Knowledge, Beliefs, and Practices Regarding Exclusive Breastfeeding of Infants Younger Than 6 Months in Mozambique: A Qualitative Study

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http://jhl.sagepub.com/content/early/2010/10/07/0890334410390039The online version of this article can be found at:

DOI: 10.1177/0890334410390039 published online 22 December 2010J Hum Lact

Maaike Arts, Diederike Geelhoed, Caroline De Schacht, Wendy Prosser, Cathrien Alons and Avone PedroMozambique: A Qualitative Study

Knowledge, Beliefs, and Practices Regarding Exclusive Breastfeeding of Infants Younger Than 6 Months in

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Knowledge, Beliefs, and Practices Regarding Exclusive Breastfeeding of Infants Younger Than 6 Months in Mozambique: A Qualitative StudyMaaike Arts, MSc, Diederike Geelhoed, MD, PhD, Caroline De Schacht, MD, MSc, Wendy Prosser, MPA, Cathrien Alons, MPH, and Avone Pedro, BS

Abstract

Only 37% of infants younger than 6 months in Mozambique are exclusively breastfed. A qualitative assessment was undertaken to identify the knowledge, beliefs, and practices around exclusive breastfeedingspecifically, those of mothers, fathers, grandmothers, and nursesand to identify the support networks. Results show many barriers. In addition to receiving breast milk, infants receive water, traditional medicines, and porridges before 6 months of age. Many mothers had heard of the recommendation to exclusively breastfeed for 6 months. However, other family decision makers had heard less about exclusive breast-feeding, and many expressed doubts about its feasibility. Some of them expressed willing-ness to support exclusive breastfeeding if they were informed by health workers. Nurses know the benefits of exclusive breastfeeding and pass this information on verbally but have insufficient counseling skills. Interventions to improve exclusive breastfeeding should tar-get family and community members and include training of health workers in counseling to resolve breastfeeding problems.

Keywords: exclusive breastfeeding, barriers, Mozambique, practices

Received for review July 9, 2010; revised manuscript accepted for publica-tion August 10, 2010.

No reported competing interests.

Maaike Arts is a nutritionist specializing in public health nutrition issues and infant and young child feeding. She has worked in Mozambique for 3 years. She was affiliated with the Elizabeth Glaser Pediatric AIDS Foundation, Mozambique, at the time of the study. Diederike Geelhoed, MD, PhD, is a public health clinician in the field of reproductive health, including HIV/AIDS, and has 20 years of postgraduate work experience in clinical care, public health, and research, mostly in sub-Saharan Africa. Diederike Geelhoed is affiliated with the International Centre for Reproductive Health, Ghent University, Belgium. Caroline De Schacht, MD, MSc, is a public health clinician with a diploma in tropical medicine and masters in clinical trials and has worked in Mozambique for over 6 years as a clinical advisor. She is affiliated with the Elizabeth Glaser Pediatric AIDS Foundation, Mozambique. Wendy Prosser, MPA, worked for 5 years in Mozambique focusing on HIV prevention, treatment, and Prevention of Mother to Child Transmission programs and is currently working in Angola on child sur-vival initiatives. She was affiliated with Population Services International, Mozambique, at the time of the study. Cathrien Alons, MPH, is a public health specialist and has more than 10 years of experience in international health, including nutrition, maternal and child health, and HIV/AIDS. She is currently the technical director for the Elizabeth Glaser Pediatric AIDS Foundation in Mozambique. Avone Pedro is a nutritionist working at the Ministry of Health of Mozambique.

Address correspondence to Caroline De Schacht, Rua Kwame Nkrumah 417, Maputo, Mozambique.

J Hum Lact XX(X), XXXXDOI: 10.1177/0890334410390039 Copyright 2010 International Lactation Consultant Association

1

Universal exclusive breastfeeding (EBF) during the first 6 months of life is one of the most effective inter-ventions to prevent child mortality.1 Suboptimal infant-feeding practices contribute to 1.4 million deaths and 10% of the disease burden in children younger than 5 years.2 EBF for the first 6 months of life is recom-mended for all infants.3 Infants do not need any other food or drink during this period, not even water4; unre-stricted EBF results in ample milk production.5 Practically all mothers can breastfeed, provided they have accurate information, as well as support within their families and communities and from the health care system.5-8 For mothers living with HIV, the World Health Organization (WHO) currently recommends that for settings where national or sub-national authorities have decided that the Maternal, Newborn and Child Health services will principally promote and support breastfeeding and antiretroviral (ARV) interventions as the strategy that will most likely give infants born to mothers known to be HIV-infected the greatest chance of HIV-free survival mothers known to be HIV-infected (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate


2 Arts et al J Hum Lact XX(X), XXXX

complementary foods thereafter, and continue breast-feeding for the first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided. In addi-tion, it is recommended to provide ARV medicines to either the mother or the child, depending on the ARV regimen that the mother followed during pregnancy and childbirth.9

In Mozambique, HIV prevalence in pregnant women was estimated at 16% in 2007.10 A risk analysis based on a mathematical model of different feeding options in the context of HIV showed that in Mozambique, in areas with an infant mortality rate above 31 per 1000 (ie, in practically the entire country), EBF for the first 6 months is the feeding option with the highest rates of HIV-free survival.11 However, EBF is an uncommon practice in many countries in sub-Saharan Africa, and only 37% of all infants younger than 6 months in Mozambique are exclusively breastfed.12

At the time of the study, the Ministry of Health recom-mended that all women EBF for 6 months. Mothers with HIV were counseled to choose either EBF or exclusive replacement feeding, if they were able to do so in a way that was affordable, feasible, acceptable, sustain-able, and safe. Mothers who opted for EBF were coun-seled to wean their children at the age of 6 months. The most recent recommendations from the WHO regarding ARV prophylaxis during breastfeeding13 are currently being adapted for Mozambique. The country started implementing the Baby-Friendly Hospital Initiative in the end of the 1990s, but no hospitals have been certified as baby-friendly.

To inform the development of a national strategy on the promotion, protection, and support of breastfeeding in Mozambique, of which EBF is a key component, a qualitative assessment of the barriers to EBF was under-taken in 4 provinces and the capital city, covering all 3 regions of the country (north, center, and south). The objectives of the assessment were threefold: (1) identify the practices and beliefs around breastfeeding (spe-cifically, EBF) of mothers, fathers, mothers-in-law, and maternal and child health (MCH) nurses in Mozambique; (2) describe the knowledge and attitudes of MCH nurses on infant feeding and their influence on mothers; and (3) identify the support networks in the area of infant feeding that are available to mothers.

Methods

A qualitative study was done in 4 of Mozam-biques 11 provinces (Gaza, Tete, Zambzia, and

Nampula) and the capital Maputo City. In each prov-ince, an urban site and a rural site were purposefully selected, which led to a total number of 9 study sites, including the urban site of Maputo City. Data collection was done in July and August 2008.

In every site, a trained facilitator conducted 4 focus group discussions (FGDs), each comprising a specific category: mothers of children younger than 2 years, mothers-in-law or grandmothers, fathers of children younger than 2 years, and MCH nurses. The facilitators were mostly community-based workers, some with pre-vious experience in FGD. Each group had 8 to 12 par-ticipants. FGDs were based on a semistructured guide. Questions in all 4 groups covered the same issues: initiation of breastfeeding, available support for breast-feeding, decision making about infant feeding, addi-tional foods and liquids provided to infants younger than 6 months, perceptions of the feasibility of EBF, and knowledge and perceptions about breastfeeding by HIV-positive women. Additional questions were asked to the MCH nurses on their role as service providers.

Participants were selected through volunteer sam-pling among the specific categories described in the previous paragraph, irrespective of their HIV status, with the exception of 2 FGDs with mothers (Zambzia and Gaza) who belonged to a local Prevention of Mother to Child Transmission support group. The discussions were recorded on tape and conducted in the presence of a trained note taker. Local languages were used in all groups except the MCH nurses, who spoke Portuguese. Notes for all groups were made in Portuguese. The taped discussions were translated into Portuguese and tran-scribed into Microsoft Word by the facilitator and note taker teams. Thematic analysis was done manually by 3 investigators in discussion until consensus was reached. Saturation was achieved on the main themes.

The research protocol was approved by the Mozambican Bioethics Committee. Participants gave verbal informed consent after the purpose and proceedings of the study were explained to them.

Results

The total number of participants in the 36 FGDs (20 urban, 16 rural) was 342: 95 mothers, 82 mothers-in-law/grandmothers, 85 fathers, and 80 MCH nurses.

Practices and Beliefs Around BreastfeedingAll groups mentioned that breast milk is usually the

first food given after a baby is born, although breast-feeding is not always initiated in the first hour after


J Hum Lact XX(X), XXXX Exclusive Breastfeeding of Infants Under 6 Months 3

birth. Reasons for this practice are related to the per-ceived need for the mother to rest and bathe after delivery.

The baby is put to the breast for the first time after more than one hour, because after [the baby] is born, the mother is tired, and when she wakes up, that is when she breastfeeds. (FGD mothers-in-law/grandmothers, Xai-Xai City, Gaza Province)

There appeared to be different views about the health benefit of colostrum for an infant. Some respon-dents said that colostrum is good, but others said that the first milk is not good for the infant. No further detail on this was explored.

Although the practice of breastfeeding appeared to be nearly universal, participants commonly mentioned that other foods or liquids were introduced before a child reached the age of 6 months. Three kinds of foods and liquids were identified. First, one widely held belief was that children need to drink water from a very early age, for their general well-being. Second, there was strong evidence for the provision of traditional medicines to children of all ages. Some of these medicines are given through a bath, a smoking pipe, or an amulet, but others are given orally, mostly in the form of a tea. Gripe watera pharmacy-sold liquid with essential oils of certain herbs, sodium bicarbonate, and sugarwas also mentioned as a traditional medicine for oral use. The participants stated that traditional medicines are given to children to prevent and cure common illnesses, including colic and diarrhea, as well as the doena de lua (moon disease) and other illnesses and symptoms deemed spiri-tual or caused by spirits.

[People] give the [traditional] medicine so that chil-dren dont become ill and so that the mother can have sexual relations with her husband without any problem, so that when a sorcerer appears he will not be able to harm the child. (FGD mothers-in-law/grandmothers, Nacala Porto, Nampula Province)

The age at which traditional medicines are intro-duced varies, but it reportedly often starts in the first weeks of life; many respondents referred to the time when the umbilical cord falls off as the moment to start giving traditional medicines. The description of the amounts of traditional medicines that are given orally was not very specific; respondents mentioned one spoonful or a few spoonfuls. It was not possible to obtain a more detailed description of the amounts.

Mothers and fathers both said that it is hard for a mother to refuse to give traditional medicines when another family member (most often, the childs grand-mother) suggests that the child needs them. If a mother refuses to use traditional medicines on her child and something happens to the child, then the mother has to take the responsibility for this, which places her in a dif-ficult position within the family. Another argument that participants used was that these medicines were good because they themselves had benefited from them as children. Some mothers, mothers-in-law, and fathers did not support the use of traditional medicines, for reasons mostly related to their Christian religious beliefs.

When a mother decides not to give the [tradi-tional] medicine to the child, conflicts arise within the family, because they say that the mother does not want to follow advice, and that the child will die of not having taken [traditional] medicine. (FGD mothers, Xai-Xai City, Gaza Province)

The third category of foods to be given to children before the age of 6 months are porridges (papas). These are given because of the assumption that children need to practice eating soft or blended foods before eating solid foods later on and because children need these foods in addition to breast milk to grow well. Although many respondents said that porridges are introduced at the ages of 4, 5, or 6 months, earlier ages were men-tioned quite regularly. Decision making about the intro-duction of these porridges appeared to be a process in which various actors are involved. All groups of respondents felt that they were involved in the decision making. Some said that it was a consultative process involving the parents and significant others. The childs grandmother was often mentioned to have an important role in this process.

Many mothers had heard of the recommendation to breastfeed exclusively for 6 months. However, knowledge of this recommendation was less widespread among the mothers-in-law and fathers. In these groups, many doubts were expressed when the participants were asked if they thought that EBF was feasible. It was believed that breastfeeding alone is not sufficient to nurture a child up to the age of 6 months, and the respondents believed that mothers nutritional status is inadequate. Some participants mentioned that mothers who work or study outside the house cannot continue to breastfeed exclu-sively. The strong perceived need to give water, tradi-tional medicines, and/or porridges was mentioned in the context of the feasibility of EBF.



Children will die, breast milk only is not enough to fill the stomach of the baby, and if the child is thirsty, it will die. (FGD mothers-in-law/grandmothers, Domu, Tete Province)

Some influential family members, such as mothers-in-law and fathers, expressed a willingness to support EBF. They said that it would be easy to accept the recommen-dation if the information came from the health center.

[We should] not listen to what other people say at home, we need to listen to that what the nurses say, and comply with that. (FGD mothers, Alto Molocue, Zambzia Province)

In all focus groups, the participants were asked about the feeding of infants of HIV-positive mothers. Many mothers-in-law and fathers said that they did not know how these infants need to be fed, although moth-ers appeared to have somewhat better knowledge of the current recommendations. Among the participants who had heard about the feeding recommendations, some said that HIV-positive women should breastfeed up to 6 months, and others thought or had heard that HIV-positive women should not breastfeed at all. MCH nurses said that mothers should breastfeed for 6 months and replacement feed when possible, which was the rec-ommendation of the Ministry of Health at the time of the study. However, nearly none of the participants, includ-ing the nurses, mentioned the importance of EBF for the prevention of mother-to-child HIV transmission. In addition, a common belief was that mothers who do not breastfeed are suspected of being sick (including hav-ing HIV or AIDS), of not wanting or liking their children, or of being a sorcerer.

If she does not breastfeed, people say that she is a sorcerer, and wants the child to die. (FGD mothers-in-law/grandmothers, Milange, Zambzia Province)

Role of MCH Nurses in Infant FeedingWhen the nurses were asked about their role in sup-

port of breastfeeding, they stressed that they informed mothers well and gave them all the necessary infor-mation. Some expressed doubts about the feasibil-ity because they assumed that the health and nutri-tional status of mothers is not sufficient and because of

the perceived need to give water, traditional medicines, and porridges before 6 months.

Many nurses reported that speaking to the mothers is not enough to ensure EBF and that it is necessary to address mothers-in-law, fathers, and communities in general. Various nurses suggested involving peer edu-cators and community leaders. Many nurses also men-tioned constraints in their worknamely, the lack of time to do counseling and a lack of job aids. They rec-ommended that they receive additional training, support for transportation to the communities, and job aids.

It is difficult because when I talk [with the mothers] they may understand the message, but in practice they do not follow it. (FGD MCH nurses, Angnia, Tete Province)

Support Networks for Infant FeedingMothers often reported receiving support with the

initiation of breastfeeding from their mothers-in-law, their mothers, other experienced women, as well as from nurses, in the form of informative messages and practical advice for positioning and attachment. Fathers talked about nutritional support for their breastfeeding partners and about sexual abstinence, because sexual activity of a breastfeeding mother is traditionally deemed harmful to the infant. Some mothers in Gaza and Zambzia mentioned that they had not received any support with breastfeeding.

I help with buying [artificial] baby milk, and clothes, and with food for the mother for the pro-duction of more milk. I talk with my wife to give breast milk, which is essential for the healthy growth of the child. (FGD fathers, Maputo City)

My mother-in-law helped me to breastfeed for the first time, she said to give one side and then the other side, at times she herself took my breast and gave it to the baby. (FGD mothers, Tete City, Tete Province)

When asked what people do in case a mother expe-riences problems with breastfeeding, many mothers and mothers-in-law said that the mother should go, or does go, to the health center. To resolve a problem with insuf-ficient milk production (or the perception thereof), many respondents said that the mother needs to consume



specific foods, such as peanuts and coconut, or improve her nutrition in general. Some mothers, mothers-in-law, and fathers said that infant formula is also a good option when there are breastfeeding problems but that they do not have access to it. Although some nurses mentioned interventions, such as emptying the breast well and offer-ing both breasts during a feed, many of the nurses referred to improving the mothers intake of foods and/or liquids as a key intervention to improve breastfeeding, and some said that they recommend mothers with breastfeeding problems to obtain infant formula.

I advise my daughter-in-law to go to the hospital, because if she would be sick, it can be transmitted to the baby. (FGD mothers-in-law/grandmothers, Domu, Tete Province)

Health centers normally refer mothers to the social ser-vices to receive artificial milk if necessary and based on strict criteria.

It is interesting to note that throughout the survey, no differences were observed in the answers provided by the participants in the focus groups from the 3 regions of the country.

Discussion

The results highlight the many barriers to EBF in Mozambique and contribute to the explanation for the low EBF rate in the country. Although not breastfeed-ing at all is rare and carries stigma, infants in the 3 regions of Mozambique usually receive water, tradi-tional medicines, and porridges before reaching 6 months of age, in addition to breastfeeding, as also documented in many other countries from sub-Saharan Africa.14-16

Several barriers were identified that may inhibit mothers from practicing EBF. First, although the partici-pating mothers had typically heard of the recommenda-tion to exclusively breastfeed for 6 months, grandmothers and fathersas important members of the family who are involved in the decision-making process on infant feedinghad heard about it less often. The impor-tance of family members in child care in general and in infant feeding in particular has been documented in other African countriesin Malawi, for example, where paternal grandmothers have an important role in infant and child care,17 or in Senegal, where the role of grand-mothers in maternal and child nutrition practices appears to be very large.18 Current information, education, and

communication activities on EBF in Mozambique are only targeting mothers, however, usually in their health clinic visits during pregnancy or for infant health care. Grandmothers and fathers are rarely actively involved in such activities, although there is some evidence that they might have a positive influence on the adoption of healthy infant care practices.17,18 Several grandmothers and fathers participating in this study expressed their willingness to support EBF if properly briefed by health care personnel. Therefore, we recommend that the Mozambican national strategy on the promotion, pro-tection, and support of breastfeeding contain a component of information, education, and communication activities aimed at these influential family members to improve their knowledge of the need for EBF in infants up to 6 months of age.

A second barrier to EBF identified from the results is the common practice of giving water, traditional medi-cines, and/or porridges to infants younger than 6 months. Many participants expressed doubts about the feasibility of EBF, convinced that no baby could grow healthily until the age of 6 months without adding these items to their breastfeeding. Again, the mother did not appear to be the principal decision maker on the administration of traditional medicines nor on the introduction of water or porridges, given that grandmothers and fathers were described as family members with important influence on these decisions. Similar to the results of another study in southern Africa, these data show that the knowledge that the mother obtained from health services alone is insufficient to enable her to withstand the powerful influ-ences on infant-feeding decisions of other family members.16 To overcome this second barrier, we again recommend the inclusion of specific measures in the national breastfeeding strategy to ensure the active par-ticipation of grandmothers and fathers in the process of improved implementation of EBF in infants until 6 months of age.

The third and last obstacle for the implementation of EBF, as indicated by the results, is the issue of insuf-ficient support for breastfeeding mothers from family members and health care personnel, especially when they face difficulties. Common constraints during breastfeed-ing, such as breast or nipple problems or a perceived lack of milk, were reported as significant barriers for the continuation of breastfeeding (as also documented in Ghana19), which few participants, including nurses, knew how to overcome. Although the participating nurses appeared to know the benefits of EBF and managed to pass this information on verbally, they felt that they had



insufficient counseling skills, materials, and time to help mothers overcome constraints. Our results show that even health care personnel sometimes contribute to the discontinuation of EBFfor example, when they rec-ommend the early introduction of infant formula when there is a perceived lack of breast milk, instead of mea-sures to enhance the production of breast milk. Such experience has been reported from Malawi.20 This is unfortunate because our participants stated they relied on the health care system to assist them in the manage-ment of breastfeeding problems. To overcome this third barrier, we recommend capacity strengthening for MCH nurses, which should include effective remedies or guidelines for common breastfeeding problems, such as engorgement, painful or cracked nipples, and perceived insufficient milk production. MCH nurses are trained in their preservice course and through in-service trainings on EBF guidelines. These trainings focus on the transfer of information and place less emphasis on the develop-ment of counseling skills and problem solving; thus, they need to be adapted accordingly. In addition, some participating grandmothers and fathersdespite their perceive lack of preparedness in this areaexpressed their interest to support EBF, particularly when a mother is experiencing difficulties breastfeeding. To encourage this willingness to support mothers to adhere to EBF, we recommend including the opportunity for dialogue with grandmothers and fathers on their support for such remedies.

There is scientific evidence that support by health care personnel as well as family and community mem-bers can indeed improve mothers breastfeeding prac-tices. The WHO published an overview of possible strategies,21 including the role of communities and com-munity-based resource persons in providing support to breastfeeding mothers, as based on a review of the litera-ture and an analysis of 10 case studies. The summary of the findings from the case studies demonstrates

1) the importance of community-based activities for achieving scale, 2) the role of the community as partners, not recipients, and 3) the feasibility of improving practices through a comprehensive approach that involves partnerships at many levels, capacity building, behavior change com-munication, and the creation of an enabling environment.21

A recent publication from KwaZulu Natal, South Africa, reported how trained lay counselors discussed infant-feeding choices and encouraged EBF among pregnant and nursing mothers, which resulted in a longer

period of EBF in supported mothers, compared to mothers with less support.22-24 Another recent publica-tion from South Africa advocates for community inter-ventions to support mothers in their infant-feeding prac-tices.25 The development of a national strategy on the promotion, protection, and support of breastfeeding pro-vides an excellent opportunity for Mozambique to recog-nize the importance of support of breastfeeding mothers and thus incorporate strong policies to generate and sus-tain support for EBF within the family unit and the wider community.

A limitation of our study is that, due to the insuffi-cient experience of the field workers, some issues were not explored in depth (eg, details on the administration of traditional medicines). The original study plan was to recruit mothers irrespective of their HIV status, but because of a misunderstanding, all mothers in 2 sites were HIV-positive. The analysis does not show any difference between the groups, so we believe that the misunderstanding did not impact the final outcomes.

Another limitation is the lack of triangulation; the methodology did not foresee any in-depth interviews or observations. However, we believed that for this explo-ration of the various issues that impede mothers to prac-tice EBF, a more elaborate methodology would have placed too much strain on the limited resources avail-able for the study. The results fit well within the current scientific knowledge reported from other countries in southern Africa, and we are confident that the lack of methods triangulation did not greatly reduce the validity of the findings.

Although the dangers of the early introduction of water and porridges are well documented, less is known about the impact of traditional medicines on the health of young infants, despite that it is frequently used in young children.26 The traditional medicines mentioned by the participants appear to be given for only short periods and in small doses. Their effects on the infants health may thus be very different from the more regular and prolonged administration of water and porridges. It would be useful to conduct more research on the com-position, frequency, and amounts of traditional medi-cines given to infants in Mozambique; on their health effects, including HIV transmission in HIV-exposed infants; and on the possible options to administer these products in a way that does not interfere with EBF. There are some local experiences in which wait-ing to give traditional medicine until after 6 months is acceptable and endorsed by community and tra-ditional leaders. A continuing dialogue between the formal and traditional health care systems on this mat-ter is recommended.



Given the study results, we conclude that interventions to promote and support breastfeeding in Mozambique should incorporate comprehensive communication strat-egies with a strong focus on influential family members such as grandmothers and fathers. To improve EBF rates, it is also crucial to include the capacity building of health care personnel, particularly for breastfeeding counseling and support and for the management of breastfeeding problems, via the establishment of mother support groups and outreach activities, for example. Revitalization of the Baby-Friendly Hospital Initiative may further increase the capacity of health staff regarding breast-feeding promotion. The Ministry of Health has recently reintroduced the initiative with a training of trainers for the southern provinces, and it is committed to fol-low it through. Family and community support for breastfeeding should be promoted and supported. All mothers, family members, and community members should have sufficient knowledge about infant feeding in the context of HIV. These interventions are laid down in Mozambiques national strategy on the promo-tion, protection, and support of breastfeeding, as pub-lished in August 2009.27 This strategy is envisaged to be implemented by the Mozambican Ministry of Health in collaboration with its partners, such as nongovern-mental organizations and community organizations, United Nations agencies, and bilateral partners. Ideally, these activities will increase the practice of EBF in infants up to 6 months of age in Mozambique and sup-port continued breastfeeding up to 2 years and beyond and, as such, contribute to the reduction of infant mor-bidity and mortality in the country.

Acknowledgment

We thank the study participants, Provincial Health Directorates, and Lourdes Fidalgo. This publication is made possible by the support of the American people through the USAID (the United States Agency for International Development) and FICA (the Flemish International Cooperation Agency). The contents are the responsibility of the participating organizations and do not necessarily reflect the views of USAID or the US government.

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Documents

Knowledge, Beliefs, and Practices Regarding Exclusive Breastfeeding of Infants Younger Than 6 Months in Mozambique: A Qualitative Study