Infant feeding Status

Export Indicator

This indicator measures three specific areas of infant feeding: • Percentage of HIV-exposed infants who are exclusively breastfeeding at three months of age • Percentage of HIV-exposed infants who are replacement feeding at three months of age • Per
What it measures

HIV transmission can occur through breastfeeding even in settings
where 100% of pregnant women in need receive antiretrovirals for PMTCT or are on ART.
Mixed feeding (giving both breast milk and other foods and liquids) before 6 months of age
increases the risk of HIV transmission when compared to exclusive breastfeeding. WHO,
therefore, recommends exclusive breastfeeding or exclusive replacement feeding for the first
six months of life at which point the addition of complementary foods is necessary.

The coverage for the third dose of diphtheria, pertussis and tetanus vaccine (DPT3) close to the
recommended age of 14 weeks is high in most countries. It is proposed to collect data at this time because most infants are seen then, and it is mid-way from birth to the point at which
exclusive breastfeeding would stop, making it somewhat comparable to the way that exclusive
breastfeeding is usually reported for the general population in the DHS.

Interpretation. This indicator is interpreted to measure the proportions of HIV-infected
mothers who choose each of the three infant feeding practices. The indicator provides
information about the extent to which HIV-infected mothers are choosing safe infant feeding
practices. Because the indicator is measured based on 24-hour recall, if clients’ practices over
the past 24 hours differ from their practices on previous days (e.g. exclusively breastfed in the
past 24 hours but mixed fed on some days prior to that), the indicator results may not
accurately reflect the infant feeding practices of the client population. Also, if clients do not
accurately report their feeding practices, this will lead to differences between indicator results
and the actual distribution of feeding practices.

The information can also be compared with population surveys (e.g. DHS), which monitor
infant-feeding practices in the general population.

Rationale

Uses. At the national or program level, this indicator can be used to track progress toward safer
infant-feeding practices among HIV-infected women and their exposed infants, and to assess
the results of infant feeding counseling during the antenatal and peripartum period. The
indicator also contributes to assessment of the quality of counseling on infant feeding (with low
rates of mixed feeding likely to indicate adequate counseling and support).

At the health facility level, the indicator is useful to monitor the extent to which women are
choosing the safest infant feeding practices. Nutrition education efforts could be tailored to
provide women the knowledge to make informed decisions about feeding practices and skills to
feed their infants as safely as possible, regardless of the practice they choose. The indicator can
also be used to help programs or facilities plan for ARV requirements based on the number of
women who are breastfeeding at 3 months.

Numerator

There are three numerators included in this indicator:
• Number of HIV-exposed infants who were exclusively breastfeeding at or around 3
months;
• Number of HIV-exposed infants who were replacement feeding (no breast milk at all) at
or around 3 months; and
• Number of HIV-exposed infants who were mixed feeding at or around 3 months.

These numerators capture infant-feeding practices among only known HIV-exposed infants who
visit the health facility.

Denominator

The denominator for each of the numerators is the number of HIV-exposed infants 3 months of
age whose feeding practice was assessed.

Calculation

Numerator / Denominator

Method of measurement

There are three numerators included in this indicator:
• Number of HIV-exposed infants who were exclusively breastfeeding at or around 3
months;
• Number of HIV-exposed infants who were replacement feeding (no breast milk at all) at
or around 3 months; and
• Number of HIV-exposed infants who were mixed feeding at or around 3 months.

These numerators capture infant-feeding practices among only known HIV-exposed infants who
visit the health facility.

The denominator for each of the numerators is the number of HIV-exposed infants 3 months of
age whose feeding practice was assessed.

Data collection method. The numerators for this indicator are calculated from national
program records aggregated from facility registers. Ideally data should be aggregated from
appropriate sites and registers such as a standalone or integrated HIV-exposed infant register,
depending on where the services take place and where data are recorded.

During each visit, the health-care provider should inquire about infant-feeding practices during
the previous 24 hours (using 24-hour recall) to determine what the caregiver gave the infant to
eat or drink on the previous day. The response will be recorded as one of the following:
exclusively breastfeeding (EBF), replacement feeding (RF) or mixed feeding (MF). While this is
collected and recorded at every visit on the child health card, providers need only record it in
the register once, during the DPT3 vaccination visit. This record will be used for compilation and
reporting to the national level. The denominator is calculated from the total number of
exposed infants whose infant-feeding practices were assessed. Exposed infants who did not
attend facilities are not included in the denominator. Countries may wish to consider
calculating the indicators using different denominators, such as the estimated number of HIV-
exposed infants who should have received follow-up care, though results calculated with
different denominators would not be comparable.1

In countries where follow-up care for HIV-exposed infants has been integrated into community
outreach services, programs should consider identifying a system for collecting data at the
community level for this indicator. It is feasible for lay service providers and outreach workers
to collect the information required to construct this indicator.

Frequency of measurement and reporting. Data for this indicator should be collected on an
annual basis or more frequently, depending on a country’s monitoring needs. Countries may wish to consider collecting this information at additional points, for example at both 6 weeks
and 6 months, in addition to at 3 months.

Disaggregation:
Disaggregations for this indicator are recommended at the following levels:

ART vs. no ART
Sex
Age
• • 6-12 months
• 13-24 months
• > 24 months

Measurement frequency

Annual

Disaggregation

Age group: (greater than) 24 months

Gender: Male, Female

Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

Strengths: A prominent strength of this indicator is that it is completely harmonized with the
infant feeding indicator being proposed by the PMTCT Interagency Task Team (IATT) and the
WHO for monitoring and evaluating PMTCT. It is also harmonized with the PEPFAR Next
Generation Recommended indicators for infant feeding.

It should be noted that the indicator says nothing about the quality of replacement feeding
given, or the impact of the feeding practices on child survival.

Weaknesses: A potential weakness of this indicator is that it may not reflect the actual
distribution of infant-feeding practices of HIV-exposed infants at the national level, as it does
not include HIV-exposed infants whose exposure status is unknown, or HIV-exposed infants
whose mothers did not attend a facility with their infant for DPT3 or for another reason at or
around 3 months. Another weakness is that it measures infant feeding practices at an
intermediary, rather than end, point in the transition to weaning (6 months). Thus, it does not
capture final outcomes in terms of exclusive breastfeeding during the first six months and
should not be used to infer outcomes at the six-month mark.

Required resources. To collect this indicator, programs need standalone or HIV-exposed infant
registers that allow them to capture infant feeding status (BF, MF, or RF) at the time of of the
DPT3 visit. If the indicator is collected nationally, it needs to be incorporated into monthly
reporting forms.

At the level of facility, it will require that providers receive training in administration of the 24-
hour recall methodology and can accurately distinguish among exclusive breastfeeding, mixed
feeding, and replacement feeding.

WHO has field-tested this indicator in Zambia. EGPAF is currently field-testing it in Lesotho.
Once both field tests are final, the indicator will be revised accordingly.