Of 1404 live births in 2010 in Maela Refugee camp there were 982 evaluable mother-newborn pairs (Figure5). Of the 982 pairs, 1.3% (13/982) were twin births and seven of these were at term. There were 8.1% (80/982) of births with a gestational age between 32+0 and 36+6 weeks. There were 35.9% (353/982) primigravidae and 64.1% (629/982) multigravidae, with a mean [min-max] age of 21 [14–42] and 29 [15–47] years. The median parity of multigravidae was 2[1–10].
Breastfeeding initiation rates
Initiation of breastfeeding within the first hour after birth in term mother-newborn pairs was high, 91.2% (823/902) (Figure6). The cumulative proportions of mother-newborn pairs initiating breastfeeding within two, three, and four hours after birth was: 92.2% (832), 92.4% (834) and 94.7% (855), respectively (Figure7). At discharge from hospital 99.3% (896) were exclusively breastfed including 31 mother-newborn pairs admitted to special care nursery. The six mother-newborn pairs who did not initiate feeding included two neonatal deaths. The other four received powdered infant formula as three of the mothers had HIV and one baby was adopted.
In mother-newborn pairs with a gestational age at birth between 32+0 and 36+6 weeks, initiation of breastfeeding within the first hour after birth was 48.8% (39/80). The proportion of breastfeeding in the first hour after birth increased significantly with increasing gestational age: 0% (0 of 3), 18.2% (2/11), 46.7% (7/15), 50.0% (7/14), 62.2% (23/37) at 32, 33, 34, 35 and 36 weeks, respectively (P = 0.003, linear trend) (Figure6). In the remaining 51.2% (41/80) mother-newborn pairs where initiation did not occur in the first hour, exact breastfeeding initiation time was identified in 70.7% (29/41) of records. Initiation of breastfeeding occurred within 4 hours in 41.5% (17/29) and by 24 hours in the remaining 58.5% (12/29) pairs. At the time of discharge 98.8% (79/80) of these preterm mother-newborn pairs were exclusively breastfeeding. One pair was discharged supplementing breastfeeding with infant formula in twins born at 35+5 week’s gestation.
Previous breastfeeding duration
The median duration of previous breastfeeding was 19 (range 2 to 72) months in the 90.3% (568/629) of multigravidae, who had a live-born, congenitally normal infant that was not a neonatal death.
Focus group discussion
A total of 50 women, including 17 primigravidae and 33 multigravidae participated in the nine FGDs. When asked the icebreaker question about how they were fed as babies, there was often laughter and surprise that the question was serious. The opening question encouraged women to speak to each other and they expressed amusement at the notion that they may not have been breastfed. Non-verbal communication was observed during FGD including nodding in agreement with another’s opinion or experience.
When asked, 100% (50/50) of women expressed their intention to breastfeed or their experience of breastfeeding with certainty. In primigravidae the intended and in multigravidae the actual duration of breastfeeding was more than one year for 96% (48/50). One multigravida breastfed her last child for only three months as she went to work outside the camp and only one primigravida showed any hesitation in her intended length of breastfeeding; “If the baby is healthy I will stop early; after 6 months, or [I will breastfeed] until I am pregnant again; if the baby is not healthy I am not sure.” (Paw Mue, first pregnancy, aged 20 years). Another women in her group spontaneously assured her that she could breastfeed for longer if she wished.
Three major themes emerged from the qualitative data: 1) Breastfeeding is “good”, 2) Bottle feeding is for other people and 3) My mother told me about breastfeeding.
Breastfeeding is “good”
The strongest theme to emerge was from positive statements about breastfeeding and the acknowledgement of breastfeeding as an inherent part of being a mother:
"
“I breastfed for more than three years because I have enough milk [laughing]”
(Moo Thu Awah, mother of two, aged 29 years). The expression ‘enough milk’ in this community is used to mean plenty of milk, so this woman continued to feed because she had an abundant milk supply. Almost all women who spoke during the FGD talked about breastfeeding as something they did for the benefit of the baby:"
"
“[Breastfeeding] will make my baby strong, have [a] good brain
” (Mu Mu, first pregnancy, aged 26 years, plans to breastfeed for more than 2 years). Other women used phrases or words with a similar meaning such as ‘good’, ‘strong’, ‘healthy’, ‘smart’, and ‘protection against diarrhoea’ or ‘protection against infection’."
A longer duration of breastfeeding was expressed as an expected commitment to the wellbeing of the baby:
"“
I feel pity for the baby if breastfeeding [is] stopped before one year as the baby is too small
” (Khee Lar Say, first pregnancy, aged 23 years, plans to breastfeed for more than 2 years) and:"
"“
I will breastfeed for more than one year- until my baby is big enough for other food, after 14 months my baby is big enough for other food
” (Mu Chai, first pregnancy, aged 21 years, plans to breastfeed for more than one year),"
"
“I breastfed for one year, seven months, the baby stopped because she didn’t like [to breastfeed] and [wanted] to eat other food.”
(Lwe Lahr Paw, mother of one, aged 26 years, breastfed her baby for more than one year), or a similar commitment to the health of the baby:"
"
“This is my only
[first]
baby so I want the baby to be very healthy”
(Ma Kyi Aye, first pregnancy, aged 20 years, plans to breastfeed for more than 3 years)
.
"
Some women also gave examples of how breastfeeding would affect both them and their baby:
"“
If I breastfeed it is good for the baby, protect for infection, if I give other wrong food the baby will get sick.
[She paused and then added]
my uterus will get smaller.”
(I Shar, mother of one, aged 25 years, breastfed for more than 2 years)."
Women sometimes gave responses that reflected their positive view of breastfeeding by stating what would happen if they did not breastfeed:
"
“If I don’t breastfeed, my breasts will become very big and hard.”
(Naw Say Khu, mother of two, aged 27 years, breastfed for more than 2 years). [She later added] “
If I breastfeed [my daughter] she will grow up to breastfeed.”
"
Bottle feeding is for other people
Within all except one of the focus groups the topic of bottle feeding was spontaneously introduced. Unlike breastfeeding, bottle feeding was not discussed as a personal experience but as something other people did. The statements about bottle feeding were contrary to those about breastfeeding:
"
“[I saw] the baby bottle feeding and [the] baby gets sick; bottle feeding is not good because of diarrhoea”
(Sha He Dar, first pregnancy, aged 24 years, plans to breastfeed for more than 2 years) and:"
"
“Other people have bottle feeding if they have HIV, [If they bottle feed] then people will think they have HIV.”
(Naw Mu, mother of two, aged 31 years, plans to breastfeed for more than one year),"
"
“Breastfeeding is easy, if my baby cries I can feed him straight away, bottle feeding takes a long time, bottle feeding is difficult”
(Phu Maung, mother of one, aged 25 years, breastfed for more than 2 years)."
My mother told me about breastfeeding
When asked how they knew about breastfeeding, almost all women acknowledged their mothers as a primary source but did not elaborate on this, just made statements such as:
"
“My mother told me about breastfeeding.”
(Moo Yay, mother of one, aged 24 years, plans to breastfeed for more than one year)."
"In each group, once one woman volunteered this information during a FGD, others mostly just nodded in agreement."
Women also talked about community sources of breastfeeding information. These included; the Karen Women’s Organisation (a community based organisation established in 1949), other camp based community groups and non-government organizations, camp libraries, the antenatal clinic, the medical clinic run by Aide Médicale Internationale, schools and ‘Health Messenger’ (a locally produced magazine for health-workers in Burmese and English).
Interviews with experienced midwives
Similar themes emerged from the transcripts of midwifery interviews as FGD sessions. Midwives emphasised the role of mothers and grandmothers as the source of their understanding of breastfeeding and made little mention of community sources of information.
My mother told me about breastfeeding
When talking about why women breastfeed one midwife said:
"“
Everybody breastfeeds because grandmother tells mother and mother tells daughter and shows them how to do it and tells them they must do this and helps them if they cannot.
” (Ju May Paw, aged 47)."
The midwives, like the women, gave responses that suggested an acceptance of breastfeeding as an unremarkable and integral aspect of being a mother:
"“
Every woman gives breastmilk after delivery. This is usual. Everybody must do this. [We know] breasts will be full otherwise –if she cannot [breastfeed] her mother or grandmother will help her by squeezing out
[expressing milk]
or show her how to do it
” (Chit Su, aged 40),"
"“
They know the baby will be born hungry so they give milk first
[immediately after birth]” (Ju May Paw, aged 47)."
One midwife drew on her personal experiences to illustrate her views:
"“
Nobody told [showed] me about breastfeeding –I just knew I would breastfeed when I had my baby. Our women are strong and we always breastfeed our babies so that they will be strong and healthy too
” (Chit Su, aged 40)."
Bottle feeding is for other people
Again, the topic of bottle feeding was spontaneously introduced by the midwives and the idea that bottle feeding is for others also emerged as a clear theme:
"
“It was difficult to find powder-milk
[infant formula]
in Karen state
[state in Eastern Myanmar mostly populated by ethnic Karen]
, so everyone gives breast milk.
” (Ju May Paw, aged 47),"
"“
If the woman is rich she can give powder milk, but our women are not rich so we cannot buy powder milk.
” (Chit Su, aged 40),"
"
Some
[women]
will go back to work after 2 or 3 months then they might give powder-milk
” (Ju May Paw, aged 47)."
Swaddling at birth
In this community swaddling soon after birth and during the first month of life is believed to calm the newborn and prevent crying. Two major themes emerged from the data: 1) The baby will not feel afraid and 2) Protection from spirits.
The baby will not feel afraid
All three midwives shared views in support of swaddling to calm the baby and make them feel secure:
"
“Swaddling calms the baby. If they are not calm this can lead them to start to cry.
” (Mu May, aged 45),"
"
“If the baby cannot move they will not feel afraid and will not have jerking of the arms. If wrapped, the baby will be warm and sleep a long time
.
If you want to pick her up, you know and breastfeed, it is easier [to do this] if the baby is wrapped.
” (Chit Su, aged 40)
,
"
"
“Swaddling is for the baby to get the feeling of being held like you would give a proper hug to someone you care for.
” (Mu May, aged 45)."
"“
Swaddling means legs [and] arms [are] not curled, how do you say, not straight? If curled we believe look not beautiful
”, [she paused and added, laughing], “
but this is not true
.” (Ju May Paw, aged 47)."
Swaddling was also believed to play an additional role in the health of newborns as it could assist the parents to recognize problems in the baby:
"“
A normal child will be calm just with being hug [ged] and proper [ly] wrapped
,
if the child cries more than usual it indicates something wrong, which extra attention need to be taken like going to hospital or get advice.
” (Mu May, aged 45)."
A second theme to emerge was about good and bad spirits and how swaddling protects the baby and the family from spirits, although not all the midwives had heard about or believed this.
Protection from spirits
"“
We believe that the spirit[s] of the newborn baby are sensitive, [and] can be slip away from their body easily, [which is] why we must tuck
[swaddle]
them tightly.
” (Mu May, aged 45) and: “
If the baby cry all the time it is believed to be bothered by the bad spirit, the over crying of the baby may bring bad luck to the parents [and] can be refer to [the spirits’] wish for the death of their parents, which [is] one of the reasons why you don’t want baby to cry too long and try to solve the mystery as soon as you can.”
(Mu May, aged 45),"
"“
If the baby is taken outside, [we swaddle] to stop the baby crying a lot; if they cry a lot the spirits will catch them. If we go out somewhere we must use ginger or galangal
[aromatic roots, commonly used in cooking]
to protect against bad spirits.”
(Ju May Paw, aged 47). It is common to see a piece of galangal or ginger placed near the newborn’s head or pinned to their swaddling cloth."
It is interesting that not all midwives mentioned animist beliefs when discussing swaddling and even after prompting did not agree that a belief in spirits was linked to swaddling practice:
"
“I don’t know [about spirits]; I will ask my aunty” [she spoke to her aunty on the phone] “My aunty does not know about spirits, maybe Buddhists know about that [laughing]”
(Chit Su, aged 40)."