Limited feasibility of exclusive breast feeding within mothers’ social and economic contexts

Per national and WHO-endorsed guidelines for infant and young child feeding, mothers who attended antenatal clinics at J J Dossen Hospital and Pleebo Health Center were instructed to exclusively breast feed their children for the first 6 months of life and to introduce safe and nutritionally adequate complementary foods at 6 months, along with continued breast feeding up to 2 years of age. However, several mothers who were interviewed introduced other liquids and solid foods within the first months of life, even though many felt that premature introduction of complementary foods may have had negative effects on their infants’ health. Health workers commented on an association of this practice with malnutrition. One nurse, for example, stated:

When I get to know the age, then I ask the parents which one of the food the child is eating. For some of the babies, they start giving them food soon. From zero to six months, they are only supposed to be on taytay water [breast milk], but some of the parents can start giving the children food sooner, sometimes at three or four months. Some of the food they give the children they can’t prepare it good; that’s why they come down with malnutrition. (Health worker at J J Dossen Hospital)

Collectively, mothers who did not exclusively breast feed provided a few key reasons to explain why. Some were young women who had babies before they were able to finish junior high or senior high school. Returning to school or vocational training required separating themselves from their infants and entrusting infant care to other caregivers, often their own mothers:

After this time, I will transfer her to her grandmother—my mother—and I will start school. I need to go to school to have a good future for me and my children. I don’t want my family to suffer. (Mother of a malnourished child at J J Dossen Hospital)

They stated that school attendance forced them to breast feed infrequently and be away from their infants for extended periods of time, impeding lactation. One nurse described a correlation between the duration of time a mother spent at school and her child’s risk of malnutrition:

When you asked the mother, ‘Why you are not breastfeeding the child?’, they tell you, ‘I am in school.’ The mother tells you how much time in school. When they come back, ‘breastfeeding the child is hard, so the breast milk is dried, and I can’t breastfeed.’ That’s why the child is malnourished. (Health worker at J J Dossen Hospital)

Multiple mothers pointed to the economic burdens they carry as their families’ primary breadwinners and caregivers. With responsibilities to feed and financially support their families, many women felt that exclusive breast feeding for a 6-month period was not feasible within their social contexts and material constraints. Jobs and informal work with limited security, leaves, pay, childcare support, accommodations or maternity support left mothers unable to tend to their babies as frequently as needed and led them to initiate complementary feeding prematurely. The time-intensive search for piecemeal work—or ‘hustle’—separated mothers from children for long periods, impeding mothers’ capacity to breast feed young infants:

Babies’ mothers do not have the means to buy food. Some of them have to hustle to find food to eat. Sometimes at the end of the day they do not have any food to eat, and so they go without breastfeeding the child, and they boiled water and force the child to drink it. (Health worker at Pleebo Health Center)

Some health workers stated that poorer Liberian mothers, in an effort to find food for family, leave children at home for many hours or in the care of community members. Many, for example, have small plots of land that they farm, which are typically situated far from their homes. To procure produce from these plots, women may leave their children at home during the day and are unable to breast feed or respond to their children’s nutritional needs on a consistent and reliable basis. A social worker specialising in nutritional and vaccination services surmised that children who are left unattended in this manner are more vulnerable to malnutrition:

There are some parents who cannot afford to feed their children on a daily basis regularly. Some go to check for something for the children to eat all day long and leave the child home. They go, and before they come back, it is the evening time. The child is not eating well, and the child is not taken care of. At the end, the child becomes malnourished. These children have poor home care. Most of the parents usually go on the farm and leave the children at home and return after noon before they decide to find food for the children. (Health worker at Pleebo Health Center)

Furthermore, several mothers felt they lacked the accompaniment they needed from family members to exclusively breast feed and that that they did not receive much in the way of financial or social support from male partners after pregnancy. Some also noted that their partners had various external financial obligations—toward extended families, for example—which diminished their contributions to feeding the nuclear family:

I have three children, and I do not have the support from their fathers. I have to work to bring food home for us to eat. I go soon in the morning and come home late in the evening. I can’t breastfeed the baby for whole six months, the time the nurse told me, because my family have to eat. When I get money, I buy milk sometimes. Most of the times I can cook the rice or fufu soft and give it to her. If no milk, I give her water. I started doing this when she was four months. (Mother of a malnourished child at Pleebo Health Center)

At the same time, some women who had completed secondary or tertiary schooling felt that their educational status permitted them greater leeway in demanding social and economic contributions from their male partners.

Views on colostrum and delayed initiation of breast feeding

While educational, work and familial obligations were the most common explanations for the impracticability of exclusive breast feeding, some interviewees also pointed to popular beliefs and misconceptions about breast feeding in the region. Some mothers explained that they avoided feeding their children colostrum—the first form of milk, produced immediately after birth, which is very nutritious and rich in antibodies—because they felt that it was diseased and could cause harm or even death; to protect their children, they delayed the initiation of breast feeding well beyond the recommended time frame of within 1 hour after delivery. One attributed the death of a previous child to the receipt of colostrum and stated that this experience drove her to avoid breast feeding her current child:

This is my second child. The first child was breastfed for five months and died at eleven months. I did not breastfeed my second child because I am afraid before the child die. I don’t know if that’s the taytay water I gave make her to die. So, I am not giving this baby taytay because I am scare. She is ten months but too small and weak. I have been bringing her to the hospital, and the doctor say she is malnourished because I did not give her taytay when she was small, and I started giving her food too soon. (Mother of a malnourished child at J J Dossen Hospital)

Health workers likewise reiterated that myths about colostrum were widespread in the region, including the idea that its yellowish hue is a sign of ill health. Said one nurse:

They feel that the first breast milk is not good for the baby, and this milk is the colostrum and has all the vitamins within it. Some of them feel that the first breast milk has disease in it, and they refused to give it to the child. Therefore…the child is deprived of that breast milk, and they wait for a certain length of time to breastfeed the child. And as a result, they start to introduce water to the baby at an early age. (Health worker at Pleebo Health Center)

In an effort to alter misconceptions about colostrum and breast milk, Liberian health authorities, community health workers and international partners have organised and implemented public awareness and outreach initiatives. One recent campaign, sponsored by the Ministry of Health of Liberia and UNICEF and executed by the nutrition unit of the Maryland County Health Team, offered workshops on the topic at county health facilities. Radio promotion was also conducted by the Ministry of Health to publicly underscore the nutritional and immunological benefits of protein-rich and antibody-rich colostrum. Some mothers explained that messaging on the radio and at health workshops helped them understand the importance of colostrum for infant health and thereby comply with recommended breast feeding practices:

On UNMIL radio, you can hear them saying, ‘Baby ma, when you give birth, give the baby taytay water.’ And they say the first taytay water [colostrum] is good for the baby. I can hear it. That’s how I managed to know, and I gave it to my baby. I also learned from a workshop that they have for the mothers concerning the yellow taytay water [colostrum]. We were told to give the baby the first taytay water, which is yellow because it is very good for the baby. (Mother of a non-malnourished child at J J Dossen Hospital)

Inadequate income to feed children and families

Mothers of malnourished children expressed a continual struggle to obtain and afford sufficient amounts of food for their children and their families. Some searched for contracts to wash clothes or clean the yards of others for meagre financial compensation. Women detailed the laborious and chronically uncertain means by which they gathered income to feed their large families:

We are nine in the house. At times, we buy only one kilo of rice, so we share it, small, small. We manage it, so you can just have something to taste and you manage to sleep. Sometimes I used to eat with my neighbor because I never had food. (Mother of a malnourished child at Pleebo Health Center)

In spite of long hours of work, many mothers reported that their family could eat only once per day. Moreover, they said that financial constraints forced them to choose nutrient-poor foods such as farina and cassava to sustain themselves and their families:

I always never had enough to eat. Sometimes, when we cook in the morning and I eat, then I will eat farina in the evening because no money to cook good food. When I have money, I can buy tea and drink it in the night before I sleep. We only used to cook one time during the whole day. (Mother of a malnourished child at J J Dossen Hospital)

Nurses working in public facilities shared similar views, citing job and income insecurity as the primary drivers of the poor outcomes they often observe among their paediatric patients:

Most often, when you ask why this child is malnourished, they [mothers] will always tell you they do not have enough food to eat, they are not working, and at the end of the month there is no earning or salary to purchase food for the family. Instead, every day, they go on the hustle to find some kind of work to enable them to find food for their family. (Health worker at Pleebo Health Center)

Sale or sharing of supplemental therapeutic foods

Qualitative interviews suggested that children treated for malnutrition on an inpatient basis are at heightened risk for relapse when they return to a home environment characterised by severe deprivation. After discharge from public health facilities in Liberia, malnourished children are given ready-to-use therapeutic foods (RUTFs) and/or other supplemental fortified foods for recovery. However, mothers reported that when they returned home with a malnourished child, they were compelled to divide RUTFs supplied by the health facility among other children or family members in the household. In other cases, these rations were sold to meet other needs:

Let me speak the truth: the food they gave me for my child at the hospital is enough, but it can finish soon because I can give some to my other children in the house. The peanut butter [RUTF], we all can eat it. Sometimes when I am not around, the children can take it from behind me and eat it. This is some of the reason the girl is not getting well fast, and she is still in the malnourished program. (Mother of a malnourished child at J J Dossen Hospital)

Nurses confirmed this trend, emphasising that when children do not receive prescribed RUTFs at home, their health and nutritional status can quickly deteriorate. They also reported that some mothers do not bring children back to the clinic when relapse occurs because they are ashamed of their inability to adhere to recommended therapeutic feeding regimens. While several nurses expressed frustration over this phenomenon, most also recognised the social and financial pressures experienced by mothers to sell or share RUTFs, acknowledging the roles that shame and stigma may play in exacerbating paediatric malnutrition:

What we noticed about the relapse is that when they go home, the way you tell them to give the food they are not giving it. Some of them even sell the food because they need money because some of them are from a poor-income family. They say if I sell few of these things given to me from the hospital, I will be able to buy rice for us to eat, so they sell it. The quantity of RUTF the child is supposed to eat the child is not eating it, and so the child starts to deteriorate. When the child deteriorates, most say I was ashamed to come back to the hospital because I ate the RUTF or I sold the RUTF. (Health worker at Pleebo Health Center)

Reasons for seeking facility-based care for malnutrition

Some mothers who had attended antenatal clinic at Pleebo Health Center or J J Dossen Hospital were very receptive to the nutritional education they received. They indicated that the relationships they formed with clinicians and social workers during pregnancy increased their confidence in the health facility and its staff, leading them to more frequently seek care for their child after delivery—for malnutrition and for other ailments as well. This confidence also appeared to motivate women to advise others within their communities to seek formal care when needed. For example, one mother who was interviewed reported that she sought treatment for her malnourished children because another woman who had had positive experiences at J J Dossen Hospital encouraged her to do so:

One of my friends advised me and said, ‘the way this boy is getting sick, why can’t you carry him to clinic so you can explain it to the people that he stopped sucking because he is still small and he needs to continue to be sucking taytay. Go and explain it to them so they can see what they can do.’ That’s how I brought him to the clinic. (Mother of a malnourished child at J J Dossen Hospital)

Facility-based health workers lauded the efforts of community health workers to promote nutritional education, early identification of acute malnutrition and referral services. They affirmed that the mothers of many of their patients had reported to the clinic because of the support they had received from community health workers:

The community health workers are in the community creating awareness and using placards. Some babies’ mothers that have benefited from this program, along with some photos, see the progressions that have been made with these children. If we continue this, most people will come to the hospital and the rate of malnutrition will reduce. (Health worker at J J Dossen Hospital)

Campaigns run by community health workers thus appeared to be an important source of knowledge about acute malnutrition and provided pathways for seeking prompt care. Mothers noted that community health workers taught them how to identify the signs and symptoms of acute malnutrition, as had other cadres of lay and traditional health workers, allowing for earlier presentation. Decentralised programmes for the early detection of malnutrition were also cited by mothers as reasons for their enrolling children in government-sponsored malnutrition programmes:

My child had been sick, and I have been taking him to the drug store and didn’t know what was happening to him. From the posters and the different things the people talked, I just felt my son had the sickness they were talking about. I brought my son, and the people put the tape around his hand, and they told me he was malnourished and I should bring him to the hospital. That was why I brought him, and they put him in the program. We can come for food every week, and this is helping him. (Mother of a malnourished child at Pleebo Health Center)

Reasons for not seeking facility-based care for malnutrition

On the other hand, some mothers who were interviewed explained that they felt ashamed to bring their child to the hospital because they anticipated being criticised by friends or health workers for their failure to nourish their child. Some mothers were also pregnant again; they worried they would be judged for not spacing their pregnancies. According to this subset of interviews, such concerns initially dissuaded some mothers against bringing their malnourished children to the hospital:

My child has been sick for more than one month, but I was ashamed to come to the hospital because this is my second child with this same sickness [severe acute malnutrition]. In my area [community], the people can always talk to me saying I cannot take good care of my children. When I go to the hospital and I see the people from my area, I can be ashamed. I can feel they have discussed me with the nurse, and I don’t want the nurse to quarrel with me. The nurses have also advised me about taking care of my children. For this reason, I was scared to bring this other child. I really brought the baby today because she is very weak, and the nurse say they will put her in the malnourished program and give us food. (Mother of a malnourished child at Pleebo Health Center)

The effects of stigmatisation on mothers’ care-seeking decisions were corroborated from the perspectives of health workers as well. A nurse at J J Dossen Hospital, who met one such mother in the community, explained:

Some of them will be bold and tell you, ‘I was ashamed; that was why I did not come earlier.’ I ask one of the mothers whose child was malnourished, and she uprightly told me she was ashamed to come to the hospital because she was pregnant, and her child was too dry and not looking good. She said she was seven months pregnant, and the child was less than two years. She was even crying when she was explaining and said she was embarrassed. Some of them are ashamed because some of them are pregnant, and these children are malnourished. To hold that child to come to the hospital, they feel ashamed that their peer group will laugh at them and say, ‘oh, their child hasn’t walk, and she is pregnant.’ So actually, to bring these children is not an easy thing. (Health worker at J J Dossen Hospital)

Additionally, signs of childhood malnutrition were occasionally viewed by communities as evidence of witchcraft. When physical manifestations of malnutrition are interpreted as such, noted some mothers and health workers, women may preliminarily seek assistance from a traditional healer or a ‘church yard’—a sacred place where patients seek prophetic healing when they believe an illness is unrelated to a biomedical condition:

My child was very sick. I took her to the hospital, and she was not getting well as I expected. She was given the malnourished food treatment but was still skinny. I decided to take her to the church yard because what was happening to her the doctors could not help me cure her. She was bewitched by some people in the community. I took her to the church yard for healing. It really didn’t help me, so I came to beg the doctor to please help my child to get well. (Mother of a malnourished child at J J Dossen Hospital)

Facility-based clinicians also explained that, in some cases, the remedies children are given in church yards may be unhelpful or even serve to worsen their condition. Said one nurse:

When the child is malnourished and the feet are swollen up and the stomach is big, they [family members and the traditional healers they consult] believe that it is food poison. In these situations, sometimes they go to the extent of giving the child herbs. Sometimes, they find herbalist that will give the child enema, and lots of herbs to drink that will not do the child any good. (Health worker at J J Dossen Hospital)