Sociocultural Factors Affecting Breastfeeding Practices of Mothers During Natural Disasters: A Critical Ethnography in Rural Pakistan

Informal support

Participants acknowledged the informal support toward their breastfeeding practices from their immediate and extended family members (parents, husband, in-laws, and older children), as well as from their neighbors, and neighboring villagers, including both females and males. The type of support included nutritional guidance, provision of a special diet (milk and goat’s meat broth) to increase breastmilk supply, encouragement for breastfeeding, financial help, accommodation at a relative’s place at the time of the disaster, donated supplies to meet daily necessitates (food, milk, and clothes), assistance in meeting child-care responsibilities and household chores, and land for placing the temporary shelter or tent. A study participant, who was facing ongoing, recurrent earthquakes of low intensity in her village and had a 3-month-old child who was born during her settlement in the temporary housing, acknowledged the support received from the mother-in-law and the immediate family members concerning breastfeeding and the importance of maintaining adequate nutrition:

My mother-in-law told me that if I pay proper attention to my diet then he [child] will be fine; otherwise, if I don’t pay attention to the diet then he [child] will not get the proper amount of breastmilk which he should be getting. . . . My family had a goat slaughtered and gave me the broth for strength. They also gave me cow’s milk in the morning so that my diet would be nutritious and that I could be healthy; in return, the child would also get properly nursed.

Another woman who was living in a transitional shelter and continuing her breastfeeding practices acknowledged a similar kind of support. She verbalized:

My mother would tell and guide me when I wasn’t able to breastfeed the child; she told me this is how I should breastfeed the child. . . . She told me how to lay him [child] down properly and breastfeed him. . . . They gave me fresh meat broth. They sacrificed the goat in the house and gave me its broth.

Field observations supported what mothers described, particularly with support in cooking, cleaning, child care, care of cattle, and fieldwork from their family members and neighbors. Participants believed that this informal support enabled them to cope and look after their child-care responsibilities during a challenging time. Participants also acknowledged the support received from their relatives and neighboring villagers who provided them refuge during the initial few days of the disaster, arranged food and clothes for them, and offered them land on which to place a shelter or tent.

Formal support

While informal supports were critical for survival post-disaster, formal support from governmental and non-governmental agencies was also important in the immediate aftermath of a disaster. Participants particularly acknowledged the formal support from the health care units. Most of the participants mentioned that the nutritional guidance from the health units during the period of disaster and displacement improved their health and facilitated the re-establishment of their breastmilk supply during their settlement in disaster relief camps. For example, a participant, who experienced low breastmilk supply soon after the disaster and fed cow’s milk as a temporary breastmilk substitute to her infant, described the role of the disaster health unit in re-establishing breastfeeding. She shared, “I went to the doctor and got myself checked. They gave me medicines and advised me to focus more on my diet, and gradually my milk supply came back to normal.”

A few other participants acknowledged the curative and health promotive aspect of the care that they received in their local or national language, including medical treatment of illness, prenatal guidance about breastfeeding, measures to prevent malaria and flu, health checkups and visits, health and hygiene training, and informational booklets in Urdu (the national language of Pakistan). The information gathered from the documents, mostly newsletters and reports maintained by the health unit also supports that at the time of the disaster several awareness sessions, health camps, and vaccination campaigns were organized for the disaster-affected communities. These services were offered by locally-trained community workers and healthcare providers, including female health visitors, vaccinators, doctors, and nurses. As disaster-affected communities could not access the healthcare setting due to health issues, non-availability of transportation, and damaged roads after a major disaster, the locally-trained healthcare providers and volunteers (nurses and doctors) from the southern parts of Pakistan formed a mobile team and travelled to the disaster-affected areas, set up free-of-cost medical camps and mobile outreach clinics, and offered health promotive, medical, and emergency services to many disaster-affected families.

Although health units were not accessible to most of the displaced families because of the scattered nature of the temporary housing across the landscape, there were a few participants whose shelters/tents were located near the health unit, and this facilitated their access to formal support related to breastfeeding. This does suggest that for mothers without this kind of access to health support, continuing to breastfeed in the months post-disaster may become increasingly challenging.

Cultural aspects

Participants shared various positive aspects of their culture that help them to sustain their breastfeeding practices even during the stressful time of the disaster, displacement, and relocation in the disaster relief camps. Participants shared that despite the barriers imposed by disaster and displacement, breastfeeding as a cultural norm encourages them to sustain their breastfeeding practices. Most of the participants shared that they exclusively breastfeed until 6 months and then continue to breastfeed until up to the age of 3 to 5 years while supplementing breastmilk with cow’s milk and solid foods. Participants further shared that as soon the child is born, female members in their family or neighborhood usually encourage them to breastfeed their first milk (colostrum) to the newborn and provide support in positioning the newborn during latching. During in-depth interviews, participants further shared that they only opt for feeding formula milk when a mother dies, is too sick, or is unable to produce adequate breast milk. There was no evidence of wet nursing among participants. The only available feeding options for the young children included breastmilk, cow’s milk (mainly cow and goat’s milk), solid foods, or formula milk if nothing is available. A participant who continued breastfeeding her child during and after the disaster acknowledged the norm of breastfeeding in the village that facilitates breastfeeding practices of nursing mothers. The participant shared:

In our village, all the mothers breastfeed their children. They don’t use the milk [formula milk] from the store because we live in a village and people don’t have jobs here or studies, so that is why they nurse their children themselves and they don’t require store-bought milk.

Participants acknowledged that at the household level there was no discrimination when it comes to breastfeeding daughters and sons. Participants’ stories regarding emergency evacuation revealed that they assured the safety of all their children (girl or boy), and despite prolonged hunger, they continued to breastfeed their children regardless of their sex. Participants also acknowledged that at the household level there is a norm of equitable distribution of food items and humanitarian aid. A participant, who believed that this household norm facilitated her to sustain her breastfeeding practices while living in the temporary housing (tent and transitional shelter), shared:

I did get the support [food items as humanitarian aid] but it wasn’t the same as what we had before in our homes. We were surviving in those times. It [food] was equally distributed among all the family members, no one used to get less or more food.

A few other participants believed that this norm of equitable distribution of food items provides nursing mothers with an equal opportunity to look after their nutritional needs while experiencing the stress of disaster, displacement, and settlement in the relief camps. These participants further acknowledged that depending on the availability of food, displaced women often decide to eat less and give more food to their children, elderly kin, and male members who work outside the home in fields. This indicated that in view of the economic circumstances and availability of food, women often go against this household-based cultural norm in view of their personal choice and societal values that expect women to sacrifice whenever required.

Spiritual practices

During fieldwork, it was noticed that attending a religious place like a mosque, shrine, or prayer hall is a common practice among families belonging to all religions. Although there were few or no health care settings in the villages where fieldwork was undertaken, most of the villages had spiritual healing clinics meant to offer spiritual advice, as well as amulets and exorcize possessions in order to alleviate sickness and improve well-being. There was a cost involved in seeking spiritual treatment; one of the participants shared that the cost is typically Pakistani Rupees 10,000/- to 25,000/- (USD 45–150). As these clinics were more accessible, many people in villages who could afford the cost of spiritual treatment opted for healing in these clinics.

Participants who could not sustain their breastfeeding practices after the disaster and did not find medical treatment effective enough shared that they would prefer to receive spiritual support or treatment if they had the money. Participants also acknowledged that prayers offered by relatives to enhance the well-being of nursing mothers and spiritual treatments administered by spiritual healers both affect mothers’ well-being and their abilities to fulfill their maternal responsibilities. A participant who was unable to sustain her breastfeeding practices right from the time of disaster underscored that an arrangement of prayers by her community people or relatives could have facilitated her to re-establish her breastfeeding practices. She verbalized:

Based on my belief, I think that when my milk got dried up at that time [during a disaster]. If someone would have given me blessings and arranged prayers for me then that would have been helpful to re-establish my milk supply instantly. But no one did that for me.

Another participant who reported ill health due to the influence of possessions by supernatural forces (Saya is the local term), and who was unable to sustain her breastfeeding practices, considered that spiritual healing often supported her recovery from the influence of these possessions and facilitated her ability to resume her child-care responsibilities.

No privacy

Lack of privacy to breastfeed was identified as the top barrier affecting the breastfeeding practices of mothers affected by natural disasters. All the participants shared that during a disaster, displacement, and their settlement in the relief camp (shelter or tent), there was no privacy or availability of women-friendly spaces to breastfeed. Participants were of the view that their privacy continued to be jeopardized while living in overcrowded tents and shelters. They felt uncomfortable to rest and breastfeed their young children in front of their relatives, male family members, and guests. A participant who was living in a tent and substituting breastmilk with cow’s milk shared:

I faced lots of troubles when my child was born. It was cold, and everyone [family members] was there. I couldn’t sleep comfortably or get relaxed, so faced lots of breastfeeding issues in this [tent]. I had trouble when people would come in [guests and relatives] while I was breastfeeding the child. I could not sleep at all. I couldn’t breastfeed my child in front of them [guests and relatives].

A participant, who on encountering the challenge of lack of privacy to breastfeed made sure to cover herself with her long shirt and scarf while breastfeeding the child but could not sustain her breastfeeding practices, shared, “There is a single room [shelter] and all the people in the family share this space. It gets difficult when the child is screaming and removing the long scarf (dupatta in local term) from over her [child] during breastfeeding.”

Women in Chitral often restrict their movement to certain locations in the village, such as canals, fields, prayer halls, and a neighbor’s house. The participants mentioned that during disaster and displacement when they had to run too far places to find refuge, they had nothing to cover themselves, had no privacy to breastfeed, and felt “unfenced” (in the state of Bay pardagi in Urdu). While sharing the nature of the painful experience, one of the participants said:

When the floods came in, we were left completely unfenced and became unveiled (“bay pardha”). We didn’t have shelter at that time, we lived in a tent for a month. The men would live outside the tent, whereas the women lived inside the tent. The mothers and children were also living inside the tent. There were no clothes for the children. They only had what they were wearing. Whenever I had to breastfeed my child, there was no privacy (“bay pardagi”). We couldn’t breastfeed them [children] comfortably like a mother does in her own house. There were difficult times.

While sharing the challenge of breastfeeding in open spaces with no privacy, another participant who initially had no place to live stated:

When you are homeless as a mother it becomes very difficult. It becomes embarrassing when you have to breastfeed your child and you are on the streets and in an open space. It doesn’t feel good nor is it something that a mother feels comfortable breastfeeding. It was very painful for us as there were many people on the streets who passed by and all that time you think that this person is watching you and you keep on adjusting yourself. It wasn’t easy to breastfeed your child at that time.

Cultural beliefs, practices, and expectations

Participants shared their cultural beliefs and practices concerning encouragement to feed breast-milk substitutes (cow’s milk and tea) to infants at 6 months, beliefs on supernatural forces, and food restrictions for breastfeeding mothers. Mothers shared that most of the time these beliefs and practices negatively affect their health, breastfeeding practices, and management of their child-care responsibilities, especially during natural disasters and displacement when they try to cope with additional responsibilities, transitions, and stressors. Most of the participants shared that according to their culture and the availability of cattle (mainly cows and goats) in their household they prefer feeding cow’s milk (boiled and diluted) to their children whenever their breastmilk is insufficient. Field observations supported that many families or their acquaintances (relatives and neighbors) had their cow and that cow’s milk was serving as the top choice of breast milk substitute. A participant shared the norm to feed cow’s milk to children when they are 6 months old. She shared:

We breastfeed our children for six months. After six months, we give him [child] some extra food to start with. We give him some cow’s milk and also feed him our milk. When he is old enough and around seven to eight months, then we start by giving him [child] some extra food, such as bread etc.

Tea (chai) is one of the most popular cultural drinks, enjoyed by Chitrali families several times a day. Participants shared that they also feed tea to their children from a very early age. One of the participants shared:

We give tea (chai) to children who are young too. My niece who is 19 months old drinks tea; she drinks tea with me in the morning. Because if we drink it alone then they scream and ask for it; so, we start by giving them small sips, and then they grow up to be habitual of that.

A few of the participants shared that in their culture they are expected to feed breastmilk substitutes (mainly cow’s milk) to their infants, especially whenever the child cries due to hunger, the mother’s breastmilk is insufficient, or when the mother is busy with household chores. The field observations supported that each village had a few local stores that were selling household items and formula milk (mainly Nestlé products). A participant, who was living in a tent and was supplementing her breastfeeding with cow’s milk, shared that her mother encourages her to initiate breast-milk substitutes (cow’s milk) whenever her child cries in hunger. She shared:

My breastmilk is insufficient so my child cries and screams. My mother scolded me and said that he [child] is hungry, that is why I should give him something extra [other than breastmilk] because now he is seven months old. That is why I feed him cow’s milk and he doesn’t even cry when he is full.

Another participant, who in view of her mother-in-law’s advice was substituting breastmilk with cow’s milk for her 6-month-old child, shared:

I feed her [my child] timely, and sometimes when she [child] cries my mother-in-law gives her cow’s milk. She [mother-in-law] uses a feeding bottle. I add a little water to the cow’s milk because the doctor says that it affects the child’s stomach. So, I add some water and boil it, cool it down, and then pour that into a bottle so that the child drinks it.

A few of the participants mentioned the cultural beliefs of their community people surrounding the influence of supernatural forces and possessions after the disaster. They were of the view that after a disaster these supernatural forces have negatively affected women’s health and their child-care responsibilities, including breastfeeding. A participant who could not sustain her breastfeeding practices due to the influence of witchcraft on her health shared:

There are many mothers who believe in the supernatural and possessions (Saya). Sometimes they go absolutely quiet and sit in the corner and cry, they don’t take care of their children after that. We strongly believe in those possessions. They [people in the community] also believe that the Jinns and Fairies [supernatural forces] can take over you.

Participants also shared their cultural beliefs and practices surrounding food restrictions. A participant talked about the food restrictions for breastfeeding mothers based on cultural beliefs that they have been following as per the received advice from their ancestors and elderly people in the family/community:

They [elderly] say that I [breastfeeding mother] shouldn’t eat cheese because that will be dangerous for the child as he will vomit the food out. They say that if the mothers eat cheese, then the child can vomit the food out. They also avoid sweet food or something sugary because they say that it can cause stomach aches. They don’t allow cow meat saying that it can also be dangerous for the child. Some people follow these regulations while others don’t. There are certain foods which are considered warm but benefit both mothers and children.

Covert oppression

In-depth interviews with the participants reflect that at the societal level women often experience covert oppression, specifically during the period of disaster and displacement. Covert oppression refers to hidden forms of control and power issues at the societal level that negatively affect the physical, mental, emotional, and spiritual well-being of women. In Chitral, where women are expected to cover themselves with a long scarf all the time, restrict their mobility to their house or neighborhood, and get the permission of the men/head of the family before going outside, study participants mentioned the challenges and struggles experienced during the period of disaster and displacement. Participants shared that during disasters many women faced criticism as during the emergency evacuation they had to leave the premises of their homes without seeking permission, had no scarf (dupatta in local terminology) to cover themselves during an emergency evacuation, and had to live and breastfeed their crying children in open spaces (fields and mountains) having limited privacy. Participants shared that the disaster (glacial lake outburst flooding and flash flooding) continued for many days, hence the relief agency could not reach all of them during the initial few days of the disaster and provide them with food or clothes to cover themselves. As disaster-affected families were escaping from one hill to the other and from one village to the other for several days, participants shared that during this period they had no long scarfs or veils to fully cover themselves, hence they felt embarrassed for going against the cultural norm and were afraid of being judged by relatives and neighboring villagers who were unaffected by the disaster and displacement.

A participant who sustained her breastfeeding practices while juggling multiple responsibilities shared societal expectations for women concerning “birth spacing,” “breastfeeding,” “workload,” and “responsibilities.” Although this participant was 40 years old, she appeared very tired and older than her age. Her quote revealed a few of the key aspects surrounding gender social locations and the gender responsibilities of being a woman:

We do all the work and duties of a man too. Secondly, we feed our children for three years with our milk [breastmilk]. After three years when they [women] stop breastfeeding the child that is when we prepare ourselves for conceiving another one. We do all the hard work and that is why we appear much older than we are. You will find many people like this who will appear as if they are their husband’s mothers but in reality, they are their wives. Men look younger than the women here because we [women] work more than them [men]. This is true for the entire village.

One of the participants who was pregnant shared that for easy labor pregnant mothers are encouraged and are expected to work more (household responsibilities, fieldwork, and cattle care) during the last trimester of pregnancy. The participant was of the view that this societal expectation increases their tiredness to a great extent during the postnatal period, hence indirectly affecting their breastfeeding practices. She shared:

In our culture, it is said that the more a pregnant woman works the sooner her child is born. They say that pregnant mothers should work as much as they can so that the child will be born early in the ninth month. Sometimes the work is too much. I think there are 85 per cent here who work this much; there are a lot fewer people here who don’t force women to work more.

A few of the participants mentioned that after the natural disaster and related economic hardships it is quite common for women to starve themselves or skip meals to fulfill the nutritional needs of their family members and older children. Participants were of the view that this practice negatively affects breastfeeding mothers’ health, nutritional status, and breast milk supply. Although participants acknowledged that at the household level there is no gender inequality, there was evidence of gender inequality at the societal level that was shaping women’s attitudes, behavior, and practices. At the societal level, it was believed that “being a woman” means often sacrificing and eating less or skipping meals when there is a shortage of food. The participant stated:

Sometimes you have to take these steps [skip meals] because men work outside, and you have to give the food to your children too. If you aren’t getting some then you need to be silent sometimes. . .women cook food but don’t eat it themselves. They [women] provide for others but skip their meals. You need to manage it for your children and in-laws too.

Another participant shared a norm related to food distribution, “We gave it [food] to those members [family members] who work outside and then to the children; I eat last. Sometimes I get more for myself, sometimes less.”

Participants further shared that disaster and displacement have increased their suffering and have increased their dependency on those who are not affected by disaster or are responsible for aid distribution. They shared that as a primary caregiver when they reach out to people to seek support, they often are ridiculed, ignored, or considered dependent. A participant who did not receive humanitarian aid or a place to live (shelter or tent) could not sustain her breastfeeding practices. She shared her suffering and the reaction of others:

In those times if they [relief agency or donors] had given me a house or taken care of my expenses, then I wouldn’t have been ridiculed amongst the people. The stress which I faced when I had to go to my relatives’ place and ask for help was also very tough for me as that also took a toll on my health. Some of my relatives make fun of me.

The same participant also verbalized her suffering and mentioned that she has no voice, limited authority, and lack of empowerment as being a woman she could not go to the males in the community (responsible for the aid distribution) to ask for humanitarian aid or support needed. She shared:

People [disaster affected] who cannot talk or stand up for themselves aren’t sent forward [to receive aid or support]. I didn’t get anything [humanitarian aid], and neither could I talk to anyone or go in front of a man and demand this. People who are cunning and can speak for themselves are sent forward [to receive aid or support], whereas the others do not get anything. I haven’t gone to any man and complained against this. I did complain to other women, but they couldn’t do anything either.

Lack of healthcare support

Although a few of the participants acknowledged the support they received from a healthcare unit, most of the participants considered inaccessibility to healthcare and inadequate healthcare support as the major barriers to sustaining their breastfeeding practices during the disaster. A participant who initiated formula feeding during disaster and displacement due to inadequate breastmilk supply shared:

No one [health care team] came here and neither did anyone advise us [about breastfeeding]. I went about with what we thought was right at that time. If they [health workers] would have given me a medicine which I could consume, and my breastmilk flow would increase, I would have readily agreed to that.

Another mother, who could not sustain her breastfeeding practices soon after the disaster and initiated formula feeding, shared, “No one [health care team] came on this site to tell us what to eat and what medicines to take to re-establish the breastmilk supply.”

Another participant talked about the infrequent visits by the health team in the village:

They [health team members] did come here and gave us free medicines once or twice. Ever since the floods, they came in once or twice. They come here almost after every six months so it’s not that helpful for us. We don’t get any medicines when we are sick. (Mother smiled and sighed).

A participant, whose child had dysentery (with fever and stomach ache) and required treatment at a government hospital located 3 to 4 hours away from her village, mentioned, “They [health team] didn’t tell me anything about breastfeeding. They gave us medications and briefed us on the timings when we should use them.”

Limitations of this study

Due to unstable roads in the northern region, volatile political circumstances, and active disasters, data could not be collected from villages in the upper Chitral and other northern regions of Pakistan that are also severely affected by natural disasters. The scope of this study was to include displaced mothers who were residing in a variety of disaster relief camps at the time of fieldwork. To prevent recall bias, mothers who have returned to stable houses and those who have never lived in disaster relief camps were excluded. This exclusion criterion may have potentially affected the richness of the data. In the northern region of Pakistan, there are various underserved areas and zones where many families affected by armed conflicts are living in relief camps. In view of the political situations and safety issues, the scope of this study was limited to communities affected by natural disasters and residing in a variety of disaster relief camps.