The Practices, Perceptions, and Beliefs of Traditional Birth Attendants Regarding Early Breastfeeding Initiation in Zimbabwe: A Qualitative Study

Neonatal mortality rate, defined as the total number of deaths within the first 28 days of life per 1,000 live births, has been on a growing trend in Zimbabwe, especially in the first week of neonatal life (1). If mortality occurs on the first seven days of birth, it is referred to as early neonatal mortality (2). The annual neonatal mortality rate has been reported to be 2 million cases, 50% of which occur in the first week of birth (3).

According to the growing scientific evidence, early breastfeeding initiation (EBFI) has a potential protective effect on the reduction of neonatal deaths by 22% (4). The EBFI refers to the actual giving of first breast milk to the newborn within the first hour following birth, and should not be mistaken by mere putting the neonate to the breast, which is not enough by itself (5). The advocacy of EBFI is one of the easiest and cost-effective practices in reducing neonatal deaths caused by sepsis, hypothermia, dehydration, and starvation.

Previous studies have confirmed the beneficial aspects of colostrum, which is the first breast milk to be produced within the first three days of giving birth. The protective effect of colostrum can be observed in a study reporting the EBFI rate of 75% in Sri Lanka, which has a neonatal mortality rate of 11/1000 live births (2). Moreover, colostrum has immunologic effects against gram-negative bacteria that are responsible for early neonatal infections (6).

The EBFI is determined by values, norms, beliefs, and sociocultural factors (7). There are different demographic factors affecting EBFI. These factors include age, parity, wellness of the mother and neonate at the time of birth, nature of the delivery, maternal experience and knowledge, as well as social support systems (8, 9). Although the Zimbabweans are a breastfeeding nation, the national EBFI rate is at an unacceptable level (58%) with Chipinge district having a rate of 52% instead of the standard rate of 90% (1). Regarding this, the researcher sought to explore the practices and beliefs of Chipinge rural community regarding EBFI.

Chipinge district is situated in the eastern corner of Zimbabwe, 443 km southeast of Harare. It shares boundaries with Chimanimani Changazi river (North), Mozambique (East), and Chiredzi (South), as well as Bikita, Save, and Buhera (West). The district comprises of 30 rural and 8 urban sections under the authority of 8 chiefs who are in charge of 335 headmen. It is home to 337,294 people, 26,319 and 310,975 of whom reside in urban and rural Chipinge districts, respectively (Health informatics office, Chipinge hospital).

Ndau and Shangani people are the dominant ethnic groups in Chipinge district. These two groups are among the few remaining groups in Zimbabwe who are strongly tied to their cultural beliefs and values. Breastfeeding, especially in immediate postpartum, is strongly valued as it serves as an indicator of mother’s innocence and newborn’s legitimacy.

To the best of our knowledge, no study has explored the practices and beliefs of Chipinge rural community regarding EBFI. With this background in mind, this study was conducted to investigate the practices, perceptions, and beliefs of Chipinge rural community regarding EBFI with aim of addressing gaps and improving
EBFI rate from the current 52% to 90% as recommended by the World Health Organisation.

Materials and Methods

This descriptive qualitative study was conducted on renowned traditional birth attendants (TBA) in Chipinge rural community, Zimbabwe. The study population was selected through purposive sampling technique to find the renowned TBAs. Ethical approval was sought from the Ethics Review Board of Zimbabwe University, Medical Research Council, and Provincial Medical Director of Manicaland province. For the purpose of unearthing sensitive issues regarding EBFI in Chipinge rural community, the one-on-one interview was preferred to a focussed group discussion.

The data were collected using an unstructured in-depth interview to explore the practices, perceptions, and beliefs on EBFI. The interviewing process lasted for one hour and a half. The data were analyzed using thematic analysis. To this aim, the data were presented in thematic categories using the deductive approach, and coded into subthemes that were then merged into themes. The emerged themes included EBFI preparation, EBFI, significance of colostrum, and determinants of EBFI.

The trustworthiness of the study was confirmed through credibility, transferability, dependability, and confirmability. These principals are equal with external and internal validity, reliability, and consistency in quantitative research, respectively (10). Credibility refers to truthfulness of the data, which was enhanced by audiotaping the interview so that no data were missed. Transferability denotes the generalizability of the findings to other situations, which was ensured by thick description of the situation. Dependability addresses the issue of reliability, which was enhanced by the use of overlapping methods. In this context, a focused group discussion was conducted with local village health workers one month prior to the study.

In order to have a deep understanding of EBFI among the Chipinge community, an in-depth interview was conducted with a sage who was purposively selected from the community through the guidance of the manager of the Maternity Ward of the Mt Selinda Hospital. A sage is a mature venerable person, who possesses wisdom, judgement, and experience in a given society regarding a particular subject (11). In the context of this study, the sage was an experienced TBA whose expertise was revered around Mt Selinda area in matters regarding childbirth and EBFI.

The purpose of using a sage was to unearth the sensitive issues regarding EBFI that cannot be discussed in groups among the Shangani and Ndau tribes. One month prior to the in-depth interview with the sage, a visit was made for familiarisation and sensitisation purposes on the topic of interest. After obtaining an informed consent, the researcher proceeded to do the in-depth interview. A guide was used to facilitate the interview process. The interview included the following questions and themes:

• How women are prepared for EBFI?
• How EBFI is perceived?
• Cultural beliefs associated with EBFI
• Challenges associated with EBFI

The interview was audiotaped and lasted for an hour. During the interviewing process, probing was done for eliciting rich data regarding the issue. Debriefing was performed to reach
an agreement for the first-hand impression. Additionally, summarisation was employed during the interviewing process for confirming the information received from the participant.

The audio was first transcribed manually verbatim in the local original language (i.e., Ndau), and then into English with the help of a professional linguist. During the transcription process, member checking was performed where necessary for confirmability. Thematic analysis was used to analyze the data. Subsequently, the transcripts were coded and developed into subthemes and major themes as suggested by qualitative authors (12).

Results

An in-depth interview was conducted in May, 2017 with a sage TBA. The findings were presented in thematic categories using the deductive approach.

Demographic Characteristics

The sage TBA was a 75-year-old widow living in the rural village of Chipinge. The sage had been a TBA for the past 45 years and had vast experiences regarding cultural practices and beliefs of Ndau and Shangani tribes concerning EBFI. She had not been exposed to formal learning and followed the native religion.

Practices regarding early breastfeeding initiation

To elicit information on practices regarding EBFI, the sage was asked on the way they prepare pregnant women for EBFI. The concept of EBFI is popular in the native community as in the hospital setting. Preparations of EBFI in Chipinge start during the antenatal period and continues throughout the intra- and post-partum periods. Preparations included ritual cleansing and removing spells on any immoral behaviour committed by either the pregnant woman herself or her biological family members.

During the intrapartum period, the woman was ensured to have comfort, followed by practical support on breastfeeding in the immediate postpartum period. Soon after delivery, the neonate was stimulated with water to ascertain wellness and readiness to feed and then warmed in towels while no early skin-to-skin contact was allowed.

The mother was required to have a bath immediately after delivery to cleanse herself before breastfeeding the newborn (Table 1). The questions and answers are as follows:

Moderator: "Our first question is how you prepare a pregnant woman for EBFI in your community?"

TBA: "We check for the wellness of the mother. When she is in labour, we ensure about her comfort so that she delivers well without harming the baby. When the baby is delivered, we stimulate the him/her with water to ascertain his/her wellness, and then the baby is wrapped in warm towels. This is done after the cord has been cut with a clean razor blade. The mother is allowed for a warm bath soon after delivery as she is not allowed to breastfeed before bathing. After the bath, I will give the woman her baby to breastfeed. During the breastfeeding period, I will support the woman and observe if the baby is suckling well."

Moderator: "How long does it take for the mother to produce the first breast milk?"

TBA: "The milk does not come out immediately. It might take a whole day; then, it starts to flow. First, it is in form of a red yellowish watery substance like blood, and then, the real milk will come out. Thereafter, it becomes so clear that it will be good enough to be given to the baby."

Moderator:  "How is the baby fed before the flowing of the first breast milk?"

TBA: "Nothing will be given to the baby, except the stimulatory thin porridge for cleansing the gut, and we continue to encourage the mother to breastfeed and bathe three times a day for cleansing the baby."

Perceptions on early breastfeeding initiation and colostrum

The sage acknowledged the need for the women to commence breastfeeding so that the newborn gets some nutrients. The sage was asked on how the community perceived EBFI and the value of colostrum. Breast milk was reported not to be readily available at birth; however, the sage stated that when the breast milk starts to flow, it begins with red yellowish milk like blood, followed by clear breast milk, which is good enough to be given to the neonate (Table 2). Regarding the rating of the breast milk, colostrum was rated poorly, and the clear breast milk had the first rank. The questions and responses are given below:

Moderator: "If you were to rate the milk according to the importance, how would you do it?"

TBA: "I judge it accordingly. The first breast milk is red yellowish and the second is creamy yellow while the last one is pure white and this is the real milk, good enough to feed the baby. The third one will be the most important followed by the second, and then the first will be the last."

According to the sage’s talk, every breast is capable of producing milk, and failure in milk production is due to the spells or curses to which the mother is exposed. From this viewpoint, the nurses should consider the need to involve the community in breastfeeding issues due to having sociocultural ties.

TBA: "Yes, our daughters-in-law should not just go straight to the hospital to deliver without being cleansed of their spells. At the hospital, the nurses are just good at receiving the baby, but are not able to address other issues tied tothe woman [21:07]. The nurse just receives the baby, but she is not able to cleanse him/her."

Beliefs regarding early breastfeeding initiation

To elicit information regarding beliefs about EBFI, the sage highlighted that the success of EBFI is dependent on the innocence of the mother and her family members.

The lack of milk supply at birth was not acceptable, and it was an indicator of maternal witchcraft, theft, or promiscuity at the time of pregnancy; therefore, the mother should admit this (Table 3). After admission, the mediator consults the gods. If the sin is not grievous, the milk will start to flow, and the newborn will suckle following the acknowledgement. If the sin is grievous, there might be the need to brew beer to appease the gods. The ideas and questions on the beliefs about early breastfeeding initiation are as follows:

TBA: "The failure of the baby to breastfeed indicates a serious problem, which you might not understand as modern nurses. Then, there will be a need for milk cleansing so that the baby will not refuse the mother’s milk as if the milk has an offensive smell [15:10]. At this point, we consult the gods for the reason behind this [15:34]. The baby will refuse to breastfeed the due to the maternal witchcraft, promiscuity, or theft. I will consult the gods and they will respond. Therefore, I ask the mother if she has done any one of the three things, and she needs to admit or confess to her relatives [15:48-15:58]. I make some consultations through her ancestors so that the spell will be removed. There will be a need to offer symbols and brewing of beer to appease the spell [28:47- 28:55]."

Moderator: "What if there were no spells and the mother cannot produce milk?"

TBA: "I do not agree with that because some women feed on demoniac creatures before and after delivering the baby, and consequently the breasts do not produce milk. In this case, the woman requires a ritual cleansing because there is no breast that cannot produce milk. It has never happened unless the mother has fed on demonic creatures before [25:25-25:34]."

The TBA was asked about the best way to harmonise the EBFI practices between the hospital and community for the benefit of the mother and neonate. She mentioned the need to work together and invest on the benefits offered by either the hospital or community.

Moderator: "So how can we harmonise the practices of the community and hospital so that the women would take benefit?"

TBA: "You need people’s assistance so that delivering the baby after cleansing is made easier. We do not want cases where the baby fails to breastfeed; therefore, you need people to assist you. The officials of hospitals should observe the fact that a mother comes from a community with sociocultural ties so that the woman faces no challenges when she delivers."

Discussion

Practices

In this study, sociocultural dynamics regarding EBFI were determined. In the context of Chipinge rural community, EBFI was not only related to physical and emotional interactions, but also to the totality of the person, including one’s sociocultural ties. While Chipinge rural community acknowledged the need to breastfeed the newborns, the timing factor was not valued as the mother was needed to bathe before initiating breastfeeding. This practice deprived the neonate of colostrum produced within the first hour of birth. In a similar study conducted in Turkey, the women did not breastfeed the newborn immediately after birth. This action was reported to negatively affect the neonatal health (13).  

In the context of Chipinge rural community, when the neonate was born, wellness was assessed by stimulating him/her with water, and then the newborn was wrapped in warm towels. Furthermore, although the early skin-to-skin contact with the newborn is one of the facilitating factors for EBFI which should be fostered, it was not allowed in this community (5).

TBA stated "The mother is required to take a warm bath before breastfeeding the baby as she is not allowed to breastfeed before bathing." However, the bathing of the mother removes the liquor odour, which is a facilitator for the newborn instinct to find the breast. The neonate is born with a strong sense of smell and instinctive capabilities for breast crawling and finding (13).

The breast crawl is the ability of the newborn to find the breast for suckling when placed on the mother’s abdomen at birth (14). The unwashed breast with the strong odour of amniotic fluid facilitates the breast crawl more than the washed breast. In a randomised controlled trial, the findings revealed that the newborns spontaneously reached the breast treated with amniotic fluid faster (within 45 min of birth) than with washed breasts (15).

Perceptions and beliefs

While the inadequate breast milk supply at the time of birth is a common challenge experienced by most of the mothers post-delivery, Chipinge rural community strongly links this event to witchcraft, promiscuity, theft, spells, and curses of the maternal family members. “If the mother is a witch or thief, or has indulged in promiscuity, the baby will refuse to breastfeed.” This notion has not been reported in the literature even those studies that have investigated the beliefs regarding breastfeeding.

In a study conducted on Somali mothers for investigating the infant feeding beliefs and practices, the issue of inadequate milk supply was raised. However, this event was not linked to any cultural ties (7). In the present study, the use of thin porridge was not regarded as a prelacteal feeding, but viewed as treatment for gut cleansing in preparation for the breast milk. Although colostrum was not thrown away, it was not favoured for the neonates. Accordingly, the Somali mothers considered colostrum as a dirty substance that should not be given to the newborns (7). According to Chipinge rural community beliefs, EBFI not only fulfills the nutritional and immunologic needs of the newborn, but also addresses the social integrity of the mother and the legitimacy of the neonate.

Many cultural ties and taboos are linked to the mothers and newborns during the immediate postpartum period, which exert detrimental effects on the maternal and neonatal health (16). In Chipinge rural community, maternal failure in breastfeeding was strongly believed to be an evil indicator. This is in line with the results of other studies reporting that the mother’s inability to breastfeed is regarded as an indicator of evil (5). "…. in women who have fed on demoniac creatures before and after delivering the baby, the breasts do not produce milk. In this case, the woman requires a ritual cleansing because there is no breast that cannot produce milk. This never happens unless the mother has fed on demonic creatures previously [25:25-25:34]."

This belief fails to address the hormonal or physical ailments that might interfere with lactation at the time of giving birth. Moreover,
it does not consider determinants, such as
age, parity, mode of delivery, pre-existing comorbidities, and neonatal conditions at birth, that may interfere with EBFI.

The researchers recommended that:

• The breastfeeding policy should be socioculturally sensitive in addressing the maternal and neonatal needs regarding EBFI.
• Health personnel should work in collaboration with the community in supporting EBFI.
• Structured health information and skills regarding EBFI should be taught to the pregnant mothers, family members, and community to improve the initiation rates.

Since this study was conducted among the ethnic groups of Chipinge rural community, the findings might not be generalized to other settings with different beliefs and contexts.

The researchers used in-depth interviews for data collection to unearth sensitive issues regarding EBFI; however, there was the need to conduct the study among several ethnic groups in the country in order to offer appropriate EBFI support to mothers and neonates from various settings. 

Conclusion

Although EBFI is acknowledged in Chipinge rural community, there is a significant gap on the way this issue is practiced, perceived, and believed, which warrants the consideration of policy makers regarding its benefits for the newborns. The EBFI success is regarded as an indicator of maternal sociocultural integrity that also portrays the legitimacy of the neonate
in that particular family. There is a need
to harmonize the hospital and community regarding the practices related to EBFI. The EBFI preparation during pregnancy should go beyond the pregnant mother to include the influential family and community members.

Acknowledgements

Our sincere acknowledgement goes to the following: University of Zimbabwe Ethics Review Committee and Medical Research Council of Zimbabwe for approving this study to be conducted. Thank you Chipinge community through your District Medical Officer for agreeing to take part in this study.

Conflicts of interest

The authors declare no conflicts of interest.