BackgroundExclusive breastfeeding (EBF) for the first six months of life is the most important determinant of child health and development, and is the recommended feeding practice for all mothers. However, EBF rates remain low in South Africa. This study aimed to prospectively explore enablers or barriers to success among mothers who planned to exclusively breastfeed their infants for the first six months of life, in KwaZulu-Natal, South Africa.MethodsA qualitative, longitudinal cohort design was adopted. Women were recruited during pregnancy from the catchment area of two hospitals (one urban and one rural) and purposively sampled to include working women, teenagers, and HIV positive pregnant women. This analysis relates to 22 women, from 30 women recruited, who planned antenatally to exclusively breastfeed for six months. These mothers were interviewed monthly for six months postpartum. Infant feeding practices were explored at each visit using in-depth interviews and 24 h feeding recall assessment. Framework analysis was conducted for qualitative data, and quantitative data analyzed using descriptive statistics.ResultsA total of 125 interviews were conducted between November 2015 and October 2016. Among 22 mothers who planned to exclusively breastfeed for six months, 17 reported adding other food or fluids before six months, and five reported exclusively breastfeeding successfully for the first six months. Key themes showed that all mothers relied strongly on health workers’ infant feeding advice and support. All mothers experienced challenges regardless of whether they succeeded in EBF, including inappropriate advice from health workers, maternal-baby issues, pressure from family members and returning to school and work. However, those who were successful at EBF for six months reported that high breastfeeding self-efficacy, HIV status and cultural meaning attached to breastfeeding were underlying factors for success.ConclusionHealth workers are key players in providing infant feeding information and support, yet some health workers give mothers infant feeding advice that is not supportive of EBF. Strategies to improve health workers’ competency in infant feeding counselling are needed to better prepare pregnant women to overcome common breastfeeding challenges and build mothers’ confidence and self-efficacy, thus increasing EBF rates.Electronic supplementary materialThe online version of this article (10.1186/s13006-017-0135-8) contains supplementary material, which is available to authorized users.

Summaryobjectives To evaluate prevention of mother to child transmission of HIV (PMTCT) implementation and integration of PMTCT with routine maternal and child health services in two districts of KwaZuluNatal; to report PMTCT coverage, to compare recorded and reported information, and to describe responsibilities of nurses and lay counsellors.methods Interviews were conducted with mothers in post-natal wards (PNW) and immunisation clinics; antenatal and child health records were reviewed. Interviews were conducted with nurses and lay counsellors in primary health care clinics.results Eight hundred and eighty-two interviews were conducted with mothers: 398 in PNWs and 484 immunisation clinics. During their recent pregnancy, 98.6% women attended antenatal care (ANC); 60.8% attended their first ANC in the third trimester, and 97.3% were tested for HIV. Of 312 mothers reporting themselves HIV positive during ANC, 91.3% received nevirapine, 78.2% had a CD4 count carried out, and 33.1% had a CD4 result recorded. In the immunisation clinic, 47.6% HIV-exposed babies had a PCR test, and 47.0% received co-trimoxazole. Of HIV-positive mothers, 42.1% received follow-up care, mainly from lay counsellors. In 12 ⁄ 26 clinics, there was a dedicated PMTCT nurse, PCR testing was not offered in 14 ⁄ 26 clinics, and co-trimoxazole was unavailable in 13 ⁄ 26 immunisation clinics. Nurses and lay counsellors disagreed about their roles and responsibilities, particularly in the post-natal period.conclusions There is high coverage of PMTCT interventions during pregnancy and delivery, but follow-up of mothers and infants is poor. Poor integration of PMTCT services into routine care, lack of clarity about health worker roles and poor record keeping create barriers to accessing services postdelivery.

BackgroundCommunity health workers (CHWs) are a component of the health system in many countries, providing effective community-based services to mothers and infants. However, implementation of CHW programmes at scale has been challenging in many settings.AimTo explore the acceptability of CHWs conducting household visits to mothers and infants during pregnancy and after delivery, from the perspective of community members, professional nurses and CHWs themselves.SettingPrimary health care clinics in five rural districts in KwaZulu-Natal, South Africa.MethodsA qualitative exploratory study was conducted where participants were purposively selected to participate in 19 focus group discussions based on their experience with CHWs or child rearing.ResultsPoor confidentiality and trust emerged as key barriers to CHW acceptability in delivering maternal and child health services in the home. Most community members felt that CHWs could not be trusted because of their lack of professionalism and inability to maintain confidentiality. Familiarity and the complex relationships between household members and CHWs caused difficulties in developing and maintaining a relationship of trust, particularly in high HIV prevalence settings. Professional staff at the clinic were crucial in supporting the CHW’s role; if they appeared to question the CHW’s competency or trustworthiness, this seriously undermined CHW credibility in the eyes of the community.ConclusionUnderstanding the complex contextual challenges faced by CHWs and community members can strengthen community-based interventions. CHWs require training, support and supervision to develop competencies navigating complex relationships within the community and the health system to provide effective care in communities.

BackgroundIntegrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children under 5 years by improving case management of common and serious illnesses at primary health care level, and was adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.Methodology/Principal FindingsSeventy-seven IMCI trained health workers were randomly selected and observed in 74 health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2 months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW's had received a follow up visit after training. In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%) children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%) children.Conclusion/SignificanceHealth workers are implementing IMCI, but assessments were frequently incomplete, and children requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.

ObjectivesRates of pregnancy and HIV infection are high among South African adolescents, yet little is known about rates of mother-to-child transmission of HIV (MTCT) in this group. We report a comparison of the characteristics of adolescent mothers and adult mothers, including HIV prevalence and MTCT rates.MethodsWe examined patterns of health service utilization during the antenatal and early postnatal period, HIV prevalence and MTCT amongst adolescent (<20-years-old) and adult (20 to 39-years-old) mothers with infants aged ≤16 weeks attending immunization clinics in six districts of KwaZulu-Natal between May 2008 and April 2009.FindingsInterviews were conducted with 19,093 mothers aged between 12 and 39 years whose infants were aged ≤16 weeks. Most mothers had attended antenatal care four or more times during their last pregnancy (80.3%), and reported having an HIV test (98.2%). A greater proportion of HIV-infected adult mothers, compared to adolescent mothers, reported themselves as HIV-positive (41.2% vs. 15.9%, p<0.0001), reported having a CD4 count taken during their pregnancy (81.0% vs. 66.5%, p<0.0001), and having received the CD4 count result (84.4% vs. 75.7%, p<0.0001). Significantly fewer adolescent mothers received the recommended PMTCT regimen. HIV antibody was detected in 40.4% of 7,800 infants aged 4–8 weeks tested for HIV, indicating HIV exposure. This was higher among infants of adult mothers (47.4%) compared to adolescent mothers (17.9%, p<0.0001). The MTCT rate at 4–8 weeks of age was significantly higher amongst infants of adolescent mothers compared to adult mothers (35/325 [10.8%] vs. 185/2,800 [6.1%], OR 1.7, 95% CI 1.2–2.4).ConclusionDespite high levels of antenatal clinic attendance among pregnant adolescents in KwaZulu-Natal, the MTCT risk is higher among infants of HIV-infected adolescent mothers compared to adult mothers. Access to adolescent-friendly family planning and PMTCT services should be prioritised for this vulnerable group.

BackgroundCommunity health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs.MethodsThis is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs.ResultsInterviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point.At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different.ConclusionsImproved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.Trial registrationClinicalTrials.Gov NCT01774136

BackgroundIncreasing the rate of exclusive breastfeeding (EBF) to 50% in the first six months of life is one of six major global targets set by the United Nations Decade of Nutrition, and is essential to achieve the sustainable development goals to eradicate hunger and end malnutrition by 2030.MethodsA survey using multistage random sampling design included 99 primary health care (PHC) clinics in all 11 districts in KwaZulu-Natal (KZN). All mothers and caregivers of infants 14 weeks of age attending the clinics in the study period were requested to participate in a structured interview to explore feeding practices since birth. As non-maternal caregivers may not have detailed knowledge of feeding practices, they provided limited information about current feeding practices. Respondents who consistently reported giving no other food or fluids except breastmilk since birth were classified as practising exclusive breastfeeding (EBF), and those who were currently breastfeeding but had given other food or fluids since birth were categorised as practising mixed breastfeeding (MBF).ResultsA total of 4172 interviews were conducted with mothers and caregivers of 14 week old infants. Among mothers 49.8% were EBF, 23.1% were MBF and 27.0% were not breastfeeding. Among non-maternal caregivers 11.8% reported EBF, 23.4% MBF and 62.3% were not giving breastmilk. Higher education (OR 0.6, 95% CI 0.4–0.8) and being in the highest socio-economic tertile (OR 0.7, 95% CI 0.6–0.9) were risk factors for not practising EBF, while returning to work (OR 0.3, 95% CI 0.2–0.3) or school (OR 0.2 95% CI, 0.1–0.3) was associated with less EBF. HIV-positive mothers were more likely to have never started breastfeeding (OR 3.6, 95% CI 2.7–4.8). However, they were similar in having stopped breastfeeding by 14 weeks (OR 1.1, 95% CI 0.9–1.4) compared to HIV-negative mothers, and, they had similar rates of EBF at 14 weeks of age (OR 1.0, 95% CI 0.9–1.3).ConclusionsEstimates of breastfeeding practices at 14 weeks in KZN are higher than previously shown. However, particular challenges that should be addressed if international targets for EBF are to be achieved include improving breastfeeding practices of HIV positive mothers and supporting all mothers, particularly working or schooling mothers to continue giving breastmilk while they are away from their children.

Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa.HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.