CoChat
Sign Up
Cited by 3HIV/AIDS Research and InterventionsBreastfeeding Practices and InfluencesGlobal Maternal and Child Health

The DOI matches its Crossref record.

Infant feeding knowledge and practice vary by maternal HIV status: a nested cohort study in rural South Africa

Open access
Yapa, H. Manisha, Drayne, Róisín, Klein, Nigel, De Neve, Jan-Walter, Petoumenos, Kathy, Jiamsakul, Awachana, Herbst, Carina, Pillay, Deenan, Post, Frank A., Bärnighausen, Till·2020·International Breastfeeding Journal
DOI 10.1186/s13006-020-00317-5PMC PMC7466779
Open this paper in CoChat — free accountOpen PDF

Abstract

BACKGROUND: We investigate whether correct infant feeding knowledge and practice differ by maternal HIV status in an era of evolving clinical guidelines in rural South Africa. METHODS: This cohort study was nested within the MONARCH stepped-wedge cluster-randomised controlled trial ( www.clinicaltrials.gov : NCT02626351 ) which tested the impact of continuous quality improvement on antenatal care quality at seven primary care clinics in KwaZulu-Natal, from July 2015 to January 2017. Women aged ≥18 years at delivery were followed up to 6 weeks postpartum. Clinical data were sourced from routine medical records at delivery. Structured interviews at early postnatal visits and the 6-week postnatal immunisation visit provided data on infant feeding knowledge and feeding practices respectively. We measured the relationship between maternal HIV status and (i) correct infant feeding knowledge at the early postnatal visit; and (ii) infant feeding practice at 6 weeks, using Poisson and multinomial regression models, respectively. RESULTS: We analysed data from 1693 women with early postnatal and 471 with 6-week postnatal interviews. HIV prevalence was 47% (95% confidence interval [CI] 42, 52%). Women living with HIV were more knowledgeable than women not living with HIV on correct infant feeding recommendations (adjusted risk ratio, aRR, 1.08, p < 0.001). More women living with HIV (33%; 95% CI 26, 41%) were not breastfeeding than women not living with HIV (15%; 95% CI 11, 21%). However, among women who were currently breastfeeding their infants, fewer women living with HIV (5%; 95% CI 2, 9%) mixed fed their babies than women not living with HIV (21%; 95% CI 14, 32%). In adjusted analyses, women living with HIV were more likely to avoid breastfeeding (adjusted relative risk ratio, aRRR, 2.78, p < 0.001) and less likely to mixed feed (aRRR 0.22, p < 0.001) than women not living with HIV. CONCLUSIONS: Many mothers in rural South Africa still do not practice exclusive breastfeeding. Women living with HIV were more knowledgeable but had lower overall uptake of breastfeeding, compared with women not living with HIV. Women living with HIV were also more likely to practice exclusive breastfeeding over mixed feeding if currently breastfeeding. Improved approaches are needed to increase awareness of correct infant feeding and exclusive breastfeeding uptake.

Overview

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1186/s13006-020-00317-5

Cites

Statistics

Verification

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Yapa et al. (2020) randomly switched clusters from control to intervention on pre-specified dates in a random sequence, with investigators and clusters blinded to randomization until 2 weeks prior to each step.

    “Clusters were randomly switched from control to intervention on pre-specified dates in a random sequence. Investigators and clusters were blinded to randomization until 2 weeks prior to each step”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [55]

    The Abstract (Methods) says this cohort study was nested within the MONARCH stepped-wedge cluster-randomised trial, supporting the general description of a cluster-randomised intervention. The Methods (Study design) says trial details are reported elsewhere; this paper does not specify pre-set switch dates, the sequence of switching, or blinding until two weeks before each step. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Yapa et al. (2020) used eight steps in the stepped wedge design.

    “8”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [55]

    The Methods (Study design; page unavailable) say the cohort was nested within a stepped-wedge cluster-randomised trial at seven clinics. Our copy does not specify eight steps in that design; it directs readers elsewhere for details of the parent trial. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Yapa et al. (2020) selected the stepped-wedge design for pragmatic and ethical reasons to ensure all clinics eventually received the intervention.

    “The stepped-wedge design was selected for both pragmatic and ethical reasons to ensure that all clinics eventually received the intervention, which aimed to improve the quality of antenatal HIV care in primary care clinics.”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [55]

    The Methods (Study design; page unavailable) identify the parent MONARCH trial as stepped-wedge and describe its intervention at seven primary care clinics. The Background says the intervention aimed to improve antenatal HIV services, but our copy does not state that the design was chosen for pragmatic or ethical reasons, or to ensure every clinic eventually received the intervention. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Yapa et al. (2020) calculated power assuming 40% of pregnant women living with HIV would receive a viral load test and 65% of pregnant women not living with HIV would receive a repeat HIV test without the intervention, estimating 80% power to detect at least a 15-percentage-point increase, assuming an ICC of 0.10 and 15% missing data.

    “The power calculation assumed that 40% of pregnant women living with HIV would receive a test for viral load (VL) monitoring and 65% of pregnant women not living with HIV would receive a repeat HIV test without the CQI intervention. They estimated 80% power to detect at least a 15-percentage-point increase in the primary endpoints at the 5% significance level, assuming an intracluster correlation”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [55]

    The Background identifies viral-load monitoring and repeat HIV testing as the parent trial’s primary endpoints. It does not give the claimed baseline assumptions, 80% power, 15-percentage-point effect, intracluster correlation, or missing-data allowance; the Methods say details of the parent trial are reported elsewhere. Searches for the power calculation and its figures found no supporting passage in this paper. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Yapa et al. (2020) included seven clusters (public-sector primary care clinics).

    “7 public-sector primary care clinics”

    From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [55]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Citations

Cites

No references could be resolved yet.

Research works printed but not linked: 38

  1. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol. 2004;554:63–77. · DOI
  2. Bar S, Milanaik R, Adesman A. Long-term neurodevelopmental benefits of breastfeeding. Curr Opin Pediatr. 2016;28:559–66. · DOI
  3. Victora CG, Vaughan JP, Lombardi C, Fuchs SMC, Gigante LP, Smith PG, et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet. 1987;2:319–22. · DOI
  4. Coovadia HM, Rollins NC, Bland RM, Little K, Coutsoudis A, Bennish ML, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study. Lancet. 2007;369:1107–16. · DOI
  5. Warszawski J, Tubiana R, Le Chenadec J, Blanche S, Teglas JP, Dollfus C, et al. Mother-to-child HIV transmission despite antiretroviral therapy in the ANRS French perinatal cohort. AIDS. 2008;22:289–99. · DOI
  6. Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS. 2005;19:699–708. · DOI
  7. Van De Perre P, Rubbo P-A, Viljoen J, Nagot N, Tylleskar T, Lepage P, et al. HIV-1 Reservoirs in Breast Milk and Challenges to Elimination of Breast-Feeding Transmission of HIV-1. Sci Transl Med. 2012;4:143sr143. · DOI
  8. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;8:CD003517.
  9. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio child survival study group: how many child deaths can we prevent this year? Lancet. 2003;362:65–71. · DOI · Paper page
  10. Tchakoute CT, Sainani KL, Osawe S, Datong P, Kiravu A, Rosenthal KL, et al. Breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity in the Option B+ era. AIDS. 2018;32:2383–91. · DOI
  11. National Department of Health South Africa. The Tshwane declaration of support for breastfeeding in South Africa. South Afr J Clin Nutr. 2011;24:214.
  12. du Plessis L, Peer N, Honikman S, English R. Breastfeeding in South Africa: are we making progress? In: Padarath A, King J, Mackie E, Casciola J, editors. South African Health Review. Durban: Health Systems Trust; 2016. p. 109-24.
  13. National Department of Health South Africa. Infant and young child feeding policy. Pretoria: National Department of Health; 2013.
  14. National Department of Health South Africa. National Consolidated Guidelines for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the Management of HIV in Children, Adolescents and Adults. Pretoria: National Department of Health; 2015.
  15. National Department of Health South Africa. Implementation of the Universal Test and Treat strategy for HIV positive patients and differentiated care for stable patients. Pretoria: National Department of Health South Africa; 2016.
  16. Mnyani CN, Tait CL, Armstrong J, Blaauw D, Chersich MF, Buchmann EJ, et al. Infant feeding knowledge, perceptions and practices among women with and without HIV in Johannesburg, South Africa: a survey in healthcare facilities. Int Breastfeed J. 2017;12:17. · DOI
  17. Horwood C, Haskins L, Engebretsen IM, Phakathi S, Connolly C, Coutsoudis A, et al. Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now? BMC Public Health. 2018;18:757. · DOI
  18. Bork K, Cames C, Cournil A, Musyoka F, Ayassou K, Naidu K, et al. Infant feeding modes and determinants among HIV-1– infected African women in the Kesho Bora study. J Acquir Immune Defic Syndr. 2013;62:109–18. · DOI
  19. Somé EN, Engebretsen IMS, Nagot N, Meda N, Lombard C, Vallo R, et al. Breastfeeding patterns and its determinants among mothers living with Human Immuno-deficiency Virus −1 in four African countries participating in the ANRS 12174 trial. Int Breastfeed J. 2017;12:22. · DOI
  20. Goga AE, Doherty T, Jackson DJ, Sanders D, Colvin M, Chopra M, et al. Infant feeding practices at routine PMTCT sites, South Africa: results of a prospective observational study amongst HIV exposed and unexposed infants - birth to 9 months. Int Breastfeed J. 2012;7:4. · DOI
  21. Patil CL, Turab A, Ambikapathi R, Nesamvuni C, Chandyo RK, Bose A, et al. Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study. J Health Popul Nutr. 2015;34:10. · DOI
  22. West NS, Schwartz SR, Yende N, Schwartz SJ, Parmley L, Gadarowski MB, et al. Infant feeding by South African mothers living with HIV: implications for future training of health care workers and the need for consistent counseling. Int Breastfeed J. 2019;14:11. · DOI
  23. Chetty T, Yapa HMN, Herbst C, Geldsetzer P, Naidu KK, De Neve J-W, et al. The MONARCH intervention to enhance the quality of antenatal and postnatal primary health services in rural South Africa: protocol for a stepped-wedge cluster-randomised controlled trial. BMC Health Serv Res. 2018;18:625. · DOI
  24. Yapa HMN, De Neve J-W, Chetty T, Herbst C, Post F, Cooper DA, et al. Does QI improve PMTCT processes in rural South Africa? A stepped-wedge cluster RCT. Conference on Retroviruses and Opportunistic Infections. Boston; 2018: Abstract #819.
  25. Hoffman SD, Duncan GJ. Multinomial and conditional logit discrete-choice models in demography. Demography. 1988;25:413–27.
  26. Onono MA, Cohen CR, Jerop M, Bukusi EA, J.M. T: HIV serostatus and disclosure: implications for infant feeding practice in rural South Nyanza, Kenya. BMC Public Health 2014; 14:390. · DOI
  27. Jama NA, Wilford A, Masango Z, Haskins L, Coutsoudis A, Spies L, et al. Enablers and barriers to success among mothers planning to exclusively breastfeed for six months: a qualitative prospective cohort study in KwaZulu-Natal, South Africa. Int Breastfeed J. 2017;12:43. · DOI
  28. Nieuwoudt S, Manderson L. Frontline health workers and exclusive breastfeeding guidelines in an HIV endemic south African community: a qualitative exploration of policy translation. Int Breastfeed J. 2018;13:20. · DOI
  29. Doherty T, Horwood C, Haskins L, Magasana V, Goga A, Feucht U, et al. Breastfeeding advice for reality: women’s perspectives on infant feeding support received in primary health care settings in South Africa. Matern Child Nutr. 2020;16:e12877. · DOI
  30. Vandormael A, Newell M-L, Bärnighausen T, Tanser F. Use of antiretroviral therapy in households and risk of HIV acquisition in rural KwaZulu-Natal, South Africa, 2004–12: a prospective cohort study. Lancet Glob Health. 2014;2:e209–15. · DOI
  31. Dinh TH, Delaney KP, Goga A, Jackson D, Lombard C, Woldesenbet S, et al. Impact of maternal HIV seroconversion during pregnancy on early mother to child transmission of HIV (MTCT) measured at 4-8 weeks postpartum in South Africa 2011-2012: a national population-based evaluation. PLoS One. 2015;10:e0125525. · DOI
  32. Ndubuka J, Ndubuka N, Li Y, Marshall CM, Ehiri J. Knowledge, attitudes and practices regarding infant feeding among HIV-infected pregnant women in Gaborone, Botswana: a cross-sectional survey. BMJ Open. 2013;3:e003749. · DOI
  33. Gewa CA, Chepkemboi J. Maternal knowledge, outcome expectancies and normative beliefs as determinants of cessation of exclusive breastfeeding: a cross-sectional study in rural Kenya. BMC Public Health. 2016;16:243. · DOI
  34. Cresswell JA, Ganaba R, Sarrassat S, Cousens S, Some H, Diallo AH, et al. Predictors of exclusive breastfeeding and consumption of soft, semi-solid or solid food among infants in Boucle du Mouhoun, Burkina Faso: A cross-sectional survey. PLoS One. 2017;12:e0179593. · DOI
  35. Adeniyi OV, Ajayi AI, Issah M, Owolabi EO, Goon DT, Avramovic G, et al. Beyond health care providers’ recommendations: understanding influences on infant feeding choices of women with HIV in the Eastern Cape, South Africa. Int Breastfeed J. 2019;14:7. · DOI
  36. Mensah KA, Acheampong E, Anokye FO, Okyere P, Appiah-Brempong E, Adjei RO. Factors influencing the practice of exclusive breastfeeding among nursing mothers in a peri-urban district of Ghana. BMC Res Notes. 2017;10:466. · DOI
  37. Rudwick S, Posel D. Contemporary functions of ilobolo (bridewealth) in urban South African Zulu society. J Contemp Afr Stud. 2014;32:118–36. · DOI
  38. National Department of Health South Africa: The South African Antiretroviral Treatment Guidelines, 2010.

Cited by

Sorted by citations

Metadata

Authors
Yapa, H. M., Drayne, R., Klein, N., De Neve, J.-W., Petoumenos, K., Jiamsakul, A., Herbst, C., Pillay, D., Post, F. A., & Bärnighausen, T.
Affiliations
  • UNSW Sydney (AU)
  • King's College London (GB)
  • Africa Health Research Institute (ZA)
  • King's College Hospital NHS Foundation Trust (GB)
  • Harvard University (US)
Corresponding author
Yapa, H. Manisha
ORCID
Venue
International Breastfeeding Journal
Publisher
Springer Science and Business Media LLC
Published
2020-09-01
Volume
15
Issue
1
Pages
77-77
ISSN
1746-4358 (ISSN-L)
DOI
10.1186/s13006-020-00317-5
PMC
PMC7466779
OpenAlex
W3082793932
Cited by
3
References
0
Citations by year
2026: 1 · 2025: 1 · 2024: 1
FWCI
0.00
Type
journal article
Language
en
Open access
Licence
Locations
  • International Breastfeeding Journal (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Research Portal (King's College London) (publishedVersion, other-oa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • UCL Discovery (University College London) (submittedVersion)
Funders
European Commission (EuropeAid/134286/L/ACT/ZA)
Topics
  • Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
  • Health Sciences › Medicine › Epidemiology › Breastfeeding Practices and Influences
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
Keywords
infant feeding knowledge, maternal HIV status, mixed feeding, postpartum care, prenatal care quality, rural South Africa, KwaZulu-Natal, continuous quality improvement, primary health centers, postpartum women
MeSH terms
Adult, Breast Feeding, Female, Humans, Infant, Health Knowledge, Attitudes, Practice, Male, Mothers, Pregnancy, Rural Population, South Africa, Cohort Studies, HIV Infections, Infectious Disease Transmission, Vertical, Young Adult

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review