Social and contextual factors affecting HIV-infected women’s feeding practices for their infants in normal practice settings : effects on growth and morbidity

Zunza, Moleen (2016-03)

Thesis (PhD)--Stellenbosch University, 2016.

Thesis

ENGLISH ABSTRACT: the significant reduction in HIV transmission through breastfeeding by antiretroviral treatment guided the current recommendations favouring breastfeeding which has to be continued until 12 months of age. Infant feeding guidelines for HIV-infected women in low-resourced settings are primarily informed by studies that spend much effort in controlling guideline adherence by investigators and participants. These studies however may not reflect the real world effects of the feeding options on important outcomes because such efforts are less enforced or rear in primary care settings. Reliable studies are lacking for predicting the real world effects of the feeding options on infant growth and morbidity to guide healthcare authorities in decision making. Social and contextual factors affecting HIV-infected women’s infant feeding practices are major barriers to uptake of infant feeding recommendations to levels that would result in a significant impact. Yet less attention is paid to these during guideline development and implementation. Methods: To address this knowledge gap we performed a longitudinal cohort study in primary healthcare settings, over a 12 months period. The objectives were to a) describe HIV-infected women’s infant feeding practices b) compare infant feeding practices of HIV-infected and HIV-uninfected breastfeeding women c) assess growth and infection-related hospitalizations among predominantly breastfed and predominantly formula-fed HIV-exposed uninfected infants. We explored infant feeding experiences of a sub-set of HIV-infected women who were followed-up for at least 6 months post-delivery in the longitudinal cohort. Results: We found that few HIV-infected women chose breastfeeding, and among those who did, many switched to formula feeding early. The proportion of women who continued predominantly breastfeeding was only slightly lower among HIV-infected compared to HIV-uninfected women (p = 0.0005). These differences were seen from about two weeks, and persisted throughout follow-up. By about four months, half of the HIV-infected women had switched to predominant formula feeding. However, the proportion of HIV-uninfected women who switched to formula feeding was also relatively high. The dual infant feeding option employed by the Western Cape PMTCT program while transitioning from formula feeding policy confused HIV-infected women who were worried that their child may contract HIV through breastmilk because of conflicting messages they received from healthcare providers, possibly explaining why some women stopped breastfeeding. Women’s interpretation of information about risks and benefits of infant feeding options, formula feeding stigma and the quality of infant feeding counselling affected women’s infant feeding practices. Mean weight velocity Z-scores (95% CI) of predominantly breastfed infants was -0.70 (-1.31 to -0.09; p = 0.024) lower than that of predominantly formula fed infants in the two to four months age interval. Protection against infections by breastfeeding was minimal and insignificant, odds ratio (OR) 0.95 (95% CI 0.33 to 2.74). In conclusion, it is important that all women, whether HIV-infected or not, be educated that breastfeeding is the feeding of choice in this setting. The potential of breastfeeding to reduce risks of infections to levels similar to those observed under highly controlled settings, involves changing women’s infant feeding practices. Strategies to promote and sustain continued breastfeeding by women, to levels that would result in a significant impact on the growth and protection against infections of their children are urgently needed. The strategies should be guided by social and contextual factors affecting women’s feeding practices

AFRIKAANSE OPSOMMING: Studies toon aan dat borsvoeding beskermend is teen aansteeklike morbiditeit en ook ‘n betekenisvolle verlaging in MIV oordrag deur borsvoeding en anti-retrovirale behandeling (ARB). Hierdie feite het daartoe aanleiding gegee tot die huidge aanbevelings van borsvoeding as voorkeur tot op 12 maande te gee. Babavoedingriglyne vir MIVgeïnfekteerde vroue in lae-inkomste omgewings word primêr gedryf deur studies wat daarin poog vir die riglynbeheer toepassing deur navorsers en deelnemers. Hierdie studies mag nie noodwendig die werklikheid van voedingsopsies ten opsigte van belangrike uitkomste lewer nie omrede verskeie pogings tot ‘n mindere mate toegepas en selfs raar is in primêre gesondheidsorgomgewings. Daar bestaan ‘n leemte in betroubare studies wat die werklikheidseffekte van voedingsopsies op babagroei en morbiditeit voorspel, en wat daarin poog om gesondheidsorg owerhede se besluitneming te kan beïnvloed. Sosiale en kontekstuele faktore wat MIV-geïnfekteerde vroue se babavoedings keuses beïnvloed, is die hoof hindernis om babavoedingaanbevelings deur te voer wat ‘n betekenisvolle impak sal maak. Minder aandag word aan hierdie aspekte tydens die riglynontwikkeling en implementering spandeer. Om die kennisgaping romdom hierdie aspek te adreseer het ons ‘n longitudinale studie in primêre gesondheidsorgeenhede oor ‘n 12 maande periode ondersoek. Die doelstellings was om a) MIV-geïnfekteerde vroue se babavoedingkeuses te beskryf b) babavoedingpraktyke van MIV-geïnfekteerde vroue en MIV-nie-geïnfekteerde borsvoedende vroue te vergelyk c) groei en infeksie-verwante hospitalisasies onder hoofsaaklik borsvoedende en formule voedende MIV-blootgestelde ongeïnfekteerde babas in primêre gesondheidsorgomgewings oor ‘n 12 maande periode te evalueer. Ons het babavoedingervarings in ‘n sub-groep MIV-geïnfekteerde vroue vir ses maande na bevalling in die longitudinale kohort ondersoek. Resultate: Ons het gevind dat min MIV-geïnfekteerde vroue borsvoeding gekies het, en onder die wat wel het, baie vroeg oorgeskakel het na formule voeding. Die aantal vroue wat hoofsaaklik by borsvoeding gehou het is betekenisvol minder onder die MIV-geïnfekteerde as die ongeïnfekteerde vroue (p = 0.0005). Hierdie verskille is sigbaar teen omtrent twee weke en is regdeur die opvolg waargeneem. Om en by vier maande het die helfte van die MIV-geïnfekteerde vroue na hoofsaaklik formule voeding oorgeskakel. Die gedeelte van die MIV-geïnfekteerde vroue wat oorgeskakel het na formule voeding was ook relatief hoog. Die dubbel babavoedingopsie, wat deur die Weskaapse PMTCT program as opsie gegee word in die oorgangsfase van formule voeding, het MIVgeïnfekteerde moeders verwar omrede hulle bekommerd was dat hulle kinders deur borsmelk MIV mag opdoen weens teenstrydige boodskappe wat hulle van gesondheidswerkers ontvang het, kan moontlik verklaar waarom sommige vroue ophou borsvoed het. Die vroue se interpretasie van die inligting oor risikos en voordele van babavoedingsopsies, formule voedingstigma en die kwaliteit van voedingsberading, het die moeders se voedingskeuses beïnvloed. Gemiddelde massa snelheid Z-tellings (95% VI) van die meerderheid borsvoedende moeders was -0.70 (-1.31 to -0.09; p=0.024) laer as die van die meerderheid formule gevoede babas in die twee tot vier maande ouderdomsinterval. Vroue wat formulevoeding gegee het, het verhoogde persepsies oor MIV oordragrisiko deur borsmelk gehad. Teen ses maande ouderdom, het hoofsaaklik borsgevoede babas gewig teen ‘n tempo van 0.08 (95% vertrouheidsinterval (VI): -0.14 tot -0.02; p = 0.01) opgetel, gewig-vir-ouderdom z-tellings per maand was laer as in die hoofsaaklik formule gevoede babas. Beskerming teen infeksies deur borsvoeding was minimaal en nie betekenisvol nie, kansverhouding (KV) 0.95 (95% VI 0.33 tot 2.74). Gevolglik, is dit belangrik dat alle vroue, ongeag of hulle met die MIV geïnfekteer is of nie, opgevoed te word dat borsvoeding die voeding van keuse is in hierdie omgewing. Strategieë om borsvoeding deur vroue te bevorder, en wat tot betekenisvolle impak op die groei en beskerming teen aansteeklike siektes van hulle kinders voort te sit, is uiters noodsaaklik. Die strategieë behoort deur sosiale en kontekstuele faktore gerig te word wat vroue se voedingskeuses beïnvloed.

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