Infant feeding practices before implementing alternatives to prolonged breastfeeding to reduce HIV transmission through breastmilk in Abidjan, Cote d'Ivoire

The aim of this study was to describe baseline infant feeding practices in women of unknown HIV status in Abidjan, C?te d'Ivoire, before the implementation of infant feeding interventions aimed at the prevention of mother-to-child transmission of HIV through breastmilk. We conducted a cross-sectional survey in March 2000 among 225 mothers attending community-run health facilities with their own child for either immunization or weighting. All but two children had ever been breastfed, of whom 94 per cent were still being breastfed at 6 months of age. Exclusive breastfeeding was not practiced in this population since all women had given water to their child, starting in median one day after birth. Moreover, 20 per cent of the mothers had introduced infant formula in median three weeks after delivery. This study provides useful information for planning purposes in this urban African population, where exclusive breastfeeding is rare and the use of infant formula relatively common.     

Determinants of adherence to a single‐dose nevirapine regimen for the prevention of mother‐to‐child HIV transmission in Gert Sibande district in South Africa

Aim: To identify factors that influence adherence to antiretroviral (ARV) prophylaxis by HIV positive mothers participating in the HIV prevention of mother to child (PMTCT) programme. Methods: Post‐delivery 815 HIV‐infected mothers aged 18 years and above with babies aged 3–6 months were interviewed in Gert Sibande District, Mpumalanga province, South Africa. Results: Eighty five percent of the mothers indicated that they had been provided with nevirapine and 78.4% took it before or at the onset of labour and infant nevirapine intake was 76.9%. In multivariate analysis it was found that women with better PMTCT knowledge had a higher perceived confidentility about HIV status at the health facility. They had a term delivery and those who had told their partner about nevirapine had a higher maternal nevirapine adherence. Women who had also told their partner about nevirapine, whose partner was asked for an HIV test and those who knew the HIV status of their infant had higher infant nevirapine adherence. Conclusion: Adherence to maternal and infant ARV prophylaxis was found to be sub‐optimal. Health services delivery factors, male involvement, communication and social support contribute to adherence to ARV prophylaxis in this largely rural setting in South Africa.     

Clinical profile and morbidity pattern of infants born to HIV infected mothers in Durban South Africa

This study describes the clinical characteristics and co-infections in infants born to HIV infected women being followed up in a high risk clinic of South Africa Sixty three percent (302 out of 476) of mothers attended clinic for varying periods during follow-up. Sixty four per cent of babies had physical clinical signs suggestive of HIV infection. In the majority of babies, persistent signs resolved by 9 months of age. In those with persistent signs, 20 percent tested positive for HIV infection. Among the HIV exposed infants, co-infections with TB, CMV, syphilis and Herpes zoster were diagnosed which appeared independent of their ultimate seroconversion status.     

Infant-feeding practices and associated factors of HIV-positive mothers at Gert Sibande, South Africa

Aim: To assess knowledge, infant‐feeding education and practices, factors that affect choice of infant feeding option, determinants of mixed feeding, psychosocial challenges and attitudes of HIV‐positive women with infants between ages 3–6 months who attended prevention of mother‐to‐child transmission of HIV services in Gert Sibande district. Methods: A cross‐sectional study was conducted with 815 HIV‐positive mothers at 47 postnatal clinics. Trained field workers collected data at health facilities, using structured questionnaires. HIV‐infected women who were at least 18 years of age were interviewed. Results: The mean age was 27.7 years (SD 6.4). Seventy‐eight percent agreed that HIV could be transmitted by breastfeeding. Fifty per cent were exclusively formula feeding, 35.6% breastfed exclusively and 12.4% mixed fed. In multivariate analysis, having a vaginal delivery, infant hospital admissions, and currently pregnant were associated with mixed feeding. Being older, knowing the HIV status of the infant and higher knowledge on HIV transmission through breastfeeding were associated with formula feeding. Conclusion: The study identified gaps in prevention of mother‐to‐child transmission (PMTCT) knowledge and infant feeding policy which seem to affect appropriate infant feeding. Various determinants of mixed feeding and exclusive formula feeding in the context of PMTCT were identified that can guide infant feeding counselling and support services of PMTCT programmes.     

艾滋病高发农村儿童人类免疫缺陷病毒感染与艾滋病发病的关系

目的了解艾滋病高发区儿童感染人类免疫缺陷病毒(HIV)情况.方法对某艾滋病高发农村高危育龄妇女及其年龄小于15岁的子女进行现场询问调查和采静脉血作HIV检测.结果 159名儿童中37例HIV阳性,其中33例为母婴途径感染,占89.2%,3例经输血感染,占8.1%,其他途径感染1例,占2.7%.HIV母婴传播率为38.4%(33/86).艾滋病状态母亲组母婴传播率(68.8%,22/32)显著高于HIV携带状态组(20.4%,11/54),P＜0.05.37名感染儿童中12例发展成艾滋病, 4例死亡,其中2例死于结核.33例中31例造成母婴传播的HIV阳性妇女在孕产前未作HIV检测,占93.9%.8名妊娠期HIV阳性妇女,1例艾滋病病情加重,2例自然流产,2例经规劝终止妊娠,3例继续妊娠.结论母婴传播是儿童感染HIV的主要途径.未对高危生育期妇女进行有效的HIV监测及咨询,未采取有效干预措施是造成儿童HIV/AIDS的主要原因.亟需采取相应的对策控制HIV进一步蔓延,保护AIDS高发区妇女及儿童的健康.     

The needs of children whose mothers have HIV infection

AIM: To ascertain the psychological, social, and educational needs of children born to mothers with HIV infection. METHODS: Review of case records of 120 children and 86 mothers. RESULTS: The cohort of 120 children were born to 92 women, and followed up for a median duration of 48 months (mean (SD) 51.1 (34.1), range 0.3-132). Sixteen children were infected with HIV, 15 were of indeterminate status, and 89 uninfected. Eighty one children (68%) were cared for by their birth mother, of whom 52% were single women and 23 (38% of 61) known to have symptomatic HIV disease. Twenty five mothers of 32 children had died; the child's mean (SD) age at maternal death was 66.9 months (37.7) (range 4-128). Compared with uninfected children, more infected children knew of their mother's diagnosis (31% v 5%) and mothers were also more likely to disclose their own illness to educational authorities (77% v 13%). A larger proportion of infected children had special educational needs (69% v 13%). Only 33 children (28%) were known not to be receiving any support from the voluntary or statutory agencies. CONCLUSION: The results highlight the multiple needs of children living with maternal HIV infection, which require dedicated resources and commitment from health, education, and social work agencies and the voluntary sector. We propose the model of chronic illness as the standard of care for these children.     

Factors associated with short-course antiretroviral prophylaxis (dual therapy) adherence for PMTCT in Nkangala district, South Africa

Aim: To identify factors that influence adherence to short‐course antiretroviral (ARV) prophylaxis by pregnant women and mothers participating in the HIV prevention of mother to child (PMTCT) programme. Methods: The sample interviewed included 139 HIV‐positive antenatal women (mean gestational age 32 weeks; sexually transmitted diseases [STD] = 2.8, range 4–9 months) and 607 postnatal HIV‐positive women, with either having an infant aged 1–10 weeks (30.8%), 11 weeks to 6 months (36.7%) or 7–12 months (32.5%) from Nkangala district, Mpumalanga province, South Africa. Results: A large percentage of antenatal and postnatal women in this study initiated ARV prophylaxis for PMTCT or were on ARV (85.6% and 98%, respectively). Sixty‐one per cent of antenatal and 85.9% of postnatal women reported complete adherence to the appropriate medication schedule in the 4 days preceding the interview or prior to delivery. In multivariate analysis, it was found that women with higher HIV status disclosure and less discrimination were better in maternal AZT adherence, women with higher male involvement were better in maternal and infant nevirapine adherence. Conclusion: Adherence to maternal and infant dual therapy prophylaxis was found to be less than optimal. Community factors (discrimination, HIV disclosure, male involvement) contribute to adherence to short‐course ARV prophylaxis in this largely rural setting in South Africa.     

Breastfeeding knowledge among health workers in rural South Africa

The aim of the study was to conduct a rapid assessment of breastfeeding knowledge amongst health workers in an area of high HIV prevalence. A cross-sectional survey using semi-structured questionnaires and problem-based scenarios was carried out. Responses were compared to those recommended in the World Health Organization (WHO) Breastfeeding Counselling Course. The setting was a rural area of KwaZulu Natal, with a population of 220 000 people. At the time of the study approximately 36 per cent of pregnant women were HIV-infected and no programme to prevent mother-to-child transmission was in place. A convenient sample of 71 healthcare workers (14 doctors, 25 professional nurses, 16 staff nurses, and 16 community health workers) were included in the study. Over 50% of respondents had given breastfeeding advice to clients over the previous month. However, there were significant discrepancies in breastfeeding knowledge compared to WHO recommendations. Ninety-three per cent (n = 13) of doctors knew that breastfeeding should be initiated within 30 min of delivery, but 71 per cent (n = 10) would recommend water, and 50 per cent (n = 7) solids to breastfed infants under 6 months of age. Fifty-seven per cent (n = 8) considered glucose water necessary for neonatal jaundice, constipation, and for infants immediately after delivery. Only 44 per cent (n = 7) of staff nurses and 56 per cent (n = 14) of professional nurses knew that breastfeeding should be on demand. The majority would recommend water, formula milk, and solids to breastfed infants under 6 months of age, and glucose water for neonatal jaundice and immediately after delivery. Knowledge of community health workers differed most from WHO recommendations: only 37 per cent (n = 6) knew that breastfeeding should be initiated within 30 min of delivery, 68 per cent (n = 11) thought breastfeeding should be on schedule and not on demand, and the majority would recommend supplements to infants under 6 months of age. Few respondents suggested taking a feeding history or observing a breastfeed in response to the problem scenarios. The most commonly given responses to problems of babies who were perceived to be thirsty, unsatisfied, or crying after feeds was to supplement with other fluids or feeds. There is a need for systematic and ongoing training in breastfeeding and infant feeding counselling in the context of HIV, so that breastfeeding is not undermined by the current HIV pandemic, and exclusive breastfeeding continues to be promoted for all HIV-uninfected women, women of unknown status, and HIV-infected women who choose to breastfeed.     

The impact of peer support training on mothers' attitudes towards and knowledge of breastfeeding

While the benefits of breastfeeding are well established, few Scottish women exclusively breastfeed, as recommended nationally and internationally. Breastfeeding peer support can help mothers to breastfeed for longer, but the training peer supporters receive is variable and few studies have measured the effectiveness of peer supporter training. This study aimed to compare mothers' attitudes towards and knowledge of breastfeeding before and after undertaking Breastfeeding Network (BfN) peer supporter training. This study used a quasi‐experimental design to investigate levels of breastfeeding knowledge and attitudes in 28 women, immediately before and after the BfN peer supporter (Helper) training programme. Data were collected using the Infant Feeding Questionnaire. Mothers had high baseline scores for attitude (88.8%) and knowledge (76.4%). After training 78% of mothers improved their attitude scores. The mean difference in attitude scores was 4.9%, which was statistically significant (t = 4.44, P < 0.001). Ninety‐six per cent of mothers had increased their knowledge scores. The mean difference in knowledge scores was 10.4%, which was statistically significant (t = 6.25, P < 0.001). This study provides evidence that the BfN's accredited peer support training can improve both breastfeeding knowledge and attitudes of breastfeeding mothers. Peer supporters who have undertaken this training are therefore suitably qualified to provide mothers with the support and information required to make informed choices in breastfeeding and to contribute to effective support and promotion of breastfeeding as suggested in the National Institute for Health and Clinical Excellence guideline on maternal and infant nutrition (PH11) and Scottish Government's Maternal and Infant Nutrition: A Framework for Action (2011).     

Factors determining HIV viral testing of infants in the context of mother‐to‐child transmission

Aim: The aim of this study was to investigate factors determining HIV viral testing of infants in the context of Prevention of Mother‐to‐Child Transmission of HIV (PMTCT). Methods: Post‐delivery HIV infected mothers 18 years and above with babies aged 3–6 months were interviewed on HIV viral testing of infants and factors associated with it. Results: Among 311 HIV infected women 61.7% had their infant tested for HIV between 4 and 8 weeks. Bivariate analyses found that older age of the mothers, lower depression scores, higher PMTCT knowledge, low PMTCT risk behaviour (maternal and infant nevirapine adherence, health facility delivery and exclusive formula feeding), HIV status disclosure and attending a support group were associated with PCR test participation. In multivariate analyses higher PMTCT knowledge, infant nevirapine adherence, and not exclusive breast feeding were associated with polymerase chain reaction test participation. Conclusion: Various determinants of acceptance of participation in HIV viral testing of infants in the context of PMTCT were identified that can guide infant testing and diagnosis counselling and support services of PMTCT programmes.     

Is exclusive artificial feeding feasible at 6 months post partum in Cameroon urban areas for HIV-exposed infants?

The aim of the study was to evaluate the feasibility of infant feeding options of HIV positive mothers in urban areas (especially compliance to artificial feeding choices), before the implementation of the infant feeding interventions and procurement of breastmilksubstitutes. We conducted a survey among seropositive women diagnosed during pregnancy and counselled for infant feeding options. At 6 months post delivery an interview was done. 47 mothers were included. Bromocriptine was prescribed to all the mothers who opted for artificial feeding from birth. FINDINGS: After counselling 85% of women opted for exclusive artificial feeding of whom 83% mothers practised this option since birth. For those who opted for replacement feeding The main given reason for infant feeding choice was related to medical or nurses advices. Overall 36% [CI 95%, 22-50] of the mothers who opted for artificial milk faced difficulties to afford supplies during the 6 months, leading into an early introduction of paps. Clinical mastitis were mentioned by all those mothers who breastfed. Infant feeding choices were related to the level of education (X2 = 24.10, P = 0.002). CONCLUSION: Artificial feeding under recovery of cost seems feasible in urban areas in Cameroon and can be facilitate by the administration of antilacteal drugs. More adequate support must be provided for the mother who breastfeed in order to prevent and to treat mastitis. Additional training for counselling in HIV and infant feeding options is recommended for health workers.     

Postnatal zidovudine in prevention of vertical HIV-1 transmission in a service setting

We sought to determine the efficacy of a 4-6 week course of zidovudine (ZDV) in a group of infants exposed to HIV-1. A retrospective chart review was conducted on HIV-1-exposed neonates identified from February 1998 to August 1999. These infants received ZDV and their mothers were counselled regarding the risks and benefits of breastfeeding. After informed consent was obtained, the HIV-1-status of the infant was determined by RNA-PCR after 1 month of age. Thirty-three HIV-1-exposed neonates were identified; seven infants were excluded, five because of insufficient data and two because of maternal ZDV administration. In all but three, the diagnosis was suspected because of maternal illness, 19 of 26 mothers having either stage 3 or 4 disease. The transmission rate was 15.4 per cent (4 of 26). Errors in ZDV administration were detected in 20 neonates of whom four were infected (p = 1; Fischer's exact test). Antenatal diagnosis of HIV-1 status was associated with fewer medication errors in HIV-1-exposed neonates (p = 0.017, Fisher's exact test). It was concluded that a transmission rate of 15.4 per cent in symptomatic mothers suggests efficacy. Under similar circumstances, transmission rates varying between 37 and 67 per cent have been reported. Antenatal diagnosis is significantly associated with compliance to the regimen. Early identification of at-risk neonates and familiarity with the regimen may improve the outcome.     

The effect of Pretoria Pasteurization on bacterial contamination of hand-expressed human breastmilk

One of the challenges facing the development of programs to reduce mother to child transmission of HIV in developing countries remains the problem of infant feeding. One of the alternative feeding methods under investigation for infants of HIV-infected mothers is heat treatment of expressed breastmilk by Pretoria Pasteurization. The objective of this study was to determine the effect of Pretoria Pasteurization on commensal and pathogenic bacteria in hand-expressed human breastmilk, and to determine the duration of time for which milk can be kept safely without refrigeration after Pretoria Pasteurization. Samples of milk were hand expressed by lactating women in the postnatal ward. The samples were split into control and pasteurized specimens. The pasteurized specimens underwent Pretoria Pasteurization. All samples were stored at room temperature and were sampled for bacterial culture every 4 h, up to 12 h. Clinically significant levels of bacterial contamination occurred in 59 per cent of control and 7.8 per cent of pasteurized samples. Four pasteurized samples showed significant contamination. There is strong evidence that the contaminating organisms in these samples were introduced by handling after pasteurization. The 53 (91 per cent) pasteurized samples that had no contamination at 4 h remained sterile for the remainder of the standing period of 12 h. Forty-one per cent of control samples already had significant growth after standing at room temperature for 4 h. In conclusion, Pretoria Pasteurization kills pathogenic and commensal bacteria in hand-expressed breastmilk. Expressed breastmilk that has undergone Pretoria Pasteurization can be kept without refrigeration for up to 12 h with minimal probability of bacterial contamination provided that it is kept in the pasteurization container and is not handled.     

Impact of maternal work outside the home during pregnancy on neonatal outcome

The impact of mothers' work during pregnancy upon neonatal outcome has not been fully elucidated. A study of maternal health habits and neonatal outcome conducted from 1977 to 1979 at Boston City Hospital assessed the effects of paid work outside the home during pregnancy, particularly third trimester work in a standing position, upon duration of gestation and intrauterine growth, while controlling for potentially confounding variables. Postpartum, 1,690 low-income women were interviewed to provide detailed information on their sociodemographic and health characteristics. Of the 1,507 women whose work status during pregnancy could be classified, 55% did not perform paid work outside the home or attend school, 7% worked into the third trimester in a standing position, and 38% had other work histories or attended school. Infants were examined according to a standard protocol by pediatricians blind to mothers' work history. There was no significant relationship between the mothers' work history during pregnancy and the infants' length of gestation, weight, or head circumference at birth, when confounding variables were controlled statistically by multiple regression analyses. However, women who worked in a standing position into the third trimester delivered infants who were longer than infants born either to mothers with other work histories or to mothers who did not work or attend school. Healthy women with uncomplicated low-risk pregnancies who feel well enough to attend school or work during pregnancy, even in a job requiring some standing, may do so without fear that their infant will suffer shortened gestation or impaired intrauterine growth.     

Maternal HIV is associated with reduced growth in the first year of life among infants in the Eastern region of Ghana: the Research to Improve Infant Nutrition and Growth (RIING) Project

Children of HIV‐infected mothers experience poor growth, but not much is understood about the extent to which such children are affected. The Research to Improve Infant Nutrition and Growth (RIING) Project used a longitudinal study design to investigate the association between maternal HIV status and growth among Ghanaian infants in the first year of life. Pregnant women in their third trimester were enrolled into three groups: HIV‐negative (HIV‐N, n = 185), HIV‐positive (HIV‐P, n = 190) and HIV‐unknown (HIV‐U, n = 177). Socioeconomic data were collected. Infant weight and length were measured at birth and every month until 12 months of age. Weight‐for‐age (WAZ), weight‐for‐length (WLZ) and length‐for‐age (LAZ) z‐scores were compared using analysis of covariance. Infant HIV status was not known as most mothers declined to test their children's status at 12 months. Adjusted mean WAZ and LAZ at birth were significantly higher for infants of HIV‐N compared with infants of HIV‐P mothers. The prevalence of underweight at 12 months in the HIV‐N, HIV‐P and HIV‐U were 6.6%, 27.5% and 9.9% (P < 0.05), respectively. By 12 months, the prevalence of stunting was significantly different (HIV‐N = 6.0%, HIV‐P = 26.5% and HIV‐U = 5.0%, P < 0.05). The adjusted mean ± SE LAZ (0.57 ± 0.11 vs. ?0.95 ± 0.12; P < 0.005) was significantly greater for infants of HIV‐N mothers than infants of HIV‐P mothers. Maternal HIV is associated with reduce infant growth in weight and length throughout the first year of life. Children of HIV‐P mothers living in socioeconomically deprived communities need special support to mitigate any negative effect on growth performance.     

Breastfeeding practices in an area of high HIV prevalence in rural South Africa

Exclusive breastfeeding (EBF) from 0 to 6 mo of age is recommended by the World Health Organization as the optimal feeding method for infants, including infants of human immunodeficiency virus (HIV)-infected women from developing countries who choose to breastfeed. EBF may be associated with less risk of postnatal HIV transmission than mixed feeding, but is still uncommonly practised for reasons that are poorly understood. This study aimed to assess EBF rates and the impediments to EBF in a South African rural area of high HIV prevalence where most mothers are unaware of their status. In a longitudinal study, 130 women attending 3 clinics, chosen for their disparate socioeconomic characteristics, were interviewed at weekly postnatal intervals. Follow-up to 16 wk was completed on 119 infants. In an additional cross-sectional survey mothers of 445 infants, aged 0-12 mo, attending immunization clinics were interviewed. In the longitudinal study 46% of infants received non-breast-milk fluids or feeds within 48 h of birth; only 10% were exclusively breastfed for 6 wk and 6% for 16 wk. Supplements, most commonly formula milk, were introduced for perceived milk insufficiency. Feeding choices were mainly self-determined (43% of women), but health staff (22%) and grandmothers (16%) were cited as sources of advice. In the cross-sectional survey caregivers reported that 47% of infants aged 2 wk, 40% aged 6 wk and 33% aged 12 wk had been exclusively breastfed since birth. CONCLUSION: EBF is uncommon in this area in spite of a baby-friendly hospital initiative in the district. Strategies to promote exclusive breastfeeding in developing countries where HIV and infant feeding policies are being formulated must strongly address local perceptions on the need for supplements and sources of feeding advice.     

The role of the village midwives in antenatal care services in the Sudan.

A study was conducted to assess the obstetric care coverage provided by the Sudanese village midwives. Mothers and village midwives, from four villages were interviewed using structured questionnaires. A total of 130 mothers who had delivered within 6 months were included in the study. Seventy per cent of these mothers contacted the village midwives at least once during their pregnancy. The average attendance was 3.8 antenatal contacts per mother. Seventy-one per cent of those who contacted the village midwives did so during the first half of pregnancy. Half of these mothers were seen in the village midwife's own home and only 20 per cent were in the mothers' homes. The village midwife attended 76 per cent of the deliveries, 11 per cent were attended by the traditional birth attendants, and the remainder delivered in hospital. The village midwives demonstrated reasonable standard of knowledge and competence in various aspects of antenatal care, history taking, examination, and selection of cases for referral. They lack adequate support and supervision, and supplies of drugs such as iron, folic acid, and chloroquine tablets.     

The behavioral risks and life circumstances of adolescent mothers involved with older adult partners.

OBJECTIVE: To investigate behavioral risks and life circumstances of adolescent mothers with older (> or =5 years) adult (> or =20 years old) vs. similar-aged (+/-2 years) male partners at 12 months' postpartum. METHODS: Nine hundred thirty-one adolescent females were interviewed after delivery and were mailed surveys to complete at 12 months' postpartum. Analysis by chi(2) and t test was used to identify differences in behavioral risks (planned repeated pregnancy, substance use, and intimate partner violence) and life circumstances (financial status, school enrollment, and social support) for adolescent mothers with older adult vs similar-aged partners. Additional stratified analyses were conducted to evaluate the extent to which living with an adult authority figure or being with the father of her infant born 12 months previously might alter observed relationships. RESULTS: At 12 months following delivery, 184 adolescent mothers (20%) reported having an older adult partner, whereas 312 (34%) had a similar-aged partner. The remaining adolescent mothers (n = 239) were excluded from further analyses. Adolescent mothers with older adult partners were significantly less likely to be employed or enrolled in school and were more likely to report planned repeated pregnancies. These adolescent mothers also received less social support. No differences were observed in intimate partner violence or the mother's substance use. Adolescent mothers with older adult partners who did not live with an adult authority figure seemed to be at greatest risk. CONCLUSIONS: The negative educational and financial impact of coupling with an older vs. similar-aged partner seems greater for those mothers who no longer reside with an adult authority figure. These adolescent mothers are also at greater risk of planned rapid repeated pregnancy. Given their limited educational attainment and family support, a subsequent pregnancy may place these young women at considerable financial and educational disadvantage.