Determinants of infant and young child feeding practices among HIV positive mothers in KIbera, Nairobi Kenya
Introduction and Background HIV/AIDS is one of the biggest health and development challenges in Africa. It is a major cause of infant and childhood morbidity and mortality. In children under five years of age, HIV/AIDS now accounts for 7.7% of mortality worldwide. It already accounts for a rise of more than 19% in infant mortality and a 36% rise in the under- five mortality. Together with factors such as declining immunization, HIV/AIDS is threatening recent gains in infant and child survival and health. Yet, for the most part, HIV infection in children is preventable (WHO/UNICEF; 2004). Objectives The main objective of the study was to determine the factors influencing infant and young child feeding choices and practices among HIV positive mothers with children below 24 months of age in Kibera, Nairobi. Specifically the study aimed at determining: The proportion of HIV positive mothers practicing different feeding methods ; Maternal knowledge and attitude on appropriate infant feeding practices in the absence of HIV/AIDS and in view of maternal to child transmission of HIV/AIDS; Socio-demographic, economic, health-related and cultural factors affecting infant feeding practices among HIV positive mothers; To compare HIV-positive mothers with different feeding methods with regard to these factors. Methodology A descriptive cross-sectional study was conducted in Kibera, Nairobi between January 2007 % and March 2007 in which the study population included HIV positive mothers living in Kibera with infants aged 0-24 months. The study applied both quantitative and qualitative data collection techniques. Quantitative analysis was performed using SPSS version 11.5.Qualitative analysis involved narrative summaries of the qualitative data along thematic areas in line with the objectives of the study. Preliminary analysis of quantitative data involved production of frequency tables and charts. Cross tabulations between the independent variables and the IFP ('ever breastfed' or 'Never Breastfed') was then performed to establish the relationships. Variables that were found to be statistically significant were then fed into a logistic regression model. Results A total of 400 mothers aged between 15-49yrs with children below 24 months were interviewed. The mean age of the respondents was 30.34 years (SD 6.74) and the mean age of the children was 16.21 months (SD 7.76). Overall, 237 (59%) of the mothers had ever breastfed while 163 (41%) had never breastfed their babies. Of the mothers who had ever breastfed, 220 (55%) had practiced exclusive breastfeeding (EBF) which varied from 1-6 months while 17 (4%) had practiced mixed feeding (MF). Forty six 46% (182) of the respondents were married, 311 (78%) had attained primary education as the highest level of education, 271 (68%) were either in informal or self employment, 366 (92%) were earning less than ksh.5000 per month and 375 (94%) had access to piped clean water. Mothers who were single were less likely to breast feed as compared to mothers who were married (p=0.046). None of the other socioeconomic factors were found to influence the infant feeding practice. Slightly less than a half 188 (47%) of the mothers came to know about their HIV status during pregnancy of their child, about two thirds 261 (65.3%) had disclosed their HIV status to their partners, and 177 (44%) had their partners tested for HIV of which 146 (83%) were HIV positive. Only 34 (9%) had a previous child as HIV positive. Mothers who came to know their HIV status before pregnancy were less likely to breastfeed as compared to the ones who knew their HIV status after delivery (p=0.001). Mothers with partners who were HIV positive were also less likely to breast feed as compared to the ones whose partners were of unknown HIV status (p=0.0356). Similarly, mothers with a previous HIV positive child were less likely to breastfeed as compared to the ones who had a previous child of unknown HIV status (p=0.0239) Majority, 389 (97.3%) of the respondents had attended ANC, about two thirds 247 (62%) had delivered in hospital while 352 (88%) had received infant feeding counselling. Mothers who had delivered in hospital were less likely to breastfeed as compared to the ones who had delivered at home (p=0.001). Mothers who had been counselled were also less likely to breastfeed as compared to the ones who had not been counselled (p=0.002). Majority of the mothers 373 (93.3%) reported that HIV could be transmitted from the mother to the child. However, adequate knowledge was found not to influence the infant feeding practices of the mothers. The factors found to be independently associated with breastfeeding or non-breastfeeding after Logistic regression analysis were: Place of delivery (AC)R=0.72 and p=0.007), time when mother came to know about her HIV status (AOR=0.72 and p=0.048) and previous history of HIV positive child (A()R=0.62 .and p=0.053). Marital status, period when infant feeding counselling was done and the number of times counselling was done (A.O.R; 1\266, 1.102, 1.247 respectively) were also factors strongly associated with breast feeding or non breastfeeding after logistic regression. Conclusions 1. Breastfeeding was the commonest infant feeding practice among HIV positive mothers in Kibera. Home delivery, knowledge of HIV status after delivery and previous history of HIV negative child were found to be independently associated with breastfeeding. 2. Majority of the mothers who breastfed practiced exclusive breast feeding which was found to vary from 1-6 months. Mixed infant feeding practice was less common and was mostly due to stigma and cultural practices. 3. Non breast feeding was mostly due to; Hospital deliveries, knowledge of HIV status before pregnancy and Previous history of HIV positive child. 4. The knowledge of the respondents on MTCT of HIV/AIDS was adequate. However this was found not to influence the infant feeding practices of the mothers. 5. Infant feeding counselling was found to be important in influencing infant feeding practices. The timing and frequency were statistically significant but not independent determinants of infant feeding practice. Key Recommendations 1. Health providers and Health Care Institutions in Kibera, majority of which are owned by NGO's and individuals, should continue to promote, protect and support exclusive breastfeeding for all mothers (unless they are able to meet the AFASS criteria for replacement feeding for HIV positive mothers) 2. HIV positive mothers should continue to be followed up into their homes after delivery preferably by community health workers trained in PMTCT in order to make sure that they adhere to safe infant feeding practices and to offer psychological support. 3. The Ministry of Health and other Health providers should initiate public awareness programmes to encourage men to take part in PMTCT activities and support their wives on issues of infant feeding. Couple counselling and HIV testing should specifically be emphasized. 4. Stigma remains the biggest obstacle in issues of HIV/AIDS. Community Health workers and other health workers should also undergo counselling and training on how to reduce stigma among themselves and negative attitude towards clients. Reduction of stigma among the workers will have a big impact on reduction of stigma especially in the PMTCT setup. Counselling sessions for clients should also emphasise on stigma reduction 5. Strengthening of Capacity for Community Health Workers so that they are up to date with the current Infant feeding Policy issues especially on breastfeeding. All Health workers involved in PMTCT activities should undergo further training on PMTCT in order to avoid passing wrong information to their clients and also to minimize bias towards one infant feeding method. 6. The Kenyan government (MOH) and other NGOs implementing infant feeding and other PMTCT activities in the slums should encourage and financially support HIV positive mothers and their support groups (Networks of people mothers with HIV/AIDS) so that these women can engage in income generating activities that can support their families and especially on issues of infant and young child feeding.