Study population and settings

This study was conducted in two slums (Korail and Kamrangirchar), in a Dhaka City Corporation area where Dushtha Shasthya Kendra (DSK), a Dhaka based NGO, has been implementing a comprehensive health, nutrition, and livelihood development project. Korail slum is surrounded by wealthy neighborhoods (Gulshan and Bonani) and Kamrangirchar slum is located in the area of old Dhaka (Puron Dhaka). Korail is the largest slum and encompasses approximately 85 acres of land owned by the state-run Bangladesh Telecommunications Company Limited (BTCL). Although there are no official population statistics, some secondary sources show that the slum has approximately 80,000 inhabitants [14]. Poor and inadequate civic facilities, such as irregular water and gas supply, poor road connectivity, and narrow walking space, are common features of slum settings. Overcrowding, a filthy environment, violence, and influence of local Mastan, (thug) conflict are prevailing phenomena in the slum. The Kamrangirchar slum is built on privately owned land. This is the largest cluster of slums located in the Kamrangirchar peninsula with nearly 400,000 inhabitants. That low-lying area was once used as a dumping ground; therefore, it has been developed as a result of waste dumping in the last few decades. Industrial toxic substances were directed to the river; consequently, inhabitants are living in a severely polluted environment. The inhabitants are poor immigrants from various parts of the county. Overcrowding pushes them to share minimal space. For example, a 100 square-foot room is shared by 5–7 people. Basic civic facilities are poor in the slum.

Project description

Dushtha Shasthya Kendra (DSK) has been implementing a scale-fund project in two urban slums in Dhaka under a project titled “Moving from extreme poverty through the economic empowerment of extreme poor families” since 2009 to support government initiatives to improve livelihood outcomes in extremely poor families. The objective of the project is to lift 30,000 extremely poor households out of poverty. The project incorporated nutritional support in 2012. The intervention included counseling pregnant and breastfeeding mothers to breastfeed exclusively, providing breastfeeding demonstrations, and promoting awareness of complementary feeding from six months onwards, food hygiene, hand washing, sanitary practice, and dietary diversity. Micronutrient powder (MNP) supplements were also provided to children aged 7–23 months. Approximately 56% of female-headed families are self-employed, indicating that a high proportion of women are engaged in cash-generating activities outside the home.

Data collection procedure

Data were collected between November 2014 and February 2015. The author conducted in-depth interviews (IDI) and focus group discussions (FGD). Sixteen IDI were conducted with the primary family caregiver in the household (e.g., mother, father, relative) to determine their IYC feeding experience and practice. We considered these as infant and child who belong to 0–23 months of age. Six FGD were conducted to explore communal attitudes and perception of factors that affect IYC feeding practice. We also conducted five key informant interviews (KII) with project staff (Nutrition Officer cum Master Trainers; NOMT) who are assisting with intervention implementation to understand various aspects of IYC feeding practices in slums. Participants were purposely chosen, which is a common guiding principle of qualitative research design [15]. The sample size was fixed based on the principle of data saturation—we stopped collecting data when no new information, dimension, or aspect emerged. Table 1 summarizes the methods in detail.

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Table 1. Methodology and Participants.

https://doi.org/10.1371/journal.pone.0172119.t001

Data management and analysis

Interviews were conducted in Bangla, the mother tongue of the interviewer and participants, and were recorded electronically. Data were analyzed using a thematic analysis technique. After verbatim transcription, the interviews were translated into English. Broad recurring themes were identified from the interviews. Next, we generated codes based on the meaning statement of the interview, and then looked for clusters of codes. To increase coding validity, independent codes were created from a few interviews by the first author and a research assistant. Finally, triangulation of interviews and focus group discussions was used to validate the data.

Ethical considerations

This study was reviewed and approved by the ethical review committee of Shiree under the research administration. The research administration of Shiree reviewed human subjects involved in the proposed protocol prior to beginning the study. Participation was voluntary. Balancing risk involvement, practicability, and ethics, we sought verbal consent. In slums, asking for a signature or thumbprint implies that the person is getting involved in a very serious and/or complex issue, which might discourage participation. We developed a consent form containing the objective, importance, and possible pros and cons of the study, which were explained to participants. Considering the circumstances, we proposed to take verbal consent of the participants, which was approved by ethical review committee. The author read the consent form and informed participants of their right to information, and then encouraged them to inquire about the study. Verbal consent was audio-recorded.

Mother’s livelihood and IYC feeding patterns

Mothers, CBO leaders, and program personnel including CPK (Community Pushti Kormi) and Nutrition Officers commonly reported that IYC in slum families were more likely to consume processed food due to their mothers’ work. Mothers reported that they were engaged in a variety of cash-earning activities that made cooking at home difficult. Consequently, IYC were commonly fed cheap processed food to meet food requirements. Such cheap food items are processed in small and medium food factories, contain poor nutritional density, and are often prepared in unhygienic conditions. Table 4 shows three categories of processed foods that are cheap, available, and easy to prepare and serve.

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Table 4. Consumption of processed food by IYC in the last 24 hours of interview.

https://doi.org/10.1371/journal.pone.0172119.t004

Although young mothers are generally aware of the nutritional value of different kinds of food, appropriate feeding times, and hygiene practices, they are often inconsistent about feeding IYC accordingly because they are away from home due to their work. They reported learning about these topics through NGO interventions like information sharing, counseling, and demonstration. In an IDI, one mother said:

“Apa (CPK) taught me how to feed a child and suggested exclusive breastfeeding until the child is six months of age. She showed me how to administer home-cooked food to the child after six months using a bati (small bowl). She also gave me a pusti packet (nutrition supplement) that is mixed with rice to increase its nutritional value. I try to follow her instructions.”

However, while mothers are working away from home, IYC are mostly looked after by older siblings (4–10 years old). It is common for mothers to leave a little cash with the caregiver so they can buy food from local groceries or vendors to feed themselves and the IYC. There are also some home-cooked meals at home, but caregivers (elder sibling, neighbor, elderly relative/kin) are generally “unable” to properly feed IYC because they lack knowledge about nutrition and hygiene needs. Apart from older siblings, grandmothers (women’s mothers-in-law) mostly take care of IYC while mothers are at work. Mothers-in-law are perceived to have minimal nutritional knowledge and are often likely to neglect IYC. In many cases, IYC are not adequately fed in a timely manner by these caregivers. Fathers rarely cooked for IYC. In Bengali culture, men do not generally participate in food preparation at home because this is perceived as a woman’s duty. Although women living in slums work and earn, men do not prepare food or care for their IYC while mothers are at work. Only one father reported that he once administered liquids to his child with the help of an older sibling. Generally, fathers preferred to buy food from local groceries or vendors, or fed the child whatever home-cooked meal was left before the mother went to work. This care pattern was corroborated by numerous respondents. For example, one mother said the following in an IDI:

“My infant was in good health until I started my business as a hawker. Since then, his health has been deteriorating. He is getting smaller, losing weight, and getting ill very often. His older sibling is not capable of looking after him properly because she is also a child. Sometimes, I leave a little money for them to buy, biscuits, bread, chips, etc. I do not have any other option because I have to be away for long hours due to work.”

Similarly, a CPK from FGD explained:

“In many cases, the responsibility of taking care of IYC, which includes feeding, cooking, and bathing, is transferred to an older sibling aged 6–7 years. This is where the main problem lies, because the caregiver does not have any knowledge of hygiene or nutrition. The young child herself needs care, how can she take care of another baby? The mothers often return home late after a day of strenuous labor and have little energy left to breastfeed the child.”

Similarly, one nutrition officer stated the following in a KII:

“How can we expect that such a little child [7–10 years old] to properly feed the infant and young child? Many times he himself eats non-family food. How can he protect the young child from the introduction of cheap, unhygienic, and poor nutritional food?”

Usually, the mothers earn very little through their works as they are mostly involved in low-paying informal job. Among them, the mothers working at garment earn comparatively bigger that ranged from US$ 40 to US$65 a month. The rest of the mothers such as housemaid or scavengers reported to earn less than US$ 30 a month. Majority of participants reported that the mothers had little and/or no scope for spending their wage to buy quality food as their husbands spend it. Usually the husbands spend it to pay house rent, basic utilities, food grains, cloth, transport, and health care. One of the CPKs in KII stated

“The women enjoy little and/or no freedom in spending their income to buy quality food for infant and young child because, they are struggling to survive. They earn very little that limit their desire to spend beyond basic need. Besides, they have to give this money to their husbands as the husbands are the key decision makers and care taker of the families.”

Breastfeeding and mothers’ livelihoods

Participants reported that mothers often skip breastfeeding due to working time constraints. This results in infants consuming semi-solid and even solid food before reaching six months of age. Nearly two thirds (9/16) of mothers interviewed told us that they were unable to breastfeed their IYC adequately and in a timely manner because their babies are sleeping or not hungry when they leave for work early in the morning. In an IDI, one mother stated:

“How can I regularly breastfeed my child? I need to go to work so that my family can survive. I had to start working when my child was only four months old. I could not breastfeed and had to choose other options.”

However, some mothers informed us that they extracted and stored milk before leaving their homes, as program individuals (mostly CPK) suggested and demonstrated. The purpose of extracting is to save milk for later use. However, caregivers did not adequately feed that milk to IYC in a timely manner. Participants commonly reported that they (caregivers) hardly maintained timeliness and frequency of feeding. Half (3/5) of the CPK reported similar things. In an FGD, one CPK said:

“We advise the mothers to extract breast milk before leaving for work. However, many mothers are unable to do so as they leave for work in the morning. We have noticed that infants often become dependent on cheap processed food such as suji and milk before reaching six months of age.”

In a KII, another nutrition officer said:

“Even when mothers stored breast milk at home before leaving for work, the caregiver could not administer it properly. Often, the milk was not properly stored, or the caregiver could not understand how many times or when to feed the child or what milk temperature was ideal for feeding. This happened, of course, because they were IYC themselves, and lacked adequate knowledge on the matter.”

There are some exceptions. In an IDI, one mother reported that her child was breastfed beyond six months of age by minimizing working hours:

“I continued exclusively breast feeding until my child was six months of age. Supplementary food/milk was out of the question because I could not afford it. Because I work as street vendor, I tried to work hours that would give me the minimum income I needed and came back home early to breastfeed my child.”

Most respondents reported that they hardly managed to maintain the minimum number of meals required for their young IYC (twice for breastfed infants 6–8 months, three times for breastfed IYC 9–23 months, and four times for non-breastfed IYC 6–23 months) [16]. Additionally, multiple caregivers, including older siblings, mothers, grandmothers, and fathers, took care of the IYC at different times during the day and fed the child according to their own convenience, not according to the needs of the child. It is not common for relatives to be taken temporarily from their village home for the purpose caring for IYC while mothers are at work. However, it is common for the relative to go back to their home, so the family must bring another relative. In a KII, one nutrition officer stated:

“The child is sometimes taken care of by an older sibling, sometimes by the husband, and sometimes by relatives. The relatives are taken from their village homes to provide care when mothers are absent. But, relatives may go back to their village at any time.”

Consequently, young infants are often fed cheap, processed food from local groceries, and feeding times are inadequately spaced. Although some participants stated that the IYC were normally fed a variety of food based on availability and cost, the minimum dietary diversity intake requirement (foods that contain protein, carbohydrates, fat, vitamins, and minerals) seemed to be inadequate in most families interviewed. IYC were less likely to be fed milk products and animal foods. Limited purchasing power and lack of knowledge of the proxy care givers are main reasons for nutrition deficiencies. One of participants in a KII informed

“Although the mothers have gained good level of knowledge as we get them involved in program intervention, the proxy caregivers often remain beyond. Therefore, the proxy caregivers lack level of knowledge about the proper feeding while the mothers are at works. … Poor level of knowledge about feeding might result in nutritional deficiency such as underweight and/or stunting among infant and young child”

Food items from local stores are introduced to the IYC along with home-cooked meals, but this still fails to maximize dietary variety due to poor nutritional quality. In Kamrangirchar, some major internal chicken organs like gizzards, kidneys, hearts, brains, and livers are cheap. Street vendors collect and sell these organs on roadsides while restaurants and chain shops reject them. However, such chicken items are not available in Korail. Thus, chicken organs are a popular food item in slum families in Kamragirchar. In an IDI, one mother said:

“In slums, you can buy leftover poultry organs at a low price, even cheaper than some vegetables. Many people sell it on street corners.”

Basic civic facilities and feeding patterns

Around two thirds (10/16) of participants in IDIs and majority in KIIs and FGDs reported that a crucial reason for not attaining minimum nutritional requirements was the lack of facilities in slums. We found that although most families had gas connectivity, an inadequate supply forced them to skip cooking. In both slums, gas burners are shared. Consequently, it is difficult to cook multiple times a day. This problem is exacerbated by an inadequate gas supply. Usually, gas pressure is adequate late at night to the morning; thus, most families try to cook at this time. Mothers often wait in line to get a turn. As a result, women often cook large quantities of food, and it is common for women who leave for work in the early morning to miss the chance to use the shared burner. Apart from that, the family has limited/no use of firewood for cooking because it is expensive. Families seem to use firewood for cooking when it is the only option. Otherwise, they avoid using firewood for cooking because it is expensive. Instead, they resort to buying food like cheap bread and butter from local vendors, which is also fed to the IYC. Such observations came from multiple participants (both mothers and CPK). In an IDI, a nutrition officer said:

“Meals are cooked once a day due to inadequate gas supply in the slums. And those that use firewood to cook tend to avoid cooking from time to time because of the high cost of firewood. This leads to buying processed food items for themselves and their IYC.”

In an IDI, one of the mothers in Kamrangirchar said:

“If you consider the cost of firewood, it is nearly the same as the cost of the food that will be cooked. I bought 40 kg of firewood, so I will be calculating about when I will use it. I have the ability to buy another 40 kg this week. I cannot use that firewood randomly. Rather, I consider using it when I really need to cook. It may be wise to use it at most once a day.”

In an IDI, another mother in Korail explained how the cost of firewood leads to feeding processed food:

“Five kg of firewood costs 50 taka. I cannot afford it every day. I can only buy three kg, and that is not sufficient for cooking more than once a day. So, I buy chewing gum, chocolate, and lollypops to feed my child. These products are very cheap and you can feed three or four young babies with only 10 taka.”

Moreover, after long hours of physical work, mothers are exhausted and do not have enough energy to care for and feed their babies. Because they have other household duties to perform, childcare is in competition with cooking, washing clothes, dusting, cleaning, and socializing. Some participants struggle to provide care for their infants because there is no one else available to look after them at home, and there is no childcare support (especially for young mothers with their first baby). This reduces the likelihood of maintaining proper feeding. Furthermore, babies are exposed to unfavorable environments that cause sickness. One nutrition officer explained the situation in a KII:

“I found a mother who was engaged in heavy construction work at night. She had to take her one-month-old baby with her to work because there was nobody at home to take care of the child. The newborn thus got a cold and fever.”

Because good quality processed food is unaffordable, mothers are pushed to choose food items for young babies that lack proper nutritional properties. More than half of the participants reported opting for cheap food items for their babies because they are cheap, available, and suitable for feeding IYC. They make this decision even though they know that inadequate feeding practices coupled with frequent introduction of cheap processed food at home might deteriorate nutritional intake in young babies.