Initiation of breast feeding- The cultural factors

http://doi.org/10.33698/NRF0090-Indarjit Walia, Raman Kalia, Suksham Chopra

Abstract : Cultural factors play important role not only in initiation but also in continuation of breastfeeding. The present study, was carried out in NSICU of Advanced Paediatric Centre of PGIMER, Chandigarh, to assess the breastfeeding practices among neonates admitted to NSICU of PGIMER. A group of 50 mothers (respondents) were interviewed during September to December, 2006. The findings revealed that 94 percent of them were either Hindus or Sikhs and 78 percent of them were below 25 years. Only one fifth of the respondents had initiated breastfeeding within a few hours after delivery (22%). Different ways were used to prepare pre lacteal feed (Ghutti) and elderly female member played important role in administring Ghutti. Colostrum was not given to neonates by sixty- six percent of the respondents as it was believed to be impure and causes obstruction in the intestines of the neonates. Thus negative attitudes towards colostrum and delay in initiation of breastfeeding should be changed by educating mothers. Nurses can play important role as they are in direct contact with mothers of the neonates while taking care of them in the ward.

Key words :

Breastfeeding, cultural factors

Correspondence at :

Indarjit Walia

National Institute of Nursing Education, PGlMER,Chandigarh

Introduction

About 10 million children in the world die before reaching the age of five and of these one fifth are from India1. Although there is reduction in infant mortality rate during the last few years, it is still very high as compared to other developing countries. In order to achieve the Millennium Development Goal of reducing the child under five mortality rate to 30/1000 by the year 2015, there is need to reduce neonatal mortality rate 2. Newborns are, no doubt, more prone to infections because of their immature immune system. The primary causes of neonatal deaths are reported to be sepsis (52%), birth asphyxia (20%), prematurity (15%), and others (13%).3 It has been reported that neonatal mortality can be reduced by adoping a package of low cost interventions including: vaccination, safe birth practices, improved care for low birth infants, antibiotics for neonatal infections and exclusive breastfeeding.4 Breastfeeding is considered to be natural food for the infant, but due to various cultural beliefs and practices in India, only one fourth of the infants are breastfed during the first hour after delivery. Early introduction of supplementary liquids is a public health problem which should be given top priority to reduce neonatal mortality rate. Nurses who are taking care of neonates admitted Neonatal Surgical Intesive Care Unit (NSICU) of PGIMER can play an impor tant role in continuation of breastfeeding. In order to evolve any educational programmes for the promotion of breastfeeding among mothers of the neonates it is necessary to understand various beliefs and practices related to breastfeeding of the infant. As mothers representing different background are visiting NSICU for the purpose of treatment of their neonates we had planned to under take this study in the NSICU of PGIMER to understand various cultural beliefs and practices related to breastfeeding. The study was carried out during 2006-2007 and funded by the PGIMER. Some of the selected findings of the study are presented below:

Objectives of the study

(i) To assess the breastfeeding practices among neonates admitted to NSICU of PGIMER. and (ii) To understand role of health professionals (Nurses) for the promotion of breast feeding among neonates.

Methodology

The study was carried out in NSICU of Advanced Paediatic Centre of PGIMER, Chandigarh. Mothers of the neonates who were admitted of NSICU during the study period were recruited as the respondents of the study. Only those mothers were included in the study who were willing to participate in the study. A group of 50 mothers who were present during September to December 2006 were included in the study. Identification data of mothers of the neonates were identified from the list prepared by the Senior Sister (Grade – I) on everyday which used to be displayed on the notice boards of the ward at the entrance of NSICU to help the attendants of the neonates to know about the bed number assigned each neonate along with the name of the mother. Data were gathered with the help of a semi-structured interview schedule which was prepared and protested to collect information pertaining to sociodemographic characteristics of the respondents, and cultural practices related to initiation and continuation of breastfeeding. Prior to collecting data, mothers were asked to sit comfortably on a chair in a separate room (factor of privacy was taken care of) and made feel free to answer the questions. Face to face interviews were carried out with the mothers in an easy to understand language. They were asked to reply the questions either in Hindi or Punjabi (Locally used languages) and were told that data collected from them will be used for the purpose of research only. Data were gathered by a trained female experienced researcher and some of the selected findings of the study are presented here.

FINDINGS OF THE STUDY

  1. Characteristics of the Respondents and Neonates

More than three-four ths of the respondents came from rural area (76%) and 94.0 percent of them were either Hindus or Sikhs. Age wise 78.0 percent of them were below 25 years, and only 4 percent of them were above 31 years. Nearly, one third of them were illiterate (32%) and more than one fifth of them had studied upto 10th standard (22%). Keeping interview their educational status and husband’s occupational status, more than seventy five percent (78.0) had monthly income of less than Rs.5000 and only one fifth of them were earning more than five thousand per month. More than seventy percent also came from joint or extended families where they were staying with their in laws and other family members. (Table – I) of the 50 neonates who were admitted to NSICU, 76 percent of them were males more than fifty percent (54%) of them were above three weeks of age. Weight wise, 16 percent of them were low birth weight babies as they weighed less than 2500 gms.

Table – I : Socio demographic characteristics of the respondents

CharacteristicsSociodemographic                        n(%)

 

A. Religion

a. Hindu

  

32 (64.0)
b. Sikhs 15 (30.0)
c. Others 03 (06.0)
B. Background

a. Rural

  

38 (76.0)
  1. Urban 12 (24.0)
  2. Age Group (in years)
  3. > 20 years 04 (08.0)
  4. 20-25 35 (70.0)
  5. 26- 30 09 (18.0)
  6. 31 and above
  7. Educational Status

 

a. Illiterate 16 (32.0)
b. Upto 8th Standard 16 (32.0)
c. Upto 10th Standard 11 (22.0)
  1. College Level and above07 (14.0)
  2. Family Income (in Rupees)
  3. Less than 2000 18 (36.0)
  4. 2001-5000 21 (42.0)
  5. 5001 and above 11 (22.0)
  6. Family Type
  7. Nuclear 14 (28.0)
  8. Joint / Extended 36 (72.0)

Total Number of Respondents = 50

But in 28 percent of the cases mothers were not able to recall the birth weight of the infant either, it was not recorded or due to

Table – II : Distribution of neonates according to their characteristics

Characteristics of the Neonates           n (%)

cultural factors at the time of birth. They   believed that weighing the child at the time of bir th may not help the child to grow properly or reduces the weight of child because of ‘evil eye’. In North India, women are generally not expected to come out of the house during the first 10 to 15 days after delivery, (postpar tum period) as it was believed that going out may not be good for the health of the infant and the mother. We found that only 32 percent of the mothers had accompanied their infants when they were admitted to NSICU for the purpose of treatment. Data obtained from the official records had revealed that 36 percent of them (neonates) had suffered from anorectal malformation; 24 percent from intestinal obstructions, and 10 percent trom hydrocephalus, stricture urethera (16%) and others (Table – II)

It was interesting to note that although 76 percent of them had rural background, but more than sixty percent of them had delivered the baby in the hospital either run by the government or private sector( 66%). Thus practice of delivering the baby in the hospital is on the increase. This is in conformity with the Government National Population Policy 2000 of India in which it is stated that more than 80 percent of the deliveries should takes place in the institutions and should be attended by trained health personnel by the year 2010.

  1. Sex
  2. Male 38 (76.0)
  3. Female 12 (24.0)
  4. Age (in days)
  5. Less then seven days 02 (04.0)
  6. 07-14 09 (18.0)
  7. 15-21 12 (24.0)
  8.   22 and above                          27 (54.0 0
  9. Birth Weigh (in )
  10. Less than 2500 gms. 08 (16.0)
  11. Above 2500 gms 28 (56.0)
  12. Not Taken/No Idea 14 (28.0)
  13. Diagnosis
a. Anorectal Malformation 18 (36.0)
b. Intestinal Obstruction 12 (24.0)
c. Stricture Urethera 08 (16.0)
d. HydroCephalus 05 (10.0)
e. Hydronephrosis 04 (08.0)
f. Tracheosphageal  

Fistula/Atresia                          03 (06.0)

Total Number of Respondents = 50

  1. Place of Delivery and Cultural Practices Related to Initiation of Dais- the traditional birth attendants had conducted nearly one third of the deliveries (32%) and the rest were conducted by trained professionals including doctors and nurses (68%). Nearly 70 percent of the mothers had reported that they had a normal delivery, while only 14 percent had delivered the baby through caesrean procedure.

There is enough evidence to show that the breastfeeding pattern established in the neonatal period influences long term breastfeeding behaviour5-6. In India only one fourth of the newborns across the country are given breast milk in the first hour after delivery due to various cultural beliefs and taboos related to initiation of breastfeeding. In the present study, it was found that nearly one fifth of them had initiated breastfeeding within few hours after delivery (22.0%). It was also found that giving of prelacteal feed and initiation of breastfeeding after three to four days was considered to be universal. More than eighty percent of the mothers had given pre lacteal feed either in the form of diluted milk (cow’s milk mixed with water) or Ghutti (78%). The findings of the study had revealed that four different ways were used to prepare Ghutti (prelacteal feed) with different types of ingredients. The most commonly used form of Ghutti was prepared after boiling mixture of Ajwain, Saunf, Sugar and Water (66.6%). Jaggery (locally known as Gur) mixed with milk and ajwain were prepared after boiling and administered to 20.5 percent of the neonates. Only honey was also administered to five percent of the neonates. Readymade mixture (commonly known as Janam Ghuti) purchased from the market was also administered by 7.8 percent of the respondents. The Ghutti was administered by an elderly female member of the family as it was believed that the infant will imbibe the same personality characteristics of the person who had administered the Ghutti. In the present study, also Ghutti was administered by an elderly female member of the family (71.8%) and in 18 percent of the cases Dai (respected female person who helps in conducting the delivery) had also administered Ghutti to the infant. (Table – III). Prelacteal feed was generally administered either with spoon or cotton wick.

Colostrum is considered to be good for the health of the infant as it protects the infant from various diseases. In the present study it was found that sixty-six percent of the respondents had not given colostrum to the infant. It was believed that colostrum (locally known as les wala dhud or kheel or khees) which is thick, causes obstructions in the intestines (54.5%) of the infant and therefore, difficult to digest (24.3%) because of its high consistency. Majority of them also considered colostrum as ‘dir ty, yellow, smelly, stagnant milk’ which should not be given to the infant because of its impurity as it is produced during the antenatal period. (Table III)Colostrum is considered to be good for the health of the infant as it protects the infant from various diseases. In the present study it was found that sixty-six percent of the respondents had not given colostrum to the infant. It was believed that colostrum (locally known as les wala dhud or kheel or khees) which is thick, causes obstructions in the intestines (54.5%) of the infant and therefore, difficult to digest (24.3%) because of its high consistency. Majority of them also considered colostrum as ‘dir ty, yellow, smelly, stagnant milk’ which should not be given to the infant because of its impurity as it is produced during the antenatal period. (Table III)

Table – III : Distribution of respondents according to practices related to initiation of breastfeeding

Practices Related to                    n (%)

Initiation of Breastfeeding

  1. Initiation of Breastfeeding*
  2. Yes 11 (22.0)
  3. No 39 (78.0)
  4. Time of Initiation of Breastfeeding**
    1. Within one hour 08 (72.7)
    2. After 2-3 hours 03 (27.3)
  5. Type of Pre lacteal feed***
a. Boiled mixture of Ajwain, Saunf, Sugar and Water 26 (66.6)
b. Mixture of Jaggery, Ajwain and Milk 08 (20.5)
c. Readymade Mixture (Janam Ghutti) 03 (07.8)
d. Only Honey 02 (05.1)
  1. Who Administered the Prelacteal Feed***
    1. Elderly Female Member 28 (71.8)
    2. Local Dai (TBA) 07 (17.9)
    3. Nurse 04 (10.3)

* Total respondents = 50                                  ** Total Respondents = 11

*** Total Respondents = 39

  1. Cultural Practices Related to Breastfeeding and disposal of Breastmilk Initiation of breastfeeding was delayed for three to four days and the infant was fed on diluted milk or cow’s milk or goat’s milk during this period. Majority of them stated that breastfeeding was delayed for three days because of different cultural practices. It was reported that regular breastfeeding should be initiated only when mother becomes ‘pure’ after ritual bath. Sister-in-law (Husband’s sister) played important role in bathing the breasts of the mother(respondents) with milk and green grass. It was believed that green grass symbolizes production of breastmilk in sufficient quantity for the infant and for a longer duration. Depending upon the economic condition of the family, sister-in-law gets some gifts in cash or kind. As preference is still given to a male child in many northern states of India (specially the first male child) there was reported to be variation in regard to sex of the new born and value of gift given to the sister-in-law. In order to avoid soreness of nipples and engorgement of breasts majority of the respondents had reported that they were told by their elderly family members for expression of breastmilk either through pressing the breasts manually or using pumping machine (available in the market). More than fifty percent had also reported that .they used to dispose off the breastmilk or colostrum either pouring in the drain or burying in the ditch (near the green grass) in order to protect from animals including cats and dogs. Burrial in the ditch (near the house) also protects the infant from evil eye (buri nazar) and green grass symbolizes production of sufficient milk. (Table – IV)

 

Table – IV : Cultural practices related to giving of colostrum and disposal of breast milk

Practices and Reasons Related to Colostrum Number Percentage
A. Giving of Colostrum

a. Yes

  

17

  

34.0
b. No 33 66.0
B. Main Reasons for not giving Colostrum*    
a. Causes obstructions in the Intestines (food pipe) 18 54.5
b. Hard to digest (Not good for health) 08 24.3
c. Impure (Stagnant and smelly) 04 12.1
d. Others (medical reasons) 03 09.1
C. Disposal of Colostrum/Breast Milk

a. Pouring in the drain

  

20

  

60.6
b. Burying in the soil (ditch) under the green grass 10 30.3
c. Wash Basin or sink 03 09.1

 

Analysis of data also revealed that initiation of breastfeeding and avoidance of giving colostrum were also related to certain characteristics of the delivery including place, type and who had conducted the delivery. It was found that those who had a normal delivery and delivered the baby at home had delayed the initiation of breastfeeding. (65.7%- and 62.5% respectively). Similar findings had emerged regarding avoidance

* Percentage from 33 Respondents of giving colostrum to the infant and type and place of delivery, as more than eighty percent of the mothers who had a normal delivery and delivered the baby at home or hospital had avoided giving colostrum (82.9%, 88.2% and 81.8% respectively Figure – 1) Some of the selected findings of the study were recently presented in a conference held during September 2008 in USA 7.

Distribution of respondents according to initiation of breastfeeding and giving of colostrum in relation to characteristics related to delivery

Discussion

The findings of the present study clearly demonstrates that due to various cultural beliefs and taboos, initiation of breastfeeding gets delayed for three and more days. Elderly female member plays important role in initiation of breastfeeding and giving of prelacteal feed (Ghutti). Avoidance of giving colostrum to the infant was also reported, from other studies from South Asian Countrie 8-11. A recent study from Turkey have also reported that only 9.9 percent of the mothers had initiated breastfeeding within four hour of bir th and 68.8 percent star ted breastfeeding after two day12. Similar findings have emerged from the present study, as 66 percent of the mothers had delayed initiation of breastfeeding and prelacteal feed was administed to 78 percent of the infants. Negative attitude towards colostrum and delay in initiation breastfeeding should be changed by educating mothers about advantages of giving colostrum and initiation of early breastfeeding within hour after bir th. Health professionals including nurses can play important role in changing negative attitudes of mothers as they are in direct contact with the mothers of the neonates while taking care of them in the ward. This will help in reducing neonatal morbidity and mortality and thus achieving the millennium development goals.

References

  1. Black RE, Morris SS, Bryce Where and Why 10 million children dying every year. Lancet 2003; 361; 2226-34.
  2. Lawn JE, Cousens S, Zupan 4 million neonatal deaths; When? Where? Why? Lancet 2005; 365: 891-900.
  3. United Nations Children State of World’s newborn 2001. Washinton DC: Save the Children Publication; 2002.
  4. Darmstad GI, Bhutta ZA, Cousens S et al. Evidence-based interventions: How many newborn babies can we save? Lancet 2005;365. 977-88.
  5. Hruscha DJ, Sellen DW et al. Delayed onset of lactation and risk of ending full breastfeeding early in rural Guatemala. J. Nutrt 2003; 2592-99.
  6. Perez-Escamill R, Segura-Millan S, et Prelacteal feeds are negatively associated with breastfeeding outcomes in Honduras J. Nutr; 1996; 126: 2765-75.
  7. alia I, Kalia R, Chopra S. Initiation of breastfeeding the North Indian Children. Presented at 34th Annual Conference of Transcultural Nursing Society  from 25th-27th,  September, 2008at Minnea polis, USA.
  8. OSrin D, Tumbahanhphe. K et at. Cross- sectional Community based study of newborn infants in Nepal. BMJ 2002; 325 (1063).
  9. Fikree F, Ali T et al. Newborn care practices in low socioeconomic, states settlements of Karachi, Pakistan. Social Science and Medicine.2005; 60; 911-921.
  10. Engle P Infant Feeding Styles. Barriers and opportunities for good Nutrition in India. Nutrition Reviews 2002; 60(5) S 109- S114.
  11. Kakar DN. Dais-The  Traditional Birth Attendants in village India. 1980. New Asian Publishers. New Delhi.
  12. Ozeki-Ergenekon  P,  Elmaci  N  et  al. Breastfeeding  beliefs  and  practices  among migrant mothers in slums of Diyarbakir, Turkey. The European Journal of Public Health 2006 (16) 2; 143-148.