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Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township
Department of Psychology, Stellenbosch University, South Africa.
Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell barnhälsa och nutrition/Persson)
Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa.
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2014 (English)In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 19, no 3, 256-266 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Progress towards MDG4 for child survival in South Africa requires effective prevention of mother-to-child transmission (PMTCT) of HIV including increasing exclusive breastfeeding, as well as a new focus on reducing neonatal deaths. This necessitates increased focus on the pregnancy and early post-natal periods, developing and scaling up appropriate models of community-based care, especially to reach the peri-urban poor.

METHODS: We used a randomised controlled trial with 30 clusters (15 in each arm) to evaluate an integrated, scalable package providing two pregnancy visits and five post-natal home visits delivered by community health workers in Umlazi, Durban, South Africa. Primary outcomes were exclusive and appropriate infant feeding at 12 weeks post-natally and HIV-free infant survival.

RESULTS: At 12 weeks of infant age, the intervention was effective in almost doubling the rate of exclusive breastfeeding (risk ratio 1.92; 95% CI: 1.59-2.33) and increasing infant weight and length-for-age z-scores (weight difference 0.09; 95% CI: 0.00-0.18, length difference 0.11; 95% CI: 0.03-0.19). No difference was seen between study arms in HIV-free survival. Women in the intervention arm were also more likely to take their infant to the clinic within the first week of life (risk ratio 1.10; 95% CI: 1.04-1.18).

CONCLUSIONS: The trial coincided with national scale up of ARVs for PMTCT, and this could have diluted the effect of the intervention on HIV-free survival. We have demonstrated that implementation of a pro-poor integrated PMTCT and maternal, neonatal and child health home visiting model is feasible and effective. This trial could inform national primary healthcare reengineering strategies in favour of home visits. The dose effect on exclusive breastfeeding is notable as improving exclusive breastfeeding has been resistant to change in other studies targeting urban poor families.

Place, publisher, year, edition, pages
2014. Vol. 19, no 3, 256-266 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-218638DOI: 10.1111/tmi.12257ISI: 000330740000002PubMedID: 24433230OAI: oai:DiVA.org:uu-218638DiVA: diva2:696322
Available from: 2014-02-13 Created: 2014-02-13 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Intervention for improved newborn feeding and survival where HIV is common: Perceptions and effects of a community-based package for maternal and newborn care in a South African township
Open this publication in new window or tab >>Intervention for improved newborn feeding and survival where HIV is common: Perceptions and effects of a community-based package for maternal and newborn care in a South African township
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

South Africa recently changed infant feeding policy within Prevention of Mother to Child Transmission (PMTCT) of HIV from free formula to recommendation of breastfeeding for all. The country is evaluating the role of Community Health Workers (CHWs) in supporting mothers and newborns.

The aim of this thesis is to explore perceptions of household members on the value given to and the social forces behind formula feeding in light of the recent policy change, and to assess the effect of a community-based package of maternal and newborn care delivered by CHWs on HIV-free survival and exclusive and appropriate infant feeding up to 12 weeks of age.

Studies were conducted in a high HIV prevalence township. Focus group discussions were performed (grandmothers, fathers and teenage mothers) and in-depth interviews with HIV-positive and HIV-negative mothers. Perceptions of household members on the formula policy change were explored and the value household members place on formula feeding and circumstances that drive it. In a cluster-randomized trial (15 intervention, 15 control clusters) CHWs provided two antenatal and five post-natal home visits to support and promote PMTCT activities.

There were misunderstandings by community members on the free formula policy change. Mothers transferred the motherhood role to their mothers while partners provided inadequate financial support, leading to risky mixed feeding. Teenage mothers rarely breastfed their infants due to perceived constraints including embarrassment, sagging breasts and loss of freedom and boyfriends.

At 12 weeks of age the intervention had doubled exclusive breastfeeding (EBF) (28% vs. 14%) and slightly increased infant weight and length. No difference was seen between study arms in HIV-free survival. The effect on EBF at12 weeks did not differ with maternal education or wealth levels, but was higher among HIV-negative mothers.

 Focusing on teenage mothers breastfeeding challenges, involvement of grandmothers and fathers in infant feeding decision-making, improving communication strategies on policy change and breastfeeding to the community and health workers and CHWs home visits supporting PMTCT activities are important for infant feeding and child health.

Place, publisher, year, edition, pages
UPPSALA: Acta Universitatis Upsaliensis, 2014. 89 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1027
Keyword
Prevention of Mother to Child Transmission of HIV, Community Health Workers, Exclusive breastfeeding, Formula feeding, South Africa
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-232110 (URN)978-91-554-9035-5 (ISBN)
Public defence
2014-10-29, Rosensalen, Barnsjukhuset Akademiska sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
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Available from: 2014-10-02 Created: 2014-09-12 Last updated: 2015-01-23Bibliographically approved

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Ijumba, PetridaPersson, Lars-Åke

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