Malnutrition is silently ravaging South African communities and the government has come under fire for its failure to enforce policies that encourage breastfeeding, proved to improve nutritional outcomes for infants.
But experts say the threat of HIV is partly to blame for this.
Vivian Black, senior clinical programme manager of maternal health and HIV at Wits University’s reproductive health and HIV research unit, said that because HIV complicates the decision about whether to breastfeed or formula feed, there is no clear-cut policy when it comes to advising women on their options.
‘There’s been more of a move towards a universal stance, but up until now it’s been a mess,” she told the Mail & Guardian this week. ‘One of the reasons there isn’t a clear policy is that both those choices are imperfect,” she said.
On the one hand, preparing milk formula with contaminated water or in unsanitary conditions carries the risk that the baby may contract infections or a diarrhoeal disease — the third-biggest cause of death among infants.
On the other, if the mother is HIV-positive breastfed babies risk being infected with the virus. However , the government ‘ s revised guidelines for treating HIV could help lower infant mortality rates and improve the overall health of babies by making breastfeeding safer for babies of HIV-positive mothers.
From this month, the new health department policy is that infants born to HIV-positive mothers will receive the anti-HIV drug nevirapine from birth to six weeks. If the mother chooses to continue breastfeeding, the baby will continue to receive nevirapine for as long as he or she is breastfed. Previously, infants received one to four weeks of treatment with the drug AZT.
In addition, mothers will be assessed to see whether they are eligible for lifelong antiretroviral therapy before they are discharged. Experts say the new regime will be more effective in preventing infants from contracting HIV from their mothers. Activists in favour of exclusive breastfeeding in the first six months of life welcomed the news.
Hoosen Coovadia, Victor Daitz professor of HIV/Aids research at the University of KwaZulu-Natal, said the change in policy is ‘just short of 360 degrees” and praised the government for addressing the issue of how to manage the health of babies born to mothers with HIV and how to feed them.
Coovadia said the new treatment regime was a cheap and effective way to save lives, as nevirapine is ‘no more expensive than the usual pain relievers” and can potentially save thousands of babies each year. But even with the new guidelines there is still a risk, albeit a small one, that babies may be infected with the virus.
Black said although breastfeeding is being encouraged, because of the low risk ‘the choice still lies with the mother”. The challenge is to balance the risk of breastfeeding with the risk of not doing so and to provide adequate counselling to mothers who have to make that choice in a healthcare environment where patients far outstrip healthcare workers.
‘One in three women in this country is HIV-positive — and in some clinics we have one midwife or healthcare worker to 40 or 50 patients,” said Black. However, she said: ‘HIV-negative women must breastfeed because, nutritionally, breastfeeding is best for babies — no question about it.”
The World Health Organisation recommends exclusive breastfeeding for the first six months of life and continued breastfeeding, with complementary foods, up to the age of two years and beyond. But even without the risk of HIV, there are problems with breastfeeding in South Africa.
A recent report on healthcare facilities in the Western Cape found that many could not produce written policies on breastfeeding and some existing policies were inappropriate or poorly implemented. Many mothers were given inconsistent messages about breastfeeding and there was poor postnatal breastfeeding support.
Fancy Mochè, who gave birth to a son at Charlotte Maxeke Johannesburg Hospital two years ago, said she was given no information on breastfeeding at the hospital and had no help in her attempts to breastfeed.
‘I needed that help. I didn’t know what was going on. I didn’t know how to hold the baby, how to hold the breast. My aunts were in Rustenburg and my mother had passed away. I didn’t have anyone to help. I had to do everything with my boyfriend,” she said.
Eventually she gave up trying and opted to formula feed her son. But Mochè, a working mother from the city, had all the necessities required to provide safe formula food — clean water, electricity and a salary with which to maintain a steady supply of formula. These are beyond the reach of most South African women.
‘Inconsistent information and a perceived lack of support from health professionals are barriers to initiating and continuing breastfeeding,” said Lisanne du Plessis, a lecturer in Stellenbosch University’s division of human nutrition and one of the authors of the report.
Other barriers are insufficient maternity leave, few facilities at work to support breastfeeding and embarrassment about breastfeeding in public. Du Plessis said the implementation of policies remains problematic and particular attention should be paid to the appropriate training of healthcare workers.
According to Coovadia, exclusive breastfeeding can reduce infant mortality rates by as much as 13%. However, in South Africa only 8% of babies under six months of age are exclusively breastfed.