Characteristics of the study participants at the beginning of the study
Table 2 shows the characteristics of the complete sample of study participants and the characteristics of the participants of the sub-sample concerning the current analysis. Among the 17 participants of the current analysis, the majority were aged above 30 years (n=12), living with partners (n=16), had the ability to read and write (n=15) and completed primary school education (n=9).
Table 2: Socio-demographic characteristics of women interviewed
Overview of the results
Data analysis revealed that mothers who followed the recommendations during the first year of child’s life used various problem-focused coping strategies to manage the everyday IYCF challenges. Coping strategies included mothers’ effort to improve their own diet to improve breastmilk production, balancing work and child feeding, prioritizing childcare, preparing child’s food in advance, active uptake of the recommendations and persistence in overcoming barriers. Data analysis also indicated personal and social factors that facilitated coping. Personal factors (intrapersonal factors that facilitated coping with challenges) included beliefs about benefits of breast feeding, self-efficacy, and religious belief while social factors (contextual factors in the form of social support on which participants relied to cope with challenging situations) consisted of support from family members, other mothers in the community and advice of CHWs and health professionals. Below we describe the different coping strategies and facilitating factors. To illustrate themes, typical quotations from participants were translated from Kinyarwanda (mother tongue) into English.
Coping strategies for appropriate breastfeeding and complementary feeding practices
Make effort to improve their own diet for adequate breastmilk production
The majority of participant mothers perceived their own diet to be linked to the quality and quantity of breast milk. In the first week, most mothers perceived their diet to be appropriate to support adequate breastmilk production. From 4 months to 6 months, those who managed to exclusively breastfeed reported to try their best to improve their diet to support the production of adequate breastmilk to satisfy the infant.
“I try my best to get porridge and to eat a balanced diet so that by the time the baby will breastfeed he will get adequate breastmilk.” (W-26, month 4)
Balancing work and child feeding and prioritizing child feeding
Some mothers described the way they deal with their heavy workload by trying to balance work and child feeding and by reducing the time they spend to other tasks and by prioritizing childcare first, including breastfeeding and complementary feeding, between 4 months and 12 months.
“Tasks never end; I only mix them with caring for the child. No rural mother can find time to care for a child exclusively, people are always busy even during dry seasons, so I try to find a way to do the work and take care of the child.” (W-34, month 4)
“Workload is not a big challenge. In my case, I reduce it and fulfil my responsibility of childcare first including feeding.” (W-8, month 12).
Mothers reported to be active and resourceful in the face of poverty and financial constraint challenges. Most of the participants reported to engage in income earning coping strategies and non- income earning coping strategies. It is worth noting that most mothers do not use a single strategy but a combination of strategies. The major reported income earning coping strategy included home production of food (farming) and sometimes selling agricultural produce to earn money and buy other food items from the market.
“I do not have a job from which I can get a salary. I grow crops, but our harvest depends on the weather. When it is favorable, we get a good harvest, but if I produce sweet potatoes or beans, I have to take some to market so that I can buy something else that children need like fruit or rice.” (W-24, month 12)
In addition, most of the respondents reported to engage in short-term income earning coping strategy by casual labor work such as cultivating, planting, weeding and harvesting in the plots of well –off neighborhood. This coping strategy was predominantly reported from 4 months until 12 months.
“I, personally, I am very poor, fortunately it happens that I work in the plots of well- off people in the neighborhood and I get money or food for the child.” (W-18, month 9)
Respondents also cited small animal rearing and selling as income earning coping strategy in case of food shortage as well as looking for small business opportunities such as making and selling handcrafted mats and baskets, selling avocadoes or bananas to earn money and buy food items.
“I also keep a hen and I can sell eggs or chickens and I can buy flour for porridge or baby’s foods in case of food shortage.” (W-24, month 9)
“Sometimes I buy avocadoes or tomatoes and resell them and I use the interest to buy the infant’s food like fruits and keep the capital for further investment. For instance, if I make 1000 Rwandan francs (Frw) I can use 500 Frw and save the remaining.” (W-18, month 12)
Reported non income earning strategies included borrowing money from mothers saving and lending groups, eating less preferred food by other family members and favoring children for certain foods.
“As for complementary feeding, sometimes it becomes not easy to get food, however one has to try and get food for the infant. For instance, we are belonging to women’s saving groups, in case of food shortage; I borrow money and buy food for the infant. Nothing cannot preclude me to care for my infant.” (W-13, month 12)
“When I have got a little money, I buy a half kilo of rice and prepare some grains for the child when I can’t find it for the entire family. I cannot let my child suffer from hunger; I prepare a few spoons for the child and keep another portion for his next meals.” (W-32, month 12).
Mothers’ anticipatory behaviors
Participants also talked about taking prior actions such as preparing baby’s cereal in advance and taking it to the farm as baby food provision or preparing much food to keep a reserve for the next feeding. Those strategies were said to facilitate mothers to feed their babies on time during the complementary feeding period.
“Sometimes I prepare baby’s cereal in advance, early in the morning and take it to the farm. For instance, if I breastfeed the bay at 6:30 in the morning, I give her the cereal around 9:00 because she gets hungry at this time instead of waiting until my return back home to prepare lunch meals.” (W-34, month 9)
Active uptake of the recommendations
Participants reported to actively implement the recommended practices based on the advice they receive from their trusted source of information including health professionals and CHWs.
“We receive the advice and teachings from health center professional that we have to introduce other foods to our babies from six months, in addition to breastmilk and that foods should be pureed. Therefore, we try to put into practice what we hear from them for the well-being of our babies”. (W- 26, month 6)
Persistence in overcoming challenges to achieve their EB goal
Despite difficult circumstances, some mothers expressed their EB related goal and their persistency in overcoming challenges. This was mainly reported between 4 months and 6 months when mothers faced challenges including the child’s interest to food while seeing others eating, pressure from family members to introduce some liquids or food before 6 months as well as mother or child’s ill-health. Those mothers reported to be more persistent and to stick to their goal and actively seeking for problem solving strategies. For instance, one mother said:
My goal is to exclusively breastfeed my baby for his first 6 months from birth. However, as he grows up he expresses envy to eat as he observes others eating. I usually respond to that challenge by isolating the baby whenever I or other siblings are going to eat but what happens is that he sometimes refuses. What I started doing hence forth was not to let the baby stay in own room while we all go and take our meal but rather I used to stay with him and not eat until his siblings are finished to eat and join him to keep his company.(W-15, month 6).
Many of the mothers reported not to give up and to stand up against the wrong recommendations.
“The challenge was that since last time you visited our home I have been sick of malaria. My husband and mother- in law advised me to give cow’s milk to baby and I said no, I cannot give it to the baby before he turns 6 months.” (W-1, month 6)
“I do not give up; I try to find a solution whatever the problem is because if I gave up it would affect the child’s health.” (W-34, month 6)
Changes in coping strategies overtime
Mothers’ coping strategies changed depending on children’s needs. The analysis of the different points in time provided a view of how the mothers’ ways of coping strategies changed over time depending on the needs of children during the first year of life. For instance, during the first six months, mothers tried to improve their own diet and eat more food for increased adequate breastmilk production, while after six months during the complementary feeding period, they made sure infants get the best food out of what was available.
Factors facilitating coping of the mothers
Personal factors
Awareness and belief about the benefits of breastmilk
Most mothers were aware of the benefits of breastfeeding. They mentioned that breastfeeding allows for the bonding between the child and the mother and that it promotes good growth. Specific to EB, mothers were aware that EB for the first 6 months reduces the child’s risk of diarrheal disease.
“It is that mother's affection and love, even when I feel weak I have to make an effort and I breastfed her even while lying on the bed and put her closer to me so that she could feel me and recognize me as her mother.”(W-34, week1)
Maternal self-efficacy
Most mothers who EB for six months expressed their feeling of confidence in the ability to breastfeed exclusively right after birth:
“The first one is my knowledge that the baby should depend on mother's milk only and I have my own breasts, I don't have to pay for them. The second is the will. I think there is no obstacle, therefore, I will succeed in breastfeeding her, except in the case of force majeure but I don't expect it, I trust in God.” (W-34, week 1)
Related to maternal self-efficacy was that some mothers reported their previous successful EB experience as a powerful source of their self-efficacy.
“Within the first hour after birth, I breastfed the baby with confidence that she was going to accept it eagerly as it used to be for the older siblings.” (W- 36, week 1)
“The baby will be exclusively breastfed until 6 months, because this is not new as I also managed to exclusively breastfeed the older siblings.” (W-01, month 4)
Religion
Participants stated that praying was one of their coping strategies for IYCF challenges including not having enough food for themselves and their children. Belief in God supported them to persist and take active steps towards coping such as working hard. For other participants, they believed that once they channeled their worries to God, they felt relaxed and believed that God would intervene to solve their problems, including not having access to enough food for the family among others.
“Sometimes I face food related challenges. But, once I deeply pray, it helps me a lot as I believe that there is God’s plan for me. I don’t give up instead I keep on working very hard because I know that God will intervene at the right time.” (W-24, month 12).
“When I pray and join praying groups, I convey to God all my worries including not having access to sufficient food, I feel relaxed because I believe God will provide.” (W-10, month 12)
Social factors
Social support
Mothers reported to experience the influences from significant others that were both favorable and unfavorable to EB. Most mothers who managed to exclusively breastfeed under 6 months considered the support provided by significant others (partners, grandmothers and other mothers) as very important for their successful breastfeeding. The support provided by partners comprised practical, financial and emotional support such as stepping in to help in performing some household daily duties such as cooking, creating a good environment by providing what is needed by the mother, extra food provision as well as providing money to buy food items.
“Also, my husband is helping me in cooking and doing other household duties in these early days after delivery.” (W-11, week 01)
“When my partner gets a casual labour, I tell him what is needed for the infant. He doesn’t reject my request; he provides me money and buys the infant’s food item we don’t grow.” (W-20, month 9)
The support provided by grandmothers included performing household daily duties such as cooking and care of other children, especially within the first weeks postpartum. At 6 months, some mothers who practiced EB reported that their family members (maternal mothers) encouraged them to continue breastfeeding. Other mothers (peers) support consisted of the provision of informational assistance to one another through sharing breastfeeding experiences which supported EB for 6 months.
For instance, one mother said:
“By the time I met with other mothers at the health center for child’s vaccination at 3 months and a half, EB for 6 months was the focus of our conversation. One mother expressed her concern that her baby wants foods and I said that mine also wants foods. Then another mother encouraged us to make more effort to keep going and delay the introduction until 6 months. Now I managed to do so.” (W-17, month 6).
Mothers also reported to start complementary foods by some specific foods such as porridge and fruits at 6 months because they had seen it being practiced by other mothers.
Advice from health care professionals and CHWs
Most mothers reported to receive IYCF information and advice from health care professionals, nurses, during prenatal education and postnatal period like during the child’s vaccination periods.
“When we visit the health center for vaccination, we get some teachings by nurses that we should not give anything else to the baby except breastmilk only for the first 6 months and thereafter give the infant other food rich in nutrients and prepared hygienically.”(W-21, month 4)
Furthermore, they reported to receive IYCF information and advice from Community Health Workers (CHWs) during the growth monitoring sessions and village kitchen cooking demonstration sessions on how best to feed their children. The mother below narrates:
“We are educated by CHWs when we meet during village kitchen activities. They tell us that under 6 months infants should only be breastfeed and that the mother should eat a balanced diet so that the baby gets adequate breastmilk. In addition, we bring different food items and learn together at that moment how to prepare a balanced diet for our children using locally available food items.” (W-17, month 4)