Breastfeeding counseling and support are associated with continuous exclusive breastfeeding from one week to six months of age among HIV exposed infants in north Gondar zone, Ethiopia: a cross-sectional study

Breastfeeding is an essential child survival intervention and provides immunological, psychological, and socio-economic benefits [1‐3]. Globally, exclusive breastfeeding prevents 1.3 million child deaths [4]. In the era of the Human Immune Deficiency Virus (HIV) pandemic, breastfeeding is considered as a source of mother-to-child transmission of HIV [1, 5, 6]. As a result, the World Health Organization (WHO) advised mothers infected with HIV to avoid breastfeeding if they were able to afford and safely prepare formula milk [7]. However, mindful of the growing evidence supporting the benefits of EBF, the WHO now recommends HIV positive mothers to exclusively breastfed their infant’s for 6 months, and to take antiretroviral drugs throughout the breastfeeding period and until the child is 12 months of age, to reduce the risk of HIV transmission [6‐9].

In spite of this fact, not exclusively breastfeeding continues as a global public health problem, and only 39% of infants are exclusively breastfed [10, 11]. In particular, mixed feeding is still practiced as the norm in developing countries, and it is found to increase the risk of child deaths from under-nutrition, diarrhea, pneumonia and other morbidities [10]. There is a marked regional variation; about 24–80% of infants exposed to HIV are exclusively breastfed in Africa [11‐18]. According to the Ethiopian Demographic and Health Survey (EDHS) Report (2011), about 51% of mothers practice EBF [19]. However, some improvements are observed among HIV infected mothers, and the prevalence of EBF is modest in Addis Ababa [20] and West Oromia (68 and 72%, respectively) [21], while it is highest in Gondar (89.5%) [22] and Mekele (90%) [11]. However, the prevalence of exclusive breastfeeding in Southern Ethiopia is even lower than the national average of 48% [7].

Studies have demonstrated that exclusive breastfeeding affected by various factors. The mother’s age [20], knowledge on the benefit of exclusive breastfeeding [12, 23], occupation [7, 12, 20, 22], urban or rural residence [24], lack of education [20], income [20], and the high cost of formula milk [13] are some the sociodemographic factors significantly associated with exclusive breastfeeding. It is also strongly related to the level of maternal healthcare utilization and morbidities, accordingly the mode and place of delivery [18, 20, 22, 25], prenatal [20] and postnatal healthcare utilization [20], receiving infant feeding counseling [20, 25, 26], breastfeeding support [20, 22], facing obstetric complications and other maternal morbidities [20, 25] and history of infant illness in the first 6 months [20, 27] are correlated with EBF. Among the psychosocial determinants, fear of stigma and discrimination [9, 14, 25] and use of herbal medicines [25] are inversely related with exclusive breastfeeding.

In Ethiopia about 1.5% of adults (15–49 years) are HIV positive and the prevalence is higher among women (1.9%) [19]. To reduce the risk of mother-to-child transmission of HIV and AIDS related child mortality, the country designed a guideline which advocates exclusive breastfeeding for the first 6 months, though the practice remains sub-optimal [20‐22, 27]. Exclusive breastfeeding among HIV positive mothers is not well investigated; the available studies have been conducted on urban dwellers [20, 22, 27], while poorer child feeding practice, lower literacy rate and maternal health care utilization are documented in the rural inhabitants [19]. Therefore this study aimed to determine the prevalence of continuous exclusive breastfeeding and associated factors from the end of first week to 6 months of age among HIV exposed infants (7–20 months) who had follow up in government hospitals of North Gondar Zone, Ethiopia.

A total of 367 mother-child pairs were included in the study. The mean (± Standard Deviation, SD) age of the mothers and the children was 31.3 (±4.4) years and 12.9 (±4.1) months, respectively. In this study, about three-fourths of the mothers (74.9, 77.7 and 82.3%, respectively) were married, urban inhabitants, and aged 20–35 years. Nearly half (44.8%) of mothers were outdoor workers (Table 1).

A substantial proportion (96.5%) of mothers had at least one antenatal care visit, of which 94.6% were counseled about EBF. Almost all (97.3%) of respondents gave birth at healthcare institutions; and cesarean-section delivery was reported by 21.5%. About 47.4% of mothers had an obstetric problem (Table 2). Despite efforts to prevent mother-to-child transmission of HIV, about 1.9% of exposed infants were HIV positive. All (100%) of the HIV infected children were from mothers who did not receive any breastfeeding support and gave birth virginally. A higher proportion of HIV infection was noted among children who were given prelacteal feeds, whose mothers were illiterate (71.4%) and who experienced an obstetric problem (57.1%) (Table 3).

The study demonstrated that, about 86.4% (95% CI: 82.9, 89.9%) of HIV exposed infants were continuously exclusively breastfed from the end of first week to 6 months of age. Two-thirds (72.8%) of mothers initiated breastfeeding within an hour of delivery, and about 79.6% of infants were given colostrum. However, prelacteal feeding was given to 19.1% of infants (Table 4).

Both bivariable and multivariable analyses were done to identify factors associated with continuous exclusive breastfeeding. Accordingly, the result of bivariable analysis noted that counseling about exclusive breastfeeding, colostrum feeding, experiencing an obstetric problem, decision to breastfeed, breastfeeding support, place of delivery, and infant illness were significantly associated with the practice of continuous exclusive breastfeeding. However, only breastfeeding support, breastfeeding counseling, and experiencing an obstetric problem remained significantly and independently associated with exclusive breastfeeding in the multivariable analysis. Consequently, the odds of continuous EBF were higher among HIV infected mothers who received prenatal EBF counseling (AOR = 5.1; 95% CI: 1.4, 18.2) compared to those who did not receive counseling. Similarly, obtaining breastfeeding support (AOR = 3.7, 95% CI: 1.3, 10.5) and not experiencing an obstetric problem (AOR = 3.4, 95% CI: 1.3, 8.8) were associated with increased odds of mothers with a continuous exclusive breastfeeding practice (Table 5).

Exclusive breastfeeding has been considered as one of the proven child survival interventions [10, 30]. Ethiopia has adopted these established facts and set a target to improve EBF to 70% by 2020 [31]. This study showed that, the prevalence of continuous EBF among infants exposed to HIV was 86.4% which was higher than the national target. The finding was also consistent with other reports from Ethiopia: Gondar (89.5%) [22] and Mekele (90%) [31]. This might be related to the contextual similarities in maternal healthcare utilization among study settings.

However, the prevalence of continuous EBF was higher than what was reported from Addis Ababa (68%) [20], Southern Ethiopia (48%) and West Oromia (72%) [21]. The observed discrepancy might be attributed to efforts made by the government in promoting the optimal child feeding practice for HIV infected mothers mainly in the PMTCT, exposed infant, and ART clinics [32, 33]. Likewise, the finding was higher than the reports of other developing countries, such as India (44%) [34], Tanzania (24–46%) [16], Kenya (80.4%) [15], Ghana (60%) [13] and Nigeria (61%) [14]. This is probably due to the fact that, there is higher cultural acceptability of breastfeeding in this study area. Furthermore, the difference in EBF practice could be related to the variations in the study design. The later studies employed a cohort study design and ascertained exclusive breastfeeding practice prospectively [15, 34], while this study measured EBF retrospectively using a cross-sectional study design. Therefore, the increased prevalence of EBF in the current study could be related to the retrospective ascertainment of the EBF practice [29].

The result of the adjusted analysis showed that, the odds of continuous exclusive breastfeeding were higher among mothers who received prenatal EBF counseling. The finding was supported by reports elsewhere [14, 17, 26, 35, 36]. In fact, birth preparedness and breastfeeding counseling are important components of prenatal care, and the repeated visits also help to bring the intended maternal behavioral change towards the optimal breastfeeding practice. The impact of prenatal care mainly operates through the role of clinicians in providing the correct and up-to-dated IYCF information to the mothers [35, 37]. In Ethiopia, implementation of the urban Health Extension Program steps-up utilization of antenatal care, which creates an extra benefit in bringing the promotive health services, including breastfeeding counseling to the household level [30, 38].

Similarly, the higher odds of continuous exclusive breastfeeding were reported among mothers who had no history of obstetric problems. The finding was consistent with the report from Addis Ababa [20]. The possible explanation might be attributed to the psychological effects of obstetric problems, such as depression, lack of confidence or worry leading to delayed initiation of breastfeeding. In fact, the delayed initiation of breastfeeding was found to negatively affect the duration of EBF [39]. Moreover, when mothers encountered obstetrics problems, they commonly perceived that their infants are not getting enough milk, and therefore they may fail to provide breast milk.

This study also affirmed that continuous exclusive breastfeeding rate was higher among mothers who received breastfeeding support. This finding was comparable with study conducted in Malawi [25] and research done in southern Ethiopia [24]. A similar finding was also reported from Swaziland [36], in which social support increased the ease of breastfeeding. In fact, socio-cultural and economical support has a great role in obtaining the full benefits of breastfeeding, and the profound effect in maintaining optimal breastfeeding was noted in case of family support [35, 37].

Of the commonly documented determinants of EBF, maternal health care utilizations, such as antenatal care and institutional delivery were consistently reported by various studies [18, 20, 22, 25, 40]. But, these variables did not show significant association with continuous EBF in the current study. The discrepancy might be attributed to difference in the maternal health care utilization, in which almost all of the mothers had antenatal and postnatal follow up, and gave birth in a healthcare facility. However in most of the above study settings, utilization of maternal health services is sub-optimal.

The study tried to show the exclusive breastfeeding practice in a wider study area, particularly including the rural residents. However, it was not free from some of the limitations. Consequently, recall bias and social desirability bias are the possible limitation of the study.

In this study, a high proportion of HIV exposed infants were exclusively breastfed from the end of first week to 6 months of age. Breastfeeding counseling, breastfeeding support and experiencing an obstetric problem were the key factors associated with continuous exclusive breastfeeding. Therefore, intensifying breastfeeding counseling and support is essential to improve exclusive breastfeeding practices. Moreover, prompt diagnosis and treatment of obstetric problems should be encouraged.