Stop dithering at death’s door

In a historic moment for South Africa, the minister of health convened a national breastfeeding consultation session last month during which almost 1 000 scientists, health workers, policymakers, traditional leaders, members of civil society and United Nations agencies unanimously committed themselves to the Tshwane Declaration of Support for Breastfeeding in South Africa. Its overall goal was to increase child survival.

We were therefore shocked at the Mail & Guardian‘s decision to feature two articles against this declaration, because such unbalanced reporting may literally be a matter of life and death, heightening confusion about infant feeding. We seek to correct this imbalance so that we can move beyond debate towards the appropriate implementation of a policy to increase child survival.

The first piece by Mia Malan (August 26) featured the irresponsible and misleading headline: “Exclusive breastfeeding plan impractical“. She highlighted the low rates of exclusive breastfeeding in South Africa and presented the opinion of one doctor who believed that exclusive breastfeeding was impractical.

Contrary to the impression given by the article, evidence from both poorly and well-resourced countries shows that the promotion of exclusive breastfeeding is achievable with the necessary protection and support, especially from ministries of health.

In fact, in Hlabisa, KwaZulu-Natal, the exclusive breastfeeding rate improved to 76% at five months and 40% at six months with home-based and clinic support.

In a subsequent article (September 9) by Professor Haroon Saloojee and colleagues it was argued that the declaration and the policy to stop providing free formula to HIV-positive mothers could reverse gains made in saving infant lives. On the contrary, this policy is being implemented precisely because South Africa has a high child mortality rate.

Although Saloojee points out the fact that HIV accounts for a large proportion of child deaths, the majority of South African children ultimately die from pneumonia, diarrhoea and malnutrition, which are all substantially preventable through breastfeeding.

Preliminary data from the first national evaluation of the South African prevention of mother-to-child transmission programme shows that 62% of HIV-positive women choose to bottle-feed in a context unsuitable for its safe preparation.

According to the latest demographic and health survey, and contrary to the much higher figures quoted by Saloojee et al, only 58% of urban and 11% of rural families have access to piped water in their homes.

Survey
The 2007 Community Survey Analysis by the Cape Town municipality showed that only 52% of black African households had piped water by 2007. In some areas up to 90 or 100 households, or 300 to 400 people, shared a single standpipe.


Data from the Africa Centre in Hlabisa showed that the mortality rate at three months was 15% among formula-fed and 6% among breastfed infants, despite similar intensive feeding counselling.

In KwaZulu-Natal an 8% increase in diarrhoea and a 4% increase in pneumonia cases between 2009 and 2010 led to a policy decision to phase out free formula as an intervention to prevent mother-to-child transmission of HIV.

In the M&G articles there was an argument that the policy change of not providing free formula milk as part of the prevention of mother-to-child transmission programme is denying individual choice.

On the contrary, the policy seeks to achieve more appropriate and safe choices by withdrawing a perverse incentive — free formula. The declaration and recent policy shift on free formula presents breastfeeding as the default option, which is appropriate for the majority of South African mothers and their infants, unless women have a rare contraindication to breastfeeding.

Individual counselling of HIV-positive women is still critical because breastfeeding may not be the most appropriate choice for a minority of these women. Some of them who meet specific criteria for safe formula feeding may, after balanced counselling, choose to avoid breastfeeding and purchase formula milk for their infants.

Healthcare personnel thus need clear guidelines on infant feeding counselling and how to identify those women who fall outside the breastfeeding group.

The chairman of the South African Medical Association is quoted as saying that “health workers must be allowed to make the final decision about whether to prescribe formula to women who are medically unable to breastfeed” (M&G Online, August 24). This message is consistent with the consultation session in which it was stated that health professionals would authorise the use of formula milk based on medical criteria.

But for the vast majority of South African HIV-positive women exclusive breastfeeding, combined with antiretrovirals, would reduce transmission risk — about 2% after six months of breastfeeding with antiretrovirals — and would be best for the health and subsequent development of their infants.

We are confident that, as occurred in KwaZulu-Natal, a pragmatic approach of phasing out (not abrupt withdrawal) of free formula after wide consultation with communities and healthcare workers will allow this new policy to be implemented effectively.

International child-health experts have estimated that, globally, about 1.1-million child deaths a year (13% of deaths of children younger than five years) could be prevented if the coverage of exclusive breastfeeding was increased to 90% among infants under six months.

The bold policy change by the minister takes a public health approach by reinstating breastfeeding as the default feeding method for all women in the country. This change is critical if South Africa is to reverse the carnage of 66 000 child deaths a year. The country stands at a crossroads — it now has the potential to reverse the dismal trend in child mortality. We cannot afford, as we did in the past, to allow a few dissident voices to derail a policy that is backed by a weight of scientific evidence, strong recommendations from the World Health Organisation and the United Nations Children’s Fund, and the majority of informed child-health workers locally and globally.

Dr Tanya Doherty and Professor Emeritus David Sanders are affiliated to the school of public health at the University of the Western Cape’s health systems research unit; Ameena Goga and Doherty are with the Medical Research Council; Professor Anna Coutsoudis is from the department of paediatrics and child health at the University of KwaZulu-Natal; Hoosen Coovadia is affiliated to the maternal, adolescent and child health unit of the University of the Witwatersrand, emeritus professor of paediatrics and child health, and emeritus Victor Daitz professor of HIV/Aids research at the University of KwaZulu-Natal

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