Infant feeding methods among HIV-positive mothers in Yei County, South Sudan

Abstract

Introduction: This study describes the infant feeding methods chosen by HIV-positive mothers in Yei County, South Sudan and the factors that influenced their choice. 

Methods: This cross-sectional study used quantitative and qualitative methods to collect data from a sample of HIV positive mothers from Yei Hospital Mother and Child Health (MCH) section, and St Bakhita Primary Health Care Centre.

Results: The results showed that the mothers’ levels of correct knowledge about HIV transmission to infants, and infant feeding guidelines to prevent transmission were high. Most mothers chose exclusive breastfeeding.

Conclusions: The factors which were significantly associated with the choice of infant feeding methods included: marital status, level of education, income, knowledge about prevention of mother-to-child transmission of HIV, cultural beliefs, social stigma and cost of infant feeding method.

Key words: HIV/AIDS, prevention-of-mother-to-child transmission, infant feeding, South Sudan

Introduction

The fourth Millennium Development Goal, that aimed to reduce mortality rates among young children by two thirds by 2015, depended on optimizing breastfeeding practices. However, there are some conditions which make breastfeeding impossible, difficult or contraindicated. For example, if the mother is HIV-positive (as the virus can be transmitted via breast milk), absent or severely ill. If a mother is HIV-positive, exclusive replacement feeding (e.g. with infant formula) is usually recommended provided it is affordable and safe. This is often not possible in resource limited settings, and then exclusive breastfeeding for 6 months with antiretroviral medication is recommended [1].

            South Sudan’s 2012 Antenatal Care (ANC) Clinics Sentinel Surveillance Report [2] showed that the national HIV prevalence rate dropped from 3.1% in 2007 and 3.0% in 2009 to 2.6% in 2012.The prevalence in Yei County, the site of this study, was1.8% (CI0.3-3.3). With a population of 8,058 pregnant women, the estimated number of mothers who are HIV-positive in Yei County may be as high as 167. This reflects the number of infants exposed to maternally-transmitted HIV [2, 3, 4].Little is known about the level of these mothers’ knowledge about the prevention of mother-to-child-transmission (PMTCT) of HIV.

Objectives

To identify the factors that influence HIV-positive mothers’ choice of infant feeding options including their knowledge of PMTCT, their attitudes towards, and preferences of, infant feeding options, and socio-economic factors.

Methodology

This was a cross-sectional study among HIV-infected women attending postnatal clinics in Yei County. Using the post-natal list from the Yei Hospital mother and child health (MCH) section, and St Bakhita Primary Health Care Centre clinics, 100 consenting mothers with babies aged 0 – 24 months were selected using simple random sampling and were interviewed using a questionnaire designed by the investigator. The sample size was based on the estimated number of HIV-positive mothers in the study areaas per the results of the 2012 ANC sentinel surveillance.

Focus group discussions were held with 20 of the mothers, and two clinic health workers were interviewed. Statistical analysis was done by SPSS version 20 software, logistic regression model was used and odds ratio obtained for the factors that have significant association with choice of exclusive breast feeding, reference p-value of <0.05 was considered as level of significance. Qualitative information was obtained from the focus group discussions and interviews by thematic content analysis.

Results

Table 1 shows the distribution of 100 mothers according to their social-demographic characteristics. The majority were aged between 18 and 34 years, were married, lived in a rural area, had a monthly income of under 1000 South Sudanese pounds and had not reached secondary school; about half were ‘unemployed’ housewives.

 

Table 1. Distribution of mothers by their social-demographic characteristics

Socio-demographic characteristic

 Category

Percent (%)

 

Age years

18-25

35

26-33

38

34-40

21

41and above

6

Marital status

Married

69

Not married

31

Level of education

Pre-School/Primary

84

Secondary/Higher

16

Employment status

Employed

48

Not employed

52

Type of  employment

Private sector

12

Government employee

6

Farmer

30

Housewife

52

Level of monthly income South Sudanese pounds

<1000

85

≥1000

15

Age of child months

0-6

61

7-11

21

≥12

18

Place of residence

Urban

30

Rural

70

 

 

 

 

Table 2 shows the distribution of the mothers’ knowledge about HIV and AIDS, PMTCT and infant feeding guidelines.

 

 

Table 2. Distribution of mothers according to their knowledge of HIV and PMTCT

Variable

Response

Percent (%)

Mother knows meaning/transmission of HIV and AIDS

Yes

97

No

3

Mother has received counselling/information about PMTCT

Yes

97

No

3

Mother thinks counselling sufficient and appropriate

Yes

No

96

4

Mother believes period/s when  HIV can be transmitted to infants is:

During pregnancy only

16

During delivery only

28

During pregnancy, delivery and breast feeding

55

Do not know

1

Mothers knows the guidelines on infant feeding

Yes

89

No

11

 

The information that the mothers were given during counselling, and the feeding option they chose are shown in Table 3.

 

Table 3. HIV-positive mothers’ answers to questions related to infant feeding methods.

Questions and mothers’ answers

Percent (%)

 

Were you counselled on recommended infant feeding options?

Yes

No

 

 

94

6

Which infant feeding options were you advised to use?

Exclusive breastfeeding

Exclusive replacement feeding

 

 

89

11

Which infant feeding option did you choose?*

Exclusive breastfeeding

Exclusive replacement feeding

Mixed feeding

 

 

78

18

4

What was the main reason for your choice of infant feeding method?

The only one I know”

“All women do the same”

“This is the accepted way in my family”

“This is the accepted way in my culture”

“It reduces infant sickness”

“It increases bonding”

“It provided infant with all nutrients”

 

 

13

29

4

13

10

11

19

Who influenced how you fed your infant?

Only myself

Husband

Other family member

 

49

42

9

Did your family influence how you fed your infant?

Yes

No

 

 

54

46

Did your community influence how you fed your infant?

Yes

No

 

 

55

45

* ‘Exclusive breastfeeding’ means giving only colostrum or breast milk (and modern medicines and micronutrients if prescribed) but no other foods, water or other drinks. ‘Replacement feeding’ (or ‘Artificial feeding’) means giving animal milks or other foods instead of breast milk. ‘Mixed feeding’ means giving both breast milk and other milks or foods.

 

The socio-economic factors in Table 4 are the ones that have statistical significance in association with the choice of the appropriate infant feeding method. Age, place of residence, employment and type of employment are the factors with no statistical significance.

 

Table 4. Factors influencing choice of exclusive breastfeeding among HIV+ mothers

Socioeconomic factors

Categories

Number of mothers in category

Number of mothers exclusively breastfeeding

Odds ratio (OR)

P-value

 

 

 

95% confidence  interval (CI)

Lower limit

Upper limit

Marital status

Married

69

68

1.881

0.028

1.681

4.058

Not married

31

10

Ref

 

 

 

Level of Education

Pre-school/primary

84

65

5.436

0.060

1.329

6.247

Secondary/higher

16

13

Ref

 

 

 

Level of Income

SSP/month

< 1000

85

66

5.635

0.050

3.632

6.243

≥ 1000

15

12

Ref

 

 

 

Knowledge of PMTCT

Yes

87

67

9.842

0.058

4.366

10.367

No

13

11

Ref

 

 

 

Cultural beliefs influence

Yes

88

68

2.764

0.010

 

1.314

2.909

No

12

10

Ref

 

 

 

Social stigma

Stigmatized

88

67

1.735

0.003

1.635

3.782

Not stigmatized

12

11

Ref

 

 

 

Perceived cost of infant feeding method 

 

Cheap

 

89

 

68

 

2.332

 

0.020

 

1.841

 

5.331

 

Expensive

 

11

 

10

Ref

 

 

 

Discussion

The results show that almost all the mothers were well informed regarding PMTCT and the recommended guidelines for feeding their babies. This may be attributed to the fact that health workers in Yei County had counselled the mothers using the PMTCT and Infant Feeding guidelines at their health facilities, and that mothers were willing to receive this information for the sake of their babies’ health. Secondly, given the HIV status of the mothers, health workers would have given them special care and counselling whenever they visited the health facility for antenatal, delivery and post natal care. Similar results were obtained in a study in Kinshasa [5] where HIV-positive mothers knew about, and adhered to, recommended infant feeding methods. Most of these mothers attended antenatal and post natal care visits where health workers gave HIV/AIDS and PMTCT counselling and other support services as required.

 

Table 3 shows that 78% mothers exclusively breastfed, 18% used exclusive replacement feeding and 4% used mixed feeding. The finding that most mothers were using exclusive breastfeeding, which provides optimal nutrition and protection against infections, is in agreement with the World Health Organization and South Sudan guidelines [1, 6].

 

The results agree with the findings of a study in Kenya and Zambia where most mothers preferred exclusive breastfeeding and continued to exclusively breastfeed their infants even after the recommended six months [7]. However they are contrary to those from a study in Nigeria where the 94% of HIV-positive mothers choose formula (replacement) feeding and 4%admitted to mixed feeding. The major factor influencing the choice of infant feeding by 85% of these Nigerian mothers was the desire to reduce the risk of HIV transmission [8]. For a third of these mothers the greatest support in maintaining their chosen infant feeding option was the spouse. Differences in these studies may be due to socio-cultural variation between South Sudan communities and those communities.

 

            In our study mothers expressed different attitudes, preferences and practices regarding the different infant feeding methods; these were based on social and economic factors as well as on the health implications involved after choosing a certain method.

            Our Yei study also found out that specific socio-economic factors have a statistical significance of association with the choice of infant feeding method (Table 4). These factors include marital status, level of education, level of income, family and community members, cultural beliefs, social stigma and perceived cost of the feeding method. Of these factors the ones that could be important when designing local interventions for PMTCT may include mothers’ knowledge and education, family and community members, cultural beliefs, social stigma and perceived cost of feeding method.

            Results from the focus group discussions and key informants’ interviews, while confirming that the majority of the mothers preferred and practiced exclusive breastfeeding, highlighted additional challenges faced by those mothers using replacement feeding These include social stigma, high costs of infant formula, and the influence of family and community members on the mother’s choice of infant feeding methods. The in-depth study in Nigeria also found that a major challenge faced by formula-feeding mothers was stigmatization [8].

            Our questionnaire was not validated, but the rigor of the study was ensured by using both quantitative and qualitative approaches which captured the factors influencing mothers’ infant feeding choices.

Conclusion

HIV/AIDS and PMTCT knowledge among HIV-positive mothers was high due to the counselling and supportive services given by health workers. Exclusive breastfeeding is the most preferred and practiced method followed by exclusive replacement feeding, while mixed feeding was the least preferred and practiced method in Yei County. Socio-economic factors such as marital status, education, social stigma, cultural beliefs, cost of infant feeding method and income were associated with the choice of the infant feeding methods among these mothers.

References

  1. World Health Organization. 2010. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO, Geneva http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf?ua=1
    http://apps.who.int/iris/bitstream/10665/44345/1/9789241599535_eng.pdf
  2. Southern Sudan Antenatal Care Clinics Sentinel Surveillance Report. Sep - Dec 2009 and South Sudan Antenatal Care Clinics Sentinel Surveillance Report. Sep - Dec 2012.
  3. Sudan Household Health Survey, 2006 (SHHS1), Final report Aug 2007 and South Sudan Household Health Survey, 2010 (SSHHS2), Final report Aug 2013.
  4. Ojukwu, IJ - ‎2010: Utilization of prevention of mother-to-child transmission of HIV(PMTCT) at Juba Teaching Hospital (South Sudan) repository.uonbi.ac.ke/handle/11295/13777.
  5. Maman S, Cathcart R, Burkhardt G, Omba S, Thompson D et al. 2012: The infant feeding choices and experiences of women living with HIV in Kinshasa, Democratic Republic of Congo. AIDS care: psychological and Socio-medical Aspects of AIDS/HIV, 24 (2) 259-265.
  6. South Sudan Prevention of Mother to Child Transmission of HIV (PMTCT) Guidelines, 2012.
  7. Rutenberg N. et al. 2003: Evaluation of United Nations-Supported Pilot Projects for prevention of mother to child transmission of HIV. New York: UNICEF and Population Council. http://www.unicef.org/evaldatabase/files/Global_2003_UN_Supported_PMTCT_Projects.pdf
  8. Oladokun RE, Brown BJ, Osinusi K. 2010: Infants Feeding Patterns of HIV Positive women in a PMTCT Programme. AIDS Care: Psychological and socio-medical Aspects of AIDS.22 (9) 1108-1114.http://www.ncbi.nlm.nih.gov/pubmed/20229369