Maternal and health care workers’ perceptions of the effects of exclusive breastfeeding by HIV positive mothers on maternal and infant health in Blantyre, Malawi

Background: HIV-positive mothers are likely to exclusively breastfeed if they perceive exclusive breastfeeding (EBF) beneficial to them and their infants. Nevertheless, very little is known in Malawi about HIV-positive mothers’ perceptions regarding EBF. In order to effectively promote EBF among these mothers, it is important to first understand their perceptions on benefits of exclusive breastfeeding. This study therefore, explored maternal and health care workers’ perceptions of the effects of exclusive breastfeeding on HIV-positive mothers’ health and that of their infants.Methods: This was a qualitative study within a larger project. Face-to-face in-depth interviews and focus group discussions using a semi- structured interview and focus group guide were conducted. Sixteen HIV-positive breastfeeding mothers, between 18 and 35 years old, were interviewed and data saturation was achieved. Two focus group discussions (FGDs) comprising of five and six adult women of unknown HIV status who were personal assistants to maternity patients, and one FGD with five nurse-midwives working in the maternity wards of Queen Elizabeth Central Hospital in Blantyre, Malawi, were also conducted. Thematic content data analysis was utilized.Results: The study revealed more positive than negative perceived effects of exclusive breastfeeding. However, the fear of transmitting HIV to infants through breast milk featured strongly in the study participants’ reports including those of the nurse-midwives. Only one nurse-midwife and a few HIV-positive mothers believed that EBF prevents mother-to-child transmission of HIV. Furthermore, participants, especially the HIV-positive mothers felt that exclusive breastfeeding leads to maternal ill- health and would accelerate their progression to full blown AIDS.Conclusion: While most participants considered exclusive breastfeeding as an important component of the wellbeing of their infants’ health, they did not share the worldwide acknowledged benefits of exclusive breastfeeding in the prevention of mother-to-child transmission (PMTCT) of HIV. These results suggest a need for more breastfeeding education for all mothers, communities and nurse-midwives involved in breastfeeding counseling in the context of HIV infection. Maternal wellbeing promotion activities such as nutrition supplementation need to be included in all PMTCT of HIV programs. © 2014 Kafulafula et al.; licensee BioMed Central Ltd. This was a qualitative study within a larger study that used in-depth interviews and focus group discussions to investigate mothers and health care workers’ perceptions of effects of exclusive breastfeeding on maternal and infant health in Blantyre, Malawi. The larger study utilized mixed methods and aimed at exploring culture-specific influences of exclusive breastfeeding among HIV-positive mothers in Blantyre, Malawi. In the current study, one-on-one in-depth interviews allowed HIV-positive mothers to participate while maintaining their privacy about their HIV status from other participants. Furthermore, in-depth interviews helped the researcher to explore the participants’ perceptions regarding effects of EBF on maternal and infant’s health. The focus group discussions helped the researchers to obtain comprehensive and diverse data in a short period of time. In addition, focus group discussions provided the researchers an opportunity to collect unanticipated data that would otherwise not have been collected through in-depth interviews. This study has adhered to the qualitative research review guidelines stipulated by BioMed Central. This study was conducted at Queen Elizabeth Central Hospital (QECH) maternity unit in Blantyre, Malawi. Blantyre is situated in the southern region of Malawi. QECH is the largest public hospital in Malawi and functions both as a district hospital for Blantyre and as a referral hospital for the southern region of Malawi. It is also a teaching hospital for different health related professions. Most of the clients that come to QECH are of low and medium socioeconomic status because it is a public and heavily subsidized hospital. The maternity unit, normally known as Chatinkha maternity unit, is one of the busiest maternity units in Malawi with a bed capacity of 250. The unit conducts about 14000 deliveries per year of which 15% are delivered through cesarean section. The unit provides antenatal care to approximately 1,300 new mothers per year and a total of approximately 5,000 visits per year. Mothers who deliver in the unit and those who are referred from other hospitals are cared for in two postnatal wards. One of these postnatal wards is a paying ward for those mothers who can manage to pay and have decided to do so. The unit also has a well established PMTCT program that provides extra services to mothers who are HIV-positive and their infants. Furthermore, the unit provides family planning services within what is called postnatal clinic to approximately 2000 new clients per year [27]. Within QECH, participants were recruited from the postnatal wards, the postnatal clinic and the Cotrim clinic (a clinic that provided early infant HIV screening and cotrimoxazole to HIV exposed infants at the time of this study). Availability of well established PMTCT services provided access for the study of HIV-positive postnatal mothers without the researchers testing the participants for HIV. A purposive sample of 16 HIV-positive breastfeeding mothers, five (5) nurse-midwives and 11 adult women of unknown HIV sero-status was utilized. Purposive sampling allowed the researcher to recruit participants who were able to articulate their experience and provide adequate information on the research phenomenon. The actual sample size of 16 for the HIV-positive breastfeeding mothers was determined based on data saturation. One research assistant (RA) who was a nurse-midwife recruited participants. This RA was from a hospital other than the study setting to prevent coercion of participants. HIV-positive mothers who were at least18 years old, able and willing to give informed consent, able to understand and speak Chichewa and were breastfeeding a single child that was less than 6 months old were recruited. HIV-positive breastfeeding mothers who were sick with AIDS, tuberculosis or other medical conditions were excluded from the study. To qualify for the “women of unknown HIV status” category, one had to be at least 18 years old, of unknown HIV status, a personal assistant/guardian to a maternity patient at Chatinkha maternity unit at the time of the study, a mother with experience of breastfeeding a baby and not related to the participating HIV-positive mothers. These women were included to represent possible views of HIV-negative mothers, and potential mothers and mothers-in-law of HIV-positive mothers on exclusive breastfeeding. Some of the recruited HIV-positive mothers had not disclosed their HIV status to their mothers, mothers-in-law and spouses for fear of being stigmatized. Therefore, significant others of the recruited HIV-positive mothers were not included even though this would have been preferred. Nurse-midwives who had a minimum of two years of experience and who were involved in the care of HIV-positive prenatal and postnatal mothers at QECH during the time of data collection were eligible for the “nurse-midwives” category. The RA introduced the study to potential participants. Recruitment scripts were utilized in order to maintain uniformity. HIV-positive mothers were recruited through the PMTCT program. No HIV testing and screening was conducted because all the mothers who were enrolled in the PMTCT program were HIV-positive. The women of unknown HIV status were recruited from QECH maternity unit guardian lounge while the nurse-midwives were recruited from QECH maternity wards. Data were collected between April 16, 2009 and May 8, 2009. The researcher conducted all the audio-recorded IDIs and FGDs that lasted approximately one hour utilizing semi-structured guides. These IDIs and FGDs were conducted in a quiet private room to promote confidentiality of participants and quality of the audio-recorded data. One RA assisted the researcher with audio-tape recording of FGD sessions. The interview guide for HIV-positive mothers had prompts that elicited information regarding their age, parity, highest level of education reached and age of the infant being breastfed. In addition, the interview guide had a question on disclosure of HIV status. In order to assess participants’ perceived effects of EBF on maternal and infant’s health, all the participants were asked two questions: (1) What are some good things that would happen if you/an HIV-positive mother exclusively breastfed your/her baby? and (2) What are some bad things that would happen if you/an HIV-positive mother exclusively breastfed your/her baby? Participants were probed to elicit more information. Data collection for HIV-positive mothers continued until subsequent interview failed to elicit new information. The two questions used to collect data were part of the semi-structured interview and focus group guides for a larger study that the current researchers conducted to explore culture specific influences of exclusive breastfeeding among HIV-positive mothers in Blantyre, Malawi. These guides were based on Theory of Planned Behavior [25]. The guides were validated by an expert in the area of breastfeeding in Malawi to ensure that they were culturally relevant and understandable to the study sample. Further refining of the guides was done once data collection had started in order to accommodate important emerging issues that the original prompts could not elicit. The main modification to the guides was on the local term used for exclusive breastfeeding because the participants came from different tribes and therefore gave different definitions of exclusive breastfeeding. This made the researchers to decide to give all the participants an operational definition of exclusive breastfeeding. This facilitated uniformity in the understanding of the participants on what exclusive breastfeeding is. See details of the guides in Additional file 1: In-depth Interview Guide; and Additional file 2: Focus Group Discussion Guide. Two transcribers knowledgeable in breastfeeding transcribed verbatim all IDI and FGD audio-tapes. Word by word transcription is helpful for quoting excerpts during data analysis and discussion [28]. The transcription was done in Chichewa (the language the IDIs and FGDs were conducted in). The researcher reviewed each transcription by comparing it to its original recorded version for accuracy. This process required listening to the audio-tapes and reading the transcriptions several times. The Chichewa transcriptions were then translated into English by one bilingual (Chichewa-English) person prior to data analysis. Data analysis was done manually and concurrently with data collection in order to identify and correct errors during the subsequent interviews and focus group discussion, and to improve the guides by incorporating any emerging issues. Thematic content analysis was utilized [29] which was appropriate for this exploratory study. At the beginning of the analysis, the researcher read through one transcript quickly to get a sense of what was in it, and then read it again, this time closely and critically to identify codes that captured meaning [30]. The researcher discussed the initial coding scheme with experts in qualitative data analysis for validation of the accuracy of the codes. After incorporating any comments from the experts, the final coding scheme was then used to code the remaining transcripts from the IDIs and the FGDs. The codes were organized into mutually exclusive categories based on their similarities [29]. The different categories were then brought together to develop overarching themes represented by the different categories [31] which were presented as findings. A detailed record of all what was done was kept to serve as audit trail. Credibility was assured through prolonged immersion of the researcher into the situation, triangulation both by methods and source of data. Additionally, participants were encouraged through probes to share their perspectives without aiming for consensus. Dependability was assured by: (1) using the same semi-structured interview guide with each IDI and FGD although they were allowed to be flexible; (2) providing similar conditions with each group of participants; (3) preparing transcripts promptly; and (4) using direct quotes (the English translations of Chichewa quotes) when presenting findings. Confirmability was assured by providing a detailed description of what was done and decisions made which later served as an audit trail. Finally, transferability was assured by describing the sample and setting in detail so that potential appliers can make transferability decisions [32, 33]. This study was part of the principle author’s academic work at New York University. It was important to get approval from the academic institution’s ethical body and from the site of the study. Therefore, the researchers sought approval from New York University Committee on Activities Involving Human Subjects (UCAIHS) and Malawi College of Medicine Research and Ethics Committee (COMREC) which was granted. Permission to access participants was obtained from the Director of QECH, the Head of Obstetric and Gynecology and Pediatric Departments of QECH. To avoid coercion of participants, health care providers of HIV-positive mothers did not directly participate in recruitment of participants. To help reduce stigmatization of FGD members, no names were used when sharing information and personal experiences were shared as if they were of someone else. Numbers were assigned to participants to be used when quoting information during data analysis. Each participant gave a written informed consent prior to participation.