In this study, the proportion of mothers practicing EBF (83.7%) for the first 6 months of age was comparatively higher than the findings reported from Nigeria (68.3%), Uganda (24%), India (44%) and South Africa (35.6%) [17
] and the proportions of mothers practicing ERF (5.7%) was lower than reported from South Africa (50%), India (44%), and Nigeria (31.7%) [17
]. This might be due to the culture of feeding habit of the Ethiopian mothers to their children than giving replacement feeding as well as the availability of resources to practice ERF. The proportion of mothers practicing EBF was also comparatively higher than what was reported from Addis Ababa, Ethiopia (30.6%) [15
]. The Ethiopian Ministry of Health guideline on infant feeding recommendations of HIV exposed infants recommends EBF for the first 6 months and introducing complementary feeding at 6 months and continues breastfeeding until 12-18 months [21
]. The difference may be also explained by the fact that in both the South African and Nigerian studies, infant formula was supplied free of charge unlike in the present study. Deep-rooted family and community norms make it difficult for mothers in Ethiopia as in most developing countries to choose ERF. In fact, choosing to use replacement feed is equivalent to announcing their HIV status, and the consequences of this are far reaching and could involve violence and divorce [22
]. About 87% of the mothers had disclosed their HIV status to their spouses, and 65.6% of the mothers had disclosed their status to their family members. This number is found to be higher than what was reported in Nigeria (50%) [19
In multivariate analysis, disclosure of HIV status with their spouse, insufficient breast milk and occupational status were found to be independently associated with the recommended way of infant feeding practice. Mothers who disclose their HIV status to spouse were 7.7 times more likely to have the recommended way of infant feeding practice. Disclosure of HIV status greatly influenced infant feeding options of HIV positive mothers when the partner was aware of the HIV status of the mother and involved in the decision [23
]. Having disclosed their status might have psychological benefits as they do not have to hide while formula feeding. Those daily laborers were 14.6 times more likely to have recommended way of infant feeding practice than government/private workers/merchants. Work overload may dispose merchants to practice MBF unconsciously.
The proportion of mothers practicing MBF (10.5%) for the first 6 months of age was almost in line with studies conducted in Addis Ababa, Ethiopia (15.3%) and South Africa (12.4%) [15
], but lower than from India (29%) [18
] and it was higher than what was reported from Cameroon (4.3%) [24
]. By tradition, mothers may consider breast milk is not enough for child growth and intend to use mixed feeding even though they have been informed. Mixed breast feeding has been shown to damage the intestinal lining of the gut in infants [14
], leading to an increased risk of HIV transmission through breast milk [9
]. In addition to MBF, duration of breast feeding is also strong determinant for HIV transmission through breast milk [13
]. According to a study conducted in Zambia, early abrupt cessation of breast-feeding by HIV-infected women in a low-resource setting does not improve the rate of HIV-free survival among children born to HIV-infected mothers [25
]. The recent guidelines of WHO stated that when ARVs are not available, mothers should be counseled to exclusively breastfeed in the first six months of life and continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding [12
]. Presence of insufficient breast milk was 85.7% times less likely to have recommended way of infant feeding practice. Due to the insufficiency of breast milk mothers might goes to mixed feeding.
In the present study, 193 (92.3%) of women knew that mother to child transmission of HIV virus can occur during pregnancy, delivery and breast milk feeding which is a higher percentage compared to the findings (70%) from a study done in South Africa [17
]. This might be achieved due to the accessibility of mother support groups by preparing coffee ceremony for mothers in two weeks interval which is organized by NGO. However, without fostered counseling including information about the risks and benefits of breastfeeding, HIV-positive women may have made suboptimal infant feeding decisions (e.g., mixed feeding, underfeeding) based only on the knowledge that HIV can be transmitted by breastfeeding. In an effort to prevent HIV transmission to their infants, women may be unintentionally endangering their infants' health. This emphasizes the need for offering clear information about postpartum HIV transmission to all women seeking antenatal care.
Availability of supply, stigma of HIV/AIDS, insufficient breast milk and husband opposition were factors that influenced choice of infant feeding options by respondents. Higher percentage (13%) of study participants complained that stigma of HIV/AIDS status affect their infant feeding option although the percentage is lower than studies conducted in Nigeria (44%) [23
]. This might be due to the cultural difference in accepting HIV/AIDS in the people of each country.
The study findings are limited in terms of overall generalization due to the small study sample size and it was health institution based. There is a possibility that study participants who received counseling on recommended way of infant feeding practice may simply answer questions accurately. This bias may underestimate the proportion of mixed feeding practice. Maternal since-birth recall of feeding patterns was also used which has its own limitations of long recall. Despite these limitations, we believe that our study findings provide essential input on infant feeding decisions.