Reasons for failure of breast-feeding counselling: mothers' perspectives in Bangladesh.

Reasons for failure of breast-feeding counselling: mothers' perspectives in Bangladesh* R. Haider,1 1. Kabir,2 J.D. Hamadani,3 & D. Habte4 During the hospitalization in the Dhaka hospital of the Intemational Centre for Diarrhoeal Disease Research, Bangladesh, of a group of partially breast-fed infants aged 1-12 weeks who had been admitted with acute diarrhoea, their mothers were individually counselled by breast-feeding counsellors to start exclusive breast- feeding. The counselling was repeated 1 week later at home, and the women's infant-feeding practices were evaluated 2 weeks after their infants had been discharged from hospital. A total of25% of the mothers failed to breast-feed exclusively despite having been counselled. The case studies of these mothers illustrate that although they generally complained about having "insufficient breast milk'; various factors such as domineering grandmothers, lack of financial support by their husbands, too much housework, or disinterest contributed to their failure to breast-feed exclusively. While family support is essential for all lactating mothers, women with familial or financial problems require special attention and extra counselling sessions so that they can be helped to identify how to achieve and sustain exclusive breast-feeding. Introduction Currently it is recommended by international health agencies that all infants be exclusively breast-fed for at least 4 months, and if possible 6 months, and that all mothers should be helped to breast-feed exclu- sively (1). In Bangladesh, a country usually noted for prolonged breast-feeding, the practice of exclusive breast-feeding is not ingrained in the culture (2). Despite a claim in a national report of a dramatic increase in exclusive breast-feeding (3), ongoing research findings fail to confirm this (R. Haider, unpublished data 1996, and El-Arifeen, personal communications, 1996). The determinants of breast-feeding have been described (4-6), but have not been disaggregated by the type of feeding- exclusive and partial breast- feeding. It is important to identify these determi- nants in order to design specific strategies to promote exclusive breast-feeding (7, 8). Promotion of breast-feeding has focused on mothers who deliver in hospitals and health facili- ties (9) but, in many developing countries, such as * From: International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B), GPO Box 128, Dhaka 1000, Bangladesh. I Associate Scientist, Clinical Sciences Division, ICDDR, B GPO Box 128, Dhaka, Bangladesh. Requests for reprints should be sent to Dr Haider at this address. 2 Scientist, Clinical Sciences Division, ICDDR, B. 3 Senior Medical Officer, Clinical Sciences Division, ICDDR, B. 4 Director, ICDDR, B. Reprint No. 5769 Bangladesh, only a small proportion of deliveries take place in these institutions. Infants are usually brought to health facilities when they are ill. Since during these visits there is an opportunity to influ- ence mothers on bre&t-feeding practices, we carried out a study to provide and evaluate counselling for mothers of young infants with diarrhoea who were attending the Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangla- desh (ICDDR, B). The methods and results of this study have been reported presiously (10). Briefly, 60% of infants were being exclusively breast-fed and 30%, predominantly breast-fed at the time of dis- charge from hospital. After 2 weeks at home, 75% of the mothers were breast-feeding exclusively. This article identifies some of the factors that might have prevented the remaining 25% of mothers from achieving or continuing exclusive breast-feeding, de- spite having been counselled during their hospital stay. Materials and methods The following WHO definitions for infants were used (11): - exclusively breast-fed: if given only breast milk (no other liquid or solid); - predominantly breast-fed: if given breast milk plus water and/or oral rehydration salts solution (ORS); and - partially breast-fed: if given other milk or gruel in addition to breast milk. Bulletin of the World Health Organization, 1997, 75 (3): 191-196 © World Health Organization 1997 191 R. Haider et al. Two breast-feeding counsellors and two research physicians (all female) were trained for 3 weeks, us- ing the WHO/UNICEF breast-feeding counselling training course (12). They were also taught about diarrhoeal disease management, how to make the anthropometric measurements required for the study, and how to compare them with the National Center for Health Statistics (NCHS) standards (13). The selection criteria for the study, details of case management, counselling, and follow-up have also been described previously (10). Statistical methods Data were analysed using the SPSS/PC+ software package. The baseline data in the groups of mothers who were exclusively breast-feeding at the end of 2 weeks, and those who were not, were compared. A logistic regression analysis was performed on those variables that might affect the feeding status of the infant, including the infant's age and sex, the moth- er's age and education level, and the father's income. Results A total of 125 mother-infant pairs were recruited for breast-feeding counselling. On follow-up at home 2 weeks later, 21 mother-infant pairs could not be evaluated since 19 families had migrated out of the area and two infants had died. There were no sig- nificant sociodemographic and feeding differences between the mother-infant pairs who were lost to follow-up and those who completed the study. Among the remaining 104 mother-infant pairs, 80 (77%) of the mothers were breast-feeding exclu- sively (two infants who received occasional water have been included with the exclusive group), when the infant's diarrhoea stopped and ORS was discon- tinued at home. A total of 24 mothers failed to breast-feed exclusively and either continued or re- started other milk at home despite about 2 hours of intensive counselling in the hospital. The admission characteristics of the infants who were exclusively breast-fed at 2 weeks were compa- rable with those who continued to be only partially breast-fed (Table 1). Table 2 shows the demographic features of the infants' mothers in the two groups. In both groups the age, parity, and mean duration of education of the mothers were comparable. The husbands of women who failed to breast-feed ex- clusively tended to have higher incomes than the husbands of women who did, but the difference was not statistically significant. There were no differences in the rates of exclu- sive breast-feeding among mothers who had re- Table 1: Infant characteristics on admission to ICDDR, B hospital, Dhaka, by breast-feeding status at home 2 weeks after discharge Exclusively Partially breast-fed breast-fed (n= 80) (n= 24) Age when CFa started (days) 17.2 ± 17.6b 17.12 + 20.3b Age at intervention (days) 52.6 ± 20.3b 47.0 ± 1 8.9b Sex of baby Female (n) 25 (31)c 8 (33) Male (n) 55 (69) 16 (67) Baby bom at: Home (n) 59 (74) 17 (71) Hospital/clinic (n) 21 (26) 7 (29) Duration of diarrhoea before 3.5 ± 1.7b 3.4 ± 1.4b admission (days) Weight-for-age (% of NCHS 76.9 ± 11.3b 75.2 ± 1 1.0b median) Weight-for-length (% of NCHS 91.2 ± 10.7b 87.8 ± 11.7b median) Hospital stay (days) 4.5 ± 1.9b 3.9 ± 1.5b a CF = complementary foods (other milk, gruel, etc.). b Mean + standard deviation. c Figures in parentheses are percentages. ceived either two or three counselling sessions dur- ing their hospital stay. When mothers in the group who did not breast-feed exclusively were asked dur- ing evaluation at home why they gave additional milk to their babies, most of them complained of having insufficient breast milk. Nevertheless, when the cases were reviewed in greater detail, including the breast-feeding counsellors' findings and impres- sions on the first week follow-up visit, other reasons for supplementation emerged, including the follow- ing: domineering grandmothers who advised the mother that the infant be given other milk; anxiety Table 2: Maternal characteristics and breast-feeding status of the study population on follow-up Exclusive Partial breast-feeding breast-feeding (n =80) (n =24) Mother's age (years) 22.8 ± 4.2a 20.9 ± 3.2a Parity First baby 38 (47)b 14 (58) Second baby 20 (25) 4 (17) Third baby 15 (19) 6 (25) Mother's education level 4.2 ± 4.3a 4.7 ± 4.4a (years) BMIc 19.7 ± 3.0a 19.0 ± 3.0a Husband's mean incomed 3940 ± 4377a 4682 ± 3871a a Mean + standard deviation. b Figures in parentheses are percentages. c Body mass index = weight (kg)/height2 (m2). d In taka: US$1.00 = 40 taka. WHO Bulletin OMS. Vol 75 1997192 Breast-feeding counselling: reasons for failure in Bangladesh owing to financial insecurity; and mothers being un- willing to breast-feed exclusively (Table 3). Some case studies (pseudonyms used) are given below. Case studies Raflq. Rafiq was the second baby born to the family concerned. His mother had no formal schooling and his father was a shoemaker, earning Tk 5000 per month (US$125). Born at home Rafiq was fed honey after birth, "refused" to suckle at the breast, and hence was bottle-fed fresh cow's milk on the first day. He was 42 days old when admitted to the hospi- tal with diarrhoea. His mother breast-fed him exclu- sively for 1 day at the hospital (total stay, 3 days) and continued to do so for the first week at home; how- ever, his maternal grandmother had considerable in- fluence over family matters and sent "gripe water" (a banned product in Bangladesh) for the baby when the mother returned to the village. Rafiq's mother had a minor road accident the week after he was discharged from hospital, and his grandmother be- lieved that her daughter's resultant blood loss would decrease the amount of breast milk that she could produce. Other family members also supported this view and hence Rafiq's mother started giving him infant formula within the second week. Asim. Asim was the first baby born to educated par- ents, both mother and father having had 14 years of education. His father, employed in a private firm, earned Tk 15000 per month (US$375). Asim was fed powdered milk (infant formula) from the day of his birth, apparently because "his mother's milk did not come". Asim was delivered by Caesarean section and his mother was sedated for a few hours; the hospital staff did not help her to initiate breast- feeding, and hence her mother-in-law requested the doctor to suggest a milk formula. Initially fed milk Table 3: Reasons given by mothers feeding exclusively for not breast- Reason No. of mothersa Influenced by baby's grandmother 8 (33)b Husband's advice 2 (8) Doctor's advicec 2 (2) Husband not/partly supporting financially or 5 (21) unemployed Had to start working outside the home 2 (8) Too much housework 3 (12) Not willing to breast-feed exclusively 5 (21) a More than one reason was given in some cases. b Figures in parentheses are percentages. c In one case when the mother was admitted to another hospital and in another when the baby was admitted to a private clinic. with a dropper, Asim was bottle-fed within a few days. He was admitted to the ICDDR, B Dhaka hospital with a 4-days' history of invasive diarrhoea at the age of 54 days. During the hospital stay, Asim was observed to be breast-feeding continuously; his mother complained that he would not leave the breast even though he was not suckling all the time, and he was discharged while partially breast-fed. During the first week, his mother managed to de- crease the frequency of other milk to one feed per day, but soon after abandoned any plans for exclu- sive breast-feeding, stating that she had no servants, had to do the housework herself, and thus had insuf- ficient time for exclusive breast-feeding. Tauhid. Tauhid was the first baby born to his par- ents. His mother had no formal education but his father had 5 years' schooling and earned Tk 6000 per month (US$150) as a car driver. Tauhid was born by normal delivery in hospital. His mother stated that because her nipples were flat, he could not suckle at first; she did not receive any advice or help from the hospital staff about this problem. After trying to feed Tauhid expressed breast milk and sugar water by spoon on the first day, his mother also started bottle- feeding powdered milk the same day. During the time Tauhid was hospitalized with diarrhoea, he cried often and his mother complained of having insufficient breast milk. Tauhid's mother seemed very anxious and, although not mentioned in her original history, she later disclosed that her husband had other children from a previous marriage, lived with his other wife, and provided her only with minimal financial support. During her stay in the hospital, she breast-fed partially for the first few days and managed to breast-feed exclusively by the time of discharge; however, she did not seem fully con- vinced about her ability to continue exclusive breast- feeding. She started giving Tauhid reconstituted powdered milk 2 days after discharge, after which he developed a second episode of diarrhoea, and was again brought to ICDDR, B. During the follow-up visit at week 1, he was being fed a soya-based for- mula on another doctor's advice, and by week 2, he was receiving cow's milk. Bithi. The third child of her parents, Bithi, born at home, first received fresh cow's milk at 15 days of age and was admitted to the hospital with diarrhoea at 33 days of age. Her father worked abroad, sending home Tk 10000 per month (US$250). Bithi's mother and siblings lived with her father's family. Dis- charged on exclusive breast-feeding, Bithi was again started on cow's milk during the first week at home. Her mother liked to go out. Despite being informed that she would be visited at home after 1 week, she WHO Bulletin OMS. Vol 75 1997 193 R. Haider et al. did not stay at home and had to be located. Although Bithi's mother complained of insufficient breast milk, the breast-feeding counsellor was able to express enough from her after the baby had breast- fed to show her that she had plenty. Since the baby was sick, the breast-feeding counsellor brought the mother and baby along to the hospital. Hospital- ization was advised for the baby, but the mother refused. The mother-in-law also favoured giving other milk to the baby, and Bithi's mother seemed generally unconcerned about her children. A few days before the follow-up visit, the elder daughter, aged about 3 years, was found wandering around some distance from her home and was brought back by a neighbour. This same child had also been lost a few days previously. Discussion The study has certain clear limitations. The group of mothers who failed to breast-feed exclusively was small and since they came from various areas of Dhaka and were admitted to the hospital at different times, we were unable to identify all the factors re- sponsible for their behaviour. Also, the mothers were anxious because their babies were sick and may have found it difficult to pay attention to apparently unrelated advice about breast-feeding. Furthermore, the short hospital stay did not allow time for ad- equate counselling. A previous study in rural Bangladesh reported that three factors were associated with differences in breast-feeding patterns: place of residence (urban/ rural), maternal education, and income/socioeco- nomic status (14). In developed countries, more edu- cation and higher social class of the parents are associated with higher breast-feeding rates among white populations (15, 16). In our study, husbands' incomes in the partially fed group seemed to be higher but the trend was not significant. During the counselling sessions, some of the mothers whose education level and socioeconomic status were higher attempted to justify partial breast-feeding by saying that since they could afford to give their babies powdered milk prepared correctly with clean boiled water in sterilized feeding bottles why should they bother with exclusive breast-feeding? Attitudes are allegedly more important deter- minants of infant feeding behaviours than demo- graphic characteristics (17), with positive attitudes being more important predictors of initiation of breast-feeding than knowledge about breast-feeding (18). All the mothers enrolled in our study knew that breast-feeding was important and accepted counsel- ling in the hospital and on home follow-up; their attitudes were therefore apparently positive to start with. None the less, at the follow-up visits at home it became apparent that some of the mothers were not enthusiastic about exclusive breast-feeding. In other studies one of the reasons mothers have given for rejecting breast-feeding is that it limits their freedom and social life (19-21); although they did not ex- plicitly state this, it is likely that some of the mothers in the present study also felt this way. The earlier mothers begin to breast-feed, the longer they continue to do so (22). Exclusive breast- feeding, however, is a different issue, and so far only one study has specifically enquired about mothers' intentions in this regard (23). In our study, there was no significant difference in the ages of their babies when mothers asked for counselling on exclusive breast-feeding; and this therefore does not explain why one group failed to breast-feed. Another important reason for bottle-feeding is the lack of support from a significant "other person" (24). Investigators of infant-feeding practices have identified the baby's father as either the most in- fluential person in decision-making about feeding method (25) or an important source of support (26- 28). In our study, the father's absence or not provid- ing financial support contributed to breast-feeding failure in five cases. Kin, friend, and neighbour net- works have a significant impact on decision-making about breast-feeding (29), and although the mothers in our study may not have correlated their inability to breast-feed exclusively to the grandmother's presence, the lactation counsellors identified this as a probable negative influence. Possibly, the grand- mother also wished to contribute towards the child's feeding as part of caring practice, and so encourage feeding the baby additional milk/gruel. Some of the mothers who did not breast-feed exclusively stated that too much housework was the reason; however, studies of women with infants less than 1 year of age show that this is pot valid (30). Mothers who received breast-feeding counsel- ling and support from the time of their babies' birth had significantly greater rates of breast-feeding ini- tiation, exclusivity, and duration of total breast- feeding than those who did not (31, 32). In our study, the counselling probably came much too late for some of the mothers and therefore could not change their practices. Peer counsellors living in the mother's neighbourhood could be more influential in this respect. We have trained peer counsellors for this purpose and studies are being carried out to evaluate their impact on infant feeding practices. Inclusion of key family members in the counsel- ling sessions at some stage is extremely important if mothers are to be enabled to breast-feed exclusively. Also, mothers with family and financial problems WHO Bulletin OMS. Vol 75 1997194 Breast-feeding counselling: reasons for failure in Bangladesh may need more counselling sessions at the hospital or at home so that they can be helped to identify how to achieve and sustain exclusive breast-feeding. Acknowledgements This research was supported by WHO (grants. GURES/ CDD/31 7/RB/94.B/300 and GURES/CDD/31 7NC/94.B/ 300) and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B). ICDDR, B is sup- ported by countries and agencies that share its concern for the health problems of developing countries. Current donors include the following: the aid agencies of the governments of Australia, Bangladesh, Belgium, Canada, China, Germany, Japan, Netherlands, Norway, Republic of Korea, Saudi Arabia, Sweden, Switzerland, United Kingdom and USA; international organizations including, the Arab Gulf Fund, Asian Development Bank, European Union, IAEA, UNDP, UNFPA, UNICEF, and WHO; private foundations, including the Child Health Foundation, Ford Foundation, Population Council, Rockefeller Foundation, and the Sasakawa Foundation; and private organizations including American Express Bank, Bayer AG, CARE, Family Health International, Helen Keller International, International Committee of the Red Cross, the Johns Hopkins University, Procter & Gamble, RAND Corpora- tion, Sandoz, and University of California at Davis. We thank the breast-feeding counsellors Tanzila Faruque and Shahara Bano. Dr S. Laston and Dr M. Ali are thanked for their helpful suggestions on improving the manuscript. Resume Raisons de I'6chec du conseil en matiere d'allaitement: le point de vue des mbres au Bangladesh Au Bangladesh, pays ou les meres allaitent gen6- ralement assez longtemps, I'allaitement maternel exclusif n'a pas de racines culturelles. Comprenant qu'il etait peut-etre possible d'influencer les pra- tiques des meres en matiere d'allaitement lorsque les nouveau-nes sont malades, nous avons mend une 6tude consistant a dispenser des conseils aux meres de nourrissons frequentant l'h6pital de Dhaka (Centre international de recherche sur les Maladies diarrheiques du Bangladesh), puis a evaluer cette operation. Pour les besoins de l'etude, on a recrut6 125 couples mere-enfant au cours de I'hospitalisation de nourrissons partiellement nourris au sein, ages de I a 12 semaines et trait6s pour diarrh6e aigue. Des conseilleres en allaitement ont conseille indi- viduellement aux meres d'allaiter leur enfant ex- clusivement au sein; ces conseils ont ete repet6s une semaine plus tard une fois la mere rentr6e chez elle, et le mode d'alimentation des nournissons a ete evalue deux semaines apres la sortie de l'hopital. Au total, 104 couples mere-enfant ont pu etre suivis a domicile 2 semaines plus tard. On n'a pas observe de difference significative entre les carac- teristiques sociodemographiques et les modes d'allaitement des couples mere-enfant qui avaient ete suivis et ceux qui ne l'avaient pas e. A la suite de la disparition de la diarrhee et de l'arret des solutions de r6hydratation orale administrees a domicile, 80 meres (77%) nourrissaient leur enfant exclusivement au sein (deux enfants a qui l'on donnait occasionnellement de l'eau ont et inclus dans le groupe des enfants exclusivement nourris au sein). Au total, 24 meres avaient cess6 d'allai- ter exclusivement au sein et soit continuaient, soit avaient recommence a utiliser d'autres preparations a domicile, malgre les conseils relativement inten- sifs qui leur avaient ete prodigu6s a l'h6pital. Les conditions d'hospitalisation des nourris- sons exclusivement nourris au sein a 2 semaines etaient comparables avec celles des enfants qui n'etaient que partiellement nourris au sein. L'age et la parite des meres 6taient comparables dans les deux groupes. La duree moyenne de scolarit6 des meres etait egalement semblable. Les conjoints des femmes qui avaient cesse de nourrir exclusive- ment au sein avaient tendance a se situer dans un groupe a revenus plus eleves, mais la difference n'6tait pas statistiquement significative. On n'a pas observe de difference dans les taux d'allaitement maternel exclusif chez les meres qui avaient suivi deux ou trois s6ances d'information pendant leur sejour a l'hopital. 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