HIV and Breastfeeding: An Update
At the International AIDS 2002 conference, breastfeeding by HIV-positive mothers received much attention in the maternal to child transmission (MTCT) discussions. According to figures published by the Centers for Disease Control (CDC), every day about 800 infants worldwide are infected with HIV via breastmilk. Moreover, bottlefeeding as a replacement feeding method can result in mortality of 2.5 to 20%.
Several HIV transmission-prevention approaches were discussed besides not breastfeeding. One approach is to give babies uninfected at birth prophylactic antiretroviral medication for the duration of breastfeeding. Nevaripine, an inexpensive drug for intrapartum prophylaxis for MTCT, will be given to infants in trials in South Africa. This means that 100 babies will be exposed to the drug to prevent 14 to 15 from acquiring HIV if the nevaripine as a single drug is effective. At present, the long-term adverse effects of the drug on infants are unknown.
Another approach is to treat the breastfeeding HIV-positive mother with highly active antiretroviral therapy (HAART), a combination of three antiretroviral drugs, to decrease the amount of virus in her blood and theoretically in her breastmilk. This approach will also treat the HIV infection in the mother, and if HAART is continued after weaning at 6 months, the treatment may allow her to live longer to raise her child. The amount of the drug exposure through breastmilk is presumably less than if the drugs were given directly to the infant. The main question is whether the drug exposure causes adverse effects in the babies. Again, 100 babies are exposed to possible adverse drug effects to prevent 15 from acquiring HIV. Some data are available for effects of some antiretrovirals on children whose mothers took the drugs during pregnancy. Children of mothers in the 076 trials (stopped in 1994) and exposed to zidovudine are 8 to 10 years old now. Documents available on the Web from the CDC (www.cdc.gov/hiv) give a good summary of what is already known about sequelae from in utero exposure and drug exposure of HIV-positive infants. The CDC is sponsoring studies in Kenya, Malawi and Thailand. WHO/UNAIDS is supporting research at multiple sites in Africa.
Another approach is pasteurization of expressed breastmilk. A small study of four women in Tanzania resulted in four healthy babies at the end of one year. A solar-powered device was developed that can pasteurize any kind of milk without power (wood fire, electricity or gas). This study was presented at the international AIDS conference 2000 in Durban; no further formal discussion about it took place at Barcelona.
Other approaches that were given less attention were trials of active and passive vaccines given to infants, exclusive breastfeeding, early abrupt weaning and various combinations. In Durban, South Africa, an ongoing study is following up on exclusive breastfeeding. In Zambia, an ongoing trial is comparing abrupt versus gradual weaning and the effect on transmission rates.
In my earlier report [E-News 4:22, May 29, 2002] I more fully discussed the study of exclusive breastfeeding and HIV. The results show that at six months infants breastfed exclusively for three months or more have no greater risk of HIV infection than those never breastfed—19.4% in both groups (neither mother or baby received antiretrovirals antepartum, intrapartum or postpartum.) Infants who had mixed feeding of breastmilk and other fluids or formula or foods had a higher risk of infection (24.7%). This is a small study; more research must be done to confirm or refute this data.
In the meantime the WHO, UNAIDS, UNICEF current policies for infant feeding remain as follows: Exclusive breastfeeding should be promoted, protected and supported for six months for women who are known to be HIV negative and whose HIV status is unknown. For HIV-positive women, the use of breastmilk substitutes is recommended where "acceptable, feasible, affordable, sustainable and safe"; otherwise exclusive breastfeeding is recommended for the first six months.
In spite of the fact that all of the trials previously cited are reviewed and approved by US interhospital review boards, I am still saddened that it is African women who are again being asked to take the risks for themselves and their infants to gather information that will benefit women and babies all over the world. Blessings to these women and their babies who will give us more information about this very important issue.
A Web site with good general information about HIV & breastfeeding is linkagesproject.org/pubs.html.
- Nancy Miller, CNM
La Leche League Statement on HIV and Breastfeeding
La Leche League International acknowledges the worldwide challenge of making informed infant feeding decisions when HIV transmission is a consideration. Parents and healthcare providers are urged to weigh the well-known, documented health and emotional benefits of human milk and breastfeeding for both mother and child against the known, documented health hazards of breastmilk substitutes, the rates of childhood illness and death from infectious diseases in the mother's area of the world, and the incomplete understanding of the risk of HIV transmission through human milk. La Leche League International challenges the scientific community to undertake the research necessary to fully define the role of breastfeeding and human milk in HIV transmission and infant protection.
In general, for women who know they are HIV positive and where infant mortality is high, exclusive breastfeeding may result in fewer infant deaths than feeding breastmilk substitutes and remains the preferred feeding approach. While breastfeeding where infant mortality is low may also carry a risk of HIV transmission for infants whose mothers test HIV positive, there is no clear, published evidence that feeding breastmilk substitutes results in lower infant morbidity and mortality in any infants. The social costs of not breastfeeding also must be considered. When a woman gives breastmilk substitutes in a culture where breastfeeding is traditional, her community may suspect that she is HIV positive, potentially putting her at risk for physical abuse, ostracism and abandonment. In most parts of the world women do not know their HIV status, therefore ongoing support of exclusive breastfeeding is most appropriate and much needed.
While current scientific thinking accepts a risk of vertical transmission with breastfeeding in general, research studies that fully define the role of breastfeeding patterns (particularly exclusive breastfeeding and optimal breastfeeding management) and related maternal and child health on HIV transmission have not yet been done. LLLI is not making a recommendation about breastfeeding for HIV-positive mothers at this time due to the inconclusive nature of the research and its various interpretations.
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Forum Talk: Marketing Your Midwifery Business
I'm curious about how and if other midwives market their practices. I currently have an ad in one of our local alternative publications. I also have a Web site. I have attached my business cards to free pregnancy tests. I use the Citizens for Midwifery "Midwifery Model of Care" brochure with my business card attached on the back as my main method for leaving information in places. I encourage my homebirth clients to place their baby's birth announcement in the local paper. Any other ideas? I'm thinking about teaming up with a doula friend and doing a childbirth information night with videos on doulas and homebirth. Have any of you done this? Suggestions, ideas?
- Pamela, CPM, LM
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Question of the Week: Cord Traction
Q: I just attended a birth where the doctor put so much traction on the umbilical cord that it broke off from the base of the placenta. I don't know the potential implications of an epidural and induction on the delivery of the placenta. But I would like to know if there is increased risk that the placenta won't come on its own after labor had been induced. The mother had her placenta manually extracted—after birthing the baby beautifully—not more than 10-20 minutes after the birth. The next morning she went to surgery to have the remaining pieces taken out since she continued to bleed. She then had a blood transfusion because her hemoglobin was so low. I am appalled by this. I really want to get some reference stats and documentation that show the detrimental effects of traction. Can you help?
- Julia Lynx, doula
Question of the Week (Repeated): Gestational Age Assessment System
Q: Has anyone developed their own system for newborn gestational age assessment? The New Ballard Scale seems more elaborate to me than is necessary for term babies who are born at home. I know experienced midwives can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.
- Amy Kieffer, student midwife
Send your responses to firstname.lastname@example.org. Responses to any Question of the Week may be sent to E-News at any time.
Exclusively on the BirthLove site: Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out!
by Gloria Lemay, compiled by Leilah McCracken
Nutrition in Pregnancy
The only two things that have ever been proven scientifically to make a difference in producing healthier babies in the general population are improving the nutrition of the pregnant woman and improving the social support of the pregnant woman. These two areas are dismissed in the "professionalization" of childbirth treatment but are contributions that midwives, birth attendants, and doulas can provide in their work.
I like to tell pregnant women the story of Agnes Higgins, who was a dietician who ran a pregnancy wellness center in Montreal, Quebec in the 1950s. This woman opened her Diet Dispensary in a very poor area where the neighborhood women had large families. Prematurity and learning disabilities were very common problems in the offspring. Agnes Higgins gave each pregnant woman a quart of whole milk, an orange and two eggs every day. The women had to agree to eat it for their unborn baby and not give it to the older children. For the first time, many of them gave birth to 7-lb., full-term, healthy babies.
The eggs and milk were a sufficient enough improvement in protein intake to make a big difference. Inquire from what sources your clients derive their protein. Some common sources of protein are chicken, fish, red meat, combinations of beans/cheese/rice, combinations of whole grain cereal/milk, cheese, yogurt, milk, eggs, tofu, tempeh, lentils/rice. At least twice a day, the pregnant woman should eat a protein source that is the size of the palm of her hand. The description of the palm of her hand for protein serving size is easier to understand than grams.
Salt: good farmers provide salt licks for their cows so that they can self-administer their own salt needs. Good doulas remind clients to "salt to taste." Every cell of the body needs salt. I recommend that people stay away from iodized, free-running white salt. This is pure sodium chloride and is not a form of salt that is intended for the human body. Buy your salt at a health food store and look for grey, wet sea salt. This is salt that comes directly from the ocean and has many trace elements and minerals that are essential for health. It is in large crystals in the plastic bag so you will need a salt mill or mortar and pestle to grind it. Once you taste real salt, you will never eat sodium chloride again.
Many women have concerns about their changing shape in pregnancy and worry that losing weight after pregnancy will be difficult. The range of weight gain in pregnancy is individual. There is no recommended maximum or minimum. The emphasis is on the quality of the food eaten. The best advice I received when I was pregnant came from a very nutrition-conscious physician. He told me, "You don't have to worry about weight gain in pregnancy as long as what you are eating is food. By food, I mean that whatever you are putting in your mouth is as close to what Mother Nature put in the ground as possible. If it's a potato, it's baked in its own skin. If it's cereal, it's granola that you made yourself. If it's a vegetable, it's organically grown and raw. If it's a sweet treat, it's a fresh peach, some watermelon or half a banana.
A good suggestion to improve pregnancy nutrition is to include the following three items every day in the food plan:
- A large bowl of raw mixed green salad
- A bowl of brown rice or a baked potato
- A source of vitamin C (i.e., an orange, 1/2 grapefruit, 2 kiwis or a red bell pepper).
I have given the above advice to many health professionals, professional cooks and nutritionists. They are often insulted that I would discuss their diets because they "know" so much. When they begin doing a daily discipline of eating the above three foods, they invariably report that they lose all craving for junk food and feel better than they have in a long time. You will notice that the above three items fit in well with almost every ethnic diet as well.
All prenatal care done by physicians and midwives in North America is designed to screen for two diseases: pregnancy-induced hypertension and gestational diabetes. Both of these diseases are treatable with changes to diet and lifestyle (exercise). Nutrition counseling early in pregnancy can help prevent these diseases.
Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove. Read more from Gloria on Midwifery Today's Web site—"Pushing for First-Time Moms"
Note: This article is also published online in French and Spanish.
What Do Readers Think?
Ultrasounds marketed as keepsakes: Lifelike ultrasound photos have become a hot commodity. Fetal Fotos in Salt Lake City, Utah, invites pregnant women to come in with their families and friends just to get a look at the baby. The company's president maintains that it is a service that women want. "They come for the video, they come for the extra reassurance, they come for the pictures and just to view the baby." For between $60 and $120, couples can have a keepsake for their child's photo album and a video set to music. Many expectant moms come more than once during their pregnancy. Fetal Fotos said it doesn't claim to offer prenatal care—"these women already have doctors."
The Food and Drug Administration (FDA) said women should be discouraged from having "keepsake" ultrasounds. The agency calls such ultrasounds an unapproved use of a medical device and said it has sent warnings to a number of these businesses. But it has not shut down any of them. No FDA guidelines exist for what it calls "enterprising commercial ultrasonic imaging of fetuses."
"Childbirth of the future will not primarily be in hospitals, but in the home, and the primary health professional for most women will not be the physician, but the midwife. Furthermore, the primary rights and responsibilities for childbirth will not be upon the professional, but upon the parents because it is they who must bear the responsibilities of raising the child."
- 21st Century Obstetrics Now!, published in 1977
Twenty-five years later, how accurate is this statement?
A: For those of us seasoned professionals who can remember back that far, we did believe that the natural childbirth movement would take us toward a more woman-centered way to birth. We made so many positive changes! Perhaps we got too comfortable (I know some of us did in certain geographical areas) and didn't see the hazards of cooptation of childbirth education and didn't stay active enough in keeping woman-centered birth in front of all women. Perhaps it is time for the pendulum to swing again... Perhaps it is time to breathe new life into this movement. Pregnancy is not a crisis waiting to happen. It is a rite of passage that should be honored and respected.
- Connie Livingston BS RN LCCE FACCE CD(DONA) CLD CCCE
Ancient 'Birth Bricks' Found in Egypt: Archaeologists have found, among artifacts from a 3,700-year-old house, a brick used by women in ancient Egypt to squat on during childbirth.
Could someone tell me how to get detailed info about the HOOP trial (hands-on or hands-poised) project?
- Esther Marilus, SAFE
In response to the statements about preeclampsia [Issue 4:34], Dr. Brewer would disagree. In recent conversations he has made it clear that woman should eat high-complex carbohydrates. Eliminating white flour and sugar from the diet is highly recommended, but a low-carbohydrate diet would actually be just as dangerous as a diet full of simple carbs. Dr. Brewer recommends a high-quality, varied diet that includes whole grains. Eating a high-protein/low-carb diet can cause a woman to be deficient in calories, B vitamins and fiber. In addition, her body may burn the extra protein for calories, where it is needed in the liver to produce albumin for water circulation and blood-volume increase. It's not just protein! He's the first to say that his research has been misinterpreted with regard to protein and carbohydrates. Women should be eating adequate protein, whole grains, fruits, vegetables, dairy (or substitute), nuts, beans, seeds, water and salt their food to taste to get the variety they need. I tell women to eat whole unprocessed foods and check how many different food sources and colors are on their plate. The more the merrier!
I am in the process of working on a new article with Dr. Brewer that debunks some of the myths and misinterpretation of his work. Hopefully it will be done soon. I'll keep you posted.
- Amy V. Haas, BCCE
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The International School of Traditional Midwifery in Ashland Oregon is accepting enrollment for February 2003 classes. Contact us at 541-488-8254 or visit us at www.globalmidwives.org
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