Tropical Medicine and International Health
doi:10.1111/tmi.12212
volume 18 no 12 pp 1547–1554 december 2013
Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods study Rose Zulliger1, Elaine J. Abrams2 and Landon Myer3 1 Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 ICAP, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, NY, USA 3 Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
Abstract
objective To explore influences on infant feeding intentions and practices in women living with HIV in South Africa. methods Structured questionnaires were completed by 207 pregnant women and 203 post-partum women in Cape Town, South Africa. Concurrently, 34 semi-structured, qualitative interviews explored the influences on infant feeding strategies in women living with HIV. results Overall, 50% (104) of pregnant women intended to breastfeed and 22% (45) of postpartum women ever breastfed. Women who breastfed or intended to breastfeed were significantly more likely to have running water in their homes, to have formal housing and to receive advice in support of breastfeeding. Advice from clinic staff was the strongest predictor of breastfeeding [adjusted relative odds (ARO) in pregnant women: 6.87; 95% confidence interval (CI): 2.67, 17.66; ARO in post-partum women: 4.04; 95% CI: 1.60, 10.19]. Other important influences included previous infant feeding experiences, desires to protect the infant from HIV and involvement of other care providers. Many women also noted that breastfeeding was not feasible due to work commitments and highlighted concerns around the discontinuation of the free provision of infant formula. conclusion These results suggest that women living with HIV balance complex influences in deciding on their preferred infant feeding strategies. This underscores the need for extensive provider, patient and community education to ensure consistent messaging, while allowing for adaptation to the circumstances of individual mothers. keywords human immunodeficiency virus, breastfeeding, formula feeding, pregnancy, antiretroviral therapy, South Africa
Introduction HIV disproportionately affects women of reproductive age, and nearly one-third of all pregnant women in South Africa are living with HIV (National Department of Health 2012). Despite this high burden of disease, policies on how pregnant women living with HIV should feed their infants have been inconsistent. International and national policies were initially supportive of breastfeeding in all pregnant women, but later shifted to promote formula feeding in certain situations after evidence emerged that HIV could be transmitted through breast milk. Subsequently, South African (SA) policies promoted exclusive breastfeeding (EBF) or exclusive formula feeding (EFF) for infants (Doherty et al. 2011; Goga et al. 2012). South Africa began to provide free formula as a part of its prevention of mother-
© 2013 John Wiley & Sons Ltd
to-child transmission of HIV strategy in 2002 (Doherty et al. 2011). The SA guidelines changed again in 2011, and the Department of Health discontinued free provision of formula for women living with HIV in favour of a policy that promoted EBF with protection against post-natal HIV transmission through antiretroviral use by the mother and the infant (Motsoaledi 2011). As a result of these changing policies, pregnant women living with HIV have received diverse and, at times, conflicting guidance on how to feed their infants, alongside suboptimal infant feeding counselling and support (Chopra et al. 2005; Goga et al. 2012). This has resulted in confusion among healthcare providers and women (Chisenga et al. 2011). Recent studies have consistently shown that breastfeeding uptake is low within South Africa (Tylleskar et al. 1547
Tropical Medicine and International Health
volume 18 no 12 pp 1547–1554 december 2013
R. Zulliger et al. Influences on infant feeding strategies
2011; Ijumba et al. 2012). For example, the most recent SA Demographic and Health Survey found that only 8.3% of infants were exclusively breastfed in 2003 (National Department of Health 2007). Women in one study who reported early breastfeeding did not maintain the practice for very long (Doherty et al. 2006). Previous research has shown that infant feeding choices of women living with HIV were influenced by a variety of actors and experiences. These actors included financial providers (Buskens et al. 2007), health workers and family members (Bland et al. 2002). Feeding choices were also driven by the desire to protect the infant from HIV (Doherty et al. 2006), ability to afford replacement feeding (Thairu et al. 2005; Buskens et al. 2007; Chisenga et al. 2011), cultural norms around mixed feeding (Doherty et al. 2006; Buskens et al. 2007) and perceptions that breast milk was inadequate or insufficient (Buskens et al. 2007). A perceived association of formula feeding with HIV infection has also been noted as influential (Thairu et al. 2005; Chisenga et al. 2011). In light of changing policies around infant feeding and HIV in South Africa and the importance of improving feeding practices in women living with HIV, there is a clear need to better understand HIV-positive women’s infant feeding motivations, experiences and practices. Previous quantitative research has demonstrated low breastfeeding uptake and qualitative research has shown diverse influences on infant feeding, but there have been few mixed methods studies that explore HIV-positive women’s experiences with infant feeding. Additionally, exploration of the factors that currently affect infant feeding decisions can highlight areas for future interventions to address breastfeeding in women living with HIV.
All women living with HIV who attended services at one antenatal clinic (ANC) and one antiretroviral therapy (ART) clinic in the urban township of Gugulethu were screened for participation in the study over 4 months in 2011. As described above, South Africa was in the process of discontinuing the free provision of infant formula to HIV-positive women during the time of data collection, but free formula was still available in these clinics. Women were eligible for the study if they had been diagnosed with HIV and were currently pregnant and/or had delivered a live baby within the past 2 years. Pregnant and post-partum women were purposively invited to participate in the qualitative study to ensure diversity of recruitment clinic and infant feeding intentions and experiences. All participants provided written informed consent and the University of Cape Town Research Ethics Committee approved the study protocol. Quantitative strand Eligible participants were interviewed in Xhosa by trained field workers. Questionnaires covered the sociodemographic background, diagnosis and treatment experiences, and infant feeding practices or intentions of participants. Quantitative data were analysed using Stata (Stata Statistical Software: Release 10.1; Stata Corp., College Station, TX, USA). Participant characteristics were compared using t-tests and Pearson’s Chi-squared tests, as appropriate; all tests were two-sided at a = 0.05. Simple logistic regression analyses determined associations between independent variables and the binary outcome of intention to breastfeed for pregnant women and ever breastfed for post-partum women. Multiple logistic regression models were used to assess the association of a priori exposures of interest and breastfeeding.
Methods This convergent parallel, mixed methods study used structured, quantitative questionnaires and semi-structured, qualitative interviews to explore infant feeding practices, intentions and influences of HIV-positive women in Cape Town, South Africa. A convergent parallel, mixed methods study is one in which researchers concurrently collect and analyse two separate strands of qualitative and quantitative data (Creswell & Plano Clark 2011). This mixed methods study design was selected because it allows for a more complete and rigorous understanding of women’s experiences through methodological triangulation (Bryman 2006; Creswell & Plano Clark 2011). These methods also allow for a more nuanced exploration of the context (Wagner et al. 2012) of infant feeding in women living with HIV. 1548
Qualitative strand Semi-structured, qualitative interviews were conducted in Xhosa with a subsample of pregnant and recently postpartum participants who were included in the quantitative strand. Interviews explored participants’ experiences during pregnancy, HIV diagnosis and disclosure, and infant feeding practices and/or intentions. Transcripts were imported into Atlast.ti 6.2.16 (Scientific Software Development 2010) and read twice prior to coding. Data were coded in a systematic manner using constant comparison to enhance comprehension. Preliminary coding used an open, grounded coding approach in which repeating ideas were identified and coded (Green & Thorogood 2009). These repeating ideas were then organised into themes of influences on feeding practices,
© 2013 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 18 no 12 pp 1547–1554 december 2013
R. Zulliger et al. Influences on infant feeding strategies
which informed the theoretical constructs for analysis (Auerbach & Silverstein 2003). Key domains of interest were infant feeding lessons, infant feeding motivations, facilitators of breastfeeding, barriers to breastfeeding and information sources. Results Of the 406 women living with HIV who participated in the quantitative strand, 203 were recently postpartum and 207 were pregnant (four women were both recently post-partum and currently pregnant). The average age of pregnant women was 28.6 years and that of post-partum women 30.0 years, as shown in Table 1. Most participants had a partner (69% of pregnant women and 76% of post-partum women), and 77% of women with partners reportedly disclosed their HIV status to their partner. Participants in both groups had an average of a tenth-grade education. On average, pregnant women
tested HIV positive more recently than post-partum women. Overall, 22% (n = 45) of post-partum women reported ever breastfeeding; the average time of cessation was 10 weeks post-partum (interquartile range: 2–12). Most (93%, n = 188) women reported that they had ever used formula, including 73% (33 of 45) of women who had ever breastfed. Eighty-four percent (n = 157) of women who used formula had received free formula from the clinic. Higher rates of breastfeeding intention were reported by pregnant women: 50% (n = 104) reported that they planned to breastfeed. Significant differences existed between women who intended to or had breastfed and those that did not. Pregnant women who intended to breastfeed were diagnosed more recently and were more likely to live in a house or hostel, to have closer access to running water and to receive advice to breastfeed (P-values < 0.05). Post-partum women who breastfed, as compared to women who never
Table 1 Characteristics of pregnant and postpartum women by infant feeding plans and practices Pregnant women
Age (years), mean (SD) Marital status, % Single With partner Education (Grade) Positive test (Year) Ever on ART, % Home, % Shack Hostel House Water source, % Tap in Home Tap in Yard Tap off Property Clinic advice, % Breastfeed Formula feed No Advice/choose for Self Friend advice, % Breastfeed Formula feed No Advice/choose for self
Postpartum women
Does not plan to breastfeed (n = 103)
Plans to breastfeed (n = 104)
Total (n = 207)
28.9 (4.8)
28.4 (6.0)
28.6 (5.5)
31.1 68.9 10.9 (1.9) 2008 (3.5) 43.7
30.1 69.9 10.6 (2.2) 2009 (3.2) 32.7
30.6 69.4 10.7 (2.1) 2008 (3.4) 38.2
68.0 3.9 28.2
51.9 9.6 38.5
59.9 6.8 33.3
29.1 18.5 52.4
43.3 26.0 30.8
36.2 22.2 41.6
64.3 3.1 32.7
90.2 0.0 9.8
76.8 1.6 21.6
5.1 19.2 75.8
16.8 0.0 83.2
11.0 9.5 79.5
P-value* 0.52 0.88
0.23 0.03 0.10 0.04
Never breastfed (n = 158)
Ever breastfed (n = 45)
Total (n = 203)
30.2 (5.6)
29.6 (4.5)
30.0 (5.4)
24.2 75.8 10.4 (1.6) 2007 (3.5) 16.5
24.4 75.6 10.6 (1.8) 2008 (3.3) 31.1
24.3 75.7 10.5 (1.6) 2007 (3.5) 19.7
62.0 8.2 29.8
46.7 6.7 46.7
58.6 7.9 33.5
27.2 20.3 52.5
44.4 26.7 28.9
31.0 21.7 47.3
45.2 15.9 38.9
82.2 2.2 15.6
53.5 12.9 33.7
5.7 30.6 63.7
20.0 20.0 60.0
8.9 28.2 62.9
0.01
P-value* 0.54 0.97
0.40 0.07 0.03 0.11
0.02
doi:10.1111/tmi.12212
volume 18 no 12 pp 1547–1554 december 2013
Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods study Rose Zulliger1, Elaine J. Abrams2 and Landon Myer3 1 Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 ICAP, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, NY, USA 3 Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
Abstract
objective To explore influences on infant feeding intentions and practices in women living with HIV in South Africa. methods Structured questionnaires were completed by 207 pregnant women and 203 post-partum women in Cape Town, South Africa. Concurrently, 34 semi-structured, qualitative interviews explored the influences on infant feeding strategies in women living with HIV. results Overall, 50% (104) of pregnant women intended to breastfeed and 22% (45) of postpartum women ever breastfed. Women who breastfed or intended to breastfeed were significantly more likely to have running water in their homes, to have formal housing and to receive advice in support of breastfeeding. Advice from clinic staff was the strongest predictor of breastfeeding [adjusted relative odds (ARO) in pregnant women: 6.87; 95% confidence interval (CI): 2.67, 17.66; ARO in post-partum women: 4.04; 95% CI: 1.60, 10.19]. Other important influences included previous infant feeding experiences, desires to protect the infant from HIV and involvement of other care providers. Many women also noted that breastfeeding was not feasible due to work commitments and highlighted concerns around the discontinuation of the free provision of infant formula. conclusion These results suggest that women living with HIV balance complex influences in deciding on their preferred infant feeding strategies. This underscores the need for extensive provider, patient and community education to ensure consistent messaging, while allowing for adaptation to the circumstances of individual mothers. keywords human immunodeficiency virus, breastfeeding, formula feeding, pregnancy, antiretroviral therapy, South Africa
Introduction HIV disproportionately affects women of reproductive age, and nearly one-third of all pregnant women in South Africa are living with HIV (National Department of Health 2012). Despite this high burden of disease, policies on how pregnant women living with HIV should feed their infants have been inconsistent. International and national policies were initially supportive of breastfeeding in all pregnant women, but later shifted to promote formula feeding in certain situations after evidence emerged that HIV could be transmitted through breast milk. Subsequently, South African (SA) policies promoted exclusive breastfeeding (EBF) or exclusive formula feeding (EFF) for infants (Doherty et al. 2011; Goga et al. 2012). South Africa began to provide free formula as a part of its prevention of mother-
© 2013 John Wiley & Sons Ltd
to-child transmission of HIV strategy in 2002 (Doherty et al. 2011). The SA guidelines changed again in 2011, and the Department of Health discontinued free provision of formula for women living with HIV in favour of a policy that promoted EBF with protection against post-natal HIV transmission through antiretroviral use by the mother and the infant (Motsoaledi 2011). As a result of these changing policies, pregnant women living with HIV have received diverse and, at times, conflicting guidance on how to feed their infants, alongside suboptimal infant feeding counselling and support (Chopra et al. 2005; Goga et al. 2012). This has resulted in confusion among healthcare providers and women (Chisenga et al. 2011). Recent studies have consistently shown that breastfeeding uptake is low within South Africa (Tylleskar et al. 1547
Tropical Medicine and International Health
volume 18 no 12 pp 1547–1554 december 2013
R. Zulliger et al. Influences on infant feeding strategies
2011; Ijumba et al. 2012). For example, the most recent SA Demographic and Health Survey found that only 8.3% of infants were exclusively breastfed in 2003 (National Department of Health 2007). Women in one study who reported early breastfeeding did not maintain the practice for very long (Doherty et al. 2006). Previous research has shown that infant feeding choices of women living with HIV were influenced by a variety of actors and experiences. These actors included financial providers (Buskens et al. 2007), health workers and family members (Bland et al. 2002). Feeding choices were also driven by the desire to protect the infant from HIV (Doherty et al. 2006), ability to afford replacement feeding (Thairu et al. 2005; Buskens et al. 2007; Chisenga et al. 2011), cultural norms around mixed feeding (Doherty et al. 2006; Buskens et al. 2007) and perceptions that breast milk was inadequate or insufficient (Buskens et al. 2007). A perceived association of formula feeding with HIV infection has also been noted as influential (Thairu et al. 2005; Chisenga et al. 2011). In light of changing policies around infant feeding and HIV in South Africa and the importance of improving feeding practices in women living with HIV, there is a clear need to better understand HIV-positive women’s infant feeding motivations, experiences and practices. Previous quantitative research has demonstrated low breastfeeding uptake and qualitative research has shown diverse influences on infant feeding, but there have been few mixed methods studies that explore HIV-positive women’s experiences with infant feeding. Additionally, exploration of the factors that currently affect infant feeding decisions can highlight areas for future interventions to address breastfeeding in women living with HIV.
All women living with HIV who attended services at one antenatal clinic (ANC) and one antiretroviral therapy (ART) clinic in the urban township of Gugulethu were screened for participation in the study over 4 months in 2011. As described above, South Africa was in the process of discontinuing the free provision of infant formula to HIV-positive women during the time of data collection, but free formula was still available in these clinics. Women were eligible for the study if they had been diagnosed with HIV and were currently pregnant and/or had delivered a live baby within the past 2 years. Pregnant and post-partum women were purposively invited to participate in the qualitative study to ensure diversity of recruitment clinic and infant feeding intentions and experiences. All participants provided written informed consent and the University of Cape Town Research Ethics Committee approved the study protocol. Quantitative strand Eligible participants were interviewed in Xhosa by trained field workers. Questionnaires covered the sociodemographic background, diagnosis and treatment experiences, and infant feeding practices or intentions of participants. Quantitative data were analysed using Stata (Stata Statistical Software: Release 10.1; Stata Corp., College Station, TX, USA). Participant characteristics were compared using t-tests and Pearson’s Chi-squared tests, as appropriate; all tests were two-sided at a = 0.05. Simple logistic regression analyses determined associations between independent variables and the binary outcome of intention to breastfeed for pregnant women and ever breastfed for post-partum women. Multiple logistic regression models were used to assess the association of a priori exposures of interest and breastfeeding.
Methods This convergent parallel, mixed methods study used structured, quantitative questionnaires and semi-structured, qualitative interviews to explore infant feeding practices, intentions and influences of HIV-positive women in Cape Town, South Africa. A convergent parallel, mixed methods study is one in which researchers concurrently collect and analyse two separate strands of qualitative and quantitative data (Creswell & Plano Clark 2011). This mixed methods study design was selected because it allows for a more complete and rigorous understanding of women’s experiences through methodological triangulation (Bryman 2006; Creswell & Plano Clark 2011). These methods also allow for a more nuanced exploration of the context (Wagner et al. 2012) of infant feeding in women living with HIV. 1548
Qualitative strand Semi-structured, qualitative interviews were conducted in Xhosa with a subsample of pregnant and recently postpartum participants who were included in the quantitative strand. Interviews explored participants’ experiences during pregnancy, HIV diagnosis and disclosure, and infant feeding practices and/or intentions. Transcripts were imported into Atlast.ti 6.2.16 (Scientific Software Development 2010) and read twice prior to coding. Data were coded in a systematic manner using constant comparison to enhance comprehension. Preliminary coding used an open, grounded coding approach in which repeating ideas were identified and coded (Green & Thorogood 2009). These repeating ideas were then organised into themes of influences on feeding practices,
© 2013 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 18 no 12 pp 1547–1554 december 2013
R. Zulliger et al. Influences on infant feeding strategies
which informed the theoretical constructs for analysis (Auerbach & Silverstein 2003). Key domains of interest were infant feeding lessons, infant feeding motivations, facilitators of breastfeeding, barriers to breastfeeding and information sources. Results Of the 406 women living with HIV who participated in the quantitative strand, 203 were recently postpartum and 207 were pregnant (four women were both recently post-partum and currently pregnant). The average age of pregnant women was 28.6 years and that of post-partum women 30.0 years, as shown in Table 1. Most participants had a partner (69% of pregnant women and 76% of post-partum women), and 77% of women with partners reportedly disclosed their HIV status to their partner. Participants in both groups had an average of a tenth-grade education. On average, pregnant women
tested HIV positive more recently than post-partum women. Overall, 22% (n = 45) of post-partum women reported ever breastfeeding; the average time of cessation was 10 weeks post-partum (interquartile range: 2–12). Most (93%, n = 188) women reported that they had ever used formula, including 73% (33 of 45) of women who had ever breastfed. Eighty-four percent (n = 157) of women who used formula had received free formula from the clinic. Higher rates of breastfeeding intention were reported by pregnant women: 50% (n = 104) reported that they planned to breastfeed. Significant differences existed between women who intended to or had breastfed and those that did not. Pregnant women who intended to breastfeed were diagnosed more recently and were more likely to live in a house or hostel, to have closer access to running water and to receive advice to breastfeed (P-values < 0.05). Post-partum women who breastfed, as compared to women who never
Table 1 Characteristics of pregnant and postpartum women by infant feeding plans and practices Pregnant women
Age (years), mean (SD) Marital status, % Single With partner Education (Grade) Positive test (Year) Ever on ART, % Home, % Shack Hostel House Water source, % Tap in Home Tap in Yard Tap off Property Clinic advice, % Breastfeed Formula feed No Advice/choose for Self Friend advice, % Breastfeed Formula feed No Advice/choose for self
Postpartum women
Does not plan to breastfeed (n = 103)
Plans to breastfeed (n = 104)
Total (n = 207)
28.9 (4.8)
28.4 (6.0)
28.6 (5.5)
31.1 68.9 10.9 (1.9) 2008 (3.5) 43.7
30.1 69.9 10.6 (2.2) 2009 (3.2) 32.7
30.6 69.4 10.7 (2.1) 2008 (3.4) 38.2
68.0 3.9 28.2
51.9 9.6 38.5
59.9 6.8 33.3
29.1 18.5 52.4
43.3 26.0 30.8
36.2 22.2 41.6
64.3 3.1 32.7
90.2 0.0 9.8
76.8 1.6 21.6
5.1 19.2 75.8
16.8 0.0 83.2
11.0 9.5 79.5
P-value* 0.52 0.88
0.23 0.03 0.10 0.04
Never breastfed (n = 158)
Ever breastfed (n = 45)
Total (n = 203)
30.2 (5.6)
29.6 (4.5)
30.0 (5.4)
24.2 75.8 10.4 (1.6) 2007 (3.5) 16.5
24.4 75.6 10.6 (1.8) 2008 (3.3) 31.1
24.3 75.7 10.5 (1.6) 2007 (3.5) 19.7
62.0 8.2 29.8
46.7 6.7 46.7
58.6 7.9 33.5
27.2 20.3 52.5
44.4 26.7 28.9
31.0 21.7 47.3
45.2 15.9 38.9
82.2 2.2 15.6
53.5 12.9 33.7
5.7 30.6 63.7
20.0 20.0 60.0
8.9 28.2 62.9
0.01
P-value* 0.54 0.97
0.40 0.07 0.03 0.11
0.02
