Policy shifts ‘stifling breastfeeding in South Africa’

[CAPE TOWN] Policy shifts in infant feeding guidelines for women living with HIV have weakened confidence in breastfeeding in South Africa, according to an analysis of interviews with experts in the field.

Over the last 20 years, World Health Organization (WHO) recommendations on breastfeeding for women with HIV have changed a number of times in line with new scientific findings, according to the analysis, published in PLOS ONE this month (10 March).

In 2001, the WHO advised women in higher-income countries with low infant mortality rates to refrain from breastfeeding because of the possibility of transmitting the virus through breast milk. But in 2006, exclusive breastfeeding was encouraged for the first six months.

In 2016, guidance changed to encourage breastfeeding for not less than 24 months for women taking antiretroviral medicines.

“Many of the old messages about breastmilk being a vector of HIV are hard for people to let go, despite the huge strides we have made.”

Sara Nieuwoudt, University of the Witwatersrand

“We have been struggling with improving breastfeeding in South Africa,” says Chantel Witten, the study co-author and a dietician based at the University of the Free State in Bloemfontein, South Africa.

“Evidence is clear, breastfeeding is no longer the norm, and formula feeding is desired, yet it is the inferior way of feeding children,” Witten said.

Researchers asked 15 respondents with expertise in implementing infant feeding eight questions around the WHO’s HIV-related infant feeding guidelines and the WHO international code of marketing of breastmilk substitutes and how breastfeeding rates could be improved.

The South African government outlined its commitment to breastfeeding through the Tshwane declaration in 2011, out of concern for rising infant and child mortality and low exclusive breastfeeding rates, according to the study.

The declaration included “provisions to enact regulations to enforce the WHO code. Also that mothers with HIV should breastfeed for 12 months as well as all public health facilities be baby-friendly by 2015, and no free distribution of formula (except by prescription) at government health facilities beginning in 2012”.

But infant formula companies have still been aggressively marketing their products, putting child health at risk in low- and middle-income countries, according to a recent WHO report.

“We have violations on breastfeeding and still no one is held accountable,” explains Witten, adding that the infant formula industry still has a huge influence as some companies fund researchers.

Before 2011, South Africa handed out free infant formula for ten years to HIV-positive mothers to prevent mother-to-child transmission.

This provided a major boost for the formula industry, as many people put their trust in health workers when it came to deciding how to feed their babies, says Sara Nieuwoudt, a participant in the study and social and behaviour change coordinator at University of the Witwatersrand, Johannesburg.

“I am concerned that the commercial formula industry benefits from such confusion,” adds Nieuwoudt.

Evidence has been updated, and breastfeeding is now recommended for all infants regardless of the mother’s HIV status, but confusion remains, according to the analysis.

“Many of the old messages about breastmilk being a vector of HIV are hard for people to let go, despite the huge strides we have made with antiretroviral therapy to prevent transmission,” Nieuwoudt explains.

Lindelani Mushaphi, a dietician and a senior lecturer in community nutrition at the South Africa-based University of Venda, tells SciDev.Net: “I don’t think, if we had the resources we had in terms of medication that we have now to stop transmissions from mothers to babies, the dependency on formula could have happened.”

Mushaphi says she has never seen any person in her province who is monitoring the implementation and violations of the code.

“In studies I have done, as early as one month, mothers start giving babies solid food on the belief that breastfeeding is not adequate,” she says.

South Africa has conducted behaviour change communications campaigns such as Side-by-Side, the Road to Health booklet, and Mom Connect, but the experts felt that information for women on early infant and young child feeding was not enough.

Mushaphi says that breastfeeding advocacy is not adequate because it usually occurs around the breastfeeding month in August, and the rest of the year not much is done.

The month of August is a national breastfeeding month, a period to raise awareness to protect and support breastfeeding in South Africa.

Nieuwoudt suggests that health workers need more training on the updated infant feeding guidelines as well as how to communicate effectively.

Witten says that research remains important to understand what happens across Africa: “If the rest of Africa does not protect itself, it will go down the same road.”

This piece was produced by SciDev.Net’s Sub-Saharan Africa English desk.