Individual Applications of Turkish Lactating Women to Increase the Their Breastmilk Production

For cited: Alp Yılmaz, F., Şener Taplak, A. & Polat, S. (2018). Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production. Journal of Current Researches on Health Sector, 8 (2), 121-134. Journal of Current Researches Year: 2018 on Health Sector

Volume: 8 (J o C R e H e S) Issue: 2 www.stracademy.com/jocheres ISSN: 2547-9636

Research Article/Araştırma Makalesi doi: 10.26579/jocrehes_8.2.12

Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production Figen ALP YILMAZ1, Ayşe ŞENER TAPLAK2 & Sevinç POLAT3

Keywords Abstract Breastmilk, Breastmilk is known to be the oldest food given to infants after birth. In applications, cases when breastmilk is inadequate, mothers resort to a variety of practices cultural. to increase breastmilk supply. The sample of the study consisted of 323 breastfeeding mothers who had 0-6-month old babies and presented to Family Health Centers (FHC) in Yozgat. The data were collected by the questionnaire form. In this study, it was determined that the participants consumed plenty of liquids and breastfed their babies frequently to comply with the recommendations to increase their breastmilk production. They Article History also resorted to the following cultural practices: eating nutritious foods such Received as grape molasses, figs, bulgur wheat pilaf, sweet, carob, legumes, walnuts, 9 Oct, 2018 onions and compote, kaynar or herb teas. In the study, it was determined Accepted that, women resorted to various cultural feeding practices in addition to 30 Dec, 2018 recommended practices to increase breastmilk production.

1. Introduction Breastmilk, the most basic right of every newborn, is the ideal food for the baby’s optimal growth and development (Mosca & Lorella, 2017; WHO, 2012). The World Health Organization suggest that infants should be exclusively breastfed for the first six months and then until the age of two, their diet should include complementary foods in addition to breastmilk (WHO, 2009). On the other hand, breastfeeding rates both in Turkey and in the other countries of the world are not at the desired level. Over two-thirds deaths occurring worldwide during the first year of life of children are often associated with inappropriate feeding practices, especially due to poor exclusive breastfeeding practices. Only 43% of newborns worldwide are breastfed within the first hour of life and only 40% of babies younger than six months of age are exclusively breastfed (Factsheet, 2014). According to the latest data in Turkey, only 58% of babies exclusively breastfed in the first two months after birth and this rate decrease to 10% in the 4-6 months postpartum (Turkey Demographic and Health Survey-TNSA 2013). However, in addition to all the known benefits of breastfeeding for infants, recent studies have

1 Assist. Prof, RN. Bozok University, School of Health 2 Assist. Prof, RN. Bozok University, School of Health, [email protected] 3 Corresponding Author. Prof. PhD, RN. Bozok University, School of Health shown that breastmilk also includes cancer-protective agents and root cells, and that nucleotide concentrations present in breastmilk vary during the daytime and nighttime, and while those being higher at nights induce night sleep and those being higher during daytime have an activity-enhancing effect (Uga et al, 2008; Kayhan, 2016). The mortality rate in breastfed infants is 88% less than that in infants who have never been breastfed, and breastfed infants have a lower risk of developing infectious diseases such as otitis media (Victora et al., 2016; Sankar et al., 2015). It has also been determined that breastfeeding significantly reduces the children’s hyperactivity score at age 4 and increases their social skills score and success rates in intelligence tests at older ages (Witkowska-Zimny & Kaminska-El- Hassan, 2017; Luby et al., 2016; Briere et al., 2016; Kayhan, 2016; Uga et al., 2008; Caspi et al., 2007; Fito et al., 2007). Breastfeeding is beneficial not only for infants but also it has numerous benefits to women's health (Victora et al., 2016; Gunderson et al., 2015; Dias and Figueiredo, 2015; Aune, Norat, Romundstad, & Vatten, 2014; Bobrow et al., 2013). Studies conducted on the issue have shown that even though the first food given to newborns is breastmilk, some problems are experienced in maintaining the continuity of breastfeeding (Çatak at al., 2012; Gün et al., 2009; Kondolot, Yalçın & Yurdakök, 2009; Ünalan et al., 2008; Midyat et al., 2008) due to several factors (Huang et al., 2017; Soomro et al., 2017; WHO, 2009; Heck et al., 2006). Among these factors, women’s perception that their milk supply is inadequate has a major place (WHO, 2009; Wood et al., 2017; Ndikom et al., 2014). This perception causes some women to resort to some practices to increase their breastmilk production, some women to terminate breastfeeding earlier and change the baby’ diet, and some women to start complementary foods earlier. Because women's breastfeeding practices to increase their breastmilk production will contribute to the continuity of breastfeeding, it is important that these practices be investigated in terms of their benefits and harms. In the literature, there is a gap related to studies investigating methods used by women to increase their breastmilk production. Practices to increase breastmilk production vary from one community to another. Sometimes a practice welcomed in one country may not be accepted in another country or may be considered risky (Osmana, Gaffer, Sharkawy, & Brandon 2017). For instance, to increase their breastmilk production, women in Iran eat candies including hazelnuts, peanuts and walnuts or drink sherbet, women in Vientiane drink only herbal tea for the first fifteen days, and women in Thailand are encouraged to consume warm foods or liquid food products (Kaewsarn et al, 2003; Özsoy & Katabi, 2008; Barennes et al., 2009). In Turkish society, breastfeeding is a cultural health behavior, and it is very important that mothers produce an abundance of breastmilk (Demirtaş, 2005; Canpolat, 2013). Breast milk is not only used as a food but also as medicine in the treatment of many health problems such as rash and earache. Therefore, because reduction or drying up of breastmilk is not desired, and because early lactation and abundant breastmilk supply are desired, practices such as consuming foods and liquids contributing to breastmilk production and avoiding attitudes affecting the mother's psychology negatively are traditionally recommended (Kurt, 2012).

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Consuming mulberry compote, boiled wheat or black meat of a rooster by women who have inadequate or no milk supply, rubbing onion or wrapping warm towel on woman's breasts are among practices aiming to increase breastmilk production in Turkey (Koyun et al., 2010; Işık, Akçınar, & Kadıoğlu, 2010; Özsoy & Katabi, 2008; Yeşildal et al., 2008; Eğri and Gölbaşı, 2007). The literature review showed that such practices vary from one region to another, and that this issue should be addressed more comprehensively (Tanrıverdi et al., 2014; Lafçı & Erdem, 2014; Koyun et al., 2010; Işık et al., 2010; Gökduman, 2009; Özsoy & Katabi, 2008; Yeşildal et al., 2008; Eğri & Gölbaşı, 2007). Therefore, within the scope of breastfeeding counseling to be provided by health personnel, it is important to identify regional differences to teach women effective practices to increase their breastmilk supply, to support appropriate behaviors for the continuity of breastfeeding and to inform them about non-beneficial practices. This study was carried out to determine practices performed by breastfeeding women to increase breastmilk supply in one of the cities located in the Central Anatolia Region and rich in cultural heritage. 2. Methods 2.1. Design This study was conducted as a cross-sectional study between March 2015 and May 2015. 2.2. Sample The study was conducted in 6 Family Health Centers (FHC) selected from the 11 FHCs in the city center of Yozgat, a province in Turkey, using the stratified sampling method. The minimum sample size was calculated with the G*Power according to the frequency of an event when the population size is known. Breastfeeding rate in the first 6 months was 30.1% according to the Turkey Demographic and Health Survey (TNSA, 2013). Based on this, the minimum sample size was calculated as 285 people. Breastfeeding women who presented to FHCs on the dates comprised the population of the study. Of these breastfeeding women, 323 women who agreed to participate in the study, who had no physiological or psychological problems, who had no communication and language problems, and who had 0-6-month old babies were included in the study sample. 2.3. Data collection In the collection of the data, a questionnaire prepared by the researchers was used. The questionnaire consists of 22 items questioning the participants' sociodemographic characteristics and the practices implemented by them to increase breastmilk production. 2.4. Setting Prior to the data collection phase of the study, the FHC principals and women were informed about the purpose and scope of the research and the data were collected after the examinations. Data collection tools were completed in 15 minutes by the researchers together with the women who agreed to participate in the study and

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gave their written informed consents through face-to-face interviews in a room in the FHC. 2.5. Data Analysis The data were analyzed in the computer environment using the descriptive statistical analysis (numbers, percentages). In the analysis, the IBM statistical package program 21 was used. 2.6. Ethical Principles of the Study The study protocol was designed in compliance with the principles of the Declaration of Helsinki. Prior to data collection, necessary approvals and permissions were obtained from the Bozok University Clinical Research Ethics Committee (Decision date and no: 2015/25) and Yozgat Public Health Institution. In addition, after the participants were informed of the purpose of the study and the confidentiality of their credentials, their informed consent was obtained. 3. Results Table 1 shows the sociodemographic characteristics of women. Of the women participating in the study, 66.6% were in the 26-45 age group, 39.6% were high school graduates and 81.4% were unemployed. The inquiry about the history of pregnancy and delivery related to the baby they had now demonstrated that of them, 53.9% gave birth through vaginal delivery, 74.9% had intended pregnancy and 64.7% had 0-3-month old babies. Table 1. Participants' Sociodemographic Characteristics (N=323) Sociodemographic Characteristics Number Percentage Age 18-25 108 33.4 26-45 215 66.6 Education status Illiterate 15 4.6 Primary school 129 39.9 High school 128 39.6 University 51 15.8 Employment status Employed 60 18.6 Unemployed 263 81.4 Economic status Income less than expenses 70 21.7 Income equal to expenses 211 65.3 Income more than expenses 42 13.0 Family type Nuclear family 178 55.1 Extended family 145 44.9 Birth type Vaginal Delivery 174 53.9 Cesarean Section 149 46.1 The number of pregnancies 1 119 36.8

124 Alp Yılmaz, F., Şener Taplak, A. & Polat, S. (2018). Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production

2 90 27.9 ≥3 114 35.3 The number of living children 1 127 39.3 2 109 33.7 ≥3 87 27.0 The baby’s age 0-3 months 209 64.7 4-6 months 114 35.3 Planned (intended) pregnancy Yes 242 74.9 No 81 25.1 Long-lasting health problem Yes 31 9.6 No 292 90.4 Medication taken for a long time Yes 37 11.5 No 286 88.5 Smoking Yes 70 21.7 No 253 78.3 Table 2 shows breastfeeding-related characteristics of the participants. Of them, 99.4% breastfeed their babies as they cry, 45.2% thought that their breastmilk was not enough for the baby, 23.5% thought that their breastmilk was not enough because the baby was still restless and did not sleep even after they breastfed and changed the baby, and 77.2% started complementary food because the baby was not full. Of the participants who thought their breastmilk supply was not enough, 20.7% started complementary food before the baby was 6 months old, and 69.3% started complementary food when the baby was 6 months old.

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Table 2. Breastfeeding-Related Characteristics of the Participants Characteristics Number Percentage Perception of whether the breastmilk production is adequate n=323 Adequate 177 54.8 Inadequate 146 45.2 Criteria for deciding whether the breastmilk production is adequate n=323 The baby’s weight is low by month; his/her 36 11.1 growth rate is low. The baby is always sleeping, not active and 20 6.2 very quiet. Even after it is breastfed, and its diaper is changed, the baby is still restless and does 76 23.5 not sleep. Fewer than 6 wet diapers a day 11 3.4 The frequency of breastfeeding (how frequently the baby is breastfed) n=323 As the baby cries 321 99.4 Every 2 or 3 hours 2 0.6 Diet including complementary food (does the include complementary food ) n=323 Yes 114 35.3 No 209 64.7 The reason for starting complementary food n=114 I was sick and taking medication. 9 7.9 My baby did not benefit from my breastmilk. 11 9.6 My baby was not full. 88 77.2 My baby stopped breastfeeding. 6 5.3 The time when complementary food was started n=114 4th month of life 10 8.7 5th month of life 25 22.0 6th month of life 79 69.3 Table 3 shows the practices performed by the participants to increase their breastmilk production. It was determined that women participating in the study consumed plenty of fluids, exercised, received breast massage, slept regularly, breastfed their babies frequently and paid attention to their diet to increase their breastmilk production. Among the foods consumed by women to increase their mothers in accordance with their culture were molasses, figs, bulgur pilaf, sweet, locusts, legumes, walnuts, onions. Among the liquid food products, they consumed were compote, herb tea and kaynar including a mixture of 7 kinds of spices.

126 Alp Yılmaz, F., Şener Taplak, A. & Polat, S. (2018). Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production

Table 3. Practices performed by the participants to increase their breastmilk production (N=323) Characteristics Number Percentage Practices aimed at increasing breastmilk production* Plenty of fluid consumption 165 51.0 Exercise 5 1.5 Massage 10 3.1 Regular sleep 8 2.5 Frequent breastfeeding 321 99.4 Regular diet (balanced diet) 48 14.9 Foods consumed to increase breastmilk supply * Grape molasses, 32 9.9 Corn 2 0.6 Bulgur wheat pilaf 87 26.9 Figs 54 16.7 Herbs 59 18.3 Sweets 19 5.9 Rice 5 1.5 Carob 10 3.0 Legumes 2 0.6 Walnuts 9 2.8 Fruit 23 7.1 Yogurt 5 1.5 Eggs 2 0.6 Onion 26 8.0 Honey 4 1.2 Beverages consumed to increase breastmilk supply * Fruit juice 80 24.7 Herbal tea 53 16.4 Milk 72 22.3 Compote 181 56.0 Kaynar 28 8.6 *More than one option was chosen. 4. Discussion Although it is known that the oldest food given after birth is breastmilk, women can resort to various behaviors such as stopping breastfeeding in a short time or starting complementary foods earlier due to the perception that their breastmilk is not enough (Yeşilçiçek, Coşar & Erkaya, 2017; Wood et al., 2017; Ndikom et al., 2014; İnanç, 2013; Bağcı, 2006). In the present study, nearly half of the women participating in the study had a perception that their breastmilk supply was inadequate and one third of them started complementary food earlier. In the present study, the participants consumed plenty of liquids and breastfed their babies frequently to comply with the recommendations to increase their breastmilk production. They also resorted to the following cultural practices: eating nutritious foods such as grape molasses, figs, bulgur wheat pilaf, sweet, carob, legumes, walnuts, onions and compote, and drinking sherbet or herb teas. In the literature, it is recommended that babies should be breastfed at frequent

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intervals using correct techniques, breasts should be emptied, and mothers’ self- confidence should be increased by encouraging them to have adequate sleep and rest (Quigley, 2007; Taşkın, 2012). In the present study, it was determined that the participants preferred to use cultural methods besides the effective methods. That most cultural practices include carbohydrate-rich diets is noteworthy and indicates that women lack knowledge regarding adequate and balanced diet and that they have the misconception that foods with sugar increase breastmilk production (Kaewsarn et al, 2003; Jamaludin, 2014; Erkaya et al, 2015; Jamaludin & Aloysius, 2017). It is known that throughout the world, there are various nutritional practices aiming to increase breastmilk (Kaewsarn et al, 2003; Barennes et al., 2009; Jamaludin, 2014; Jamaludin & Aloysius, 2017). Barennes et al., reported that in Vientiane, 95% of the women in the postpartum period traditionally consume sugar free herbal tea, because they believed that this tea increases breastmilk supply, cures birth-related tissue defects and prevents heart failure (Barennes et al., 2009). In Malay, Chinese and Indian cultures, traditionally, foods are thought to play a role in the cause and treatment of a disease, and information on 'warm' and 'cold' food is passed on to family members. According to this, for example, some fish species and vegetables and fruits are included in the cold food classification and feeding with cold foods is restricted due to the blood loss of the woman during the birth (Jamaludin, 2014; Jamaludin & Aloysius, 2017). It was also found that, in Thailand, to increase breastmilk supply, foods to be consumed were restricted and women were encouraged to consume warm or liquid food products (Kaewsarn et al, 2003). In various studies conducted on the issue in Turkey, different results were obtained. In their study carried out in Trabzon, a province in the Black Sea Region of Turkey, Erkaya et al. found that the foods most believed to increase breastmilk production were vegetables-herbs, soups, compote, fruits, fennel tea, Humana Still Tea (a mixture of vitamin c, sucrose, maltodextrin and several herbs such as fenugreek, fennel, vervain, musk mallow, rooibos, raspberry), milk puddings and bulgur wheat pilafs (Erkaya et al., 2015). Folk culture in Dogansar, a district of Sivas Province of Turkey, requires women to consume bulgur wheat pilaf with onion, kaygana (a kind of food made with eggs and butter), helle or kuymak (a kind of dessert made with sugar, starch and butter), honey, grape molasses, Turkish delight, rice pudding, lentil bulgur pilaf to increase breastmilk production. They also breastfeed their babies when they are alone to protect their baby and to maintain continuity of breastfeeding against evil eye (Kurt, 2012). In Tanrıverdi's study, it was reported that to increase breastmilk supply, puerperae were encouraged to consume whatever they wished, to eat excessively, to consume foods including sugar more, to drink lohusa sherbet, a kind of sherbet made with water, sugar, cinnamon, and cloves, and to receive warm breast massage (Tanrıverdi, 2015). In their study, Lafçı and Erdem reported that to increase breastmilk supply, breastfeeding mothers were encouraged to consume rice with lentil, liver, meat, bulgur pilaf, halva, onion and salad and liquid food products such as grape molasses, mulberry juice, quince compote, light tea and milk (Lafçı and Erdem, 2014). In Uğurlu’s study, among foods regarded to increase breastmilk supply were halva (dessert including sugar and tahini-

128 Alp Yılmaz, F., Şener Taplak, A. & Polat, S. (2018). Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production condiment made from toasted ground hulled sesame seeds), onion, kidney beans and rice (Uğurlu, 2013). In similar studies conducted in different regions, it was determined that breastfeeding women consumed bulgur wheat pilaf and beverages such as linden tea, fennel tea and nettle tea to increase their breastmilk production (Koyun et al., 2010, Özsoy and Katabi, 2008; Eğri and Gölbaşı, 2007). These results are consistent with those of the present study. In the present study, increased intake of water, herbal teas and sweetened liquids were among the methods implemented to increase breastmilk supply. Breastfeeding women whose breastmilk production is not sufficient are recommended to increase their fluid intake during the lactation period (National Health and Medical Research Council, 2012; Ndikom et al., 2014). While Gökduman determined that consumption of water, milk, and fruit juice in abundance was thought to increase breastmilk production, Tanriverdi et al. determined that consumption of water, cow milk and buttermilk was thought to increase breastmilk production (Gökduman, 2009; Tanriverdi et al., 2014). In studies conducted on this issue in Turkey, consumption of herbal teas was thought to increase breastmilk production and among the herbal teas, the most preferred ones were made with fennel, linden, anise, rosehip, sage, nettle, galactagogue, or quince leaf (Tırak, Dilli, Emeksiz, & Dallar, 2008; Atılgan, Oguz & Dilmen 2009; Gökduman &Balkaya, 2010). In the present study, among methods implemented to increase breastmilk supply were exercise and breast massage. In the literature, acupressure is recommended to increase breastmilk supply because it is non-invasive, natural, inexpensive and very easy to apply, and has no side effects, (Maraşlı, Ünal, Harman, & Sert 2015). In Savabi Esfahani et al.’s study, it was determined that applying acupressure to SI1, LI4 and GB21 for 2-5 minutes three times a day for twelve days increased the breastmilk production (Savabi et al., 2015). 5. Conclusion Breastfeeding is of great importance in terms of having healthy individuals and healthy generations. To increase breastmilk production, cultural nutrition practices are increasingly used in the Turkish society. Therefore, to ensure the continuity of breastfeeding, breastfeeding counseling practices should include training given to people by health personnel to assist them to cope with the problems they experience in this process, and to raise the public’s awareness of relevant cultural practices. In this respect, of the traditional practices, those which contribute to breastmilk production should be protected and maintained, and those which are non-beneficial should be determined and the public should be informed about them, which will help increase breastmilk production and ensure the continuity of breastfeeding. Limitations Research results are limited to this population only. Another limitation of the study is that it was conducted in only FHC and limited time.

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134 Alp Yılmaz, F., Şener Taplak, A. & Polat, S. (2018). Individual Applications of Turkish Lactating Women to Increase the their Breastmilk Production