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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
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (CHILD HEALTH)
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 [en]
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: urn:nbn:se:uu:diva-232110ISBN: 978-91-554-9035-5 (print)OAI: oai:DiVA.org:uu-232110DiVA: diva2:746533
Public defence
2014-10-29, Rosensalen, Barnsjukhuset Akademiska sjukhuset, Entrance 95/96, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2014-10-02 Created: 2014-09-12 Last updated: 2015-01-23Bibliographically approved
List of papers
1. Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change
Open this publication in new window or tab >>Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change
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2013 (English)In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 28, no 7, 761-768 p.Article in journal (Refereed) Published
Abstract [en]

Background: In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme.

Objective: To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa.

Methods: An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis.

Results: Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change.

Conclusion: There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.

Keyword
Formula feeding, policy change, HIV, community perceptions, qualitative research, focus group discussions
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-211033 (URN)10.1093/heapol/czs114 (DOI)000325771200008 ()
Available from: 2013-11-19 Created: 2013-11-19 Last updated: 2017-12-06Bibliographically approved
2. Social circumstances that drive early introduction of formula milk: an exploratory qualitative study in a peri-urban South African community
Open this publication in new window or tab >>Social circumstances that drive early introduction of formula milk: an exploratory qualitative study in a peri-urban South African community
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2014 (English)In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 10, no 1, 102-111 p.Article in journal (Refereed) Published
Abstract [en]

Breastfeeding is widely endorsed as the optimal strategy for feeding newborns and young infants, as well as improving child survival and achieving Millennium Development Goal 4. Exclusive breastfeeding (EBF) for the first 6 months of life is rarely practised in South Africa. Following the 2010 World Health Organization (WHO) infant feeding recommendations (EBF for HIV-positive mothers with maternal or infant antiretroviral treatment), South Africa adopted breastfeeding promotion as a National Infant Feeding Strategy and removed free formula milk from the Prevention of Mother-to-Child Transmission of HIV programme. This study aimed to explore the perceptions of mothers and household members at community level regarding the value they placed on formula feeding and circumstances that drive the practice in a peri-urban community. We conducted in-depth interviews with HIV-positive and HIV-negative mothers in a community-randomised trial (Good Start III). Focus group discussions were held with grandmothers, fathers and teenage mothers. Data were analysed using thematic analysis. The following themes were identified; inadequate involvement of teenage mothers; grandmothers who become replacement mothers; fear of failing to practise EBF for 6 months; partners as formula providers and costly formula milk leading to risky feeding practices. The new South African Infant Feeding Strategy needs to address the gaps in key health messages and develop community-orientated programmes with a focus on teenage mothers. These should encourage the involvement of grandmothers and fathers in decision-making about infant feeding so that they can support EBF for optimal child survival.

Keyword
formula feeding, community perception, HIV, qualitative research focus group discussion, social circumstances
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-232039 (URN)10.1111/mcn.12012 (DOI)
Available from: 2014-09-12 Created: 2014-09-12 Last updated: 2017-12-05Bibliographically approved
3. 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
Open this publication in new window or tab >>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
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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.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-218638 (URN)10.1111/tmi.12257 (DOI)000330740000002 ()24433230 (PubMedID)
Available from: 2014-02-13 Created: 2014-02-13 Last updated: 2017-12-06Bibliographically approved
4. Effect of an integrated community-based package for maternal and newborn care on feeding patterns during the first twelve weeks of life: a cluster randomized trial in a South African township
Open this publication in new window or tab >>Effect of an integrated community-based package for maternal and newborn care on feeding patterns during the first twelve weeks of life: a cluster randomized trial in a South African township
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(English)Manuscript (preprint) (Other academic)
Keyword
Key words: Community Health Workers, counselling, infant feeding, HIV, educational lev-els and household wealth
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-232107 (URN)
Available from: 2014-09-12 Created: 2014-09-12 Last updated: 2014-10-07

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