Background
Study participants and methods
Study design
Study sites
Study participants
Data collection methods
Focus group discussions
Key informant interviews
Data analysis
Ethical considerations
Results
Characteristics of study participants
Category of participants | Number of FGDs & KIIs | Study participants by gender |
---|---|---|
Focus group discussions Mbale District | ||
Peer counsellors | 1 | 7 female |
VHT | 1 | 6 (3 female and 3 male) |
Young mothers (18–24 years) | 2 | 13 female |
Older mothers (30–40 years) | 2 | 17 female |
Fathers (32–50 years) | 1 | 7 male |
Total | 7 | 50 (40 female &10 male) |
Key informant interviews Mbale District | ||
Community leaders | 2 | 1 female & 1 male |
District Health Team | 2 | 1 female & 1 male |
Non-Government Organizations | 1 | 1 male |
Faith based organization | 1 | 1 female |
Health workers | 2 | 2 female |
Total | 8 | 5 female & 3 male |
Key informant interviews Kampala | ||
Ministry of Health | 1 | 1female |
Mulago Hospital | 1 | 1female |
Non-Government Organizations | 4 | 2 female & 2 male |
Professional association | 1 | 1 female |
Total | 7 | 5 female & 2 male |
Emerging themes for scale-up of peer counselling support for EBF
Need for peer counselling support for exclusive breastfeeding
Other study participants reasoned that some mothers often stop breastfeeding when they experience breast pain and such women need guidance:Peer supporters are needed especially for young mothers . . . some of them have not seen anyone breastfeed. They need guidance on how to position the baby on the breast but also for someone to answer their questions . . . thus peer counsellors, if trained, can help to address such concerns (KI Mbale District).
Evident in the above voices is that peer counselling support can help to motivate mothers to carry on with breastfeeding and address the challenges they face at home, especially during the early days of breastfeeding initiation.Some women stop breastfeeding when they experience pain in [their] breasts and such mothers need someone who has breastfed before to talk to and to encourage them… (FGD Peer counsellors, Mbale District).
The above narrative reveals that while breastfeeding information is being introduced by health workers during antenatal and maternity care, mothers require follow-up support to address the practical challenges that emerge during the early breastfeeding period. Under such circumstances, peer counsellors are instrumental.Mothers are given some information on infant feeding during antenatal and delivery care. But most of the struggles with regard to breastfeeding manifest during the initial weeks after giving birth and at home; this is when peer counsellors can be of great help (KI Kampala).
Barriers to scale-up peer counselling support for EBF
Organizing theme | Sub-theme |
---|---|
Limited resources and high community expectations | - Mobilization and support of peer counsellors - Motivation of peer counsellors - High community expectations |
HIV related challenges | - Stigma and non-disclosure of HIV status - Confusing messages on HIV transmission through breastfeeding |
Health facility challenges | - Few health workers - Lack of appropriate IEC materials on EBF promotion - Negative attitude of some health workers |
Cultural beliefs and practices | - Breast milk is not enough especially for the boy child - Giving complimentary feeds is a norm, highly acceptable and widely practiced - Influence and advice from significant others e.g. mothers and mothers’ in-laws - Expressing breast milk a taboo and can kill |
Economic barriers | - A belief that EBF only is for the poor who cannot afford supplementary feeds - Lack of food for the mother to produce adequate breast milk - Heavy domestic chores among women |
Lack of supportive policies and programmes | - Work places not suitable for breastfeeding (lack space and short leave) |
Low male involvement for maternal health | - Men do not attend antenatal clinics - Men are not informed and unsupportive of EBF |
Limited resources and high community expectations
The high community expectations were also echoed in all FGDs and by key informants, as one informant noted:Politicians give handouts whenever they come to meet community members. So, when we visit mothers to guide them on breastfeeding some of them expect us to have taken food, milk or to give them financial support when their children fall sick . . . Some of the mothers come to us asking for school fees for their children . . . (FGD Peer counsellors, Mbale District).
Some informants, especially those at the Ministry of Health and the District Health Team, mentioned that insufficient resources made it difficult to expand such initiatives and was a source of demotivation for community volunteers.These days, things have changed, even when you call community members for a brief meeting to educate them on something, they expect transport or a soda because politicians and some organizations are doing it. These expectations can make the peer support programme very expensive and unaffordable . . . (KI Mbale District).
Lack of financial incentives can be a challenge for peer counsellors. If there are no incentives, the peer support programme will have minimal impact like the village health team (VHT) programme which is good but most VHT members are not active except where there are partners which give them some incentives. Like VHTs, peer counsellors for exclusive breastfeeding cannot work fully as volunteers . . . they need facilitation such as bicycles, t-shirts and some allowance . . . (KI District Official, Mbale District).
The fear of stigma, HIV and breastfeeding challenges
The challenge of providing peer support for EBF in the context of HIV and breastfeeding, was further compounded by the rapid changes in information about breastfeeding and HIV which some of the mothers and peer counsellors found unclear and confusing.HIV stigma is still a big problem. The current policy promotes exclusive breastfeeding for all women regardless of HIV status, but this message has not yet been well understood by both health workers and community members. So, providing peer support in such a setting may be a challenge (KI Kampala).
In relation to the challenge of HIV and breastfeeding, VHT members added:We have been told before that HIV positive women should not breastfeed, but recently we are being told that HIV positive women can breastfeed even for a long time without infecting their babies. These messages are really confusing us and [are] difficult to explain . . . (FGD Peer counsellors Mbale).
Similarly, most informants were concerned that the policies and guidelines on infant feeding continue to change, causing confusion among health workers as well as community members. Informants noted that it is difficult for the peer counsellors to convince HIV positive mothers to exclusively breastfeed.There is fear of transmission of HIV from mothers to their children through breastfeeding among those who are HIV positive and it hinders the work of peer counsellors. Mothers don’t want to exclusively breastfeed for fear of infecting their children with HIV (FGD-VHTs Mbale).
It has been known widely that HIV can be transmitted from mother to child through breastfeeding. These days breastfeeding is being promoted for all women, including HIV positive mothers, so communities have a lot of questions, and peer counsellors will encounter this confusion as a barrier in doing their work (KI Kampala).
Health facility challenges
Study participants also noted that some health workers do not have the right attitude to support EBF.Most health facilities lack posters and information on the promotion of breastfeeding. This is because most of the breastfeeding activities have been done under the programme for prevention of mother to child transmission of HIV, thus the focus has been on breastfeeding for HIV positive women as opposed to targeting the general women who are the majority. Besides, health workers are few and overworked. This makes it difficult for health workers to educate mothers and community members on breastfeeding (KI Kampala).
Key informants also reported that most health workers lack adequate time in which to share detailed information with the mothers, especially during antenatal clinics and in the postnatal period, yet it would be a basis on which peer counsellors could build maternal knowledge.The majority of health workers are not ready to support breastfeeding mothers. Health workers are not friendly and lack policies and guidelines to enforce and promote exclusive breastfeeding . . . (KI Kampala).
We know that, as health workers . . . we should promote breastfeeding, and peer counsellors can build on that information. But in practice we are very busy, so we do not give adequate information on breastfeeding to mothers . . . (KI Health Worker Mbale District).
Negative socio-cultural beliefs
In Mbale District expressing breast milk in case a mother was to be away was viewed as a taboo by most community level study participants who reasoned that expressing breast milk would lead to death of children and family isolation.Many women in our communities say that breast milk is not enough for the baby especially for boys. So, it is normal to give a child other feeds like porridge, soup, juice cow’s milk . . . (FGD Young women, Mbale District).
Some community members believe that if a child who is not the one being breastfed drinks breast milk or uses a container in which breast milk was (stored); he/she would die, so people fear to express breast milk (KI Health Worker Mbale District).
In most FGDs men and women equated women who express breast milk to ‘milking them like cows’; a practice that was not acceptable. Women, especially those who had to stay away from home, were unable to exclusively breastfeed for the recommended time even with the peer counsellor available because of such beliefs.Breast milk is only supposed to be in the mother’s breast but not ‘in home’ utensils. Who will ever eat food in your home if they discover you express breast milk? Tradition does not allow this (FGD Mothers Mbale District).
Such beliefs serve to keep the role of peer counsellors unrecognized, thus limiting potential for scaling-up of the programme.Most people take breastfeeding for granted, they think they know about it and others think breastfeeding is natural and does not require support which is not the case . . . (KI Kampala)
Economic barriers
Poverty was another barrier to limited activities and the scale-up of peer counselling support for EBF. Study participants identified the long work hours that women endured as a reason for their inability to exclusively breastfeed their children and the difficulties of being reached by peer counsellors. They also mentioned that because most mothers in Mbale were overworked and poorly fed, they would not produce adequate breast milk for their infants.Breast milk alone is not enough for the baby. So, if I have the money . . . I cannot allow my baby to breast feed only. We buy porridge, milk, soda or juice . . . to help the child get satisfied (FGD Men Mbale District).
Over working of women is a big challenge . . . they eat only once [a day] and maybe one type of food like cassava. The other crops we grow like beans and soybeans are sold to get money for school fees and other family needs. So, a woman who eats one meal a day and is overworked will not produce enough milk for the baby . . . (FGD men Mbale).
Lack of supportive policies and programs for EBF promotion
Participants also noted a lack of clear policies and guidelines on the selection, training and support of peer counsellors for EBF as a major barrier.Most working mothers are given 90 working days for maternity leave but due to financial constraints even those days are not fully given to the baby since the mother has to run here and there looking for survival and trying to make ends meet (KI Kampala).
If a mother can support herself or if she has a daily income so that she doesn’t leave home, she can be able to stay home with her baby and breastfeed. But now some of us are casual laborers. We go to pick coffee at BCU and there is nowhere you can place your baby or even breast feed . . . so it becomes a challenge (FGD-mothers, Mbale District).
Low male involvement in child health
In most cases husbands rarely interface with the health system. Many do not attend antenatal care with their wives, thus missing out on health education including on infant feeding but are influential on how to feed their children. So, they rely on informal sources of information such as their mothers and sisters who may not have accurate information on EBF . . . (KI Kampala).
In such settings, it becomes difficult for peer counsellors to access women and support them on EBF if their partners are uninformed and not involved.Men are important decision makers and can hinder exclusive breastfeeding if not brought on board. For example, it can be difficult for a woman to refuse to give milk or any other feeds that a man has bought to the child (KI Kampala).
Facilitators to scale-up peer counselling for EBF
Structure | Solution |
---|---|
Health facilities | - Integrate breastfeeding messages in health education, antenatal, maternity, postnatal and outreach services - Train and supervise peer counsellors |
Village heath teams | - Ministry of Health Structure, available in most districts - Already involved in maternal and child health |
The media (radio and newspapers) | - Dissemination of information on breastfeeding - Opportunity to correct misconceptions |
Role models | - Use of influential and respected community members to promote EBF |
Existing peer counsellors in Mbale | - Knowledgeable and can provide opportunity for learning |
Community and faith-based groups | - Breastfeeding promotion in existing membership of women/mothers - Widespread and trusted |
Professional associations | - Uganda Paediatric Association, Nurses and Midwives Association with country-wide reach - Technical expertise spread throughout the country |
The health system to promote peer support for EBF
Use of existing peer counsellors in Mbale and support groups
Existing community and faith-based groups like women’s groups, were also identified as another facilitator for the scale-up of peer support for EBF. Study participants noted that church, savings and credit groups, and women and famers groups can disseminate information about the benefits of EBF and promote it among group members. Also, group leaders could be trained as peer counsellors to provide the needed support to breastfeeding women within their groups and communities.For us, we have been providing peer support to mothers. Even when the study ended, we still provided information and guidance to mothers near us . . . we can share this experience with other peer counsellors (FGD Peer counsellors, Mbale District).
Use of role models
In relation to role models, other informants explained:Reaching out to church leaders to provide them with information on breastfeeding can help them to integrate such messages in teaching sermons. For example, on March 25thevery year we celebrate Mary’s day, so we could add breastfeeding messages on the theme for such celebrations to popularize breastfeeding and ask people to volunteer as peer counsellors . . . (KI Mbale District).
Role models such as the first lady or the speaker of parliament who are women themselves, if given appropriate information on breastfeeding . . . can be good champions for its promotion. I heard on news that the speaker of parliament has initiated a breastfeeding corner in parliament . . . (KI Kampala)
What emerges from the above narratives is that role models can leverage their status and popularity to promote peer support for EBF but require up-to-date information.Some of the role models such as musicians, religious, political and cultural leaders are well known, respected and people believe in what they say. Such people should be trained and given summary information on the benefits of breastfeeding, challenges mothers face and how they can be addressed . . . (KI Kampala)