Counselling on infant feeding choice: Some practical realities from South Africa

Implications of infant feeding choice Programmes for prevention of mother to child transmission (MTCT) need to focus not only on preventing HIV transmission but also on improving child survival. Exclusive breastfeeding has been identified as the single most effective way of saving the lives of millions of young children in developing countries1, a fact that is supported by international policy2 and operational guidance for emergency contexts3.

Although most infants in sub-Saharan Africa are breastfed, rates of exclusive breastfeeding are low as early introduction of liquids is a common practice. It is against this background that infant feeding recommendations for women with HIV are being implemented. If women with HIV are to succeed in practising exclusive infant feeding, then improvements in infant feeding practices in the general population are necessary to ensure that exclusive breastfeeding is the norm rather than an exception.

A recent study4 from South Africa has confirmed earlier findings5 that exclusive breastfeeding results in a lower rate of postnatal HIV transmission compared to mixed feeding. This study, undertaken in a rural area in KwaZulu- Natal province, found a cumulative postnatal HIV transmission risk of 4.04% after five months of exclusive breastfeeding. Infants who were fed both breast and formula milk at age twelve weeks were twice as likely as exclusively breastfed infants to be infected (HR 1.82, 95% CI: 0.98-3.36).

Recent data from Mozambique6 and the ZVITAMBO study in Zimbabwe7 have highlighted the dangers of early cessation of breastfeeding under conditions of underlying poor socio-economic status and food insecurity. In Mozambique, commonly consumed, locally available foods would not meet the nutritional needs of non-breastfed infants between 6-12 months of age and replacing breastmilk with local foods would double the estimated daily cost of feeding a 6-12 month infant. In Zimbabwe, most of the infant diets only met 58% of the infants energy needs and were insufficient in animal milks or formula.

Replacement feeding means feeding an infant a diet that provides the necessary nutrients while receiving no breastmilk. Recent research and experiences from Botswana (see research summaries in this issue of Field Exchange) highlight the risks of formula feeding and reinforce the importance of individual assessments of home and environmental circumstances in the process of decision-making. In low and middle income countries and in emergency contexts, replacement feeding is unlikely to be the most appropriate choice for HIV positive women due to socio-economic environments that are not conducive to safe replacement feeding.

The importance of counselling
Given the implications that infant feeding choice may have for child survival, infant feeding counselling and support is one of the most important components of PMTCT programmes. In many countries, shortcomings in the implementation of the WHO guidelines have been found. Inadequate training of health workers, particularly infant feeding counsellors, about the relative risks associated with infant feeding in the context of HIV, lack of culturally sensitive counselling tools, and the stigma associated with replacement feeding, all make appropriate and effective infant feeding counselling difficult.

Within the context of busy antenatal clinics, it is not surprising that the quality of infant feeding counselling has generally been found to be poor.

One intervention that has been shown in a variety of settings to increase exclusive breastfeeding is peer counselling. Peer counselling is a proven cost-effective approach for changing behaviour. Community-based interventions using local womens groups have also been shown to change behaviour in relation to infant feeding and birth outcomes.