Sixteen mother infant pairs (eight mothers with less than six months old children and ten mothers with infants between six months to one year of age) and 34 PHMs participated in the study. Mothers’ ages ranged from 21–40 years. All mothers except one were educated up to or beyond grade eleven. Four mothers were working and the remaining were housewives. The force field analysis of barriers and facilitators for EI and EBF at critical time periods relating to personal and environmental factors are presented in Fig. 1.
Early initiation of breastfeeding
Facilitators of early breastfeeding initiation
All mothers knew about the concept of EBI. This is consistent with the fact that PHMs mentioned that health education covering breastfeeding is done at multiple opportunities that during routine antenatal care. According to them, mothers are introduced to the topic of BF in their second antenatal session in the second trimester of pregnancy and are provided with more detailed information in the third trimester. In the last antenatal domiciliary visit PHMs remind mothers about EBI and emphasize importance of adherence.
“We ask mothers to demand the opportunity for early initiation; to hand over the baby and let the child start feeding early as possible, even if the staff in the labor room are very busy” (PHM)
The Sri Lankan EBI policy has been well implemented in the local hospitals and according to PHMs, it has been implemented with care. They also mentioned that health staff in the hospital labor rooms and operation theaters were dedicated to facilitate EBI.
Barriers for early breastfeeding initiation
The only reported reason for not practicing EBI were medical complications of mother and child. Maternal anaphylaxis and severe postpartum hemorrhage resulting in admission of the mother directly to the intensive care unit, premature delivery (at or before 28 weeks of gestation) and in situations where the child had serious birth complications such as asphyxia were the reported medical complications in this community. In spite of not being able to follow EBI due to these conditions, the maternity ward staff with the help of the lactation management center, ensured that BF was established before discharging the mother from the hospital.
“I didn’t see my child immediately after birth. As soon as the child was delivered the nurses ran taking him to the PBU (Premature Baby Unit). I saw my child only after two days. I told them that I want to see my child. They took me to the PBU but I couldn’t see him he was surrounded by tubes…. They have given formula milk to the child but I was not informed. Actually, I cannot remember things very well. I was also ill. After two days, I was allowed to expressed milk and feed the child. I expressed in the ward and send the milk to the PBU. On the fourth day, the baby was given to me and was attached to the breast. While in the ward I listened to the education sessions that were done for mothers on BF daily by the nurses. Although initially formula milk was given subsequently I gave only breastmilk.” (mother 03 who underwent emergency cesarean section for a child who was suspected of meconium aspiration)
The time periods of interruption of EBF
Figure 1 shows that time periods when EBF was interrupted in the study sample clustered around three periods. Firstly, within the first 2–3 days, second within the second or third week of delivery, and ultimately around four to five months after birth. The barriers were different at these different time periods and exceeded the driving forces.
Barriers for EBF around the first 2–3 days of life
We identified maternal, child related and environment related factors that act as barriers for EBF continuation (Fig. 1).
Lack of maternal self-efficacy
Some mothers, who had delivered their first child had many doubts about how to position and attach the child to the breast.
“I didn’t understand how to position the child. The baby did not seem to suckle well. It is only after 2–3 weeks that I got used to hold and attach the baby properly to the breast. After then only that I was satisfied.” (mother 01)
The PHMs reported that EBF was interrupted during the first few days among mothers who undergo cesarean section. One of the PHMs mentioned that they were taught so in their training and that they needed to keep the mothers well hydrated. Mothers complained of pain interfering with position of breastfeeding.
“Most mothers who encounter problems in BF are mothers who undergo section. We try to promote mothers to go for a normal vaginal delivery as much as possible at the antenatal health education sessions. (PHM)
“On the second day I haven’t had enough milk. I could not attach the baby properly to breast. The midwives asked me to hold the child under the arm stating that it will help in attachment. But I could not hold like that as the caesarian section wound was painful and the baby was heavy. I could not lay down on one side either due to pain. I had no milk to express and feed” (mother 16)
However, we found that even among mothers who had a normal delivery, pain had been a barrier to proper BF.
“I had a normal vaginal delivery. So, I could not sit. Therefore, I fed the baby in lying down position for the first three weeks” (mother 01)
Social pressure to practice EBF
Some mothers who were well aware of the value of EBF had been anxious about not being able to do so given the strong recommendation coming from the health care workers.
“I know that it’s best to give only breast milk. But I was worried that I would not be able to do so” (mother 16)
Sub optimal maternity ward environment
Some ward environments were uncomfortable to mothers. The wards were hot due to the prevailing high temperate in Sri Lanka. The beds in the post-operative wards were high and it was difficult for the mothers to move from bed to chair in trying to feed the child. This challenge was even more pronounced as accompanying person(s) are not allowed even during the first night. The ward staff on duty had to see to every mothers’ problems.
“It was a very hot climate and in the ward it was very uncomfortable. I was counting my fingers to leave the hospital. That first night after delivery, almost every newborn had fever. Although fans were there it was unbearably warm. The beds were high. I could not get on the bed alone due to pain. Could not ask for help from the health staff all the time. I was awake all night and was carrying the child. It was very stressful” (mother 16)
Although most of the mothers and public health staff mentioned that hospital health personnel and the nurses from the lactation management center helped them in establishing breastfeeding, some mothers faced negative comments from them which further reduced their confidence.
“Sometimes they speak without thinking how it would hurt us. I wanted to burp the child and asked for help. The nurse told me that I did not feed my child properly and therefore no point in trying to burp” (mother 16)
Newborn’s medical conditions
Prematurity seemed to be a main reason for introducing infant formula. In some occasions few formula feeds were given initially, but discontinued and practiced EBF after the prematurity-related problems were resolved.
“One of the mothers in my field (allocated area for a PHM) had a premature infant. Initially the hospital asked not to let the baby suckle. So, formula milk was started. But later, the mother started breastfeeding and now she is giving both. I asked the mother to gradually reduce formula feeds and continue breastmilk. I have only this mother infant dyad in my field with disrupted EBF.” (a PHM)
Sometimes problems occurred after coming home from the hospital and the mother was uncertain of the actual reason for the problem.
“I was discharged and at home but on the 3rd day the child became yellow. Even the eyes! I got admitted to the hospital. The health staff said that baby was not fed enough and they gave formula milk. But I had enough milk. though the baby kept sleeping and didn’t suckle for long.” (mother 11)
During the focus group discussions, each PHM described occasional instances they had experienced when infant formula feeds were given in the first 2–3 days on newborns that developed jaundice, fever and multiple deliveries.
“In my field, there were three babies who developed jaundice while in hospital. They were started on formula feeds” (a PHM)
“One of the mother in my field had a triplet and one of them was not suckling. They consulted a specialist and the child was put on formula feeds (a PHM)
PHMs time constraints for early post-partum home visits
The PHMs do home visits as soon as the mother and newborn are discharge from the hospital to provide domiciliary care. They spent lots of time troubleshooting and solving early BF problems. Although PHMs were fully devoted to providing such care, several barriers were identified for the optimal provision of early breastfeeding services.
“For a mother with breastfeeding issues, it takes around 2–3 hours to counsel her, lift her mood and solve the problem. We have to do this even if it is a weekend and a mother needs help. If the mother is having a problem in breastfeeding we would not be able to fall asleep without solving it. These mothers are helpless after coming home. When we visit them, not only the mother, even the family members are relieved and happy. Regardless of their ethnicity all of them are equally expecting and admiring our service” (a PHM)
PHMs reported time constraints due to the many other obligations that they have beyond home based BF support, and sometimes the long distances between the mothers’ homes.
“When we have to cover up vacant areas [an area that does not have a PHM which is covered by a PHM from an adjacent area] and when they are at a distance, sometimes the mothers needing help will be far away from one another. It is very difficult to offer the recommended services when we have cover up duties and I had coverup an additional area since I was appointed. That is for the past whole five years.” (a PHM)
Facilitators and barriers for EBF at 2–3 weeks post-partum
Sub optimal practices of health staff before mother’s discharge
Sometimes mothers with serious medical conditions are trained on cup feeding and at the discharge breastfeeding is not established. This creates challenges for the PHMs who have to counsel women on BF difficulties after hospital discharge.
“I had three newborns in my field who were given formula feeds due to maternal problems. After the mother is stable, they were asked to express the breast milk and feed the child using the cup. When there are maternal complications, they come home after several days. One such mother, I met only on day eight after the delivery. When I visited her at home, she was trying to express milk and was crying! She was unable to attach to child to the breast and was trying to express breast milk all the time. It is exhausting and she had no rest. It is with great difficulty and through mother’s devotion that I was able to establish suckling. One of these mothers actually commenced formula feeds as she could not express enough. They easily go for other options. Therefore, its better if the hospital staff can re-establish child’s attachment to the breast before discharging the mother.” (a PHM)
Influence of family members
Negative comments of extended family members affected the mothers’ confidence on BF leading to introduction of infant formula feeds or feeding water to the child. Comments about “child is getting not enough milk” were mostly made by the mothers in law. Mothers as well as PHMs shared this experience.
“The mother in laws try to force mother to breastfeed the baby too often. They keep complaining that the mother does not have enough milk throughout the day. One of them said that the child should be breastfed as often times a leaf falls from a “tamarind” tree. Ultimately this mother could not bear the situation and went to her own mothers place.”. (a PHM)
“When the newborn have hiccups, all the people at home including grandparents get anxious and ask to feed the baby all the time. If a mother is intended to do that she will not have time even to have a bath.” (mother 16)
By contrast, it was also mentioned that the social norms have been changing towards EBF during recent times. According to the mothers and the PHMs, the female adults in the families seem to accept that breastfeeding practices have now changed for the benefit of the children. They seem to believe the current knowledge and have faith on PHMs advise.
“No one asked me to give other substitutes at my home. At times of my mother’s delivery, the practice has been to give a glucose solution for the child first. But she knows that now only breastmilk is given. She also asks to get the opinion of the PHM before doing anything new.” (mother 05)
The husbands’ support on EBF was also highlighted during the discussions.
“Since the fathers participate in the antenatal sessions, they know very well about the support that should be given to a mother. Therefore, the husbands support breastfeeding and counteract negative family forces against it. It is a huge benefit” (a PHM)
Past experience, benefits and misconceptions of mothers
Mothers past feeding experience influenced the EBF practices. Some mothers talked proudly of their past experiences and how these would help them to continue with EBF for their new child even in the face of some challenges.
“When you hold the child like this [the mother shows the exact positioning] it’s very easy to feed. My sons, they very well-kept suckling until they detach on their own. But this new one (daughter) is not that interested. I sat and fed my sons. But as this one was problematic I tried all positions and somehow kept on feeding.” (mother 05)
Some mothers had strong BF misconceptions which were properly addressed by the PHMs and specialists with positive messaging.
“Sometimes, even though there is enough breast milk, mothers want to give formula milk to their children. I had one such mother. She was a graduate. She has fed her first child with formula milk due to a medical problem. Now this particular child is doing well and has received national level awards. So, the mother thinks that if she gives formula to the second child, she will be intelligent too. I kept on advising her and forcing her not to do so. Referred her to the MOH. She also consulted a specialist (neonatologist). Listening to them both made her change her mind and adhere to EBF.” (a PHM)
Maternal norms and medical practitioners’ prescription of formula feeds
According to the PHMs, some medical practitioners seemed to prescribe formula unnecessarily to mothers. A reason for this may be that in this culture, a “chubby baby” is perceived as a healthy baby. When the babies do not look chubby, they tend to think that its due to inadequate breast milk. This leads mothers to seek help of medical practitioners and demand to prescribe formula milk.
“The main reason to start formula milk is that when the mothers go and ask for it from the doctors, they just prescribe it. Of course, mothers prefer to listen to what doctors say rather than what we keep saying. Mother is happy as her intention was served by the doctor” (a PHM)
Early introduction of water
Mothers tended to give water during the neonatal period due to several proclaimed reasons including the hot weather, hiccups, and feeling that the child is dehydrated.
“At that time, my baby wanted to get fed every 15–20 minutes. I thought it was due to the dry environment. It was a very hot climate at that time with the drought…There was no rain for two years. So, my mother also asked me to give some water to the baby. I only fed two teaspoons at a time” (mother 15)
“At that time, the child was not getting enough milk and was yellowish and the skin looked dry. Although I didn’t give water at that time, I feel that its better if I had the opportunity to give a little water in a clean manner to get rid of dryness of the child.” (mother 16)
“One child had got frequent hiccups and when mother has consulted a general practitioner he has asked to give a little amount of water when the child is having hiccups” (a PHM)
Facilitators and barriers for EBF during 4–5 months post-partum
Returning to work was discussed as the main factor for cessation of breastfeeding before six months after birth.
Returning to work
According to the PHMs, most mothers working in the government sector would take the government approved maternity leave of fully paid first four months and half paid next 84 days so that the mother could return to work after introducing complementary foods to the child at six months of age. By contrast, mothers working in other sectors had to report to duty at least around 4 months after birth. While some mothers needed to return to work to keep their jobs those in the lower socio-economic groups had to do so to earn money for daily expenses and pay loans.
Lack of support after returning to work
Practicing EBF seemed to be difficult when returning to work due to long working hours, long distance between the work place and home, type of job and lack of facilities at the work place to express breastmilk or feed the child.
“One of my employed mothers had started formula milk. She is a bank officer and had to work until late. Another one was a cashier and could only leave her seat to have lunch. It was a small place and she didn’t have a place to express breastmilk during working hours” (a PHM)
“I like to continue only breast milk. As I don’t get official maternity leave, I have submitted a medical leave these days. Ideally, I have to report for duty after 4 months. First, I thought of coming home at the lunch interval and feeding the child. But the distance is too far.” (mother 02)
Lack of self-efficacy expressing breastmilk
Despite being a main strategy in promoting breastfeeding, feeding the child with expressed breast milk did not seem to be common in the community. Mothers didn’t have confidence to be successful with it.
“Some of the working mothers told me about expressing breastmilk. I was supposed to get advice and learn it from the PHM. But I don’t think I will be able to express a lot in the morning and when the child grows she needs more. So, I decided to start complementary foods” (mother 02)
Introducing complementary foods before six months after delivery
Few mothers introduced water, fruits and some started recommended complementary foods on their own. Some of these actions were due to social influences. The following quotes are from mothers who introduced foods at around four months.
“Although the PHMs ask us to feed until six months there are mothers in the village who gives rice at four months in the same way that they eat. Even though we give meals according to the recommended method our babies are not chubby” (Mother 15)
“I felt that the baby loves bananas. So, I gave some at four months. No one told me to give. I thought the baby will like it” (Mother 08)
Misconceptions about on demand breastfeeding among health workers and mothers
BF on demand was one aspect that was found to be challenging. Although the mothers were able to identify their children’s signals of hunger after a few months, they faced many problems learning when to breastfeed during the neonatal period. Health workers including medical officers and practitioners both in the institution and the field advised to feed the child according to a set schedule. Almost every mother mentioned that a child should be fed every two hours. Some mothers thought that feeding on demand makes them feel exhausted and some expressed that unless the child is awaken and fed every two hours, the child will sleep and will not get adequate milk.
“I was asked to feed the child two hourly. But the child does not wait that much. He cries within one hour of the previous feed” (mother 11)
“My doctor asked me to feed the child every two hours for around half an hour duration” (mother 10)