1. Nobanzi Dana PATH Infant Feeding Buddies : A Strategy for Supporting Mothers for Optimal Infant and Young Child Feeding

2. Background PATH/Khusela Project supports 3 sub-districts of the EC to provide comprehensive PMTCT HIV+ pregnant mothers are still counseled on two feeding options (EBF or EFF). Routine facility visits revealed that more than 90% of HIV+ mothers chose to formula feed their babies after birth despite long standing stock outs of free formula from the facilities and without any regard for meeting AFFASS Mixed feeding was seen as a norm, with babies receiving traditional mixtures ( most popular – isicakathi ), water, solids, etc within the first few days after delivery

3. Background A strategy to support the mothers to exclusively feed their babies was developed Phase I: Acceptability study - 2009 Phase II: Pilot feasibility study - 2010

4. Goal To identify a mechanism and provide support for HIV infected mothers at the home and community levels for optimal infant and young child feeding (IYCF).

5. Phase I: Acceptability Study

6. Objectives Gather background information on existing IYCF practices and support Explore understanding and experiences around stigma on HIV and infant feeding Determine acceptability of “Infant feeding buddies” concept

7. What is an infant feeding buddy Mother chooses trusted person who knows her status to serve as ‘buddy’ Buddy attends PMTCT counseling sessions with mother Provides support for mother –Recall counseling messages –Adhere to infant feeding choice –Practice optimal IYCF –Counter stigma and pressure from family and community

8. Methods 8 focus groups discussions (FGDs) in July – August 2009 at Centane, Fort Malan, Ngqamakwe, Willowvale, Idutywa Participants –HIV+ mothers (n=17) –Fathers (n=9) –Grandmothers (n=11) –Nurses (n=10) –Counselors (n=10)

9. Data Analysis - Concepts and themes identified Concept 1: Infant feeding –Four major themes a)Conflicting influences on infant feeding b)Difficulty of sustaining choices c)Cultural importance of breastfeeding d)Difficulties surrounding formula feeding

10. Concepts and themes identified, cont’d Concept 2: Stigma –Two major themes a.The lived experience of stigma Disparities in perception b. Resistance to stigma Education Disclosure Support

11. Results: Infant feeding Conflicting influences –Most advice comes from nurses/counselors and clinics –Mothers showed knowledge of dangers of mixed feeding –Other groups see grandmothers as influential –Grandmothers Do not see themselves as influential Insist on isicakathi or other “medicinal” liquids Expressed confusion about what is right “We do not really understand” - grandmother

12. Results: Infant feeding, cont’d Difficulty sustaining choices –Perception that breast milk is inadequate –Infant is left with other caregivers –Mixed feeding Most babies receive breast milk plus another food: cow’s milk, formula, solids, prelacteal liquids “Mixed feeding is commonly done even though it annoys nurses” - mother

13. Results: Infant feeding, cont’d The importance of breastfeeding –Consensus among all that breastfeeding is best “the ancient wisdom of being a woman” - grandmothers “it’s just the way things are done” - mothers –Dilemma for HIV-infected mothers Disclose or not disclose - impacts infant feeding practices

14. Results: Infant feeding, cont’d Disclose? Yes No Support for infant feeding choice No support for infant feeding choice “We fear she would infect the baby” - grandmother Give excuses: “their breasts hurt” Give no reason: “the family will question the mother’s unusual approach” Let others formula feed while she breastfeeds

15. Results: Infant feeding, cont’d Difficulties of formula feeding –Inadequate supply provided “Four tins of milk powder are inadequate for one month” –Costs “Expensive to us as grandparents” –Fear of stigma Consensus among all groups Strongest among mothers and nurses/counselors “Now, when you are given milk, onlookers watch you and guess that you are HIV positive”

16. Results: Infant feeding buddies as potential method of providing support Well-received Concerns –Mothers Buddy would be inconsistent or untrustworthy Demands for reciprocity –Fathers Important that it be a family member Disagreement about men’s roles –Grandmothers Potential for confidentiality to be an issue –Nurse and counselors Potential for confidentiality to be an issue

17. Results: Infant feeding buddy choice Who would be most effective buddy? –Mothers: siblings and friends –Fathers: grandmothers and siblings (including brothers) –Grandmothers: grandmothers –Nurse/Counselors: “personal choice” of mother; needs “durable relationship” with “frequent contact”

18. Phase II: Pilot Feasibility Study

19. Objective To pilot implementation of infant feeding buddies strategy within routine PMTCT programming.

20. Methods: Recruitment Mother eligibility criteria –18 years of age or older –Enrolled in PMTCT program –In 3 rd trimester of pregnancy –Amenable to having an infant feeding buddy –Willing to disclose/had disclosed to this buddy Buddy eligibility criteria –18 years of age or older –HIV status not inclusion criteria

21. Results: Mothers’ demographics and characteristics Average age of mothers was 26 years Out of 14 mothers in the study, 7 had children and 5 had breastfed their children None of the 5 women had practiced exclusive breastfeeding of their last child

22. Results: Reasons for buddy selection Mothers selected infant feeding buddy because: –He/she was a family member –Mother trust this person –Mother previously disclosed their HIV+ status to this person

23. Results: Who is the ideal buddy? Mothers’ first choice of potential buddy: –mother –sister –husband –friend Buddies’ first choice of potential buddy: –sister –mother –husband 9/12 mothers chose their “ideal” buddy 9/12 buddies felt they were the “ideal” buddy

24. Results: Infant feeding method All mothers said that they had been given enough information to feed correctly All mothers said that having a feeding buddy made it easier to safely feed their baby

25. Results: Infant feeding practices PlannedActual practice Non-exclusive breastfeeding (n=3) Exclusive breastfeeding (n=3) Exclusive breastfeeding (n=4) Exclusive breastfeeding  formula (n=1) Formula (n=5)

26. Results: Infant feeding concerns Mothers’ main concerns about infant feeding choice –Money for formula –Not enough breast milk –Money for food to breastfeed –Baby not eating enough

27. Mothers - Support provided by her buddy “She reminds me of everything that was said during our visit [to clinic].” “Reminds me to breastfeed only.” “Someone to confide in, someone who boosts your self esteem.” “Defends me when anyone says bad things about [me].”

28. Mothers: Support provided by her buddy Form of SupportHoped for (Int 1) n=14 Received (Int 3) n=12 Remind what counselor said 711 Help breastfeed correctly 45 Help breastfeed exclusively 43 Help prepare formula correctly 65 Help feed formula to baby 23 Explain feeding method to family and friends 20

29. Results: Buddies’ perception of role All affirmed having a buddy is helpful to mothers. All responded that they would be a buddy for someone again. “Knowing you can help someone.” “You learn so many things from counseling” “Seeing baby grow well though (she initially) had fear of transmission of HIV to baby.”

30. Conclusions All study participants agreed that having an infant feeding buddy is helpful to mothers Recommending infant feeding buddies was successfully integrated into routine focused antenatal and postnatal care services Counseling and support changed plans from mixed feeding to EBF Mothers face challenges with IYCF and a community and home-based support system is needed.

31. Recommendations Educate health care staff on the importance of community and home-based support for optimal IYCF Incorporating the recommendation of an IF buddy into routine PMTCT programs could be one simple and cost- effective strategy to support mothers to practice safe IYCF.

32. Follow up Study participants (EBF) were followed up during routine PMTCT support All mothers exclusively breast fed for 6 months 3 mothers were still breastfeeding in July ’11. They are always available to give talks to nurses in our IF seminars on importance of counselling and to promoting breast feeding even for HIV+ mothers 1 buddy started a dialogue group in her village promoting EBF Number breast feeding mothers still low - promoting EBF forms part of PATH’s magnet theatre sessions

33. For more information, please contact: Nobanzi Dana PATH South Africa Principal Investigator ndana@path.org Kiersten Israel-Ballard PATH US Principal Investigator kisrael-ballard@path.org