The three themes and 10 sub-themes identified are illustrated in Table 1.
TABLE 1: Breastfeeding perceptions of adolescent mothers in NMBHD.
THEMES
|
SUB-THEMES
|
Theme 1: The intricacies of breastfeeding
|
1.1 Insufficient knowledge regarding specifics of exclusive breastfeeding (EBF)
|
1.2 Perceived breastmilk insufficiency
|
1.3 Economic benefits of breastfeeding
|
1.4 Bonding achieved by breastfeeding
|
Theme 2: Challenges experienced during breastfeeding
|
2.1 Lack of knowledge regarding breastfeeding practices
|
2.2 Lack of support
|
2.3 Physiological challenges associated with breastfeeding
|
Theme 3: Participants’
suggestions to support
adolescent mothers
|
3.1 Health care professionals should show compassion
|
3.2 Adolescent mothers should know that “breast is best”
|
3.3 More education is necessary to improve mothering
|
Demographic background of participants
Of the 14 African participants (aged 15 to 19 years), two had completed high school, three had dropped out of school, and nine were still in high school. Eight participants were still breastfeeding at the time of the interview and six had stopped breastfeeding by five months. Two participants had commenced mixed feeding with formula which is defined by the WHO as giving an infant (six months and younger) formula or solid food simultaneously with breastmilk [18]. The demographic details of the participants are shown in Table 2.
TABLE 2: Demographic details of participants.
Participant
|
Age at time of delivery in years
|
Interviewed at xx days/ months after delivery
|
Educational status at time of interview
|
Breastfed (BF) for (at time of interview)
|
Still breastfeeding at time of interview? Yes/No
|
Participant 1
|
18
|
19 months
|
Grade 12
|
12 months
|
No
|
Participant 2
|
18
|
14 months
|
Grade 10
|
6 months
|
No
|
Participant 3
|
17
|
21 months
|
Grade 10
|
21 months
|
Yes
|
Participant 4
|
15
|
5 days
|
Grade 9
|
5 days
|
Yes
|
Participant 5
|
18
|
10 months
|
Grade 10
|
14 days
|
No
|
Participant 6
|
17
|
1 month
|
Grade 10
|
1 month
|
Yes
|
Participant 7
|
18
|
9 months
|
Grade 11
|
7 months
|
No
|
Participant 8
|
18
|
9 months
|
Grade 12
|
4 months
|
No
|
Participant 9
|
19
|
8 months
|
Grade 11
|
8 months
|
Yes
|
Participant 10
|
17
|
27 days
|
Grade 10
|
27 days
|
Yes
|
Participant 11
|
19
|
9 months
|
Grade 12
|
1 day
|
No
|
Participant 12
|
16
|
4 months
|
Grade 10
|
Mixed Feeding
|
Yes
|
Participant 13
|
18
|
1 month
|
Grade12
|
1 month
|
Yes
|
Participant 14
|
17
|
12 months
|
Grade 11
|
Mixed Feeding
|
Yes
|
Participants described the intricacies of breastfeeding
Insufficient knowledge regarding specifics of EBF
Participants in this study were unable to explain the concept of (EBF) or adhere to EBF. Insufficient knowledge emerged as a major barrier to EBF and was associated with the early introduction of complementary feeding:
“Wow, you know I do not know what does exclusive breastfeeding mean, I truly don’t.” (P1, 18-year-old mother, baby aged 19 months).
“I don’t know” (P5, 18-year-old mother, baby aged 10 months).
Apparently, many of the participants had a poor understanding of the EBF concept. Maternal mothers were reported to be the primary decision-makers regarding infant feeding practices, and caregivers, since most participants returned to school immediately after birth. Of concern is that the reported advice given by maternal mothers and grandmothers regarding infant feeding practices was often incorrect due to their misconceptions about breastfeeding which undermined the evidence based EBF counselling provided at PHC facilities.
“She doesn’t like breastfeeding, she will tell you that your breasts will be lump, they will be weak like granny’s breasts, that’s what she will say. She will even tell us, ‘I didn’t breastfeed you guys but look at you, you are big now. But you think you can tell me that you are going to breastfeed, breastfeed then, let your breasts be lump and be so dull.’...” (P6, 17-year-old mother, baby aged 1 month).
Perceived breastmilk insufficiency
The misconception of breast milk insufficiency was reported by some participants. Infant hunger, crying and the perceived refusal of breastmilk were described as the indicators highlighting the misconception of breastmilk insufficiency which seemingly resulted in the early introduction of complementary foods:
“Because she (the baby) doesn’t want to breastfeed and then my mother said I must mix the breastfeeding (breastmilk) in the porridge and then give him.” (P5, 18-year-old mother, baby aged 10 months).
“I had no choice because he was crying all day and he’s giving me headaches so I can get something to satisfy him.” (P9, 19-year-old mother, baby aged 8 months).
The above quotes suggest that perceived refusal of breastmilk increases the perception of breastmilk insufficiency which leads to the early introduction of complementary foods. Crying or noticing that their babies “drink a lot of (breast) milk” are some of the common signals they use to determine if their babies are hungry.
Economic benefits of breastfeeding
It emerged from the interviews with the mothers that the economic benefits of breastfeeding played a socio-economic role in participants choosing and recommending breastfeeding:
“So, we are dependent on her (participants’ mother) wages, so I will rather breastfeed because of that reason…so you save that money for formula or whatever because formula is expensive.” (P1, 18-year-old mother, baby aged 19 months).
Most participants in this study were unemployed and only qualified for a child support grant from the South African Social Security Agency (SASSA), which pays a mere R445 a month. A participant sums it up:
“Because na, as people our circumstances at home, they are not the same, sometimes we will have the money to buy the milk, sometimes you don’t…It’s best for me to breastfeed.” (P6, 17-year-old mother, baby aged 1 month).
Bonding achieved by breastfeeding
Bonding with the baby was a motivating factor for breastfeeding for many of the mothers, who expressed enjoyment of the unique bond they developed with their infant while breastfeeding:
“Um, I would just say that, I enjoy the bonding session we have each time I breastfeed her.” (P3, 17-year-old mother, baby aged 21 months).
“I want to bond with my baby. Breastfeeding is the best way to bond with your baby.” (P13, 18-year-old mother, baby aged 1 month).
Challenges experienced during breastfeeding
Lack of knowledge regarding breastfeeding practices
The participants’ knowledge regarding breastfeeding practices was generally poor, leading to early cessation of breastfeeding. Returning to school was a significant barrier to breastfeeding:
“Because I was going to school so I decided my mother should have something (formula) to feed the baby when I’m at school.” (P14, 17-year-old mother, baby aged 12 months).
“…So, I stopped breastfeeding when my baby was 7 months and then I gave him the formula because I was attending school and so I couldn’t breastfeed fine and properly. And so that’s why I gave him the formula.” (P8, 18-year-old mother, baby aged 9 months).
This participant appeared to lack knowledge regarding expressing breastmilk. Returning to school was commonly cited by the participants for the cessation of breastfeeding.
Lack of support
The adolescent fathers’ lack of support and involvement was echoed by participants leading to sadness or depression:
“At that point of time I was like…at that point of time my anxiety and my depression came from knowing that the father of my child doesn’t care.” (P1, 18-year-old mother, baby aged 19 months).
“He’s not supportive….to me. We have problems.” (P8, 18-year-old mother, baby aged 9 months).
Those who received support from the fathers cited emotional and physical support, such as ‘babysitting’ the baby, as most valued. It was interesting to note that participants who received support from the baby’s father breastfed for longer than those who did not, further highlighting the need to include fathers in breastfeeding promotion.
Over half of the participants reported limited support and assistance from health care providers during the ante- and postnatal period:
“I just I had to figure it out myself like how I’m gonna hold the baby and which unfortunately the milk was not coming out yet.” (P9, 19-year-old mother, baby aged 8 months).
“…you don’t know when you arrive at the clinic which nurse will you arrive to. So, you save the embarrassment and ignorance and ask your mum.” (P13, 18-year-old mother, baby aged 1 month).
It seems as though adolescent mothers do not receive the necessary assistance required to breastfeed successfully, which could negatively impact the young mother’s feeding decisions. According to the Health Belief Model (HBM), the resultant reinforcement of feelings of incapability and helplessness act as barriers in preventing adolescent mothers from breastfeeding.
When participants sought help from health care providers due to breastfeeding problems, they were advised to formula feed instead of receiving education to improve their breastfeeding experience:
“They said I must give him uhm (infant formula).” (P5, 18-year-old mother, baby aged 10 months).
There is no doubt that promoting formula, unless there is a justifiable medical reason, is a direct violation of the Tshwane Declaration where South Africa (SA) declared itself a country that actively promotes, protects and supports EBF as a health intervention to optimise child survival [21].
Physiological challenges associated with breastfeeding
Participants who experienced breastmilk leakage in public expressed embarrassment:
“When I go to town and my bra is wet. (laughs). And then people who are in the taxi are like, “there’s something that stinks,” … And I will be like, no I left my baby behind because I’m breastfeeding and then I would sit like this [sits with her hands crossed around her breasts] in a taxi because it stinks, it really stinks, it’s like I didn’t take a bath but I did.” (P1, 18-year-old mother, baby aged 19 months).
This participants’ reflection suggests that adolescent mothers may be uncomfortable when people notice that they are breastfeeding.
Another challenge was nipple pain, a negative consequence of breastfeeding, also leading to early cessation of breastfeeding. Pain was experienced when initiating breastfeeding:
“Ya, I felt like crying. I thought he was biting.... And during that time, I was thinking of like no man let me just stop breastfeeding and start with formula because it was so painful ya.” (P9, 19-year-old mother, baby aged 8 months).
There is a clear lack of knowledge of proper breast attachment and positioning during breastfeeding, resulting in pain when initiating breastfeeding.
Participants’ suggestions to support adolescent mothers
Health care professionals should show compassion
In this study participants who had negative experiences at PHC, in the form of judgement and discrimination, were reluctant to return:
“Based on MOU they should be more supportive instead of being judgemental. And encourage them (adolescent mothers) to breastfeed. Because the more they judge, the more they're being mean, the more they're getting the child stressed. And in my mind then, this person's breastfeeding and the baby's drinking the stress out of the person. So I think they should be more supportive and stop being mean. Stop being judgemental as well.” (P12, 16-year-old mother, baby aged 4 months).
Furthermore, according to the HBM, discriminatory and judgemental treatment resulting in the adolescent feeling ashamed and incompetent discourages breastfeeding. A participant explains:
“I got emotional. I used to cry myself every night. Cry myself every night and my baby was always restless. He even had a runny tummy after that…I wasn't okay.” (P12, 16-year-old mother, baby aged 4 months).
There was an appeal for health care providers to be delicate in their approach to adolescent mothers:
“Firstly, they should be gentle with people, they should be nice, they should not be harsh. Because people mostly they say that the nurses they take their stresses out of them…they should be nice and then they should act as if they are in that persons shoes. They should act as if they know how does this person feels. Not say, “No I’m a nurse by profession, why did you get pregnant, why did you do this, why did you that.” Because our people they have small hearts, they cry easily...” (P6, 17-year-old mother, baby aged 1 month).
Most of the participants expressed their concerns related to being treated with less respect compared with their older counterparts. Stereotypes against adolescents who have children may perpetuate psychological stress, rejection, stigma, and discrimination. The sentiments expressed emphasise the need for health care providers to be trained on how to provide care for adolescent mothers that is empathetic and understanding and addresses the plight of the participants.
Adolescent mothers should know that “breast is best”
Despite the challenges associated with breastfeeding, the participants agreed they would advise other adolescent mothers to breastfeed instead of formula feeding:
“I will advise her to give her child breastfeeding because it’s too important, I’ve learnt here in the clinic that breast fed children are healthier, I’d advise her to give her child breastfeeding and not to stop breastfeeding.” (P2, 18-year-old mother, baby aged 14 months).
Thus, the results reveal that contrary to the expected belief that adolescent mothers are anti-breastfeeding; most of the mothers who participated in the study were pro-breastfeeding.
More education is necessary to improve mothering
Participants emphasised the need for health care professionals to provide specific, comprehensive, and consistent breastfeeding education for adolescent mothers:
“…so they should just you know try to give them (adolescent mothers) full information on breastfeeding and pregnancy and all that and not just give them half information or this one tells me breastfeeding is wrong and then the other one tells me breastfeeding is right.” (P1, 18-year-old mother, baby aged 19 months).
Clearly, adolescent mothers in this study were not satisfied with the breastfeeding education they received and desire to learn more about breastfeeding.