Perceived Breastmilk Insufficiency and HIV are Associated with Exclusive Breastfeeding at 1 and 3 Months among Mothers in Northern Uganda
Authors: Martin Stephanie L. , Collins Shalean M. , Widen Elizabeth M. , Achidri Daniel , Young Sera L. 
Published: June 2021

Exclusive breastfeeding (EBF) contributes to the health and survival of HIV‐exposed and HIV‐unexposed infants and is recommended for 6 months. However, infant feeding practices are typically suboptimal in areas with high HIV‐prevalence, such as East Africa. Understanding the determinants of EBF is essential for designing comprehensive programs to support HIV‐infected and HIV‐uninfected mothers to EBF for 6 months, but these are not well understood. Therefore, our objective was to evaluate factors associated with EBF at 1 and 3 months among HIV‐infected and HIV‐uninfected mothers in Uganda.A sample of postpartum women, purposively selected to achieve a 2:1 proportion of HIV‐uninfected to HIV‐infected (n=238, 36.2% HIV), were recruited into a longitudinal cohort study at Gulu Regional Referral Hospital in northern Uganda. Demographics, psychosocial factors, individual food insecurity, HIV status, depression (using the Center for Epidemiologic Studies Depression Scale), breastmilk sufficiency, EBF intention, EBF knowledge, EBF‐specific social support (using an adaptation of the Hughes Breastfeeding Support Scale), and EBF self‐efficacy (using an adaptation of the Breastfeeding Self‐Efficacy Scale‐Short Form) were assessed at 1 and 3 months. These characteristics were compared between women who reported practicing EBF and those who did not at both 1 and 3 months postpartum, using chi‐square and t‐tests. We then built multivariate logistic models to explore factors associated with EBF at 1 and 3 months.Breastfeeding initiation was nearly universal in this sample (98%), with 64% reporting EBF at 1 month and 61% at 3 months. In multivariate logistic models of EBF at 1 month, perceived breastmilk insufficiency was negatively associated with EBF (OR 0.34, p=0.001) and HIV‐infected status was positively associated with EBF (OR 1.97, p=0.04). At 3 months, perceived breastmilk insufficiency was negatively associated with EBF (OR 0.24, p<0.001) and HIV‐infected status (OR 2.24, p= 0.02) and EBF self‐efficacy (OR 1.16, p=0.05) were positively associated with EBF.In conclusion, perceived breastmilk insufficiency was associated with a substantially decreased likelihood of EBF at both 1 and 3 months, and low EBF self‐efficacy was associated with a decreased likelihood of EBF at 3 months. In addition, HIV‐infected women were much more likely to EBF at 1 and 3 months, compared to HIV‐uninfected women. These findings have important implications for programs, suggesting the need to address women's concerns about breastmilk insufficiency and better support women to feel confident in their ability to breastfeed in the early postpartum period in order to achieve EBF for 6 months. Because breastmilk insufficiency has been identified as a barrier to EBF globally, future research might also explore if breastmilk is objectively insufficient, or “only” perceived as such. The positive association between EBF and HIV‐infected status suggests infant feeding counseling to prevent mother‐to‐child transmission of HIV has likely been successful at increasing EBF. These lessons may be leveraged to increase EBF among HIV‐unexposed infants as well.Support or Funding InformationFunding: K01 MH098902, USAID Coop. Agreement AID‐OAA‐L‐10‐00006, and Cornell University‐Weill Medical College Inter‐campus Seed Funds