Mental health predictors of breastfeeding initiation and continuation among HIV infected and uninfected women in a South African birth cohort study
Introduction
Breastfeeding confers numerous health benefits to mothers and infant and is an essential strategy for reducing morbidity and mortality in low and middle income countries (LMICs) where malnutrition and infectious diseases are common (Doherty et al., 2011, Chowdhury et al., 2015). The World Health Organization's (WHO) infant feeding guidelines emphasize exclusive breastfeeding for the first 6 months of life as a cost-effective, safe source of nutrition (World Health Organization, 2010). In LMICs with large HIV epidemics such as South Africa, in the presence of national ART programmes with high coverage of pregnant and breastfeeding women, breastfeeding benefits outweigh risks of vertical HIV transmission (Bispo et al., 2017). As such, WHO recommends HIV-infected mothers exclusively breastfeed from birth to 6 months and receive antiretroviral therapy (ARV) to limit mother to child (PMTCT) HIV transmission; breastfeeding is recommended until 12 months (Department of Health, 2014a, WHO, n.d). South African PMTCT guidelines emphasize exclusive breastfeeding for the first 6 months, and complementary feeding thereafter (Department of Health, 2014b).
In South Africa, Prevention of Mother to Child Transmission (PMTCT) commenced in 2002 and included provision of free infant formula milk provision at public health facilities to HIV infected mothers who chose not to breastfeed (Vythilingum et al., 2013). The South African PMTCT program underwent several revisions between 2002 and 2015 in tandem with emerging global health evidence (WHO, 2012, Coutsoudis et al., 2002). Policies to encourage initiation and continuation of exclusive breastfeeding regardless of mother's HIV-status were adopted in 2012 (Meeting, 2011) and 2013 (Health TND of, 2013). These included halting the provision of formula milk to HIV-infected mothers, unless medically indicated (Meeting, 2011). However, the phasing-out of free infant formula milk occurred at different time point across the 9 provinces of South Africa. In the Western Cape Province, no new PMTCT mothers were issued formula milk only from 1 April 2015 and distribution was concluded by 30 September 2015 (Directorate, 2015).
Despite clear best-evidence clinical guidelines and strong policy support, initiation and continuation of breastfeeding remain a challenge for women in general (Patel et al., 2015, Victora et al., 2016a), and among HIV-infected mothers specifically (Marquis et al., 2016). In South Africa, exclusive breastfeeding rates, regardless of HIV status, remains low at approximately 32% (South Africa Demographic and Health Survey, 2016). Breastfeeding practices among uninfected mothers are slightly better compared to HIV-infected mothers (Gewa et al., 2011a, Doherty et al., 2012), but are still below ideal targets (Victora et al., 2016b).
Many studies examining barriers and facilitators of breastfeeding in LMIC, including South Africa, have been generated (Doherty et al., 2012). Pregnancy and gestational factors such as unplanned pregnancy, nulliparity, caesarean section, infant male gender and low birth weight have been found to be negatively associated with breastfeeding behaviour (Patel et al., 2015, Kimani-Murage et al., 2015, Gewa et al., 2011b). Among HIV-infected mothers HIV-infection and a low CD4+ T-cell count during pregnancy have been found to be associated with non-initiation (Bork et al., 2013, Fadnes et al., 2009, Mnyani et al., 2016), while low socioeconomic status and large family size have been associated with early breastfeeding cessation (Haile et al., 2014). Notably absent are studies in in the context of a generalized HIV epidemic that examine factors that disproportionately affect LMIC mothers such as mental disorders.
The prevalence of maternal mental disorders is a significant issue in LMICs (Gelaye et al., 2016, Baron et al., 2016), and among populations infected or affected by HIV (Stein et al., 2015). Women in LMICs are more likely to be exposed to risk factors for poor mental health including trauma and HIV (Gelaye et al., 2016, Herba et al., 2016). Depression, anxiety, intimate partner violence (IPV), as well as alcohol and smoking during pregnancy have all been shown to negatively influence breastfeeding behaviour (Fairlie et al., 2009, Arifunhera et al., 2015, Misch and Yount, 2014a, Zureick-Brown et al., 2015, Nkala and Msuya, 2011, Zakarija-Grković et al., 2015). Nevertheless, most data on the relationship between maternal mental health and breastfeeding come from high-income countries.
The aim of this study was to investigate mental health predictors of breastfeeding initiation and continuation in a South African birth cohort study in a LMIC with a high prevalence of HIV.
Section snippets
Methods
Data were derived from a prospective study of mother-infant pairs enrolled in the Drakenstein Child Health Study (DCHS), a multidisciplinary, population-based birth cohort study investigating the determinants of child health in the Western Cape, South Africa (Zar et al., 2015).
Sociodemographic characteristics
The median age of enrolled women was 25.9 years (inter-quartile range (IQR) 22.0–30.8) at enrolment (Table 1). Approximately half were of black African ancestry (54%), with the remainder of mixed ancestry. Only 38% had completed secondary/tertiary level of education. Participants were predominantly unemployed (73%). Most mothers reported single relationship status, with 39% reporting that they were currently married or cohabiting. The majority of participants described receiving support from
Discussion
Despite near universal initiation of breastfeeding by uninfected mothers, breastfeeding initiation was low among HIV-infected mothers. In contrast, HIV-infected mothers had longer durations of any and exclusive breastfeeding when compared to uninfected mothers. Notable though, was that duration of breastfeeding continuation was sub-optimal for all mothers, regardless of HIV status. Predictors of breastfeeding initiation and duration of any and exclusive breastfeeding also differed by maternal
Study limitations and strengths
Results are from a single low socio-economic area and may not be generalizable to women of dissimilar ethnic and sociodemographic backgrounds. The sample size of HIV infected mothers who initiated breastfeeding was small and may have affected precision of estimates. On the other hand, this study contributes to existing literature by addressing geographic disparities through use of a large dataset from a LMIC setting, and via a robust comparison of mothers by HIV status in a country with one of
Conclusion
Findings highlight important issues that need to be addressed to promote optimal infant feeding among all mothers regardless of HIV status. HIV infected mothers face differential challenges in adhering to recommended breastfeeding guidelines and require targeted interventions to improve breastfeeding initiation and exclusive breastfeeding duration.
Conflicts of interest and sources of funding
We do not have any conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest. Support for this study was provided by the Bill and Melinda Gates Foundation (grant number OPP1017641). DJS, HJZ, NK, and WB are supported by the Medical Research Council of South Africa. CK derived support for analysis, interpretation and writing from National Institute of Mental Health (NIMH 096646).
Transparency document
Acknowledgements
The authors would like to thank colleagues for their helpful comments and contributions: Nienke Groenewald, Attie Stadler and Raymond Nhapi and the entire on-site Drakenstein clinical and research team for its tireless work and commitment, as well as all the mothers and infants enrolled in the Drakenstein Child Lung Health Study.
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