ABSTRACT
Mother-to-child HIV transmission
occurs during pregnancy, at birth and during breastfeeding and it is the
leading cause of infant mortality in Africa where 1700 children are infected
each day principally by mother to child transmission, without antiretroviral
treatment. This study therefore examined the barriers to exclusive
breastfeeding practice among HIV positive mothers attending prevention of
mother to child transmission clinic, Sagamu, Ogun State.
The study employed cross-sectional
design. Purposive sampling method was used to select the 85 HIV positive
mothers attending Prevention of mother to child transmission clinic in Ogun
state. These 85 respondents participated in the study, using a validated
structured questionnaire (Cronbach alpha result was 0.712) to measure the level
of knowledge of HIV positive mothers in Olabisi Onabanjo University Teaching
Hospital (OOUTH) on mother to child transmission of HIV, to ascertain the
perceived barriers to exclusive breastfeeding practice, to determine the roles
individual beliefs play in exclusive breastfeeding practice among HIV positive
mothers in OOUTH and to assess the practice level of EBF adoption among HIV
positive mothers in OOUTH, Ogun state. Data were analysed and presented as
descriptive statistics using SPSS version 21 was used to analyse the
socio-demographic characteristics of the respondents, mean and standard
deviation were also used to analyse the findings from the study. The
significance level was tested at P < 0.05.
Findings revealed that the mean age
of respondents was given at 35.89 ± 6.176. There were 42 respondents (49.4%)
with secondary school education and another 25 respondents (29.4%) with primary
education, only 10 respondents (11.8%) had tertiary education. This indicated
that more respondents with less than secondary school education receive
treatment in this centre. Results also showed that respondents’ knowledge on
mother to child transmission of HIV stood at 86.25% which indicated its high
priority. The perceived barriers to this research work are:that their babies
would get infected through breast milk,may not get enough nutrients from only
breast milk, while some believedEBF would make their nipples sore. The overall
respondents’ perceived barriers indicated a barrier presence of 26% which
showed a little above a quarter barriers preventing them from practicing
exclusive breastfeeding. It was found that respondents’ individual beliefs had
a 25.9% influence on respondents practice of EBF. Findings also revealed that
exclusive breastfeeding was practiced at a level slightly above average
(52.17%).
This study showed
that despite a high level of knowledge on PMTCT by respondents and the
importance of exclusive breastfeeding, the practice of EBF was just above
average. There is need tofurther reinforce the improvement on the practice of
exclusive breastfeeding especially among HIV positive mothers. There is a need
to explore salient factors predicting practice of exclusive breastfeeding among
HIV positive mothers as most of the identified barriers were not rampant among
this community of individuals.Findings from this study revealed that there is
need for a public health program aimed at establishing an external motivation
to improve exclusive breastfeeding among HIV positive mothers.This study
therefore recommends that there is need for a public health program aimed at
establishing an external motivation to improve exclusive breastfeeding among
HIV positive mothers.Few studies have
identified that influence of spouses on improvement of EBF practice, this can
be used in designing intervention towards improving EBF among this community of
people.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
There are 36.7 million (34.0 million – 39.8
million) people estimated to be living with Human Immunodeficiency Virus (HIV)
Worldwide in 2015, with 15.7 million and 2 million of these being women and
children younger than 15 years of Age respectively, with a global HIV
prevalence of 0.8% (WHO, 2015). It has also been established as the leading
cause of mortality among women of reproductive age worldwide, a major
contributor to maternal, infant and child Morbidity and mortality (UNAIDS 2009;
UNICEF, 2009). In 2015, it was estimated that 1.8 million pregnant women living
with HIV in low- and middle-income countries, most especially in sub-Saharan
Africa, gave birth but without treatment the infants are at risk as one third
of children living with HIV die before the age of one year and over 50% die by
the second year of life (UNAIDS, 2009).
Of all people living with HIV
globally, 9% of them live in Nigeria, with the size of the population of
Nigeria, this means 3.5 million people were living with HIV in 2015. (UNAIDS, 2014). Since the
beginning of the epidemic in the mid-1980s, a total of 2,200,000 new HIV
infections have been reported in 2014 (WHO, 2015). Most cases were adults over
the age of 15 years. Nigeria is now the second largest HIV disease burden
in the world with 3.2 million after South Africa which has 6.8 million burden
of the disease though prevalence is stable at 3.4% (Federal Ministry of
Health, 2013; Nigeria National
Agency for the Control of AIDS, 2012).
Ogun State has been rated as the state with the second
highest prevalence rate of Human Immunodeficiency Virus (HIV) in the South-West
zone of the country with the prevalence of the disease in the state, it was
gathered, increased from 1.5 percent in 2003 to 3.1 percent in 2010 (UNAIDS,
2010).
Mother-to-child
HIV transmission occurs intrauterine (during pregnancy), intra-partum (at
birth) and during breastfeeding and it is the leading cause of infant mortality
in Africa where 1700 children are infected each day principally by mother to
child transmission (WHO & UNICEF 2013), without antiretroviral treatment,
the risk of an infected woman transmitting the virus to her child is between 16
and 40% with breastfeeding contributing at least 10% risk of transmission (De
Cock, Fowler, Mercier , de Vincenzi,
Saba, Hoff, et al, 2000).
An effective Prevention of Mother to
Child Transmissions (PMTCT) programme requires mothers and their
babies to receive antenatal services and HIV testing during
pregnancy, have access to antiretroviral treatment (ART), and practice safe
childbirth practices and appropriate infant feeding.
In developing countries where
replacement feeding is generally not feasible or safe, hundreds of thousands of
infants acquire HIV infection during breastfeeding (Bhandari, Bahl &
Mazumadar, 2000). While breastfeeding improves child survival especially in
resource settings, breastfeeding by HIV infected women however increases the
incidence of HIV infection among breastfed infants (Pilay & Kam Kuhn, 2001;
Coutsouchis, Goga, Rollins & Coovadia, 2002;Chopra,
Piwoz & Sengwai, 2002; WHO, 2006). Mixed feeding has also been established
to be more risky for HIV transmission than exclusive breastfeeding, this is
partially due to damage to the epithelial integrity of the infant intestine
that facilitates entry of the virus and because of breast engorgement that
increases the viral load in breast milk between 3 to 6 months (Goga,
Rollins & Coovadia, 2002; WHO, 2009).
Breastfeeding remains a common
practice in parts of the world where the burden of HIV is highest. The
difficult dilemma faced by HIV positive mothers is whether to breastfeed their
infants in keeping with cultural norms, knowing the risk of transmitting the
virus through breastfeeding, or to pursue formula feeding, which also comes
with its own set of risks including a higher rate of infant mortality from
diarrheal illnesses, while reducing transmission of HIV (Kruger & Gericke,
2001; Iliff, Piwoz, Tavengwa & Clare, 2005; WHO & UNICEF, 2013).
Breast milk transmission of HIV can
occur at any time during the entire duration of breastfeeding and the risk of
late postnatal transmission which occurs after 2.5 months of age into
breastfeeding is revealed to be 3.2 per 100 child (Bulterys, Ellington &
Kourtis, 2010). Breast milk contains immunoactive cells, antiinfectious
substances, immune globulins, cytokines, and complement factors, however, HIV
has been found in breast milk from HIV-infected mothers as both cell-associated
and cell-free particle. Increased maternal ribonucleic acid (RNA) viral load in
plasma and breast milk is strongly associated with increased risk of
transmission through breast-feeding, and it has been suggested that exclusive
breast-feeding could be associated with lower rates of breast-feeding
transmission than mixed feeding of both breast- and other milk or feeds, (WHO,
UNFPA & UNAIDS, 2010). Transmission through breast-feeding can take place
at any point during lactation, and the cumulative probability of acquisition of
infection increases with duration of breast-feeding WHO (2009).
World Health
Organization (2009) released the “rapid advice” guideline where the use of ART
prophylaxis during the breastfeeding period until one week after all exposure
to breast milk has stopped is recommended. It was also recommended that
HIV-infected mothers intending to breastfeed should do so exclusively for the
first six months, and should introduce appropriate complementary food
thereafter, and continue breastfeeding until the infant is 12 months of age. In
a study by Onubogu, Ugochukwu, Egnuonu & Onyeaka (2015) where it was
determined that HIV positive mothers who practiced Exclusive Breastfeeding
declined within the first six months of stipulated period owing to the fear of
transmitting the infection to their child where as it has been established to
be the best feeding option for Prevention of Mother To Child Transmission
(PMTCT) of HIV (Lunnney, Lliff, Mutasa, Ntozini, Magder, Moulton et al,2010;
Nwaozuzu & Dozie, 2014; Saloojee & Cooper, 2010).
Several
strategies have been initiated by UNICEF and WHO in order to promote optimal
breastfeeding practices that is, start breastfeeding within one hour thirty
minutes after birth, Exclusive Breast Feeding (EBF) for first 6 months of
infant life and after 6 months introduction of appropriate weaning foods while
continuing to breastfeed for 2 years (WHO & UNICEF, 2003; Black, Victoria,
Walker & Bhutta, 2013; WHO & UNICEF, 2013). Nigerian government has
endorsed these global commitments to improve EBF practices. These strategies
are Baby Friendly Hospital initiative (BFHI), Infant Young Child Feeding policy
(IYCF) and breastfeeding recommendation in Prevention of Mother to Child
Transmission of HIV (PMTCT) (WHO & UNICEF, 2003; MOHSW 2014). The
investment should be targeted to effectively prevent infants from becoming
infected with HIV through breastfeeding, improve HIV free-survival of infants
and achieve international developments goals, such as Millennium Development
Goals (MDGs) (WHO, 2010).
As key gatekeepers in influencing
mothers' decisions on infant feeding, health workers can help to reduce rates
of postnatal transmission of
HIV by providing
HIV infected mothers with
accurate information on
infant feeding that captures
the risks and
benefits of different feeding options. Studying what health workers currently believe and
practice regarding infant
feeding for HIV infected
women is an
important concern because attitudes and
cultural beliefs may affect
their counselling behaviour (Setegn,
Belachew, Gerbaba, Deribe, Deribew & Biadgilign, 2012). Transmission of HIV
by breastfeeding has to be taken into account in designing interventions to
reduce/prevent mother-to-child transmission in developing countries especially
Nigeria (Townsend, Byrne & Cortina-Borja, 2011). Interventions that offer
alternatives to prolonged breastfeeding and are both socially acceptable and
safe for infant can effectively reduce the risk of postnatal HIV transmission.
But operational implementation of these postnatal interventions remains complex.
1.2 Statement of the Problem
The risk of HIV transmission
increases between 25% and 45% with the age of infant and maternal practice of
mixed feeding before 6 months of life (Federal Ministry of Health, 2010).
Supporting optimal infant feeding practices was a challenge for health systems
especially in Nigeria where it was influenced by limited number of health
facilities, health workers, competing demands on time, inadequate capacity,
illiteracy among mothers and poor information sharing. There are limited
comprehensive intervention package available to postpartum mothers in most
health facilities in Ogun State. Interventions on PMTCT were offered in some
facilities in Ogun State through the AIDS Prevention Initiative in Nigeria
(APIN) project funded by President’s Emergency Plan for AIDS Relief (PEPFAR).
Feeding of the HIV-exposed infant in settings where a high premium is placed on
breastfeeding is therefore a major challenge. Few researches have highlighted
factors influencing infant feeding choice of HIV positive mothers in Nigeria, including
resumption of work and family support (Agbo, Envuladu, Adams, Inalegwu, Okoh,
Agba et al, 2013) however, Uchendu,
Ikefuna and Emodi (2009) revealed that a good perception of EBF lead to better
practice of EBF among mothers.
Despite all efforts made in recent
years to increase the awareness of HIV mothers on the great importance of
exclusive breastfeeding to their infants regardless of their viral load and CD4
count, none have been able to completely ascertain that all HIV mothers now
breastfeed their infants exclusively (Brown, Oladokun & Osinusi, 2009;
Olatona, Ginigeme, Roberts & Amu, 2014). This has continued to pose a
serious public health problem with devastating outcome.
1.3 Objective of the Study
The main objective of this study is
to examine the barriers to exclusive breastfeeding practice among HIV positive
mothers in PMTCT Clinic, Olabisi Onabanjo University Teaching Hospital in
Sagamu, Ogun state. The specific objectives are to:
1. determine the level of knowledge of HIV
positive mothers in OOUTH on mother-to-child transmission
of HIV;
2. ascertain the perceived barriers to
exclusive breastfeeding practice;
3. determine
the roles individual beliefs play in exclusive breastfeeding practice among HIV positive mothers in OOUTH and
4. assess
the practice level of EBF adoption among HIV positive mothers in OOUTH, Ogun
State.
1.4 Research Questions
1. What
is the level of knowledge of HIV positive mothers accessing care in Olabisi Onabanjo University Teaching Hospital on mother-to-
child transmission of HIV?
2. What
are the perceived barriers to exclusive breastfeeding practice among HIV
positive mothers in OOUTH?
3. What
roles do individual beliefs play in exclusive breastfeeding practice among HIV positive mothers in OOUTH and;
4. What
is the level of practice of EBF among HIV positive mothers in OOUTH?
1.5 Justification for the Study
Although some
progress has been reported in scaling up of access to prevention of mother to
child transmission of HIV (PMTCT) services in Nigeria, with annual HIV positive
births of 56,681, much work remains to be done (NACA Fact Sheet, 2011). The
highest pediatric HIV burden, and the second highest burden of HIV infection in
women of childbearing age, globally, is accounted for in Nigeria preceding the
enlisting of Nigeria as one of 22 priority countries targeted for the
elimination of the MTCT of HIV by 2015 (IATT, 2015; UNICEF, 2015). However,
this target was not achieved, and Nigeria was recently reported to account for
approximately one third of all new pediatric HIV infections in priority
countries with a Mother to Child Transmission (MTCT) of HIV rate of 28% (The
Joint United Nations Programme on HIV/AIDS, 2013).
It is of great
importance that studies unveiling the factors delimiting the adoption of
exclusive breastfeeding which have been proven to reduce mother to child
transmission of HIV be carried out which is the aim of this study, this will
help in reduction of burden of pediatric HIV infection.
1.6 Hypotheses
H1: There will be a significant difference in the level of
knowledge of HIV positive mothers on mother to child transmission of HIV and
the educational status of these mothers.
H2: There will be a significant difference
between perceived barriers on exclusive breastfeeding
and the practice of EBF among the respondents.
H3: There will be a significant difference
between individual beliefs of respondents on
EBF and the practice of EBF among the respondents.
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