Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia

Introduction The dilemma posed between lifesaving benefit and risk of transmission through breast feeding complicates infant feedings among communities grossly affected by HIV/AIDS. According to the world health organization’s guideline which was revised in 2010, exclusive breast feeding and exclusive replacement feeding are the recommended infant feeding practices for HIV positive mothers. The aim of this study was to assess infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital, North West Ethiopia. Methods An institutional based cross sectional study was conducted from May to September 2013. A Randomly selected 260 HIV positive mothers were included. The data were collected by using a pretested and structured questionnaire. Bivariate and multivariate analysis were performed to check association and to control confounders. Results From a total of 260 HIV positive mothers, 85.8% of them were feeding their children based on the recommended feeding way of infant feeding practice with the remaining percentage 14.2% were practicing mixed feeding. In multivariate analysis mothers attending high school and above AOR = 5.3 [95% CI = 1.25-22.1], having antenatal care follow up AOR = 5.5 [95% CI = 1.5-20.16], being on anti-retro viral therapy AOR = 6.5 [95% CI = 1.88-22.51] and disclosure of HIV status AOR = 7.1 [95% CI = 1.26-39.76] were found to be independently associated with infant feeding practice. Conclusion This study revealed that large proportion of HIV positive mothers had followed the recommended infant feeding practice and significantly high number of mothers had practiced mixed feeding. Educating mothers, increasing ANC utilization, counseling mothers to start ART, encouraging and supporting mothers to disclose their HIV status were recommended.


Introduction
Globally 34.0 million people were living with HIV by the end of 2011. In the same year 3.3 million children were living with HIV and more than 90% of them were living in sub-Saharan Africa. In Ethiopia the point estimate of the total HIV population among children aged 0-14 years in 2012 were 168,598 [1]. In sub Saharan Africa, mother to child transmission (MTCT) of HIV is responsible for about 90% of infection in children, and about half of these infection thought have been acquired through breast feeding. The availability of ART alone does not solve the problem of HIV transmission through breastfeeding which is responsible for as much as 5-20% [2]. The dilemma posed between life saving benefit and risk of transmission through breastfeeding complicate infant feedings in a communities affected by HIV/AIDS. The main challenge is how to improve, through optimal feeding the nutritional status, growth and healthy development and thus survival of infants and young children in the given circumstances in the middle of HIV/AIDS pandemics [3]. The World Health Organizations guideline on HIV and infant feeding which was revised in 2010 recommends that in order to reduce the risk of the baby becoming infected, mothers or their infants are advised to take a course of antiretroviral drugs through the breastfeeding period.
Mothers are also advised to exclusively breastfeed their infants for 6 months meanwhile introduces other food substances while continuing breastfeed up to a year. The guideline also lists special conditions needed to safely formula feed [3]. Some studies revealed that the risk of mother to child transmission is lower among mothers who exclusively breastfed when compared to those who practiced mixed feeding. Evidences also indicates that exclusive replacement feeding (ERF) is associated with low risk of post natal HIV transmission and high mortality when compared to breast feeding [4][5][6]. The type and duration of recommended infant feeding practices is one of the critical decisions that should be made to maximize prevention benefits for the child. This is also the part of strategies of PMTCT in a plan to create the future HIV free generation. However there was no information regarding the infant feeding practice and associated factors of the HIV positive mothers in Debre Markos referral hospital which supposed to serve over 5 million peoples. It also provides evidence based information to policy makers and stake holders to exert maximum effort in improving recommended feeding practice for HIV positive mothers.

Methods
A cross sectional study was conducted in Debre Markos referral hospital, North West Ethiopia, from May to September, 2014. Debre Markos town is located in east Gojam zone of Amhara regional state, North West Ethiopia 300 kilometers far from the capital Addis Ababa. The total population of the town was 62,497 out of this 52.1% were females and 48.9% were males. The source populations were all HIV positive mothers who had an infant or last child less than or equal to 2 years of age attending PMTCT and services and or on ARV treatment in Debre Markos referral hospital.
Study population were all HIV positive mothers who had an infant or last child less than or equal to 2 years of age attending PMTCT services and or on ARV treatment in Debre Markos referral hospital and were volunteer to participate in the study. The sample size was determined by using single population proportion formula based on the following assumption; proportion of RFP 89.5% taken form study done in Gondar Ethiopia, 95% confidence level (Z =1.96) and 5% margin of error and the final sample size was 260. Systematic random sampling technique was employed to select the study participants and the intervals were found to be 2 and the starting point was selected randomly. Therefore all mothers who came at every second interval were recruited until the final 260 HIV positive mothers were obtained. The data was collected by face to face interview by using structured and pretested questionnaire. To ensure the quality of data, training was given for two days for data collectors by the principal investigators. The collected data were entered into Epi Info version 3.5.1 and then exported into SPSS version 20.0 software package for analysis. After cleaning the data for internal consistency descriptive statistics like frequencies and percentages were calculated. Odds ratios and 95% confidence interval were computed to determine the presence and the degree of association between dependent and independent variables. P value less than 0.05 was considered to decide statistical significance. More over multivariate logistic regression was  (Table 1).  (Table   3).Two hundred one (77.3%) of respondents practiced exclusive breast feeding whereas 37(14.2%) and 22(8.5%) practiced mixed feeding and exclusive replacement feeding respectively ( Figure 1).

Obstetrics and ARV prophylaxis history and disclosure status of HIV positive mothers
Regarding the initiation of breastfeeding the majority of mothers 162(62.3%) breastfed their babies within the first hour after delivery Norm of society and 18(48.7%) and mother unwell 11(28.9%), were the major reasons cited by respondents who practiced mixed feeding ( Figure 2). The frequently given food for infants in addition to breast milk was cow milk 34(91.9%). Only two respondents had ever practiced wet nursing (Table 4). Twenty two (8.5%) of this mothers had ever expressed their breast milk, but only 16(72.7%) gave the expressed to their children and none of them have treated it with heat. Among the mothers who practiced ERF 22(8.5%), most of them used commercial infant formula and all of respondents have used cup and spoon to provide these foods (Table 4).

Factors affecting infant feeding practices
In binary logistic regression analysis mother's educational level COR

Discussion
This study has tried to assess infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral hospital, North West Ethiopia. In this study the proportion of respondents who practiced EBF 2.1(77.1%) is consistent with the finding reported from Gondar (83.8%); however it was higher than the findings of Addis Ababa, India and South Africa which was (30.6%), (47.7%) and (27%) respectively [7][8][9][10]. The possible reason for this difference is participants of these comparative studies were more of relied on replacement feeding. This study revealed that the proportion of respondents who practiced ERF were 22(8.5%). This finding was in line with the study conducted in eastern Uganda (8.5%) and Gondar (5.7%) [10,11]. But lower than what was reported from India (51.3%), South Africa (50%) and Addis Ababa (46.8%) [7][8][9]. These discrepancies might be due to difference in culture of feeding habit, study time, economic potential, health policy and strategies of intervention. Mothers who choose to breast feed their infants should never practice mixed feeding as this may increase the risk of HIV transmission and illness or death from diarrhea and other illnesses. The rate of mixed feeding among participants in the present study (14.2%) is in line with study done in Kenya (14%), Addis Ababa (15.3%), and Gondar (10.5%) [7,10,12]. However it is comparatively higher than the study conducted in Cameroon (4.3%) [13]. This difference might be due to all participants included in the comparative study area were those who previously seen at the prenatal period and counseled on infant feeding options, this probably helped them to follow the recommended feeding options and few proportion of respondents who practiced mixed feeding compared to this study. On the other hand the proportion of respondents who practiced MF in the present study was comparatively less than what was reported from eastern Uganda (51%) and Abidjan, Cote d'ivoire (39%) [14,15]. The discrepancy can be explained as; in the comparative studies the proportion of mixed feeding was computed among mothers with infants less than 6 months of age whereas in the present study mothers who had a child above 6 months of age were also included.
In the present study the commonest reason raised by respondents who practiced mixed feeding was norm of society (48.6%) while neighbor's advice (40%) was a major reason reported from Addis Ababa [7]. This highlighted that there was a deep rooted norm that made mothers to practice mixed feeding in both study areas. This study also revealed that, among mothers who ever breast feed, 162(68%) of mothers initiated breast milk within one hour of delivery. This finding was comparatively lower than the study done in Gondar (82.3%) [10]. The discrepancy might be due to the difference in characteristics of study population and the study area.
Ethiopian ministry of health Guideline on PMTCT recommends introduction of complementary food at six months of age. In the present study the majority of respondents 127(84.7%) have started complementary feeding at 6 months of age. However in Lusaka, Zambia more than half of participants (52%) started complementary feeding at 4 months [16]. This could be due to the difference in sample size and study period. In this study maternal educational status, ANC follow up, being on ART and disclosure of HIV status to spouse were significantly and independently associated with feeding practice. This study revealed that mothers who had educational level of high school and above were 5.3 times more likely to follow recommended way of infant feeding practice than those who were unable to read and write. This finding is consistent with study done in Southern Ghana [17]. This might be due to the fact that; as mothers are educated their decision making power increases and this helps them to practice the recommended IFO irrespective of the pressure from partner, family and society as compared to those mothers who were uneducated. Mothers who had ANC follow up were 5.5 times more likely to follow the recommended feeding option than those who had no ANC follow up. This finding is consistent with what was reported from India, where numbers of ANC visits were positively associated with ideal infant feeding options [18]. This might be due to; mothers who had ANC follow up Page number not for citation purposes 5 had a high chance of obtaining counseling on recommended feeding options as compared to mothers who had no ANC follow up. Even though being on ART was not indicated as factor influencing infant feeding options in any of the comparative study, it was significantly associated with RFP in the present study. Mothers who have been on ART were 6.5 times more likely to follow RFP than those who are not on ART. The possible reason could be due to; health professionals follow the infant feeding practice of mothers during their visit to ART. This study also showed that mothers who disclosed their HIV status with their spouses were 7 times more likely to follow recommended feeding options than those who did not disclosed their HIV status. This finding is consistent with study done in Tanzania and Northwest Ethiopia [10,19]. This could be

Conclusion
The study revealed that large proportion of HIV positive mothers followed the recommended infant feeding practice and significantly high number of mothers had practiced mixed feeding. The proportion of mothers who followed the RFP in this study was almost similar with that of other studies conducted in Ethiopia.
Maternal educational status, ANC follow up, being on ART and disclosure of HIV status were significantly associated with recommended way of infant feeding practice.
What is known about this topic  Since there is no study done on this topic in Debre Markos Hospital nothing is known about this topic.
What this study adds  The prevalence of mixed feeding among HIV positive mothers is still not few;  Number of antenatal care follow up is associated with feeding practice;  The knowledge of mothers on recommended feeding practice is high.

Competing interests
The authors declare no competing interests.