Abstract
Background:
There is strong evidence that exclusive breastfeeding (EBF) in the first 6 months of life reduces the risk of diseases in infancy and in later life.
Objective:
To understand the maternal reasoning that influences optimum infant feeding practices of caregivers in semirural communities of Limpopo province.
Methods:
Nested qualitative study among mothers in an ongoing birth cohort study was conducted; structured and semi-structured interviews were used to collect data. Data from 234 infants after 6 months of follow-up was included for quantitative analysis. Four focus discussion groups comprising 7 to 10 caregivers were used to obtain perception of mothers on breastfeeding. A semi-structured interview guide was used to stimulate discussions. Thematic content analyses were conducted to identify the main themes that influence breastfeeding practices of caregivers.
Results:
Over 90% of the caregivers initiated breastfeeding after delivery. However, less than 1% of mothers practiced EBF by 3 months, and none of the children were exclusively breastfed for up to 6 months. All caregivers introduced non–breast milk liquids and solids by the second month of child’s life. Common reasons for introducing non–breast milk foods included insufficiency of breast milk production, going back to work or school, and influence by elderly women (mothers/mothers-in-law) and church members.
Conclusion:
Exclusive breastfeeding was not practiced in this community due to cultural and religious beliefs and misinformation. The involvement of elderly women and church members in infant feeding education and promotion programs and the dissemination of breastfeeding information through mobile phones to younger mothers are recommended.
Keywords
Introduction
Inappropriate infant feeding practices are the major contributors to undernutrition in developing countries. 1 Children with suboptimal feeding practices have repeated infections, lower growth velocity, and are almost 6 times more likely to die by the age of 1 month. 2 United Nations Children’s Fund (UNICEF) estimated that 9.5 million children died before their first birthday, and 35% of those deaths are associated with undernutrition. 3 Bhutta and Salam reported that worldwide 6.9 million children under the age of 5 die as a result of undernutrition. 4 Furthermore, 32% of the children under 5 years of age are stunted and 10% are wasted, and this could be solely attributed to the lack of exclusive breastfeeding (EBF) in the first 6 months of life, unsafe complementary feeding practices, and infectious diseases. 5
The World Health Organization (WHO/UNICEF) recommends that “infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health” (p. 6). 1 Thereafter, to meet the infant’s evolving requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to 2 years of age or beyond. According to UNICEF, breastfeeding is widely practiced in developing countries, but EBF is rarely practiced. 3 The benefit of EBF to the mother and baby are well documented in both developed and developing countries. 3 Despite these health benefits, very few children are exclusively breastfed for 6 months in most developing and developed societies.
Globally, it is estimated that less than 40% of infants are exclusively breastfed for the first 6 months of life. 3 This can be attributed to several cultural and socioeconomic factors. Most common barriers to EBF are a perception of not having enough breast milk, poor maternal knowledge, and going back to work or school. 6,7 Previous studies have shown that the rate of EBF in the first 6 months of life is lower than 15% in most parts of South Africa. 8,9 South African mothers have also been reported to believe that breast milk alone cannot satisfy the baby’s hunger; hence, they introduce complementary foods too early. 8,10 In other rural African settings, researchers report that family and community pressure was the primary reason why mothers introduced complementary foods early. 11
Several studies in South Africa revealed that nearly 70% of children are given inappropriate complementary foods, which are mainly cereal based and other foods with low-nutrient density. 12 –14 A similar trend was observed in a study done in Cameroon, where infants were given soft porridge as the first food before the age of 6 months. 11 As previously reported, the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED)–South Africa cohort found that rapid decline in EBF in the first month was primarily attributed to introducing prelacteals, water, formula, and semisolid porridge very early. 15
Given the low uptake of recommendations for EBF for 6 months, there is a need to understand the factors that influence mothers’ decisions about infant feeding. Such understanding may help organizations to design more effective infant feeding intervention strategies by leveraging facilitating factors and addressing relevant barriers. Therefore, the current study aimed to identify maternal reasoning that influences infant feeding practices in a semirural community in South Africa. This article presents data both from the first 6 months of the cohort study as well as a qualitative study conducted with the mothers of the enrolled children.
Methods
Study Design
A nested qualitative study was conducted among mothers in an ongoing birth cohort study, where structured and semi-structured interviews were used to collect data.
Birth Cohort Study
Baseline information was collected at the beginning of the MAL-ED South Africa birth cohort study, which was initiated in November 2009 in the Dzimauli community in Limpopo, South Africa. 16 Briefly, newborns who weighed at least 1500 g with no congenital conditions and were less than 17 days of age were enrolled after signed informed consent was obtained. At enrollment, caretakers were queried about household demographics and information about breastfeeding initiation, colostrum, and prelacteal fluids given to the child. In addition, anthropometric measurements such as weight, length, and head circumference were measured by trained fieldworkers. Twice weekly surveillance on illnesses and infant feeding practices was initiated at enrollment as described by Caulfield et al. 17 Information on surveillance has been reported elsewhere. 18 Briefly, caregivers were asked information on consumption of breast milk, animal milk, formula milk, and other liquids such as water, tea, juices, and sugar water. Based on Labbok and Krasovek breastfeeding definitions, each visit was categorized as exclusive, predominant, partial, and no breastfeeding. 19
For this analysis, a total of 314 children were included, while 56 children were excluded for the following reasons: death (n = 1), moved away from the study area (n = 36), dropped out of the study (n = 16), and missing data (n = 3). Primary reason for loss to follow-up was that many mothers were returning to school or work far from the study area and leaving children in the care of grandparents or other extended family members.
Qualitative Study
The qualitative study focused on infant feeding as prompted by the preliminary results of the MAL-ED study, where it was observed that none of the infants were exclusively breastfed for 6 months. Purposive sampling was used to select the caregivers in the MAL-ED project. Four focus group interviews were conducted between January and February 2014. Each focus group comprised of 7 to 10 caregivers.
The main purpose of this follow-up was to investigate the contributing factors that influence child feeding in the community. As indicated, there was 0% EBF by 6 months of age in the study cohort. Four groups of caregivers were purposively selected from the main study based on the duration of EBF to form focus groups for the qualitative study.
Overall, 37 caregivers participated in focus group discussions. Focus groups were conducted in the village, and the meetings were held in the local clinic, church, or community hall. The questions used to carry out the focus groups included the importance of breastfeeding, correct period of EBF, and reasons why mothers are not breastfeeding their infant exclusively. They were also queried on the age at which first food was given to their infant and the type of food given. Qualified nutritionists and experienced qualitative researchers were used to conduct the focus group discussions. The focus group discussion sessions lasted between 75 and 105 minutes. Group discussions were video-recorded, and field notes were taken by an assistant nutritionist in each session. The interviews were conducted using the local language (Tshivenda) and translated to English by a bilingual qualitative researcher.
Quality Control
For the cohort, there were multiple levels of quality control. First, a field supervisor checked the data as they were collected and conducted 5% repeat visits at random. Second, data were entered into a database using a double data entry protocol. Third, there were built-in checks in the database to detect skipped patterns and missing information. Finally, data were further scrutinized for anomalies, extreme outliers, and missing data at the Data Coordinating Center at the Fogarty International Center (National Institutes of Health, Bethesda, Maryland). Any discrepancy was verified and corrected.
For the qualitative study, there were also several levels of quality control. First, focus group discussions were video-recorded and reviewed multiple times to ensure accuracy. Second, field notes were independently taken by 2 research assistants. The questions were posed to stimulate discussion, and further questions were asked to ensure that reliable information was gathered. Third, transcription was also done twice by 2 Tshivenda-speaking nutritionists independent of each other. In addition, transcripts were translated into English by 2 people competent in both English and Tshivenda. Finally, the field notes and video-recording transcripts were compared for discrepancies or omitted information manually by a third person.
Data Analysis
Data analyses of the birth cohort were conducted using STATA version 13.1 (StataCorp LP, College Station, Texas). Duration of EBF and full breastfeeding was estimated using the survival function at various time points.
With regard to the semi-structured interview, data were transcribed verbatim and translated from Tshivenda to English. A thematic content analysis was used to analyze each focus group and interview transcripts. Analysis was interpretive. Responses were transcribed, analyzed, and categorized into themes that would provide accounts of the experiences of the participants. 20 NVIVO for Mac qualitative data analysis software version 11.0.0 (QSR International) assisted in open coding and analysis of the transcripts. Codes were created based on their similarities. Subcategories were developed from the open-coding categories and linked with other categories depending on the context.
Ethical Considerations
The study was conducted in accordance with the protocol approved by the institutional review boards at the University of Venda and University of Virginia, collaborating institutions in South Africa and United States, respectively. Informed consent was obtained from all individuals prior to their participation.
Results
Sociodemographic Data
Table 1 shows demographic data of the birth cohort study. The median age of the infant at enrollment in the study was 5 days. The average birthweight for newborn enrollment was 3130 g. The mothers were 16 years of age and older. About half of the participants were married, while 44.1% were never married. More than two-thirds of mothers were married before the age of 20. Majority of mothers had secondary education or above, while 5.9% had only primary education. Almost 60% of mothers had 2 children or more.
Sociodemographic Information of the South African MAL-ED Birth Cohort.
Abbreviation: MAL-ED, Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project.
Breastfeeding Initiation at Birth
About 60% of mothers initiated breastfeeding within an hour after delivery, 35.7% initiated breastfeeding within 24 hours after delivery, while 2.5% initiated breastfeeding within 3 days after delivery. Majority (95.9%) of infants were given colostrum, while very few (4.1%) were not given colostrum. Very few (3.5%) infants were given prelacteal feeds.
When asked how long it took them to initiate breastfeeding after delivery, almost all of the focus group mothers in all 4 groups reported that they initiated breastfeeding immediately after delivery with the help of nurses. “Nurses in the clinic helped me to initiate breastfeeding after delivery”—one mother said. Conversely, some mothers in group B reported that they did not initiate breastfeeding within first hour after delivery. The reason mothers cited for delaying initiation of breastfeeding was due to cesarean delivery, while other mothers mentioned that they slept immediately after delivery. “I was too drowsy to feed the baby after cesarean section”—one mother mentioned in group B. On the other hand, some mothers in group C reported lack of support by health-care practitioners as the reason for not initiating breastfeeding immediately after delivery: “Nurses did not help me to initiate breastfeeding and the nurses were busy.”
Age of Introducing Complementary Foods
Exclusive breastfeeding was not practiced, as all infants were introduced to other liquids or foods as early as in the first month. Overall, 67.4% of the children received water as their first food and the median age of introduction was 31 days (interquartile range [IQR]: 18-54 days). Porridge was the second most popular food introduced to children at the median age of 62 days (IQR: 47-90 days). Other first foods given to the child included infant formula and tea. Infant formula was given to 41% of the children in the cohort, and the median age of introduction among these infants was 136 days (IQR: 104-158) (Table 2).
Infant Feeding Practices From the Cohort Study.
Abbreviation: IQR, interquartile range.
Most mothers in the focus groups reported giving water or soft porridge from the first or second month of the baby’s life. “I breastfeed my baby and also give him water.” Mothers in group B introduced water in the second month, while soft porridge was introduced in the fourth month. In group D, some mothers reported that they gave water, sugar, and salt solution to infants at the age of 4 months. Mothers in groups A and C reported giving water or soft porridge from first months of infant’s life. A mother in group A said “I started giving soft porridge when my baby was 2 months.”
All groups reported that the main reason for giving complementary foods earlier than 6 months was baby crying a lot, and this was interpreted as hunger.
“The baby cry, cry, and cry at night so I started giving water and soft porridge”—mother in group D. “My baby did not sleep for long when I was just breastfeeding only”—mother in group C.
Mothers reported that grandmothers told them that baby who are fed with artificial milk are more satisfied and sleep longer than their breastfed counterparts. “Give artificial milk and the baby will sleep longer and he will be satisfied”—mother in group B.
In all groups, mothers cited going back to work or school as one of the main reason for introducing complementary feeds early than 6 months. “I started giving soft porridge when I was going back to school”—mother in group A.
Another mother in group D stated that “church members advised me to breastfeed and also give the baby boiled water until the age of 6 months” (Table 3).
Common Themes, Illustrative Quotes, and Recommendations From the Qualitative Study.
Types of Complementary Foods or Liquids Given to the Child
By 4 months of age, the majority of infants (95.2%) were given complementary foods, which increased to 99.2% by the sixth month. Most of the infants had water and soft porridge in their diet. Infant formula was given to more than 90% of children before 6 months of age. Almost three-quarter of infants were given porridge, rice, and bread from 3 months, and 90.9% were given these at the age of 4 months. Very few infants were given commercial infant foods at the age of 2 (1.8%) months. About 26% of infants were given fruit juice before the age of 6 months. It should be also noted that animal milk is rarely given to infants in this community due to cultural beliefs.
Some mothers in group A reported that infants were given water, glucose water in a feeding bottle, as well as soft porridge and traditional medicines. On the other hand, mothers in all groups reported that the infants were given foods such as tea and juices as they show interest or desire. “I give my baby tea if he wants it”—another mother in group C said.
Group C reported that Maltabella (sorghum soft porridge) soft porridge was cooked with cooking oil. All groups reported that the babies were given sorghum soft porridge, cream of maize soft porridge, and dairy foods such as yoghurt. At the age of 5 months, all groups reported that children were introduced to family foods such as stiff porridge with beans, stiff porridge with eggs, and stiff porridge with broth (groups D and C). Rice, mageu (maize meal soft porridge fermented to make a drink), and snacks were also among the family foods introduced before 6 months.
All groups reported that babies were given tshiunza (traditional fermented soft porridge with different medicinal roots) as the first food item to be introduced at any age. Furthermore, some mothers in all groups reported that babies are given tshiunza from the age of 2 to 3 months after birth. However, it is the mother/caregiver who decides on when and how to introduce tshiunza. Some mothers in all groups reported that elderly women (grandmothers and mothers/mothers-in-law) are the ones who advise mothers on when and how to introduce tshiunza. Mother in group A said “tshiunza is given after the traditional doctor performs some cultural rituals.” All groups reported that babies were given tshiunza after cultural rituals are performed. Tshiunza is believed to help treat the baby’s stomach pains, prevent constipation, and treat baby’s fontanel (ngoma). Some mothers in group B said “tshiunza treat the baby’s stomach pains, prevent constipation and fontanel.” On the other hand, some mothers in group D reported that they have given the baby plain soft porridge called tshiruthule. “I give my baby plain soft porridge only.”
Source of Infant Feeding Information
Mothers cited nurses as the main source of information on infant feeding practices. In addition, most mothers in all of the focus groups reported that this information was given immediately after delivery or during routine growth monitoring visit at the clinic. Another mother in group D said “we also ask nurses on how to feed the baby, especially if you are first time mother.” On the other hand, mothers in all groups reported that the elderly women (mother/mother-in-law and grandmother) told them to give the baby soft porridge. Another mother in group C said “my mother-in-law advised me to give soft porridge.” It was worth noting that some mothers of groups A, C, and D were influenced by Christian church members who advise them to give water and breast milk only for the first 6 months. Some mothers in group D said “the elderly women at Christian church told us to breastfeed and also give water for 6 months.”
All groups reported that they do not listen to health talk radio shows or read magazines or newspapers. One mother in group A said “I read the infant feeding information on the Road to Health card.” It was also interesting to observe that some mothers in group C use Internet as a source of information. The use of Internet was observed among young mothers who had access to Internet through their cell phone. “I read about infant feeding on the Internet”—young mother in group C.
Knowledge of the Importance of Breastfeeding
In all groups, mothers seems to be aware of the correct infant feeding practices. Mothers were able to list the following advantages: helps prevent or protect the baby from illness, helps in preventing respiratory diseases, as well as helping the child to grow well. One mother in group D said “early introduction of food to our children makes us visit the clinic more frequently because it causes the child to have flu.” In addition, mothers in group C also indicated that “breastfed baby is cleverer.” Mothers in all groups reported that breastfeeding saves money, and breast milk is always at the right temperature.
Duration of Breastfeeding
Group B reported that the child should be breastfed for 2 years. However, in practice, all groups reported that they stopped breastfeeding their babies before 12 months and some reported to have breastfed their babies for 24 months. One mother in group B said “I stopped breastfeeding my baby when he was 12 months.” All groups reported reasons for stopping breastfeeding before 2 years as that they were returning to school or work. Another mother in group A said “I stopped breastfeeding because I was going back to school.” In addition, mothers in all groups also reported that they were exhausted and not having enough milk; hence, they introduced infant formula. “I was tired of breastfeeding and I did not have enough breast milk”—mother in group D said. All groups indicated that breastfeeding for 2 years was not possible because many of the young mothers were going back to school or work. Group C reported that they stopped breastfeeding at the age of 17 to 19 months. Furthermore, some mothers indicated that they were tired of breastfeeding as the child was “sucking too much.” On the other hand, some mothers in group C reported that they stopped breastfeeding as the baby had low appetite and rely on the breast milk, only resulting in poor growth. Mother in group C said “I stopped breastfeeding because he was no longer eating well.”
Discussion
Breastfeeding was initiated and continued by most mothers in the first 6 months of child’s life. However, EBF up to 6 months was not practiced in any of the cohort of children. In the current study, most mothers believed that breast milk alone cannot satisfy the baby’s hunger, and as a result, they introduced water or soft porridge before the recommended age of 6 months. Similarly, most Hispanic mothers believed that breast milk alone will not satisfy the baby’s hunger. 21 It was interesting to note that mothers interpreted baby’s cry as hunger and introduced complementary food earlier than recommended. A similar trend was also observed in previous studies where baby’s cry was interpreted as hunger by caregivers. 9,10,22
In the current study, grandmothers play a significant role related to how infants are fed early on in life and with regard to when the baby should be introduced to complementary foods or liquids. A similar observation was made in the study done in periurban areas of Ghana, where grandmothers believed that breast milk alone will not satisfy the baby and encourage mothers to give other foods or liquids. 23 In addition, grandmothers in Ghana strongly adhere to traditional infant feeding methods of mix feeding and would prefer younger mothers to adopt the same feeding option for their grandchildren. 6,23 Elderly women are culturally seen as experts in young child feeding, and as a result, it is difficult for young mothers to resist advice from them as they are also the main line of support. Agunbiade and Ogunleye made similar observation where elderly women apply pressure to mothers to give other foods or infant formula or water. 24 These results reveal that EBF is still a challenge for many mothers, as they could not adhere to recommended duration.
Going back to work or school was one of the main reasons for introducing complementary feeds early than 6 months as cited by most mothers. Previous studies have also reported that mothers introduced complementary foods or fluid too early if they were going back to work or school. 8,9,24 Going to work or school is one of the biggest challenges that mothers face when it comes to following recommended infant feeding practices, as majority of them may not qualify for paid maternity leave or they are in low-paying jobs.
In the current study, most mothers initiated breastfeeding immediately after delivery with the help of nurses. However, a small number of mothers did not initiate breastfeeding immediately after delivery. In the current study, method of delivery and complications during delivery were cited as the main reason why mothers did not initiate breastfeeding immediately after delivery. Ukegbu et al reported that mothers delay initiation of breastfeeding if they deliver via cesarean section or if they experience any complications during delivery. 25 However, some mothers in the current study also reported that they fell asleep immediately after delivery. Furthermore, lack of support by health-care practitioners was cited as a top reason as to why mothers could not initiate breastfeeding immediately after delivery.
Several studies have reported that government health facilities (health professionals) were the main source of infant feeding information for mothers. 9,23,25 Otoo et al reported infant feeding information was obtained during antenatal or postnatal visits or growth monitoring visits. 23 A similar trend was also observed in the current study, where mothers cited clinic nurses as the main source of information. In addition, the majority of mothers reported that information on how to feed the baby was given immediately after delivery or when they visited the clinic for postnatal visits. On the other hand, mothers reported that the elderly women (mother/mother-in-law and grandmother) told them to give the baby soft porridge. Some mothers were influenced by Christian church members who advise them to give water and breast milk only for the first 6 months. Burdette and Pilkauskas suggested that attending church once a week or more was associated with a 55% increase in the odds of initiating breastfeeding among mothers in contrast to never attending services. 26 Almost all mothers reported that they receive infant feeding information immediately after delivery and during routine postnatal visits to the clinic.
Mothers in the focus group discussion mentioned that they did pay attention to health-related radio talk shows or read magazines or newspapers. However, some mothers reported that they got infant feeding information on the Road to Health Card. It was also interesting to observe that young mothers use Internet as a source of infant feeding information as they had access through their mobile phones.
Infants in the current study were given sorghum soft porridge, cream of maize porridge (commercial), and yoghurt (Danone). In addition, infants were given tea, juice, water, and glucose water in a feeding bottle and tshiunza (porridge). In the current study, mothers believed that infants should be given tshiunza, as it helps to treat the baby’s stomach pains, prevent constipation, and promote closure of baby’s fontanel. Tshiunza was among the first food items to be introduced at age of 2 to 3 months of baby’s life after a traditional healer had performed the cultural rituals. Family foods such as stiff porridge, rice, mageu, beans, eggs, and broth were given to infants from the age of 5 months.
Despite mother’s knowledge of the advantages of optimum infant feeding practices, very little was translated into practice. This finding concurred with other studies; for example, Otoo et al reported that most mothers in the study knew the importance of EBF. 23 However, they did not practice EBF for the entire 6 months. 23 This could be potentially attributed to the lack of family support, especially from the grandparents.
Mothers indicated that babies should be breastfed for 2 years and beyond. However, in practice, almost all mothers reported that they stopped breastfeeding their babies before 24 months. A small number of mothers reported having breastfed their babies for 24 months. Going back to school or work was the main reason why mothers stopped breastfeeding. In addition, some mothers also reported that they were exhausted and that they did not have enough milk; hence, they introduced infant formula. Most of the mothers stopped breastfeeding when the baby was 17 to 19 months of age.
Limitations of the Study
The observations of the study should be interpreted in the context of certain limitations. First, the mothers were not interviewed individually. As a result, it is possible that infant feeding practices which certain individuals are not happy talking about in an open discussion may have been missed. Second, in-depth interviews were not done to understand the influence of elderly women and church members on infant feeding practices. The findings from this attempt would have been useful in the development of educational programs targeting this group of the population.
Conclusion
Breastfeeding was practiced by almost all mothers. However, EBF for the first 6 months was rarely practiced, as most infants were introduced to complementary foods or liquids before the age of 3 months. Cultural and religious practices influenced the way mothers fed their babies. Elderly women were influential on how the babies should be fed as well as when the complementary foods should be given.
Recommendations
Based on the findings of this study, it is recommended that programs aimed at advancing the usefulness of EBF should not only focus on first time or young mothers but should also be designed to target all women in the community irrespective of age. In particular, grandmothers taking care of babies and church leaders should be considered. Also, disseminating infant feeding information through cell phones to target young mothers, who are increasingly using mobile technology, is an option. Future studies should also include elderly women in the programmatic work in order to better target and address important infant feeding practices in this community. In addition, it is important to create supportive environments for working mothers through increasing maternity leave from 4 months to 6 months as well as establishing day care centers for babies in the workplace in order to encourage EBF.
Footnotes
Authors’ Note
The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED) is carried out as a collaborative project supported by the Bill & Melinda Gates Foundation; the Foundation for the National Institute of Health; and the Fogarty International Center, National Institute of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Foundation for the National Institutes of Health, or the Bill & Melinda Gates Foundation. Study sponsors were not involved in the study design, collection, analysis or interpretation of data, writing of the manuscript, or the decision to submit the manuscript for publication.
Acknowledgments
The authors thank the study participants and Dzimauli community leaders for their important contributions.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: LFM was supported by award number D43 TW009359 from the Fogarty International Center/National Institutes of Health.