Mother’s perceptions and experiences of infant feeding within a community-based peer counselling intervention in South Africa Barni Nor*, Beth Maina Ahlberg* † , Tanya Doherty ‡§ , Yanga Zembe ‡ , Debra Jackson § and Eva-Charlotte Ekström* for the PROMISE-EBF Study Group 1 *Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden, † Skaraborg Institute for Research and Development, Skövde, Sweden, ‡ Health Systems Research Unit, Medical Research Council, Cape Town, South Africa, and § School of Public Health, University of Western Cape, Cape Town, South Africa Abstract Exclusive breastfeeding (EBF) has the potential to significantly reduce infant mortality, but is frequently not practiced in low-income settings where infants are vulnerable to malnutrition and infections including human immunodeficiency virus (HIV). This study explores mothers’ experiences of infant feeding after receiving peer counselling promoting exclusive breast or formula feeding. This qualitative study was embedded in a cluster randomized peer counselling intervention trial in South Africa that aimed to evaluate the effect of peer counselling on EBF. Participants were selected from the three districts that were part of the trial reflecting different socio-economic conditions, rural–urban locations and HIV prevalence rates. Seventeen HIV-positive and -negative mothers allocated to intervention clusters were recruited. Despite perceived health and economic benefits of breastfeeding, several barriers to EBF remained, which contributed to a preference for mixed feeding. The understanding of the promotional message of ‘exclusive’ feeding was limited to ‘not mixing two milks’: breast or formula and did not address early introduction of foods and other liquids. Further, a crying infant or an infant who did not sleep at night were given as strong reasons for introducing semi-solid foods as early as 1 month. In addition, the need to adhere to the cultural practice of ‘cleansing’ and the knowledge that this practice is not compatible with EBF appeared to promote the decision to formula feed in HIV-positive mothers. Efforts to reduce barriers to EBF need to be intensified and further take into account the strong cultural beliefs that promote mixed feeding. Keywords: HIV, exclusive breastfeeding, formula feeding, peer counselling, South Africa. Correspondence: Ms Barni Nor, Department of Women’s and Children’s Health, Uppsala University, University Hospital, SE-751 85 Uppsala, Sweden. E-mail: barni.nor@kbh.uu.se 1 List of members of the PROMISE-EBF Study Group: Steering Committee: Thorkild Tylleskär, Philippe Van de Perre, Eva-Charlotte Ekström, Nicolas Meda, James K.Tumwine, Chipepo Kankasa, Debra Jackson. Participating countries and investigators: • Uganda: James K. Tumwine, Caleb Bwengye, Charles Karamagi, Victoria Nankabirwa, Jolly Nankunda, Grace Ndeezi, Margaret Wandera. • Zambia: Chipepo Kankasa, Mary Katepa-Bwalya, Chafye Siuluta, Seter Siziya. • Burkina Faso: Nicolas Meda, Hama Diallo,Thomas Ouedrago, Jeremi Rouamba, Bernadette Traoré Germain Traoré, Emmanuel Zabsonré. • South Africa: Debra Jackson, Mickey Chopra, Mark Colvin,Tanya Doherty,Ameena E Goga, Lyness Matizirofa, Lungiswa Nkonki, David Sanders, Wanga Zembe. • Norway: Thorkild Tylleskär, Ingunn MS Engebretsen, Lars Thore Fadnes, Eli Fjeld, Knut Fylkesnes, Jørn Klungsøyr, Anne Nordrehaug-Åstrøm, Øystein Evjen Olsen, Bjarne Robberstad, Halvor Sommerfelt. • France: Philippe Van de Perre. • Sweden: Eva-Charlotte Ekström, Barni Nor (country PI first, others in alphabetical order of surname). DOI: 10.1111/j.1740-8709.2011.00332.x Original Article 448 © 2011 Blackwell Publishing Ltd Maternal and Child Nutrition (2012), 8, pp. 448–458