Avoiding mixed breastfeeding strategies and experiences

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Avoiding mixed breastfeeding- strategies and
experiences

• Nigel Rollins
• Africa Centre for Health and Populations Studies
• University of Natal, Durban
• South Africa

Ruth Bland Jerry Coovadia Anna
Coutsoudis Wellcome Trust
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The Vertical transmission study

• Non-randomised intervention study to support
  infant feeding practices of HIV-infected and
  uninfected women

• Community-based breastfeeding support (BCSS)
  given independent of HIV status

• Feeding data collected by a separate monitoring
  field team

• Monthly filter paper samples collected to
  determine infection status ( real-time testing
  at 6 and 22 weeks)

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The Vertical transmission study
HIV infected and uninfected women
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Daily feeding data

• EBF frequency
• EBF only
• EBF gt½ days other fluids/milk/solids
• EBF lt½ days other fluids/milk/solids
• EFF only

• Type of mixed feeding
• water
• other milk
• solids
• medicines
• Any combination

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Infant feeding counselling

• UNAIDS guidelines on infant feeding choices
  recommend that HIV-infected women are given
  specific guidance in selecting the option most
  likely to be suitable for their situation
• Assumes that women can enforce their choice

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Infant feeding counselling algorithm
Check appropriateness of planned feeding
option If appropriate encourage feeding option
Introduction about infant feeding
Find out woman's planned feeding method
Dont know
Replacement feeding
Breastfeeding
Information about BF, replacement feeding and HIV
transmission
HIV and transmission
HIV and transmission
If mother indicates choice, explore first
Explore feasibility
If alternative feeding option may be feasible
explore
Support choice
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Results
P0.028
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Cumulative number of conditions by feeding group
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Feeding practice 1st week vs. intention
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Counselling vs. practice

• Obvious determinants of practice are not always
  the principal basis of choice
• Womens status in society allows or prevents her
  from making and exercising her choice
• Counselling approaches need to effectively
  guide women to informed viable choices

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Breastfeeding counselling and support strategy
(BCSS)

• Breastfeeding counsellors
• Av. - 27 yrs
• Mixed educational backgrounds
• 32 never been pregnant
• Others had all BF
• Selected after assessing innate counselling
  skills
• Trained on WHO BFC course

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Breastfeeding counselling and support strategy
(BCSS)

• BCSS
• Infant feeding counselling
• Home visits (x4) antenatally
• Counsellor support on postnatal ward
• Early home support (x4 visits in first 2 wks)
• Early discussion of when to stop breastfeeding

• Breastfeeding counsellors
• Av. - 27 yrs
• Mixed educational backgrounds
• 32 never been pregnant
• Others had all BF
• Selected after assessing innate counselling
  skills
• Trained on WHO BFC course
• Supervised practice

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How have you generally found women to respond to
your counselling and home visits?

• Generally very welcoming
• Most understand the messages but doubt if it
  (EBF) is possible
• Women are influenced by the community
• The antenatal visits can be difficult
• Young mothers are scared to ask when they do not
  understand things
• Excited about the knowledge

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What have you found most difficult about the
counselling part of your work?

• Hard to talk about counselling/EBF if you know
  the mother is hungry
• .. becoming part of the family
• Knowing how to sustain EBF after 4 months
• Discussing traditional beliefs
• Knowing that the mother is not telling everything

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What have you found most difficult about the
technical part of your work?

• Influences from the family
• Babys behaviour makes the mothers change
• non-nutritive suckling
• growth spurts
• post-immunisation fever the mother gives gripe
  water
• Need to renew skills
• It takes time to counsel
• Modifying old patterns the caesar grip

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Any suggestions to make your work more effective?

• Organise community event
• Explain to family elders
• BFC meetings to share experiences
• Need consistency between clinic and community
• Give an incentive at 6 months

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Early weaning what strategy to follow?

• Rapid weaning

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Change in Nutritional Status with Age - Hlabisa.
Chopra M. 1996
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Managing the transition

• Discuss antenatally
• Determine feasibility and preference
• Encourage disclosure of HIV status to at least
  one person at home
• Start expressing breastmilk
• Accustom the infant to feeding with cup

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Managing the transition

• Plan strategies for comforting the child
• Day
• Night
• Monitor growth which growth chart?
• ?Micronutrients
• Support and care for the mother
• Family planning
• Support networks for mother and family

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Experience to date

• Botswana
• 37.5 mothers who stopped breastfeeding before 6
  mths criticised by their own mother and family,
  vs. 20 after 6 mths
• 50 mothers who stopped before 6 mths became
  engorged and 37.5 got mastitis, vs. 20 of
  mothers who stopped after 6mths got engorged and
  none suffered mastitis

• Very mixed response
• In SA formula feed now available from government
  programme

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Questions

• How exclusive BF is necessary?
• For how long?
• transmission risk vs. physiology
• What level of support is needed to sustain EBF?
• How to increase community acceptability of infant
  feeding options?
• What is the impact on IMR?