Breastfeeding, mother's HIV status and choices
Q.18 Do the Guidelines remove a mother's right to decide regarding the way in which she feeds her infant?
No. A clear recommendation by a national authority, either for breastfeeding while providing ARVs or avoidance of all breastfeeding, is fully consistent with respecting individual human rights.
Previously, when the most appropriate infant feeding practice for individual mothers was dependent on her personal circumstances, health workers were asked to present the different infant feeding options and to help mothers make a decision. This approach is sometimes referred to as non-directive counselling. It is appropriate when the balance of risks of a particular option for the general population is not clear but varies widely according to individual circumstances. When highly effective interventions, such as ARVs to prevent HIV transmission through breastfeeding, are available and supported by high quality research, then it is justifiable for health authorities to promote and practically support a single approach, such as providing ARVs and relevant counselling.
The Guidelines do not force a mother to accept the national recommendation. Mothers can still choose to ignore the services offered by health authorities. The Guidelines do not therefore represent a conflict with the individual patient’s interests, either the infant’s or the mother’s. Information about options should be made available, but services can promote and support one approach. If women choose not to accept the national recommendation, they should still receive counselling and support to optimally practise their choice. However, this does not mean that health authorities must provide free replacement feeds.
Some interested groups have commented that by not providing free formula milk, national health authorities remove the choice from poor mothers to feed their infants as they prefer. However, this perspective is not consistent with other public health approaches and recommendations. National authorities have the obligation to determine and provide the best approach for the majority of mothers and infants who attend public health facilities. When high-quality evidence demonstrates that one approach:
- is highly effective and cost beneficial (e.g. breastfeeding and ARVs); and
- can be generalized across large populations with reasonable expectation of large-scale benefit (e.g. populations with poor water and sanitation and significant infant mortality due to diarrhoea, pneumonia and malnutrition);
then there is no obligation to continue to provide an intervention based on a previous recommendation (e.g. formula with increased risk of death from diarrhoea, pneumonia and malnutrition) in addition to the new intervention. Health workers should instead counsel mothers how to safely provide replacement feeds to their infants if they wish to do so. However, health authorities are not obligated to provide the replacement feed as a free commodity.