To identify barriers to early initiation and continuation of breastfeeding, we gathered exploratory qualitative data through Focus Group Discussions (FGDs) among the nursing care providers during the breastfeeding week. We collected data during the month of August 2014.

A tertiary care institute, BPS Government Medical College for Women, Khanpur Kalan seleced, Haryana, India was the site for this study. The Government of Haryana planned this institute to promote women’s health in the state. This institute started in the year 2011 with the aim of recruiting 100 female students in MBBS course. It has provision of curative, preventive and rehabilitative services for all kinds of patients including Maternal and Child Health (MCH). However, MCH services contributed a substantial proportion of the regular patient load. A total of 3500-4000 deliveries occurred yearly in this institute. All the nursing care providers are regularly posted on a rotation basis in labour room, maternity ward, and operation theatre of the Department of Obstetrics and Gynaecology. Hence, each of them has experience of every aspect of MCH related issues due to their close association with health care seekers in the institution.

This study was done to improve the MCH related services in the institute. We maintained the anonymity of participants and confidentiality of information as per the ethical principles stated in Declaration of Helsinki. All participants gave verbal informed consent. All of the participants were hesitant in the presence of audio recorder, so, it was decided not to audio record the FGDs. After completing data collection, all the study participants were explained the current breastfeeding guidelines and role of nursing care providers in the facilitation of breastfeeding.

A team of three members consisted of a Moderator and two Assistant Moderators with a speciality in the field of Community Medicine conducted the data collection. The Moderator asked the questions and explored the emerged themes and Assistant Moderators took notes.

The nursing care providers in tertiary care hospitals are the first level care providers in maternity wards. They have an important role in the initiation and in counselling for the continuation of breastfeeding. Hence, there point of view has utmost importance in knowing the circumstances related to breastfeeding at such facilities. The nursing care providers who have worked since the start of the institute were considered eligible for participation in the study.

A total 34 participants were found eligible and we decided to conduct either maximum five FGDs. Every FGD included seven participants in each discussion, or to stop earlier in case of saturation of themes. All of the researchers prepared an FGD guide and translated a into local language (Hindi) for better understanding. This guide was used to explore the perceptions of participants on barriers to early initiation of breastfeeding through the flexible approach. We used similar topic guide with the same themes for all FGDs, and selected themes were agreed upon by two of the investigators to maintain the validity of the guide. The data saturation or exhaustion of themes was achieved in the fourth FGD and subsequently last FGD was done to confirm the saturation.

We analysed the FGDs transcripts and documents in English. The analyses continued throughout the group discussions as the newly emerged themes were tested in the subsequent discussion. Hence, the initial analysis was inductive which was followed by the preparation of the utilization model to enhance the robustness of the emerged domain.

The results of this study [Table/Fig-1] are presented according to themes that emerge in FGD:

1. Mother related factors.

2. Newborn related factors.

3. Health care delivery related factors.

4. Social factors.

The verbatim of participants (nursing care providers) were mentioned according to the place of posting such as in labour room and maternity ward.

Lack of Awareness: For most nursing care providers, lack of knowledge of benefits of breastfeeding especially regarding first milk (Colostrum) is the major barrier to the timely start of breastfeeding. The participants perceived that most of the mothers did not feel it much important to give feed immediately after delivery. If few of the mothers valued breastfeeds then, awareness of proper techniques or position are lacking, and it gets worse in case of primigravida where the first-time mother is hesitant. Nursing care providers who receive mothers shifted from labour room described the lack of awareness among mothers.

“(You) forget about early starting of breastfeeding because almost all of the mothers do not know much about the breastfeeding. Fortunately, if few want to do it then either they do not know how or they are not comfortable?”

The relatives have the immense pressure of not starting it so early that delayed start of breastfeeding and colostrum even if care providers counsel them (mother and guardians) again and again.

Obstetrics complications: Most of the pregnant women delivery at the study site (being a tertiary care institute) were referred from the peripheral health facilities. Care providers emphasized that most of the pregnant women referred from other health facilities undergoes any of the interventions such as episiotomy, caesarean section, manual removal of the placenta. These interventions cause substantial delay, ranging from an hour (episiotomy) to a day (Caesarean Section), to starting of breastfeeding.

“Look...we cannot expect every delivery to happen normally at this kind of hospital [tertiary care]. We get the maximum of referred cases where the trial of normal delivery already has had happened in peripheral institutes. There is no other option but episiotomy, instrumentation, and caesarean. (Off course) that takes time.”

A significant proportion of the pregnant women sequentially referred from one health facility to other peripheral health facilities lend up to the delivery room after prolonged, exhaustive painful labour that lead to post-delivery fatigue. It makes the early breastfeeding more uncomfortable for her. Besides, in few cases, management of postpartum haemorrhage and retained placenta or other complications are also contribute to delayed breastfeeding. In such cases mother is the foremost priority both for care providers and relatives and feeding gets delayed.

“When a mother comes to us after travelling from Primary Health Centre, Community Health Centre and the Sub-District Hospital, she is too exhausted to feed her baby immediately.”

The birth of a malformed baby that causes psychological stress to mother and family makes the situation worse as was also identified the cause of delay for initiation of breastfeeding. Two of the nursing care providers also mentioned that pre-existing psychiatric disorder delays breastfeeding for many days to not at all.

“We remember very clearly that a psychiatric patient who took our lots of effort in delivery and we could not convince her for breastfeeding.”

Many of the first-time mothers face problems in initiating breastfeeding because of the pre-existing breast abnormalities that are retracted and inverted nipple. Hence, early feeding of the baby gets delayed till the correction of retraction and inversion of the nipple. It is disheartening for them to know of these problems at such point of time. This stress is more evident in those mothers who are keen to feed their baby than who are reluctant. The participants elicited that these mothers were never told about such problems during pregnancy even though they repeatedly visited the peripheral health facilities for antenatal care. Nursing staffs who attends such cases have described this situation as the unacceptable reason.

“(Just imagine) everything (delivery) went well and mother is ready for feeding and all of sudden she comes to know (that) you have breast abnormality that need to correct. Without that, don’t expect to breastfeed. Who is responsible for it.”

Besides breast abnormality, other co-morbidities that include HIV, Hepatitis B delay the early feeding and in many cases mother or relatives refuse to give mother’s feed. Families are not convinced even though baby has been given prophylaxis. A nursing care provider explained did painful story of such a mother.

“HIV and Hepatitis b positive mother did not even allow the baby on her bed. She [mother] said that at least my baby should not get it (HIV or Hepatitis B)”

Most of the nursing care providers reported the birth of preterm and low birth weight baby as significant causes of delayed breastfeeding. It is one of the most common reasons for a referral from the primary care facilities, as these are not well equipped to manage such cases. They highlighted that among these one-third needs intensive care that affects initiation and continuation of breastfeeding.

“Nobody (care provider) in the field (peripheral facilities) wants to do delivery of preterm cases. Just referral to the higher centre is a safe solution for them.”

Participants also mentioned the birth of malformed baby with cleft lip and palate as reasons for the delay in few cases. Even nursing care providers are also not equipped to address the feeding issue in these babies, as is also felt by the nursing care providers.

Deficiency of manpower: Almost all of the participants echoed that workload on staff nurses create a barrier to facilitation of early breastfeeding. There is a single multitasking staff nurse available per delivery, as the number of deliveries in tertiary care institutes is disproportionate to the available nursing staff. Sometimes more than one delivery happens simultaneously that occupy all the doctors and staff nurses.

“Just delivering a baby is not the only task in the labour room and maternity wards. Placenta removal, maintenance of IV fluids, assistance in episiotomy stitching are also to be done by that staff nurse apart from record keeping and maintaining drug stocks.”

Lack of breastfeeding related counselling: The multitasking overworked staff nurses found the task of early initiation of breastfeeding more daunting when the mothers have no knowledge about breastfeeding, retracted or inverted nipple. Antenatal counselling on breastfeeding and breast examination during Antenatal Check-up (ANC) at peripheral health centres can give support to tertiary care providers and also enhance the acceptability of early initiation of breastfeeding. A staff nurse expressed her basic expectation from the field health providers.

“Simple counselling (on breastfeeding) and breast examination can be of a great help to us in the facilitation of breast feeding.”

Cultural belief and practices: Almost half of the mothers want to give Ghutti (pre-lacteal feed) to newborn. The practice of pre-lacteal feed is discouraged by the nursing care providers. However, few families are too firm to give it even if they have to give it secretly. This practice is not socioeconomic class specific, in fact, many educated mothers follow it. A staff nurse, who caught mothers giving ghutti, described her experience.

“No matter what if the family have decided to give ghutti, they will give it. Secretly may be. It disheartens a care provider when well-educated mothers do it.”

The practice of giving ghutti follows the ritual of “Choochi Duhaai” (Cleaning of the breast) that means breast of mother will be cleaned or washed before putting the baby to it. This ritual is specifical to be done by the paternal aunt (Bua), and hence, the baby has to wait for first breast feed till the aunt arrive. Followed by this, they discard the first milk because it is not believed healthy for the newborn. This whole process takes enough time to delay the breastfeed.

Over the period, it has been seen that many families are accepting the advice of not to give ghooti. Now, they call the paternal aunt before the delivery happen, so that, the baby has not to wait too long.

“Culture of discarding first milk (Colostrum) is still prevailing in the families, but people have started compromising on the ritual of Choochi Duhaai.”

Gender-based discrimination: It is an important social issue that significantly delay early initiation of breastfeeding. If the newborn happens to be a baby girl, then mother either refuse to feed baby immediately or react reluctantly. Further, in case of twin baby (one being a girl), the birth of the second female baby and marital conflict, the early initiation of breastfeeding get delayed. Gender- based preference not affects the only female baby but also to the boy. Because family tend to follow all the rituals in case of the boy that delay the timely start of breastfeeding.

“Golden hour for initiation of breastfeeding is missed both for boy and girl as well. In case of boy, it is lost in feastings and rituals and if it happens to be girl...then they need time to come out of the shock........”

The National Health Mission (NHM) intends for 100% institutional deliveries to control the infant mortality rate and maternal mortality rate [11]. National Rural Health Mission (NRHM), one of the components of NHM, has succeeded in increasing institutional delivery to 72.6% [12,13]. It is known that the institutional delivery enhance the early initiation and continuation of breastfeeding [14,15]. India is committed for early and exclusive breastfeeding to its all newborns [16,17]. However, all is not well with our children’s health. A report of World Breast Feeding Trends Initiative 2015 shows that only 44.6% of the newborns enjoy the early breastfeeding in India [18].

While institutional deliveries have increased, the responsibility of timely initiation of breastfeeding in these cases has shifted from peripheral health workers and families to the nursing care providers of health facilities where the births take place. Therefore, we conducted this study to identify the barriers to timely initiation of breastfeeding perceived by the nursing care providers. The identified barriers perceived, for the purpose of analysis and interpretation of the results by the nursing care providers, are grouped into four domains namely maternal, newborn, health care delivery, social factors related.

The results of this study show that except the health care delivery related barriers, the perceived barriers reported by the nursing care providers are not different from the already known factors [19–29]. Though these barriers can be overcome by the motivation of pregnant/nursing mothers by nursing care providers of the Institute. However, the respondents felt excessive workload as one of the major barriers to initiation and continuation of breastfeeding due to multi-tasking nature of their job. Furthermore, it was reported that ever increasing number of institutional deliveries have compounded the situation, as the manpower has not been rationalised with the increasing workload [30].

We further observed that under or no preparedness of the mothers for breastfeeding including identification of abnormalities and variations during antenatal care at peripheral level health centres has also been identified as barriers. Birth preparedness by the health workers and community health volunteers has positive impact of the breastfeeding practices [22,31,32].

The new challenges to the initiation and continuation of breastfeeding are emerging due to change in the place of delivery that need to be addressed at the policy level. According to report of World Breastfeeding Trend Initiative 2015, India scored zero out of ten on Baby Friendly Hospital Initiative (BFHI) indicators. There is a need to reassess the status of BFHI, rooming-in, in all the institutions in the changing scenario [18,33]. Rationalisation of health manpower at institutions with the increasing workload due to ever increasing number of institutional deliveries. Universal implementation of community volunteers such as Yashoda in the labour room itself at all facility level will ensure early breastfeeding and will also create a support to nursing care providers [34].

The use of single topic guide for all FGDs and agreement between the investigators on the selected themes maximised the validity of the results. Also, our few of the themes were consistent with the previously reported research findings that further enhance the validity of the study.

However, it is necessary to admit the limitations of this study. We reported the findings from a tertiary care institute; hence, the results may not be applicable to the other level of health facilities. The years of experience of a nursing care providers may have an influence on the reported perceptions. Fear of getting noticed by higher authority may have caused the respondents to conceal some of the perceived barriers.

Increased number of institutional deliveries has shifted the responsibilty of early initiation and continuation of breast feeding on the nursing care providers of the respective institutions. This increased workload without rationalising the manpower, has been reported as the most important barrier to the initiation and continuation of breastfeeding among the babies delivered at the institutions.

It is recommended to rationalise the manpower in the institutions to ensure the initiation of breastfeeding within the golden hour. It is further recommeded to ensure availabilty of community volunteers such as Yashoda in the labour room and postnatal wards.