Findings from pre-testing the booklet, Breastfeeding: frequently asked questions

1. Findings from pre-testing the booklet, Breastfeeding: frequently asked questions Laura Myers, CADRE

2. Outline • Pre-testing methodology • A little about context.. • Acceptability of breastfeeding (BF) • Barriers and enablers to exclusive breastfeeding • Relevant cultural beliefs • The booklet! • Overall impressions • Perceived message • New information learned • Indications of potential behaviour change • Feedback on key messages • Booklet format • Recommendations

3. Pre-testing process • Focus groups and interviews with mothers and healthcare workers (including CHWs and professional nurses) • Met 56 women in three districts: O.R. Tambo (EC), Waterberg (Limpopo), Ekurhuleni (Gauteng)

4. Enabling factors • Acceptability • Enablers: • Knowledge of BF benefits • Traditional; supported by elders • Economical! • Sources of information— good relationship with HCWs, early ANC, regular postnatal attendance • HCW pressure • Breastfeeding becoming more popular again • Less HIV stigma

5. Barriers • Breast problems • Attachment; infants that ‘refuse the breast’ • Incorrect feeding methods • Nipple discomfort • Not understanding: • Breastfeeding can be resumed • Milk can be expressed • Difference between foremilk/hindmilk • Colostrum • Fears of HIV transmission • Healthcare provision: • Not asking for help from HCWs • Not being honest with HCWs • HCWs giving formula in secret

6. Barriers • Bottle-feeding is fashionable • Concern about changes to breast shape • Concern about BF in public • Other caregivers • Customary practice to give infants water, porridge, maize, etc • Need to educate gogos, fathers, mothers-in-laws • HIV disclosure • Cultural beliefs • Nursing while pregnant will ‘spoil’milk • Miscarriage • Mastitis • Funerals and crowded spaces • Sex • Muti

7. Overall responses • Very well-received • ‘Useful’, ‘informative’, ‘interesting’, ‘first class’ • ‘I think I learned everything I wanted to know about breastfeeding’ • ‘It just asks questions and then it gives you answers; short, simple answers’ • Almost none had come across written info about BF • ‘I think this booklet will help us a lot’ • Reinforces info that is given at clinics • Strengthened understanding further • A useful tool for HCWs • Seems to have the right amount of detail • ‘Perfect’, ‘nothing to change’, ‘we liked everything’

8. Overall message • Generally understood to promote breastfeeding, particularly the benefits of exclusive BF • ‘the best thing for the baby and the mother’ • ‘it encourages people to breastfeed in any circumstances’ • ‘you must breastfeed your children, even if you are HIV positive’ • Explains how to breastfeed ‘properly, so that the baby doesn’t get sick’ • Encouraging families and communities to support breastfeeding mothers

9. New information • Most participants reported learning new info • ‘this taught us about many things that we didn’t know, we didn’t realise’ • ‘there are things I think I didn’t know here in the book, so when I am doing education, I will include those things’ • Learned: • Importance of exclusive breastfeeding (and dangers of mixed feeding) • Breast milk can be expressed • Bottles and dummies can make BF more difficult • Nipples can be soothed with breastmilk

10. Behaviour change • The pre-testing itself seemed to have a significant effect on participants’ views • Strengthened commitments of all three pregnant women to breastfeed exclusively • Two women shared the booklet with their partners; this opened communication between them and built fathers’ support • Sense of regret from the EC formula-feeding mothers who wished they had this information earlier • Physical, shareable nature of pamphlets…

11. Key messages • Maternal benefits • Breast care • Colostrum, foremilk, hindmilk • Expressing and storing milk • Resumption of breastfeeding • Breastfeeding while pregnant • Contraceptive benefits • Breastfeeding and HIV • The wet nurse • Milk banks • Cultural beliefs

12. Questions mothers have • How will a baby get rid of ‘the dirt’in their body if they are not given water? • Does infant formula contains antibodies, like breast milk does? • What causes jaundice? • Is it okay to breastfeed my baby if I have breast cancer? • Can anything be done during pregnancy to reduce the chances of experiencing mastitis? • Will putting Vaseline on your nipples while pregnant help the breast milk to flow more easily after birth? • How could someone access donated breast milk from a milk bank? • What happens if someone experiences complications during labour and cannot breastfeed immediately? • What if you are coming back from theatre, and then you find the nurse gave your baby formula? • What if my milk doesn't come straightaway? If the baby wants milk but there is nothing, what should I do then?

13. Questions HCWs reported • Are you sure the baby is getting enough nutrients from breast milk? • Why can’t I give my baby water? I have to give my baby water because the breasts only contain milk. • I don’t have any breast milk, what should I do? • I’m still waiting for the milk to come out. (They complain that the colostrum is ‘dirty or something’ and not what they expected.) • How much milk is a new baby supposed to drink? • How should I hold my baby so my nipples aren’t sore? • What will happen if I need to go away and won’t be there to breastfeed my baby? • Can I go to work? Is it safe to express milk? Will the milk be okay? How does it work? Where will I store it? • Why haven’t I gotten my period? • What if the baby vomits while breastfeeding? • How long can I breastfeed if I’m HIV positive? • Where does breast milk come from?

14. Other stuff Material that was less relevant • Milk banks • Milk stimulating products • HCWs who take newborns awy • La leche league Format • The ‘look’ of the booklet; balance of words and pictures • Clarity: overcomplicated words and medical jargon • Language: need for translation Graphics • Male involvement was very appreciated • Depict younger, less traditional women • Mixed race mothers Target audience

15. Conclusion • Because this information is so rare, consider other communication channels (e.g. TV and radio) to compliment this content. • Widespread distribution of this booklet has potential to have an extremely beneficial effect on women’s ability to breastfeed exclusively • Proposes to strengthen knowledge of the benefits of exclusive BF • Build motivation to manage challenges that may arise • Enhance the knowledge and support of others who influence infant feeding practices • The booklet stands to be a very useful tool in the overall promotion of maternal and child health.

16. Recommendations • Translate the booklet • Wide distribution to all clinics, in sufficient quantities • Use booklet to supplement existing social mobilisation strategies • Create a similar booklet about healthy pregnancy and delivery • Include drawings of younger, less traditional women and some mothers of other races

17. Recommendations • Add some content about traditional medicine (particularly that is ingested) • Add a recommendation about BF after caesarian delivery or other labour complications • Add’l contact about HIV risk? • Possibly less on La Leche League, more on community health workers, add mothers2mothers • Add some online resources

18. Many additional edits 

20. Partners For more info: Laura Myers, CADRE laura@cadre.org.za, www.cadre.org.za