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South African Journal of Occupational Therapy

On-line version ISSN 2310-3833
Print version ISSN 0038-2337

S. Afr. j. occup. ther. vol.46 n.2 Pretoria Aug. 2016 



Breastfeeding among mothers in the public health sector: the role of the occupational therapist



Marieta VisserI; Mariette NelII; Tanya la CockIII; Netske LabuschagneIII; Wihanli LindequeIII; Annelize MalanIII; Carli ViljoenIII

IB OT (UFS), MSc (OT) (Wits). Lecturer, Department of Occupational Therapy, School for Allied Health Professions, Faculty of Health Sciences, University of the Free State
IIMMedSc (Biostatistics) (UFS). Lecturer, Department of Biostatistics, Faculty of Health Sciences, University of the Free State
IIIB OT (UFS). Students in the Department of Occupational Therapy at the University of the Free State at the time the study was carried out





BACKGROUND AND AIM: South Africa has an unacceptably high child mortality rate. Preventable causes such as malnutrition account for a high percentage of these deaths. Breastfeeding as infant feeding practice is recognised for its potential to radically reduce child mortality and is therefore promoted globally. Yet, SA presents with the lowest breastfeeding rates worldwide. Breastfeeding is a child rearing co-occupation, and occupational therapists (OTs) are well positioned to become role players on a transdisciplinary level to address the infant child mortality rate through promoting and supporting breastfeeding. Although not well described in the literature and traditionally not considered part of occupational therapy practice, this study aimed to determine the role of the OT in addressing breastfeeding among mothers in the public health sector (PHS).
METHOD: A purposive sample of 9 OTs from Bloemfontein working in the Public Health Service (PHS) participated in this study. An e-Delphi technique was used to set up four rounds of sequential questionnaires developed from and structured according to the Occupational Therapy Practice Framework (OTPF) Domain and Process.
RESULTS: From the 128 initial statements, 95 statements reached consensus determined at 80% agreement. Statements were clustered according to OT roles identified, which included clinician, consultant, educator, trainer, advocate and facilitator.
CONCLUSION: OTs have a role to play in addressing breastfeeding among mothers in the PHS, within a transdisciplinary team. If OTs aligned their practice with global and national initiatives and policies, the population-based health issue of infant child mortality could be addressed collectively.

Keywords: child mortality; breastfeeding; child rearing; co-occupation; Delphi technique




Globally, malnutrition is the leading cause of child mortality1. Based on current projections, between 2015 and 2028, 35 million children will die world-wide before their fifth birthday2, unless the call to improve child survival is strengthened within population-based health. These deaths in children are largely due to preventable causes, such as pneumonia, diarrhoea and malaria, which mostly occur in children weakened by malnutrition3-5. Therefore, malnutrition should be prevented, considering that it is the right of every child to have access to basic nutrition6,7.

The infant feeding practice of breastfeeding is recognised as the greatest strategy in combating malnutrition and alleviating child mortality8-10. Inappropriate infant feeding practices are a significant threat to child health11. The many health benefits that breastfeeding holds regarding an infant's nutritional needs and immune system, have been well researched8,12,13. Exclusive breastfeeding has also been proven to pose minimal risk for mother-to-child transmission of the human immunodeficiency virus (HIV)l4. The benefits overarch the lifespan of the mother-child-dyad, contributing to a stronger bond and mental and physical wellbeing15. Investment in early childhood development during critical periods has been shown to positively contribute to socio-economic aspects relating to human capital10,15-17. Yet, the exclusive breastfeeding rate (mothers only breastfeeding with no additional feeding) of only 8% in South Africa is the lowest in the world18, directly relating to the unacceptably high rate of 47 000 deaths annually among children younger than five years of age2,18,19.

When dealt with in a transdisciplinary team20, breastfeeding has the potential to address this population-based crisis of infant mortality. Although the Occupational Therapy (OTy) profession is grounded on the construct of "supporting and promoting health through participation in occupations"2l:SI,22:507, including the child rearing co-occupation of breastfeeding, Occupational Therapists (OTs) have not traditionally considered it within the scope of their profession to address breastfeeding in the public health sector (PHS). Consequently, the role of the Occupational Therapist (OT) in this regard, as a member of the transdisciplinary team, is not well described in the literature.

Globally and nationally, ample guiding initiatives aim to promote breastfeeding with the aim of alleviating child mortality. The 2005 Innocenti Declaration of Infant and Young Child Feeding recognises the significance of breastfeeding to improve infant survival and support child health11. Furthermore, the release of the 2010 World Health Organization (WHO) guidelines on HIV and infant feeding14 transformed existing breastfeeding agendas into a key child survival strategy. The fourth Millennium Developmental Goal (count-down 2015) aimed to reduce child mortality by two thirds, which South Africa has failed to fully achieve5,3,22. Building on the progress made globally, the two new sets of targets include the Sustainable Developmental Goals23, and A Promise Renewed: Committing to Child Survival2,9. The Tshwane Declaration resolutions direct South Africa to promote, support and protect breastfeeding24. The Infant and Young Child Feeding Policy (IYCFP)1 is an initiative that demonstrates South Africa's commitment towards promoting child health, and provides clear guidelines regarding feeding the infant in the context of HIV.

Considering these guiding initiatives, the call for a response from OTs as members of the health profession echoes with the ethos of 'A Promise Renewed', which stated that child survival is a shared responsibility and everyone has a contribution to make2. Since OTs are well positioned within the transdisciplinary team, to become role players in the child rearing co-occupation of breastfeeding, they should become involved with initiatives aimed at protecting, promoting, and supporting breastfeeding10,11,20.

This article reports on a study that aimed to investigate the role of the OT in addressing breastfeeding among mothers in the PHS, and further provides a review of the literature and recommendations.



According to the Occupational Therapy Practice Framework (OTPF) Domain and Process, 3rd edition21, breastfeeding is considered as one of the "instrumental activities of daily living" (IADLs), which are defined as "activities to support daily life within the home and community that often require more complex interactions than those used in ADLs"21:S19. Within the broad range of IADLs, breastfeeding will be more specifically classified as a "...child rearing activity"21:S19 defined as "providing care and supervision to support the developmental needs of a child" 21:S19. Furthermore, occupation that "implicitly involves two or more individuals may be termed co-occupations"21:S42. It involves active participation on the part of both the caregiver and the recipient of care. It is also referred to as a mother-child dyad20.

The child rearing co-occupation of breastfeeding transcends the typical classifications of eating and feeding10,21, and this relationship benefits both the mother and child across the lifespan15, resulting in a positive impact on the greater society. Breastfeeding is indeed "the great equaliser"25:1,26:6 as infants from all social or economic backgrounds, who are optimally fed, have an equal start on a healthy life.

Breastfeeding is also the most nutritious and economical method of feeding an infantl2, making it an ideal solution in poverty stricken countries, such as South Africa where 45.5% of the population live in poverty27. One of the benefits of breast milk is that it contains antibodies that boost the infant's immune system, providing protection against numerous infections8,12,13,28.

Breastfeeding has long-term benefits for the mother, which include a decreased risk of ovarian and breast cancer, and facilitating weight loss to a pre-pregnancy level, thereby reducing the risk for type 2 diabetes and metabolic syndrome10,12,13. Breastfeeding also reduces the risk of depression and promotes a general sense of physical health in the mother15.

For the society and economy, breastfeeding benefits include decreased annual public healthcare costs, decreased absenteeism of the working mother with associated loss of family income, and a decreased environmental burden for production, transport and disposal of artificial feeding productsl0,l6. With regard to the management of population growth, breastfeeding has a contraceptive effect which contributes to family planning10 and natural spacing of children25.

In order to explain how OTy fits into the bigger picture in addressing breastfeeding, we will use Labbok's20 framework of four pillars for population-based breastfeeding support. These pillars are (i) national and governmental commitments aimed at supporting the rights of women and children; (ii) legislations and policies regarding infant feeding; (iii) improving health worker skills and health system support; and (iv) improving family and community practices.

The first two pillars are concerned with world leaders' vision of a brighter future. As we enter a post-millennial era, actions are intensified through initiatives such as the Sustainable Developmental Goals23, and A Promise Renewed: Committing to Child Survival2, with the target to attain 20 or fewer deaths under the age of five per 1000 live births by 20359,29. South Africa has aligned itself with the first two pillars by forming policies such as the Tshwane Dec-laration24 and the Infant and Young Child Feeding Policy (IYCFP)1 that recognise the urgency of improving breastfeeding rates. The IYCFP specifically states that all healthcare personnel require sufficient knowledge and training in child feeding in order to provide support for mothers2. It also guides OTs to apply their unique set of knowledge and skills to live up to the core credence of promoting health and wellbeing through participation and engagement in occupations30.

The third pillar constitutes public health-related issues. The PHS of South Africa serves 82% of the population31. For every 100 000 individuals there are 430 healthcare workers32 and 2.6 OTs31,33. Consequently, collaboration between all disciplines is vital for a transdisciplinary approach to population-based health. A population-based health approach enables OTs to deliver cost- and time-effective services to a larger population group when compared to one-on-one intervention, while simultaneously applying the fourth pillar of providing and facilitating support to families and communities. OTs are therefore well positioned to become role players in promoting and supporting breastfeeding.

The role of OTs is defined as the attributes and behaviours expected of them when they act in accordance with their responsibility as they are held accountable by the standards of OT practice34. Research is required to articulate the value of the profession's involvement in addressing child survival in South Africa. Therefore, clarifying the OT's role within the transdisciplinary team regarding breastfeeding is critical to address the unacceptably high child mortality rate in South Africa.

The aim of the study was to determine the role of the OT in addressing breastfeeding among mothers in the public health sector (PHS).



An observational, descriptive study design using the Delphi technique. The Delphi technique, a research approach used to structure group communication about practice-related problems, and is known for consensus development by using multiple rounds of data collection, was used35,36. It seeks consensus on a certain topic among a panel of experts when there is limited evidence on a topic. For this study, the electronic Delphi (e-Delphi)35 was used to clarify a specific role in OTy relating to breastfeeding and to determine the extent of agreement and disagreement over given OTy roles relating to breastfeeding. The Delphi process in this study extended to four rounds in an iterative manner, i.e. questions in the second round were developed based on the responses from the first round. Consensus was determined at 80% agreement35,37.


Approval for this study was obtained from the Ethics Committee of the Faculty of Health Sciences at the University of the Free State. To ensure ethical conduct, written permission was received from the Head of the Free State Province Department of Health (DOH) and written consent was obtained from all participating OTs prior to the study.

Study participants

The population consisted of a homogeneous group of 36 OTs (N = 36) practising within the PHS in Bloemfontein (personal communication; Corne Vrey, 15 February 2015). The PHS consists of one primary care hospital, one secondary care hospital, one tertiary care hospital and approximately 43 clinics.

The inclusion criteria for the study were as follows: qualified OTs, female, with experience in paediatrics, who have practised in the PHS of Bloemfontein within the previous five years. The OTs should have had experience in the field of paediatrics in areas such as developmental screening clinics, where the therapist had access to mothers and children two years of age or younger. For practical reasons, the therapists needed to be literate in English, competent in the use of a computer and have internet access.

The 36 OTs working in PHS were all informed about the study and invited to participate. Through purposeful selection35,37, thirteen OTs who met the inclusion criteria were approached telephonically and invited to participate. Each of these OTs was read a study overview from the same pre-planned script. This overview informed the possible participants that a maximum of four rounds were possible within the Delphi process and that the participants who completed the study would be remunerated for their time with six continuous professional development (CPD) points, (Clearance to allocate these CPD points was obtained prior to the study). The OTs who considered participation in this study, were then e-mailed a comprehensive information sheet and a consent form. Nine therapists (n=9) consented to participate and formed the panel of experts after which they received a code to ensure confidentiality. These experts (panel members) included therapists from the following clinical areas; Pelonomi Regional Hospital (5 therapists), Universi-tas Academic Hospital (3 therapists), MUCPP Clinic (1 therapist).

Measurement instrument

The questionnaire for Round 1 was developed from the Occupational Therapy Practice Framework (OTPF) Domain and Process, 3rd edition21. Each OTPF domain area (i.e. occupational areas; client factors; performance skills; performance patterns and contextual and environmental factors), as indicated in Table I, was considered in the development of the questions and hence reflected accordingly in the questionnaire of Round 1. A baseline question was formed and adapted for each aspect of the domain, for example: "What role can the OT assume in addressing breastfeeding in the following Occupational Areas: Sleep" (the latter is altered according to the specified aspect of the domain). The questionnaire of Round 1 consisted of six sections, of which section one comprised 10 demographic questions, and the other five sections represented the five OTy domain areas, consisting of a total of 24 open-ended questions.



Two objective reviewers (an OT with experience in the field of paediatrics and breastfeeding and an expert in the use of the Delphi technique) revised the draft of the questionnaire for Round 1 and modifications were made accordingly before it was sent out. The modifications included adding definitions of terminology to ensure that the knowledge of the OTs was not assessed, but rather that their professional opinion was obtained; improved user-friendliness of the questionnaire; and incorporating the OTPF domain together with the process, in an information letter.

For Round 1, the panel members received an information letter and the Round 1 questionnaire via e-mail, with three working days to complete this questionnaire. A description of Round 2 to Round 4 will follow in the Result section.

Data collection and analysis

SurveyMonkey,38 was used to electronically compile and distribute the four rounds of questionnaires. The primary investigator (study leader) and student researchers compiled the content of the questionnaires for each round, consolidated the statements and re-entered the questionnaires for each round onto SuveyMon-key. Descriptive statistics, namely frequencies and percentages for categorical data, and medians and percentiles for continuous data, were calculated by the Department of Biostatistics of the University of the Free State.



In Round 1, it was determined that the panel members had a median of 8 years paediatric experience, with all levels of public healthcare represented. Four had personal experience with breastfeeding (meaning that they had personally breastfed their own child), ranging from 3 to more than 12 months. The opinion relating to breastfeeding of the panel members were influenced by personal and clinical experience, relatives and friends. Table II indicates the aspects that influenced their opinion gauged on a 4-point Likert scale.



The questionnaire distributed in Round 1 (representing the five OTy domain areas and consisting of 24 open-ended questions) provided the researchers with 216 responses. The responses were consolidated to generate a list of 128 statements.

In Round 2, the panel members had to either agree or disagree with the 128 statements. At the end of each section a question was also asked to establish if the OT considered that specific role as either unique to the profession, or an aspect that could be addressed in the transdisciplinary team. They were given two working days to complete this questionnaire. Consensus was reached on 91 statements.

For Round 3, the 37 statements on which consensus was not reached, re-entered the Delphi process. The panel members had two working days to complete this questionnaire. Consensus was reached on three more statements, resulting in a total of 94 statements on which panel members reached consensus.

For Round 4, the remaining 34 statements re-entered the Delphi process. The panel members had one working day to complete this questionnaire. Consensus was reached on one more statement, giving a total of 95 statements on which consensus was eventually reached. Due to time constraints, the remaining 33 statements were not re-entered into a next round.