Liezel Engelbrecht is a registered dietitian currently busy with a Masters of Public Health Nutrition at Stellenbosch University.

This week marks World Breastfeeding Week 2021. The Nourished Child project focuses on how interconnecting systems shape the diets of women and young children. In line with this year’s theme of Protect Breastfeeding: A Shared Responsibility, two women in one of the Nourished Child study sites share their experiences of breastfeeding in their community, and talk about the systems and environments that influenced their choices.

Esther Nqakala is 55 years old. She was born in Zweletemba, a low resourced neighbourhood near Worcester, the largest town in the Western Cape interior region, about 120km from Cape Town. Apart from six years spent in Johannesburg in the early 1990s, Zweletemba is the place she’s called home for all her life. 

Esther is also a keen breastfeeding advocate, as this is something she believes can help the children in her community reach their full potential and get their “minds prepared for school”. 

But Esther wasn’t always this familiar with breastfeeding and all its benefits. 

When Esther gave birth to her three daughters in 1985, 1990 and 1995 respectively, no one told her about exclusive breastfeeding, the practice of only offering your baby breastmilk and no other food and drinks. Though South Africa’s breastfeeding policy between 1980 and 1999 did include recommendations to exclusively breastfeed for four to six months, Esther was not aware of this. 

“I started giving foods like baby cereal from one month already. Nobody told me about exclusive breastfeeding.” Though Esther continued to breastfeed all her children until the age of three, she practised mixed feeding from an early age.

South Africa has since aligned itself with Unicef and the World Health Organization recommendations of exclusive breastfeeding for the first six months of life, and the continuation of breastfeeding for two years and beyond. The benefits of breastfeeding are now more well-researched and well-known, with evidence for optimal breastfeeding practices reducing the risk of infant mortality through a variety of mechanisms, including offering protection against diarrhoea and respiratory infections, as well as offering long-term benefits for both the child and the mother. 

“If I knew then, I would have done better,” says Esther.

More than 30 years later, there are however many other women who are still doing exactly what Esther did in the 1980s and 1990s, which is to introduce solid foods and other liquids before the age of six months. Though exclusive breastfeeding rates in South Africa for the first month of life have increased from 11.3% in 2011 to 44% in 2016, only about 32% of women continue to exclusively breastfeed at five months. In a country where diarrhoea and respiratory infections are two of the leading causes of death among children under five, in addition to high levels of food insecurity, this may come as a surprise. 

So why aren’t more women, especially those whose children are more vulnerable to malnutrition due to unemployment (making formula milk financially out of reach) and diarrhoea due to poor water and hygiene facilities (thus making it more difficult to wash and sterilise bottles) not adhering to these recommendations?

According to Esther, it was only when she was recruited and trained as a fieldworker in 2011 to work on a research project related to breastfeeding, that she came to know and trust the benefits of breastfeeding. She has since been involved in many research projects as a fieldworker. So when Esther’s youngest, Ermillia Mutombeme, had her baby girl in February of 2020, it was understandable that Esther would encourage her to breastfeed from the start. 

Ermillia’s experience at Zweletemba hospital also reflected some of the work South Africa has done in promoting breastfeeding. “The nurse at the clinic told me to exclusively breastfeed until six months. She was very supportive and even helped me to hold my child so that she can drink better,” Ermillia recalls. “I plan on breastfeeding at least until my little girl is 24 months,” Ermillia says. 

Ermillia is, however, one of a few that are lucky to have her mother’s support. She says one of the biggest challenges is community support. “Women listen to their mothers. But most grandmothers will say ‘just give the baby food, then they will stop crying’. Then the mothers do that.”

But even with her mother’s support, Ermillia had to constantly remind herself why she chose to breastfeed, as alternative support was lacking.

“Having a baby is hard. For me, the first four months were really difficult. I had issues with the baby’s daddy and I didn’t sleep. I was depressed. So, it’s easy to resort to being negligent and drink alcohol. You start thinking if you really want to be a full-time mom… I also had a lot of pressure from friends. I don’t even blame other mothers if they don’t breastfeed — it’s difficult if you don’t have the motivation or support. But for me, I knew that it was the best for my baby and I wanted to give the best that I can.” 

Esther and Ermillia’s stories echo what many researchers on this topic have found, and this year’s World Breastfeeding Week theme calls for: breastfeeding needs to be seen as a shared responsibility. 

“There are many reasons people give you not to breastfeed. For example, they will say that it is too difficult to breastfeed if you work, or others will say you should rather give your baby food so that they don’t cry in the evening. People listen too much to each other’s advice. I think the fathers should also be more involved,” says Esther, highlighting that it is not as simple as an individual choice, but needs to be supported, protected and promoted by communities, health systems and workplaces.  

With Covid-19 seeing an increase in the country’s food insecurity and unemployment, it makes even more sense not to rely on expensive formula milk and to support breastfeeding. 

“At least buying formula milk is one less thing I have to worry about,” says Ermillia who, despite having completed a national diploma in human resources management recently, is currently unemployed and living in a room in her mother’s backyard. Since 2016 she has also joined her mother on research projects as a fieldworker.

If they could draw up a wish list of actions they think will improve breastfeeding in their community, Esther and Ermillia both believe that it starts with educating the whole of the community — the grandparents, the men and the younger boys and girls — about the benefits of breastfeeding and the risks of not breastfeeding. 

Practical tips for action Esther and Ermillia believe would work to increase breastfeeding in the Zweletemba community:

• Create more capacity at clinics so that there is enough time for maternal and child health information sessions. “The clinics are very busy. Even though the nurses want to give more information, there isn’t always time with everything else they need to do,” Esther reflects.
• Bring grandmothers along to clinic visits when the young mothers come for check-ups or bring their children for immunisations so that they too can hear the information sessions where the benefits of breastfeeding are shared. “Because in our community, you do as your mother tells you to do,” says Ermillia.
• Have workshops for men and young boys about the responsibility of having a child and the importance of healthy living for the mother while she is pregnant and for the baby to be breastfed exclusively for six months because it is superior to formula milk. “Men can have a big influence in this way,” Esther suggests.
• Emphasise to young men and women some of the personal sacrifices one needs to make when you have a child. “Parents and mothers need to know that life can’t just continue like it was before the baby. You need to be okay if the baby cries without giving her food to stay quiet, and you can’t always go out when you want to,” say Ermillia. DM/MC

Liezel Engelbrecht is a registered dietitian currently busy with a Masters of Public Health Nutrition at Stellenbosch University.

The Nourished Child project is a joint research study by researchers from the University of Cape Town, Stellenbosch University and City University, London. It is currently investigating what a systems approach to improving the quality of diets among children under five and women of childbearing age would look like in an urban setting to address under- and overnutrition. 

As one of its aims, the study seeks to increase the understanding of how interconnections between systems can influence nutrition.