Are we ready for universal breastfeeding in South Africa? A response to Vuyiseka Dubula

Are we ready for universal breastfeeding in South Africa?

In South Africa now, the contribution of HIV/AIDS to child deaths is decreasing due to effective scale up of prevention of mother to child HIV transmission (PMTCT) whilst pneumonia and diarrhoea deaths contribute 12% and 5% respectively to under 5 deaths with malnutrition a common underlying cause of death. The recent decline observed in under five mortality is extremely unlikely to continue at the same rate without attention to other leading causes of child mortality, namely newborn deaths and those due to pneumonia and diarrhoea which can both be reduced through increased rates of exclusive breastfeeding.

We absolutely agree that the mother’s decision on how to feed her infant should be a free choice, and that women should be supported in making the choice and in maintaining safe feeding. The 2013 South African Infant and Young Child Feeding Policy explicitly states that “mothers who may still decide not to breastfeed after counselling and education and who meet specific conditions, should be educated and given information on age specific types of infant formula to purchase and shown how to prepare and use formula feeds safely.”

However, research has shown that free provision of formula in health facilities as part of the PMTCT programme influences choice. What woman – especially a poor one – would not choose free formula even if she had intended to breastfeed? This means that most women engage in ‘mixed’ feeding. And there is now overwhelming evidence that HIV transmission is increased by mixed feeding AND infections and malnutrition are worsened.

It is true that it may sound difficult for working mothers to exclusively breastfeed for about six months and continue breastfeeding thereafter; however expressing breastmilk for feeding a baby while at work is an option. While it is time consuming, it has been done successfully by many women, and breastmilk remains sterile unrefrigerated for at least 8 hours. Furthermore, nursing mothers are protected by current South African legislation and it is time that we seriously implement existing legislation aimed at improving maternal and child health.

We strongly support the Department of Health’s new infant and young child feeding policy – which is in line with global best practice. This policy strongly promotes breastfeeding as the feeding method of choice, and with the April 2013 policy decision to adopt option B for PMTCT, all HIV-positive mothers are now eligible for highly active antiretroviral treatment (HAART). This policy also supports women who choose to formula feed given the appropriate circumstances - such as clean water and good sanitation – which generally do not exist in poor communities. But support does not mean encouragement – which is what free formula in health facilities suggests. This new policy focusing on promotion of exclusive breastfeeding, in a country with one of the lowest rates of breastfeeding in the world, is likely to result in improved child survival and development in South Africa.

Professor David Sanders, Dr Tanya Doherty, Professor Debra Jackson, Dr Ameena Goga. School of Public Health, University of the Western Cape, Medical Research Council.