Socio-demographic characteristics of respondents
A total of 432 respondents were involved with 100% response rate. Their mean age was 28.38 years with a standard deviation ±4.61 years. More than one fourth (29.2%) and half (50.7%) of the participants were less than 25 years old and had attended primary school respectively. Majority of the participants were Amhara (83.6%) by ethnicity and orthodox (83.8%) by religion. One hundred twenty (27.8%) of the respondents were economically dependent. Regarding occupational status, 140 (32.4%) and 159 (36.8%) of the participants were daily laborer and housewife respectively (Table 1).
*** Table 1***
Frequency distribution of selected explanatory variables
Majority (88.2%), (89.4%) and (85%) of the respondents had antenatal care follow-up, heard about exclusive breast feeding and disclosed their HIV status either to their husband, mother, or any close friends respectively. Almost two-third (64.6%) of the participants had good knowledge about exclusive breast feeding (Table 2).
Practice of EBF
Majority (89.8%) of HIV positive mothers were practicing exclusive breast feeding. Only14 (3.2%) of the participants were feeding their child exclusive formula feeding. their reasons were fear of HIV virus transmission or had doubt on transmission even with ART (Figure 1). Exclusive breast feeding practice among HIV positive mothers who had previous information about EBF was 94.7%, while it was 54.7% among mothers who had not previous information. Huge difference in EBF practice was seen between mothers who walked short and long distance from home to workplace. For instance, among mothers who walked less than 30 minutes it was 96.8%, however, it was 80.2% among mothers who walked more than 30 minutes. About 97.3% of HIV positive mothers who attended primary school practiced EBF. But, only 42% of HIV positive mothers who had no formal education practiced EBF.
Determinants of exclusive breast feeding
We found that having information/awareness about EBF, time to go/distance from home to work place, disclosing HIV status, place of residence, living with mother/mother in law, knowledge on EBF, maternal education, and ANC follow up had statistically significant association with EBF among HIV positive mothers. More specifically, compared to mothers who had previous awareness about EBF, mother who had no information were 98% less likely to practice EBF. (aOR=0.02, 95% CI; 0.01, 0.12).
Time taken to go from home to work place also had significant association with EBF practice. In fact, the result showed the odd of EBF practice among HIV positive mothers who traveled from home to their work place in less than 30 minute were about 5 times (aOR=4.96, 95% CI; 1.17, 20.95) higher as compared to mother who traveled more than 30 minutes and above.
Another factor that had significant association with EBF practice was disclosing of HIV status. Compared to mothers who disclosed their HIV status, EBF practice among mothers who are not disclosed their HIV status were lower by 91% (aOR=0.09, 95% CI; 0.02, 0.37)..
Place of residence had significant association with EBF practice. In fact, the finding shows, the odd of EBF practice among HIV positive mothers living in urban setting were 5.3 times (aOR=5.37, 95% CI; 1.12, 25.77) higher as compared to their counterparts.
The finding from the current study showed, living with mother/mother in-law had significant association with practice of EBF among HIV positive mothers. Compared to HIV positive mothers living either with their mother or mother in law, the odd of EBF practice were 6 times (aOR=6.03, 95% CI; 1.26, 28.86) higher among HIV positive mothers who were living alone.
Knowledge related to EBF also had significant association with EBF practice. In fact, the present study shows EBF practice among HIV positive mothers who had poor knowledge regarding EBF were lower by 94% (aOR=0.06, 95% CI; 0.01, 0.34) as compared to mother who had good knowledge.
Maternal educational level had significant association with EBF practice among HIV positive mothers. Compared to HIV positive mothers who were attended secondary school and above, EBF practice among HIV positive mothers who had no formal education were lower by 93% (aOR=0.07, 95% CI; 0.01, 0.48).
ANC follow up had significant association with EBF. The finding from the present study showed EBF practice among HIV positive mothers who had no ANC follow up were lower by 90% (aOR=0.10, 95% CI; 0.02, 0.55) as compared to mothers who had ANC follow up (Table 3).
*** Table 3***
Socio-demographic characteristics of the participants
A total of eighteen female and twenty seven male participants were involved in the qualitative study. Twenty five respondents whose age ranges from 28 to 40 years and who were not participated in quantitative study were involved for the in-depth interview. About fifteen of the IDI participants had no formal education, the rest eight and two participants were attended primary and secondary schools respectively. While, seven of them were from the rural residents, eighteen were livening in urban area.
Thematic areas identified during the analysis
Different concepts about EBF practice were raised both from IDI and FGD participants. After familiarized and coded it, themes were formed. Then those themes were reviewed for its accuracy as the concepts of their original meaning. Finally those themes were defined, named and written as the followings.
Habit of EBF
Participants in FGD reported that breast feeding are practicing both by HIV positive and HIV negative mothers but better among HIV positive mothers in the town. A 29 years old woreda HIV officer explained:
“I stayed for more than 3 years in this town and I understood two different points from what I am looking and report I found from health facilities. The first is, among the general population or both among HIV positive and HIV negative mothers, the practice is nearly similar. What I said this is, even if the practice seemed a little increased among some group of the population like rural setting related to expansion of education and health facilities, as well as media exposure as compared to previous years, still I have seen mothers living in urban setting ignoring breast feeding for fear of disfigurement in their physical shape, modernization and considering formula feeding as an indicator of rich family and breast milk for the poor. However, among HIV positive mothers I believed it is better as compared to HIV negative mothers” [FGD 1].
Awareness about EBF
The participants stated that majority of the mothers in the town practice exclusive breast feeding. However, few mothers may not strictly feed as recommended. This might be either related to illness, or work related challenges and awareness problems.
“I shared my friends’ idea. With few exception most of the mothers feed their baby exclusively. Since it is town mothers got information from health professionals in their ANC follow up or delivery or they may exposed for media directly or indirectly. Not only that, most of them attended a minimum of primary school. But those who lived in rural area may not have media exposure as urban residents” [FGD 2].
The FGD participants described that HIV positive mothers are highly sensitive to make their child safe or free and they apply what health professionals’ advice. Despite majority mothers accept HCWs advice and feed exclusively, still some mothers completely avoid breast feeding. The main reason could be due to poor counseling during their ANC, they may become confused about HIV virus transmission to their child and prefer to use exclusive formula feeding or giving other food and cow milk instead.
“I know one mother not want to breast feed her child exclusively due to fear of HIV transmission. Even if I counseled her several times about risk and benefit of both option, she can’t believe it and choice feeding formula feeding or even cow milk with known risks like diarrheal disease and malnutrition”. [FGD 2]
Non-disclosure of HIV status
The society’s perception can substantially affect HIV positive mothers to apply mixed feeding especially in rural area. The societies are highly interconnected socially. Particularly, mothers who are not disclosed their HIV status commonly practice mixed feeding. This could be by two main reasons; one by fearing social discrimination and stigma and the second is due to fearing of divorce and its consequence such as lack of social support and family disintegration. A 39 year Woreda HIV officer explained:
I see this idea by two point of view. The first is, if they believe they their husband can’t accept this truth, divorcing is inevitable and very complicated economic and social crisis they will face, they may choice keeping it as secret and praying to God or Allah to be free of their child with mixed feeding. The other point is, if they believed their husband infected them, disclosing may not reach to this level, they can economically survive by themselves, shoulder social discrimination and prioritized their baby, they decided to disclose their HIV status. Whatever it is, I believed disclosing for their husband or mother or their close friend can hugely support them to practice EBF as I looked from my experience”.
Pressure from mother/mother-in-law
Mothers participated in-depth interview reported that the pressure from mother in-law and other members of family including the husband can highly affect in the choice of infant feeding either during the starting or persistent of EBF. A 23 years old mother explained: “I had antenatal care follow up and the health professionals were counseled me about feeding. However, both my husband and my mother in-law were not volunteered to feed only my breast. They told me that not for mother who delivered for the first time, breast milk is not enough for mothers who had many children also and I decided to give water and other fluid” [IDI 1].