This study shows that the mothers knew of the many benefits of breastfeeding on the overall health, emotional, and intellectual development of their infants, in helping their bodies to recover from the weight gain from pregnancy, in promoting their emotional health, and in bonding with their newborns. Previous breastfeeding studies conducted in Jamaica support our finding that majority of mothers had satisfactory knowledge of the benefits of breastfeeding and that 95–98% of mothers initiate breastfeeding their newborns [15, 16]. Therefore, the fact that only 33% of mothers practiced exclusive breastfeeding to six months is not due to lack of knowledge but to conditions beyond their control during the early postpartum period and beyond [15, 16]. A recent paper by Baker et al. discusses in depth societal, political and economic systems that undervalue women and inadequately protect the rights of mothers and children resulting in inadequate support and promotion of breastfeeding [20]. These authors strongly recommend reforms to overcome the many structural barriers. Many of the barriers to breastfeeding reported by our study participants such as lack of family and child support, physical exhaustion of mothers, pressure to return to work, inadequate breastfeeding education including lack of discussion on potential breastfeeding problems such as sore nipples and painful breasts that occur when mothers return home, are associated with societal, political, and economic structures in the society.
The UNICEF Baby Friendly Hospital Initiative (BFHI) was launched by the WHO in 1991 and adopted by the JMOHW in 1993. However, in a survey conducted by the WHO during August 2016-January 2017 (the time that this study was conducted), Jamaican health officials reported that only 2.3% of births in the country occurred in designated Baby Friendly Hospitals and Maternities [21]. In 2023, the JMOHW officials reported that ten institutions that provide maternity services have been certified as Baby Friendly (eight of which were being prepared for reassessment) and that four new hospitals were being targeted for assessment [22, 23]. Thus, the staff providing maternity services are trained using the JMOHW BFHI manual to inform all pregnant women about the benefits and management of breastfeeding, ensure skin to skin contact between mother and baby immediately after birth, and initiate breastfeeding within half hour of birth. The staff are also trained to show mothers how to breastfeed, how to maintain lactation even if they should be separated from their infants, and on other matters pertaining to exclusive breastfeeding and feeding infants on demand. Maternity clinic staff are also expected to discuss issues such as sore nipples, painful breasts, and breast care with each woman during antenatal visits and inform the women of how to get help so that they can be prepared to deal with these issues when they arise at home. Posters on breastfeeding and proper child nutrition are also displayed in maternity clinics. The JMOHW has also launched a breastfeeding video that discusses the benefits of breastfeeding and demonstrates how to feed and safely express breast milk [12]. This should be helpful since some of the women indicated that they are already using social media to educate themselves.
Although pregnant women receive training in the maternity clinics, the specific problems that they reported such as soreness of their nipples and breasts, insufficient sleep, fatigue, and stress occur at home after they are discharged from the hospitals with their babies. These are barriers that are more likely to be overcome if the WHO recommendations regarding providing pregnant women, new mothers, and caregivers, with supportive care including community support, support groups, and community-based health promotion and education activities including demonstrative activities are instituted [24]. Pregnant women need appropriate prenatal preparation but also need significant postnatal support to help them breastfeed successfully. The BFHI and the JMOHW also encourages maternity service providers to foster establishing breastfeeding support groups and referring mothers to these groups upon their discharge from the maternity facility. Support Groups for mothers exist in some parishes in Jamaica and WhatsApp groups have also been established in areas with internet connections, however, we cannot tell how widespread or prevalent support groups are in the western region without additional specific studies. There may also be a gap in education and support for women who do not attend clinics throughout the antenatal period or those who attend some private maternity facilities that do not provide all the intended information in an effective and demonstrable way. The women in our study were favorable of having support groups to discuss matters related to breastfeeding as well as personal matters such as postpartum depression.
The JMOHW has also encouraged the entire family to support the care of infants and children. Since mothers complained that the frequent required feeding of their infants did not allow them to get sufficient sleep and rest and left them fatigued, a more involved and guaranteed supportive post-delivery childcare plan that includes fathers, grandparents and other willing and available family members would be beneficial and may foster increase in exclusive breastfeeding. A systematic review of research conducted in a variety of low- and high-income countries on the effect of grandmothers on breastfeeding found that in some studies, grandmothers who had previously breastfed their infants or who were positively inclined towards breastfeeding had a significant positive impact on exclusive breastfeeding of their grandchildren [25]. Aspects of these studies that foster breastfeeding can be investigated among Jamaican grandmothers and other maternal figures.
A revolutionary change regarding breastfeeding over the years is that many mothers have been using electric breast pumps to express breast milk so that infants can be fed with mother’s milk by the father, other family member, or caregiver, when the mother is at rest, at appointments, or otherwise separated from the infant such as when they return to work [26, 27]. Pumping milk allows for collection of larger volumes that can be stored frozen and used over time. This also provides opportunity for fathers to bond with the infants. A 2019 survey reported that 95% of breastfeeding mothers pump breast milk [28]. The mothers would continue to express milk when they return to work and are separated from the baby providing they have the appropriate facilities [29,30,31].
Mothers in our study reported that the need to return to work early interrupts their ability to exclusively breastfeed and bond with their infants. The Maternity Leave Act of Jamaica allows women 12 weeks (60 working days) of maternity leave of which eight weeks are paid, if the women have been working for the employer for a minimum of one year (52 weeks) [32]. Women may apply for no-pay leave or vacation leave to extend the period spent with their infants. However, many women may be dependent on the income and so need to return to work after eight weeks. The Breastfeeding Act “Right to Nursing Breaks or Daily Reduction of Hours of Work” states that “An employer shall provide a reasonable break time for an employee to express breast milk for her nursing child for one year after the child’s birth each time such employee has need to express the milk” [33]. However, pumping and storing facilities are not widely available at businesses, especially those that employ minimum wage earners, so businesses need to be encouraged to facilitate pumping and refrigeration of breast milk by mothers. Further, in Jamaica, the cost of breast pumps varies from JMD4,000 to JMD200,000 depending on the brand and if the pump is manual or electric and has any ‘high-tech’ functions [34]. Since electric pumps are more efficient, acquisition of a pump by a mother on minimum wage is a major investment. Mothers also need to plan to safely transport the milk to avoid contamination and transmission of infection to the infants.
In deciding to resume work without pumping and storing breast milk, mothers face the difficulty of having to purchase formula for the infant. If the infant is breastfed for the first three months and partially breastfed for months 4–6, the cost is estimated to be JMD10,532 [11]. For households earning minimum wage (JMD 6,200 per week in 2016), at least 14% of the monthly income would be spent to feed the infant alone. Thus, there is a relatively high level of spending on infant feeding when breast milk is not utilized. Mothers also discussed difficulty in getting infants to adjust to formula when they need to return to work after having started the infants on breast milk. This is a crucial finding of this study and one for which a solution should be given serious consideration by health officials.
The mothers in this study named a variety of complementary foods and teas that they feed their infants. One mother expressed that a complementary food such as porridge helped babies to be “big, thick and healthy.” Thus, many infants may not be receiving the optimal nutrition to give them the healthiest start and promote good health and development later in life. An issue that some mothers brought up to justify feeding infants complementary food is that they felt that breast milk alone could not fill the babies’ stomachs. Some mothers felt that their babies cried because they were still hungry after breastfeeding. Harrison et al. found that the mothers’ belief that exclusive breastfeeding satisfied the infants was significantly associated with exclusive breastfeeding [16]. The belief that breast milk does not fully satisfy infants is pervasive in the Jamaican society [14] and needs to be addressed in the training given to maternity staff so that they can educate mothers and the larger society about the appropriate time for adding complementary foods to infants and the time that different types of complementary foods can be added. Baker et al. point out that common early infant adaptative/adjustment behaviors such as crying and irregular sleep durations are often misconceived by mothers and caretakers as signs of feeding problems resulting in addition of commercial milk formula to the infant’s diet. Additional educational efforts are needed for health workers, families, and the public to eradicate these misconceptions and to uphold breastfeeding [20].
Body image was a cultural factor that was discussed in relation to exclusive breastfeeding. Some mothers were positive about breastfeeding because it helped women return to their pre-pregnancy figure faster after giving birth. Although we could find no published paper on body image as it relates to body size in Jamaica, we found a study conducted in St. Kitts that reported that participants were somewhat more likely to value heavier than thinner women [35]. In Jamaica, a fulsome body is favored similar to more traditional “non-western” societies including African cultures where there is acceptance of larger body size [36]. The women in our study seemed to be more concerned about losing the weight in their abdominal region more than overall body weight, but further studies need to be conducted to verify this.
Limitations
There are certain limitations that should be considered in interpreting the results of this study. First, the results may not be generalizable to the total population of postnatal mothers in Jamaica since it involved a convenience sample of women from western Jamaica. Although the sample size is small, we did achieve data saturation and the findings are comparable to national data reported in the MICS and in other studies conducted in northeastern and southeastern Jamaica. Since the data were self-reported, they are subject to social desirability bias and recall bias of participants. Additionally, since these data were collected in 2016, several changes started pre-COVID and ramped up post-COVID may lead to increased pace in exclusive breastfeeding rates in Jamaica. Despite these limitations, this study highlights difficult challenges to exclusive breastfeeding that if addressed would help to make it possible for mothers to exclusively breastfeed and for the early and long-term benefits of breastfeeding to be achieved.
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