BackgroundIn 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.ObjectivesThe aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.MethodsWe applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980–2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.ResultsFrom an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.ConclusionsFrom a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.
BackgroundMothers rely heavily on health worker advice to make infant feeding decisions. Confusing or misleading advice can lead to suboptimal feeding practices. From 2001, HIV positive mothers in South Africa were counseled to choose either exclusive breastfeeding or exclusive formula feeding to minimize vertical HIV transmission. On the basis of revised World Health Organization guidelines, the government amended this policy in 2011, by promoting exclusive breastfeeding and discontinuing the provision of free formula. We explored how health workers experienced this new policy in an HIV endemic community in 2015–16, with attention to their knowledge of the policy, counselling practices, and observations of any changes.MethodsWe interviewed eleven health workers, from four community health clinics, who had counseled mothers before and after the policy change. The transcribed interviews were analyzed thematically, using a hybrid coding approach.ResultsThe scientific rationale of the policy was not explained to most health workers, who mostly thought that the discontinuation of the formula program was cost-related. The content of their counseling reflected knowledge about promoting breastfeeding for all women, and accordingly they mentioned the nutritional and developmental benefits of breastfeeding. The importance of exclusive breastfeeding for all infants was not emphasized, instead counseling focused on HIV prevention, even for uninfected mothers. The health workers noted an increased incidence of breastfeeding, but some worried that to avoid HIV disclosure, HIV positive mothers were mixed feeding rather than exclusively breastfeeding.ConclusionsCausal links between the policy, counseling content and feeding practices were unclear. Some participants believed that breastfeeding practices were driven by finance or family pressures rather than the health information they provided. Health workers generally lacked training on the policy’s evidence base, particularly the health benefits of exclusive breastfeeding for non-exposed infants. They wanted clarity on their counseling role, based on individual risk or to promote exclusive breastfeeding as a single option. If the latter, they needed training on how to assist mothers with community-based barriers. Infant feeding messages from health workers are likely to remain confusing until their uncertainties are addressed. Their insights should inform future guideline development as key actors.
Background Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage. Methods For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February–March 2018 in South Africa’s KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes. Results Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media. Conclusions Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women’s knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women’s breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.
Globally, communication plays an integral role in public health strategies, from infectious diseases to diseases related to lifestyles. The evolution of the field of social and behaviour change communication (SBCC), combined with the need for evidence based practice and multi-level interventions to promote health, and human resource gaps in sub-Saharan Africa have led to the imperative to standardise and formalise the field. Moreover, current practitioners come from different disciplinary backgrounds underlining the need to define common core skills and competencies. This paper describes the partnership between the Wits School of Public Health and the Soul City Institute for Health and Development Communication and how the partners responded to this need. It highlights the factors influencing sustainable institutional capacity to provide quality assured, accredited training. We describe an unexpected positive response from a number of practitioner organisations that have chosen to send multiple staff members for training, specifically to build a critical mass within their organisations. Finally, we note the interest from (mostly) southern-based academic institutions in setting up similar programmes and postulate that south–south collaborations can contribute to building sustainable context specific and evidence-informed SBCC programmes in the global south.
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