tag:theconversation.com,2011:/us/topics/breastfeeding2021-108131/articlesBreastfeeding2021 – The Conversation2021-08-10T15:34:56Ztag:theconversation.com,2011:article/1655482021-08-10T15:34:56Z2021-08-10T15:34:56ZWhat’s missing in South Africa’s strategy to get breastfeeding levels up<figure><img src="https://images.theconversation.com/files/414796/original/file-20210805-23-wmksjl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Jose Luis Pelaez Inc/GettyImages</span></span></figcaption></figure><p>This year marks the 40th anniversary of the <a href="https://www.who.int/nutrition/publications/code_english.pdf">International Code for the Marketing of Breastmilk Substitutes</a>. This was a landmark policy framework designed to stop commercial interests from discouraging breastfeeding and hence endangering the health and nutrition of the world’s infants and young children. </p>
<p>It was driven by <a href="https://pediatrics.aappublications.org/content/100/6/1035">research</a> <a href="https://pubmed.ncbi.nlm.nih.gov/26869575/">that showed</a> human milk can meet all the nutritional needs of an infant during the first <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">six months of life</a>. </p>
<p>In line with the code South Africa published <a href="https://www.gov.za/sites/default/files/gcis_document/201409/35100rg9700gon184.pdf">regulations</a> on infant formula in 2012. These stipulated a set of requirements in relation to product formulation, packaging and labelling, including clear and visible instructions for formula feeds. The regulations also prohibited direct marketing to the mothers, including rebates, marked down prices and free gifts and gadgets to incentivise sales. </p>
<p>But South Africa still falls short of its breastfeeding target. The country failed to reach the ambitious exclusive breastfeeding target of <a href="https://extranet.who.int/nutrition/gina/en/node/7994">75% by 2017</a>. By 2016 only <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=211">32% of babies</a> were being exclusively breastfed. </p>
<p>Formula is still widely accepted in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-021-01441-2">South Africa</a>.
But feeding babies formula is <a href="https://pubmed.ncbi.nlm.nih.gov/27174145/">associated with</a> increased child illness like middle ear infection, allergies and diarrhoea. On top of this, the proper use of infant formula is nearly impossible in settings with no clean running water and a lack of fuel to sterilise feeding utensils and boil water for the formula. </p>
<p>Also, in low-income households the use of infant formula is a higher economic burden. In South Africa, adequate amounts of formula for an infant under six months cost more per month than the <a href="https://theconversation.com/south-africa-can-and-should-top-up-child-support-grants-to-avoid-a-humanitarian-crisis-135222">child support grant</a>. </p>
<p>To increase breastfeeding rates South Africa must enforce the regulations around the marketing of infant formula. It must also do more to support mothers to breastfeed. </p>
<h2>Breastfeeding and infant formula</h2>
<p>Exclusive breastfeeding is defined as providing no other food or drink, not even water, except breastmilk (including expressed breastmilk or breastmilk from a wet nurse) for the first six months of life. It does allow for the infant to receive oral rehydration solution, drops and syrups (vitamins, minerals and medicines). </p>
<p>WHO <a href="https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/">recommendations</a> encourage continued breastfeeding up to two years or beyond with the introduction of appropriate nutrient-dense foods at age six months when complementary feeding is appropriate. </p>
<p>But the infant formula industry remains a powerful force. The top five companies are Nestlé, Danone, Mead Johnson, Abbott and FrieslandCampina. Combined they represent <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">over 60%</a> of the global market.</p>
<p>Manufacturers began to advertise directly to physicians in the early 20th century as formulas <a href="https://pubmed.ncbi.nlm.nih.gov/11160571/">evolved</a> supported by research. By 1929, the American Medical Association formed the Committee on Foods to approve the safety and quality of formula composition. By the 1940s and 1950s, physicians and consumers regarded the use of formula as an accepted, popular, and safe substitute for breastmilk. Consequently, breastfeeding rates in the US steadily declined until the <a href="https://www.contemporarypediatrics.com/view/concise-history-infant-formula-twists-and-turns-included">1970s</a>. </p>
<p>At about the same time the aggressive marketing of infant formula in suboptimal conditions in Africa led to <a href="https://www.who.int/nutrition/publications/code_english.pdf">letters</a> of concern to WHO and to UNICEF as child mortality numbers increased. This resulted in a raft of reports about the effects Nestlé’s marketing strategy on developing countries. They included the <a href="https://newint.org/issues/1973/08/01">New Internationalist’s Baby Food Tragedy issue in 1973</a>, <a href="https://waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf">War on Want’s “Baby Killer” by Mike Muller in 1974</a>, and the <a href="https://collections.nlm.nih.gov/catalog/nlm:nlmuid-8100588A-vid">Bottle Babies documentary in 1975</a>.</p>
<p>The reports caused global outrage and an <a href="https://www.nestle.com/ask-nestle/our-company/answers/nestle-boycott">international boycott</a> of Nestlé products.</p>
<p>Nevertheless, the industry continues to <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">invest heavily</a> in marketing. One of the consequences of some of the campaigns is that it sows doubt in mothers’ confidence in breastfeeding. An example is a <a href="http://www.babymilkaction.org/archives/8683">campaign</a> funded by Nestlé through the Paediatric Society of Rio Grande do Sul in Brazil. </p>
<p>Research also <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w">shows</a> that infant formula campaigns use emotional appeals, such as tapping into concerns mothers might have about their babies crying or being hungry or not sleeping. </p>
<p>Social media has made it <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w">even easier for the infant formula companies</a> to pose as the friend and supporter of parents. It is also providing companies with a rich stream of personal data with which they hone and target their campaigns. </p>
<p>In addition, the industry has designed a set of formula products to <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">displace breastfeeding</a>: starter formula from 0-6 months, follow-on formulas from 6-12 months and growing-up milks from 12 months. </p>
<p>But breastfeeding is the perfect food for the healthy growth and development of infants and young children. Low breastfeeding rates lead to <a href="https://pubmed.ncbi.nlm.nih.gov/26869575/">increased mortality and morbidity</a>. South Africa’s low breastfeeding rates underlie the increase in child malnutrition which is reflected in increased stunting and obesity rates. </p>
<p>More than a <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/CG2020_CC_child%20nutrition.pdf">quarter (27%)</a> of the country’s children are stunted. </p>
<h2>Beyond regulating</h2>
<p>South Africa, like a number of other countries, has taken steps to regulate the marketing of infant formula. But many individuals and organisations don’t recognise the regulations. Some even <a href="https://health-e.org.za/2021/08/02/npos-slam-governments-handling-of-infant-formula-donations/">challenged the government</a> for trying to enforce the rules. This points to the lack of awareness and the understanding of the regulations. It also points to a gap in monitoring and enforcement. </p>
<p>But regulating the marketing of infant formula is only the first step towards improving breastfeeding rates in the country.</p>
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Read more:
<a href="https://theconversation.com/why-many-south-african-mothers-give-up-breastfeeding-their-babies-so-soon-145557">Why many South African mothers give up breastfeeding their babies so soon</a>
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<p>Other important steps include: upskilling health professionals on the regulations to protect mothers from the inappropriate promotion of infant formula; engaging the media on the inappropriate marketing and promotion of infant formula; and building an environment in communities that supports mothers to breastfeed.</p><img src="https://counter.theconversation.com/content/165548/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten is the Chairperson of the Child Health Priorities Association and the Nutrition Lead for the South African Civil Society for Women's, Adolescents' and Children's Health (SACSoWACH).</span></em></p>South Africa needs to ensure regulations on formula foods for babies are enforced.Chantell Witten, Lecturer, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1651772021-07-30T07:52:29Z2021-07-30T07:52:29ZCommunity initiative keeps Kenyan women breastfeeding exclusively for longer<figure><img src="https://images.theconversation.com/files/413704/original/file-20210729-17-k25vm4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenyan women march towards a restaurant after a female client was allegedly thrown out for breastfeeding and not covering up. </span> <span class="attribution"><span class="source">Photo credit should read SIMON MAINA/AFP via Getty Images</span></span></figcaption></figure><p>Exclusive breastfeeding in the first six months, as recommended by the <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_1">World Health Organisation</a>, is vital for child growth and survival. Exclusive breastfeeding means that the infant receives only breast milk. This is because breast milk has adequate amounts of nutrients and water required for healthy growth as well as immune factors required for the development of the infants immune system in the first 4-6 months of life.</p>
<p>Other benefits of breastfeeding include protection against common childhood illnesses such as diarrhoea and pneumonia, and infant death. Scaling up exclusive breastfeeding can prevent <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf">823,000 child deaths every year</a>, and protect against <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01024-7.pdf">overweight and diabetes</a>.</p>
<p>There are benefits for <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01024-7.pdf">mothers too</a>. It’s been shown to reduce risks of breast and ovarian cancer, improve the spacing between births and reduce the risk of diabetes.</p>
<p>Kenya has made great efforts to increase the number of women breastfeeding their babies. Exclusive breastfeeding rates have increased over the years from 32% in 2008 to 61% in <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">2014</a>, which is higher than the the current <a href="https://apps.who.int/iris/bitstream/handle/10665/326049/WHO-NMH-NHD-19.22-eng.pdf?sequence=1&isAllowed=y">global average</a> of 43%. </p>
<p>But Kenya’s exclusive breastfeeding rates vary with age. For example, the percentage of children exclusively breastfed decreases sharply from 84% of infants age 0-1 month to 63% of infants age 2-3 months and, further, to 42% of infants <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">age 4-5 months</a>. </p>
<p>In a bid to address these patterns, the Kenyan government has put a number of initiatives in place to promote exclusive breastfeeding during the first six months of a baby’s life. </p>
<p>One is the <a href="https://www.who.int/elena/titles/bbc/implementation_bfhi/en/">baby friendly hospital initiative</a>. Launched in 1991, it aims to scale up 10 interventions in maternity facilities to support successful breastfeeding. The initiative has been effective in promoting exclusive breastfeeding during the <a href="https://onlinelibrary.wiley.com/doi/10.1111/mcn.12294">first weeks</a>, but not as effective in sustaining it through to the recommended six months. </p>
<p>This highlighted the need to scale up the promotion of breastfeeding in communities, which led to the baby friendly community initiative. This equips primary healthcare workers and community health volunteers with skills to help mothers breastfeed and feed their infants and young children. It also empowers other family and community members to support breastfeeding mothers.</p>
<p>The intervention is important particularly in regions such as Africa where 60% of women give birth at <a href="https://www.who.int/pmnch/media/publications/aonsectionIII_3.pdf?ua=1#:%7E:text=Yet%20almost%2060%20percent%20of,care%20do%20not%20receive%20it.">home</a>. </p>
<p>We conducted <a href="https://pubmed.ncbi.nlm.nih.gov/33528102/">a study</a> to assess the effectiveness of the baby friendly community initiative in Koibatek, a rural area in the Rift valley region of Kenya where mothers exclusively breastfeed for an average of <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">three months</a>. </p>
<h2>What we found</h2>
<p>The study was conducted in 13 community units in Koibatek sub-county. Pregnant women aged 15-49 years were recruited and followed up until their children were at least six months old. Mothers in the intervention group received standard maternal, infant and young child nutrition counselling and support from trained community health volunteers, health professionals, community mother support groups and mother to mother support groups. Those in the control group received standard counselling only, consisting of messages on infant and young child nutrition. No maternal and child nutrition related support was given to the mothers in the control group. Data on breastfeeding practices were collected.</p>
<p>A total of 823 pregnant women were recruited. Compared with mothers in the control group, the 351 mothers in the intervention group were three times more likely to exclusively breastfeed for six months and for a longer time (19 days longer). </p>
<p>The intervention used minimal resources because it was implemented within the existing health system by community health volunteers who were instrumental in providing information on maternal infant and young child nutrition. </p>
<p>They were required to visit mothers in their homes and provide support through community mother support groups and mother to mother support groups. </p>
<p>The mother to mother support groups consisted of 9-15 pregnant, lactating women and in some cases fathers and grandmothers. The group met monthly to discuss issues around pregnancy and young child feeding and nutrition. Community health volunteers and a lead mother, who acted as the leader of the group, facilitated the meetings.</p>
<p>The community mother support group included a nutritionist, community health volunteers, a local administrator, a community leader and a lead mother. The role of the support group was to oversee, plan and execute community meetings on the baby friendly community initiative; mobilise all community members to participate in its activities; support community health extension workers and nutritionists in monitoring and documenting monthly activities at the community level; and to monitor and document the maternal, infant and young child nutrition activities monthly.</p>
<h2>Next steps</h2>
<p>We believe our findings show that supporting mothers in their communities has the potential to increase exclusive breastfeeding for longer. </p>
<p>This is because the help women get in their communities addresses some key reasons that have been identified for the drop off in women breastfeeding exclusively in the first six months. These are:</p>
<ul>
<li><p>Lack of information/knowledge on the importance of breastfeeding</p></li>
<li><p>Advice and cultural beliefs and practices which negatively impact breastfeeding</p></li>
<li><p>Poor breastfeeding positioning and latching</p></li>
<li><p>Inadequate breastfeeding support</p></li>
</ul>
<p>Our findings showed that supporting breastfeeding in communities, and providing information, led to a significant increase in exclusive breastfeeding rates. We concluded from our findings that the baby friendly community initiative has the potential to improve exclusive breastfeeding rates in similar settings. It should be scaled up in Kenya and extended to other African countries.</p><img src="https://counter.theconversation.com/content/165177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Antonina Mutoro works for the African Population and Health Research Center. She is affiliated with the University of Glasgow, United Kingdom</span></em></p><p class="fine-print"><em><span>Elizabeth Kimani-Murage works for the African Population and Health Research Center (APHRC). She receives funding from the Wellcome Trust, USAID, NIH. She is affiliated with Brown University, USA. </span></em></p>Provision of breastfeeding support and information within the community can lead to a significant increase in exclusive breastfeeding rates.Antonina Mutoro, Postdoctoral Research Scientist, African Population and Health Research CenterElizabeth Kimani-Murage, Senior Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1641442021-07-20T13:57:40Z2021-07-20T13:57:40ZShould I get the COVID-19 vaccine while pregnant or breastfeeding? Experts explain the safety, evidence and clinical trials<figure><img src="https://images.theconversation.com/files/411166/original/file-20210714-21-2a1bml.jpg?ixlib=rb-1.1.0&rect=82%2C19%2C2476%2C1725&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Information on COVID-19 vaccines for pregnant or breastfeeding individuals has been inconsistent and hard to find.</span> <span class="attribution"><span class="source">(AP Photo/Charles Krupa)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/should-i-get-the-covid-19-vaccine-while-pregnant-or-breastfeeding--experts-explain-the-safety--evidence-and-clinical-trials" width="100%" height="400"></iframe>
<p>Since the COVID-19 pandemic began, public health communications put a special focus on helping high-risk populations, such as seniors, stay safe. Yet, information for pregnant or breastfeeding individuals has been inconsistent and hard to find.</p>
<p>Though most pregnant people who become ill with COVID-19 have mild symptoms, pregnancy does <a href="http://med-fom-ridprogram.sites.olt.ubc.ca/files/2021/06/CANCOVID_Preg-Report-4-ON-BC-QC-MB-AB_FINAL.pdf">increase the risk</a> of being admitted to <a href="https://sogc.org/common/Uploaded%20files/Latest%20News/Committee%20Opinion%20No.%20400%20COVID-19%20and%20Pregnancy.pdf">hospital and intensive care</a>, as well as the risk of <a href="https://doi.org/10.1503/cmaj.202604">preterm birth and dangerously high blood pressure</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://theconversation.com/ca/topics/vaccine-confidence-in-canada-107061">Click here for more articles in our series about vaccine confidence.</a></span>
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<p>Currently, all Canadian provinces and territories <a href="https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/vaccine/COVID-19_vaccination_rec_special_populations.pdf">offer COVID-19 vaccines to eligible pregnant individuals</a>. However, inconsistent information can lead to confusion among those looking to make informed decisions about vaccination for themselves and their families. </p>
<p>We research vaccination in pregnant populations, including <a href="https://doi.org/10.1016/j.vaccine.2019.09.063">ways to improve consistency</a> in information. For example, information about vaccination during pregnancy contained in vaccine package inserts approved by Health Canada may differ from the recommendations of the Canadian National Advisory Committee on Immunization (NACI).</p>
<h2>Exclusion from trials</h2>
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<img alt="A hand preparing a dose of COVID-19 vaccine" src="https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=758&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=758&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=758&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=952&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=952&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411172/original/file-20210714-27-il83.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=952&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Gaps in data contributed to caution regarding COVID-19 vaccination during pregnancy in the National Advisory Committee on Immunization’s initial recommendations.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
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<p>Inconsistencies in information about COVID-19 vaccination arose because pregnant and breastfeeding people <a href="https://doi.org/10.1016/j.vaccine.2020.12.074">were initially excluded</a> from gold-standard randomized clinical trials. Experts in reproductive health, vaccination and medicine have <a href="https://doi.org/10.1016/j.vaccine.2019.01.011">developed guidelines</a> for ethically including pregnant and breastfeeding people in vaccine development and deployment. These guidelines were available before the COVID-19 pandemic and could have informed early COVID-19 vaccine development.</p>
<p>The reasons for excluding pregnant and breastfeeding people from trials are complex. They may include fear or legal concerns about <a href="https://doi.org/10.1186/s12978-017-0430-2">harming the fetus or infant</a>. In the case of COVID-19 vaccines, the “need for speed” <a href="http://doi.org/10.1097/AOG.0000000000004290">made clinical development the top priority</a>. That meant proceeding with trials before completing the pre-clinical requirements for involving pregnant participants in clinical trials. These prerequisites include animal studies on the effects of COVID-19 vaccines on fetal development and reproduction. </p>
<p>Exclusion from trials has created inconsistencies between <a href="http://doi.org/10.1001/jama.2021.2264">international recommendations</a>, <a href="http://www.comitglobal.org/">national policies</a> and vaccine eligibility and prioritization in different provinces (<a href="https://www.cp24.com/news/who-have-provinces-pegged-to-receive-covid-19-vaccines-in-the-coming-weeks-1.5380609">Alberta</a>, <a href="https://globalnews.ca/news/7782835/ontario-covid-19-coronavirus-pregnant-women-vaccines/">Ontario</a> and <a href="https://montreal.ctvnews.ca/pregnant-people-in-quebec-can-soon-book-covid-19-vaccination-appointments-1.5404475">Québec</a>) about COVID-19 vaccination while pregnant or breastfeeding.</p>
<h2>Inconsistent messages</h2>
<p>Since May 2021, <a href="https://www.ctvnews.ca/health/coronavirus/naci-releases-new-recommendation-for-vaccinating-pregnant-people-1.5412781">NACI has recommended COVID-19 vaccination for pregnant or breastfeeding people</a>. However, gaps in data contributed to caution regarding COVID-19 vaccination during pregnancy in NACI’s initial recommendations. In contrast, the Society of Obstetricians and Gynaecologists of Canada (SOGC) and other <a href="https://s3.amazonaws.com/cdn.smfm.org/media/2684/Vaccination_for_HCWs.pdf">expert advisory bodies</a> in maternal health recommended that pregnant people were offered the vaccines from the outset. </p>
<p>As more information became available demonstrating the safety of vaccination in pregnancy, these guidelines have been updated and are now more closely aligned.</p>
<p>Clinical trials on mRNA vaccination in pregnancy are underway, including at the U.S. <a href="https://www.ctvnews.ca/health/coronavirus/u-s-begins-clinical-trial-testing-covid-19-vaccine-in-pregnant-women-1.5482764">National Institutes of Health</a> and <a href="https://clinicaltrials.gov/ct2/show/NCT04754594?term=pfizer&cond=Covid19&draw=2&rank=18">Pfizer/BioNTech</a>). AstraZeneca and <a href="https://clinicaltrials.gov/ct2/show/NCT04765384">Johnson & Johnson</a> had planned clinical trials in pregnancy, <a href="https://www.acog.org/news/news-releases/2021/04/acog-statement-on-johnson-johnson-covid-19-vaccine">but they are paused pending investigation into risks of a rare form of blood clot</a>. It will be several months before any trial data become available, long after most Canadians will have made their decisions about COVID-19 vaccination.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A health-care worker puts a bandage on a pregnant woman's arm after a vaccination" src="https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411170/original/file-20210714-13-1tbcyv2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Lack of information made it difficult for health-care and other essential workers who were pregnant or breastfeeding to make decisions about COVID-19 vaccination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The highest quality evidence should have been available to inform vaccine policies, recommendations and individuals’ decisions about whether to receive a vaccine while pregnant or breastfeeding. </p>
<p>Health-care and other essential workers who were pregnant or breastfeeding had a difficult decision to make. They had to weigh the known dangers of COVID-19 against uncertainties about vaccine safety information in the early weeks of vaccine rollout. Exclusion from clinical trials left these front-line workers to make decisions about COVID-19 vaccines based on incomplete information. </p>
<h2>Good quality information is now available</h2>
<p>Evidence is now available to show that COVID-19 vaccines are safe for people who are pregnant or breastfeeding and their infants. More than 130,000 people who received COVID-19 vaccines while pregnant or breastfeeding have joined the <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafepregnancyregistry.html">V-safe registry</a> in the United States. Most received Pfizer/BioNTech or Moderna mRNA vaccines. <a href="https://doi.org/10.1056/NEJMoa2104983">Initial findings from that registry</a> have been published, showing no safety concerns so far. </p>
<p>Recent studies also suggest that after vaccination, COVID-19 antibodies <a href="http://doi.org/10.1097/AOG.0000000000004438">can cross the placenta</a> and also <a href="https://doi.org/10.1016/j.ajog.2021.03.023">pass into breast milk</a> and may protect the infant.</p>
<p>For pregnant or breastfeeding people seeking information, SOGC offers answers to COVID-19 vaccine <a href="https://www.pregnancyinfo.ca/wp-content/uploads/2021/05/EN_PatientFAQ_SOGC_FINAL-2.pdf">Frequently Asked Questions</a>, a detailed <a href="https://sogc.org/common/Uploaded%20files/Latest%20News/SOGC_Statement_COVID-19_Vaccination_in_Pregnancy.pdf">statement about vaccination in pregnancy</a> and other resources. Local and <a href="http://rcp.nshealth.ca/clinical-practice-guidelines/covid-19-vaccination-pregnant-breastfeeding-individuals">provincial public health</a> and <a href="https://www.bornontario.ca/en/whats-happening/covid-19-vaccination-during-pregnancy-in-ontario.aspx">maternal health programs</a> have also developed information to help pregnant or breastfeeding individuals make informed decisions about COVID-19 vaccination.</p>
<h2>Long-term followup</h2>
<p>There is a need for long-term followup of people vaccinated in early stages of pregnancy and their infants. Public Health and researchers in Canada continue to monitor pregnant individuals who have received a COVID-19 vaccine. Pregnant and breastfeeding individuals can sign up to participate in these programs: <a href="https://ridprogram.med.ubc.ca/vaccine-surveillance/">Canadian COVID-19 Vaccine Registry for Pregnant and Lactating Individuals</a> and the <a href="https://canvas-covid.ca">Canadian National Vaccine Safety Network COVID study</a>.</p>
<p>Earlier access to data about vaccination while pregnant or breastfeeding is needed to develop equitable public health guidelines. Pregnant and breastfeeding people include front-line workers at greater risk of exposure to COVID-19 and other viruses. </p>
<p>About <a href="https://mspgh.unimelb.edu.au/__data/assets/pdf_file/0011/3334889/Policy-brief_v3.pdf">70 per cent of the world’s health and social care workers</a> are women, many of whom are of reproductive age. In Canada, <a href="https://www150.statcan.gc.ca/n1/en/pub/45-28-0001/2020001/article/00036-eng.pdf?st=awjwKG9r">visible minorities, immigrants and women are over-represented</a> among nurse aides, orderlies and patient service associates who may be prioritized for vaccination.</p>
<p>As we take stock of our response to this pandemic, it is important to consider the implications of excluding pregnant and breastfeeding people from clinical trials and consider how we can do better next time.</p>
<p><em>Do you have a question about COVID-19 vaccines? Email us at <a href="mailto:ca-vaccination@theconversation.com">ca‑vaccination@theconversation.com</a> and vaccine experts will answer questions in upcoming articles.</em></p><img src="https://counter.theconversation.com/content/164144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Terra Manca receives funding from a Canadian Immunization Research Network trainee grant and an IWK postdoctoral fellow grant in Halifax, Canada. </span></em></p><p class="fine-print"><em><span>Karina A Top receives funding from the Canadian Institutes of Health Research and Public Health Agency of Canada via the Canadian Immunization Research Network and COVID-19 Immunity Task Force. She has received funding from the Addison Fund and Big Gifts for Little Lives through the Canadian Donation and Transplant Research Program. Dr. Top is a member of the Canadian Paediatric Society's Infectious Disease and Immunization Committee and a Director on the Association of Medical Microbiology and Infectious Disease Canada Council. </span></em></p>Exclusion from clinical trials, lack of data and inconsistent information made it difficult for pregnant and breastfeeding people to make decisions about COVID-19 vaccines early in the rollout.Terra Manca, Postdoctoral Fellow, Canadian Center for Vaccinology (IWK Health Centre); Department of Pediatrics, Dalhousie UniversityKarina A Top, Associate Professor, Department of Pediatrics, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1597712021-06-14T12:24:51Z2021-06-14T12:24:51ZNew technologies claiming to copy human milk reuse old marketing tactics to sell baby formula and undermine breastfeeding<figure><img src="https://images.theconversation.com/files/401396/original/file-20210518-23-ss0njf.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5099%2C3397&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite claims to the contrary, the real thing cannot be replicated.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mixed-race-mother-nursing-newborn-baby-royalty-free-image/601801509">Jose Luis Pelaez Inc/DigitalVision via Getty Images</a></span></figcaption></figure><p>New products that <a href="https://www.foodnavigator-usa.com/Article/2020/12/17/TurtleTree-Labs-raises-6.2m-to-support-cell-cultured-milk-platform">claim to replicate mother’s milk</a> have entered the lucrative market for infant formula. </p>
<p>To an <a href="https://scholar.google.com/citations?user=0VycH7AAAAAJ&hl=en">anthropologist and public health scholar</a> who studies breastfeeding, these claims appear to be built on old patterns of misleading scientific statements – and reveal the power of marketing to exploit gaps created by inadequate societal support for breastfeeding. </p>
<p>The costs of undermining breastfeeding are enormous. <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">Globally, over 823,000 child deaths</a> could be prevented annually with appropriate breastfeeding. Additionally, <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">20,000 maternal deaths</a> could be averted each year worldwide from breast cancer. Poor communities of color around the world disproportionately shoulder this harm.</p>
<h2>The rise of commercial formula</h2>
<p><a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">Throughout most of history and across cultures</a>, communities understood that breastfeeding ensured the best chance for infants to survive and thrive. Breastfeeding continued, on average, <a href="https://www.doi.org/10.4324/9781315145129-10">from two to four years</a>, with caregivers introducing new foods while continuing to breastfeed.</p>
<p>Attempts to fully replace human milk, <a href="https://www.springer.com/gp/book/9783030273927">usually with animal milk and gruels</a>, were relatively rare. Such attempts were most common when mothers were ill or dead, and caregivers couldn’t locate a lactating woman. <a href="https://www.springer.com/gp/book/9783030273927">Compared with breastfeeding, replacement feeding reduced babies’ chances of survival</a>.</p>
<p>Efforts to mimic breast milk <a href="https://uwpress.wisc.edu/books/0655.htm">escalated with the rise of scientific thinking and industrial capitalism</a> in Europe and the U.S. in the late 18th and early 19th centuries. Mass migration to urban centers eroded community support – and poor labor conditions made breastfeeding challenging. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Old advertisement for Nestlé formula with lead text that reads 'Don't Wait Too Long Before You Wean the Baby.'" src="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=875&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=875&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=875&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1100&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1100&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1100&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nestlé advertisement, 1911.</span>
<span class="attribution"><a class="source" href="https://www.aims.org.uk/journal/item/nestle">Nestlé</a></span>
</figcaption>
</figure>
<p>From the first commercial milk formula <a href="https://yalebooks.yale.edu/book/9780300188127/milk">patented in 1865 by Justus von Liebig</a>, formula-makers drew on science to gain the trust of medical providers and <a href="https://uwpress.wisc.edu/books/0655.htm">argue their products were as good as</a> – or even superior to – human milk. A study prepared for and published by Nestlé in 1878 <a href="https://yalebooks.yale.edu/book/9780300188127/milk">asserted that mother’s milk was deficient in key nutrients</a> and infants aged 6 to 8 weeks already required supplementation – with Nestlé’s food.</p>
<p>Physicians often claimed to support breastfeeding while undermining it in practice with poor advice and an increasing focus on formula feeding. Pioneering American pediatrician Emmett Holt advocated <a href="https://uwpress.wisc.edu/books/0655.htm">his own method of making formula</a>. <a href="https://archive.org/details/carefeedingof00holt/page/20/mode/2up">In his bestselling book, first published in 1894</a>, Holt claimed infants could be harmed by mother’s milk that was corrupted by emotion. Holt also advised mothers to schedule brief breastfeeding sessions and limit physical contact. Such advice <a href="https://dro.dur.ac.uk/26620/1/26620.pdf">impeded the physiology of breastfeeding</a>, which relies on frequent, responsive feedings and close contact – and contributed to growing reliance on supplementation with formula. </p>
<p>Physicians ultimately <a href="https://uwpress.wisc.edu/books/0655.htm">incorporated formula into their routine medical practices</a> and institutionalized them in <a href="https://history.wisc.edu/publications/brought-to-bed-childbearing-in-america-1750-1950/">hospital childbirth protocols</a>. </p>
<h2>Global spread</h2>
<p>In the first half of the 20th century, colonial administrations spread these new “scientific” infant care norms and products around the globe. They saw bottle-feeding as a <a href="https://doi.org/10.1093/ahr/121.4.1196">solution to infant mortality, disease and malnutrition</a> – and ultimately as an answer to labor shortages in the colonies. </p>
<p>In the 1950s, Nestlé used marketing techniques perfected in Europe to <a href="https://doi.org/10.1080/03086534.2020.1816624">dramatically expand its market in Africa</a>, <a href="https://doi.org/10.1093/ahr/121.4.1196">Asia and other parts of the world</a>. The growing number of infant deaths associated with the use of these products drew international attention and ultimately led to the <a href="https://doi.org/10.1093/ahr/121.4.1196">Nestlé boycott in 1977</a>. </p>
<p>Nestlé’s practices were not unique among formula-makers. Growing concerns about the <a href="https://doi.org/10.1111/j.1753-4887.1972.tb04042.x">role of inappropriate marketing practices</a> in declining breastfeeding rates and infant illness and death led to the development of the <a href="https://www.who.int/nutrition/publications/code_english.pdf">International Code of Marketing of Breast-milk Substitutes</a>, which was adopted by the World Health Assembly 40 years ago, in 1981. The U.S. was the <a href="https://doi.org/10.1136/archdischild-2011-301299">only nation that voted against it</a>, driven by formula lobbying efforts.</p>
<h2>Milking profits</h2>
<p>In the 1950s through the 1970s, multiple social movements fueled <a href="https://doi.org/10.2307/2080604">increased interest in breastfeeding in the U.S.</a>. Medical experts supported these movements with a growing body of <a href="https://doi.org/10.1093/ahr/121.4.1196">scientific research demonstrating the importance of breastfeeding for infant, child and maternal health</a>. But despite <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">significant gains in breastfeeding</a> in some settings, like the U.S., the formula industry <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">continues to expand</a>. </p>
<p>Between 2005 and 2019, global <a href="https://doi.org/10.1111/mcn.13097">formula sales increased 121%</a>, led by middle-income countries. The global industry is <a href="https://doi.org/10.1111/mcn.13097">currently valued at US$50.6 billion</a> and <a href="https://www.globenewswire.com/news-release/2021/01/29/2166545/0/en/Global-Infant-Formula-Market-Size-Will-Reach-USD-110-26-Billion-by-2026-Facts-Factors.html">projected to double by 2026</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman stands in front of a massive grocery store display of infant formula." src="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Infant formula is big business.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rear-view-of-young-asian-mother-groceries-shopping-royalty-free-image/1255253039">d3sign/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Formula-makers devote <a href="https://doi.org/10.1111/mcn.13097">billions of dollars each year to marketing</a> that co-opts scientific and medical authority and <a href="https://www.who.int/publications/i/item/9789240006010">undermines breastfeeding globally</a>. These marketing practices have <a href="https://www.who.int/publications/i/item/9789240006010">continued to defy the International Code of Marketing of Breast-milk Substitutes</a>. </p>
<p>As in the 19th century, <a href="https://www.savethechildren.org.uk/what-we-do/policy-and-practice/our-featured-reports/dont-push-it">formula marketing</a> still <a href="https://doi.org/10.1186/s12992-020-00597-w">presents breastfeeding as an inherently problematic</a>, unreliable process to which formula provides the solution. </p>
<p>Yet most breastfeeding challenges, like the perception of insufficient milk and the difficulties faced by lactating workers, are the product of <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">structural and social conditions</a> that can be addressed by <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">investing in policies</a> that provide quality perinatal care, skilled breastfeeding support, parental leave and workplace accommodations for lactating parents. </p>
<h2>More than a food</h2>
<p>Formula companies focus on human milk as the only important element of breastfeeding – and claim near equivalence between their product and human milk. Yet human milk is a living, life-sustaining substance with a <a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">long evolutionary history and cultural meaning</a>. </p>
<p>Human milk is <a href="https://jhupbooks.press.jhu.edu/title/milk">specific to our species</a>. It is <a href="https://doi.org/10.1002/ajhb.23564">dynamic and adaptive</a> – ever-changing in response to local environments. Human milk contains <a href="https://doi.org/10.1002/ajhb.23564">bioactive compounds</a> and has <a href="https://doi.org/10.1002/ajp.22994">a unique microbiome that varies by setting and over time</a>. New technology, including <a href="https://www.foodnavigator-usa.com/Article/2020/12/17/TurtleTree-Labs-raises-6.2m-to-support-cell-cultured-milk-platform">the culturing of human cells</a>, cannot replicate any of this. </p>
<p>Through complex interactions among mothers, infants and their communities, breastfeeding provides infants with <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">optimal nutrition and protection from infectious disease</a>. Across cultures, lactation and human milk create <a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">relationships that bind families</a> and communities together. </p>
<p>Families need accurate information free of commercial influence to make informed decisions about breastfeeding. I believe when lactation is not possible or desired, <a href="https://doi.org/10.1016/S2214-109X(19)30402-4">families could benefit</a> from <a href="https://doi.org/10.1177/0890334419850820">donor human milk</a>. <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">Government investment in policies</a> that protect, promote and support breastfeeding remains key to creating an environment in which breastfeeding can thrive.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/159771/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cecília Tomori has received funding from the National Institutes of Health, US Health Resources & Services Administration, Johns Hopkins University, and the University of Michigan.</span></em></p>Around the globe, 823,000 child deaths could be prevented annually with appropriate breastfeeding. Formula makers continue to defy a 40-year-old international code on marketing their product.Cecília Tomori, Associate Professor and Director of Global Public Health and Community Health, Johns Hopkins University School of NursingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1455572020-10-05T15:06:01Z2020-10-05T15:06:01ZWhy many South African mothers give up breastfeeding their babies so soon<figure><img src="https://images.theconversation.com/files/361569/original/file-20201005-24-1w4e9gf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lot is still uncertain about breastfeeding practices in South Africa.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Breast milk plays a vital role in reducing child mortality. It has all the nutrients a baby needs in the first six months of life and its health benefits extend into adulthood. This is why organisations, like UNICEF and the World Health Organisation (WHO), recommend <a href="https://www.who.int/elena/titles/exclusive_breastfeeding/en/">exclusive breastfeeding</a> – no other food or drink, not even water – for infants in this period. </p>
<p>Globally, numerous <a href="https://www.who.int/bulletin/volumes/91/6/12-109363/en/">policies and programmes</a> have been put in place to promote and support breastfeeding. South Africa has also been promoting exclusive breastfeeding. But the country has one of the <a href="https://www.nature.com/articles/s41591-019-0525-0">lowest</a> rates of exclusive breastfeeding in Africa and globally.</p>
<p>Within the country, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6799928/#:%7E:text=In%202011%2C%20South%20Africa%20committed,2011%20to%2032%25%20by%202016.">rate</a> varies substantially. There have been remarkable improvements in some age groups. In 2003, only 11.2% of babies were breastfeeding exclusively in the first month of life. By 2016, that number had jumped to 44%. But, at five months, only 31.6% of babies were being exclusively breastfed. </p>
<p>These patterns were echoed in my <a href="https://link.springer.com/epdf/10.1186/s13006-020-00320-w?sharing_token=DQiu5G7OcEt-gvfz_FOTKW_BpE1tBhCbnbw3BuzI2RMVNeuGNqr5t7js5_IpkDN6vYhu6wCty9qZhtTFDgALHUYROUrv7xKEd1T0YdA_7mIgeGyvRYttjmDKzKuDWzKfa-7MkTal6UdDkDoBsZjDMe0e6Dif3dLQQNpxMvfvSzU%3D">doctoral study</a> conducted in the Tlokwe sub-district – an area with nine primary healthcare clinics and a district hospital – in South Africa’s North West province. I examined the rate and reasons of exclusive breastfeeding discontinuation among a particular group of mothers. </p>
<p>It’s important to understand why mothers, despite the decades of breastfeeding promotion campaigns, still do not optimally breastfeed their infants. Understanding the reasons can inform policy and interventions to make it easier to give babies the best start in life. </p>
<h2>Breastfeeding practices</h2>
<p>The Tlokwe sub-district is like many low-income neighbourhoods in South Africa. It’s burdened with high unemployment, poor living conditions, high levels of violence and crime and low levels of social capital. Most households in setting like this are headed by women and have multiple children. The men are often drawn to cities for better employment opportunities. I followed a cohort of 178 breastfeeding mothers with infants from age 14 days to 24 weeks.</p>
<p>In my study, exclusive breastfeeding rates decreased from 34% at 4-8 weeks to a mere 9.7% by weeks 20-24. Over the same period, mixed feeding with infant formula increased from 17% to 50.1%, and food feeding from 3.1% to 54.2%. These numbers mirror the <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=215">national trends</a>.</p>
<p>A lot is still uncertain about breastfeeding practices in South Africa. But my research suggests that womens’ decisions around breastfeeding are shaped by a host of personal, social, economic and cultural factors. These often get in the way of the mother’s intentions to breastfeed her infant as recommended. This is especially true for women living in poverty.</p>
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Read more:
<a href="https://theconversation.com/how-health-workers-have-adapted-to-south-africas-breastfeeding-policy-99688">How health workers have adapted to South Africa's breastfeeding policy</a>
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<p>Of all the factors that determine women’s decisions on breastfeeding, the most dominant one – in my study, at least – was the stress that mothers endure in difficult home environments. </p>
<p>Many South African women face daily challenges of poverty – no food, rent to pay, children to put through school. </p>
<p>One <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860892/#:%7E:text=Most%20women%20initiated%20breastfeeding%3A%2091.6,those%20with%20severe%20food%20insecurity">study</a> found that a major concern and source of stress for breastfeeding mothers was the lack of food in the home. In 2017, <a href="http://www.statssa.gov.za/publications/P0211/P02113rdQuarter2019.pdf">almost 20%</a> of South African households had inadequate or severely inadequate access to food. The North West province – where I did my study – had the highest proportion of food insecure households at 63%.</p>
<p>Under such trying conditions, women often have to care for children alone. Studies have <a href="https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-017-0135-8">found</a> that most new mothers live with their families of origin rather than their partners or spouses. And these families have their own struggles with poverty. </p>
<p>This elevates stress. Family stress and the lack of food and money take a toll on a mother’s mental health. I used the <a href="https://journals.co.za/content/ajpherd/20/sup-1/EJC162286">Edinburg Postnatal Depression Scale</a> to measure mothers’ mental health and found that nearly 45% had clinical signs of distress. This rate is higher than found in previous studies of mental health among HIV-positive mothers. </p>
<p>Around <a href="https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/#:%7E:text=Worldwide%20about%2010%25%20of%20pregnant,and%2019.8%25%20after%20child%20birth">13%</a> of mothers in developing countries experience clinical depression after childbirth – a condition also known as postpartum or postnatal depression. Women with high levels of postpartum depression are more likely to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492376/">stop breastfeeding</a> within three months. </p>
<p>In my study, mothers feared that the stress they experienced could be passed on to their infants through breastfeeding. Mothers are reluctant to pass on their stress and distress to their infants. Their decision to seek alternative feeding is a protective action to spare their infants their negative stress.</p>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901002/">shows</a> that stress in mothers increases corticosteroids in breast milk. This validates mothers’ concern for their infants and the negative impact of stress.</p>
<p>My qualitative data showed that many mothers had difficult and strained relationships in the home and experienced a hostile social environment towards breastfeeding. Mothers expressed discomfort and shame about breastfeeding in public spaces and places.</p>
<p>There are additional factors that influence breastfeeding choices. These include the mother’s breastfeeding knowledge, and breastfeeding support from health professionals. Mothers knew about the health benefits of breastfeeding for their infants. But surprisingly, baby cues were often interpreted and internalised as negative responses to their breast milk. These cues included the baby crying, the baby breastfeeding frequently, and the baby not sleeping for long periods. Often these aspects of baby care and breastfeeding were not discussed at the health facilities. </p>
<p>The infant <a href="https://www.huffpost.com/entry/baby-formula-industry-has-a-long-history-of-undermining-breastfeeding-moms_n_5b44bf07e4b07aea75446989">formula industry</a> markets infant formula as a superior response to the crying baby, the “hungry baby” and the difficult sleeper. These were some of the reasons that mothers switched to infant formula. </p>
<p>Guidance from family, relatives and health professionals is also likely to shape the decision to continue – or discontinue – with breastfeeding. </p>
<h2>Recommendations</h2>
<p>Most mothers deliver their babies in a health facility where exclusive breastfeeding is recommended and encouraged. But the fact that mixed feeding is the norm suggests that mothers are confronted with environments that make it hard for them to follow this advice. </p>
<p>My findings suggest that breastfeeding information and education is reaching mothers, which mothers value and want to breastfeed.</p>
<p>But telling a mother that breastfeeding is good for the baby does not address the challenge of household food insecurity, internalised misconceptions about breast milk production, and difficult family relations. These barriers inhibit optimal breastfeeding practices and demand broader society engagement on supporting women and their child care responsibilities.</p>
<p>Breastfeeding support programmes narrowly focused on the health and social benefits of breastfeeding need to take a broader approach. Child nutrition can’t be addressed without addressing the challenges that women, and mothers in particular, face.</p><img src="https://counter.theconversation.com/content/145557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Breastfeeding support programmes need to engage more with the challenges that mothers face.Chantell Witten, Lecturer, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1467002020-09-29T14:49:59Z2020-09-29T14:49:59ZZambian study points to why some mothers don’t carry on taking HIV drugs<figure><img src="https://images.theconversation.com/files/360255/original/file-20200928-16-78vutp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many factors influence how consistently women take their HIV medicine.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>There are more than <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia">85,000 children</a> living with HIV in Zambia. The primary source of infection is from mother to child during pregnancy, childbirth or breastfeeding. Antiretroviral therapy (ART) is an <a href="https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child">effective</a> strategy to eliminate these new infections. But it only works if women take their medications consistently.</p>
<p>Adherence to ART is still a major challenge in sub-Saharan Africa, especially among <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5651-y">pregnant and breastfeeding women</a>. In 2012, the World Health Organisation (WHO) introduced <a href="https://www.who.int/hiv/PMTCT_update.pdf#page=7">new guidelines</a> for the prevention of mother-to-child transmission of HIV. Women with HIV are provided with the antiretrovirals as soon as they become pregnant and have to take treatment for life. </p>
<p>The use of ART among pregnant and breastfeeding women in Zambia increased from 65% in 2012 to <a href="https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/zambia">80% in 2018</a> – but adherence has been problematic. </p>
<p>A <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111421">number of factors</a> can influence whether women take their HIV medicine consistently. They may forget or be too busy. They may fear stigma and discrimination in their communities. They might have difficulty paying for the medication or be unable to access healthcare. Adverse side effects of the drugs can also drive people to stop taking them. Sometimes women intend to take the medication, but circumstances like inadequate access to water or food get in the way. Some intentionally don’t take the drugs because of their attitudes and beliefs. </p>
<p>In a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09505-8">recent study</a> we investigated whether attitudes or behavioural beliefs about ART influenced women’s intentions to adhere to antiretroviral drug regimens. We surveyed pregnant and breastfeeding women in Zambia. We found that the intention to adhere to ART differed significantly by income, knowledge about HIV transmission, attitudes, and behavioural beliefs. Older women with little knowledge about HIV transmission, and a more negative attitude towards ART, had the weakest intention to adhere to their medication. </p>
<p>Whatever the reason, poor adherence carries serious consequences. For the individual, it can mean increased risk of passing HIV to their children. For the community and the world, it can mean drug resistance and transmission of resistant mutations. </p>
<h2>Attitudes and beliefs about antiretrovirals</h2>
<p>It’s common for people living with HIV to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286200/">unintentionally lapse</a> in taking their drugs. But intentional lack of adherence has been on the rise in low-resource countries. </p>
<p>My colleagues and I launched the <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09505-8">first study in Zambia</a> to explore how attitudes and beliefs affect HIV-positive pregnant and breastfeeding women’s intention to take ART consistently. These attitudes and beliefs are influenced by education, religion and socio-cultural norms. People who believe ART improves health are more likely to adhere than those who doubt that HIV exists or the effectiveness of the drugs.</p>
<p>We surveyed women at hospitals and clinics in the urban Lusaka district and the rural Sinazongwe district. We assessed their attitudes by asking them to rate their agreement with statements like: </p>
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<p>Taking ART drugs is easy for me; and </p>
<p>It is tiresome to take ART drugs every day. </p>
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<p>Their beliefs were captured with statements such as: </p>
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<p>I am confident that I will take my ART drugs consistently as prescribed by my healthcare provider; and </p>
<p>I feel comfortable about talking to my healthcare provider about taking my ART drugs.</p>
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<p>We found a significant association between attitude towards ART and women’s intention to take it. Most of the women with a negative attitude towards ART had the weakest intention to adhere to their medication. And most women with a positive attitude had the strongest intention to adhere to their medication regimen. Similarly, those with negative beliefs were less likely to have a strong intention to adhere to their medication regimen. </p>
<p>After accounting for where people lived (rural vs urban) and other factors such as education, income, age and occupation, we found that attitude rather than belief was the key to adherence intention, regardless of where the women lived. </p>
<p>Older rural women with less knowledge about HIV transmission were less likely to plan to adhere to the medication. Positive attitudes about ART were linked with strong intention to adhere.</p>
<h2>What next</h2>
<p>These findings have implications for research, clinical care and policy. Researchers should design and test interventions that specifically target women’s negative attitudes and behavioural beliefs and follow them to see if their intention translates to adherence to ART.</p>
<p>Insights about attitude and beliefs may be useful in improving adherence intention by paying attention to rural communities where resources and knowledge about HIV transmission may be less available.</p>
<p>Health educators can use these findings to advocate for education programmes and materials that reach more vulnerable populations, especially in rural and low-resource areas. Information about HIV and transmission to infants should be presented to women prior to starting ART treatment, including those in rural areas. Women should be given sufficient time to acknowledge the importance of this information for their own health and the health of their entire families.</p>
<p>Interventions that specifically target women’s negative beliefs about ART should effectively increase their adherence to ART. Countries like Zambia, with a high HIV prevalence, urgently need to develop tailored approaches to foster more positive attitudes and beliefs towards ART.</p><img src="https://counter.theconversation.com/content/146700/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerry John Nutor does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The use of antiretroviral therapy among pregnant and breastfeeding women in Zambia has increased but adherence is a problem.Jerry John Nutor, Assistant Professor, Family Health Care Nursing, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.