The European Journal of Public Health Advance Access originally published online on February 9, 2006
The European Journal of Public Health 2006 16(2):143-148; doi:10.1093/eurpub/cki170
Maternal and Child Health |
Breastfeeding beliefs and practices among migrant mothers in slums of Diyarbakir, Turkey, 2001
P. Ergenekon-Ozelci1, N. Elmaci2, M. Ertem2 and G. Saka2
1 General Directorate of Maternal and Child Health and Family Planning, Ministry of Health, Ankara, Turkey
2 Department of Public Health Medical Faculty of Dicle University, Diyarbakir, Turkey
Correspondence: Meliksah Ertem, Dicle Universitesi T
p Fakultesi, Halk Sagligi Anabilim Dali, 21280, Diyarbakir, Turkey, tel/fax: +90 412 2488432, e-mail: mertem{at}dicle.edu.tr
Received March 23, 2004, accepted October 6, 2004
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Abstract |
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Background: A qualitative investigation and a population survey were conducted to explore the breastfeeding beliefs and practices of mothers who were forced to migrate from their original villages and were currently living in the slums of Diyarbakir in Turkey. Methods: Qualitative data collection on breastfeeding beliefs was conducted using in-depth interviews. In-depth interviews were tape-recorded. Quantitative data on breastfeeding practices were collected using a structured questionnaire. Results: Mothers generally have a positive attitude towards breastfeeding, but colostrum is usually perceived negatively. No woman was found to feed her infant exclusively by breastfeeding. Only 9.9% of mothers initiated breastfeeding within the first hour of birth. Forty per cent of mothers started solid foods before 4 months. Mother's education appeared as a significant factor influencing the introduction of colostrum to the newborn. Mothers with lower education generally believed that the colostrum should not be fed to the infant and that a pregnant woman's milk is unhealthy for the baby. There was also a belief that ‘working under the sun’ decreased the quality of milk of a mother. Conclusion: Cultural beliefs have a significant influence on breastfeeding practices. Some of these practices are potentially harmful to newborns. Health education programmes should address these beliefs and practices in culture sensitive ways.
Keywords: beliefs and attitudes, breastfeeding, qualitative data
The benefits of breastfeeding for both mothers and infants are well known. However, despite generally undisputed advantages, many women either do not breastfeed or breastfeed for only a short period of time. In some other instances, a mother may start breastfeeding too late. There are many factors that affect how women feed their infants and the length of time for which they breastfeed. Some of these factors are (i) urban or rural residence, (ii) socioeconomic status, (iii) maternal education, (iv) women's employment status, and (v) market pressures for using formulas and knowledge about, and the availability of, breast milk substitutes.1 Breastfeeding promotion must be seen as a priority for the improvement of the health and the quality of life of children and their families. The strategies should vary according to the population and its cultural characteristics, habits, beliefs, and socioeconomic level.2 Understanding of culture and beliefs are important for health care providers who are challenged to provide culturally sensitive care to diverse populations. Different ethnic groups may have different beliefs, attitudes, and practices in terms of nutrition and breastfeeding even though they are living in the same region. However, there is insufficient information about differences in nutritional habits, particularly infant feeding patterns, in Turkey. According to the Turkish Demographic and Health Survey,3 51.8% of infants were breastfed within 1 h of delivery and solid foods were given to 49.3% of infants under 1 month. Despite high breastfeeding initiation rates and long total duration of breastfeeding, exclusive breastfeeding is a rare practice in developing countries.4 The aim of this study was to explore in depth the traditional beliefs and practices of Kurdish women who were forced to migrate from their villages to the slums of Diyarbakir province. Both qualitative and quantitative methods were used for this study and the data include perceptions of mothers about infant feeding practices. Qualitative methods were used to elaborate the understanding of cultural values and belief systems, whereas quantitative methods were employed to identify the extent of the use of traditional practices. This study will inform effective breastfeeding promotional activities which are culture specific and culture sensitive.
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Methods |
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Population
The participants in this study were forcefully displaced women who had at least one child <5 years old. Most of the people living in the 450 Evler slum region of Diyarbakir speak Kurdish as their mother tongue and cannot speak the official language, which is Turkish. The literacy rate in this slum area is very low. Because of the conflicts between terrorists and military forces, many people from rural areas were forced to leave their villages and migrated to Diyarbakir city centre between 1992 and 1996. These people populated the slum areas of Diyarbakir and created new slum areas, which generally have semi-rural characteristics. The traditional beliefs of this group have an important influence on their health behaviours.
Study area
Diyarbakir is one of the provinces of southeastern Turkey, which is one of the least developed regions. The data collection was conducted in the 450 Evler slum area of Diyarbakir province during the year 2000. Most of the people living in this slum had been subject to forced migration. People who migrated to Diyarbakir were resettled in the 450 Evler region, which is close to the city centre. The total population of 450 Evler was 2783 according to the records of the primary health centre of this area. Over half of these inhabitants were families with an average of four or more persons occupying a single room. Most of the households consisted of extended families. The major source of income was temporary labour which provided very little money. A few women worked outside the home, usually as seasonal workers in the cotton fields. There is a government-run primary health centre in the area which offers antenatal care, immunization, contraceptive services, and some outpatient health services. Most deliveries took place at home and were assisted by traditional midwives.
Design
This study was conducted in two stages. Initial information about demographic characteristics and breastfeeding practices were collected from 143 women by quantitative methods using a formal questionnaire. In the second stage, in-depth interviews were conducted to understand the beliefs about and attitudes towards breastfeeding among women living in 450 Evler and to generate rich descriptions of women's experiences. All interviewers, who were bilingual for Turkish and Kurdish, were trained for in-depth interviewing. All interviews were audio tape-recorded with the consent of each individual and then transcribed verbatim. Nine in-depth interviews were conducted with women who had breastfeeding experience. Each interview lasted between 45 min and 1 h.
The survey
Mothers residing in the 450 Evler region who had at least one child <5 years old were the participants in the study. Based on the primary health care centre records, 166 women were identified who fulfilled this criterion. Among the 166 women, 143 (86.1%) were contacted and interviewed at their homes. We could not find 15 mothers after visiting their homes three times, and 8 mothers did not want to participate in the study but cited no reason for this. The questionnaire covered information on breastfeeding practices relevant to the mother's experience with her youngest child.
Definitions
‘Exclusively breastfeeding’ was used to define initiating breastfeeding immediately after birth and not giving any other solid food (including water) to the infants. ‘Starting solid foods’ is defined as giving any food in addition to breast milk other than water.
Analyses
The software package EpiInfo2000 was used for the analysis of the quantitative data. Basic descriptive findings were performed using frequency distributions. 
2 analyses were performed to compare the effects of different factors on breastfeeding practices. Sex of the baby, type of assistance during birth, education level of women, the ability to speak Turkish, and the type of family were the independent variables of the 2 analyses.
The qualitative data were sorted, categorized, and conceptualized in a systematic way to uncover patterns or themes of breastfeeding. This paper presents the wide range of the experiences mentioned by mothers who participated in the study.
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Results |
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Demographic characteristics of mothers
Table 1 summarizes the demographic characteristics of the mothers. Forty-six mothers (32.2%) were living in patriarchal extended families. The overall socioeconomic level was low, and 61 of the husbands (43.2%) had no permanent job. Most women spoke Kurdish as their mother tongue; some were bilingual, but 96 (67.1%) could not speak any Turkish. The illiteracy rate was also very high (117 women, 81.8%). Fertility determinants showed that short birth intervals and multiparity were important health risks for women.
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Infant feeding patterns
None of the mothers exclusively breastfed her infant, as shown in table 2. All mothers gave either plain water or water with sugar to their infants when they felt that they were still hungry. Only 14 mothers (9.9%) breastfed their infants within the first hour of birth. The most widely used practice in terms of breastfeeding was to start breastfeeding after the first 2 days of birth. Only 29.1% (37 mothers) started solid foods at or after 4 months. Fifty-one mothers (40.2%) initiated solid foods within the first 3 months of birth. Initiating solid food too late was another potentially harmful practice, and 30.7% of the mothers (39 mothers) waited until later than 7 months to start giving solid foods.
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In table 3 breastfeeding starting times are shown. Fourteen mothers (9.9%) started breastfeeding within the first hour, but 97 mothers (68.8%) started breastfeeding after waiting for 2 days or more. Seventeen per cent of the mothers whose birth was assisted by a trained health professional started breastfeeding within the first hour, compared with 7.0% of mothers who delivered with a traditional birth attendant; the difference was definitely important but not statistically significant (P = 0.19). The only factor significantly associated with breastfeeding starting time was found to be the educational level of the mother (P = 0.04). Initiating breastfeeding within the first hour was significantly more common among the literate mothers (16%) than the illiterate ones (8.6%).
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Beliefs and attitudes
Women had negative attitudes about giving colostrum to the newborn. Table 4 provides the reasons for not giving colostrum as cited by 127 mothers who did not give their infants breast milk within the first hour of birth.
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In the local language mothers called colostrum mawu or fro. Mawu literally means ‘new milk’ and fro means ‘dense milk’.
Mothers believe that ‘mawu or fro is always produced within the first 3 days of birth’ and that ‘it should not be given to newborns’.
Mothers report that ‘mawu or fro causes stomach ache’ and ‘infants dislike this milk’.
Mothers squeeze their breast to get rid of this first milk until white milk is produced and then they place a clean white piece of cloth on their breast. Mothers made correlations between meconium and colostrum, indicating they were similar in their unwanted characteristics because both of them lasted around the same time.
Some other mothers believed that milk produced while the mother was still pregnant, because it stayed in the breast for a long time, was stale and dirty. Besides these beliefs, mothers also cited religious leaders' opinions which reportedly indicated that for the first 3 days the yellowish milk coming from the mother's breast should not be given to newborns.
Table 5 shows the first nutrient given to newborns. Most of the mothers (73.4%) gave sugared water upon the birth of their babies. They gave these nutrients until the production of white milk, usually for up to 3 days. Some mothers gave different kinds of nutrients in the first days of life. Herbal teas especially were regarded as having curative effects on indigestion and stomach ache. Additionally, herbal teas were considered to cleanse the stomach of the baby.
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On the other hand, most of the mothers had a positive attitude towards breastfeeding if the milk was white and mature. They called mature milk ‘clean milk’ or ‘legitimate milk’. Almost all mothers considered human milk to be the best nutrient for the growth, development, and health of a child. One woman said, ‘Breast milk prevents diseases ... . Breastfed babies grow rapidly and they are healthier... . Breast milk contains vitamins and good substances.’ Mothers were found to breastfeed for a long time, and the median duration of breastfeeding was found to be 18 months. According to mothers, if the growth, development, and health of the child went well, initiation of solid foods could be delayed until the complete cessation of breastfeeding.
Seventy-two mothers stopped breastfeeding and 15.3% of these mothers (11 mothers) stopped breastfeeding before 6 months. Forty-three per cent of these mothers (31 of 72 mothers) continued breastfeeding for >19 months (table 6). Mothers valued the mature milk produced after the first 3 days of birth highly and they tended to breastfeed their babies for long durations.
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Table 7 lists some of the considerations of mothers for stopping breastfeeding. Getting pregnant was the most frequently reported cause for stopping breastfeeding.
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Women believe that pregnant women's milk is ‘spoiled milk’, and religiously it is forbidden to feed a baby with it. A young woman noted that ‘because I am pregnant my milk is the right of my baby inside me.... If I breastfeed, my breastfeeding child will get sick.’ Another woman said, ‘Pregnant women's milk is spoiled milk. It may give harm to the breastfed baby... . I know it because the imam [religious man in Islam] said pregnant women should not breastfeed their babies.’ One mother said, ‘When I was pregnant I vomited and my children also vomited. My milk caused the sickness of my children.’
Breastfeeding mothers also wanted to avoid working under the sun. If a breastfeeding mother works under the sun and gets tired, her milk is called ‘fatigue milk’ or ‘warm milk’. ‘Fatigue milk’ is also believed to be harmful for the baby. Two mothers explained why they stopped breastfeeding in the following terms: ‘I worked in the cotton field under the sun; the weather was very hot and my breast milk became warm. Warm milk always causes infant diarrhoea.’ Another mother said, ‘Warm milk should be discarded by squeezing the breast or the mother should compress ice box or wash her breast with cold water to avoid the illness of the infant.’
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Discussion |
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Breastfeeding was almost universally practised among the mothers who participated in this study. However, the mothers' knowledge about and attitudes towards breastfeeding and related conditions were not always consistent with healthy practices. It is very important to understand mothers' beliefs and attitudes for appropriate health education or other interventions on breastfeeding.
The characteristics of the participants of this study are very similar to those of the rural populations in the southeastern regions of Turkey. Most of the women were illiterate and could not speak Turkish. The literacy rate of the women in this study (18.2%) was significantly lower than the overall literacy rates among women in Turkey (76.1 %).5 The illiteracy rate of the study population is also lower than that in many other developing countries. Multiparity, early marriages, living in an extended family structure, and short birth intervals were the features representing a traditional lifestyle.
In the study population a wide range of mothers (98.6%) ever breastfed their infants. In all other traditional populations a great majority of mothers choose to breastfeed during the first years of the infant, and breastfeeding is regarded highly for the health of the infant.6–9 On the other hand, in some accounts of Western society, breastfeeding is perceived as denigrating women's bodies, leading women to believe that their bodies are inadequately suited for breastfeeding. Consequently, many women may perceive breastfeeding as something which will be difficult (or impossible) to achieve successfully.10 Mothers consistently ranked breastfeeding as the best nutrition for infant growth and health, but the value of exclusively breastfeeding was not well known by the mothers. An important factor for not practising exclusive breastfeeding was the perception of water as being indispensable for the infant's health. Exclusively breastfeeding is not frequently practised in other communities either. Rates for 4 months of exclusive breastfeeding were 0.0% in rural Malawi9 and 1.3% in Turkey.3 Mothers supplemented infants' feeding with other fluids until the mature milk began to flow. Mothers also fed water to their babies, which they thought to be a requirement for the infant. Participants of another study among African American women perceived that giving infants water was essential, and they believed that cereal and solid foods should be introduced much earlier.11 But in Nepal breast milk was considered to be pure, and while the infant was drinking only breast milk, he or she, unlike adults, was not yet polluted.12
Between 15 and 65% of mothers studied in different regions of the world had not given colostrum to their babies.13–15 In Ibadan mothers claimed to have discarded the colostrum produced in the first 24 h postpartum and infants were fed on glucose water or herbal preparations.13 In Guinea-Bissau mothers also had negative cultural perceptions about colostrum.16 In Nigeria mothers said that colostrum should be discarded because it is dirty, ‘like pus’, and therefore potentially harmful to the infant.17 In those communities breastfeeding was traditionally delayed and glucose water and herbal preparations were given to infants, in a similar way to our study population. Similar to many other cultures, mothers in our study perceived colostrum as a harmful, pus-like, and religiously forbidden milk. It is interesting that some of them related meconium to colostrum. Another, different perception of colostrum was that it was the milk which had stayed in the breast during the 9 months of pregnancy and thus became stale. Nigerian women also claimed that water and herbal teas would purge the baby and clean its stomach, similar to the findings in our study.17 These traditional beliefs made mothers not give breast milk for the first days of life. In the survey 38.6% of the women stated that they did not have white milk, and 24.4% of them stated that colostrum was too dirty for breastfeeding during the first hours. These and all the other answers demonstrate the strong misperceptions about colostrum.
Literate women and women who had professional birth attendance during their most recent birth were more likely to initiate breastfeeding earlier. These results indicate that traditional beliefs and attitudes can be changed, and acceptance of colostrum can be enhanced, through the training of mothers and the provision of health professionals for deliveries.
Once breastfeeding has been initiated, it was widely accepted and highly valued in our study population, similar to other communities.17,18 In our study population the median duration of breastfeeding was found to be 18 months. This result was higher than in other parts of Turkey, where the average is 16.2 months.3
In Ethiopia, the majority of the mothers studied stopped breastfeeding when they became sick or pregnant or their child became sick.18 More than half of the women decided to discontinue breastfeeding because they had become pregnant again.19 In our study, getting pregnant or becoming ill were also shown to be important reasons for the cessation of breastfeeding. Women stated that if a pregnant woman breastfed, both the breastfed child and the fetus could be harmed. Pregnant women were not expected to breastfeed according to the Yoruba culture either.17
One of the other interesting findings of this study was the avoidance of breastfeeding once the mother worked under the sun.
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Conclusion |
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TopAbstractMethodsResultsDiscussionConclusionReferences |
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This study helped us to understand the beliefs and traditional practices of Kurdish women who were forced to migrate from their villages to the slums of Diyarbakir. The data revealed that inadequate nutritional knowledge and adherence to cultural practices may lead to poor quality feeding patterns for newborns. Most of the mothers' perceptions about breast milk were strong and positive, but colostrum had no positive value for them. Despite the high prevalence of breastfeeding, women avoided giving colostrum, refrained from breastfeeding after they worked under the sun, and stopped lactation once a new pregnancy began. These potentially harmful beliefs should be addressed and minimized through the training of mothers. On the other hand, the general positive attitude towards breastfeeding and the long duration of breastfeeding are culturally favourable conditions to advance and build upon for healthier breastfeeding practices. Community intervention programmes should always explore, address, and, where appropriate, incorporate the traditional beliefs and practices of the community. New ways of doing things or interventions to change attitudes and behaviours will be received more effectively when health professionals establish linkages between traditions and modern health promotion messages.
Key points
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References |
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