Need to optimise infant feeding counselling:

A cross-sectional survey among HIV-positive mothers in

Eastern Uganda

Lars T Fadnes*1, Ingunn MS Engebretsen1, Henry Wamani2,3, Jonathan Wangisi4, James K

Tumwine2, Thorkild Tylleskär1

1
Centre for International Health, University of Bergen, Norway
2
Department of Paediatrics and Child Health, Makerere University, Uganda
3
School of Public Health, Makerere University, Uganda
4
TASO- Mbale, Uganda

*
Corresponding author

E-mail addresses:

LTF: [email protected]

IMSE: [email protected]

HW: [email protected]

JW: [email protected]

JKT: [email protected]

TT: [email protected]

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Abstract:

Background

The choice of infant feeding method is important for HIV-positive mothers in order to

optimise the chance of survival of their infants and to minimise the risk of HIV transmission.

The aim of this study was to investigate feeding practices, including breastfeeding, in the

context of PMTCT for infants and children under two years of age born to HIV-positive

mothers in Uganda.

Methods

In collaboration with The Aids Support Organisation Mbale, we conducted a cross-sectional

survey involving 235 HIV-positive mothers in Uganda. Infant feeding practices, reasons for

stopping breastfeeding, and breast health problems were studied. Breastfeeding duration was

analysed using the Kaplan-Meier method based on retrospective recall.

Results

Breastfeeding was initiated by most of the mothers, but 20 of them (8.5%) opted exclusively

for replacement feeding. Pre-lacteal feeding was given to 150 (64%) infants and 65 (28%)

practised exclusive breastfeeding during the first three days. One-fifth of the infants less than

6 months old were exclusively breastfed, the majority being complementary fed including

breast milk. The median duration of breastfeeding was 12 months (95% confidence interval

[CI] 11.5 to 12.5). Adjusted Cox regression analysis indicated that a mother’s education,

socio-economic status, participation in the PMTCT-program and her positive attitude to

breastfeeding exclusively, were all associated with a reduction in breastfeeding duration.

Median duration was 3 months (95% CI 0–10.2) among the most educated mothers, and 18

months (95% CI 15.0–21.0) among uneducated mothers. Participation in the PMTCT program

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and being socio-economically better-off were also associated with earlier cessation of

breastfeeding (9 months [95% CI 7.2–10.8] vs. 14 months [95% CI 10.8–17.2] and 8 months

[95% CI 5.9–10.1] vs. 17 months [95% CI 15.2–18.8], respectively). The main reasons for

stopping breastfeeding were reported as: advice from health workers, maternal illness, and the

HIV-positive status of the mother.

Conclusions

Exclusive breastfeeding was uncommon. Exclusive replacement feeding was practised by few

HIV-positive mothers. Well-educated mothers, mothers who were socio-economically better-

off and PMTCT-attendees had the shortest durations of breastfeeding. Further efforts are

needed to optimise infant feeding counselling and to increase the feasibility of the

recommendations.

Background

Widespread promotion of exclusive breastfeeding could prevent child mortality by 8% [1].

However, transmission of HIV through breast milk has made breastfeeding counselling more

complicated in low-income countries where HIV is prevalent.

Every year, more than half a million infants become infected with HIV. These infection rates

are disproportionately distributed geographically; mother-to-child-transmission, in the context

of antiretroviral prophylaxis is below 1% in Europe and the USA, but exceeds 30% in many

poorly resourced countries, with Sub-Saharan Africa carrying the highest burden [2, 3]. The

incidence of HIV infection among children has fallen in many areas, but this seems to be

more related to a reduction of the HIV prevalence among mothers than gains in the PMTCT

program [4].

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In many countries where HIV is prevalent, the infant mortality rate is high. Considering the

risks of both infant mortality and HIV transmission, breastfeeding is strongly correlated with

a higher HIV-free child survival rate compared to formula feeding where the infant mortality

rate is above 4% [5, 6]. Exclusive breastfeeding can be associated with higher HIV-free

survival at 6 months than mixed feeding [6, 7]. Post-natal vertical HIV transmissions increase

with a longer breastfeeding duration [8]. Cessation of breastfeeding at the age of 6 months has

consequently been recommended wherever replacement feeding at that age is acceptable,

feasible, affordable, sustainable and safe [8, 9]. Failure to sustain replacement feeding and re-

introduction of breastfeeding after initial cessation is particularly risky in terms of mother-to-

child transmission of HIV [10]. Infant feeding recommendations for HIV-positive mothers are

confusing and have resulted in disadvantageous feeding patterns and mixed feeding in

particular [11]. Mixed feeding is associated with a higher morbidity and mortality risk than

exclusive breastfeeding for infants of both HIV-positive and HIV-negative mothers, and with

increased HIV transmission from HIV-positive mothers [6, 7, 12-16]. Exclusive breastfeeding

is also associated with a reduced risk of breast health problems [17].

The frequencies with which exclusive breastfeeding, mixed feeding, prelacteal feeding and

replacement feeding are practised differ widely throughout Africa [18]. Region-specific

measurements are essential to develop regional-specific recommendations.

We have investigated infant feeding practices, including breastfeeding, for infants and

children under 2 years of age born to HIV-positive mothers in Mbale, Eastern Uganda.

Methods

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Study area

The study was conducted during 2005 in Eastern Uganda in collaboration with The Aids

Support Organisation (TASO). TASO is the largest national-based non-governmental

organisation working with HIV-positive people in Africa. It is a grassroots movement

providing counselling, information, support and medical treatment.

The study area included Mbale district, together with areas accessed through TASO Outreach

Clinics in adjacent regions in the districts of Sironko, Pallisa and Kumi. Mbale district has a

population of 720,000 of predominantly Bagisu people, with 90% living as subsistence

farmers in rural environments. The overall literacy rate is 64% for men and 49% for women

[19]. Uganda has an HIV prevalence of 7.5% in women aged 15–49 years (2005) [20]. In the

period of the study, introduction of routine HIV counselling and testing was starting in

Ugandan hospitals [21]. The acceptance of testing had increased substantially. The national

PMTCT program was introduced in Uganda first as a pilot in 1998 and more widely in 2001

[22].

This cross-sectional study collected information from 240 HIV-positive mothers with children

aged 0-23 months. All mothers were recruited from TASO by consecutive sampling, and they

participated voluntarily with informed consent. No mother contacted as a potential

interviewee refused to participate. Five mother-infant pairs were excluded from the study

because of missing information or the child was over 23 months old. Accordingly, 235 HIV-

positive mothers were included in the study. Three pairs of data collectors who were fluent in

Lumasaba (the local language), Luganda (the language of the central region) and English

conducted the interviews with the mothers.

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To check the reliability, 15 mothers were re-interviewed by another pair of data collectors 2–4

weeks after the initial interview. The answers showed only minor discrepancies and a high

degree of consistency.

Questionnaire

The structured interview contained topics concerning breastfeeding and feeding habits,

feeding knowledge, mother’s and father’s education, occupation, household assets, time of

HIV diagnosis, self-rated health [23], mother-rated health of infant and PMTCT program

participation. A list of 30 liquid, semi-solid and solid foods was utilized with 24-hour recall,

1-week recall and recall since birth. Using a symptom-based semi-quantitative approach, we

examined breastfeeding problems and reasons for stopping breastfeeding. The questionnaire

was pre-tested to ensure correct understanding of the questions.

Data handling

Double entry was done in EpiData 3.1, and SPSS 14 was used for data analysis.

Definitions

Feeding information was based on World Health Organisation (WHO) definitions and

recommendations [24], as follows. Exclusive breastfeeding: giving breast milk only, except

for medicines and vitamin or mineral supplements; predominant breastfeeding: breast milk is

nutritionally dominant, but with the possible addition of water-based fluids, fruit juices, tea

without milk or oral rehydration salts; complementary feeding including breast milk (often

referred to as mixed feeding): non-human milk, semi-solids or other solids given in addition

to breast milk; replacement feeding: breastfeeding stopped or never being given any breast

milk. Exclusive replacement feeding was defined as never having given any breast milk. Pre-

lacteal feeding was defined as any food item or liquid other than breast milk given to the

infant during the first 3 days after delivery.

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Ethics

Ethical approval was obtained from Makerere University, Faculty of Medicine Ethics and

Research Committee, and the Uganda National Council for Science and Technology.

Informed consent was obtained from each participant.

Statistics

Baseline characteristics were examined with frequency tables. Feeding patterns were

compared using χ2 statistics. Consistency was checked by Cohen’s Kappa statistic.

The participants were grouped socio-economically into quintiles based on wealth assessment

using principal component factor analysis [25]. Housing characteristics and assets including

toilet facilities, number of rooms and beds, roof material, lantern, radio, television, bicycle

and vehicles were included in the model. The quintiles were based on the first principal

component, a recognised method as a good proxy for household wealth [26]. Breastfeeding

duration in this cross-sectional study was estimated using Kaplan-Meier survival analysis with

a Mantel-Cox log rank test to compare the estimates. Self-reported breastfeeding duration is

used in the model. Cox regression analysis was used to estimate the independent impact of

each factor on breastfeeding duration. Co-linearity, hazard plots and residual plots were

checked. A backward “conditional” regression model was used in the multivariate analysis

with removal set at a 0.1 level of significance.

Results

The median maternal age was 30 years (inter-quartile range [IQR] 28–35) (Table 1). The age

distribution of the infants and children was: 0–5 months: 37 infants; 6–11 months: 53 infants;

12–17 months: 65 children; 18–23 months: 80 children [see Additional file 1]. Median

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maternal education was 5 years of schooling (IQR 3–7). Fathers were more educated than

mothers with a median of 7 years of education (IQR 5–10). Half the mothers were widowed.

Feeding practices

Of 235 HIV-positive mothers, 215 (91.5%) initiated breastfeeding while 20 (8.5%) never

breastfed their infants. Among 128 mothers who attended the PMTCT program, 18 (14%)

avoided breastfeeding completely, while 2 of those not participating did not breastfeed

(p<0.001). Among the attendees and non-attendees in the PMTCT program, the proportions

opting for exclusive breastfeeding during the first three days were not significantly different,

28.1% versus 27.1%, respectively. Ten among the 46 mothers in the better-off quintile did not

initiate breastfeeding within the first three days. Nine of these 10 (90%) mothers continued

with exclusive replacement feeding. Among the poorer 189 mothers, 11 (42%) out of 26

mothers who did not initiate breastfeeding within the first three days continued with exclusive

replacement feeding, whereas 15 mothers introduced breastfeeding later on (p<0.05).

Within the first two hours after delivery, 131 (56%) had initiated breastfeeding, with 178

(76%) having done so within the first day. Pre-lacteal feeding was given by 150 (64%) while

65 (28%) practised exclusive breastfeeding during the first three days. Replacement feeding

was practised by only one of the 85 mothers diagnosed with HIV after delivery.

One-week recall and 24-hour recall gave similar results for the infant feeding patterns, giving

a Spearman correlation coefficient of 0.96 among infants below 6 months of age and 1.0

above 6 months of age (Table 2). Among the infants less than 6 months old, one-fifth were

exclusively breastfed and most were fed complementary including breast milk. Two-thirds of

the infants older than 6 months were fed complementary including breast milk and the

remaining third were replacement fed. The rate of replacement feeding increased with age.

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Among children aged 12–17 months, 37 (58%) were replacement fed, while 75 (93%) of

children aged 18–23 months were replacement fed.

Breastfeeding duration

The median duration of breastfeeding was 12 months (95% confidence interval 11.5–12.5).

Education was associated with a marked reduction in duration of breastfeeding, with a median

duration of 3 months (95% CI 0–10.2) among mothers with more than 12 years of schooling,

and a median of 18 months (95% CI 15.0–21.0) among mothers lacking education (Figure 1).

This effect was seen both with and without adjusting for other factors with Cox regression

with a 4.5 and 6.4-fold increase in hazard ratio for breastfeeding cessation, respectively

(Table 3). The level of the father’s education, whether the mother was a farmer, and the

timing of HIV-diagnosis in relation to birth had similar effects on the crude analysis, but not

in the adjusted Cox regression analysis. Breastfeeding duration differed substantially among

mothers in the poorest and least poor quintiles. The median duration was 8 months (95% CI

5.9–10.1) among the least poor and 17 months (95% CI 15.2–18.8) among the poorest (Figure

2). Mother’s age, marital status, rural or urban life, self-rated health of the mother and mother-

rated health of the infant were not significantly associated with breastfeeding duration.

Mothers counselled in the PMTCT program stopped breastfeeding earlier than those who did

not attend the program. Duration of breastfeeding was shorter among mothers who had

discussed breastfeeding with someone compared to those who had not. Those who considered

exclusive breastfeeding to be beneficial for the infant, stopped breastfeeding earlier compared

to those who considered it harmful. In a restricted analysis including children above 18

months of age, the median duration of breastfeeding was 12 months (95% CI 11.4–12.6).

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Reasons for cessation of breastfeeding

Breastfeeding had been stopped by 116 mothers at the time of the interview. Advice from

health workers, illness of the mother, and the fact that the mother was HIV-positive were

reported as the main reasons for stopping breastfeeding (Table 4). Other reasons for stopping

breastfeeding were: breastfeeding difficulties, perceived insufficient milk production, the

notion that the child was “old enough” or “big enough”, and that the child could eat without

help. Family pressure, work and new pregnancies were reported by only a few mothers. Those

stopping breastfeeding before the infant was six months old gave similar reasons to all the

mothers stopping breastfeeding.

Fewer than half the breastfeeding mothers experienced problems relating to breastfeeding [see

Additional file 2]. A fifth had problems with breastfeeding related to illnesses, such as

generalised pain, frequent fever and a feeling of weakness. Breast pain, sore and cracked

nipples, and swelling of the breast also burdened 40 (19%) mothers. Three mothers (1%) were

diagnosed with mastitis or breast abscess.

Discussion

This study shows that exclusive breastfeeding was uncommon among the HIV-positive

women who opted to breastfeed. Thus, most infants received complementary feeding

including breast milk from a very early age, which is an unfavourable situation. Our findings

in Uganda agree with studies in other parts of Africa among both HIV-positive mothers and

the general population [18, 27]. A positive finding is that breastfeeding duration is shortened

by many HIV-positive mothers, especially among the well educated, the socio-economically

better-off, and those who have attended the PMTCT program or discussed infant feeding with

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someone. Well-educated mothers breastfed for ~1 year less than their uneducated peers.

Whether the shortened breastfeeding duration had any negative effects on the children was not

assessed in our study. A recently published randomised study from Zambia indicates that

early abrupt weaning of breastfeeding does not significantly reduce HIV-free mortality rates

[28]. In addition, prolonged breastfeeding gave a higher survival rate for HIV-positive

children compared to those weaned early. HIV screening using a dried blood spot from infants

was a feasible approach to the early identification of HIV-positive infants who may benefit

from prolonged breastfeeding [29].

Exclusive breastfeeding of infants under 6 months old was less commonly practised among

HIV-positive mothers than among the general population reported in the DHS-study in

Uganda – 24% of HIV-positive mothers and 63.2% of the general population mothers

according to the 24-hour recall data [18]. Similarly, a study of the general population in the

same area also reported higher rates of exclusive breastfeeding [30]. Is this an effect of

information about the risk of HIV transmission through breastfeeding reaching the HIV-

positive mothers? Counselling on infant feeding in many African countries, including

Uganda, has been reported to be suboptimal and may be one of the important reasons for the

widespread practice of complementary feeding including breast milk [31]. Health workers

often overestimated the risk of HIV transmission through breastfeeding and many gave the

impression that HIV transmission from mother-to-child is nearly universal [22, 31]. Based on

key informant interviews, our impression was that replacement feeding was promoted more

strongly in the national PMTCT program, whereas exclusive breastfeeding seemed to be more

counselled in the non-governmental organisations working with HIV (unpublished data).

Although breastfeeding duration was shorter among participants in the national PMTCT

program than those not participating, we did not see differences in the rates of exclusive

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breastfeeding. Another explanation for the dominance of complementary feeding including

breast milk may be the fear of making the infant totally reliant on breast milk, which could be

particularly true for HIV-positive mothers [32].

In rural and semi-urban HIV-positive mothers in Eastern Uganda, replacement feeding was

uncommon. This agrees with a Tanzanian study where replacement feeding with infant

formula or cow’s milk was seen as unacceptable or infeasible [11]. Introduction of

breastfeeding after initial replacement feeding was common except among the socio-

economically better-off. Initiating breastfeeding after abrupt weaning is associated with

increased viral loads of breast milk, and consequently could be hazardous [10].

Only 56% of the mothers initiated breastfeeding within the first two hours after delivery and

76% initiated it within the first day. A study in Ghana indicated a 2.4-fold increase in risk of

neonatal death among infants for whom breastfeeding was not begun within the first day

compared to those for whom it was [15]. The authors of that study calculated that 16.3% of

neonatal deaths could have been prevented if all neonates had been breastfed within the first

hour. Pre-lacteal feeding was given by 64% of the HIV-positive mothers in our study. Not

breastfeeding exclusively during the first days has also been shown to increase neonatal

mortality [15, 33].

Although being HIV-positive was a major reason for stopping breastfeeding by 64% of the

mothers, the median breastfeeding duration was 12 months. Breastfeeding duration among

HIV-positive mothers was clearly shorter than among the general population, which in the

DHS-study in Uganda was 19.9 months [18]. It may seem counterintuitive that mothers

perceiving exclusive breastfeeding to be beneficial were breastfeeding for a shorter time than

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mothers considering exclusive breastfeeding to be harmful. We interpret this as an indication

that counselling had some impact, both in terms of increasing knowledge of infant feeding

and of influencing behaviour.

Self-reported breastfeeding problems were similar to those given by mothers in the general

population in the same area of Uganda, and were slightly more common than among HIV-

positive and general population mothers in South Africa [17, 34]. The low rate of exclusive

breastfeeding probably contributed to the higher proportion of breastfeeding problems.

Mothers with breast health problems have a greatly increased risk of infecting their children

with HIV [17, 35]. Data from South Africa indicate a greater than threefold risk of

transmitting HIV from mother to infant when the mother had a serious breast health problem.

Similarly, any breast health problems show an increased hazard ratio for HIV transmission

compared to the absence of such problems [17].

The cross-sectional design of the study inherently left out diseased children. A similar cross-

sectional study in 2003 provided a comparative group in the general population [30]. A

limitation of this study is that Kaplan-Meier and Cox regression analyses were conducted in a

population where half the infants were censored at the last time-point due to ongoing

breastfeeding, which may limit the precision of our estimates and could introduce bias.

However, we observed similar associations in an analysis restricted to children with at least

18 month follow-up, and with much lower censoring rates. A third of the HIV-positive

mothers acquired their HIV-status after delivery, which might influence the Cox regression

analysis compared to the situation where all mothers were diagnosed HIV-positive before

delivery. A restricted analysis excluding the mothers acquiring their HIV-diagnosis after

delivery gave similar results in the Cox regression compared to when all mothers were

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included (not published). The use of anti-retroviral medicines was not recorded, but was not

common even if roll-out started approximately at the time as the study in Mbale. The recall

setting in this study was not optimal, and there may also have been socially desirable answers.

It has been suggested that dietary recall once a week has high sensitivity and specificity for

exclusive breastfeeding and other feeding patterns to a given age [36]. In our study, recall

periods of 24 hours and 1 week yielded similar results. Some studies have indicated that

breastfeeding duration is overestimated to an escalating degree with increasing age [37, 38],

while others have stated that breastfeeding duration is accurately reported [39]. The fact that

there was full agreement about breastfeeding duration between the initial and re-interviews

reduces the likelihood that this measurement was significantly biased. The fact that all

mothers were recruited through TASO may have caused a socio-economically skewed

selection. We still feel confident that the data are representative of a large proportion of HIV-

positive women in the region in Uganda.

There was a wide difference between the infant feeding practices in this group and WHO

recommendations. Infant feeding recommendations for HIV-positive mothers have been

confusing [11], which might explain the shortcomings of the practices. More beneficial

practices among the well educated is a reason to increase the level of education, while also

putting more efforts into counselling of less well-educated mothers.

Conclusions

Well-educated mothers breastfed for a substantially shorter time than their less well-educated

peers. Mothers who were socio-economically better-off or had participated in the PMTCT

program also breastfed for shorter durations.

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Except among a limited group in this population, replacement feeding was not considered a

realistic option in this rural setting. Complementary feeding including breast milk was the

dominant practice for infants under 6 months old among the HIV-positive mothers.

There still seems to be many obstacles to optimal infant feeding. Further efforts are needed to

optimise counselling on infant feeding and increase the implementation of the

recommendations.

Competing interests:

The authors declare that they have no competing interests.

Authors’ contributions:

LTF: design, implementation, analysis and writing. IMSE: design, analysis and co-writing.

HW: analysis and co-writing. JW: implementation of the study and co-writing. JKT: initiation

of the study and co-writing. TT: initiation of the study, design, implementation, analysis and

co-writing.

Abbreviations:

C.I., confidence interval; DHS, Demographic and Health Surveys; HIV, human

immunodeficiency virus; IQR, inter-quartile range; PMTCT, Prevention of Mother-to-Child

Transmission; SPSS, Statistical Package for the Social Sciences; TASO, The Aids Support

Organisation; WHO, World Health Organisation.

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Acknowledgements:

We thank Nulu Semiyaga, Herbert Mugooda, Harriet Mukiibi, Faith Kakai, Edward Kutusi,

Sarah Wayero and Philip Kabiri for their efforts in collecting the data; TASO-Mbale

including counsellors and administrative staff for their collaboration; and all the mothers and

children who contributed to this study.

The study was funded by The Norwegian Programme for Development, Research and

Education (NUFU) by grant no 43/2002 "Essential nutrition and child Health in Uganda."

LTF, IE and TT were employed and funded by the University of Bergen. JKT was employed

and funded by Makerere University. JW was employed by TASO. HW was funded by the

Norwegian Quota Programme – Scholarship for Studies in Norway. The funding bodies had

no influence on the study design, data collection, analysis and interpretation of data, writing

of the manuscript or the decision to submit the manuscript for publication.

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cross-sectional study comparing dietary recall since birth with 24-hour recall.
BMC Pediatr 2007, 7:10.
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feeding policy and programmes in four African countries scaling up prevention
of mother to child transmission programmes. Arch Dis Child 2008, 93(4):288-291.
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sister, the breast alone is not enough for my baby' A qualitative assessment of
potentials and barriers in the promotion of exclusive breastfeeding in southern
Zambia. Int Breastfeed J 2008, 3(1):26.
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Gambia. Ann Trop Paediatr 1999, 19(1):33-43.
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Cultural obstacles to exclusive breastfeeding in eastern Uganda: experiences and
attitudes. 18th ICN (International Congress of Nutrition), Durban Sept 05 2005.
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transmission of HIV-1. Aids 2000, 14(16):2535-2541.
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Maternal recall of infant feeding events is accurate. J Epidemiol Community Health
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Figure legends:

Figure 1: Breastfeeding duration in months (x-axis) for different groups of mothers based on

their education. Proportion still breastfeeding (y-axis) visualised with a Kaplan-Meier-plot

Figure 2: Breastfeeding duration in months (x-axis) for different socio-economic groups.

Proportion still breastfeeding (y-axis) visualised with a Kaplan-Meier-plot

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Table 1: Median breastfeeding duration with Kaplan-Meier analysis including all the infants

(n=235) and a Mantel-Cox log rank test to compare ranking of the estimates

n (%) Median in 95% CI Log Rank test

months (Mantel-Cox)
2
Mother’s education χ = 24.0 (4 df )
a

None 27 (11) 18 15.0 – 21.0 p <0.001

Stopped in primary 125 (53) 14 12.1 – 15.9
Completed primary (7 years) 39 (17) 12 8.0 – 16.0
Secondary education 37 (16) 8 6.8 – 9.2
Higher education (≥12 years ) 7 ( 3) 3 0 – 10.2
2
Father’s education χ = 11.4 (4 df)
b b
None 14 ( 6) p <0.05
Stopped in primary 72 (32) 13 11.6 – 14.4
Completed primary (7 years) 62 (27) 15 11.8 – 18.2
Secondary education 50 (22) 9 7.3 – 10.7
Higher education (≥12 years ) 30 (13) 8 3.8 – 12.2
2
Mother’s age ac
χ = 1.7 (1 df )
≤ 24 22 (10) 18 16.3 – 19.7 p = 0.20
25 – 29 61 (26) 12 10.9 – 13.1
30 – 34 85 (36) 12 11.3 – 12.7
≥ 35 67 (29) 12 11.3 – 12.7
2
Marital status χ = 2.5 (2 df)
Married/ cohabiting 91 (39) 12 9.4 – 14.6 p = 0.29
Widowed 112 (48) 12 11.4 – 12.6
Divorced /separated or single 32 (14) 13 4.5 – 21.5
2
Socio-economic status c
χ = 9.3 (1 df )
Bottom quintile, poorest 47 (20) 17 15.2 – 18.8 p <0.01
2nd quintile 47 (20) 12 11.3 – 12.7
3rd quintile 46 (20) 9 6.0 – 12.0
4th quintile 48 (20) 16 11.4 – 20.6
Top quintile, least poor 46 (20) 8 5.9 – 10.1
2
Mother’s work χ = 7.5 (1 df)
Farming 201 (86) 12 10.9 – 13.1 p <0.01
Do not farm 34 (14) 8 6.9 – 9.1
2
Living area χ = 3.3 (1 df)
Rural 205 (87) 12 11.0 – 13.0 p = 0.07
Urban 30 (13) 8 4.7 – 11.3
2
HIV-diagnosis χ = 10.1 (1 df)
After delivery 85 (36) 15 10.5 – 19.5 p <0.01
Before delivery 150 (64) 12 10.4 – 13.6
2
Participation in the PMTCT- program χ = 17.5 (1 df)
Did not attend 107 (46) 14 10.8 – 17.2 p <0.001
Attended 128 (54) 9 7.2 – 10.8
2
Anyone talked about breastfeeding χ = 12.6 (1 df)
No 44 (19) 18 15.7 – 20.3 p <0.001
Yes 191 (81) 12 11.5 – 12.5
2
Mothers’ self-rated health c
χ = 0.1 (1 df )
Very healthy 33 (14) 12 9.5 – 14.5 p = 0.73

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 Quite healthy 138 (59) 12 11.4 – 12.6
Not very healthy 64 (27) 14 9.7 – 18.3
2
Mothers’-rated health of child c
χ = 0.4 (1 df )
Very healthy 37 (16) 9 5.1 – 12.9 p = 0.54
Quite healthy 111 (48) 12 10.1 – 13.9
Not very healthy 83 (36) 12 10.8 – 13.2
2
Belief about 6 months of exclusive breastfeeding c
χ = 9.2 (1 df )
Sure it would be good 29 (12) 7 5.6 – 8.4 p <0.01
Think it would be good 42 (18) 12 8.6 – 15.4
Think it would hurt 104 (44) 12 11.0 – 13.0
Sure it would hurt 59 (25) 15 12.0 – 18.0
a
df (degrees or freedom)
b
could not be measured (only 3 stopped among 14 cases and 151 months of follow-up)
c
linear trend assumed

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Table 2: Recall comparison of different feeding patterns based on 24-hour, 1-week and since
birth recall. N (%) of infants in age range feeding in particular pattern based on specific recall
period.

24-hour recall 1-week recall Since birth recall

0 – 5 months
Exclusive breastfeeding 9 (24) 8 (22) 5 (14)
Predominant breastfeeding 3 ( 8) 3 ( 8) 5 (14)
Complementary feeding incl. breast milk 19 (51) 20 (54) 21 (57)
Replacement feeding 6 (16) 6 (16) 6 (16)

6 – 11 months
Exclusive breastfeeding 0 ( 0) 0 ( 0) 0 ( 0)
Predominant breastfeeding 0 ( 0) 0 ( 0) 0 ( 0)
Complementary feeding incl. breast milk 36 (68) 36 (68) 36 (68)
Replacement feeding 17 (32) 17 (32) 17 (32)
0–5 months: n = 37; 6–11 months: n = 53.

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Table 3: Cox regression of breastfeeding cessation, unadjusted and adjusted hazard ratio
(HR). Only factors in the final adjusted model have HR estimates (right-hand columns).

Breastfeeding cessation, Breastfeeding cessation,

unadjusted (crude) adjusted
HR 95% CI HR 95% CI
Mother’s education
None 1 1
Stopped in primary 1.3 0.7 – 2.4 1.3 0.7 – 2.5
Completed primary (7 years) 1.9* 1.0 – 3.7 2.1* 1.0 – 4.2
Secondary education 3.0* 1.5 – 6.0 2.4* 1.1 – 5.0
Higher education (≥12 years ) 6.4* 2.2 – 18 4.5* 1.4 – 15

Father’s education
None 1
Stopped in primary 1.7 0.6 – 4.8
Completed primary (7 years) 1.7 0.6 – 4.9
Secondary education 3.0* 1.1 – 8.4
Higher education (≥12 years ) 3.0 1.0 – 8.8

Mother’s age
≤ 24 1
25 – 29 1.8 0.8 – 3.7
30 – 34 1.7 0.9 – 3.5
≥ 35 1.8 0.9 – 3.7

Marital status
Married/ cohabiting 1
Widowed 1.2 0.9 – 1.8
Divorced / separated or single 1.5 0.8 – 2.6

Socio-economic status
Bottom quintile, poorest 1 1
2nd quintile 1.8 1.0 – 3.2 2.4* 1.2 – 4.8
3rd quintile 2.2* 1.2 – 4.0 2.6* 1.3 – 5.1
4th quintile 1.3 0.7 – 2.4 1.1 0.5 – 2.3
Top quintile, least poor 3.1* 1.7 – 5.5 3.0* 1.5 – 6.0

Mother’s work
Farming 1
Do not farm 1.8* 1.1 – 2.7

Living area
Rural 1
Urban 1.5 0.9 – 2.5

HIV-diagnosis
After delivery 1
Before delivery 1.7* 1.2 – 2.4

Participation in the PMTCT- program

Did not attend 1 1
Attended 2.0* 1.4 – 2.8 2.0* 1.3 – 3.0

Anyone talked about breastfeeding

No 1 1
Yes 2.2* 1.4 – 3.7 1.9* 1.1 – 3.3

Mothers self-rated health

Very healthy 1.1 0.6 – 1.9
Quite healthy 1.1 0.8 – 1.7
Not very healthy 1

Mothers-rated health of child

Very healthy 1.3 0.7 – 2.1

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 Quite healthy 1.0 0.7 – 1.4
Not very healthy 1

Belief about 6 months of exclusive breastfeeding

Sure it would be good 2.8* 1.5 – 5.0 3.1* 1.6 – 5.8
Think it would be good 1.3 0.7 – 2.2 1.7 1.0 – 3.1
Think it would hurt 1.3 0.9 – 2.1 2.0* 1.2 – 3.2
Sure it would hurt 1 1
p < 0.05 (group is significantly different from reference group)
HR (hazard ratio)

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Table 4: Reasons for stopping breastfeeding

a a
Main reason Additional reasons Total
n (%) n (%) n (%)
Health workers advice 32 (28) 22 (19) 54 (47)
Illness (weakness, body pain etc) 29 (25) 23 (20) 52 (45)
HIV-diagnosis 20 (17) 54 (47) 74 (64)
Not enough milk 10 ( 9) 16 (14) 26 (22)
Breastfeeding difficulties 10 ( 9) 5 ( 4) 15 (13)
Custom related (e.g. grown “big enough”) 9 ( 8) 11 ( 9) 20 (17)
Family pressure 2 ( 2) 0 ( 0) 2 ( 2)
New pregnancy 2 ( 2) 0 ( 0) 2 ( 2)
Work situation 1 ( 1) 4 ( 3) 5 ( 4)
Other reasons 1 ( 1) 4 ( 3) 5 ( 4)
Total 116 (100)
a
Reasons other than main reason reported to be important for the choice to stop breastfeeding. 16 (14%)
reported main reason only, 66 (57%) reported one additional reason, 28 (24%) reported two additional reasons
and 6 (5%) reported three additional reasons.

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Additional files
Additional file 1
File format: PDF
Title: Infant age histogram; age in months.
Description: Age distribution of infants at the time of the interview represented with
histogram.

Additional file 2
File format: PDF
Title: Reported breastfeeding problems among 215 breastfeeding mothers.
Description: Frequency of breastfeeding problems among 215 breastfeeding mothers.

- 27 -
 Breastfeeding duration, Kaplan-Meier-plot

1,0 Mothers education,

completed years
No education
1- 6 years
0,8 Primary school completed
8- 11 years
12 years or above
Proportion

0,6

0,4

0,2

0,0

0,00 6,00 12,00 18,00 24,00

Months
Figure 1
 Breastfeeding duration, Kaplan-Meier-plot
1,0

QuintileHIV+
0,8
Poorest quintile
2
Middle quintile
4
Least poor quintile
Proportion

0,6

0,4

0,2

0,0

0,00 6,00 12,00 18,00 24,00

Months
Figure 2
Additional files provided with this submission:

Additional file 1: table - reported breastfeeding problems.pdf, 11K

http://www.biomedcentral.com/imedia/8097062602208421/supp1.pdf
Additional file 2: infant age histogram - age in months.pdf, 24K
http://www.biomedcentral.com/imedia/5943358542208421/supp2.pdf