Two themes emerged from the data analysis. These were; 1. “Challenges, empowerment, support and resilience during initiation of exclusive breastfeeding” with a sub-category, “Support and resilience during EBF initiation”, and 2. “Diverse support and resilience during maintenance of exclusive breastfeeding” with a sub-category, “Support and resilience during EBF maintenance”.
Support and resilience during EBF initiation
Some first-time mothers reported having received support during the initiation of exclusive breastfeeding. The support was from mixed sources; information and practical support were from nurses and social support from family members, friends, and community members. Practical support included the nurse bringing the baby for initiation of breastfeeding, being shown positioning and attachment, managing not enough milk.
Most first-time mothers emphasized that the baby was brought to them by nurses and were asked to start breastfeeding. One participant reported,
“I was given the baby; it was not that long. I kept him with me…” P1
“My baby was brought in. Nurses, they said I must pull the nipple and put it in his mouth.” P6
However, she reported that she was not supported as expected regarding the initiation of breastfeeding as the nurse seemed busy.
“I was never shown that you do this way for you to breastfeed. … the nurse was busy with other things but she was saying put the breast in…” P1
“I expected that when I get the baby I will be shown; how the baby sucks, hold the baby this way, insert the nipple this way.” P1
First-time mothers saw a demonstration of positioning and attachment as supportive.
“I was taught how to breastfeed and the way of holding the breast for him. I was taught by the nurse that delivered me.” P4
“They showed me that ‘hold him this way’.” P5
“The Nurses showed me how I need to position him here on my breast” P10
“The nurse … showed me that I need to hold him with my left arm and I supported my right one…” P2
Practical support to manage early breastfeeding challenges such as ‘not enough milk' through the supply of tablets and giving of injection were also seen as supportive.
“Nothing was coming out. I was given tablets. ….. then it started to come now” P7
Other mothers who delivered around the same time as first-time mothers gave social support by encouraging these mothers by an example.
“Also seeing from other mothers when they are breastfeeding” P8
First-time mother’s lack of experience and breastfeeding challenges can influence the initiation of breastfeeding. To achieve initiation, support is needed. Nurses were helpful in the initiation of EBF however, more support is needed for the maintenance of EBF.
Support and resilience during EBF maintenance
During EBF maintenance, social support was mostly from family members, friends, and other community members while information and practical support, which included teaching and observing the first-time mother’s breastfeeding techniques, were from nurses. Scheduled postnatal follow-up visits within three days of delivery were cited as helping support first-time mothers' maintenance of EBF through practical assistance with breastfeeding challenges. One mother who initially did not feel well supported to initiate EBF confirmed that she did get the knowledge and skill later during this period.
“When I went back to the clinic, that is where I was taught that you breastfeed the baby, how you hold him when you are breastfeeding.” P1
“Support from the clinic is really good”. P3
“Yes, there were students that were teaching there. The Nurses there at the clinic are supporting me. … they motivate me to breastfeed the baby" P9
Most of the first-time mothers enjoyed the support from the family members, friends, and other mothers in the delivery unit whom they considered more experienced in breastfeeding than they were.
“It is my grandmother and my older sister, my family, and my cousins. When I have a problem I tell them.” P6
“Another lady I was with there said it is not the first time she is having a baby. I must request tablets to produce milk. She said ‘I have seven children but my children, I do not have a child that I say he is not breastfeeding’.” P7
Different aspects of support were cited by first-time mothers included information-sharing, practical support and emotional support received including positive motivation from nurses. One participant who previously did not have enough milk reported,
“When I started having tea then I had a lot of milk. My sister said, ‘my sister, I did not breastfeed my child because I was working, you are not working so for your baby to grow quick you need to give the breast’.” P7
“His weight was already increased; the nurses said ‘well done. I love what you have done’.” P5
While most first-time mothers received support from family members, one first-time mother explained the pressure to mix-feed she received from community members.
“Other mothers that normally come to my house to visit my mother say I am keeping the baby hungry. I am supposed to be feeding him solids now. “ P4
Some mothers highlighted the importance of a supportive relationship between first-time mothers and nurses.
“It is important that there is a relationship between her and her nurses” P1
One mother reported in-depth the need for formulation of first-time mother's EBF support groups. She highlighted how it should be run to ensure compliance by first-time mothers, including its benefits.
“It would be beneficial, something nice the availability of those support groups … if the clinic is organising it at least it would give some weight. Maybe it can be done once a month or once a week or fortnightly but there must be interaction among first-time mothers so that they can share their experiences. Soon after breastfeeding the baby, she must attend those things those meetings.” P1
While one first-time mother voiced her frustrations with inadequate support she received from the nurses during initiation of EBF, most first-time mothers were satisfied with the support they received from the nurses and family members during the maintenance of EBF. First-time mothers highlighted socio-cultural aspects of breastfeeding through the comments of family members, friends, and community members’ involvement in the breastfeeding practice. Some comments were, neither accepted nor appreciated by these mothers.
Some mothers explained the socio-cultural difference in breastfeeding practice between healthcare professionals and elderly community members. This was cited as possibly causing conflict between first-time mothers, community members, and the nurses.
“My mother said, ‘we did not grow up like this, we fed children roasted this and that.” P3
“…In our homes, you are shown the thing this way but when you arrive at the clinic, all of that is criticised… At home, you are told to use the second finger next to the thumb and the one next to it, you put the breast in and support with your thumb.” P1
First-time mothers reported feeling pressured to feed formula or porridge to their babies against their own choice. Most mothers did not like these suggestions.
“He was crying … my cousins, my friends came to see the baby and they already have children, said ‘I did not breastfeed … I bought a formula … buy him formula milk.” P3
“I did not want anyone who is going to say, ‘No feed, steal a spoon for him or two spoons of porridge. Yes, there are such like ones, who say, ‘no this child is not getting enough from the breast.” P7
“I do not feel well because my friends want me to be able to leave the baby behind to go out with them. So I do not feel well.” P9
Two mothers voiced the need to take advice with caution, as not all advice is good advice. These mothers explained the need to reject unhelpful advice as the motive might not always be genuine.
“… your child will never gain weight. Your child will never grow well because you are exclusively breastfeeding. Give him porridge. Do not listen to a friend because a friend sometimes misleads” P5
“People from the streets will advise the wrong things. Their motive … is that as I am getting the grant on the date for grant pay-outs they want to go with me to the shebeen.” P6
Support received by first-time mothers included socio-cultural values which sometimes was in line with the knowledge and skills received by first-time mothers during antenatal care. First-time mothers were able to accept or reject the support that they deemed harmful to the breastfeeding practice and maintenance of EBF. There is, however, a need to include the communities in information sharing on EBF support to avoid conflict between nurses, communities, and first-time mothers.