Infant feeding and HIV positive mothers in the Capricorn District of Limpopo Province

Correspondence address MS Maputle Department of Advanced Nursing University of Venda Private Bag X5050 Thohoyandou 0950 Abstract: Curationis 33 (1): 5-16 HIV-positive mothers who practise infant feeding of their choice at Mankweng clinic in the Limpopo province are experiencing specific problems with various feeding methods. This study was undertaken with the aim to explore and describe the socio­ economic and cultural experiences of HIV-positive mothers who practise infant feed­ ing of their choice. The research design was exploratory, descriptive, qualitative and contextual in nature. A phenomenological approach was adopted to focus on the lived experiences of HIV-positive mothers. The study sample was purposely se­ lected. Ten HIV-positive mothers volunteered to participate in the study. Data were collected through in-depth unstructured interviews. All participants responded to an open-ended question: “Could you please tell me, in detail, your experience on infant feeding of your choice?” Interviews were conducted until saturation, as was reflected in repeating themes, was reached. The model of trustworthiness, as out­ lined in Guba and Lincoln (1985:301 -318), to ensure credibility and dependability, was used in this study. The study adhered to the ethical standards as set by DENOSA (1998:2.3.2-2.3.4). Data were analysed according to Tesch’s method, as outlined in Creswell (2003:192) and De Vos (1998:343). Literature control was performed to verify the results. Two main categories that emerged were guided by options for infant feeding; namely those that chose formula feeding for their babies and those partici­ pants who opted to breast-feed their babies The study proposed to recommend guidelines for the development of relevent con­ tent for inclusion in health education programmes of registered midwives who, in turn, can use such information to educate mothers


Introduction
Vertical transmission o f the HIV virus from mother to child can occur during pregnancy, during delivery or postn atally th ro u g h b re ast-m ilk (Coutsoudis, Pillay, Kuhn, Spooner, Tsai & Coovadia, 2001:380).Rates of mother-to-child-transmission (MTCT) range from 5-25% in developed and 13-42% in developing countries.With out specific interventions, the rate of vertical transmission is around 15-20%, but breastfeeding might increase the rate to 35-40% (Coutsoudis et, 2001: 381).Data from various studies indi cate that breastfeeding may be respon sible for one-third to one-half o f HIV infections in infants and young chil dren in Africa (Coutsoudis et al, 2001: 382).The reduction o f HIV transmis sion during lactation is one of the most pressing global health dilemmas con fronting health policy makers and HIVinfected women in many regions o f the world (Van de Perre, Lepage, Homsy & Dabis, 2005:506;Bertolli, Hu, Nieburg, Macalalad & Simonds, 2003:2090).Coutsoudis (2005:89) and Van de Perre (1999:503) asserted that MTCT occurs primarily through contact between the virus and infant mucosal surfaces.It was further speculated that HIV might enter through breaches in the mucosal barrier, or through infection of mucosalassociated lymphoid tissue.If a cellfree or cell-associated virus is able to infect lymphocytes in the submucosa by passing through disruptions in the intestinal epithelial, damage may in crease the risk o f transmission.HIV-positive women's multiple respon sibilities combined with their relative powerlessness, and cultural values which tend to stigmatise them as vec tors o f disease, make them particularly vulnerable to psychological stresses associated with HIV/AIDS such as: iso lation, guilt, fear about the future of their children, and loss o f esteem and dignity.Stigma and discrimination may be fiercer and the consequences more severe for women than for men.They may include rejection, abandonment, extreme poverty and sometimes vio lence.Women's lack of decision-mak ing power with regard to reproductive health matters not only exacerbates the problems relating to HIV and infant feeding but also increases the women's stress.It is known that the success of interventions relates strongly to the degree of control women exercise over decisions and practices.Where a part ner or family opposes or disapproves of a woman's informed choice, she will need support for her decision from counsellors and health workers.
Pregnant mothers are encouraged to undergo Voluntary Confidential Coun selling and Testing (VCCT) so that in formation to make an informed choice regarding infant feeding is provided (Misihairabwi, Sabatier & Chikukwa, 1998:12).The programme on the pre vention o f transmission o f HIV/AIDS from mother to child (PMTCT) is be lieved to be instrumental in the preven tion o f AIDS in children if instituted early in pregnancy, as it provides for the care o f mothers who have tested positive for HIV.O f importance is the advice and support given regarding infant feeding.The programme empha sises the im portance o f exclusive breast-feeding or formula feeding in the first six months, at least.Pregnant women who are HIV infected, or o f un known serostatus, are given informa tion about exclusive breast-feeding for the first six months o f the infant's life, with sustained breast-feeding thereaf ter.HIV-infected women are counselled on different feeding options available to them (WHO, 2004).
When free formula for infants o f HIV mothers is provided in tandem with counselling, MTCT decreases (PMTCT Advisory Group and Infant Feeding Study Group, 2002:430).When in formed choices on infant-feeding meth ods are promoted, women's decisions might still be compromised by the ad vice given, due to some options not being accurately explained by the health worker (De Paoli, Manongi & Klepp, 2004:148).
In developed countries, mothers use commercial formulas to feed their in fants, whereas in developing countries, HIV-positive mothers experience chal lenges, for example, when feeding ba bies on commercial formulas.The challenges experienced by HIVpositive mothers intending to formula feed their babies include: In an attempt to contribute to meeting this goal the researcher endeavoured to explore and describe how socio-economic and cul tural experiences impact on the infant feeding choices o f HIV-positive moth ers.The study was conducted at Mankweng Clinic, in the Capricorn Dis trict in the Limpopo Province.Based on the findings, relevant and contex tual content o f health education was proposed to be utilised by registered midwives in educating and supporting HIV-positive mothers who practise in fant feeding of their choice.According to UNICEFF in action (b) (2002 online), policy makers and health care managers are faced with the chal lenge of providing the necessary sup port to enable mothers to make and carry out their choices, whether to breastfeed or to use supplementary feeds.Moreover, health workers are morally and ethically obliged to com municate appropriate information re garding infant feeding practices to HIVpositive mothers.Added to the peril facing HIV-positive mothers is the bur den of making the right decision with respect to infant feeding options in re lation to their socio-economic circum stances.Studies conducted in Sub-Saharan Africa and Uganda showed that HIV-positive mothers invariably find it difficult to adhere to the infant feeding method they have chosen dur ing or sh o rtly after co u n sellin g (Wendo, 2001 :online).After delivery, all infants bom to HIVpositive mothers need regular followup to ensure that infant feeding choices are sustained and to monitor infant weight and health.The Integrated Management o f Childhood Strategy (IMCI) has been adopted to include care o f infants bom to HIV-positive 6 mothers.Therefore, all infants bom to HIV-positive mothers should be fol lowed up according to the IMCI guide lines, regardless o f infant feeding choice.The guidelines describe the feeding option for consideration by HIV-positive mothers, which include the following: • replacement feeding with com mercial or home prepared for mula; • exclusively breast-feeding for the first six months; • use of heat-treated expressed breast milk.Providing adequate formula for HIVinfected women in resource-poor set tings may be difficult because o f lack of infrastructure.The decision o f what to do must rest with the mothers, who will want to do what is best for their babies.In African communities where breastfeeding is still the norm, mothers would opt for breastfeeding because o f the fear of stigmatisation; hence the grandmothers make decisions regard ing infant feeding (Coutsoudis, Pillay, Spooner, Coovadia. Pembrey & Newell (2003:890).Lyall (1998:127) argues that many women face ostracism from their families when diagnosed as HIV-positive, and in other parts of the world where breastfeeding is the norm, a woman who does not breastfeed will be suspected of HIV infection.Like wise, mothers may be anxious at being seen collecting tins of formula from the clinic and may stop such an arrange ment or process altogether (Laura, Guay, Andrea & Ruff, 2001:5;UNICEF in action (b), 2002: online).This study investigates the aggravat ing experiences of HIV-positive moth ers who practise infant feeding meth ods of their choice, and how their needs can be addressed through proposed co n tex tu al health education p ro grammes.

Problem Statement
The virus is known to be present in breast milk.However, the timing and mechanism of transmission remain un clear.Mothers must have the appro priate information about their chances of transmitting HIV to infants, and also be informed of the risks of artificial feed ing, breastfeeding and mixed feeding.
The key role of health workers includes counselling and encouraging women to consider their circumstances and sustain their decisions (Department of Health, 2000:11;UNICEF in action, 2002 (a): online).Governments in the devel oping countries are faced not only with the problem o f providing HIV-positive mothers with infant formula for the first six months of life, but also have to make provision for training of health care workers so that they can support HIVpositive mothers throughout the infant feeding period.However, due to the contextual socio-cultural dynamics, lit tle is known about what content is pro vided by midwives to mothers during the infant feeding period.Therefore, it became imperative that the relevant items specific to infant feeding should be taught to HIV-positive mothers.

Aim of study
The aim o f the study was to explore and describe the socio-economic and cultural experiences o f HIV-positive mothers regarding infant feeding at one clinic in the Capricorn District of the Limpopo Province.Furthermore, the study's aim was to compile content for health education programmes that can be utilised by midwives when educat ing HIV-positive mothers on infant feeding.

Research questions
The follow ing research questions guided the study: • What are the socio-economic and cultural experiences of HIVpositive mothers regarding in fant feeding?• How might the research find ings contribute to the develop ment o f content for the health education programme that will be utilised by registered mid wives when educating HIVpositive mothers regarding in fant feeding?

Objectives of the study
The objectives o f the study will be to: • explore and describe the socio economic and cultural experi ences of HIV-positive mothers regarding infant feeding • propose the development of content for health education programme that will be utilised by registered midwives when educating HIV-positive moth ers regarding infant feeding

Conceptual definitions of terms
For the purpose of this study, the fol lowing concepts were used:

HIV-positive Mother
HIV-positive mother in this study re fers to a mother who has delivered a live infant, who has undergone Volun tary Confidential Counselling and Test ing, tested HIV positive and is practis ing infant feeding of her own choice.

Infant Feeding
Infant feeding shall refer to feeding of the baby from birth to six months, choosing one o f the following feeding options: Exclusive breastfeeding Exclusive breast-feeding is the recom mended mode o f infant feeding for those HIV-infected women for whom replacement feeding is not acceptable, feasible, affordable, sustainable or safe (WHO, 2006).It refers to giving the baby no other food or drink (not even water), apart from breast milk (includ ing expressed breast milk fed by cup), with the exception of drops or syrup consisting o f vitamins, mineral supple ments or prescribed medicines during the first six months (DOH, 2000:3).Exclusive form ula or supplem entary feeding This refers to the giving of breast milk substitute to a child who is not receiv ing any breast milk.A breast milk sub stitute, when prepared correctly, pro vides all the nutrients the child needs until that child is ready to be fully fed on family foods.Breast milk substi tutes include commercial infant formula.Mixed feeding Mixed feeding means feeding the baby with breast milk and formula as well as with foods such as porridge and drinks or water.

Experiences
E xperience is defined as " living through" what happens and how a per son reacts to his/her surroundings (Hawkins, 1998:225).In this study, ex perience shall mean lived socio-eco nomic and cultural experiences of HIVpositive mothers who practise infant feeding o f their choice.

Theoretical assumptions
These assumptions are testable and offer theoretical pronouncements about infant feeding in the era o f HIV and AIDS.In this study, theoretical as sumptions will be based on the UNFPA/ UNICEF/WHO/UNAIDS (nd) guide lines and Global strategy on infant and young child feeding.According to these guidelines, HIV infection can be transm itted through breast-feeding.Appropriate alternatives to breast-feeding should be available and affordable in adequate amounts for women whom testing have shown to be HIV-positive.

Research methodology
Research Design Bums and Grove (2003:43) refer to qualitative research design as a sys tematic, subjective approach used to describe life experiences and give them meaning.In this study an exploratory, descriptive, qualitative design was used to explore and describe the lived experiences o f HIV-positive mothers re g ard in g in fan t feeding.Phenomenological research was used to describe the socio-economic and cultural experiences regarding infant feeding as lived by HIV-positive moth ers.

Study Population and Sampling
The study was co n d u cted at M ankweng Clinic, which was pur posely sampled as it was accessible to the researcher.The population com prised of all HIV-positive mothers who had undergone Voluntary Confidential Counselling and Testing during preg nancy, tested HIV positive and who attended child health care services at the Mankweng Clinic o f the Capricorn District in the Limpopo Province.Out o f the total population o f pregnant women who attend antenatal care at this clinic monthly, 5% had tested HIV p o sitiv e .The n o n -p ro b ab ility purposive sampling method was used.Purposive sampling is a type o f non probability sampling in which data are collected from a group o f respondents chosen for a specific key characteristic (Sells, 1997:172).

Inclusion Criteria
The criteria for inclusion were as fol lows: • mothers who had undergone VCCT and were found to be HIV positive and practising infant feeding o f their choice; and • mothers who were willing to participate in the study and signed an informed consent form.A sample o f ten participants was used in this study because at this point theo retical saturation o f each new category was reached as the researcher planned an intense, in-depth study o f partici pants' experience (Strauss & Corbin, 1990:188).

Ethical Considerations
Ethical considerations were based on the Democratic Nurses Association of South Africa (DENOSA) Ethical Stand ards for Nurse Researchers (DENOSA, 1998:2.3.2-2.3.4).The approval and permission to conduct the study was o b tain ed from the U n iv ersity o f Limpopo Ethics Committee, Department o f Health Research Committee and the management o f the clinic.The re searcher selected participants on the basis o f their HIV status and infant feeding of their choice.To access HIVpositive mothers, the HIV and AIDS counsellor introduced the researcher to the participants.The researcher ex plained the purpose o f the study to the participants, and indicated that partici pation would be voluntary and ano nymity and confidentiality would be ensured.Consent form was signed by the participants.

Data Collection
Data was collected by the researcher who began by collecting the bio graphical data of the HIV-positive moth ers through a structured interview guide, and in three sessions through in-depth unstructured interviews.One central question was asked ''Couldyou please tell me your experiences re garding infantfeeding in detail?" The question was followed by probing as a communication skill, as postulated in De Vos (1998:318).Sells (1997:172) in dicated that open-ended interviews should start with a broad, non-directive question that allows informants to say whatever they think with minimum guidance from the interviewer.During the interviews, open-ended questions were asked and ethical aspects related to research were observed.Interviews were conducted at the clinic in a pri vate room that was utilised by the coun sellor, away from distractions, to en sure privacy and confidentiality.Inter views were conducted in the local lan guage (vernacular) and were tran scribed verbatim and translated into English.Permission to use a tape re corder was obtained and field notes were taken to validate the taped com ments.The recording was done on a small notebook tape recorder that eas ily fits into the pocket and the tape in cluded the empirical observations and their interpretations.

Data Analysis
Data analysis is a process o f bringing order, structure and meaning to the mass o f collected data for its interpre tive and meaningful quality (Marshall & Rossman, 1999:111).To meet this objective, Tesch's open-coding method was used to analyse data as outlined in Cresswell (2003:192) and De Vos (1998:343).

Trustworthiness
The criteria for ensuring trustworthi ness as outlined in Guba and Lincoln (1985:301-318) were used.Credibility was ensured by prolonged engagement wherein the researcher had contact with the HIV-positive mothers during three sessions.Triangulation was used through the following data collection methods: • unstructured interview; • field notes; • use o f tape recorder as well as literature control (De Vos, 1998:318;Sells, 1997:172); • member checks: the last ses sion was conducted on comple tion o f data analysis and the participants were visited at their homes for member checks.This was done to validate the truth and to confirm the results.

Dependability
A ccording to Babbie and M outon (2001:277), dependability refers to an inquiry that must provide its audience with evidence that if it were to be re peated with the same respondents in the exact context, the findings would be similar.In this study, dependability was established through thick descrip tion that is a complete description of the design, method and accompanying literature control, and through peer re views.Stepwise replication was used in which the researcher and the inde-

Transferability
Transferability is the extent to which the findings can be applied in other contexts or with other respondents (Babbie & Mouton, 2001:278).In this study tran sferability was attained through thick description o f research methodology.The researcher collected sufficiently detailed descriptions of data in context and reported.A nomi nated sample was fully described to allow adequate comparison with other samples.

Confirmability
Confirmability is a measure o f the de gree to which the findings are the prod uct of the focus o f the inquiry and not the biases o f the researcher (Babbie & M outon, 2001:278).In this study confirmability was tested through the involvement o f an experienced super visor who, as an independent coder, analysed transcriptions, reviewed raw data, tape-recorded data, written field notes, documents and results inde pendently.The representativeness of data, that is, whether the researcher hd indeed interviewed all categories of participants needed to obtain a com plete picture of the topic, was exam ined by referring back to the in-depth interview discussions because all par ticipants were to have contributed.The independent coder also reviewed opencoding (analysis) products, axial (syn thesis) products, selective and theo retical coding materials relating to in tention (proposals) and instrument de velopment information.Seminars were attended to establish the truth-value o f the data.

Discussion of results
HIV-positive mothers should be ena bled to make fully informed decisions about the best way to feed their infants in their particular circumstances.What ever they decide, they should receive educational, psychosocial and material support to carry out their decision as safely as possible, including access to adequate alternatives to breast-feeding if they so choose.To make fully in formed decisions about infant feeding, as well as about other aspects of HIV, MTCT and reproductive life, women need to know and accept their HIV sta tus (WHO, 1998).HIV infection can be transm itted through breast-feeding.Appropriate alternatives to breast-feeding should be available and affordable in adequate amounts for women whom testing have shown to be HIV-positive.
The results were discussed in relation to the socio-economic and cultural ex periences o f HIV-positive mothers who attend Mankweng Clinic in the Capri corn district o f the Limpopo Province.
The sample comprised 10 HIV-positive mothers (Table 1) who were practising infant feeding o f their choice.Inter views were conducted until the data reached saturation w ith repeating themes.The results o f the experiences of HIV-positive mothers revealed two major categories with sub-categories (Table 2), namely, those who opted for replacement feeding for their infants and those who opted for breastfeeding for their infants.

Experiences of mothers who opted to formula feed their infants (n=8)
Formula feeding is designed to meet the nutritional needs o f the baby for the first six months of life (DOH, 2000:3;WHO, 2001).The National PMTCT pro tocol ensures that mothers who choose to formula feed their infants are given a six-month supply of free infant formula.

Socio-Economic Experiences
Adequate Supply of Infant Formula from the Clinic (1) Eight participants indicated that they received four (4) tins o f formula per month from the clinic, which equaled twenty-four tins of (500 g) formula for six months.According to the DOH (2000:6), at least a two-week supply of free infant formula should be given to the mother on discharge.Mother no. 1 stated that she received an adequate supply o f formula: " The tins which I receive from the clinic are enough as the newborn baby d o e s n ' t eat too much".She subsequently made a con tradictory statement: '7 used my social grant to buy extra tins o f formula fo r my infant".In an informal conversa tion with the lay counsellor, it was es tablished that HIV-positive mothers who practised exclusive formula feed ing were given 3 tins (500 g each) of formula per month for the first three months o f life and 4 tins o f formula per month for the second 3 months.This equaled 21 tins of formula for 6 months.
Minimal Supply of Infant Formula from the Clinic (7) HIV-positive mothers who opted for infant formula experienced problems with the minimal supply of formula from the clinic.

Support from Family Members and Spouses/Partners
The majority (90%) of mothers inter viewed were unemployed and only 10% were employed.Some received finan cial support from their family members and spouses and others did not.

Support from Family Members (3)
Mothers no.2, no.6 and no. 8 indicated that they received financial support from their parents and/or partner: "Mj' parents helped me and bought a tin o f formula fo r my child"."He helped me as much as he can because he does not have a full-time job, he has piece jobs but when he has money he helped me by buying tins o f milk and clothes fo r the child".The DOH (2004) pro motes the notion that both parents share the responsibility for the health and welfare of their children.The type of infant feeding method has health and financial implications for the entire fam ily.Mothers, fathers and other mem bers o f the family should understand the issues and risks, and be encour aged to reach informed decisions about infant feeding matters together.Ulti mately, the decisions about infant feed ing tend to be the mother's.

Support from Their Family Members
(6) The choice not to breastfeed is espe cially difficult for poor women in de veloping countries.Raisler (2005:279) states that poor moth ers who lack fuel, running water or re frigeration, are often unable to prepare the form ula safely.A ccording to UNICEF in action (a) (2002), the for mula distribution programme made bottle-feeding affordable, but not feasible, safe or acceptable.

Early Introduction of Solids (6)
In the study 'Exclusive breastfeeding in Vietnam by Almroth, Arts, Quang , Thuy-Hoa and Williams (2008:1067) it is clear that exclusive breast-feeding is not practised, None o f the mothers in terviewed in their study had practised exclusive breast-feeding.All o f them had given their infants a variety of flu ids and foods from an early age.Simi larly, the grandmothers and the oldest women reported that they had intro duced fluids and foods to their chil dren early.It was established that HIV-positive mothers who experienced problems with the minimal supply o f tinned for mula from the clinic resorted to early introduction o f solids.Cultural factors influence the m others' decisions to practise mixed feeding for their babies.Mothers believed that babies intro duced to solids at an early age will grow in size and in weight.Mother no.2: "I have started my infant on Maltabella on the second month because tins o f milk finish quickly and I had to come back to the clinic before the last tin finishes and I fo u n d that they have nothing in stock''.Mother no. 3 indi cated that she had started her infant on soft porridge when she was 2 months old: '7 have started my child on soft porridge at two months, and tins o f milk which I receive from the clinic do not finish quickly any more ".Mother no.4: '7 have started feeding my child on soft porridge at six weeks because the tins o f milk which I re ceive from the clinic are too little and when I go back to the clinic to request fo r some more tins, I fo u n d that the clinic is out o f stock".Coustsoudis, Pillay, Spooner, Kuhn & Coovadia (1999:473) suggest that the practice of supplying free milk formula should be carried out with caution as this seems to encourage mixed feeding, especially if inadequate formula is supplied.In addition, running out o f formula is one o f the reasons that HIV-positive moth ers do not always use formula feeding exclusively.Laura et al (2001:6) state that HIV-positive mothers who live in resource-poor settings find it difficult to source an uninterrupted supply of free formula.

Lack of Physical Rest (2)
The normal lives o f HIV-positive moth ers often become disrupted and some do not cope with the preparation of feeds for their infants.This was evi denced by the follow ing citations.Mother no.3: "It is difficult with this child because I am feeding him on bot tle, I don't have rest day and night is the same.I have to prepare during the day and night I woke up to prepare again ".She further stated: "I fin d it better to breast-feed because the first child I was breastfeeding and I was not suffering like this HIV-positive mothers may find it difficult to cope with the constraints o f replacement feeding, in terms of cost, workload and time, and with the additional health care needs of non-breastfed infants.De Wagt & Clark (2003) support this view by noting that the preparation o f safe formula feeds requires a substantial amount o f work and time on the part of the mother, particularly in a resourcepoor setting.In particular, HIV-positive mothers have practical difficulties in preparing formula at night, as they have to wake up and prepare formula.Bland, Rollins, Coovadia, Coutsoudis and Newell (2007:295), indicate in their study that "those women with inad equate fuel were less likely to adhere to replacem ent feeding, suggesting there were practical difficulties in pre paring formula with wood or no fuel".

Cultural Experiences
Support and Lack of Support from Significant Others In respect of the feeding methods they have chosen it appeared that some mothers received support from their spouses or partners while others did not.
Support from Significant Others (5) Some of the mothers indicated that they received support from family members regarding the feeding options they had chosen.M other no. 10 said: "My mother accepted the method I have chosen because I am still at school and she wants me to finish as next year is my last y e a r".Mother no. 9 indicated that she received support from her hus band and her sister's child who helped her with household chores.She cited the following " The father o f my child and my sister s child help me with preparation o f feeds as I have indi cated that the baby cries a lo t".Ac cording to the DOH (2004), infant feed ing methods have health, cultural and financial implications for the entire fam ily.Mothers, fathers and other mem bers o f the family should be helped to understand the issues and risks, and be encouraged to reach informed deci sions about feeding matters together.De Wagt & Clark (2003: 100) maintain that the father and grandmothers have a considerable amount of influence on the choice of infant feeding method.
Where possible and when appropriate, the partner o f the mother should be counselled and assisted in understand ing the situation so that he will provide the mother with the necessary support.A negative attitude contributes signifi cantly to an unfavourable outcome (DOH, 2000:2).It has been affirmed that formula feeding becomes easier if the baby's father knows the mother's HIV status and supports her decisions (Raisler, 2005:279).Both parents are responsible for the health and welfare o f their children and the chosen infant feeding method has health-and finan cial implications for the entire family.
Therefore, the involvement of the male partner in decision-making about infant feeding seems to be a key factor in the acceptability of formula use by HIVpositive mothers (De Wagt & Clark, 2003:98).

No Support from Significant Others and Partners (3)
In many cultures there is a stigma at tach ed to m others who do not breastfeed (UNICEF in Action (b), 2002 online).In this context, 90% of partici pant mothers were Northern Sotho speaking.It was clear from the partici pants' responses that breastfeeding is regarded as the norm.This was con firmed by Mother no.5: "I am staying with my sister and she doesn' t under stand why I am not breast-feeding.She said I am not a good mother because each and every mother is supposed to breast-feed her child".Mother no. 1 indicated that she was afraid of going home because o f her HIV status: "lam afraid o f going home because my part ner has told them my status." Mother 2: "Hmm...I don', know whether to call it support or not, because he saw the baby once and on that day he asked me why I am not breast-feeding the baby."Thus, where breastfeeding is the cultural norm, women who do not breastfeed are concerned that this may signal their HIV-infected status to oth ers.Some women may find it difficult for social or cultural reasons, includ ing fear o f violence, stigma, ostracism or being abandoned because they are HIV-positive (Laura et al, 2001:4;DOH, 2004).According to De Wagt and Clark (2003:99), fathers and grandmothers of the infant have considerable influence on the choice of infant feeding method.Grandmothers are the main secondary carers for infants, especially when the mother has to be away at work.How ever, fathers claim to help and partici pate in child feeding, child care and housework, assisting with tasks such as: 'helping the wife to take care o f the baby with feeding and drinking' '; 'Hold baby, give baby a bath'; 'Some times cooking, and washing (Almroth, etal, 2008(Almroth, etal, :1068)).
In an attempt to assist those who have to provide formula feeds, the Depart ment of Health (DOH) (2000:2) (Dorosko & Rollins, 2003:119).Linkages (2005) support the above re flection in which mixed feeding is thought to irritate the infant's internal stomach lining and allow easier access to the virus through the infant's stom ach Besides, the practice of mixed feed ing in the first three months o f life puts the baby at an increased risk o f HIV infection com pared with exclusive breast-feeding (WHO, 2000;Laura et al, 2001:4;DOH, 2004).Exclusive breastfeeding is uncommon in Africa and most women give their babies mixed feeds (Hankins, 2000:23).In this study, one mother who chose to breastfeed, felt compelled by the hos pital staff to breastfeed as there was no provision for formula feeding in the hospital.Another mother was reluc tant to resist the pressure to breastfeed, as this would reveal her status or fear o f her HIV status.These mothers prac tised mixed feeding from the first month o f their babies' lives.Citations re corded in support o f this include: mother no.9: '7 am breastfeeding my c h ild a n d g iv in g h er w a ter an d Maltabella once a day This mother seem ed to be lacking appropriate knowledge because she further gave the baby formula as she said, '7 am m ixing M altabella with fre sh milk which I buy from the shop.I wanted to test the baby as to whether she will be able to take Maltabella Mother no.6 said "From the first month 1 breastfed my child and gave him water only Coutsoudis et al, (1999:474) indicate that women who chose to breastfeed were co u n selled to co n sid er exclusive breastfeeding because o f the possible dangers o f damage to the wall of the intestines .For most mothers this is a difficult concept because it is cultur ally acceptable to give water and herbal teas early during breastfeeding and to introduce solids, such as infant cere als, within the first month of life.Raisler (2005:279) cited some obstacles asso ciated with mixed feeding: these include preparation o f formula, which is more time-consuming, especially in the ab sence o f a refrigerator, clean running water or a ready supply of fuel for boil ing water than mixed feeding, even if the mother has access to formula.There is strong evidence that mixed feeding carries considerable risk for HIV trans mission (Coutsoudis et al, 2001:379).

Recommendations
On the basis of the findings discussed in this study, there is a need to pro pose the development o f the relevant health education programmes that can be utilised by midwives educating HIVpositive mothers regarding the infant feeding of their choice.The main ob jective is to establish safe infant feed ing practices.Whatever feeding prac tice is chosen by the HIV-positive mother, counselling on infant feeding must take the following key factors into account (Raisler, 2005:279)

Conclusion
A total of 80% o f mothers opted to for mula feed their infants.However, most participants lacked appropriate facili ties to sustain availability o f the milk formula, basic sanitation and electric ity.Those who opted for breast-feed ing (20% o f mothers) also practised mixed feeding.Decisions about feed ing options should be based on ad equate and unbiased information rather than ignorance -this is what informed choices is all about.Mothers who are HIV-positive have the right to informa tion when they are making decisions about infant feeding.These decisions should be based on awareness o f all the risks that the mother is taking in relation to her own health as well as her infant's future.Comprehensive in formation on the possibility of MTCT, no matter how inconclusive, must be made accessible to all women who wish to weigh the risks against the social, cultural and economic realities o f their own lives and those o f families and communities.It was clear from the find ings that HIV-positive mothers who practise infant feeding o f their own choice do experience socio-economic and cultural problems.
the data analysis and reached consensuses on the findings.
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