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Table 3 Included studies 2011–2020

From: Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? – A systematic scoping review

Study Participants Infant feeding Outcomes Findings
Qualitative
 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
Randomized Controlled Trials
 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.
Observational
 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
Other
 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
  1. Legend: EBF Exclusive breastfeeding, EFF Exclusive formula feeding, MF Mixed feeding