Replacement Feeding Experiences of HIV


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Replacement Feeding Experiences of HIV-Positive Mothers in Ethiopia Bogale Abera Woldegiyorgis a & James L. Scherrer b a Hawassa College of Teacher Education, Hawassa, Ethiopia b Graduate School of Social Work, Dominican University, River Forest, Illinois, USA Version of record first published: 12 Mar 2012.

To cite this article: Bogale Abera Woldegiyorgis & James L. Scherrer (2012): Replacement Feeding Experiences 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, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 1070-5422 print/1543-3706 online DOI: 10.1080/10705422.2012.648123


Replacement Feeding Experiences of HIV-Positive Mothers in Ethiopia

BOGALE ABERA WOLDEGIYORGIS Hawassa College of Teacher Education, Hawassa, Ethiopia

JAMES L. SCHERRER Graduate 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 unless replacement foods meet the criteria of acceptability, feasibility, affordability, sustainability, and safety (AFASS). However, the fear of HIV transmission through breastfeeding has pressured these mothers into choosing replacement feeding whether they meet AFASS criteria or not. This choice has subjected infants to malnutrition and related deaths. This qualitative study is based on Scheper-Hughes and Lock’s (1987) Three Bodies Model. Discussions were carried out in a Prevention of Mother-to-Child Transmission Program (PMTCT) in Hawassa, Ethiopia using in-depth interviews, key informant interviews and focus groups. The study focused on the challenges that HIV positive mothers face due to inadequate counseling services, poor economic situations, and lack of support and follow up. The Three Bodies Model exposes the deficits in the comprehensive delivery of services by PMTCT pro- grams. Implications for social work practice and funding policies are 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 Ababa University, School of Social Work.

Address correspondence to Bogale Abera Woldegiyorgis, Hawassa College of Teacher Education, P.O. Box 115, SNNPR, Hawassa, Ethiopia. E-mail: [email protected]


70 B. A. Woldegiyorgis and J. L. Scherrer

The emergence of the human immunodeficiency virus (HIV) epidemic in the past few decades threatened breastfeeding as a safe and healthy method of feeding infants in economically distressed parts of the world. The World Health Organization (WHO) Update (2007b) recommended that HIV-positive mothers 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-positive mothers often choose replacement feeding whether or not AFASS criteria are met, because they fear transmitting the HIV virus to their infants through their breast milk. When AFASS criteria are not met, infants are subjected to malnutrition, infections, and diseases that may result in death. The purpose of this study is to assess the difficulties in replacement feeding experiences faced by HIV-positive mothers enrolled in the prevention of mother-to-child transmission (PMTCT) program in Hawassa, Ethiopia. The study aims to know the challenges HIV-positive mothers faced in their infant feeding experience, how community infant feeding practices and social meanings influence feeding choice, and how replacement-feeding mothers feel about the 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. The interviews were transcribed and analyzed to discover common influences on HIV-positive mothers’ decisions to breastfeed, replacement feed, or mix feed their infants. In addition, common themes about support and information provided to them were explored. The implications for future social work community practice are examined and courses of action recommended.


Feeding options for infants of HIV-positive mothers are either exclusive replacement feeding or exclusive breastfeeding (Koniz-Booher, Burkhalter, de Wagt, Iliff, & Willumsen, 2004). However, both feeding options involve risks to child health and survival. Although exclusive breastfeeding is more practical, it has a 5% to 15% chance of transmitting HIV to infants (Israel & Kroeger, 2003). This incident rate of mother-to-child transmission could be reduced through drug intervention, and an awareness of precautions such as minimizing the duration of breastfeeding (WHO, 2003). Exclusive replacement feeding is an ideal option, because there is no chance of HIV transmission. However, it is difficult to apply in resource-limited nations, where exclusively replacement fed infants have a six-fold increased risk of dying in the first 2 months of life, compared with those who were breastfed (WHO, 2008).

Replacement Feeding Experiences in Ethiopia 71

Over 530,000 new cases of pediatric HIV infection occur each year throughout 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 in such settings can safely provide formula to their infants so that they can avoid breastfeeding. In resource-limited settings, however, alternatives to breastfeeding do not usually meet the requirements of AFASS for many HIV- infected women. HIV-positive mothers tend to overestimate that all breastfed babies will be HIV-infected. As a result, they exclusively replacement feed their infants, even though AFASS criteria are not met (Koniz-Booher et al., 2004). A study in Tanzania showed that replacement feeding is rare in a breastfeeding culture, because the community believes that infants cannot survive without breast milk (Leshabari, Blystad, & Moland, 2007). Thus, exclusive replacement feeding in early infancy violates the rules of good motherhood. Those who practice it are considered failures as mothers. As a result, the community pressures HIV-positive mothers to mix breastfeeding with replacement feeding.

Replacement feeding also has some negative socially constructed mean- ings (Leshabari et al., 2007). Replacement-feeding mothers are thought to be concerned more about their body shape than child rearing, and to engage in extramarital affairs, or to be HIV positive. Njunga’s (2008) study in Malawi recommended that PMTCT programs should take into consideration the spectrum of such cultural factors that influence experiences, behav- ior, and attitudes (Sevelius, 2011). Partners and/or family members of the replacement-feeding mothers may attempt to exert control over her feeding method (Koniz-Booher et al., 2004). Unless partners and family members are involved in the infant feeding decision, adherence to replacement feeding will be challenging (Aubel, 2011). These mothers also face the challenge pre- sented to them by rapidly changing recommendations from WHO (Moland et al., 2010). The WHO (2001) guidelines recommend that mothers meet AFASS 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 exclusively breastfeed their infants. These guidelines were in effect until 2007, when WHO 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 the mothers themselves, healthy. Current guidelines differ significantly from those of 2001, yet many postnatal counselors have been trained only to the 2001guidelines (Moland et al., 2010; WHO, 2010).

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