Infant feeding in the context of HIV infection: Mothers’ experiences and programme implications for maternal and child health services in Tanzania
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The documentation of breastfeeding as a source of HIV infection in babies has come to represent a public health dilemma in countries with a high prevalence rate of HIV and where breastfeeding is the standard norm and essential to child survival (DeCock et al. 2000; WHO 2003). UNAIDS estimated that 630,000 infants are HIV infected through their mothers every year, 280,000 being infected through their mother’s milk (UNAIDS/WHO 2004). The HIV prevalence in the antenatal population in Tanzania was 9.6% among pregnant women in 2005. Mother-to-child transmission (MTCT) of HIV contributes to about 5% of the HIV prevalence in Tanzania (Ministry of Health 2005). This study aimed to generate knowledge on infant feeding and infant feeding counselling to HIV-positive mothers that can strengthen programmes for prevention of mother-to-child transmission of HIV (pMTCT) and policy development in Tanzania. More specifically the study investigated HIV-positive mothers’ experiences connected to choice of and adherence to the particular infant feeding methods recommended in pMTCT programmes. It also explored the challenges experienced by nurses as counsellors in pMTCT programmes, and hence, developed counselling tools to strengthen the knowledge and performance of counsellors and the adherence to infant feeding choice among HIV-positive mothers. Finally, the study evaluated the effectiveness of the counselling tools in strengthening the quality of counselling and the adherence to infant feeding choice among HIV-positive mothers. The study used an explorative qualitative research design employing qualitative triangulation mainly in-depth interview, focus group discussions and participant observation. The study was composed of a formative research part and an intervention part. The formative research focused on the customary infant feeding concepts and practices in the Kilimanjaro region, as well as on mothers’ and counsellors’ experiences with infant feeding recommendations in pMTCT programmes. The intervention study focused on the development of culturally-sensitive counselling tools (‘job aids’) to be employed by nursecounsellors during the counselling of women linked to pMTCT programmes, as well as by HIV-positive mothers for reference on how to perform safer infant feeding. The formative research findings contributed to the identification of the key messages to be communicated and illustrated in relation to infant feeding method. The intervention study also assessed the impact of the developed counselling tools on mothers’ infant feeding knowledge and practice. The findings revealed that there is a gap between intensions and infant feeding practices in the context where the social expectations to breastfeed are high, and where kin and neighbours are part of the decision-making team surrounding infant feeding. The study highlighted the tension between the competing concerns of the medical and social risks involved in the choice of infant feeding methods. The findings pointed to the expectations from the environment that a mother should breastfeed and not breastfeeding was seen as a serious failing of motherhood and might be interpreted as a sign of HIV infection. Other methods were practiced in hidden. Furthermore, the study argues that the feeding methods recommended might be difficult to adhere to whether a mother chooses exclusive breastfeeding or exclusive replacement feeding. The nurse-counsellors expressed a lack of confidence in their own knowledge of HIV and infant feeding, as well as in their own skills in assessing a woman’s possibilities of adhering to a particular method of feeding. The nurse-counsellors were found unable to give qualified and relevant advice to HIV-positive women on how best to feed their infants. They were confused regarding the appropriateness of the feeding options they were expected to advice HIV-positive women to employ, and perceived both exclusive breastfeeding and replacement feeding as culturally and socially unsuitable. However, most counsellors believed that formula feeding was the right way for an HIV-positive woman to feed her infant. Furthermore, the nurse-counsellors were in general not comfortable in their newly gained role as counsellors and felt that it undermined the authority and trust traditionally vested in nursing as a knowledgeable and caring profession. The study argued that the condition under which counsellors are expected to provide quality care needs careful consideration, and indicated an urgent need for pre- and post service training and support structure necessary to promote professional confidence and skills for nurse-counsellors. The findings showed that the national and international guidelines on infant feeding conflict with local knowledge and reality constructions, and it suggested that strategies to increase safer infant feeding practices among HIV-positive women should be culturally relevant. A complementary set of counselling materials was developed and included brochures on the three feeding methods that were found to be socially and culturally acceptable, a Question and Answer Guide for counsellors, and a toolbox for demonstration. The three brochures on exclusive breastfeeding, formula feeding and cow’s milk feeding describe the steps to safe infant feeding, illustrated with images based on local ideas and resources. The brochures serve as reference material during infant feeding counselling in the ongoing pMTCT programme and as take-home material for the mother. The counselling tools increased the knowledge about infant feeding among mothers and strengthened certain aspects of infant feeding counselling compared with the counselling offered in the standard pMTCT programme. However, some clear limitations and challenges were revealed in the course of the study. These were particularly linked to limited counselling related to the risks involved in mixed feeding and counsellors' bias towards formula feeding among HIV-positive mothers. Further, poor judgement of the ‘acceptability, feasibility, affordability, sustainability and safety’ criteria (AFASS) of the various feeding methods in the particular infant feeding situation of each mother, compromised the quality of infant feeding counselling and hence, complicated the process of choice. The study calls for a critical assessment of the concept of informed choice which underlies the international infant feeding guidelines. Moreover, it argues for the need of a multi-dimensional behaviour change strategy involving both mothers and counsellors and if possible significant others who influence choice and decision-making processes. The study discusses practical, research and policy measures and recommends locally appropriate interventions that facilitate promotion of exclusive breastfeeding to all mothers in the community and strengthening infant feeding counselling services as part of an attempt to reduce MTCT and stigma related to HIV and infant feeding methods.
Består avPaper I: Journal of Social Aspects of HIV/AIDS Research Alliance (SAHARA) 4(2), Leshabari, Sebalda C.; Blystad, A. & K. M. Moland, Difficult choices: Infant feeding experiences of HIV-positive mothers in northern Tanzania, pp. 544-555. Published with permission. Published version. The published article is also available at journal site: http://www.sahara.org.za/index.php/Journal/SAHARA-J.html
Paper II: Human Resources for Health Journal 5(18), Leshabari Sebalda C.; Blystad, A.; de Paoli, M. & Karen M Moland, HIV and infant feeding counselling: Challenges faced by nurse-counsellors in northern Tanzania. Copyright 2007 Leshabari et al; licensee BioMed Central Ltd. Published with permission.Published version. The published article is also available at: http://dx.doi.org/10.1186/1478-4491-5-18
Paper III: Implementation Sciences Journal 1(22), Leshabari Sebalda C.; Koniz-Booher, P.; Åstrøm, Anne N.; de Paoli, M. & Karen M Moland, Translating global recommendations on HIV and infant feeding to the local context: The development of culturally sensitive counselling tools in the Kilimanjaro region, Tanzania. Copyright 2006 Leshabari et al; licensee BioMed Central Ltd. Published with permission. Published version. The published article is also available at: http://dx.doi.org/10.1186/1748-5908-1-22
Paper IV: Leshabari Sebalda C.; Koniz-Booher, P.; Blystad, A.; Burkhalter, B.; Kwesigabo, G. & Karen Marie Moland, Counselling tools in the promotion of safer infant feeding practices in the context of HIV: An evaluation study from Kilimanjaro region, northern Tanzania, 2007. Submitted version