The debate about whether “breast is best” when it comes to feeding babies can be traced back to ancient cultures, many of whom devised clever alternatives to breastfeeding. It is thought that mothers in ancient Greece fed their babies honey and wine as supplements. More recently, those who couldn’t breastfeed in Renaissance Europe fashioned bottles out of cows’ horns.
The arrival of bottle sterilisation and pediatrician-approved formula in the 1950s made bottle feeding safe in most countries. But that doesn’t mean the debate is settled: in certain environments breastfeeding – which protects against gastrointestinal disease and infections – can be the difference between life and death for newborns at risk of such infections.
Communities throughout the African continent have enjoyed high rates of breastfeeding for centuries. But the spread of the HIV virus in the 1990s introduced a new debate about whether breastfeeding was safe. Access to better data and antiretroviral treatments over the 2000s have led experts to decide that it is, but the effects of diverging messages are still causing confusion.
The safest option
In the early days of the HIV crisis, health workers knew that breastfeeding was important, but also knew that HIV could be transmitted through it. This made it difficult to determine the best way forward for women in particular cases, and the nuanced guidance was almost impossible to enact in practice on the ground.
In the late 1980s and early 1990s, the evidence available to researchers suggested that of the 1million children infected with HIV, the majority were infected by their mothers through pregnancy, birth, or breastfeeding. But more data was needed to understand the breakdown of these risks.
By 1998, when UNAIDS and the WHO published a review of HIV transmission through breastfeeding, further studies suggested that breastfeeding carried a significant and preventable risk for babies of HIV-positive mothers.
Because breastfeeding was so important for the safety of babies in areas of malnutrition, this new information presented an especially complex challenge. As UNAIDS and the WHO laid out in their 1998 guide for HIV and Infant Feeding, health workers were tasked with preventing HIV-positive mothers from transmitting the virus through breastfeeding, while also promoting breastfeeding as the safest option for HIV-negative mothers.
Pamela Morrison, a lactation consultant with a special interest in HIV and breastfeeding, says that although it was known that 85% of babies would not become infected through breast milk, formula-feeding was considered to be the safest option, where it was found to be acceptable, feasible, affordable, sustainable and safe.
“It was just an impossible situation”
But determining whether formula feeding was safe and feasible presented another layer of challenges.
Nigel Rollins, who works on maternal and newborn health at the WHO, explains that at the time, the method for weighing up the risks of breastfeeding vs. formula feeding was through counselling individual mothers based on their situation.
The problem was that lack of resources made doing so nearly impossible. “It was a very difficult task for individual nurses to ascertain the mothers’ whole circumstances,” he said.
Criteria that health workers had to take into account included the availability of water, the availability of stoves for boiling water 7 times a day and the ability of a mother to sterilise bottles 7-8 times a day. “All while the health worker has 40 women waiting with their children,” Rollins added, “so he/she has 2-3 minutes to try to do all the counselling . . . it was just an impossible situation.”
Between the years 2000 and 2010, the situation changed dramatically. New studies suggested that discouraging breastfeeding altogether for HIV-positive mothers could be dangerous.
In many communities, women feared the social repercussions of disclosing their HIV status. A study in Eastern Uganda showed that in the absence of professional support, many women would breastfeed their babies when in their communities but then formula-feed their child in private, believing that this would lower their risk of infection.
Sadly, this was a mistake: even for HIV-positive mothers, exclusive breastfeeding was safer than what is called “mixed feeding”. Adding formula to breastfeeding could double the transmission risk of HIV, said Rollins.
Further, when devastating floods hit Botswana in 2006, the U.S. Centres for Disease Control found that with the spread of waterborne diseases and malnutrition after the flooding, formula-fed babies became ill and died where breastfed babies survived.
These new findings called into question the early guidelines, where the default suggestion for HIV-positive mothers was formula feeding.
While researchers were refining their understanding of the risks of formula feeding, another huge development was underway.
By 2009, new antiretroviral drugs (ARV) to treat the HIV virus were proven to save lives. What’s more, in mothers who received ARV treatment, the risk of infecting their babies through breastfeeding became virtually nonexistent.
This ARV breakthrough turned the former guidance on its head. The WHO HIV and infant feeding guidelines in 2010 advised that where ARVs were available, mothers known to be HIV-infected were recommended to breastfeed until their babies were 12 months old.
As part of the 2010 turnaround there was also a shift in how the care would be delivered. Health recommendations were no longer targeted at individual mothers on a case by case basis.
“Policies to promote formula feeding for HIV+ mothers remain the major challenge for health workers in promoting breastfeeding”
Because randomised trials from multiple countries all showed that the drugs worked, Rollins said, the 2010 guidelines became public health recommendations. It was now in the hands of national health authorities to make a decision about whether health workers in their jurisdictions should recommend ARV treatments and breastfeeding, or no breastfeeding.
This decision would be taken based on the quality of healthcare, the prevalence of HIV in mothers and babies, and the level of nutrition in each country.
After two decades of uncertainty around the value and importance of breastfeeding in the context of HIV, restoring confidence in breastfeeding at the community level is a huge challenge.
An analysis in 2012 showed that translating the new guidelines into practice remained difficult. Even though the evidence about when breastfeeding is safe is now clear, some health workers and communities find it difficult to act on this data with confidence after it was unclear for so many years.
Pamela Morrison sees part of the challenge as “spillover” from the complicated story told for such a long time. “Policies to promote formula feeding for HIV+ mothers . . . remain the major challenge of health workers in promoting breastfeeding,” she said.
Communities experience the spillover in different ways. In certain areas in southern Africa, exclusive breastfeeding became associated with HIV status, so women worry that their communities might stigmatise them if they are seen breastfeeding.
But in other environments where the formula feeding message throughout the 1990s was particularly impactful, the opposite is true. Women who formula feed fear they will be labelled as HIV-positive.
Although these complexities remain, there is reason to believe that continually improved data and better access to accurate information will improve the situation.
The World Alliance for Breastfeeding Action has released a Breastfeeding and HIV toolkit with policy recommendations to help address the inconsistent health advice that mothers still receive when trying to discern the best way to feed their babies.
For Nigel Rollins, the most powerful way forward, as well as the biggest challenge, is keeping women in good quality medical care, for their own lives and health, as well as the ability to breastfeed. “That’s a huge programmatic issue. It’s not just about the quality of the services, it’s about helping women navigate the complexities of life when they are living with HIV,” he said. “The big issue is one around heart and soul more than anything else.” – Megan Dent
(Picture credit: Pexels)