Infant feeding counselling for HIV-infected and uninfected women: Appropriateness of choice and practice

  • Bulletin of the World Health Organization, Volume 85, No. 4, Year 2007

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Study Justification:
This study aimed to examine the infant feeding intentions of HIV-infected and uninfected women and assess the appropriateness of their choices based on their available resources. The study also aimed to determine the adherence to these feeding intentions in the first week postnatal. The justification for this study is to provide insights into the factors influencing infant feeding choices among HIV-infected women and to identify the need for appropriate counseling and support.
Study Highlights:
– The study found that most HIV-infected women did not have the necessary resources for safe replacement feeding and therefore chose to exclusively breastfeed.
– Adherence to feeding intentions among HIV-infected women was higher in those who chose to exclusively breastfeed compared to those who chose replacement feeding.
– Among HIV-uninfected women, a majority intended to exclusively breastfeed and had high adherence to this intention postnatally.
– The number of antenatal home visits significantly influenced adherence to feeding intention.
Study Recommendations:
– Provide appropriate counseling and support to HIV-infected women to ensure safe infant feeding practices.
– Increase access to resources such as clean water, adequate fuel, access to a refrigerator, and regular maternal income for HIV-infected women who choose replacement feeding.
– Increase the number of antenatal home visits to improve adherence to feeding intentions.
– Ensure that counseling and support for HIV-infected women do not negatively impact HIV-negative women’s feeding practices.
Key Role Players:
– Lay staff with 12 years of schooling, literacy, numeracy, and basic counseling skills to provide HIV and infant feeding counseling.
– Breastfeeding counselors to support women in their feeding options and provide necessary guidance.
– Project infant feeding specialist to demonstrate safe replacement feeding preparation.
– Healthcare professionals and policymakers to implement and support the recommendations.
Cost Items for Planning Recommendations:
– Training programs for lay staff on HIV counseling, breastfeeding counseling, and HIV and infant feeding counseling.
– Provision of free commercial infant formula for HIV-infected women.
– Resources for antenatal home visits, including transportation and logistics.
– Support for increasing access to clean water, fuel, refrigeration, and regular maternal income for HIV-infected women.
– Monitoring and evaluation of counseling and support programs.
Please note that the cost items mentioned are for planning purposes and not actual costs. The actual budget would depend on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides data on the feeding intentions and practices of HIV-infected and uninfected women, as well as the resources available to them. The study uses a large sample size and includes both rural and urban clinics in South Africa. However, the abstract does not provide information on the study design or methodology, which limits the ability to assess the quality of the evidence. To improve the strength of the evidence, the abstract should include details on the study design, such as whether it was a randomized controlled trial or an observational study. Additionally, information on the statistical analysis methods used would be helpful.

Objective: To examine infant feeding intentions of HIV-infected and uninfected women and the appropriateness of their choices according to their home resources; and to determine their adherence to their intentions in the first postnatal week. Methods: Feeding intentions of pregnant women were compared against four resources that facilitate replacement feeding: clean water, adequate fuel, access to a refrigerator and regular maternal income. First-week feeding practices were documented. Findings: The antenatal feeding intentions of 1253 HIV-infected women were: exclusive breastfeeding 73%; replacement feeding 9%; undecided 18%. Three percent had access to all four resources, of whom 23% chose replacement feeding. Of those choosing replacement feeding, 8% had access to all four resources. A clean water supply and regular maternal income were independently associated with intention to replacement feed (adjusted odds ratio (AOR) 1.94, 95% confidence interval (CI) 1.2-3.2; AOR 2.1, 95% CI: 1.2-3.5, respectively). Significantly more HIV-infected women intending to exclusively breastfeed, rather than replacement feed, adhered to their intention in week one (exclusive breastfeeding 78%; replacement feeding 42%; P < 0.001). Of 1238 HIV-uninfected women, 82% intended to exclusively breastfeed; 2% to replacement feed; and 16% were undecided. Seventy-five percent who intended to exclusively breastfeed adhered to this intention postnatally, and only 11 infants (< 1%) received no breast milk. The number of antenatal home visits significantly influenced adherence to feeding intention. Conclusion: Most HIV-infected women did not have the resources for safe replacement feeding, instead choosing appropriately to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counselling and support, spillover of suboptimal feeding practices to HIV-negative women is minimal.

Pregnant women attending seven rural clinics, one semi-urban clinic and one urban clinic in KwaZulu Natal, South Africa, were offered confidential HIV counselling and testing as part of a cohort study investigating breastfeeding and MTCT. From August 2001 to June 2003 all HIV-infected, and a subsample of uninfected, women were offered enrolment in the study. From July 2003 all women attending antenatal clinics were offered enrolment before HIV testing. After post-test counselling, HIV-infected women were offered a further infant feeding counselling session one to two weeks later. HIV and infant feeding counselling were provided by lay staff who had completed 12 years of schooling and were selected after assessment of literacy, numeracy and basic counselling skills. Their initial training included an HIV counselling course (two weeks), a WHO/UNICEF breastfeeding counselling course (five days),14 and a WHO/UNICEF HIV and infant feeding counselling course (three days).5 Free commercial infant formula for HIV-infected women was not available initially, but was provided by the KwaZulu Natal provincial prevention of mother-to-child transmission (PMTCT) programme starting in December 2002. Personal details including age, past pregnancies, education, water supply, sanitation, access to a refrigerator and income were recorded antenatally. Feeding intentions were compared against four resources considered necessary for safe replacement feeding: access to clean water, a refrigerator, fuel for boiling water (electricity, gas or paraffin) and a regular maternal income. The latter was used as a proxy for a woman’s ability to control financial resources in the household, particularly important in this area where few couples cohabit because of high levels of migration.15,16 Pregnancy outcomes and feeding practices in the first week of life were collected during home visits. Data were captured using optical imaging recognition software (Teleform V7.1, Cardiff Inc., San Diego, CA, USA) in a Microsoft SQL server database. Analyses were carried out using SPSS version 12 (SPSS Inc., Chicago, IL, USA). Univariable and multivariable logistic regression analyses were used to obtain unadjusted and adjusted odds ratios (AOR) and 95% confidence intervals (CIs). The study was approved by the ethics committee of the University of KwaZulu Natal, Durban, South Africa. Pregnant women who were HIV uninfected, or of unknown serostatus, were given information about exclusive breastfeeding for the first six months of the infant’s life, with sustained breastfeeding thereafter. HIV-infected women were counselled on different feeding options available to them. We developed an algorithm for the counsellors to use when presenting infant feeding choices to an HIV-infected woman (Fig. 1). The approach considers the woman’s feeding intention and explores the appropriateness of this based on her home circumstances. Her choice is discussed to understand what she means by breastfeeding and replacement feeding, i.e. whether her choice is based on previous experience or family preferences, whether breastfeeding would be mixed or exclusive, and how long she planned to use this feeding method. Finally, the feasibility of the woman’s intention is explored, focusing on home circumstances, past experiences, family expectations and likelihood of disclosure of HIV status at home. If the woman’s intention seems consistent with her circumstances, the counsellor affirms the woman’s intention, but also mentions that there are options that other women may choose. If the woman’s circumstances do not favour her intention, or a better practice may be feasible, e.g. the woman has the conditions for giving replacement feeding safely, then the counsellor discusses these options in more detail. Counselling algorithm on infant feeding choices for use by lay HIV counsellors After counselling at the clinic, all women received one antenatal home visit by a breastfeeding counsellor (blinded to HIV status) to discuss study logistics and to support the woman in her feeding option. Those choosing replacement feeding were referred to the project infant feeding specialist for a home visit to demonstrate safe replacement feeding preparation. Women who chose to breastfeed received up to three further antenatal home visits (up to four sessions) by the lay breastfeeding counsellor. If a woman changed her mind about her feeding choice antenatally, her intention nearest to the time of delivery was used for analysis. Strict WHO feeding definitions were applied throughout this study.5 Exclusive breastfeeding means an infant receives only breast milk and no other liquids or solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines.

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Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with access to information and resources related to maternal health, including infant feeding counseling. These apps can provide guidance on safe feeding practices, reminders for prenatal and postnatal visits, and access to virtual counseling sessions.

2. Community Health Workers: Train and deploy community health workers who can provide personalized counseling and support to pregnant women, especially those who are HIV-infected. These workers can visit women in their homes, assess their resources and circumstances, and provide tailored advice on infant feeding options based on their individual situations.

3. Peer Support Groups: Establish peer support groups for pregnant women, where they can share experiences, receive emotional support, and learn from each other about infant feeding choices. These groups can be facilitated by trained counselors or community health workers and can provide a safe and non-judgmental space for women to discuss their concerns and receive guidance.

4. Improved Access to Resources: Work towards improving access to clean water, adequate fuel, refrigeration, and regular maternal income for pregnant women. This can involve collaborations with local governments, NGOs, and community organizations to address infrastructure gaps and provide financial support to women in need.

5. Integration of Services: Integrate infant feeding counseling into existing maternal health services, such as antenatal and postnatal care visits. This ensures that pregnant women have access to comprehensive support and information throughout their pregnancy and after childbirth.

6. Training and Capacity Building: Provide training and capacity building programs for healthcare providers, including lay staff and community health workers, on infant feeding counseling. This will ensure that they have the necessary knowledge and skills to provide accurate and appropriate guidance to pregnant women.

7. Continuous Monitoring and Evaluation: Implement a system for continuous monitoring and evaluation of infant feeding practices and counseling outcomes. This will help identify gaps and areas for improvement, and enable the development of evidence-based interventions to further enhance access to maternal health services.
AI Innovations Description
The recommendation to improve access to maternal health in this study is to provide infant feeding counseling to HIV-infected and uninfected women. The counseling should focus on helping women make appropriate choices for infant feeding based on their home resources. This includes considering factors such as access to clean water, adequate fuel, a refrigerator, and regular maternal income.

The study found that most HIV-infected women did not have the resources for safe replacement feeding and instead chose to exclusively breastfeed. Adherence to feeding intentions was higher among HIV-infected women who chose to exclusively breastfeed compared to those who chose replacement feeding.

To implement this recommendation, trained lay staff who have completed counseling courses on HIV and infant feeding should provide counseling sessions to pregnant women. The counseling should include discussing the woman’s feeding intentions, exploring the appropriateness of these intentions based on her home circumstances, and considering the feasibility of her intentions.

After counseling at the clinic, women should receive antenatal home visits by breastfeeding counselors to discuss logistics and provide support for their chosen feeding option. Women choosing replacement feeding should receive a home visit by an infant feeding specialist to demonstrate safe preparation. Women choosing to breastfeed should receive additional antenatal home visits by the breastfeeding counselor.

By providing appropriate counseling and support, the study suggests that the spillover of suboptimal feeding practices to HIV-negative women is minimal. This approach can help improve access to maternal health by ensuring that women make informed and appropriate choices for infant feeding based on their resources and circumstances.
AI Innovations Methodology
In order to improve access to maternal health, one potential recommendation is to provide infant feeding counseling for HIV-infected and uninfected women. This recommendation is based on the findings that most HIV-infected women did not have the resources for safe replacement feeding and instead chose to exclusively breastfeed. Adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than to replacement feed. With appropriate counseling and support, the spillover of suboptimal feeding practices to HIV-negative women is minimal.

To simulate the impact of this recommendation on improving access to maternal health, a methodology could be developed as follows:

1. Identify the target population: Determine the specific group of HIV-infected and uninfected women who would benefit from infant feeding counseling. This could include pregnant women attending antenatal clinics in rural, semi-urban, and urban areas.

2. Develop a counseling program: Design an infant feeding counseling program that includes training for lay staff on HIV counseling, breastfeeding counseling, and HIV and infant feeding counseling. The program should also include guidelines and algorithms for counselors to use when presenting infant feeding choices to women.

3. Implement the counseling program: Offer confidential HIV counseling and testing to all pregnant women attending antenatal clinics. Enroll HIV-infected and a subsample of uninfected women in the study. Offer infant feeding counseling sessions to HIV-infected women one to two weeks after post-test counseling. Provide up to three further antenatal home visits by breastfeeding counselors for women who choose to breastfeed.

4. Collect data: Record personal details of pregnant women, including age, past pregnancies, education, water supply, sanitation, access to a refrigerator, and income. Document feeding intentions and practices during home visits in the first week of life. Use optical imaging recognition software to capture and store the data.

5. Analyze the data: Use statistical software to analyze the data collected. Conduct univariable and multivariable logistic regression analyses to obtain unadjusted and adjusted odds ratios and confidence intervals. Compare feeding intentions and practices among HIV-infected and uninfected women, as well as the impact of counseling on adherence to feeding intentions.

6. Evaluate the impact: Assess the impact of the counseling program on improving access to maternal health by examining the changes in feeding intentions and practices among HIV-infected and uninfected women. Determine if the counseling program leads to increased adherence to safe feeding practices and improved maternal and infant health outcomes.

By following this methodology, it would be possible to simulate the impact of infant feeding counseling on improving access to maternal health and determine its effectiveness in promoting safe feeding practices among HIV-infected and uninfected women.

Statistics:
Citations: 54
Authors: 5
Identifiers:
DOI: 10.2471/BLT.06.032441
ISSN: 00429686
Research Areas:
Community Interventions, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
South Africa
Study Design:
Case-Control Study, Cohort Study
Study Approach:
Quantitative
Participants Gender:
Female
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