Table 3 Included studies 2011–2020

 Horwood et al., 2019

11 HIV+ women, 15-41y

EBF for 6 months – 3 women; 4 stopped breastfeeding, and 2 were MF by 6 months

Health workers influenced feeding decisions

 Chaponda et al., 2017

30 HIV+ women, >18y

EBF - 50% mothers; Initiation of complementary foods from 1 to 4 months

Nurses primarily influenced feeding choices, followed by mothers and other relatives

 Jama, Ngcwalisa et al., 2017

22 women (mixed HIV status); median age 25.5y.

EBF for the 1st 6 months – 23% (5/22); Food/fluids before 6 months – 77% (17/22)

Health workers were a strong influence on choice; All women experienced challenges including incorrect info from health staff, family pressure and having to return to school/work.

 Mushaphi et al., 2017

37 caregivers, ≥ 16y;

Over 90% initiated breastfeeding after delivery; EBF by 3 months - < 1%

No infant was EBF for up to 6 months; Liquids/solids by the 2nd month- 100%

EBF up to 6 months was not practiced; most women believed that breast milk alone was inadequate for baby’s needs and introduced water and other foods before 6 months.

 Ntuli and Modibedi, 201

32 HIV-positive women, 22–38 years

EBF - 68.8% women; EFF - 31.3%; MF −5 mothers

Healthcare staff, SES, past participation in PMTCT and fear of infecting the baby, impacted mothers on infant feeding choices; Counselling needed throughout the perinatal period to enable mothers to choose and maintain appropriate infant feeding choice

 Jones et al., 2018

1368 HIV+ pregnant women and male partners; Women’s mean age – 28y

Overall EBF – 74% women; EFF – 13%;

Infant feeding at 6 weeks: EBF - 73.7%; EFF - 12.6%.

Study intervention was not effective on EBF. Male involvement, HIV disclosure, or stigma did not influence EBF

 Reimers et al., 2018

619 HIV+ mothers (277 control and 273 intervention); Median age (years): control 28.8y (27.5–30.0); intervention 28.4y (27.5–29.2)

EBF rates at 22 weeks: 44.68% (105/235) control and 42.75% (109/255 intervention group.

EBF rates at the final interview (about 22 weeks postpartum) were similar for the control and intervention groups.

 West et al., 2019

Quant - 8116 HIV+ and HIV- women; Qual- 12 healthcare providers, 22 HIV+ women, median age 31y.

Initiated breastfeeding - 86.3%. 93.1% HIV+ women initiated breastfeeding vs 66.3% HIV- women. EBF: 86.3% (day 7), 73.1% (week 14) and 51.7% (month six).

Overall exclusive breastfeeding and breastfeeding intent was higher among HIV-neg than HIV-pos women. Infant feeding choices were guided by a variety of reasons including healthcare staff, finances and social pressure

 Goosen et al., 2014

Cross-sectional - 140 women, mean age 26.4y; Focus groups - 65

Initiated breastfeeding −77% women; EBF - 6 94% suboptimal breastfeeding: 36% predominant breastfeeding, 27%; partial breastfeeding, 31% not breastfeeding; 44% introduced food/formula milk to infant; Intro of foods - 75% < 3 months old.

Women engaged in suboptimal infant feeding methods; EBF was hardly done and other liquids and foods introduced at an early age

 Chakona,G., 2020

Survey and FGD; 84 caregiver-infant pairs (0-24 m); mean age 34.7y

1st 6 months: EBF 36%; FF - 49%

Although women knew the benefits of breastfeeding, it was hardly practiced due to cultural and other reasons; Most infants were weaned by 2 months

 Zulliger et al., 2013

207 pregnant and 203 post-partum women; mean age pregnant women 28.6y and 30.0y postpartum

Ever breastfed - 22% (45) women; Ever used formula – 93% (188); Mean time cessation – 10 weeks.

Advice from healthcare staff was a strong indicator of breastfeeding; Women with running water in home more likely to breastfeed

 Budree et al., 2017

1071 women, median age 25.8y;

Initiation of BF at birth – 86%; EBF for 6 months – 13%; Solid foods before 4 months – 19%; 46% HIV-exposed infants vs 96% unexposed were breastfed at birth. Women who initiated breastfeeding −26% HIV-pos vs 12% HIV-neg women did EBF for ≥6 months.

Poor dietary practices and use of non-nutritious foods were noted; EBF decreased after 3 months, early use of other foods, and low use of iron rich foods between 6 and 9 months.

 Ellis, K., 2013

260 HIV+ and 251 HIV- women

By 3 months: EBF −30.9% HIV-pos; MF -

86.2% HIV-neg women.

Although early infant feeding practices were low among HIV+ and HIV- women, HIV+ women continued safe

infant feeding practices for 3 months.

 LeRoux et al., 2020

869 mother–infant pairs; Age: HIV+ 28y, HIV- 27y

Early initiation of breastfeeding: All - 90%; HIV-pos 87%; HIV-neg 94%; Duration of EBF (months): All 1·4, HIV-pos 1·5; HIV-neg 1·4.

Suboptimal breastfeeding practices increased risk of infections for infants.

 LeRoux et al., 2018

521 mother-infant pairs, Median age: All 28y, HIV-pos women 29y, HIV-neg 28y

Median duration of breastfeeding - 6 months in HIV-exposed vs 10 months for HIV unexposed infants

HIV exposed infants might be at increased risk of cognitive and motor delays, despite being breastfed and mother receiving ART.

 Zunza et al., 2018

316 mothers-infants: 188 HIV+ mothers and 128 HIV- mothers; HIV-pos b/feed 27.99y; HIV-neg formula 28.09y

All HIV-neg mothers breastfed; HIV-pos (2 weeks): Breastmilk 42%; Formula 58%.

Analysis indicates inadequate duration of breastfeeding among HIV-pos and HIV-neg mothers.

 Kennedy, Y et al., 2016

132 mothers, 18-42y, with mean age 27y

At 6 weeks: EBF - 69.36%; FF - 15.21%; MF- 15.21%; Complimentary foods by 6 weeks – 15.32%.

Although women had high knowledge on benefits of breastfeeding, they made unsuitable choices

 Nguyen, K., 2017

471 mother-infant pairs; Median age - 28 years

Ever EBF – 91%; Median duration of EBF- 1.5 months; EBF ≥ 4 months – 24%.

Sub-optimal levels of EBF identified; Need for breastfeeding support

 Van De Venter, C., 2019

584 women; median age 28 years

Infant feeding intentions:

EBF - 81%; EFF- 16%; MF - 3%.

1 week postpartum: EBF −9%; EFF, 2%; MF - 90%.

Majority of women engaged in mixed feeding; non-disclosure of HIV status impacted infant feeding practices

 Tchakoute et al., 2018

749 HIV-exposed uninfected and HIV-unexposed uninfected infants

EBF at birth - 99% HIV-exposed infants vs. 92% HIV-unexposed infants.

Infants EBF had lower cumulative infectious disease incidence than those who were not breastfed; no significant difference in mortality among HIV-exposed infants and HIV-unexposed infants during the first year of life in this cohort; EBF for just 4 months had protective effects on morbidity up to 1 year.

 Horwood et al., 2018

4172 caregivers (mothers, fathers and other relatives); Age > 15y

Mothers: EBF - 49.8% MF- 23.1%; No BF - 27.0%; Other caregivers: EBF −11.8%; MF- 23.4% and no breast milk - 62.3%.

Although breastfeeding practices in the study were higher than previous studies, problems persist. Breastfeeding support needed for HIV+ women and those returning to work/school.

 Jackson et al., 2019

Caregiver-infant pairs - 10,182, 10,106, & 9120 in 2010, 2011–12, & 2012–2013

National EBF rates (4–8 weeks of age) were:

22.9% in 2010; 35.7%

in 2011–12 and 59.1%

in 2012–13.

There was an increase in early EBF among infants 4 to 8 weeks due to major national policy change in breastfeeding from 2010 to 2013. Lower odds of EBF for mothers: with high SES; HIV- positive, unplanned pregnancy, primipara, caesarean delivery, and no breastfeeding counselling.

 du Plessis et al., 2016

443 mother-infant pairs; mean age 29.5y; children 9.85 months

Breastfeeding initiation - 75.2%; Infants < 6 months: EBF - 38.5%; EFF - 19.7%; BF at 12–15 months old: 32.5%

Results indicated subpar infant feeding practices with both under and over nutrition observed.

 Faber et al., 2016

Children 6–24 months: 158 urban and 158 rural area

Ever breastfed: rural - 79.1%; urban - 78.5%; BF 18–24 months – 14.4%.

Dietary diversity (minimum) attained by < 25% children; High levels of animal protein & cholesterol vs low levels of fiber & plant protein for urban vs rural children (18–24 months)

 Fuls et al., 2020

200 infants 6–12 months, mean age 8.54 months

Overall BF - 87%.

Complementary feeding (6–8 months)- 82%; Mean BF – 7.5 months; BF > 6 months – 53.7%

6.5% children experienced feeding problems, such as oral motor dysfunction; Care giver education and health-care professional training needed on transitional feeding.

 Madiba et al., 2015

202 post-natal women, mean age was 31.4y.

55.6% EBF and EFF mothers practiced MF. EFF - 56.8%.

EBF and EFF mothers had problems adhering to initial infant feeding choice. Interventions needed to address cultural practices and other factors impacting EBF among HIV-pos women

 Matsungo et al., 2017

750 infants, age 6 months

EBF (≤ 6 months age) – 5.9%; EBF (6 months) – 70.1%. Intro of liquids and semi-solids was 2·5 months and 3·8 months, respectively.

Interventions to encourage appropriate infant feeding practices, needed to prevent stunting.

  Motadi et al., 2019

360 participants; mean age adults - 29.3y; mean age infants - infants were 12.2 months.

Initiation of BF within 1 h of birth – 67.2%. Of the 17% of women who stopped BF: 16 and 14 stopped within 1 month and 3 months of delivery respectively.

While the women were quite knowledgeable about breastfeeding, this did not translate into appropriate practices.

 Nieuwoudt et al., 2018

298 HIV-pos and HIV-neg women. Median age 29y

Breastfeeding initiation – 99.5%. HIV-pos women (infants < 3 months): EBF – 44%; FF – 28.9%. HIV-pos women (infants 3–6 months): EBF – 31.8%.

HIV-positive mothers engaged in longer EBF and FF than the HIV-neg women. Mixed feeding occurred frequently

 Pillay et al., 2018

73 teenage mothers, ≤ 19 (15–19) years

Initiation of BF – 100%. BF (Visit 1) – 68.5%.

14-week visit: EBF - 50.7%; MF/No breastmilk - 49.3%.

Early cessation of breastfeeding linked to maternal age ≤ 17y; Interventions needed to promote and support EBF

 Remmert et al., 2020

156 HIV-pos women, mean age 28.1y

No initiation of BF: > 50%. EBF- 28.2%; EFF- 71.4%.

Low rates of EBF; Social support and services needed to promote EBF. Primary reason for not breastfeeding was fear of HIV transmission to the child.

 Seonandan & McKerrow, 2016

11 dieticians, 14 nurses & 94 caregivers (41 infants < 6 months; 26 infants 6 to 24 months, and 27 children 2 to 5 years)

Ever EBF −76%.

EBF (>  3 months) – 36%; EBF (<  6 months) – 84%

Although there have been better breastfeeding rates since 2003, EBF occurs for a short time. Appropriate feeding of infants and young children varies at state hospitals. Regular training needed for staff.

 Siziba et al., 2015

580 mothers/caregivers; Mean age of infants, 2.9 months.

Initiated BF within 1st hour – 90%. EBF for (infants ≤6 months) – 12%; No BF (≤ 1 month) – 40%; Mean duration of EBF – 2 months.

Interventions needed to address knowledge and increase EBF, particularly at the community levels. Work, school, health status and inadequate milk affected infant feeding practices.

 VanDerMerwe et al., 2015

435 mother-infant pairs;

Mean age 26y; Infants 1 day – 5 months

Emalahleni vs Mbombela health subdistricts. Early initiation of breastfeeding

57% vs. 43%; EBF 60% vs 48%; ERF - 18% vs. 33%. MF - 19% vs. 15%; Mean age for complementary foods - 50 vs 35 days.

Baby-Friendly Hospital Initiative (BFHI) in community contributed to better infant feeding practices

 Frans, R., 2014

175 HIV-pos & HIV-neg mothers, 12 to 49 years

EBF - 42.3%; MF - 48.6%; Formula - 9.1%.

Issues that impacted EBF were work, school, family pressure, and knowledge deficits.

Recommendation to increase individual counselling sessions.

 Makwela, M., 2019

146 mothers

Initiated breastfeeding – 94%; EBF - 39%; MF - 61%; 5% stopped breastfeeding < 1 month after initiation.

While there are high rates of breastfeeding initiation, problems exist with the practice of EBF

 Mandiwana, T., 2017

160 mothers, 15–40 years

EBF for 6 months – 6.25%; EBF (4–6 months) 1.5%.

Adherence to 6 months of EBF was inadequate. Complimentary foods introduced at an early age; Reasons for non EBF: not enough milk, crying baby, school or work.

 Mohlajoa, K., 2016

75 HIV-positive women, 18 to 45y

Initiation of BF (immediately after birth) -67.6%. EBF for 6 months – 40%.

Interventions needed to educate women on infant feeding; Lack of support, fear of stigma and cultural norms contributed to poor EBF

 Morgan and Jeggels, 2015

100 HIV-positive mothers, mean age - 29 years

EBF - 54%; EFF - 46%

Poor EBF practices; Women not aware of Government’s policy to eliminate free formula; Consistent messaging needed on infant feeding

 Muravha, N., 2014

122 health staff at 40 health facilities

4 violations by 4 health workers in 7.5% (3/40) facilities (violation of Article 7.3) - receipt of free gifts.

All health workers were familiar with the International Code of Marketing of Breast-milk Substitutes. Ongoing training needed on The Code

 Radebe, P., 2014

4 TV channels, 9 radio stations, 116 magazines and 10 newspapers

30 violations from 117 baby product advertisements published in 8 of 169 magazines; No violations were found from advertisements on TV, radio or newspapers

Code violations identified in (4.7%) of magazines targeting mainly pregnant women. Data needed to determine full extent of violations in the media

 Siziba, L., 2014

580 mothers/caregivers with infants < 6 months

Initiation of BF within 1 h of birth – 90%. EBF – 12%; No BF – 16%

Low rates of EBF, and early intro to other foods major concerns

 Author

Type of document

Issue

Findings

 Lake et al., 2019

Expert Commentary

Breastfeeding in SA and the BMS Industry

Effective leadership urgently required to stem violations of BMS industry