Culture-specific influences on exclusive breastfeeding among HIV-positive mothers in Blantyre, Malawi

Mother-to-child transmission (MTCT) of HIV accounts for 90% of all HIV infections in children in Malawi. Replacement feeding (feeding a breast milk substitute to an infant who is not receiving any breast milk) is not an option for most of the HIV-positive mothers in Malawi because of poverty. For those who might access infant formula, the risk of infant morbidity and mortality from diarrhea and other infections is high owing to inadequate availability of safe water and containers for feeding the infants that are easily contaminated. Although not the norm in Malawi, exclusive breastfeeding (EBF) is a better and safer option for infants and is recommended by World Health Organization (WHO). This mixed methods study sought to explore salient culture-specific external influences on EBF, EBF beliefs, intentions and behaviors among HIV-positive mothers in Blantyre, Malawi. Framed within the Theory of Planned Behavior (TPB), (1) The qualitative component utilizing focus group discussions and in-depth interviews with a purposive sample consisting of 16 HIV-positive mothers (18-35 years old), 5 nurse-midwives (25-55 years old), and 11 adult women (30-55 years old). Semi-structured and piloted focus group and in-depth interview guides were used to collect data which were analyzed through thematic content analysis. The identified themes were organized according to the main concepts of the Theory of Planned Behavior to identify key behavioral, normative and control beliefs associated with exclusive breastfeeding. (2) The quantitative component utilized face-to-face surveys to collect data at baseline and at 12 weeks postnatal from a convenience sample of 110 HIV-positive women (18-41 years) who were at least 36 weeks pregnant at baseline. The adapted and piloted Breastfeeding Attrition Prediction Tool (BAPT) was used to measure the participants' culture-specific EBF beliefs, intentions and external salient influences at baseline. Actual duration of EBF was measured at the 12-week postnatal follow-up. Descriptive and association statistics were used to analyze data. Additionally, multiple regressions were used to determine significant predictors of EBF prenatal intentions and the actual EBF duration at 12 weeks postnatal. The findings revealed high EBF prenatal intentions among HIV-positive mothers. Among others, lack of money for purchasing baby formula, promoting the well-being of the baby, preventing MTCT of HIV, being expected to do so and concealing one's HIV status were reasons for intending to breastfeed the baby. More positive than negative EBF beliefs emerged from the study. Key normative referents of EBF included husbands, mothers, mothers-in-law, sisters, doctors and nurses. Maternal diet, maternal health, and postnatal sex and sexual abstinence were some of the themes of factors that would make EBF easier or harder for HIV-positive mothers. EBF prenatal intentions were positively associated with parity (p < .05), normative (p < .05) and control beliefs (p < .01), and negatively associated with high maternal education (p < .001), disclosure of HIV status (p <.05) and positive EBF beliefs (p < .05). Actual EBF duration at 12 weeks postnatal was positively associated with parity (p < .05) and previous experience of EBF (p < .05), and negatively associated with high maternal education (p < .01) and late timing of decision to breastfeed (p <.05). High maternal education (p <.001), positive EBF beliefs (p < .01) and EBF control beliefs (p < .001) were significant predictors of EBF prenatal intentions, while parity (p < .05), previous EBF experience (p < .05) and maternal education (p < .05) were significant predictors of actual EBF duration at 12 weeks postnatal. The rate of EBF at 12 weeks postnatal was 83.6%.