Factors affecting breastfeeding practices in working women of Pakistan Jamil Ahmed Soomro Supervisor: Professor Per Nafstad University of Oslo, Faculty of Medicine Institute of Health and Society, department of Community Medicine Section for International Health Thesis submitted as a part of the Master of Philosophy Degree in International Health May 2015 - LIST OF CONTENTS ACKNOWLEDGEMENTS………………………………………………………………….3-4 ABBREVIATIONS………………………………………………………………………….5-6 ABSTRACT…………………………………………………………………………………...7 Chapter One: Introduction and literature review 1. Background and Introduction……………………………………………………………9-10 1.2 Breastfeeding: History, physiology and health benefits, cultural view……………….11-12 1.3 Benefits of breastfeeding……………………………………………………………...13-14 1.4 Barriers to breastfeeding…………………………………………………………............14 1.5 Workplace breastfeeding facilities ………………………………………………………14 1.6 Breast milk substitute and workplace breastfeeding policies ……………………………15 1.7 Literature review ………………………………………………………..………….…16-24 1.8 Problem statement and Rationale……..…………………………………………...… 24-25 1.9 Objectives and research questions…………………………………………………….... 26 Chapter Two: Methodology 2.1 Study Population ……………………………………………………………………..….28 2.2 Workplace selection criteria ……………………………………………………………..28 2.3 Sampling Technique ……………………………………………………………………..29 2.4 Selection Criteria …………………………………………………………………...........29 2.5 Sample size ……………………………………………………………………………....30 2.6 Operational definitions…………………………………………………………….…......31 2.7 Ethical Consideration …………………………………………………………………31-32 2.8 Data collection and analysis procedure ………………………………………………34-35 Chapter Three: Results 3.1 General Characteristics of the sample …….………………………………………….…..37 3.2 Breastfeeding facilities provided by type of respondent ……………………………..39-40 3.3 Breastfeeding facilities provided: by type of employer ………………………………41-42 3.4 Type of breastfeeding facilities provided by site level ……………………………….43-44 3.5 Mother perception of breastfeeding support ………………………………………….45-47 Chapter four: Discussion 4.1 Methodological discussions ………………………………………………………......49-51 4.2 Discussion of findings ………………………………………………………………..52-57 4.3 Strengths and Limitations ……………………………………………………………….57 5. Reference List ….…………………………………………………………………......60-67 6. Appendices ……….…………………………………………………………………...68-77 1 LIST OF TABLES AND FIGURES Figure 1. Map of Pakistan & location of Karachi city where the research was conducted…. 9 Figure 2 Mothers perception of breastfeeding support……………..………………………. 45 Figure 3. Mothers perception of breastfeeding support by type of employer………………. 46 Figure 4. Mothers perception of breastfeeding support by site level……………………… ...47 Table 1. Project timetable…………………………………………………………….……...33 Table 2. General characteristics of sample. ……………………………………………..…..37 Table 3. Breastfeeding facilities provided by type of respondent….……………….……….38 Table 4. Breastfeeding facilities provided by type of employer………………….….…........41 Table 5. Breastfeeding facilities provided by site level……………………………………..43 2 ACKNOWLEDGEMENTS Thanks to God, for blessing me with the power and health to continue this study. Various foundations, individuals provided valuable contributions at every phase of my master thesis and they really deserve special thanks and admiration. I am especially indebted to the Norwegian government for offering me the study fund through quota program, this serves as the cornerstone by giving me the chance to take part in this master program and got my life easy in Norway. Thanks to the international office, University of Oslo team for being always available for assistance and guidance from the beginning of my stay in Norway. I would like to extend my special thanks to my supervisor, Professor Per Nafstad for his guidance, valuable comments and suggestions. His support, patience and continuous encouragement take me through this challenging journey to complete this work. This work would have not been possible without you. I am likewise thankful to Dr Zeeshan Noor Shaikh, Assistant professor Dow medical university for his support during my field study, which enable me to successfully complete my fieldwork in time. Great thanks go to institute of health and society, the Department of community medicine, section of international health teachers, staff and our sweet coordinator Terese Eriksen for providing best academic environment and support throughout our master study. I would wish as well to thank Abraham Mdala for his help in statistics during my data analysis. I am indebted to my M.Phil, fellow colleagues who made my stay in Norway very comfortable with their nice company and support, tusen takk!. Mazim the great, I will always remember your funny jokes and phrases that reminded me there is more to life than academia… Special thanks to Dow university Karachi members represented by Vice chancellor professor Masood Hameed Khan for their support and providing me with the institutional backing to complete my fieldwork. Furthermore, I also extend thanks to Department of public health at the Dow university for their support and encouragement throughout my fieldwork. All thanks to my research assistant who helped me allot during data collection and shared all the agony and problems that I encounter during my fieldwork. I would like to thank all mothers and employers who participated in my study for willingly sharing their experience and spared their valuable time through data collection and also thanks to the organizations for providing me access to conduct my study. 3 To my wife, Nayab Soomro, thank you for your untiring support in so many ways, which enable me to fulfil my passions and dream. I cannot forget to thank my children (Rutaba & Aryan) and my parents, their love, support and encouragement made it possible for me to follow my aspiration. I would like to express my great thanks to my friend Ziauddin Khoso in Pakistan, who was always available for me whenever I am in need of him. 4 ABBREVIATIONS ANC Antenatal visit CI Confidence interval CPR Contraceptive prevalence rate FP Family planning IRB Institutional review board GDP Gross domestic product ILO International labour organization IYCF Infant and young child feeding MDGs Millennium development goals NIPS National institute of population studies NSD Norwegian social science data service NGO Non-government organization PTH Parathyroid hormone PDHS Pakistan demographic and health survey PHC Primary health care PMDC Pakistan Medical and dental council PNC Postnatal care REC Regional ethical committee SPSS Statistical package for social sciences UK United Kingdom 5 UN United Nations UNICEF United Nations children's emergency fund USA United States of America WBTI World breastfeeding trends initiative tool WHO World health organization 6 ABSTRACT Background, rationale and aim of the study Breastfeeding is considered to be an important measure to secure child’s optimal health and survival. In urban areas of Pakistan most of the women can’t afford to live at home longer because they serve as an important contributor of their family income. A woman's return to work has frequently been found to be a main contributor to the early termination of breastfeeding. Most workplaces do not have the supportive environment for breastfeeding. This will probably result in discontinuation of mother's milk and breastfeeding. Little research exists regarding workplace breastfeeding facilities. The current study aimed to assess the factors affecting breastfeeding practices among employed mothers in the workplace. Methodology A cross-sectional study was conducted in Karachi, Pakistan, using a random sampling procedure where 297 workplace sites were assessed. One mother and one employer from each site were interviewed using a structured questionnaire. Data were collected between June 2014 to December 2014. The eligibility criterion for mothers was that they had initiated breastfeeding 3-24 months prior to the survey. Studied factors were workplace breastfeeding facilities. Results Only 12 % of the sites were providing breastfeeding breaks for working mothers. Almost 86% of the mother’s had received 3 months maternity leave. Provision of lighter jobs and information about breastfeeding options upon mothers return to work were reported from 15% and 5% of the work places respectively. Less than 1% of the sites had separate lactation rooms, a nursery for childcare, breast milk pump and refrigerator for storing mother's milk. There were statistically significant difference by type of employer (government or private) and site level (national or multinational) with regards to flexible time, lactation room, lighter job, paid maternity leave and provision of breastfeeding options upon mothers return. Conclusion We found that the majority of the workplace sites lacked basic facilities to support mothers to combine breastfeeding with work such as breastfeeding breaks, lactation room, and nursery for childcare, breast milk pump, refrigerator and provision of lighter job. Key words: Breastfeeding, working mother, workplace, breastfeeding support, employer. 7 Chapter One BACKGROUND AND INTRODUCTION 8 I. BACKGROUND, INTRODUCTION AND LITERATURE REVIEW 1.1 Introduction to the study area 1.1.1. Country location and climate Pakistan is a sovereign country, located in south Asia with a population exceeding 180 million people. It shares borders with four countries: Afghanistan and Iran to the west; India to the east and China to the north (1). Pakistan covers an area of 796,095 km2 with the dry climate and hot near the coast, becoming progressively cooler toward the northeast uplands (1). Figure 1: Map of Pakistan and location of Karachi city where research was performed (1). 1.1.2. Economy Pakistan has a semi-industrialized economy. It has an estimated gross domestic product (GDP) of US$ 928.43 billion, with US$ 4882 GDP of per capita income. During the current century, the country has the potential to become one of the world's largest economies. However, after decades of war and societal instability, severe deficiencies in basic services such as railway transportation and electric power generation, large government outlays on public enterprises, bad administration, low tax revenues, high degrees of defense expenditure, and a rapid rise in 9