8
Breastfeeding patterns, beliefs and attitudes among Kurdish mothers in Diyarbakir, Turkey GUNAY SAKA 1 , MELIKSAH ERTEM 1 , ALIDA MUSAYEVA 2 , ALI CEYLAN 1 & TAHIRE KOCTURK 3 1 Department of Public Health, School of Medicine, Dicle University, Diyarbakir, Turkey, 2 UNICEF Office, Ankara, Turkey, and 3 Centre for Family Medicine, Karolinska Institute, Stockholm, Sweden Abstract Aim: The aim was to rapidly assess existing breastfeeding patterns, beliefs and attitudes in the province of Diyarbakir, a socio-economically disadvantaged region of Turkey. Methods: A cross-sectional survey exploring demographic and breast- feeding patterns was carried out among 921 mothers with children 6–18 mo of age. Results were quantitatively analysed. Focus group interviews dealing with beliefs and attitudes were separately carried out among 107 mothers and analysed by qualitative content analysis. Results: Nearly all mothers had breastfed their infants at some time, but exclusive breastfeeding was rare. About 62.2% of the mothers had waited for at least 24 h before initiating breastfeeding. Almost half of the infants received sweetened water as a first feeding. There was agreement on the superiority of breastfeeding and awareness of its contraceptive effect. Early introduction of sugared water, water and supplementary feeds was considered desirable. Working in the fields and pregnancy were considered situations counteracting breastfeeding. Conclusion: The attitude to breastfeeding was highly positive, but more information is needed to encourage the use of colostrum, discourage early supplementation and promote exclusive breastfeeding during the first 6 mo of life. Key Words: Breastfeeding, colostrum, Diyarbakir, mothers, Kurdish Introduction Breastfeeding has unique qualities of importance for mother and child health. This is why international organizations [1,2] as well as national authorities, including the Turkish government, recommend ex- clusive breastfeeding during the first 6 mo, continued thereafter for at least 1 y or beyond [3]. A recent country-wide demographic and health survey shows that breastfeeding is well established in Turkey. In 1998 the average duration of breastfeeding was almost 14 mo, and 95% of all infants received breast milk at some time. Basic problems were late initiation of breastfeeding, early weaning, the absence of exclusive breastfeeding and the widespread useage of bottle feeding (increasing the risk for gastrointestinal infections) [4,5]. In 2003 the largest province in southeastern Turkey, Diyarbakir, was selected for launching a programme to protect, promote and support breastfeeding. This programme is supported by the government and UNICEF [6]. Knowledge of local breastfeeding patterns, cultural practices, beliefs and attitudes facilitate planning strategies for promoting breastfeeding. This knowledge can be derived through rapid ethnographic assessment methods which have been successfully utilized in a number of community health and nutrition projects [7–9]. The purpose of this explorative study was to rapidly assess the existing breastfeeding patterns and beliefs in southeastern Turkey by employing a quantitative and a qualitative approach. The quantitative part of the study aimed at describing socio-demographic factors and breastfeeding patterns among mothers with children 6–18 mo of age, living in urban and rural areas of the province. This was complemented with a series of focus group interviews among women with breast- feeding experience, to reach a better understanding of cultural beliefs and attitudes. The study was carried Correspondence: Meliksah Ertem, Dicle Universitesi Tip Fakultesi, Halk Sagligi Anabilim Dali O ¨ gretim Uyesi, 21280 Diyarbakir, Turkey. Tel: +90 4122488432. Fax: +90 4122488432. E-mail: [email protected] (Received 11 February 2005; accepted 15 March 2005) Acta Pædiatrica, 2005; 94: 1303–1309 ISSN 0803-5253 print/ISSN 1651-2227 online # 2005 Taylor & Francis Group Ltd DOI: 10.1080/08035250510036732

Breastfeeding Patterns, Beliefs and Attitudes Among

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Page 1: Breastfeeding Patterns, Beliefs and Attitudes Among

Breastfeeding patterns, beliefs and attitudes amongKurdish mothers in Diyarbakir, Turkey

GUNAY SAKA1, MELIKSAH ERTEM1, ALIDA MUSAYEVA2, ALI CEYLAN1

& TAHIRE KOCTURK3

1Department of Public Health, School of Medicine, Dicle University, Diyarbakir, Turkey, 2UNICEF Office, Ankara,

Turkey, and 3Centre for Family Medicine, Karolinska Institute, Stockholm, Sweden

AbstractAim: The aim was to rapidly assess existing breastfeeding patterns, beliefs and attitudes in the province of Diyarbakir, asocio-economically disadvantaged region of Turkey. Methods: A cross-sectional survey exploring demographic and breast-feeding patterns was carried out among 921 mothers with children 6–18 mo of age. Results were quantitatively analysed.Focus group interviews dealing with beliefs and attitudes were separately carried out among 107 mothers and analysed byqualitative content analysis. Results: Nearly all mothers had breastfed their infants at some time, but exclusive breastfeedingwas rare. About 62.2% of the mothers had waited for at least 24 h before initiating breastfeeding. Almost half of the infantsreceived sweetened water as a first feeding. There was agreement on the superiority of breastfeeding and awareness of itscontraceptive effect. Early introduction of sugared water, water and supplementary feeds was considered desirable. Workingin the fields and pregnancy were considered situations counteracting breastfeeding.

Conclusion: The attitude to breastfeeding was highly positive, but more information is needed to encourage the use ofcolostrum, discourage early supplementation and promote exclusive breastfeeding during the first 6 mo of life.

Key Words: Breastfeeding, colostrum, Diyarbakir, mothers, Kurdish

Introduction

Breastfeeding has unique qualities of importance for

mother and child health. This is why international

organizations [1,2] as well as national authorities,

including the Turkish government, recommend ex-

clusive breastfeeding during the first 6 mo, continued

thereafter for at least 1 y or beyond [3].

A recent country-wide demographic and health

survey shows that breastfeeding is well established in

Turkey. In 1998 the average duration of breastfeeding

was almost 14 mo, and 95% of all infants received

breast milk at some time. Basic problems were late

initiation of breastfeeding, early weaning, the absence

of exclusive breastfeeding and the widespread useage

of bottle feeding (increasing the risk for gastrointestinal

infections) [4,5].

In 2003 the largest province in southeastern Turkey,

Diyarbakir, was selected for launching a programme

to protect, promote and support breastfeeding. This

programme is supported by the government and

UNICEF [6].

Knowledge of local breastfeeding patterns, cultural

practices, beliefs and attitudes facilitate planning

strategies for promoting breastfeeding. This knowledge

can be derived through rapid ethnographic assessment

methods which have been successfully utilized in a

number of community health and nutrition projects

[7–9].

The purpose of this explorative study was to rapidly

assess the existing breastfeeding patterns and beliefs

in southeastern Turkey by employing a quantitative

and a qualitative approach. The quantitative part of the

study aimed at describing socio-demographic factors

and breastfeeding patterns among mothers with

children 6–18 mo of age, living in urban and rural areas

of the province. This was complemented with a series

of focus group interviews among women with breast-

feeding experience, to reach a better understanding

of cultural beliefs and attitudes. The study was carried

Correspondence: Meliksah Ertem, Dicle Universitesi Tip Fakultesi, Halk Sagligi Anabilim Dali Ogretim Uyesi, 21280 Diyarbakir, Turkey.

Tel: +90 4122488432. Fax: +90 4122488432. E-mail: [email protected]

(Received 11 February 2005; accepted 15 March 2005)

Acta Pædiatrica, 2005; 94: 1303–1309

ISSN 0803-5253 print/ISSN 1651-2227 online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/08035250510036732

Page 2: Breastfeeding Patterns, Beliefs and Attitudes Among

out in 2003. To the best of our knowledge, this is the

first study of its kind carried out in this region.

Material and methods

Rapid ethnographic assessment (REA) method

REA is a holistic methodology based on the triangu-

lation of quantitative and qualitative data into one

source of knowledge. REA methodology aims at

reaching a synthesis of both traditional and modern

health practices in a community. Its methodology can

involve any or all procedures including formal and

informal interviews, conversations with key persons

or groups, participant observations, and focus group

discussions (FGDs) [8,9]. In this study, a cross-

sectional survey provided quantitative data. This was

complemented with qualitative information gathered

through FGDs, providing insights into beliefs and

attitudes supporting these practices.

Quantitative survey

Study population. This study was conducted in the

province of Diyarbakir in southeastern Turkey, with

a population size of 1 362 708 and a growth rate of

2.1%. Sixty per cent of the population lives in urban

areas. Basic occupations are agriculture and animal

husbandry, with an unemployment rate of 14%. About

half of the population is younger than 18 y of age. The

infant mortality rate is 6.2%, and the literacy rate

is 70%. As such, the province constitutes one of the

poorest regions in the country [10].

Thirty clusters of women with children 6–18 mo of

age from urban and rural areas were selected from

health centre registries. Mothers were approached by

the interview team and verbally informed about the

aims of the study. The impartiality of the study aims

regarding ethnicity, creed and political opinion, and

the anonymity of participants were ensured. Only

women who gave informed verbal consent were

included in the study. About 15–18 mothers from

each cluster participated. Thirty mothers refused to

participate, without giving any reason. Thus, a total

sample of 921 mothers were interviewed.

Questionnaire. The questionnaire was pre-tested on a

group of 100 women (subsequently excluded from

the study) living in a peri-urban district of Diyarbakir,

and the questions were revised and adjusted by

the research team. The final questionnaire included

33 close-ended questions with multiple choice

alternatives. The questionnaires were administered

face-to-face by trained interviewers speaking the local

Kurdish dialect (Kurmanch).

Statistical analysis. Data from the questionnaires were

quantitatively analysed with help of the programme

package EpiInfo 2000. Breastfeeding and the intro-

duction of supplements were described in terms of

frequencies. Differences between mothers living in

urban and rural areas were compared with w2 and

simple odds ratio analysis.

Focus group interviews

The sample. Mothers aged 15–49 y with at least one

child and experience of breastfeeding, living in four

urban and four rural areas in different households

were invited to participate in focus group discussions

(FGDs). Each FGD was attended by 10–15 mothers.

The total number of participants was 107.

Focus group discussions. FGD methodology is used for

exploring beliefs and attitudes in a community, and is

extensively used in health research [11,12]. A set of

questions probing beliefs and attitudes on prelacteal

feedings, colostrum, exclusive breastfeeding, food

taboos, and the benefits and disadvantages of breast-

feeding were prepared. Interviews were conducted in

the local Kurdish dialect and supervised by the social

scientists in the research team. Each session lasted

about 1 h. All FGDs were tape recorded with the

consent of the participants, transcribed verbatim and

translated into Turkish. Interviews continued until a

different opinion failed to arise (saturation).

Qualitative analysis. Transcripts were analysed by a

modified content analysis method [13]. Through the

coding of phrases and statements, themes regarding

different aspects of breastfeeding were identified and

explained.

Results

The survey

Table I presents the demographic characteristics of

the mothers. Demographic differences between urban

and rural areas were not significant. Only 4.8% of the

mothers were gainfully employed. Mean maternal age

at the time of interview was 27.2 (SD 5.8) y. Six per

cent of the mothers were adolescents, and 4.2% were

older than 40. As many as 45.1% of the mothers

had received no schooling, whereas only 3.4% had

university-level education. About a quarter (24.9%) of

the mothers had five or more children (mean 3.26, SD

2.1). About a third (30.9%) of the mothers lived in

extended families, i.e. they shared the household with

other relatives. During the prenatal period, 42.3% of

the mothers had had no contact with health personnel

1304 G. Saka et al.

Page 3: Breastfeeding Patterns, Beliefs and Attitudes Among

and 33.3% had performed their last delivery at home,

without professional assistance.

Table II shows the pattern of breastfeeding among

mothers. Ninety-eight per cent of the mothers had

breastfed their infants at one time or another. The

percentage of mothers initiating breastfeeding within

an hour after delivery was, on average, 37.8%, whereas

a majority of mothers (62.2%) had waited for at least

Table II. Patterns of breastfeeding among 921 mothers in Diyarbakir (%).

Total Urban Rural p

Odds ratio

(95% CI)

Breastfeeding

Mothers who ever breastfed 904 (98.1) 488 (98.4) 413 (97.9) 0.56 1.32

Mothers who never breastfed 17 (1.9) 8 (1.6) 9 (2.1) (0.50–3.47)

Time of initiation of breastfeeding

Within 1 h postpartum 348 (37.8) 208 (41.8) 140 (33.1) 0.007 1.45

After 24 h postpartum 573 (62.2) 290 (58.2) 283 (66.9) (1.10–1.89)

Introducing sweetened water first

Not given 477 (51.8) 269 (54.0) 208 (49.2) 0.14 1.21

Given 444 (48.2) 229 (46.0) 215 (50.8) (0.93–1.57)

Exclusive breastfeeding

No 911 (98.8) 493 (99.0) 417 (98.6) 0.55 1.43

Yes 11 (1.2) 5 (1.0) 6 (1.4) (0.39–5.44)

Timing of breastfeeding

On demand 546 (59.3) 307 (72.4) 239 (66.0) 0.05 1.35

Every 1–4 h 240 (26.1) 117 (27.6) 123 (34.0) (0.99–1.83)

Other 135 (14.6)

Introducing additional nutrients other than water within first 6 mo

Such nutrients not introduced for 6 mo 415 (45.1) 224 (45.0) 191 (45.2) 0.95 0.95

Such nutrients introduced within 6 mo 506 (54.9) 274 (55.0) 232 (54.8) (0.76–1.28)

Table I. Demographic characteristics of the sample of 921 mothers in Diyarbakir, Turkey (%).

Total Urban Rural p

921 498 (54.1) 423 (45.9)

Employment

Not employed 864 (93.8) 469 (94.2) 408 (96.5) 0.10

Age

Under 19 55 (6.0) 32 (6.4) 23 (5.4)

20 to 24 276 (30.0) 141 (28.3) 135 (31.9)

25 to 29 286 (31.1) 152 (30.5) 134 (31.7)

30 to 34 184 (20.0) 110 (22.1) 74 (17.5)

35 to 39 82 (8.9) 46 (9.2) 36 (8.5)

40 and above 38 (4.19) 17 (3.4) 21 (5.0) 0.37

Education

university 31 (3.4) 17 (3.3) 14 (3.4)

high school 56 (6.1) 30 (6.0) 26 (6.1)

primary school 290 (31.5) 173 (34.7) 117 (27.7)

literate 129 (14.0) 67 (13.5) 62 (14.7)

illiterate 415 (45.1) 211 (42.4) 204 (48.2) 0.38

Number of children

1–2 401 (43.5) 214 (43.0) 187 (44.2)

3–4 291 (31.6) 168 (33.7) 123 (29.1)

5 or more 229 (24.9) 116 (23.3) 113 (26.7) 0.25

Family formation

Nuclear family 636 (69.1) 364 (73.1) 272 (64.3)

Extended family 285 (30.9) 134 (26.9) 151 (35.7) 0.04

Prenatal care

PNC received at least once 531 (57.7) 301 (61.7) 230 (54.8) 0.03

No PNC received at all 390 (42.3) 488 (38.3) 190 (45.2) 0.03

Type of delivery

Health personnel assistance 614 (66.7) 334 (67.1) 280 (66.2)

At home with local midwife 307 (33.3) 164 (32.9) 143 (33.8) 0.77

Breastfeeding and Kurdish mothers 1305

Page 4: Breastfeeding Patterns, Beliefs and Attitudes Among

24 h before introducing the breast. A significantly

higher percentage (41.8%) of urban mothers than rural

mothers (33.1%) had initiated breastfeeding within

an hour postpartum. Forty-six per cent of the mothers

in urban areas and 50.8% in rural areas in this study

had also introduced water sweetened with sugar or

pekmez (grape molasses) immediately after birth as

a first feeding. The primary reason for not breastfeed-

ing immediately after birth was “lack of milk”. Other

reasons included “not knowing it was necessary”,

“having been hindered from breastfeeding because

of a caesarean section”, “traditions such as waiting

for the first three ezan (prayer calls)” and “concern

that this might have been harmful”, etc. (not shown in

table form).

The most common breastfeeding timing method

was on demand (59.3%). Urban mothers used on-

demand feeding significantly more often than rural

mothers (72.4% and 66.0%, respectively; Table II).

Two hundred and twenty-six mothers (24.5%) had

already weaned their infants from breast milk at the

time of the study (Table 4). Sixty-five mothers were

exclusively breastfeeding at the time of the study. Table

III shows the pattern of supplementary feeding among

the 856 mothers who were partially breastfeeding.

Tables II and III show that the frequency of exclusive

breastfeeding during the first 6 mo was very low. Only

1.2% of the mothers stated they exclusively breastfed

their infants during the first 6 mos. More than half of

the mothers (54.9%) had introduced supplementary

foods other than water during this period. Other

noteworthy practices included a somewhat high useage

of pacifiers (39.5%) and bottles for giving supplements

(38.9%).

Qualitative findings

Content analysis of data compiled through FGDs were

codified and collected under eight major themes.

1. Breastfeeding is best for baby. There was universal

agreement on the superiority of breastfeeding. State-

ments included: “Breast milk is very good . . . it protects

babies from disease . . . the baby will gain more weight

. . . breast milk is always ready and does not need

heating or preparing . . . easier than giving other food

. . . comfortable.”

2. Breastfeeding is protective against a new pregnancy.

Mothers were well aware of the contraceptive effect

of breastfeeding. Many mothers stated that they had

breastfed their babies for a long period in order to

prevent pregnancy. Having many children, especially

boys, enhanced the woman’s status and was a source of

Table III. Pattern of introducing supplementary foods into infant diets among 856 mothers.

Total Urban Rural p CI (95%)

Using dummy/pacifier 364 (39.5) 205 (41.2) 159 (37.6) 0.26 0.86 (0.66–1.12)

Time for introducing additional foodsa

After 6 mo 349 (37.9) 204 (42.7) 145 (38.4) 0.13 1

First month 49 (5.3) 30 (6.3) 19 (5.0) 0.71 1.12 (0.58–2.17)

Second month 58 (6.3) 37 (7.7) 21 (5.6) 0.44 1.25 (0.65–2.32)

Third month 73 (7.9) 35 (7.3) 38 (10.1) 0.09 0.65 (0.38–1.12)

Fourth month 108 (11.7) 61 (12.8) 47 (12.4) 0.71 0.92 (0.58–1.46)

Fifth month 104 (11.3) 47 (9.8) 57 (15.1) 0.06 0.66 (0.41–1.05)

Sixth month 115 (12.5) 64 (13.4) 51 (13.5) 0.59 0.89 (0.57–1.40)

Feeding methoda

With spoon or glass 523 (61.1) 289 (60.6) 234 (61.7) 0.73 0.95 (0.72–1.26)

With feeding bottle 333 (38.9) 189 (39.4) 145 (38.3) 1

Total 856 (92.9) 478 (100.0) 378 (100.0)

a Sixty-five women (7.1%) who had not yet started to give additional nutrients were not taken into account.

Table IV. Breastfeeding cessation time in 226 mothers (%).

Breastfeeding

cessation time, mo Total Urban Rural p CI (95%)

1 19 (8.4) 10 (7.3) 9 (10.1) 0.17 2.03 (0.65–6.31)

2 21 (9.3) 10 (7.3) 11 (12.4) 0.06 2.47 (0.84–7.39)

3 21 (9.3) 11 (8.0) 10 (11.2) 0.14 2.05 (0.69–6.09)

4 25 (11.1) 14 (10.2) 11 (12.4) 0.22 1.77 (0.64–4.91)

5 29 (12.8) 16 (11.7) 13 (14.6) 0.17 1.83 (0.70–4.80)

6 33 (14.6) 22 (16.1) 11 (12.4) 0.79 1.13 (0.43–2.91)

After 6 78 (34.5) 54 (39.4) 24 (26.9) 0.41 1

Total 226 (100.0) 137 (100.0) 89 (100.0)

1306 G. Saka et al.

Page 5: Breastfeeding Patterns, Beliefs and Attitudes Among

prestige. It was witheld that mothers who want to get

pregnant should stop breastfeeding.

3. The newborn baby should be given liquids. In most

situations, the first food given to the newborn was

water sweetened with sugar (sucrose) or pekmez (grape

molasses). It is believed that such prelacteals cleanse

the bowels of the newborn. One mother said: “The

child who takes sweetened water vomits the black dirt

in its stomach, and it clears its inside”.

Generally, colostrum is not perceived as having

nutritive value. Mothers complained they could not

produce milk right after birth: “My baby cried and was

hungry . . . I wanted to breastfeed but there was no

milk, so I gave sugar water . . .” An older woman said:

“the mother should rest a little after delivery. Preg-

nancy and birth makes the mother tired . . . after resting

for a while, she can breastfeed.”

4. Colostrum is not good food for babies. Not holding

the infant to the breast soon after delivery was

common practice. Opinions on how long to wait before

presenting the breast varied: some suggested a waiting

period of 3 to 6 ezan (Islamic prayer calls), or until the

mother had taken a bath. Others suggested periods of

up to 3 d. One mother stated, “the baby does not need

to be fed for the first two days, and therefore there is

no harm in not giving the breast during this time”.

Colostrum was often deemed unsuitable for babies.

Mothers referred to colostrum with local names such

as: “yellow milk, afterbirth milk, dirty milk, first milk,

corrupt milk” (“fro”, “herrish” in Kurdish). The view

that it is necessary to remove this “yellow, dirty milk”

that had loitered inside the breasts throughout preg-

nancy was widespread. Opinions such as the first milk

“can cause discomfort for the babmake the baby ill or

be harmful in some way . . . will make the baby ‘swell

up’. . . cause jaundice” were expressed. A 45-y-old

grandmother explained: “we squeeze this pus-like dirty

milk and pour it away until white milk begins to come.

Meanwhile the baby is fed with sugared milk.”

5. Colostrum is good food for babies. Although the view

that colostrum should not be given to infants prevailed,

some participants thought otherwise. A woman with

an urban background said, “I know colostrum is very

good . . . it is the first vaccine of the infant . . .” Another

mother said: “I know that this first milk is very useful

for the baby, but in the first days of birth it is very hard

to breastfeed . . . First of all, milk does not come and

the mother is very tired . . .”

6. Water is essential for babies. Water was not perceived

as a supplementary food by the mothers, but a necessity

for the maintenance of infant health. Statements

included: “it is absolutely necessary to introduce water

to the baby . . . water is good . . . water makes internal

organs work properly . . . the infant’s bowels will stick to

each other if not given water . . . everybody gives water

to their babies . . . our elders tell us to give water . . . a

baby who does not get water will become dehydrated

and ill.” In addition to water, different types of teas

were given. These included teas made with anise

(agastache foeniculum) and “meryemotu” (avens, geum

urbanum), used to treat colic.

7. Supplementary feeding before 6 mo is desirable. Exclu-

sive breastfeeding for at least the first 6 mo was a very

rare practice. Only one older mother said: “I formerly

fed my babies with breast milk only and, as a result, my

babies were protected from disease and have been

stronger and healthier”. Otherwise, none of the parti-

cipants had breastfed exclusively for 6 mo, and the

attitude towards supplementary foods was positive.

Some mothers were proud of themselves for having

started supplementary feedings early. A mother said,

“I am good at managing baby growth . . . I have five

children . . . I gave all kind of foods to my babies within

the first four months . . . all of them are healthy.”

Another mother said, “if you start giving foods to

your baby early, he/she will become familiar and

accept them easier . . . he/she will grow faster . . . he/she

will be stronger . . . so I think supplements should be

introduced as early as possible.”

8. Some situations counteract breastfeeding. Some

mothers thought that the ability to produce good milk

was something women inherited from their mothers.

One woman gave the reason for stopping breastfeeding

early as: “I had to stop earlier . . . My mother’s milk also

stopped early . . . this is our hereditary feature.” Some

mothers were considered simply unable to produce

good milk: “Some women’s milk is not good for their

babies. Children breastfed by such women remain

weak, do not develop, become ill and get diarrhoea . . .Such women should not breastfeed, and must use

baby food instead.”

Some of the participants engaged in seasonal agri-

culture work. Working outside the home was con-

sidered something that makes breastfeeding difficult,

but still possible. In this context, a situation termed

“weariness milk” or “heated milk” was believed to

occur when a mother stays or works under the sun for

a long time and is tired. This causes the milk in her

breasts to get warm and reduces its nutritive value. It

is believed that children fed with such milk may

have diarrhoea or suffer from a griping pain in their

stomach. Mothers said: “weariness milk should not

be given to a baby . . . the baby should be suckled only

after this milk is squeezed out or the breasts are

washed with cold water . . . a breastfeeding woman

should not work under the sun.” Furthermore, it is

believed that breastfeeding when the mother is sad or

Breastfeeding and Kurdish mothers 1307

Page 6: Breastfeeding Patterns, Beliefs and Attitudes Among

ill can be harmful to the baby: “When the mother is

sad, her milk is no good to the baby . . . it disturbs the

baby . . . A breastfeeding woman has to be free from

grief, troubles or other things like that . . . if a mother is

grieving she should not breastfeed.”

Furthermore, all participants considered pregnancy

a situation counteracting breastfeeding: “It is wrong for

a pregnant woman to go on breastfeeding. Once a

mother is pregnant, her milk is due to the baby in her

womb . . . A mother who has become pregnant, even

if not deliberately, must stop breastfeeding.” Another

opinion was: “When a woman becomes pregnant, her

milk will stop automatically anyway” or “a pregnant

woman’s milk will make her baby ill. It is yellow milk

and should not be given.”

An interesting opinion against prolonged breast-

feeding was also expressed: “Everybody says that if a

child is breastfed for a long period, he will be imbecile

. . . mothers should stop breastfeeding before one and

one and a half years . . .”

Discussion

This paper explores the pattern, beliefs and attitudes

towards breastfeeding in a socio-economically dis-

advantaged region of Turkey, inhabited mostly by

people of Kurdish ethnicity. The promotion of breast-

feeding in this area is crucial, since the infant mortality

rate in the region is the highest in the country (38%)

[5] and the poverty and low level of education among

mothers increases the vulnerability of their children.

It is noteworthy that breastfeeding patterns in

urban and rural areas were similar, despite the fact

that women living in urban areas had more access

to health services. This shows the need to improve

maternal and child health services, and especially the

knowledge and efficiency of health personnel, so they

can be better motivated to counsel mothers about

infant feeding.

Findings confirm the positive attitude to breast-

feeding and its universal practice among this group of

mothers, which can partly be explained by the religion

(Islam) [14] and also by the fact that poor and less-

educated mothers in developing countries seem to

breastfeed with higher frequencies than more affluent

groups [15,17,19,20]. Mothers in this study, as in

other parts of Turkey [18], were also well aware of the

contraceptive effects of breastfeeding.

Despite the positive attitude towards breastfeeding,

there were several problematic practices. One problem

was that many mothers did not give colostrum based

on beliefs that this was somewhat unsuitable food

for a baby. This is common in many parts of the

world [15,17,18]. Neonates are not held to the breast

for various periods of time either because of unfavor-

able maternity ward routines [19] or because of

traditions allowing the discarding of colostrum and

delaying introduction to the breast for 1–3 d, during

which time the infants receive various concoctions of

sugar water, herbal teas, cow’s milk, honey and

butter, etc.

Some mothers can initiate breastfeeding without

help, but most need information from health pro-

fessionals on skin-to-skin contact, positioning of the

infant to the breast, the imporatnce of colostrum,

etc. during the prelacteal period. Mothers should be

informed that such prelacteal fluids can cause delay

in the production of breast milk [15,20,26]. Colostrum

is a source of bioactive and immunological substances,

including some important micronutrient minerals

with high bioavailability. That the newborn infant

receives colostrum soon after delivery is important

from an immunological point of view, and WHO’s

baby-friendly hospital initiative promotes early initia-

tion. In this study, mothers were replacing colostrum

with diluted sugar or pekmez, solutions which may

be contaminated with micro-organisms and increase

neonatal morbidity, especially diarrhoea. Acute diar-

rhoea in this region is particularly high among infants

[5,27].

Another problem was the early introduction and

frequent use of water and herbal teas. Early supple-

mentation of breastfeeding with water is common

practice [21–23], while in other communities breast

milk is considered to be pure and the infant is con-

sidered unpolluted as long as it is being exclusively

breastfed [24]. However, breast milk consists of about

90% water, and exclusively breastfed infants can

maintain water homeostasis, even under high summer

temperatures [25]. Giving water may counteract

optimal breast milk production and is unneccesary

for exclusively breastfed infants. Many mothers also

used herbal teas in order to reduce colic or act as a

laxative. Herbal teas in infant feeding are also perceived

as beneficial in other communities [26,27], but there

are some questions as to how appropriate these may

be [28,29].

Other problems included the early introduction of

supplements and the virtual absence of exclusive

breastfeeding on the grounds of having insufficient

milk; a common finding in many studies [7,30].

Another reason for early supplementation was that

mothers believed the infants will have a better appetite

in the future, if they receive small portions of food as

early as possible.

Most mothers mentioned contraception as an added

advantage of breastfeeding and did not wish to stop

breastfeeding unless a new pregnancy occured. Next

to insufficient milk, a new pregnancy or a desire for

getting pregnant were reasons for discontinuing

breastfeeding [18,20]. There was a belief that pregnant

women should not continue breastfeeding, because in

such an occurrence, the nutrient value of breast milk

is due the fetus. It was believed that breast milk from

1308 G. Saka et al.

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a pregnant woman would be harmful and cause illness

in the child [17,30].

Conclusions

In this study, the attitude towards breastfeeding

is highly positive among mothers, regardless of differ-

ences in demographic variables. Mothers are aware of

the contraceptive value of breastfeeding. Most infants

are generally breastfed. Problem areas are the intro-

duction of sugar water instead of colostrum during

the prelacteal period, the early introduction of water,

use of herbal teas and other supplements, and the

virtual absence of exclusive breastfeeding. A strategy

for promoting breastfeeding in the region should

encourage a higher level of engagement of maternity

and child health personnel in infant nutrition and

advocacy of an early initiation of breastfeeding, intro-

duction of colostrum as a highly valuable infant

food, and maintenance of exclusive breastfeeding

without additional fluids or supplements for 6 mo.

Information on the health hazards of bottle feeding is

needed. The advocacy should incorporate the positive

aspects of traditional beliefs and practices into modern

messages on optimal breastfeeding.

References

[1] WHO Secretariat. Infant and young child nutrition; global

strategy on infant and young child feeding, Resolution WHA55/

15, 2002, Geneva. URL: http://www.who.int/gb/EB_WHA/

PDF/WHA55/ea5515.pdf (accessed 25 September 2003).

[2] Unit of Health Services Research and International Health.

Blueprint for action on breastfeeding in Europe, 2002, WHO

Collaborating Centre, Trieste, Italy, 2002.

[3] Department of Maternal and Child Health, Ministry of Health

and Social Welfare; Resolution 3393, Ankara, Turkey, 2004.

[4] FAO. Nutrition country profiles: Turkey. Rome: FAO; 2001.

[5] Tuncbilek E, Kurtulus E, Hancioglu A. Nutrition of infants,

children and mothers. Turkish National Health Survey 1998.

Hacettepe: UNPF, Population Institutemd, Hacettepe

University, Macro Int. Inc.; 1999. p 123–32.

[6] UNICEF. Nutrition activities and programmes for 2001–2005.

URL: http://www.unicef.org/turkey/untr/pr/ip_nv.html?ip4.

html&2

[7] Guerrero ML, Morrow RC, Calva JJ, Ortega-Gallegos H,

Weller HC, Ruiz-Palacios GM, et al. Rapid ethnographic

assessment of breastfeeding practices in periurban Mexico City.

Bull WHO 1999;77:323–8.

[8] Scrimshaw SCM. Adaptation of anthropological method-

ologies to rapid assessment of nutrition and primary health care.

In: Scrimshaw NS, Gleason GR, editors. Rapid assessment

procedures: Qualitative methodologies for planning and

evaluation of health related programmes, 1992. URL: http://

www.unu.edu/unupress/food2/UIN08E/uin08e00.htm

[9] Afonja SA. Rapid assessment methodologies: Application to

health and nutrition programmes in Africa. In: Scrimshaw NS,

Gleason GR, editors. Rapid assessment procedures: Qualitative

methodologies for planning and evaluation of health related

programmes, 1992. Boston, USA: International Nutrition

Foundation for Developing Countries. URL: http://www.

unu.edu/unupress/food2/UIN08E/uin08e00.htm

[10] Turkish population census 2000. Social and economic

characteristics of the population, province Diyarbakir. Ankara:

State Institute of Statistics, Office of the Prime Minister,

Republic of Turkey; 2002.

[11] Powell RA, Single HM. Focus group. Int J Qual Health Care

1996;8:499–504.

[12] White GE, Thomson AN. Focus groups as a research tool for

health professionals. Qual Health Res 1995;5:256–61.

[13] Altheide DL. Ethnographic content analysis. In: Bryman A,

editor. Ethnography, part IV. London: Sage Publications;

2001. URL: http://www.sagepub.com/printerfriendly.aspx?pid

=7247&ptype=B

[14] Kocturk T. Foetal development and breastfeeding in early texts

of the Islamic tradition. Acta Paediatr 2003;92:617–20.

[15] Kocturk T, Zetterstrom R. Thoughts about rates of breast-

feeding. Acta Paediatr 1999;88:356–8.

[16] Omotola BD, Akinyele IO. Infant feeding practices of urban

low income group in Ibadan. Nutr Rep Int 1985;31:837–48.

[17] Davies-Adetugbo AA. Sociocultural factors and the promotion

of exclusive breast feeding in rural Yoruba communities of

Osun State, Nigeria. Soc Sci Med 1997;45:113–25.

[18] Kocturk T. Advantages of breastfeeding according to Turkish

mothers living in Istanbul and Stockholm. Soc Sci Med

1988;27:405–10.

[19] Woldegebriel A. Mother’s knowledge and beliefs on breast

feeding. J Pak Med Assoc 1997;47:54–60.

[20] Harrison GG, Zaghloul SS, Galal OM, Gabr A. Breastfeeding

and weaning in a poor urban neighborhood in Cairo, Egypt:

Maternal beliefs and perceptions. Soc Sci Med 1993;36:

1063–9.

[21] Kulsoom U, Saeed A. Breastfeeding practices and weaning

among mothers of infants 0–12 mo. J Pak Med Assoc

1997;47:54–60.

[22] Reissland N, Burghart R. The quality of a mother’s milk and

the health of her child: beliefs and practices of the women

of Mithila. Soc Sci Med 1988;27:461–9.

[23] Lipsky S, Stephan PA, Koepsell TD, Gloyd SS, Lopez JL,

Bain CE. Breastfeeding and weaning practices in rural Mexico.

Nutr Health 1994;9:255–63.

[24] Moffat T. A biocultural investigation of the weanling’s

dilemma in Kathmandu, Nepal: Do universal recommend-

ations for weaning practices make sense? J Biosoc Sci

2001;33:321–38.

[25] Sachdev HP, Krishna J, Puri RK, Satyanarayana L, Kumar S.

Water supplementation in exclusively breastfed infants during

summer in the tropics. Lancet 1991;337:929–33.

[26] Fikree FF, Ali TS, Durocher JM, Rahbar MH. Newborn

care practices in low socioeconomic settlements of Karachi,

Pakistan. Soc Sci Med 2005;60:911–21.

[27] Kruger R, Gericke GJ. A qualitative exploration of rural feeding

and weaning practices, knowledge and attitudes on nutrition.

Publ Hlth Nutr 2003;6:217–23.

[28] Ize-Ludlow D, Ragone S, Bruck IS, Bernstein JN, Duchowny

M, Pena BM. Neurotoxicities in infants seen with the con-

sumption of star anise tea. Pediatrics 2004;114:e653–6.

[29] Allen JR, Thompson S, Jeffs D, Craven B. Are herbal teas

safe for infants and children? Aust Fam Physician

1989;18:1017–9.

[30] Bohler E, Ingstad B. The struggle of weaning: Factors deter-

mining breastfeeding duration in East Bhutan. Soc Sci Med

1996;43:1805–15.

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