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Ugandan policy regarding infant feeding for HIV-positive mothers is replacement feeding (RF), if feasible; otherwise, exclusive breastfeeding (EBF) for 3 months is advised (or EBF for 6 months, if RF is still not feasible). HIV-negative mothers should practise EBF for 6 months. The study objective was to explore the association between maternal HIV status and breastfeeding practices in Kabarole, Uganda. Data were collected from questionnaires administered at home to 182 women (44 HIV-positive and 138 HIV-negative) 3 months post-partum and from medical charts. The HIV-negative women were matched on delivery date to HIV-positive women at a ratio of 3:1. Interviewers were blinded to HIV status. There was no statistically significant association between adherence to Ugandan national feeding guidelines and maternal HIV status in bivariate analysis [odds ratio (OR)=1.52; confidence interval (CI): 0.76-3.04]. Multivariate analyses showed a significant association between adherence to feeding guidelines and child illness (OR=0.40; CI: 0.21-0.79) and between adherence to feeding guidelines and rural residence in Burahya county (OR=2.43; CI: 1.15-5.13). Many mothers do not follow the feeding guidelines for HIV infection. This region-specific information on breastfeeding practice determinants will be used to inform local Prevention of Mother-to-Child Transmission (PMTCT) programmes. The nature of the association between child illness and EBF should be further explored. © 2010 Blackwell Publishing Ltd.
This prospective cohort study involved home‐based interviewer‐administered questionnaires and hospital‐based medical chart reviews in Kabarole district, Uganda. Kabarole district is situated in Western Uganda and is made up of three counties: Fort Portal Municipality (urban), Burahya and Bunyangabu (rural). The HIV prevalence rate among pregnant women, as studied over a 14‐year period (1991–2004) in Western Uganda, was 15.3% throughout the study area but 21.3% in urban Fort Portal (Kipp et al. 2009). PMTCT programmes are run in all levels of health facilities offering services ranging from group information sessions to individual HIV testing and counselling. Women in this district were not offered free formula during the study period. The study population comprised a cohort of new mothers, aged 16 years and older who delivered a live singleton baby at Fort Portal Regional Referral Hospital (FPRRH) in Kabarole district between June 20 and September 21, 2007; had a known HIV status (previous HIV‐positive confirmed test or current HIV‐positive or HIV‐negative test result in medical chart); resided in Kabarole district; and had provided informed consent. No participant had a medical condition or had an infant with a medical condition which prohibited breastfeeding. Sample size estimation was based on proportions of HIV‐positive and HIV‐negative women adhering to guidelines documented in published literature and discussions with local and Canadian physicians. It was expected that with a power of 90% and an alpha of 0.05, 44 HIV‐positive and 132 HIV‐negative (1:3 ratio) mothers would be required to detect a 20% difference in adherence to guidelines proportions between HIV‐positive and HIV‐negative mothers given the expectation that approximately 90% of HIV‐positive mothers and 70% of HIV‐negative mothers would EBF for 3 months (STATA 9.1 1984–2005). Based on conservative estimates of 8% HIV prevalence and 700 deliveries in a 3‐month period and to allow for 20% loss‐to‐follow up, the study aimed to recruit 56 HIV‐positive mothers. Women who delivered at FPRRH during the study period were offered HIV testing. Although national guidelines stipulate HIV testing for women who present to deliver, HIV testing was not routinely provided before study initiation because of logistical problems. Therefore, financial incentives were given to nurses (approved by the Uganda National Council of Science and Technology), and the researchers made HIV test kits available, to ensure that testing was done. Nurses were encouraged to provide Nevirapine (as per national PMTCT guidelines) to women and newborns, and to inform women of their HIV test results. Sixty‐one HIV‐positive women delivered at FPRRH within the study period. To obtain a 1:3 ratio of HIV‐positive to HIV‐negative women, 183 HIV‐negative women, matched on delivery date, were selected. All 61 HIV‐positive women and the 183 HIV‐negative women were given information pertaining to the study and provided an initial consent to be contacted (stage 1 consent). A list of addresses and delivery dates was compiled and used to schedule data collection visits. About 3 months post‐delivery, a research assistant (RA) visited the study participants in their homes (or a more convenient location for the participant). Each participant was read an information letter and final consent (stage 2 consent) was obtained. Structured questionnaires were administered to participating women between October 3, 2007 and January 8, 2008. The questionnaires, constructed in English, were based on Modules 2 and 6 of the ‘Breastfeeding and Replacement Feeding Practices in the Context of Mother‐to‐Child Transmission of HIV’ (WHO 2001). The questionnaires consisted of both closed and open‐ended questions to ascertain specific infant feeding information: preferred and actual infant feeding choice, all foods or liquids the infant had been given since birth (with age of introduction and duration), breastfeeding interruption, use of wet nurses, current breastfeeding status, intention to stop breastfeeding, timing and reason, if breastfeeding cessation had already occurred, source of advice, family support and infant feeding problems. Other information from questionnaires included the following variables: HIV knowledge, antenatal attendance, child illness, child immunizations, child survival and demographic data (age, marital status, household composition, education, occupation). In order to verify the type of breastfeeding responses (to obtain a reliable representation of ATG), additional questions were asked on complementary feeding. EBF status was attributed to participants who had fed their child only breast milk from birth to 3 months of age. Questionnaires were translated into Rutooro and back‐translated by a different translator to verify accuracy. The questionnaires were pre‐tested in two Kabarole subcounties to ensure proper interpretation and cultural appropriateness. Each woman was interviewed once between 91 and 121 days post‐delivery. A retest was conducted with 13 randomly selected women as a reliability check approximately 1 week later. The principal investigator (EL) checked questionnaires daily for completeness. RAs also collected socio‐economic information based on fuel source, wall, floor and roof materials, and household possessions. EL and the RAs who administered the questionnaires were blinded to HIV status (unless revealed voluntarily) during participant selection and during the interview process. Questionnaire data were double‐entered into a Microsoft Access 2007 database (Microsoft Corporation, Redmond, WA, USA) to increase accuracy and then transferred to STATA 9.1 (1984–2005). Medical chart reviews were subsequently conducted by the principal investigator (EL) to maintain confidentiality. Data retrieved from the charts related to delivery method, HIV status, parity, gestational age and birthweight of the newborn, and were double‐entered to ensure accuracy. All medical chart data were used in bivariate analyses, but of the medical chart data, only HIV status was used for the multivariate analyses. Analyses included descriptive frequency distributions, chi‐squared tests for categorical variables, t‐tests for continuous variables and multivariate analyses (logistic regression) using STATA 9.1 (1984–2005). For the logistic regression analyses, the dependent variable was adherence to guidelines at 3 months (yes/no). ATG was defined as EBF since birth (or exclusive formula feeding since birth, but no participant met this criterion). The main covariate of interest (and included in all models) was mother’s HIV status (positive or negative); other covariates assessed for inclusion were variables from the questionnaires: demographic variables, health information, socio‐economic characteristics, infant feeding information and medical chart information. If these variables had P ≤ 0.20 on bivariate analyses, they were selected and fit into a multivariate model with HIV status. Variables not included in the model were EBF preference (as this would overshadow all other variables) and variables that were subsets of other variables. For example, respiratory tract infection is a subset of child illness at least once since birth, so the multivariate model included the variable ‘child ever sick’ instead of each significant illness. Covariates were added to the original model (i.e. model with HIV status) one by one. The model was checked for effect modification and confounding of all combinations of variables, by including them in the model and assessing changes in odds ratios of variables previously included. Variables found to be statistically significant in the multivariate model (P < 0.05) were kept in the final model. Ethics approval was obtained from the University of Alberta's Health Research Ethics Board Panel B and the Uganda National Council of Science and Technology. Approval was also obtained from Kabarole's District Health Officer (DHO).
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