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Background: South Africa has a history of low breastfeeding rates among women with and without Human Immunodeficiency Virus (HIV). In this study, we assessed infant feeding knowledge, perceptions and practices among pregnant and postpartum women with and without HIV, in the context of changes in infant feeding and Prevention of Mother-to-Child Transmission of HIV (PMTCT) guidelines. Methods: This was a cross-sectional survey conducted from April 2014 to March 2015 in 10 healthcare facilities in Johannesburg, South Africa. A total of 190 pregnant and 180 postpartum women (74 and 67, respectively, were HIV positive) were interviewed using a semi-structured questionnaire. Multiple regression analyses assessed factors associated with an intention to exclusively breastfeed, and exclusive breastfeeding of infants less than six months of age. Results: Women with HIV had better overall knowledge on safe infant feeding practices, both in general and in the context of HIV infection. There were however gaps in knowledge among women with and without HIV. Information from healthcare facilities was the main source of information for all groups of women in the study. A greater percentage of women without HIV 80.9% (93/115), reported an intention to exclusively breastfeed, compared to 64.9% (48/74) of women with HIV, p = 0.014. Not having HIV was positively associated with a reported intention to breastfeed, Adjusted Odds Ratio (AOR) 3.60, 95% CI 1.50, 8.62. Other factors associated with a reported intention to exclusively breastfeed were prior breastfeeding experience and higher knowledge scores on safe infant feeding practices in the context of HIV infection. Among postpartum women, higher scores on general knowledge of safe infant feeding practices were positively associated with reported exclusive breastfeeding, AOR 2.18, 95% CI 1.52, 3.12. Most women perceived that it was difficult to exclusively breastfeed and that cultural factors were a barrier to exclusive breastfeeding. Conclusions: While a greater proportion of women are electing to breastfeed, HIV infection and cultural factors remain an important influence on safe infant feeding practices. Healthcare workers are the main source of information, and highlight the need for accurate and consistent messaging for both women with and without HIV.
A survey was undertaken from April 2014 to March 2015 in Soweto, Johannesburg. Ten medium and high volume public healthcare facilities, with 50–100 first antenatal care visit patients per month, and providing both antepartum and postpartum care, were selected for the study. Five facilities were selected from each of the two sub-districts in Soweto, a densely populated low and middle income area. At the time of study, the HIV prevalence among pregnant women attending antenatal clinics in Soweto was approximately 29% (unpublished programme data). All pregnant women receive group counselling on infant feeding, with individual counselling also provided for women with HIV. Group and individual counselling on safe infant feeding practices is provided by trained lay-counsellors and professional nurses, and at the time of the study reflected the 2013 and 2015 South African PMTCT guidelines, which are adapted from the WHO guidelines on infant feeding in the context of HIV infection [1, 5, 11]. In both the 2013 and 2015 South African guidelines, the recommendation is for women with HIV to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to 12 months [5, 11]. In the 2013 guidelines, there was provision for either extended infant or maternal antiretroviral prophylaxis for the duration of breastfeeding in women who did not need lifelong ART for their own health [11]. The current recommendation, based on the 2015 guidelines, is for all pregnant and breastfeeding women with HIV to be initiated on lifelong ART, regardless of level of immune suppression [5]. Women without HIV are counselled to exclusively breastfeed for six months, with introduction of complementary food from six months and continued breastfeeding for up to two years or more [5]. A systematic sampling procedure was used to recruit women with and without HIV during pregnancy and up to 12 months postpartum. Every fifth pregnant or postpartum client to enter the facility was invited to participate in the study, and if she declined the next client was recruited. Pregnant women were recruited if they were attending a follow-up antenatal visit, and postpartum if they were attending a clinic visit beyond the sixweeks visit. The study was approved by the University of the Witwatersrand Human Research Ethics Committee (No. M130801), and access to the facilities was granted by the Johannesburg District Health Department. Women who agreed to be part of the study, and were 18 years and older, were interviewed using a semi-structured questionnaire. All study participants provided written informed consent. Approximately 20 antepartum and 20 postpartum women were interviewed in each facility. The questionnaire was in English and the interviews were conducted by lay-educators who had a good understanding of the infant feeding guidelines as they provided PMTCT education sessions at the sites. The interviewers completed the questionnaire and were trained on how to explain the technical terms, and where necessary, translated from the English interview into the two predominant vernacular languages in Soweto, Sesotho and Zulu. A field manager and the study investigators provided supervision throughout the study period. The questionnaire had subsections in the following order: demographics, self-reported HIV status and ART use if HIV-infected, infant feeding intentions among pregnant women and practices among postpartum women, and factors influencing the intentions and practices, sources of infant feeding information, general knowledge on infant feeding, perceptions on exclusive breastfeeding, knowledge of infant feeding in the context of HIV infection, and factors supportive of exclusive breastfeeding. The questions in the questionnaire were a mixture of open-ended and closed questions. The closed questions had predefined options of Yes/No, True/False, and multiple response items. The Food and Agriculture Organization of the United Nations (FAO) guidelines for assessing nutrition-related knowledge, attitudes and practices manual lists open-ended and closed questions as types of questions that can be used in infant feeding surveys [12]. In formulating the knowledge questions, we identified key items that are integral to core knowledge on safe infant feeding practices in general and in the context of HIV infection. The questions were based on the WHO definitions and guidelines on infant feeding, South African PMTCT guidelines and published literature [1, 5, 11, 13, 14]. Several studies on infant feeding, conducted in sub-Saharan Africa, have used questions based on WHO definitions and guidelines on infant feeding to assess knowledge in pregnant and postpartum women with and without HIV [7, 15–19]. In our survey, a total of 16 key-knowledge questions were selected for both pregnant and postpartum women (Table 1). Questions on general knowledge of safe infant feeding practices were asked first, followed by questions on infant feeding in the context of HIV infection, and the questions were ordered such that earlier questions in the questionnaire did not influence responses to later questions. Each question was assigned a score of 1 for a correct answer, and 0 for an incorrect answer, with a maximum score of 16. To assess perceptions on exclusive breastfeeding, we formulated four statements with response options of True, False and Don’t know. The four statements were on perceived ease of exclusive breastfeeding and factors that impact on this practice. Our statements to assess perceptions on exclusive breastfeeding are similar to those used by Kafulafula et al. and Mogre et al. in assessing attitudes towards exclusive breastfeeding [19, 20]. Questions on safe infant feeding practices Study data were collected and managed using REDCap electronic data capture tools hosted at the University of the Witwatersrand, and analysed using Dell Statistica (data analysis software system), version 12, software.dell.com, Dell Inc. (2015) [21]. Means, with standard deviations (SD), and medians with interquartile ranges (IQR) were calculated for continuous data, and frequencies were determined for categorical data. Student’s t-tests and Mann-Whitney tests were used for comparison of means and medians, respectively. Chi-squared and Fisher’s exact tests were used for categorical data and statistical significance was accepted as the two-tailed p < 0.05. Multiple logistic regression analyses were done to determine associations between independent variables and the binary outcome of intention to exclusively breastfeed among pregnant women and exclusive breastfeeding among postpartum women with infants less than six months of age. Variables that had an association with the binary outcomes with a p – value of 0.20 or less in the bivariate analyses were included in the final multivariate model. Variables of particular interest in this study, such as HIV status and feeding knowledge scores, were also included in the final models, irrespective of their significance in the bivariate analyses. The Wald test statistic was used to assess the significance of association between the independent variables, and the intention and practice of exclusive breastfeeding.
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