Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review

Abstract

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.

Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces

“…An initial list of content areas and Fig. 1 Breastfeeding Conceptual Framework for South Africa [8] draft questions were prepared by the study designers who are mHealth and breastfeeding experts respectively. This list was then revised by the first author based on prior experience conducting interviews in South Africa.…”

“…In order to identify appropriate interventions to promote breastfeeding, Rollins et al [7] have proposed that breastfeeding determinants should be analyzed using a socioecological framework. The framework was further adapted by Nieuwoudt and colleagues [8] to account for intention during the antenatal period, as well as South Africa-specific feeding guideline changes over time ( Fig. 1).…”

“…1). Between 1980 and 2018 these guidelines shifted from EBF for 4-6 months for all women, to either EBF or exclusive formula feeding (EFF) for the first 3-6 months for women living with HIV, to either EBF or EFF for 6 months for women living with HIV, to EBF for all women for a full 6 months [8]. The framework emphasizes the importance of considering both interpersonal and structural contexts, in addition to the maternal attributes that have traditionally been the focus of breastfeeding behavioral change efforts, when investigating how feeding practices are explained or predicted.…”

Publics, technologies and interventions in reproduction and early life in South Africa

“…Caregivers may be aware of the significance of the information in booklets, but the booklets are written in languages (usually English or Afrikaans) that are unfamiliar to many caregivers. Some of the advice, such as best feeding practices (including exclusive breastfeeding for at least 6 months followed by the introduction of solid food with high iron content) is not possible given people's material circumstances and conditions of employment, for middle class as well as poor women (Ngcowa, 2019;Nieuwoudt et al, 2019). Le Roux et al (2017) found that despite carefully completed booklets, caregivers had to return to clinics repeatedly because of vaccine and medication stock-outs.…”

The updated South African National Guideline for the Prevention of Mother to Child Transmission of Communicable Infections (2019)

“…The evidence indicates that the benefits of breastfeeding outweigh the risks of not breastfeeding, regardless of the maternal HIV status. 13 , 14 , 15 As the HIV epidemic matures, it is clear that the breastfeeding period must be one of the main priorities in the prevention of vertical transmission of HIV. New innovative strategies are required to achieve and maintain maternal viral suppression in the period after birth, whilst simultaneously promoting breastfeeding as a major child survival strategy.…”