Factors influencing migrant maternal and infant nutrition in Cape Town, South Africa

Abstract

Migration is a social determinant of health. The relationships between migration and health are not well understood for the large numbers of migrants in low- and middle-income countries, including South Africa. In particular, nutrition during pregnancy and the first two years of a child’s life impact infant morbidity (e.g. diarrhoea, chronic disease) and mortality, yet little is known about maternal and infant nutrition in relation to migration. Positing that migration alters the family structures that traditionally provide social support and advice for mothers, this study was framed in terms of migrants’ loss of these social supports in Cape Town. This framing provided context for the broader investigation of migrants’ nutrition during pregnancy and the first two years of their infants’ lives. This qualitative study with migrants from the Democratic Republic of Congo (DRC), Somalia, and Zimbabwe included 23 in-depth interviews with recently (<2 years) postpartum women, and nine focus groups with adult men (N=3; n=21) and women (N=6; n=27). While in-depth interviews provided insights into individual nutritional motivations, focus groups provided insights into the social context of nutrition. Language interpretation was used in cases where participants did not speak English. Interviews and focus groups were recorded and transcribed verbatim; bilingual research assistants checked the quality of language interpretation and transcription. Rooted in notions of social constructivism, thematic analysis guided the development of a codebook of themes and subthemes. These analytic themes were grouped in relation to (1) maternal nutrition, (2) infant nutrition, and (3) past and present social support. Thereafter, a “thick description” involved interpreting key themes and producing the narrative that integrated focus group data and in-depth interview data. Analysis of maternal nutrition involved documenting foods consumed during pregnancy, as well as investigating the motivations that undergird nutrition during this period. The findings related to migrant maternal nutrition affirmed and built on previous research, which suggested that pregnant women generally maintained their previous non-pregnant eating habits. While cravings were dominated by self-perceived “traditional” foods of home, that were expensive and hard to find in Cape Town, women also commonly described consumption of fast foods and junk foods during pregnancy. Participants did not mention food scarcity, despite the fact that some migrants appeared to be food insecure. These findings illuminated the role of the nutrition transition in Cape Town, that is, migrants were at risk of consuming energy-dense, nutrient-poor diets, particularly during pregnancy. Secondly, analysis of participants’ experience of breastfeeding, formula feeding, and complementary feeding took place in the context of high rates of breastfeeding initiation but low rates of exclusive breastfeeding in many parts of Africa, including migrants’ countries of origin. In this study, migrants presented the common decision to introduce formula in light of their experiences of Cape Town as a work environment. Participants framed the introduction of formula and complementary food early in an infant’s life as primarily a pragmatic and intuitive decision in response to their infant’s cues. Whereas past studies conducted in LMIC tend to present breastfeeding as an important intervention to improve child “survival”, participants in this study were not primarily concerned with child survival. Rather, they were concerned with their family’s tenuous circumstances in Cape Town. As such, efforts by the health system to promote breastfeeding amongst migrants should emphasize benefits to long-term health as well as the short-term financial costs of formula feeding. However, I argue that this shift cannot occur without recognition of, and attention to, migrants’ pressing short-term needs, including housing, legal work status, and safety. Another important factor influencing maternal and infant nutrition revolved around the loss of social support, particularly the loss of the elder generation. Elder women played a central role in providing physical, social and informational support to new mothers in migrants’ countries of origin. As such, the absence of grandmothers in migrant communities in Cape Town was central to understanding participants’ maternal and infant nutrition decisions. Yet participants focused on the loss of household help, including cooking, rather than on grandmothers’ traditional authority or nutritional advice. Given the relative absence of the older, nonworking, generation in Cape Town, community support was limited by the pressures of work and survival. These pressures seemed to make healthy nutrition during pregnancy, or exclusive breastfeeding very difficult. Given this lack of support, medical providers presented one avenue of additional support. However, migrants were frequently unable to communicate with health care providers, and felt discriminated against and unwelcome in the health care system. The three primary findings relating migration and maternal and infant nutrition in Cape Town suggest several avenues for intervention and further study. Firstly, migrants’ descriptions of energy-dense, nutrient-poor diets suggest a role of policy-makers to improve the overall accessibility, availability, and affordability of more nutritious food to the poor in Cape Town. Recognising that foods from migrants’ countries of origin were of particular cultural and nutritional value, a smaller scale intervention might involve creating space and time for the preparation of “traditional” foods. Secondly, improving infant feeding involves re-orientating migrants towards the long-term benefits of breastfeeding and complementary feeding, and engaging spouses and male partners as integral to this process. Further research is needed to create a strong evidence base for the increasing rates of breastfeeding, both in Cape Town and in other urban centres in LMIC. Thirdly, given self-described social isolation and poor experiences in healthcare settings, free-to-patient medical interpretation may play an important role in connecting migrants to both healthcare services as well as broader social services. The improved communication facilitated by medical interpretation may also play a role in combatting the xenophobia that migrants face, both in the healthcare setting as well as in daily life. Indeed, my recommendations must be part of a broader public health research effort to explicate the negative health consequences of xenophobia. To design appropriate research and interventions for migrants, it is important to acknowledge the overarching roles played by xenophobia, legal status, and the broader socio-economic context in shaping maternal and infant nutrition