In the past 20 years, there has been a massive global push for mothers to breastfeed their newborns exclusively for the first six months of their lives. The science suggests this is a good way to improve their children's later development.
There has also been a large body of research on the effects of formula milk, and other replacement foods, on the health of babies during their first six months. A great deal shows that they have negative effects. But for many years HIV positive mothers were advised to either exclusively breastfeed their babies, or only feed them formula. They could choose which they preferred — but not a mixture of the two.
This was very confusing for many mothers. Many fell back on mixed feeding. They started using both approaches at the same time — sometimes breastfeeding their babies, sometimes using commercial formula or other replacement liquids and foods. In South Africa this practice was very common — close to 90 percent of the country's babies were mixed fed in the early 2000s.
In 2010 this changed. The World Health Organisation took a stand and recommended that governments should make a choice between the two options. They either had to encourage HIV positive mothers to exclusively breastfeed or to exclusively formula feed. They shouldn't do both.
These guidelines prompted South Africa to end its free formula programme in public facilities. Instead, it promoted exclusive breastfeeding for all mothers. This meant that frontline health workers, including nurses and clinic staff, had to change the way they counselled mothers about feeding practices. Seven years after the new policy was introduced we wanted to find out how well frontline workers had adjusted. Did they understand the new policy and its purpose? And did it make a difference to breastfeeding rates?
Our findings were surprising. When it came to HIV positive mothers, the frontline workers encouraged them to breastfeed their babies exclusively. But when it came to HIV negative mothers, the workers didn't highlight the importance of exclusive breastfeeding, nor did they discourage mothers from mixed feeding.
Our study suggests that South Africa could improve exclusive breastfeeding rates. The rate has improved in recent years — by 2016 32 percent of mothers were exclusively breastfeeding their babies. But there's still a great deal of room for improvement. Kenya, for example, has achieved a rate of over 60 percent.
The onus is on the South African government to engage health workers about the benefits of exclusive breastfeeding for babies born to HIV positive as well as HIV negative mothers. They need to provide clear communication tools and counselling skills that can help health workers address the barriers mothers face.
The health workers believed that breastmilk was best for babies and were able to rattle off the nutritional benefits and other advantages — such as allowing the mother and the baby to bond, and the fact that it was cheaper.
Reliant on advice
Studies have shown that new mothers rely heavily on the advice they get from health workers about infant feeding.
Mothers who get confusing or misleading advice from health workers are less likely to breastfeed exclusively, or to do so for a shorter time. On the other hand, those who receive clear, positive messages about exclusive breastfeeding from their health workers are more likely to breastfeed.
That's why our study focused on health workers. We interviewed frontline health workers from four community health clinics in Soweto. They included nurses, ward-based outreach team members and staff seconded from nongovernmental organisations. Each of them had counselled mothers about baby feeding before and after the policy change.
Few health workers understood the scientific rationale of the policy to promote exclusive breastfeeding. Many were under the impression that the formula programme had been stopped due to costs, and most hadn't been trained on the new policy.
The health workers believed that breastmilk was best for babies, and were able to rattle off the nutritional benefits and other advantages — such as allowing the mother and the baby to bond, and the fact that it was cheaper.
But there were differences in the way they responded to HIV positive and negative mothers. They advised all mothers to breastfeed their babies. But they spent more time educating HIV positive mothers about the importance of exclusive breastfeeding rather than HIV negative mothers. The subtext was that mixed feeding was mostly an HIV-related risk.
When they spoke to HIV negative mothers they spent more time warning them about HIV and advising them on how to protect themselves. They did not emphasise the benefits of exclusively breastfeeding.
South Africa's health department should provide health workers with updated information on the benefits of exclusive breastfeeding and the risks of mixed feeding.
There are still structural barriers around exclusive breastfeeding that need attention. These includes maternity leave policies that fall short of the six-month exclusive breastfeeding period, an absence of public and workplace spaces for breastfeeding, and the idea that exclusive breastfeeding is only for HIV-exposed babies. On top of this, mixed feeding remains a cultural norm in many communities.
On the bright side, exclusive breastfeeding rates are increasing in South Africa, and health workers have an important role to play in explaining the health and development benefits of exclusive breastfeeding for all babies.
South Africa's health department should provide health workers with updated information on the benefits of exclusive breastfeeding and the risks of mixed feeding. This needs to include pre-tested materials that can be placed in public spaces like clinics.
In addition, they should continuously provide interactive content on the health workers' cellphones through platforms like NurseConnect, which they could access during consultations.
Health workers also need training on how to navigate between health education and counselling that empowers mothers. To get the best outcome for both mother and baby, a single directive from above is less likely to result in behaviour change than a two-way conversation about overcoming barriers.