Gearing up to improve exclusive breastfeeding practices in South Africa.

South Africa has one of the lowest breastfeeding rates on the African continent. Globally, just 44% of infants are breastfed soon after birth, and 40% of those less than six months old are exclusively breastfed. To improve infant nutrition by 2025, the United Nations established targets to eliminate malnutrition and increase exclusive breastfeeding (EBF) rates to at least 50%. Despite the WHO Code regulations endorsed by the World Health Assembly since 1981, breaches continue to be prevalent due to a combination of weak implementation, monitoring and enforcement in low-to-middle income countries. Over the years, infant formula sales in LMICs (including South Africa) have skyrocketed contributing to excess infant morbidity and mortality. To that end, the specific aims of this study was to gain an understanding of priority actions and strategies necessary to improve breastfeeding outcomes in South Africa in the context of the HIV pandemic. The team used a qualitative study design based on a semi-structured interview guide. The guide consisted of eight open-ended questions addressing the WHO HIV-related infant feeding guidelines, the WHO International Code of Marketing of Breastmilk Substitutes, political will, and advocacy. Of the 24 individuals contacted, 19 responded and 15 agreed to participate. The Breastfeeding Gear Model guided the thematic analysis. The three main themes identified were 1) WHO guidelines on HIV and infant feeding, 2) Improving exclusive breastfeeding, and 3) Advocacy. Key informants identified issues that need to be addressed to improve breastfeeding outcomes in South Africa. Strong political will is a key ingredient to harness the resources (human, financial) needed to implement, monitor, and act against Code violators. South Africa and other countries with similar challenges should consider using the WHOs Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent relevant World Health Assembly Resolutions (NetCode) methodology.

Psychosocial barriers and enablers of exclusive breastfeeding: lived experiences of mothers in low-income townships, North West Province, South Africa.

BACKGROUND: Despite national efforts to promote exclusive breastfeeding (EBF), South Africa's EBF rate is only 32 %. The aim of this study was to examine the rate of EBF discontinuation and the lived experiences of breastfeeding mothers at postnatal time points 3-14 days, 4-8 weeks, 10-14 weeks and 20-24 weeks. METHODS: This community-based mixed-methods study collected data within a prospective cohort study on sociodemographics, 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 was used for the quantitative data and thematic analysis for qualitative data. RESULTS: The majority of mothers were unmarried (84.9%), living with family (69.2%) and unemployed (74.2%). Exclusive breastfeeding decreased from 34% at 4-8 weeks to 9.7% at 20-24 weeks. Mixed feeding with infant formula increased from 17.0 to 30.6% and food feeding from 3.1 to 54.2%. While there were no statistically significant associations between EBF and any of the quantitative sociodemographic variables, in the qualitative data, codes associated with barriers were more than enablers. The themes were Mothers' attributes (wellbeing, experiences and relationships) with the code mother's stress the strongest barrier, Mother's knowledge, attitudes and practices of breastfeeding with the code conventional medicines the strongest barrier, Family environment with the code home setting the strongest barrier, Social environment with public spaces and places a barrier and in Baby cues the code baby stomach ailments the barrier. Within these same themes mother's positive emotions, benefits of breastfeeding, support in the home, access to information and services from health professionals and baby's health were strong enabling factors. CONCLUSIONS: Low EBF, high mixed feeding and a high EPDS score were explained by the barriers identified in the qualitative data. The data suggests that mothers from low-income households would be better supported through interventions that address food insecurity; family relationships and those that build confidence in mothers and resilience in confronting difficult and hostile breastfeeding environments.

HIV and infant feeding: issues in developed and developing countries.

Women in developed countries who are human immunodeficiency virus (HIV)-positive generally feed their infants formula to avoid virus transmission via breastfeeding. However, for most of the world's women who are HIV positive, the choice of infant feeding method is not so clear. Poor socioeconomic and living conditions place infants on breast milk substitutes at higher risk of non-HIV infectious diseases as compared with breastfed infants. Mothers in these settings who are HIV positive must weigh the risks and benefits of breastfeeding to choose the best infant feeding option.