Our study aimed to examine the prevalence and factors influencing six-month EBF practice among mothers on ART in the Eastern Cape Province, South Africa. Although programmes on six months infant breastfeeding have been developed and approved in South Africa, the uptake of EBF remains low. In this study, the prevalence of six-month EBF of 32.0% was sub-optimal. However, direct comparison of EBF prevalence in this study with many other studies on EBF practice is a difficult task, given the variations in the definitions of EBF in different studies, the timing, duration of recall, methods of analysis, and sample biases . Notwithstanding, the EBF prevalence obtained in this study is comparable to 31.6% among infants exclusively breastfeed for the first six months after delivery in Malawi, which was measured by recall method .
Generally, the low prevalence of EBF in South Africa is worrying and suggests concerted interventions to promote, support, and protect breastfeeding, beyond policy and programme formulations are needed. Some studies in other provinces in South Africa reported higher EBF prevalence at 43.2% among HIV-positive mothers in Merafong sub-district in Gauteng , and 35.6% in Gert Sibande district in Mpumulanga . An earlier study by Siziba et al.  reported a low summative prevalence of 12.0% in North-West, Gauteng, Free State, and Eastern Cape Provinces. 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 prevalence in our study is almost at par with prevalences 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 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%) . The differences in EBF prevalences reported across various countries or regions in the literature could be explained in the light of differences in the definition of EBF and geographic variations in the interplay of cultural, economic, and sociodemographic 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 infants are exclusively breastfed . Exclusive breastfeeding is associated with a reduction in child mortality in low-income countries [58, 59]; 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 encourage 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. In contrast, alcohol use was significantly associated with lower odds of six-month exclusive breastfeeding practice. Previous studies have linked maternal employment with lower prevalences 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 are not employed do 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 of 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 breastfeed children. The code of Good Practice on the protection of employees during pregnancy and after childbirth included in the Basic Conditions of Employment Act (Republic of South Africa, 1997), stipulated that arrangement should be made to accommodate employees who are breastfeeding, with 30-minutes breastfeeding breaks twice a day to breastfeed or express for the first six months of the child's life (paragraph 5.13) (the Republic of South Africa, Department of Labour, 1998). However, the actual situation is that women employees and their employers are mostly unaware of this legislation on breastfeeding breaks [68, 69], which are seldom provided or requested in the workplace. 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 inclined to practise EBF. Previous studies have reported similar findings [43, 70-73]. 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 [74,75]. 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 antenatal 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 survey 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 [70-72,76]. However, Mgongo et al.  reported a contrary result. Previous studies have linked alcohol intake with HIV and poor child immunisation [77,78]. 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 lactating are crucial. Alcohol use, whilst breastfeeding, has negative effects on newborns, EBF, and general infant growth [80,81].
Though the measure of EBF (nothing but breast milk) and its duration was clearly explained to the mothers, we could not ascertain if there was any confusion between maternal definitions of EBF and the EBF definition in this study. Often, retrospective data collection tends to result in overestimation of the prevalence and duration of EBF practice in general . Hence, the extent of recall bias and social desirability bias cannot be ascertained, given that this study was a follow up of an existing cohort, which occurred between 18 – 29 months after the delivery of the index infants. Also, telephonic survey with its inherent challenges might have impacted the responses of the parturient women. Regardless of these limitations, our study provides useful information for future comparative studies on the factors influencing infant-feeding practices by mothers on antiretroviral therapy in the Eastern Cape Province, South Africa. Such information would be relevant in shaping maternal and child health interventions in the context of paediatric HIV infection, at least in this setting. A qualitative study would provide better insight and understanding of the reasons why the majority of the women did not practise EBF in the region.