When breastfeeding isn’t best

The joy of a new baby brings new challenges, not the least of which is breastfeeding. These challenges are compounded when the mother is also living with human immunodeficiency virus (HIV).

A woman living with HIV has a small but significant chance of passing the virus on to a newborn infant by consistent breastfeeding. Although available data is limited, this risk is estimated to be around 10 percent for mothers who are not undergoing treatment and around one percent for mothers who are taking anti-retroviral medications.

As a result, women in high-income countries (where formula and clean water are regularly available) are advised to avoid exposing their infants to HIV by forgoing breastfeeding in favor of a replacement feeding option.

Recent studies, however, have described the pressure that some HIV-positive women feel to breastfeed their infants against these recommendations. Cultural norms, societal expectations, “breast is best” messaging, or a desire to keep her HIV status secret may prompt a mother to breastfeed despite the risks. A particular concern is that such women might breastfeed intermittently, a practice which doubles the risk of HIV transmission between mother and infant.

In light of these data, our recent paper, a collaboration among Baylor College of Medicine’s Department of Obstetrics and Gynecology and the Center for Medical Ethics and Health Policy, argues that clinicians should avoid taking a hardline counseling approach against breastfeeding for HIV-positive women.

Alternatively, seeking to understand a new mother’s beliefs and values about breastfeeding can create a dialog that paves the way for open and honest communication between a patient and her physician. They can then work together to develop the safest practicable feeding plan for the infant.

This approach is controversial, with opponents arguing that the clinician’s obligation to prevent harm to a newborn infant should take precedence over accommodation of a mother’s social issues or other competing considerations. While the hardline approach makes theoretical sense in an idealized world, it fails to take into account the nuances and practical concerns facing women in the real one.

-By Janet Malek, Ph.D., associate professor of medical ethics at Baylor College of Medicine’s Center for Medical Ethics and Health Policy

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