Professional Documents
Culture Documents
http://jhl.sagepub.com/
Knowledge, Beliefs, and Practices Regarding Exclusive Breastfeeding of Infants Younger Than 6 Months in
Mozambique: A Qualitative Study
Maaike Arts, Diederike Geelhoed, Caroline De Schacht, Wendy Prosser, Cathrien Alons and Avone Pedro
J Hum Lact published online 22 December 2010
DOI: 10.1177/0890334410390039
The online version of this article can be found at:
http://jhl.sagepub.com/content/early/2010/10/07/0890334410390039
Published by:
http://www.sagepublications.com
On behalf of:
Additional services and information for Journal of Human Lactation can be found at:
Email Alerts: http://jhl.sagepub.com/cgi/alerts
Subscriptions: http://jhl.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
Abstract
Only 37% of infants younger than 6 months in Mozambique are exclusively breastfed.
A qualitative assessment was undertaken to identify the knowledge, beliefs, and practices
around exclusive breastfeedingspecifically, those of mothers, fathers, grandmothers, and
nursesand to identify the support networks. Results show many barriers. In addition to
receiving breast milk, infants receive water, traditional medicines, and porridges before
6 months of age. Many mothers had heard of the recommendation to exclusively breastfeed
for 6 months. However, other family decision makers had heard less about exclusive breastfeeding, and many expressed doubts about its feasibility. Some of them expressed willingness to support exclusive breastfeeding if they were informed by health workers. Nurses
know the benefits of exclusive breastfeeding and pass this information on verbally but have
insufficient counseling skills. Interventions to improve exclusive breastfeeding should target family and community members and include training of health workers in counseling to
resolve breastfeeding problems.
Keywords: exclusive breastfeeding, barriers, Mozambique, practices
Received for review July 9, 2010; revised manuscript accepted for publication August 10, 2010.
No reported competing interests.
Maaike Arts is a nutritionist specializing in public health nutrition issues
and infant and young child feeding. She has worked in Mozambique for
3 years. She was affiliated with the Elizabeth Glaser Pediatric AIDS
Foundation, Mozambique, at the time of the study. Diederike Geelhoed,
MD, PhD, is a public health clinician in the field of reproductive health,
including HIV/AIDS, and has 20 years of postgraduate work experience in
clinical care, public health, and research, mostly in sub-Saharan Africa.
Diederike Geelhoed is affiliated with the International Centre for Reproductive
Health, Ghent University, Belgium. Caroline De Schacht, MD, MSc, is a
public health clinician with a diploma in tropical medicine and masters in
clinical trials and has worked in Mozambique for over 6 years as a clinical
advisor. She is affiliated with the Elizabeth Glaser Pediatric AIDS Foundation,
Mozambique. Wendy Prosser, MPA, worked for 5 years in Mozambique
focusing on HIV prevention, treatment, and Prevention of Mother to Child
Transmission programs and is currently working in Angola on child survival initiatives. She was affiliated with Population Services International,
Mozambique, at the time of the study. Cathrien Alons, MPH, is a public
health specialist and has more than 10 years of experience in international
health, including nutrition, maternal and child health, and HIV/AIDS. She
is currently the technical director for the Elizabeth Glaser Pediatric AIDS
Foundation in Mozambique. Avone Pedro is a nutritionist working at the
Ministry of Health of Mozambique.
Address correspondence to Caroline De Schacht, Rua Kwame Nkrumah
417, Maputo, Mozambique.
J Hum Lact XX(X), XXXX
DOI: 10.1177/0890334410390039
Copyright 2010 International Lactation Consultant Association
Arts et al
complementary foods thereafter, and continue breastfeeding for the first 12 months of life. Breastfeeding
should then only stop once a nutritionally adequate and
safe diet without breast milk can be provided. In addition, it is recommended to provide ARV medicines to
either the mother or the child, depending on the ARV
regimen that the mother followed during pregnancy and
childbirth.9
In Mozambique, HIV prevalence in pregnant women
was estimated at 16% in 2007.10 A risk analysis based
on a mathematical model of different feeding options
in the context of HIV showed that in Mozambique, in
areas with an infant mortality rate above 31 per 1000
(ie, in practically the entire country), EBF for the first
6 months is the feeding option with the highest rates
of HIV-free survival.11 However, EBF is an uncommon
practice in many countries in sub-Saharan Africa,
and only 37% of all infants younger than 6 months in
Mozambique are exclusively breastfed.12
At the time of the study, the Ministry of Health recommended that all women EBF for 6 months. Mothers with
HIV were counseled to choose either EBF or exclusive
replacement feeding, if they were able to do so in a
way that was affordable, feasible, acceptable, sustainable, and safe. Mothers who opted for EBF were counseled to wean their children at the age of 6 months. The
most recent recommendations from the WHO
regarding ARV prophylaxis during breastfeeding13 are
currently being adapted for Mozambique. The country
started implementing the Baby-Friendly Hospital
Initiative in the end of the 1990s, but no hospitals have
been certified as baby-friendly.
To inform the development of a national strategy on
the promotion, protection, and support of breastfeeding
in Mozambique, of which EBF is a key component, a
qualitative assessment of the barriers to EBF was undertaken in 4 provinces and the capital city, covering all
3 regions of the country (north, center, and south). The
objectives of the assessment were threefold: (1) identify
the practices and beliefs around breastfeeding (specifically, EBF) of mothers, fathers, mothers-in-law, and
maternal and child health (MCH) nurses in Mozambique;
(2) describe the knowledge and attitudes of MCH nurses
on infant feeding and their influence on mothers; and
(3) identify the support networks in the area of infant
feeding that are available to mothers.
Nampula) and the capital Maputo City. In each province, an urban site and a rural site were purposefully
selected, which led to a total number of 9 study sites,
including the urban site of Maputo City. Data collection
was done in July and August 2008.
In every site, a trained facilitator conducted 4 focus
group discussions (FGDs), each comprising a specific
category: mothers of children younger than 2 years,
mothers-in-law or grandmothers, fathers of children
younger than 2 years, and MCH nurses. The facilitators
were mostly community-based workers, some with previous experience in FGD. Each group had 8 to 12 participants. FGDs were based on a semistructured guide.
Questions in all 4 groups covered the same issues:
initiation of breastfeeding, available support for breastfeeding, decision making about infant feeding, additional foods and liquids provided to infants younger
than 6 months, perceptions of the feasibility of EBF, and
knowledge and perceptions about breastfeeding by HIVpositive women. Additional questions were asked to the
MCH nurses on their role as service providers.
Participants were selected through volunteer sampling among the specific categories described in the
previous paragraph, irrespective of their HIV status,
with the exception of 2 FGDs with mothers (Zambzia
and Gaza) who belonged to a local Prevention of Mother
to Child Transmission support group. The discussions
were recorded on tape and conducted in the presence
of a trained note taker. Local languages were used in all
groups except the MCH nurses, who spoke Portuguese.
Notes for all groups were made in Portuguese. The taped
discussions were translated into Portuguese and transcribed into Microsoft Word by the facilitator and note
taker teams. Thematic analysis was done manually
by 3 investigators in discussion until consensus was
reached. Saturation was achieved on the main themes.
The research protocol was approved by the Mozambican
Bioethics Committee. Participants gave verbal informed
consent after the purpose and proceedings of the study
were explained to them.
Results
Methods
A qualitative study was done in 4 of Mozambiques 11 provinces (Gaza, Tete, Zambzia, and
birth. Reasons for this practice are related to the perceived need for the mother to rest and bathe after
delivery.
The baby is put to the breast for the first time after
more than one hour, because after [the baby] is
born, the mother is tired, and when she wakes up,
that is when she breastfeeds. (FGD mothers-inlaw/grandmothers, Xai-Xai City, Gaza Province)
There appeared to be different views about the
health benefit of colostrum for an infant. Some respondents said that colostrum is good, but others said that
the first milk is not good for the infant. No further detail
on this was explored.
Although the practice of breastfeeding appeared to
be nearly universal, participants commonly mentioned
that other foods or liquids were introduced before a child
reached the age of 6 months. Three kinds of foods and
liquids were identified. First, one widely held belief was
that children need to drink water from a very early age,
for their general well-being. Second, there was strong
evidence for the provision of traditional medicines to
children of all ages. Some of these medicines are given
through a bath, a smoking pipe, or an amulet, but others
are given orally, mostly in the form of a tea. Gripe
watera pharmacy-sold liquid with essential oils of
certain herbs, sodium bicarbonate, and sugarwas also
mentioned as a traditional medicine for oral use. The
participants stated that traditional medicines are given to
children to prevent and cure common illnesses, including
colic and diarrhea, as well as the doena de lua (moon
disease) and other illnesses and symptoms deemed spiritual or caused by spirits.
[People] give the [traditional] medicine so that children dont become ill and so that the mother can
have sexual relations with her husband without any
problem, so that when a sorcerer appears he will not
be able to harm the child. (FGD mothers-in-law/
grandmothers, Nacala Porto, Nampula Province)
The age at which traditional medicines are introduced varies, but it reportedly often starts in the first
weeks of life; many respondents referred to the time
when the umbilical cord falls off as the moment to start
giving traditional medicines. The description of the
amounts of traditional medicines that are given orally
was not very specific; respondents mentioned one
spoonful or a few spoonfuls. It was not possible to
obtain a more detailed description of the amounts.
Arts et al
When the nurses were asked about their role in support of breastfeeding, they stressed that they informed
mothers well and gave them all the necessary information. Some expressed doubts about the feasibility because they assumed that the health and nutritional status of mothers is not sufficient and because of
Arts et al
Arts et al
26. Bland RM, Rollins NC, Van den Broeck J, Coovadia HM. The use of
non-prescribed medication in the first 3 months of life in rural South
Africa. Trop Med Int Health. 2004;9:118-124.
27. Ministrio da Sade. Plano de communicao e mobilizao social
para a promoo, proteco e apoio ao aleitamento 2009-2013.
Brazil: Ministrio da Sade.