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Background: Exclusive breastfeeding for the first six months of life is recommended for all infants. However, breastfeeding rates remain suboptimal; around 37% of infants are exclusively breastfed for the first six months globally. In Nyanza region, western Kenya, numerous challenges to breastfeeding have been identified, including food insecurity, hunger, depressive symptoms, and HIV infection. Yet, evidence to inform our understanding of how these problems influence women’s breastfeeding behaviors across time is lacking. We therefore sought to examine these factors and how they interact to affect the initiation and duration of exclusive breastfeeding in this region. We hypothesized that women experiencing greater food insecurity, hunger, and/or depressive symptoms would be less likely to maintain exclusive breastfeeding for six months than women who were food secure or not depressed. We also hypothesized that women living with HIV would be more likely to maintain exclusive breastfeeding to six months compared to HIV-uninfected women. Methods: Women in Pith Moromo, a longitudinal cohort study in western Kenya, were surveyed at two antenatal and three postpartum timepoints (n = 275). Data were collected on breastfeeding behavior and self-efficacy, maternal food insecurity and hunger, maternal psychosocial health, and HIV status. Cox proportional hazards models were used to identify predictors of early exclusive breastfeeding cessation. Results: The majority of women (52.3%) exclusively breastfed for the first six months. In the final multivariable Cox proportional hazards model, living with HIV was associated with a 64% decrease in the rate of early exclusive breastfeeding cessation. Additionally, the rate of early exclusive breastfeeding cessation increased by 100 and 98% for those experiencing probable depression or hunger, respectively. Although there was no main effect of breastfeeding self-efficacy, the interaction between breastfeeding self-efficacy and hunger was significant, such that the rate of early exclusive breastfeeding cessation was predicted to decrease by 2% for every point increase in breastfeeding self-efficacy score (range: 0-56). Conclusions: This study contributes to previous work demonstrating that women living with HIV more consistently exclusively breastfeed and suggests that rates of exclusive breastfeeding could be increased through targeted support that promotes maternal mental health and breastfeeding self-efficacy, while reducing maternal hunger. Trial registration: Study registration NCT02974972.
Data were drawn from Pith Moromo, a longitudinal observational cohort study designed to explore the consequences of food insecurity and HIV during the first 1000 days ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT02974972″,”term_id”:”NCT02974972″}}NCT02974972). Pregnant women (n = 371) were recruited from seven rural, peri-urban, and urban FACES antenatal clinics in Nyanza region, Kenya (near Lake Victoria) between September 2014 and June 2015. Women were eligible for inclusion if they were within their first seven months of pregnancy (assessed using last menstrual period on antenatal cards) and intended to live in the catchment area until their infant(s) reached at least nine months of age. All women living with HIV were prescribed antiretroviral therapy per national guidelines. Quota sampling was used in order to achieve equal numbers of pregnant HIV-unifected women and pregnant women living with HIV (confirmed using colloidal gold rapid tests) by food insecurity categories, assessed using the nine-item Individual Food Insecurity Access Scale (low 0–9, moderate 10–18, and severe 19–27) [45]. Women with HIV were oversampled to detect differences in primary study outcomes (e.g. maternal BMI) by HIV status at a power of 0.8. Luo is both the predominant language spoken and the ethnic group with which the majority of individuals identify. Survey data were collected by Kenyan clinic-based study nurses using paper forms and tablet-based electronic surveys. Interviews were conducted at five time points: twice during the index pregnancy (16–30 weeks and 24–40 weeks) and three times after delivery (1.5, 3, and 9 months postpartum). Sociodemographic characteristics, including age, religion, and ethnic group, were collected at baseline. A principal component analysis was performed on reported household assets and used to represent household wealth. Maternal and infant weight and height/length were collected at all visits. Women were queried about knowledge and intention to breastfeed at the second antenatal visit. Of note, women received standard-care counseling on breastfeeding during their antenatal appointments, with no additional counseling from participation in the study. Women were considered knowledgeable about breastfeeding if they responded that infants should be exclusively breastfed for six months and did not indicate that any other foods or fluids, aside from medicines, could be given. Women were also asked if they intended to exclusively breastfeed for the first six months after birth. At the first postnatal visit, mothers reported on breastfeeding self-efficacy (range: 0–56) [46], defined as the confidence one has in their perceived ability to breastfeed [47], and breastfeeding social support (range: 0–18), defined as the interactions that convey caring, trust, and love to the breastfeeding mother, or task and knowledge sharing that directly assist that person [48]. Participants also reported on infant feeding practices at all postnatal visits, including whether other foods or fluids were provided to the infant, and when. Duration of exclusive breastfeeding was operationalized as the number of days between birth (date extracted from child clinic cards) and the introduction of foods or fluids other than human milk, based on maternal recall. Exclusive breastfeeding was defined using the WHO standard as having provided only breast milk and no other foods or fluids (except medicine). Following reported methodologies, we used both a six-month and 5.5-month cut-off for determining whether infants were exclusively breastfed or not [49–51]. Maternal dietary diversity was assessed at each time point using a 24-h food frequency questionnaire [52]. Maternal food insecurity was measured using the Individual Food Insecurity Access Scale (range: 0–27) [45], which asks about experiences of food insecurity in the past four weeks. Maternal hunger is a measure of severe food insecurity derived from responses to the three most extreme experiences queried in the Individual Food Insecurity Access Scale (range: 0–6) [53]. Individuals were then classified as having low (0–1), moderate (2–3), or high (4–6) hunger. Finally, maternal perceived stress and depression were measured at 1.5 and 9 months postpartum. Depression was assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D, range: 0–60) [54]. We used the cut-off of a score of 17 or higher for probable depression [55, 56]. Maternal stress levels were measured using the Perceived Stress Scale (PSS) (range: 0–40) [57]. Statistical analyses were conducted using Stata 14.0 software with an α of 0.05. Sociodemographic characteristics were compared between women who exclusively breastfed to six months and women who did not using chi-square and t-tests. Cox proportional hazards models were used to identify predictors of early exclusive breastfeeding cessation. In multivariable models, this is a preferred technique because it can account for the length of exclusive breastfeeding for each mother-infant dyad. Time-variant predictors (e.g. food insecurity, depression) measured at the first postnatal visit were used to approximate experiences at delivery. Significant predictors (p < 0.2) of exclusive breastfeeding duration in bivariate analyses were included in multivariable Cox proportional hazards models; variables were then eliminated using a backwards stepwise approach (p < 0.1).
