don't think it makes difference in development… b) Ignorance about feeding mode, feeding schedule A quote of an educated mother illustrates Sometimes due to back ache… I used to feed only from one breast. So I had breast knots. Also I had more milk……my family members told me to squeeze milk and throw away. ….But my doctor advised that only breastfeeding from both the breasts is the only curative thing for all my problems.
Another mother said I fed the baby the baby every 2-3 hours ……during night I did not feed much…may be once… c) Knowledge and myths about foods to be consumed during pregnancy and lactation A mother quoted I was advised by my mother and mother-in-law to consume methy and other green leafy vegetables citrus fruits ………My family members said not to take Papaya, Jackfruit, Jamun fruit……I know nothing happens (smiles). But still I did not want to take chance. So I avoided. It was said that these foods cause heat and lead to miscarriage.
After delivery I was given Alvi (garden cress seeds), dry fruits laddu, sajjaka, soft rice, vermicelli. These food were given to give me strength and increase lactation. I was told to avoid hard rotis, brinjal, spices. Since I had a male baby, all my family members insisted not to drink more water. It is believed that it create problem during urination… But I consumed lot of water as advised by my doctor.
Another mother said I was encouraged to take good fruits, vegetables, milk. But I did not take papaya, sesame, pumpkin, cluster beans, bengal gram and such thing which causes heat. They say it leads to miscarriage I was encouraged to take Alvi (garden cress seeds), methy seeds chutney, methy bhaji, dry fruit mixture immediately afterdelivery. I had caesarian, so I was not allowed to take green chillies and spices for 3 months. Also I did not take any acidic fruits…mmm…specially citrus fruits Theme IV. A sense of satisfaction vs guilt The two subthemes developed under the theme-IV are as follows.
a)An experience of breast fed mother It helps in developing attachment and a kind of emotional bond with the baby…The emotions I experience when I held baby to my breast ……I don't know how to express ……a special connection is established. I can feel in me that my baby feels secure and relaxed. b)An experience of never breast fed mother Oh!! It is the main essence of motherhood. I had that deprivation of motherhood. But what can I do…… I have to accept the situation and ……I had to feed with formula because it is my child's life……But I really … really feel bad sometimes.

Theme V Normal development vs. developmental delay
The two subthemes developed under the theme-IV are as follows.
A quote from exclusively breast fed mother for six months and still feeding at 15 months Smiles with sheer happiness……. At 7 months of age she told abba (father) and by 10 months she and started walking. She is very fast in all developmental milestones she is active, very calm and everybody in the family and neighborhood likes her. Now a she speaks everything…… And since ours is a joint family she sits with her elder siblings and tries to write and do what they do while studying.
A quote from formula fed mother My son he is going to be one year old in two days…He has just started moving front by crawling. If we hold him he steps. He doesn't speak anything………I can feel the difference…I have two daughters elder to him……I could feed them with breast milk ……my daughter's were very fast. By this time…… they had started walking and also they talked at an early age…… I feel my son is bit slow compared to them. His growth is also slow and is little weak. He also responds less.
Qualitative analysis of present study thus shows that the support of husband, family and health personnel were the promoters of breastfeeding and the barriers were the cultural beliefs , roles and responsibilities of mothers , physical feeding di culties like caesarean delivery , no or less than two antenatal visits , illness in infants and mothers. Titaley et al. (2014) and Meedya et al. (2010) also found that increased odds of delayed initiation of breastfeeding included caesarean-section deliveries and deliveries in government-owned facility and mothers with obstetric complication at childbirth.
The concept that breastfeeding is a natural phenomena and it is universal was endorsed by the study.
Knowledge about breastfeeding, con icting advice by health personnel and elders in the family, judgemental attitude of health personnel and promotion of formula and other prelacteal feeds by popular brands were also the determinants of breastfeeding practices in mothers.Similar results were found by Arya et al. (2015) where more than 50 per cent mothers had initiated breastfeeding within one hour and feeding prelacteal feeds was not uncommon. Mothers' knowledge regarding successful feeding practices had positive in uence on initiation, exclusive breastfeeding and duration of breastfeeding. Myths and ignorance had negative in uence on breastfeeding practices. The present study is consistent with results of Garg et al. (2016) and Mekuria et al. (2015) who also reported that the lactating mothers in who had good knowledge about breastfeeding practices practised successful breast feeding practices.
The results also indicate that the mothers who had breast fed their infants had a sense of deep satisfaction and felt that it increased the bonding, between the mother and child. The feeling that breastfeeding is the essence of motherhood was universal among mothers. However, the mothers who were not able to feed for various reasons felt a sense of guilt.
The experience of mothers with respect to the developmental progress indicated that most of the exclusively breast fed mothers perceived that their children had normal development or they felt they were ahead compared to the other children of the same age group. However, complementarily fed and never breast fed mothers perceived the development of their children as a bit slow compared to their counterparts and also with the elder siblings in the family. Der et al. (2006) also observed that one standard deviation advantage in maternal IQ more than doubled the odds of breastfeeding.
Thus the qualitative study clearly projects that most common factors for improper breastfeeding practices, prelacteal feeding, delayed initiation of breastfeeding continues to be family customs and cultural practices .This highlights the need that all the family members, particularly the elderly females and husbands to be included in awareness and training programs. Training of health workers and volunteers should focus on counseling rather than just giving messages. Table   Table 1 Characteristics of the Sample N=12