Harmony in healthcare: recommended infant feeding practices and associated factors among HIV positive mothers in Eastern Ethiopian hospitals

Abstract

Background

For mothers identified as HIV-infected, recommended infant feeding practices must prioritize the highest likelihood of ensuring HIV-free survival for their children while preserving maternal health. Consequently, understanding the feeding status during critical infancy stages, especially under the risk of HIV, plays a crucial role in enhancing the quality of life within this specific population segment. Hence, this study was conducted to assess the magnitude and associated factors of recommended infant feeding practices and its associated factors among HIV-positive mothers in Eastern Ethiopian Hospitals.

Methods

A cross-sectional study conducted in Eastern Ethiopian Hospitals from June to July 2022 included 371 mothers of infants. Participants were selected using systematic random sampling techniques. Data was collected through pre-tested structured face-to-face interviews administered by trained interviewers. Following data collection, information was cleaned and entered using Kobo tool collection software, then exported to Statistical Package for Social Sciences (SPSS) version 25 for analysis. Binary logistic regression analysis was employed to assess the strength of association between explanatory and outcome variables. Variables with a p-value < 0.25 in univariable logistic regression analysis were considered for multivariable logistic regression analysis, and statistical significance was determined at a P-value < 0.05 with a 95% confidence interval.

Results

The magnitude of recommended feeding practice was found to be 86% (95% CI: 81.9, 89.1). HIV-positive mothers who had a child age of 0–6 months [AOR = 5.21 (95% CI: 2.54, 10.70], spontaneous vaginal delivery [AOR = 2.11 (95% CI: 1.05, 4.24], and ever provided expressed breast milk [AOR = 2.82 (95% CI: 1.33, 5.95] were significantly associated with recommended Infant feeding practice.

Conclusion

the study identified a moderate level of adherence to recommended infant feeding practices among HIV-positive mothers in Eastern Ethiopian hospitals. Key factors influencing adherence included the child’s age, mode of delivery, and the provision of expressed breast milk. Target interventions to improve infant feeding practices among HIV-positive mothers, focusing on younger infants, cesarean-delivered mothers, and those not providing expressed breast milk. Strengthen counseling and education in healthcare facilities to address these significant factors and enhance adherence to recommended feeding practices.

Introduction

Recommended infant feeding practices for HIV-positive mothers aim to maximize HIV-free survival without compromising maternal health. Balancing HIV prevention with nutritional needs is essential for safeguarding infants from non-HIV-related morbidity and mortality [1]. Current international guidelines recommend that HIV-positive mothers should refrain from breastfeeding when suitable replacement feeding is acceptable, feasible, affordable, sustainable, and safe. Alternatively, exclusive breastfeeding is advised for the initial months, ceasing when conditions for replacement feeding are met. Counselors should ensure comprehensive information on risks and benefits, enabling informed decisions [2].

Globally, over 37.9 million individuals are affected by HIV, with 1.7 million being children. A significant majority of these children reside in sub-Saharan Africa [3] and over one hundred thousand children are living in Ethiopia [4]. Vertical transmission is the primary mode (90%) through which children contract HIV, with breastfeeding serving as the main transmission route in the absence of Preventing Mother-to-Child Transmission (PMTCT) care for the exposed infant [3].

The WHO recommends either exclusive breastfeeding or replacement feeding for the initial six months of life for HIV-exposed infants, coupled with robust maternal antiretroviral therapy (ART) and ART prophylaxis for exposed neonates. Subsequently, complementary feeding is advised with sustained breastfeeding until 12–24 months of age [5]. While breastfeeding poses a risk of HIV transmission, the alternative of replacement feedings carries a heightened risk of mortality and morbidity. In resource-limited settings, non-breastfed infant’s face up to six times higher chances of succumbing to diarrheal illnesses, malnutrition, and pneumonia. Breastfeeding is crucial for protecting against various child infections, fostering oral health, enhancing intelligence, and preventing early childhood obesity and diabetes [5, 6].

In Ethiopia, 74% of women are aware of HIV transmission through breast milk. Among infants under six months, 58% practice Exclusive Breastfeeding (EBF), 17% are given plain water, and 5% are not breastfed [7]. The Federal Ministry of Health (FMOH) has embraced the WHO 2010/2013 report’s Option B + regimen guideline, aiming to deliver prolonged prevention against new pediatric infections [8]. Insufficient counseling, follow-up, and family support for HIV-positive mothers, coupled with a shortage of training for counselors and relevant health professionals in delivering timely and crucial nutritional messages, pose significant challenges in minimizing the transmission of HIV to exposed infants and young children [1].

The study targeted HIV-positive mothers with children under two years, a sensitive group challenging to locate at the community level. Conducting the research within a health facility ensured access to the intended population, particularly those utilizing PMTCT services or ARV treatment. This approach effectively captured the study’s focus. The study area has seen a scarcity of prior studies on this recommended infant feeding practice and its associated factors. Consequently, understanding the feeding status during critical infancy stages in the context of HIV risk is pivotal for enhancing the quality of life within this specific population segment, Hence, this study aimed to assess the magnitude and associated factors of recommended infant feeding practice and its associated factors among HIV positive mothers in Eastern Ethiopian Hospitals.

Methods and materials

Study area, period, and study design

A facility-based cross-sectional study was conducted in Dire Dawa City, Eastern Ethiopian Hospitals from June -July 2022. Dire Dawa is one of Ethiopia’s two chartered cities, located 515 km east of Addis Ababa the capital. With a total population of 506,640, 58% reside in urban and 42% in rural areas. The city has 9 urban and 38 rural kebeles, and its City Administration oversees 2 governmental hospitals, 4 private hospitals, 15 health centers, and 17 private clinics.

Population

All HIV-positive mothers who had an infant or last child ≤ 2 years of age attending PMTCT services and or on ARV treatment in Dire Dawa City Administration were the source of the study. All selected HIV-positive mothers who had an infant or last child ≤ 2 years of age attending PMTCT services and or on ARV treatment and present during data collection time were taken as the study population. All selected HIV-positive mothers who have children less than two years old attending PMTCT service and or are on ARV treatment are included in the study. Critically ill individuals unable to communicate during data collection were excluded.

Sample size, sampling procedures, and techniques

The study’s required sample size (n) was calculated using the formula for estimating a single population proportion by considering the following assumption: 5% margin of error, 95% confidence level, and 5% non-response rate, and proportion of child feeding practices among HIV mothers (37.4%) from a study done on Addis Ababa [9]. The final proposed sample size was 378, proportionally allocated to hospitals in Dire Dawa city administration. The initial participant was chosen via the Lottery method, followed by a systematic random sampling technique based on attendance at the ART clinic, with participant cards coded by data collectors to prevent repetition.

Operational definitions

Exclusive breastfeeding

– means that the infant receives only breast milk (and if required, medication, minerals, vitamins, and oral rehydration solution [10].

Exclusive replacement feeding

– means feeding a child who is not receiving breast milk with a diet that provides all the nutrients the child needs. During the first six months, this should be a suitable breast milk substitute, such as commercial or homemade formula [11].

Mixed breastfeeding

– the infant is given some breastfeeds and some artificial feeds, either milk or cereal or other food or water [11].

Wet-nursing

– having another woman breastfeed an infant; in this case, ensuring that the woman is HIV-negative [11].

Expressing and heat-treating breast milk

– removing the milk from the breasts manually or with a pump, and then heating it to kill HIV [11].

Recommended feeding practice

– those who practiced either exclusive breastfeeding exclusive replacement feeding or Wet-nursing [11].

Non-recommended feeding practice

– those who practiced mixed feeding [11].

Safe feeding

Replacement foods are correctly and hygienically stored and prepared and fed with clean hands using clean cups and utensils, not bottles or teats [11].

Data collection tools and procedure

Data collection utilized a interviewer -administered interview technique employing a pre-tested structured questionnaire developed through a review of relevant literature [1, 5, 6]. The questionnaire, derived from previous similar studies and literature, was prepared by the principal investigator. Four BSc clinical nurses fluent in the local language were recruited for data collection, assigned by shift, along with one senior public health professional as a data collector. The questionnaire encompassed 8 questions on socio-demographic characteristics, 15 on maternal and infant health-related factors, 17 on infant feeding characteristics of HIV-positive mothers, and 3 on personal and social factors.

The data collectors were briefed and kept informed about the prevailing COVID-19 situation, including the necessary precautions during data collection. They were equipped with personal protective tools such as face masks, gloves, and hand sanitizer rubs. Strict adherence to the established protocol for precautions aimed at minimizing exposure to COVID-19 during data collection was mandatory.

Data quality assurance

To ensure data quality, a questionnaire was initially crafted in English and subsequently translated into Amharic and Afan Oromo. The translation underwent verification through a back-translation process facilitated by an independent translator, with consistency maintained by the principal investigator and language experts. Two days of training were provided to data collectors and supervisors, covering familiarity with the data collection tool, study objectives, sampling techniques, questionnaire sections, data handling, ethical conduct, and data quality. Participants engaged in pretesting the questionnaire to identify any necessary adjustments.

Before the official data collection, the questionnaire underwent a pretest on a 5% randomly selected group of residents, later excluded from the main study. The pretest occurred at Haramaya General Hospital. The assessment of infant feeding practices adhered to the definitions and recommendations of the WHO and the National Strategy for Infant and Young Child Feeding (IYCF). Mothers were specifically asked to provide information on how they fed their babies if they were HIV-positive.

Data processing and analysis

Data entry was conducted using Kobo Collect software, followed by exporting the data to SPSS version 25 for analysis. Descriptive statistics were used to summarize the data, and results were presented in text and tables highlighting socio-demographic characteristics, disclosure status of HIV-positive mothers, maternal and infant health-related histories, and infant feeding-related characteristics. Bivariable logistic regression was employed to explore associations between explanatory variables and recommended infant feeding practices. Variables with a P-value ≤ 0.25 in the bivariable analysis were included in the multivariable logistic regression model. Assumptions for binary logistic regression were thoroughly assessed. The goodness of fit was evaluated using the Hosmer-Lemeshow test, with a P-value of 0.42, and multicollinearity was checked, yielding a variance inflation factor (VIF) of 3.9. Odds ratios with 95% confidence intervals were calculated to measure the strength of associations, with statistical significance set at P < 0.05.

Results

Socio-demographic characteristics of the study participants

Out of the 378 recruited HIV-positive mothers, 371 participated, yielding a response rate of 98.1%. The mean age of mothers was 26.9 years (± SD 3.67), and for infants, it was 8.47 months (± SD 6.09). The majority of mothers, 362 (97.6%), were married, with 41 (11.4%) having not attended formal education. Regarding occupation, almost all participants, 354 (95.4%), were housewives, and 40 (19.3%) of the HIV-positive mothers were daily laborers (Table 1).

Table 1 Socio-demographic characteristics of HIV positive mothers mother at PMCT or ART clinics in Eastern Ethiopian hospitals, 2022 (n = 371)

Disclosure status of HIV-positive mothers, maternal and infant health-related history of participants

The majority, 350 (94.3%), reported no breast problems, and nearly all infants, 356 (96%), had not experienced any oral ulcers. Only 42 children (11.3%) tested positive for HIV. Among 230 infants, 51 (22.2%) developed illnesses, with 17 (7.4%) experiencing diarrhea. Almost all mothers, 368 (99.2%), attended antenatal follow-ups, with 98.7% visiting ANC clinics at least three to four times. A significant number, 351 (94.1%), delivered at governmental hospitals and health centers. Most respondents, 276 (74.4%), had spontaneous vaginal deliveries, while 94 (25.3%) underwent Cesarean section deliveries. A high percentage, 367 (98.9%), had postnatal follow-ups. Among the total 371 mothers, the majority, 303 (96.1%), demonstrated sufficient knowledge about mother-to-child transmission (PMTCT), and 368 (99.2%) were on antiretroviral therapy (ART). Additionally, the greatest proportion, 339 (91.4%), had disclosed their HIV status (Table 2).

Table 2 Maternal and infant health-related history of participants among HIV-positive mothers at PMCT or ART clinics in Eastern Ethiopian hospitals, 2022 (n = 371)

Infant feeding-related characteristics of HIV-positive mothers

The majority of mothers, 252 (67.9%), breastfed their children, with 116 (97.5%) initiating breastfeeding within the first hour of the child’s birth. Additionally, 300 (80.9%) exclusively breastfed their infants for up to six months, while 18 (4.9%) opted for exclusive replacement feeding. Complementary food introduction was observed in 321 mothers (86.5%), with 116 (36.1%) initiating it at six months, and the remaining 63.9% starting after six months of age (Table 3).

Table 3 Infant feeding practice among HIV-positive mothers at PMCT or ART clinics in Eastern Ethiopian hospitals, 2022(n = 371)

The magnitude of recommended infant feeding practice of HIV-positive mothers

The proportion of mothers practicing recommended infant feeding options was 86% (95% CI: 81.9, 89.1) (Figure 1). Accordingly, 300(80.9%) were practicing Exclusive Breast Feeding (EBF) whereas 53(14.3%) and 18(4.9%) were practicing Mixed Feeding (MF) and Exclusive Replacement Feeding (ERF), respectively.

Fig. 1

Magnitude of recommended infant feeding among HIV-positive mothers in Eastern Ethiopian hospitals, 2022 (n = 371)

Factors associated with recommended infant feeding practice among HIV-positive mothers

The age of the child, mode of delivery, and the provision of expressed breast milk were independently associated with infant feeding practices (p-value < 0.05). Those mothers who had a child aged 0–6 months were 5.25 times more likely to follow the recommended way of infant feeding practice than those who were children aged 7–12 and 13–24 months [AOR = 5.21 (95% CI:2.54, 10.70)]. Mothers who had spontaneous vaginal delivery were 2.11 times more likely to follow recommended infant feeding practices compared to those who had delivered cesarean section [AOR = 2.11(95% CI: 1.05, 4.24)]. Mothers who have been provided expressed breast milk were 2.82 times more likely to follow recommended infant feeding practices than those who were not Ever provided expressed breast milk [AOR = 2.82 (95% CI: 1.33,5.95](Table 4).

Table 4 Factors associated with recommended infant feeding practice among HIV-positive mothers at PMCT or ART clinics in Eastern Ethiopian hospitals, 2022(n = 371)

Discussion

The proportion of mothers adhering to recommended infant feeding practices was 86% (95% CI: 81.9, 89.1). The prevalence of exclusive breastfeeding (EBF) in this study, 80.9% (95% CI: 76.5, 84.6), aligns with the reported rate in Gondar (83.8%). However, it surpasses the figures in Addis Ababa, India, and South Africa, which were (30.6%), (47.7%), and (27%) respectively [12, 13,14,15,16]. Possible reasons include variations in cultural practices, socio-economic conditions, healthcare infrastructure, and awareness campaigns. Regional differences in the implementation of public health interventions, support systems for breastfeeding mothers, and access to healthcare services can also impact breastfeeding practices. Additionally, differences in the study population characteristics, methodologies, and timeframes may influence the reported EBF rates. These variations highlight the complex interplay of contextual factors that shape infant feeding practices and emphasize the need for tailored interventions based on regional considerations [17, 18]. The study’s internal reliability is strong, supported by a high adherence proportion (86%) and narrow confidence interval (95% CI: 81.9–89.1), indicating consistent, precise findings.

This study revealed that the proportion of respondents who practiced ERF was 4.9% (95% CI: 2.7, 7.00). This finding was in line with the study conducted in Gondar (5.7%) (36). But lower than what was reported from India (51.3%), South Africa (50%), and Addis Ababa (46.8%) [13,14,15,16]. The observed variations could stem from differences in cultural feeding practices, study timelines, economic capacities, health policies, and intervention strategies. It is imperative for mothers opting for breastfeeding to avoid mixed feeding, as it may elevate the risk of HIV transmission and increase susceptibility to illnesses such as diarrhea, potentially leading to severe outcomes, including death [19].

This study revealed that mothers who had age of child up to six months were more likely to follow the recommended way of infant feeding practice than those who had age of child six up to 24 months. This finding is consistent with the study done in the Analysis of the 2019 Ethiopia Mini Demographic and Health Survey [20]. Mothers may opt to replace breastfeeding with alternative child-feeding methods as their child grows older, which could be a contributing factor. This substitution may be linked to an increased likelihood of mothers returning to work as their child ages and their maternity leave comes to an end, resulting in the early cessation of breastfeeding [21].

Moreover, Mothers who had spontaneous vaginal delivery were more likely to follow the recommended feeding option than those who had delivered cesarean section. This finding is consistent with what was reported from Addis Ababa [13], where the mode of delivery was positively associated with ideal infant feeding options. One possible reason for this finding could be that mothers who have a spontaneous vaginal delivery may have an easier time initiating breastfeeding due to the release of hormones during labor and delivery that promote lactation. In contrast, mothers who have a cesarean section may experience more pain and discomfort, which could make it more difficult to breastfeed. Additionally, cesarean sections are often associated with longer hospital stays and more interventions, which could disrupt the early establishment of breastfeeding [22].

Furthermore, Mothers who have been ever provided with expressed breast milk were more likely to follow recommended infant feeding practices than those who were not ever provided expressed breast milk. However, another study in Brazil [23] found no significant difference in breastfeeding rates between mothers who were provided with expressed breast milk and those who were not. It is important to note that the results of these studies may be influenced by various factors, such as the type and frequency of breastfeeding support provided, the cultural context, and the socioeconomic status of the participants [24, 25]. Further research is needed to better understand the relationship between expressed breast milk and infant feeding practices.

The limitation of the study

The cross-sectional nature of this study limits its ability to establish causal relationships between recommended infant feeding practices and associated factors among HIV-positive mothers. Temporal relationships cannot be determined, as data on exposure and outcomes were collected simultaneously. Additionally, recall bias may affect the accuracy of self-reported information, particularly regarding infant feeding practices. The study’s focus on hospitals in Eastern Ethiopia may limit its generalizability to other regions or settings with differing healthcare access or cultural practices.

Policy implication of the study

The study highlights critical policy implications for enhancing recommended infant feeding practices among HIV-positive mothers in Eastern Ethiopian hospitals. Targeted interventions are essential to address medium adherence levels compared to other regions. Hospitals should prioritize counseling and support for mothers of younger infants, ensuring optimal feeding practices during this crucial developmental period. Policies should emphasize breastfeeding guidance for mothers who undergo cesarean delivery, as this group faces unique challenges. Furthermore, promoting the provision of expressed breast milk can significantly improve adherence to recommended practices. Integrating these strategies into maternal health programs will strengthen infant nutrition and reduce HIV transmission risk.

Conclusion

In summary, the study identified a moderate level of adherence to recommended infant feeding practices among HIV-positive mothers in Eastern Ethiopian hospitals. Key factors influencing adherence included the child’s age, mode of delivery, and the provision of expressed breast milk. Target interventions to improve infant feeding practices among HIV-positive mothers, focusing on younger infants, cesarean-delivered mothers, and those not providing expressed breast milk. Strengthen counseling and education in healthcare facilities to address these significant factors and enhance adherence to recommended feeding practices.