Experiences and beliefs related to exclusive breastfeeding and early supplementation in low income urban slums of Karachi, Pakistan- a qualitative study

In Pakistan, exclusive breastfeeding (EBF) is often difficult to establish and sustain in low-income urban settings due to limited access to antenatal and postnatal care, maternal undernutrition, socioeconomic constraints, sociocultural myths, and extended family influence. These factors frequently lead to early supplementation when breastfeeding is perceived as insufficient. We conducted a qualitative exploratory study using focus group discussions in four low-income urban slums of Karachi, Pakistan in January 2020. Our study aimed to explore the community beliefs and barriers relating to EBF practices. Nine focus group discussions were held with 84 caregivers, including mothers, fathers, and grandmothers of infants, as well as community health workers. Data was collected, translated and transcribed verbatim, and analyzed using an inductive thematic approach informed by a sociocultural conceptual framework. Overall, participants were aware of breastfeeding benefits, but many mothers lacked knowledge of proper breastfeeding techniques. The key dominant barriers we identified realting to sustained EBF included perceived inadequate milk production by mother, maternal health concerns, limited psychosocial support, and the influence of extended family members. In situations where breastfeeding was not possible, early complementary feeding was often preferred over expressed breast milk or formula. Caregivers were aware of the recommended feeding practices, yet adherence remained challenging as many mothers lacked practical knowledge of proper breastfeeding techniques and reported physical difficulties such as pain, perceived insufficient milk supple, and fatigue related to post partum workload. Concerns about infant size and growth frequently prompted early supplementation, often with liquids, herbal preparations, or semi-solid foods, rather than expressed breast milk or formula. While caregivers were broadly aware of recommended feeding practices, adherence remained difficult within the constraints of poverty, joint family systems, and limited health system engagement. Strengthening family-centered counseling which takes into account famuly dynamics during antenatal and postnatal care, empowering community health workers to address common myths, and improving support for mothers in low-resource households are essential strategies to improve EBF rates. Further research is also needed on the role of early supplementation in contexts of maternal undernutrition. This study aims to explore caregivers’ perceptions, practices, and challenges regarding exclusive breastfeeding and early supplementation in low-resource urban communities of Karachi, Pakistan.