Professors provoke breastfeeding outrage

South African HIV activists are outraged by a recommendation from world-renowned University of KwaZulu-Natal researchers, professors Hoosen Coovadia and Anna Coutsoudis, that the government should stop providing free formula milk to all HIV-infected mothers at state clinics.

This follows an article in the prestigious British medical journal, the Lancet, this month, in which the two professors argued that “the time has come to confront the obvious dangers of infant malnutrition and mortality associated with formula feeding.”

In an accompanying briefing document, Coovadia and Coutsoudis wrote that “precious health funds, which could be better spent on more effective interventions, are being wasted on provision of free formula, with very little positive impact on the health of infants”.

According to Mark Colvin from Maromi Health Research in Durban, which conducts intensive research into HIV, there is a 15% chance of HIV-infected women who breastfeed transmitting the virus to their babies.
The likelihood of infection can be reduced to as low as 2% if these mothers breastfeed exclusively for six months and are also on antiretroviral treatment (ART). However, in South Africa, many women don’t have access to ART. “It is for this reason that in developed countries, HIV-positive women do not breastfeed but give their babies formula, which eliminates the risk of HIV transmission to nil once the baby has been delivered,” said Colvin. “In addition, it is not the cultural norm to only exclusively breastfeed, and studies have shown that only a small minority of women are able to sustain exclusive breastfeeding in the absence of substantial support.”

But in an interview with the Mail & Guardian this week, Coovadia, who also works for the reproductive health unit at the University of the Witwatersrand, argued that the risk of infant death from formula feeding in poor communities is often higher than the risk of HIV infection. “Women in particularly rural communities rarely have access to clean water and, as a result, babies die of diarrhoea and pneumonia because formula feeding provides them with little immune protection.”

In addition to this, Coovadia said, the state often runs out of formula milk, “as evidently happened in Johannesburg earlier this year”, leaving HIV-infected mothers with no other option than to breastfeed until formula is available again and thereby increasing the risk of HIV transmission to their babies via mixed feeding (i.e. breastfeeding combined with formula feeding). “You should never depend on technology if nature can provide it,” he said.

Professor Glenda Gray from Chris Hani-Baragwanath Hospital’s perinatal HIV research unit in Soweto disagrees. “What concerns me is that they would want to take away women’s choices. Feeding options are a human rights choice. The same option doesn’t work for everyone. Exclusive breastfeeding, meaning the baby gets nothing other than breast milk, not even water, is impractical if a woman needs to return to work.”

Coovadia, however, maintained that women do have the right to choose, but it needs to be a choice based on research. “If a woman thinks her rights supersede the rights of her baby, then so be it. But what does she believe in—science or voodoo?”

According to Colvin, in a relatively wealthy country like South Africa, we should be striving for greater equity whereby all HIV-infected mothers can safely formula feed their babies. “Instead, Coovadia and Coutsoudis seem content to maintain the old divisions in our society. If you are a wealthy or white mother who is HIV-infected, then obviously you formula feed your baby. As for the poor and black majority, these researchers suggest that they should exclusively breastfeed their infants and run the risk of giving their child a lethal disease. Coovadia and Coutsoudis would argue for greater equity in access to antiretrovirals or primary healthcare, but when it comes to safe infant feeding, suddenly equity goes out of the window.”

According to Coovadia, the World Health Organisation (WHO) recommends that HIV-negative women exclusively breastfeed for six months, as it increases the chance of survival of their babies by up to four times. HIV has, however, brought about a significant decrease in breastfeeding, not only among infected women in South Africa. “In some areas in KwaZulu-Natal, breastfeeding rates have decreased from 90% in the 1980s to as low as 50%,” said Coovadia.

In the Lancet article, the researchers accuse formula milk companies of contravening the WHO’s International Code of the Marketing of Breast Milk Substitutes, to which South Africa subscribes. According to this code, formula milk companies are not allowed to advertise in health facilities or to promote formula milk for babies younger than six months. “But all over the country they advertise follow-on formula with special vitamins for young babies,” Coutsoudis said. “They thereby create the impression that the ‘special’ formula milk is better than breast milk and further add to the decrease in breast feeding rates in the country.”

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