Exclusive breastfeeding and HIV/AIDS: a crossectional survey of mothers attending
prevention of mother-to-child transmission of HIV clinics in southwestern Nigeria
Usman Aishat1,2,&, Dairo David1,3, Fawole Olufunmilayo1,3
1Nigeria Field Epidemiology and Laboratory Training Programme, Abuja,
Nigeria, 2Department of Community Medicine, LAUTECH Teaching Hospital,
State, Nigeria, 3Department of Epidemiology and Medical statistics,
of Ibadan, Oyo State, Nigeria
Usman Aishat, Department of Community Medicine,LAUTECH Teaching Hospital Osogbo,
Osun State, Nigeria
prevention of Mother-To-Child-Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) guideline recommends replacement feeding where it is acceptable, feasible, affordable, sustainable and safe. Where this is un-achievable, exclusive breastfeeding (EBF) is recommended during the first six months of life.
a hospital-based cross-sectional study was conducted among 600 HIV-positive using a two-stage sampling technique. Data on socio-demographics, infant feeding choice and factors influencing these choices were collected using semi-structured questionnaires.
majority of the mothers (86.0%) were married and aged 31.0 ± 5.7years. Slightly above half (53.0%) had≤2 children and more than two-third had disclosed their HIV status to their spouses. About two-third (61.0%) were traders with 75.0% earning monthly income ≤N5,000.00k. Half of the mothers had ≥4 antenatal care visits and 85.0% had infant feeding counselling. Infant feeding choices among the mothers were EBF (61.0%), ERF (26.0%) and MF (13.0%). The choice of EBF was influenced by spouse influence (84.0%), family influence (81.0%) and fear of stigmatisation (53.0%). Predictors of EBF were; monthly income (AOR = 2.6, C.I. =1.4-4.5), infant feeding counselling (AOR = 2.7, C.I. = 1.6-6.9) and fear of stigmatisation (AOR = 7. 2, C.I. = 2.1-23.6).
HIV positive mothers are faced with multiple challenges as they strive to practice exclusive breastfeeding. More extensive and comprehensive approach of infant feeding counseling with emphasis on behavioural change programmes in the context of HIV/AIDS within communities is advocated.
Breastfeeding plays a major role in nutrition, health and development for both HIV infected and non HIV infected infants, due to the fact that human milk is the ideal nourishment for infants' survival, growth and development . When the infants are exclusively breastfed for the first six months of life, there is stimulation of immune system and this goes hand in hand with protecting them from diseases like diarrhoea and acute respiratory infections, which are two of the major causes of infant mortality in the developing world .When exclusive breast-feeding is practice, there is a lower risk of HIV transmission than mixed feeding [2,3].
Exclusive Breast Feeding (EBF) is giving the infant no other food or drink, not even water, apart from breast milk (including expressed breast milk), with exception of drops or syrups consisting of vitamins, mineral supplements or prescribed medicine; if it is practice for the first six months of an infant´s life, is a beneficial intervention in saving children´s lives [4,5]. Despite the benefits which results from its practice, EBF rates remain low throughout the world, where globally the rate of exclusive breastfeeding is around 35% . Different regions in the world have reported increase of EBF, for instance from 22% (1996) to 30% (2006) in sub-Saharan Africa, East Asia /Pacific, (excluding China) 27% (1996) to 32% (2006) and in Latin America and the Caribbean, (excluding Brazil, and Mexico) 30% to 45%, despite the reported increase of EBF, the rates are still low . However; according to Nigeria Demographic and Health Survey 2013, only 17.0% of infants at the age below 6 months regardless of their HIV status are exclusively breastfed . This rate suggests some improvement from the previous Nigeria Demographic and Health Survey of 2008 which indicated that only 13% were exclusively breastfed, still the rates are low with observed variations.
Transmission of HIV from mother to child is higher among the mixed fed infants than exclusively breast-fed infants. It is estimated that with Exclusive Breastfeeding (EBF) practice, 13% to 15% deaths of children below 5 years of age could be averted in low and middle-income countries . WHO recommends EBF to both HIV exposed and non exposed infants for the first six months of life, but still EBF rates remain low throughout the world. Globally, the estimated prevalence of exclusive breastfeeding is 35% .
Thus, this study intends to add the knowledge on the observed gap in this area by assessing factors influencing EBF practice among HIV positive mothers in Oyo State. The findings of this study are expected to tell policy decision makers to develop right interventions to promote exclusive breastfeeding hence improvement of child health in Oyo State and Nigeria.
Study area: we conducted a cross-sectional study in PMTCT clinics in
Oyo State between 2012 and 2013. There are three senatorial zones in Oyo State
namely Oyo Central, Oyo South and Oyo North with 10 PMTCT clinics.The location
of the PMTCT clinics within the zones is as follows; Oyo Central-2, Oyo South-5,
Study population : the respondents who were eligible to take part in the
study included; HIV positive mothers who participated in the PMTCT programme
in the 6 facilities, mothers who had babies between the age of 6 weeks to 12
months and mothers attending PMTCT clinics for a period not less than six months
before the study. We excluded mothers or infants who were too sick from the study.
Sample size determination: we calculated the sample size using formula
for single proportion  with prevalence of 0.68 
and 10% non-response rate ,the sample size was 600.
Sampling procedure: a two-stage sampling technique was used. In stage
1: The list of all the PMTCT clinics in each senatorial zone was obtained, and
stratified into three senatorial zones. We used simple random sampling to select
6 clinics out of the 10 in the State using proportional allocation. We selected
three clinics from Oyo South senatorial zone,1 clinic from Oyo Central zone and
2 clinics from Oyo North senatorial zone. Stage 2: The last 6 months' patient
load list from each of the PMTCT clinics was gotten and the total client load
in the 6 facilities was the sampling frame. Respondents were proportionately
allocated based on patients load. The first mother in each clinic was randomly
selected afterwards; every 4th mother selected using systematic sampling until
we arrived at desired sample size per facility.
Study variables :the dependent variable was mother's infant feeding practice
(Exclusive Breast Feeding, Exclusive Replacement Feeding, and Mixed Feeding)
while the independent variables were age, marital status, education and occupation
status of mothers, monthly income, disclosure of HIV status, place of delivery,
mode of delivery, antenatal care visits, gestational age at first antenatal care
Data collection: four trained research assistants collected data from
the selected PMTCT clinics for a period of four weeks using interviewer administered
semi-structured questionnaire. Questionnaire consisted of 4 sections namely:
Socio-demographics, knowledge of mothers on exclusive breastfeeding, infant feeding
practices and factors influencing choice of exclusive breastfeeding practice.
Data analysis: we computed descriptive statistics using Epi-info Version
7.0 (CDC, 2007) to generate summary statistics. Bivariate analyses were done
to measure association between independent variables and infant feeding options
using crude odd's ratio. The p < 0.05 was used to find level of statistical significance.
Logistic regression model was fitted to find factors influencing choice of infant
feeding practice by HIV positive mothers.
Ethical consideration: ethical Review Committee of Oyo State Ministry
of Health gave ethical clearance for this study. Mothers gave written informed
consent. In order to make sure there is confidentiality of any information provided,
the data collection procedure was anonymous.
Background characteristics of HIV positive mothers:
Table 1 shows
background characteristics of HIV positive mothers. The mean age of the mothers
was 31.0 ± 5.7years. Majority of the mothers (86.0%) married and (80.0%) had
babies less than six months of age. More than half had (53.0%) had two children
or less. Two hundred and fifty-three mothers (42.0%) completed secondary school
education and their main occupation was trading. Three hundred and forty-three
(57.0%) were Christians.
Knowledge of HIV mothers on exclusive breast-feeding:
Table 2 shows
two categories of mothers, first group: that is having good knowledge on EBF
if a mother could define EBF properly (that is how to do it correctly and its
duration), second group: having poor knowledge if she could not define it properly.
In this regard, mothers who were able to define it as breastfeeding only without
any other food or liquid for first six months of infant's life had good knowledge
on EBF. The results show that most 158(79%) knew what EBF is, with few (16.2%)
though managed to defined how it is done correctly, missed and reported the duration
for EBF as four and three months, where (4.8%) reported not knowing what it is
as indicated in Table
Infant feeding Practices of HIV positive mothers:
Figure 1 shows the infant
feeding practices of HIV positive mothers. From 600 HIV positive mothers, 480
(80.0%) HIV positive mothers had children with age less than 7 months. Of the
480(80.0%) HIV positive mothers, 293(61.0%) exclusively breastfed their children,
62(12.9%) practiced mixed feeding and 125(26.0%) practiced exclusive replacement
Reasons for choosing exclusive breast feeding by mothers:
Table 3 shows
the reasons for choosing Exclusive Breast Feeding among the mothers. One hundred
and fifty-six (53.0%) chose EBF because they fear stigmatization, one hundred
and seventy-six (60.0%) because breastfeeding prevents childhood infections and
one hundred and forty-seven because of health worker/counselor's influence. Two
hundred and forty-six (84.0%) chose EBF because of their spouse influence, while
two hundred and thirty-six (81.0%) was because of family influence.
Factors influencing the choice of exclusive breastfeeding practice :
Table 4 shows
factors influencing the choice of exclusive breastfeeding practice. Mothers who
earned less than N18,000 were five times more likely to practice EBF (OR = 4.6,
95% CI = 2.45-41.19). Mothers who had ANC visits more than three times were five
times more likely to practice EBF (OR = 4.6, 95% CI = 1.66-32.2). Mothers who
had infant feeding counseling were five times more likely to practice EBF (OR
= 5.2, 95% CI = 2.69-61.94). Fear of stigmatization was one of the predictors
of exclusive breastfeeding. Mothers who fear stigmatization were five times more
likely to practice EBF (OR = 5.2, 95% CI = 2.15-13.00).
Majority of the mothers (93.0%) had monthly income less or equal
N18,000.00k.This similar to finding from Abuja Nigeria where 82.0% of mothers
were earning less than N30,000.00k per month .
Muko et al. reported that 52.0% of mothers in Cameroon were earning less
than $1 per day . This finding suggests that majority
of the mothers were of low socio-economic status and this characteristics
of most African countries. One of the factors that influenced the choice
of exclusive breastfeeding was mother's income. Income influences purchasing
power at household level. It affects affordability and access to infants
feed . Majority of the mothers interviewed had
low monthly income of < N18,000k.Variations in level of income exposed mothers
to different levels of purchasing power. There was a statistical significant
association between monthly income and practicing EBF. This similar to finding
from Kenya by Wapang'ana (2013) where 68.7% of mothers had low annual income
of less than Ksh 12,000 and practiced EBF .
Another factor that influenced the choice of EBF was the receipt of counseling
on infant feeding options during ANC visits. Mothers who received counselling
on infant feeding options recommended for HIV positive mothers chose exclusive
breastfeeding as an option to feeding their children. This finding is in
line with report of Ndubuka et al. where receiving infant feeding counseling
was significantly associated with decision to exclusively breast feed. This
shows that the counseling had good impact on the mother's choice of infant
Comprehensive and explanatory counseling has the potential to greatly influence
mothers' understanding and dedication to exclusive breastfeed and should
form the holistic interventions to improve breastfeeding and exclusive breastfeeding
rates. Strengthening the counseling being provided during antenatal visits
of mothers in health institutions in the study areas and reinforcing counseling
of the HIV positive mothers delivered in the maternity wards on safer infant
feeding options is recommended as part of the PMTCT program in Oyo State.
Number of ANC attendance was also one of the factors that influenced the choice
of exclusive breastfeeding. Mothers who attended ANC clinic three or more
times were four times likely to practice exclusive breastfeeding that those
mothers who did not attend. This also in line with what Hailu (2005) found
in Ethiopia . He reported that there was statistical
significance relationship between ANC attendance and exclusive breastfeeding.
Also Mengistie (2013) reported that mothers who had ANC follow-up were five
times more likely to practice exclusive breastfeeding .
One possible explanation for this finding is the repeated counseling sessions
received by mothers with emphasis on exclusive breastfeeding in the various
health facilities. There was association between practicing exclusive breastfeeding
and fear of stigmatization. Mothers who fear stigmatization were seven times
more seven times more likely to practice exclusive breastfeeding. This finding
is similar to findings of Muhammed et al (2010) and Aswa (2010) where mothers
practice exclusive breastfeeding were doing so to prevent stigmatization
and there was statistical significance between the two [11,17].
Stigmatization within the community makes HIV mothers prone to the practice
of mixed feeding which increases childhood morbidity and mortality.
This study highlights the factors that contributed to adherence to EBF among HIV positive mothers as: mother's belief that breast milk is enough for infant for the first six months of life, health workers influence on breastfeeding specifically EBF, mother's own decision on infant feeding and health workers facilitate immediate initiation of breastfeeding. Other factors were having knowledge on EBF and believing that if one practices it properly, the MTCT through breast milk is almost non- existing. However, there were barriers like lack of disclosure of one's HIV status, community and family pressure to mix feed as it is a norm, breast problems and contradicting messages of health workers on infant feeding.
These findings suggest a need for a more extensive and comprehensive approach of breastfeeding education and especially of exclusive breastfeeding. These important issues related to infant feeding in the context of HIV/AIDS brought up by this study, should taken into account by implementers and policy makers for accelerating exclusive breastfeeding practice among HIV positive mothers. However, since health workers are the sole supporters of infant feeding practices, in particular exclusive breastfeeding, we need to build their capacity to make sure they have current information and positive attitude towards EBF.
Authors declare no competing interest.
AB and MD developed the study protocol, AB participated in data
collection and data analysis and OI Fawole supervised and read
revised version of the manuscripts. All authors have read and approved
the final version of the manuscript.
Authors wish to acknowledge Nigeria Field Epidemiology and Laboratory Training Programme and African Field Epidemiology Network (AFENET) for funding this research.
1: socio-demographic characteristics of respondents
Table 2: knowledge of study participants on EBF (n=600)
respondents reasons for choosing exclusive breast feeding
Table 4: factors influencing the choice of exclusive breastfeeding practice by mothers
Figure 1: infant feeding practices of mothers
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