Abstract
Introduction
In resource-constrained settings, infant feeding decisions among women with HIV (WHIV) must balance the risk of infant HIV acquisition from breastfeeding with increased mortality associated with formula feeding. WHO guidelines recommend countries principally promote a single feeding method for WHIV, either breastfeeding or formula feeding. In 2016, Botswana revised its policy of formula feeding for infants born to WHIV, instead promoting exclusive breastfeeding during the first 6 months of life.
Methods
We sought to understand factors influencing infant feeding choices among WHIV by administering a questionnaire to pregnant and postpartum WHIV (2013–2015) participating in a clinical trial in Botswana (the Mpepu Study). Logistic regression analyses were used to identify factors associated with infant feeding choices.
Results
Of 810 surveyed participants, 24.0% chose breastfeeding and 76.0% chose formula feeding. Women were more likely to choose formula feeding if advised by a health worker to formula feed (aOR 1.90; 95% CI 1.02–3.57) or if they harboured doubts about the potency of antiretroviral treatment (ART) to prevent infant HIV acquisition (aOR 9.06; 95% CI 4.78–17.17). Women who reported lack of confidence in preparing infant formula safely (aOR 0.09; 95% CI 0.04–0.19) or low concerns about infant HIV acquisition (aOR 0.35; 95% CI 0.22–0.55) were significantly less likely to formula feed.
Discussion
Perceptions about ART effectiveness, social circumstances and health worker recommendations were key influencers of infant feeding choices among WHIV. Health system factors and maternal education interventions represent ideal targets for any programmatic actions aiming to shape informed decision-making towards HIV-free survival of infants.
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Data Availability
Available on request.
Code availability
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Acknowledgements
We wish to thank the women and infants who participated in the Mpepu Study and the Mpepu Study Team at Botswana-Harvard AIDS Institute Partnership.
Funding
The study was funded by the US National Institutes of Health (Grant Number R01 HD061265). The funding source had no role in the design and conduct of the study, data collection, analysis, reporting, and decision to submit the manuscript for publication.
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AM cleaned and analysed the data. AM wrote the first draft of the paper and KMP and HBT contributed to subsequent drafts of the manuscript. EM, GA, JM, RLS and SL critically reviewed the manuscript. All authors have read and approved the final manuscript.
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Ethical approval was obtained from the Botswana Health Research Development Committee, the Office for Human Research Administration at Harvard T. H. Chan School of Public Health, and Imperial College Research Ethics Committee.
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All women provided informed, written consent to authorise study participation.
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Appendices
Appendix 1: Infant Feeding Choice Questionnaire
Section I: Previous Pregnancies
-
(1)
This pregnancy represents the first time I have had to make an infant feeding choice (Y/N)
-
(2)
For the last infant, I practiced the following feeding method:
-
a.
Exclusive breastfeeding for at least the first 6 months
-
b.
Exclusive breastfeeding for the first part of the 6 months followed by exclusive formula feeding for the remainder of the 6 months (no other liquids or solids in first 6 months)
-
c.
Mixed breast and formula feeding at the same time during the first 6 months
-
d.
Mixed breastfeeding with introduction of liquids or solids other than formula in the first 6 months
-
e.
Exclusive formula feeding for the entire 6 months
-
f.
Mixed formula feeding with introduction of other liquids or solids in the first 6 months
-
g.
Other (Describe)
-
a.
-
(3)
I was aware of my HIV status when I made the feeding decision for the infant described in question 2 (Y/N)
Section II:
-
(1)
I have disclosed my HIV status to:
-
a.
0 persons in my household
-
b.
1 person in my household
-
c.
2 people in my household
-
d.
3 or more people in my household
-
a.
-
(2)
I have disclosed my HIV status to the father of the child: (Y/N)
-
(3)
I have disclosed my HIV status to:
-
a.
0 persons outside my household
-
b.
1 person outside my household
-
c.
2 people outside my household
-
d.
3 or more people outside my household
-
a.
-
(4)
The individual(s) most influential in assisting me in making an appropriate feeding choice is: (Pick all that apply)
-
a.
The father of my child
-
b.
My mother
-
c.
My sister
-
d.
Family members of the father of my child
-
e.
The antenatal clinic (ANC) feeding counsellors
-
f.
The ANC nurses
-
g.
The ANC physicians
-
h.
Other (describe)
-
i.
No other individual will influence my feeding choice
-
a.
-
(5)
My feeding choice will be influenced by my need to return to work (Y/N)
-
(6)
If Y to question 5, I plan to return to work:
-
a.
1 month after delivery
-
b.
2 months after delivery
-
c.
3 months after delivery
-
d.
> 3 months after delivery
-
e.
Other (describe)
-
a.
-
(7)
Please let us know if you agree or disagree with the following statements
-
a.
“I am worried that my baby will become HIV infected if he/she breastfeeds”
-
b.
“I am worried that my baby is at risk of dying in the next 2 years”
-
c.
“I worry more about my baby getting HIV than about my baby dying”
-
d.
“I worry more about my baby dying than about my baby getting HIV”
-
e.
“I feel I can breastfeed and still keep my baby from getting HIV by using antiretroviral medicines”
-
f.
“I feel I can safely prepare formula for my baby”
-
g.
“I understand the risks and benefits of breastfeeding and formula feeding for my baby”
-
h.
“I am the person who can make the best feeding choice for my baby”
-
i.
“A nurse or a doctor should tell me the best way to feed my baby”
-
a.
(Likert Scale—Strongly disagree to strongly agree range)
Section III. Current Feeding Decisions
-
(1)
I received training/education on the risks and benefits of breastfeeding and formula feeding (Y/N)
-
a.
If Y: I received this training:
(a) at ANC,
(b) at the labour and delivery ward before delivery,
(c) at the maternity ward after delivery
-
a.
-
b.
If Y: The training increased my understanding of the risks and benefits of breastfeeding and formula feeding (Likert Scale—Strongly disagree to strongly agree range)
-
c.
If Y: this training changed my mind about how I am choosing to feed my baby (Y/N)
-
(2)
I have already made a feeding choice for my infant (Y/N)
-
a.
If Y: I made this feeding decision:
(a) before the last trimester of my pregnancy,
(b) during the last trimester of my pregnancy,
(c) at the labour and delivery ward before delivery,
(d) at the maternity ward after delivery
-
a.
-
b.
If N: I have not yet decided how to feed my baby because (check all that apply):
(a) waiting for more advice from nurses/doctors,
(b) waiting for partner input,
(c) waiting for other family member input,
(d) still thinking it over,
(e) unsure
Appendix 2
Mpepu Study infant feeding script outlining the risks and benefits of infant feeding choices.
How you decide to feed your baby is your choice. The health team will support you in whichever choice you make. Before you decide how you will feed your baby, it is important that you understand what the risks and the benefits of the different feeding methods are.
If you are HIV positive, feeding your baby with infant formula is the surest way to protect your baby from becoming infected with HIV after birth. However, babies who are formula fed are more likely to become ill from infections like diarrhoea and respiratory diseases. Babies who are formula fed are also more likely to die from these infections than babies who are breastfed, especially early in life. By 2 years of age, the difference between formula and breastfeeding is smaller, but still present. In a previous study in Botswana, about 9 out of 100 babies died by 2 years if they formula fed, compared with about 7 out of 100 babies who breastfed. Formula feeding has been shown to be a higher risk to infants at times when there are outbreaks of diarrhoeal illnesses in the community. If you choose to formula feed your baby, you can reduce the chance that your baby will become ill from diarrhoea by making sure that the formula is prepared safely, using clean and boiled water, and using clean bottles or a cup and spoon for each feeding. If you choose to formula feed, the Botswana government will provide you with free formula until the baby is 12 months of age.
If you are HIV positive and you breastfeed your baby, your baby may become infected with HIV during breastfeeding. However, the risk of HIV transmission can be reduced if mothers take highly active antiretroviral therapy (HAART) during pregnancy and breastfeeding. Research has shown that HIV transmission during breastfeeding can be lowered to less than 1 in 100 babies when the mother takes HAART from pregnancy and throughout breastfeeding. If you choose to breastfeed your baby, you should not mix breastfeeding with infant formula and other foods/liquids during the first 6 months; rather, you should breastfeed exclusively for the first 6 months (giving only breast milk). Most HIV-infected women who prefer to breastfeed will be able to receive HAART from the Botswana government during pregnancy and breastfeeding, to protect their babies.
If you feel that you can always safely prepare formula, without breastfeeding at all, and can bring your baby in quickly for good medical care any time that he/she becomes ill, then formula feeding may be the best option for your baby. If you are not sure that you can do this, but you do think that you can take HAART, then breastfeeding exclusively for the first 6 months, while taking HAART, may be the best option for your baby.
Appendix 3
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Mussa, A., Taddese, H.B., Maslova, E. et al. Factors Associated with Infant Feeding Choices Among Women with HIV in Botswana. Matern Child Health J 25, 1376–1391 (2021). https://doi.org/10.1007/s10995-021-03155-x
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DOI: https://doi.org/10.1007/s10995-021-03155-x