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Table 6 Joint display of factors influencing exclusive breastfeeding in a cohort of mothers with infants aged 6–24 weeks, arranged by themes and codes with the highest frequency count by barrier (B) and enabler (E)

From: Psychosocial barriers and enablers of exclusive breastfeeding: lived experiences of mothers in low-income townships, North West Province, South Africa

Socio-demographic data Themes and codes by frequency counts for barrier (B) and enabler (E) Interpretation of findings
There were no statistically significant associations between any of the socio-demographic factors and EBF practices. Mothers’ attributes: physical and mental wellbeing, experience and relationships
Mother’s stress ++++B / mother’s positive emotions++E
Mothers’ knowledge, attitudes & practices of breastfeeding
Mixed feeding ++++B / Benefits of breastfeeding +++E
Although there were no statistically significant associations between any of the socio-demographic factors and EBF, in all themes except Mothers’ knowledge, attitudes & practices of breastfeeding, mothers mentioned and discussed barriers much more than enablers of EBF.
Furthermore, as an infant feeding practice, the high prevalence of mixed feeding was supported by the qualitative data with the code Mixed feeding having emerged as the only infant feeding description and topic of discussion. EBF itself did not emerge as a code but was discussed in relation to the benefits of breastfeeding, information on infant feeding, and in relation to the frequency and duration of breastfeeding. The three barrier codes were Mixed feeding, Mother’s stress and Home environment as explained by the quotes below
Family environment
Home setting ++++B / Home setting +++E
Social environment
Public spaces & places (malls, taxis, other people)+++B / Health professionals++E
Baby cues
Baby’s stomach ailments++B / Baby’s Health ++E
Supporting quotes for mixed feeding from mothers by dominant codes (F = FGD number: M = Mother number)
Mixed feeding ++++B
I realised that when I feed the baby formula, the baby was getting full and gained weight but not with breastmilk. Then I decided to only give formula and stop breastfeeding’.- 27 years old, 17 week old baby has three children (F3:M1)
Mother’s stress ++++B
Let me say, maybe I am stressing about something, I can’t breastfeed with my high level of stress because it can cause problems for the baby like diarrhoea for the baby. My breastmilk is not okay (for the baby). Even though the baby cries, I must try to reduce the level of stress before I breastfeed so that it doesn’t affect the baby. That’s why they say, if you are breastfeeding, do it with love. Love your baby.’ –38 years old with three children (F1: M3)
Home environment ++++B
Or maybe she is angry, her man is not around to assist with the baby and the baby doesn’t want to or struggles to suck at her breast’.- 26 years old, 18 week old baby, has 3 children – (F2:M4)
EBF practice Themes and codes by frequency counts for barrier (B) and enabler (E) Interpretation of findings
EBF rates with infant age
EBF 4–8 weeks: 34.0%
EBF 10–14 weeks: 15.1%
EBF 20–24 weeks: 9.1%
Mothers’ knowledge, attitudes & practices of breastfeeding
Benefits of breastfeeding +++E
Family environment
Home setting +++E
Mothers’ attributes: physical and mental wellbeing, experience and relationships
Mother’s positive emotions++E
Social environment
Health professionals++E
Baby cues
Baby’s health ++E
EBF decreased significantly with infant age with the highest EBF rate at 4–8 weeks. This may be explained by the increased contact with health services during ANC and the first 6-weeks post-partum during which BF support and promotion is the main focus of post-natal care of the infant. This high rate of EBF at 4–8 weeks was supported by the codes Benefits of breastfeeding, Baby health and Health professionals. Illustrating the positive influence of the health services on EBF.
The codes Home setting, Mother’s positive emotions and Health professionals were reflected in the high BSES scores (85.6%). The BSES domain of physiological and affective states infers that positive interpretations from cues, support BF such as support and encouragement from family, health professionals or a positive interaction with the infant such as Baby’s health.
Supporting quotes from mothers by dominant codes (F = FGD number: M = Mother)
Benefits of breastfeeding +++E
‘At the clinic, they said that mixed feeding - both formula and breast milk - the baby can have a reaction. As you go out to the clinic, the baby wants to feed and you don’t have anywhere to warmth up the formula bottle and you don’t know where and the breast milk it’s always warm and that’s how we end up having frequently sick babies. So I think breast feeding is much better.’-.26 years old, 14 week old baby, mother of three children (F4:M2)
Home setting +++E
‘Because if you get more support from the family then you will also feel that you should keep breastfeeding the baby. Breastfeed and breastfeed. Now and then you feel like you are not getting support from the family then you say to yourself, I will just leave this baby here. Then I am going to leave and I am not going to give the child my breast.’- 24 years with 2 children (F6:M3)
Mother’s positive emotions++E
you just become happy when you breastfeed. You are happy all the time. Anyway, circumstances make us give our babies formula milk. It’s like with me or maybe it was because I was a first time mother and I was happy about having a baby’- 33 years with three children (F3:M4)
Health professionals++E
I told the nurse that I didn’t know what was going on and that’s when she showed me how to breastfeed the baby’- 21 years old with first baby (F5:M1)
Screening measures Themes and codes by frequency counts for barrier (B) and enabler (B) Interpretation of findings
Edinburgh Postnatal Depression Scale (EPDS) score
EPDS < 10: 74 (55.2)
EPDS ≥10: 60 (44.8)
EPDS score was not statistically associated with breastfeeding practices
Mothers’ attributes: physical and mental wellbeing, experience and relationships
Mother’s stress ++++B
Mothers’ knowledge, attitudes & practices of breastfeeding
Mixed feeding ++++B
Home environment
Home setting ++++B
Social environment
Public spaces & places (malls, taxis, other people)+++B
Baby cues
Baby’s stomach ailments++B
The unexpected high prevalence of postnatal depression (44.8%) found amongst mothers is reflected in higher number of barriers in most of the themes. Furthermore, it is understandable and reasonable that mothers who are in a negative mental disposition would be distressed.
This high level of negative mental disposition was reflected in the code Mother’s stress.
The codes Home setting, Public spaces and places and Baby’s stomach ailments illustrate the sources of Mother’s stress.
Baby’s stomach ailments support and explained the use of inappropriate Traditional beliefs & practices which led to the high prevalence of Mixed feeding. Low breastmilk supply is understood by mothers to cause Baby’s stomach ailments and in turn mothers mix fed and gave their babies traditional medicines to remedy the situation.
Mothers’ stress was also understood to affect the baby emotional state and caused an unhappy baby. Mother’s believed that their negative emotions could be felt and carried over to their babies through their breastmilk.
Mother’s stress++++B
It gives me stress (laughs) you will be instructed to eat soft-porridge while staring at them (family) eating a decent plate (of food). By that time you are been told that you will feed the baby unhealthy milk, and remember that porridge it’s like water it won’t make you full and does not have all the nutrients required (for making breastmilk).- 26 years old, 14 week old baby, mother of three children (F4:M2)
Family environment ++++B
When you are not in a good home environment, you are always angry, you get mood swings and sometimes you
lose appetite, so you don’t eat and the baby suffers to get enough breastmilk from you. -29 years old first time mother, baby 6 weeks old (F1:M5)
Social environment+++B
We are giving our babies the Muthi wenyoni and Qhuma (traditional medicines) because that’s how we were raised. For us, it is easy to consider those (medicines) and give them to our babies to drink. We are grown up by elderly people who advise us. It is their advice that we must buy our children those medicines.- 33 years old, 23 week old baby, mother of three children (F4:M4)
Screening measures Dominant codes Interpretation of findings
Breastfeeding Self-Efficacy Score- Short-Form
BSES < 60: 27 (19.4%)
BSES ≥60: 112 (80.6%)
BSES-SF score was not statistically associated with breastfeeding practices
Mothers’ knowledge, attitudes & practices of breastfeeding
Benefits of breastfeeding +++E
Home environment
Home setting +++E
Mothers’ attributes: physical and mental wellbeing, experience and relationships
Mother’s positive emotions++E
Social environment
Health professionals ++E
Baby cues
Baby’s Health ++E
Despite the prevalence of high breastfeeding efficacy (80.6%) at 4–8 weeks, EBF prevalence was low (34.0%).
For those mothers EBF, motivators were Benefits of breastfeeding, and Baby’s health, support in the home setting and from health professionals. Positive emotional cues and reinforcement of Mother’s positive emotions supported EBF.
Benefits of breastfeeding+++E
Healthy baby doesn’t get affected from anything because the baby only breastfeeds from the mother. The baby doesn’t get affected by any infection or any disease complications because the baby only gets breastmilk.- 26 years old, baby 18-week, mother of two children (F1:M4)
Home environment+++E
So when you get the support at home from your husband or family members, you can breastfeed easily. When you don’t get that support in most cases, you won’t easily breastfeed like a stress-free mother. - 38 years old, 10-week old baby, mother of three children (F3:M3)
Mother’s positive emotion++E
Breastfeeding as a happy smiling mom means the breastmilk its more healthier than when you are angry, … breast feeding with love, enjoying what she is doing (breastfeeding)’ – 22 year old, first time mother, 7-week old baby (F6:M4)