This article Max Kroon of Mowbray Maternity Hospital and I wrote for the Western Cape at a time when the Department of Health was beginning a process of “Breast Feeding Restoration” policy, taking advantage of the window of opportunity new evidence on the very low transmission HIV-transmission rates now possible with exclusive breast feeding covered by anti-retroviral drugs provides. Breast feeding is a major saver of lives, especially among people with limited access to basic services and income generation. The Cape Times published it on 24th November 2011 with the sub-heading “HIV should not cause confusion” so the editor had clearly understood our point. This article was written two months after controversy was stirred when two sets of experts in child health had clashed over the issue of breast feeding and HIV in the Mail & Guardian newspaper. We put our perspectives to the people of the Western Cape (at least those who read the paper version of the Cape Times; unfortunately this is not available to non-subscribers online so I thought it worthwhile to put it here).

I note here that this a complex issue: there are many unknowns and variables; perspectives will be different on the meaning and weighting of  any risk/benefit equation. Amid all of this, policy has to be made and adjusted. Max and I stated what we thought policy should do in our province, and tried to lay before the lay public our reasons for this position. We may also have laid our heads on the line in the volatile and sometimes polarised South African HIV context.

“Breast feeding is best for all babies”

South Africa is in the invidious position of being one of only a handful of countries in which child mortality rates are not falling. In this regard we are sadly not on track to meet the United Nations Fourth Millennium Development Goal (MDG4) – to reduce child mortality by two thirds between 1990 and 2015 – and time is running out. There are welcome initiatives to address this with improvements in the national Programme for Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the introduction of important new childhood vaccinations. But in the face of widespread poverty and unemployment, these interventions alone cannot get us to MDG4 unless the scourge of child malnutrition, a potent cause of child mortality, is addressed as well. This is true for the Western Cape province despite the fact that its infant mortality is the lowest in the country.

We therefore focus on the most logical way to significantly enhance the health and survival of children: BREASTFEEDING.

The well-established benefits of breastfeeding are more pronounced with exclusive breastfeeding (that is: no other liquids, no solids, only breast milk). These benefits include a perfectly tuned growth pattern in early life which has life-long positive effects, excellent protection from common life threatening infections such as diarrhoea and pneumonia, enhanced mental health and development, and lower rates of some allergic diseases. The benefits also extend well beyond childhood, producing lower rates of obesity, diabetes, cardiovascular disease and other diseases of adulthood. These benefits have significant economic spin-offs through decreased health spending and greater human productivity. Breastfeeding is an affordable and effective intervention with an irresistible per capita reduction in health costs. It is a single intervention that has multiple lifelong impacts and empowers individual citizens to make a difference to the health of the nation in a very meaningful way.

Exclusive breastfeeding is all that most infants require for the first six months of life. Breast milk is complete low-cost, purpose-perfect nutrition with added immune system enhancers. There is no need for extra liquids. Studies in the hottest, most arid climates have shown that even under these conditions, infants require no added water or other fluids for the first six months of life. In addition, children who are exclusively breastfed never become severely malnourished unless they have an underlying illness. In contrast, the addition of other liquids or solids during the first six months undermines the health benefits of breastfeeding, increases the risk of infections and at least doubles the risk of mother-to-child transmission of HIV.

Even in the all too common instance of maternal HIV, exclusive breastfeeding in the first months of life confers a significant health, nutrition and survival advantage while incurring a similar overall risk of HIV transmission as formula feeding. Breastfed HIV-infected infants grow better, are healthier and have a better survival rate. The WHO recommends that they breastfeed for two years and more.

Antibodies and other immune substances in breast milk play a crucial anti-infection role and are significant factors that explain why breastfeeding continued beyond six months is so important for child health and survival even in HIV-exposed infants. Solid food needs to be added after six months to meet increased nutrient requirements and breastfeeding is necessarily no longer exclusive after this time.

The link between South Africa’s high infant mortality rate and the fact that we have one of the lowest exclusive breastfeeding rates globally needs to be spotlighted. The argument that this is primarily due to HIV ignores the reality that seventy percent of infants are not HIV-exposed and that sixty percent of children who die are malnourished. Improving our exclusive breastfeeding rate is central to improving our population’s health status and achieving MDG4.

How are we to do this? What is preventing so many babies from being breastfed?

Obstacles to sustained breastfeeding include the absence of laws against the promotion of formula milks, and inadequate legal protection of maternity leave for young female temporary workers in the Basic Conditions of Employment Act. There is a lack of private space and opportunity for breastfeeding and expressing breast milk in our public buildings and private businesses.  Suboptimal implementation of policy and practice at community level to support breastfeeding  in the crucial first weeks after birth truncates the duration of exclusive breastfeeding. A lack of knowledge and understanding of the immediate and life-long benefits of breastfeeding for mother and child in general society conspires to perpetuate widespread and dangerous practices such as giving babies porridge or rooibos tea well before the recommended six months of age. Easy access to formula milk for HIV-infected women has had a ‘spill-over’ effect on general breastfeeding rates.

The national Minister of Health, Aaron Motsoaledi, is personally leading the national onslaught on all that prevents babies being breastfed.  The August 2011 Tshwane Declaration of Support for Breastfeeding in South Africa is a very welcome development and constitutes high level support for the crucial national public health priority to promote, protect and support breastfeeding. The Western Cape province requires similar bold governmental leadership on this matter.

Breastfeeding is a noble task that most mothers, no matter how poor, are biologically empowered to perform, but they are often hampered by lack of support, misinformation, inadequate maternity benefits and other difficulties in their daily lives. They should be supported in this endeavour with all the means at our disposal including health care facilities that are friendly to breastfeeding and policies, as well as workplace legislation and social development policies that promote, protect and support breastfeeding.

The Tshwane declaration comes out strongly in support of the development of a donor milk service. Breast milk compared to formula milk reduces the risk of infection and death in preterm babies and donated human milk supports the practice of exclusive breast milk feeding in this particularly vulnerable group. Milk banks could also be used to increase access to safe human milk for infants whose mothers are too sick to breastfeed. Policy briefs commissioned by the Human Milk Banking Association of South Africa (HMBASA) prepared by the Programme for Appropriate Technology in Health (PATH) were presented at the Tshwane summit and are available to inform health system planners.

Specific mention needs to be made of breastfeeding and HIV in this province. Data from recent randomised controlled trials shows that maternal or infant antiretroviral therapy (ART) is safe and reduces HIV transmission during breastfeeding to less than one percent. This is “game-changing” evidence that argues strongly for breastfeeding to be the default infant feeding policy position in the province’s PMTCT program. The public health imperative to promote breastfeeding also argues strongly for a simplification of our PMTCT regimen to Option B of the World Health Organisation 2010 PMTCT guidelines i.e. ART for all pregnant and breastfeeding women living with HIV.

In the light of this new evidence, there has even been a recent argument in a respected peer-reviewed journal for the consideration of breastfeeding by HIV-infected mothers in industrialised countries!

We can talk with one voice: HIV need no longer be a source of confusion in the promotion of breastfeeding.

Some argue for the retention of state-subsidised formula milk for HIV-infected mothers who cannot financially afford it, but this loses sight of the central issue that formula milk cannot replace the protective effects of breast milk. Making it simple for many mothers to select an unsafe infant feeding option is ethically questionable. Provision of ‘free’ formula also ignores the reality that the highest burden of HIV is in the very communities where not to breastfeed is most dangerous. In our most deprived communities, not breastfeeding will always incur significant morbidity and mortality for children, and it can never be safe in the unhygienic, under-serviced and overcrowded living conditions that prevail in much of this province. These conditions will persist until the immense disparity in wealth between the richest and poorest is addressed. Providing formula for ‘free’ also creates the impression that government endorses an unsafe infant feeding practice resulting in potential “spill-over” to mothers who are not HIV-infected.

In Cape Town it is reassuring to note that increasing numbers of women living with HIV are choosing to breastfeed their babies. Systems to support them in their choice that have a strong evidence base from international studies, such as baby friendly health facilities, community worker programs and breast feeding support groups, need to be upscaled rapidly.

All good people believe that apartheid was a bad thing. The alliance of forces that opposed apartheid had one goal – its elimination. Likewise, all good people would say that child hunger; malnutrition; illness and death are bad things that need to be eliminated. Exclusive breastfeeding for the first six months of life and ongoing breastfeeding until two years of age or more gives our children the best possible start in life and is a vital and logical way to significantly reduce these scourges before 2015.

The time has come for government, civil society and the mothers of this province and the nation to rally behind the call to promote and protect breastfeeding, eliminate obstacles to its widespread use and restore it to the very heart of efforts to improve child health and survival.

“There can be no keener revelation of a society’s soul than the way in which it treats its children” – Nelson Mandela.


Tony Westwood and Max Kroon, School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town