Mothers’ breastfeeding experiences and
practices: An explorative mixed methods
study in the sub-district of Tlokwe,
North West Province, South Africa
CB Witten
orcid.org/
0000-0001-5172-279X
Thesis submitted for the degree PhD in Nutrition
at the North-West University
Promoter:
Prof HS Kruger
Co-promoter:
Prof H Grobler
Assistant promoter:
Prof A Coutsoudis
Graduation:
July 2020
i PREFACE
“I know the plans I have for you,” declares the Lord,
“plans to prosper you and not to harm you, plans to give you hope and a future.”
Jeremiah 29:11
This thesis for the degree PhD in Nutrition of Chantell Beverley Witten has been completed in article format. This research study was completed under the supervision of Prof. Salome Kruger and Prof. H Grobler with technical inputs from Prof Anna Coutsoudis. The thesis was written according to guidelines stipulated by the “Manual for master’s and doctoral studies” (NWU, 2018).
I, Chantell Beverley Witten, student number: 26764946; ID number: 7202180307089 declare that:
I have read the West University’s “Conduct regarding plagiarism at the North-West University (NWU, 2006).
I am aware that plagiarism is an offence representing intellectual/academic theft. I have followed the required conventions in referencing to give recognition to original
authors whose ideas or facts I have used.
This thesis is my own work and I acknowledge and recognise all contributions made by my research team and supervisors.
______________________ Chantell Beverley Witten July 2020
ii ACKNOWLEDGEMENTS
While this was a solo sojourn and a gift to myself, I am grateful for many who have encouraged and supported me from the side lines and to those who have walked this journey with me. The journey started in 2004.
To Professor Seyi Ladele Amosun past Head of Department, Health and Rehabilitation Sciences, the University of Cape Town who made me promise back in 2004 that I would not allow circumstance to rob me of my dreams. I have kept that promise albeit more than a decade later, thank you.
To Professor Edelweiss Wentzel-Viljoen, my mentor from my first year of Dietetics, thank you for your unwavering confidence that I was PhD material long before Black academics became a sought after commodity. Thank you for opening my path back into academics without which my PhD would have remained the elusive dream.
To Professor Salome Kruger, my PhD supervisor and chaperon, thank you for allowing me the freedom to carve my path and to explore my capabilities. It has been a tough but rewarding experience and a more suited companion for this gruelling undertaking, I could not have chosen better. I am deeply grateful to have been able to drink from your proverbial cup of wisdom.
To Professor Herman Grobler, my PhD supervisor and guardian, thank you for your quiet and gentle persuasion to dig deeper and explore more within myself and within my PhD process. It was truly a journey of discovery with many highs and many lows. Thank you for making me keep a journal and always picking up on my Freudian slips or my silent screams.
To Professor Anna Coutsoudis, who has been an inspiration and a stalwart in the field of breastfeeding in South Africa, especially at a time when she was a lone voice bravely supporting and promoting exclusive breastfeeding in the context of HIV. You have walked deep footprints and cast long shadows for those of us who follow in your stead to support mothers and their infants.
To my research team and companions, Mrs Noloyiso Matiwane, Ms Bakang Olifant and Mr Nkululeko Semenekane, our study Lerato La Mme was like a ‘Black Panthers’ sequel. No matter how tough or defeating the journey, you persevered and enthused me on. Without you there was no PhD study.
iii
To my parents, my husband and my children whom I neglected in favour to complete this sojourn. Daddy this is your eightieth birthday gift and mommy this is my thank you for always expecting me to be more than I thought I could be. To my husband Evan, thank you for giving me the space and the time to conquer my personal Everest. Finally, to my children, Emma and Cael, you can be anything you want to be, don’t wait for approval or permission. The world is your oyster. Without the love and support of my family, this sojourn would not have been possible. Thank you for your sacrifices and may this PhD serve our family well and be a blessing for us all.
My ever-enticing D.R I’ve chased you since 2004 A missing piece, a longing in my core!
Then in twenty-sixteen came my chance A four-year torturous slow dance.
High highs and low lows, Lots of comments and lots of nos.
A battle with me, in me and for me! I often thought to end it and let it be.
Proverbial blood and literal tears, It took from me more than those four years.
The ever-enticing D.R
iv ABSTRACT
Background: The World Health Organization has set a target for exclusive breastfeeding (EBF) of 50% at country level by 2025. Despite national efforts, without accelerated efforts at scale, South Africa will not meet the 2025 target for EBF. The aim of this mixed methods study was to examine the rate of EBF discontinuation after birth, explore the lived experiences of breastfeeding mothers at postnatal time points 3-14 days, and 4-8, 10-14 and 20-24 weeks and to identify home, family and community-based interventions to promote EBF and overall breastfeeding rates for infants aged 6-24 weeks in low- and middle-income settings (LMICs).
Methods: This community-based mixed-methods study collected data within a prospective cohort study on socio-demographics characteritics, the Edinburgh Postnatal Depression Scale (EPDS) and the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) at 6-8 weeks with infant feeding data collected at 4-8, 10-14 and 20-24 weeks from 159 mothers living in low income areas. Six focus groups with 32 mothers with infants aged 6-24 weeks were conducted. Descriptive statistics were used for the quantitative data and thematic analysis for qualitative data. A systematic review of reviews was also conducted
Results: In the cohort of 178 breastfeeding mothers, EBF decreased from 34% at 4-8 weeks (n = 159) to 9.7% at 20-24 weeks (n = 72) (p<0.0001), while at the same time points, mixed feeding with infant formula increased from 17.0% to 50.1% (p = 0.19) and food feeding from 3.1% to 54.2% (p = 0.04). There were no statistically significant associations between EBF (at any of the time points) with any socio-demogratic factors, breastfeeding self-efficacy or postnatal depression scores. In the qualitative data, all themes, except for Mother’s knowledge, attitudes and practices of breastfeeding, emerged as barriers to BF. The theme Mothers’ attributes (wellbeing, experiences and relationships) underscored by the codes mother’s stress, lack of support in the family environment, negative influences in the social environment and baby’s stomach ailments in baby cues were the dominant barriers. Within these themes, the codes mother’s positive emotions, benefits of breastfeeding, support in the family environment, access to information and services from health professionals and baby’s health emerged as strong enabling factors. From the systematic review of reviews, a plethora of interventions were found to have a positive effect on EBF and any breastfeeding. Most studies (n = 32) found a positive impact while seven from across different regions found no impact on EBF. More importantly there is a growing recognition that multi-pronged, multi-level interventions that have an ecological approach and offer psycho-social support are needed to create an enabling environment
v for mothers to successfully practice EBF.
Conclusions: Low EBF, high rates of mixed feeding and a high levels of depression in a group of mothers from a low-income setting were explained by the qualitative data indicating that mothers’ stress, a difficult family environment, and a hostile social environment towards breastfeeding are barriers to BF. Despite, high levels of breastfeeding self-efficacy, to support mothers to overcome these barriers, mothers from low-income households may be better supported through interventions that are multi-pronged and multi-level, implemented at the household, family and community level to build resilience in confronting difficult and hostile breastfeeding environments.
Keywords
Exclusive breastfeeding, psychosocial factors, barriers, enablers, South Africa, mixed methods
vi DEFINITIONS
Breastfeeding: The child is receiving breastmilk, either directly from the breast or expressed. This definition may include exclusive, predominant and partial breastfeeding (WHO, 2010).
Breastfeeding self-efficacy: Breastfeeding self-efficacy refers to a mother’s confidence in her ability to breastfeed her infant and it predicts: (1) whether a mother chooses to breastfeed or not; (2) how much effort she will expend; (3) whether she will have self -enhancing or self-defeating thought patterns; and (4) how she will emotionally respond to breastfeeding difficulties. Breastfeeding self-efficacy is influenced by four main sources of information: (1) performance accomplishments (e.g., past breastfeeding experiences); (2) vicarious experiences (e.g., watching other women breastfeed); (3) verbal persuasion (e.g., encouragement from influential others such as friends, family, and lactation consultants); and (4) physiological responses (e.g., fatigue, stress, anxiety) (Dennis, 1999).
Breastmilk substitute: Any food or drink marketed as or otherwise representing a partial or total replacement of breastmilk, whether or not suitable for that purpose (WHO, 2008)
Dysphoria: A state of unease or generalized dissatisfaction with life (Stewart et al., 2003).
Exclusive breastfeeding: No other food or drink, not even water, except breastmilk (including milk expressed or from a wet nurse) for six months of life, but allows the infant to receive oral rehydration solution (ORS), drops and syrups (vitamins, minerals and medicines) when medically prescribed (WHO & UNICEF, 2003) .
Medico-centric: The values and normalities of biomedicine (biomedicine= looking at health as it relates to the physical aspects of disease or injury, not including features we cannot see so readily like feelings, emotions, attitudes) to judge and understand health, illness, and the body (Segall & Fries, 2011).
Mental disposition: The predominant or prevailing tendency of one's state of mind, one’s own spirit; natural mental and emotional outlook or mood; characteristic attitude of your state of being (Stewart et al., 2003)
Mixed feeding: Feeding breastmilk as well as other kinds of milk (including commercial formula or home-prepared milk), foods or solids before the age of six months (WHO & UNICEF, 2003).
vii
Partial breastfeeding: Partial breastfeeding refers to a situation where the baby is receiving some breastfeeds but also other food or food-based fluids, such as formula milk or foods before the age of six months (WHO & UNICEF, 2003).
Positive deviance: An approach to behavioral and social change based on the observation that in any community there are people whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources (WHO & UNICEF, 2003).
Predominant breastfeeding: The infant’s predominant source of nourishment has been breastmilk. However, the infant may also have received water and water-based drinks (sweetened and flavoured water, teas, infusions etc.); fruit juice; oral rehydration salts solution; drop and syrup forms of vitamins, minerals and medicines; and ritual fluids (in limited quantities). With the exception of fruit juice and sugar-water, no food-based fluid is allowed under this definition (WHO & UNICEF, 2003).
Prelacteal feed: This refers to a substance given to an infant before initiating breastfeeding (WHO & UNICEF, 2003).
Resilience: The ability to withstand and rebound from adversity. (Luthar, Cicchetti & Becker, 2000).
Self-efficacy: Self-confidence and self-belief in one’s ability to exert control over one's own motivation, behaviour and social environment (Dennis, 1977).
viii ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care
BF Breastfeeding
BSES-SF Breastfeeding Self-Efficacy Scale - Short Form CHW Community Health Worker
DHS Demographic Health Survey DoH Department of Health EBF Exclusive Breastfeeding EFF Exclusive Formula Feeding
EPDS Edinburgh Postnatal Depression Scale FGD Focus Group Discussion
HIV Human Immunodeficiency Virus HREC Health Research Ethics Committee IQ Intelligence Quotient
IYCF Infant and Young Child Feeding LMIC Low- and Middle-income Countries
MF Mixed feeding
NWU North-West University
MF Mixed feeding
PHC Primary Health Care
SADHS South Africa Demographic Health Survey SAMRC South African Medical Research Council SDG Sustainable Development Goals
UNICEF United Nations Children’s Fund WHO World Health Organisation
ix TABLE OF CONTENTS
CHAPTER 1: BACKGROUND INFORMATION AND RATIONALE FOR THE STUDY ...1
INTRODUCTION ...1
AIM AND OBJECTIVES ...3
AIM ...3
OBJECTIVES ...3
ETHICAL Approval ...6
STRUCTURE OF THE THESIS ...6
RESEARCH Team ...8
CHAPTER 2: BACKGROUND AND RATIONALE FOR THE STUDY ...9
BACKGROUND ...9
2.1.1 Global evidence and progress in understanding exclusive breastfeeding practices ...9
2.1.2 Breastfeeding in the context of the HIV epidemic ...10
2.1.3 Marketing of breastmilk substitutes ...11
DETERMINANTS OF SUCCESSFUL BREASTFEEDING ...12
GLOBAL EXCLUSIVE BREASTFEEDING TRENDS ...15
EXCLUSIVE BREASTFEEDING PRACTICES IN THE CONTEXT OF SOUTH AFRICA ...16
SOCIO-DEMOGRAPHIC DETERMINANTS OF BREASTFEEDING PRACTICES ...21
PSYCHO-SOCIAL PARAMETERS OF BREASTFEEDING PRACTICES ...23
INTERVENTIONS TO IMPROVE EBF RATES...26
SUMMARY ...27
CHAPTER 3: MATERIALS AND METHODS ...28
SCIENTIFIC DESIGN ...28
THE SEQUENTIAL CONSENSUAL QUALITATIVE DESIGN (SCQD) ...31
STUDY SITES ...32
SAMPLE SIZE FOR EACH PHASE OF THE STUDY ...33
3.4.1 Sample estimation for validation of the Breastfeeding Self-Efficacy Scale- Short Form (BSES-SF) ...33
x
3.4.2 Sample size calculation for in-depth interviews with exclusive
breastfeeding mothers at week 4-8, week 12-14 and week 24 ...34
SAMPLING ...34
3.5.1 Translation and face validity testing of the Breastfeeding Self Efficacy Scale-Short Form (BSES-SF), the Edinburgh Postnatal Depression Scale (EPDS) and the infant feeding questionnaire ...35
3.5.2 Phase 1: Validation of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) ...36
3.5.3 Phase 2: Execution of the infant feeding cohort and the in-depth interviews ...37
3.5.4 Phase 3: Focus group discussions ...37
STUDY PARTICIPANT IDENTIFICATION AND RECRUITMENT ...38
3.6.1 Study participant identification ...38
3.6.2 Inclusion and exclusion criteria ...39
STUDY PARTICIPANT RECRUITMENT, CONSENT AND ENROLMENT ...39
3.7.1 Selection of prenatal participants for the BSES validation study and the infant feeding cohort study ...40
3.7.2 Focus Group Discussion (FGD) participants ...41
DATA COLLECTION & ANALYSIS ...42
3.8.1 Translate, test and validate the Breastfeeding Self-Efficacy Scale Short-Form (BSES-SF) among breastfeeding women ...46
3.8.2 Measure breastfeeding self-efficacy using the Breast-Feeding Self-Efficacy Scale Short-Form (BSES-SF) among breastfeeding mothers .48 3.8.3 Measure postnatal depression using the translated edinburgh postnatal depression scale among breastfeeding mothers ...48
3.8.4 Measure Infant Feeding Practices Using The Infant Feeding Questionnaire Method ...48
3.8.5 Explore mothers’ experiences of breastfeeding their infants aged 0-6 months through in-depth interviews ...49
3.8.6 Focus group discussions with mothers with infants aged 0-6 months on interventions to adequately support breastfeeding ...50
3.8.7 Systematic review of reviews to identify effective community-based interventions from low and middle-income countries to improve exclusive breastfeeding rates ...52
MANAGEMENT OF DATA ...52
3.9.1 Breastfeeding Self-Efficacy Score-Short Form (BSES-SF) questionnaire data ...53
xi
3.9.2 Edinburgh Postnatal Depression Scale (EPDS) data ...53
3.9.3 Systematic review of reviews ...53
3.9.4 Infant feeding recall data ...53
3.9.5 In-depth interview data ...54
3.9.6 Focus group discussion data ...54
CHAPTER 4: MANUSCRIPT 1: TRANSLATION AND PSYCHOMETRIC ASSESSMENT OF THE SETSWANA VERSION OF THE BREASTFEEDING SELF-EFFICACY SCALE – SHORT FORM IN NORTH WEST PROVINCE, SOUTH AFRICA ...55
CHAPTER 5: MANUSCRIPT 2: PSYCHOSOCIAL BARRIERS AND ENABLERS OF EXCLUSIVE BREASTFEEDING: LIVED EXPERIENCES OF MOTHERS IN LOW-INCOME TOWNSHIPS, NORTH WEST PROVINCE, SOUTH AFRICA ...79
CHAPTER 6: MANUSCRIPT 3: A SYSTEMATIC REVIEW OF REVIEWS ON EFFECTIVE HOME, FAMILY, AND COMMUNITY-BASED INTERVENTIONS TO IMPROVE BREASTFEEDING IN LOW- AND MIDDLE-INCOME COUNTRIES ... 110
CHAPTER 7: REFLECTIONS ... 161
REFLECTIONS ... 161
7.1.1 I am a mother ... 161
7.1.2 The working mother ... 163
7.1.3 I am a mother of colour ... 166
7.1.4 Race in research and academics ... 167
7.1.5 Finding myself on this PhD journey ... 169
CHAPTER 8: CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS ... 170
Summary ... 170
Conclusions And Recommendations ... 170
Recommendations ... 172
Limitations ... 172
xii ANNEXURES
Annexure 1 NWU Ethics Certificate
Annexure 2 Screening tool for potential study participants
Annexure 3a Breastfeeding self-efficacy score - short form (English) Annexure 3b Breastfeeding self-efficacy score - short form (Setswana) Annexure 3c Breastfeeding self-efficacy score - short form (Afrikaans) Annexure 3d Breastfeeding self-efficacy score - short form (IsiXhosa) Annexure 4a Edinburgh postnatal depression scale (EPDS) (English) Annexure 4b Edinburgh postnatal depression scale (Setswana) Annexure 4c Edinburgh postnatal depression scale (Afrikaans) Annexure 4d Edinburgh postnatal depression scale (IsiXhosa)
Annexure 5a Infant feeding and food frequency Questionnaire (English) Annexure 5b Infant feeding and food frequency Questionnaire (Setswana) Annexure 5c Infant feeding and food frequency Questionnaire (Afrikaans) Annexure 5d Infant feeding and food frequency Questionnaire (IsiXhosa) Annexure 6a Study participant invite (English)
Annexure 6b Study participant invite (Setswana) Annexure 6c Study participant invite (Afrikaans)
Annexure 7a Informed consent form – face validity (English) Annexure 7b Informed consent form – face validity (Setswana) Annexure 7c Informed consent form – face validity (Afrikaans) Annexure 7d Informed consent form – face validity (IsiXhosa) Annexure 8a Face validity Questionnaire (English)
Annexure 8b Face validity Questionnaire (Setswana) Annexure 8c Face validity Questionnaire (Afrikaans) Annexure 8d Face validity Questionnaire (IsiXhosa)
Annexure 9a Informed consent for the BSES-SF validation study (English) Annexure 9b Informed consent form for the BSES-SF validation study
(Setswana)
Annexure 9c Informed consent form for the BSES-SF validation study (Afrikaans)
Annexure 9d Informed consent form for the BSES-SF validation study (IsiXhosa) Annexure 10a Informed consent form for the infant feeding cohort study (English) Annexure 10b Informed consent form for infant feeding cohort study (Setswana) Annexure 10c Informed consent form for infant feeding cohort study (Afrikaans)
xiii
Annexure 10d Informed consent form for the infant feeding cohort study (IsiXhosa)
Annexure 11a Socio-demographic questionnaire (English) Annexure 11b Socio-demographic questionnaire (Setswana) Annexure 11c Socio-demographic questionnaire (Afrikaans) Annexure 11d Socio-demographic questionnaire (IsiXhosa)
Annexure 12 a-c In-depth interview questions (6-8 weeks; 10-14 weeks; 20-24 weeks)
Annexure 13 Invite for focus group discussion study participants Annexure 14 Focus group discussion guide
Annexure 15a Informed consent form for focus group discussion (English) Annexure 15b Informed consent form for focus group discussion ((Setswana) Annexure 15c Informed consent form for focus group discussion (Afrikaans) Annexure 15d Informed consent form for focus group discussion (IsiXhosa) Annexure 16 Protocol for the systematic review of reviews
Annexure 17 PLOS One journal submission guidelines
Annexure 18 Confirmation of submission to International Breastfeeding Journal Annexure 19 Letter from language editor
xiv LIST OF TABLES
Table 2.1: Comparison of breastfeeding practices in 2003 and 2016 ...17
Table 2.2: EBF rates for infants 0-6 months reported in the literature by location for the period 2007 – 2019 ...18
Table 3.1A: Phase 1 of the research study ...30
Table 3.1B: Phase 2 of the research study ...30
Table 3.1C: Phase 3 of the research study ...30
Table 3.2: Summary of a selection of studies on breastfeeding efficacy assessment of non-hospitalized breastfeeding mothers using the Breastfeeding Efficacy Scale-Short Form (BSES-SF) ...33
Table 3.3: The SANHANES reported prevalence of EBF infants at each critical time ...34
Table 3.4: The selection of clinics and samples per clinic for each component of the study ...35
Table 3.5: Inclusion and exclusion criteria for study participants ...39
Table 3.6: An overview of the proposed data collection methods, proposed analysis and justification of the methods for the objectives of the study ...43
CHAPTER 4: MANUSCRIPT 1: TABLES Table 1. Socio-demographic and infant feeding characteristics of participants at 4-8 weeks postpartum (n = 180) ... 63
Table 2. Sociodemographic factors, bses and epds scores according to breastfeeding practices at 4-8 weeks (median and interquartile range)* (n=180) ... 64
Table 3. Comparison of breastfeeding self-efficacy score by contrast groups (n=178). 64 Table 4. BSES-SF items with principal components factor loadings and communalities ... 65
Table 5. Multivariate logistic regression: factors associated with ebf at 4-8 weeks (n = 178) and at 10-14 weeks postpartum (n = 70)... 66
CHAPTER 5: MANUSCRIPT 2: TABLES Table 1. Socio-demographic characteristics of cohort study participants at 4-8 weeks postpartum (n = 159) ... 86
Table 2. Infant feeding practices for the cohort of mothers with infants aged 4-24 weeks (n = 159) ... 86
xv
Table 3: Association of sociodemographic factors and EBFB practices at 4-8 weeks ... 87
Table 4 : Characteristics of the mothers in the cohort study in Tlokwe sub-district and mothers in the FGDS from the neighbouring sub-district, Matlosana... 88
Table 5. Focus group discussion themes and codes arranged by frequency counts .... 89
Table 6. Joint display of factors influencing exclusive breastfeeding in a cohort of mothers with infants aged 6-24 weeks, arranged by themes and codes with the highest frequency count by Barrier (B) and Enabler (E) ... .106
CHAPTER 6: MANUSCRIPT 3: TABLES Table 1. Supplemental Table 1. picos details for systematic review searches ... 114
Table 2. Search strategy for systematic review articles ... 115
Table 3. Systematic review eligibility criteria ... 116
Table 4: Selection of systematic reviews, Amstar 2 quality check ... 120
Table 5: Data extraction for seven systematic reviews and resulting number of eligible primary studies ... 138
xvi LIST OF FIGURES
Figure 1.1: Illustration of the study components and phases for the mixed methods
study ...5
Figure 2.1: Conceptual framework for the determinants of successful breastfeeding ..13
Figure 2.2: An adapted conceptual framework of the ecological approach to breastfeeding practices ...22
Figure 3.1: Graphic representation of the mixed methods study design ...29
Figure 3.2A: The sample size and contact points for the validation of the BSES-SF and measure of infant feeding and epds ...36
Figure 3.2B: Estimated cohort for the infant feeding and food frequency questionnaire and the in-depth interviews ...37
Figure 3.2C: Illustration of the infant age-specific FGDs ...38
Figure 3.3: Illustration of participant recruitment, consent and enrolment process ...40
Figure 3.4: Picture of an fgd session with a facilitator and note-taker ...51
Figure 7.1: Grandma, mom and me ... 161
Figure 7.2: Headline from Parent24 ... 164
Figure 7.3: Women’s contribution to unpaid household and care work ... 165
Figure 7.4: Slave mother nurses a white infant... 167
CHAPTER 4: MANUSCRIPT 1: FIGURES Figure 1. Flow diagram of participant recruitment and data collection ...62
CHAPTER 5: MANUSCRIPT 2: FIGURES Figure 1. Flow diagram for the enrolment of study participants for the prospective cohort infant feeding study ...85
Figure 2. Decrease in EBFB between each time point from 3-4 days to 20-24 weeks ...87
CHAPTER 6: MANUSCRIPT 3: FIGURES Figure 1. Primsa flow diagram for database searches ... 119
EXPLORATIVE MIXED METHODS STUDY IN THE SUB-DISTRICT OF TLOKWE, NORTH WEST PROVINCE, SOUTH AFRICA
CHAPTER 1
BACKGROUND INFORMATION AND RATIONALE FOR THE STUDY
INTRODUCTION
Literature over the past decades, have shown that the absence of human milk increases infant morbidity and mortality (American Academy of Pediatrics, 1997:1036; Golding et al., 1997:145; WHO et al., 1998:2; Chetty et al., 2010:4; Victora et al., 2016:475). Human milk is a vital life-sustaining liquid that can, with its property to transform to meet the infant’s needs, meet an infant’s nutritional needs completely during the first six months of life (Victora et al., 2016:477) in various and even in extreme maternal health conditions such as maternal malnutrition and cancer (Miranda et al., 1983:634; American Academy of Pediatrics, 1997:1038). Breastfeeding is the undisputed feeding option for the optimal growth and development of children (American Academy of Pediatrics, 1997:1035; Victora et al., 2016:477). In 2008, the WHO compiled definitions for the assessment of breastfeeding patterns. This may range from ‘no breastfeeding’; “partial breastfeeding”; ‘predominant breastfeeding’ and the gold standard of ‘exclusive breastfeeding’ (WHO, 2008:5).
Exclusive breastfeeding (EBF) is defined by the WHO as providing no other food or drink, not even water, except breastmilk (including expressed breastmilk or breastmilk from a wet nurse) for the first six months of life, but allows for the infant to receive oral rehydration solution (ORS), drops and syrups (vitamins, minerals and medicines) (WHO, 2008:5). Labbok and Krasovec (1990) proposed the strictest definition of EBF that excludes all other fluids, including water, non-nutritive supplements such as conventional medicines or self-prescribed over-the-counter medicines. Almost a decade later, this definition would come to bear on a landmark study by Coutsoudis et al. (1999) which showed that EBF, without non-nutritive supplements, had a lower transmission of HIV from mother-to-child than mixed feeding with other fluids. Since then, a number of breastfeeding related studies in South Africa have used this definition of EBF as “only breastmilk with no other food of any type (no water, juice, formula, animal milk or solid foods), except for vitamins, minerals and medicines prescribed by a doctor or nurse (Bland et al., 2004; Rollins et al., 2004; Bland et al., 2008; Tylleskar et al., 2011; Goosen et al., 2014a). The South African national
Department of Health (NDoH) continues to communicate to the public that EBF means breastmilk only and excludes all non-prescribed vitamins, minerals and over-the-counter medicines (Department of Health, 2018).
While South Africa has a reported high rate of initiation of breastfeeding (85%) (Human Science Research Council, 2013), the long standing evidence is that the majority of mothers do not practice EBF for six months and tend to introduce non-prescribed over-the-counter medicines (Abrahams et al., 2002; Bland et al., 2004; Goosen et al., 2014a), plain and sugar-sweetened water, infant formula and food (Department of Health & Medical Research Council, 2002; Department of Health & Medical Research Council, 2007; National Department of Health et al., 2017). In the last five years, studies from across South Africa have reported higher rates of EBF (Goosen et al., 2014b; Siziba et al., 2015; Van der Merwe et al., 2015; Budree et al., 2016; Horwood et al., 2018; West et al., 2019) than previously documented but mixed feeding remains the norm for the majority of infants aged less than six months (National Department of Health et al., 2017).
Moreover, the high percentage of infants aged 0-5 months not breastfeeding at all (25.2%) and use of formula milk amongst the younger age group of 0-3 months (25.9%) is particularly concerning when 66% of infants live in households below the upper bound poverty line and 30% lack potable water on site, with consequent vulnerability to diarrhoea and pneumonia, the major killers of infants (National Department of Health et al., 2017). If South Africa is to accelerate efforts to improve breastfeeding practices, it will need evidence-based interventions that target barriers and exploit enabling factors. Despite significant progress in child health indicators, such as the decreased rates of HIV transmission from mother-to-child, improved rates of infant immunization and decreased rates of infant mortality, South Africa continues to have poor exclusive breastfeeding rates. It is imperative to acknowledge and consider that breastfeeding is not a simple or simplified intervention located in a medico-centric space. Breastfeeding is a complex behavior influenced by many environmental and psychosocial factors.
Therefore, given the national and global commitments to improve breastfeeding rates, a robust and context-specific study to gain understanding and insights particularly from breastfeeding mothers at critical infant age-specific points in time, along the age continuum 0-6 months, is warranted. This study sought to specifically and purposefully explore the positive deviance of successful exclusive breastfeeding along the age continuum from 6 to 24 weeks. In an effort to reach national and global breastfeeding targets, findings from this study could inform the national breastfeeding communication and advocacy strategies on
how best to support mothers to exclusively breastfeed their infants aged 0-6 months successfully.
AIM AND OBJECTIVES
The Aim and Objectives of the PhD thesis are outlined below and presented in graphic format in Figure 1.1.
AIM
The aim of this PhD thesis was to identify and understand the breastfeeding experiences and practices of mothers with infants aged 0-6 months in the sub-district of Tlokwe in the North West Province, South Africa.
OBJECTIVES
The objectives of this PhD thesis are described for each phase of the study which were:
Phase 1
i. To translate and test the reliability, the validity and the predictive ability of the Breastfeeding Self-Efficacy Score (BSES-SF) among Setswana-speaking post-partum women in South Africa.
ii. To determine prospectively the breastfeeding practices of mothers with infants aged 0-8 weeks.
Phase 2
i. To determine prospectively the breastfeeding practices of mothers with infants aged 0-24 weeks.
ii. To determine breastfeeding self-efficacy among mothers with infants aged 6-8 weeks. iii. To determine the prevalence of postnatal depression among mothers with infants aged
6-8 weeks. Phase 3
1. To explore mothers’ experiences of breastfeeding their infants aged 0-6 months 2. To identify the psycho-social factors associated with successful breastfeeding.
3. To conduct a systematic review of reviews of intervention studies to identify effective community-based interventions to improve exclusive breastfeeding practices and rates among mothers with infants aged 0-6 months.
5
EBF = Exclusive breastfeeding, Non-EBF = Non-exclusive breastfeeding, FGDs = Focus group discissions
ETHICAL APPROVAL
The research was approved by the North-West University, Faculty of Health Sciences, Health Research Ethics Committee (cf. Annexure 1: Ethics Certificate NWU-00030-17-S1) and the study was conducted in line with the Helsinki Declaration and the South African National Department of Health Ethics in Health Research Guidelines (Department of Health, 2015).
STRUCTURE OF THE THESIS
This thesis is presented in article format and is divided into seven chapters. The format and referencing of the three articles (cf. Chapters 4 – 6) are according to the respective journals’ guidelines and these are attached in Annexures 17 and 18.
Chapter 1 provides background information on the study, establishes the need for the study, states the aim and objectives and the structure of the thesis and lists the role of each member of the research team.
Chapter 2 examines the relevant literature on breastfeeding globally and specifically in South Africa, the determinants of breastfeeding and its relevance to the South African context, the cultural context of women and breastfeeding mothers in low socio-economic contexts and interventions to improve breastfeeding rates.
Chapter 3 presents the methods for each component of this prospective cohort study which was an exploratory descriptive study using convergent parallel fixed mixed methods design which is the basis of this PhD thesis.
Chapter 4 presents the second article manuscript. The title of Manuscript 1 reads: Translation and Psychometric Assessment of the Setswana Version of the Breastfeeding Self-Efficacy Scale – Short Form in North West province, South Africa. This manuscript documents the process and procedures to translate and test the reliability, the validity and the predictive ability of the BSES-SF among Setswana-speaking post-partum women in the Tlokwe sub-district in the North West province of South Africa. Submitted to the journal PLOS One (cf. Annexure 17).
Chapter 5 presents the second article manuscript. The title of Manuscript 2 reads: Psychosocial barriers and enablers of exclusive breastfeeding: lived experiences of
mothers in low-income townships, North West Province, South Africa. This manuscript documents the process and procedures of a prospective cohort study to examine the rate of discontinuation of EBF at three specific postnatal time points 4-8 weeks, 10-14 weeks and 20-24 weeks and through focus group discussions with mothers with infants aged 6-24 weeks captured the lived experiences of breastfeeding mothers in the sub-district of Tlokwe in the North West Province, South Africa. Submitted to the Intenational Breastfeeding Journal (cf. Annexure 18: Acknowledgement of receipt from the International Breastfeeding Journal).
Chapter 6 presents the third article manuscript. The title of Manuscript 3 reads: A systematic review of reviews on effective home, family and community-based interventions from low- and middle-income countries to inform the breastfeeding agenda in South Africa. This systematic review of reviews was undertaken to review the evidence from multiple systematic reviews across diverse community-based interventions, across different populations within LMICs and to produce contextual recommendations for South Africa. We aimed to i) identify home, family and community-based interventions compared to routine care to improve exclusive breastfeeding and all breastfeeding rates in LMICs and ii) identify interventions targeting the mother to improve exclusive breastfeeding of her own infant and subsequently breastfeeding rates in home, family and community-based settings. Submitted to the journal PLOS One (cf. Annexure 17).
Chapter 7 presents my reflections on the PhD process, my location within academia and as a child health advocate.
Chapter 8 presents conclusions as a summary of the key findings of the study, recommendations for future research and acknowledgement of the limitations of the study.
RESEARCH TEAM
TEAM MEMBER AFFILIATION ROLE & RESPONSIBILITIES
Chantell Witten School of
Physiology, Nutrition and Consumer Science, North-West University
Part-time PhD student. Conceptualized and developed the research proposal, secured funding for the study, executed the study, collected data, managed data quality, analysed and interpreted data. Co-supervised two Master students’ sub-studies. First author on all scientific manuscripts. Prof Salome
Kruger
Centre of Excellence for Nutrition, North-West University
PhD study promoter. Provided technical inputs for the study design, the research methods for the quantitative components of the study and supported me through the learning process of developing, executing and writing up my PhD thesis. Co-author of all scientific manuscripts.
Prof Herman Grobler Community Psycho-social Research, North-West University
PhD co-promoter. Provided technical inputs on qualitative research methods and subject matter expert on identity and community psychology. Supported me through the learning process of developing my skills and competencies in qualitative research and the PhD process. Co-author of all scientific manuscripts.
Prof Anna Coutsoudis
Paediatrics & Child Health, University of Kwazulu-Natal, South Africa
Co-promoter and subject matter expert on breastfeeding and breastfeeding promotion efforts, paediatric public health and translational research to address the policy-practice gaps. Co-author of all scientific manuscripts.
Prof Mieke Faber South African Medical Research Council
Dietary data expert to provide technical inputs for the development of the protocol, the infant feeding and food frequency questionnaire. Advisory role in data analysis and interpretation. Co-supervised and provided student support to one of the Master's students.
Dr Nicole Claasen African Unit for Transdisciplinary Health Research, North-West University,
Accredited Atlas.ti trainer and independent co-coder for the qualitative data, advisory role for data analysis and interpretation. Co-author on all scientific manuscripts reporting on the qualitative data. Noloyiso Matiwane School of Physiology, Nutrition and Consumer Science, North-West University
Research Assistant to assist with research tool translations into Setswana and isiXhosa, collected data, participant follow ups, moderator for all focus group discussions in Setswana, transcript quality checks and cultural insights and perspectives on data interpretation.
Bakang Olifant Centre of Excellence for Nutrition, North-West University
Part-time Master student on sub-study. Research Assistant to assist with data collection, participant follow ups, moderator for all focus group discussions in Setswana, transcript quality checks and cultural insights and perspectives on data interpretation. Milton
Semenekane
Centre of Excellence for Nutrition, North-West University
Full-time Master student on sub-study. Assisted with back-translations of research tools from Setswana into English, collected data, did participant follow ups, and logistical support for focus group discussions.
BACKGROUND AND RATIONALE FOR THE STUDY
BACKGROUND
2.1.1 Global evidence and progress in understanding exclusive breastfeeding practices
The World Health Organization (WHO) and UNICEF (2014) set as one of the Global Nutrition targets for supporting the realization of the Sustainable Development Goals (SDGs) for 2025, an exclusive breastfeeding (EBF) rate of 50% at country-level; a global effort that undisputedly will contribute towards the SDGs (WHO, 2014:1; Kakietek et al., 2017:1). Despite this more recent global recognition and affirmation of breastfeeding as a life-saving and life-changing intervention, ancient texts and pictorial writings have made reference to breastfeeding throughout human history (Papastavrou et al., 2015:1). Similarly, breastfeeding and wet nursing are referred to in many religious scripts (Burdette & Pilkauskas, 2012:1865; Papastavrou et al., 2015:2). Until the industrial production of formula milk, human milk was needed for human survival. Despite the wide use of infant formula, recent scientific findings reaffirm and assert that no food is more nutritious for an infant than human milk. Human milk is a unique, biomedical product that is the best and most complete natural food that provides for all the infant’s physiological needs during the first six months of life (WHO & UNICEF 2003:7; Kramer & Kakuma 2012:10; Sankar et al., 2015:3; Victora et al., 2016:475).
Increased infant morbidity and mortality in the absence of human milk is well established (American Academy of Pediatrics, 1997:1035; Golding et al., 1997:143; Chetty et al., 2010:1; Sankar et al., 2015:3; Victora et al., 2016:476). Human milk is not only perfect nutrition for the human infant it also provides vital immunity. Human milk has the property to transform to meet an infant’s nutritional and health needs completely during the first six months of life (Victora et al., 2016:477) in various and even in extreme maternal health conditions such as maternal malnutrition and cancer (Miranda et al., 1983:634; American Academy of Pediatrics 1997:1038). Breastfeeding is the undisputed feeding option for the optimal growth and development of children (American Academy of Pediatrics, 1997:1035; Victora et al., 2016:477). Labbok and Krasovec (1990) proposed a classification of breastfeeding to assist researchers and agencies in their efforts to accurately describe and interpret breastfeeding practices to gain better insights into the practices and its implications
for health outcomes in children. Unlike, the WHO definitions of 2008 (WHO 2008:5), Labbok and Krasovec proposed the strictest definition of breastfeeding that excluded all other fluids including non-nutritive supplements and conventional medicines or over-the-counter medicines. Almost a decade later, this definition would come to bear on a landmark study by Coutsoudis et al. (1999) which showed that exclusive breastfeeding, without non-nutritive supplements, had a lower transmission of HIV from mother-to-child then mixed feeding with other fluids. This landmark study compelled WHO to revisit breastfeeding in the context of HIV. Almost a decade later, the WHO compiled definitions for the assessment of breastfeeding patterns. This may range from ‘no breastfeeding’; “partial breastfeeding”; ‘predominant breastfeeding’ and the gold standard of ‘exclusive breastfeeding’, which include syrups, drops, vitamins and medicines (WHO 2008:5).
Over the past few decades, an enormous amount of research has been invested in understanding the different aspects of breastfeeding. Aspects such as the mechanics or physiology of breastmilk production; the technical aspects of breastfeeding (timing, duration, techniques); the composition of breastmilk and the variation in breastfeeding practices; and the benefits of breastfeeding for mothers and infants; are well documented (American Academy of Pediatrics, 1997:1036; Golding et al., 1997:145; WHO et al., 1998:2; Chetty et al., 2010:4; Victora et al., 2016:475). This reductionist approach to breastfeeding as a phenomenon is in line with the philosophy of science of the past 50 years. Verschuren (2001:389) points out that over the past few decades reductionism or reductionist research has become mainstream for empirical research to build a body of abstract and generalizable theoretical knowledge successfully. This said, Verschuren (2001:390) poses the challenge to researchers to critically evaluate whether reductionism fully grasps reality in its full extent, and does studying a phenomenon in part, help us to understand the complexity and the issue in its entirety in order to find solutions. There is no better example of deconstructing the phenomena, establishing the evidence base of its importance to life itself and documenting its monumental failure in practice, than the field of breastfeeding. Godfrey and Lawrence (2010:1597) described breastfeeding as an intricate process of interaction between mother and infant that surpasses nutrition and includes establishing a life-saving immune system, promoting and supporting the development of brain function and initiating socialization.
2.1.2 Breastfeeding in the context of the HIV epidemic
Globally, the breastfeeding agenda has been complicated by the human immunodeficiency virus (HIV) epidemic (Dunn et al., 1992). Breastfeeding in the context of HIV and the
acquired immune-deficiency syndrome (AIDS) posed significant challenges due to the risk of transmission of the virus in breastmilk (WHO et al., 1998:4). In 2006, WHO guidelines on infant feeding in the context of HIV recommended that breastfeeding should be avoided and replacement feeding i.e. infant formula be used. Where breastfeeding could not be avoided, rapid cessation of breastfeeding after the infant reached six months, followed by complementary feeding, was recommended (WHO 2010:2). The repercussions of these recommendations for the health and survival of non-breastfed infants were serious. Without the anti-infective protection of breastmilk, the increased exposure to contaminants in water and on feeding utensils resulted in higher morbidity and mortality rates among non-breastfed HIV-exposed infants (Sint et al., 2013:169). Independent of HIV, studies had already made this observation of higher morbidity and mortality among non-breastfeed infants in both developing and developed countries (Victora et al., 1987:319; Golding et al., 1997:144; Black et al., 2008:244; Kramer & Kakuma 2012:10).
Although HIV transmission was lower in non-breastfed HIV-exposed infants, studies showed much higher, up to seven times higher, rates of mortality among non-breastfed infants compared to breastfed infants, due to diarrhoea, malnutrition and other diseases in non-breastfed children (Chetty et al., 2010:3; Cournila et al., 2013:1621), highlighting the live-saving impact of breastfeeding. The most recent WHO guidelines on infant feeding in the context of HIV are based on the evidence of positive health outcomes for HIV-free survival through the provision of ARVs to mothers and the breastfed HIV-exposed infant (WHO 2010:4). The World Health Assembly endorsed the 2010 WHO guidelines on infant feeding in the context of HIV guidelines and encouraged countries with child mortality rates above 40/1000 live births to have one public health infant feeding strategy supporting exclusive breastfeeding for the first six months with or without ARVs (WHO 2010:4). WHO re-affirmed and endorsed that despite the transmission of HIV through breastfeeding, breastfeeding remained the most effective child survival strategy, saving millions of infant lives (Chetty et al., 2010:1; WHO 2014:1). Furthermore, despite the advances in medical technology such as immunizations and advances in food processing and enhancements, breastmilk was still proven to be superior to all other foods. And the absence of breastmilk or the reduced duration of breastfeeding has negative health and development outcomes for infants and countries (Sankar et al., 2015:1; Victora et al., 2016:475; Bell et al., 2018:1).
2.1.3 Marketing of breastmilk substitutes
Despite the 1981 World Health Assembly resolutions on the marketing of breastmilk substitutes (WHO 1981:4) and the global evidence of violations of the International Code
(Taylor, 1998:1118; Rosenberg et al., 2008:292; Sweet et al., 2016:108), it was only in 2016 at the 69th World Health Assembly that the Assembly endorsed the recommendations of a WHO convened Scientific and Technical Advisory Group (STAG) to provide clarification and guidance on what constituted inappropriate promotion of foods for infants and young children (Scaling Up Nutrition 2016:1; WHO 2017:4). According to the reports of the WHO convened STAG, evidence from numerous countries showed that foods are being promoted as being suitable for infants under six months of age; that breastmilk substitutes are being indirectly promoted through association with commercial complementary foods, and that inaccurate claims are being made that products will improve a child’s health or intellectual performance. In addition, complementary foods that represent a substantial portion of energy requirements have shown to displace the intake of breast-milk (WHO Scientific and Technical Advisory Group, 2013). This unanimous motion by the Assembly was a show of acknowledgement and action against the uncontrolled marketing of breastmilk substitutes that has been shown to undermine successful breastfeeding (Dougherty & Kramer, 1983:1149; Taylor, 1998:1118; Sweet et al., 2013:13; Champeny et al., 2016:128).
DETERMINANTS OF SUCCESSFUL BREASTFEEDING
Since South Africa’s landmark infant feeding policy shift facilitated by the 2011 Tshwane Declaration (Department of Health, 2011), several studies in South Africa (Ladzani et al., 2011:539; Nor et al., 2011:448; Ahmadu-Ali & Couper 2013:387; Goosen et al., 2014a:21; Nkonki et al., 2014:6; Jama et al., 2018:5; Nieuwoudt et al., 2019:3) have identified barriers that are interlinked and correspond very well with the conceptual model for the determinants of successful breastfeeding presented by Rollins et al. (2016) shown in the diagram below in Figure 2.1.
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Over the past ten years, hundreds of systematic reviews have been published which have explored interventions that are effective at improving EBF rates (Sinha et al., 2015; Sinha et al., 2017). The majority of these studies have been conducted in high-income countries most notably Canada, Australia, the Scandinavian countries and the United Kingdom. Many of the interventions from low and middle-income countries have been conducted outside of Southern Africa and those from Africa have been conducted in the context of HIV (Nor, 2011:420; Tylleskar et al., 2011:421; Nkonki et al., 2014:797; Tomlinson et al., 2014:256; Kimani-Murage et al., 2015:315). All the interventions can be placed within the framework described by Rollins et al. (2016) and all of these interventions respond in one way or another to factors that influence breastfeeding practices across the ecological framework from the individual to the societal level.
Pregnancy and childbirth are natural health transitions; biophysical, psychosocial, cultural, and social factors are integral to the experience and impact the outcomes. This often manifests in either negative or positive measures either mourned in the case of death or disease or celebrated as joyous motherhood with the addition of a healthy new member to two or more families. Despite this complex milieu of factors to consider, many of the interventions to address breastfeeding have focused on the anatomical and physical technical support to mothers to breastfeed (Tylleskar et al., 2011; Jaafar et al., 2012; Sudfeld et al., 2012; Gilmore & McAuliffe, 2013; Fallon et al., 2014; Kimani-Murage et al., 2015). Very few breastfeeding interventions have addressed the known mother-infant attributes affected by psycho-social barriers (Binns & Scott, 2002; O’Brien et al., 2008; Bai et al., 2009; Afoakwah et al., 2013; Goosen et al., 2014a; Balogun, 2015; Raman et al., 2016) such as convention and family influence or local beliefs and practices.
The conceptual framework of Rollins et al. (2016) helps us to understand what the determinants of successful breastfeeding, as defined by optimal breastfeeding across the continuum from 0-24 months, are. The WHO recommends three key breastfeeding practices: initiation of breastfeeding within one hour after birth (also referred to as immediate breastfeeding), exclusive breastfeeding (EBF) through six months of age, and continued breastfeeding until 24 months of age (WHO, 2010). According to the conceptual framework shown in Figure 1.1, beyond the mother-infant dyad, breastfeeding culture and practice is influenced by the environment in three distinct settings, namely: health systems and services, which are primarily antenatal and postnatal services, family and community support and in workplace and employment. These three settings are the environments in which breastfeeding mothers will find themselves at any given point in time. It is therefore imperative to also understand what the innate and self-driven factors are that could enable
mothers to exclusively breastfeed despite hostile and unsupportive environments.
Drawing on the work of several researchers, Dennis (1999) put forward the theoretical underpinnings to measure breastfeeding self-confidence now referred to as breastfeeding self-efficacy. Dennis (1999) argued then, that to effectively address the low breastfeeding rates it would be better for health professionals to identify and intervene with high-risk mothers on modifiable variables like maternal confidence rather than non-modifiable socio-demographic variables. Applying Bandura’s Social Learning Theory (Bandura, 1977), Dennis (1999) asserts that in the context of breastfeeding, breastfeeding self-efficacy expectations can influence women’s judgements of their ability to initiate, persist and continue breastfeeding. Exploring and measuring breastfeeding self-efficacy could provide some insights into why exclusive breastfeeding is improving despite an unchanged hostile breastfeeding environment presented in the health system, the family and home setting and/or at the workplace (Martin-Wiesner, 2018).
GLOBAL EXCLUSIVE BREASTFEEDING TRENDS
Globally, breastfeeding rates and especially EBF rates are below desired targets and many countries are not on track to meet the WHO target of 50% EBF for infants 0-6 months by 2025 (WHO, 2014). The fairly recent emergence and focus on the first 1000 days of a child’s development from conception to roughly age 2 years, as a public health intervention programme to create awareness and urgency to address optimal nutrition and stimulation for brain development (Horton 2008:178) has seen a re-focus on infant and young child feeding agenda with renewed commitment to breastfeeding at the global level (Bhutta et al., 2008:417; WHO 2014:1; Gupta & Sur 2016:8; Victora et al., 2016:475; Kakietek et al., 2017:2). However, exclusive breastfeeding trends globally are slow to improve (Labbok et al., 2006:273; Cai et al., 2012:3; Gupta & Sur 2016:11). Furthermore, analysis of geo-spatial breastfeeding data from across Africa, has indicated that without concerted effort or interventions into supporting breastfeeding, breastfeeding rates will decrease (Bhattacharjee et al., 2019). South Africa has garnered the energy to pursue the United Nations’ global breastfeeding target of 50% country-level exclusive breastfeeding by 2025. Since 2011, South Africa has progressed in leaps and bounds with commitments to the breastfeeding agenda moving from policy commitments to operationalizing these commitments with increased investments in breastfeeding promotion and communication to support exclusive breastfeeding, scale up of the Mother-Baby Friendly Initiative and the use of community health workers to promote and support exclusive breastfeeding (Department of Health, 2011; Department of Health, 2012; Department of Health, 2016; Martin-Wiesner, 2018).
EXCLUSIVE BREASTFEEDING PRACTICES IN THE CONTEXT OF SOUTH AFRICA
Since the first demographic and health survey in 1998, South Africa has had some serious data gaps in the field of infant and young child feeding. In the recent past five years, a number of national and local studies have provided some insights into the changing landscape of infant and young child feeding (Human Science Research Council, 2013:17; Goosen et al., 2014b; Siziba et al., 2015; Budree et al., 2016; National Department of Health et al., 2016; Horwood et al., 2018). While breastfeeding practices and rates are evidently improving, barriers to exclusive breastfeeding (EBF) from the perspective of mothers are not completely understood.
Despite the research evidence that breastfeeding and exclusive breastfeeding is the most effective child health intervention for both child survival and development (WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality, 2000; Chetty et al., 2010:8; Sankar et al., 2015; Victora et al., 2016:480), and in spite of the numerous policies and programmes to promote and support breastfeeding, South Africa still lags behind many other countries on either side of the economic development scale with respect to breastfeeding and in particular EBF rates (Department of Health 2015:8; International Food Policy Research Institute, 2015:126). Despite global (Bai et al., 2009:136; De Jager et al., 2014:659; Balogun, 2015:436) and local (Bergh, 1987:117-118; Netshandama, 2002:23; Sibeko et al., 2005:32-33; Goosen et al., 2014b:52; Ijumba et al., 2014:104; Siziba et al., 2015:172; Jama et al., 2018:8) evidence documenting women’s reasons for not breastfeeding, South Africa has yet to make progress in shifting the norm of artificial infant feeding and mixed feeding towards exclusive breastfeeding as the first and optimal feeding choice for infants 0-6 months.
Despite the strong calls for action and commitments to the breastfeeding agenda (Malan 1987:1; Behr 2008:42; Department of Health 2012:5; Department of Health 2013b:10; Department of Health 2015:8; Department of Health 2016:1-2), data from the most recent Demographic and Health survey (National Department of Health et al., 2017) has shown slow progress since 2003 as shown in Table 2.1 below. Comparison of data from 2003 and 2016 showed that the percentage of infants not being breastfed has remained consistent (26.7 vs 25.2%). Improvements have been made among breastfeeding mothers with the largest changes in decreased mixed feeding with food, other kinds of milk and water, respectively. Despite this significant improvement in EBF rates over the last decade (8.3 vs 31.6%), at the rate of improvement of only 1.8 percentage points per year, and with only
eight years to the United Nations 2025 EBF target of 50% at the country level for children 0-6 months, South Africa will not meet the set target.
Table 2.1: Comparison of breastfeeding practices in 2003 and 2016
AGE IN MONTHS
% NOT BF % EBF BF + WATER BF + OTHER
MILKS BF + FOODS 2003 2016 2003 2016 2003 2016 2003 2016 2003 2016 0-1 16.9 19.2 11.2 44.0 26.8 14.0% 27.7 14.9% 8.8 6.7% 2-3 22.4 28.9 12.2 28.2 14.1 6.7% 19.5 11.0 % 26.8 24.9% 4-5 39.7 27.2 1.3 23.7 16.8 19.5% 11.4 8.5% 27.8 20.8% 0-5 26.7 25.2 8.3 31.6 18.6 13.6% 19.1 11.4% 22.0 17.6%
BF = Breastfeeding, EBF = Exclusive breastfeeding. Data sourced Department of Health & Medical Research Council, 2007 and National Department of Health et al. (2017).
The largest increase in EBF rates has been in the age group of 4-5 months, with roughly a 23-fold increase (1.3% vs 23.7%). While this is a very significant and large increase, the findings of the 2016 DHS were not completely unexpected. Already in 2010, there had been reported signs of improvement at specific time points along the 0-6 months age continuum. Goga et al. (2012a) reported that EBF among HIV-exposed infants at 4-8 weeks breastfeeding increased in all provinces between 2010 and 2012/13. Rates in two provinces, namely, KwaZulu-Natal (KZN) and Northern Cape (NC) showed substantial increases. Breastfeeding amongst infants aged 4-8 weeks in KZN increased from 26.1% in 2010 to 42.5% in 2011 and 53.8% in 2012/13. A similar sharp upward trend was observed in the Northern Cape where EBF increased from 43.5% in 2011 to 76.4% in 2012/13. The most recent data from KZN shows continued increases with 23% EBF at 14 weeks (Horwood et al., 2018). While there are signs of improvements, other provinces still grapple with very low rates of EBF (Goosen et al., 2014b; Siziba et al., 2015:1; Van der Merwe et al., 2015:123; Budree et al., 2016:1). Table 2.2 lists the EBF rates for infants 0-6 months by province as reported in the literature from 2011 - 2016.
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Table 2.2: EBF rates for infants 0-6 months reported in the literature by location for the period 2007 – 2019
REFERENCE PROVINCE STUDY POPULATION EBF RATE
Department of Health and Medical Research Council (2007)
National Mothers with infants < 24 months (n=194) 8.3% <6months
Mushaphi et al. (2008)
Vhembe district, Limpopo Province
Mothers with infants <12 months (n=185) 14% <6 months of these only 7.6% EBF
Ladzani et al. (2011)
Mpumalanga HIV-positive mothers at PHC clinics (n=815) EBF rate 3-6 months: 35.6%
Tylleskar et al. (2011)
KZN & Western Cape (WC)
Community-based mother-infant pairs (n=485) EBF rate at 24 weeks: 2%
Goga et al. (2012b) KZN, Eastern Cape, & WC
PMTCT sites at PHC clinics (n=665 HIV+)
(n=218 HIV-)
At 3 weeks 42% in HIV+ versus 17% in HIV-. At four months postpartum dropped to 11% vs 0.7%
Ahmadu-Ali & Couper (2013)
HIV+ and HIV- postpartum women 7 clinic sites (n=289 HIV-) (n=71 HIV+) (n=17 HIV unknown) At 6 weeks EBF 53.1%, (n = 205) EFF 26.6%, (n = 103) MF 20.3%, n = 78). Goosen et al. (2014b)
Western Cape Community-based mother-infant pairs (n=140) EBF rate 0-6 months: 6%
Siziba et al. (2015) North West, Free State, Gauteng and Eastern Cape
Mothers and caregivers at PHC clinics (n=580) EBF rate 0-6 months: 12%
Van der Merwe et
al. (2015)
Mpumalanga Mother and infant pairs at PHC clinics (n=218) EBF rate 0-6 months: 54% EBF at 20-24 weeks: 36% Mulol and
Coutsoudis (2016)
KwaZulu-Natal Mother-infant pairs (24hr recall) (n = 100) EBF at 6 months 8.3%
Budree et al. (2016)
Western Cape Mother and infant pairs at PHC clinics (n=710) EBF rate 0-6 months: 13%
Mnyani et al. (2017b)
Johannesburg, Gauteng Postpartum mothers with infants <6 months (n=100) Reported EBF 63.9% among HIV+ women and 70.3% in HIV- women
Reimers et al. (2018)
KwaZulu-Natal HIV+ women
Control (n = 326), Intervention (n = 299).
At 22 weeks
Control group: 44.68% (105/235) Intervention group: 42.75% (109/255)
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REFERENCE PROVINCE STUDY POPULATION EBF RATE
Nieuwoudt et al. (2018)
Gauteng Mother-infant pairs (24-hour recall) (n=298) 3-6 months 31.8% Horwood et al.
(2018)
KZN Mother-infant pairs at PHC clinics (n=4172) EBF rate at 14 weeks: 23%
West et al. (2019) Gauteng FRESH Start database (n=1913) 10 weeks HIV- 85% HIV+ 58% 14 weeks HIV- 81% HIV+ 55% 6 months HIV- 58% HIV+ 37% EBF = Exclusive Breastfeeding , EFF = Exclusive Formula Feeding, MF = Mixed Feeding
From the data presented in Table 2.2, the EBF rates have improved over time for infants aged 0-6 months and have increased at specific age-points. But given the wide variation in the reported EBF rates and independent of the study designs, many of the studies did not use the standardized and recommended WHO infant and young child feeding indicators (WHO 2008:5), nor the standardized tools and calculations prescribed and recommended by WHO (WHO 2010:34). Furthermore using gold standard measurements (dose-to-infant deuterium dilution stable isotope technique), Mulol and Coutsoudis (2016) found little or no agreement between the stable isotope technique and reported exclusive breastfeeding; showing up to 30% over-reporting of exclusive breastfeeding. A major difference in EBF rates has been with or without the inclusion of self-prescribed over-the-counter medication. Lower rates without the inclusion of self-prescribed over the counter medication (Goosen et al., 2014b; Siziba et al., 2015:1; Van der Merwe et al., 2015:123; Budree et al., 2016:1) and higher rates with the inclusion of self-prescribed over-the-counter medications (Ahmadu-Ali & Couper, 2013:386; Mnyani et al., 2017b:4; West et al., 2019:4). Horwood et al. (2018) did not specifically ask about self-prescribed over-the-counter medications.
An interesting development over time has been the switch in higher reported rates of exclusive breastfeeding among HIV-negative mothers (Ahmadu-Ali & Couper, 2013:387; Mnyani et al., 2017b:4; West et al., 2019:3) than HIV-positive mothers (Doherty et al., 2006:90; Goga et al., 2012b:5). This may be explained by the strongly held fear of HIV transmission through breastfeeding (Doherty et al., 2006:91; Tylleskar et al., 2011:422; Barron et al., 2013:72; Ijumba et al., 2013:762; Reimers et al., 2018:219), but with the implementation of life-long ARVs and the increased awareness that breastfeeding is safer with ARVs, HIV-positive mothers have come to rely on ARVs rather than improved breastfeeding practices to keep their infants safe (Tylleskar et al., 2011:420; Reimers et al., 2018:212). Intervention studies focused on peer-support have not been able to improve exclusive breastfeeding among HIV-positive mothers (Nor, 2011:420; Tylleskar et al., 2011:420; Ijumba et al., 2015:2660; Reimers et al., 2018:212). What these findings may allude to is that better information, greater awareness and self-efficacy lead to improved breastfeeding practices.
There have been a series of calls to action for better information, robust data sources and evidence-based actions to improve breastfeeding rates, most notably from the first World Breastfeeding Conference in India in 2012 (BPNI & IBFAN-Asia 2013:15), the launch of the first Global Nutrition Report in 2015 (IFPRI 2015:34) and the first-ever Lancet Series on Breastfeeding in 2016 (Rollins et al., 2016:493). Since then there have been concerted efforts and resources committed by countries to meet the 2025 breastfeeding targets (WHO
