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Breastfeeding is widely endorsed as the optimal strategy for feeding newborns and young infants, as well as improving child survival and achieving Millennium Development Goal 4. Exclusive breastfeeding (EBF) for the first 6 months of life is rarely practised in South Africa. Following the 2010 World Health Organization (WHO) infant feeding recommendations (EBF for HIV-positive mothers with maternal or infant antiretroviral treatment), South Africa adopted breastfeeding promotion as a National Infant Feeding Strategy and removed free formula milk from the Prevention of Mother-to-Child Transmission of HIV programme. This study aimed to explore the perceptions of mothers and household members at community level regarding the value they placed on formula feeding and circumstances that drive the practice in a peri-urban community. We conducted in-depth interviews with HIV-positive and HIV-negative mothers in a community-randomised trial (Good Start III). Focus group discussions were held with grandmothers, fathers and teenage mothers. Data were analysed using thematic analysis. The following themes were identified; inadequate involvement of teenage mothers; grandmothers who become replacement mothers; fear of failing to practise EBF for 6 months; partners as formula providers and costly formula milk leading to risky feeding practices. The new South African Infant Feeding Strategy needs to address the gaps in key health messages and develop community-orientated programmes with a focus on teenage mothers. These should encourage the involvement of grandmothers and fathers in decision-making about infant feeding so that they can support EBF for optimal child survival. © 2012 John Wiley & Sons Ltd.
This qualitative study was a sub‐study of a randomised controlled trial known as Good Start III, (ISRCTN41046462), which was implemented in a township on the periphery of Durban, KwaZulu‐Natal province between 2008 and 2011. The township has an estimated population of 1 million people. HIV prevalence is estimated at 41% among women attending antenatal public health facilities (National Department of Health South Africa 2011a). The goal of the trial was to develop, evaluate and cost an integrated and scaleable package delivered in households by community health workers, targeting pregnant and post‐natal women and their newborns to provide essential maternal/newborn care, as well as support for access to PMTCT (Tomlinson et al. 2011). We used a qualitative study design, including focus group discussions (FGDs) and in‐depth interviews. The interview guide and FGDs sought responses to the following key questions: (1) What motivates mothers to use formula milk? (2) How does formula get into the households? (3) What are your views of mothers who formula feed? Two data collection methods were used because while infant feeding is personal, it is also embedded in the culture and social norms of the community, and hence group discussions were deemed a suitable forum to explore these norms. The FGDs and in‐depth interviews were conducted by two experienced interviewers/FGD facilitators, fluent in isiZulu and English. We purposively selected 11 HIV‐positive mothers and 9 HIV‐negative mothers from the larger trial who indicated that they were formula feeding their infants under‐6 months of age. Interviewers telephonically contacted 20 grandmothers and 20 fathers related to the said HIV‐negative and HIV‐positive mothers. Out of these 20 grandmothers and 20 fathers, we selected the first 14 of each group who agreed to participate in FGDs (i.e. seven for HIV‐exposed, seven for non‐HIV‐exposed grandchildren and babies, respectively). The majority of mothers (19 out of 20), who participated in the in‐depth interviews, were 20 years old or above. However, 842 out of 3653 (23%) women who participated in the Good Start III trial were aged between 16 and 19 years and 3194 (87%) were single. To address this difference, we purposively selected 14 teenage mothers aged between 16 and 19 years who reported formula feeding their infants less than 6 months of age (Fig. 1). One father and one teenage mother declined to participate on the day of the FGDs. Participants’ profile. Interviewers explained the purpose of the study during the recruitment process to each of the participant mothers, fathers and grandmothers. All interviews and FGDs were carried out at Prince Mshiyeni Memorial Hospital, from March to May 2011. The first author, who is not conversant with the isiZulu language, attended all interviews and FGDs as an observer and gained insight into the interviews and FGDs through the body language and other non‐verbal cues. Interviews lasted from 50 to 90 min and FGDs lasted from 90 to 180 min. We obtained Ethical approval (10/09/29) from the University of the Western Cape Research and Ethics Committee and acquired signed informed consent from all participants. In order to preserve anonymity, codes were used to identify individuals in FGDs and in‐depth interviews. For the in‐depth interviews, the code denoted the participant’s identification letters, the HIV status and age in years. For the FGDs, the code denoted the category of the group, the number, the identification letter for the individual in the group and the age in years. For the teenage mother’s individual codes, age and HIV status were used to identify each participant and group. Results of the study will be communicated to the community through meetings organised by the Community Health Committees. Thematic analysis as described by Braun and Clarke (Braun & Clarke 2006) was used to analyse the data. The transcripts were coded, collated and grouped into themes. Data analysis was a continuous process. After each interview or FGD, the interviewers met with the first author to reflect on the findings. Gaps and new emerging questions were included in subsequent interviews and FGDs. The voice‐recorded interviews and FGDs were transcribed verbatim and translated into English. Both the isiZulu and English versions were read several times by the interviewers/FGD facilitators and PI to ensure that the content was retained after translation. TD also read several of the transcripts to confirm the identified themes. Multiple strategies were used to ensure trustworthiness of the research findings. Firstly, triangulation of the results from in‐depth interviews and FGDs were used to compare findings across data collection methods. In addition, four different groups of participants were included (mothers, fathers, grandmothers and teenage mothers) and information was compared across these four groups. Finally, the first author and TD identified themes independently.
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