Determinants of Infant Feeding Options among HIV Infected Women in a PMTCT Setting in Zaria

1. By Musa S, Muktar HM and Abdulkadir I. Nasara Treatment and Care Centre, ABUTH Zaria. Determinants of Infant Feeding Options among HIV Infected Women in a PMTCT Setting in Zaria

2. Introduction Counselling on Infant feeding (IF) options is a routine part of PMTCT programs Options available include exclusive breast-feeding feeding with heat-treated human milk wet-nursing by an HIV-negative woman exclusive replacement feeding with commercial infant formula

3. Introduction Content of counselling is based on accepted standards and recommendations Informed choice The content and quality of the counselling could have substantial impact on choice and outcome

4. Introduction A range of complex interaction of physical & psycho-social factors could bear on IF choice and outcome A recent report detailed IF practices of HIV positive mothers in SW Nigeria Determinants of actual choice of option remains unclear in our setting (Adejuyigbe E, Orji E, Onayade A, Makinde N, Anyabolu H. Infant feeding intentions and practices of HIV-positive mothers in southwestern Nigeria. J Hum Lact. 2008 Aug;24(3):303-10.) (Adejuyigbe E, Orji E, Onayade A, Makinde N, Anyabolu H. Infant feeding intentions and practices of HIV-positive mothers in southwestern Nigeria. J Hum Lact. 2008 Aug;24(3):303-10.)

5. Objectives To determine the content and quality of IF counselling delivered to HIV positive mothers To determine the prevalence of various IF methods To establish the determinants of IF choices & practices

6. Methodology Used qualitative and quantitative research methods Participants observation during IF counselling sessions at both ANC and PNC clinics over 3 months In-depth interviews with purposively selected IF counsellors and nursing mothers at 6 weeks post-delivery using open-ended interview guides to explore infant-feeding decision-making Focus group discussions were also conducted with a purposive sample of pregnant mothers and nursing mothers on IF choices and practices Study was conducted at the PMTCT Clinic of the Nasara Treatment and Care Centre of ABUTH Zaria over a span of 6 months Twenty group and individual IF counselling sessions were observed over 3 months as it was routinely done at both ANC and PNC clinics formally and informally by both trained and untrained counsellors Twenty group and individual IF counselling sessions were observed over 3 months as it was routinely done at both ANC and PNC clinics formally and informally by both trained and untrained counsellors

7. Methodology Informed consent and ethical approval for the study were duly obtained Data analysis Qualitative data analysis involved identifying key categories and recurrent themes concerning infant feeding option, which continued until no new themes or ideas were emerging. Quantitative data was analysed using SPSS Results presented in tables and graphs as appropriate

8. Results IF counselling sessions were observed to be routine part of both ANC and PNC aspects of the PMTCT clinic Both group and individual counselling sessions were done formally and informally Documentation was not universal – often, pregnant women were not even asked of their choices or no reference to previous sessions/choice

9. Results Counselling was more directive than informative Issues of AFASS were not thoroughly discussed before recommending replacement feeding Counsellors sometimes oblige mothers to help them decide on “the best option” Counsellors say their choices for their clients were influenced by their “knowledge” Counsellors often “advise” and sometimes instructs mothers on what infant feeding option to adopt “out of concern” for the babies

11. A total of 67 women were followed up and further observed for IF practices and interviewed at 6 weeks post delivery Two Focus Group Discussions were done with purposively chosen group of HIV infected pregnant women and nursing mothers attending the PMTCT clinic Results

12. Demographic characteristics of FGD Participants

13. Results

14. Results

15. Results 60% of respondents and Majority of Focus Group discussants indicated that there choice of option was based on “what the nurse told me”, “I was advised by the nurse...” Fear of infecting the baby was a major determinant of feeding option for a number of the women: “I don't want my baby to get infected”, “I don’t want to pass it to my baby.” Others said they made IF choice based on the availability of “free formula given to me in the hospital”.

16. Other major determinants of IF option by the mothers were “according to want my husband wanted”, “due to pressures from relatives”, or neighbours, “...there were too many eyes on us” Cost was a major reason for choice for some women: “We could not afford another option”, “Both I and my husband wanted to use formula, but we could not buy... when supplies stopped in the hospital.” Stigma and fear of discrimination was an important determinant of IF option for some of the women: “choosing otherwise would mean disclosing our status!” “did not want to disclose our status” , “People will not buy my wares once they know of my status.” Results

17. Those not breastfeeding say they feel certain emotions such as anger, guilt and inadequacy on occasions: “I feel somehow to see others breastfeed their children while I can not do that to my own baby.” Two nursing mothers indeed had to switch to breastfeeding because of these psychological feelings: “I returned the formula. I could not stand denying the baby breast milk” Results

18. This study is important because it examines the actual determinants of infant feeding choices and practices of HIV-infected women in a PMTCT setting in Zaria The basic principle of ‘informed choice’, promoted through the international guidelines on HIV and infant feeding, requires that an HIV-positive woman be provided with adequate information about the recommended feeding options to make her choice (WHO, 2003). Infant feeding counselling was routinely done at ANC and PNC visits An important strategy to reduce MTCT of HIV Quality and content could influence outcome. This study demonstrates that IF counselling appears sub-optimal in content and quality.

19. Several reports from India, South Africa and Zimbabwe describe women’s choices and their experience with making difficult infant feeding decisions in the context of HIV. 84% of the women in this study opted for replacement feeding as against 13% on exclusive breastfeeding. Similar to the Mashi sub-study in Botswana that reported very high levels (91%) of adherence to formula feeding compared to only 18% adherence to exclusive breastfeeding Contrary to a study from Lusaka, Zambia where less than a quarter were using infant formula

20. This high rate of formula use was on the advice of a counsellor, out of fear of the baby getting infected and because it is given free. In Botswana, formula feeding in HIV-positive women is strongly encouraged and offered free of charge in PMTCT programmes In the Zambian study, cost was given as a factor limiting use of formula Women using infant formula in this study were less optimistic that they could sustain the choice without free milk Social barriers to not breastfeeding as an option such as stigma, discrimination, lack of support from spouse/relatives and cost were identified in the study A recent report from Southwest Nigeria detailed the difficulty of replacement feeding for HIV-infected mothers Those using infant formula were found to be more ready to bear the social consequences of not breastfeeding

21. The majority of mothers reported they had been advised or instructed by midwives and nurses This was a major determinant of choice for many Indicative of the role of the Nurse/counsellor as demonstrated by a study from India Counsellors often “advise” and sometimes instructs mothers on formula “out of concern” for the babies. Advice is not in keeping with counselling concepts based on “informed choice” Informed decision also assumes that “the right decision” will always follow information. Advice also does not take into cognisance the other confounding variables as determinants of IF option

22. Issues of affordability, feasibility, acceptability, safety and sustainability were not being thoroughly discussed before recommending replacement feeding. This negates the guidelines and recommendations Exposes the infants to other potentially life-threatening conditions Women who opted for breastfeeding did that due to possible stigmatization, do not want to disclose status, other options not acceptable by spouse or relatives and pressures from relatives and others. None of those who were breastfeeding believed that their child may not get infected informed their choice. Discussion

23. Those observed to be doing mixed-feeding did so because pressures from others. There were questions on the safety of exclusive breastfeeding which is indicative of the lack of success with the attempts to promote EBF even in the general population Mothers regarded other feeding options as not viable in our community Discussion

24. The findings show that the issue of infant feeding decisions goes beyond mere ‘informed choice’ The choice of infant feeding method is not made in a social vacuum unlinked to the circumstances in which the decision is made Infant feeding choice in the context of HIV infection involves several complex factors including attitudinal, behavioural, economic and social factors. We showed that there was a gap between intentions and choices in a context where decision-making is a complex interaction of several other factors beyond the control of the HIV infected woman Conclusion

25. Recommendations Adopt a more holistic approach in counselling the HIV woman on Infant feeding to include the broader socio-cultural context and the psychological aspects to guide choice Intensify training and re-training of infant feeding counsellors to improve skills and practice Improve support for options taken and encourage greater support by family Need to improve exclusivity of breastfeeding

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