Starting well: infant feeding in the first six months,soweto, south africa

Abstract

The health and development benefits of exclusive breastfeeding (EBF) for the first six months of life are well documented. However, breastfeeding has also been associated with HIV transmission. With around 30% of pregnant mothers testing HIV-positive during antenatal visits nationally, the potential HIV risks of breastfeeding have been weighed against the benefits. This has resulted in numerous different infant feeding guidelines over the past 20 years, changing with the evidence base for this risk-benefit equation. The latest guidelines were passed in South Africa in 2011, with the South African government deciding to support EBF only for all mothers and to end the programme that, from 2000, had provided free formula to HIV-exposed infants. However, infant feeding decisions are not influenced by health advice alone. Such decisions are made within a context that also includes family, friends, colleagues and social norms; in this context knowledge does not always reign supreme. Interventions to promote breastfeeding need to address existing barriers and amplify facilitators if South Africa hopes to continue increasing EBF beyond the current rate of 32%. In order to invest in the right mix of interventions, insight is needed into the levers of decision-making. Methods A mixed methods study design was applied to respond to the question, “What influences infant feeding decisions during the first six months?” To gain a national and historical perspective, a mixed methods systematic review of 71 articles was conducted for the period 1980-2018 on EBF influences specific to South Africa. Primary cross-sectional data were also collected from 2015-2016 in Soweto, a large urban township outside of Johannesburg. Data collection included a survey of 298 mothers of infants below six months, who were accessing care at community health clinics, and of whom two thirds were HIV positive. Qualitative in-depth interviews with mothers (46), frontline health workers (11) and key informants (3) were also conducted. For the systematic review, articles were analysed by method and the findings were then synthesized. Descriptive and inferential statistics were used to analyse the quantitative findings from the survey and thematic analysis was used for qualitative data. Findings Collectively, the findings highlighted longstanding challenges, such as mixed feeding norms and beliefs in milk insufficiency, as well as context-specific barriers to EBF, such as the government’s free formula programme. Evolving definitions of “optimal” feeding were not developed in consultation with communities and thus reflected strong biomedical biases. Health worker counselling content and approaches were identified as highly influential for breastfeeding initiation, with waning influence during the postnatal period except in community health worker programmes. Mothers’ HIV status was very influential in terms of following exclusive feeding practices out of fears of transmission, which was also reflected health workers’ focus on EBF as an HIV-specific issue. Family influences were cited as reasons for abandoning breastfeeding, along with the need for the mother to return to school or work. Honouring traditions and culture were other reasons to mix feed. Specific factors were identified and discussed at all levels of the socio-ecological model. Blind spots in research were also found in terms of who is researched (mostly Black Africans), where (provinces with large research universities) and how (minimal participatory designs). Conclusion A multi-sectoral and multi-level initiative is needed to bring about continued improvements in EBF. Mothers will not be able to act on knowledge without supportive environments, whether they are in health facilities, at home, work, school or in public spaces. Messages about breastfeeding need to emphasize the benefits for all infants, rather than HIVexposed infants only. Similarly, the health risks of mixed feeding need to be explained in a clear, but culturally sensitive manner. Mothers and frontline health workers have abundant insights that can be drawn upon in the creation of supportive interventions. The postpartum period is particularly important, which means more needs to be done to engage directly with families and communities. For those mothers who will not or cannot opt for EBF, there are still mechanisms within public health responses to support the nutrition and growth of their infants. Rather than blaming mothers, collective efforts are needed to support a healthy start for all infants in South Africa.