Determinants of infant feeding choices by Zambian mothers: a mixed quantitative and qualitative study

Abstract

Choosing an infant feeding mode is complex for human immunodeficiency virus (HIV)-infected African women. We documented infant feeding choices by 811 mothers of infants aged less than 18 months enrolled in the Chilenje Infant Growth, Nutrition and Infection Study of fortified complementary or replacement foods. We also conducted 20 interviews and 4 focus group discussions among women and nurses to explore the issues in depth. Practices of most HIV-infected women did not closely follow national or international guidelines: 26% never initiated breastfeeding, and 55% were not breastfeeding by 6 months post partum. Women of lower socio-economic status and those not meeting criteria for safe replacement feeding were more likely to initiate breastfeeding, to continue longer and to stop at 6 months when provided with free food within the trial. Most HIV-negative women and women of unknown HIV status continued breastfeeding into the infant's second year, indicating limited 'spillover' of infant feeding messages designed for HIV-infected women into the uninfected population. Qualitative work indicated that the main factors affecting HIV-infected women's infant feeding decisions were the cost of formula, the advice of health workers, influence of relatives, stigma and difficulties with using an exclusive feeding mode. Rapidly changing international recommendations confused both mothers and nurses. Many HIV-infected women chose replacement feeding without meeting criteria to do this safely. Women were influenced by health workers but, for several reasons, found it difficult to follow their advice. The recently revised international HIV and infant feeding recommendations may make the counselling process simpler for health workers and makes following their advice easier for HIV-infected women.

Figure 1

Maternal HIV status and duration of breastfeeding. HIV, human immunodeficiency virus.

Figure 2

(a) Breastfeeding duration among HIV‐infected women who did (n = 73) or did not (n = 104) meet criteria for replacement feeding. (b) Duration of breastfeeding according to socio‐economic tertile of HIV‐infected mothers. Socio‐economic tertiles were derived from a principal components analysis that included all study women, irrespective of HIV status. P‐value from log‐rank test for the effect on breastfeeding duration of meeting replacement criteria was P = 0.009, and for the effect of socio‐economic tertile was P = 0.02. HIV, human immunodeficiency virus.