Targeted Evaluation on Early Breastfeeding Cessation Presentation of preliminary results

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Early Breastfeeding Cessation and Replacement
Feeding Options in Manica, Sofala, and Gaza
Provinces Targeted Evaluation Preliminary
Findings August 2006 Wendy Johnson, MD,MPH
Health Alliance Internationalwendyj_at_igc.org
With funding from
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WHO recommendations on infant feeding for HIV
women

• When replacement feeding is acceptable,
  feasible, affordable, sustainable and safe
  (AFASS), avoidance of all breastfeeding by
  HIV-infected mothers is recommended.
• Otherwise, exclusive breastfeeding is recommended
  during the first months of life. To minimize HIV
  transmission risk, breastfeeding should be
  discontinued as soon as feasible, taking into
  account local circumstances, the individual
  womans situation and the risks of replacement
  feeding (including infections other than HIV and
• malnutrition).

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Programmatic Relevance

• Avoidance of all breastfeeding from birth is
  recommended for HIV mothers if RF options are
  AFASS, otherwise exclusive breastfeeding with
  early cessation is recommended
• There is little/no guidance on safe feeding of
  the non-breastfed child who has been weaned early
  
• Optimal timing
• Types of foods, frequency of feeding,
  affordability, acceptability, etc.
• There is concern that inadequate RF will cause
  malnutrition and increase the risk of infant
  death
• This is an especially grave concern in Mozambique
  where young child malnutrition and mortality
  rates are high

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Mozambique targeted evaluation of early
breastfeeding cessation and replacement feeding
options in Manica, Sofala, and Gaza Provinces

• PURPOSE
• To gather information on early breastfeeding
  cessation and replacement feeding after cessation
  for HIV-exposed infants in the Mozambican context
  
• To develop and test recommendations for improved
  feeding of HIV-exposed infants.

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Study sites (7 locations)

• Manica
• Chimoio
• Catandica
• Sofala
• Beira (Munhava)
• Nhamatanda
• Gaza
• Xai-Xai
• Macia
• Chibuto

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HIV, malnutrition, infant mortality rates in
study provinces
Sources IDS 2003 MOH 2005 (Ronda 4)
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Methodology -1

• A combination of qualitative and quantitative
  methods were used
• In-depth interviews (67) and focus group
  discussions (10) with HIV mothers participating
  in support groups
• IDI (70) and FGD (14) with mothers recruited from
  the community and health centers with PMTCT
  services
• IDI (60) and FGD (21) with other key informants,
  including fathers, mothers-in law, health workers
  and community activists
• Mothers interviews included modified food
  frequency questionnaire

Note Purposive sampling methods were used
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Methodology -2

• Linear programming (LP) methods were used to
  identify possible feeding recommendations for
  non-breastfed infants from 6-8 and 9-11 months.
  (Nutrisurvey software)
• This approach was recently recommended by WHO but
  not previously tested in a program setting (WHO
  provided TA)
• LP uses locally gathered information on available
  foods, consumption patterns, daily food
  expenditures and prices (based on market surveys)
  to identify the combination of foods needed to
  meet the nutritional needs of infants at lowest
  cost (i.e., meeting AFASS criteria)
• Can be used for breastfed and non-breastfed
  infants
• Nutrient database includes values for energy,
  protein, and 11 essential vitamins and minerals

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Preliminary Results

• Most data come from in-depth interviews with 137
  mothers and the linear programming

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Selected characteristics of study mothers -1
US 1 25,000 meticais (MT) Manica mothers
less likely to have electricity or fridge
(plt0.001) HIV mothers less likely to read
Portuguese (p0.05)
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Selected characteristics of study mothers -2
52 of Gaza mothers reported a current food
shortage HIV mothers in Manica Sofala more
likely to receive food assistance (plt0.0001)
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Current breastfeeding practices (N137)
plt0.0001
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Attitudes toward early breastfeeding cessation
(EBC)

• HIV mothers and other FGD participants felt that
  EBC was good advice to prevent infants from
  getting HIV, but there are practical constraints
• Cost/affordability
• Concern that baby would be hungry, become
  malnourished
• Stigma discrimination
• I will have to lie that my milk is not good
• Most HIV mothers (41/67) said they received only
  general information about feeding after EBC
• give fruits and a better diet (35)
• give a varied diet (6)

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Results of food frequency infants regularly
consuming different food groups by age (reported
gt 4 times/week)

• consumption increases significantly with
  infant age for all items except meat/poultry and
  eggs which are rarely consumed.

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Median IQR number of food groups consumed
according to infant age

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Preliminary results from linear programming

• 6-8 months
• 9-11 months

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Results for infants Manica Sofala

• A diet that is adequate in most nutrients (low in
  iron) can be developed using local foods ever
  consumed by gt 20 of infants
• However, foods that will need to be eaten daily
  (or at least several times a week) include milk,
  maize/sorghum flour, beans/lentils, peanuts,
  dried fish, GLV, carrots/sweet potato, tomato,
  papaya/banana, coconut milk oil (8 food groups)
• Estimated cost is 0.15-0.21/day for infant
  only
• Respondents felt that they would probably have to
  buy these foods for others in family too cost
  implications
• This may not be feasible, however, for the
  majority of families due to cost and large number
  of different foods required to meet most
  nutritional needs further testing is underway

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Cost adequacy of typical diet with without
breast milk 6-8 mo (Manica Sofala)
Diet with breast milk 2600 MT (0.11)
Diet without breast milk 5100 MT(0.21)
Sorghum flour, beans, dried fish, tomato, GLV,
carrots, sweet potato
Sorghum flour, beans, dried fish, tomato, GLV,
sweet potato, papaya, coconut oil, formula,
powdered cows milk
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Results for infants Gaza

• An adequate replacement diet can not be developed
  using local foods consumed by infants at 6-8 and
  9-11 months food shortage at time of study
• Foods currently consumed are low in iron, zinc,
  calcium, some vitamins
• Early breastfeeding cessation is likely to lead
  to significant malnutrition and related risks
  unless nutrient-rich supplemental foods are
  provided - requires further testing

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Conclusions

• HIV mothers reported early breastfeeding
  cessation (EBC) in response to advice from PMTCT
  health providers
• Little specific information is presently given to
  these mothers about how to feed their children
  after EBC
• Meeting the nutritional needs of infants gt 6
  months is challenging taking into account local
  food availability, variety, and price even when
  breastfeed
• Removing BM from the diets of infants gt 6 months
  creates several challenges, including the need to
  increase food expenditure 2-3 fold/day just to
  keep even
• EBC is likely to lead to increased risk of
  malnutrition in the study sites

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Recommendations

• If no diet meets AFASS criteria, consideration
  should be given to providing specialized
  replacement foods to fill the nutritional gaps
  exacerbated by EBC. (ready to use foods or
  formula.)
• There is an urgent need for improved access to
  ART for eligible women during pregnancy and post
  partum to reduce MTCT and improve maternal and
  child survival.
• The benefits of EBC at 6 months must be weighed
  against the risk of malnutrition in each context.
  --Future studies are needed.
• HIV mothers need additional guidance and support
  to safely feed their infants after 6 months.

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Collaborators

• Elizabeth Glaser Pediatric AIDS Foundation
• Cathrien Alons, Victorino Chavane, Ellen
  Warming, Cathy Wilfert
• Health Alliance International
• Wendy Johnson, Florencia Floriano, James
  Pfieffer
• ANSA
• Lourdes Fidalgo
• Academy for Educational Development
• Ellen Piwoz
• Ministry of Health
• Sonia Kahn, Atalia Macombe
• Save the Children
• Katarina Regina, Ronnie Lovich
• WHO