Counseling and choosing between infant-feeding options: Overall limits and local interpretations by health care providers and women living with HIV in resource-poor countries (Burkina Faso, Cambodia, Cameroon)
Introduction
As part of Prevention of Mother-to-Child HIV Transmission (PMTCT) strategies, HIV-positive women are asked to choose from two options regarding the feeding of their infant: replacement feeding (with breast-milk substitutes) or exclusive breastfeeding with early weaning (WHO/UNICEF/UNFPA/UNAIDS, 2007a, WHO/UNICEF/UNFPA/UNAIDS, (2007b)).1 Health services must offer women counseling on infant feeding, “specific guidance” and support to enable them to make an “informed choice” between these options. In fact, “All HIV-infected mothers should receive counseling, which includes provision of general information about the risks and benefits of various infant feeding options, and specific guidance in selecting the option most likely to be suitable for their situation. Whatever a mother decides, she should be supported in her choice” (WHO/UNICEF/UNFPA/UNAIDS, 2007a, WHO/UNICEF/UNFPA/UNAIDS, (2007b).
Though in developed countries nearly all women living with HIV turn to replacement feeding, the choice is more difficult in developing countries where, due to sanitary conditions, inappropriate use of formula may lead to diarrhoea and dehydration, major causes of infant mortality (UNICEF, 2007). Moreover, insufficient adherence to preventive options resulting in mixed feeding leads to a high risk for HIV transmission. The two preventive options may be considered under these conditions: (i.) replacement feeding must be “acceptable, feasible, affordable, sustainable, and safe;” (ii.) the mother must get follow-up and support; and (iii.) the selected feeding option must be appropriate for each case (WHO/UNICEF/UNFPA/UNAIDS, 2007b). While debate continues about the definition of the most appropriate option at population levels in low-income settings (Coutsoudis, Coovadia, & Wilfert, 2008), there is consensus in favor of selecting the feeding option at the individual level, considering environmental, social, economic and medical situations. This stresses the importance of how women's choices between feeding options are constructed.
According to international recommendations, women should choose on the basis of information adapted to their situation and given to them before or during counseling. Health professionals hold a prominent role since they should also provide guidance and support. Counseling for infant feeding has been defined in international recommendations, emphasizing relational more than technical content, as follows:
“Counseling is a helping relationship. It is usually one-to-one communication specific to the needs of the individual. When you counsel a mother, you
Listen to her,
Help her to understand the choices that she has to make
Help her to decide what to do, and
Help her to develop confidence to carry out her decision. […]
A counselor does NOT make a decision for a woman, nor push her towards a particular course of action, nor enforce a health policy.” (WHO/UNAIDS/UNICEF, 2000: 2)
The definition of health professionals' role has been slightly different in various editions of international or national guidelines, following new evidence-based recommendations involving specifications about “guidance.” This role is defined according to the counseling model of the patient-healer relationship that has been generalized in the context of the HIV epidemic.
At the women's level, this information meets their perceptions of each infant-feeding option regarding its value and social implications. Infant-feeding practices, especially breastfeeding, have a rich symbolic content in all cultures and settings, translated into local norms about the way an infant should be fed and about those who maintain authority about it (Maher, 1992, Stuart-Macadam & Dettwyler, 1995). Moreover, in developing countries, the public health history of infant feeding is marked by an international crisis due to the widespread use of formula during the 20th century in Africa (Van Esterik, 1989). While some populations were confronted with this dangerous change in feeding patterns, other populations living in poorer settings still shape their infant-feeding practices according to long-standing norms. Perceptions about exclusive breastfeeding and artificial feeding are presently heterogeneous and shaped by local cultures of breastfeeding (Bonnet & Pourchez, 2007). These draw on the local contexts of choices between infant-feeding options.
HIV infection also has strong symbolic meaning around death, sex, and morality, with nuances in various settings (Becker et al., 1998, Narain, 2004). HIV infection still conveys stigma, even if attitudes have changed slightly where antiretroviral treatments are available. Though moral accusation may be less frequent, social rejection still occurs, often related to the foreseen social and economic distress attached to victims of this chronic disease that is still considered to be fatal. Attitudes entangle pity, empathy, avoidance or ostracism towards people living with HIV (PLHIV), which influences relationships between HIV-positive mothers and their families, and—in different ways—between mothers and caregivers. The impact of this social and symbolic background on mothers' practices regarding both infant feeding and HIV has been documented in African settings (Doherty et al., 2006, Leshabari et al., 2007).
This background may also influence health care providers' local interpretations of preventive options, counseling, and guidance. A previous study on breastfeeding and HIV conducted in Burkina Faso showed that most health professionals' attitudes about prevention were based on a combination of medical knowledge, transformed into lay principles, and personal and professional experiences regarding breastfeeding on one hand and HIV infection and PLHIV on another hand (Desclaux & Taverne, 2000). In Abidjan, Côte d'Ivoire, gender and religious values shape how PMTCT health workers, who are mainly women, adapt the messages they give women during “Information Education Communication” sessions (Gobatto & Lafaye, 2007). Moreover, since international recommendations request that counseling consider economic, environmental, social and medical situations, health workers may give adapted messages; they may also orientate them according to mothers' perceptions about each feeding option or to overall constraints in prevention. These hypotheses open the possibility for common or varied interpretations of counseling and guidance for infant-feeding options among countries or settings, which have not yet been documented.
The purpose of this article is to shed light on these issues by considering three aspects: (i.) how, in various countries and health services settings, recommendations are translated into clinical practices of “counseling” and “guidance”; (ii.) what aspects women consider when building their “choice”; and (iii.) how health care workers' “guidance” and women's “choices” interact in a context of constraints. By considering these issues in three countries, our aim is to show overall features and local characteristics, in order to provide an understanding of counseling and choice for infant feeding as a particular form of the relationship between HIV-positive women and the health care system.
Section snippets
The study
A research program aimed at shedding light on the determinants of infant feeding in the context of HIV was conducted in five developing countries (Cambodia, Côte d'Ivoire, Burkina Faso, Cameroon and Kenya) with ongoing PMTCT programs. The study was based on a qualitative approach with comprehensive aims. It was conducted in varied contexts of PMTCT program implementation: (i). Mother and Child Health services in the public health system; (ii.) Services where research projects were conducted;
Results
Women's interviews and our observations of individual or collective counseling sessions show diversity in practices regarding information provision about each infant-feeding option, both in aspects considered in counseling and in contents of encounters between women and health professionals.
Discussion
Though defined to some extent by international recommendations and national guidelines, the practical and theoretical contents of counseling and guidance by caregivers and their relationships to mothers' choices in PMTCT programs differ across sites. A study on the effectiveness of WHO/UNICEF guidelines on infant feeding in South Africa that focused on the evaluation of the appropriateness of choices made under guidance by health professionals concluded that counseling practices showed
Study limitations
The differences described here may be partly due to the circumstances and the timing of our enquiry: data were collected a few months or a few years after the implementation of PMTCT programs, when health professionals had received different levels of training and might have dealt with different guidelines. However, even when health workers have been fully trained in PMTCT, their commitment is not consistent across teams, varying with health service dynamics and their level of specialization
Overall trends
Across sites, counseling by health professionals and women's choices are shaped by their perceptions of each feeding option. Most health professionals, as well as women, think that formula feeding is the best option if local conditions were not considered. This preference is due to the capacity of replacement feeding to eradicate HIV transmission. This ranking of feeding options implies that the aim of counseling in clinical practice is interpreted as a guiding choice between an ideal option
Local interpretations
The ranking of feeding options and the prominence of economic aspects described in health workers' perceptions also underlie national programs and institutions' policies in the studied countries. On this common basis, various strategies are engendered by public health considerations regarding the standard of care that should be considered (highest/universal or related to context) and regarding responsibilities shared between mothers and the health system. Some, such as Cameroon's national
Conclusion
Counseling by health care providers for infant feeding in the context of HIV is a difficult matter, since it claims, by providing complex information and adapted guidance, to enable women to change behaviors by overcoming mainly structural barriers: poor accessibility of replacement food (including breast-milk substitutes); poor tolerance for advised options in some local cultures of infant feeding; lack of agency for women in patriarchal societies; ongoing stigma related to HIV; and
Acknowledgements
The study program ANRS 1271 [Determining factors of HIV transmission through breastfeeding. A multicentric study] has been funded by Agence Nationale de Recherches sur le Sida et les hépatites virales (ANRS, France). Field data collection was done by Sophie Djetcha in Cameroon and Soizick Crochet in Cambodia. Sophie Djetcha was granted scholarships from ANRS and Sidaction (France). We would like to thank Centre Muraz and Kesho Bora Group (Burkina Faso), Institut Pasteur du Cambodge, Centre
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