Recruitment and baseline characteristics
As shown in , 643 HIV infected pregnant women were consecutively enrolled between March 2001 and March 2003. Sixty-three women with HIV-2 infection only or lost to follow-up prior to delivery were excluded from the analysis. Overall, 580 women gave birth, and after exclusion of stillbirth as well as second and third born babies of multiple birth outcomes, 569 mother-infant pairs were eligible for analysis. Among the 557 mothers whose livebirth was fed at least once, 262 (47%) initiated breastfeeding and constituted the breastfeeding group for the present analysis.
Cohort profile according to the infant feeding options. ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d’Ivoire
Their baseline socio-demographic, clinical and biological characteristics as well as the delivery circumstances and their newborn characteristics are detailed in . Overall, 47% were illiterate, and 70% were living with their partner, of whom a quarter had shared their HIV status with him before delivery. All but eight had electricity at home, all of them had access to tap water and 74% lived in a shared housing. Three quarters of the women included were at WHO clinical stage 1 or 2, the remaining at stage 3. Their baseline median CD4 count was 392 (IQR: 266–540) and their median viral load was 4.2 log (IQR: 3.6–4.7).
Baseline characteristics of mother-infant pairs according to the infant’s age at complete cessation of breastfeeding, ANRS 1201/1202 Ditrame Plus study, Abidjan, Côte d’Ivoire (N=262)
Mother-infant pairs follow-up
From birth until nine months of age, among the 262 mother-infant pairs analyzed, 34 (13%) were lost to follow-up at a median age of 51 days (IQR: 7–133) and 12 (4%) infants died. Among the remaining 216 mother-infant pairs, 197 (91%) completed the 15 visits scheduled from birth until nine months of age, the reminders completing 11 visits on average.
Among the 262 women initiating breastfeeding, 255 (97%) made their choice during the prenatal period on how to feed their forthcoming infant. Of these women, 227 (89%) intended to breastfeed, of whom 84 (37%) underlined they would exclusively breastfeed. Among the 227 women wishing to breastfeed their infant, four (2%) considered ceasing breastfeeding before three months, 88 (39%) between three and four months, 60 (26%) after four months, and the remainder (33%) did not express an opinion antenatally.
Initial infant feeding practice
In this breastfeeding group (n=262), the first liquid given from birth was breastmilk (73%), tap water (9%), boiled or mineral water (4%), sugar water (1%), infant formula (3%), fruit juice (1%) and could not be documented for 9% of the women. Infant formula had been given by the staff of hospitals where women had been hospitalized for a caesarian section. In the first 48 hours of life, 160 (61%) children were predominantly breastfed, 90 (34%) exclusively breastfed and 12 (5%) mixed fed.
Among the 84 mothers who had prenatally chosen to exclusively breastfeed their infant, 51% did so, whereas 75% of the 143 mothers who had prenatally chosen to predominantly breastfeed actually initiated this practice (p<0.001).
Exclusivity of breastfeeding
As shown in , at one and three months of age, the majority of infants had not been exclusively but predominantly breastfed the week before the interview (respectively 59% and 62%) as they were also given water, essentially from a tap. Use of boiled or mineral water was relatively common at one month of age (30%). Most of the infants (39%) were mixed fed at four months of age, of whom 83% were in the process of being weaned and were thus receiving infant formula. From six months of age, most of the infants were not breastfed any more and received artificial feeding instead, while the remaining breastfed infants were essentially mixed fed as they also received baby food, other solid or semi solid foods such as dairy products, meat, fish, or all sorts of plants.
Infant feeding practices at ages M1, M3, M4, M6 and M9 in the breastfeeding group. ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d’Ivoire (N=262)
The cumulative probabilities of being exclusively breastfed from birth were 0.18 (95% CI: 0.13–0.22), 0.10 (0.06–0.13) and 0.01 (0–0.02) at ages M1, M3 and M6 respectively ().
Kaplan-Meier probability of being exclusively breastfed from birth. ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d’Ivoire (N=262)
Duration of breastfeeding
Overall, 167 mothers (64%) had completely ceased breastfeeding before M9, 38 infants (14%) died or were lost to follow-up before reaching that age while they were still being breastfed at their last contact and 57 (22%) infants were still breastfed at M9. Overall, 24 women (9%) ceased breastfeeding before M3: 12 mothers were counseled by the medical and nutritional staff of the study to cease breastfeeding for maternal medical reasons (chickenpox, breast pathology, AIDS-related disease), child’s disease (candidiasis), or breastmilk deficiency, and 12 mothers changed their mind and switched to artificially feed their infant. Altogether, 100 women (38%) completely ceased breastfeeding at M3-M4 as recommended.
The cumulative probabilities of beginning the weaning process and having completely ceased breastfeeding are detailed in . The median age of infants at initiation of the weaning process was 97 days (IQR: 91–125) ; it was 106 days (IQR: 94–136) at complete cessation of breastfeeding. Complete cessation of breastfeeding was achieved for 94% of these infants after one endeavor of weaning. The weaning process was initiated with the introduction of infant formula to replace breastfeeding. At that time, 4% of the women preferred to be kept away from the child for a while and 2% used bandages to cover their breasts. None of the women reported to have used any repellent products to facilitate the weaning process. Women reported breast pain (33%), breast engorgement (18%), or baby tears (17%) related to the weaning process. Only 2% of the women reported partner or family disapproval to the early breastfeeding cessation.
Kaplan-Meier probability of having initiated weaning and completely ceased breastfeeding. ANRS 1201/1202 Ditrame Plus, Abidjan, Côte d’Ivoire (N=262)
Success of the intervention proposed
Among the 262 mothers-infant pairs who had initiated breastfeeding, 4 (1%) infants died or were lost to follow-up before M4 while they were still being exclusively breastfed at their last contact. Only 14 (5%) succeeded in practicing exclusive breastfeeding until weaning in having completely ceased breastfeeding between M3 and M4, i.e. did it as planned in the protocol concerning the quality of breastfeeding and its duration.
Women who failed to achieve this objective had in median fewer living children (1 vs. 3, p=0.01) and were at less advanced stages of HIV disease than those who succeeded (HIV-1 RNA plasma viral load of 4.2 vs. 4.6, p=0.04).
We then considered the second, less stringent definition of success. Among the 262 mother-infant pairs who had initiated breastfeeding, 33 (13%) infants died or were lost to follow-up before M3 while they were still being breastfed at their last contact, irrespective of the exclusivity of the breastfeeding practice. Among the 229 mothers who could thus be classified, 24 (10%) ceased breastfeeding before M3, 100 (44%) between M3 and M4 and 105 (46%) beyond M4.
In an unadjusted analysis detailed in , being followed in the clinic based in the district of Abobo, living in a typical shared housing and having delivered at home were associated with failure of the proposed intervention. Women who failed to practice the recommended intervention also had significantly higher CD4 count than those who succeeded.
The results of the multivariate logistic regression model investigating the determinants of a complete cessation of breastfeeding occurring beyond the M3-M4 period (n=105 vs. n=100) are detailed in . After adjustment, failure of the proposed intervention was significantly associated with being followed in the Abobo site, having a maternal CD4 count above 500 and living with partner’s family. Similar results were obtained when investigating the determinants of a complete cessation of breastfeeding after vs. before M4 completed i.e. in pooling together women who ceased breastfeeding before M3 and in the M3-M4 period.
Determinants of ceasing breastfeeding beyond the M3–M4 period (failure to the recommended practice), multivariate logistic regression, ANRS 1201/1202 Ditrame Plus study, Abidjan, Côte d’Ivoire (N=205).