Demographic characteristics of the women
The pregnant women participated in this study were mostly in their mid-twenties. All of them were between 24 to 28 weeks of gestation, the majority were from Bamar followed by Chin, Kayin, and Indian and Chinese ethnicity. All women came from nuclear families and majority were Buddhist and lived in urban slum area. They had varying levels of education. Among 14 pregnant women, majority of them (42%, n = 6) completed middle school, one fifth (n = 3) completed primary school, 15% (n = 2) completed high school and 15% (n = 2) were graduate while a woman was a university student (distance learning). Among interviewee women, half of them were employed and working as vendors, casual workers or government staff.
Perceptions of infant feeding and sources of information
Women and accompanying family members were aware of breast milk benefits for babies, colostrum and the correct time to initiate breastfeeding. Interestingly no woman mentioned the benefits of breast milk for themselves.
“I know breast milk is good and has good elements.” (A pregnant woman, employed)
“I thought colostrum (noh-oo-ye) was same as breast milk, both come from breast, what is the difference?” (A grandmother, unemployed)
Though most women had heard about exclusive breastfeeding for 6 months, detailed probing revealed that majority of them thought that exclusive breastfeeding meant giving breast milk only with no infant formula or other drinks or semi-solid foods, but small sips of water were acceptable. More than two thirds of women felt that breastfeeding alone for 6 months would not provide sufficient water and nutrients for their babies. Some women considered that mixed infant feeding (breast and infant formula) provided the best nutritional value.
“I will practice exclusive breastfeeding and only give water via cotton bud to prevent dry mouth, hiccough, etc.” (A pregnant woman, employed)
Majority reported that 2 to 4 months of age were the best timing to introduce complementary food. Regarding sources of information on infant feeding, respondents mentioned various sources, such as television, bill boards, pamphlets, health magazines, health staff, and family members especially mothers or mothers-in-law while no one mentioned of listening to radio as a source. A husband mentioned mobile internet as his source of knowledge. Although respondents acknowledged of hospital breastfeeding education activities, they claimed these were not enough.
“Doctors examined only a few minutes, they are too busy and I scare to ask information to them.” (A pregnant woman, housewife)
Infant feeding practices in the community and influencing factors
All women noticed all mothers in their community fed breast milk to their babies while only one woman knew of a mother practiced exclusive breastfeeding for six months successfully. They felt that underlying socio-economic factors played an important role and work was the main reason for introducing infant formula. Two respondents from Ayeyarwady region (one of the most populous areas in Myanmar and occupy the delta region of the Ayeyarwady River) mentioned that in their villages, honey was given soon after delivery by traditional birth attendants due to cultural belief-for example- “the child needs honey to freshen up himself as he /she stays inside mothers’ womb for a long time”. Mixed feeding was the most commonly seen feeding pattern and water was found to be given as early as less than four weeks after delivery. Formula supplementation was commonly used before child reach 4 months and poor usually used formula made in China and the rich preferred branded infant formula such as Nestle or Dumex. A vast majority of respondents reported of knowing mothers introduced various kinds of soft and semi-solid foods at different age of children mostly at 2–4 months such as pasted rice powder or soft, mushy rice or chewed rice added by oil and salt. They noticed that mothers gave fruity ORS in hot weather, added blended carrots, beans or eggs while meat or dark green vegetables was not commonly given.
Perceived reasons for low exclusive breastfeeding rate in the community revealed as community did not believe that breast milk alone could provide all nutrients needed for children for 6 months, worried that child could be thirsty or hungry, beliefs that infant formula could enhance child memory or physical strength, work related constraints and grandmothers’ influences.
“My niece is tall and smart. My sister fed her Dumex (a branded infant formula), in addition to breast milk.” (A pregnant woman, employed)
The findings from the nurses, doctors, program managers and staff working in the infant feeding promotion programs in Myanmar about the community current feeding patterns were similar to the participant women responses. Finding from the FGD with nurses and program staff revealed that mothers gave water followed by infant formula or condensed milk mixed with water even before they discharged from the hospital after delivery, mostly influenced by grandmothers.
“After delivery, grandmothers or family members fed sips of water via cotton or spoon during hospital stay behind my back.” (A hospital nurse)
Limited capacity to overcome barriers, accessibility to resources and poverty served as contributing factors for failed exclusive breastfeeding practices.
“There are not many maternity leaves in private (industry) and no favorable breastfeeding environment, job security is more important for them.” (Nutrition program manager, non-governmental sector)
Intended feeding patterns and influencing factors for exclusive breastfeeding practice
Though all pregnant women intended to breastfeed, detailed probing revealed the women were prepared to add water, infant formula or other foods when their infants was from 1 to 4 months of age thus showing their determination was not as they stated. Women provided various examples as their intended feeding practices such as rice water, pasted rice powder, porridge, cooked or chewed rice when baby would be 2 to 4 months old, with added salt and oil. Upon exploring diversity of food to be added, carrots, peas, eggs and chicken were the most commonly examples given and they did not intend to add either ‘vegetables, meat or chicken or pork organs’ to prevent belching, hiccough, indigestion and worms(than-hta).
“Will give rice meshed and sieved through a clean washed thin cloth at 2–4 months along with breastfeeding. Baby could be strong.” (A pregnant woman, employed)
To practice exclusive breastfeeding successfully for six months was not an easy task for respondents and emerging barriers appeared as work as a major barrier for the working women, doubt on the quantity and quality of breast milk, grandmothers’ influences, limited ‘know-how ‘capacity and resources to overcome challenges . Some selected quotes were;
“I need to get back to work, maternity leave is short, infant formula is an only option.” (A pregnant woman, employed)
“My mother said child will be small and short if we did not add other food.” (A pregnant woman, unemployed)
Almost all women reported that they did not have any idea on how and where to access health information to overcome the barriers. Consequently, they reported low confidence level to manage breast problems if occurred.
“How could I breastfeed if I have cracked nipples or mastitis, my sisters cried all the time when she had it.” (A pregnant woman, employed)
Majority of them did not aware importance of position and attachment to have enough milk and techniques to express milk for working mothers.
“I heard of express milk but never saw it. I don’t know how many hours I could keep it at room temperature or in the fridge.” (A pregnant woman, employed)
In terms of supporting factors to exclusive breastfeeding, women mentioned about support from husband and mothers and mother-in-law. In all interviews, women said they had freedom of choice to breastfeed, however, couples reported the possibility of grandmothers of both sides’ influences. Not engaging in work outside home was also perceived as a supportive factor.
“I will support my wife to breastfeed and will tell my mom (living with them), ‘it is for your grandchild’” (A husband, employed).
“If my mom or mother-in-law insisted me to add infant formula or water, I need to follow.” (A pregnant woman, unemployed).
Respondent use of mobile phones
Most of the respondents had mobile phones and the rest shared phones with their husbands. All of their handsets were made in China and almost all of them installed Myanmar font in their handsets. At the time of the study, original setting of handsets available in Myanmar did not have Myanmar font installed in key pad and additional set up is needed and could be done in mobile shops. They mainly used mobile phones to communicate with their families and friends. A few of them preferred text messages to phone calls to save cost. None of them had heard or experienced of receiving health information via mobile phones. Husbands appeared to have better knowledge on using mobile phones than their wives and willing to share health promotion messages to their wives.
“Our village recently has mobile network and my husband bought me this cheap mobile handset in previous month. I know how to make a call and answer phone.” (A pregnant woman, own small grocery store)
“I think it should not be a problem for me to access, read and understand incoming text messages.” (A pregnant woman, unemployed)
Opinions about a mobile phone based intervention
All women and their husbands, welcomed the idea of receiving health promotional SMS into their phones and had positive attitudes on program successes in receiving health education messages to their mobile phones did not appear to be a potential downside for respondents women, their husbands, mother and mother-in-law. They felt that sending SMS 2–3 times per week as appropriate frequency. No one described of feeling annoying by receiving SMS and some even reported that they were willing to spend money on mobile bill to get health information.
“In receiving SMS, it will be good if there is a picture in SMS.” (A pregnant woman, unemployed)
“I will forget what I learnt form TV or radio, but for SMS, I can look at any time I want and I can keep at all time.” (A pregnant woman, employed)
In examining service providers opinions on the planned mobile phone based intervention, there were generally positive views on the intervention idea. A few participants mentioned that the study would use the integrated approach by leveraging the power of mobile phones at perfect timing which could enhance the community mobilization to participate in the study. Findings from FGD with nurses reported that sending health promotion SMS could attract mothers than traditional distribution of pamphlets, however younger nurses had higher positive attitudes toward using mobile phone messages than older staff. All respondents agreed that using SMS as a service delivery would be the best modality for current moment and suggested to send SMS at evenings or weekends to avoid mothers’ busy time. Perceived barriers found to be the unreliable mobile networks, affordability for handset, time needed to spend to send SMS, recipients’ willingness to read SMS if there were too many messages, and possibility of changing phone numbers in six months’ time. A staff reported of a potential downside as participants did not receive SMS as claimed to be due to natural disaster or unforeseen circumstances.
Recommendations made were to explore the best timing to send SMS to the selected women; to use simple, easily understandable and culturally appropriate terms, to use relevant ethnic languages such as Shan, Karen or Kachin in some areas; to add interactive or pictorial messages for better attraction. Other suggestions came out as conducting a proper evaluation after intervention, arranging for more media coverage, sharing and advocating for political commitment in order to scaling up of similar design to the national level.
Some selected positive quotes were;
“I prefer SMS, no not need special skill to use, not need to wait for airtime like Television or radio, can read anytime & could not be intervened by noises.” (Staff, Government sector)“The idea of using mobile phone as right time as country situations has been significantly changed and more political commitment to promote breastfeeding.” (Staff, non-government sector)
In an in-depth interview with a staff from mobile operator revealed that, “We are aiming to cover 95% of the country in coming 3 years.” He supported the intervention idea in principle and reminded to work carefully in developing text messages in limiting numbers of characters (word count) to be put in a message and to consider and assess participants’ literacy level as reading text message need to have some level of education.