Mothers' breastfeeding experiences and practices: An explorative mixed methods study in the sub-district of Tlokwe, North West Province, South Africa

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 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.