This cohort of mothers had low prevalence of EBF and high prevalence of mixed feeding which reflects the findings of many other studies in South Africa [47-49]. There was a significant drop in EBF prevalence from 4-8 weeks to 20-24 weeks which corresponded with the increasing prevalence of formula milk and food feeding over time, with half of all infants respectively getting formula and/or food. This pattern of suboptimal breastfeeding of infants was reflected in mothers discussing more barriers than enablers of EBF during the FGDs. Furthermore, mixed feeding was a dominant code in the theme Mother’s knowledge, attitudes & practices of breastfeeding.
The findings of the qualitative data highlighted five main themes, Mothers’ attributes: physical and mental wellbeing, experience and relationships, Mothers’ knowledge, attitudes & practices of breastfeeding,Family environment, Social environment and Baby cues. These themes are in line with other research on the ecological framework of breastfeeding [50] which has been further expanded by the model for the determinants of breastfeeding [8] which recognizes the mother-infant dyad, family and home setting and the broader social environment.
Of all the themes, the code mothers stress was the single highest scoring code and reflects the immense and difficult circumstances mothers from low-income households are faced with in general, but particularly as breastfeeding mothers. The intersectionality of inequity and poverty for mothers was expressed by mothers as experiences of stress and at times distress. The discussions revolved around the unsupportive home environment which was supported by the finding that the majority of mothers lived with their families rather than with their partners or spouses.
South Africa has a high number of single mothers with just over 60% of children born in 2017 not having a registered father [51]. Furthermore, given the general high levels of poverty in South African townships and the high levels of unemployment amongst mothers in the cohort study, 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, with the North West province having the highest number of food insecure households at 63% [36].
Both family stress and the lack of food to support breastfeeding, affected mothers’ mental health. This negative mental disposition was reflected in the high EPDS scores compared to global norms. A meta-analysis showed that about 13% of mothers in developing countries experience clinical depression after childbirth [52]. WHO further asserts that the global prevalence is much higher than this figure which was derived from research conducted mostly from developed countries [53]. Mental disposition among breastfeeding women can be measured as postnatal depression [54]. Women with high EPDS scores have been found to be more likely to stop breastfeeding within three months [55]. However, in the context of South Africa, because of financial constraints mothers are less likely to stop breastfeeding completely but are more likely to mix feed their infants as reflected in the most recent DHS [47]. In the current study, EPDS scores at 4-8 weeks postpartum had no association with EBF or exclusive formula feeding.
Despite the evidence of limited maternal nutrition impact on breastmilk supply and quality [53], mothers perceived and internalized that the stress in the home and the lack of food negatively affected their mental disposition and in turn negatively impacted on their ability to produce sufficient breastmilk of good quality for her infant [54]. Public health interventions to support breastfeeding also counsel mothers on nutrition during pregnancy and lactation. In a study, 84% of mothers had knowledge that diet should be changed by increasing, adding or avoiding some special food items in the diet during pregnancy and lactation [55].
In our study, mothers were acutely aware that what they eat or do not eat will affect their ability to produce breastmilk and the quality of their breastmilk. They were also able to name foods that they believed or were told would improve breastmilk production. Nutrition during pregnancy and lactation has opened a multi-billion-dollar industry for nutrition supplements and supplemental feeds for pregnant and breastfeeding mothers. Mothers are also bombarded by food and nutrition guidance from family, relatives and health professionals as illustrated by this quote, ‘If after birth, you are under your mom’s care it becomes difficult because you get instructed, “you will drink coffee and eat your soft porridge” always, and they don’t give you fatty food before the umbilical cord is healed’.
Furthermore, aggressive marketing of infant formula has exploited this understanding that a mother’s nutrition affects her quality of breastmilk and what she is able to provide her breastfeeding baby, as graphically illustrated in a formula industry funded marketing campaign in Brazil on ‘Your child is what you eat. Your habits in the first thousand days of gestation can prevent your child from developing serious diseases’ [56]. Mothers’ decisions to mix feed their infants are in response to a number of Baby cues that the mother interprets that the baby is not getting enough breastmilk. Mothers interpret and internalize these Baby cues as signalling that their breastmilk is not good enough in quantity or quality and therefore an alternative solution is needed. This solution, more often than not, is to complement breastfeeding with infant formula and food.
Though EBF was low, there were enablers identified in each of the themes. Of all the themes, only the codes benefits of breastfeeding in the theme Mother’s knowledge, attitudes & practices of breastfeeding and access to and information and/or services from health professionals in the theme Social environment were stronger enablers compared to the barriers identified in those themes. With more than 75% of public health facilities accredited as baby-friendly [57], over 95% of mothers delivering in a health facility [47] and 90% registered on the national mHealth platform [58], mothers knowledge, attitudes of breastfeeding should have been well established. The fact that mixed feeding is a norm reflects on the disempowering and hostile environments breastfeeding mothers are confronted with [59, 60]. Hence the number of global and national initiatives to improve the breastfeeding environments with specific focus on addressing psychosocial barriers to breastfeeding [25, 61, 62].
Other enablers identified were the codes, mother’s positive emotion (happy, feels good) in the theme Mothers attributes, support in the home setting in the theme Family environment and baby’shealth in the theme Baby cues. This was also supported in the relatively high BSES score of the cohort. BSES is influenced by four main sources of information: (1) performance accomplishments (e.g., past breastfeeding experiences); (2) vicarious experiences (e.g., watching other women breastfeed, seeing breastfeeding in public spaces); (3) verbal persuasion (e.g., encouragement from influential others such as friends, family, and health professionals); and (4) physiological responses (e.g., fatigue, stress, anxiety). In each of these domains, the cohort had positive features with trends of higher BSES scores with higher parity, with high breastfeeding practices, regular access to breastfeeding information and contact with breastfeeding promoting health professionals and their positive disposition towards breastfeeding.
While BSES has demonstrated to predict EBF in other settings [45, 66-70], this was not the case for this cohort. Unlike other settings this cohort displayed both high BSES scores and high EPDS scores, which may be explained by South African’s chronic stressful environments, but generally, mothers’ strong coping mechanisms and resilience to shocks and insults at the individual and societal level [52, 71, 72].
Mothers have mentioned both the Family and Social environment more often as barriers than as enablers of EBF. In the context of our research setting, the lived realities of low-income households are plagued with food insecurity, hardship and strife [36, 72, 79]. EBF is an additional burden on an unsupported, unemployed breastfeeding mother who is physically the sole provider for the health and wellbeing of herself and her infant. In the Family environment the lack of support from family to assist the breastfeeding mother with household chores and family members’ negative interventions when there are breastfeeding difficulties were reported. Furthermore, mothers experienced the social environment as hostile with negative judgements of breastfeeding, or high expectations of breastfeeding mothers from complete strangers or from society at large with no or few facilities to support breastfeeding mothers in public spaces and places like shopping malls, restaurants, and public institutions. This is supported by the efforts of civil society to normalize breastfeeding in public spaces [60, 74, 75].
With the majority of mothers being unemployed, the work setting did not emerge as a strong theme and is captured within the theme Social environment. While the health setting did emerge as an enabling factor, it was limited to the mother’s encounter with health professionals at the health clinic or hospital. This was not unexpected as South Africa has a high coverage of primary health care facilities and high utilization rates especially for antenatal care and child health services [47]. Additionally, South Africa has a very well established and a 25-year history of the Baby Friendly hospital initiative which has significantly scaled up in coverage since 2011 [56]. In recent times, South Africa has implemented at scale mHealth services to pregnant women and mothers of infants through cell phone based health messaging [11, 73], increasing the reach and intensity of health service-driven breastfeeding messaging to mothers.
The lower emphasis on the theme Baby cues is supported by literature that responsive parenting skills and identification and appropriate response to baby needs is lacking [77]. The South African National Department of Health has responded to this need with the revised road-to-health booklet which is in line with the nurturing care framework that focuses on five pillars namely, nutrition, love, protection, health care and extra care [78]. Mothers interpret and internalize baby crying, baby breastfeeding frequently and baby stomach ailments like cramps, burps, and not passing stools as signals that their breastmilk is not enough or is not of good quality to satisfy their infants’ nutritional needs. While the mother’s decision to introduce other foods to her baby may silence the negative Baby cues and soothe the mother and the household, scientific research has established that infants who are mixed fed have poorer health and development outcomes than EBF infants [7]. Literature has correctly reported that there is a gap in proven effective interventions that are delivered at the household level [9]. Furthermore, in the South African context, studies using breastfeeding education, peer support and counselling have not rendered the desired EBF outcomes [39, 77]. This calls for a redesign of breastfeeding support programmes that will adequately and appropriately address the psychosocial barriers as articulated by mothers themselves.