Barriers and facilitators of breastfeeding practices and their associations with infant growth at six months of age, a study in Soweto, South Africa
Introduction: Infant and young child feeding practices directly affect the nutritional status of children from 0-2 years postpartum and the World Health Organization recommends exclusive breastfeeding (EBF) for the first six months of life. Factors such as breastfeeding history, socio-economic status, cultural and individual factors may greatly influence a mother’s choice of infant feeding method. Amongst other factors, infant weight, and length gain (Length-for-age Z-scores) in the first year of life are used to measure the outcome of infant feeding. Aim: The aim of this study was to explore the different barriers and facilitators to breastfeeding practices amongst women in Soweto, South Africa and the association between infant feeding practices and infant linear growth at six months of age. Methods: This study utilized a mixed-methods sequential design. The study began with secondary data analysis of a longitudinal quantitative dataset, followed by a qualitative component to expand on findings from the quantitative results. One-time in-depth interviews (IDIs) were done with mothers who participated in the quantitative survey, to collect qualitative insights on their infant feeding choices. Descriptive statistics were used to describe the feeding practices, and logistic regression was used to assess the association between breastfeeding practices and the determining factors. Finally, linear regression was used to determine the association between the described infant feeding practices, covariates, and infant linear growth (HAZ). Thematic analysis was used to explore the decision-making process of mothers regarding infant feeding methods. Results: Of the 79 mother-infant dyads for whom there was data at six months, the majority (67.9%) reported mixed feeding, 29.5% predominantly breastfeeding and only 2.6% EBF. Having higher gestational age and maternal unemployment were the only factors that were significantly associated with exclusive and predominant breastfeeding. The sex of the infant was the only factor significantly associated with HAZ at 6 months (being female was associated with smaller height-for-age z-scores by -0.19). The twelve mothers who were interviewed, elaborated on factors that influenced their choice of infant feeding method, which included maternal and infant survival strategies, breastfeeding being incompatible with work, family practices and social norms, biomedical knowledge (breastfeeding knowledge), escaping judgement from the community and structural barriers (separation of the mother and infant). Perceived barriers to EBF far outweighed perceived facilitators for most mothers, explaining high rates of mixed feeding. Conclusion Even with the infant feeding policies and programmes put in place by the government, this study shows that the rate of EBF remains low. There are numerous factors that make it challenging for mothers to choose EBF, particularly in terms of family and social norms. Thus, new interventions that target families and the community to shift breastfeeding norms are needed outside of the healthcare setting. Educating mothers during pregnancy is not enough. ‘It takes a village to raise a child’, so everyone needs to be educated about age-appropriate infant feeding methods so they can make a more meaningful contribution to child development.
A dissertation submitted in fulfilment of the requirements for the degree of Master of Science in Medicine to the Faculty of Health Science, School of Clinical Medicine, University of Witwatersrand, Johannesburg, 2022.