Social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in South Africa

Background: Maternal and child undernutrition remain prevalent in developing countries with 45 and 11% of child deaths linked to poor nutrition and suboptimal breastfeeding, respectively. This also has adverse effects on child growth and development. The study determined maternal dietary diversity, breastfeeding and, infant and young child feeding (IYCF) practices and identified reasons for such behavior in five rural communities in South Africa, in the context of cultural beliefs and social aspects. Methods: The study used mixed methodology technique. Questionnaires were administered to 84 households, pairing mother/caregiver and a child (0-24 months old) to obtain information on maternal dietary diversity, IYCF and breastfeeding practices. Qualitative data on breastfeeding perceptions, IYCF practices, perceived eating habits for lactating mothers and cultural beliefs related to mothers’ decision on IYCF and breastfeeding practices were obtained through focus group discussions. Results: Maternal dietary diversity was very low and exclusive breastfeeding for the first 6 months of life was rarely practiced, with young children exposed to poor-quality diets lacking essential nutrients for child growth and development. Social circumstances including lack of income, dependence on food purchasing, young mothers’ feelings regarding breastfeeding and cultural beliefs were the major drivers of mothers’ eating habits, breastfeeding behaviour and IYCF practices. Fathers were left out in breastfeeding and IYCF decision making and young mothers were unwilling to employ indigenous knowledge when preparing food (especially traditional foods) and feeding their children. Conclusion: The study provides comprehensive information for South African context that can be used as an intervention measure to fight against malnutrition in young children. Finding a balance between mothers’ income, dietary diversity, cultural beliefs, breastfeeding and considering life of lactating mothers so that they won’t feel burdened and isolated when breastfeeding and taking care of their children is crucial. Paternal inclusion in breastfeeding decisions and safeguarding indigenous knowledge on IYCF practices is recommended.

The study was conducted in five settlements (Hertzog, Balfour, Ekhupumuleni, Blinkwater and Ntilini) along the Kat River Valley in the Eastern Cape province of South Africa. The area is home to about 50,000 people, mainly IsiXhosa (84%) [35], which made it ideal for a study involving cultural beliefs and indigenous knowledge in the African context. The majority of the households are female-headed and many households rely on food purchasing. Education levels are poor with approximately 9.7% of the population having a matric3 qualification and none was recorded as having a tertiary qualification [35]. The area is characterized with high unemployment rates [35] with 90% of households receiving either an old age pension, disability grant of R1570 per month or child support grant of R480 per month. The South African Rand to US Dollar exchange rate was approximately 12:1 at the time. This study was conducted in February and March 2018. A ‘mixed suite’ [36] of research tools, including both quantitative and qualitative techniques, was used. These included household surveys and focus group discussions. All interviews were conducted in the respondent’s preferred language of isiXhosa or English. Both translators and enumerators were trained on how to conduct interviews using the questionnaire so as to provide full understanding of the administered questions. Ethics approval was granted by the Rhodes University Ethical Standards Committee on 6 November 2017 with reference number 8628531. Although seasonal variation is known to have an effect on local diets, nutrition and food access, this does not apply to South African households as many depend on food purchasing [37] using social support grants which they receive on monthly basis. However, sampling was spread throughout the month to cater for the times when households had received their government support grants. The study used a purposive sampling approach which is a nonrandom, key informant selection technique to gather data using the deliberate choice of an informant based on the qualities that the informant possesses [38]. Here, we targeted households with mothers or caregivers with infants and/ or young children aged 0–24 months. Mothers or caregivers (ideally the person in the household who takes care of the child) were interviewed to gather information on their individual diets consumed in the previous 24 h using the standard 24 h recall technique [39, 40]. Eighty-four pairs of child-mother or child-caregiver were available for interviews across the communities. Of these pairs, 48 were mother-child whilst 36 were caregiver-child pairs which included 21 grandmothers and the other 15 pairs were other female family members including aunties. Individual dietary diversity scores and the nutrient adequacy in the women’s diets were measured following FAO and FHI 360 [40] and Martin-Prével et al. [41]’s minimum dietary diversity for women (MDD-W) of reproductive age (WRA) indicator. The MDD-W indicator is the sum of food groups consumed by women over a reference period, and it can also be used as a measure of household access to a micronutrient rich diet [42, 43]. Therefore, MDD-W is noted as a conservative estimate of household nutritional security as well as micronutrient adequacy of the women’s diet [40, 41]. The women were asked to recall and name all the food they had consumed in the past 24 h (day and night), that is, all dishes, snacks, and drinks. They were encouraged to remember all the food consumed per meal and in-between meals, fully describing all the ingredients in mixed dishes. For example, if they had rice and beef stew for lunch, they were supposed to list all the ingredients that were used to make rice (e.g. rice, water, salt) and beef stew (e.g. beef, water, cooking oil, salt, carrots, onion, tomatoes, potatoes, spices etc.). All the ingredients were then coded by the researcher into a list of 14 major food groups which were aggregated to ten for analysis [40, 41]. Following FAO and FHI 360 [40], MDD-W was calculated as the sum of food groups consumed by a woman from the total of ten specific food groups required, which consider nutrient-rich foods including animal-source foods; fruits and vegetables; and pulses, nuts, and seeds. The ten food groups included: (1) Grains, white roots and tubers, and plantains (also known as starchy staples); (2) Pulses (beans, peas, lentils); (3) Nuts and seeds; (4) Dairy; (5) Meat, poultry and fish; (6) Eggs; (7) Dark green leafy vegetables; (8) Other Vitamin A-rich fruits and vegetables; (9) Other fruits and (10) Other vegetables. These food groups included in the MDD-W mostly reflect the diet quality with the probability of minimum micronutrient adequacy of the women’s diets summarized across 11 important micronutrients which are vitamin A, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, vitamin C, calcium, iron, and zinc [41]. The Fats and oils food group was not included for MDD-W as this do not contribute to the micronutrient density of the diet [40]. Using MDD-W allows grouping women into classes of food secure or food insecure, therefore, women were grouped into these classes. A woman was considered as having poor dietary diversity and food insecure if she had consumed < 5 food groups or had achieved MDD-W with good dietary diversity and was food secure if she had consumed ≥5 food groups in the previous 24 h [40]. Surveys also included open-ended questions on breastfeeding and IYCF practices, specifically on the perceived “proper” diet for children and what mothers or caregivers actually fed their children with, if there were any foods which they avoided or did not give to children, as well as if mothers consumed different foods to their children and the reasons for this. Food group intake for infant and young children up to 24 months of age was determined using the seven-category child indicator as recommended by the World Health Organisation (WHO) [44]. The child indicator only represents the complementary foods in the diet, excluding breast milk intake, where children are expected to consume a minimum of ≥4 food groups per day out of the seven recommended. The seven recommended food groups for children are: (1) Grains, roots and tubers, (2) Legumes, nuts and seeds, (3) Dairy products, (4) Flesh foods (meat, fish, poultry and liver/organ meats), (5) Eggs, (6) Vitamin-A rich fruits and vegetables and (7) Other fruits and vegetables. Data were entered and cleaned using Microsoft Excel and quantitative data were analysed using Statistica version 12 (StatSoft Inc., Tulsa, OK, USA). Descriptive data are presented as means and standard deviations (SDs) (mean ± SD) and percentages and are presented as tables. The study also implemented focus group discussions (FGDs) which actively make use of group interaction on the issues relevant to a specific topic. These gave insights into collective meanings attached to breastfeeding behaviour, IYCF practices and maternal food consumption behaviour that could not be elicited through questionnaires as participants were able to build on each other’s ideas and comments. For example, we were able to obtain information on the cultural beliefs and feelings of individuals and why they acted in the way they did. Like other qualitative research methods, these FGDs were used to develop an understanding of the meaning and experiences of peoples’ lives from the point of view of those who experience it [45, 46]. The participants who had not participated in the household surveys, were purposively recruited by the community leaders, village or ward leaders who also helped with organizing the venues and times for the FGDs. Information about the study and its purpose was shared with those who were approached and they had the right to agree or decline to participate in the study. Informed consent was obtained from each FGD participant after the researcher had explained the purpose of the study. Nine focus groups were conducted with 7–12 women of mixed age groups particularly young and old women with 94 participants in total (Table 1). The majority of participants had informal employment as those who were formally employed were not available at the times when FGDs were conducted. Participants were informed that they were allowed to withdraw from participation at any time without any penalties and no incentives were offered for taking part in the study. For each FGD, there was an interpreter, translator and an assistant and it took between 60 and 90 min. The principal researcher led all the discussions and both the principal researcher and an assistant made notes of all the discussions and the responses that appeared most often in the group discussions. Group discussions were also recorded, only after consent was provided by the participants. Number and age distribution of focus group discussions participants in the Kat River Valley communities The focus group questions did not directly ask about breastfeeding because the researcher wanted to determine if breastfeeding was deemed the best feeding practice for infants and young children by the participants in the study communities. All questions asked in the FGDs were open-ended, formulated from some of the household survey questions, with new questions arising from the responses given in the FGD. The FGDs sought responses to the following core questions: Data from all the FGDs, which were mostly handwritten field notes, were entered into Microsoft Word 13 and were edited. Everything was translated from IsiXhosa to English. Some important IsiXhosa words were written in IsiXhosa with their English meaning given in brackets. The researcher read the transcripts several times to understand the information. During data analysis, we used qualitative content analysis (QCA) which is useful to interpret textual data content by using a systematic classification process that involves coding to identify patterns or themes. This involves four steps: repeated review of the transcript to gain thorough sense of the overall content in the texts, identifying central meaningful units in the material, condensation of the content through a coding of the text, and finally creating categories that contain the condensed meaning of the main themes in the material [47]. Themes were then analysed through coding [48] using NVivo software for qualitative data analysis. Similarities between the codes were identified and those that were connected were combined to form primary themes for the discussions. Most sections of the discussions were quoted verbatim with a few modifications to increase readability.

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