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Background: In 2013, the World Health Organization released a new set of guidelines widely known as Option B+. Prior to that there were guidelines released in 2010. Option B+ recommends lifelong antiretroviral treatment for all pregnant and breastfeeding women living with Human Immunodeficiency Virus. The study aimed at investigating challenges and opportunities in implementing Infant and Young Child Feeding in the context of Prevention of Mother To Child Transmission (PMTCT) guidelines among HIV positive mothers of children aged 0-24 months. The study also examined implications presented by implementing the 2013 PMTCT consolidated guidelines in the transition phase from the 2010 approach in Zambia. Methods: A mixed methods approach was employed in the descriptive cross sectional study utilizing semi structured questionnaires and Focused Group Discussions. Further, data was captured from the Health Information Management System. Results: During the PMTCT transition, associated needs and challenges in institutionalizing the enhanced guidelines from option A and B to option B+ were observed. Nonetheless, there was a decline in Mother to Child Transmission (MTCT) of HIV rates with an average of 4%. Mothers faced challenges in complying with optimal breastfeeding practices owing to lack of community support systems and breast infections due to poor breast feeding occasioned by infants’ oral health challenges. Moreover, some mothers were hesitant of lifelong ARVs. Health workers faced programmatic and operational challenges such as compromised counseling services. Conclusion: Despite the ambitious timelines for PMTCT transition, the need to inculcate new knowledge and vary known practice among mothers and the shift in counseling content for health workers, the consolidated guidelines for PMTCT proved effective. Some mothers were hesitant of lifelong ARVs, rationalizing the debated paradigm that prolonged chemotherapy/polypharmacy may be a future challenge in the success of ART in PMTCT. Conflicting breast feeding practices was a common observation across mothers thus underpinning the need to strongly invigorate Infant and Young Child Feeding information sharing across the continuum of heath care from facility level to community and up to the family; for cultural norms, practices and attitudes enshrined within communities play a vital role in child care.
The study was conducted in Choma district which is situated in the Southern Province of Zambia along the rail line and the major Lusaka – Livingstone highway. It is 289 km (kms) south of Lusaka (the capital city of Zambia) and 188 kms north of Livingstone, one of the tourist cities in Zambia. According to the Choma District Community Medical Office action plan 2013, the expected pregnancies in the district were 5.4% (10812), expected deliveries, 5.2% (10411) and expected live births 4.95% (9911). Shampande and Railway Surgery clinics in Choma district were purposively selected for this study because they were among the model clinics in Zambia to start implementing the PMTCT program, had a high antenatal clinic case load and have a high burden of antenatal HIV (as reported in the District Community Medical Office Action plan, 2013). A cross sectional study design employing mixed methods approach was adopted in the survey. Semi structured questionnaires and focused group discussions (FGDs) were used to collect data. Data were collected between January and April 2015. The study population comprised of HIV positive mothers with children aged 0–24 months who attended PMTCT clinics, nurses who provide PMTCT services and had served in MCH departments for at least five months as well as community health volunteers. Only mothers who had enrolled onto the PMTCT programme from January 2011 (date under the 2010 guidelines roll out) were considered for inclusion in the interviews. This was to ensure that we capture mothers who had transitioned from the 2010 to the 2013 WHO PMTCT guidelines adopted in Zambia. Therefore, a list with names of mothers who met the inclusion criteria in the selected facilities was compiled from the electronic register. Sample size for the mothers component was calculated based on the principle of single population proportion [16, 17]. Considering the proportion of expected mothers per Health Information Management System (HIMS) – Choma district, the estimated number of pregnancies in the catchment population was 5.4% of the total catchment population (Choma DCMO, HIMS, 2013). Hence n = z 2 p (1-p)/ ∂ 2 where: n is the desired sample size; z represents the corresponding z score value at 95% confidence level (1.96); p is the estimated proportion of the target population of mothers enrolled into PMTCT program and ∂ is the margin of error. Therefore, n = 1.962 *0.054(1–0.054) / 0.052. Thus n = 79. To take care of attrition and non-response, a 6% attrition rate was expected and hence the sample size was adjusted upwards, to arrive at a study sample of eighty five (85). Thus, eighty five (85) mothers participated in the study. The mothers were stratified into two age group categories, those below and above 30 years old. Women in the two age categories may have different health seeking behaviors due to mainly differences in education, responsibilities and access to antenatal care [18–20], and may experience different challenges in IYCF. Simple random sampling was used to select participants from these two groups. Ten (10) nurses (five from each clinic) were purposively sampled to participate in the study. Only those who had worked for a minimum of five months in the selected facilities and had been equally involved in transitional implementation of the new guidelines (either in the present facilities or related model facilities under government consideration) were interviewed on the IYCF/PMTCT services that were being provided at these two health facilities. Hence, the 10 nurses represent the total population of health personnel under the criteria providing MCH/PMTCT services at the facilities. A semi structured questionnaire for HIV positive mothers was used to collect information on maternal and infant demographic characteristics, maternal socio-economic characteristics, ANC/PMTCT services uptake and utility, the kind of challenges faced as regards breastfeeding and any social support received. Furthermore, health records on the two clinics were accessed from the Choma DCMO. Data on numbers of all mothers who underwent the PMTCT program, HIV positive mothers enrolled into the PMTCT programme, number of exposed infants taking HIV test, MTCT status from January 2011 to December 2014 was retrieved from these records. Data on antenatal visits, institutional deliveries, HIV status of infants and mothers for the period 2011–2014, infant and young child feeding practices for select clinics was captured from the Health Information Management System (HIMS). An electronic system that tracks relevant clinical information for patients per clinical guidelines across the continuum of health care as earlier described [8, 13, 21–23]. The district health information system feeds into the nation health information system, via the provincial level system. Information from all health facilities within Choma is centrally available at the Choma district health information system unit. Health centres use duplicate systems i.e. paper based (patient cards, registers and tally sheets) and electronic record systems (smartcare) to record client information on a daily basis and ensure all records are progressively captured in electronic version. This is compiled at the end of the month for onward transmission to the district where it is aggregated for progressive submission. Before entries, compilation and aggregation are made and transmitted; reports are checked for completeness correctness and consistence at each level enhanced by systems quality control checks standards for quality threshold. The data was available in excel format and only information on variables of interest for the study was extracted and was found to be complete. A self-administered semi structured questionnaire was used to collect data from health care providers on service delivery information which included: PMTCT/IYCF training, orientations and national guidelines/recommendations, ANC/PMTCT services provision, acceptance and challenges faced in provision of PMTCT/IYCF services. Data collected from the interview and HIMS were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 21. Quantitative data was analyzed by means of descriptive statistics. For focus groups discussion, participants were selected through a combination of convenience and purposeful sampling. Thus, for the pre-screening inclusion guide, the lead researchers agreed by consensus on an inclusion criterion that purposively targeted: (1) volunteers who had received training or orientation (in HIV testing, Infant and young child feeding counseling, Growth Monitoring and Promotion, Adherence counseling, PMTCT lay counseling and related guidelines) and were actively serving the selected facilities MCH departments in tune with Infant and Young Child Feeding (IYCF) as well as PMTCT guidelines, (2) Volunteers who had worked consistently for a minimum of five months in the selected facilities at the time of the study and had prior involvement in transitional implementation of the new PMTCT guidelines. Verification of CHVs meeting the criteria was based on stakeholder recommendations informed by Zambia’s National Community Health Worker Strategy unit on training and tracking of CHVs involvement in the health systems and services delivery [24]. As a result, from the pre-screened CHVs list as guided by inclusion criteria, a sample was purposively selected factoring convenience. Consequently, six CHVs were available for the FGD at Shampande and six from Railway attended out of the targeted eight hence, the considered final coverage from both facilities was deemed sufficient for FGDs scope of objective [25, 26] incorporating the healthcare providers who were willing and available. The two FGDs, one per site were aimed at eliciting information on kinds of community support systems provided to breastfeeding mothers in general and to HIV positive mothers, any challenges faced in PMTCT/IYCF activities and breastfeeding practices in order to cross check mothers responses. The conduct and reporting presented in this paper adhered to the consolidated criteria for reporting qualitative research (COREQ) guidelines [27]. A qualitative design using focus group discussion (FGD) methodology was applied as is an ideal approach to explore perceived motivators and barriers to healthy behaviors [28]. The Focus group discussion sessions lasted between 43 to 65 min. In the course of data collection, probes were used to clarify, and explore the topics. In the concluding minutes of each FGD session a verbal summary of responses was provided to participants by the moderator. Participants were asked to review the summary with an option to provide any other additional comments that may have been missed. The items in FGD interviews were initially formulated in English then translated into Tonga, (a language that is commonly spoken in Southern province of Zambia) for the use in the study location. Data collected in Tonga versions were translated back to English to ensure consistency with the data collected in English versions. All data tools used were pretested at a non-participating Choma Hospital Affiliated Health Centre (HAHC) where HIV positive mothers and health care providers could be accessed for the pretest exercise. All the data from the FGDs; supported by the comprehensive handwritten field notes were transcribed and analyzed into themes manually using the principles of systematic text condensation as described by Malterud [29, 30].The qualitative data generated was organized into thematic content which involved identifying main categories and recurrent themes concerning challenges and opportunities to optimal infant feeding in the context of PMTCT.
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