Zithulele Birth Follow Up

Study
Yoni Kirsch

WHO Recommendations
Mothers known to be HIV-infected should be
provided with lifelong antiretroviral therapy or
antiretroviral prophylaxis interventions to
reduce HIV transmission through
breastfeeding.
Exclusive breastfeeding is recommended for
HIV-infected mothers for the first six months
of life unless replacement feeding is
acceptable, feasible, affordable, sustainable,
and safe for them and their infants before that
time.

Evidence benefits of breastfeeding

Infants who were PCR-negative at
week 6 and EBF for first six months,
estimated transmission rate of 4.04%
Infants who received breast milk and
formula were twice as likely to be
infected
Infants who received breast milk and
solids had a transmission rate 11x
higher
Coovodia et al, 2007

Evidence Problems with

Formula
Multi-site study in SA
Found E. coli in 63% of feeds and
enterococci in 56% of feeds collected
from home
Over-dilution in 57% of feeds, but
only in 14% of demonstration feeds
People mostly aware of correct amounts

Bergstrom, 2003

The Study
470 mothers and 479 newborn babies (one
twin excluded for analysis) recruited during
a 3 month period (14/01/2013-14/04/2013)
Participants interviewed at birth, 3, 6, 9,
12, and 24 months
Aim: to find out what is happening with
children in the Zithulele catachment area
outside the hospital gate during their first
two years of life

Rates of Follow-Up
Number of
Women

Percentage

Birth

470

100%

3 months

390

83.0%

6 months

419

89.1%

9 months

401

85.3%

12 months

410

87.2%

24 months

384

81.7%

Age Distribution
90
80
70
60
50
40
30
20
10
0

(n=469)

Education Level Achieved

(n=469)
90
80
70
60
50
40
30
20
10
0
No formal education

Grade 2

Grade 4

Grade 6

Grade 8

Grade 10

Grade 12

Degree

HIV Status
93.6% tested during pregnancy
(440/470)

26 already knew status

28.5% HIV-positive

(134/470)

Intentions at Birth

(n=469)

70

60

59.3

50

40

Percentage
30

18.1

20

11.7
10

4.5
0.4

EBF

Mixe
d

Don
t
Kno
w

EFF

EBF->
Mix

EFF->
Mix

Intentions to EBF
71.3% if received any feeding advice
(201/282) 39.5% if received no feeding
advice (68/172)
34.1% if mother is employed or in school
(31/91) 65.3% if mother is unemployed
(247/378)

62.5% if mother > 18 years (228/365)

47.17% if mother 18 or younger
(50/106)

Three Months

Age at Three Month Interview

(n=390)
12

10

Mean Age = 3.46 month

Rates of Breastfeeding Based on

Feeding Intentions (n=390)

115

70.5%

Not Breast Feeding

Breast Feeding
57

75.3%
275

174

76.2%

23.5%

15
48
13
4

Rates of EBF at Three Months

Based on Feeding Intentions
(n=390)

Not EBF

323

EBF

180

17.2%

67

22.8%
53

57
12.3%
8

Why Stopped EBF?

Sore nipples (19)
Not producing enough breast milk
(76)
General belief that breast milk is not
enough for baby (51)
Baby crying and so believe that
breast milk is not enough for baby
(53)
Went back to school (40)
Went back to work (21)

Self-Reported Data
Rates of EBF likely higher due to the
delay in interviewing the mothers
29.2% reported EBF until 3 months
(114/390)

17.2% reported currently EBF (67/390)

450

Percentage Giving Formula at Three

Months Based on Feeding Intentions
(n=390)

400

350
111
300

250

71.5%

200

150

No Formula
Formula
90

279

61.4%

100
143
50

9
86.2%
56

95.5%
1
21

Percentage Giving Solids at Three

Months Based on Feeding Intentions
(n=390)
74.1% have given either
formula or solids

450

400

17.2% are exclusively

breastfeeding

350

300

185

Remaining 8.7% have

given OTC, xhosa meds,
or other liquids

250

200

52.6%

No
Solids
Solids

125
150

100

50

205

46.4%
108

60.0%
26
39

72.7%
6
16

Dietary Recall (n=390)

Three Months
One week
24 hours

Statistics at Six Months

Age at Six Month Interview (n=419)

Mean age of interview = 6.35 mont

Rates of Breastfeeding Based on

Feeding Intentions (n=419)

198

Not Breastfeeding
Breastfeeding

52.7%
100

60.2%
221

53.5%
136

33
38

25.0%
15
5

Rates of EBF Based on Feeding

Intentions (n=419)

Not EBF

385

8.1%
34

EBF

116

19.1%
20

7.9%
20.0%
36
3

4
1

Rates of Breastfeeding at Six Months

Using Three Months as a Base

195
61
Not Breastfeeding
Still Breastfeeding

76.1%
42.5%
194
144

82.0%
11
50

Rates of EBF at Six Months Using

Three Months as a Base

Not EBF
165

15.4%
30

EBF
164

15.5%
30

29
42.0%
21

Percentage Giving Formula at Six

Months Based on Feeding
Intentions (n=419)
67

84.0
%

No Formula
Formula

45
352

81.1
%

193
6
91.9
%
68

96.0
%1
24

Percentage Giving Solids at Six

Months Based on Feeding
Intentions (n=419)
88.3% have given either
formula or solids

8.1% are exclusively breastfeed

Remaining 3.6% have given
OTC, xhosa meds, or other
liquids

165

60.6
%
97

254

No
Solids
Solids

59.2
%
141

21
48.0
%53

71.6
%
13
12

Why Didnt EBF until Six

Months
Sore nipples (19)
Not producing enough breast milk (90)
General belief that breast milk is not
enough for baby (47)
Baby crying and so believe that breast
milk is not enough for baby (65)
Went back to school (39)
Went back to work (15)
Child did not want to breast feed (32)

Self-Reported Data
Rates of EBF likely higher due to the
delay in interviewing the mothers
19.3% reported EBF until 6 months
(81/419)

8.1% currently EBF (34/419)

Dietary Recall (n=419)

Three Months
One week
24 hours

Summary of EBF
Percentage of Women Breast Feeding By Week

59.3% intended to
EBF
17.2% at three
months
Self-reported
29.2%
8.1% at six months
Self-reported
19.3%

Percentage of Women Exclusively Breast Feeding

Z-scores

Birth

HAZ
86.9%
within 2 SDs
(n=464)
Mean =
-0.352
SD = 1.610
Range:
[-9.35, 3.66]

WAZ
87.4% within
2 SDs
(n=467)
Mean = -0.70
SD = 1.152
Range:
[-5.81, 2.78]

WHZ
67.0% within
2 SDs
(n=442)
Mean =
-1.102
SD = 1.723
Range:
[-6.16, 4.13]

BMI
74.1% within
2 SDs
(n=463)
Mean =
-0.849
SD = 1.707
Range:
[-5.75, 8.89]

Three Months

HAZ
85.1% within
2 SDs
(n=390)
Mean =
0.1549
SD = 1.3856
Range:
[-5.48, 4.43]

WAZ
90.0% within
2 SDs
(n=390)
Mean =
-0.2590
SD = 1.3027
Range:
[-5.18, 3.15]

WHZ
82.8% within
2 SDs
(n=390)
Mean =
-0.4204
SD = 1.4458
Range:
[-4.88, 4.05]

BMIZ
83.8% within
2 SDs
(n=390)
Mean = 0.4707
SD = 1.4028
Range:
[-5.14, 3.75]

Six Months

HAZ
81.1% within
2 SDs
(n=419)
Mean =
0.1099
SD = 1.5113
Range:
[-4.25, 5.14]

WAZ
86.6% within
2 SDs
(n=419)
Mean =
0.0657
SD = 1.3257
Range:
[-4.45, 4.51]

WHZ
86.6% within
2 SDs
(n=419)
Mean =
0.1331 SD =
1.3865
Range:
[-3.96, 5.44]

BMIZ
87.6% within
2 SDs
(n=419)
Mean =
0.0100
SD = 1.4031
Range:
[-3.95, 5.47]

Average Z-Scores Over Two

Years

HAZ
WAZ
WHZ
BMIZ

Birth

3 Months

6 Months

1 Year

Two Years

Effect of Feeding Choices

on Z-Scores

Three Month Groups (n=390)

Six Month Groups (n=419)

Final Groups
THREE
MONTH
S

BF

BF+F

BF+F+
S

F, F+S

Total

None

67

13

27

26

133

OTC/Oth
er

24

21

44

49

138

Xhosa

10

17

52

40

119

Total
SIX
MONTH
S

101
BF

51
BF+S

123
BF+F+
S

115
F, F+S

390
Total

None

31

21

32

89

OTC/Oth
er

12

67

87

173

Xhosa

81

69

154

Total

41

18

169

188

416

Results
Difference in average z-scores birth
to three months and birth to six
months
Overall, babies have grown better
than expected
Problems with sample size
Survey not designed for this question

Still working out significance

Questions?