Breast milk plays a vital role in reducing child mortality. It has all the nutrients a baby needs in the first six months of life and its health benefits extend into adulthood. This is why organisations, like UNICEF and the World Health Organisation (WHO), recommend exclusive breastfeeding – no other food or drink, not even water – for infants in this period.
Globally, numerous policies and programmes have been put in place to promote and support breastfeeding. South Africa has also been promoting exclusive breastfeeding. But the country has one of the lowest rates of exclusive breastfeeding in Africa and globally.
Within the country, the rate varies substantially. There have been remarkable improvements in some age groups. In 2003, only 11.2% of babies were breastfeeding exclusively in the first month of life. By 2016, that number had jumped to 44%. But, at five months, only 31.6% of babies were being exclusively breastfed.
These patterns were echoed in my doctoral study conducted in the Tlokwe sub-district – an area with nine primary healthcare clinics and a district hospital – in South Africa’s North West province. I examined the rate and reasons of exclusive breastfeeding discontinuation among a particular group of mothers.
It’s important to understand why mothers, despite the decades of breastfeeding promotion campaigns, still do not optimally breastfeed their infants. Understanding the reasons can inform policy and interventions to make it easier to give babies the best start in life.
The Tlokwe sub-district is like many low-income neighbourhoods in South Africa. It’s burdened with high unemployment, poor living conditions, high levels of violence and crime and low levels of social capital. Most households in setting like this are headed by women and have multiple children. The men are often drawn to cities for better employment opportunities. I followed a cohort of 178 breastfeeding mothers with infants from age 14 days to 24 weeks.
In my study, exclusive breastfeeding rates decreased from 34% at 4-8 weeks to a mere 9.7% by weeks 20-24. Over the same period, mixed feeding with infant formula increased from 17% to 50.1%, and food feeding from 3.1% to 54.2%. These numbers mirror the national trends.
A lot is still uncertain about breastfeeding practices in South Africa. But my research suggests that womens’ decisions around breastfeeding are shaped by a host of personal, social, economic and cultural factors. These often get in the way of the mother’s intentions to breastfeed her infant as recommended. This is especially true for women living in poverty.
Of all the factors that determine women’s decisions on breastfeeding, the most dominant one – in my study, at least – was the stress that mothers endure in difficult home environments.
Many South African women face daily challenges of poverty – no food, rent to pay, children to put through school.
One study found that a major concern and source of stress for breastfeeding mothers was the lack of food in the home. In 2017, almost 20% of South African households had inadequate or severely inadequate access to food. The North West province – where I did my study – had the highest proportion of food insecure households at 63%.
Under such trying conditions, women often have to care for children alone. Studies have found that most new mothers live with their families of origin rather than their partners or spouses. And these families have their own struggles with poverty.
This elevates stress. Family stress and the lack of food and money take a toll on a mother’s mental health. I used the Edinburg Postnatal Depression Scale to measure mothers’ mental health and found that nearly 45% had clinical signs of distress. This rate is higher than found in previous studies of mental health among HIV-positive mothers.
Around 13% of mothers in developing countries experience clinical depression after childbirth – a condition also known as postpartum or postnatal depression. Women with high levels of postpartum depression are more likely to stop breastfeeding within three months.
In my study, mothers feared that the stress they experienced could be passed on to their infants through breastfeeding. Mothers are reluctant to pass on their stress and distress to their infants. Their decision to seek alternative feeding is a protective action to spare their infants their negative stress.
Research shows that stress in mothers increases corticosteroids in breast milk. This validates mothers’ concern for their infants and the negative impact of stress.
My qualitative data showed that many mothers had difficult and strained relationships in the home and experienced a hostile social environment towards breastfeeding. Mothers expressed discomfort and shame about breastfeeding in public spaces and places.
There are additional factors that influence breastfeeding choices. These include the mother’s breastfeeding knowledge, and breastfeeding support from health professionals. Mothers knew about the health benefits of breastfeeding for their infants. But surprisingly, baby cues were often interpreted and internalised as negative responses to their breast milk. These cues included the baby crying, the baby breastfeeding frequently, and the baby not sleeping for long periods. Often these aspects of baby care and breastfeeding were not discussed at the health facilities.
The infant formula industry markets infant formula as a superior response to the crying baby, the “hungry baby” and the difficult sleeper. These were some of the reasons that mothers switched to infant formula.
Guidance from family, relatives and health professionals is also likely to shape the decision to continue – or discontinue – with breastfeeding.
Most mothers deliver their babies in a health facility where exclusive breastfeeding is recommended and encouraged. But the fact that mixed feeding is the norm suggests that mothers are confronted with environments that make it hard for them to follow this advice.
My findings suggest that breastfeeding information and education is reaching mothers, which mothers value and want to breastfeed.
But telling a mother that breastfeeding is good for the baby does not address the challenge of household food insecurity, internalised misconceptions about breast milk production, and difficult family relations. These barriers inhibit optimal breastfeeding practices and demand broader society engagement on supporting women and their child care responsibilities.
Breastfeeding support programmes narrowly focused on the health and social benefits of breastfeeding need to take a broader approach. Child nutrition can’t be addressed without addressing the challenges that women, and mothers in particular, face.