Unveiling Maternal Narratives and Experiences in Lesotho: Insights into Breastfeeding Choices, Practices, And Hurdles

This research investigated maternal and infant care in Lesotho, with an emphasis on exclusive breastfeeding practices during the first year of life. A quantitative, descriptive survey included 97 mothers attending healthcare facilities. The findings highlighted a prevalent preference for exclusive breastfeeding in the initial three months, which decreases during the following 3 months. Yet around 7% introduced complementary foods or fluids early on and many did not breastfeed exclusively until the 6-month recommended period. The majority began breastfeeding within the recommended one-hour post-delivery window. Distinct decision-making dynamics emerged: nearly half of the mothers made autonomous feeding decisions, around a quarter collaborated with the child’s father or partner, and 11.3% involved extended family in these choices. Colostrum's recognized value as a new-born’s first nutrient source aligned with global health recommendations. However, the early introduction of other foods indicates a need to explore mothers’ beliefs and knowledge about feeding practices further. Common breastfeeding challenges encompassed issues like sore nipples and perceived milk insufficiency, underlining the importance of educational support. Healthcare professionals, especially nurses, played a key role in offering guidance and support on breastfeeding. The frequent practice of immediate skin-to-skin contact post-birth emphasized the trend towards promoting early bonding and breastfeeding initiation. Furthermore, the community’s positive reception to public breastfeeding signalled societal acceptance. In conclusion, this study illuminates the nuances of breastfeeding practices and decision-making in Lesotho, providing insights for interventions and policies to enhance maternal and child health in the country


Introduction
In the earliest moments of life, breastfeeding emerges as a wellspring of essential nutrients, providing infants with the sustenance necessary to fuel their growth and development (WHO, 2023;Nangolo, et al. 2023;Mphasha et al., 2023;Matias et al., 2023;Giang et al., 2023Horta et al., 2022;Carsley, et al., 2019;Bider-Canfield, 2017).Yet its significance extends far beyond the realm of nutrition; it stands as a natural shield, fortifying new-borns against a multitude of infections and illnesses.By bolstering the child's immune system and enhancing overall resilience, breastfeeding acts as a powerful safeguard for their health (Horta et al., 2022;UNICEF, 2018;Grote et al., 2018).Moreover, breastfeeding serves as a conduit for the profound emotional bond that blossoms between mothers and their new-borns (UNICEF, 2018).This nurturing connection forms the bedrock of a supportive and caring environment, setting the stage for a child's physical and emotional well-being (Davis and Sclafani, 2022;Branjerdporn, et al., 2019).
The global consensus on the matter is unequivocal, encapsulated in the following statement: "Breastfeeding, initiated within the first hour of birth, provided exclusively for six months, and continued up to two years or beyond with the provision of safe and appropriate complementary foods, is one of the most powerful practices for promoting child survival and wellbeing" (UNICEF, 2018, p. 1).This assertion underscores the far-reaching impact of breastfeeding on the health and prospects of children worldwide, emphasizing not only the importance of initiating breastfeeding promptly but also sustaining it throughout infancy and beyond.Guided by the recommendations of the World Health Organization (WHO, 2023), the practice of exclusive breastfeeding during the first six months of an infant's life, followed by continued breastfeeding alongside complementary foods for up to two years or more, has garnered global endorsement as a pivotal strategy.Its overarching aim is to reduce child mortality and lay the foundation for improved long-term health outcomes (Nangolo, et al., 2023;Mphasha et al., 2023;Giang et al., 2023.In the heart of Southern Africa lies Lesotho, a small, landlocked nation grappling with a myriad of challenges in maternal and child health (Ferreira, 2023;Gebrekidan, et al., 2020;Gianni et al., 2019).This country is characterized by rugged mountains and remote villages, creating a complex terrain for delivering essential healthcare services to its predominantly rural population, often residing in hard-to-reach areas.Within this intricate landscape, the practice of breastfeeding emerges as a vital lifeline, deeply interwoven with the cultural fabric of Basotho society and passed down through generations.However, even within this rich cultural context, variations in breastfeeding practices are discernible.These variations stem from a multitude of factors, including socio-economic circumstances, maternal education levels, and access to healthcare services.Moreover, deeply entrenched cultural myths and misconceptions, coupled with limited access to essential maternal health resources and support networks, frequently deter mothers from exclusively breastfeeding their infants (Ferreira, 2023).
The repercussions of these challenges are profound and enduring.They manifest as developmental disparities in children's lives and heightened health risks for mothers (Ferreira, 2023).Left unaddressed, these nutritional deficits can have a cascading effect, casting a shadow not only on individual lives but also on the nation's demographic trajectory and future prospects.Therefore, the narrative surrounding breastfeeding in Lesotho extends beyond individual choice, evolving into a symbol of broader societal, cultural, and health-related dialogues (Ferreira, 2023).To address the unique health challenges faced by Lesotho and similar nations in the region, a nuanced understanding of breastfeeding practices and the intricate decision-making processes that shape them is of paramount importance.This research endeavors to unravel the complexity dynamics of maternal and infant care in Lesotho, placing exclusive breastfeeding practices at the forefront.Through our exploration of when and how breastfeeding occurs, the factors that influence it, and the roles of key stakeholders, we aim to provide valuable insights that can inform targeted interventions and policies to improve the health and well-being of mothers and children in Lesotho.

Methodology
The methodology employed in this study was designed to investigate and understand the infant feeding practices among women who attend postnatal care at Mother and Child Health Clinics in Lesotho.

Study design
The study adopted a descriptive design.The survey aimed to capture their reported perceptions, opinions, and experiences related to infant feeding practices, with a particular focus on breastfeeding.Women eligible for participation had to meet several criteria: they needed to be older than 16 years of age, currently breastfeeding, and residing within a 20 km radius of the study site.

Study sample
A convenience sample of 97 participants (mother and baby pairs) was selected for this study, with a specific focus on mothers attending the selected Mother and Child Health (MCH) clinics for postnatal care.This sample specifically sheds light on the infant feeding practices of mothers who are already engaged in postnatal healthcare services, offering critical insights for understanding and improving health outcomes within the existing healthcare infrastructure.Moreover, the inclusion of clinics from different ecological zones further enhances the study's value by providing a diverse representation of maternal and child health across various geographic and socio-economic contexts in Lesotho.The data presented here offers insights into the distribution of healthcare facilities across various sites.Among these sites, Ntsekhe Hospital stands out prominently, accounting for approximately 20.62% of the total healthcare facilities surveyed.Following closely is Seboche Hospital, making a substantial contribution of approximately 18.56%, which further emphasizes the robust healthcare infrastructure in that particular area.Motebang Hospital, Quthing Hospital, and Paray Hospital each make comparable contributions, each representing around 15.46%.Shifting our focus to education-related findings, it's worth noting that a small yet noteworthy percentage-specifically, 4.1% of participants-indicated that they had never attended school or had only completed the first grade of formal education.This segment of the population represents individuals with limited or no formal educational background.In contrast, a substantial majority, accounting for approximately 63.9% of respondents, reported that their highest educational attainment ranged from completing grades 1 to 11.This indicates that a significant portion of the surveyed population had received a foundational level of formal education, spanning from primary to lower secondary levels.Furthermore, approximately 32.0% of participants had achieved a higher level of education by successfully passing Grade 12.These findings underscore the considerable diversity in educational backgrounds among the study participants, encompassing individuals with minimal or no formal education as well as those who have completed secondary schooling.This educational diversity assumes significance in interpreting various aspects of the study, including participants' responses to inquiries related to infant feeding practices and other socioeconomic factors influenced by their educational attainment.Understanding this spectrum of educational backgrounds allows for a more nuanced analysis of the data and its implications for maternal and infant well-being.When considering the composition of participants' families, our survey specifically inquired about the presence of other biological children in their households and, if so, the number of such children.

Data Management and Analysis
The data collection framework was designed to gather relevant insights from participating mothers.Each step was executed with stringent adherence to ethical standards to safeguard participants' rights, ensure confidentiality, and prioritize their well-being, all while striving to secure reliable and valid data (as elaborated in the following section of this report).The objective was to create a comprehensive and ethically sound dataset that would serve as a reliable foundation for informed decision-making in the program's future interventions.To effectively manage this wealth of information, the assessment team established a secure database.Initially, the raw data was input into Microsoft Excel spreadsheets, where it underwent a critical pre-processing phase.This crucial step was instrumental for 'data cleaning,' a meticulous process to identify and rectify any inconsistencies, outliers, or missing values in the dataset.Upon the successful completion of the data cleaning phase in Excel, the nowrefined dataset was migrated to SPSS (Statistical Package for the Social Sciences) for comprehensive statistical analysis.

Ethical Considerations and Compliance Standards
The assessment rigorously adhered to the United Nations Evaluation Group (UNEG) Norms and Standards, establishing a framework that upheld essential principles such as beneficence, non-maleficence, autonomy, justice, professionalism, and impartiality.These principles were translated into core ethical tenets as follows:  Integrity: The entire evaluation process was conducted with unwavering independence.The evaluation team operated free from conflicts of interest, and proactive measures were taken to mitigate any potential sources of bias, ensuring objective and impartial assessments. Accountability: To maintain transparency, regular consultations were held with various stakeholders.This ensured that all parties were well-informed about the evaluation's purpose, methodology, and any actions taken in the study.Participants were explicitly briefed about the evaluation's objectives and the broader intentions behind the data collection efforts.
 Respect and Inclusiveness: All relevant stakeholders, from policymakers to beneficiaries, were actively engaged throughout the evaluation process.Their inputs were sought, validated, and integrated into the evaluation approach and subsequent dissemination of findings. Beneficence and Voluntary Participation: Prior to participation, oral informed consent was obtained from each participant.The study was outlined in detail, including any 51.5% 48.5% Yes No associated risks and benefits, affirming that participation was entirely voluntary and free from any form of coercion. Confidentiality: Stringent confidentiality protocols were employed to protect individual-level information.Access to complete databases was restricted to the evaluation team, and all data were anonymized before any form of dissemination.Only aggregated, de-identified data were communicated to external stakeholders. Data Protection: Personal information was meticulously separated from the main data files and stored securely.Restricted access codes were employed to link anonymized data with individual participants' identities.All collected data were housed in passwordprotected directories to ensure maximum security. Legal Approvals and Permissions: Prior to initiating the assessment, all necessary approvals were diligently obtained.This included obtaining ethical clearance from the Ministry of Health's Ethical Review Committee as well as UNICEF's Ethical Review Board.Additionally, localized permissions were sought and acquired from the relevant local authorities.The evaluation commenced only after receiving the green light from these bodies, thereby ensuring full compliance with legal and ethical standards.

Findings
In this section, we delve into the principal findings of the study.The data pertaining to immediate post-birth breastfeeding practices reveals a complex and intriguing landscape.The practice of skin-to-skin contact between a mother and her baby, often recommended for its potential benefits in neonatal care and maternal bonding, reveals a nuanced landscape in our findings.Notably, a significant portion of participants (24.7%) chose not to provide a definitive answer to the question regarding whether their baby was placed skin-to-skin with them.This lack of response suggests the existence of complexities or sensitivities surrounding this practice that were not fully captured by our survey instrument, indicating the need for further investigation.Among the respondents who did provide a clear answer, the data presents an almost even split in experiences: 40.2% indicated that they did not have skin-to-skin contact with their newborn, while 35.1% confirmed that they did engage in this practice.These figures raise intriguing questions about the adherence to and perceptions of skin-to-skin care within the studied population, pointing to potential variations in its adoption and the need to explore the reasons behind these differences more comprehensively.It is noteworthy that the majority of participants, constituting 50.5%, reported engaging in immediate breastfeeding following the birth of their child.This practice, highly recommended for its numerous benefits such as stimulating maternal milk production and fostering early bonding between mother and infant, is significant.However, it is equally important to highlight that nearly an equal proportion of participants, accounting for 46.3%, did not breastfeed their babies immediately after birth.The nearly even split in percentages raises important questions about the factors contributing to this divergence in experiences among new mothers.Additionally, a small segment of our sample, comprising 3.1%, opted not to provide an answer to this specific question.This omission could potentially indicate underlying complexities or sensitivities that the study failed to capture.Therefore, it becomes imperative for future studies to delve deeper into understanding the reasons behind this omission, whether they are related to personal choice, medical advice, cultural factors, or other external influences.The data concerning the initial feeding practices for newborns also presents a nuanced picture that warrants further investigation.Approximately one-third of the mothers, totaling 33.0%, reported giving their infants foods or fluids other than breast milk during the first days following birth.This finding raises questions about the reasons behind this choice and its potential implications for infant health.Conversely, a slightly higher percentage, 35.0%, reported exclusive breastfeeding during this crucial period, aligning with common medical guidelines that emphasize breast milk as the most balanced form of nutrition for newborns.This preference for exclusive breastfeeding is encouraging and aligns with global health recommendations.However, it is noteworthy that a significant proportion of the participants, amounting to 32.0%, did not respond to this question.The lack of responses may be attributed to various factors, including uncertainty, cultural sensitivities, or perhaps the challenges of recalling specific details from the early post-birth period.This absence of data underscores the need for more comprehensive data collection methods in future studies, potentially involving real-time reporting to accurately capture such critical information.When participants were asked about the type of first fluid their infants received, breast milk was the leading choice at 36.1%, which aligns with global health guidelines promoting

Exclusive breastfeeding
Other foods or fluids Did not reply breastfeeding as the best initial source of nutrition.However, it is also noteworthy that formula milk, water, and other fluids comprised a smaller percentage of initial feeds, indicating a preference for breast milk as the first fluid.Interestingly, another 2.1% reported that someone else provided the initial fluid to the infant.This raises intriguing questions about the role of healthcare providers or family members in this pivotal moment and how their choices may align or conflict with the intentions of the mothers.Of particular interest is the high percentage of non-responses to the question about the first fluid given.Over half of the participants, totaling 50.5%, did not specify what was initially fed to their infants.This omission highlights a substantial gap in our understanding and prompts questions for subsequent studies.Was this omission due to oversight, or does it signify a more complex set of considerations and factors at play, such as the mother's emotional state or the level of healthcare support received at the time of birth?To gain deeper insights, further research is essential to explore these nuances comprehensively.The majority of participants (73.2%) reported that they received guidance on how to feed their baby from someone at the health facility where their child was born.However, a notable proportion (24.7%) indicated that they did not receive any advice regarding infant feeding.Additionally, a small fraction (2.1%) did not provide a response to this question.For those participants who responded to the sub-question about the source of advice on infant feeding, the advisors included healthcare professionals such as nurses or doctors (1.0%), Lay Counselors (3.1%), and Nutrition advisors (5.2%).It's worth noting that a significant percentage (66%) did not provide a response to this sub-question, indicating the need for further exploration to understand the reasons behind non-responses and to gather more detailed insights into the sources of advice received regarding infant feeding.Shifting our focus to the participants' Knowledge and Attitudes towards Breastfeeding, specifically regarding their awareness of the nutritional value of colostrum, a commendable 79.4% demonstrated a solid understanding of the vital role that colostrum plays in providing essential nutrition to newborns.This finding reflects their alignment with established healthcare guidelines and highlights their well-informed perspectives on this crucial aspect of infant care.However, it is crucial to address the 15.5% of participants who did not recognize the nutritional significance of colostrum.This knowledge gap among a segment of participants underscores the importance of enhancing the dissemination of information regarding the substantial benefits of colostrum.By targeting this subgroup with educational initiatives, we can contribute to a more comprehensive understanding of the significance of early breastfeeding practices and potentially bridge this knowledge gap.Furthermore, it's noteworthy that 5.1% of participants chose not to respond to this question.This may indicate an opportunity for improving survey engagement or providing additional clarification regarding the question's significance.Taking steps to reduce non-responses in future surveys can lead to more complete data and a more thorough understanding of participants' knowledge and attitudes towards breastfeeding.The idea that three months of breastfeeding is adequate met with strong disagreement from the majority of participants.An impressive 92.8% of respondents demonstrated a clear understanding of the importance of more extended breastfeeding durations for the well-being of infants, aligning with established healthcare guidelines that emphasize prolonged breastfeeding.However, it's noteworthy that 3.1% of participants expressed the belief that three months of breastfeeding is sufficient, indicating potential misconceptions or differing beliefs regarding the optimal duration of breastfeeding.This underscores the importance of targeted information and educational efforts to ensure that all mothers have access to accurate and comprehensive guidance on breastfeeding practices.

Yes No
The level of understanding regarding the nutritional disparities between infant formula and human breast milk of most participants is high.A significant majority (86.6%) expressed disagreement with the statement suggesting that infant formula replicates all the ingredients found in breast milk.This collective disagreement reflects their awareness of the distinct nutritional composition of breast milk, which is essential for infant health and development.However, it is noteworthy that 8.2% of participants expressed agreement with this statement, indicating the presence of a subset of respondents who may have misconceptions or gaps in their understanding of infant nutrition.When participants were asked in more detail about their views on breastfeeding compared to using infant formula, a substantial majority (92.8%) expressed agreement that breastfeeding is more complete than using infant formula.This consensus highlights a clear and prevailing preference for breastfeeding within the surveyed population.
Opinions regarding breastfeeding practices within the community revealed a range of perspectives.Approximately 47.4% of the participants agreed that most young people in their community breastfeed their babies, while 46.4% held differing views.This variation suggests that there may be differences in community norms and perceptions related to breastfeeding.Additionally, 6.25% of respondents chose not to provide a response to this question, indicating the complexity of understanding the diverse dynamics among communities and the need for further exploration to discern the factors influencing these perceptions.Such exploration could involve considering variations in attitudes based on factors like maternal age, perceived community support, and other contextual factors.A substantial 83.5% of participants believed that their community actively promotes breastfeeding over infant formula, indicating the presence of a supportive social environment that values and encourages breastfeeding as the preferred method of infant feeding.However, 8.2% held differing views, suggesting potential variations in community norms and attitudes towards breastfeeding promotion.

8.2%
Agree Do not agree Did not reply The trust in healthcare professionals was notably strong, with a significant 93.8% of participants expressing belief that doctors and nurses actively promote breastfeeding.This finding underscores the influential role healthcare providers play in advocating for and supporting breastfeeding among mothers, highlighting the potential impact of healthcare professionals in encouraging optimal infant feeding practices.Nevertheless, it is worth noting that 6.2% of respondents did not provide a response to this question.This suggests a need for further exploration to understand the reasons behind this non-response and potentially uncover additional insights related to trust in healthcare providers.

Conclusions
This comprehensive study provides valuable insights into maternal and infant care practices in Lesotho, shedding light on familial dynamics, maternal autonomy, and the multifaceted challenges faced during the infant feeding journey.While the sample size has limitations, the results have significant implications for understanding breastfeeding practices, maternal and infant healthcare, and the development of targeted interventions in Lesotho.The study findings underscore a generally positive outlook on breastfeeding among the participants.Notably, a significant portion of the participants recognized the nutritional significance of colostrum and the importance of extended breastfeeding, aligning with international recommendations and best practices in infant care (WHO, 2023;Nangolo, et al. 2023;Mphasha et al., 2023;Matias et al., 2023;Ferreira, 2023;Giang et al., 2023Horta et al., 2022;Carsley, et al., 2019;Bider-Canfield, 2017).However, despite these positive attitudes, there remains a need for further efforts to promote exclusive breastfeeding during the early postnatal period.However, there is a need for improvement, particularly in promoting exclusive breastfeeding practices during the early postnatal period.One notable aspect that deserves attention is the presence of misinformation and common misconceptions related to breastfeeding.While healthcare professionals play a critical role in providing guidance and support to mothers, targeted educational interventions should not only focus on the benefits of exclusive breastfeeding but also address and dispel these prevalent misconceptions.Ensuring that mothers have accurate information is essential for making informed decisions about infant nutrition.It is important to acknowledge that the study's effectiveness is somewhat hindered by non-response rates to certain survey questions, which create gaps in our understanding of specific issues.To address this limitation, further research should explore the reasons behind non-participation and consider alternative data collection methods to gather comprehensive insights.Despite these challenges, the findings provide a robust foundation for informed interventions and policies aimed at enhancing maternal and infant health outcomes in Lesotho.By addressing the identified areas of improvement and leveraging the existing positive attitudes and practices,

Figure 1 :
Figure 1: Health care facilities

Figure 5 :
Figure 5: Skin-to-skin contact between the mother and the baby

Figure 7 :
Figure 7: Feeding practices after birth

Figure 8 :
Figure 8: Feeding the child after birth

Figure
Figure 9: Assistance with breastfeeding

Figure 10 :
Figure 10: Nutritional value of colostrum

Figure 11 :
Figure 11: Three months of breastfeeding is sufficient

Figure 12 :
Figure 12: Infant formula is not equivalent to Breastfeeding

Figure 13 :
Figure 13: Community actively promotes breastfeeding over infant formula

Table 1 :
Brief summary of Participants per ecological zone and site The findings are illuminating, with approximately 51.50% of respondents confirming the presence of additional biological children, while the remaining 48.50% reported not having any additional biological children beyond those mentioned earlier.This data holds particular significance, highlighting that a significant majority of participants are part of families with multiple biological children.Delving deeper into the details of participants with other biological children, we uncover a diverse distribution in the number of offspring.
Approximately 51.10% of participants with more than one child reported having two biological children.Additionally, 27.7% stated that they had three biological children, and 17.0% mentioned having four biological children.A smaller yet notable percentage of participants, approximately 2.1%, reported having either five or six biological children.
and healthcare providers can work together to create a more supportive and conducive environment for breastfeeding mothers, ultimately contributing to the well-being of both mothers and infants in the region. policymakers