25 August 2011

South Africa: Mother's Milk the Only Way

Photo: Olivier Asselin/UNICEF
While HIV is no longer the prime reason why women do not exclusively breast-feed their new-born babies, trying to juggle work and being a new mother, combined with one’s living conditions are some of the reasons new mothers give for not exclusively breast-feeding.

In a strong move to encourage breast-feeding as a key intervention to promote child survival, the national Health Department has decided to promote exclusive breast-feeding for the first six months of an infant's life even for those with HIV-positive mothers.

Years of research into the prevention of mother-to-child HIV transmission have resulted in confusion over feeding options for new mothers who have HIV. Science has shown that HIV-positive mothers could infect their babies with the HI virus through breast-feeding.

Scientific recommendations have since advocated for HIV-positive women to either exclusively breast-feed their babies for the first six months of life or to give them formula milk only.

As a result, the Health Department offers free formula feed to HIV-infected mothers. Some mothers mix-feed their babies and give them both breast and formula milk. But public health experts say this form of feeding makes for easy HIV infection in infants.

"It's felt that exclusive breast-feeding, although HIV is present in breast milk, offers some kind of protection to the gut of the baby that makes it less likely to be infected, particularly in the first few months of life. It's not completely what are the protective factors, but it appears that when milk is mixed with formula that may be contaminated there's introduction of infective agents that cause a break-down or a weakness in the integrity of the intestinal linings that may make the passage of the virus much more easy to pass into the baby. So, it's felt that exclusive breast-feeding offers that protection", says Professor Ashraf Coovadia, a paediatrician at the Rahima Moosa Mother and Child Hospital, in Johannesburg.

The province of KwaZulu-Natal decided last year already to phase out the provision of free infant formula by January this year. The decision came as the province recorded a significant drop in HIV transmission from mother to child. The national rate has dropped from over 30% about 10 years ago to 3.5 % nationally and 2.8 % in KwaZulu-Natal.

"We seem to be doing exceptionally well on PMTCT and the results are now showing.

But why should we put such an effort prevent a child from getting infected in the womb only then to have all these combinations - infant formula feed and mixed feeding which reverse all that you have done? You might as well not have PMTCT if you are going to reverse your gains. Why don't we follow what they are advocating - successful PMTCT, follow it up with exclusive breast-feeding, at least, for six months you will see the benefit? While it is an economic issue that we seem to have stopped the infant formula feed, the results are now showing that we are now having less and less children being admitted in our hospitals for diarrhoeal disease, pneumonia and malnutrition. We are not yet able to say that in big numbers we are just observing. But we hope that is where are going by what we are seeing as a trend", according to the provincial Health MEC, Dr Sibongiseni Dhlomo,

KwaZulu-Natal's decision is in line with the World Health Organisation's recommendations of 2010.

"National health authorities should decide whether health services will principally counsel and support all mothers known to be HIV-infected to breast-feed and receive ARV interventions or to avoid all breast-feeding so that you can have a single national strategy.

This decision should be based on international recommendations and considerations of the socio-economic and cultural context of the populations served by those services, the availability and quality of those services, the local epidemiology such as the HIV prevalence amongst pregnant women and the other causes of infant and child mortality and under-nutrition.

The second main change was that in countries where national authorities decided to support breast-feeding and ARVs, that there was a categorical statement that mothers known to be HIV-infected should exclusively breast-feed their infants for the first six months, introduce complementary feeds thereafter and continue breast-feeding with no consideration of stopping for the first 12 months of life', explains Dr Nigel Rollins of the WHO.

Health Department Director-General, Precious Matsoso, says exclusive breast-feeding needs to be promoted as a basic need for child survival, regardless of a mother's HIV status. She says the Health Department is proposing legislation to encourage the practice in all spheres of society.

"We'll come up with consensus on legislative, policy and programme changes that are required to better support, promote and protect breast-feeding. We'll also come up with concrete actions that will help us promote, protect and support breast-feeding for all stakeholders but to ensure that we have a responsive health system that will help us promote breast-feeding amongst communities as well as breast-feeding in the work-place", Matsoso says.

From now on, all pregnant women who have HIV and attend public sector antenatal facilities will not be given an option to formula feed their babies. They will be advised to breast-feed in addition to being put on ARV therapy. The eight other provinces will follow the lead of KwaZulu-Natal and phase out the distribution of free formula feed. If, for any medical reason, a woman cannot breast-feed her baby, infant formula will be given by way of prescription by a doctor or another health care worker.

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