Acceptable, Feasible, Affordable, Sustainable, Safe?

Since 2001, the World Health Organization recommends exclusive breastfeeding for six months for all infants, followed by the introduction of nutritionally adequate, safe and appropriate complementary foods with continued breastfeeding for at least two years (1). While experts agree that breastmilk is the best infant diet and protects the child against various infections, there has been debate over the optimal duration of exclusive breastfeeding. Compared to the previously recommended duration of four to six months, the main advantage of exclusive breastfeeding for six months lies in an additional reduced risk of gastrointestinal infections and of all-cause child morbidity. Hence, in the context of developing countries, infant feeding experts conclude that the benefits of exclusive breastfeeding in terms of decreased morbidity and mortality overweigh potential risks associated with exclusive breastfeeding for 6 months. In the absence of safe replacement feeding, these risks include the mother-to-child transmission of HIV/AIDS, which is significantly reduced by exclusive breastfeeding, but can be totally avoided only by not breastfeeding.

According to the latest consensus statement based on new evidence regarding HIV and infant feeding (2), the WHO recommends exclusive breastfeeding for 6 months to HIV infected mothers unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS). If at six months AFASS criteria are still not met, the mother is advised to introduce suitable complementary foods and to continue breastfeeding until an adequate and safe diet without breastmilk can be provided. The overall paradigm of the global infant feeding strategy in the context of HIV/AIDS now is HIV-free survival at 18-24 months. Low maternal CD4 counts as well as high viral load in breastmilk and plasma have been identified as important risk factors for HIV transmission and child mortality, though the recommendations regarding infant feeding do not integrate differential transmission risks.

Prolonged and continuous exclusive breastfeeding is not the norm

The WHO strategy suggests that, in resource-poor settings, it is more realistic successfully to promote exclusive breastfeeding for six months than to make replacement feeding AFASS for HIV-infected mothers. While the consensus statement largely encourages governments and stakeholders to promote and support exclusive breastfeeding, it only invites them to take measures to make replacement feeding safer for HIV-infected women after they chose this option. Worldwide, infant feeding patterns give a less optimistic picture. Fifteen years after the Innocenti Declaration, only one third of all infants in the developing world are exclusively breastfed for the first six months of life (3). In Sub-Saharan Africa, where HIV prevalence is highest, exclusive breastfeeding rates increased from 15 % to 32 % between 1990 and 2004. However, the estimations of these rates are currently based on single 24h feeding recalls, an assessment method that leads to a large overestimation of exclusive breastfeeding, which is not a regular feeding pattern in practice (4). Continuous and prolonged exclusive breastfeeding remains highly uncommon worldwide. The last WHO consensus statement declares that it is feasible to improve adherence and duration of exclusive breastfeeding if women are provided with consistent messages and frequent high-quality counselling. At the same time, it states that infant feeding counselling remains insufficient, inaccurate or non-existing due to weak and poorly organized health facilities.

Ethnographic evidence further shows that a solely technical response is not enough to ensure the sustainable improvement of exclusive breastfeeding practices. While breastfeeding is valued and practiced in most developing countries, exclusive breastfeeding for six months could and cannot be a “natural” feeding practice (5). C. Makhlouf Obermeyer and S. Castle showed that the real and/or perceived “insufficient milk syndrome” (IMS) appears to be the most important factor in early supplementation, cited both as an a priori justification for introducing other food and as an a posteriori explanation. Women discontinue breastfeeding, which leads to a decrease of their breastmilk production and encourages in return further supplementing. Health practitioners echo the widespread perception of insufficient milk by women and thus contribute to discourage exclusive breastfeeding. At once, according to the authors, the development of breastmilk substitutes devalued the women’s role as a nurturing mother. The promotion of infant formula had been greatly facilitated by early supplementation habits and women’s doubts about their own breastmilk “product”. Various beliefs regarding the fragility of breastmilk as a bodily substance, which is thought to reflect a woman’s moral rather than her physical weakness, do nourish these doubts. At the same time, breastfeeding is strongly controlled by male authority, making continuous breastfeeding difficult, especially in regions where lactation and sexual intercourse are regarded as incompatible. Makhlouf Obermeyer and Castle conclude that breastfeeding is strongly woven into the cultural fabric of society and must hence be re-thought as something more than a product. Finally, the underlying factors of insufficient milk are “poverty, sexism and powerlessness” that technical information cannot eliminate.

“Breast is best”. What about women?

This powerful analysis can be further refined by making a systematic link between breastfeeding and gendered reproduction. Breastfeeding is part of the whole reproductive process set off by the conception of a new human being, and even before that moment since, in some cultures, infants are seen as returning ancestors. As anthropologist M. Godelier has demonstrated (6), reproduction is universally regarded as a result of the sexual union between a woman and a man that requires the intervention of a third agent, namely the divine in its various manifestations. Therefore, breastmilk is understood as a bodily substance that results from the transformation of one or more other bodily substances that participate in the generation of a child (7). Breastmilk comes most often from female blood or male semen or from both. Sometimes, it also stems, fully or partially, from the food taken by the mother. Although breastmilk is a substance produced by a female body, it is not automatically regarded as a female by nature. In some Arab societies, for example, breastmilk is understood as transformed semen and, therefore, as a male substance. Where breastmilk is believed to come from female blood, milk is indeed seen as a female substance, but as such it is not a perfect substance, rather a perfectible fluid. A wide range of life-cycle rituals, traditional medicines and other prophylactic practices are performed in order to improve the quality of breast milk and to assure “good” and sufficient milk that furthers the child’s growth and health. Where breast milk is seen as a male substance, it might be perceived as more akin to a perfect fluid. Here, breast milk is produced in a female body and flows through a female body that is often seen as potentially dangerous or impure. Hence, a whole range of rituals and practices are necessitated to prevent intrinsically “good” milk from becoming “bad” milk. When breast milk comes from the food ingested by the mother, it is important to ensure the right intake of the right kind of food in right amounts in order to produce good breast milk. Not only the woman, but also the husband and father as well as the family and the community are held responsible for this. In no case is breast milk seen as a purely female and intrinsically perfect, self-sufficient substance. This combination stems exclusively from modern biomedicine, prior to the context of HIV, and it hardly exists elsewhere. It is what one might call the “modern paradox” of scientific knowledge on breastmilk, which has been made possible only through the conceptual and analytical separation of breastmilk from the living female body where it is produced. By stating that “breast is best”, the implicit message is “woman is best”. Thus, as widespread ideas of “bad” or “insufficient” milk and correlated early supplementation demonstrate, this message does not seem to be shared by most cultures, despite various cultural efforts to improve a woman’s breastmilk.

“A child cannot survive on breastmilk alone”

It is not only for those societies where a strong gender hierarchy obtains that breastmilk is not regarded as sufficient for the healthy development of a child. As a physical and emotional act being part of the whole reproduction process, most cultures believe that breastmilk finalizes the construction of the child’s body and personhood. Hence, the belief that the woman makes the child on her own, by way of gestation and later breastfeeding, cannot be found in any culture. “A child cannot survive on breastmilk alone” is a statement frequently heard in Kenya and elsewhere, even from women who simultaneously complain to have painful breasts because they produce too much breastmilk. It is not only about “insufficient milk” in quantity and/or quality. It is also about breastmilk that does not suffice, because a woman does not make the child alone. But, it is precisely this message that is implicitly promoted through the fostering of exclusive breastfeeding. Here again, it is the conceptual and analytical separation between breastmilk and breastfeeding and, thus, the separation between breastfeeding and the gendered generation of a child that paved the way to the recent recommendation of exclusive breastfeeding for six months.

In short, there is strong anthropological evidence to support the fact that exclusive breastfeeding is not the norm, for the very reason that it is exclusive: it excludes the father of the child as well as the wider family and community from the reproductive process of which breastfeeding and infant feeding are constitutive elements. Hence, it provides a woman with too much power in that it states that she is able to finish a child’s body and person by virtue of a perfect bodily fluid produced by her body alone! In this anthropological context, improving exclusive breastfeeding rates implies working against deeply rooted universal ideas and perceptions regarding the coming into being of a child, as well as undermining male power in and over this process. Here, however, we touch on something that is anything but easy to achieve. The same anthropological context might explain why prolonged exclusive breastfeeding is not the norm in Western societies either. Poverty, sexism and powerlessness as underlying factors of “insufficient milk” in developing countries are not the primary causes, but aggravating factors of a paradox where a perfect vital fluid comes out of a living female body that is most often, but not necessarily everywhere, considered as subaltern. In this regard, it is interesting to know that among the highly gender balanced Tuareg society in the Western Sahara, breastmilk is regarded as a sacred female and male substance that needs to be supplemented by… breastmilk from other women in order to nourish the child with various social links that are vital to its physical, cognitive and emotional integrity.

Is exclusive breastfeeding AFASS ?

Anthropological evidence sheds a different light on the WHO recommendations of prolonged exclusive breastfeeding for all infants, including those whose HIV-infected mothers do not meet AFASS criteria in order to avoid all breastfeeding. One could say that exclusive breastfeeding does not appear to be AFASS in the cultural context of many mothers. It is not acceptable because of the strong belief that a child cannot survive nor develop correctly with breastmilk alone; not feasible for those mothers who cannot take their infants to working places and therefore are not able to breastfeed them at any time, and, more importantly, for those who live in settings where early supplementation is the norm, so that infants are likely to be fed with whatever kind of food as they are commonly believed to “belong to the community”; not affordable in the many cultures where breastmilk is thought to be (partially) made of the food taken by the mother who can hardly afford regular meals; not sustainable because of all the reasons mentioned previously, and, finally, not safe because of the risk of mother-to-child-transmission of HIV/AIDS. In addition, according to strong and widespread beliefs regarding “bad” milk, including colostrum regarded as “unfinished” milk, “poisonous” milk of a mother who got pregnant again, and other breastmilk that is often considered to be as dubious in its nature as the women who produce it, there are many occasions in which breastmilk is believed to be “unsafe”, because it makes the child sick or even can kill it.

But, with reference to scientific knowledge, AFASS criteria are not applied to exclusive breastfeeding because of the multiple benefits of breastmilk that hade been identified as a perfect and readily available food as soon as it had been analysed outside a woman’s body. Breastmilk, however, does not exist independently of a living female body and person behind it. For this reason, improving adherence and duration of exclusive breastfeeding, be it in the general population or only among HIV-infected mothers, is not easy to achieve on a large scale simply by providing frequent high-quality counselling, even if it could be made available tomorrow. Joint public and international efforts should be undertaken in order to promote and improve exclusive breastfeeding in the general population as well as among HIV-infected mothers who want to breastfeed, by trying to make it AFASS in specific local contexts. But the same efforts should also be undertaken in order to make replacement safe for HIV-infected mothers who choose not to breastfeed or who are not able to breastfeed exclusively for the first six months of life. Making replacement feeding safe for HIV-infected mothers, by considering it as a monitored generic drug such as antiretrovirals, would also help to prevent negative feeding outcomes associated with early infant cessation. For the moment, no expert has a convincing solution for this huge problem that cannot simply be overlooked by assuming that mothers will continue to breastfeed their infants exclusively for six months because they to not meet AFASS criteria for replacement feeding. Infant feeding choice is an ongoing process that proceeds with changing individual circumstances. Mothers might disclose their status to their husbands who tend to prefer replacement feeding. With increasing access to early infant diagnosis, more and more mothers who learn that there infant is HIV-negative will not be likely to accept to continue to expose their children to HIV, even if it seems more indicated in the absence of safe replacement feeding. Finally, more and more mothers are aware of their HIV status and knowingly lost previous children to the disease. These mothers might not want to breastfeed regardless her individual circumstances, but might be willing to do the impossible to make replacement feeding safe. Is it ethical to leave the delicate issue of safe replacement feeding to the mothers in the privacy of their homes, while promoting public efforts in favour of exclusive breastfeeding, assuming against socio-cultural and health-system related evidence that it is the more realistic feeding option? Unsafe replacement feeding is not a fatality. But unless one eventually recognizes that some of the currently tested anti-retroviral treatments have a significant impact on mother-to-child-transmission of HIV/AIDS through breastmilk, transmission rates through exclusive breastfeeding remain the same. Recommending exclusive breastfeeding for six months for HIV-infected mothers while neglecting the issue of safe replacement feeding in this contetx, means: encouraging mixed feeding, unsafe replacement feeding as well as inappropriate infant feeding after early breastfeeding cessation.

*Saskia Walentowitz lectures in social anthropology at the University of Bern. She has written her doctoral thesis on reproduction, kinship and politics among the Twareg in Niger and is currently doing research on the social and cultural determinants of mother-to-child-transmission of HIV/AIDS through breastmilk in Kenya. Contact: walentowitz@anthro.unibe.ch.

References

1. www.childinfo.org/areas/breastfeeding/status.php

2. www.who.int/hiv/mediacentre/Infantfeedingconsensusstatement.pf.pdf

3. www.childinfo.org/areas/breastfeeding/status.php

4. Aarts, Clare, Kylberg, Elisabeth, Hörnell, Agneta, Hofvander, Yngve, Gebre-Medhin, Mehari and Greiner, Ted, 2000, « How exclusive is exclusive breastfeeding ? A comparison of data since birth with current status data », International Journal of Epidemiology, 29 : 1041-1046.

5. Obermeyer Makhlouf, Clara & Castle, Sarah, 1997: “Back to nature? Historical and Cross-Cultural Perspectives on Barriers to Optimal Breastfeeding”, Medical Anthropology, vol. 17 : 39-63.

6. Godelier, Maurice, 2004, Metamorphose de la parenté. Paris, Fayard.

7. Héritier, Françoise, 1996, Masculin/Féminin. La pensée de la difference. Paris, Odile Jacob.