Women, work and Breastfeeding
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Women, work and
Breastfeeding - extracted text
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SDA-RF-CH-1.12
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A forum for the exchange of news and views on primary health care
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Women who work outside the home often assume that they have to stop breastfeeding when they
return to work. Suggested ways in which working mothers can continue breastfeeding.
Every mother is a working mother, whether in formal
or informal enjoyment, self-employed or working in the
home. The UN Economic Commission for Africa
calculates that women carry out up to 75 per cent of
all agricultural work in addition to doing 95 per cent
of domestic work.
As a result of increasing industrialisation, more
women are working away from home in large
workplaces such as offices, factories, shops and
hospitals, while continuing to take the main
responsibility for child care. Often women working
^vay from home believe that they cannot continue
breastfeeding, although this does not have to be the
case.
■u. Plan your pregnancy so that you can combine
maternity leave with annual leave and spend more
time at home with your baby.
2. Prepare yourself during pregnancy by learning
about breastfeeding and how to continue
breastfeeding when you return to work.
The following are some suggestions about how
women can combine paid employment with
breastfeeding.
In this issue :
Breastfeeding
HIV Infection and Breastfeeding
ffi Clinical challenge of the HIV epidemic
HIV Infection and Pregnancy
CMAI
Christian Medical
Association
of India
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
AHRTAG
Appropriate Health
Resources & Technologies
Action Group
BREASTFEEDING
3.
Ask advice from a friend or
relative who has breastfed; join a
breastfeeding support group; talk
with a health worker; or read about
breastfeeding.
4.
Exclusively breastfeed your
baby during your maternity leave.
5.
When you return to work,
continue to breastfeed your baby
whenever you are at home, at
night and on days off. If the baby
sleeps in your bed, you can
breastfeed more than usual during
the night with less disturbance.
Many babies need less milk during
the day if they are fed well during
the night.
®. If possible take your baby to
your workplace so that you can
breastfeed when he or she is
hungry.
7. Alternatively, ask a helper to
bring the baby to you at work to
be breastfed. Or, if your home is
not far away, you may be able to
go home during breaks to
breastfeed.
8. If the suggestions in 6 and 7
are not possible, it is best to leave
expressed breast milk for a helper
to feed your baby while you are
away.
Expressing milk
Learn to express your
breastmilk soon after the baby is
born. In the week before you
return to work, start feeding your
baby expressed breastmilk by cup
during the day.
Express your breastmilk early in
the morning, so that you are
relaxed and not rushed.
Most babies need to be fed
about every three hours. If
possible, express 1/2 cup of
breastmilk for each feed. Many
mothers find they can express a
total of 2 cups or more. However,
do not worry if this is not possible.
If you can only express enough
milk for one feed, then that is still
helpful. If necessary, give the
baby other milk later in the day.
After you have expressed your
milk into a clean container,
breastfeed your baby. Even
though you have expressed as
much milk as you can, your baby
will still be able to get milk from
your breast because suckling is
more effective than expressing.
Cover the container with a cloth
and store it in a cool place. Even
at room temperature, expressed
breastmilk can be kept for at least
eight hours. Teach your helper
how to feed the expressed
breastmilk to your baby using a
cup.
While you are at work, express
your breastmilk two or three times
during the day. This will help
ensure that your milk production is
maintained. If you have access to
a refrigerator at work, the
expressed breastmilk can be
stored and taken home to feed to
the baby the next day.
Household and workplace
support
Make sure other household
members share the workload so
that you have more time with your
baby in the morning and when you
return from work.
Employers have an important
role to play in promoting
breastfeeding. Supportive policies
should incluude:
•
adequate maternity leave
(women should not have to
return to work until the baby is
at least four months old and
can be given complementary
foods in addition to breastmilk)
•
providing a room at the
workplace for child care and
breastfeeding
•
allowing women to have two
half-hour breastfeeding breaks
• .arranging working hours whichx
enable breastfeeding.
Workers need to negotiate with
employers for these conditions.
Women should seek support from
their colleagues and workplace
organisations such as trade unions
to improve conditions at their
workplaces.
Nomajoni Ntombela, IBFAN
Africa Co-ordinator, PO Box 781,
Mbabane, Swaziland.
(Dialogue on Diarrhoea Issue No. 59)
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
BREASTFEEDING
Training health care workers to
counsel! breastfeeding mothers
Felicity Savage and Bernadette Daelmans describe a new WHO training course.
Health workers can play a key
role in promoting breastfeeding.
Research has shown that if they
give appropriate and skilled
support, it is more likely that
mothers will breastfeed
successfully and for longer.
In the last 20 years knowledge
of the scientific basis of lactation
fVid suckling and about how to
prevent and overcome
breastfeeding difficulties has
increased enormously. But this
new information has not been
included in the training of most
health workers, leaving an
important gap in their knowledge
and skills. To address this, WHO
and UNICEF have developed a
40-hour breastfeeding counselling
course designed for health
workers who care for mothers and
young children. The course
emphasises the development of
counselling and clinical skills to
support good breast-feeding
^gpractices and to help mothers
- overcome difficulties according to
the new understanding of
breastfeeding.
Counselling
0 giving practical help
For breastfeeding support to
be effective, a health worker
needs to communicate well with a
mother. Asking too many
questions, giving a lot of
instructions, or being critical can
make a mother doubt her ability to
breastfeed. Instead a health
worker needs to listen to a mother
and learn how she feels. Course
participants learn the following
listening and learning skills:
. C* giving a little, relevant
information (for example,
explaining what has happened
or what to expect^
$ using helpful non-verbal'
communication (showing your
attitude through your posture,
facial expression and gestures)
❖ asking open questions
(questions that require more
than just a 'yes' or 'no' answer)
0 making responses or gestures
that show interest (e.g. nodding
or saying 'Aha')
0 making one or two suggestions,
not commands.
Clinical skills
Correct attachment of the baby
to the breast is important to
establish breastfeeding and to
prevent and overcome most
common difficulties. Participants
learn how to assess breastfeeding
by looking for the following signs of
good attachment:
0 the baby's chin is touching the
breast (or is very close to it)
❖ the mouth is wide open
0 the lower lip is turned outwards
♦ reflecting back (repeating in
different words) what a mother
says
❖ more areola (the circle of dark
skin around the nipple) is
showing above the baby's
mouth than below it
$ empathising (showing that you
understand how she feels)
0 the baby takes slow, deep
sucks, sometimes pausing
♦ avoiding words that sound
judging.
Health workers also need to be
able to build a mother's
confidence and give her support.
Course participants learn six
confidence and support skills :
♦ accepting what a mother thinks
and feels
Good positioning: the baby takes a mouthful
of breast tissue.
❖ using simple language
♦ recognising and praising what
a mother and baby are doing
right
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
Next, participants learn how to
BREASTFEEDING
help a mother to position her baby
at her breast so that the baby
attaches well and suckles
effectively. There are four key
signs of good positioning :
♦ the baby's head and body
should be in a straight line, not
twisted
♦ the baby should face the
breast with his or her nose
opposite the nipple
♦ the mother should hold her
baby close to her body
♦ if the baby is newborn, the
mother should support his or
her whole body, not just the
head and shoulders.
The same principles apply
whether a mother is sitting,
standing or lying down to
breastfeed. In the training course,
participants help a mother to hold
her baby in a good position and to
touch the baby's mouth with her
nipple. When the baby opens its
mouth wide, the mother quickly
moves the baby onto her breast,
aiming the baby's lower lip well
below the nipple. This helps the
baby to take a big mouthful of
breast tissue including the milk
collecting ducts under the areola
which enables the baby to remove
the milk effectively.
Participants study and practise
the skills in the classroom, then
practise applying them with
mothers and babies in maternity
wards and outpatients facilities.
They learn how to use these skills
to help mothers with common
difficulties such as worries that
they cannot produce enough milk,
sore nipples, a baby's refusal to
breastfeed, engorgement, breast
infections and when a baby is sick
or is low birthweight.
Dr Felicity Savage, Dr Bernadette
Daelmans, CDR, WHO, CH-1211
Geneva 27, Switzerland.
For more information about
'Breastfeeding counselling: A
training course’ (Ref. WHO/CDR/
93.3-6) contact CDR Division,
WHO.
(From Dialogue on Diarrhoea Issue
No. 59.)
Breastfeedmg in emergencies
Marion Kelly proposes a strategy to support breastfeeding in emergency situations where
good infant feeding is crucial to survival.
reople affected by wars or
natural disasters often have to live
in crowded and insanitary
conditions. Their access to food
and health care services may also
be restricted. In these settings, the
danger of diarrhoea and other
infections is great. This means that
during emergencies breastfeeding
becomes even more important in
protecting infant health.
Experience of relief operations
in a range of countries has shown
that anxieties about breastfeeding
were most common in countries
where artificial feeding was
widespread before the emergency
began. Even during war and
famine in Ethiopia and Sudan,
inability to breastfeed was much
less commonly reported than in
recent emergencies in Iraq,
Eastern Europe and the former
Soviet Union.
This difference suggests that
cultural factors are more important
in influencing breastfeeding than
the emergency itself. As countries
become more industrialised,
artificial infant feeding is often
introduced and breastfeeding
skills tend to be lost. In many
cases, inaccurate and out-of-date
information about breastfeeding
replaces traditional knowledge.
For example, it is often said
that poor diet or psychological
stress can make a mother's milk
'dry up'. However, this is not
supported by evidence. Although
a good diet is important for the
health of mothers themselves,
even women who are quite
undernourished are capable of
producing enough milk to
breastfeed their babies.
Psychological stress can
temporarily prevent the release of
milk from the breast, but it does
- not affect milk production. If
suckling continues and a mother's
confidence in her ability to
breastfeed is not undermined, then
breastmilk will soon flow normally
again.
Failure to understand this has
led to a mistaken belief that during
emergencies large supplies of
infant formula are needed to save
lives. However, unrestricted
distribution of breastmilk
substitutes can undermine
breastfeeding and increase the
risk of disease and death.
Although almost all mothers are
physically capable of breastfeeding,
some mothers may give up or never
start breastfeeding if they do not
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
BREASTFEEDING
the culture, health beliefs and
circumstances of the mothers
they assist.
• Provide assistance with
relactation to mothers of infants
who have stopped
breastfeeding early (see DD50).
° Supply adequate basic food
rations to every family. Target
supplementary food to
pregnant and breastfeeding
women and to children of
weaning age, not to young
infants.
Unrestricted distribution of infant formula could undermine breastfeeding.
receive encouragement, support and
appropriate advice. Also, all
pregnant and breastfeeding women
need extra food in order to protect
their own health.
Those who provide health care
and relief assistance during
emergencies should take the
following measures to support
breastfeeding and protect the
health of mothers.
• Work to get agreement
between outside agencies and
u
local health workers on
breastfeeding policy and
practice. Share up-to-date
information on breastfeeding
with those who do not have all
the facts. Establish mechanism
to ensure that all of the
following actions are
implemented in a co-ordinated
way.
0 Make sure that maternity care
practices follow the WHO/
UNICEFguidelines.'
0 Do not condemn or criticise
women who are not
breastfeeding. Instead, take a
positive approach by
encouraging mothers to choose
breastfeeding and reassuring
them of their ability to do so.
° Educate the whole community
about the benefits of
. breastfeeding. Highlight the
importance of family and social
support for breastfeeding.
° Offer one-to-one assistance for
mothers who experience
difficulties with breastfeeding.
This can be done by helping
local women to set up a
network through which new
mothers can get practical
advice and moral support from
other mothers who have
successfully breast fed.
Another option is to train
women to work as
breastfeeding counsellors. In
either case, those who provide
support must be sensitive to
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
0 Only provide infant formula to
infants who do not have access
to breastmilk. Remember that
such infants are usually few in
number, and take care to
identify them correctly. Make
sure that their care givers have
the knowledge, skills and
resources to prepare and give
feeds hygienically, using cups
rather than bottles.
Marion Kelly, Lecturer in Public
Health, Centre for International
Health, University of Wales
College of Medicine, Heath Park,
Cardiff CF 44XN, UK.
(From Dialogue on Diarrhoea Issue
No. 59)
Protecting, promoting and
supporting breastfeeding: the
special role of maternity services' .
is available free from local offices
of WHO and UNICEF or by writing
to WHO publications, CH-1211
Geneva 27, Switzerland.
Further reading: Write to
AHRTAG for a copy of Kelly, M,
1993. Infant feeding in
emergencies, Disasters 17 (2):
110-121.
BREASTFEEDING
Congratulations to the mothers
Mary Fukumoto and Hilary Creed Kanashiro report on a project where increasing mothers'
knowledge about exclusive breastfeeding was found to be important.
I] n the shanty towns of Peru's
capital, Lima, almost all mothers
breastfeed their children, but
exclusive breastfeeding is rare.
Most mothers supplement
breastmilk with herbal teas and
many also give other milks.
We wanted to know what
influences mothers in making
decisions about how they feed
their infants. First, we found out
local views about early feeding
practices and what advice health
workers were giving. We then
followed the progress of a group
of pregnant women.
We interviewed them in their
homes on several occasions:
before delivery, as soon as
possible after the birth of their
babies, and twice a week until
their babies were one month old.
We found that decision making
about infant feeding is a complex
process. A key factor is mothers'
previous experience of feeding
infants. Advice from relatives,
neighbours and health personnel
is also important.
Lack of information about
exclusive breastfeeding was
common. Nearly all the mothers
believed breastmilk was good for
their babies, but they did not know
that exclusive breastfeeding was •
best. Health workers'
understanding was also
incomplete. They advised mothers
not to give other milks, but they
did not always advise against
giving other fluids such as
sweetened water and herbal teas.
Mothers commonly believed
that they could not produce
enough milk for their babies
because they felt they themselves
were undernourished. Some
believed that although
breastfeeding was good for
babies, it could make their own
health worse. Other mothers
experienced difficulties with sore
nipples when starting
breastfeeding.
Breastmilk is good for satisfying thirst;
other liquids are not needed until a baby
is between four and six months old.
These beliefs led many mothers
to introduce other milks to
supplement breastfeeding. Herbal
teas were also given because they
were thought to prevent and cure
colic and flatulence, and to
quench infants' thirst.
Based on these findings, the
project decided to focus on
providing better information in
order to help mothers to produce
enough milk, overcome
breastfeeding difficulties, and
build their confidence that giving
other milks was not necessary.
In addition, the project also
stressed that breastmilk is good
for satisfying thirst and has
benefits similar to herbal teas.
Since mothers commonly believe
that everything they eat or drink is
transmitted to their babies through
breastmilk, they were advised to
drink herbal teas themselves,
instead of giving them to their
infants.
Because breastfeeding
practices were so closely linked to
mothers' beliefs about their own
needs, the project paid particular
attention to mothers, recognising
them as valued people whb
deserve care and promoting the
benefits of breastfeeding for
mothers as well as infants. The
slogan for the education —
'Congratulations to the mothers,
and happy breastfeeding’ —
reflected this.
Education was done mainly
through showing locally produced
videos to small groups of mothers.
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
i
1
HIV INFECTION AND BREASTFEEDING
Other channels for information
included posters, loud-speaker
broadcasts from a mobile van,
and the distribution of booklets
describing breastfeeding
techniques.
The educational activities
continued for 12 months, so that
some women were involved from
when they were first pregnant until
the first few months of
breastfeeding.
The evaluation showed that
there was a significant increase in
the number of children aged 0-4
months being exclusively
~ reastfed. However, the
improvement had occurred in the
second, third and fourth months.
The number of children being
exclusively breastfed in the first
month of life had not increased.
The increase in exclusive
breastfeeding seemed to be a
direct result of a decrease in the
use of sweetened herbal teas and
waters. The number of women
supplementing breastmilk with
other milks did not decrease
significantly.
This indicates that the
intervention was successful in
persuading mothers that herbal
' fas and waters were not
necessary. However, it was more
difficult to convince-mothers that
they could produce enough
breastmik without needing to
supplement it. It suggests that we
need to explore other ways of
increasing mothers' confidence.
Dr Mary Fukumoto and Hilary
Creed Kanashiro, Institute de
Investigation Nutricional,
Apartado 18--0191, Lima 18,
Peru.
(From Dialogue on Diarrhoie
Issued No. 59.)
HIV infection and
Breastfeeding
no v infection has no adverse
effect on lactation and lactation
has no adverse effect on the
course and outcome of HIV
infection. Both HIV and antibodies
to HIV are present in breast milk;
presence of antibodies to HIV may
provide some protection against
transmission of HIV infection
through breast milk. Research
studies indicate that transmission
of HIV through breast milk
accounts for 1-3 per cent of all
mother to infant transmissions.
Isolation of HIV from breast milk
and the reported instances of HIV
transmission through—breast milk
have led to the public
apprehension and debate about
advantages of breast feeding in
the era of the HIV pandemic. The
concern has been heightened by
the apparently conflicting
recommendations of the advisory
panels on breast feeding in
seropositive women.
Breast feeding offers protection
against a wide variety of infection
and hence is crucial for survival
for the high risk HIV infected
neonates who might also be pre
term and have low birth weight.
There are no tests by which HIV
infected infants could be identified
at birth. Unless all infants born to
seropositive mothers are breast
fed, HIV infected infants will be
denied the benefit of breast
feeding. The advantages of breast
feeding by far out weigh the small
potential risk of HIV infection
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
through breast feeding. Therefore,
in the Indian context, breast
feeding by the biological mother is
to be advocated in all infants born
to seropositive women.
In India very few of the infected
mothers can be detected because
universal HIV testing is not
possible. Breast feeding is
essential for infant survival and
growth especially among the
poorer segments of the population,
because infant food formulae are
neither affordable nor safe. Hence
breast feeding by the biological
mother should continue
irrespective of the HIV infection
status of the mother or infant,
known or unknown. Promotion of
breast feeding by all mothers will
therefore continue to be the
national policy.
(Reprinted by permission from ICMR
bulletin, Vol. 25, pages 78-79 written by
Dr. P. Ramachandran, Advisor—Health
Planning Commission, New Delhi.)
What is HIV?
The human immunodeficiency
virus (HIV) attacks the body's
immune (defence system,
weakening the body's ability to
fight off illness. Many people
with HIV stay well for some
time, but eventually their bodies
become unable to fight off
illness. In the later stages of HIV
infection, people usually
develop a group of infections
called acquired immune
deficiency syndrome (AIDS).
HIV AND PNEUMONIA
The clinical challenge of the
HIV epidemic
Charles Gilks argues that health systems in developing countries need to focus on
treating common diseases such as pneumonia which are the main cause of illnesses
in people with HIV.
Africa is bearing the brunt of the
HIV epidemic, but the virus is now
spreading most rapidly in Asia. It
is clear that HIV infection will.be a
major problem in most developing
countries for the foreseeable
future.
However few comprehensive
studies have been carried out to
find out how HIV (which slowly,
but progressively, weakens the
body’s immune defences)- is
affecting the pattern of illness and
death in developing countries.
Most research has focused on
adults rather than children.
Nevertheless, several facts are
becoming clear.
First, there are many
differences between HIV infection
in developing countries and AIDS
in rich, industrialised countries.
Unfortunately this means that
much of the information and
knowledge from the USA and
Europe is of little practical
relevance or use to health workers
in developing countries.
Secondly, a different range of
infections is found in HIV positive
people in developing countries. In '
these communities ordinary
infections such as Streptococcus
pneumoniae, Mycobacterium
tuberculosis and the salmonellae
are common causes of illnesses in
HIV-infected people because of
intense exposure to these
organisms in poor and
overcrowded communities.
Thirdly, these infections occur
relatively early in the course of HIV
infection when the body is still
able to respond well to standard
treatment, so special drugs are
not usually necessary. The
bacteria that cause these
infections are virulent and cause
much illness and death even in
adults and children with normal
immune defences.
Fourthly, relatively few adults
and children with HIV survive for
long when they only have access
to limited health care. Death
t ;
occurs in the early stages of HIV
caused by problems that are often
treatable with standard drugs. Few
people with HIV live long enough
to develop unusual opportunistic
infections such as pneumocystis
pneumonia, atypical mycobacteria,
disseminated viral infections or
unusual lymphomas which are.
common in the USA and Europe.
This is because these illnesses
occur only with advanced HIV
when the immune system is very
badly damaged.
Finally, focusing on a clinical
definition of AIDS will miss much
of the disease burden caused
directly by HIV in developing
countries where ordinary illnesses
early in the course of HIV are
much more likely. The clinical
definition of AIDS emphasises
end-stage problems such as
chronic diarrhoea and wasting, for
which symptomatic relief is usually
the only affordable option.
Concentrating on this tends to
divert attention away from the
treatable illnesses that are
common in early HIV infection
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
HIV AND PNEUMONIA
such as pneumonia,
tuberculosis and salmonellosis.
The most important lesson is
that much early HIV disease is
already being successfully treated,
although it is usually not
recognised as being HIV-related.
The despair that health workers
tend to feel when confronted with
HIV/AIDS related illnesses should
be balanced by the knowledge
that effective treatment can often
be given. A range of care needs
to be available - from cure of early
HIV-related infections, to giving
(^mptomatic care for end-stage
illness - with support and
counselling at all stages.
straight forward pneumonia,
tuberculosis' and salmonellosis diseases which are already
important public health problems.
The challenge is to provide
more of the existing drugs and
services with limited resources,
staff and infrastructure. Much
treatment will need to be hospital
based. There will also be large
increase in specific HIV-related
problems such as chronic
diarrhoea and wasting, for which
new solutions have to be
developed. These chronic,
incurable problems are often best
dealt with in the home with active
community involvement.
The clearest implication is that
there will be a large increase in
Internationally, more
attention needs to be given to
the numbers of people with
the issue of care. The
consequences of ignoring the
health care needs of millions of
individuals with HIV infection are
catastrophic. Much can be done
to confront the clinical challenge of
the HIV epidemic. Indeed much is
already being done to great effect.
In the words of a slogan I saw
recently at The AIDS Support
Organisation (TASO)' in Uganda:
‘No hope? Just cope.'
Dr Charles Gilks, Liverpool
School of Tropical Medicine,
Pembroke
Place, Liverpool, L3 5aA, UK.
Editor's note: This article is based
on the author’s experience in
Africa. We would welcome
feedback from readers in India
about how HIV is affecting child
health care.
HIV Infection And Pregnancy
HIV
Infection - Pregnancy
Interactions
Contrary to the initial reports,
pregnancy does not have any
adverse impact on course of HIV
infection. HIV infection, does not
^appear to have any adverse effect
on health of the pregnant women,
course of pregnancy, labour
peurperium or lactation.
HIV readily crosses the
placental barrier. The
consequences of intrauterine
infection on the foetus vary
depending upon the period of
gestation at the time of infection,
degree and duration of viraemia.
Increased abortion rates have
been reported from Africa but it is
not clear whether this is due to
HIV infection or to other
confounding factors. The available
minimal data mainly from the
European collaborative study
indicate that use of AZT in early
pregnancy is not associated with
any increase in the abortion rates
or congenital malformation rates.
Data from collaborative studies in
the USA indicate that use of AZ T.
in the second and third trimesters
of pregnancy is not associated
with any adverse effect on the
baby except for a higher
prevalence of anaemia. Data,
however, are insufficient to draw
any firm conclusions regarding the
absence of any-adverse
consequences on the foetus or
beneficial effect in terms of
reduction in the intrauterine
transmission rate. Maternal HIV
infection is associated with a
higher rate of premature delivery,
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
intrauterine growth retardation and
higher perinatal mortality rates.
Screening for HIV in Pregnancy
Screening for HIV during
pregnancy along the lines of
screening for syphilis during
pregnancy has many ardent
advocates. The major reason for
screening for STD like syphilis in
pregnancy is to provide
therapeutic intervention to prevent
intrauterine infection. This
justification does not exist for HIV.
In many developed countries
counseling women about STDs
and HIV and, after obtaining
informed consent screening them
for STD including HIV has been
included as a part of the "routine"
antenatal care. In these situations
there are adequate facilities for
post test counseling and care of
HIV INFECTION AND PREGNANCY
women if any are found to be
seropositive. In India such facilities
are neither available nor
affordable. Counseling for medical
termination of pregnancy (MTP) in
early pregnancy in parous
seropositive pregnant women may
provide the rationale for HIV
screening in women who report
early in pregnancy in our country.
However,screening of all pregnant
women is impossible because
majority do not attend antenatal
clinics; screening facilities are
neither available nor affordable. So
most HIV infected asymptomatic
women will continue to remain
undetected.
Management of Pregnancy .in #
Seropositive Women ■
'W
The fate of the unborn child is
the major reason for concern
regarding HIV infection in
pregnancy. To prevent these
potential calamities, MTP may be
done in the first trimester, should
the patients desire it. However,
many of the known seropositive
women may not opt for it
especially if they do not have a
living child.
Women who want to continue
pregnancy should be provided
with adequate, appropriate,
antenatal care. In the USA in
woman who opt to continue
pregnancy, the prophylactic use of
AZT is considered especially with
falling CD4 count8; many
obstetricians prescribe
prophylactic chemotherapy against
pnuemocystis pneumonia. In
developing countries like India,
seropositive women who opt to
continue pregnancy are provided
with antenatal care; specific efforts
are made to promptly diagnose
and treat any opportunistic or
pathogenic infections in these
women. Routine CD4 cell counts,
prophylactic chemotherapy against
infections in immunocompromised
individuals and prophylactic therapy
with AZT or similar virucidal drugs
are not possible or affordable.
During labour specific efforts
may be taken to reduce any
invasive procedures such as scalp
vein blood sampling, use of scalp
electrodes to monitor foetal heart
rate, to reduce the risk of
transmission of infection to the
foetus during labour. In the Indian
context caesarean section is
associated with maternal
consequences not only in the
present pregnancy but also in the
subsequent conception. Hence
normal vaginal delivery will
continue to be the mode of
delivery in HIV infected women
who do not have any specific
indications for caesarean section
until such time as there is
unequivocal proof that the risk of
HIV transmission is lower with
caesarean section. Stringent
precautions should be taken to
prevent accidental spread of HIV
infection while providing health
care especially during delivery.
Specific efforts have to be made
to keep appropriate provisions for
looking after the low birth weight
neonates.
HIV And Breast Feeding
HIV infection has no adverse
effect on lactation and lactation
has no adverse effect on the
course and outcome of HIV
infection. HIV has been isolated
from breast milk. HIV antibodies
are also present in breast milk and
their presence may provide some
protection against transmission of
HIV infection through breast
milk.Estimated risk of transmission
of HIV infection through breast
milk is between 1-3 per cent of all
the perinatal infections.
Breast Feeding in Seropositive
Women______________________
All available data suggest that
breast feeding will protect HIV
infected infants from other
infections and may prolong the
survival period.There are no tests
by which infected infants could be
identified at birth. Unless all
infants born to seropositive
mothers are breast fed, HIV
infected infants will be denied the
benefit of breast feeding. In view
of this it is essential to encourage
all seropositive women to breast
feed. In India, the advantage of
breast feeding by far outweigh tfw.
small potential risk of HIV infection
through breast feeding; this is
especially important in seropositive
mothers from low income groups
among whom, breast feeding
holds the key for infant nutrition,
growth,relative freedom from
infection.and survival. Therefore, in
the Indian context, breast feeding
by the biological mother is to be
advocated for all
infants born to seropositive women.
Breast Feeding in the HIV Epidemic
In India breast feeding is
essential for infant survival and
growth especially among the
poorer segments of the population^
Hence breast feeding by the
'■ ■'
biological mothers should continue
irrespective of the HIV infection
status of the mother or infant,
known or unknown. Promotion of
breast feeding should continue to
be the national policy.
HIV Infection And Immunisation
increasing prevalence and
awareness of HIV infection has led
to concern about efficacy and
safety of immunisation of the
infants born to seropositive
mothers and queries about the
Universal Immunisation
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
HIV INFECTION AND PREGNANCY
Programme (UIP) in the absence
of any information on the HIV
status of the majority of infants.
Immunisation in Seropositive
Infants
HIV infected infants are
apparently healthy and do not
have any immunodepression at
birth. They usually remain
asymptomatic during the first six
months of life. They respond
normally to immmunisation
administered during the
asymptomatic period. Experience
with inactivated vaccines given to
HIV infected children indicate that
l ese immunisation are free from
major short or long term side
effects. Immunisation might offer
some protection against the
common infections during infancy
in HIV infected children when
immunodepression occurs. It is
therefore essential that all infants
born to seropositive mothers
should receive all the vaccines on
schedule. Special attention should
be given to ensure that these
infants receive BCG vaccination
soon after birth, because (i) BCG
vaccination cannot be given to
infants once immunodepression
sets in, and (ii) tuberculosis is one
of the most common pathogenic
Elections in HIV infected infants in
developing countries like India. If
for any reason BCG vaccination
was not administered at birth it
should be administered as soon
after birth as possible. However,
BCG vaccination should not be
administered in seropositive
infants if they have become
symptomatic for AIDS.
It is essential to ensure that all
seropositive infants receive DPT,
polio and measles vaccines on
schedule. If given on schedule
most of the infants would have
completed their immunisation prior
to onset of symptoms. If
seropositive infants had not
received immunisation on time and
have become symptomatic, it is
essential to give them DPT, polio
and measles vaccine, because (i)
all the available data indicate that
in immunocompromised HIV
infected infants risk of natural
infections is greater than the risk
of immunisation even with live
attenuated vaccines (except
BCG); and (ii) so far no major
adverse effects of vaccination on
HIV infected infants have been
reported. Some paediatricians
advocate that in symptomatic HIV
seropositive infants killed polio
vaccine may be used instead of
OPV.
infections and growth faltering
appear. Paediatric AIDS is
characterised by failure to thrive,
poor weight gain/actual weight
loss, hepatosplenomegaly,
recurrent fever, respiratory
infection, diarrhoeal diseases and
bacterial or fungal infections of the
skin.
Because of the limitations of the
HIV screening programme in
women, the majority of
seropositive infants in India will
remain undetected during infancy.
Growth monitoring and
investigation of infants showing
growth retardation and repeated
infections is likely to be the
common method by which
paediatric AIDS patients are
detected in India.
I Care of HIV Infected Infants
The WHO Expert Group on
Immunisation has recommended
that there is no need to modify
any of the existing guidelines for
the Universal Immunisation
Programme; all asymptomatic
infants irrespective of the fact that
HIV status of the mother or infant
is not known, should receive all
vaccines both live attenuated and
killed as per the existing schedule.
The advent of the HIV infection
only calls for continued vigorous
implementation of UIP even after
the advent of the HIV epidemic. It
is essential that the immunisations
are administered on schedule so
that all infants receive all the
immunisations except measles
before six months of age when
almost all the HIV infected infants
are in the asymptomatic phase.
HIV And Children
During the first six months of
life, growth and morbidity of HIV
infected infants is similar to
uninfected infants from the same
community; subsequently repeated
Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
Physicians in developing
countries advise admission only for
treatment of life threatening
infections and malignancies in
children with AIDS. Monitoring of
HIV infected children, providing
appropriate care for repeated
episodes of pathogenic/
opportunistic infection are best
done at home with the help and'
cooperation of the family
members. Children are certainly
happier at home, than in the
crowded hospital wards among
strange, ill children. Hospital
admission for only gravely ill
children is a useful strategy to
ensure that inpatient beds are not
all taken up in the care of
chronically ill children with AIDS
and adequate beds are available
for care of children suffering from
other illnesses.
Reprinted by permission from
ICMR bulletin, Vol. 24 Pages 122-124
written by Dr. P. Ramachandran
Dy. Director General ICMR H.Q.
New Delhi).
Breastfeeding and
Reproductive Rights
HOW Breastfeeding
Empowers Women
Breastfeeding has been given
global recognition for its
contribution to child survival at
international conferences and in
international documents.
jjF] Breastfeeding confirms women's
power to control their bodies,
and challenges the bio-medical
model and business interests
that promote bottle-feeding.
Less attention, however, is
given to its significant role in
empowering women.
Breastfeeding empowers a woman
by allowing her to control her own
fertility and enhance her health as
well as that of her children. The
knowledge that a breastfeeding
mother is less likely to become
pregnant is part of the traditional
wisdom of many cultures.
Breastfeeding is a woman's
reproductive right which should be
protected, supported and
promoted.
E Breastfeeding reduces women's
dependence on medical
professionals and validates the
tried and trusted knowledge
that mothers and midwives have
about infant care and feeding.
Current research confirms that
as long as a woman is fully or
nearly fully breastfeeding, and has
not resumed menstruation, she
has a less than 2% risk of
becoming pregnant. Family
planners know this method as
Lactational Amenorrhea Method
(LAM). In areas of the world where
artificial contraception is
unaffordable, unavailable or
unacceptable, breastfeeding
provides a woman with an
effective means of family planning.
A decline in breastfeeding rates
contributes to the increase in
birthrate where artificial means of
family planning are not used.
Breastfeeding allows a woman
to space births effectively,
according to her own fertility,
independently of any possible
forces within her society which
would hinder her right to control
her own fertility.
H Breastfeeding encourages
women's self-reliance by
increasing their confidence in
their ability to meet the needs
of their infants.
Breastfeeding helps child
spacing, reduces the risks of
anaemia and provides
protection against ovarian and
breast cancer, osteoporosis
and multiple sclerosis.
E Breastfeeding requires a new
definition of women's work-one
that more realistically integrates
women's productive and
reproductive activities, and
which values both equally.
12Breastfeeding requires
structural changes in society to
improve the position and
condition of women.
B Breastfeeding challenges the
Health Dialogue is published quarterly by
the Christian Medical Association of India
and Is available in English. It has a
circulation of over 22,000 in India.
Scientific editor: Dr. Shanti Ghosh.
Executive editor : Ms. Latika Singha.
Editorial advisory group : Dr. Cherian
Thomas, Dr. Shanti Ghosh, Ms. Razia Ismail,
Dr, M.K. Bhan Dr. Narender Gupta, Dr.
Beverley Booth, Dr. Kalindi Thomas, Dr.
Alfred Edwards.
DTP input: Ms Susamma Mathew, Ms. R.
Kamakshi.
Distribution & mailing list:
Ms. R.Kamakshi.
Co-director and head of programmes and
publishing services (AHRTAG):
Mr. Andrew Chetley
Dialogue on Diarrhoea
Scientific editor: Dr. William Cutting.
ARI News
Editor-in-chief: Dr. Harry Campbell.
Technical editors : Prof. Peter Burney (UK);
Dr. Anthony Costello (UK); Prof. Michael
Levin (UK); Prof. David Miller (UK).
AHRTAG address:
AHRTAG
Farringdon Point
29-35 Farringdon Road
London ECIM 3JB, UK
Tel.: +44 171 242 0606 (International)
Fax: +44 171 242 0041 (International)
E mail: (Geonet) GEO2: AHRTAG or
(Internet) ahrtag @ geo2. geonet. de
The views expressed in Health
Christian Medical
Association of India
Local Shopping Centre,
view of the breast as primarily a
sex object.
B Breastfeeding encourages
solidarity and cooperation
among women at the
household, community, national
and international level.
Acknowledgement: WABA Brazil/
Origem in WABA women’s work task
force, La Leche league international,
Kathy Shelton and the institute for
Reproductive Health.
|
Dialogue are not necessarily those of the
editorial advisory group.
Janakpuri, New Delhi -110058
Phones:5521502.5599991,5599992,
5599993.
Telex: 31-76288 CMAI IN,
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Health Dialogue, Issue No. 4, December 1995, Published quarterly by CMAI
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