Our findings are presented as they relate to the feeding options described in the current 2009 national guidelines (Table 1).
Exclusive and continued breastfeeding
Of the feeding options outlined in the Papua New Guinea HIV and infant feeding guidelines, most informants discussed option (1): Exclusive and continued breastfeeding. Exclusive breastfeeding was mentioned by almost all informants, the majority of whom reflected the most up-to-date national guidelines for exclusive breastfeeding to six months. Others who discussed this feeding option did not specify how long an HIV-positive mother should exclusively breastfeed.
“I usually tell the mothers that after they have delivered don’t give any cold water. Don’t give even any juice or anything [it] is forbidden to positive mothers. I said [it’s] very forbidden . . . Give only this breast milk until six months . . . When the child reaches four months and five months it will want to eat and will suck its hands and such, don’t give anything. . . only give breast milk for some time until it reaches six months”. (Volunteer Ato, PLHIV patient expert, antenatal clinic)
The continuation of breastfeeding after six months was the area in which key informants appeared to have the least accurate knowledge of current guidelines. While some key informants mentioned that breastfeeding should not continue beyond six months in HIV-exposed infants, others did not mention whether or not breastfeeding should continue after that time. Of those who mentioned exclusive breastfeeding to six months, half mentioned that breastfeeding should continue after the introduction of foods and other fluids at six months. Of the informants reflecting the national breastfeeding guidelines, the majority were senior members of health staff reflecting knowledge gained through access to timely training and policy changes. Other informants who mentioned the continuation of breastfeeding after six months were a well-baby clinic sister and a PLHIV patient expert volunteer working in an antenatal clinic.
For those informants who had attended a PMTCT training program knowledge relating to the recommendation of continuing with breastfeeding after the introduction of food at six months varied, yet continuation after six months is critical to reducing overall infant mortality and morbidity, irrespective of HIV. The majority of these informants knew that infants should exclusively breastfeed for six months. A minority of these highly trained and experienced health care professionals were aware of the importance of the continuation of breastfeeding after the introduction of other food and fluids. A few informants stated that breastfeeding should not continue at this time - two of whom did not know that infants should exclusively breastfeed for six months. The remaining informants did not specify whether breastfeeding should continue or not after the introduction of food and other fluids.
A minority of the informants who discussed exclusive breastfeeding mentioned the importance of the mother continuing with ART while breastfeeding, in line with the current Papua New Guinea HIV and infant feeding guidelines. One informant described how she encouraged mothers to exclusively breastfeed at least until the infant has been tested for HIV.
“. . . we said if you are adherent we’d like you to breastfeed up to 6 months, the Health Department policy is 6 months. The babies are tested at 6 weeks, if you are working and you have money and all that sort of thing, fridge, everything you can afford if you want to put your baby on the formula it’s up to you and your husband. But you have to seriously consider if you can maintain that formula feeding otherwise breast is best . . . you just have to stick to breast but some ask if they can [artificial feed] right at birth and I tell them it’s not wise because what if the babies positive at 6 weeks then all that money on starting the baby on formula is wasted. It’s best to be adherent to your ART and test at 6 weeks”. (Sr Nepina, PMTCT coordinator)
Only a minority of informants did not discuss exclusive and continued breastfeeding at all. The fact that they did not specifically discuss this feeding option is likely to be a reflection of their role and capacity within their work place. The doctors included within this minority group were in fact involved to differing degrees in the formation of the country’s HIV feeding guidelines, but did not work in the PMTCT clinic and were therefore not in a position to provide specific education and information to mothers relating to infant feeding practices.
Express and heat treat breast milk
While listed as the preferred second option for HIV infant feeding in Papua New Guinea national guidelines only two informants mentioned this option. Both informants expressed a feeling that this option would be too difficult for the majority of mothers in terms of financial implications and time as well as issues relating to hygiene and women would more likely opt to breastfeed.
“You could teach them things like boil the breast milk and you know the other things like the WHO says you can do and reduce the risk but a set up like this [women living in settlements] does not have that kind of thing, who’s going to do it, who’s going to you know have time to do all those things . . .” (Dr Leota, Paediatrician)
Breastfeeding by another woman
Although mentioned as the third most suitable feeding option for mothers in PNG, only one participant discussed this feeding option. This key informant clearly listed all the feeding options as described in the 2009 HIV infant feeding guidelines.
“. . . the other one [option] is heat and treat . . . we just provide all the information . . . they choose (an option) . . . but they haven’t chosen heat and treat or wet nursing. In most of my counselling that has been done I’ve realized that the two other options are not taken on-board” (Sr Zamila, ANC & breastfeeding advocate).
Artificial or replacement feeding
Highlighted within the national HIV feeding guidelines as the last option to be used in rare situations, artificial or replacement feeding was the second most commonly mentioned feeding method among informants. Of the informants who discussed replacement or artificial feeding, almost all mentioned this option within the context of mothers specifically requesting information or support relating to this option. They recognised that in many situations it would not be an easy option for mothers to choose, and four mentioned how they explained to mothers about the increased risk of their infant dying from diarrhoeal illness or malnutrition rather than from HIV if they artificially feed their infants.
“. . . we have some who have like have lost their first or second child and this is like their third child and they are not willing to even risk that little percent that will come through the breast milk. So they opt to just bottle feed straight away . . . they think any kind of breastfeeding will bring the virus over. Even if its exclusive breastfeeding they don’t have enough knowledge to say that [make that choice]. . . But now, if the counselling has been given very well, I have spoken to a few mothers . . . who have been counselled through Susu Mama and counselled through the other clinic and they’ve been told that you have to exclusively breastfeed for 6 months and they have”. (Dr. Min, paediatrician)
“. . . because your baby won’t die of HIV, it will die from bottle feeding if you are not careful.” (Sr Naomi, well baby clinic)
Infant feeding options and the idea of informed choice
A number of the informants who discussed feeding options specifically discussed the importance of providing mothers with necessary information relating to feeding options, enabling them to make an informed choice based on their individual circumstances.
“. . . we don’t choose for them [the mothers] we just tell them the advantages and the disadvantages of it [the option they have chosen]. So they choose for themselves, we do not choose for them . . . then we ask them [if they choose formula feeding], whether the parents are working, are you able to buy milk for one year? And then sometimes we tell them go and sit down with your husband and talk it over again and see which option is best for you”. (Sr. Naomi, Well baby clinic)
A small number of these informants described the importance of informed choice within the context of Papua New Guinean culture, particularly the culture of blame and retribution. Specifically they discussed the importance of choice in relation to feeding options with mothers choosing the most suitable option themselves. It was felt that this is necessary in order to protect the health care worker from any repercussions if an infant was later diagnosed as HIV-positive.
“. . . we give them options, we just don’t want to tell them to continue on breastfeeding and all that [because] later [if] they find that they have problem with the baby, we don’t want them to blame us so we give them option we just say choose, what do you want to choose to feed them . . .” (Sr Kaira, antenatal clinic).
The majority of informants who discussed feeding options described that while the feeding options of exclusive breastfeeding and artificial feeding are discussed with mothers, breastfeeding was ultimately encouraged or emphasized. They went onto explain that breastfeeding is the most suitable option within the context of PNG because of the high financial burden of replacement feeding (approximately USD$40 for one tin of formula milk) in a country with around 80% unemployment, as well as the challenges associated with ensuring adequate hygiene standards particularly with those living in rural areas and settlements.
“Some they can afford to buy this bottle and give them but these things are very expensive and then it is not safe for the baby too so we are encouraging them to breastfeed”. (Sr. Karim, Labour ward)
“[After] the babies are born we normally follow the protocol and see it’s in place. . . the mother is on treatment and we normally encourage exclusive breastfeeding. Because of the cost and also . . . the reason of the hygiene . . .” (Dr Nais, Obstetrician)