Messages influencing infant feeding decisions made by mothers utilising private health care facilities in Johannesburg, South Africa
Background: Exclusive breastfeeding (EBF) has been shown to have better overall health outcomes for both mother and infant. However, South Africa has one of the lowest EBF rates in sub- Saharan Africa with high levels of mixed feeding, formula feeding and the early introduction of solids being practiced (1-3). There are complex reasons for this low uptake and policy has been developed to ensure that mothers get correct and consistent messaging, are supported to initiate and continue breastfeeding, and that factors that impact on the continuation of breastfeeding are improved (4). There are significant disparities in health care resources between the private and public sector and this study was designed to address critical gaps in our understanding of the dynamics that may be playing out in the private sector, in order to identify interventions that support optimal feeding. Methodology: A grounded qualitative study design comprising in-depth interviews and a group discussion was used. The study population comprised women whose infant was under one-year of age at the time of the study in Johannesburg, South Africa, who had accessed private health care facilities. Participants were solicited voluntarily, purposely sampled for diversity, and data were collected between July 2016 and November 2018. Electronic recordings of interviews were professionally transcribed and analysed using NVivo 11. Initial thematic analysis was undertaken with deductive and inductive analysis in the coding. Key themes were aligned and using a framework linked to the objectives during the final analysis stage. Trustworthiness of the data and positionality of the PI were considered. Results A total of 19 mothers, with a mean age of 35, from various racial groups participated. Infant feeding practices varied, with mixed feeding most commonly practiced. Intention to breastfeed was high, with most women initiating breastfeeding immediately. However, prelacteal formula were commonly offered and given in some health facilities. Mothers reported varying and limited ante-natal support in hospital and scant support once they returned home. Where lactation management was strong and knowledge of benefits of breast milk was good, women were more likely to successfully EBF. Public spaces and workplaces were barriers to breastfeeding; women would rather feed in their cars and stopped breastfeeding shortly after returning to work. Women were exposed to many conflicting messages from different sources, with key influencers being health care personnel, family and friends, and the media. In an effort to be a good mother and make sure that their babies did not go hungry, new mothers made decisions based on messages received and a number of contextual factors. As a result, feeding practices changed over time and most women did not breastfeed for the full six months; complementary foods were generally introduced from four months. Discussion and Conclusion: Feeding practices in the private sector are similar to those seen in the public sector with mixed feeding most prevalent. EBF is more likely amongst those mothers attending a MBFI accredited facility. Breastfeeding intention and initiation is good but contextual factors at key points can influence feeding trajectories. Interactions in health settings (offices, antenatal classes, and neonatal wards), lactation support at home and a supportive environment identified as key intervention points. In order to improve EBF rates and duration, a multilevel intervention is recommended which includes: (1) targeting key influencers with consistent messaging (2) improving the knowledge and skills of health care personnel to support mothers (3) heightening knowledge of the benefits of BF amongst mothers, partners and the wider support network (4) creating enabling and supportive environments that assist women to continue breastfeeding – lactation support at home, supportive workplaces and public facilities and (5) initiating mass media campaigns to shift public perception of BF. Without these interventions EBF rates aren’t likely to improve as mothers will continue to make decisions based on a multitude of factors and continued mixed messaging.
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Public Health Johannesburg, South Africa