Demotivating infant feeding counselling encounters in southern Africa: Do counsellors need more or different training?

Abstract

Ethnographic research was conducted in eleven low-resource settings across Swaziland, Namibia and South Africa to explore how the perceptions and experiences of counselling health workers, pregnant women and recent mothers could be used to improve infant feeding counselling in the context of mother to child transmission (MTCT) of HIV. We found many counselling encounters to be demotivating. Mothers often reported feeling judged, stigmatised and shamed. Counsellors complained of mothers’ poor compliance and passive resistance and reported suffering from stress, depression and burnout. We observed a rift between the mothers and counselling nurses, with both parties holding opposing agendas grounded in conflicting realities, expectations, experiences and needs. While the clients framed the visit as a consultation, counsellors framed it as health education, towards one exclusive purpose; to save the baby. Two communication modes prevailed in the counselling encounter: in theory, the counselling format was non-directive and client-centred but, in practice, most encounters reverted to information-based health education. Neither counselling format enabled the counsellors to acknowledge the reality of the two opposing agendas in the conversation and manage its dynamics. In order to achieve success – which, for the health service, is framed as persuading mothers to test for HIV and disclose the result – counsellors often felt compelled to be prescriptive and authoritative and reverted at times to confronting, judging and shaming mothers. Yet to adhere to their feeding choice consistently, mothers need to be motivated towards the significant behaviour change that this implies: to change their traditional roles and identities as women. For infant feeding counselling in the context of HIV/AIDS to become effective in southern Africa, a different format is therefore required; one that can acknowledge and manage these opposing agendas and conflicting realities and also enable counsellors to motivate mothers to make significant behaviour change.

Keywords:

• HIV/AIDS
• PMTCT
• infant feeding
• counselling
• training

Acknowledgements

We acknowledge the funder, Secure the Future, an initiative of Bristol Myers Squibb, for their contribution and trust. We appreciate all our researchers for their commitment, courage and tenacity: Raylene Titus, Ieshrit Sayeed, Nobantu Gantana, Josephine Malala, Zodwa Radebe, Joolekeni Komati, Kaarina Amutenya, Kathe Hofnie, Olivia Ndjadila, Gregentia Shapumba, Kholeka Mooi, Ndumi Sikotoyi, Sindisiwe Sikotoyi, Zaheeda Kadir, Happiness Mkhatshwa and Nomsa Magagula. We thank their mentors for their field research support: Ezelle Theunissen, Nokuthula Skhosana, Scholastika Iipinge, Ndapeua Shifiona, Teresa Connor, Anna Voce and Gladys Matsebula. We thank our core team for guiding the process: Judy Dick, Jenni Gordon and Pia Bombardella for guiding the process and Katy Menell for comments on this article. We appreciate the support of the Swaziland, Namibian and South African Ministries and Directorates of Health and Social Services/Welfare, their Hospitals, as well as the Universities of Stellenbosch, Namibia and Swaziland. Our deepest gratitude is reserved for the courageous women respondents, especially those living openly with HIV.

Notes

1. The table has been used before in a poster presentation (Buskens, 2004).