Perception and practice of breastfeeding among HIV positive mothers receiving care for prevention of mother to child transmission in South-East, Nigeria

Human breast milk is the ideal food for human infants [1]. It offers nutrients that are essential for normal growth and proper development, and is central to establishing the foundation for a long healthy life [2, 3]. The antibodies contained in breast milk, which mothers transfer to their infants, act as first line defense against some childhood killer diseases [4]. This mother-to-child transfer of antibodies is considered as passive immunisation. Breastfeeding is also of immense benefit to the mother. When exclusively done, it could be a natural method of delaying pregnancy. This is called lactational amenorrhea method (LAM); a form of contraception that has wide cultural acceptability [5]. Mother to Child Transmission (MTCT) of HIV, also known as vertical transmission, remains the major route of pediatric HIV infection in sub-Saharan Africa [5‐7]. Mothers who are HIV positive can transfer the virus to their infants during pregnancy, labour, delivery and breastfeeding [8]. Although it is reported that progress towards the elimination of MTCT is one of the greatest successes of global AIDS response, with MTCT rates of under 5% in some priority countries, there are still challenges with breastfeeding transmission in countries where coverage of antiretroviral treatment (ART) among pregnant women is very low [9].

Infant feeding by HIV-infected mothers is a controversial issue that constitutes global public health dilemma [8]. It is particularly challenging because available options, whether to breastfeed or not, both involve risks to the child that affect their health and survival. Weighing these risks against benefits generates intense debates among policymakers, program managers and service providers in sub-Saharan Africa. This is particularly so when considering that the major causes of infant death, malnutrition and infectious diseases, could be prevented if mothers breastfeed their babies. Whereas breastfeeding involves a small risk of HIV transmission, not breastfeeding poses a considerable risk to infant survival [10, 11].

The recommendation for breastfeeding among HIV mothers has changed over time. Initially, it was recommended that HIV positive mothers should practice exclusive breastfeeding with early and rapid cessation (at 6 months) and exclusive replacement feeding with infant formula or modified cow’s milk [12]. This was replaced by the WHO 2010 recommendation [13], and later by the 2016 guidance for infant feeding and HIV which recommends that mothers known to be HIV should exclusively breastfeed their infants for the first 6 months of life, and can continue breastfeeding with complementary feeds up till 24 months of life [14]. The latter are more in line with public health recommendations for all mothers, as well as customary infant feeding practices in sub-Saharan Africa. This also protects HIV positive women from suspicion and stigma attached to non-normative infant feeding practices [15]. Although the decision to breastfeed an infant is not solely made by the mother, she has the upper hand in determining whether or not to follow through with any decisions and her actions are influenced by her perceptions.

The purpose of this study was to examine the perception and practice of breastfeeding among HIV positive mothers receiving care in public and private facilities that offer comprehensive HIV care and PMTCT of HIV.

A total of 550 HIV positive mothers participated in the study, 275 from public facilities and 275 from private facilities. All 550 questionnaires were analysed and the results are presented in Tables 2, 3, 4, 5, 6 and 7.

Table 2 shows the demographic characteristics of the respondents. The mean age of those receiving care from public health facilities was 30.41 (± 3.25) years, and 124 (45.1%) of them were within the 30–34 years age category. A total of 265 (96.4%) had formal education, of which 144 (52.4%) had secondary level education. More than half of the women, 162 (58.9%), were self-employed, and 174 (63.3%) stated that their partners were the only providers of the household income. A total of 241 (87.6%) were currently married and the highest proportion, 102 (37.1%) had three children.

The mean age of those receiving care from private health facilities was 31.02 (± 3.80) years. Most of them were within 30–34 years age category, 144 (52.4%). A greater proportion had formal education, 260 (94.5%), with 121 (44%) reporting secondary level as their highest level of education. Majority, 111 (40.4%) were self-employed and 170 (61.8%) stated that their partners were the only household income provider. A total of 235 (85.5%) were currently married and the highest proportion, 82 (31.3%), had two children.

Table 3 shows the respondents’ perception of their HIV positive status. In the private health facilities, 131 (47.6%) HIV positive mothers reported feeling inferior to their HIV negative peers and 209 (76.0%) of them felt they were treated differently by family members because of their HIV positive status. The majority of them, 236 (85.8%), also felt excluded/isolated by their communities because of their HIV positive status. In the public facility, 159 (57.8%) HIV positive mothers reported feeling inferior to their HIV negative peers and 116 (42.2%) feel equal to their peers and 236 (85.8%) of them felt they were treated differently by family members because of their HIV positive status. Majority of them, 242 (88.0%), also felt excluded/isolated by their communities because of their HIV positive status.

Table 4 shows respondents’ perceptions and practices of any type of breastfeeding of HIV-exposed infants. Among respondents in the private health facilities, 184 (66.9%) knew that HIV could be transmitted through breast milk. The majority of them, 230 (83.6%) perceived breastfeeding as beneficial to infants. Among 221 (80.4%) who reported breastfeeding their infants, 149 (54.2%) chose to do so for personal reasons, 106 (38.5%) breastfed because it is a cultural norm while 30 (40.9%) women did so for fear of disclosure of HIV status. A total of 45 (16.3%) women were influenced by family members to breastfeed their infants.

Among those receiving care from public health facilities, 172 (62.7%) knew HIV could be transmitted through breast milk and 188 (68.4%) perceived it to be beneficial to their infants. About three-quarters of them, 207 (75.3%) actually breastfed and their reasons for breastfeeding were personal choice 106 (38.5%), cultural norms 106 (38.9%), fear of HIV status being disclosed 67 (24.4%), and pressure from family members 25 (10.4%).

Table 5 shows relationship between respondents’ demographic characteristics and practice of breastfeeding. In the private health facilities, there was an association between practice of breastfeeding of HIV-exposed infant and mothers’ marital status (p < 0.01). In the public health facilities, there was an association between practice of breastfeeding of HIV-exposed infant and household income provider (p = 0.02).

Table 6 shows relationship between practice of breastfeeding and perceptions of HIV positive status. There was no statistically significant association between the practice of breastfeeding and self, family and community perception of positive HIV status.

Table 7 shows results of analysis of predictors of practice of breastfeeding. For public facility users, being the household income provider did not significantly predict practice of breastfeeding of HIV-exposed infants (AOR 2.1; 95% CI 0.7, 5.5) (AOR 4.9; 95% CI 0.6, 12.9). Similarly, for private facility users, marital status did not significantly predict practice of breastfeeding of HIV-exposed infants (AOR 1.4; 95% CI 0.3, 6.8).

The proportion of HIV positive pregnant mothers who knew that HIV could be transmitted through breast milk was higher than those who did not know. Owing to recent increase in interventions aimed at HIV prevention, more people have become aware of HIV transmission [20]. However, the figures we obtained are still lower than what is expected from mothers who are already receiving care for HIV and PMTCT from health facilities where health workers typically provide basic information on HIV prevention particularly as it relates to PMTCT [21]. Failure to do this results in mothers holding onto their misconceptions or picking up incorrect information that could be harmful to the wellbeing of exposed infants. We also observed that mothers receiving PMTCT care from private health facilities were more aware about HIV transmission through breastfeeding than their counterparts in public facilities. The private health facilities that were selected for this study are known to provide health talks routinely to mothers attending antenatal clinics, including PMTCT. Previous studies that have assessed the level of general health knowledge among mothers receiving maternity care have shown variations based on the type of health care facility [22‐24]. Although health education sessions are routinely provided to mothers receiving antenatal care in most public health facilities, overall quality of care in public facilities has been reported to be less than that received in private health facilities [22‐24], and this may account for the variation observed in this study.

Practice of breastfeeding among the HIV positive mothers was high as majority of them perceived breast milk as beneficial to their infants, hence they breastfed their infants. Although current PMTCT guidelines promote exclusive breastfeeding as a feeding option for HIV-exposed infants (HEI), at the time of this study, HIV positive mothers were not encouraged to breastfeed in order to prevent transmission of the virus to their infants [25, 26]. Breastfeeding of infants is a social norm among Africans, and some studies have reported that since mothers who failed to breastfeed their babies were suspected of having HIV, many HIV positive mothers choose to breastfeed their infants to prevent this suspicion and the resultant stigma [27‐29]. The proportion of respondents among those in public facilities that perceived breastfeeding of HIV-exposed infant beneficial is similar to a study conducted in South Africa that reported 64.9% [25], while lower than 83.6% among those in private facilities. The difference could be due to differences in health education of respondents in the facilities. Our findings concerning practice of breastfeeding among the HIV positive mothers was higher than the study conducted in Ibadan, Nigeria where 93.5% choice of infant feeding was formula [29].

A statistical significant association was found between practice of breastfeeding and some independent demographic variables amongst HIV positive mothers. These variables include marital status and household income provider. Irrespective of the type of facility, the patterns of association between demographic variables and practice of breastfeeding were inconsistent. For instance, the relationship between age and breastfeeding shows all women aged 24 years and younger, and over 80% of those aged 30 years and older breast fed their babies whereas about three-quarters of those aged 25–29 breastfed their babies.

At the time of the study, the policy on feeding practices in Nigeria was an option between exclusive use of infant formula, where sustainability is guaranteed, or exclusive breastfeeding for 6 months and continuing with complementary feeds till 12 months [19]. Currently, there has been a change in the dynamics of infant feeding and breastfeeding is no longer considered a significant risk factor for MTCT of HIV because all HIV positive individuals are now placed on lifelong ARVs [14]. This policy is according to WHO HIV and infant guidelines that was revised in 2016, which recommends exclusive breastfeeding for the first 6 months of life while on ARV drugs and continuing breastfeeding with complementary feeds till 24 months [14]. As such, breastfeeding among HIV positive mothers is now encouraged. With the current policy it is important to examine how these factors may be utilized to increase the practice among these women.

Finally, differences between users of private versus public health facilities are critical to informing intervention for PMTCT. However, the focus of our study was not to compare users of private and public facilities. We therefore recommend that future studies could focus on comparing the differences between users of private and public facilities.

This paper contributes evidence of factors that influence practice of breastfeeding among HIV positive mothers. This information is valuable for designing interventions aimed at reducing MTCT of HIV in developing countries. This study reveals that breastfeeding remains a common trend among HIV positive women in developing countries and that the practice is strongly associated with fear of stigma in society as well as economic independence of the women. In order to guarantee the wellbeing of HIV positive women in developing countries, they need to be supported by caregivers and community members to make the best choices for their children and themselves.