shouted at me to discontinue exclusive breastfeeding”: narratives of mothers in Limpopo Province of South Africa as they grabble with exclusive breastfeeding

“They Abstract Objective : Exclusive breastfeeding for the first six months of an infant’s life is an internationally recognised practice that promotes maternal and child health. Mothers and their infants reap health and socioeconomic benefits from exclusive breastfeeding. Even with these benefits, exclusive breastfeeding is still a challenge for some mothers to practice. Many studies revealed numerous challenges and enablers, and proposed comprehensive solutions, but implementation of exclusive breastfeeding for six months remains a challenge although there is some improvement. This study therefore explored barriers and facilitators to practice exclusive breastfeeding for the first six months of the infant’s life among mothers attending a health centre in Limpopo Province of South Africa, to contribute to the ongoing measures to increase the practice. Materials and methods : Mothers were selected through purposive sampling and semi-structured interviews were held with those willing to participate until saturation of data was reached. Interviews were audio-recorded, transcribed verbatim and analysed using a thematic analysis approach. Ethical issues of consent, permission and confidentiality were respected as well as trustworthiness criteria. Results and Discussion : Nine mothers narrated their experiences as they navigated through the exclusive breastfeeding practice. Education on exclusive breastfeeding and social support to a breastfeeding mother emerged as both barriers and facilitators to practice exclusive breastfeeding for six months. Conclusion: The study recommends that vigorous education on exclusive breastfeeding for six months be given to mothers during antenatal care and be extended to include relatives to empower them to support a breastfeeding mother.


Introduction
Exclusive breastfeeding refers to feeding an infant with human milk only during the first six months of life 1 . Human milk contains the required nutrients for the child, is clean and supports the infant's own immune function [2][3][4] . When practicing exclusive breastfeeding, other liquids such as oral rehydration solutions, liquid-based vitamins and mineral supplements as well as prescribed medicines may be given to the infant but ordinary water and fruit juice are not allowed before the infant reaches six months. The infant can suck the mother's own milk directly from the mother or can drink expressed milk from its own mother or from a donor mother. Exclusive breastfeeding should be initiated during the first hour after birth and continue for the first six months to improve the nutrition status of infants and unlock their potentials as human milk stimulates cognitive development. Exclusive breastfeeding is an important intervention to reduce child morbidity and mortality as it protects infants from childhood diseases and conditions such as ear infections, respiratory tract infections, gastrointestinal infections and childhood malnutrition 5 . Mothers also reap health benefits such as reduced risk of cardiovascular diseases, stress and anxiety, diabetes and gynaecologic cancers when they practice exclusive breastfeeding 6 .
Exclusive breastfeeding is monitored regularly in South Africa and globally, although there are challenges with availability of reliable data 7 . Globally, less than half (41%) of infants under six months of age were exclusively breastfed in 2018 5 . The demographic and health survey of 2016 estimated the exclusive breastfeeding rate for South Africa at 32% 8 . Exclusive breastfeeding is a challenge which mothers have to grabble with. To navigate successfully through the exclusive breastfeeding practice, mothers need social support from close relatives as well as from the health system as a whole. Practicing exclusive breastfeeding is not an easy task for some mothers as they face socioeconomic, health and cultural challenges to initiate breastfeeding early and to breastfeed exclusively for six months 9 . Fathers and other relatives can provide social support and protection to mothers as a way to facilitate exclusive breastfeeding [10][11][12] .
In 2017, statistics at a health centre in Limpopo Province revealedthat only 10.7% of infants coming for Hexavalent vaccination 3rd dose were being exclusively breastfed. Hexavalent vaccination 3rd dose is given to infants around three months after birth. Exclusive breastfeeding at Hexavalent vaccination 3rd dose is a nutrition indicator on the District Health Information System (DHIS) and is monitored monthly by using data input forms at primary health care (PHC) to check if mothers are still breastfeeding exclusively. Health education on the benefits of exclusive breastfeeding to the health of both the mother and the infant has been given to mothers during antenatal and postnatal care, but the exclusive breastfeeding rate remained low. It therefore became necessary to explore mothers' perceptions of facilitators and barriers to exclusively breastfeed their infants for six months.
The purpose of the study was to explore mothers' perceptions of facilitators and barriers to exclusively breastfeed their infants for six months after birth. The objectives were to explore and describe the way mothers thought and viewed factors that contribute to success and failure to exclusively breastfeed for the first six months of an infant's life.

Materials and Methods
The study used a qualitative descriptive research design 13 . This design was relevant for a study that sought to understand the way mothers thought and viewed factors that contributed to success and failure to exclusively breastfeed for six months.

Research site and population
This study took place at a community health centre (CHC) in Mopani district of Limpopo Province, South Africa among breastfeeding mothers with children of less than six months old. Limpopo Province is one of the nine provinces of South Africa and it is divided into five district municipalities, which are Mopani, Capricorn, Vhembe, Sekhukhune and Waterberg. There are human milk banks in Limpopo Province and some mothers are willing to donate and to receive human milk from these banks [14][15][16] .
The CHC was in a rural area govern by a traditional authority. Most people in the area spoke Xitsonga as their home language with few speaking Sepedi. There were also some foreign nationals speaking languages like Shona, English and others. The catchment area of the CHC consisted of six villages, and family structures included extended family, nuclear family and single parenting. The CHC was providing comprehensive primary health services, which included immunisation and promotion of exclusive breastfeeding. Healthcare workers participating in the promotion and monitoring of exclusive breastfeeding in the catchment area of the CHC included nurses, a dietician, data capturers, community health workers and five Ward Based Outreach Teams. The researchers recruited mothers during immunisation visits for the 3 rd dose of Hexavalent. The recruitment process involved giving information to all mothers in the waiting area of the CHC about the study then evaluating those showing interest for eligibility to participate.

Sampling
The researchers chose purposive sampling as the most relevant sampling method for this study. Researchers, through their own judgement, use purposive sampling to select participants able and willing to share information that will answer the research question 17,18 . In this study, the researchers purposely selected mothers with infants of up to six months and able to speak Xitsonga, Sepedi or English. Researchers believed those mothers were able to recall and describe factors contributing to their failure to breastfeed exclusively, the period at which they started feeding their infants with breastmilk substitutes and factors that enabled them to continue with exclusive breastfeeding. Many mothers were available to participate, however, only nine participated due to saturation of data. Researcher realise they have reached saturation of data when beginning to hear similar sentiments during interviews 18 .

Data collection
The researchers were ready to conduct interviews in English, Xitsonga and Sepedi depending on preferences of individual participants. As only Xitsonga speaking mothers were available, all semistructured interviews were conducted in Xitsonga and lasted for 30 to 60 minutes. An interview guide, with a section to collect demographic data and another section having the main question for the interview as well as questions to probe, was used. To ensure that the interviewer focused on the interview, all interviews were audio-recorded with a smartphone voice recording application and the recordings were uploaded into a computer at the end. The voice recording application on a smartphone makes it easy to upload audio recordings, using Bluetooth or USB drive, to a computer for analysis 19 . It is important for researchers to focus during the interview so that they do not miss opportunities to probe as well as to avoid asking questions that participants may have already provided answers for while answering the main question. Mothers were interviewed one-by-one as they became available between attentions by nurses until saturation of data was reached.

Data analysis
In qualitative research, data analysis starts during data collection and the process involves several back and forth steps between data collection and data analysis 20 . Starting data analysis while still collecting data helps a researcher to probe and become aware of achieving data saturation.The current study used thematic analysis. Thematic analysis is a nonlinear and iterative process, but having identifiable steps 21 . These steps are overlapping and include preparing and organizing data, transcribing the audio recordings, becoming familiar with the data, memoing the data, coding the data, producing categories and themes and then making the analysis process transparent. As indicated above, all interviews were conducted in Xitsonga, following that, audio recordings were transcribed verbatim and were then translated to English.

Ethical considerations
The study respected research ethics principles by obtaining ethical clearance (TREC/15/2019: PG), asking for voluntary participation and obtaining permission from a Department of Health (Ref: LP_201903_005) as well as from a district office (Ref: S4/2/2) to access mothers at the CHC. Furthermore, mothers' confidentiality and anonymity were respected by using numbers instead of real names when capturing data and reporting results.

Trustworthiness
Trustworthiness of a qualitative study refers to its truthfulness and worthiness of being used by other researchers 22 . Four criteria, which are credibility, confirmability, dependability and transferability, are used to ensure trustworthiness.The current study satisfied all the four criteria. As an additional way to ensure trustworthiness, the researchers gave an independent coder, with experience in qualitative research and reproductive health, all transcriptions to analyse. The themes found were compared with those found by the researchers and a meeting was held to discuss and agree on the final themes.

Results
Saturation of data resulted in nine mothers participating, with one being between 15 and 19 years old, another being between 20 and 24 years old, four being between 25 and 29 years old and three being between 35 and 39 years old. Three were still attending school while four had passed Grade 12, two passed Grade 11 and three passed Grade 10. Out of all the nine mothers, three were primiparous while six were multiparous. Only two mothers were employed, one was self-employed and three were unemployed.
Data analysis yielded two themes and four subthemes which are presented with narratives in Table  1 below. The themes show barriers and facilitators to exclusive breastfeeding for the first six months of the baby's life. Barriers are those descriptions that discourage exclusive breastfeeding while facilitators are those that support exclusive breastfeeding 23 . Sub-themes show that knowledge, awareness or education on exclusive breastfeeding as well as social support are key factors to the practice of exclusive breastfeeding for the first six months. The presence or absence of each of the key factors is a facilitator and a barrier respectively.

Discussion
Mothers in the current study possess characteristics that can act as facilitators and also as barriers to breastfeedexclusively for six months.Research shows that younger and less educated mothers without prior breastfeeding experience are likely to experience barriers to breastfeed exclusively 24 . Returning to work and returning to school for a breastfeeding mothers are barriers to continuation of exclusive breastfeeding and these two factors can also lead to early weaning 25,26 .
Mothers perceive lack of knowledge and lack of social support as barriers to exclusive breastfeeding. Mothers' narratives suggest that some grandmothers lack knowledge that human milk contains `the required nutrients to satisfy an infant. They also lack knowledge that a less than six months infant's gut is not fully developed to process solids and other liquids except human milk and some medicines. Furthermore, some fathers also lack knowledge that human milk satisfies both hunger and thirst. These narratives that grandmothers and fathers lack knowledge that human milk alone will satisfy an infant are similar to those narrated in two African studies, one from Ghana 27 and another from Tanzania 28 . Due to lack of knowledge, infant's cry is understood as sign of hunger or thirst. Furthermore, some relatives advise mothers to gradually introduce some type of complementary foods as a way to prepare the infant's gut for full introduction of complementary foods, without knowing that early introduction of complementary foods can be harmful.
Grandmothers are sources of wisdom and their advice is heeded, as such, mothers will discontinue exclusive breastfeeding if grandmothers instruct 28 .
Heeding the adviceof grandparents is a good practice but it becomes dangerous if their advice is based on lack of knowledge.
In the current study, mothers narrate that some relatives frustrate their intention to breastfeed exclusively. It shows lack of social support when close relatives frustrate a mother's intention to breastfeed exclusively. Social support refers to the help and reassurance that social networks give to a person facing challenges 29 , and this can apply to mothers facing challenges to breastfeed exclusively, so that she can have confidence to succeed in breastfeeding her infant for the first six months after birth. Besides showing lack of knowledge that human milk builds, supports and nourishes the infant's gut, some relatives put pressure on mothers to introduce complementary foods within the first six months of the infant's life. Relatives put pressure on the mother by scolding her to introduce complementary foods. Furthermore, a participant narrated that her mother frustrated her intention to practice exclusive breastfeeding by giving water to the infant when she had left it with her. Grandmothers should support mothers when they return to wok or to school by continuing exclusive breastfeeding which the infant's mother are intending to practice. They can achieve this by giving the infant its own mother's expressed milk. Returning to work and to school are some of the reasons to discontinue exclusive breastfeeding in a situation where there is lack of social support by relatives 28,30 . Grandmothers can provide negative social support to mothers, especially young and new ones, as they navigate the exclusive breastfeeding practice 10 . Breastfeeding-friendly home and workplace environments are important to support mothers as they practice exclusive breastfeeding 31 .
Mothers narrated that adequate knowledge and social support are facilitators to exclusive breastfeeding. Some narrate that their PHC clinics provide knowledge on exclusive breastfeeding which emphasise that human milk is adequate food for a young infant of less than six months, it quenches thirst and that colostrum should be fed to infants to promote their growth. Studies show that human milk alone is sufficient to promote growth in a young infant of less than six months [2][3][4] . PHC clinics, as part of a health system, should give correct information to the community on exclusive breastfeeding to promote maternal and child health 32 .
Mothers expect health workers to support and promote exclusive breastfeeding by teaching and reminding mothers about the benefits of exclusive breastfeeding. Health workers should also inform mothers about the dangers of mixed feeding. Mothers also narrates that an adequately-informed father provides social support to a mother who intends to breastfeed exclusively. The supportive role of fathers to breastfeeding is sufficiently described in many studies [10][11][12]33 .

Conclusion
Exclusive breastfeeding has benefits for maternal and child health yet is not easy to practice for some mothers. Those who get social support find it easy to breast feed their infants exclusively for six months while those without social support fail even when they had intended to practice it. Having adequate knowledge about exclusive breastfeeding by mothers and their parents as well as their male partners facilitates exclusive breastfeeding. The health system as a whole can promote exclusive breastfeeding by educating mothers and their relatives so that breastfeeding becomes the responsibility of all, not just of mothers.

Recommendations
Exclusive breastfeeding must be approached as a responsibility of many players who are all educated so they can all support its practice. The role of grandparents and fathers in promoting exclusive breastfeeding has to be recognised and programmes be put in place to facilitate their contributions. It is not possible for mothers to be with their infants all the time as they have to attend to other responsibilities like going to work or to school, as such, there should be knowledgeable people to look after their infants and allow continuation of exclusive breastfeeding.

Limitations
This qualitative study has achieved its stated objectives which were to explore and describe barriers and facilitator to exclusive breastfeeding amongst mothers attending a specific health facility in Limpopo Province. Mothers narrated their journeys as they navigate exclusive breastfeeding practice. The views narrated are their own and cannot be generalised to mothers who did not participate in this study.