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Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan:

A ualitative study
Kinga Pemoa,* , Diane Phillipsa , Alison M. Hutchinsona,b,c
a
Deakin University, School of Nursing and Midwifery, Geelong, Victoria 3220, Australia
b
Deakin University, Centre for Quality and Patient Safety Research, Geelong, Victoria 3220, Australia
c
Monash Health, 246 Clayton Road, Clayton, 3168 Victoria, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Problem: In Bhutan, exclusive breastfeeding is not routinely practised according to the World Health
Received 25 February 2019 Organisation recommendation, thereby placing infants and women at increased risk of morbidity and
Received in revised form 7 July 2019 mortality.
Accepted 8 July 2019
Background: Research indicates that support from midwives is positively associated with longer
Available online xxx
breastfeeding duration. Previously, no studies had been conducted in Bhutan to explore midwives’
perceptions of the barriers to the promotion of exclusive breastfeeding.
Keywords:
Aim: To explore midwives’ perceptions of the barriers to promoting exclusive breastfeeding among
Bhutan
Exclusive breastfeeding
Bhutanese women.
Midwives Methods: A qualitative exploratory descriptive study design was used, involving individual semi-
Breastfeeding support structured audio-recorded interviews. The Framework approach was utilised for data analysis.
Breastfeeding barriers Findings: Five themes emerged from a total of 26 interviews. The themes were: ‘cultural and traditional
practices’, ‘women’s return to work’, ‘midwives’ advice in response to breastfeeding problems’, ‘shortage
of staff in a busy maternity service’ and ‘lack of professional development about breastfeeding’.
Discussion: Midwives reported that upholding Bhutanese cultural and traditional practices by women
and their families was a powerful barrier to the promotion of exclusive breastfeeding. Midwives
experienced difficulty in promoting exclusive breastfeeding among women in the immediate postnatal
period during women’s short hospital stay. A shortage of midwives, coupled with a lack of professional
development about breastfeeding promotion and support, were additional barriers to the promotion of
exclusive breastfeeding.
Conclusion: The study findings highlight the need for continuing professional development of midwives
in relation to exclusive breastfeeding. Additionally, a review of the midwifery workforce model is
recommended, to ensure midwives have time to provide women with breastfeeding support.
© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

What this paper adds

Statement of significance Barriers to midwives’ support of exclusive breastfeeding
Problem or issue included continued promotion of cultural and traditional
In Bhutan exclusive breastfeeding for at least six months practices, women’s intention to return to work, staff short-
after birth, as recommended by WHO, is not routinely ages, busy workloads, and lack of continuing professional
practised by breastfeeding mothers thereby placing infants development for midwives.
and women at increased risk of morbidity and mortality.
What is already known
Studies show support from midwives is positively associat-
ed with exclusive breastfeeding in women.
1. Introduction

In Bhutan, exclusive breastfeeding is not routinely practised

* Corresponding author at: 527 Elgar Road, Mont Albert North, Vic 3129 Australia.
E-mail addresses: kingapem@gmail.com (K. Pemo), adp2010@live.com.au
(D. Phillips), alison.hutchinson@deakin.edu.au (A.M. Hutchinson).
according to the World Health Organisation recommendation
(WHO), thereby placing infants as well as women at increased risk
of morbidity and mortality.1 The WHO defines exclusive breast-
feeding (EBF) for at least six months after birth as: “ . . . no other

http://dx.doi.org/10.1016/j.wombi.2019.07.003
1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
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food or drink, not even water, except breast milk (including milk
expressed or from a wet nurse) for six months of life but allows the
infant to receive oral rehydration solution (ORS), drops and syrups
(vitamins, minerals and medicines)”.1 After six months of age, and
up to two years of age or beyond, infants should be given nutritious
complementary foods in conjunction with breastfeeding.1 In 2015,
a survey conducted by the Nutrition Program, Ministry of Health,
Bhutan found an EBF rate of 51% at six months after birth.2 In 2018,
a report from the Ministry of Health indicated the EBF rate was
48.7% at six months.3 The same report indicated that a large
number of infants under the age of one year suffer from
morbidities, for example, diarrhoea, dysentery, otitis media,
pneumonia, and skin infection, conditions that could otherwise
be protected by EBF.4,5 In Bhutan, no studies have been conducted
to investigate the morbidity among non-breastfeeding women;
however, world-wide international research shows that breast-
feeding has a protective effect against breast cancer, ovarian
cancer, type 2 diabetes,5,6 and depression.7
Midwives are responsible for ensuring women fully understand
what is meant by EBF and how it is to be practised to achieve
optimal infant health outcomes. Importantly, support from health
professionals is positively associated with breastfeeding duration
and its exclusivity.8–11 Conversely, lack of support from health
professionals is negatively associated with EBF among new
mothers.12,13 In the first study to explore the perceptions of
Bhutanese women about breastfeeding and EBF, women reported
receiving little or no information or support from health
professionals.14 As a consequence, women adopted various
cultural and traditional practices in the belief they would not
affect the exclusivity of breastfeeding.14 In view of these findings,
eliciting an understanding of the challenges, midwives encounter
when providing support and education to women about breast-
feeding is important. This study aimed to explore midwives’
perceptions of the barriers to promoting EBF among women in
Bhutan.
2. Participants and methods
2.1. Research design
A Qualitative Exploratory Descriptive (QED) design was used for
this study. This approach allows exploration of attitudes, beliefs or
perceptions; the motivation for decisions, actions or non-actions;
the origins of the formation of an event, experience or occurrence;
and the context in which phenomena occur.15
2.2. Setting
The study was conducted in the Jigme Dorji Wangchuck
National Referral Hospital (JDWNRH) located in Thimphu, the
national capital of Bhutan. Specifically, the research was conducted
within the hospital’s reproductive health unit (RHU), comprising
the community health unit, antenatal clinic, postnatal clinic, a
well-baby clinic, birthing centre, and maternity ward.
2.3. Participants and recruitment
All staff holding registration as a ‘midwife’ with Bhutan Medical
and Health Council and employed at RHU, maternity wards and
labour rooms were eligible to participate in the study. Prior to data
collection, the first author, a Bhutanese national, met with the
Nursing Superintendent of JDWNRH to explain the purpose of the
study. The Nursing Superintendent then provided operational
approval for the conduct of the study. Approval was also obtained
from the acting Medical Superintendent prior to the commence-
ment of data collection. The first author approached midwives at
Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
their workstations, at a mutually convenient time, to introduce and
explain the study. Midwives were informed about the purpose of
the study, the requirements for participation, the voluntary nature
of participation, how confidentiality of their information would be
maintained, and that they could withdraw from the study at any
time. They were also given the opportunity to ask questions.
Midwives were given a plain language statement to read at their
convenience and they were invited to consider participation in the
study. They were asked to then contact the researcher if they were
willing to participate.
2.4. Data collection
Interviews were undertaken by the first author after consent
forms were signed by participants. If convenient, some midwives
were interviewed immediately following the signing of the
consent form, while for others an interview time was arranged
for a later, mutually convenient time. At the start of each interview,
participants were asked to provide their demographic details,
including their age, years of experience and areas of work. All
interviews were conducted in English; English is the language of
instruction in schools and tertiary institutions in Bhutan. Inter-
views with midwives were conducted in the privacy of meeting
rooms within the hospital.
Data were collected through individual, face-to-face, semi-
structured interviews using an interview guide (Table 1). The
interviews were used to elicit participant’s perceptions and
identify the commonalities and differences in perceptions among
participants.16 All interviews were audio-recorded, and data,
including audio recordings, transcripts, and notes, were kept
confidential, de-identified with an ID number and stored
separately from the participants’ contact details.
2.5. Reflexivity
In this study reflexivity was ensured, as recommended by
Jootun, et al.17 using a range of strategies: keeping a research diary;
recording descriptions of the research context; constructing
decision trails; and making sure the process of interpretation of
nuances in the data was clearly articulated. The interviewer noted
her personal feelings about the interviews and reflected on any
personal bias she may have unconsciously adopted. This helped her
to approach subsequent interviews with more reflexivity. All
processes and decisions were documented along with the
rationale.
2.6. Data analysis
Descriptive statistics, including frequencies and percentages,
and means and standard deviations, were used to analyse the
demographic characteristics of participants. The framework
analysis process was used to guide qualitative data analysis.18
The process of framework analysis consists of: familiarisation;
identifying a thematic framework; indexing; charting; and
mapping and interpretation.18 The approach uses systematic and
visible stages in the analysis process, which provides clarity about
the stages through which the results have been obtained. NVivo
(Version 10)19 was used to organise data.
During the familiarisation process, a selection of transcripts was
coded by all three authors. In the process of identifying the
thematic framework, the codes were compared for consistencies,
similarities, and differences. The process of indexing involved the
application of textual codes to categories.20 Codes that arose from
three or more transcripts were assigned to categories.18 During the
indexing stage the data were imported into NVivo (Version 10)19
and then codes were systematically applied to the data. Following
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Table 1
Interview guides for midwives.

1 Explain what is meant by EBF.

2 What is your understanding of the benefits of breastfeeding and EBF?

3 What is your thought on the current status of breastfeeding in Bhutan?

4 What factors do you think may prevent women from not being able to exclusively breastfeed their babies until at least six months of age in our society?

5 What strategies can you apply to support mothers to exclusively breastfeed their babies until at least six months of age?

6 Have you cared for many women with breastfeeding difficulties occurring soon after birth while in the hospital, or during the visits following discharge from the
hospital or at community visits? How? (Probe on common reasons for supplementing breastmilk in hospital, breast conditions, and mode of birth such as an assisted
vaginal birth or caesarean birth, breastmilk expression, formula feed, main reasons women tell you for why they supplemented the baby?)

7 In your experience which cultural belief have you seen are useful or not useful/ harmful to breastfeeding?

8 What cultural aspects do you support or encourage to promote breastfeeding?

9 What roles do family and friends play in women’s action? How do you support them?

10 What do hospital management and your colleagues expect from you in terms of breastfeeding promotion?

11 What BF advice and support do you provide mothers? (Probes on when during pregnancy women discuss their feeding plan, what is discussed, who is involved, hands-
on support while in hospital, at discharge, postnatal visits, and community visits)

12 What are your perceptions of the barriers in promoting breastfeeding and giving education programs and support to women and their families during pregnancy,
immediately after birth and at six weeks?

13 What do you think can better equip you to deal with all these problems? (Probe: staffing, proper knowledge, and skills, relevant training, staff support)

14 What strategies would you apply?

15 How confident are you in assisting and advising women on breastfeeding?

16 Do you wish to make any further comments?

17 Thank you for your participation in this interview

completion, all three authors scrutinised the indexed data, and
discussions ensued until a mutual agreement was reached about
the soundness and relevance of the indexing. Once agreement
about the textual codes was achieved among all authors, the first
author charted the data. During charting, framework matrices
were created on a case-wise basis across all categories. All three
authors then synthesised key characteristics of the data in order to
map and interpret the data set as a whole. Themes were generated
by studying the matrices while being mindful of relationships
across participants, their demographic characteristics, and in
reference to field notes to ensure accuracy.
3.1. Cultural and traditional practices
Cultural and traditional practices were perceived by partic-
ipants to hinder EBF because women supplemented their
breastmilk with other fluids or foods. There was a belief that
infants would become thirsty when immersed in bath water.
Consequently, the practice of giving infants several drops of bath
water was common: “Whenever they do the baby bath, they say
Table 2
Demographic characteristics of midwives (N = 38).

Characteristic Midwives (%) (N = 26)

2.7. Ethical considerations
Gender
Male
Approval to conduct the study was provided by the Deakin Female 26 (100)
University Human Research and Ethics Committee (DUHREC 2014- Age in years
003) on 10th March 2014 and the Ministry of Health, Royal 21–29 11 (42.31)
30–39 10 (38.46)
Government of Bhutan (REBH/2013/021) on 13th January 2014.
40–49 3 (11.54)
>50 2 (7.69)
3. Results Years of work experience
<1 2 (7.69)
Twenty-six midwives, who were between 21 to 53 years of age, 1–5 4 (15.38)
6–10 7 (26.92)
participated in interviews. Two (7.69%) had been in their position
11–15 2 (7.69)
for less than a year, and 11 (42.31%) had been practising as >15 11 (42.31)
midwives for more than 15 years. The demographic characteristics Area of work
of the participants are presented in Table 2. Birthing centre 10 (38.46)
Five themes emerged from the interviews: ‘cultural and Maternity ward 9 (34.62)
Well baby clinic 3 (11.54)
traditional practices’, ‘women’s return to work’, midwives’ advice Antenatal clinic 2 (7.69)
in response to breastfeeding problems’, ‘shortage of staff in a busy Postnatal clinic 1 (3.85)
maternity service’ and ‘lack of professional development about Immunisation clinic 1 (3.85)
breastfeeding’. Verbatim quotes are provided to illustrate the Breastfeeding training
Undertaken 11 (42.31)
themes. Table 3 shows the codes, categories and themes that
Not undertaken 15 (57.69)
emerged from the data.

Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
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Table 3
Theme generation.

Initial Codes Categories Final themes

 Mothers give butter to the newborn so that newborn will get to eat butter throughout Beliefs and influence of family Cultural and traditional practices
his life or as a gesture of welcoming them to the world.

 Whenever they give the newborn a bath, newborn is given one or two drops of water
to prevent their throat from becoming dry.

 Honey is given as it believed the infant will be intelligent.

 Grandparents feed supplement as they believe newborn should have something solid
in their stomach.

 A tradition passed from generation to generation. Mothers or mother-in- law would

enforce olden days beliefs and influence, new mothers, to give butter or water to their
newborns.

 Bhutanese mothers take it for granted that EBF is not required by the infants as
someone survived before without EBF.

 EBF cannot be achieved because some women have to go to work. Short maternity leave Women’s return to work

 Working mothers cannot feed her infants exclusively because they only get three
months maternity leave.

 Government policy state EBF, for six months and the maternity leave, is three months.
And it does not tally.

 For those returning to work, the rules and regulation are not BF friendly.

 EBF is possible if mothers stay at home.

 Those in private organisation get only 1-2 months of leave.

 Health staff gives 10% dextrose to make newborn latch. BF problems Midwives’ advice in response to
breastfeeding problems
 If the baby is sick and mother has less milk production formula feeding is advised by
the physicians.

 After trying with BF as well as giving metoclopermide to mothers if mother’s milk is

insufficient, supplements is advised by the physician.

 When health workers are not able to help with BF problems they start on formula.

 Newborns suffering from jaundice are advised formula.

 When an infant is sick or not gaining weight top up is being given

 Maternity ward has multiple cases gynaecology, pre-operative, post-operative, many Barriers to BF support Shortage of staff in a busy
newborns, and shortage of staff maternity service

 Most of the time only three staff are there in Birthing Centre and all are involved with
other routine work so no time to help with BF.

 Not able to help with each one with BF because of busyness.

 Limited staff more focused on conducting births than postnatal activities.

 Health education on BF is not given in detail because of so much work in the antenatal
clinic, Maternity Ward, and Birthing Centre.

 Very busy with many patients, no time to talk about BF with mothers.

 It is not possible to initiate BF within half an hour because of staff shortages

 Some of the staff are not aware of the importance of BF. Lack of BF skills and knowledge Lack of Professional Development
about Breastfeeding
 New staff not trained in BF skills and knowledge.

 Health staff does not have required knowledge or skills.

 Not trained in any BF skills or knowledge.

 Had no formal training on BF, therefore, faces a problem when dealing with BF
problems.

Note: BF = breastfeeding; EBF = exclusive breastfeeding.

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Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
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that [the] baby is very thirsty so before giving bath they give one or
two drops of water to the baby” (MID14). Butter was believed to be
healthy food, far more nutritious than human milk, as explained by
a midwife.
This is a belief in our community, in our society that newborn
should be fed with butter before the breastmilk. I heard my
mum saying if you feed the baby with butter, the baby will
always be fed throughout his life. Butter is very good and very
rich food and baby will always be having that in life. Another
thing is, in our Bhutanese society, butter is said to be very
nutritious, I think more than the breastmilk. I think that belief is
still there. (MID 13)
According to a midwife, honey is given for a similar reason:
Our grandmothers, what they think is honey and the butter are
the best things to be given to the baby, so this is the culture. So,
they think whatever sweet thing they have taken in the first
time, the baby will be like that. (MID 14)
Family elders, mainly grandmothers, were reported by partic-
ipants to be most influential in encouraging women to follow
traditional practices because human milk alone was perceived as
insufficient to satisfy infant hunger and thirst. Elders were
reported to pressure women into giving their newborn infants
solid foods to promote health and faster growth. One midwife
reported:
The older people, they feel if the baby is only breastfed, they are
not getting enough food, they will not grow well, they will not
be healthy, the baby should be given other food to grow faster
and be healthy. I think it is the culture (MID 24).
3.2. Women’s return to work
Women’s return to work after the birth was frequently cited by
participants as a barrier to EBF. They reported that women,
employed in both the government and private sectors, reported
that when their maternity leave was completed, they were for a
variety of reasons, unable to continue EBF.
This could be like working women, mostly it is because of that
[they cannot breastfeed exclusively until six months]. The
mothers are working, they get only three months maternity
leave, so they have to join back [to work] (MID 15).
Factors such as the lack of time, lack of flexibility and absence of
facilities in the workplace for breastfeeding or expression of
breastmilk, reportedly hindered women’s ability to practise EBF for
at least six months:
Six months, I think mothers can’t do exclusive breastfeeding
due to the inflexibility of the time for the mothers and there is
no place or secret [private] place for expressing breastmilk.
They can’t express their milk. They don’t have like high-tech
pumping facilities (MID 23).
Another participant reported that women often did not have
any other choice but to leave their infant at home in the care of
others who used infant-formula.
After three months they have to go back to their office and
during their absence, their nanny or their mother, they give
water and/or something with milk, and is not exclusively
breastfeeding. They think the baby is hungry. And they give
supplements (MID 10).
Participants noted the discrepancy between the recommenda-
tion for an EBF duration of at least six months after birth and the
policy for only three months of maternity leave. They also observed
that for women employed in private organisations, their maternity
leave entitlement was less than two months in duration.
Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
5
I think another one like we say that government policy like
exclusive breast feeding, we say breastfeeding is 6 months and
the maternity leave is 3 months. And it doesn't tally. And I told
you [EBF] breakdown happens when the mothers go back to
work. The government 3 months and the mothers who work in
private sector is only 1 month or 1 and half month and then we
say six months? And I think the new government promised us
that maternity leave would be I mean increased to six months.
(MID 06)
3.3. Midwives’ advice in response to breastfeeding problems
It was reported by participants that breastfeeding problems, for
example, cracked and sore nipples, breast engorgement, and
mastitis, were among the main reasons for women supplementing
their milk with infant formula, thus hindering EBF. Participants
argued that diverse breastfeeding problems were experienced by
women, resulting in their inability to breastfeed. One participant
explained, this is because women either “have inverted nipples,
and nipples are very small. Then they find it very difficult in
breastfeeding. And they tend not to give, they don’t give proper
breastfeeding. And that develops sore. Then it hampers their
breastfeeding” (MID 24). Participants also reported women who
used infant formula perceived their milk supply to be inadequate
because of their crying infant, which was interpreted as a sign of
hunger. A participant reported formula-feed was given to infants
within the first 24 h after birth, during their hospital admission.
Another participant explained women chose to do this because of
their perceived inability to produce sufficient milk. They remained
sceptical about their milk production, even when they were
reassured that they had a sufficient supply: “When the mother’s
[milk] production is less, they think it is not enough for the baby
and they start supplementing without asking us. Some asked us.
Even if we say it is enough, they are not convinced” (MID 07).
Participants sometimes advised women to give infant formula if
there was inadequate human milk production. Some participants
stated they reported this issue to the physicians only after all
support strategies for successful breastfeeding had been
exhausted. Not all midwives waited for a physician’s order and
proceeded to advise women to use infant formula. The explanation
for this approach was, “ . . . usually, babies, they develop
dehydration, fever and we have to send blood for sepsis, so I
think it is better to supplement if there is no breastmilk production
at all. If there is breastmilk production, then we don’t supplement”
(MID 19).
This was supported by another participant who stated:
For the first few days, some mothers do not have breastmilk
production, so some staff advises them to give them formula. Of
course, we try to feed them [the babies], also we try to help
them [the women] breastfeed, but if there is no breastmilk, I
think that is the best step. Otherwise, the baby will be
dehydrated. (MID 05)
Practices used by midwives to encourage an infant to attach to
the mother’s breast included use of 10% glucose or smearing
glucose onto her nipples. A participant acknowledged: “when a
baby is not sucking or opening their mouth we give dextrose 10%,
but when we were not there they were using water. Yes, we are. We
give [a] few drops for putting the baby to [the] breast” (MID 17).
3.4. Shortage of staff in a busy maternity service
Participants reported that whenever possible they tried to
promote breastfeeding, but because of the shortage of staff and the
large number of women seeking care, they lacked sufficient time to
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provide both education and support. For example, in the Antenatal
Clinic, it was reported that two midwives provide care for up to 50–
60 women per day, and they would briefly inform women about
EBF but were not able to provide any further information due to
time constraints. Similarly, the Birthing Centre participants
claimed they were always occupied with assisting women during
birth and did not get time to provide breastfeeding information
and support.
We have staff shortage here and plus most of the time we are
busy. Sometimes we have fetal distress and other complication
and because of that, we are not able to do much on
breastfeeding. Due to staff shortage and most of the time, it
will be very busy so. (MID 8)
In another section of the Maternity Ward, three midwives on
each shift provide care of 36 women admitted for induction of
labour, complications during pregnancy (e.g. hypertensive dis-
orders), postnatal women and newborns, women admitted for pre-
and post-caesarean section care and gynaecological care. These
participants reported that due to workload demands, they were
constrained in their ability to provide women with breastfeeding
support or education:
We have multiple cases like gynae, we have to give care for all.
Pre-operative, post-operative and sometimes we have so many
babies, more than twenty, and because of a shortage of staff we
are not able to provide effective breastfeeding support (MID 17)
3.5. Lack of professional development about breastfeeding
Participants claimed that their lack of knowledge about
breastfeeding created barriers for the delivery of best practice
care, education and promotion of EBF. Of the 26 participants, 11
reported having received breastfeeding-related training. As a result
of a lack of continuing education, most participants stated they did
not have the required knowledge and skills to effectively support
breastfeeding women. A participant from the antenatal clinic also
identified this need, stating “I think breastfeeding workshops or
training as such . . . I have never attended [any]” (MID 02).
Participants reported that due to a lack of professional
development about breastfeeding, they had little confidence in
assisting women who sought their help, which also had an impact
on EBF practice. One participant who had attended a training
program said “I think I need more training, I am not confident. I am
just trained in infant and young child feeding and I am not much
confident in helping with breastfeeding” (MID 04).
4. Discussion
According to participants, cultural and traditional practices,
including, for example, giving an infant butter, honey and drops of
water when bathing, affected the exclusivity of breastfeeding. The
justification for non-EBF was reported to be underpinned by the
belief that breast milk alone would not satiate an infant’s hunger
and thirst. While cultural and traditional practices influenced
women’s breastfeeding, family elders were usually responsible for
enforcing them. The culture of living in an extended family, as
exists in Bhutanese society, enables elders to impose their views on
women. The decision about how to feed an infant is usually made
by the individual who has the most authority in the family,
typically grandmothers.14 This type of culture is also prevalent in
Nepal, where advice from grandmothers is most influential for
infant feeding.21 The influence of elders, especially grandmothers,
encourage supplementary foods for infants is also seen in Egypt,22
Zimbabwe,23 and in Tanzania.24 This issue in Bhutan could be
addressed through the introduction of formalised breastfeeding
education programs for childbearing women and their family. Such
Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
a program in other countries, such as Brazil,25 Thailand26 and
China,27 has been found to improve breastfeeding outcomes.
The participants of the current study also considered women’s
return to work as a reason for non-EBF of infants. They suggested
that family circumstances sometimes prompted women to
trivialise breastfeeding because they had higher priorities such
as earning a living. Studies have revealed an association between
the return of women to work and a short duration of, or decline in
breastfeeding among women in Ethiopia,28 Mexico,29 the USA,30
China31 and Hong Kong.32
This study’s participants argued that the rate of EBF until at
least six months after birth could be improved if there was an
equivalent increase in maternity leave. They contended this time
extension would not only promote EBF but also increase
breastfeeding duration to benefit both maternal and infant health.
At the time of this study, Bhutanese women working for the
government received paid maternity leave for three months, while
those employed by private or corporate organisations received one
to two months paid maternity leave. It has been found that women
who had longer maternity leave, breastfed for longer than those
who received a shorter leave duration.33,34 While a longer duration
of maternity leave is more compatible with longer breastfeeding
duration, it could impose financial hardship for women and their
families.14 More recently, the Bhutanese government increased
paid maternity leave to six months, followed by six months of
working half days.35 The effectiveness of this initiative has not yet
been evaluated.
All participants argued the main reason for use of infant
formula was women’s perceptions that they were not producing
enough milk. Similar findings are reported from studies conducted
in China and the USA.31,36,37 In the present study, supplementation
of breastmilk was reportedly recommended by midwives, in the
absence of a physician’s order. The justification for this was to
prevent infant dehydration when women perceived they had an
insufficient milk supply. This action was further justified as
minimising the requirement for the infant to be subjected to
diagnostic procedures (e.g. taking blood to rule out sepsis) and
being admitted to the nursery for care. Such advice contravenes the
WHO Baby-Friendly Hospital Initiative Step 6 recommendation,
which states that newborn infants should be given no food or drink
other than human-milk unless there is a medical indication.38
Although midwives were attempting to prevent negative infant
health outcomes, they were interfering with a woman’s milk
production by not encouraging the continuation of breastfeeding,
thereby interrupting EBF practice.
Staff shortages prevented participants of the current study from
providing breastfeeding education and support for women, which
they perceived as a barrier for EBF. Care was prioritised for women
during labour, birth and immediately following birth, with little or
no time to provide for breastfeeding education or support. Similar
issues have been identified in other studies,39,40 leading to low
levels of breastfeeding promotion, education, and support deliv-
ered to women by midwives.41
The participants acknowledged that they lacked an in-depth
understanding about breastfeeding. This limited their ability to
function in their role to support breastfeeding and presented a
barrier to EBF. The Diploma of General Nursing and Midwifery
offered in Bhutan is a three-year course, incorporating two and half
years of nursing and six months of midwifery education.42 At the
time of data collection, Bhutan was not an affiliate of the
International Confederation of Midwives, and this situation
remains current. The short duration of the midwifery education
program along with the lack of ongoing professional development
for midwives were associated with challenges for midwives in
providing evidence-informed advice and support for women about
breastfeeding and possible problems they could encounter. The
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need for refresher courses to update breastfeeding knowledge has
been expressed by midwives in Australia43 and Ireland.39
Professional development updates, specifically for nurses and
midwives, has been found to be an effective strategy for improving
not only midwives’ knowledge about breastfeeding but also
breastfeeding rates.13,44 The lack of continuing education on
breastfeeding and EBF for midwives in Bhutan needs to be
addressed. Additionally, the introduction of a mandate for mid-
wives to provide evidence of their professional development in
relation to breastfeeding is recommended. Adoption of these
recommendations would help promote best practice in the
delivery of care for breastfeeding women and their infants.
5. Limitations
The findings of this study, conducted in a single hospital in
Bhutan, may not be transferable to other countries. However, the
findings may be transferable to other hospitals within Bhutan
because they have structures, policies, and processes similar to the
JDWNRH. The strength of this study lies in the fact that it is the first
study conducted in Bhutan to elicit midwives’ perceptions about
the barriers to promoting EBF among women. If addressed, the
barriers identified by participants in this study may contribute to
improved EBF practices in Bhutan.
6. Conclusion
Bhutanese midwives continue to encounter cultural and
traditional practices, mostly enforced by family elders, as a
significant barrier to EBF. This could, in part, be redressed through
delivery by midwives of formalised education programs for
childbearing women and relevant family members. Return to
work was also identified as one of the barriers to EBF and an area
where midwives could provide education for women about
breastmilk expression and storage, to support the continuation
of EBF. Strategies to address the shortage of staff, heavy workloads
and lack of continuing breastfeeding education may assist mid-
wives to provide best practice care through promotion and support
of breastfeeding.
Ethical statement
Approval to conduct the study was provided by the Deakin
University Human Research and Ethics Committee (DUHREC 2014-
003) on 10th March 2014 and the Ministry of Health, Royal
Government of Bhutan (REBH/2013/021) on 13th January 2014.
Conflict of interest
We declare we have no conflict of interest with any product or
distributor of product.
Funding
No funding was received for this work.
Author contributions
Kinga Pemo: Conceptualization; Methodology; Software;
Validation; Formal Analysis; Investigation; Resources; Data
Curation; Writing – Original Draft; Writing – Review & Editing;
Visualization.
Diane Phillips: Conceptualization; Methodology; Software;
Validation; Formal Analysis; Investigation; Resources; Data
Curation; Writing – Review & Editing; Visualization.
Please cite this article in press as: K. Pemo, et al., Midwives’ perceptions of barriers to exclusive breastfeeding in Bhutan: A qualitative study,
Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.003
7
Alison M. Hutchinson: Conceptualization; Methodology;
Software; Validation; Formal Analysis; Investigation; Resources;
Data Curation; Writing – Review & Editing; Visualization.
Acknowledgement
The authors would like to express their grateful thanks to the
midwives who participated in this study.
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