The results capture learnings from 37 FGDs (with 213 individuals) and 142 IDIs conducted in four sites on practices, beliefs, facilitators, and barriers related to feeding LBW infants MOM and alternative feeding types. Although mother FGDs were stratified by preterm and term status, reported feeding practices did not differ between these two groups nor was a distinction made by other respondents. Minimal variation in insights was found between countries and respondents; we have highlighted any meaningful differences below. Table 2 includes frequently and less frequently mentioned themes, categorized into facilitators and barriers. Select respondent quotations, further illuminating the results shared below, can be found in Table 3. We did not include specific quotations from family members since they aligned with those of mothers and the latter were more illustrative.

Table 2 Facilitators and barriers to infant feeding options Table 3 Select quotes from LIFE study sites* Mother’s own milk

Direct breastfeeding.

Practices and beliefs

Direct breastfeeding, defined as feeding an infant at the breast, was the predominant feeding method practiced by mothers and supported by all respondent types in all sites. Infant growth and physical and mental development were universally reported as key benefits of direct breastfeeding. Most FGD participants in all sites believed that breastfeeding provided essential nutrients for the infant. HCPs in all sites believed that breastfeeding provided immunity for LBW infants, and those in India-Karnataka thought that breastfeeding increased the quality of mother-child bonding. Only one female family member in Malawi expressed the importance of feeding colostrum to a newborn. HCPs in all sites believed that LBW infants should be exclusively breastfed for the first six months, a sentiment shared by all types of participants in all sites. However, a few mothers reported introducing other foods and liquids earlier to facilitate infant growth, reduce crying, supplement breast milk, or satiate the infant. In India, there were reports of feeding a mixture of honey and water after birth until mother’s milk came in, and in Malawi and Tanzania, some mothers fed their infant porridge or cow’s milk.

Facilitators

Adequate maternal nutrition, described by participants as having a diverse diet and good nutrition, and counseling by HCPs were identified as common facilitators to breastfeeding in all sites and respondent types (Table 2). Additional facilitators mentioned by mothers included repositioning the infant (India-Karnataka), a supportive home environment (India-Odisha), the convenience of breast milk being free/readily available (Malawi), and massaging breasts to stimulate breast milk production (Tanzania). HCPs and mothers in all sites reported that breastfeeding initiation varied based on when milk came in and that the proximity of the mother to the infant could make initiation happen sooner. Mothers, family members, and community leaders in India-Odisha, Malawi, and Tanzania believed that mothers should maintain a nutritious diet to facilitate breast milk production. Some mothers in the African sites shared that porridge and fruit were key components of a nutritious maternal diet; family members in Tanzania recommended meat and vegetables; and HCPs in the African sites emphasized diversity of foods and adequate liquids. Providers in Tanzania described counseling mothers on the importance of breastfeeding and stress reduction to aid in milk production. In Malawi and India, HCPs advised on breastfeeding positioning and frequency. Some HCPs further explained that they monitored LBW infants’ swallowing efforts (non-specified) and promoted skin-to-skin contact to stimulate breast milk production.

Barriers

In all sites, frequently mentioned breastfeeding barriers (by mothers, male and female family members and HCPs) were perceived insufficient milk production and the infant’s inability to properly attach to the nipple (Table 2). Other barriers included infants falling asleep while feeding (mothers in India-Odisha and Tanzania); breast or nipple pain, particularly engorged breasts (HCPs in all sites); infant vomiting or coughing, which required burping and feeding of smaller quantities (mothers in India-Karnataka); overcrowded wards, which made observation and counseling difficult (HCPs in Malawi); and maternal stress (HCPs in Tanzania). Mothers, family members, religious leaders, and HCPs in Tanzania cited insufficient milk production as a challenge and in some cases, felt that infant formula, animal milk, water, or porridge needed to be fed to the infant as a supplement to breast milk. HCPs believed that stress could lead to reduced production, and counseling with a focus on maternal nutrition could help address this challenge. LBW infants’ inability to suck or latch onto the nipple was another breastfeeding challenge reported by HCPs in all sites, mothers in India-Odisha and Tanzania, female family members in Tanzania, and community elders and traditional healers in Malawi. To help with this challenge, counseling from HCPs or family members was felt to be useful.

Expressed breast milk (EBM) feedingPractices and beliefs

Breast milk expression was acceptable in all sites, but practiced infrequently, especially in the community setting; direct breastfeeding was more common. Mothers most often expressed by hand into a cup (all sites); the use of a breast pump was rarely reported and only in health facilities since pumps were largely unavailable. EBM was usually fed immediately using a cup (all sites), syringe (all sites), or palladai (a cross between a spoon and cup used to feed infants in Indian sites only). Unlike in Malawi, some mothers in Tanzania and India reported storing EBM at room temperature or in a refrigerator and feeding it after a few hours. Mothers, family members, community leaders and HCPs in Malawi as well as mothers in India-Odisha felt that EBM was an appropriate option for infants who had difficulty latching or suckling at the breast. There was also a shared belief in all FGDs that EBM was useful because it could be fed by someone other than the mother, particularly when she had to attend to other duties/work. Mothers and HCPs in India-Karnataka reported that EBM was beneficial in preventing breast engorgement. An additional benefit of EBM was that caregivers could determine the amount of milk the infant consumed (HCPs in Malawi and mothers in Tanzania). Health-related and cultural beliefs formed the basis of perceived risks of EBM feeding in the community setting. Fear of illness resulting from contaminated EBM was most commonly mentioned by mothers and some family members. Some mothers and family members in the African sites worried about choking or aspiration when feeding EBM. Select religious leaders in Malawi, Ayurvedic providers (providers in India who focus on the holistic health of a person), and community leaders in India-Odisha believed EBM was less nutritious than direct breast milk. A few mothers in the Indian sites believed that an evil eye would be put on an infant who was fed EBM, and community and religious leaders felt that it would reduce mother-infant bonding.

Facilitators

In addition to the above-mentioned facilitators of direct breastfeeding, provision of equipment, support and space were commonly reported facilitators for EBM in all sites. Mothers in India-Odisha also found it helpful to observe others expressing breast milk (Table 2). HCPs in all sites believed that physically aiding and providing cups/syringes for EBM made the process easier. In Malawi and India-Karnataka, HCPs reported teaching mothers how to massage the breast to stimulate production and nurses in India-Karnataka physically helped mothers express and feed their infants breast milk in the neonatal intensive care unit (NICU). Having a private space to express breast milk was a frequently mentioned facilitator by HCPs in all sites.

Barriers

Common barriers to EBM included the perception of insufficient milk production (as reported above under direct breastfeeding), breast pain, and hygiene concerns (Table 2). Similar to direct breastfeeding, perceived insufficient milk production was reported by some mothers, family members, community leaders, and HCPs in India-Odisha, Malawi, and Tanzania. Breast pain was mentioned as a barrier by mothers and HCPs in all sites, some family members in India-Karnataka and Malawi, and religious leaders in Malawi. Breast pain was described generally by mothers while HCPs in sites described pain as engorgement, retracted nipples, and sores. HCPs in all sites believed that maintaining hand and breast hygiene, cleanliness of equipment, and proper storage due to lack of refrigeration made EBM difficult. Mothers, family members, community leaders, and HCPs in all sites reported that lack of hygiene standards for manual expression and feeding vessels could lead to infant illness (e.g., diarrhea). HCPs proposed solutions for maintaining cleanliness such as teaching caregivers how to clean feeding utensils (Malawi) and discarding unused milk (Malawi and India-Karnataka). Mothers in India-Odisha and Tanzania reported difficulties with physical hand expression of milk; and HCPs shared facility-level barriers, including lack of cups (Tanzania), limited staff to assist mother-infant dyads in the NICU (India-Karnataka and Tanzania) and high cost in procuring breast pumps (Malawi).

Alternative feeding types

Donor human milk (DHM).

Practices and beliefs

DHM was a new concept for most participants so responses are based on theoretical rather than actual use; India-Karnataka was the only site with an HMB, therefore, some participants from Karnataka were more familiar with the concept. In general, mothers in all sites indicated that they would be more willing to donate their breast milk rather than to feed DHM to their own infants, but shared concerns around maintaining milk supply for their own infant when donating. While most mothers indicated no expectation of an incentive for donating, describing it as a “noble act” (India), some felt that provision of extra food would be helpful to assist with milk production (Malawi). HMB experts in the African sites believed that caregivers would accept DHM to facilitate infant growth and survival when breast milk was not available or delayed. Similarly, religious and community leaders in Malawi felt that DHM could be a good option if it were more affordable than infant formula. HCPs and some family members in both Indian sites, as well as DHM experts in the African sites, stated that DHM was a better option than infant formula because it was human milk. In terms of establishing an HMB, participants in all sites felt strongly that community- and facility-based individuals as well as government officials should be involved to assist with education, logistics, and policies. DHM experts and male family members felt that more mothers would be willing to donate milk if they knew that their milk would benefit an infant in need.

Facilitators

Respondents suggested that community awareness and health system inputs, such as trained staff and HMB maintenance, could facilitate human HMB establishment, acceptance and uptake (Table 2). Since DHM was a new concept in most sites, the majority of participants felt that robust outreach and education on its benefits, accessibility, and use to all stakeholders (e.g., donating and receiving mothers, HCPs, government officials, and community members) was needed to achieve acceptance. To facilitate the successful establishment and implementation of an HMB, participants highlighted the need for demand generation and maintenance (e.g., through community engagement and peer counseling by previous donors) and logistics (e.g., cold chain and training of staff).

Barriers

A general lack of knowledge, concerns about milk safety, the donor’s profile, and family resistance were reported as common barriers to DHM acceptance and potential future uptake (Table 2). While rare, all types of participants shared various misconceptions, including a lack of regulation of HMBs, availability of DHM based on affordability rather than need, and DHM serving as a barrier to breastfeeding. In all sites, participants expressed a general concern around safety related to milk collection, pasteurization, and storage. Many mothers and HCPs in all sites worried about potential transmission of HIV, Hepatitis B, diarrhea and other infections. In all sites, the donor’s health and social background were reported as potential barriers. In India, HCPs and religious leaders were concerned about the mismatch of caste and religion between the donor and recipient of the milk. Mothers in African sites worried that certain traits and/or illnesses of the donor could be passed through the milk to the receiving infant. Further, mothers in all sites and HCPs in India mentioned family (unspecified) resistance towards feeding DHM as a barrier, and some participants in Malawi warned that in spite of community awareness, resistance could persist in rural communities due to skepticism regarding research and policies related to infant feeding.

Infant formulaPractices and beliefs

In general, all participant types in all sites were against the use of infant formula unless absolutely necessary (i.e., mother-infant separation or maternal death). In rare instances when infant formula was provided, it was usually fed as a supplement to breast milk to encourage growth and save an infant’s life, rather than a replacement feed.

Facilitators

Among mothers who fed infant formula to their LBW infants, only a few facilitators were mentioned. For example, HCPs across all study sites felt that teaching mothers how to mix and feed infant formula was helpful. Similarly, having a family member or HCP prepare the infant formula facilitated its use. Although rare, the provision or donation of infant formula by a HCP, family member, community leader, or a well-wisher/organization facilitated access to infant formula for mothers and caregivers who needed it.

Barriers

Lack of affordability, knowledge, maintenance of hygiene during preparation, storage of infant formula, and fear of illness were commonly reported barriers to infant formula feeding (Table 2). Additionally, some family members in Tanzania reported confusion about which infant formula products to buy and beliefs that fake products were being sold. Many mothers, family members, and HCPs in all sites reported that the cost of infant formula was burdensome. In rare cases, some mothers in India-Odisha heard of others diluting infant formula to make it last longer. HCPs in Tanzania felt that understanding the right proportions of water to powder could be difficult for mothers, especially with changing infant needs over time. HCPs reported that some mothers in Malawi had limited literacy and were unable to read the instructions on infant formula containers. Finally, respondents from all participant types in all sites perceived that infant formula feeding could lead to infant illness, including diarrhea, constipation, digestive issues, vomiting, and necrotizing enterocolitis (HCPs only), if infant formula was not prepared correctly or hygienically or if the infant’s intestines were not mature enough to digest it.