Over the last decade, overwhelming scientific evidence supporting the integral role of breastfeeding in the survival, growth and development of a child, as well as the in the health and well-being of a mother, has come to light. According to the World Health Organisation (WHO), breast milk has the complete nutritional requirements that a baby needs for healthy development. Furthermore, it is safe and contains antibodies that help protect infants and boost immunity. Consequently, breastfeeding contributes to reduced infant morbidity and mortality due to diarrhoea, respiratory or ear infections and other infectious diseases. For the mother, breastfeeding is economical; breast milk is always available, clean and at the right temperature. Breastfeeding also delays the return of fertility and reduces the risk of developing breast and ovarian cancers.⁽²⁾ The WHO recommends that for the first six months of life, infants should be exclusively breastfed to achieve optimal growth, development and health. Thereafter, infants should receive nutritionally adequate and safe complementary foods, while continuing to breastfeed for up to two years or more.⁽³⁾

Globally, less than 40% of infants under six months of age are exclusively breastfed, despite the documented benefits of breastfeeding.⁽⁴⁾ In addition, only 38% of infants aged less than six months in the developing world, Africa included, are exclusively breastfed.⁽⁵⁾ In many African societies, exclusive breastfeeding is influenced by various socio-economic, cultural and biological factors. In light of the surprising breastfeeding statistics, this paper, the first in a two-part series, attempts to highlight the knowledge, attitudes and practices regarding exclusive breastfeeding (EBF) that continue to affect its successful uptake in Southern Africa. The paper concludes by outlining the measures, based on the findings of scientific research, that must be implemented to encourage EBF in Southern Africa.

Definition of exclusive breastfeeding

According to the WHO, “Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines.”⁽⁶⁾

To enable mothers to establish and sustain exclusive breastfeeding for six months, the WHO and the United Nations Children's Fund (UNICEF) recommend:

• “Initiation of breastfeeding within the first hour of life;
• Exclusive breastfeeding - that is, the infant only receives breast milk without any additional food or drink, not even water;
• Breastfeeding on demand - that is, as often as the child wants, day and night;
• No use of bottles, teats or pacifiers.”⁽⁷⁾

While breastfeeding is a natural act, it is also a learned behaviour. Extensive research has confirmed that mothers require active support to begin and sustain appropriate breastfeeding practices.⁽⁸⁾

It is important to note that for mothers living with HIV, the WHO recommends the promotion and support  of breastfeeding in conjunction with antiretroviral (ARV) interventions as the strategy that will most likely give infants born to HIV-infected mothers the greatest chance for HIV-free survival. The organisation recommends that when HIV-infected mothers breastfeed, they should receive ARVs and exclusively breastfeed their infants for the first six months of life, followed by prompt weaning and the introduction of appropriate complementary foods.⁽⁹⁾ Breastfeeding must be interrupted after six months based on evidence showing that the risk of HIV transmission through breastfeeding increases gradually the longer the period a mother breastfeeds.⁽¹⁰⁾

Knowledge, attitudes and practices regarding exclusive breastfeeding

Trends in breast feeding differ among African countries. For example, while only 37% of all infants in Mozambique younger than six months are exclusively breastfed,⁽¹¹⁾ breastfeeding has been found to be universal in Zambia, and almost every child is breastfed after birth.⁽¹²⁾ However, studies have found several commonalities regarding breastfeeding knowledge, attitudes and practices among Sub-Saharan African countries.

Several studies conducted in countries in Africa have documented the importance of family members in child care and infant feeding. Studies conducted in Mozambique and Malawi, for example, show that babies’ fathers and grandmothers are particularly influential regarding infant feeding.⁽¹³⁾ Studies have generally highlighted the lack of autonomy and decision making power among young mothers, as decisions on infant feeding significantly involves the extended family.⁽¹⁴⁾ In Malawi for instance, mixed feeding was found to begin within the first 48 hours after birth, as advised by paternal grandmothers, who are perceived to be key decision makers when it comes to good parenting.⁽¹⁵⁾ However, grandmothers (and fathers) are reported not to be actively involved in information, education and communication (IEC) activities on EBF that largely target mothers.⁽¹⁶⁾ Even when women have heard of the recommendation to exclusively breastfeed for six months, grandmothers and fathers have heard the recommendation less often.⁽¹⁷⁾ Grandmothers’ and fathers’ lack of information on and support for EBF have been reported as a significant barrier to the continuation of breastfeeding.⁽¹⁸⁾

Furthermore, a study conducted in Zambia ⁽¹⁹⁾ indicated that mothers were unsure of whether breastfeeding could be continued if the mother is HIV positive. Participants in that study reported that babies’ fathers and grandmothers stated that an HIV positive mother could not breastfeed at all. Additionally, in this study the early introduction of complementary food and reduced interest for EBF was associated with the fear of dying or becoming too sick to be able breastfeed.

In a study conducted in Malawi, some HIV positive women reported not practising EBF, as loss of weight and feeling lethargic was associated with frequent breastfeeding. For an HIV positive mother trying to breastfeed while keeping her status a secret, “any visible sign that can be associated with AIDS is perceived as an added psychological burden.”⁽²⁰⁾ Thus, to avoid negative labels, these women tended to introduce mixed feeding before their babies were six months old.

In Malawi and Mozambique, in addition to breastfeeding, most women start practising mixed feeding, including the introduction of water, traditional medicines and porridge to their babies’ diets, before they reach six months of age.⁽²¹⁾ This is influenced partly by a lack of knowledge about breastfeeding. Studies have found that women sometimes doubt the feasibility of EBF ⁽²²⁾ and lack conviction that a baby can grow healthily until the age of six months on breast milk alone.⁽²³⁾ A study conducted in Zambia found that mixed feeding, particularly with water, other fluids and light mealie-meal porridge, was perceived as the best way to feed an infant - mainly because of the misconception that breast milk contains insufficient water.⁽²⁴⁾

Studies have also identified insufficient support for breastfeeding mothers from healthcare personnel as an obstacle to the successful uptake or continuation of EBF. In one study, women in Malawi seemed less knowledgeable about proper breastfeeding practices largely as a result of poor quality of counselling from hospital staff.⁽²⁵⁾ Healthcare personnel in Mozambique were reported to have insufficient skills to offer remedies to deal with breastfeeding problems such as painful or cracked nipples, inflammation or perceived insufficient milk production.⁽²⁶⁾ Studies have found that a major barrier in practicing EBF faced by mothers is the perception of insufficient milk production.⁽²⁷⁾ Inadequate information about how to stimulate milk production often leaves mothers frustrated with inadequate amounts of milk, which leads them to introduce mixed feeding.⁽²⁸⁾

Finally, cultural and traditional beliefs have been found to influence EBF. While not breastfeeding at all is rare and carries stigma in Mozambique,⁽²⁹⁾ in Malawi EBF is not culturally acceptable at all. One study reported a common Central or Southern Africa traditional belief that the behaviour of the mother can negatively affect the quality of breast milk, thus making it ‘bad’ for the baby.⁽³⁰⁾ Specifically in the rural part of the study area, women had a stronger belief in ‘bad’ milk and were less educated about infant feeding, most likely as a result of poor access to health care.

Conclusion

It is of utmost public health importance that optimal breastfeeding practices, particularly EBF, are encouraged and practised in order to promote the growth, survival and health of children.

It is evident from the literature that countries in Southern Africa share similar attitudes and practices regarding EBF. Major obstacles faced by mothers that affect the successful implementation of EBF include: the perception of insufficient milk production, the fear of dying or becoming too sick to be able to breastfeed, mixed feeding, the perception of ‘bad milk’, the strong role of the extended family in decision making concerning infant feeding, stigma and inadequate health education provided by health personnel on optimal breastfeeding practices and remedies.

The abovementioned studies clearly show that there is a dire need for improved IEC activities and interventions on EBF, targeting not only mothers, but also influential members of the family. EBF is unlikely to be practised if mothers continue to face problems with breastfeeding without adequate support. Counselling for mothers on EBF needs to be improved and healthcare workers need to be better trained to provide counselling services. Healthcare providers’ capacity to conduct outreach activities on EBF needs to be built in order to improve EBF rates. There is also great need to create awareness of optimal breastfeeding practices and behavioural change among mothers and their extended families, which play a significant role in infant feeding choices and practices. Furthermore, interventions need to be scaled up to empower HIV positive women to practice EBF and to educate family members in conjunction with mothers about the benefits of EBF.

In addition to the improvements required in the education of mothers and family members, there is also a need to educate the broader public.  There is a need for unrelenting anti-stigma efforts to encourage communities to accept people living with HIV and their children.

The second part of this series discusses the health implications of the attitudes towards and practices of exclusive breastfeeding outlined above. The WHO/UNICEF Global Strategy for Infant and Young Child Feeding (IYCF), designed and implemented to support and encourage optimal breastfeeding practices, is discussed in relation to the African context. Finally, recommendations for the successful implementation of the strategy are presented.

Click here to read Part 2 of this discussion paper.

Written by Rita Magawa ⁽¹⁾

NOTES:

(1) Contact Rita Magawa through Consultancy Africa Intelligence’s Public Health Unit (public.health@consultancyafrica.com).
(2) ‘Maternal, newborn, child and adolescent health: Breastfeeding’, World Health Organisation, http://www.who.int.
(3) ‘Exclusive breastfeeding for six months best for babies everywhere’, World Health Organisation, January 2011, http://www.who.int.
(4) ‘10 facts on breastfeeding’, World Health Organisation, July 2012, http://www.who.int.
(5) ‘Breastfeeding: Impact on child survival and global situation’, United Nations Children's Fund, January 2005, http://www.unicef.org.
(6) ‘E-Library of evidence for nutrition actions (eLENA): Exclusive breastfeeding’, World Health Organisation, December 2011, http://www.who.int.
(7) ‘Maternal, newborn, child and adolescent health: Breastfeeding’, World Health Organisation, http://www.who.int.
(8) Ibid.
(9) ‘Rapid advice: HIV and infant feeding. Revised principles and recommendations’, World Health Organisation, November 2009, http://www.who.int.
(10) ‘HIV and infant feeding: Guidelines for decision makers’, World Health Organisation, et al., 2003, http://www.unfpa.org.
(11) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32.
(12) Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(13) For example, Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32; Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-110; Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(14) Ibid.
(15) Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-1105.
(16) For example, Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32; Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(17) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32.
(18) Ibid.
(19) Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(20) Østergaard, R.L. and Bula, A., 2010. “They call our children ‘Nevirapine Babies’”: A qualitative study about exclusive breastfeeding among HIV positive mothers in Malawi. African Journal of Reproductive Health, 14 (3), pp. 213-222.
(21) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32; Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-1105.
(22) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32.
(23) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32; Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(24) Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(25) Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-1105.
(26) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32.
(27) For example, Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-1105; Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.
(28) Ibid.
(29) Arts, M., et al., 2011. Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than six months in Mozambique: A qualitative study. Journal of Human Lactation, 27(1), pp. 25-32.
(30) Bezner-Kerr, R.M., et al., 2007.“We grandmothers know plenty”: Breastfeeding, complimentary feeding and the multifaceted role of grandmothers in Malawi. Social Science & Medicine, 66, pp. 1095-1105; Fjeld, E., et al., 2008. “No sister, the breast alone is not enough for my baby”: A qualitative assessment of potentials and barriers in the promotion of exclusive breastfeeding in southern Zambia. International Breastfeeding Journal, 3, pp. 26-38.