BackgroundExclusive breastfeeding (EBF) for the first six months of life is the most important determinant of child health and development, and is the recommended feeding practice for all mothers. However, EBF rates remain low in South Africa. This study aimed to prospectively explore enablers or barriers to success among mothers who planned to exclusively breastfeed their infants for the first six months of life, in KwaZulu-Natal, South Africa.MethodsA qualitative, longitudinal cohort design was adopted. Women were recruited during pregnancy from the catchment area of two hospitals (one urban and one rural) and purposively sampled to include working women, teenagers, and HIV positive pregnant women. This analysis relates to 22 women, from 30 women recruited, who planned antenatally to exclusively breastfeed for six months. These mothers were interviewed monthly for six months postpartum. Infant feeding practices were explored at each visit using in-depth interviews and 24 h feeding recall assessment. Framework analysis was conducted for qualitative data, and quantitative data analyzed using descriptive statistics.ResultsA total of 125 interviews were conducted between November 2015 and October 2016. Among 22 mothers who planned to exclusively breastfeed for six months, 17 reported adding other food or fluids before six months, and five reported exclusively breastfeeding successfully for the first six months. Key themes showed that all mothers relied strongly on health workers’ infant feeding advice and support. All mothers experienced challenges regardless of whether they succeeded in EBF, including inappropriate advice from health workers, maternal-baby issues, pressure from family members and returning to school and work. However, those who were successful at EBF for six months reported that high breastfeeding self-efficacy, HIV status and cultural meaning attached to breastfeeding were underlying factors for success.ConclusionHealth workers are key players in providing infant feeding information and support, yet some health workers give mothers infant feeding advice that is not supportive of EBF. Strategies to improve health workers’ competency in infant feeding counselling are needed to better prepare pregnant women to overcome common breastfeeding challenges and build mothers’ confidence and self-efficacy, thus increasing EBF rates.Electronic supplementary materialThe online version of this article (10.1186/s13006-017-0135-8) contains supplementary material, which is available to authorized users.

Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa.HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.

BackgroundCommunity health workers (CHWs) provide maternal and child health services to communities in many low and middle-income countries, including South Africa (SA). CHWs can improve access to important health interventions for isolated and vulnerable communities. In this study we explored the performance of CHWs providing maternal and child health services at household level and the quality of the CHW-mother interaction.MethodsA qualitative study design was employed using observations and in-depth interviews to explore the content of household interactions, and experiences and perceptions of mothers and CHWs. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, SA. CHW household visits to mothers were observed and field notes taken, followed by in-depth interviews with mothers and CHWs. Observations and interviews were audio-recorded. We performed thematic analysis on transcribed discussions, and content analysis on observational data.ResultsCHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits.ConclusionsKey building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.

Introduction: Key stakeholders’ involvement is crucial to the sustainability of quality point-of-care (POC) diagnostics services in low-and-middle income countries. The aim of this study was to explore key stakeholder perceptions on the implementation of POC diagnostics in rural primary healthcare (PHC) clinics in South Africa. Method: We conducted a qualitative study encompassing in-depth interviews with multiple key stakeholders of POC diagnostic services for rural and resource-limited PHC clinics. Interviews were digitally recorded and transcribed verbatim prior to thematic content analysis. Thematic content analysis was conducted using themes guided by the World Health Organisation (WHO) quality-ASSURED (Affordable, Sensitive, Specific, User friendly, Rapid and to enable treatment at first visit and Robust, Equipment free and Delivered to those who need it) criteria for POC diagnostic services in resource-limited settings. Results: 11 key stakeholders participated in the study. All stakeholders perceived the main advantage of POC diagnostics as enabling access to healthcare for rural patients. Stakeholders perceived the current POC diagnostic services to have an ability to meet patients’ needs, but recommended further improvement of the following areas: research on cost-effectiveness; improved quality management systems; development of affordable POC diagnostic and clinic-based monitoring and evaluation. Conclusions: Key stakeholders of POC diagnostics in rural PHC clinics in South Africa highlighted the need to assess affordability and ensure quality assurance of current services before adopting new POC diagnostics and scaling up current POC diagnostics.

BackgroundSouth African infant and child mortality remains high, with many deaths occurring outside the formal health services. Delayed health care seeking represents a large proportion of these deaths.AimTo generate knowledge about the role of, and influences on, caregivers with regard to decision-making about when and where to seek care for sick children.SettingTwo communities in KwaZulu-Natal.MethodsA qualitative, exploratory design employing participatory research techniques was used to undertake focus group discussions with community members.ResultsHealth care seeking for a sick child was described as a complex process influenced by multiple carers using multiple providers. Decision-making about seeking health care for a sick child was not an individual effort, but was shared with others in the household and guided by how the symptoms were perceived, either a Western illness or African illness. A sick child could either be treated at home or be taken to a variety of places including clinics, private doctors, traditional healers, faith healers and hospitals. Traditional healers were associated with the treatment of illnesses perceived to be traditional. Few participants said that they would take their child back to the original health provider if the child remained ill, but would move from one provider to another until the child’s health improved.ConclusionThe formal health system needs to ensure that sick children are identified and managed appropriately to reduce child deaths. Knowledge and understanding of health care seeking behaviour for sick children by carers is an important aspect. Interventions need to be designed with these contextual issues in mind.