Social Determinants of Exclusive Breast Feeding Among Family Farmers in Central Myanmar

INTRODUCTION

The breast milk consists of 87% water, 7% lactose, 4% fat, and 1% protein (Bjarnadottir, 2024). There are several evidence that breast milk is good for baby’s health. It can provide the necessary nutrients for the baby, protect against allergies and infections. Breast fed babies have healthier body weights and better IQ scores. Breast feeding can strengthen the bonding between mother and child (Bjarnadottir, 2024).

According to World Health Organization, if an infant consumes human milk with no supplements like water, juice, non-human milk, food except for vitamins, minerals and medications, that situation can be regarded as exclusive breastfeeding. It is recommended that exclusive breastfeeding is important for the first six months of life and breastfeeding can be continued for 2 years or beyond (Anand, 2013; Andrino et al., 2016).

The development of brain, eyesight and digestive system in a baby can be enhanced by breastfeeding. Until 6 months of age, baby’s intestine is not suitable for non-human proteins which can cause allergies. The early months of baby’s life are important for long-term growth and colostrum (immature milk for the first 3 days of life) can protect baby against diseases (Taylor and Cameron, 2023).

The breast milk is not only free and convenient, but also it has the ideal combination of proteins, fats, vitamins, and carbohydrates. Leukocytes in breast milk can help to fight infection and the fat and lactose can provide the energy for the baby (Agrawal et al., 2022). Breastfeeding can lose pregnancy weight faster by burning the extra calories in mother. By releasing oxytocin, uterus can return to per-pregnancy size and reduce the postpartum haemorrhage. The risk of osteoporosis, ovarian and breast cancers can be reduced by breastfeeding. It also can reduce the risk of Type II Diabetes and hypertension in mother (Center for Disease Control and Prevention, 2023)

Although the benefits of breastfeeding are comprehensible, cultural practices like delay in breastfeeding initiatives, colostrum discarding, the use of complementary foods before age of 6 months can discourage exclusive breastfeeding (Brown, 2018). Barriers such as promotion of infant formula, poor knowledge about breastfeeding, lactation problems and misconception that formula is equivalent to breast milk can jeopardise infant feeding. Lack of supporting childcare especially for working mother who must return to the workforce while infant is still young is another constraint for the breastfeeding. Barriers to breastfeeding are more common among younger mothers, those from low socio-economic background and aboriginal population (Brown, 2018).

To enable mother to establish and sustain exclusive breastfeeding for six months, WHO and UNICEF recommend initiating breastfeeding within the first 4 hr of life; feed mother’s milk exclusively without any additional food or drink, not even water; breastfeed on demand that is as often as the child wants, day and night; not to use of bottles, teats, or pacifiers (Chen et al., 2019).

Nutritional improvement is also an essential component of the second goal of the Sustainable Developments Goals (SDGs) (Walters D et al., 2016). Based on 2015-2016 Myanmar Demographic and Health Survey, it was revealed that exclusive breastfeeding prevalence was only 52.2% (Dukuzumuremyi et al., 2020). Under-nutrition is still a public health problem in the country and a hospital-based study reported that returning to work was one of the main barriers to breastfeeding (United Nations, 2023).

Agriculture is the main sector in the country and approximately 60% of GDP depends on agriculture and 70% of population live in rural area and majority of them are farmers (Hernández-Vásquez et al., 2021). Providing better care and nutrition for rural population has become public health challenges in Myanmar. There is a paucity of knowledge on breastfeeding among family farmers and therefore, this study aimed to find out the knowledge and attitude of exclusive breastfeeding and its social determinants among Myanmar family farmers.

MATERIALS AND METHODS

A cross-sectional study was conducted in Magway Division which was in central Myanmar from June to September 2020. Total 160 mothers of 6 to 24 months aged infants who resided in rural area took part in this study by convenience sampling. The mothers who have 6 to 24 months children at the time of data collection were eligible to include in this study. Those mothers who had admitted hospitals for certain reasons and who were travelling at the time of data collection were excluded from this study. Data was collected by face-to-face interview method by using the structured questionnaire.

A total of 10 questions were asked to assess the knowledge level and another 10 questions were asked to assess the attitude level of the respondents. Those who scored more than 70% were considered as having good knowledge, whereas those who scored less than or equal to 70% were considered as having poor knowledge. For attitude towards exclusive breastfeeding, those who scored more than 75% were considered with a good attitude and those with score less than or equal to 75% were considered as poor attitude.

Data entry, data checking and data analysis was done with SPSS software version 25.0. Chi-square test was used to identify the association between the practice of exclusive breastfeeding and socio-demographic characteristics, family characteristics, obstetric characteristics, knowledge, and attitude of mother. p-value of <0.05 was considered to indicate statistical significance.

Ethical Consideration

Ethical clearance was taken from the Ethical Review Committee, University of Community Health, Magway, Myanmar. (Reference: UCH/SP/2019/21). Privacy and confidentiality were maintained throughout the study.

RESULTS

Total 160 mothers involved in this study and majority of them were aged in between 21-30 years (49.7%), Burmese Buddhist (99%), those with primary school education (57.5%), farmers (77.1%) and having partner’s occupation as farmers (78.4%) and partner’s education as primary (47.1%).

As for the family characteristics, majority of them were from nuclear families (56.9%). Most of them had more than 5 family members (54.9%), 19-24 months old baby (35.3%), male child (52.9%), first born baby (45.1%) and single child in their family (47.2%).

Obstetric history reported that majority of the respondents took proper antenatal care (98.7%), had at least 4 antenatal visits, had received information on exclusive breastfeeding during antenatal visit (85.4%) and post-natal visit (91.7%). Findings showed that more than half (56.9%) of the respondents gave birth in the hospital and home delivery is the second highest among the participants.

The prevalence of exclusive breastfeeding among the respondents was 64.7% and 89.5% of mothers started breastfeeding within half an hour. The proportion of individuals who did not practice exclusive breastfeeding was 35.29%, with the most commonly reported reasons being maternal health issues and insufficient breast milk production.

The respondents' knowledge and attitudes were evaluated through a series of questions, with individuals achieving a score above 70% classified as possessing good knowledge, while those scoring 70% or below were categorized as having poor knowledge. Findings reported that 61.4% of the study population had a good level of knowledge and 38.6% had poor knowledge related to exclusive breastfeeding (Table 1).

For attitude towards exclusive breastfeeding, those who scored more than 75% were considered with a good attitude and those with a score less than or equal to 75% were considered as poor attitude. In this study, 89.5% of mothers were identified with a good attitude and 10.5% were identified with a poor attitude towards exclusive breastfeeding (Table 1). Majority of mothers strongly agreed that colostrum was important for the infant, and they also agreed with the benefits of breastfeeding (Table 2).

Based on the results, parental education level, as well as respondents' knowledge and attitude toward exclusive breastfeeding, were identified as key determinants of exclusive breastfeeding. (Table 3).

DISCUSSION

The maternal and child health care in Myanmar had been improved and the criteria of adequacy of contacts included having 4 or more Antenatal visits and delivery at a health care facility with skilled birth attendant(s). Most of the study population had proper Antenatal care and Antenatal visit, and more than half (56.9%) of the respondents used hospital for delivery (Hmone et al., 2017).

Home delivery was the second most common preference method and approximately one third of the respondents gave birth at home attended by midwives. Despite promoting safe delivery, pregnant women in rural area of Myanmar still preferred home delivery. It was supported by a study done in 2022, showing that lower socio-economic condition, husband’s occupation in agriculture were negatively associated to institutional delivery (Lwin and Punpuing, 2022). A meta-analysis study based on low- and middle-income countries revealed that women in the rural area chose more home birth than those in urban area (Tong, 2012). The main reasons of home birth among Asian women were being identified as poverty, affordability, accessibility to birth attendant, remote access to health centre and traditional belief (Neves et al., 2021).

The prevalence of exclusive breastfeeding based on 2015-2016 Myanmar Demographic and Health Survey was 52.2% and it was 64.7% in the current study. A national survey in Myanmar stated that breastfeeding did not depend on socio-economic factors of the family and this study indicated that the exclusive breastfeeding was quite satisfactory among family farmers although they had low education level. Moreover, breastfeeding practice among rural community and working mothers was improved by Community-based promotion of breast-feeding practices in Myanmar (Sarker et al., 2016).

Breastfeeding practice did not depend on occupation and farmer women in this study had satisfactory practice of exclusive breastfeeding, showing 61.4% had good level of knowledge and 89.5% had a good attitude towards breastfeeding. These findings supported findings from the studies done in farmer women in Nigeria and China (Chen et al., 2019). It was revealed that agriculture related occupations were positively associated to breastfeeding, whereas white collar and industry related occupations were negatively associated to breastfeeding (Thet et al., 2018).

Maternal education was a determinant for exclusive breastfeeding in this study and most of the respondents had primary education. Survey findings from 81 low- and middle-income countries reported that the prevalence of exclusive breastfeeding and early initiation increased in all education levels, predominantly in women with low level of education. The same study highlighted continued breastfeeding at 1 and 2 years was reduced among women with no formal education (American Pregnancy Association, 2023). Sustainability of proper breastfeeding practice should be encouraged to all mothers.

Although majority of father’s education was primary, and paternal education is another important factor for breastfeeding in family farmer. Father’s role was important for exclusive breastfeeding. Partner’s involvement in household chores, childcare, preparing meals indirectly helped mother in initiating breastfeeding and nursing a child (Yadanar et al., 2020).

To achieve the global target to increase rate of exclusive breastfeeding to at least 50% by 2025, Myanmar Government led maternal and child health services raised the awareness of breastfeeding among the pregnant mothers, giving satisfactory level of knowledge and attitude towards exclusive breastfeeding in this study (Yadanar et al., 2020). A systematic review by Dukuzumuremyi and colleagues (2020), indicated that better knowledge and positive attitude of mother were key roles in exclusive breastfeeding practices. The same findings were noticed in the current study.

Limitations of the study

This study did not assess breastfeeding practices, and there is a possibility of recall bias and selection bias in the data collection process.

CONCLUSION

The prevalence of exclusive breastfeeding among family farmer in the rural area of Myanmar was 64.7%. The knowledge and attitude towards exclusive among the respondents were satisfactory and parental education was identified as a determinant factor on breastfeeding. Findings from this study can be served as baseline data for more exploratory studies and the practice of breastfeeding, maternal nutritional intake, vaccination, and birth spacing should also be considered along with the exclusive breastfeeding.

Acknowledgement

We extend our sincere gratitude to all the mothers who participated in this study and generously shared their time and experiences. Special thanks to University of Community Health, Magway for providing the necessary resources and support for this research.

Conflict of Interest

The authors declare that there is no conflict of interest.