Maternity services differ across the globe due to access to healthcare provision, political stability, education and population. This comparative study will discuss HIV in pregnancy, and attitudes to, and rates of breastfeeding in the UK and South Africa due to a personal interest in the latter country. HIV can be transmitted through unprotected sexual intercourse, sharing of contaminated needles, transfusion of contaminated blood, during pregnancy or through childbirth or breastfeeding (World Health Organization (WHO), 2013a).
It is well known that breastfeeding provides all the nutrients an infant needs for its growth and development up to 6 months of age (Inch, 2009; WHO, 2013b); however, attitudes to and rates of breastfeeding differ according to culture, social beliefs and resources. South Africa has undergone significant changes in terms of attitudes to breastfeeding (UNICEF, 2012a) and the UK is working towards increasing breastfeeding rates through the Baby Friendly Initiative, which was established in 1992 by UNICEF and WHO (UNICEF, 2010). Despite the economic, cultural and political differences between South Africa and the UK, HIV and breastfeeding remain important and current issues for both countries through which similarities can be drawn.
According to the 2011 census, South Africa has a population of over 51 million, of which 51.3% are female. The country has a diverse population—41 million of its citizens are of African descent and 4.5 million are of White origin (Statistics South Africa, 2011). South Africa is often called the ‘rainbow nation’ a phrase coined by Nobel Peace Prize Winner Archbishop Desmond Tutu (South Africa.net, 2014), owing to its diverse races, tribes, creeds and languages. The country has had a difficult and often violent past in the ethnic struggle to maintain a balanced and fair government (Applebaum, 2013) and this continued until the end of apartheid in 1991 (Smith, 2005). Post-apartheid South Africa is unrecognisable (in parts) in terms of different races coexisting; however, the corrupt economic system and policies are still evident (Applebaum, 2013).
South Africa's healthcare system varies from very basic health care offered for free by the state to highly specialised care available in both the private and public sector (South Africa.info, 2012). As a significant proportion of South Africa's population is rural–38%, (UNICEF, 2012a) the public health care as well as the 1994 implementation of free maternity services (Pretorius and Greeff, 2004) largely remains inaccessible to a lot of the population.
In contrast, the UK is a relatively stable and democratic country, albeit a representative one (History Learning Site, 2006). However, the UK is not without conflict, for example, the well-known and deep rooted religious struggle between Protestants and Catholics in Northern Ireland is still an issue (Tonge, 2002).
An increasingly diverse population of over 64 million (Office for National Statistics (ONS), 2014), the UK has had the benefit of a publicly funded and extensive National Health Service (NHS) since 1948 (NHS, 2013a).
Similarities and contrasts
The United Nations joint Programme on AIDS (UNAIDS) stated that approximately 7000 new diagnoses of HIV occur every day globally (UNAIDS, 2010). In South Africa in 2012, 6.1 million people were living with HIV, of which 3.4 million were women aged 15 and over and 410 000 children aged 0–14 years (UNAIDS, 2012a). Furthermore in 2012 240 000 people died due to AIDS in South Africa (UNAIDS, 2012a). In contrast, the UK has an estimated 96 000 people of all ages living with HIV (NHS, 2013b) and of this 23 000–37 000 are women aged 15 and over and approximately <500–<1000 deaths were as a result of AIDS in 2012 (UNAIDS, 2012b) The HIV Testing Action Plan by NAT (2012) aims to reduce late HIV diagnosis in the UK, particularly in pregnant women. Routine antenatal screening was first introduced in the UK in 1999 when it was realised that a late diagnosis in pregnancy or being unaware of a diagnosis posed a bigger risk to the baby. Antenatal screening was fully implemented by 2003 and has resulted in a higher amount of pregnant women and their partners being diagnosed in the antenatal period (Kelly et al, 2009). HIV is seen as one of the biggest threats to pregnant women in South Africa, and is a major cause of death among pregnant women in its most populated city, Johannesburg (Black et al, 2009). Unlike the UK, there is a palpable gap in antenatal screening so many HIV-positive mothers remain unaware of their HIV status and do not get access to the necessary treatment to prevent mother-to-child transmission (PMTCT) (Black et al, 2009). Black et al (2009) states that 28–33% of women attending antenatal clinics in South Africa were unaware of their HIV status and that a lack of antenatal and postnatal care is linked to high mortality rates among HIV-positive women.
In the mid-1990s, the UK experienced a turning point with the introduction of an effective HIV treatment—highly active antiretroviral therapy (HAART). It changed HIV from a terminal illness to a chronic disease (Kelly et al, 2011). Management of HIV in pregnancy has reduced the rate of mother-to-child transmission in the UK (Kelly et al, 2009) and although progress is slower, the South African government's programme to PMTCT is becoming a reality, with figures suggesting the transmission rate has decreased from 8% in 2008 to 2.7% in 2011 (Harvard School of Public Health, 2013). South Africa is moving forward in the management of HIV in pregnancy through packages that focus on contraceptive and fertility advice and support for the HIV-positive mother (Sonto et al, 2010). This balanced and holistic approach to care is as important. In the UK, there still remains a certain stigma for a HIV-positive mother regardless of where she resides and it remains a difficult and challenging time for the mother, her partner and the midwife (Kelly et al, 2013). Midwifery 2020 (Department of Health, 2010) highlights the importance of continuity of care for all pregnant women and normalising the childbirth experience where possible.
South Africa's President Jacob Zuma's National Strategic Plan (NSP) for HIV/AIDS 2012–2016 (UNAIDS, 2011) and the Millennium Development Goal (MDG) 6, which aims to combat HIV/AIDS, malaria and other diseases by 2015 and universal access to treatment for HIV/AIDS for all those who need it (UN, 2014) must remain a global priority. Combatting HIV/AIDS must remain a priority in the UK as with an ever increasing ethnically diverse population, late diagnosis and 25% of HIV-positive people being unaware of their status, HIV-positive numbers will only increase without due attention (NAT, 2012).
Breastfeeding and HIV
Breastfeeding is an issue closely linked to HIV for South Africa, due to the high risk of transmission to the newborn: from the 1980s all HIV-positive mothers were advised to avoid breastfeeding and were offered free formula (Urwin, 2009). However, over time it became clear that without the nutrients and antibodies that only breastmilk can provide (UNICEF, 2012b) infants were susceptible to infections such as pneumonia or diarrhoea. Furthermore risks to the infant's health became evident due to poorly made up feeds and unsanitary living conditions and water sources (Bloemen, 2012). Infant mortality rates remain high in South Africa at a rate of 33 per 1000 live births (UNICEF, 2012a) creating a bigger challenge in reaching the MDG 4 of reducing child mortality by 2015 (UN, 2014). A shift in policy has meant that women are now advised, regardless of their HIV status, to exclusively breastfeed for the first 6 months of life, a move supported by UNICEF and WHO (Bloemen, 2012). This strengthens the infant's immune system, promotes bonding and attachment, and together with antiretroviral drugs, will dramatically reduce the risk of HIV transmission (Bloemen, 2012).
Initiation of breastfeeding is relatively high in South Africa—between 2008 and 2012, there was a rate of 61% (UNICEF, 2012a); however, due to a long standing culture of introducing formula or solids in the form of the staple maize flour, mielie meal (Urwin, 2009), exclusive breastfeeding rates remain as low as 8% (Bloemen, 2012). Postnatal care needs to be improved in South Africa, especially in rural areas, if these rates are to increase and the midwife should be the driving force behind this being the advocate for the breastfeeding mother (Nyasulu, 2012).
Breastfeeding in the UK is regarded as an integral part of an infant's development; however, exclusive breastfeeding rates do not reflect this (Guyer et al, 2012). UNICEF (2012b) report through the Infant Feeding Survey 2010, which is performed every 5 years by the NHS Information Centre, that initial breastfeeding rates actually rose from 76% in 2005 to 81% in 2010. However, exclusive breastfeeding rates decreased to 1% at 6 months in 2010. Mothers are breastfeeding for longer in the UK as a whole although there are differences according to certain demographics (Hall, 2011). Breastfeeding rates are highest in mothers aged 30 years or over, in professional occupations, in ethnic minority groups, from least deprived areas and where infants had early skin-to-skin contact (NHS Information Centre, 2012). This highlights the important role midwives play in initiating skin-to-skin contact where possible in the promotion of breastfeeding.
In the UK, breastfeeding can become a moral dilemma for women (Guyer et al, 2012). Women may feel unprepared for the reality of breastfeeding challenges, anxieties surface over milk production and frequency of feeding, feelings of guilt, pain and a lack of support from health professionals. Peer pressure can become an issue, the Infant Feeding Survey in 2010 (NHS Information Centre, 2012) found that 26% of women stopped breastfeeding within the first 2 weeks postnatally if their friends were artificially feeding, compared to only 6% whose friends were breastfeeding. Family beliefs and cultural traditions can influence exclusive breastfeeding rates and this is a trait seen in both the UK and South Africa. In African households it is often a lead figure such as a grandmother who makes the decisions surrounding breastfeeding and not the mother herself (Nyasulu, 2012) and introducing formula, water and solids before 6 months of life is common family practice in South Africa (Urwin, 2009). In the UK family tradition such as whether or not a mother herself was breastfed can heavily influence feeding choices, 27% of mothers who were artificially fed stopped breastfeeding within 2 weeks, comparable again with 9% of breastfed mothers (NHS Information Centre, 2012).
Midwife and resource shortages undoubtedly have an impact on breastfeeding rates as the support necessary to sustain exclusive breastfeeding is not available. The demands on the NHS in the UK are increasing, but the finances are not (Day, 2006; Labour, 2013) and the Royal College of Midwives has reported a serious shortage of trained midwives (RCM, 2013). Similarities can be drawn between both South Africa and the UK's health care systems, the public sector in South Africa is under strain to provide care to an estimated 80% of the population (South Africa.info, 2012) and long queues and staff shortages are considered the norm (Urwin, 2011). The State of the World's Midwifery Report (UNFPA, 2014) also names transport and distance to care, inadequate midwifery training, poor working conditions and post-apartheid issues as some of the challenges facing South Africa's maternity services.
Increasing breastfeeding rates in both countries could be an invaluable asset to each health care system in the future. In South Africa, exclusive breastfeeding will mean that infants will have a strengthened immune system which may help to decrease child mortality (UNAIDS, 2010). In the UK, the Baby Friendly Initiative aims to implement the Ten Steps to Successful Breastfeeding (UNICEF, 2010) in every maternity hospital as the potential to prevent disease and save NHS resources (UNICEF, 2012b).
Reducing the spread of HIV is a global priority (UNAIDS, 2010; UN, 2013) particularly in South Africa; however, despite being a developed country the UK must address its own issues in HIV management. Increased ethnic diversity and late diagnosis will led to an increase in HIV transmission and so the number of new diagnoses will rise (NAT, 2012). Both health care systems are under strain financially and suffering from midwife shortages (Labour, 2013; UNFPA, 2014). Similarities can also be seen in the support offered to HIV-positive or breastfeeding women (Guyer et al, 2012; Nyasulu, 2012). However although the UK has an increasingly stretched health service, it has the benefit of a relatively stable and democratic government, where South Africa does not (South Africa.info, 2012) owing to post-apartheid legacies. Both HIV and increased breastfeeding are issues that need to be at the forefront of South Africa and the UK's individual strategies going forward for improved world health. Increasing breastfeeding rates can help in the fight to reduce HIV infections, infant mortality, alleviate building pressures on health care systems and improve maternity care for all women.