Introduction: KwaZulu-Natal is one of the provinces most affected by HIV/AIDS in South Africa. The estimated HIV prevalence among pregnant women attending ante-natal clinic at LUDWMH in Empangeni is high (40%). Infant feeding practices by these mothers are critical to reducing MTCT of HIV. The objectives of the study are: to describe the ante-natal infant feeding choices of a group of HIV-positive women attending the PMTCT clinic at LUDWMH; to determine the infant feeding practices of these women during the six weeks post-natal period; to determine the correlation between these mothers‟ infant feeding choices and their actual infant feeding practices six weeks after childbirth; to describe these women‟s socio-environmental conditions; and to determine the compliance of their infant feeding practices to safe infant feeding guidelines. Materials and methods: A descriptive cross-sectional study design was used. The mothers were from the predominantly poor-rural communities in Area 3 of northern KwaZulu-Natal. Data were obtained by the use of structured questionnaires which were directly administered to 395 mothers attending the PMTCT clinic six weeks after childbirth. Their ante-natal clinic records were also reviewed. Data entry was done with Microsoft Access. The data were analysed using Epi Info and Microsoft Excel. Results: The commonest ante-natal infant feeding choice was exclusive breastfeeding (78.2%) which was more than the combined number of women who chose replacement feeding (19.2%) and mixed feeding (2.5%). Majority of the mothers practiced their infant feeding choices in the six weeks post-natal period (p-value = 0.000). Expectedly, access to regular maternal income was low (36.7%; 95% CI 32.0 – 41.7). However, access to the other three individual socio-environmental resources was high [safe water (66.8%; CI 61.9 – 71.4); fuel (83%; CI 79.0 – 86.6); fridge/freezer (82.5%; CI 78.4 – 86.1)]. Approximately 61% of women had access to all three of these resources (cumulatively). Discussion and conclusions The study demonstrated that exclusive breastfeeding is the predominant infant feeding choice and practice amongst women attending LUDWMH, Empangeni in KwaZulu-Natal province. The high uptake of exclusive breastfeeding (77.7%) in the six weeks post-natal period is encouraging given the heavy burden of diarrhoeal diseases and protein-energy malnutrition with associated high mortality rates in this setting. Another encouraging finding that may help to improve prevention of MTCT of HIV was that mixed feeding was uncommon in these women. The finding that almost two-thirds of mothers who practiced replacement feeding complied with WHO/National guidelines for safe replacement feeding in this largely poor-rural setting is commendable.

A paper submitted to The University of Arizona College of Medicine - Phoenix, History of Medicine course.

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Decision making could be defined as the ability to make a choice or a judgement before an individual takes action. How the individual works through the process of making a decision is influenced by a number of factors. It is acknowledged decision making is a complex process that involves cognitive and affective thought processing, together with interpretation, understanding, choosing between alternatives and taking action. The steps involved in this process are varied and range from a few to many depending on whose literature one is reading at the time. This descriptive cross sectional study aimed to determine what factors influenced a woman's decision when choosing the infant feeding method for her newborn. The information was gathered by means of a survey questionnaire and follow-up telephone interview. The factors identified as being important or influencing the decision were included on the survey. These factors were highlighted in previous studies and were considered part of the Theory of Reasoned Action (TRA) the framework on which this study was based. The one hundred and sixteen women who participated in this study had delivered term babies - that is babies over thirty-seven weeks gestation, in two hospitals in metropolitan Melbourne. A number of assumptions were tested. The descriptive statistics was generated using Statistical Package for Social Sciences (SPSS) Version 7. The qualitative data was analysed using thematic analysis. Eighty-five per cent (85%) of the women in this study made the decision to breastfeed and seventy-five per cent (75%) made this decision prior to their pregnancy being confirmed. Ninety-seven (83.6%) of the women stated their own values and beliefs had a major influence (i) on their infant feeding decision with just over twenty per cent (20.2%) of the women indicating the midwife had a major influence on their decision. Results of data supported or refuted the assumptions made at the beginning of the study and previous studies. These results also identified areas in midwifery practice that require change. This in itself will be a challenge for midwives. How they respond to this challenge may have an impact of the way women make the decision regarding their choice of infant feeding

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In Tanzania where HIV transmission is high, decisions to avoid or modify breastfeeding are crucial for infant survival yet difficult due to competing risks. This thesis explores the attitudes towards HIV and infant feeding of mothers and significant members of their social networks in Central Tanzania. It seeks to understand the perceived and potential role of social dynamics in infant feeding decisions to prevent HIV. Qualitative data was collected from in-depth interviews with twenty key informants, six HIV-positive mothers and four relatives of HIV-infected mothers. Thirteen focus group discussions were conducted in one urban and three village sites in the Dodoma region with mothers, fathers, grandparents, traditional midwives and healers, village leaders and people living with HIV. This process was adapted to benefit and maximise participation of respondents and people with HIV. Data was analysed using grounded theory and natural Swahili language. Cases of HIV-positive mothers and their close networks are used to explore the findings. Social graphs visually map and communicate the complex social context around infant feeding in new ways. Emerging themes based on Swahili categorisations provide original conceptualising of how social relations (jamii) are involved in decision-making. In the context of HIV, infant feeding is a moral issue of fear and safety (salama): decisions seek to maximise kinga (immunity). Social ties wield influence on infant feeding decisions by acting as kinga, and as gates or open paths for the flow of capacities (uwezo) into and within networks. Various kinds of capacities affect perceived possibilities for infant feeding and how social ties are involved. The embracing or rejecting of responsibilities within ties, especially after HIV status disclosure, affects mothers?? networks and choices. Networks of influence are constantly changing: resource availability and social support are dynamic. Original conceptualisations of infant-feeding, risk, trust and disclosure networks and their interaction and change explain these patterns of involvement. Swahili-based conceptualisations are used to explain how social ties manage HIV and infant feeding in complex, dynamic ways. This thesis helps reposition approaches to working with Tanzanian mothers, families and communities to enhance support for mothers?? choices by building on collective capacities and responsibilities.

Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder diagnosed in childhood. It is largely accepted that ADHD is a product of gene-environment interactions and method of infant feeding has been proposed as a factor influencing the expression and/or severity of ADHD. The objectives of this study were to determine the relationship between infant feeding (i.e. formula feeding or breast feeding) and subsequent hyperactive/inattentive (H/I) behaviours and ADHD diagnosis and if the relationship between infant feeding and academic performance is moderated by H/I scale score. This study used data from the 2000/1, 2002/3, 2006/7 and 2008/9 cycles of the National Longitudinal Survey of Children and Youth (NLSCY) (n= 3,895) to follow children longitudinally from the age of 0 to 1 years old to 6 to 7 years old. Infant feeding at 0 to 1 years old, and child H/I score, ADHD diagnosis and academic performance scores at 6 to 7 years old were reported by the biological mother. Multivariable logistic and linear regression were used to determine the relationship between infant feeding and H/I score, ADHD and academic performance adjusting for a range of sociodemographic, birth and home environment factors. Breastfeeding for more than 12 months was found to be significantly associated with decreased H/I scale scores in the most adjusted model (OR=0.3; 95% CI 0.2-0.8, p<0.01). Infant feeding was not associated with ADHD diagnosis and there was no moderating effect of the H/I score on the relationship between breastfeeding and academic performance. A small proportion of mothers breastfeed beyond one year in Canada and this study shows that there might be important child benefits incurred by breastfeeding for longer than 12 months. / May 2016

Introduction: There has been a lack of longitudinal studies on maternal and infant factors associated with feeding difficulties. Feeding difficulties are common, cause much anxiety for parents, and are associated with a range of child health and behavioural outcomes. This study aims to gain an understanding of the prevalence and type of feeding difficulties found in a community sample, the prevalence of maternal mental ill-health and identify maternal and infant factors predictive of feeding difficulties. A final aim is to identify factors associated with successful and unsuccessful feeding experiences from a maternal perspective. Method: A short questionnaire with questions about support and help-seeking was compiled, and several standardised measures were included in the pack; a measure of maternal mood (DASS-21), social support (SOS-S), and eating disorder symptomatology (EAT-26). Questionnaires were given to mothers in pregnancy, and again when infants were around 3 and 7 months old. An adapted version of the Child Feeding Assessment Questionnaire, and the food fussiness subscale from the Children’s Eating Behaviour Questionnaire examined feeding behaviour and maternal response. The Infant Temperament Questionnaire examined maternal perception of infant temperament. Content analysis was used to identify themes in mother’s narrative about factors which help feeding and barriers to a successful feeding experience. A within subjects design was employed to examine predictors of infant feeding difficulties. Results: 23% of mothers of 3 to 5 month old infants, and 13% of mothers of 7 to 10 month olds reported their child as having one or more feeding difficulties. Levels of stress remained stable across the length of the study, but prevalence of maternal anxiety and depression reduced. 47% of those mothers who breast fed found breast feeding difficult or very difficult. Maternally identified barriers to successful feeding with feeding were child illness, and painful or difficult breastfeeding. Mothers wanted an improvement in support and knowledge of health professionals, and a reduction in pressure from health professionals in relation to feeding method. Maternal depression and stress were correlated with severity of food refusal in infants, as well as maternal anxiety and food fussiness, prior to post-hoc analyses. Following post-hoc analyses these relationships were no longer significant. Discussion: Relationships between infant behaviour, maternal health and feeding difficulties are explored. The low prevalence of feeding difficulties and reasons for negative findings in relation to predictors of feeding difficulties are discussed. Implications for health services are presented in the light of maternal views about support and barriers to successfully feeding their child.

Context: Despite the many initiatives implemented over the past decades as part of the global priority on child survival, there still exists high infant mortality in Southern Africa. Although studies have examined factors contributing to poor child health outcomes including the effect of the HIV/AIDS pandemic, there is paucity of studies on the possible effect of infant feeding practices on infant mortality in the region. This study examines the association between infant feeding practices and infant mortality in Southern Africa. The need to reduce infant mortality is a global health concern hence the United Nations through the Millennium Development Goals (MDGs) declared the reduction of infant and child mortality as one of its major targets by the year 2015. Methods: A merged dataset from the most recent Demographic and Health Surveys for Lesotho, Swaziland, Zambia and Zimbabwe was analysed in this study. A total number of 13, 218 infants born in the last five years preceding the surveys whose information on infant feeding practices was available formed the analysis sample. The outcome variable was infant mortality and infant feeding practices which had the categories, no breastfeeding, partial breastfeeding and exclusive breastfeeding was the main explanatory variable of the study. Other explanatory variables used in the study pertained to maternal demographic and socioeconomic characteristics as well as the infants’ bio-demographic characteristics. The Cox Hazard Regression Model was employed to examine both the unadjusted and adjusted effect of infant feeding practices on infant mortality in Southern Africa. Results: Although, exclusive breastfeeding was quite low (12%), its mortality reduction effect was significant, and infants who were exclusively breastfed exhibited a 97% lower risk of dying during infancy compared to no breastfeeding in the region. Further, variations exist by country in the levels and patterns of both infant mortality and infant feeding practices. Country, highest educational level, marital status, sex of child, preceding birth interval and birth weight were the significant predictors of infant mortality in Southern Africa. Conclusions: Overall, the study found that any form of breastfeeding whether exclusive or partial breastfeeding greatly reduces the risk of infant mortality, with the mortality reduction effect being higher among exclusively breastfed infants in the Southern African region. Thus, in order to reduce the upsurge of infant mortality, there is need to step up the effectiveness of child nutrition programmes that promote breastfeeding and put emphasis on exclusive breastfeeding of infants in the region.