The slogan “breast is best” is popular and widely recognised. Breast-feeding protects infants from infections such as gastroenteritis and pneumonia, malnutrition, obesity and it promotes maternal health.
The recent “Tshwane Declaration of support for breast-feeding” championed by the national health department serves to halt the scourge of mixed feeding and other practices deterring optimal breast-feeding in South Africa.
In the pre-HIV era, South Africa had reasonable breast-feeding initiation rates (90%) and continuation rates (80% at 12 months), but the difficulty has always been in securing adequate exclusive breast-feeding — which means providing nothing other than breast milk — for six months.
In South Africa, only 10% of infants are solely breastfed by three months and this diminishes to a paltry 2% by six months. Explanations for this unhealthy behaviour include false caregiver notions that the child is hungry and needs more than just milk, the pressure exerted by commercial companies promoting formula and baby food as superior and the need for mothers to return to work or school.
Many initiatives, both international and local, have demonstrated that the rate of breast-feeding, particularly exclusive breast-feeding, can be improved. These include a baby friendly hospital initiative which facilitates breast-feeding soon after birth, community health promoters visiting homes and supporting mothers with breast-feeding, workplace support for breast-feeding mothers and stricter monitoring of the milk industry’s compliance with the code of marketing of breast-milk substitutes.
The declaration of increased support for these activities by the health department is most welcome and is likely to boost appropriate breast-feeding practices in the country. Wider promotion and acceptance of breast-feeding in South Africa has been complicated in the past two decades by the fact that almost a third of pregnant women in the country are HIV-positive and that most transmission of HIV from mother to infant occurs through breast-feeding.
The contribution of breast-feeding to the transmission of the disease has become more pronounced as strategies preventing transmission at the time of birth (such as nevirapine) have been more widely implemented. Newer drug combinations provided to the mother and/or baby during the pregnancy or around the time of birth can reduce HIV transmission to 1%-5%.
However, every month of breast-feeding thereafter adds an additional 1% increase to the transmission risk, so the chance of HIV acquisition may be closer to about 10%-15% if a HIV-positive mother chooses to breastfeed for 12 months. Indeed, the risk of acquiring HIV from breast-feeding far exceeds that from unprotected heterosexual sexual intercourse with a HIV-positive partner (by about hundred-fold per exposure).
Therefore, advising HIV-positive women to stop breast-feeding their infants and instead providing a replacement feed such as infant formula seems logical, if HIV prevention is a priority (which it is, since more than half of infant deaths in South Africa are HIV-related). This is the favoured option selected by parents in high-income countries.
But, in less resourced settings (such as in Zambia and Malawi), the benefit of preventing HIV by not breast-feeding is counter-balanced by the danger of children dying from the diseases that breast-feeding helps prevent such as gastroenteritis and malnutrition. Thus HIV-free survival rates — being alive and HIV-free — at 18 months is similar for children who are either exclusively breast- or formula-fed in the first six months of life in these poorly resourced settings.
More recent research has confirmed that a different strategy can reduce the risk of breast-feeding transmission at six months by about 50%-70%. The two available options are either to provide mothers with antiretroviral drugs during her pregnancy and during lactation or for HIV-exposed infants to receive daily nevirapine for the duration they are breastfed in the first year or until they reach one year of age, whichever is longer.
The first option has the benefit of improving the mother’s health too, particularly if therapy is continued even after she stops breast-feeding. The infant option is, however, cheaper, easier to administer, less toxic and less likely to generate viral resistance in mothers. It is this development that has primarily prompted the health department to withdraw its support for the continued provision of free formula to infants of HIV-positive mothers who were eligible for this, a policy that has been implemented since 2003.
However, there have been other concerns about formula provision including the preference for formula use by some caregivers without adequate safe preparation and storage resources (such as water and refrigeration), the stigmatisation of women who choose formula and a fear that it undermines breast-feeding in the general population.
So, is the removal for free infant-formula provision the right decision for South Africa? There are many reasons why the health department’s new plan for HIV infant feeding may, in fact, be shortsighted, not sufficiently evidence-based and even counterproductive.
First, using data from poorer Southern African countries to argue that replacement (formula) feeding cannot be safely undertaken in South Africa may not be appropriate. More than half of South African children are urbanised. Many have good access to safe water (61%), sanitation (63%) and electricity and these statistics exceed 95% in urban areas, including townships.
In 2007, the infant mortality rate was lower than 25 per 1?000 live births in three of the nine provinces of South Africa. This is below the accepted threshold value used to determine when formula feeding can be safely delivered. Thus, at least a third to one half of South African caregivers should be able to formula feed their children safely. Data from Soweto confirm that this is the case.
This does not mean that choosing to formula feed an infant in some rural parts of the country or in an informal settlement could ever be considered an appropriate choice. However, denying individualised choice and failing to support a legitimate HIV-prevention strategy in circumstances where this can be safely done violates caregivers’ and infants’ rights to basic healthcare and may be unconstitutional.
Arguing that parents can choose to pay for formula from their own pockets may seem reasonable, but this denies access to as many as 25?000 infants when formula feeding may be safely undertaken, but is unaffordable. During this time of fiscal restraint where healthcare resources are finite, information about both effectiveness and costs are important for policymakers as evidence-based decisions are made.
When the issue of cost was raised during the recent breast-feeding consultation, the comment that “a back-of-the-envelope calculation shows that breast-feeding is much more cost-effective than formula and could save R200-million a year” was met with wild applause. This type of fuzzy evidence to support a major policy shift is unfortunate.
Cost is one of several factors that should be considered when setting policy. What should also not be under-estimated are the demands on the health system of the new policy. It requires that about 300?000 mothers each year be convinced to breastfeed exclusively for six months, and to provide healthy, uninfected (but HIV-exposed) infants with a daily dose of a drug (nevirapine) for up to one year.
The health service will need to monitor these children at least monthly and ensure that their drug supplies do not falter. The benefit of nevirapine if a mother starts mixed feeding (breast milk and other foods) or forgets to provide the drug for any period is unknown. A failure to meet any of these requirements will mean that transmission rates of infant HIV could start escalating again.
A “one- size-fits-all policy” is certainly simpler to promote and the notion that “mixed messages lead to mixed feeding” makes sense. In the case of South Africa, however, the best should not be the enemy of the good. Until recently, infant feeding policy was made at provincial level. This makes sense because South Africa is heterogeneous in so many respects– the rural-urban mix, the availability of water and sanitation, the background infant mortality and the provincial variation in the percentage of mothers with HIV.
The newly proposed policy demands that the whole country assume the same position, namely, no free formula provision. Nevertheless, even if the arguments advanced in this piece are ignored and all provincial departments of health embark on the process of formula withdrawal, it is advised that they invest efforts towards a carefully considered implementation plan.
The cultural factors that influence feeding practices are highly complex and, at best, this new breast-feeding policy needs to be carefully and deliberately phased in. It requires enlisting commitment from obstetricians, paediatricians, midwives and nurses in both the private and the public sectors to promote the notion that breast is best.
Some might say that revitalisation of primary care is on its way and that the deployment of thousands of community health workers will facilitate this new infant feeding policy. This may be true in some settings, but it is hardly a fait accompli. In the rush to ensure that South Africa is on a path to decreasing infant mortality from all causes, it is critical to ensure that the recent gains in the number of HIV-exposed children’s lives saved through existing interventions, including formula feeding, are not erased.
Haroon Saloojee is professor, division of community paediatrics, University of the Witwatersrand. Glenda Gray is executive director of the Perinatal HIV Research Unit and associate professor, University of the Witwatersrand. James McIntyre is executive director of the Anova Health Institute. Avy Violari is researcher, Perinatal HIV Research Unit