Such incomplete counselling is unlikely to lead to successful implementation of South Africa’s infant feeding policy. According to Dr. Lungiswa Nkonki, of the University of Cape Town, who presented another sub-study of the Good Start Study, “there are distinct challenges inherent in both [feeding] options. In the South African setting, an initial period of breastfeeding is seen as the norm for 86% of African mothers, combined with the early introduction of liquids such as water and tea. The most recent Demographic and Health Survey (DHS) from South Africa found a wide range of sub-optimal early feeding practices in the general population, and very limited advice, skills and support being given by health providers on infant feeding issues.”
“There are a number of social, cultural and economic constraints on the ability of women to provide exclusive formula feeding,” Dr. Nkonki said “with the consequence that they may resort to mixing formula feeds with breastmilk.” She also noted that it isn’t clear how poor women are to feed their child after their free six-month supply of formula runs out. Likewise, no one really knows what will happen when women who are exclusively breastfeeding try to wean the infant abruptly, and how those women will feed their child “which could have serious consequences for the nutritional status of the infant, especially given that access to formula milk is not guaranteed in many settings,” said Dr. Nkonki.
Her research involved interviewing 40 mothers (about half of whom were first-time mothers) from the Good Start study in order to gain a better understanding of the factors influencing their infant feeding choices and behaviours by HIV positive caregivers.
She identified a few key themes.
First, mothers want to protect their infants but, being insecure about their choices or their ability to feed their infant correctly, they are quite easily influenced by what counsellors or others tell them — so whether or not the counsellor is giving them complete or incomplete information, they are apt to try to act on the advice if they believe it is for the best.
There are supply problems. Occasionally, there are stock outs of the formula (see http://www.aidsmap.com/en/news/0624EC9F-F6EE-4624-982C-D14E43B0A984.asp)
and other times, mothers will run out of their monthly supply early and are usually afraid to ask for more.
Finally, both formula feeding and early weaning are against the societal norm, and stigmatising to the mother within her community. The mothers are continually under pressure from neighbours, mothers and others in the community to whom they have not disclosed their HIV status to continue breastfeeding — though not to exclusively breastfeed.
At a session on breastfeeding at the WHO meeting on Nutrition and HIV earlier in the year, Dr. Magdalena Nghatanga from Namibia also raised this point: “The problem we are having with early cessation of breastfeeding where women understand their options and choices regarding infant feeding but when it comes to the young HIV-positive mothers — they are not necessarily independent. They live within the family where the mother or the mother-in-law still have control over them. When they decide to stop breastfeeding, and their status is not disclosed, it becomes a big problem because they are under pressure to continue breastfeeding.”
According to Dr. Siobhan Crowley, who helped organize the WHO meeting, “the support that mums need to effectively follow their infant feeding options is critical and is not well characterised or implemented in most of the resource constrained settings where this could make important contributions to reducing HIV transmission and improving nutritional outcomes for exposed info and uninfected kids. The role for PLHA and other community structure here is little explored and poorly utilised and not at all well characterised or documented.”
Said Dr. Nigel Rollins, who co-chaired the WHO session on breastfeeding, “we need to identify community interventions to increase the acceptability of other feeding practices. This is a key intervention that we need to understand better.”
While it is prudent to involve the community in developing programmes that support mothers with HIV where they live, it’s difficult to see how breastfeeding practices that run counter to what is recommended for most mothers can be supported without exposing the woman’s HIV status. Many young mothers will have only recently learned their HIV status in the antenatal clinic, and most are relatively healthy.