CASE STUDY:
Barriers to healthy infant feeding practices and community responses to
malnutrition: Insights from Capricorn and Waterberg Districts in Limpopo
Developed By1
Intended Audience
Development Date
FAMSA, Limpopo and CHoiCe Trust
Department of Health, Limpopo:
District Clinic Specialist Teams (DCST) and
Maternal, New-born, Child and Women’s Health (MNCWH) Directorate
December, 2014
1. Introduction
Although the rates for infant and child mortality in South Africa declined between 2009 and 2011, the
country continues to lag behind in achieving Millennium Development Goal (MDG) 4 with a target of a
mortality rate of 20 per 1,000 live births of under-five year olds by 20152. Child malnutrition is the largest
contributor to under-five mortality due to vulnerability to infection and slow recovery from illness.
Proportion of children aged 1-9 years
National and provincial malnutrition, 2005
24%
25.00%
18%
20.00%
15.00%
12%
9.30%
National
Limpopo
10.00%
4.50%
5.00%
0.00%
Underweight
Stunted
Wasted
In order to achieve the relevant MDGs, the South Africa government (lead by the Department of Health),
established the Integrated Nutrition Programme (INP) in 1995 and launched its Roadmap for Nutrition
in South Africa in 2010. The INP aims to improve the nutritional status of children under 6 years of age,
at risk pregnant and lactating women, primary school children from poor households, persons suffering
from chronic diseases or communicable diseases, and at risk elderly persons. The four key intervention
areas identified as having high impact in eradicating malnutrition include (a) the promotion of
breastfeeding3; (b) targeted meal supplementation; (c) food parcels; and (d) food security / home
gardens.
1
This document was developed with the support of the Department of Health, Limpopo Province and the
stakeholders who shared their time and experiences during the consultations. The Okuhlekodwa Research and
Development Consultants was used to serve as a learning officer and document the process and tools.
2
Health Systems Trust, 2013
3
Breastfeeding is regarded as a key child survival strategy in resource-poor countries as exclusive
breastfeeding effectively reduces the incidence of diarrhoea, respiratory infections and allergies.
Some definitions:
Wasting
Stunting
Underweight
acute malnutrition
chronic malnutrition
both acute and chronic malnutrition
2. The Intervention
In order to interrogate and unpack the role of culture and traditional practices in the demand for and
uptake of mother and child services, RMCH supported FAMSA and CHoiCe Trust in the facilitation of
community consultations with relevant stakeholders from July to November 2014. Four consultations
took place in each of Waterberg and Capricorn Districts in Limpopo Province, engaging groups of (i)
men; (ii) women; (iii) health practitioners from public health; and (iv) traditional health practitioners
(THP). Ten stakeholders from within each group came together for a multi-stakeholder consultation in
Waterberg to further interrogate the findings of the individual consultations and identify an Action Plan
and way forward.
The consultations adopted a dialogue methodology based on the Partnership Defined Quality (PDQ)
model4 to explore different perspectives on harmful cultural practices with regards to maternal and child
health. The purpose of this methodology was to create a space of open sharing in which participants
could prioritise the key challenges they faced and how they could address the root causes of these
issues. The outcomes of these consultations was (1) findings on harmful cultural practices which impact
on maternal and child health; and (2) recommendations on how to address the issue, incorporating
activities in a Work Plan developed by the participants following the consultations.
3. Findings
3.1 Potentially Harmful Feeding Practices
The community members illustrated significant lack of knowledge about most effective feeding practices
for young children. None of the participants properly understood exclusive breastfeeding, none had
exclusive breastfed themselves, and none knew of any other person who had exclusively breastfed.
The common assumption was that breastmilk should be supplemented with solids that are administered
in a liquid form for 3 months after birth, some starting as early as the first few days of life. Knowledge
of the nutritional value of breastmilk itself was very poor. In addition, there was absence of knowledge
of measurements of items such as formula, which resulted in insufficient amounts of formula being
mixed with water, as well as poor hygiene practices being used in the preparation of the water and the
bottles themselves. Men in particular lacked both knowledge and experience in feeding children under
12 months.
The nutrition of the mother was an additional aspect that was raised as a concern with regards to the
feeding of the baby. It was clear that poor eating habits and under-nutrition of the mother was an aspect
which made people cautious of breastfeeding as a source of nutrition for the baby, and participants
questioned whether a woman from Somalia and a woman from the Western Cape would produce
breastmilk of the same nutritional value.
Caregivers from DICs and home-based care organisations did not display significantly greater amounts
of knowledge on healthy feeding practices than other community members, and engaged in the same
4
This model was developed by Save the Children (Lovich, R., Rubardt, M., and Powers, M.B., 2005). The
methodology seeks to engage and link the supply side with the demand side through individual and multistakeholder consultations.
potentially harmful practices themselves. Even the health specialists illustrated that while they had
knowledge of best infant feeding practices, their personal experiences were not always consistent with
this.
When explaining some potentially harmful practices that they were using, (such as the feeding of soft
porridge within 2 months of birth), some community members shared that they had been advised on
this by nurses and even marketers of formula products. The health specialists themselves cautioned
that where a health professional specialises in a specific area (such as youth services) they may not
have extensive knowledge on other areas and may not be able to give appropriate advice on maternal
and child health, resorting instead to advice based on their own practices. The product marketers give
information to encourage sales of their product and not to promote the health of the baby.
Grannies and older women play a large role in the determination of feeding practices, and many female
community members shared that they had learned to give their babies certain foods from grannies and
mothers. Some shared that they had learned a different practice from the clinic, but often the
grandmother or mother was responsible for the feeding and was not following this practice; if the young
woman followed what the clinic had instructed instead of what her grandmother had advised this was
then upsetting for her. The grandmothers and mothers promoted the introduction of solids at an early
stage as well as the promotion of cultural practices. Traditional health practitioners also report advising
mothers to feed babies motepe from birth to avoid babies crying due to hunger. Mothers are instructed
not to disclose to health practitioners and to report that they are exclusively breastfeeding instead. Some
cultural norms which were encouraged included using the size of the child’s naval to determine
quantities that the child requires (if a child has a large naval, this means that they need to be fed often
and large quantities, which requires supplementing breastmilk with formula), the expression and
discarding of milk after a funeral to prevent the passing on of evil spirits, and the belief that expressed
milk is ‘dirty’ and must be stored separately from other food items.
Status was another factor that impacted on feeding practices, with infants being fed items such as
yoghurt (commonly referred to as Danone) or chips from an early age as this illustrated the mother’s
financial ability to provide for her children. Some health specialists indicated that they had observed
these practices at the times when mothers brought their children to the clinics for immunisations.
The Road to Health Card was illustrated to have been under-utilised, by community members,
community health workers and health professionals alike. A chart on the RTH Card actually provides
guidance on what solids may be introduced to the child depending on the weight and size of the child;
this is not adequately and consistently used or understood.
A practice which is of great concern is the forced feeding of infants which is carried out through the
blocking of the infants nose and the insertion of food into the mouth of the child when the child gasps
for air. The participants were aware that this was a dangerous practice which could result in trauma for
the child, asphyxia and death.
3.2 Responses to Malnutrition
From the consultations with community members it was clear that in instances where they had noted
potential malnutrition (evidenced through shrinking skin, swollen bellies, and diarrhoea amongst
others), they would most frequently refer to clinics and specialists for support, although they would also
rely on traditional health professionals (THPs), prophets and older family members. THPs were more
likely to be approached on some conditions, such as where fluffy hair is noted (as this is believed to be
due to bewitchment) or where there is a bulging stomach (as herbs from the healers can be used to
treat this).
Scales at clinics were specifically mentioned as attributing to improved nutrition amongst children as
the weight of the child gave the mother an indication of their progress and nurses would discuss nutrition
with the mother if the weight of the child was not sufficient. A concern voiced by the health specialists
was that the community members may place too much emphasis on the weight of the child and not
relate this back to nutrition – this can lead to over-feeding or the assumption that a ‘chubby’ baby is
healthy.
Caregivers at DICs and home-based care organisations were aware of the various signs and symptoms
of malnutrition and would consult clinics and health specialists for the various conditions that they could
identify. They emphasised the importance of community members themselves having knowledge of
how to create a re-hydration mixture for the child, sharing that they had heard of instances where
mothers were expected to have first prepared motswako before taking their child to the clinic and that
they were sent home to first re-hydrate the infant themselves before returning for health services.
However, although children exhibiting signs of being malnourished were taken to a health facility by
caregivers (mother), caregivers could not easily identify the onset of malnutrition, and thus only
consulted a health facility when the child’s condition had deteriorated considerably. If a child loses
appetite, has diarrhoea and/or vomiting, as well as loses weight, home remedies and traditional
medicines are first used. It is only in the event that these do not have the desired effect and the child’s
condition worsens (wasted), is the child taken to a health facility.
The attitudes of health professionals and distances to clinics were discussed by community members
as deterrents to the uptake of services. Fear of judgment and dismissal by nurses made community
members reluctant to take their children for nutritional support.
4. Recommendations
The following recommendations were extracted from the findings as well as from the way forward
identified by the participants in the consultants who developed an Action Plan as part of the process.
a. Increasing knowledge of nutrition – It was clear that there was lack of knowledge of the
nutritional needs of infants and mothers. Community members in joint consultations requested
health talks and campaigns to address this. Specific areas included:
(i)
Potentially harmful feeding practices are perpetuated due to lack of information amongst
the feeders of the children. While young women may have knowledge of the most
appropriate practices as recommended by clinics, they are subjected to the opinions of the
elder women in their families. Information to promote the health of the mother and the child
and outline the potential harm from these practices must reach beyond the young mother
at the clinic and target older women who provide the support and even guardianship of the
infants.
(ii)
While there is some knowledge on the extreme signs of malnutrition, there is less known
about the more moderate signs of some of the variations of malnutrition which are difficult
to detect. More information on this can be shared to prevent children from existing with
chronic malnutrition that leads to wasting and complications in maintaining wellness.
(iii)
The Road to Health Card is not understood by mothers and knowledge of this (most
particularly with regards to the feeding chart) could be enhanced. Health professionals
themselves identified a need to continuously update their knowledge on developments in
nutrition and child feeding practices as these are ever evolving and guidelines updated.
(iv)
Drop-In Centres and Home-Based Care organisations should be further capacitated to
provide additional support on nutrition, most specifically as DICs are responsible for
providing food to young children on a daily basis.
b. Engagement with Traditional Health Practitioners and Prophets – Some traditional and
religious feeding practices or treatments place the mother and infant at risk. Discussions
between health practitioners and traditional health practitioners should aim to enhance the
understanding of the cultural practices taking place and to put safety mechanisms in place to
improve the health of mothers and children
c.
Promotion of Food gardens – As part of the way forward identified by community members,
the aspects of poverty which result in single-sourced and non-nutritious foods (for both the
mother and the child) was specified as a root cause of malnutrition. The promotion of food
gardens, with a corresponding understanding of principles of nutritional planting, will ensure
that each household is able to access at least basic foods on a daily basis.
d. Professionalism of Clinic Services – In order to promote early presentation at clinics in
instances of potential malnutrition, guardians require an open and receptive space. If health
professionals castigate them (particularly in front of others), they are less willing to bring their
infants in for support which prevents the early detection of malnutrition and access to treatment.
This project was implemented by CHoiCe Trust in partnership with FAMSA, Limpopo and with the
support of the Reducing Maternal and Child Mortality through Strengthening Primary Health Care in
South Africa (RMCH) Programme. The RMCH programme is implemented by GRM Futures Group in
partnership with Health Systems Trust, Save the Children South Africa and Social Development Direct,
with funding from the UK Government. www.rmchsa.org
ANNEXURE
Some different foods fed to infants
Chips and sweets
–
from 9 months onwards can be given to infants as a treat
DANONE and “mayo”
–
a yoghurt fed to infants from 6 months onwards
Disha / ntsho / letsele
–
a mixture of herbs and water and sugar
Goats milk
–
a substitute for cow’s milk
Gripe water
–
a mixture from the pharmacies for treating infant illness (colic)
Mothufi
–
raw eggs which can be given to the infant between 4 – 6 months
Pap and sauce
–
sauce made from packet soup and fed to infants under the age of 6
months
Rooibos tea
–
even reported to have been recommended by nurses for diarrhoea as
a substitute for formula
Soft foods
–
such as potatoes or biscuits, softened and fed to the infant, anywhere
from 3 months onwards
Soft porridge
–
a watery mixture of pap which can be given to the infant directly after
birth (brown and white varieties)
Motepe
–
a watery mixture of pap which can be given to the infant directly after
birth (brown and white varieties)
Sorghum
–
A starch to fill the infant which can be given from 6 months onwards