Horizons | Research Summary| Infant Feeding Counseling Within Kenyan and Zambian PMTCT Services: How Well Does It Promote Good Feeding Practices?

RESEARCH SUMMARY

December 2003

Infant Feeding Counseling Within Kenyan and Zambian PMTCT Services: How Well Does It Promote Good Feeding Practices?

Key Findings

Infant feeding counselors explore some but not all key issues with clients.

When speaking to an HIV-positive woman about infant feeding, PMTCT providers in Zambia reported their role as one of giving information, encouragement, and support, and helping women make a decision about an infant feeding option. This was observed to be the case in most counseling sessions. In slightly over half (26/42) of sessions observed, the providers adequately explored (and in 12 observations “somewhat” explored) the feasibility and acceptability of various feeding options. With one exception, every provider made suggestions rather than commands about infant feeding options. Most (87 percent) clients were married or living with a partner, and providers directly addressed partner involvement in infant feeding decisions in three-quarters of the sessions.

But in the majority of sessions, counselors did not ascertain the clients’ specific circumstances regarding household resources, which is necessary to help women consider their ability to implement various feeding choices. For example, while formula was discussed in 38 of the 42 sessions, in only 10 of the 42 sessions did providers inquire whether the mother had money to buy infant formula. Whether the client had access to adequate supplies of water and fuel was asked in only 6 of 42 sessions. Discussions about disclosing HIV status to partners were observed in only 7 of the 42 sessions, and in only 5 of the 42 was the client asked whether she had disclosed her HIV status to other family members or close friends.

Many counselors have biases about infant feeding choices for HIV-positive women.

Data from interviews with providers in Zambia reveal that most providers showed a bias toward infant formula as the preferred infant feeding method for HIV-positive women. For example, when asked, “What are your opinions about HIV-positive women who breastfeed?” five providers gave a positive opinion, 20 were negative (mostly about the risk of infecting the child through breast milk), and seven were neutral and said that it was the woman’s choice (three voiced difficulties about the implementation of this choice rather than whether it is appropriate).

Similarly, in response to the question, “What are your opinions about HIV-positive women who do not breastfeed?” 28 providers had a positive opinion that the woman was doing the “right thing,” one was negative, and six were neutral. Finally, in response to a question on whether they thought there was one best infant feeding method for HIV-positive women, 23 providers replied formula, one replied exclusive breastfeeding for six months, and 11 said there was no best method, because each had advantages and disadvantages. Providers’ opinions about breastfeeding by HIV-positive women and the optimal choice of feeding method for their infants was unrelated to whether he/she had received training on infant feeding counseling.

Clients express satisfaction with counselors and feel they’ve been given choices.

Clients see the counselors as providing convincing, sound, and comforting information about what the optimal choice is and are helping women feel they have made a good decision (even if they have not made much of a decision but rather followed the counselor’s lead). About half (33/67) of women interviewed felt that the infant feeding counseling session had helped them decide how to feed their babies. Twenty-six of the respondents said they had chosen formula feeding, 24 had decided to breastfeed (with about half specifically mentioning exclusive breastfeeding), and five were undecided (the choices of 12 were unknown). Only 19/67 reported that they felt a particular option was being promoted. Instead most felt as this client did:

“[The counseling] did help me decide because I now know advantages and disadvantages [of the infant feeding options].”

PMTCT programs in study sites had mixed success in improving infant feeding practices.

PMTCT infant feeding guidelines recommend exclusive breastfeeding for mothers who are HIV-negative or do not know their HIV status—the majority of women—and either replacement feeding or exclusive breastfeeding for HIV-positive mothers. Successful PMTCT programs should thus be able to show that increasing numbers of women are practicing exclusive breastfeeding, with a proportion of HIV-positive women using replacement feeding, and little use overall of the more dangerous practice of mixed feeding. The extent to which PMTCT programs have improved infant feeding practice were examined by comparing practices among women who used the MCH services before the introduction of PMTCT services (the comparison group) and women in the cohort studies who were exposed to PMTCT information and counseling. Infant feeding practice based on a 24-hour recall for mothers of three-month-old infants in Zambia and six-week-old infants in Kenya are shown in Table 1.

Table 1. Comparison of feeding practiced in 24 hours before interview between women of all HIV status in baseline and in intervention group, by selected age of infant and site

	Lusaka		Karatina		Homa Bay
	Comp.* 2 months n=264 %	Inter.** 3 months n = 374 %	Comp.* 6 weeks n = 328 %	Inter.** 6 weeks n = 588 %	Comp.* 6 weeks n = 329 %	Inter.** 6 weeks n = 380 %
Exclusive breast-feeding	59.8	53.4	34.1	27.0	21.7	25.8
Mixed feeding	38.4	36.8	65.6	68.5	76.5	70.3
Replace-ment feeding	2.4	9.8	0.3	4.4	1.9	4.0
Total	100.0	100.0	100.0	100.0	100.0	100.0
Comp. = Comparison *Inter. = Intervention

The results show that a slightly larger proportion of women who were exposed to PMTCT services reported using replacement feeding, which was expected because infant formula was offered to HIV-infected mothers. However, there is little evidence of a shift from the undesirable practice of mixed feeding to the safer practice of exclusive breastfeeding; a large proportion—about one-third of women in Lusaka and 70 percent of women in the two sites in Kenya—continue to practice mixed feeding. In fact, there was a significant decline in exclusive breastfeeding at one site (Karatina) in Kenya.

In contrast, a study conducted in Ndola, Zambia, by Horizons and its partners1 of the Ndola Demonstration Project (NDP) showed that intensive efforts to improve infant feeding counseling as part of PMTCT programs can help pregnant women make informed choices to protect their health and the health of their infants.

Box: HIV and Infant Feeding Interventions

HIV-negative mothers were somewhat more likely than HIV-positive women to exclusively breastfeed, although they also tended to start mixed feeding earlier.

High rates of exclusive breastfeeding of young babies were seen in Lusaka, where more than 90 percent of HIV-negative and 56 percent of HIV-positive women in the study exclusively breastfed in the first week postpartum (Figure 1). However, by three months, only 56 percent of HIV-negative and 40 percent of HIV-positive women were exclusively breastfeeding, and by six months few children of either HIV-negative or HIV-positive mothers were still being exclusively breastfed.

Most infants at three and six months of age in Lusaka were given mixed feeding: both breast milk and other foods. HIV-negative women were more likely than HIV-positive women to mix breastfeeding and other feeds, with four out of ten HIV-negative women giving mixed feeding by the third month of life and nearly 90 percent by six months (Figure 2). One-quarter of HIV-positive women were practicing mixed feeding at three months and just over half at six months.

Exclusive breastfeeding rates were lower in Kenya, where slightly more than one-quarter of HIV-negative and 15 to 25 percent of HIV-positive women were exclusively breastfeeding their infants at six weeks of age (Table 2). Mixed feeding was quite common in Homa Bay, with 71 and 64 percent of HIV-negative and HIV-positive women, respectively, practicing mixed feeding for six-week-old infants. The lowest use of mixed feeding for young infants was among HIV-positive women in Karatina. The most common feeding practice of HIV-positive women in this site was the use of local foods to completely replace breast milk. Most HIV-negative mothers in Kenya ceased exclusive breastfeeding when their infants were between the ages of three and six months and offered a mix of breast milk and other foods. HIV-positive mothers in Karatina also stopped exclusive breastfeeding at this age but were likely to wean their infants, while most HIV-positive mothers in Homa Bay had stopped exclusive breastfeeding before their children reached three months of age but continued to offer breast milk along with other foods.

Table 2. Feeding practiced in 24 hours before interview for selected ages of infant, by maternal HIV status at Kenyan PMTCT sites

	Karatina			Homa Bay
	HIV-	HIV+	Unknown	HIV-	HIV+	Unknown
Exclusive breastfeeding
6 weeks	28.6	14.9	23.6	28.1	22.3	24.5
3 months	23.9	12.9	18.1	21.4	9.7	14.7
6 months	4.6	2.7	6.2	5.5	4.8	0.0
Mixed feeding
6 weeks	70.9	34.0	73.7	71.4	63.8	74.5
3 months	75.7	25.8	80.6	78.6	69.4	85.3
6 months	94.5	35.1	92.3	93.9	74.2	98.3
Exclusive formula feeding
6 weeks	0	8.5	0	0	3.2	0
3 months	0	12.9	0	0	5.6	0
6 months	0	2.7	0	0	0.0	0
Complementary feeding only (no breast-feeding)
6 weeks	0.5	42.6	0.0	0.5	10.6	1.1
3 months	0.3	48.4	0.0	0.0	15.3	0.0
6 months	0.8	59.5	1.5	0.6	21.0	1.7

A minority of HIV-positive women chose formula feeding.

At the three study sites, HIV-positive women in Lusaka and Karatina used formula more often. The highest use of formula was among HIV-positive women in Lusaka, where 17 percent reported exclusively formula feeding their infants at one week postpartum and 11 percent at three months postpartum. Comparable levels were found in Karatina, with 9 percent reporting exclusively formula feeding their infants at six weeks postpartum and 13 percent at three months postpartum.

Formula was least common in Homa Bay, the most impoverished and most HIV-affected of the three sites, with only 3 and 6 percent of HIV-positive women reporting exclusively using infant formula at the six- week and three-month postpartum visits, respectively. Figure 2 Percent practicing mixed feeding, by maternal HIV status and age of infant, Lusaka, Zambia

Many HIV-positive women did not follow the PMTCT program’s recommendation to wean early.

Though program guidelines recommend a shortened duration of four to six months of breastfeeding for HIV-positive women, a significant number of HIV-positive women at all sites continued to breastfeed their infants at six months of age (Figure 2 and Table 2). More than half of the infants of HIV-positive women in Lusaka and nearly 80 percent of the infants of HIV-positive women in Homa Bay were still receiving breast milk at six months of age. The figure was lower in Karatina, where more than 60 percent of infants had been weaned by the age of six months but where a substantial minority was still receiving breast milk.

There is no evidence of “spillover” of the practice of replacement feeding to women of unknown HIV status.

Some observers have expressed concern that PMTCT programs that discuss replacement feeding for HIV-positive mothers may inadvertently cause other mothers who do not know their HIV status to avoid breastfeeding. This evaluation found little evidence of this “spillover” effect. In Kenya, less than 2 percent of women of unknown status in both Karatina and Homa Bay report exclusive use of infant formula or other replacement feeds (Table 2). This is similar to the very low proportion (less than 1 percent) of HIV-negative women at both sites who use replacement feeds. Thus, women of unknown HIV status living in areas with a PMTCT program are not disproportionately using replacement feeds.

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