Insights on exclusive breastfeeding norms in Kinshasa: findings from a qualitative study.

BACKGROUND For optimal growth and development, the World Health Organization recommends that children be exclusively breastfed for the first 6 months of life. However, according to the nationally-representative 2013-2014 Demographic and Health Survey, under 50% of babies in the Democratic Republic of Congo are exclusively breastfed. Although breastfeeding was common in the capital city of Kinshasa, one in five newborns received alternatives to breastmilk during the first 3 days of life. This analysis aimed to identify social norms influencing exclusive breastfeeding, the role of a young first-time mother's (FTM's) social network for her choice to exclusively breastfeed, and perceived social sanctions associated with breastfeeding practices in Kinshasa. METHODS The qualitative analysis was based on a vignette presented during 14 focus group discussions, with a purposively selected sample (n = 162) of FTMs age 15-24, and the male partners, mothers and mothers-in-law of FTMs age 15-24 in three health zones in Kinshasa in 2017. Thematic content analysis was performed to identify concepts and patterns in the participants' discussions. RESULTS Overall, community norms were not supportive of exclusive breastfeeding. The main barriers to exclusive breastfeeding were the belief held by most FTMs that exclusive breastfeeding was an uncommon practice; the desire to avoid negative sanctions such as name-calling and mockery for refusal to give babies water in the first 6 months of life; the desire to please key members of their social networks, specifically their mothers and friends, by doing what these influencers expected or preferred them to do; FTMs' own lack of experience with infant feeding; and trust placed in their mothers and friends. CONCLUSION Social norms can be maintained by the belief about what others do, perceived expectations about what individuals ought to do, the negative sanctions they can face and their preference to conform to social expectations. Thus, addressing cultural beliefs and targeting sensitization efforts to key influencers that provide support to FTMs are needed to promote exclusive breastfeeding in Kinshasa. In doing so, strategies should address the barriers to exclusive breastfeeding including related misconceptions, and improve FTMs' self-efficacy to overcome the influence of others.