Women's rights

At the 1990 World Summit for Children, it was stated that more than a million infant deaths could have been avoided if infants had been exclusively breastfed for six months (UNICEF, 1995). Three of the four most important threats to survival of children in South Africa are diarrhoeal disease, acute respiratory infection, and malnutrition (UNICEF, 1993). Failure to breastfeed has been linked to all these health problems.

Aim: To assess the quality of counselling provided to mothers through the programme to prevent mother-to-child transmission (PMTCT) of HIV in South Africa.

As African women celebrate the rising numbers of ratifications towards the attainment of the statutory number of fifteen ratifications to bring into force the Protocol to the African Charter on Womens Rights in Africa (Nigeria is the latest member state to ratify the Protocol), it is relevant for us to embark on a simplification of the obligations on Member States and the potential benefits of its provisions for women.

Johannesburg, Sep. 4 Women have held their own at the World Summit on Sustainable Development, which ended today with a promise by the 7,000 delegates to reduce poverty while protecting Earth’s environment. The victory reinstated language affirming women’s rights that has been included in United Nations conference documents since 1993 but that was absent from this summit’s draft document. Conservative delegates backed by the Vatican and the United States, among others, fought until late Tuesday to keep a reference to human rights out of the list of elements that the document said should be considered in providing health services to women. Without such language, Zeitlin and others said, the document would have named only “cultural and religious values” as considerations, leaving countries free to continue such practices as female genital mutilation or denying health care to women as cultural values. The Bush administration said it opposed adding the language on procedural grounds. Delegates from South Africa and Barbados were among the strongest advocates for including the human rights phrase in the draft document’s Paragraph 47, which describes elements that should be considered in providing health care for women as part of promoting sustainable development. Defeat on this issue would have represented a rollback on women’s rights from language approved by UN conferences in 1993, 1994, 1995, 1999 and 2000. Opponents of women’s rights would also have cited the Johannesburg language as the new standard for documents from future gatherings. “We are very happy with the final document and its recognition that women’s human rights are a critical element of reproductive health care around the world,” said Stirling Scruggs, spokesperson for UNFPA, the UN Population Fund, which is active in providing such care to women in more than 140 countries.(PLANetWIRE,Johannesburg, Sep.4)

Doctors, researchers as well as nutrition and child health experts have warned that a decision to offer free formula feed to HIV positive mothers could be doing more harm than good, especially for those infants living in rural settings or poor peri-urban poverty. In the 18 prevention of mother-to-child transmission (PMTCT) test sites, government has been offering formula milk to HIV positive mothers and encouraging those with access to clean running water to forego breastfeeding in favour of the formula. A government commissioned report written by the Health Systems Trust provides an overview of the 18 sites and warns that with all the publicity surrounding government’s position on nevirapine, the more important and serious issue of its policy on infant feeding and providing free formula has been neglected. Dr David McCoy, programme director at HST and lead author of the report, said that although the long-term aim should be to enable all HIV positive women to provide safe and affordable exclusive formula feeding, under the current circumstances, the policy may lead to higher rates of mortality and morbidity due to other diseases, as well as higher rates of mixed (formula plus breast) feeding. His views are backed up by leading nutrition experts at the University of the Western Cape’s School of Public Health, Drs David Sanders and Mickey Chopra. Sanders and Chopra said that if all HIV positive women elected to bottle feed, all of their infants would be susceptible to the dangers attendant thereto, with increased risk of death from other infections especially diarrhoea, one of the commonest causes of child death in South Africa. They pointed out that there was very little known about the psychosocial effects on a HIV positive mother when she is told that she might infect her child by breastfeeding. Professor Jerry Coovadia, paediatrician and Head of Research at the Nelson Mandela Medical School at Natal University, also believes that government should not be providing formula milk – the most expensive aspect of its PMTCT programme – but rather encouraging women to breastfeed exclusively. According to a study done by the University of Natal, the risk of HIV transmission from exclusive breastfeeding for six months and then rapid weaning was less than 5%, said Coovadia. Head of the HIV/AIDS programme in the health department, Dr Nono Simelela confirmed that in places where women don’t have access to clean running water, they have been advised to exclusively breastfeed – and exclusively means just that – no water, no tea, just breastmilk. Sanders, Chopra and Dr Jon Rohde of the Equity Project in the Eastern Cape, supported the call in the HST report for a national commission of experts to be urgently set up to review the current policy and guidelines on infant feeding and mother-to-child transmission. It was suggested that the so-called national commission of experts should incorporate experts from the field of nutrition, HIV and child health, and not just HIV. Health minister Dr Manto Tshabalala-Msimang recently recognised the issues in the HST report while addressing parliament. She said she was particularly interested in the HST assertion that the key policy issue that confronted government was not the provision of anti-retrovirals, but the question of infant feeding. She said it broadened the debate from an HIV issue to a general public health issue. The challenge is not only to reduce HIV rates among the babies, but ultimately to reduce the overall infant mortality and morbidity rates. (Source: Health-e News Service, 19 March 2002)

The issues surrounding the choice of infant feeding in HIV positive women is very complex, as the report on the PMTCT Pilot Sites (released by HST last week) explains. There is clearly not consensus internationally on the best approach for low-resource settings, and even existing research results provide conflicting evidence. A number of letters were published in JAMA this week in response to the results of the trial, Morbidity and Mortality in Breastfed and Formula-Fed Infants of HIV-1 Infected Women A Randomized Clinical Trial published last year in JAMA [http://jama.ama-assn.org/issues/v286n19/abs/joc10358.html] The conclusion reached by the researchers was: Conclusions: In this randomized clinical trial, infants assigned to be formula fed or breastfed had similar mortality rates and incidence of diarrhea and pneumonia during the first 2 years of life. However, HIV-1 free survival at 2 years was significantly higher in the formula arm. With appropriate education and access to clean water, formula feeding can be a safe alternative to breastfeeding for infants of HIV-1 infected mothers in a resource-poor setting. However the responses raise a number of issues and potential problems with the trial methodology, which can be read at http://jama.ama-assn.org/issues/v287n9/ffull/jlt0306-2.html A number of posters and abstracts from the 9th Conference on Retroviruses and Opportunistics Infections (24-28 Feb 2002 http://63.126.3.84/2002/) covered issues of relevance including: Breastmilk HIV-1 Viral Load Is Associated with Viral Load in Other Compartments, Host Genotype, and Perinatal Transmission http://63.126.3.84/2002/Abstract/12760.htm Factors Associated with Vertical Transmission in a Cohort of HIV+ Pregnant Women in Rio de Janeiro, Brazil http://63.126.3.84/2002/Abstract/12832.htm On the training side, a set of online tutorials from ReproLine provide powerpoint slides, text transcripts and multi-media references on a number of topics relating to the Care of Women Living with HIV in Limited-Resource Settings. One of these tutorials covers breastfeeding and the range of international research and knowledge in this area. Available from http://www.reproline.jhu.edu/english/4morerh/4hivaid/hivreal.htm.

There have been claims that Unicef is about to form partnerships with companies that produce infant formula, and market beast milk substitute products in violation of the international code of marketing of breast milk substitutes.

A workshop to develop guidelines. The effects of commercial products from some industries on the health and well being of communities has been a subject of debate for many years. The tobacco, alcohol and infant formula industries have been under special scrutiny in this regard. In the case of the infant formula industry, the debates have focused more on how breast milk substitutes affect health promotion efforts aimed at promoting breastfeeding. To this end, international health groups such as UNICEF and WHO have embarked on global campaigns, some of which have led to the formulation of a number of international codes. These codes are intended to help regulate the use and marketing of breast milk substitutes, for example, the international code of marketing of breast milk substitutes adopted by the World Health Assembly in 1981.