Although most African women living with HIV in the UK do
comply with medical recommendations to avoid breastfeeding, doing so comes at a
high social and personal cost, according to qualitative research presented to
the British HIV Association conference last week. There are considerable
structural, cultural and personal barriers to formula feeding, reported Dr
Shema Tariq of City University.
Whereas women living with HIV in resource-limited settings
are advised to breastfeed their babies (because of the unavailability of clean
water supplies), the advice in resource-rich settings is to bottle-feed with
powdered milk formula. This reduces the risk of passing on HIV to the child,
although in the context of antiretroviral therapy and an undetectable viral
load, there are questions about how risky breastfeeding would be.
Furthermore, health information for the general population
in the UK – which women living with HIV are frequently exposed to – usually
states that ‘breast is best’.
Women who have grown up in African countries and have
migrated to the UK or other western countries must therefore grapple with
conflicting messages and expectations. Women frequently maintain significant
social connections with other African people, both in the diaspora and their
country of origin.
Very little research has explored the impact of infant
feeding decisions on migrant mothers living in resource-rich settings (although
a Canadian study
was presented last year). Researchers in London therefore conducted in-depth
qualitative interviews with 23 African women living with HIV who were pregnant
or had recently given birth. In addition, six professionals (clinicians,
midwives, voluntary sector workers) were interviewed.
With one exception, all the women were exclusively bottle-feeding
or intended to. However women had to overcome a number of barriers in order to
“That’s what really
make me feel sad because our culture in Africa you’re supposed to breastfeed.”
There was a widespread expectation – from both the women
themselves and from other members of their communities – that breastfeeding was an
essential aspect of being a woman and a mother. There could be considerable
pressure from other people to breastfeed. This didn’t just come from friends or
relatives. If the baby cried, strangers on a bus could even forcibly suggest
that he or she should be put to the breast.
Women feared that formula feeding would lead to unwanted
disclosure of their HIV status. This could include disclosure to the baby’s
Most of the interviewees were extremely poor and formula
milk was very expensive for them. Although BHIVA recommend that free formula
milk and feeding equipment be supplied in this situation, resources were not
When bottle-feeding, women frequently felt that they were
missing out on bonding with their baby, and felt a sense of personal loss.
Moreover many were anxious about their child’s health, concerned that he or she
would miss out on the health benefits of breastfeeding that are extolled in
mainstream health information for mothers.
Moreover, in order to avoid unwanted disclosure and
stigmatisation, many women isolated themselves and stayed away from social
In order to face these challenges, Dr Tariq says that women
required considerable resilience. The most important of the resources that they
drew upon was the knowledge that they were safeguarding their baby.
“The most important
thing is my child not having it [HIV], you understand? If there’s anything
that’ll make them not have it, why wouldn’t I do it?”
Although many of the fathers were absent or semi-absent,
when they were present and supportive, this was extremely important. Knowing
other mothers who had given birth to HIV-negative babies was also valuable.
Women deployed creative excuses to explain why
they weren’t breastfeeding, for example saying that they had mastitis or had
recently taken antibiotics. When provided, free formula milk and feeding
equipment were of considerable help.