Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? – A systematic scoping review

Abstract

Introduction Suboptimal breastfeeding rates in South Africa have been attributed to the relatively easy access that women and families have had to infant formula, in part as a result of programs to prevent maternal-to-child transmission (MTCT) of HIV. This policy may have had an undesirable spill-over effect on HIV-negative women as well. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the WHO HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa. Methods We applied the Joanna Briggs Institute guidelines for scoping reviews and reported our work in compliance with the PRISMA Extension (PRISMA-ScR). Twelve databases and platforms were searched. We included all study designs (no language restrictions) from South Africa published between 2006 and 2020. Eligible participants were women in South Africa who delivered a healthy live newborn who was between birth and 24 months of age at the time of study, and with known infant feeding practices. Results A total of 5431 citations were retrieved. Duplicates were removed in EndNote and by Covidence. Of the 1588 unique records processed in Covidence, 179 records met the criteria for full-text screening and 83 were included in the review. It was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1–3 months). EBF rates rapidly declined after birth. School and work commitments were also reasons for discontinuation of EBF. HIV-positive women expressed fear of HIV MTCT transmission as a reason for not breastfeeding. Conclusion The Review found that while enforcing the most recent WHO HIV infant feeding guidelines and the WHO Code may be necessary to improve breastfeeding outcomes in South Africa, they may not be sufficient because there are additional barriers that impact breastfeeding outcomes. Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to improve breastfeeding outcomes in South Africa.

Feeding practices and cost of diet of six-month-old HIV exposed uninfected compared to HIV unexposed uninfected infants in a peri-urban community in South Africa

“…In our study, the self-reported percentage of early initiation of breastfeeding (EIBF) was high in both WLHIV and HIV-negative women (75.0%; 75.5%), and higher than previously reported in WLHIV (56.6%), HIV-negative women (61.2%) and the general population (67.3%) in South Africa [15,36], as well as globally in the general population (57.6%) as stated in a WHO global survey [37] and 58.3% in Ethiopia [38]. The EIBF rates also surpassed the WHO global target of 70% in both groups.…”

Gearing up to improve exclusive breastfeeding practices in South Africa

“…It was developed and used in English with all participants. Topics for the guide were developed by DV based on the authors’ systematic scoping review [ 22 ], and reviewed by RPE taking into account his experience in the field. The study was approved by Yale University’s Institutional Review Board.…”

“…A recent systematic scoping review by the authors on breastfeeding inequities in South Africa [ 22 ] identified free distribution of infant formula and aggressive marketing tactics by the formula industry as negatively impacting EBF practices among both HIV-negative and positive women in South Africa. The review also highlighted that enforcement of the WHO Code is necessary but not sufficient to improve breastfeeding outcomes as other factors such as social support and quality maternity care services are needed by women antenatally and post-delivery.…”

Interventions and policy approaches to promote equity in breastfeeding

“…This collection highlights the relevance and existing challenges in implementing structural policies needed to reduce breastfeeding inequities. Vitalis et al [ 32 ] document the experience of South Africa on how the initial WHO infant feeding recommendations for HIV positive women ended up negatively affecting breastfeeding practices also in HIV negative women and introduced major challenges to the enforcement of the International Code of Marketing of Breast-milk Substitutes (The Code). Through a scoping review Vitalis et al [ 32 ] highlighted that maternal HIV, which usually coexists with poverty became a powerful syndemic, as breastfeeding was disincentivized in the early WHO guidelines issued in the context of the then lack of access to effective antiretroviral treatments.…”

“…Vitalis et al [ 32 ] document the experience of South Africa on how the initial WHO infant feeding recommendations for HIV positive women ended up negatively affecting breastfeeding practices also in HIV negative women and introduced major challenges to the enforcement of the International Code of Marketing of Breast-milk Substitutes (The Code). Through a scoping review Vitalis et al [ 32 ] highlighted that maternal HIV, which usually coexists with poverty became a powerful syndemic, as breastfeeding was disincentivized in the early WHO guidelines issued in the context of the then lack of access to effective antiretroviral treatments. Despite the enormous improvements in access to antiretrovirals as time went by in South Africa, and the issuing of new guidelines by WHO supporting breastfeeding in this new context, the legacy of the initial recommendations continues to be a formidable challenge for South African efforts at enforcing the Code.…”