Dataset Information

Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: A mixed-methods systematic review.

ABSTRACT:

Background

In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.

Objectives

The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.

Methods

We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980-2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analysed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.

Results

From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.

Conclusions

From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

SUBMITTER: Nieuwoudt SJ

PROVIDER: S-EPMC6799928 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveBetween 1998 and 2009 reported exclusive breastfeeding (EBF) rates in South African infants, aged 0-6 months, ranged from 6.2% to 25.7%. In 2011, the National Minister of Health shifted policy to promote 'exclusive' breast feeding for all women in South Africa irrespective of HIV status (Tshwane Declaration of Support for Breastfeeding in South Africa). This analysis examines early EBF prior to and through implementation of the declaration.SettingData from the three South Africa national, cross-sectional, facility-based surveys, conducted in 2010, 2011-12 and 2012-13, were analysed. Primary health facilities (n=580) were randomly selected after a stratified multistage probability proportional-to-size sampling to provide valid national and provincial estimates.ParticipantsA national sample of all infants attending their 6 weeks vaccination at selected facilities. The number of caregiver-infant pairs enrolled were 10 182, 10 106 and 9120 in 2010, 2011-12, and 2012-13, respectively.Primary outcome measureExclusive breast feeding as measured using structured 24 hours recall plus prior 7 days (8 days inclusive prior to day interview) and WHO definition.ResultsThe adjusted OR comparing EBF prevalence in 2011-12 and 2012-13 with 2010 were 2.08 and 5.51, respectively. Mothers with generally higher socioeconomic status, HIV-positive, unplanned pregnancy, primipara, postcaesarean delivery, resided in certain provinces and women who did not receive breastfeeding counselling had significantly lower odds of EBF.ConclusionWith what seemed to be an intransigently low EBF rate since 1998, South Africa saw an increase in early EBF for infants aged 4-8 weeks from 2010 to 2013, coinciding with a major national breastfeeding policy change. These increases were seen across all provinces and subgroups, suggesting a population-wide effect, rather than an increase in certain subgroups or locations. While these increases in EBF were significant, the 59.1% prevalence is still below desired levels of early EBF. Further improvements in EBF programmes are needed.

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Project description:BACKGROUND:In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region. METHODS:We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5?months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5?months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted. DISCUSSION:This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings. TRIAL REGISTRATION:The study and its outcomes were registered at clinicaltrials.gov ( #NCT03688217 ) on September 27th, 2018.