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Banking on Breastfeeding: Brazil's Approach
By Alexandra Mazur
Brazilian mail carriers deliver more than just the mail. Over six thousand mail carriers and firefighters are part of a nationwide project to collect human breast milk at the homes of pregnant women and bring it for pasteurization to the country's hundred and fifty milk banks. The Brazilian Ministry of Health implemented this program in the early 1990s; today, Brazil has the most effective milk bank network in the world, a network which is one of several projects designed to offer the benefits of breastfeeding to women who cannot do so on their own. As research continues to uncover new evidence for the vital role breastfeeding can play in a child's lifelong health, countries should look to Brazil for inspiration in implementing their own programs, even if these programs should be tailored to the socioeconomic and cultural differences between nations.
The importance of Brazil's network must be understood in light of the country's experience with AIDS. Brazil accounts for fifty-seven percent of all HIV cases in Latin America and the Caribbean. The adult prevalence rate is 0.6 percent, which corresponds to 660,000 people living with HIV. Although successful intellectual property agreements allowed Brazil to begin universal access to anti-retroviral therapy (ART) in 1996, cutting AIDS-related mortality in half, AIDS still seriously complicates efforts to promote breastfeeding. The network of milk banks represents one way in which Brazil has tried to preserve the great benefits of breastfeeding against the threat of AIDS.
The science of breast milk
Medical research has demonstrated that breastfeeding protects the health of both mother and child. Women who breastfeed show a lower incidence of breast cancer later in life; in turn, their children, when compared to infants sustained on formulas, consistently have a lower rate of diarrhea, asthma, malnutrition, food allergies, obesity, and infectious diseases.
Breast milk contains all the nutrients a baby needs in the first year of life, including water, high amounts of readily-digestible fat, lactose, amino acids, proteins, minerals, and vitamins. The nutrients are present at neutral pH and with high energy content. Breast milk also promotes the growth of helpful bacteria in a baby's gut, and immunoglobin aids digestion by inhibiting pathogens from interfering.
A mother can continue breastfeeding indefinitely, as long as nipple stimulation from periodic suckling maintains a high level of the hormone prolactin in the blood. As time passes, the nutrient content of milk changes to meet the developing needs of the maturing baby. The World Health Organization (WHO) recommends that women breastfeed exclusively for at least six months. However, only thirty percent of women in Brazil, and a similar proportion of women in the United States, follow this advice. Many cultural, economic, and biological factors underlie this low number, including lack of education about breastfeeding, the demands of work, and frustration with complications such as cracked nipple and mastitis.
The lack of exclusive breastfeeding in Brazilian women contributes to the country's high infant mortality rate of 3.1 percent, as reported by the CIA World Factbook in 2004. Indeed, in countries like Brazil, where good sanitation, baby formula made with clean water, and adequate nutrition are not always present, breastfeeding becomes particularly important. Breastfeeding promotion campaigns in Brazil and the United States should not ignore societal disparities in wealth and sanitation, but rather should tailor their recommendations to the needs of each group of mothers.
HIV transmission through breast milk
The choice to breastfeed becomes complicated when a woman is infected with HIV because the many benefits of breast milk must be considered alongside the threat of viral transmission. Each year, 2.5 million HIV-infected pregnant women in the world give birth, 800,000 of whom transmit the virus to their children. Mother-to-child transmission accounts for sixteen percent of all new infections, and transmission can occur during pregnancy, labor, delivery, or breastfeeding.
HIV-1 has been found in breast milk from HIV-positive mothers as both cell-associated and cell-free particles. Importantly, the postnatal risk of transmission increases the longer breastfeeding continues, in part because cracked nipple can expose a baby directly to the mother's blood. Furthermore, mixed feeding (alternately breastfeeding and giving other food) increases the risk of transmission because water, porridge, and cooking oil irritate the lining of the intestines and increase the chance that an infant's body will contract HIV.
Nevertheless, nearly eighty-five percent of babies breastfed by HIV-positive mothers do not become infected. Research has shown that the milk itself protects babies from viral infection. The compounds Anti-HIV-1, SigA, and IgM, all present in breast milk, may confer some protection. Also, erythropoietin (EPO), a hormone in human milk, may help by maintaining mammary epithelium integrity in the mother, which reduces the viral load in milk. By maintaining intestinal epithelial integrity in the breastfed neonate, EPO may also prevent ingested milk-borne HIV from infecting the infant.
Also, following a carefully planned program of breastfeeding may significantly reduce the chance of HIV-transmission. A study done in Africa at the University of KwaZulu-Natal showed that women who adhere to a program of six months of exclusive breastfeeding followed by abrupt weaning have as low as a six percent chance of passing HIV to their infants. Another study published in The Lancet claims that HIV-positive women who breastfeed for six months with abrupt weaning have almost no chance of passing on the virus. The study followed nine hundred babies born to HIV-positive mothers in Africa, forty-nine of whom were infected through breastfeeding, but concluded that none would have been infected had the mothers followed the recommendations. Anna Coutsoudis, the world's leading expert on HIV-transmission through breastfeeding, says: "The latest data shows that the risk is about four percent for every six months of breastfeeding. My new operational research from Zimbabwe suggests that where exclusive breastfeeding is practiced in the first six months followed by abrupt weaning, the risk is lowered to between one and two percent. The risks of mortality from formula feeding will outweigh the risk of breastfeeding." Coutsoudis adds that "breast milk is the most important type of food in a baby's diet, more importantly to babies who are infected with HIV. It has immunological properties and is very important for growth and the development of the brain."
"Safer Breastfeeding": Alternatives in Brazil and the United States
As knowledge of breastfeeding's numerous health benefits increases, countries are experimenting with a variety of programs to ensure that as many infants as possible benefit from proper nutrition. In Brazil, the national government has invested in awareness and educational programs that encourage mothers to breastfeed their children according to the newest recommendations.
However, countries must consider how to respond to the threat of AIDS. When a radio announcer in Zaire mentioned the risk of HIV infection from breast milk, the breastfeeding rate immediately dropped by thirty percent. Such a drastic response is unwarranted. Rather, more education and attention should be given to the specific needs of HIV-positive women, even as campaigns continue to promote breastfeeding for the entire population. In fact, widespread recommendations against breastfeeding because of the risk of HIV transmission can endanger public health, since these recommendations influence more women than just those who are certain they have HIV.
In Brazil, wet-nursing and milk banking provide alternatives for concerned women. Unlike in the United States, wet-nursing is an accepted part of Brazilian culture, a practice which offers an alternative to mothers whose health or work makes breastfeeding difficult. Still, wet-nurses must be made aware of the slight risk to themselves of contracting HIV from an already-infected infant, and they should be tested regularly to make sure that babies are not put at unnecessary risk.
Milk banking is also more widespread in Brazilian culture than in that of the United States, where government funding has been lacking. In 2000, Brazil collected over 79,000 liters of breast milk, distributed it to 150 banks that not only collect and pasteurize the milk, but also act as centers for pro-breastfeeding education. In Brasília, the capital, seventy-one percent of HIV-positive women receive affordable banked milk for their infants. In contrast, fear of HIV has actually inhibited milk banking in Africa, though recently, in 2000, the first bank opened for AIDS orphans and babies abandoned by HIV-positive mothers.
Although widespread education and coordinated national planning have caused the overall rate at which Brazilian women breastfeed correctly to increase from four percent in 1986 to thirty percent today, many areas of Brazilian society remain isolated from the education and care needed to promote breastfeeding and its alternatives. Research in Brazil has shown that poorer women breastfeed for a shorter period of time than wealthier women. Without information about breastfeeding, many of these women think that breastfeeding is embarrassing, that their milk is weak, or that breastfeeding will cause their breasts to sag. Also, many women introduce water, tea, and powdered milk into their infants' diet at the early age of three months. In the Brazilian shanty-towns called favelas, women do not talk about breastfeeding issues, including AIDS, and milk banking programs do not reach women there. At one daycare center - União de Mulheres pro Melhoramentos da Roupa Suja (Union of Women for the Betterment of Roupa Suja) in the favela of Rocinha - fifty-three children are provided with three meals daily and a place to play. While a few women wet-nurse several babies in addition to their own, there is little support for their efforts or for programs to help babies receive breast milk. However, it is precisely the children in towns like this, where poor sanitation, nutrition, and treatment facilities threaten public health, for whom the benefits of breast milk are most important.
Comparing Countries
Children in all countries can benefit from the advantages of breast milk, whether through an increase in breastfeeding, or through surrogate programs like milk banks and wet-nursing. However, breastfeeding campaigns in developed countries like the United States must take a different approach from that of Brazil. In the United States, breastfeeding children is critical to maintaining a low infant-mortality rate and should be promoted in the general population. However, unlike in Brazil, where sanitation and the conditions of life make the benefits of breast milk particularly important, American women with HIV should not breastfeed - the risk of transmission is widely seen to outweigh health benefits. Even still, these women should be certain that they are HIV-positive based on proper testing. In particular, health care providers should not discourage women from breastfeeding simply because they are in an at-risk group. According to the New York State Department of Health, "Not only has the HIV epidemic affected infant mortality and morbidity, but evidence suggests that it has set back the effort to promote breastfeeding among precisely those populations most in need of encouragement and education in populations where AIDS is more prevalent. [One New York] survey revealed that many providers were recommending pregnant women and new mothers not breastfeed, even when the woman's HIV status was unknown; providers cited race and place of residence, among other factors, as reasons for discouraging breastfeeding."
But for those women who cannot breastfeed, the United States should follow Brazil in working to promote wet-nursing and milk banking as safe alternatives. Dr. Susan Richman, an OB/GYN at the Yale Medical School, advises her HIV-positive patients to use formula so as to avoid the risk of infection because she does not see a practical alternative. When Richman asked a medical student passing by if she would consider breastfeeding another woman's baby, the woman answered, "No! Not if I had to give back the baby." In America, wet-nursing and milk banking are largely foreign concepts. As Dr. Richman asks, "Can you imagine a woman in Greenwich, CT, wet-nursing with white gloves?"
With conflicting scientific evidence of the benefits and risks of breastfeeding for HIV positive women, campaigns should be tailored to cultural and economic context. The campaign in Brazil is a model for the world because of relatively high spending breastfeeding promotion and safe alternatives. However, more education about the scientific advantages of exclusive breastfeeding, the relative risks for HIV women, and the interpretation of this evidence must be given to women all over the world. This is a difficult task since breastfeeding is politically charged. In fact, many medical associations such as the American Academy of Pediatrics (AAP) are heavily funded by the formula industry. In December of 2003, President Johnson of AAP voiced his concern about what was to be the largest U.S. government advertising campaign to promote breastfeeding. His objection to the campaign's negative tone came after representatives of one of AAP's biggest financial contributors, the $3 billion U.S. infant formula industry, personally lobbied him. The breastfeeding campaign did feature startling ads such as a pregnant woman riding a mechanical bull with a quote, "If you wouldn't take risks before your baby was born, why start now?". Johnson had strong views that the advertisement campaign would cause guilt among mothers with unhealthy children. As long as the formula industry controls the media with its own large advertisement campaigns and stalls breastfeeding campaigns such as this recent one, mothers remain over-protected, influenced by politics, and largely ignorant of current scientific research.
Help needed in Rocinha
If you would like to donate to the daycare center in Rocinha, please visit www.roupasuja.org for information, and write to Alanna Campus at alannaraecampus@hotmail.com. Money would be used to provide good nutrition to these kids from the time of birth, to increase knowledge of HIV, and to access to safer forms of breast milk already present in Brazil but unknown to many.
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