Strengthening counseling on barriers to exclusive breastfeeding through use of job aids in Nampula, Mozambique.

Introduction: While the Government of Mozambique has galvanized action around exclusive breastfeeding (EBF) as a national priority, only 43% of Mozambican children under six months of age are exclusively breastfed. In the absence of skilled lactation support, challenges mothers experience with breastfeeding may inhibit initiation, exclusivity and duration. There is insufficient evidence on how to strengthen health providers' competencies to address breastfeeding challenges in low- and middle-income countries. The objectives of this study were to 1) assess EBF challenges, from the perspectives of health providers and mothers; 2) ascertain the quality of health provider counseling to address EBF challenges; and 3) gain an understanding of the usefulness of job aids to improve counseling within routine health contact points in Nampula, Mozambique.

Methods: This implementation science study was conducted in Meconta and Mogovolas districts, Nampula province, Mozambique from July-November 2018. In Phase 1, 46 in-depth interviews with mothers and providers, and 11 observations of counseling sessions were conducted. In Phase 2, health providers were trained to use three job aids (i.e., facility, community or maternity contacts) to identify and address EBF problems during routine health services. In Phase 3, 30 in-depth interviews with mothers and providers were conducted to assess the experience with job aid use. In both Phase 1 and 3, we conducted a thematic analysis using a grounded theory approach involving a step-wise coding process.

Results: Poor latch and positioning, perceived insufficient breastmilk and breast engorgement emerged as barriers to EBF. Providers often lacked the knowledge, skillset, and self-efficacy to manage EBF problems, with little counseling provided at community or facility levels. Following job aid rollout, providers reported improved assessment of breastfeeding technique, and increased self-efficacy and motivation to identify and resolve EBF problems.

Conclusions: Integration of job aids, with clear lactation management guidance, into maternal and child health training curricula and supportive supervision is critical to building providers' skillsets and competencies to provide quality lactation counseling and support.