/ 8 April 2022

Policy changes around HIV lead to drop in breastfeeding

China Health Family
A new study suggests that changes in policies have led to decreased breastfeeding. (Photo by STR/AFP via Getty Images)

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 past 20 years, World Health Organisation (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 last month.

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.

“We have been struggling with improving breastfeeding in South Africa,” says Chantel Witten, the study’s co-author and a dietician based at the University of the Free State. “Evidence is clear, breastfeeding is no longer the norm, and formula feeding is desired, yet it is the inferior way of feeding children.” 

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

The government outlined its commitment to breastfeeding through the Tshwane declaration in 2011, 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 aggressively market 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,” says Witten, adding that the infant formula industry has a huge influence because some companies fund researchers.

Before 2011, South Africa handed out free infant formula for 10 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.

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

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.

Lindelani Mushaphi, a dietician and a senior lecturer in community nutrition at the University of Venda, says: “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 anyone in her province 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.”

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

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

Nieuwoudt suggests that health workers need more training on the updated infant feeding guidelines and 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 article was produced by SciDev.Net’s Sub-Saharan Africa English desk