Our study aimed to examine the prevalence and the associated factors influencing six-month EBF among mothers on ART in the Eastern Cape Province, South Africa. Although many policies and programmes on six months infant breastfeeding have been promulgated in South Africa, the rate of EBF is low. In this study, the prevalence of six-month EBF was low (32.0%), which falls far below the WHO recommendation of 90% coverage . However, the EBF rate obtained in this study is comparable to the EBF rates of 31.6% among infants aged under six months . Generally, the low prevalence rates of EBF in South Africa is worrying and suggests concerted interventions to promote, support and protect breastfeeding, beyond policy and programme formulations. Exclusive breastfeeding prevalence rates vary from one geographic setting to another. Some studies have reported higher EBF rates of 43.2% in Merafong sub-district, Gauteng , and 35.6% in Gert, Sibande and Mpumulanga  in other provinces or settings in South Africa. An earlier study by Siziba et al.  reported a summative low prevalence rate of 12.0% in North-West, Gauteng, Free State and Eastern Cape. Also, 18.0%, 6.0%, 13.0%, 7.6%, and 6.7% of mothers practiced EBF up to six months in Kwa-Zulu Natal, Western Cape, Limpopo and Gauteng provinces, respectively [36–40]. Compared with other settings elsewhere, the EBF rate in our study is almost at par with rates reported in Ethiopia (30.6%, 31.0%) [41, 42], Bangladesh (35.0%)  and India (34.0%) , but higher than the EBF prevalence reported in Kaiyuan Yunnan, Southwest China (27.34%) , Saudi Arabia (24.4%) , USA (16.8%) , Egypt (9.7%)  and Nigeria (14.8%) . Yet, other studies have reported higher EBF prevalence rates in Ethiopia (88.8%, 75.2%; 77.3%) [28, 50, 51], Kenya (71.4%; 52.3%) [52, 53], Western India (61.5%)  and Tanzania (55.5%) . These differences in EBF rates reported across various countries or regions in the literature could be explained in the light of geographic variations in the interplay of cultural, economic and socio-demographic factors affecting EBF.
Notwithstanding the many advantages of breastfeeding and the strategies to promote it, EBF uptake still, remains low in many developing countries [16, 56]. Worryingly, worldwide, only 35% of the infants are exclusively breastfed . Exclusive breastfeeding is associated with child mortality in low-income countries [58, 59] and morbidity ; thus, interventions on EBF should be accorded top priority. In this regard, there is a need to sensitise the community on the benefits and inherent problems associated with mixed feeding . In the South African context, one of the pragmatic approach to promote women’s awareness of EBF, outside of health facility channels, could be to utilise and promote the Ward-Based-Outreach-Teams (WBOT) in the community or women’s groups to increase the duration of EBF. One of the cardinal objectives of WBOT is to promote and create awareness on various health issues affecting the community, as part of the government efforts of improving the primary healthcare re-engineering agenda. This is advisable because community beliefs could have considerable influence on EBF practice.
Our findings demonstrated that being unemployed and having a low level of education (secondary or less) was significantly associated with a higher likelihood of EBF, while alcohol use was significantly associated with lower odds of six-month exclusive breastfeeding practice. Previous studies have linked maternal employment with lower rates of EBF and earlier cessation of breastfeeding [60, 61]. In this study, consistent with studies conducted in Bangladesh , Saudi Arabia , Ethiopia [62–64], Tanzania , Canada , and Guatemala , unemployed mothers are likely to practise EBF as compared to those who are employed. It is plausible that mothers who do not have salary employment stay or work at home, and thus, have enough opportunity while at home to breastfeed their infants. Contrastingly, employed mothers, perhaps due to the nature of their work, the challenge to return early to work after giving birth, work shifts, and maternal fatigue, may collectively hinder them from having frequent contact with their infant to provide exclusive breastfeeding. In South Africa, working mothers are granted only four months maternity leave, which may begin at any time from at least four weeks before the birth of the baby; and there are no available workplace facilities for mothers to breastfed children. This suggests that policies about maternity leave in South Africa warrant scrutiny to encourage EBF practice. This is very crucial in the context of achieving comprehensive PMTCT.
In this study, mothers with a low level of education are more incline to practise EBF. Previous studies have reported similar findings [43, 68–71]. However, Mango et al.  study in Tanzania, found the level of education had no association with EBF practice. Other studies conducted in Ethiopia and Bangladesh reported similar findings [72, 73]. The association of a lower level of education with EBF could be explained by the higher rate of unemployment in this population. As such, strategies aimed at strengthening EBF practise in this population should also address the needs of women with higher levels of education. Specifically, the concerns and fears of educated women need to be addressed during counselling sessions at ante-natal and postnatal clinics.
This study revealed that alcohol use was significantly associated with lower odds of six-month exclusive breastfeeding practice. About 22.9% of mothers drink alcohol. A study conducted in the Kilimanjaro region, Tanzania, showed that mothers’ alcohol intake was associated with EBF up to 6 months . Other studies have reported similar findings elsewhere [68–70, 74]. However, Mgongo et al.  reported a contrary result. Previous studies have linked alcohol intake with HIV and poor child immunisation [75, 76]. A recent study has reported high binge drinking (10.8%) among women in South Africa . Alcohol consumption is widely practised in South Africa , at various events or celebrations such as weddings, burials, and other social events, work or community engagements. Advocacy programmes on the effects of alcohol intake during pregnancy and on lactating women is crucial. Alcohol use during pregnancy or whilst breastfeeding have negative effects on newborns, EBF, and general infant growth [80, 82].