1. Nobody’s Unpredictable EXTENT OF EXCLUSIVE INFANT FEEDING AMONG INFANTS IN RESOURCE POOR SETTINGS B Ochieng 1 & C Mbakaya 2 1 Jomo Kenyatta University of Agriculture and Technology/ Synovate, Nairobi, Kenya 2 Kenya Medical Research Institute, Nairobi, Kenya International Conference on AIDS and STI in Africa, 4-8 th December 2011

2. Discover Ipsos Background Breast milk is the best food for infant 0-6 months Breastfeeding is associated with between 5-20% MTCT of HIV (De Cock et al., 2000; Coutsoudis et al., 2001; WHO, 2004) Exclusive breastfeeding recommended option for HIV exposed infants 0-6 months old Exclusive replacement feeding recommended when Acceptable, Feasible, Affordable, Sustainable & Safe (AFASS) WHO 2009 rapid advice – exclusive breastfeeding for 6 months followed by complementary feeding with continued breastfeeding until child is 12 months

3. Discover Ipsos Problem statement Mixed feeding among general public is high  KDHS 2008-09: 67.2% mixed feed infant 0-5 months Mixed feeding increases risk of PMTCT  Zvitambo study in Harare: HIV transmission fourfold among mixed feeding arm as compared to exclusive breastfeeding Several PMTCT programs in Kenya  Number of PMTCT sites were over 3,000 Limited information on breastfeeding practices among HIV positive mothers (prevalence and drivers)

4. Discover Ipsos Objectives To determine knowledge levels on appropriate infant feeding options To determine the prevalence of exclusive breastfeeding; To determine factors associated with the practice of exclusive breastfeeding To identify the role of other individuals (partners or spouses, relatives or friends) in the selection of appropriate infant feeding options To identify key challenges to exclusive breastfeeding

5. Discover Ipsos Materials and methods Cross sectional study Focus Group Discussion (FGD) Mothers living with HIV 2 FGDs – 18 participants Significant Others (influencers of infant feeding) 2 FGDs – 19 participants Survey Exit interviews with mothers living with HIV 387 participants

6. Discover Ipsos SUMMARY OF FINDINGS

7. Discover Ipsos Participants Demographic Characteristics Characteristic(n=387) % Mean Age26.32 Working (full & part time)39.9 No formal education/ some primary10.1 Married (monogamous & polygamous)79.1 Parity Pregnancies (mean)2.1 Live-births (mean)1.96 Children alive (mean)1.86 Mode of delivery – normal vaginal delivery91.7 Place of delivery – hospital delivery88.4

8. Discover Ipsos Household Demographic Characteristics Characteristic(n=387) % Access to piped water99.5 Treatment of drinking water Boil66.9 Filter/ allow to settle3.4 Bleach16.3 Do not treat13.4 Stores in container without lid0.8 Main source of cooking fuel Paraffin60.2 Charcoal23.3 Access to cold storage (fridge)13.7

9. Discover Ipsos HIV status – participant and partner

10. Discover Ipsos Knowledge of appropriate infant feeding Exposure to infant feeding information was at 94.8%  Mother’s nutrition (47.5%)  Avoid mixed feeding (13.4%)  Early cessation of breastfeeding (10.8%) Exclusive breastfeeding recommended to 93.4% Infant feeding during separation  5.3% told to continue breastfeeding upon return and give replacement when away Knowledge on the benefits of breast milk is high HIV exposed infants should either be exclusive breastfeed or exclusive replacement feed ... right from birth without giving breast milk (MM)

11. Discover Ipsos Knowledge of appropriate infant feeding Mixed feeding was described as  “breastfeeding and mixing with cow/ shop milk when breast milk is not enough” or “giving porridge to a baby who is not yet even 3 months” alongside breast milk (MR)  “breastfeeding while at the same time giving other foods” (SOR, SOM) Reasons for practicing mixed feeding:  Ignorance/ attitude – “nothing will happen to my baby”  “pressure from family members especially when the baby is crying” (MR)  “when one is a business person and probably the baby is just one month and you need to go to your business then it forces you to give the baby cow milk” (MR) Disadvantages of mixed feeding:  “the baby can be exposed to getting infected by the virus [HIV]” (MR)

12. Discover Ipsos Prevalence of exclusive infant feeding

13. Discover Ipsos FactorEffect on EIF*P-value Place of deliveryHospital delivered more likely to EIF0.014 Mother’s working statusWorking least likely to EIF0.031 Main person feeding infantMothers more likely to EIF0.010 Infant’s ageThose below 3 months more likely to EIF0.005 Suggestions on infant feeding Those who received suggestions more likely to EIF 0.006 Advice on how to breastfeed Those advised more likely to EIF0.001 Exposure to advertsThose exposed more likely to EIF0.006 Disclosure of HIV statusThose that disclosed more likely to EIF0.006 Infant’s father’s HIV statusThose reporting father tested more likely to EIF 0.001 Painful/ engorged breastsThose who experienced least likely to EIF 0.029 *P-value <= 0.05 Factors associated with exclusive infant feeding (EIF)

14. Discover Ipsos Health worker  64.3% selected the feeding option following HW advice  67.5% discussed their selected option with HW  82.9% indicated HW key confidant on infant feeding Father of child  24.3% discussed their selected option Own mother (grandmother of child)  7.8% perceived them as their confidant on infant feeding Other family member/ friend  5.4% consider then key confidant Role of other individuals in selection of infant feeding

15. Discover Ipsos Key challenges of exclusive breastfeeding “The baby is not getting enough forcing the mother to mix” (MR) “Sometimes the baby cries a lot such that the mum in order to silence the baby she has to give other food, to satisfy her emotion” (MR) “Members like mother [mother in law] tell you that the baby has reached an age to take porridge” (MR) Mother has “to go everywhere with the baby” (MM). “Comes with a lot of demands on the mother to eat well and the biggest challenge is finances”. (SOM, SOR)

16. Discover Ipsos “Disclosing one’s status to family members (mother in-law) [explaining] why one is not breastfeeding or why you are breast feeding exclusively” (MR) “Proper counselling [to mother] to accept [and get them to] disclose their status and be able to get social support in feeding their babies” (SOM)  Disclosure a risk as people could “decide to say that you [the person disclosing] is the cause of the HIV” (MR) Overcoming challenges of exclusive breastfeeding

17. Discover Ipsos Conclusions Good knowledge on relation between infant feeding and HIV transmission  Lack of clarity on cessation of breastfeeding, feeding during mother-child separation and when mother’s breasts are painful/ engorged Overall, 35% of mothers are practicing mixed feeding EBF associated with place of delivery, mother’s working status, information received, and HIV testing/ disclosure of parents Health workers key influencers of infant feeding decisions Lack of knowledge, misconceptions on breast milk and fear of stigmatization are the main hindrance s to EBF

18. Discover Ipsos Recommendations Promote exclusive breastfeeding for 1 st 6 month for general public Advocate for ANC attendance and hospital deliveries Strengthen infant feeding counseling at ANC and PNC Support partner involvement through partner counseling and testing, at ANC, PNC Support programs on flexible work hours for nursing mothers Conduct an assessment on health workers knowledge and perception on infant feeding Hold regular capacity building sessions for health workers

19. Discover Ipsos Acknowledgement Synovate Kenya My supervisors Health facilities  Riruta Health Center  Mathare North Health Center  Kariobangi North Health Center  Lunga Lunga Health Center Study participants Research assistants

20. Discover Ipsos Thank you Comments/ Questions