Barriers and Enablers of Exclusive breast

feeding among working mothers of formal

sectors Visiting Immunization clinic of Kanti
Bal Hospital

Rojina Basnet
Roll no: 3
MPHN (1st Batch)
 Introduction
• Background
• Statement of the problem
• Rationale of the study
• Objectives
• Research questions
• Variables
• Conceptual framework
• Operational definition
 Methodology
 Work Plan
 Budget plan
 References

2
 The process of feeding human breast milk to
an infant, either directly from the breast or by
pumping out the milk from the breast and
bottle-feeding it to the infant is termed as
breast feeding or nursing (1).
 Infants should be exclusively breast fed upto

six months after birth to achieve optimal

growth, development and health (2).
 Globally only about 29 percent of the infants are
exclusively breastfeed (EBF) (1).
 Those infants who are EBF are 14 times more likely to
survive than those who are not (5).
 EBF up to 6 months of age and breastfeeding up to 12
months was ranked number one, among top 15 child
survival and growth interventions (7).
 Among 13 cost effective child survival intervention given
by SUN movement 2010, EBF is one (13)
 Work status whether it is full time or part time is very
likely to affect breastfeeding (8,9,10).
 60 percent of women are currently employed in
Nepal(14).
 Maternity leave determines the initiation of breastfeeding
and EBF. BF women who returned to work weaned their
infants earlier compared to breastfeeding women who
did not work (12)
 The theme of World breastfeeding week 2015 is
breastfeeding and work (supporting stronger workplace
policies that promote breastfeeding).
 Globally 1.5 million infant die due to lack of
knowledge on EBF and due to lack of proper
infant and young child feeding knowledge and
inappropriate practices (6)
 Prevalence of EBF

Eastern and Southern Africa has 52 percent

South Asia region is 47 percent (6).
 The trends in EBF had reversed in Nepal.

Prevalence (70 percent to 57 percent) (3).

 Many women who need to return to their work are
compelled to end up with their breastfeeding
because of their less available time to give to their
child (5).
 Maternity leave is only 60 days according to our

Civil Service Regulation 2050

 Many studies in EBF have been conducted but

very few studies have been done in working

mothers and EBF in Nepal, so the area need to
be explored
 From the literature reviews it was found one of the
main reason for not exclusive breastfeeding is the
work status, thus this study will identify whether
working status of mother is related with EBF or
not.
 The result of the study will be beneficial to policy

makers to review the maternity leave and its

insufficiency.
 This will help an organization to make
organizational policy to support for breastfeeding
in workplace which will help an organization to
reduce absenteeism of the mother and frequent
turnover of the woman employee.
 Also the study will help Program managers for

development of intervention programs for

emphasizing EBF practices in workplace.
 What is the status and duration of
exclusive breastfeeding among working
mothers?

 Do the barriers and enablers associated

with work place influence the continuation
of exclusive breastfeeding among working
mothers?
General Objective

 To assess status, barriers and enablers of

exclusive breastfeeding among working mothers
of formal sectors.
Specific objectives
 To assess the knowledge and attitude of working mother

on exclusive breastfeeing
 To find out the status of exclusive breastfeeding among

working mothers
 To assess the barriers and enablers of exclusive

breastfeeding among working mothers.

 To explore the organization policy supporting exclusive

breastfeeding.
Dependent Variable: exclusive Breastfeeding 
Maternal Demography : Family type, Age of
Characteristics
mother, Marital Status
Socio-cultural Factor: Beliefs and norms on
breastfeeding, , Education status, Knowledge,
attitude and practice on Exclusive breastfeeding),
body image concern (shape of breast, weight gain)
support from in-laws and husband
Economic status: Income level, Major
Source of Income
Child Characteristics Sex, Birth order, wanted/unwanted
Disabilities or any congenital
abnormalities
Morbidity status of child

Organization Variables Maternity Leave, Flexible work hours

break provision, Let mothers bring their
babies to work, Facilities in Workplace
(Separate room for breastfeeding,
expressing breast milk and storing)
support of managers, coworkers,
Discrimination Practices,
Distance between workplace and house
Maternal Characteristics
Demography: Family type, Age of mother, Marital Status
Socio-cultural Factor: Ethnicity, religion, Beliefs and norms
on breastfeeding, , Education status, Knowledge, attitude
and practice on Exclusive breastfeeding), body image
concern (shape of breast, weight gain) support from in-
laws and husband
Economic status: Income level, Major Source of Income

Exclusive
Child Characteristics Breastfeeding
Sex, Birth order, wanted/unwanted
Disabilities or any congenital abnormalities
Morbidity status of child

Organization Variables: Maternity Leave, Flexible work

hours, break provision, Let mothers bring their babies to
work, Facilities in Workplace (Separate room for
breastfeeding, expressing breast milk and storing),
support of managers, coworkers, Discrimination Practices,
distance between workplace and house
 Exclusive breastfeeding (EBF) : breastfeeding from the mother or wet
nurse with no other food or drink and water, except drops or syrups
consisting of vitamins, mineral supplements or medicines.
 Family type: nuclear (father, mother and their children)/joint (father,
mother, grandfather grandmother and grand children)/extended
(father mother, grandfather, grandmother their grand children,
uncle, aunt)
 Separate room for breastfeeding: Clean, Safe and Separate room
where a lactating mother can easily breastfeed her child without
disturbance or where a mother can easily express her milk with
adequate privacy and facility of refrigerator for storing milk.
 Beliefs and attitude on EBF: Important/ not
important, healthy/unhealthy, natural/unnatural,
local myths.
 Knowledge on Exclusive breastfeeding:
Definition of EBF, Knowledge on Pre-lacteal
feeding, Importance of early initiation of
breastfeeding within one hour, benefits of
colostrums feeding, duration of EBF (Six month)
 Support from in-laws and husband: support in
household work, encourage to breastfeed
 Working mothers: working in formal sectors
 Formal Sectors: Public and Private (Academic
sectors, NGO/INGOs, Banking Sectors, Hospitals)
 Disabilities or any congenital abnormalities: Any
physical, mental disabilities
 Morbidity status of child: Diarrhoea, Dysentary,
Fever,
 Body image concern: Concern of women on weight
gain during breastfeeding due to need of extra
food for lactating and concern for breast structure.
 Maternity Leave: Leave provided to a woman during
her pregnancy and after delivery of her child
 Support of managers: Making working environment
supporting breastfeeding, providing sufficient paid/unpaid
leave, providing breaks and flexible work hours.
 Support of coworkers: Sharing of work, supporting during
breastfeeding.
 Discrimination in workplace: Making distinction based on
lactating and treating worst than other time. This includes,
not providing support for lactation, not providing full salary,
cutting off benefits and opportunity based on lactation.
 Flexible work Hours: Breaks, provision of part time work
Study Design
 Cross sectional.
 Concurrent mixed method wilth quantitative

domain.
Study Area
 Immunization Clinic of Kanti Bal Hospital.

Study period
 From October 2015 to March 2015 
Study Population
 Working mothers of infants from 6-12 months

working in formal sectors for quantitative study

and organization head for qualitative
study(Government/Private Sectors/NGOs/INGOs).
Sampling Frame
 All the working mothers with 6-12 months infant

visiting immunization clinic for quantitative and

organization head for qualitative study.
The sample size of the study will be 206 working mothers as
calculated below.
assuming probability of exclusive breastfeeding among working
mothers (p) = 0.5 (As no such national data on prevalence of
exclusive breastfeeding among working mothers in formal
sectors was available)
Probability of not exclusive breastfeeding is (q) = 0.5
Z= 1.96 for 5 % level of significance
Allowable error or desired level of precision (d) =7%
Now we have
Sample size (n) = Z2pq/d2

=196
Supposing non response error = 5 percent. So the final sample
size will be 206
 For Qualitative: Members for in-depth interview
will be selected purposively and will not be a part
of main sample. In-depth interview will be taken
from organization head (at least one from each
type of formal organization selected based on
quantitative study).
 For quantitative study, all the working mothers visiting
immunization clinic of Kanti Baal Hospital will be
chosen purposively until sample size will be met.
 For qualitative study, all the organization head of

respective organization will be chosen until the purpose

of the study will be fulfilled.
 Quantitative
Technique: Interview
Tool: Semi-Structured interview schedule
 Qualitative:

Technique: In-depth Interview

Tool: In-depth Interview Guideline
Data collection tools will be prepared according to the
objectives of study with rigorous literature review
and expert consultation and for qualitative study,
tool will be developed based on quantitative study.
 The duration of data collection will be 6-8 weeks until
required sample size will be met.
 Data will be collected by researcher herself and with the
help of few enumerators with close supervision.
 Necessary orientation will be provided to the
enumerators.
 Day to day filled interview form will be checked and
rechecked for accuracy and completeness.
 Data entry will be done using Epidata 3.1, will be
imported to SPSS 17 for analysis.
 Descriptive Analysis: Frequency and percentage will be
presented in frequency table. Mean, median and standard
deviation will be calculated as per the need
 Bi-variate Analysis: Chi-Square test will be applied to test
the significance of association between independent and
dependent variables
 Multivariate analysis: Variables significantly associated in
bivariate analysis will be fitted into Logistic regression model.
For Qualitative data
 Documentation of the data: Field notes will be
compiled, transcribed and based on initial reading
coding will be done
 Organization/categorization of the data: content
analysis will be done and based on that the data will
be further categorized
 Data will be sorted for further thematic analysis.
Validity of the study will be maintained by
 consultation with advisor and subject expert

 related literature review

 Translation/Re-translation of tools (English- Nepali)

 Orientation of the enumerators in data collection tool and

procedure
 Involvement of the researcher herself in data collection

 Triangulation of information will be carried out for

validating qualitative data.

Reliability of the study will be maintained by pretesting the
instrument and necessary modification of the tools.
Exclusion Criteria
 Mothers of infant below six months and of children

above one year

 Those who do not give consent.
Limitations
 Study will not be able to include mothers of informal

sectors and mothers not attending immunization clinic

with baby due to work, illness etc.
 Infants coming with care takers will be missed in the study

 Since Govt. hospital is selected purposively, the findings

with working mothers visiting private clinic may not be the

same.
 The study being cross-sectional, data collected will not

reveal whether the reported factors varied from one day to

another.
 Approval will be taken from Department of Community
Medicine and Public Health of Maharajgunj Medical
Campus, Institute of Medicine (IOM) and Institutional
Review Board (IRB).
 Request letters to specified Hospital authority and
respective organization for granting permission for
conducting the study will be sent.
 Purpose of the study will be explained to the entire study
participants.
 Informed written consent will be taken from
participants prior to the study.
 Study participants will be ensured of confidentiality

of their response and their autonomy will be

respected.
 Study Participants will be allowed to refuse to

participate in the study at any time if they wish.

 No coercion in the form of any threat or undue

influence will be practiced.

 Asoj Kartik Mangsir Poush Magh Falgun
Weeks Weeks Weeks weeks weeks Weeks
Activities 1 2 3 4 1 2 3 4 1 2 3 4 12 3 4 1 2 3 4 1 2 3 4

Literature review                                        

Proposal preparation                                        
Proposal submission/
presentation in IRB                                        
Ethical clearance                                        
Pretesting of tool and
finalization of tool
Data collection                                        
Data analysis                                      
Report writing                                        

Final dissemination
and presentation to
department                                        

Final presentation with

S.N Particulars Quantity Per unit cost Duration Total cost
(in NRs.) (days) (in NRs.)
1 Literature review (internet access) 6 Hours 30 154 27720
2 Stationaries
•A4 Paper 5 Rim 500 - 2500
•Copy 5 pieces 20 100
•Pen 2Packet 240 480
•pencils 2 Packet 100 200
3 Proposal development and printing 3 sets 150 - 450
4 Registration fee in Kanti Hospital - - - !0000
5 Tools finalization and printing 206 sets 30 - 6180
6 Orientation on data collection 5 persons 20 2 200
7 Data collection Enumerators 5 persons 600 30 90,000
8 Travel and snacks cost 5 persons 150 30 22,500
9 Report printing 5 sets 800 - 4,000
10 Hard cover Report binding 5 sets 300 - 1,500
11 Report dissemination 10 persons 2,000 1 8,000
12 Miscellaneous       4,000
Grand total 169830
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Breastfeeding rates in central and western China in 2010: implications for
child and population health. World health organization Bulletin, 2013.
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Department of Health & Human Services (USDHHS) (2011)., available at:
http://www.surgeongeneral.gov/library/calls/breastfeeding Access date 30
August 2015
3. Global Nutrition Report, Actions and Accountability to Advance Nutrition and
Sustainable Development, 2015
4. Management of Acute Malnutrition in Infants (MAMI), Unpublished report
5. McALPINE, M, The mother’s invention: Breastfeeding and working, 1998, 30,
80 Improving Child Nutrition, The achievable imperative for global progress,
UNICEF 2013
6. Nguyen, K. Nutrition spectrum backgrounder: select interventions and
country snapshots. The National Bureau of Asian Research: Centre for
Health and Aging, 2009
7. Jones G. et al. How many child deaths can we prevent this year? (Child Survival
Series) The Lancet 2003 Vol. 362
8. Aline Alves BrasileiroGláucia Maria Bovi Ambrosano SérgioTadeu Martins
MarbaRosana de FátimaPossobon, Breastfeeding among children of women Workers,
Universidade Estadual de Campinas (Unicamp). Campinas, SP, Brasil, available at:
http://www.scielo.br/pdf/rsp/v46n4/en_3731.pdf, access date 13 September 2015
9. Netshandama VO, MACur, Breastfeeding practices of working women, University of
Venda for Science and Technology, US National Library of Medicine, National Institute
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10. M. Ahmadi& S. M. Moosavi, Evaluation of Occupational Factors on Continuation of
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Center of Science and Education. 25 September 2013
11. Sara B. Fein, and Brian Roe, The Effect of Work Status on Initiation and Duration of
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12. Moore JF and Jansa N. A survey of policies and practices in support of breastfeeding
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