Ways ahead: protecting, promoting and supporting breastfeeding in the context of HIV

Cultural beliefs, attitudes and perceptions of lactating mothers on exclusive breastfeeding in The Gambia: an ethnographic study

BACKGROUND

WHO/UNICEF recommends that women in resource-poor developing countries- like the Gambia, should exclusively breastfeed their infants for the first six months of their lives because of its health benefits to both mother and infant. The study aimed to explore the cultural beliefs, attitudes, and perceptions of lactating mothers towards exclusive breastfeeding in The Gambia.

METHODS

This was a qualitative ethnographic study of culture-sharing groups of mothers with infants 4 to 6 months old. The study was conducted from July to October 2014 and data collection was done through a face-to-face, in-depth interview and moderate participant observation. The study recruited 22 breastfeeding mothers attending government health facilities in the Kanifing Municipality. The collected data were transcribed verbatim and analyzed through a constant comparison method generating six cultural themes, each with sub-themes.

RESULTS

Baby's welfare is traditionally based on the types of food mother's eat. To this end, mothers reportedly shunned eating green leafy vegetables, liquid and hot foods for their infants' wellbeing. Encounters such as weight loss, nipple inflammation, and backache, which mothers associated with hyper latching and sitting for prolonged breastfeeding, respectively, were among major undesirable physical effects revealed by the participants. Furthermore, the necessity of giving water to infants for their survival was illustrated as a barricade to exclusive breastfeeding practices. Likewise, the entrenched practice of giving charm water to instill the Islamic faith and shielding infants against evil spirits was another factor influencing exclusive breastfeeding practices. Finally, the belief that breast milk adequacy is based on breast size and nurturing men's physical strength by starting prelacteal feeds early in infancy also contributes to the meek exclusive breastfeeding rate among mothers.

CONCLUSION

This study could be a gazette piece for effective policy making and enhance nurses' cultural sensitivity while caring for lactating mothers. Cultural meanings of health care behaviors in lactating mothers challenge universally applying guidelines of exclusive breastfeeding to all societies. The study findings could benefit healthcare providers in informing policies and designing culturally adaptive and acceptable community-based breastfeeding intervention programs in resource-limited settings.

Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care

BACKGROUND

In an effort to prevent infants being infected with SARS-CoV-2, some governments, professional organisations, and health facilities are instituting policies that isolate newborns from their mothers and otherwise prevent or impede breastfeeding.

WEIGHING OF RISKS IS NECESSARY IN POLICY DEVELOPMENT

Such policies are risky as was shown in the early response to the HIV pandemic where efforts to prevent mother to child transmission by replacing breastfeeding with infant formula feeding ultimately resulted in more infant deaths. In the COVID-19 pandemic, the risk of maternal SARS-CoV-2 transmission needs to be weighed against the protection skin-to-skin contact, maternal proximity, and breastfeeding affords infants.

CONCLUSION

Policy makers and practitioners need to learn from the mistakes of the HIV pandemic and not undermine breastfeeding in the COVID-19 pandemic. It is clear that in order to maximise infant health and wellbeing, COVID-19 policies should support skin-to-skin contact, maternal proximity, and breastfeeding.

A qualitative study exploring infant feeding decision-making between birth and 6 months among HIV-positive mothers

Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa. HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.

Individual and Community Perspectives, Attitudes, and Practices to Mother-to-Child-Transmission and Infant Feeding among HIV-Positive Mothers in Sub-Saharan Africa: A Systematic Literature Review

OBJECTIVES

International guidelines on infant feeding for HIV- positive mothers promote Exclusive Replacement Feeding (ERF) (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission of HIV and is strongly discouraged. However, little is known about the ability of women to adhere to recommended feeding strategies to prevent mother-to-child transmission (MTCT) of HIV from breast milk. The objective of this study was to assess the individual and community-level factors that affect perspectives, attitudes and practices of HIV-positive mothers on MTCT and infant feeding in sub-Saharan Africa as documented in peer-reviewed and grey literature.

METHODS

This work is based on an extensive review of peer-reviewed articles and grey literature from the period 2000-2012. The literature search was carried out using electronic databases like Medline Ovid, Google Scholar, PubMed and EBSCOhost. Both quantitative and qualitative studies written in English language on HIV and infant feeding with particular emphasis on Sub-Saharan Africa were included.

RESULTS

The review found low adherence to the chosen infant feeding method by HIV-positive mothers. The following factors emerged as influencing infant feeding decisions: cultural and social norms; economic conditions; inadequate counselling; and mother's level of education.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

Unless local beliefs and customs surrounding infant feeding is understood by policy makers and program implementers, Prevention of Mother-to-Child Transmission (PMTCT) programs will only be partially successful in influencing feeding practices of HIV-positive women. Hence programs should provide affordable, acceptable, feasible, safe and sustainable feeding recommendations that do not erode strong cultural practices. Advice to HIV-positive mothers should be based on local conditions that are acceptable to the community.

HIV and infant feeding in Malawi: public health simplicity in complex social and cultural contexts

Background

The question of when and how to best wean infants born to mothers with HIV requires complex answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse low-income settings. In such settings, infant-feeding practices are not only dependent on individual women’s choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early age of six months and b) explore how the women adhered to their infant-feeding options while facing and managing these challenges.

Methods

This study was conducted between February 2008 and April 2009 at two public health facilities where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included home visits.

Results

Several interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure on them to ignore the medical advice.

Conclusions

The infant-feeding dilemmas for women with HIV are complex. The integration of public health efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome these challenges.

Current knowledge and future research on infant feeding in the context of HIV: basic, clinical, behavioral, and programmatic perspectives

In 2008, between 129,000 and 194,000 of the 430,000 pediatric HIV infections worldwide were attributable to breastfeeding. Yet in many settings, the health, economic, and social consequences of not breastfeeding would have dire consequences for many more children. In the first part of this review we provide an overview of current knowledge about infant feeding in the context of HIV. Namely, we describe the benefits and risks of breastmilk, the evolution of recommended infant feeding modalities in high-income and low-income countries in the last two decades, and contextualize the recently revised guidelines for infant feeding in the context of HIV current knowledge. In the second section, we suggest areas for future research on the postnatal prevention of mother-to-child transmission of HIV (PMTCT) in developing and industrialized countries. We suggest two shifts in perspective. The first is to evaluate PMTCT interventions more holistically, to include the psychosocial and economic consequences as well as the biomedical ones. The second shift in perspective should be one that contextualizes postnatal PMTCT efforts in the cascade of maternal health services. We conclude by discussing basic, clinical, behavioral, and programmatic research questions pertaining to a number of PMTCT efforts, including extended postnatal ARV prophylaxis, exclusive breastfeeding promotion, counseling, breast milk pasteurization, breast milk banking, novel techniques for making breast milk safer, and optimal breastfeeding practices. We believe the research efforts outlined here will maximize the number of healthy, thriving, HIV-free children around the world.