South Africa’s high child mortality rates have forced the government to rethink its policy on infant feeding and move to discontinue the free provision of formula milk at hospitals and clinics, as well as promote an exclusive breastfeeding strategy for all mothers, including those living with HIV.
Minister of Health Aaron Motsoaledi made the announcement on 23 August after a two-day national consultation on breastfeeding in the capital, Pretoria, after participants unanimously recommended the changes.
South Africa is one of only 12 countries in the world where infant mortality is rising. It also has one of the world’s lowest levels of exclusive breastfeeding: an estimated 8 percent, dropping to 1.5 percent for babies between four and six months old, government surveys have found.
Motsoaledi admitted the new infant feeding policy had been prompted by the country’s “unacceptable” child mortality rates. “Our country is going through a rough patch – one that no country would like to see itself in. Child mortality is increasing at a very disturbing rate,” he told delegates.
The impact of not breastfeeding has long been recognized. Children who are not breastfed are six times more likely to die from diarrhoea and have a higher chance of respiratory illnesses.
“Breastfeeding has been scientifically shown to be far and away the single most important intervention [to prevent] child deaths ... let's stop talking now and do something about it," said Hoosen Coovadia of the Reproductive Health and Research Unit in Durban.
Lack of support
But the country's health system has not supported the practice. Mothers are often discharged as soon as six hours after birth, not giving time for young, inexperienced mothers to establish breastfeeding. In addition, counselling on infant feeding was poor, with mothers given formula, Motsoaledi noted.
Formula milk manufacturers and distributors have also promoted their products aggressively, because of the absence of legislation to regulate the marketing of formula milk, cautioned the UN Children’s Fund (UNICEF) legal officer Dave Clark. South Africa has been targeted as one of the fastest-growing markets for formula in the world.
According to Thulani Ntshani, a Department of Health official, working mothers were also not adequately supported and often stopped breastfeeding once they returned to work as most working environments made it difficult to breastfeed.
In addition, South Africa's high teenage pregnancy rate meant teenage mothers often left their babies with their mothers and relied on formula feeding.
But the biggest barrier to breastfeeding has been the "confusion" surrounding infant feeding and the risk of HIV transmission. The dilemma has been to balance the risk of infants acquiring HIV through breastfeeding against the risk of death from causes other than HIV, in particular malnutrition and serious illnesses such as diarrhoea and pneumonia.
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Health officials now recognize, however, that the benefits far outweigh the risks. Recent studies have shown that giving antiretroviral drugs (ARVs) to either the HIV-positive mother or HIV-exposed infant can significantly reduce the risk of transmitting HIV through breastfeeding.
In December 2009, the UN World Health Organization (WHO) issued guidelines recommending that infants born to HIV-positive women be exclusively breastfed for the first six months, but South Africa's programme to prevent mother to child HIV transmission has continued to provide free formula to HIV-positive mothers.
A broad study in South Africa found that about 62 percent of HIV-positive women were choosing formula even in rural areas, where there was an inadequate supply of clean drinking water.
The study found that many of the women were mixed-feeding - giving their babies formula and solids such as porridge - from as early as three weeks. Research has shown that babies born to HIV-positive women who are fed solids as well as formula or their mother's milk are almost 11 times more likely to contract HIV than those who are exclusively breastfed.
According to Nigel Rollins from WHO’s child and adolescent health unit, providing ARVs is also more cost-effective, as the provision of formula is four times more expensive than using ARVs.
Rollins cautioned that the delays in implementing the new guidelines on infant feeding were "denying HIV-positive mums and their infants their best chance of an HIV-free survival since the beginning of the epidemic".