Mothers' Perspectives on Exclusive Breastfeeding During the First Six Months of Life: A Qualitative Study from Urban and Rural South Andaman, India

Mothers' Perspectives on Exclusive Breastfeeding During the First Six Months of Life: A Qualitative Study from Urban and Rural South Andaman, India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mothers' Perspectives on Exclusive Breastfeeding During the First Six Months of Life: A Qualitative Study from Urban and Rural South Andaman, India Samar Hossain¹, Aanchal Anand¹, Ajay Raj Sethuraman¹, Gayathri Ponath Sukumaran¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9352280/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Despite near-universal institutional delivery (> 99%) in the Andaman & Nicobar Islands, early breastfeeding initiation within one hour of birth remains as low as 46.9%, suggesting significant missed opportunities for postpartum lactation support. The experiential and socio-cultural determinants underlying this paradox are poorly understood. This study aimed to explore mothers' lived experiences, knowledge, and contextual barriers and facilitators related to exclusive breastfeeding (EBF) during the first six months of life in urban and rural South Andaman. Methods A descriptive qualitative study was conducted using semi-structured in-depth interviews (IDIs) with 28 purposively sampled mothers of infants aged 0–6 months from an urban (UHTC Haddo) and a rural (CHC Bambooflat) site in South Andaman. Maximum-variation sampling ensured diversity across parity, education, employment, delivery mode, and family structure. Data were analysed using reflexive thematic analysis (Braun & Clarke). Rigour was enhanced through independent coding, triangulation, and peer debriefing. Results Six themes were identified: (1) early breastfeeding experiences including postpartum pain, latch difficulties, and post-caesarean delays; (2) a knowledge–practice gap driven by persistent cultural misconceptions despite high baseline awareness; (3) dual-role family dynamics offering both practical support and conflicting feeding advice; (4) inconsistent health-system counselling and limited postnatal follow-up; (5) structural barriers including maternal fatigue (82.1%), workplace constraints, and formula marketing; and (6) divergent urban–rural contextual patterns. Maternal fatigue was the most prevalent barrier. Urban mothers faced predominantly structural barriers; rural mothers faced stronger socio-cultural pressures. Conclusions Sustained EBF in South Andaman is undermined by interacting physical, psychological, cultural, and structural determinants rather than knowledge deficits alone. Context-sensitive, multi-level interventions encompassing skilled postpartum lactation support, family-inclusive counselling, community peer networks, and strengthened postnatal follow-up are essential. exclusive breastfeeding qualitative research barriers and facilitators knowledge–practice gap maternal self-efficacy Andaman & Nicobar Islands postnatal support socio-cultural determinants Background The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of life, defined as providing only breast milk without any additional liquids or solids, with the sole exception of prescribed vitamins, minerals, or medicines [ 1 ]. The evidence base is extensive: EBF substantially reduces infant morbidity from diarrhoeal disease, acute respiratory infections, and necrotising enterocolitis, and is associated with improved cognitive development and long-term health outcomes [ 2 ]. Despite this, only 48% of infants globally under six months are exclusively breastfed, well below the WHO target of 70% by 2030 [ 3 ]. In India, the National Family Health Survey (NFHS-5, 2019–2021) reported national EBF prevalence at 63.7%, with substantial subnational variation [ 4 ]. The Andaman & Nicobar Islands present a distinctive epidemiological paradox: EBF prevalence has risen to 73.3% (NFHS-5), exceeding the national average, yet early initiation of breastfeeding within one hour of birth remains as low as 46.9%, despite institutional delivery rates exceeding 99% [ 5 ]. This discrepancy indicates significant missed opportunities for skilled postpartum support during the immediate postnatal period. Determinants of suboptimal EBF are multifactorial. Physiological challenges—nipple pain, engorgement, poor latch, and perceived insufficient milk—are among the most consistently reported proximal barriers [ 6 ]. Psychological factors including anxiety and reduced self-efficacy further compound early difficulties [ 7 ]. Socio-cultural norms such as prelacteal feeding, discarding colostrum, and family pressure to supplement with formula or water are well-documented in Indian settings [ 8 , 9 ]. Health-system factors—quality of antenatal counselling, immediate postpartum support, and postnatal follow-up—are equally important modifiable determinants [ 10 , 11 ]. While quantitative surveys estimate prevalence and identify statistical associations, they cannot capture the experiential, contextual, and cultural nuances that shape feeding behaviour. Qualitative evidence from the Andaman & Nicobar Islands is absent from the published literature. This study was therefore designed to systematically explore mothers' lived experiences, knowledge, and perceived barriers and facilitators of EBF in urban and rural South Andaman, with the aim of informing locally relevant, evidence-based interventions. Methods Study design and setting A descriptive qualitative study was conducted using semi-structured in-depth interviews (IDIs). Qualitative methodology was selected for its established capacity to generate contextually rich, experientially grounded data on health behaviours [ 12 ]. Two sites in South Andaman were purposively selected to enable urban–rural comparison: the Urban Health and Training Centre (UHTC), Haddo (urban site) and the Community Health Centre (CHC), Bambooflat (rural site). Participants and sampling The study population comprised mothers of infants aged 0–6 months residing in the catchment areas of the two sites. Eligible participants were mothers aged ≥ 18 years, resident in the catchment area for ≥ 1 year, and caring for an infant aged 0–6 months. Mothers with a psychiatric illness or cognitive impairment were excluded. Purposive maximum-variation sampling was employed to ensure diversity across parity, educational attainment, employment status, mode of delivery, and family structure. Recruitment continued until thematic saturation was achieved, defined as the point at which no new codes or conceptual categories emerged across successive interviews. A total of 28 IDIs were conducted (approximately 14 per site). Data collection A semi-structured interview guide was developed covering five domains: socio-demographic profile; EBF knowledge; personal breastfeeding experiences; perceived barriers and facilitators; and urban–rural contextual differences. The guide was pilot-tested with four mothers (two per site) and refined for clarity and cultural suitability. Interviews were conducted by trained female interviewers in the participant's preferred language (Tamil, Hindi, Bengali, or English), lasted 30–60 minutes, and were audio-recorded with written informed consent. Field notes documented non-verbal cues and contextual observations. Data analysis Audio recordings were transcribed verbatim, translated where necessary, anonymised, and stored in encrypted folders. Reflexive thematic analysis was conducted as described by Braun and Clarke [ 12 ], comprising six phases: familiarisation; initial code generation; theme searching; theme review; theme definition; and reporting. Two independent researchers coded transcripts manually and using NVivo, subsequently grouping codes into subthemes and overarching themes. Cross-site comparison identified urban–rural patterns. Rigour was enhanced through coding triangulation, peer debriefing, and maintenance of a reflexivity journal throughout the analytical process. Ethical considerations Ethical approval was granted by the Institutional Ethics Committee of ANIIMS (Approval No. ANIIMS/IEC/2025/37, dated 10 December 2025). Written informed consent was obtained from all participants prior to interview. Participation was voluntary; participants were informed of their right to withdraw at any stage without consequence. Confidentiality and anonymity were maintained throughout. Results Participant characteristics A total of 28 mothers participated. Most (64.3%; n = 18) were aged 20–30 years. Index infants were distributed across both age sub-groups: 53.6% (n = 15) aged 0–3 months and 46.4% (n = 13) aged 4–6 months. Parity was equal (50% primiparous; 50% multiparous). Among participants, 60.7% had vaginal delivery and 39.3% had a caesarean section. Most (71.4%) resided in joint or extended family households and 78.6% were homemakers. Participant characteristics are summarised in Table 1 . Table 1 Socio-demographic and obstetric profile of study participants (N = 28) Characteristic n % Age of mother 20–30 years 18 64.3 >30 years 10 35.7 Age of index infant 0–3 months 15 53.6 4–6 months 13 46.4 Parity Primiparous 14 50.0 Multiparous 14 50.0 Mode of delivery Normal vaginal delivery 17 60.7 Caesarean section 11 39.3 Family type Joint/extended family 20 71.4 Nuclear family 8 28.6 Maternal occupation Homemaker 22 78.6 Employed 6 21.4 Note. Percentages may not sum to 100.0 due to rounding. Overview of themes Reflexive thematic analysis identified six overarching themes with 17 subthemes characterising the determinants of EBF practices in South Andaman (Table 2 ). These are elaborated in the sections that follow. Table 2 Master thematic framework: themes, subthemes, and key interpretive meanings Theme Subtheme Key Interpretive Meaning 1. Early Breastfeeding Experiences Initiation and first feeds Post-caesarean delays and poor early latch shaped confidence and subsequent EBF trajectory Physical challenges Nipple pain, engorgement, and latch difficulties were pivotal early deterrents, triggering emotional distress Emotional responses Anxiety and self-doubt created a negative reinforcing cycle reducing feeding frequency 2. Knowledge, Beliefs, and Misconceptions Accurate knowledge Strong foundational awareness of EBF definitions, colostrum importance, and exclusions Persistent misconceptions Prelacteal feeds, colostrum discarding, dietary restrictions; cultural norms frequently overrode biomedical guidance Influence of elder women Mothers-in-law held directive authority in postpartum feeding decisions, often conflicting with health worker advice 3. Family and Social Support Enabling support Practical help with chores and emotional reassurance from partners reduced fatigue and improved self-efficacy Conflicting advice Family pressure for supplementation undermined medical recommendations and eroded maternal agency 4. Health-System Engagement Counselling quality Inconsistent messages across providers generated confusion; inconsistency eroded confidence Postnatal follow-up gaps Limited structured home-based lactation support after discharge; particularly pronounced in rural settings 5. Structural Barriers Maternal fatigue Most universal barrier (82.1%); cumulative exhaustion precipitated consideration of supplementation Workplace constraints Return to work before six months and absence of lactation facilities undermined EBF continuity (urban) Formula marketing Exposure via social media and pharmacies created competing narratives against EBF (urban) 6. Urban–Rural Contextual Differences Urban context Better counselling access; stronger structural and workplace-related barriers Rural context Stronger practical family support; stronger socio-cultural pressures and limited technical guidance Shared experiences Nipple pain, fear of insufficient milk, and emotional vulnerability common to both settings Note. EBF = exclusive breastfeeding. Themes derived using reflexive thematic analysis (Braun & Clarke, 2006). Theme 1: Early breastfeeding experiences Early postpartum experiences profoundly shaped maternal confidence and subsequent breastfeeding trajectory. Mothers who achieved successful early latch and perceived adequate milk in the first 24–48 hours described a reinforcing cycle of confidence that sustained EBF. Conversely, delayed initiation—particularly among caesarean section mothers (39.3%)—was associated with reduced self-efficacy and emotional distress, with several participants describing gaps of 12–24 hours before first breastfeeding contact due to postoperative pain and limited mobility. Severe nipple and areolar pain within the first 14 days was reported by 67.9% (n = 19) of participants and was a pivotal early deterrent. Latching difficulties affected 60.7% (n = 17) and were attributed to breast engorgement, inverted nipples, and insufficient hands-on guidance from health workers. These physical challenges were closely intertwined with emotional responses—anxiety, self-doubt, and fear—that reduced feeding frequency and reinforced perceptions of low milk supply. "The pain was so bad in the first week that I thought something was wrong with me. No one showed me how to position the baby properly. Once the nurse helped me, everything became easier." — Urban mother, primiparous, caesarean section Theme 2: Knowledge, beliefs, and misconceptions Most participants demonstrated strong foundational EBF knowledge: 92.9% correctly defined EBF, all 28 (100%) recognised the importance of colostrum, and 85.7% were aware that no supplementary liquids should be provided during the EBF period. Awareness of infant immunity benefits was universal, whereas awareness of maternal health benefits (uterine involution, postpartum weight loss) was substantially lower (28.6%), representing a missed counselling opportunity. Despite this, persistent cultural misconceptions coexisted and frequently influenced practice. Dietary restrictions during lactation were reported by 64.3% (n = 18), with elder family members advising avoidance of 'cold' or 'gas-producing' foods without scientific basis—practices contributing to maternal under-nutrition and anxiety. Prelacteal feeding with honey or sugar water was reported by 32.1% (n = 9), colostrum was discarded by 17.9% (n = 5), and 25.0% (n = 7) believed formula supplementation was necessary for a 'thirsty' infant. These misconceptions were transmitted predominantly through elder female relatives and reinforced by community peer norms, frequently overriding correct biomedical knowledge. "My mother-in-law said colostrum is 'dirty milk' and must not be given. She is very experienced, so I listened to her at first." — Rural mother, primiparous, vaginal delivery Theme 3: Family and social support dynamics Family support emerged as a decisive bidirectional determinant. Practical assistance—help with household chores, meal preparation, and facilitation of maternal rest—was described as directly enabling more frequent breastfeeding and attenuating fatigue-related supplementation. Emotional reassurance from husbands was consistently described as protective, with several mothers attributing persistence through early difficulties to spousal encouragement. However, the same family environment also produced conflicting and counterproductive advice. Mothers-in-law and elder female relatives held directive authority in postpartum feeding decisions, particularly in joint family households (71.4%). Their recommendations—rooted in traditional practice—were perceived as authoritative and difficult to challenge, even when contradicting health worker guidance. This competing advisory landscape reduced maternal agency and undermined medical recommendations. "My husband was very supportive—he helped with everything at night. But my mother-in-law kept saying the baby is crying because my milk is not enough and I should give formula." — Urban mother, multiparous, vaginal delivery Theme 4: Health-system engagement Urban mothers more frequently reported access to structured antenatal breastfeeding counselling and immediate postpartum lactation demonstrations. However, inconsistent and contradictory counselling messages across different providers—nursing staff, medical officers, and ANMs—were reported at both sites, generating confusion and eroding confidence at the point of greatest vulnerability. Postnatal follow-up was identified as a critical structural gap. The majority of participants reported little or no structured home-based lactation guidance after hospital discharge. Frontline workers (ASHAs, ANMs) were described as focused primarily on immunisation and growth monitoring, with limited capacity for skilled breastfeeding support. Facility-level practices varied: skin-to-skin contact was not consistently implemented, and post-caesarean initiation was frequently delayed beyond recommended timelines. "After discharge, no one came to check. I had so many problems with feeding and didn't know who to call. I just started giving formula because the baby was crying." — Rural mother, primiparous, caesarean section Theme 5: Structural and environmental barriers Maternal fatigue was the most universally reported barrier (82.1%; n = 23), transcending urban and rural settings, parity, and family structure. Fatigue was cumulative—arising from disrupted nocturnal sleep, frequent feeding demands, early resumption of domestic duties, and postpartum physical recovery. In joint family settings, social expectations to resume household responsibilities within days of delivery compounded exhaustion and reduced rest essential for breastfeeding continuity. Workplace-related barriers were more prevalent in the urban setting. Among the 21.4% (n = 6) of employed mothers, anticipated return to work before six months was a significant source of distress and was associated with plans for early weaning. The absence of dedicated breastfeeding breaks, private spaces for expressing milk, and secure storage facilities were cited as key structural impediments. Exposure to commercial infant formula marketing—through social media, pharmacies, and peer networks—was more prominent among urban participants and was associated with reduced confidence in breastmilk adequacy. Theme 6: Urban–rural contextual differences Systematic contextual differences emerged across the two settings. Urban mothers at UHTC Haddo had better access to skilled lactation counselling, more frequent antenatal health contacts, and greater exposure to breastfeeding information through digital media, contributing to higher early initiation confidence. However, they faced stronger structural barriers: workplace inflexibility, formula marketing exposure, and reduced extended family support in nuclear households. Rural mothers at CHC Bambooflat benefited from stronger day-to-day practical support from extended family networks and lower workplace pressures. However, they faced more pronounced socio-cultural barriers—stronger intergenerational influence on feeding decisions, greater fear of insufficient milk reinforced by community norms, and more limited access to technical lactation guidance. Despite these contextual differences, core challenges—nipple pain, fear of insufficient milk, and emotional vulnerability—were shared across both settings, indicating a universal substrate of early breastfeeding difficulty irrespective of residence. Key indicators: knowledge and barriers Key quantitative indicators derived from participant accounts are presented in Table 3 , encompassing EBF knowledge and misconceptions, early feeding practices, and reported barriers. Table 3 Key breastfeeding knowledge, practice, and barrier indicators among participants (N = 28) Item n (%) Domain Correct definition of EBF 26 92.9 Knowledge Colostrum recognised as essential 28 100.0 Knowledge Awareness: no water/formula during EBF 24 85.7 Knowledge Awareness of maternal health benefits of EBF 8 28.6 Knowledge Dietary restrictions imposed during lactation 18 64.3 Misconception Prelacteal feeds (honey/sugar water) 9 32.1 Misconception Colostrum discarded 5 17.9 Misconception Formula perceived necessary for 'thirsty' infant 7 25.0 Misconception Early breastfeeding initiation (within 1 hour) 22 78.6 Practice Exclusive breastfeeding sustained at 0–6 months 19 67.9 Practice Severe nipple/areolar pain (days 1–14) 19 67.9 Barrier Latch difficulties in first two weeks 17 60.7 Barrier Fear of insufficient milk 18 64.3 Barrier Maternal fatigue / sleep deprivation 23 82.1 Barrier Family pressure for prelacteal feeds/water 9 32.1 Barrier Anticipated early return to work (< 6 months) 6 21.4 Barrier Note. EBF = exclusive breastfeeding. Data derived from participant self-report during in-depth interviews. Multiple responses were permitted within the knowledge domain. Discussion This qualitative study examined the lived experiences and contextual determinants of exclusive breastfeeding among mothers in urban and rural South Andaman. The central finding is a consistent and clinically significant knowledge–practice gap: despite near-universal awareness of EBF recommendations, sustained exclusive feeding was undermined by an interacting constellation of early physical challenges, psychological vulnerability, intergenerational cultural norms, and health-system inadequacies. This pattern is well-established in the global breastfeeding literature [ 8 , 9 , 11 ] and this study contributes the first published qualitative evidence from the Andaman & Nicobar Islands. The high prevalence of early postpartum barriers—nipple pain (67.9%), latching difficulties (60.7%), fear of insufficient milk (64.3%), and maternal fatigue (82.1%)—is consistent with mixed-methods studies across diverse low- and middle-income settings [ 6 , 11 ]. These barriers do not operate in isolation; they function as catalysts for a negative reinforcing cycle in which reduced feeding frequency compounds perceptions of low milk supply, driving early supplementation. The disproportionate impact on caesarean section mothers—who constituted 39.3% of the sample—is consistent with international evidence that operative delivery delays the hormonal cascade involved in milk ejection and impairs early breastfeeding establishment [ 6 ]. This finding underscores the need for dedicated post-caesarean lactation protocols within maternity facilities. The persistence of cultural misconceptions despite high baseline knowledge is particularly important. Practices such as prelacteal feeding (32.1%), colostrum discarding (17.9%), and maternal dietary restrictions (64.3%) are well-documented determinants of EBF discontinuation in South Asian contexts [ 8 , 9 , 14 ]. These beliefs were embedded within intergenerational networks of knowledge transmission and were reinforced by the cultural authority of elder women—particularly mothers-in-law—who occupied a directive role in postpartum feeding decisions. This finding has a clear programmatic implication: knowledge-centric interventions directed at mothers alone are unlikely to be sufficient unless they simultaneously engage key household decision-makers. 'Grandmother counselling' programmes have demonstrated efficacy in Indian settings and represent a scalable model for the Andaman context [ 11 ]. Urban–rural differences in breastfeeding determinants highlight the need for differentiated strategies. Urban mothers experienced stronger structural barriers—workplace inflexibility, formula marketing, and reduced extended family support—consistent with the growing paradox of urbanisation in which increasing access to health services coexists with structural environments that undermine breastfeeding continuity [ 12 ]. Rural mothers, by contrast, were more constrained by socio-cultural pressures and limited technical guidance from trained providers. The relatively low prevalence of technical lactation support in rural settings—evidenced by reliance on informal elder and peer advice—suggests that current health-system configurations inadequately support rural mothers beyond the provision of emotional and practical assistance. Health-system inconsistency emerged as a critical modifiable determinant at both sites. Contradictory counselling messages from different providers eroded maternal confidence precisely when consistent guidance is most needed. Evidence from the Baby-Friendly Hospital Initiative (BFHI) demonstrates that standardised, multi-component postpartum support significantly improves both EBF initiation and continuation [ 10 ]. The near-absence of structured home-based postnatal lactation support after discharge—a finding shared across both sites—represents a significant system-level gap. Structured home visits in the first two postpartum weeks are among the most effective single interventions for improving EBF continuation in community settings [ 10 , 11 ] and their absence in both urban and rural South Andaman is a priority for remediation. Collectively, these findings support a multi-level intervention framework for improving EBF outcomes in South Andaman: skilled hands-on lactation support within 24 hours of delivery and structured postnatal follow-up at one and six weeks; family-inclusive counselling targeting mothers-in-law and partners; community peer-support networks led by ASHAs and trained peer mothers; breastfeeding-friendly workplace policies; and rigorous enforcement of the Infant Milk Substitutes (IMS) Act. No single-level intervention is likely to be sufficient given the multi-factorial and context-dependent nature of the barriers identified. Strengths and Limitations A key strength of this study is the qualitative design, which enabled exploration of experiential, contextual, and cultural dimensions of breastfeeding not capturable through structured questionnaires. The inclusion of urban and rural sites facilitated comparative contextual analysis. Maximum-variation purposive sampling ensured representational diversity. Analytical rigour was enhanced through independent coding, triangulation, and peer debriefing. This study provides the first published qualitative evidence on breastfeeding experiences in the Andaman & Nicobar Islands. Several limitations should be acknowledged. The study was conducted in a single district, limiting geographical generalisation. The sample size, though appropriate for qualitative saturation, precludes quantitative inference. Social desirability bias cannot be excluded, as breastfeeding is socially valorised and participants may have overstated EBF adherence. The study captured mothers' perspectives exclusively; integration of data from fathers, mothers-in-law, and frontline health workers would provide a more comprehensive understanding of the breastfeeding ecosystem. Conclusions This study demonstrates that exclusive breastfeeding in South Andaman is shaped by a complex interplay of early physical challenges, psychological vulnerability, intergenerational cultural norms, family dynamics, and health-system gaps. The central finding—a persistent knowledge–practice gap—indicates that addressing knowledge deficits alone is insufficient. Effective strategies must simultaneously target the structural, psychological, and socio-cultural determinants that undermine the translation of knowledge into sustained practice. The divergent urban–rural profiles identified—urban mothers facing predominantly structural barriers and rural mothers experiencing stronger socio-cultural pressures—underscore the need for context-sensitive, differentiated approaches. Priority interventions include skilled postpartum lactation support within 24 hours of delivery, structured postnatal home-based follow-up, family-inclusive counselling engaging elder women and partners, community peer-support networks, breastfeeding-friendly workplace policies, and strengthened enforcement of the IMS Act. Future research should employ longitudinal designs to track breastfeeding trajectories, evaluate targeted multi-level interventions, and incorporate the perspectives of healthcare providers and family decision-makers to develop a more comprehensive understanding of the breastfeeding ecosystem in this geographically unique setting. Declarations Ethics approval and consent to participate Ethical approval was granted by the Institutional Ethics Committee (IEC) of Andaman and Nicobar Islands Institute of Medical Sciences (ANIIMS), Sri Vijaya Puram, Andaman and Nicobar Islands (Approval No. ANIIMS/IEC/2025/37, dated 10 December 2025). Written informed consent was obtained from all participants. All procedures complied with the Declaration of Helsinki. Consent for publication Not applicable. No individually identifiable participant data are presented in this manuscript. Availability of data and materials Datasets are not publicly available due to the sensitive and qualitative nature of the interview data. Data are available from the corresponding author on reasonable request and subject to Institutional Ethics Committee approval. Competing interests The authors declare that they have no competing interests. Funding This study received no external funding. It was conducted as part of postgraduate academic research at ANIIMS. Authors' contributions SH: conceptualisation, questionnaire development, field coordination, data collection, manuscript drafting. AA: study supervision, ethical compliance, data interpretation, critical manuscript revision, corresponding author. ARS: methodological planning, data analysis, manuscript refinement. GPS: data collection and compilation. All authors read and approved the final manuscript. Acknowledgements The authors thank all participating mothers for their time and candour. We acknowledge the MBBS interns who contributed to data collection, and Dr M.C. Jyothi (CMO), Dr Sagar (CHC Bambooflat), and Dr P.P. Razeeda Bano (UHTC Haddo) for institutional support. The contributions of ASHA workers and ANMs in participant recruitment and field coordination are gratefully acknowledged. References World Health Organization. Global nutrition targets 2030: breastfeeding brief. Geneva: WHO. 2023. Available from: https://www.who.int/publications/i/item/B09382 Lee H, Park H, Ha E, Hong YC, Ha M, Park H, et al. Effect of breastfeeding duration on cognitive development in infants: 3-year follow-up study. J Korean Med Sci. 2016;31(4):579–84. Global B, Collective UNICEF, WHO. Global breastfeeding scorecard 2024. New York: UNICEF; 2024. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019–21: India. Mumbai: IIPS; 2022. International Institute for Population Sciences. NFHS-5, 2019–2020: Union Territory Fact Sheet – Andaman & Nicobar Islands. Mumbai: IIPS; 2021. World Health Organization. Management of breast conditions and other breastfeeding difficulties. In: Infant and Young Child Feeding: Model Chapter. Geneva: WHO. 2009. Available from: https://www.ncbi.nlm.nih.gov/books/NBK148955/ World Health Organization. Continuing support for infant and young child feeding. In: Infant and Young Child Feeding: Model Chapter. Geneva: WHO. 2009. Available from: https://www.ncbi.nlm.nih.gov/books/NBK148966/ Gala Z, Shetye S, Sadawarte DM, Autade M. Barriers in exclusive breastfeeding encountered by mothers in urban slum area of a metropolitan city. J Family Med Prim Care. 2023;12(11):2690–5. Okafor AE, Uche OA, Uche IB. Sociocultural factors as predictors of exclusive breastfeeding practice among nursing mothers in communities in eastern Nigeria. Soc Work Public Health. 2023;38(4):298–310. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-Friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402–17. Patil DS, Pundir P, Renjith V. A mixed-methods systematic review on barriers to exclusive breastfeeding. Nutr Health. 2020;26(4):323–46. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Heymann J, Raub A, Earle A. Breastfeeding policy: a globally comparative analysis. Bull World Health Organ. 2013;91(6):398–406. Kazmi S, Akparibo R, Ahmed D, Faizi N. Prevalence and predictors of exclusive breastfeeding in urban slums, Bihar. J Family Med Prim Care. 2021;10(3):1301–7. Naik SA, Naik AS, Patel SA, Patel RA. A retrospective study of breastfeeding practices in the first six months of lactation among mothers in a metropolitan city. J Med Sci Health. 2021;7(3):26–31. Bhattacharjee NV, Schaeffer LE, Marczak LB, et al. Mapping exclusive breastfeeding in Africa between 2000 and 2017. Nat Med. 2019;25:1205–12. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1InterviewGuideEBFSouthAndaman.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 May, 2026 Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 10 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers invited by journal 19 Apr, 2026 Editor assigned by journal 14 Apr, 2026 Editor invited by journal 13 Apr, 2026 Submission checks completed at journal 13 Apr, 2026 First submitted to journal 13 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9352280","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":629111608,"identity":"c35c1599-ab25-4f24-86ae-3db822f04d9a","order_by":0,"name":"Samar Hossain¹","email":"","orcid":"","institution":"Andaman and Nicobar Islands Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Samar","middleName":"","lastName":"Hossain¹","suffix":""},{"id":629111609,"identity":"4c6833de-7344-4753-8a87-bcc8133ccf62","order_by":1,"name":"Aanchal Anand¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYJACZgYGCwiLx0BCDkQfeEBYiwRUS4GFMVhLAvFaPlQkNoAY+LTwt589+LmgRoKBf3bzswdvDCTS54cdfgi0xU5OtwG7FokzecnSM45JMEjcOWZuOMdAInfj7TQDoJZkY7MDOKw5kGPGzMMGdNiNBDNpHpCW2QkgLQcSt+HQIn/+DVDLPwkG+Rvp30Ba0g1np3/Aq8XgBtAW3jYJMAOkJUFeOge/LYY33hhL8/ZJ8BjeyCmTBPrFcIN0TsGBBAPcfpE7n2P4meebjZzcjfRtEm/+1MnLz07f/OFDhZ0cTu9DAQ/CqWCVBviVowL5BlJUj4JRMApGwUgAAF5vWaXn8S0MAAAAAElFTkSuQmCC","orcid":"","institution":"Andaman and Nicobar Islands Institute of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Aanchal","middleName":"","lastName":"Anand¹","suffix":""},{"id":629111610,"identity":"75205240-076c-44f5-a6d3-836697aa6180","order_by":2,"name":"Ajay Raj Sethuraman¹","email":"","orcid":"","institution":"Andaman and Nicobar Islands Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ajay","middleName":"Raj","lastName":"Sethuraman¹","suffix":""},{"id":629111611,"identity":"be29cddb-e9f0-4117-b8e3-758ae7b693ed","order_by":3,"name":"Gayathri Ponath Sukumaran¹","email":"","orcid":"","institution":"Andaman and Nicobar Islands Institute of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Gayathri","middleName":"Ponath","lastName":"Sukumaran¹","suffix":""}],"badges":[],"createdAt":"2026-04-08 06:10:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9352280/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9352280/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107926198,"identity":"b8d5653f-5600-472d-89bb-5bdb76923b5b","added_by":"auto","created_at":"2026-04-27 15:42:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":303698,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9352280/v1/26500a14-5ff4-4128-9694-15488dadf000.pdf"},{"id":107926084,"identity":"d98ac298-3668-412f-8897-8b8a381fd40e","added_by":"auto","created_at":"2026-04-27 15:42:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":280103,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1InterviewGuideEBFSouthAndaman.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9352280/v1/40ac85c9b9ac1805093778a7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mothers' Perspectives on Exclusive Breastfeeding During the First Six Months of Life: A Qualitative Study from Urban and Rural South Andaman, India","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months of life, defined as providing only breast milk without any additional liquids or solids, with the sole exception of prescribed vitamins, minerals, or medicines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The evidence base is extensive: EBF substantially reduces infant morbidity from diarrhoeal disease, acute respiratory infections, and necrotising enterocolitis, and is associated with improved cognitive development and long-term health outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite this, only 48% of infants globally under six months are exclusively breastfed, well below the WHO target of 70% by 2030 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn India, the National Family Health Survey (NFHS-5, 2019\u0026ndash;2021) reported national EBF prevalence at 63.7%, with substantial subnational variation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The Andaman \u0026amp; Nicobar Islands present a distinctive epidemiological paradox: EBF prevalence has risen to 73.3% (NFHS-5), exceeding the national average, yet early initiation of breastfeeding within one hour of birth remains as low as 46.9%, despite institutional delivery rates exceeding 99% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This discrepancy indicates significant missed opportunities for skilled postpartum support during the immediate postnatal period.\u003c/p\u003e \u003cp\u003eDeterminants of suboptimal EBF are multifactorial. Physiological challenges\u0026mdash;nipple pain, engorgement, poor latch, and perceived insufficient milk\u0026mdash;are among the most consistently reported proximal barriers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Psychological factors including anxiety and reduced self-efficacy further compound early difficulties [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Socio-cultural norms such as prelacteal feeding, discarding colostrum, and family pressure to supplement with formula or water are well-documented in Indian settings [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Health-system factors\u0026mdash;quality of antenatal counselling, immediate postpartum support, and postnatal follow-up\u0026mdash;are equally important modifiable determinants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile quantitative surveys estimate prevalence and identify statistical associations, they cannot capture the experiential, contextual, and cultural nuances that shape feeding behaviour. Qualitative evidence from the Andaman \u0026amp; Nicobar Islands is absent from the published literature. This study was therefore designed to systematically explore mothers' lived experiences, knowledge, and perceived barriers and facilitators of EBF in urban and rural South Andaman, with the aim of informing locally relevant, evidence-based interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA descriptive qualitative study was conducted using semi-structured in-depth interviews (IDIs). Qualitative methodology was selected for its established capacity to generate contextually rich, experientially grounded data on health behaviours [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Two sites in South Andaman were purposively selected to enable urban\u0026ndash;rural comparison: the Urban Health and Training Centre (UHTC), Haddo (urban site) and the Community Health Centre (CHC), Bambooflat (rural site).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and sampling\u003c/h3\u003e\n\u003cp\u003eThe study population comprised mothers of infants aged 0\u0026ndash;6 months residing in the catchment areas of the two sites. Eligible participants were mothers aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, resident in the catchment area for \u0026ge;\u0026thinsp;1 year, and caring for an infant aged 0\u0026ndash;6 months. Mothers with a psychiatric illness or cognitive impairment were excluded. Purposive maximum-variation sampling was employed to ensure diversity across parity, educational attainment, employment status, mode of delivery, and family structure. Recruitment continued until thematic saturation was achieved, defined as the point at which no new codes or conceptual categories emerged across successive interviews. A total of 28 IDIs were conducted (approximately 14 per site).\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured interview guide was developed covering five domains: socio-demographic profile; EBF knowledge; personal breastfeeding experiences; perceived barriers and facilitators; and urban\u0026ndash;rural contextual differences. The guide was pilot-tested with four mothers (two per site) and refined for clarity and cultural suitability. Interviews were conducted by trained female interviewers in the participant's preferred language (Tamil, Hindi, Bengali, or English), lasted 30\u0026ndash;60 minutes, and were audio-recorded with written informed consent. Field notes documented non-verbal cues and contextual observations.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAudio recordings were transcribed verbatim, translated where necessary, anonymised, and stored in encrypted folders. Reflexive thematic analysis was conducted as described by Braun and Clarke [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], comprising six phases: familiarisation; initial code generation; theme searching; theme review; theme definition; and reporting. Two independent researchers coded transcripts manually and using NVivo, subsequently grouping codes into subthemes and overarching themes. Cross-site comparison identified urban\u0026ndash;rural patterns. Rigour was enhanced through coding triangulation, peer debriefing, and maintenance of a reflexivity journal throughout the analytical process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas granted by the Institutional Ethics Committee of ANIIMS (Approval No. ANIIMS/IEC/2025/37, dated 10 December 2025). Written informed consent was obtained from all participants prior to interview. Participation was voluntary; participants were informed of their right to withdraw at any stage without consequence. Confidentiality and anonymity were maintained throughout.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eA total of 28 mothers participated. Most (64.3%; n\u0026thinsp;=\u0026thinsp;18) were aged 20\u0026ndash;30 years. Index infants were distributed across both age sub-groups: 53.6% (n\u0026thinsp;=\u0026thinsp;15) aged 0\u0026ndash;3 months and 46.4% (n\u0026thinsp;=\u0026thinsp;13) aged 4\u0026ndash;6 months. Parity was equal (50% primiparous; 50% multiparous). Among participants, 60.7% had vaginal delivery and 39.3% had a caesarean section. Most (71.4%) resided in joint or extended family households and 78.6% were homemakers. Participant characteristics are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and obstetric profile of study participants (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of mother\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of index infant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal vaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint/extended family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u003cem\u003ePercentages may not sum to 100.0 due to rounding.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOverview of themes\u003c/h3\u003e\n\u003cp\u003eReflexive thematic analysis identified six overarching themes with 17 subthemes characterising the determinants of EBF practices in South Andaman (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These are elaborated in the sections that follow.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaster thematic framework: themes, subthemes, and key interpretive meanings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Interpretive Meaning\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Early Breastfeeding Experiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitiation and first feeds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-caesarean delays and poor early latch shaped confidence and subsequent EBF trajectory\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNipple pain, engorgement, and latch difficulties were pivotal early deterrents, triggering emotional distress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmotional responses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety and self-doubt created a negative reinforcing cycle reducing feeding frequency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Knowledge, Beliefs, and Misconceptions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccurate knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong foundational awareness of EBF definitions, colostrum importance, and exclusions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent misconceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrelacteal feeds, colostrum discarding, dietary restrictions; cultural norms frequently overrode biomedical guidance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfluence of elder women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMothers-in-law held directive authority in postpartum feeding decisions, often conflicting with health worker advice\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. Family and Social Support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnabling support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePractical help with chores and emotional reassurance from partners reduced fatigue and improved self-efficacy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConflicting advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFamily pressure for supplementation undermined medical recommendations and eroded maternal agency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4. Health-System Engagement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCounselling quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInconsistent messages across providers generated confusion; inconsistency eroded confidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostnatal follow-up gaps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited structured home-based lactation support after discharge; particularly pronounced in rural settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5. Structural Barriers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaternal fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMost universal barrier (82.1%); cumulative exhaustion precipitated consideration of supplementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkplace constraints\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReturn to work before six months and absence of lactation facilities undermined EBF continuity (urban)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormula marketing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExposure via social media and pharmacies created competing narratives against EBF (urban)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6. Urban\u0026ndash;Rural Contextual Differences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBetter counselling access; stronger structural and workplace-related barriers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStronger practical family support; stronger socio-cultural pressures and limited technical guidance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShared experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNipple pain, fear of insufficient milk, and emotional vulnerability common to both settings\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u003cem\u003eEBF\u0026thinsp;=\u0026thinsp;exclusive breastfeeding. Themes derived using reflexive thematic analysis (Braun \u0026amp; Clarke, 2006).\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Early breastfeeding experiences\u003c/h2\u003e \u003cp\u003eEarly postpartum experiences profoundly shaped maternal confidence and subsequent breastfeeding trajectory. Mothers who achieved successful early latch and perceived adequate milk in the first 24\u0026ndash;48 hours described a reinforcing cycle of confidence that sustained EBF. Conversely, delayed initiation\u0026mdash;particularly among caesarean section mothers (39.3%)\u0026mdash;was associated with reduced self-efficacy and emotional distress, with several participants describing gaps of 12\u0026ndash;24 hours before first breastfeeding contact due to postoperative pain and limited mobility.\u003c/p\u003e \u003cp\u003eSevere nipple and areolar pain within the first 14 days was reported by 67.9% (n\u0026thinsp;=\u0026thinsp;19) of participants and was a pivotal early deterrent. Latching difficulties affected 60.7% (n\u0026thinsp;=\u0026thinsp;17) and were attributed to breast engorgement, inverted nipples, and insufficient hands-on guidance from health workers. These physical challenges were closely intertwined with emotional responses\u0026mdash;anxiety, self-doubt, and fear\u0026mdash;that reduced feeding frequency and reinforced perceptions of low milk supply.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The pain was so bad in the first week that I thought something was wrong with me. No one showed me how to position the baby properly. Once the nurse helped me, everything became easier.\" \u0026mdash; Urban mother, primiparous, caesarean section\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Knowledge, beliefs, and misconceptions\u003c/h2\u003e \u003cp\u003eMost participants demonstrated strong foundational EBF knowledge: 92.9% correctly defined EBF, all 28 (100%) recognised the importance of colostrum, and 85.7% were aware that no supplementary liquids should be provided during the EBF period. Awareness of infant immunity benefits was universal, whereas awareness of maternal health benefits (uterine involution, postpartum weight loss) was substantially lower (28.6%), representing a missed counselling opportunity.\u003c/p\u003e \u003cp\u003eDespite this, persistent cultural misconceptions coexisted and frequently influenced practice. Dietary restrictions during lactation were reported by 64.3% (n\u0026thinsp;=\u0026thinsp;18), with elder family members advising avoidance of 'cold' or 'gas-producing' foods without scientific basis\u0026mdash;practices contributing to maternal under-nutrition and anxiety. Prelacteal feeding with honey or sugar water was reported by 32.1% (n\u0026thinsp;=\u0026thinsp;9), colostrum was discarded by 17.9% (n\u0026thinsp;=\u0026thinsp;5), and 25.0% (n\u0026thinsp;=\u0026thinsp;7) believed formula supplementation was necessary for a 'thirsty' infant. These misconceptions were transmitted predominantly through elder female relatives and reinforced by community peer norms, frequently overriding correct biomedical knowledge.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"My mother-in-law said colostrum is 'dirty milk' and must not be given. She is very experienced, so I listened to her at first.\" \u0026mdash; Rural mother, primiparous, vaginal delivery\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Family and social support dynamics\u003c/h2\u003e \u003cp\u003eFamily support emerged as a decisive bidirectional determinant. Practical assistance\u0026mdash;help with household chores, meal preparation, and facilitation of maternal rest\u0026mdash;was described as directly enabling more frequent breastfeeding and attenuating fatigue-related supplementation. Emotional reassurance from husbands was consistently described as protective, with several mothers attributing persistence through early difficulties to spousal encouragement.\u003c/p\u003e \u003cp\u003eHowever, the same family environment also produced conflicting and counterproductive advice. Mothers-in-law and elder female relatives held directive authority in postpartum feeding decisions, particularly in joint family households (71.4%). Their recommendations\u0026mdash;rooted in traditional practice\u0026mdash;were perceived as authoritative and difficult to challenge, even when contradicting health worker guidance. This competing advisory landscape reduced maternal agency and undermined medical recommendations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"My husband was very supportive\u0026mdash;he helped with everything at night. But my mother-in-law kept saying the baby is crying because my milk is not enough and I should give formula.\" \u0026mdash; Urban mother, multiparous, vaginal delivery\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Health-system engagement\u003c/h2\u003e \u003cp\u003eUrban mothers more frequently reported access to structured antenatal breastfeeding counselling and immediate postpartum lactation demonstrations. However, inconsistent and contradictory counselling messages across different providers\u0026mdash;nursing staff, medical officers, and ANMs\u0026mdash;were reported at both sites, generating confusion and eroding confidence at the point of greatest vulnerability.\u003c/p\u003e \u003cp\u003ePostnatal follow-up was identified as a critical structural gap. The majority of participants reported little or no structured home-based lactation guidance after hospital discharge. Frontline workers (ASHAs, ANMs) were described as focused primarily on immunisation and growth monitoring, with limited capacity for skilled breastfeeding support. Facility-level practices varied: skin-to-skin contact was not consistently implemented, and post-caesarean initiation was frequently delayed beyond recommended timelines.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"After discharge, no one came to check. I had so many problems with feeding and didn't know who to call. I just started giving formula because the baby was crying.\" \u0026mdash; Rural mother, primiparous, caesarean section\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 5: Structural and environmental barriers\u003c/h2\u003e \u003cp\u003eMaternal fatigue was the most universally reported barrier (82.1%; n\u0026thinsp;=\u0026thinsp;23), transcending urban and rural settings, parity, and family structure. Fatigue was cumulative\u0026mdash;arising from disrupted nocturnal sleep, frequent feeding demands, early resumption of domestic duties, and postpartum physical recovery. In joint family settings, social expectations to resume household responsibilities within days of delivery compounded exhaustion and reduced rest essential for breastfeeding continuity.\u003c/p\u003e \u003cp\u003eWorkplace-related barriers were more prevalent in the urban setting. Among the 21.4% (n\u0026thinsp;=\u0026thinsp;6) of employed mothers, anticipated return to work before six months was a significant source of distress and was associated with plans for early weaning. The absence of dedicated breastfeeding breaks, private spaces for expressing milk, and secure storage facilities were cited as key structural impediments. Exposure to commercial infant formula marketing\u0026mdash;through social media, pharmacies, and peer networks\u0026mdash;was more prominent among urban participants and was associated with reduced confidence in breastmilk adequacy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6: Urban\u0026ndash;rural contextual differences\u003c/h2\u003e \u003cp\u003eSystematic contextual differences emerged across the two settings. Urban mothers at UHTC Haddo had better access to skilled lactation counselling, more frequent antenatal health contacts, and greater exposure to breastfeeding information through digital media, contributing to higher early initiation confidence. However, they faced stronger structural barriers: workplace inflexibility, formula marketing exposure, and reduced extended family support in nuclear households.\u003c/p\u003e \u003cp\u003eRural mothers at CHC Bambooflat benefited from stronger day-to-day practical support from extended family networks and lower workplace pressures. However, they faced more pronounced socio-cultural barriers\u0026mdash;stronger intergenerational influence on feeding decisions, greater fear of insufficient milk reinforced by community norms, and more limited access to technical lactation guidance. Despite these contextual differences, core challenges\u0026mdash;nipple pain, fear of insufficient milk, and emotional vulnerability\u0026mdash;were shared across both settings, indicating a universal substrate of early breastfeeding difficulty irrespective of residence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eKey indicators: knowledge and barriers\u003c/h2\u003e \u003cp\u003eKey quantitative indicators derived from participant accounts are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, encompassing EBF knowledge and misconceptions, early feeding practices, and reported barriers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey breastfeeding knowledge, practice, and barrier indicators among participants (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCorrect definition of EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostrum recognised as essential\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness: no water/formula during EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of maternal health benefits of EBF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietary restrictions imposed during lactation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMisconception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrelacteal feeds (honey/sugar water)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMisconception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColostrum discarded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMisconception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula perceived necessary for 'thirsty' infant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMisconception\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly breastfeeding initiation (within 1 hour)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusive breastfeeding sustained at 0\u0026ndash;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere nipple/areolar pain (days 1\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatch difficulties in first two weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFear of insufficient milk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal fatigue / sleep deprivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily pressure for prelacteal feeds/water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticipated early return to work (\u0026lt;\u0026thinsp;6 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eBarrier\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u003cem\u003eEBF\u0026thinsp;=\u0026thinsp;exclusive breastfeeding. Data derived from participant self-report during in-depth interviews. Multiple responses were permitted within the knowledge domain.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study examined the lived experiences and contextual determinants of exclusive breastfeeding among mothers in urban and rural South Andaman. The central finding is a consistent and clinically significant knowledge\u0026ndash;practice gap: despite near-universal awareness of EBF recommendations, sustained exclusive feeding was undermined by an interacting constellation of early physical challenges, psychological vulnerability, intergenerational cultural norms, and health-system inadequacies. This pattern is well-established in the global breastfeeding literature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and this study contributes the first published qualitative evidence from the Andaman \u0026amp; Nicobar Islands.\u003c/p\u003e \u003cp\u003eThe high prevalence of early postpartum barriers\u0026mdash;nipple pain (67.9%), latching difficulties (60.7%), fear of insufficient milk (64.3%), and maternal fatigue (82.1%)\u0026mdash;is consistent with mixed-methods studies across diverse low- and middle-income settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These barriers do not operate in isolation; they function as catalysts for a negative reinforcing cycle in which reduced feeding frequency compounds perceptions of low milk supply, driving early supplementation. The disproportionate impact on caesarean section mothers\u0026mdash;who constituted 39.3% of the sample\u0026mdash;is consistent with international evidence that operative delivery delays the hormonal cascade involved in milk ejection and impairs early breastfeeding establishment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This finding underscores the need for dedicated post-caesarean lactation protocols within maternity facilities.\u003c/p\u003e \u003cp\u003eThe persistence of cultural misconceptions despite high baseline knowledge is particularly important. Practices such as prelacteal feeding (32.1%), colostrum discarding (17.9%), and maternal dietary restrictions (64.3%) are well-documented determinants of EBF discontinuation in South Asian contexts [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These beliefs were embedded within intergenerational networks of knowledge transmission and were reinforced by the cultural authority of elder women\u0026mdash;particularly mothers-in-law\u0026mdash;who occupied a directive role in postpartum feeding decisions. This finding has a clear programmatic implication: knowledge-centric interventions directed at mothers alone are unlikely to be sufficient unless they simultaneously engage key household decision-makers. 'Grandmother counselling' programmes have demonstrated efficacy in Indian settings and represent a scalable model for the Andaman context [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUrban\u0026ndash;rural differences in breastfeeding determinants highlight the need for differentiated strategies. Urban mothers experienced stronger structural barriers\u0026mdash;workplace inflexibility, formula marketing, and reduced extended family support\u0026mdash;consistent with the growing paradox of urbanisation in which increasing access to health services coexists with structural environments that undermine breastfeeding continuity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Rural mothers, by contrast, were more constrained by socio-cultural pressures and limited technical guidance from trained providers. The relatively low prevalence of technical lactation support in rural settings\u0026mdash;evidenced by reliance on informal elder and peer advice\u0026mdash;suggests that current health-system configurations inadequately support rural mothers beyond the provision of emotional and practical assistance.\u003c/p\u003e \u003cp\u003eHealth-system inconsistency emerged as a critical modifiable determinant at both sites. Contradictory counselling messages from different providers eroded maternal confidence precisely when consistent guidance is most needed. Evidence from the Baby-Friendly Hospital Initiative (BFHI) demonstrates that standardised, multi-component postpartum support significantly improves both EBF initiation and continuation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The near-absence of structured home-based postnatal lactation support after discharge\u0026mdash;a finding shared across both sites\u0026mdash;represents a significant system-level gap. Structured home visits in the first two postpartum weeks are among the most effective single interventions for improving EBF continuation in community settings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and their absence in both urban and rural South Andaman is a priority for remediation.\u003c/p\u003e \u003cp\u003eCollectively, these findings support a multi-level intervention framework for improving EBF outcomes in South Andaman: skilled hands-on lactation support within 24 hours of delivery and structured postnatal follow-up at one and six weeks; family-inclusive counselling targeting mothers-in-law and partners; community peer-support networks led by ASHAs and trained peer mothers; breastfeeding-friendly workplace policies; and rigorous enforcement of the Infant Milk Substitutes (IMS) Act. No single-level intervention is likely to be sufficient given the multi-factorial and context-dependent nature of the barriers identified.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study is the qualitative design, which enabled exploration of experiential, contextual, and cultural dimensions of breastfeeding not capturable through structured questionnaires. The inclusion of urban and rural sites facilitated comparative contextual analysis. Maximum-variation purposive sampling ensured representational diversity. Analytical rigour was enhanced through independent coding, triangulation, and peer debriefing. This study provides the first published qualitative evidence on breastfeeding experiences in the Andaman \u0026amp; Nicobar Islands.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. The study was conducted in a single district, limiting geographical generalisation. The sample size, though appropriate for qualitative saturation, precludes quantitative inference. Social desirability bias cannot be excluded, as breastfeeding is socially valorised and participants may have overstated EBF adherence. The study captured mothers' perspectives exclusively; integration of data from fathers, mothers-in-law, and frontline health workers would provide a more comprehensive understanding of the breastfeeding ecosystem.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that exclusive breastfeeding in South Andaman is shaped by a complex interplay of early physical challenges, psychological vulnerability, intergenerational cultural norms, family dynamics, and health-system gaps. The central finding\u0026mdash;a persistent knowledge\u0026ndash;practice gap\u0026mdash;indicates that addressing knowledge deficits alone is insufficient. Effective strategies must simultaneously target the structural, psychological, and socio-cultural determinants that undermine the translation of knowledge into sustained practice.\u003c/p\u003e \u003cp\u003eThe divergent urban\u0026ndash;rural profiles identified\u0026mdash;urban mothers facing predominantly structural barriers and rural mothers experiencing stronger socio-cultural pressures\u0026mdash;underscore the need for context-sensitive, differentiated approaches. Priority interventions include skilled postpartum lactation support within 24 hours of delivery, structured postnatal home-based follow-up, family-inclusive counselling engaging elder women and partners, community peer-support networks, breastfeeding-friendly workplace policies, and strengthened enforcement of the IMS Act. Future research should employ longitudinal designs to track breastfeeding trajectories, evaluate targeted multi-level interventions, and incorporate the perspectives of healthcare providers and family decision-makers to develop a more comprehensive understanding of the breastfeeding ecosystem in this geographically unique setting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Institutional Ethics Committee (IEC) of Andaman and Nicobar Islands Institute of Medical Sciences (ANIIMS), Sri Vijaya Puram, Andaman and Nicobar Islands (Approval No. ANIIMS/IEC/2025/37, dated 10 December 2025). Written informed consent was obtained from all participants. All procedures complied with the Declaration of Helsinki.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No individually identifiable participant data are presented in this manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets are not publicly available due to the sensitive and qualitative nature of the interview data. Data are available from the corresponding author on reasonable request and subject to Institutional Ethics Committee approval.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding. It was conducted as part of postgraduate academic research at ANIIMS.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSH: conceptualisation, questionnaire development, field coordination, data collection, manuscript drafting. AA: study supervision, ethical compliance, data interpretation, critical manuscript revision, corresponding author. ARS: methodological planning, data analysis, manuscript refinement. GPS: data collection and compilation. All authors read and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participating mothers for their time and candour. We acknowledge the MBBS interns who contributed to data collection, and Dr M.C. Jyothi (CMO), Dr Sagar (CHC Bambooflat), and Dr P.P. Razeeda Bano (UHTC Haddo) for institutional support. The contributions of ASHA workers and ANMs in participant recruitment and field coordination are gratefully acknowledged.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global nutrition targets 2030: breastfeeding brief. Geneva: WHO. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/B09382\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/B09382\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Park H, Ha E, Hong YC, Ha M, Park H, et al. Effect of breastfeeding duration on cognitive development in infants: 3-year follow-up study. J Korean Med Sci. 2016;31(4):579\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal B, Collective UNICEF, WHO. Global breastfeeding scorecard 2024. New York: UNICEF; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019\u0026ndash;21: India. Mumbai: IIPS; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences. NFHS-5, 2019\u0026ndash;2020: Union Territory Fact Sheet \u0026ndash; Andaman \u0026amp; Nicobar Islands. Mumbai: IIPS; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Management of breast conditions and other breastfeeding difficulties. In: Infant and Young Child Feeding: Model Chapter. Geneva: WHO. 2009. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK148955/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK148955/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Continuing support for infant and young child feeding. In: Infant and Young Child Feeding: Model Chapter. Geneva: WHO. 2009. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK148966/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK148966/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGala Z, Shetye S, Sadawarte DM, Autade M. Barriers in exclusive breastfeeding encountered by mothers in urban slum area of a metropolitan city. J Family Med Prim Care. 2023;12(11):2690\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkafor AE, Uche OA, Uche IB. Sociocultural factors as predictors of exclusive breastfeeding practice among nursing mothers in communities in eastern Nigeria. Soc Work Public Health. 2023;38(4):298\u0026ndash;310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eP\u0026eacute;rez-Escamilla R, Martinez JL, Segura-P\u0026eacute;rez S. Impact of the Baby-Friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatil DS, Pundir P, Renjith V. A mixed-methods systematic review on barriers to exclusive breastfeeding. Nutr Health. 2020;26(4):323\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeymann J, Raub A, Earle A. Breastfeeding policy: a globally comparative analysis. Bull World Health Organ. 2013;91(6):398\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKazmi S, Akparibo R, Ahmed D, Faizi N. Prevalence and predictors of exclusive breastfeeding in urban slums, Bihar. J Family Med Prim Care. 2021;10(3):1301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaik SA, Naik AS, Patel SA, Patel RA. A retrospective study of breastfeeding practices in the first six months of lactation among mothers in a metropolitan city. J Med Sci Health. 2021;7(3):26\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhattacharjee NV, Schaeffer LE, Marczak LB, et al. Mapping exclusive breastfeeding in Africa between 2000 and 2017. Nat Med. 2019;25:1205\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"exclusive breastfeeding, qualitative research, barriers and facilitators, knowledge–practice gap, maternal self-efficacy, Andaman \u0026 Nicobar Islands, postnatal support, socio-cultural determinants","lastPublishedDoi":"10.21203/rs.3.rs-9352280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9352280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite near-universal institutional delivery (\u0026gt;\u0026thinsp;99%) in the Andaman \u0026amp; Nicobar Islands, early breastfeeding initiation within one hour of birth remains as low as 46.9%, suggesting significant missed opportunities for postpartum lactation support. The experiential and socio-cultural determinants underlying this paradox are poorly understood. This study aimed to explore mothers' lived experiences, knowledge, and contextual barriers and facilitators related to exclusive breastfeeding (EBF) during the first six months of life in urban and rural South Andaman.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive qualitative study was conducted using semi-structured in-depth interviews (IDIs) with 28 purposively sampled mothers of infants aged 0\u0026ndash;6 months from an urban (UHTC Haddo) and a rural (CHC Bambooflat) site in South Andaman. Maximum-variation sampling ensured diversity across parity, education, employment, delivery mode, and family structure. Data were analysed using reflexive thematic analysis (Braun \u0026amp; Clarke). Rigour was enhanced through independent coding, triangulation, and peer debriefing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix themes were identified: (1) early breastfeeding experiences including postpartum pain, latch difficulties, and post-caesarean delays; (2) a knowledge\u0026ndash;practice gap driven by persistent cultural misconceptions despite high baseline awareness; (3) dual-role family dynamics offering both practical support and conflicting feeding advice; (4) inconsistent health-system counselling and limited postnatal follow-up; (5) structural barriers including maternal fatigue (82.1%), workplace constraints, and formula marketing; and (6) divergent urban\u0026ndash;rural contextual patterns. Maternal fatigue was the most prevalent barrier. Urban mothers faced predominantly structural barriers; rural mothers faced stronger socio-cultural pressures.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSustained EBF in South Andaman is undermined by interacting physical, psychological, cultural, and structural determinants rather than knowledge deficits alone. Context-sensitive, multi-level interventions encompassing skilled postpartum lactation support, family-inclusive counselling, community peer networks, and strengthened postnatal follow-up are essential.\u003c/p\u003e","manuscriptTitle":"Mothers' Perspectives on Exclusive Breastfeeding During the First Six Months of Life: A Qualitative Study from Urban and Rural South Andaman, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 15:40:52","doi":"10.21203/rs.3.rs-9352280/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-15T21:15:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305394408642125188279953455901854504734","date":"2026-05-13T10:01:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131636191406352872143945951851913900607","date":"2026-05-10T10:54:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109788644466119733968817333946512893004","date":"2026-05-07T20:53:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T16:13:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178009214049962913103162485050779606581","date":"2026-04-24T15:28:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201180408854250751451863306277054853030","date":"2026-04-20T03:25:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-20T01:45:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-14T05:05:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T17:00:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T14:53:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-13T11:49:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93c496f4-e18e-406a-8fa6-5598b7fd6975","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-15T21:15:59+00:00","index":117,"fulltext":""},{"type":"reviewerAgreed","content":"305394408642125188279953455901854504734","date":"2026-05-13T10:01:10+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"131636191406352872143945951851913900607","date":"2026-05-10T10:54:46+00:00","index":112,"fulltext":""},{"type":"reviewerAgreed","content":"109788644466119733968817333946512893004","date":"2026-05-07T20:53:38+00:00","index":65,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T16:13:13+00:00","index":64,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T15:40:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 15:40:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9352280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9352280","identity":"rs-9352280","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}