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Replacement Feeding Experiences ofHIV-Positive Mothers in EthiopiaBogale Abera Woldegiyorgis a & James L. Scherrer ba Hawassa College of Teacher Education, Hawassa, Ethiopiab Graduate School of Social Work, Dominican University, RiverForest, Illinois, USAVersion of record first published: 12 Mar 2012.
To cite this article: Bogale Abera Woldegiyorgis & James L. Scherrer (2012): Replacement FeedingExperiences of HIV-Positive Mothers in Ethiopia, Journal of Community Practice, 20:1-2, 69-88
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Journal of Community Practice, 20:69–88, 2012Copyright © Taylor & Francis Group, LLCISSN: 1070-5422 print/1543-3706 onlineDOI: 10.1080/10705422.2012.648123
PART 2: POLICY
Replacement Feeding Experiencesof HIV-Positive Mothers in Ethiopia
BOGALE ABERA WOLDEGIYORGISHawassa College of Teacher Education, Hawassa, Ethiopia
JAMES L. SCHERRERGraduate School of Social Work, Dominican University, River Forest, Illinois, USA
The World Health Organization most recent guidelines recom-mend that HIV-positive mothers exclusively breastfeed unlessreplacement foods meet the criteria of acceptability, feasibility,affordability, sustainability, and safety (AFASS). However, thefear of HIV transmission through breastfeeding has pressuredthese mothers into choosing replacement feeding whether theymeet AFASS criteria or not. This choice has subjected infantsto malnutrition and related deaths. This qualitative study isbased on Scheper-Hughes and Lock’s (1987) Three Bodies Model.Discussions were carried out in a Prevention of Mother-to-ChildTransmission Program (PMTCT) in Hawassa, Ethiopia usingin-depth interviews, key informant interviews and focus groups.The study focused on the challenges that HIV positive mothers facedue to inadequate counseling services, poor economic situations,and lack of support and follow up. The Three Bodies Model exposesthe deficits in the comprehensive delivery of services by PMTCT pro-grams. Implications for social work practice and funding policiesare discussed.
KEYWORDS replacement feeding, social meanings, PMTCT,HIV/AIDS, breastfeeding, mothers
We acknowledge Haile Michael Tesfahun, Addis Ababa University, School of Social Work,for his critical comments on the original thesis. The research was funded through Addis AbabaUniversity, School of Social Work.
Address correspondence to Bogale Abera Woldegiyorgis, Hawassa College of TeacherEducation, P.O. Box 115, SNNPR, Hawassa, Ethiopia. E-mail: [email protected]
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70 B. A. Woldegiyorgis and J. L. Scherrer
The emergence of the human immunodeficiency virus (HIV) epidemic inthe past few decades threatened breastfeeding as a safe and healthy methodof feeding infants in economically distressed parts of the world. The WorldHealth Organization (WHO) Update (2007b) recommended that HIV-positivemothers exclusively breastfeed their infants unless replacement feeding,which does not include breast milk, meets the criteria of accessibility, feasi-bility, affordability, sustainability, and safety (AFASS). However, HIV-positivemothers often choose replacement feeding whether or not AFASS criteria aremet, because they fear transmitting the HIV virus to their infants throughtheir breast milk. When AFASS criteria are not met, infants are subjected tomalnutrition, infections, and diseases that may result in death. The purposeof this study is to assess the difficulties in replacement feeding experiencesfaced by HIV-positive mothers enrolled in the prevention of mother-to-childtransmission (PMTCT) program in Hawassa, Ethiopia. The study aims toknow the challenges HIV-positive mothers faced in their infant feedingexperience, how community infant feeding practices and social meaningsinfluence feeding choice, and how replacement-feeding mothers feel aboutthe support and services they receive.
This qualitative study uses the Three Bodies Model (Scheper-Hughes& Lock, 1987) to set up in-depth interviews with HIV-positive moth-ers, breastfeeding counselors, and members of the HIV community. Theinterviews were transcribed and analyzed to discover common influenceson HIV-positive mothers’ decisions to breastfeed, replacement feed, ormix feed their infants. In addition, common themes about support andinformation provided to them were explored. The implications for futuresocial work community practice are examined and courses of actionrecommended.
PMTCT OF HIV
Feeding options for infants of HIV-positive mothers are either exclusivereplacement feeding or exclusive breastfeeding (Koniz-Booher, Burkhalter,de Wagt, Iliff, & Willumsen, 2004). However, both feeding options involverisks to child health and survival. Although exclusive breastfeeding is morepractical, it has a 5% to 15% chance of transmitting HIV to infants (Israel& Kroeger, 2003). This incident rate of mother-to-child transmission couldbe reduced through drug intervention, and an awareness of precautionssuch as minimizing the duration of breastfeeding (WHO, 2003). Exclusivereplacement feeding is an ideal option, because there is no chance of HIVtransmission. However, it is difficult to apply in resource-limited nations,where exclusively replacement fed infants have a six-fold increased risk ofdying in the first 2 months of life, compared with those who were breastfed(WHO, 2008).
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Replacement Feeding Experiences in Ethiopia 71
Over 530,000 new cases of pediatric HIV infection occur each yearthroughout the world, primarily due to mother-to-child transmission of HIV(WHO, 2007a). In resource-rich settings, prenatal transmission rates of 2%or less are achieved with the use of a combination of antiretroviral, obstet-rical interventions and avoidance of breastfeeding. HIV-positive mothers insuch settings can safely provide formula to their infants so that they canavoid breastfeeding. In resource-limited settings, however, alternatives tobreastfeeding do not usually meet the requirements of AFASS for many HIV-infected women. HIV-positive mothers tend to overestimate that all breastfedbabies will be HIV-infected. As a result, they exclusively replacement feedtheir infants, even though AFASS criteria are not met (Koniz-Booher et al.,2004). A study in Tanzania showed that replacement feeding is rare in abreastfeeding culture, because the community believes that infants cannotsurvive without breast milk (Leshabari, Blystad, & Moland, 2007). Thus,exclusive replacement feeding in early infancy violates the rules of goodmotherhood. Those who practice it are considered failures as mothers. As aresult, the community pressures HIV-positive mothers to mix breastfeedingwith replacement feeding.
Replacement feeding also has some negative socially constructed mean-ings (Leshabari et al., 2007). Replacement-feeding mothers are thought tobe concerned more about their body shape than child rearing, and toengage in extramarital affairs, or to be HIV positive. Njunga’s (2008) study inMalawi recommended that PMTCT programs should take into considerationthe spectrum of such cultural factors that influence experiences, behav-ior, and attitudes (Sevelius, 2011). Partners and/or family members of thereplacement-feeding mothers may attempt to exert control over her feedingmethod (Koniz-Booher et al., 2004). Unless partners and family members areinvolved in the infant feeding decision, adherence to replacement feedingwill be challenging (Aubel, 2011). These mothers also face the challenge pre-sented to them by rapidly changing recommendations from WHO (Molandet al., 2010). The WHO (2001) guidelines recommend that mothers meetAFASS criteria before choosing replacement feeding as the form of nutri-tion for their infants (Koniz-Booher et al., 2004; Koricho, Moland, & Blystad,2010). If AFASS criteria cannot be met, these mothers should exclusivelybreastfeed their infants. These guidelines were in effect until 2007, whenWHO shifted the focus to breastfeeding first and AFASS criteria second.They were changed again in 2009, and still again in 2010, to reflect ongo-ing research in what would keep infants of HIV-positive mothers, and themothers themselves, healthy. Current guidelines differ significantly fromthose of 2001, yet many postnatal counselors have been trained only tothe 2001guidelines (Moland et al., 2010; WHO, 2010).
AFASS criteria may impose significant economic challenges for moth-ers choosing to replacement feed in Ethiopia (Koricho, 2008). Health carecenters may provide formula for replacement feeding of infants, but often
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72 B. A. Woldegiyorgis and J. L. Scherrer
it is not enough. Mothers are then forced to use replacement feeding meth-ods that do not meet AFASS criteria. The issue is further complicated bythe fact that health service counselors only examine the affordability por-tion of AFASS and nothing else. Even the availability of free formula maynot ensure that the decision to replacement feed translated into successfulpractice (Koniz-Booher et al., 2004). Besides knowing their HIV status andhaving access to free or subsidized formula, these mothers needed properadvice from counselors, partner or family involvement, better educationallevel, assistance with being the primary income provider, and participationin structured PMTCT programs. Instead, HIV-positive mothers were oftenexposed to conflicting messages from the local mission hospital, familymembers, and traditional healers (Bond, Chase, & Aggleton, 2002).
Mothers using replacement feeding in a breastfeeding culture facedcriticism from the community and were given some negative social mean-ings, which PMTCT programs overlooked. However, a study of HIV-positivemothers in Botswana (Nyblade, Kidd, & Field, 2000) indicated that moth-ers were able to override any traditional norms by prioritizing their infants’health. This, coupled with the benefits of follow-up counseling (Matovu,Bukenya, Musoka, Kikonyogo, & Guay, 2002), was hampered by a slowand crippled program beginning that has limited access to HIV/AIDS-relatedservices. As a result, replacement-feeding mothers were trapped betweenthe demand of the health care system wanting mothers to either exclusivelybreastfeed or exclusively replacement feed and the community cultural prac-tice demanding them to mix feed. They also struggled with the control effortsfrom their partner and in the home environment (Aubel, 2011; Bland, Rollins,Coutsoudis, & Coovadia, 2002).
Mulugeta’s (2008) study of economic and social adaptations of womenin Addis Ababa, Ethiopia, found that HIV-positive mothers using replace-ment feeding methods employed various strategies to cope with thechallenges facing them. They entered formal and informal employment sec-tors, diversified survival strategies, went on informal migration, minimizedhousehold expenditures, changed dietary habits, and sought the support offamily members, friends, and other kin. Informal associations also providedcrucial supportive roles. Generally, replacement feeding in resource-poorsettings caused more harm than good to infant survival and became a sourceof fear and challenge for mothers in Africa who could not afford to buy eventheir own meals. This was supported by Sethuraman et al.’s (2011) study ofrural Vietnamese HIV-positive mothers. They found that replacement feed-ing occurred early out of necessity and social pressure even though AFASScriteria were not met.
PMTCT of HIV services are being rendered in all hospitals in regionaltowns and in satellite health centers in Ethiopia (Amare & Deneke, 2003).According to the Ethiopian Federal Ministry of Health (2007), the preven-tion of HIV transmission from infected women to their infants is one of
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Replacement Feeding Experiences in Ethiopia 73
the strategies of PMTCT. A behavior surveillance survey in Ethiopia foundthat HIV/AIDS-prevention programs have some impact on knowledge aboutHIV/AIDS (Federal Ministry of Health, et al., 2006). However, neither theincrease in knowledge of HIV/AIDS nor the WHO Update (2007b) rec-ommendation that infant feeding counseling and support for HIV-positivewomen be provided during pregnancy and for 2 years after the infant’s birthhave led to corresponding behavior change (Federal Ministry of Health,2009). According to a World Bank (2008) report, to date only 2% of HIV-positive pregnant women needing PMTCT have benefited from the servicein Ethiopia. In 2006, only 2,028 pregnant women received Nevirapine, ofwhom only 1,341 took a complete course for themselves and their infants.Although 1,400 sites are planned to have PMTCT services by the end of2007, only 184 sites provided the services.
THE THREE BODIES MODEL
The results of these studies can be synthesized using Scheper-Hughesand Lock’s (1987) conceptual framework, The Three Bodies Model(see Figure 1). The framework analyzes the body using three differentapproaches, representing three levels of analysis. The first level is the indi-vidual body, which is the lived experiences of the body self and the meaningattached to these experiences. The second level is the social body, whichrefers to the body as a natural symbol with which to think about nature,society, and culture. The social body is developed through being a memberof a particular social or cultural group. The third level is the body politic,referring to the regulation, surveillance, and control of bodies.
Social Body:Infant feeding
culture andsocial
meanings
Coping Strategies
ExclusiveReplacementFeeding (ERF)
Politic Body:
Control inhome and
health caresystems
Individual Body:
Feedingchallenges,
perceptions, andfears
FIGURE 1 The three bodies and exclusive replacement feeding. Source. Developed by theauthors from the concepts presented in Scheper-Hughes and Lock (1987)
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74 B. A. Woldegiyorgis and J. L. Scherrer
Incorporated in this framework are feeding-related challenges that HIV-positive mothers face: fears regarding feeding choice, influences and socialmeanings of community infant feeding practices, and controls exerted overthe HIV-positive mother in the home environment and by the health caresystem. HIV-positive mothers are faced with the infant feeding dilemma ofexposing their infants to HIV infection through breastfeeding, or replace-ment feeding which, although HIV-free, exposed infants to malnutritionand infectious diseases. In addition, because breastfeeding is socially con-structed as being an essential feature of motherhood, replacement feedingreflects negatively on the mother’s commitment to motherhood and her chil-dren. Husbands, mothers, mother-in laws, friends, and communities applypressure to the HIV-positive mother at least to mix breastfeeding withreplacement feeding. Finally, the HIV-positive mother is faced with chal-lenges in implementing the requirements of the health care system withlimited resources. According to Leshabari (2007), the interconnectednessand dynamics of these influences and challenges are well illustrated by thisframework.
RESEARCH METHODS
The study was conducted in 2009 in Hawassa, Ethiopia, a small city ofabout 157,879 residents (Federal Democratic Republic of Ethiopia, Office ofPopulation Census Commission, Central Statistics Agency, 2010). Participantsin the study were drawn from Hawassa Referral Hospital (HRH), TillaAssociation of Women Living with HIV/AIDS (Tilla), and key informantsfrom the community. HRH is the only government hospital in the city and itprovides free PMTCT services to Tilla members, most of whom replacementfeed their infants. An ethnographic research design was used, to obtaina holistic picture of the infant feeding practices of HIV-positive mothers.Selection of participants sought to obtain respondents representing each ofthe Three Bodies. Seven exclusive-replacement-feeding mothers who usedvaried methods of replacement feeding such as formula, cow’s milk, andgruel represented the individual body. The respondents were selected usingmaximum variation sampling, a technique that purposefully selects a widerange of variations on a dimension of interest (WHO, 1994). None of thesemothers completed high school. Their family income is less than $20 US permonth. Their average age was 27 years. All were married except one. Theirfamily size ranged between three and 10 children. Four counselors in HRHand Tilla represented the body politic and were selected by intensity sam-pling, a sampling technique that focuses on excellent, but not necessarilyextreme, examples of the phenomenon (Ulin, Robinson, Tolloy, & McNeill,2002). Their experience in infant feeding counseling ranged from 1 year to6 years. Three female Infant Feeding Counselors, who have a diploma in
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Replacement Feeding Experiences in Ethiopia 75
nursing, from HRH and one male nurse, who has a Bachelor of Science innursing, from Tilla participated in this part of the study.
Key community members, selected by homogenous sampling (Ulinet al., 2002) and divided into two focus groups of seven members, rep-resented the social body. This sampling technique is typically used to selectpeople with similar characteristics and a common identity to discuss andshare their experiences in focus groups. One focus group consisted of older(ages 30–40) HIV-positive women from Tilla who did not participate inthe individual interviews. The other focus group consisted of older (ages45–65) HIV-positive men from the Union of Iddirs of People Living WithHIV/AIDS. Iddirs are community-based organizations set up for arrangingburial ceremonies of a deceased member, comfort the family on the lossof the beloved one, and support one another during problematic situations.Currently, the government has started to include them in efforts to solvecommunity problems like helping orphans and other development activities.
Data collection instruments consisted of open-ended questions toguide interviews and focus group discussions. These instruments wereproduced from WHO standard questionnaires, reports, and readings onHIV-positive mothers’ infant feeding experiences. The concepts includedwere: HIV-positive mothers’ replacement feeding experiences and their per-ceptions of these; community infant feeding culture and meaning attachedto feeding practices; the influence on mothers’ choice of feeding by herfamily and relatives and by the health facility; and the coping strategiesexclusive-replacement-feeding mothers used to manage these environmentaldemands. The instruments were pretested at HRH and Tilla with respon-dents who did not participate in the actual study, and modified based onthe pretest results. Written consent was obtained from all of the participants.Participation was voluntary and the participants were told of their right towithdraw without giving a reason at any time and to request that their databe excluded. The rights of participants to refuse answers for a few or allinterview questions were respected. Each participant was given $1.75 US forhis or her time spent in the study.
There were some potential risks to the study participants. HIV-positiveinfant-feeding mothers who have not disclosed their status could have beenrejected by their husbands, physically abused, or divorced. The communitymembers could have breached confidentiality of information discussed inthe focus group. Their participation in the study could have affected theservices they receive from HRH. The nurse counselors’ job might be endan-gered for revealing actions of their health facilities that compromised thequality of infant feeding follow-up visits. These risks were discussed withthe participants, as well as an explanation of how they would be minimized.To reduce these potential risks, the names of participants were coded toprotect identifying information. Written commitments were obtained fromthe participants to respect the confidentiality of the interviews. Interviews
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76 B. A. Woldegiyorgis and J. L. Scherrer
and focus group discussions were conducted in Amharic and tape recorded.Participants were told they could speak without being tape-recordedwhenever they chose. In addition, field notes recording environmentalsetting and verbal and nonverbal information during the interviews weretaken.
Data analysis involved first transcribing the tape recordings of the inter-views and discussions. The Amharic transcripts were then translated intoEnglish and the English translations were analyzed. When the informationfrom different data sources did not agree, the original Amharic transcriptswere consulted either to reconcile contradictions or to present divergentinterpretations. The data were analyzed in five steps as suggested by Ulinet al. (2002). The translated transcripts and field notes were read and rereadcarefully to become familiar with the text. Emerging themes were codedusing informant and researcher concepts. Principal themes and subthemeswere identified through data display. The most essential concepts and rela-tionships were made visible through condensation of the data. Finally,interpretations were made by identifying and explaining core meanings ofthe data, communicating the essential ideas of the participants, and remain-ing faithful to their perspectives. All information obtained in the study wasmaintained on a secure computer that was password protected.
FINDINGS
The Individual Body: Mothers and Replacement Feeding
Three themes around replacement feeding challenges were evident in theinterviews with the mothers. The first theme was that replacement-feedingmothers do not get proper infant feeding counseling. Neglecting otherAFASS criteria, counselors only asked mothers if they could afford to buythe replacement foods. The counseling focused on scaring mothers aboutthe possibility of infecting their infants and favoring the choice of formulafeeding. The mothers were sometimes exposed to conflicting counselingmessages as noted by a mother of three:
A home-care provider advised me to exclusively breastfeed the child for6 months. I began exclusive breastfeeding as per her advice. However,when I went to Referral Hospital, the doctor told me that the infanthad been fed the virus. I was shocked and planned to immediately stopbreastfeeding. In the hospital, the child spent 24 hours without havingany food until the virus he had been sucking was “removed.” After all thevirus is removed from his stomach, I began cow’s milk. (Selam, personalcommunication, March 26, 2009)
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Replacement Feeding Experiences in Ethiopia 77
The mothers were orally informed about replacement feeding but theywere given no demonstration during the counseling. Fathers were notinvolved in infant feeding counseling because they did not accompany themothers and their infants to the counseling room. HIV-positive mothers werenot instructed on preparing for the delivery of their child, by bringing for-mula or cow’s milk and a feeding bottle to replacement feed their infantsafter delivery, resulting in infants waiting long hours until the replacementfood was found in the town. There were no follow-up visits by HRH onhow well, or even if, the replacement-feeding mothers were implementingthe instructions they had been given on replacement feeding.
The second theme that evolved was on the challenges in maintainingreplacement feeding that met AFASS criteria. Economics presented the majorchallenge. Most of the mothers began with formula, but changed to cow’smilk and then to mitin, a gruel-type of substance made from different typesof grains, because that was what they could afford. Other common replace-ment foods identified by the mothers are raw milk, boiled cow’s milk, abishor fenugreek, a soup made from a local plant, and atmit, a gruel made fromone kind of grain. Only one mother was able to feed her infant formulafor 6 months. The others all stopped much sooner, some after only 1 week.An infant feeding counselor noted:
I don’t think mothers sustainably adhere to their feeding choice. Marketsituation and their income do not match. Lots of replacement-fed childrenare malnourished and admitted to the hospital. They get balanced dietin the hospital and recover. When these children go home, motherscannot properly feed them and you see the same child in the therapeuticfeeding center next month. There is a cycle of malnutrition. They goto hospital, get better, go home, and are malnourished and admitted tohospital again. This shows that the mother couldn’t sustainably providereplacement feeds. (Tibebu, personal communication, April 7, 2009)
Some of the reasons for this lack of sustainability include mothers whostayed at home to care for their children and could not go out to earn addi-tional income. Most of the fathers have no regular income to contributetoward purchasing replacement food. As a result, the nutrition of other fam-ily members was neglected because the family’s economic resources wentfor purchasing the replacement food. In addition, sustainability was threat-ened by a policy of providing mothers with infant nutritional support foronly a week or a month at a time at most. A mother of triplets described herdilemma in sustaining her feeding choice:
The counselors told me to exclusively replacement-feed the infants orexclusively breastfeed them. When I and my husband examine it, thisis very useful for one child. However, ours are three and neither of the
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choices was feasible for us. My breast milk will not suffice for three ofthem. We could not afford to buy replacement feed for them. I haven’tthought they will survive. One of them died after 2 months. I suspectit could be due to starvation. Then I was worried about the survival ofthe other two and feed them everything thought to be good for infants.(Tarikua, personal communication, April 3, 2009)
Most of the study mothers overcame these challenges in their replacementfeeding by shifting the nutritional support that they received for themselvesfrom a nongovernmental organization (NGO) to their infants, which resultedin compromising their own health. They also coped by cutting back familyexpenditures, creating additional income sources, and immediately takinginfants to health institutions whenever they became ill.
The third theme that became evident was the mothers’ fears of replace-ment feeding their infants. They have doubts about the nutritional adequacyof their replacement feeding method. Most of the study mothers (5/7) fearedthe possibility that other nursing mothers who could breastfeed their infantswould be HIV-positive, thus exposing their infants to the virus. Almost allmothers (6/7) feared that they did not show love to their infants becausethey replacement fed rather than breastfed them. A mother of one childnoted:
I think I missed a lot due to replacement feeding. I began to worry justas I got pregnant. One day I was exploring my breast and milk began toflow. When I thought that I couldn’t breastfeed my child, I wept for thewhole night. I feel that my child would not love me because I have notbreastfed her. I often ask, “How do I make her know I love her? How doI express my love to my child?” Though I devoted my full time to care forher, I still feel unsatisfied. I don’t think I shared my full love, motherlylove. I feel that my infant has missed something from me, and I missedsomething from my infant. I feel discomfort when I see breastfeedingmothers—a kind of jealously. I want to compensate that gap by cradlingher for long, keeping her clean, and being available around her. But still,I don’t think I have expressed my love to my child. (Beyenech, personalcommunication, March 25, 2009)
Almost all mothers (6/7) worried about the possibility of subjecting theirinfants to disease such as diarrhea, malnutrition, and constipation becauseof replacement feeding. Even though they had these worries, they werehappy about their decision to replacement feed to protect their infants fromHIV infections. Mothers overcame the fears related to replacement feed-ing in many ways. They dealt with fears related to sanitation by preparing,storing, and feeding their infants themselves. They shifted resources thatwere available to feeding their infants. Some borrowed money when they
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Replacement Feeding Experiences in Ethiopia 79
were in need and paid back when they were able. They leaned on their reli-gious beliefs and sought support from family members and their association.An infant feeding counselor discussed Tilla’s program to encourage plannedpregnancies:
The association’s plan is to minimize the number of women who saythey might have got pregnant because their periods have not come.We want them to have planned pregnancy. In reality; however, this isnot happening. They often get pregnancy in casual relationship. Thisunplanned pregnancy leads them to poor adherence. When the childcries, the mother gives infant her breast milk to soothe the child. Whenthe child cries bitterly, it is difficult to think about the virus that is presentin the breast milk. We first think to quiet the child. (Tibebu, personalcommunication, April 7, 2009)
The Social Body: Community Infant Feeding Culture
The customary infant feeding practice in the community is prolonged breast-feeding and early introduction of other foods such as cow’s milk or atmit.Infants also were encouraged to lick fresh butter to build up their strength.Replacement feeding in such a breastfeeding culture exposes the mother’sHIV status to her community. An infant feeding counselor describes howthis happens:
Replacement feeding in breastfeeding culture hints the mothers’ HIVstatus. They ask her why she is not breastfeeding her infant. This isbecause HIV transmission through breastfeeding is widely disseminated.The community also knows that HIV-positive mothers are often advisedto replacement feed their infants. As a result, they immediately con-clude that the mother is HIV-positive. Unless she disclosed her status,the practice of replacement feeding in breastfeeding community posesmany challenges to the mother. (Woinhareg, personal communication,April 9, 2009)
Infants are fed abish in early infancy. It is the most common infantfood identified by all mothers. They either bottle-feed infants or feed themfrom their hands to get them full. The community expects mothers to feedtheir infants both abish and breast milk. Traditional medications that arecommon in the town are also used by replacement-feeding mothers to healsome infant diseases. Among these medications are komomela, which isbelieved to wash infants’ intestines; fiancho, which is believed to heal theincompatibility between children’s bodies and cow’s milk; and qacha, whichis believed to heal the evil eye. Other grains, cooked with water and then fedwith a spoon or finger to the newborn, such as amessa, tena’adam, anamro
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and extracts of cooked rue, are used for prelacteal feeding. The communityinfluences these mothers to use such foods that could compromise the healthof replacement fed infants.
All mothers reported that the community was aware that HIV couldbe transmitted through breastfeeding. The community expectation was thatHIV-positive mothers choose replacement feeding for their infants even ifAFASS criteria are not met. Consequently, two study mothers stopped breast-feeding after a few days. A mother who chose formula feeding for her infantnoted:
The community expects HIV-positive mothers to replacement feed theirinfants. I don’t know why some mothers breastfeed. The communityopposes breastfeeding by HIV-positive mothers. They say, “Since thesemothers are not compassionate for their own infants, they will not becompassionate for us.” Our neighbors tell me how the community dis-likes breastfeeding HIV-positive mothers. They think she is killing thepoor child. (Wosene, personal communication, March 27, 2009)
The meaning attached to the practice of prolonged breastfeeding is thatit makes infants stronger, healthier, and faster in development, and should beconsidered the only infant food. All of the mothers reported that they fearedtheir replacement-fed children are denied these advantages. The communityattached negative meanings to replacement feeding practices, and identi-fied mothers who used replacement feeding as being irresponsible. Suchnegative meanings include: mother’s opposition to the ideals of good moth-erhood, dislike of the child, desire to kill the child, selfishness for theirown health, greater concern for their body shape, engagement in extramar-ital affairs, desire for adultery, and/or desire to maintain breast beauty. Thecommunity accepted replacement feeding when the mother revealed herHIV-positive status, had breast disease, or was not allowed to breastfeed bydoctors. In these cases, mothers were seen as sacrificing an essential func-tion of motherhood for the welfare of their infants. Replacement-feedingmothers developed several ways to cope with the influences of the socialbody. They focused on the health gains of their infants while disclosing theirHIV-positive status to the community. They openly rejected some harmfulinfant feeding practices and became selective in the use of traditional prac-tices. Finally, they explained the reason behind their not breastfeeding, andcorrected misconceptions.
The Body Politic: Persons Around the Mother and HealthCare Systems
Especially during their confinement period right after giving birth,replacement-feeding mothers faced pressure to breastfeed from their
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Replacement Feeding Experiences in Ethiopia 81
husbands, mothers, and mother-in-laws. Friends and neighbors also pres-sured them to breastfeed, although not as intensely as their immediatefamily members pressured them. Two out of the seven mothers interviewedreported no such pressures. A mother of four children commented on thepressure to breastfeed:
Some of my friends and neighbors pressure me to breastfeed. One of myfriends saw my financial crisis and asked me to breastfeed. She knowsthat my husband is laid off from job and she sees how I am overwhelmedwith the problem. I have to pay for milk rental, house rent, sending chil-dren to school, and the household food consumption with the meagersalary. She tells me that I wouldn’t have faced such stress if I had breast-fed my child. Though the advice is from good will, it often disturbs me.Then I told her not to come with such proposal and disturb me that way.(Wosene, personal communication, March 27, 2009)
All mothers reported that health care counselors ask whether they can affordto buy replacement foods, and sustain their choice, as a precondition topracticing replacement feeding. If they could not afford replacement food,they were counseled to exclusively breastfeed for 6 months. The counselorsproposed infant formula as the most suitable infant food, followed by cow’smilk. The majority of the mothers (5/7) started replacement feeding withoutbeing able to afford it because of their fear of HIV transmission throughbreastfeeding.
Because health care counselors do not demonstrate formula prepa-ration, replacement-feeding mothers prepare it either by reading theinstructions on the container or by trial and error. All counselors indicatedthat there is no replacement-feeding support to needy mothers from thehospital, nor is there a system of referring them to organizations providingsupport. Nonetheless, they believe access to replacement feeding will solvemost of the problems, as noted by one counselor, who compared formulato khat and replacement feeding to ketema:
If formula is affordable and accessible, I think the major problem issolved. In the absence of formula, teaching about it is meaningless. Thebig challenge is making it available. If it is available, the rest thingsare easier. If someone invites you [to chew] khat (somewhat expensiveleaves with a mild narcotic quality) it is easier for you to come withketema (sedge, a cheap kind of grass) which is to be scattered on thefloor to make the khat chewing ceremony attractive. Ten cents ketemais easier. If replacement feeds are made available, mothers’ responsiblyrespond to it. I often saw them want to be committed to their infants.(Tibebu, personal communication, April 7, 2009)
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82 B. A. Woldegiyorgis and J. L. Scherrer
The majority of the mothers (6/7) introduced complimentary foodsat 6 months, as instructed by the counselors. However, most counselors(3/4) believed that few mothers actually introduce complimentary feedingat 6 months. Although counselors advised mothers to feed infants with fiveor more meals per day, mothers could not do this because of the cost.Counselors tell replacement-feeding mothers to give infants diversified dietsconsisting of at least five kinds of foods to keep them healthy and growingwell. However, economic problems have severely limited their ability to doso. Two counselors said these mothers can provide infants with this dietarydiversity and denied that it would be costly.
The interviewed replacement-feeding mothers noted that they copedwith the pressures from the body politic through several avenues. Theydisclosed their HIV- positive status and involved their husbands in infant-feeding counseling. One replacement-feeding mother indicated that shegave socially acceptable reasons for replacement feeding, and one reliedon God as well as disclosure. They generally did their best to comply withcounselors’ instructions on replacement feeding despite the challenges thatconfronted them. In addition, HIV-positive mothers clarified misconceptions,and became selective about following the advice they received. Finally, theyparticipated in income-generating activities to become self-sufficient, andsought peer advice and legal support from their association.
DISCUSSION
In reflecting on the findings as related to the individual body taken from theframework, replacement-feeding mothers received inadequate counselingon infant feeding. Although WHO (2010) recommended that prioritization ofprevention of HIV transmission should be balanced with meeting the nutri-tional requirements and protection of infants against non-HIV morbidity andmortality, counselors’ bias of favoring replacement feeding and mothers’ fearof infecting their children through breastfeeding strongly influence mothers’choice of replacement feeding. These mothers were also exposed to con-flicting messages from health care workers and home-based care providers,and this further eroded their confidence in breastfeeding.
Results indicate that there is no proper AFASS assessment, a finding sup-ported by Koricho (2008). Even so, nurse counselors promote replacementfeeding using WHO 2001 guidelines. However, new guidelines (WHO, 2010)note that with current knowledge and technology, most cases of postnatalmother-to-child-transmission of HIV are preventable through antiretroviral(ARV) drugs and modifications in infant feeding practices As a result,exclusive breastfeeding becomes the recommended first choice.
The findings suggest that most of the mothers face a number of chal-lenges in implementing their replacement feeding intentions. Because most
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Replacement Feeding Experiences in Ethiopia 83
of the mothers did not make prearrangements for their delivery day, theyfound it difficult in the labor ward both to soothe their infants who were cry-ing for breast milk and to reassure neighbors who were pressuring them tobreastfeed. The prohibitive cost of formula and its preparation, and the dif-ficulty of modifying cow’s milk and maintaining nutritional adequacy withgruel were problematic for these mothers. The hospital provided no freeor subsidized formula to needy mothers, nor did it refer them to supportorganizations. Consequently, infants were at high risk for malnutrition andserious illnesses. Problems related to implementing replacement feeding inthis study are similar to those found in other studies (Koniz-Booher et al.,2004; Koricho, 2008; Leshabari, 2007). The WHO 2001guidelines thus pre-sented requirements that could not be met economically or socially, eventhough they succeeded in bringing about a social ideal of what should beachieved. As a result, the individual body came into conflict with the socialbody and the body politic, resulting in half measures (mixed feeding) thatonly made matters worse (Moland et al., 2010).
Most of the study mothers overcame these challenges in their replace-ment feeding by shifting the nutritional support given to them by NGOs totheir infants, thus compromising their own health, cutting back family expen-ditures, creating additional income sources, and immediately taking infantsto health institutions. Mothers who want to remain firm in their decisionto replacement-feed did not get support and follow up from the health caresystem. Counselors had no feedback on how the mothers implemented theirfeeding decisions unless the infants were sick and brought to the hospital.There was no formula support or referral of mothers to supporting organiza-tions. Contrary to these findings, other studies show that mothers generallyreceived ongoing advice and support on their practice of infant feeding(Koniz-Booher et al., 2004; Matovu et al., 2002; WHO, 2010). Guidelinesfor providing support through grandmothers and men in the families ofHIV-positive nursing mothers have not been provided in any of the WHOpublications (Aubel, 2011). This oversight misses an important element inensuring that infants are nutritionally and healthily fed. Mothers have fearssurrounding their replacement feeding. They are worried about the sustain-ability of the foods, their nutritional adequacy, loss of emotional bonds, andthe subsequent exposure of their infants to childhood illnesses. Such moth-ers’ concerns are reflected in other studies, as well (Koricho, 2008; WHO,2003). Study mothers have no fear of disclosing their status and feedingmethod. They received the courage to disclose from the counseling in theirassociations, peer support, participation in trainings and workshops, andsecuring some income. This is in contrast to other studies that showed thatHIV-positive women fear disclosure due to subsequent negative responses(Leshabari, 2007; Njunga, 2008).
In reflecting on the findings as related to the social body taken fromthe framework, the infant feeding culture is prolonged breastfeeding for as
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84 B. A. Woldegiyorgis and J. L. Scherrer
long as 3 years with early introduction of supplements. HIV-positive moth-ers managed the social pressure of this customary breastfeeding practiceby disclosing their HIV positive status and making it their priority to havean HIV-negative child. This prioritizing of the infant’s health agrees withwhat Nyblade et al. (2000) found in Botswana. However, it disagrees withmore recent WHO (2010) guidelines and the results of more recent studiesthat indicate prolonged exclusive breastfeeding enhances the health of theinfant, even when the mother is HIV-positive (Aubel, 2011; Moland et al.,2010).
The findings suggested that replacement-feeding mothers were dis-turbed by the social meanings attached to breastfeeding, namely thatbreastfed children will be healthier and stronger, have faster development,and have brighter minds; nonbreastfed children would not have the advan-tage of breast milk and, consequently, would be subjected to diseases.Leshabari (2007), Koricho (2008) and Sevelius (2011) found similar atti-tudes. The findings suggested that the study mothers were selective in theirchoices of traditional medications even though the community thought thatall traditional medications were better cures, have no side effects, and arecheaper and easily accessible. This finding differs from Njunga (2008), prob-ably reflecting the study mothers’ greater access to trainings, workshops,and other information regarding the use of medications. Even so, the useof medications amounted to mixed feeding of the infants. Mixed feedingenhances the possibility of HIV infection of the infants, because their imma-ture stomachs cannot handle the food being used. This results in lesionsor sores in the lining of their stomachs, which present ideal places for HIVinfection (Moland et al., 2010).
In reflecting on the findings as related to the body politic taken from theframework, most of the replacement-feeding mothers are trapped betweentwo competing control efforts. In their home environment, their feedingmethod is under the surveillance of their partners, their mothers, mothers-in-law, and friends. Outside of the home environment, there are the dosand don’ts of the hospital staff attempting to conform to the WHO 2001infant feeding recommendations. HIV-positive mothers reduce the pres-sure in the home environment through disclosure, a finding that supportsMulugeta’s (2008) research. However, they could not comply with the con-ditions of AFASS largely due to their economic situation. These controlefforts of mothers’ infant feeding practices are consistent with Aubel (2011).However, these social pressures are usually viewed to be sources of prob-lems for the HIV-positive mother in making her decisions about how tofeed her infant. The individual body then is in conflict with the social body.Because the pressures from the social body do not always conform to therecommendations of the body politic, all three bodies then conflict witheach other. What should be a supportive environment becomes a conflictive,nonsupportive one.
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Replacement Feeding Experiences in Ethiopia 85
IMPLICATIONS FOR SOCIAL WORK AND SOCIAL DEVLOPMENT
The Three Bodies Model of Scheper-Hughes and Lock (1987) illustratesthe interaction between the individual, family, community, social, and cul-tural influences. Although the bodies have definite boundaries, they cometogether in influencing decisions people make that affect their welfare andthat of those who depend upon them. Social workers who work with clientsat these decision points must take into account this interaction among thebodies, and their impact on the decision, and work with all three to bringthem into harmony with each other.
As this study illustrates, social workers cannot just focus on the individ-ual body in providing services because the influence of the other two bodiescould negate all social work progress with their clients. In the case of HIV-positive mothers of newborns, these three bodies come closer into harmonywith each other when mothers are able to disclose their HIV-positive statusopenly. Only the health care system of the body politic remains nonalignedwith the rest of the body politic, all of the social body, and all of the individ-ual body. If the health care system better harmonized with the other bodies,ARVs would be available to the HIV-positive mothers and, where not avail-able, AFASS criteria would be seriously considered before recommendingthe mothers replacement feed their infants. Although both the individualbodies and the social body attempted to compensate for the inadequacies ofthe body politic, they could not fully achieve that goal. As a result, infantsremained unacceptably exposed to HIV infection and/or to malnutrition ordisease.
Both the mothers and the key informants seemed aware of the necessityfor the harmonious interactions between the three bodies. The interviewswith the counselors revealed their lack of awareness of the need for the threebodies to work together to address this particular issue. Although a lack ofresources was a factor, the use of outdated WHO guidelines and the failureto fully explore whether AFASS criteria were present before recommendingreplacement feeding had the effect of enhancing the risks to the infants ofinfection, starvation and even death.
Non-Ethiopian funders of HIV/AIDS programs should remember that itwould not be enough to simply provide ARVs to HIV-positive mothers withinfants. They also need to address the attitudes, beliefs, and practices offamily and community members that will affect the efficacy of appropriatelyusing the drugs. They need to ensure that counselors are not only trained inthe administration of the drug, but also in working with the cultural beliefsand social pressures that HIV-positive mother’s experience. It is also impor-tant to remember that, although self-disclosure of HIV-positive status had apositive effect for the women in this study, such would not necessarily bethe case in other communities, cultures, or societies. Funders and managersof HIV/AIDS programs should have direct and intimate knowledge of the
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86 B. A. Woldegiyorgis and J. L. Scherrer
social and cultural context in which the recipients of their services live andadjust the services accordingly.
CONCLUSION
This study used the Three Bodies Model to examine how individual,sociocultural, familial, and medical factors interacted to affect decisions HIV-positive mothers made on whether to breastfeed or replacement feed theirinfants. It found that self-disclosure of one’s positive HIV status had theresult of realigning social, cultural, community, family, and individual influ-ences from one of being critical of the mother to one of being supportive ofher efforts to ensure the safety of her infant. It also found that breastfeedingcounselors were using outdated guidelines that had been found, throughresearch, to actually be harmful to the infant. The recommendations fromthese counselors hence often ran counter to the beliefs of the family andcommunity surrounding the HIV-positive mother, leading her to engage inpractices that were more threatening to the well-being of her infant. Thus,the conflict within the social body led to harmful actions on the part of theindividual body. The importance of working with all three bodies simultane-ously to achieve better health for infants born to HIV-positive mothers wasemphasized along with recommendations on ways to achieve that.
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