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Aids and maternity in India

 | 
Patrice Cohen
, 
Suniti Solomon

Part 4. Mtct risks factors and practices in India: social sciences perspectives

10. Socio-cultural Obstacles to the Prevention of HIV Transmission through Breastfeeding in West Africa

Alice Desclaux

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Introduction

1In 1998, UNICEF, UNAIDS and WHO published guidelines for the prevention of HIV transmission through breastfeeding, and gave a range of infant feeding options.

2We need to know if these options match with practical possibilities for women and with perceptions and attitudes about infant feeding in various social and cultural environments. What are the social and cultural factors that restrict prevention in the health system? How can these limits be overcome? Is it possible to do so, or is HIV prevention incompatible with the medical culture of breastfeeding?

  • 1 This research was undertaken by SSD (Laboratoire Societies, Health, Development, University of Bord (...)

3The results presented here about West Africa come from a two-year research programme1, the aim of which was to identify social and cultural factors that enhance or reduce HIV transmission through breastfeeding, and cultural conditions of prevention. It was held in Burkina- Faso and the Ivory Coast in 1998-1999.

4The situations of the HIV/AIDS epidemic is quite different in West Africa and in India. But we offer here results from an African experience in the hope of enriching the consideration of the socio-cultural obstacles to HIV prevention through breastfeeding in India. Although there are numerous social differences between these two areas, this paper presents various situations worth consideration in the Indian context.

Methods

5The programme used a range of methods, including:

  • an ethnological study of breastfeeding among three ethnic groups (Mossi, Bobo and Peuls);
  • a research among HIV+ mothers who had undergone a MTCT trial in Bobo-Dioulasso (Burkina-Faso) and Abidjan (Ivory Coast): we studied their perceptions of risk and prevention two years after delivery and the difficulties they had to face to feed their babies in two urban settings;
  • qualitative studies among health professionals of MCH services (in Burkina-Faso) on knowledge and attitudes about HIV/AIDS;
  • a study of patterns of care and feeding in health services and in families of orphans, to know which solutions are found when a baby cannot be breastfed by its mother;
  • a study of the management of breastfeeding and HIV in social and health services and organizations in a country that had started to work on prevention at the national level (Ivory Coast) and in a country that had not yet started (Burkina-Faso).

Results: Limitations to Preventive Behaviours for HIV+ Mothers

6The results show that HIV+ mothers do face several kinds of limitations to preventive behaviours, due to social and economic constraints, the difficulties of choice and various restrictions related to the health system.

Social and Economic Limits

Cost of Breastmilk Substitutes and Other Feeding Options

7First of all, breastfeeding is free. The cost of substitutes is higher than the minimum wages in West African countries. The cost of formula feeding also includes the cost of wood, fuel or charcoal. We know that preventive programmes must provide substitutes; they must also help mothers to meet these additional costs. Early weaning also has a cost that should be considered in programmes.

Attitude of Fathers

8Choosing an alternative feeding option requires that women speak with their husbands about their HIV status. But nearly half of the 60 women interviewed in Abidjan and Bobo-Dioulasso had not told their husbands, two years after learning of their status. Women have good reasons to hide their seropositivity: telling the truth often opens the way to mutual accusation, sometimes to a true social risk of being rejected, and, a minima, the father refuses to pay for the child’s care because he considers that the problem is due to the mother, who is also responsible for the care of the child.

The Normative Value of Breastfeeding

9In Bobo-Dioulasso and Abidjan, not-breastfeeding is highly stigmatized. It is not necessarily related to HIV. A woman who does not breastfeed is accused of imitating the Whites, of spending money, or neglecting her child, of being a « bad mother », especially by mothers-in-law, but also by neighbours and families, as breastfeeding is a public act.

The Difficulties of Choice

10The choice for a feeding option is especially difficult for women, for several reasons: four main reasons are presented below.

Ambiguous Iinformation Delivered in Health Services about Breastfeeding and HIV

11Many health care services still teach that mother’s milk is best for all babies. Thus, women get contradictory messages and make false interpretations. For instance, some of them think that HIV is transmitted only after six months of breastfeeding.

Perceptions of the Symbolic and Biological Value of Human Milk

12Perceptions that enhance the value of breast-milk are firmly rooted in African cultures. From a symbolic point of view, breastfeeding inserts a child in his parenthood and contributes to his identity. Breastfeeding is also considered to be necessary for the child to grow up and become strong (women often say that white babies are tall but flabby because they were not breastfed enough). Negative perceptions are associated to formula in Abidjan, as well as in Bobo-Dioulasso.

Few Feeding Options Available

13Few feeding options are available. Cow milk is available only where Peul populations live, and is difficult to find in town; all ethnic groups have negative perceptions about animal milk, except the Peul, who are shepherds. Wet nurses are not easily available in Burkina-Faso, where a woman spends more than fourteen years of her life being pregnant or breastfeeding. In any case, the wet nurse requested to feed a child should be tested for HIV, which is a confidentiality problem.

Psychological Burden of “Choice”

14To choose between options is very difficult for women. They think that no risk is low enough for a mother not to take it conciously for her child. It is not a choice, but a decision under many constraints. Nearly all the mothers interviewed said that, if they could, they would have chosen substitutes because it’s the only zero-risk option. Only a few of them could do so.

Limitations Related to the Health Care System

15Health services still do not implement prevention. Although 8 to 15 % of the pregnant women are HIV+ in Burkina-Faso and Ivory Coast, programmes to promote breastfeeding remain unchanged at the national level. The main limitations in prevention in the health system are related to the following points.

Unchanged Promotion of Breastfeeding for all Mothers

16The message that health professionals give to pregnant women and mothers is that they must breastfeed their baby. This message is often delivered in an authoritarian way ( « In this hospital, it is compulsory to breastfeed » Abidjan, 1998). Mother and Child Health (MCH) professionals seem to believe that there is no medical condition that can justify formula-feeding. HIV+ women may be obliged to disclose their status to justify that they do not breastfeed their babies.

Failure of Exclusive Breastfeeding Promotion

17In West African countries where more than 95 % of the babies are breastfed, the main message about breastfeeding should be in favour of exclusive breastfeeding. This message is still relevant in the time of AIDS. But few MCH professionals believe that exclusive breastfeeding is important. Many think that water is necessary for babies in a hot climate, and herbal teas are a popular preventive treatment that they use themselves. Although regional strategies defined by IBFAN (International Baby Food Action Network) for Africa promote exclusive breastfeeding, international strategies focus on “breastfeeding promotion”. Breastfeeding programmes failed to increase exclusive breastfeeding rates in West Africa during the last ten years, and rarely focused on exclusive breastfeeding, as if this fight was “lost in advance”.

The Rejection of Formula by Health Services

18The struggle against formula use has led programmes promoting breastfeeding to forbid formula in health services. But in doing so, not only has the use of formula disappeared from the health services, but also the knowledge of professionals about how to teach parents to use it in a safe way. The consequences are obvious in the case of orphans and babies who cannot be breastfed by their mothers: health services are seldom able to provide them proper care and help. UNAIDS recommended that controlled programmes of the supply of non-commercial formula through the health system be established. When this food becomes available, the lack of culture and knowledge of MCH professionals in formula feeding management must be filled.

Lack of Knowledge about HIV among Health Care Workers

19MCH professionals were trained in AIDS later than any other health professionals. Moreover, information about HIV transmission through breastfeeding has not been delivered by the national AIDS programme in Burkina-Faso. When given, the information was often imprecise or minimized, and MCH professionals got it through media rather than through professional channels. Competence in the field of HIV prevention (from scientific knowledge to counselling ability and capacity to deal with HIV-affected families) is still lacking among MCH professionals.

The Existence of Preventive Messages that Stigmatize Women who do not Breastfeed

20The programmes promoting breastfeeding often use health messages that stigmatize women who do not breastfeed. They say that such women do not love their babies, that they unnecessarily spend money on formula, or that their babies will be like cows. These messages are explicit, especially during the World Week of Breastfeeding Promotion, when conferences are held and poems and plays are peformed for the general population. These messages reinforce the social norm in favour of breastfeeding. They make it more difficult for women who would like to breastfeed, but choose to protect their child from HIV by adopting preventive measures.

21Other factors related to health services limit HIV prevention, such as insufficient care for breast ailments, which are mainly treated in the traditional sector.

Origins of Health Service Failure

22Health services and institutions have been slow in facing the reality of HIV transmission through breastfeeding for several reasons.

Social History of Breastfeeding Promotion

23In the 1960s, the shift to formula feeding in environments with poor sanitation had dreadful consequences on infant mortality in Africa. Multinational firms selling formula are still a threat for the health of babies when, for instance, they refuse to obey the code for baby-food commercialization. The struggle to defend the health of African babies against commercial interests has brought together over the last twenty years many scientists, politicians, health professionals, activists and churches. This wide consensus may explain the lack of critical analysis of breastfeeding promotion programs during the last ten years, and the delay in considering that the prevention of HIV transmission does not necessarily open a way to commercial strategies on the formula market.

Social Organization of Breastfeeding Promotion Programmes

24Programmes to promote brestfeeding are vertical programmes. As such, they have their own priorities and agendas, different from the those of AIDS programmes. Coordination was rarely set up in West African countries (it was the case in Ivory Coast as early as 1994). The problems of HIV+ women were not a priority for breastfeeding programmes, and babies were not a priority for AIDS programmes. Moreover, as the breastfeeding programme is an top-down centralized institution, the messages spread all over the world are defined in Washington, and are the same in developed countries and in Africa. Thus, the institutional organization of breastfeeding treatment in health services hindered the initiation of preventive strategies, which are still missing at the national level in many countries.

Cultural Reasons for not Believing that Human Milk may be Harmful

25The symbolic value of milk is very important in all cultures and all religions. In Western culture, which is the one of health institutions, milk is a symbol of purity and breastfeeding a symbol of motherhood and love. For many MCH professionals and for some scientists, it was simply unbelievable to think that breastfeeding may be harmful to the baby. The same doubt about scientific data still appears in the last Declaration of the World Health Assembly (May 2000).

Difficulties in Defining Preventive Strategies

26Of course, health institutions would have already set up international strategies of prevention if preventive measures were easy to apply and without any risk. But, health professionals to often consider the social and cultural limitations of the population (such as the lack of knowledge, or population attitudes) to be the only problems impeding prevention. Facing social and cultural limits related to health services is now necessary.

Conclusions

27No feeding option is easy to choose for HIV+ women. And no strategy is effortless to define. The complexity of the problem is due to the fact that social and cultural limits are more related to others than to the women, and are located in the health system as well as in the population.

28A pre-requisite for prevention is to involve all services caring for mothers and children: hospitals, MCH clinics, nutrition centres. Another prerequisite is to involve associations of people living with HIV who have become experts in fighting stigmatization and who may help women to face their situation.

  • 2 From a public health point of view, this research programme has made it possible to define recommen (...)

29Preventive programmes should include2:

  • Counselling about infant feeding as soon as possible (during pregnancy), since it takes time to remove the constraints that limit women’s choices;
  • Access to substitutes, and education / information about the use of formula for parents and care for children, either orphans or babies of HIV+ mothers, must be provided in the health services;
  • The threat of spillover is not relevant in West African societies, where women are too poor to buy formula and where social perceptions and norms are opposed to its use.
  • Breastfeeding programmes should be adapted on at least three points:
  • Promoting exclusive breastfeeding, which is not the case now at a local level in Burkina- Faso and Ivory Coast, where breastfeeding is promoted without specification for all women;
  • Removing messages that stigmatize women that do not breastfeed;
  • Developing care for breast ailments that are currently treated in the traditional sector, and promoting « best practices » of breastfeeding.

Notes

1 This research was undertaken by SSD (Laboratoire Societies, Health, Development, University of Bordeaux II), IRD (Institute of Research for Development). The research was funded by ANRS (French National Agency for Research on HIV/AIDS) and MAE (French Ministry of Foreign Affairs). The research team included: C. Alfieri, M. Querre, A. Desclaux (University of Bordeaux), B. Taverne (IRD, Ouagadougou), D. Coulibaly, L. Vidal, P. Msellati, A. Desgrées du Lou (IRD, Abidjan), O. Ky-Zerbo, P. Van de Perre (Centre Muraz Bobo-Dioulasso).

2 From a public health point of view, this research programme has made it possible to define recommendations from local to international levels for African countries. The results have been published in a book: "Allaitement et VIH en Afrique de l’ouest. De l’anthropologie à la santé publique". Desclaux A., Taverne B. (eds.), 2000. Paris, Karthala, 556 p.

© Institut Français de Pondichéry, 2004

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