Feasibility, acceptability and lessons learned from an infant feeding intervention trial among women living with HIV in western Kenya

Breastfeeding exclusively for the first six months of an infant’s life followed by safe and adequate complementary feeding in addition to continued breastfeeding for 24 months or beyond is the recommended practice for all women [1]. However, the practice of breastfeeding requires time, knowledge, skill, commitment and resilience. That women are willing, capable, and have what is required to breastfeed their infants, especially exclusively, should not be presumed.

In Kenya where 890,000 women are living with HIV, the Ministry of Health has widely promoted optimal care for HIV exposed infants including the World Health Organization’s (WHO) recommendation to exclusively breastfeed for the first six months, lifelong antiretroviral therapy (ART) for women, and HIV prophylaxis medications for breastfeeding infants and children [2‐7]. Yet, women living with HIV (WLWH) in this setting face many barriers to exclusive breastfeeding such as financial insecurity and the need to return to work, [8] a lack of resources to pump or store milk, fear of HIV transmission, [9] stigma, [10‐12] perceived milk insufficiency, [13, 14] a lack of knowledge about infant satiety cues and nutritional requirements, [8] cultural norms such as giving water or food to babies before six months, [15] and pressure from neighbors or family [12].

Despite evidence that counseling from healthcare workers can increase rates of exclusive breastfeeding [8, 16], support from healthcare workers is not always enough to overcome barriers [12, 17]. Moreover, strong messaging from providers can hinder conversations with mothers about the pros and cons of various infant feeding choices [13, 18, 19]. Other challenges with current support for infant feeding include inconsistent, inaccurate or biased messaging, as well as insufficient training, knowledge, assessment skills, personnel and/or educational materials [12, 20‐23]. Indeed, a dearth of resources and time constraints imposed by heavy workloads for healthcare providers in this setting has left a gap in support for breastfeeding initiation, technique and timing [23, 24]. Furthermore, support from certified lactation specialists is non-existent in public healthcare facilities in Kenya. Yet, the expectation to exclusively breastfeed remains. Thus, there is a need for a greater number of skilled and knowledgeable providers to engage women in conversations about the risks and benefits associated with infant feeding options, the barriers they face to optimal infant feeding (namely breastfeeding), and practical ways to overcome challenges.

To address this need, we developed Supporting Healthy Mothers, a theory and evidence-based multilevel intervention to support pregnant and postpartum (perinatal) WLWH. Supporting Healthy Mothers was specifically designed to address the mental health burden associated with financial and food insecurity and provide personalized support for optimal infant feeding postpartum. What follows is an overview of the infant feeding support component of Supporting Healthy Mothers. Drawing from clinical notes, detailed observations and team discussions, we describe the infant feeding support activities carried out and give an overview of the feasibility, acceptability, strengths, limitations and recommendations for future development.

The Lactation Specialist delivered the planned curriculum and was also able to personalize the sessions addressing a number of specific questions and concerns outside the curriculum during the sessions. Good rapport with the Lactation Specialist likely prompted women to inquire about a broad range of topics, some unrelated to infant feeding. As such, several distinct topic areas emerged during the sessions that may be considered for further development including infant skin care, the safety of traditional practices and maternal self-care. Regular calls from participants with concerns, especially early postpartum, further points to the trust and confidence women had in the Research Coordinator and Lactation Specialist as well as the need women had for support on-demand during times of high vulnerability. Despite unexpected topics emerging and the number of phone calls fielded between sessions, the Lactation Specialist delivered the planned curriculum at the planned timepoints with no significant modifications.

We found the curriculum delivered aptly addressed women’s infant feeding challenges and concerns. Concerns regarding breastfeeding technique, milk insufficiency and the transmission of HIV through breastmilk as well as worries about “plastic teeth” decreased across time with support from the Lactation Specialist. The near perfect attendance by participants is noteworthy, especially considering several of the missed sessions occurred during the aftermath of Kenya’s presidential elections when civil unrest was feared. Furthermore, given the cash transfer was provided regardless of appointment attendance, the majority of women traveled 30 min or more to the clinic, and the frequency (every 2-weeks) of the early post-partum sessions, we believe this attendance record illustrates high acceptability of the intervention. Women benefited from the sessions and therefore willingly made an effort to attend even when they were not making a trip to the clinic for other patient visits.

We also found that holding face-to-face meetings with a skilled provider was important for identifying challenges that at times participants themselves had not identified. A myriad of remote or online interventions aimed at supporting perinatal women exist that are synergistic to in-person meetings [32‐37]. However, we found that the Lactation Specialist’s physical assessments of women and their breastfeeding techniques led to key feedback including how to improve positioning and latch—important for effective milk exchange and milk supply development. Often the Lactation Specialist identified issues with technique the women themselves were not picking up on. Thus, without a face-to-face session, these issues would likely have gone undetected, potentially resulting in poor milk exchange, breast health issues and suboptimal infant growth. The Lactation Specialist also visually assessed many cases of engorged breasts and unequal breast sizes and offered suggestions for optimizing breast health and feeding accordingly. Furthermore, attending in-person sessions allowed women to appreciate the difference between foremilk and hindmilk, convincing many women that giving their babies water in addition to breastmilk (a common practice in this setting) [15] was unnecessary. In-person sessions also allowed us to collect infant weights. Infant weights have been used to assess the adequacy of early milk production in other settings, [38] and we found this was a key objective measure of breastmilk intake early postpartum. Typically, infant weights in this setting are only collected at birth and then again at six weeks postpartum. Thus, weights measured, on a highly accurate digital scale, at two weeks and four weeks postpartum provided important information to the Lactation Specialist and reassurance to mothers who worried about having enough milk. This was particularly important, given perceived milk insufficiency is widely known to be a primary reason for women to stop breastfeeding or prematurely introduce complementary foods [13, 14]. Finally, another important benefit of face-to-face sessions was allowing the Lactation Specialist to assess mother-infant bonding and identify any postpartum blues or depression concerns.

In addition to sessions being face to face, we found women needed regular support early postpartum to develop their breastfeeding technique, receive affirmation that their milk supply was adequate and ensure proper administration of their infant’s HIV prophylaxis medications. Early postpartum sessions allowed the Lactation Specialist to make timely referrals to medical providers for the few infants who were not thriving as expected. Interestingly, a common concern (especially at 2-weeks and 4-weeks postpartum) was the perception that infants were feeding “too much/ too frequently”. Given breastfeeding frequency early postpartum has been shown to directly impact the development of milk supply, [39] repeatedly reinforcing the milk supply/demand concept and the importance of feeding on demand was critical support for optimal breastfeeding early postpartum. Frequent, early postpartum support for breastfeeding mothers is also recommended in the WHO’s Infant and Young Child Feeding Counselling course manual which suggests, women and their infants should be assessed and supported at the time of birth, 2–4 days postpartum and 5–8 days postpartum, in addition to the timepoints our sessions were conducted [28]. The need for skilled support for breastfeeding initiation immediately postpartum has also been identified in other settings [40].

Frequent, personalized support for infant feeding through the early postpartum period was similarly part of the baby-friendly community initiative introduced in several counties in rural Kenya including, Kisumu County from 2014–2017 [41]. The baby-friendly community initiative offered 12 home-based counseling sessions—every two weeks from 37 weeks of pregnancy to one month after birth. The sessions were delivered in women’s homes by trained community health volunteers and effectively supported increased rates of exclusive breastfeeding [12]. Overall, there are unique benefits from support provided by clinic-based, skilled professionals as well as benefits to having lower cost more widely available community-based support. Thus, there is great potential for lay and professional healthcare workers to collaborate to support optimal infant feeding in future programming in this setting.

While frequent early postpartum visits from 2 weeks on and the accessibility of our team were key strengths of our lactation sessions, we identified areas for improvement. First of all, while we were able to address many early postpartum needs by fielding participant’s phone calls, support provided immediately postpartum could ensure infants properly receive their first dose of HIV prophylaxis and facilitate the prompt initiation of breastfeeding. Secondly, due to project time constraints, our last support session occurred when women were about three months postpartum. Three months postpartum was an ideal time for breastfeeding support since many babies go through a growth spurt at this time with bouts of cluster feeding. However, we would have ideally held another session closer to six months postpartum and provided women with the information about introducing the baby’s first foods and complementary feeding at that time. Other sessions beyond 6-months could also support women to continue breastfeeding beyond 12-months as most women planned to stop breastfeeding at around 12-months, well short of the recommended period (24-months).

The infant feeding support component of Supporting Healthy Mothers was successfully executed with high levels of attendance. The planned curriculum was feasible to deliver via face-to-face, personalized infant feeding support sessions from pregnancy to three months postpartum. Supportive sessions were highly acceptable to women who attended 94% of the sessions where their infant feeding concerns and challenges were addressed. At three months postpartum all women reported practicing exclusive breastfeeding as recommended. Qualitative data collected during the infant feeding support component of Supporting Healthy Mothers provide an overview of the breastfeeding support sessions including the primary concerns or challenges to optimal infant feeding women faced, how they were addressed by the Lactation Specialist at each session and areas where more support may be needed.