Demographic characteristics of participants

Altogether, 79 mothers, 77 mothers-in-law, 90 fathers, and 99 LHWs participated in FGDs. The mean age of mothers was 29 years, and 70% of them were illiterate. Forty-nine per cent of mothers were housewives, and 51% were doing labor work (See Table 2).

Table 2 Demographic characteristics

The mean age of mothers-in-law was 58 years, 88% of them were illiterate, and 70% were housewives. The mean age of fathers was 40 years; 20% were illiterate, while 31% had received education below matriculation, and the rest were above matriculation. Most fathers were associated with labor work (30%), and farming (25%). The mean age of LHWs was 38 years; 85% of them had achieved an education level of matriculation and above.

Awareness and practices about breastfeeding

Most of the participants from all focus groups mentioned that breast milk is essential for the health and physical growth of children due to its nutritional properties; however, very few participants explained the benefits of EBF. Moreover, a number of participants reported the use of prelacteal feeds instead of early initiation of breast milk. Most mothers, and mothers-in-law mentioned that they give honey, tea (without milk), molasses and jaggery to the baby immediately after birth. Honey was the most frequently mentioned prelacteal feeds. Mothers stated that it is a tradition to offer such items to newborns, and they do it under the influence of mothers-in-law and elders in the home. Most of the mothers also mentioned that they used mixed feeding within the first six months. Moreover, mothers-in-law were of the view that honey and jaggery are good for a baby’s digestive system and should be given immediately after birth. A few participants also mentioned that honey protects children from fever, cough, and other respiratory ailments. It also helps to clear the mucus from the newborn’s body. One of the participants stated:

“First of all, we give honey to the newborn. Elder women told us that it is good, and baby does not get fever or breathing problems.” (Mother, FGD #1).

LHWs also mentioned similar cultural practices about prelacteal feeds; however, they believed that these practices are less common these days. One of the LHWs mentioned:

“They believe that prelacteal feed keeps the baby’s digestion well, and baby can pass stool easily. Also, if baby develops chest congestion, it gets well too, this is their understanding but medical findings did not support this claim.Thus it should not happen.” (LHW, FGD #2).

Barriers to exclusive breastfeedingInsufficient breast milk

A number of barriers and facilitators were reported by FGD participants. Table 3 ranks these based on the most number of responses for a particular barrier and a facilitator. Although most of the mothers reported that they breastfed their children, they could not practice EBF. The majority of mothers mentioned that breast milk was not sufficiently produced, and they had to give other food items such as cow’s milk, goat’s milk, tea without milk, or in a few instances, infant formula milk in addition to breast milk for children under six months of age.

Table 3 Barriers and facilitators to exclusive breastfeeding ranked based on number of responses

One of the mothers stated:

“Breast milk is important for a child’s health and growth. It is also important to protect the baby from illnesses. But my milk is not sufficient, and the baby’s tummy does not get filled, and I give goat’s milk in addition to breast milk.” (Mother, FGD #1).

Another participant stated:

“When breast milk is less produced, then I go to the doctor for a checkup, and he advises me to use powder (formula) milk.” (Mother, FGD #3).

Undernourishment of mothers

Undernourishment of mothers was another frequently cited barrier by mothers and fathers. Fathers explained that due to poverty, they were unable to buy a variety of foods necessary for the nourishment of mother and child. They had to rely on the available staple food such as ‘lassi’ (a drink made from yogurt) and bread or rice. Other participants mentioned that when the mother is weak (undernourished), insufficient breast milk is produced and the child’s requirements are not fully met.

Resuming fieldwork

Several mothers reported that they go to agricultural fields for their routine work, such as harvesting crops, and yielding vegetables. Due to harsh weather conditions, they leave the children at home. Caretakers at home, such as mothers-in-law, are responsible for feeding the children, due to which they cannot practice EBF.

One of the mothers said:

“I give breast milk to my child before going to the fields, but I cannot take my child along as it is too hot outside. If I return late, my mother-in-law feeds my child with yogurt, khichri (wet rice), or a goat’s milk (Mother, FGD #3).

A few mothers-in-law reported that mothers also express breast milk for their children before leaving for work.

“... sometimes she keeps her breast milk in a glass for her baby at home. “ (Mother-in- law, FGD # 2).

Short birth interval

Participants also mentioned that a brief interval between pregnancies results in less production of milk due to which they are unable to continue breastfeeding. A few mothers also perceived that it is not good for a child to be fed breast milk during pregnancy. As stated:

“They do not do break in between pregnancies and the mother does not get a chance to recover, and continue breastfeeding.” (Mother-in- law, FGD # 4).

“Sometimes, the mother gets another pregnancy. The first baby is younger than one year. Then she leaves breastfeeding, that is also one reason.” (LHW, FGD # 3).

Baby positioning

LHWs also mentioned that new mothers were not aware of the techniques of holding children in the appropriate positions for breastfeeding.

“When it is first child, mothers do not know about the position where the baby can easily suck breast. If the position of a baby was right, the baby would breastfeed properly. Girls at our community usually wed in young age, and they need proper training. We often brief them about breastfeeding, and tell them that now you are a mother, you must breastfeed your child.” (LHW, FGD # 5).

Mother’s or child’s sickness

Mothers and fathers mentioned that breastfeeding is sometimes discontinued temporarily when either mother or the child becomes sick, or mother is getting treatment for any ailment. In addition, a few mothers reported breast and nipple deformities as reasons for discontinuation of breastfeeding. A few mothers also mentioned that their children could not suck properly. Mothers and mothers-in-law also discussed the role of weather affecting breastfeeding as:

“In the winter season, if I put my hand in cold water, then breast milk gets cold, and the baby’s chest gets affected. In such situations, we avoid breastfeeding.” (Mother, FGD# 6).

Influence of grandmothers and family

Several mothers verbalized that the influence of grandmothers significantly impacts the decision to continue EBF. They perceived that grandmothers being elderly members of the family, are more experienced and knowledgeable in handling children. They often influence mothers to start top-up feeding, in addition, to breastfeed for children less than six months of age, so that their nutritional requirements are adequately met. Top-up feed mostly constitute animal milk. As stated:

“I have given goat’s milk to my children. My elder son was born through surgery, my breast milk was insufficient, and my mother-in-law asked me to give him goat’s milk. She also asked me to make ‘kichdi’ (cooked mashed wet rice) for him.” (Mother, FGD # 7).

Another mother said:

“Our elders have raised us in that way, and now, we are doing the same.” (Mother, FGD # 7).

Substance abuse by mothers

A few mothers-in-law also perceived that substance abuse by mothers, such as the use of betels and chewing tobacco, makes mothers weak and consequently affects breastfeedings.

FacilitatorsFamily support

Participants also mentioned factors that facilitate the continuation of EBF, such as support from family members, including husband and mother-in-law.

“If my mother-in-law tells me that I should give breast milk to the baby, I will do that. If she asks me to give yogurt or goat’s milk, then I give that to my child so that he can grow.” (Mother, FGD # 6).

Maternal health and diet

Fathers and mothers-in-law mentioned that if the mother is healthy and the maternal diet is appropriate, then she can continue to breastfeed the child.

“When she gets pregnant, she should get more bread, or she should eat at least two breads because now she is one-and-a half person. Also, when the baby is born, she should increase her food in the shape of fruits, milk, and there are other things. Then she will be able to feed the baby.” (Father, FGD #4).

A few mothers also mentioned that if there are any nursing mother among the neighbors, she can sometimes feed their children when they go to the fields for work.

“When I go to the fields, I give my baby to a neighbor and she breastfeeds my child in my absence.” (Mother, FGD # 6).