Skip to main content
Download PDF

Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? – A systematic scoping review

International Journal for Equity in Health volume 20, Article number: 114 (2021) Cite this article

Abstract

Introduction

Suboptimal breastfeeding rates in South Africa have been attributed to the relatively easy access that women and families have had to infant formula, in part as a result of programs to prevent maternal-to-child transmission (MTCT) of HIV. This policy may have had an undesirable spill-over effect on HIV-negative women as well. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the WHO HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa.

Methods

We applied the Joanna Briggs Institute guidelines for scoping reviews and reported our work in compliance with the PRISMA Extension (PRISMA-ScR). Twelve databases and platforms were searched. We included all study designs (no language restrictions) from South Africa published between 2006 and 2020. Eligible participants were women in South Africa who delivered a healthy live newborn who was between birth and 24 months of age at the time of study, and with known infant feeding practices.

Results

A total of 5431 citations were retrieved. Duplicates were removed in EndNote and by Covidence. Of the 1588 unique records processed in Covidence, 179 records met the criteria for full-text screening and 83 were included in the review. It was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1–3 months). EBF rates rapidly declined after birth. School and work commitments were also reasons for discontinuation of EBF. HIV-positive women expressed fear of HIV MTCT transmission as a reason for not breastfeeding.

Conclusion

The Review found that while enforcing the most recent WHO HIV infant feeding guidelines and the WHO Code may be necessary to improve breastfeeding outcomes in South Africa, they may not be sufficient because there are additional barriers that impact breastfeeding outcomes. Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to improve breastfeeding outcomes in South Africa.

This article is a part of the Interventions and policy approaches to promote equity in breastfeeding collection, guest-edited by Rafael Pérez-Escamilla, PhD and Mireya Vilar-Compte, PhD

Introduction

In 2016, South Africa recorded 67.3% of infants initiating breastfeeding within 1 h of birth, and only 31.6% being exclusively breastfed, with a mean exclusive breastfeeding duration of 2.9 months [1], the lowest rates on the African continent [2]. South Africa, an upper-middle income country in Sub-Saharan Africa has a population of about 58 million [3, 4]. While South Africa is rich in natural resources, its social indices reflect structural vulnerabilities and inequities, such as healthcare gaps and the uneven impact of HIV/AIDS [5]. South Africa’s maternal mortality ratio is 119/100,000 live births [6], and child mortality rates have been steadily declining with infant and under-5 mortality rates of 28 and 35 per 1000 live births compared to Sub-Saharan Africa’s rates of 52 and 76 respectively [7, 8].

Breastfeeding is vital for an infant’s development and survival as it reduces morbidity and mortality from diarrhea, pneumonia and malnutrition, particularly in infants under-5 years [9,10,11]. Breastfeeding also reduces the risk of childhood obesity and fosters cognitive development [10, 12,13,14]. Furthermore, it confers health benefits to mothers including reduced risk of cancers (breast, ovarian), hypertension and diabetes [10, 15, 16].

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend exclusive breastfeeding (EBF) of infants from birth to 6 months, followed by the introduction of nutritious and safe complementary foods with continued breastfeeding for at least 2 years [9]. The United Nations (UN) policy brief on The UN Decade of Action on Nutrition includes five targets to eradicate all types of malnutrition, as well as six targets to improve maternal, child health and nutrition by 2025 [17]. Target 5 on breastfeeding, aims to increase exclusive EBF rates to at least 50% by 2025 [17]. Hence, it is of concern that globally just 44% of infants are breastfed soon after birth, and 40% of those less than 6 months old are exclusively breastfed [9, 18]. In 1985, HIV infection through human milk or breastfeeding was first recognized in the United States [19, 20] and the Centers for Disease Control and Prevention issued guidelines for HIV-positive women to adopt replacement feeding [21].

In terms of HIV-positive women, WHO guidelines on infant feeding have drastically evolved over time. Initially in 2001, the WHO advised women not to breastfeed when affordable and safe human milk substitutes were available due to evidence supporting the mother to child transmission (MTCT) of HIV through human milk or breastfeeding [22]. By 2006, WHO advised that early cessation of breastfeeding before 6 months was no longer required for HIV-positive women [23]. In 2010, they advised women on anti-retroviral treatment (ART) to exclusively breastfeed for 6 months and continue breastfeeding for 1 year [10, 24]. Finally in 2016, the timeline for breastfeeding was extended to at least 24 months, and mixed feeding was no longer considered a risk factor for MTCT as long as ART was available [9].

In 2011, South Africa changed its infant feeding policy to EBF for all women regardless of HIV status [25]. This shift in policy conveyed through the Tshwane declaration was aligned with WHOs 2010 guidelines on HIV and infant feeding that realigned breastfeeding guidelines of HIV-positive women with HIV-negative women as long as ARTs are available [25, 26]. The declaration also called for not distributing free infant formula for HIV-positive women (except for medical reasons) at public health facilities, and for these facilities to become “baby-friendly” by 2015 [18, 25].

The UNICEF/WHO Baby Friendly Hospital Initiative (BFHI) launched in 1991 was designed to strengthen the capacity of maternity facilities to protect, promote, and support successful breastfeeding [27]. The Tshwane declaration also called for the government to establish legislation to enforce the WHO International Code on Marketing of Breast Milk substitutes (The Code) [25]. The Code includes specific guidelines to protect, promote and support breastfeeding by regulating the advertising and sales of breastmilk substitutes (BMS), bottles and teats [28, 29].

While The Code was approved since 1981 by the World Health Assembly [29] violations continue to be widespread globally due to weak Code monitoring and enforcement mechanisms across countries, especially in low-to-middle income countries (LMIC) [30,31,32]. As a result, infant formula sales have increased exponentially in LMICs, including in South Africa resulting in higher rates of morbidity and mortality [30, 31, 33, 34].

South Africa also has one of the highest rates of HIV in the world with an adult prevalence of 19.2% [4]. Breastfeeding outcomes are suboptimal in South Africa [11, 33, 35]. Some have attributed it, at least in part, to the relatively easy access that women and families have had to infant formula as a result of infant formula distribution programs designed to prevent MTCT of HIV [36]. Apparently, this policy may have had an undesirable spill-over effect on HIV-negative women as well. Hence, South African academics and advocates have called for enforcing The Code within the framework of the most recent WHO guidelines on infant feeding in the context of HIV [9, 33]. Enforcing The Code is paramount in the context of WHOs most recent guidelines on infant feeding [9] to improve EBF. Thus, the aims of this scoping review were to: (a) describe EBF practices in South Africa, (b) determine how EBF has been affected by the HIV infant feeding policies followed since 2006, and (c) assess if the renewed interest in The Code has had any impact on breastfeeding practices in South Africa.

Methods and analyses

We applied the PRISMA Extension (PRISMA-ScR) and Joanna Briggs Institute guidelines for scoping reviews [37, 38]. The review protocol was registered in Open Science Framework (OSF) (https://osf.io/sxcfv/). A highly experienced medical librarian (KN) conducted a peer-reviewed comprehensive search of multiple databases.

Information sources and methods

The databases searched in this project and their platforms were: MEDLINE All (Ovid), PsycINFO (Ovid), Embase (Ovid), Global Health (Ovid), Web of Science Core Collection (as licensed by Yale University, Core Collection included Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Arts & Humanities Citation Index (A&HCI), Conference Proceedings Citation Index- Science (CPCI-S), Conference Proceedings Citation Index- Social Science & Humanities (CPCI-SSH), Book Citation Index– Science (BKCI-S), Book Citation Index– Social Sciences & Humanities (BKCI-SSH), Emerging Sources Citation Index (ESCI) --2015-present, Current Chemical Reactions (CCR-EXPANDED), and Index Chemicus (IC), Dissertations and Theses Global (ProQuest), Africa-Wide Information (Ebsco), CENTRAL (Cochrane Library), CINAHL (Ebsco), and Africa Index Medicus (Global Index Medicus). All titles/abstracts and texts were screened in Covidence except for the South African National ETD Portal (via netd.ac.za). This portal was searched online, but because records’ export was not possible, the potentially relevant records were screened by an author (DV) online and only records requiring full text screening were added to Covidence. Each database was searched individually, using a combination of keywords and (if available) controlled vocabulary. No study registries were searched. No citation chaining was done.

Records published between 2006 and the dates of the searches in 2020 were retrieved. This date limit was used because this was the period of major policy shifts in WHOs infant feeding guidelines in the context of HIV. No limits were imposed with respect to study design and languages. Conference papers were not retrieved. Papers with animal subject indexing were excluded in some databases, but only if they did not also have human subject indexing. This search strategy was developed independently and did not use any published or validated filters. The MEDLINE search strategy was peer reviewed by an independent medical librarian using the Peer Review of Electronic Search Strategies Guideline [39].

Search strategies

The search strategies for each database are available in full. Search terms for Ovid Medline are presented in Table 1. While the strategies used appropriate syntax, indexes, and controlled vocabulary for the various databases, each one includes queries for the setting (South Africa) and queries for the broad topic (infant feeding). The strategies do not require an explicit reference to the WHO HIV infant feeding guidelines or The Code.

Table 1 Search terms for Ovid MEDLINE
Full size table

Inclusion and exclusion study criteria

For studies to be included, they needed to be peer reviewed, grey literature technical reports or theses and dissertations. We considered quantitative, mixed-methods and qualitative study designs. Studies had to be conducted in South Africa.

Types of participants

Eligible participants were women in South Africa who delivered a healthy live birth (birth to 24 months) with known infant feeding practices.

Interventions

We focused on two policy-level interventions, namely, the World Health Organization (WHO) Updates on HIV and Infant Feeding Guidelines (2016) [9], and The International Code of Marketing of Breastmilk Substitutes (The Code) [28, 29]. The updated 2016 (most recent) infant feeding guidelines recommend lifelong antiretroviral therapy for anyone diagnosed with HIV, including those who are pregnant and breastfeeding. It also provides guidance on appropriate infant feeding practices for mothers living with HIV [9]. Women who are HIV-positive and receiving antiretrovirals are advised to breastfeed following the same breastfeeding recommendations for HIV-negative women. The objective of The Code initially endorsed in 1981 by the World Health Assembly of WHO was to ensure safe and adequate nutrition for infants by protecting and promoting breastfeeding. It specifically sought to regulate the marketing of products such as breastmilk substitutes including formula, other types of milk, beverages and equipment (bottles, teats) [28, 29].

Outcomes

The infant feeding/breastfeeding outcomes considered were: Breastfeeding initiation within 1 h of birth; Exclusive breastfeeding up to 6 months; Any breastfeeding up to 12 months of age; and Continued breastfeeding from 12 to 23 months.

Screening

All references retrieved were first de-duplicated by KN, then uploaded into Covidence [40]. Two independent reviewers (DV and MVC) initially screened a sample of 20 references (titles/abstracts) to ensure consistency and measure inter-rater literature screening reliability.

Data collection and analyses

Data extraction

Data were independently extracted and entered on a standard Microsoft Excel spreadsheet form by two authors (DV and MVC). Studies which did not meet inclusion criteria and outcomes were excluded. Any disagreement was resolved in consultation with the senior author (RPE). Data extraction fields included author names, journal name and year of publication, study design, location of study, sample characteristics, number of participants, and outcomes. These outcomes included: Breastfeeding initiation within 1 h of birth; Exclusive breastfeeding up to 6 months; Any breastfeeding up to 12 months of age; and Continued breastfeeding from 12 to 23 months.

Assessment of methodological quality of the included studies

We did not evaluate the methodological quality and risk of bias of the included studies since this is not required for a scoping review [37, 38].

Analyses and reporting

Our findings are reported based on the PRISMA Extension and Joanna Briggs Institute guidelines for scoping reviews. We analyzed the data extracted from included studies based on the HIV status of participants and their infant feeding practices and outcomes wherever provided.

Results

A total of 5431 citations were retrieved from eleven databases. Duplicates were removed in EndNote and by Covidence. Records from all the databases except National EDT Portal underwent title-abstract screening in Covidence; records from National EDT Portal underwent title-abstract screening on the National EDT Portal website. 35 National EDT Portal Records were identified as deserving full text screening and were added to Covidence at that stage. 1588 unique records were processed in Covidence and 179 records met the criteria for full-text screening. The final number of included records was 83 (Fig. 1 PRISMA flow diagram).

Fig. 1
figure 1

PRISMA flow diagram)

Full size image

Characteristics of included studies

Of the 83 studies included, nine were qualitative, 11 RCTs, and 63 observational. All nine South Africa provinces were represented; the highest number of studies were conducted in Kwa-Zulu Natal (34) and the lowest number in Northern Cape (2). Other studies were in Western Cape (25), Gauteng (15), Eastern Cape (14), Limpopo (13), North West (7), Mpumalanga (6) and Free State (5). Studies were conducted primarily in rural (31) and urban (25) settings; other settings included semi-rural (3), semi-urban (6) and peri-urban (22).

While the articles were published between 2006 and 2020, we interpreted findings in the context of the time period when the study was conducted. The number of articles were about evenly divided between the two periods of major changes in WHOs breastfeeding guidelines for HIV-positive women; prior to 2011 (n = 40 articles) and from 2011 onward (n = 43 articles).

Infant feeding practices in South Africa (2006–2010)

The studies conducted during 2006–2010, i.e. before the release of the 2010 guidelines recommended HIV-positive women on ARVs to exclusively breastfeed for the first 6 months after birth (Table 2) revealed that HIV-positive women with 0–6 months infants mainly practiced formula and mixed feeding [41,42,43,44]. EBF rates in this age group ranged from 13 to 77% [44, 45].

Table 2 Included studies 2006–2010
Full size table

During this period, it was common for HIV-positive women who initiated breastfeeding to stop doing so prior to 6 months after birth (1–3 months) [46,47,48,49]. Low rates of breastfeeding were observed for a variety of reasons including free formula distribution, not wanting to transmit the virus to the infant, and work/school obligations [43, 50,51,52,53]. However, for HIV-positive women who practiced exclusive formula feeding (EFF) initially, lack of access to infant formula was one of the reasons for mixed feeding [54, 55].

While breastfeeding initiation rates were high among HIV-negative women, ranging from 52.7 to 97% [48, 49, 56,57,58,59], EBF rates declined as liquids and solids were introduced before the infants were 6 months old [60,61,62,63]. Other reasons for infant formula use included non-disclosure of HIV status, family pressure, and cultural practices [41, 54, 55, 57].

Infant feeding practices in South Africa (2011–2020)

The post-2010 period (Table 3) after South Africa endorsed the 2010 WHO infant feeding guidelines for HIV-positive women recommending EBF for 6 months irrespective of HIV status resulted in a wide range of EBF rates among HIV-positive (26–99%) and HIV-negative (12–92%) women [64,65,66,67,68,69]. However, EBF duration was brief (1-3 months) [66, 70, 71]. While initiation of breastfeeding was high, there were low rates of EBF among HIV-negative women with introduction of liquids and other foods prior to 3 months [72,73,74,75]. In some instances, weaning occurred as early as 2 months [76]. HIV-positive women expressed fear of HIV transmission to their infants, as well as school and work commitments as reasons for discontinuation of EBF [68, 77,78,79,80].

Table 3 Included studies 2011–2020
Full size table

RCTs testing interventions to improve breastfeeding practices and outcomes

Two major multi-country RCTs conducted during 2005–2008 among HIV-positive women and infants ≤6 months old were the Kesho Bora trial [81, 82] and the PROMISE-EBF trial [83].

In the Kesho Bora trial [81, 82], conducted in Burkina Faso, Kenya and South Africa (Durban, Somkhele), HIV-positive pregnant women were randomized into two groups who received either triple ART during pregnancy through the breastfeeding period (intervention), or short course prophylactic therapy until delivery (control). All HIV-exposed infants received single-dose nevirapine at birth. Women were also counselled to either breastfeed with cessation by 6 months or formula feed from birth (free infant formula was provided for 6 months). The main objectives were to determine rates of HIV transmission, infant survival at 6 weeks and 12 months and adverse events. Bork and colleagues [81], found breastfeeding initiation to be lower in Durban (57.1%) than rural Somkhele (80.9%) among 751 HIV-exposed infants. Overall, they found that non-breastfed infants (0–6 months) had higher morbidity risks than those breastfed, with increased risk for serious infections (e.g. severe diarrhea) between 0 and 2.9 months [81].

The PROMISE-EBF trial was a behavior change intervention to promote EBF using peer counsellors in Burkina Faso, South Africa (Paarl, Rietvlei and Umlazi), and Uganda [47, 83,84,85,86]. This counselling intervention (N = 2579 mother-infant pairs) included one antenatal breastfeeding peer counselling visit and four postnatal peer visits. The two main outcomes of interest were prevalence of EBF and diarrhea at ages 12 and 24 weeks. Overall, Tylleskar and colleagues [83] found that EBF prevalence (all countries) in the intervention groups at 12 weeks was double that of the control groups. However, South Africa had exceedingly low EBF rates at baseline (10%), compared with 79% in Burkina Faso and 82% in Uganda [83]. There were no significant differences in the prevalence of diarrhea (all countries) between the two groups at either 12 or 24 weeks of age [83]. Finally, the authors [83] found that while the peer counselling intervention was effective in increasing EBF rates in Uganda and Burkina Faso, it was not effective in improving breastfeeding rates in South Africa.

Violations of the international code of marketing of breastmilk substitutes

South Africa took another bold step in 2012 to enforce The Code via legislative action (i.e., regulation R991 of 2012), which sought to regulate the sales, advertising, marketing, information and education of foods promoted for infants and young children [87, 88]. The specific objective of regulation R991 was to protect and support breastfeeding by creating an environment free from the relentless marketing strategies of BMS manufacturers, and prevent conflicts of interest among the healthcare staff or other child care providers [87, 88]. Unfortunately, this legislation has had limited positive effects as violations of the Code are still prevalent, highlighted in the three articles discussed below.

Of the three included studies which focused on Code violations, two were Master of Public Health theses [89, 90] and the other was an expert commentary from academics [33] (Table 3). Muravha [89] investigated Code violations among health workers in four Provinces and 40 health facilities and found that four health workers accepted free gifts (pens, calendars, posters) from a BMS company, despite being aware of the R991 regulations. Health workers also received education materials (leaflets, booklets) and equipment (South African water bags for adult usage) which were branded with the manufacturer’s name, but not the name of a specific product marketed by the BMS company. Radebe [90] examined media (radio, television, print) infractions and identified 30 marketing violations from 117 baby products (formula, bottles and teats) advertised in magazines targeting primarily pregnant women or families. The author reported that these numbers are likely to be underestimated, since the analysis did not include all media sources.

Finally, Lake and colleagues’ commentary [33] documented anecdotally the marketing strategies of the BMS industry and their reach to health workers and other stakeholders through sponsorships of conferences and other scientific meetings, misleading information on infant formula on company websites, health promotion materials and support for staff salaries. The authors called for improved leadership efforts in enforcing the Code and strengthening breastfeeding interventions.

Discussion

During the early years of the HIV pandemic, recommendations for infant feeding were guided by scientific evidence indicating that when safe feeding with breast milk substitutes was universally available, as was the case in the United States and other high income countries, it was appropriate to recommend for HIV-positive mothers to not breastfeed at all [21].

By contrast, as part of their infant feeding decisions HIV-positive mothers in low income countries needed to consider the risk of their children dying if they were not breastfed as a result of having access to safe replacement feeding alternatives. Since then, HIV infant feeding guidelines have evolved over time. WHO guidelines in this area switched from exclusive breastfeeding with abrupt weaning from the breast before 6 months to current guidelines recommending EBF for 6 months followed by breastfeeding continuation for at least 12 months if the mothers have ART access [9, 22,23,24].

The initial guidelines implemented in South Africa in 2008 [36] provided HIV-positive mothers with widespread access to cost-free infant formula at public health facilities. Unfortunately, these polices, albeit well-intentioned may have inadvertently negatively impacted the EBF behaviors among HIV-negative mothers and led to subsequent increases in infant morbidity and mortality in South Africa and similar settings [91]. Our review indeed suggests as reported in other studies that there may have been a spill-over from an infant feeding policy driven by HIV-positive women to HIV-negative mothers explaining why EBF rates are still low in South Africa [44, 92]. Unfortunately, there is no evidence that EBF rates significantly increased after the Tshwane declaration.

One of the challenges highlighted in this review is that HIV usually coexists with poverty creating a syndemic-like effect in the lives of women, as breastfeeding was disincentivized in the early WHO guidelines, generating inequities in access to infant feeding choices. In addition, as the South African HIV infant feeding guidelines evolved and pushed for phasing out free formula distribution [25, 36], some key challenges remain: (i) changing breastfeeding behaviors, social norms and medical practices have been slower than desired; and (ii) marketing of BMS and Code violations have persisted. These factors have disproportionately affected HIV-positive mothers mainly located in rural and peri-urban areas of South Africa where not breastfeeding was associated with increased risk for serious infections (chronic diarrhea, lower respiratory tract infections) and death [45, 81, 84]. Further research is needed to address how poverty affects women’s ability to successfully implement the national infant feeding guidelines for HIV-positive and HIV-negative women.

One of the strengths of this review is that it highlights diverse studies conducted in South Africa on breastfeeding in the era of HIV among both HIV-infected and uninfected women, and that EBF rates are subpar in both groups as a result of the premature introduction of liquids and solids. However, there is a dearth of policy-responsive implementation research to inform how the more recent HIV infant feeding national guidelines can be successfully implemented in South Africa, a country where this should be possible because there is now almost universal access to ART among HIV-positive women [93,94,95,96], and a call for strong protection, promotion and support for breastfeeding including those who are HIV-positive [33, 97]. As it has been found in other countries [98,99,100,101], our findings suggest that strong Code enforcement combined with increased investments in breastfeeding protection, promotion and support programs in South Africa are needed for the country to make progress towards meeting the United Nations target to increase breastfeeding rates to at least 50% by 2025 [17].

Because the infant formula distribution program was coordinated by the health sector, the findings from our review are highly consistent with previous studies showing that health workers play an important and influential role in counseling or advising mothers on infant feeding practices [77, 102,103,104,105,106].

Therefore, it is key that the WHO Code is properly enforced to allow for the environment conditions surrounding mothers in South Africa to become stronger enablers of optimal breastfeeding practices [106]. Unfortunately, in our review we did not find evidence that this has already started to happen yet in South Africa.

Although penalties exist for first and subsequent violations of regulation R991, with the first penalty being a fine and at most 6 months imprisonment [107], to date no individual or organization has been prosecuted for Code violations, a strong indicator of lack of enforcement or commitment to change the status quo. Thus, routine monitoring of this key legislation is required as encouraged by other academics and advocates [33, 97, 108]. As such, enforcing regulation R991, particularly the outreach to health workers by BMS manufacturers and their associates is imperative.

Conclusion

The free distribution of infant formula combined with the BMS industry’s marketing practices that violate the WHO Code have played a role in suboptimal breastfeeding practices among both HIV-positive and negative women in South Africa [33, 109, 110].

This scoping review integrated evidence on infant feeding practices, especially EBF rates among HIV-positive and HIV-negative women in South Africa in the context of rapidly evolving HIV infant feeding guidelines from the WHO. Although highly effective ARTs has made breastfeeding for HIV-positive women safe, and South Africa has widespread access to ART [93, 95, 96], it is discouraging that women continue to cite fear of HIV transmission to their infants as a reason for either not breastfeeding or doing so for short periods of time. This finding calls for improved access to high quality breastfeeding counselling, education and awareness campaigns from the local health care facility to the national level.

Although monitoring and enforcement of the Code remain nonexistent, there has been progress in strengthening legislation. The most recent Status Report (2020) from WHO, UNICEF and IBFAN found 70% (136/194) of WHO Member States had new Code legislation [111]. However, only 31 countries regulated milk products for infants up to at least 36 months. Moreover, just 58% (79/136) ban the promotion of BMS at health facilities [111].

Even though enforcing the most recent WHO guidelines and the WHO Code are necessary to improve breastfeeding outcomes in South Africa, they are not sufficient because as our review shows, there are additional barriers that impact breastfeeding outcomes, including lack of social support among women returning to work or school after the birth of their children.

Mixed-methods research, including in-depth interviews with key informants representing different government sectors and civil society is needed to prioritize actions and strategies to make this happen in South Africa. This effort should be followed by implementation research and policy instruments [112, 113] that can guide South Africa in its efforts to scale up the protection, promotion, and support of breastfeeding programs at the national level in the context of the HIV pandemic.

Availability of data and materials

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

References

  1. The DHS Program STATcompiler - South Africa [https://www.statcompiler.com/en/].

  2. South Africa Demographic and Health Survey 2016: Key Indicators Report [http://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf].

  3. World Development Indicators - South Africa [https://data.worldbank.org/country/south-africa?view=chart].

  4. Country Profile - South Africa [https://databank.worldbank.org/views/reports/reportwidget.aspx?Report_Name=CountryProfile&Id=b450fd57&tbar=y&dd=y&inf=n&zm=n&country=ZAF].

  5. The World Factbook- South Africa [https://www.cia.gov/library/publications/the-world-factbook/geos/sf.html].

  6. Maternal mortality data: Trends in estimates of maternal mortality ratio (maternal deaths per 100,000 live births) 2000-2017 [https://data.unicef.org/resources/dataset/maternal-mortality-data/#].

  7. Mortality rate, under-5 (per 1,000 live births) [https://data.worldbank.org/indicator/SH.DYN.MORT?locations=ZG].

  8. Mortality rate, infant (per 1,000 live births) [https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ZG].

  9. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV [https://apps.who.int/iris/bitstream/handle/10665/246260/9789241549707-eng.pdf?sequence=1].

  10. Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. https://doi.org/10.1016/S0140-6736(15)01024-7.

    PubMed  Article  Google Scholar 

  11. Ogbo FA, Agho K, Ogeleka P, Woolfenden S, Page A, Eastwood J. Infant feeding practices and diarrhoea in sub-Saharan African countries with high diarrhoea mortality. PLoS One. 2017;12(2):e0171792. https://doi.org/10.1371/journal.pone.0171792.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  12. Yan J, Liu L, Zhu Y, Huang G, Wang PP. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health. 2014;14(1):1267. https://doi.org/10.1186/1471-2458-14-1267.

    PubMed  PubMed Central  Article  Google Scholar 

  13. Rito AI, Buoncristiano M, Spinelli A, Salanave B, Kunešová M, Hejgaard T, et al. Association between characteristics at birth, breastfeeding and obesity in 22 countries: the WHO European childhood obesity surveillance initiative - COSI 2015/2017. Obes Facts. 2019;12(2):226–43. https://doi.org/10.1159/000500425.

    PubMed  PubMed Central  Article  Google Scholar 

  14. DHHS. Benefits of breastfeeding. Nutr Clin Care. 2003;6(3):125–31.

    Google Scholar 

  15. Del Ciampo LA, Del Ciampo IRL. Breastfeeding and the benefits of lactation for Women's health. Rev Bras Ginecol Obstet. 2018;40(6):354–9.

    PubMed  Article  Google Scholar 

  16. Sattari M, Serwint JR, Levine DM. Maternal implications of breastfeeding: a review for the internist. Am J Med. 2019;132(8):912–20. https://doi.org/10.1016/j.amjmed.2019.02.021.

    PubMed  Article  Google Scholar 

  17. Driving commitment for nutrition within the UN Decade of Action on Nutrition: Policy Brief [https://apps.who.int/iris/bitstream/handle/10665/274375/WHO-NMH-NHD-17.11-eng.pdf?ua=1].

  18. Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative [https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807-eng.pdf?ua=1].

  19. Kuhn L, Aldrovandi G. Pendulum swings in HIV-1 and infant feeding policies: now halfway back. Adv Exp Med Biol. 2012;743:273–87. https://doi.org/10.1007/978-1-4614-2251-8_20.

    PubMed  Article  Google Scholar 

  20. MMWR. Achievements in public health. Reduction in perinatal transmission of HIV infection--United States, 1985-2005. MMWR Morb Mortal Wkly Rep. 2006, 55(21):592–7.

  21. CDC. Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. MMWR Morb Mortal Wkly Rep. 1985;34(48):721–6 731–722.

    Google Scholar 

  22. New data on the prevention of mother-to-child transmission of HIV and their policy implications: Conclusions and Recommendations [https://apps.who.int/iris/bitstream/handle/10665/66851/WHO_RHR_01.28.pdf?sequence=1&isAllowed=y].

  23. HIV and infant feeding: update based on the technical consultation held on behalf ofthe Inter-agency Team (IATT) on Prevention of HIV Infections in Pregnant Women,Mothers and their Infants, Geneva, 25–27 October 2006 [https://apps.who.int/iris/bitstream/handle/10665/43747/9789241595964_eng.pdf?sequence=1&isAllowed=y].

  24. Guidelines on HIV and infant feeding 2010: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence [https://apps.who.int/iris/bitstream/handle/10665/44345/9789241599535_eng.pdf?sequence=1].

  25. South-Africa-DOH. The Tshwane declaration of support for breastfeeding in South Africa. South Afr J Clin Nutr. 2011;24(4):214.

    Google Scholar 

  26. HIV and Infant Feeding 2010: An Updated Framework for Priority Action [https://apps.who.int/iris/bitstream/handle/10665/75152/FWC_MCA_12.1_eng.pdf;jsessionid=38B65CED28E1E8B387DBBE4F71B61A58?sequence=1].

  27. Baby-friendly Hospital Initiative [https://www.who.int/nutrition/topics/bfhi/en/].

  28. The International Code of Marketing of Breast-Milk Substitutes – 2017 update: frequently asked questions [https://apps.who.int/iris/bitstream/handle/10665/254911/WHO-NMH-NHD-17.1-eng.pdf?sequence=1].

  29. International Code of Marketing of Breast-milk Substitutes [https://www.who.int/nutrition/publications/code_english.pdf].

  30. McFadden A, Mason F, Baker J, Begin F, Dykes F, Grummer-Strawn L, et al. Spotlight on infant formula: coordinated global action needed. Lancet. 2016;387(10017):413–5. https://doi.org/10.1016/S0140-6736(16)00103-3.

    PubMed  Article  Google Scholar 

  31. Robinson H, Buccini G, Curry L, Perez-Escamilla R. The World Health Organization code and exclusive breastfeeding in China, India, and Vietnam. Matern Child Nutr. 2019;15(1):e12685. https://doi.org/10.1111/mcn.12685.

    PubMed  Article  Google Scholar 

  32. Barennes H, Slesak G, Goyet S, Aaron P, Srour LM. Enforcing the international code of Marketing of Breast-milk Substitutes for better promotion of exclusive breastfeeding: can lessons be learned? J Hum Lact. 2016;32(1):20–7. https://doi.org/10.1177/0890334415607816.

    PubMed  Article  Google Scholar 

  33. Lake L, Kroon M, Sanders D, Goga A, Witten C, Swart R, et al. Child health, infant formula funding and south African health professionals: eliminating conflict of interest. S Afr Med J. 2019;109(12):902–6. https://doi.org/10.7196/SAMJ.2019.v109i12.14336.

    CAS  PubMed  Article  Google Scholar 

  34. Baker P, Smith J, Salmon L, Friel S, Kent G, Iellamo A, et al. Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway? Public Health Nutr. 2016;19(14):2540–50. https://doi.org/10.1017/S1368980016001117.

    PubMed  Article  Google Scholar 

  35. Nieuwoudt SJ, Ngandu CB, Manderson L, Norris SA. Exclusive breastfeeding policy, practice and influences in South Africa, 1980 to 2018: a mixed-methods systematic review. PLoS One. 2019;14(10):e0224029. https://doi.org/10.1371/journal.pone.0224029.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  36. Policy and guidlines for the implemention of the PMTCT programme [https://static.pmg.org.za/docs/080226pmtct.pdf].

  37. Peters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping Reviews (2020 version). In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer's Manual: JBI; 2020.

    Google Scholar 

  38. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/M18-0850.

    PubMed  Article  Google Scholar 

  39. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol. 2016, 75:40–6.

  40. Covidence [https://www.covidence.org/].

  41. Doherty T, Chopra M, Nkonki L, Jackson D, Persson L-A. A longitudinal qualitative study of infant-feeding decision making and practices among HIV-positive women in South Africa. J Nutr. 2006;136(9):2421–6. https://doi.org/10.1093/jn/136.9.2421.

    CAS  PubMed  Article  Google Scholar 

  42. Andreson J, Dana N, Hepfer B, King'ori E, Oketch J, Wojnar D, et al. Infant feeding buddies: a strategy to support safe infant feeding for HIV-positive mothers. J Hum Lact. 2013;29(1):90–3. https://doi.org/10.1177/0890334412469056.

    PubMed  Article  Google Scholar 

  43. Ladzani R, Peltzer K, Mlambo MG, Phaweni K. Infant-feeding practices and associated factors of HIV-positive mothers at Gert Sibande, South Africa. Acta paediatrica (Oslo, Norway : 1992). 2011;100(4):538–42.

    Article  Google Scholar 

  44. Doherty T, Chopra M, Jackson D, Goga A, Colvin M, Persson L-A. Effectiveness of the WHO/UNICEF guidelines on infant feeding for HIV-positive women: results from a prospective cohort study in South Africa. AIDS (London, England). 2007;21(13):1791–7.

    Article  Google Scholar 

  45. Cournil A, De Vincenzi I, Gaillard P, Cames C, Fao P, Luchters S, et al. Relationship between mortality and feeding modality among children born to HIV-infected mothers in a research setting: the Kesho Bora study. AIDS (London, England). 2013;27(10):1621–30.

    CAS  Article  Google Scholar 

  46. Bork K, Cames C, Cournil A, Musyoka F, Ayassou K, Naidu K, et al. Infant feeding modes and determinants among HIV-1-infected African Women in the Kesho Bora Study. J Acquir Immune Defic Syndr (1999). 2013;62(1):109–18.

    Article  Google Scholar 

  47. Ramokolo V, Lombard C, Chhagan M, Engebretsen IM, Doherty T, Goga AE, et al. Effects of early feeding on growth velocity and overweight/obesity in a cohort of HIV unexposed south African infants and children. Int Breastfeed J. 2015;10(101251562):14. https://doi.org/10.1186/s13006-015-0041-x.

    PubMed  PubMed Central  Article  Google Scholar 

  48. Goga AE, Van Wyk B, Doherty T, Colvin M, Jackson DJ, Chopra M. Good Start Study G: Operational effectiveness of guidelines on complete breast-feeding cessation to reduce mother-to-child transmission of HIV: results from a prospective observational cohort study at routine prevention of mother-to-child transmission sites, South Africa. J Acquir Immune Defic Syndr (1999). 2009;50(5):521–8.

    Article  Google Scholar 

  49. Bland RM, Little KE, Coovadia HM, Coutsoudis A, Rollins NC, Newell M-L. Intervention to promote exclusive breast-feeding for the first 6 months of life in a high HIV prevalence area. AIDS (London, England). 2008;22(7):883–91.

    Article  Google Scholar 

  50. Rossouw ME, Cornell M, Cotton MF, Esser MM. Feeding practices and nutritional status of HIV-exposed and HIV-unexposed infants in the Western cape. Southern African journal of HIV medicine. 2016;17(1):398. https://doi.org/10.4102/sajhivmed.v17i1.398.

    PubMed  PubMed Central  Article  Google Scholar 

  51. Aku A. The influence of maternal socio-economic status on infant feeding practices and anthropometry of HIV-exposed infants; 2013.

    Google Scholar 

  52. Masters DP. Beliefs and practices of mothers living with HIV/AIDS regarding infant feeding; 2006.

    Google Scholar 

  53. Some EN, Engebretsen IMS, Nagot N, Meda N, Lombard C, Vallo R, et al. Breastfeeding patterns and its determinants among mothers living with Human Immuno-deficiency Virus-1 in four African countries participating in the ANRS 12174 trial. Int Breastfeed J. 2017;12(22). https://doi.org/10.1186/s13006-017-0112-2.

  54. Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T. Effect of the HIV epidemic on infant feeding in South Africa: "when they see me coming with the tins they laugh at me". Bull World Health Organ. 2006;84(2):90–6. https://doi.org/10.2471/BLT.04.019448.

    PubMed  PubMed Central  Article  Google Scholar 

  55. Sibeko L, Coutsoudis A, Sp N, Gray-Donald K. Mothers' infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa. Public Health Nutr. 2009;12(11):1983–90. https://doi.org/10.1017/S1368980009005199.

    PubMed  Article  Google Scholar 

  56. Chetty T, Carter RJ, Bland RM, Newell M-L. HIV status, breastfeeding modality at 5 months and postpartum maternal weight changes over 24 months in rural South Africa. Trop Med Int Health. 2014;19(7):852–62. https://doi.org/10.1111/tmi.12320.

    PubMed  PubMed Central  Article  Google Scholar 

  57. Matji JN, Wittenberg DF, Makin JD, Jeffery B, MacIntyre UE, Forsyth BWC. Factors affecting HIV-infected mothers' ability to adhere to antenatally intended infant feeding choice in Tshwane. SAJCH South Afr J Child Health. 2009;3(1):20–3.

    Google Scholar 

  58. Rollins NC, Ndirangu J, Bland RM, Coutsoudis A, Coovadia HM, Newell M-L. Exclusive breastfeeding, diarrhoeal morbidity and all-cause mortality in infants of HIV-infected and HIV uninfected mothers: an intervention cohort study in KwaZulu Natal, South Africa. PloS one. 2013;8(12):e81307. https://doi.org/10.1371/journal.pone.0081307.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  59. Ahmadu-Ali UA, Couper ID. The practice of exclusive breastfeeding among mothers attending a postnatal clinic in Tswaing subdistrict, north West province. S Afr Fam Pract. 2013;55(4):385–90. https://doi.org/10.1080/20786204.2013.10874381.

    Article  Google Scholar 

  60. Faber M, Benade AJS. Breastfeeding, complementary feeding and nutritional status of 6–12-month-old infants in rural KwaZulu-Natal. South Afr J Clin Nutr. 2007;20(1):16–24.

    Article  Google Scholar 

  61. Patil CL, Turab A, Ambikapathi R, Nesamvuni C, Chandyo RK, Bose A, et al. Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study. J Health Popul Nutr. 2015;34(100959228, dtt):10.

    PubMed  PubMed Central  Article  Google Scholar 

  62. Kyei KA, Netshikweta ML, Spio K. Breastfeeding in the Vhembe district of Limpopo Province, South Africa: duration and factors. Stud Ethno-Medicine. 2014;8(3):317–24. https://doi.org/10.1080/09735070.2014.11917648.

    Article  Google Scholar 

  63. Gbadamosi MA, Goon DT, Tugli A. Relationship between feeding practices and patterns of infant growth: a cross-sectional study. Re J Med Sci. 2017;11(4):166–73.

    Google Scholar 

  64. West NS, Schwartz SR, Yende N, Schwartz SJ, Parmley L, Gadarowski MB, et al. Infant feeding by south African mothers living with HIV: implications for future training of health care workers and the need for consistent counseling. Int Breastfeed J. 2019;14(101251562):11. https://doi.org/10.1186/s13006-019-0205-1.

    PubMed  PubMed Central  Article  Google Scholar 

  65. Budree S, Goddard E, Brittain K, Cader S, Myer L, Zar HJ. Infant feeding practices in a South African birth cohort-A longitudinal study. Matern Child Nutr 2017;13(3). https://doi.org/10.1111/mcn.12371.

  66. le Roux SM, Abrams EJ, Donald KA, Brittain K, Phillips TK, Zerbe A, et al. Infectious morbidity of breastfed, HIV-exposed uninfected infants under conditions of universal antiretroviral therapy in South Africa: a prospective cohort study. Lancet Child Adolesc Health. 2020;4(3):220–31. https://doi.org/10.1016/S2352-4642(19)30375-X.

    PubMed  PubMed Central  Article  Google Scholar 

  67. Tchakoute CT, Sainani KL, Osawe S, Datong P, Kiravu A, Rosenthal KL, et al. Breastfeeding mitigates the effects of maternal HIV on infant infectious morbidity in the Option B+ era. AIDS (London, England). 2018;32(16):2383–91.

    Article  Google Scholar 

  68. Remmert JE, Mosery N, Goodman G, Bangsberg DR, Safren SA, Smit JA, et al. Breastfeeding practices among women living with HIV in KwaZulu-Natal, South Africa: an observational study. Matern Child Health J. 2020;24(2):127–34. https://doi.org/10.1007/s10995-019-02848-8.

    PubMed  PubMed Central  Article  Google Scholar 

  69. Nieuwoudt S, Manderson L, Norris SA. Infant feeding practices in Soweto, South Africa: implications for healthcare providers. S Afr Med J. 2018;108(9):756–62. https://doi.org/10.7196/SAMJ.2018.v108i9.13358.

    CAS  PubMed  Article  Google Scholar 

  70. Motadi SA. Breastfeeding knowledge and practices among mothers of children younger than 2 years from a rural area in the Limpopo Province, South Africa. SAJCH S Afr J Child Health. 2019;13(3):115–9. https://doi.org/10.7196/SAJCH.2019.v13i3.1570.

    Article  Google Scholar 

  71. Siziba LP. Feeding practices of mothers and/or caregivers of infants below the age of 6 months in South Africa; 2014.

    Google Scholar 

  72. Mushaphi LF, Mahopo TC, Nesamvuni CN, Baloyi B, Mashau E, Richardson J, et al. Recommendations for infant feeding policy and programs in Dzimauli region, South Africa: results from the MAL-ED birth cohort. Food Nutr Bull. 2017;38(3):428–40. https://doi.org/10.1177/0379572117696662.

    PubMed  PubMed Central  Article  Google Scholar 

  73. Goosen C, McLachlan MH, Schubl C. Infant feeding practices during the first 6 months of life in a low-income area of the Western Cape Province. SAJCH S Afr J Child Health. 2014;8(2):50–4. https://doi.org/10.7196/sajch.675.

    Article  Google Scholar 

  74. Kennedy YP. An assessment of infant feeding knowledge, attitude and intended practice of women delivering at Chris Hani Baragwanath hospital. Dissertation. 2016.

  75. Matsungo TM, Kruger HS, Faber M, Rothman M, Smuts CM. The prevalence and factors associated with stunting among infants aged 6 months in a peri-urban south African community. Public Health Nutr. 2017;20(17):3209–18. https://doi.org/10.1017/S1368980017002087.

    PubMed  Article  Google Scholar 

  76. Chakona G. Social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in South Africa. Nutr J. 2020;19(1):47. https://doi.org/10.1186/s12937-020-00566-4.

    PubMed  PubMed Central  Article  Google Scholar 

  77. Jama NA, Wilford A, Masango Z, Haskins L, Coutsoudis A, Spies L, et al. Enablers and barriers to success among mothers planning to exclusively breastfeed for six months: a qualitative prospective cohort study in KwaZulu-Natal, South Africa. Int Breastfeed J. 2017;12(101251562):43. https://doi.org/10.1186/s13006-017-0135-8.

    PubMed  PubMed Central  Article  Google Scholar 

  78. Horwood C, Haskins L, Engebretsen IM, Phakathi S, Connolly C, Coutsoudis A, et al. Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now? BMC Public Health. 2018;18(1):757. https://doi.org/10.1186/s12889-018-5657-5.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  79. Madiba S. Factors associated with mixed feeding practices among HIV positive post-natal women in Merafong sub-district, Gauteng Province, South Africa: public health intervention for maternal and child health. Special Issue. 2015;21(Suppl. 2.1):25–38.

    Google Scholar 

  80. Siziba LP, Jerling J, Hanekom SM, Wentzel-Viljoen E. Low rates of exclusive breastfeeding are still evident in four south African provinces. S Afr J Clin Nutr. 2015;28(4):170–9. https://doi.org/10.1080/16070658.2015.11734557.

    Article  Google Scholar 

  81. Bork KA, Cournil A, Read JS, Newell M-L, Cames C, Meda N, et al. Morbidity in relation to feeding mode in African HIV-exposed, uninfected infants during the first 6 mo of life: the Kesho bora study. Am J Clin Nutr. 2014;100(6):1559–68. https://doi.org/10.3945/ajcn.113.082149.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  82. KeshoBora-Study-Group. Safety and effectiveness of antiretroviral drugs during pregnancy, delivery and breastfeeding for prevention of mother-to-child transmission of HIV-1: the Kesho Bora Multicentre Collaborative Study rationale, design, and implementation challenges. Contemp Clin Trials. 2011;32(1):74–85.

    Article  Google Scholar 

  83. Tylleskar T, Jackson D, Meda N, Engebretsen IM, Chopra M, Diallo AH, et al. Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial. Lancet. 2011;378(9789):420–7. https://doi.org/10.1016/S0140-6736(11)60738-1.

    PubMed  Article  Google Scholar 

  84. Doherty T, Jackson D, Swanevelder S, Lombard C, Engebretsen IMS, Tylleskar T, et al. Severe events in the first 6 months of life in a cohort of HIV-unexposed infants from South Africa: effects of low birthweight and breastfeeding status. Trop Med Int Health. 2014;19(10):1162–9. https://doi.org/10.1111/tmi.12355.

    PubMed  PubMed Central  Article  Google Scholar 

  85. Doherty T, Sanders D, Jackson D, Swanevelder S, Lombard C, Zembe W, et al. Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health. BMC Pediatr. 2012;12(100967804):105. https://doi.org/10.1186/1471-2431-12-105.

    PubMed  PubMed Central  Article  Google Scholar 

  86. Engebretsen IMS, Nankabirwa V, Doherty T, Diallo AH, Nankunda J, Fadnes LT, et al. Early infant feeding practices in three African countries: the PROMISE-EBF trial promoting exclusive breastfeeding by peer counsellors. Int Breastfeed J. 2014;9(101251562):19. https://doi.org/10.1186/1746-4358-9-19.

    PubMed  PubMed Central  Article  Google Scholar 

  87. Guidelines to Industry and health care personnel: The regulations relating to foodstufs for infants and young children [file:///C:/Users/dv334/Downloads/GuidelinesIndustry.pdf].

  88. Foodstufs, cosmetics & disinfectants Act, 1972 (Act 54 of 1972) [http://blogs.sun.ac.za/iplaw/files/2013/12/ZAF-2012-Regulations-relating-to-foodstuffs-for-infants-and-young-children-R.-No.-991-of-2012_0.pdf].

  89. Muravha N. Violations of the international code of Marketing of Breast Milk Substitutes in south African health facilities; 2014.

    Google Scholar 

  90. Radebe P. Assessing the extent of violations of the international code of Marketing of Breast Milk Substitutes in south African advertising media; 2014.

    Google Scholar 

  91. Anttila-Hughes JK, Fernald LCH, Gertler PJ, Krause P, Wydick B. Mortality from Nestlé's Marketing of Infant Formula in low and middle income countries. In. Cambridge, MA: National Bureau of Economic Research; 2018.

    Google Scholar 

  92. Ijumba P, Doherty T, Jackson D, Tomlinson M, Sanders D, Persson LA. Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change. Health Policy Plan. 2013;28(7):761–8. https://doi.org/10.1093/heapol/czs114.

    PubMed  Article  Google Scholar 

  93. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults [https://sahivsoc.org/Files/ART%20Guidelines%2015052015.pdf].

  94. Larsen A, Magasana V, Dinh TH, Ngandu N, Lombard C, Cheyip M, et al. Longitudinal adherence to maternal antiretroviral therapy and infant Nevirapine prophylaxis from 6 weeks to 18 months postpartum amongst a cohort of mothers and infants in South Africa. BMC Infect Dis. 2019;19(Suppl 1):789. https://doi.org/10.1186/s12879-019-4341-4.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  95. Country Report, South Africa: Overview 2018 [https://www.unaids.org/en/regionscountries/countries/southafrica].

  96. Country progress report - South Africa: Global AIDS Monitoring 2018 [https://www.unaids.org/sites/default/files/country/documents/ZAF_2018_countryreport.pdf].

  97. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491–504. https://doi.org/10.1016/S0140-6736(15)01044-2.

    PubMed  Article  Google Scholar 

  98. Carroll G, Atuobi-Yeboah A, Hromi-Fiedler A, Aryeetey R, Safon C, Pérez-Escamilla R. Factors influencing the implementation of the becoming breastfeeding friendly initiative in Ghana. Matern Child Nutr. 2019;15(3):e12787. https://doi.org/10.1111/mcn.12787.

    PubMed  PubMed Central  Article  Google Scholar 

  99. González de Cosío T, Ferré I, Mazariegos M, Pérez-Escamilla R. Scaling Up Breastfeeding Programs in Mexico: Lessons Learned from the Becoming Breastfeeding Friendly Initiative. Curr Dev Nutr. 2018;2(6):nzy018.

    PubMed  PubMed Central  Article  Google Scholar 

  100. Than MK, Nyi SN, Hlaing LM, Mar SL, Thwin T, Cashin J, et al. Scaling Up Breastfeeding in Myanmar through the Becoming Breastfeeding Friendly Initiative. Curr Dev Nutr. 2019;3(8):nzz078.

    PubMed  PubMed Central  Article  Google Scholar 

  101. Soti-Ulberg C, Hromi-Fiedler A, Hawley NL, Naseri T, Manuele-Magele A, Ah-Ching J, et al. Scaling up breastfeeding policy and programs in Samoa: application of the becoming breastfeeding friendly initiative. Int Breastfeed J. 2020;15(1):1. https://doi.org/10.1186/s13006-019-0245-6.

    PubMed  PubMed Central  Article  Google Scholar 

  102. Horwood C, Jama NA, Haskins L, Coutsoudis A, Spies L. A qualitative study exploring infant feeding decision-making between birth and 6 months among HIV-positive mothers. Matern Child Nutr. 2019;15(2):e12726. https://doi.org/10.1111/mcn.12726.

    PubMed  Article  Google Scholar 

  103. Chaponda A, Goon DT, Hoque ME. Infant feeding practices among HIV-positive mothers at Tembisa hospital, South Africa. Afr J Prim Health Care Fam Med. 2017;9(1):e1–6. https://doi.org/10.4102/phcfm.v9i1.1278.

    PubMed  Article  Google Scholar 

  104. Ijumba P, Doherty T, Jackson D, Tomlinson M, Sanders D, Swanevelder S, et al. Effect of an integrated community-based package for maternal and newborn care on feeding patterns during the first 12 weeks of life: a cluster-randomized trial in a south African township. Public Health Nutr. 2015;18(14):2660–8. https://doi.org/10.1017/S1368980015000099.

    PubMed  PubMed Central  Article  Google Scholar 

  105. Zulliger R, Abrams EJ, Myer L. Diversity of influences on infant feeding strategies in women living with HIV in Cape Town, South Africa: a mixed methods study. Trop Med Int Health. 2013;18(12):1547–54. https://doi.org/10.1111/tmi.12212.

    PubMed  Article  Google Scholar 

  106. Pérez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the "breastfeeding gear" model. Adv Nutr. 2012;3(6):790–800. https://doi.org/10.3945/an.112.002873.

    PubMed  PubMed Central  Article  Google Scholar 

  107. Foodstuffs, Cosmetics and Disinfeefants Act 1972 [https://www.gov.za/sites/default/files/gcis_document/201504/act-54-1972.pdf].

  108. Clarke M, Koen N, du Plessis L. Perspectives from south African dietitians on infant and young child feeding regulations. Public Health Nutr. 2021;24(1):169-81. https://doi.org/10.1017/S1368980020000233.

    PubMed  Article  Google Scholar 

  109. Zunza M, Esser M, Slogrove A, Bettinger JA, Machekano R, Cotton MF. Early breastfeeding cessation among HIV-infected and HIV-uninfected women in Western Cape Province, South Africa. AIDS Behav. 2018;22(Suppl 1):114–20. https://doi.org/10.1007/s10461-018-2208-0.

    PubMed  PubMed Central  Article  Google Scholar 

  110. Jackson D, Swanevelder S, Doherty T, Lombard C, Bhardwaj S, Goga A. Changes in rates of early exclusive breast feeding in South Africa from 2010 to 2013: data from three national surveys before and during implementation of a change in national breastfeeding policy. BMJ Open. 2019;9(11):e028095. https://doi.org/10.1136/bmjopen-2018-028095.

    PubMed  PubMed Central  Article  Google Scholar 

  111. Marketing of breast-milk substitutes: national implementation of the international code, status report 2020 [file:///C:/Users/dv334/AppData/Local/Temp/1/9789240006010-eng.pdf].

  112. Pérez-Escamilla R, Hromi-Fiedler AJ, Gubert MB, Doucet K, Meyers S, Dos Santos BG. Becoming breastfeeding friendly index: development and application for scaling-up breastfeeding programmes globally. Matern Child Nutr. 2018;14(3):e12596. https://doi.org/10.1111/mcn.12596.

    PubMed  PubMed Central  Article  Google Scholar 

  113. Hromi-Fiedler AJ, Dos Santos BG, Gubert MB, Doucet K, Pérez-Escamilla R. Development and pretesting of "becoming breastfeeding friendly": empowering governments for global scaling up of breastfeeding programmes. Matern Child Nutr. 2019;15(1):e12659. https://doi.org/10.1111/mcn.12659.

    PubMed  Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

No funding sources.

Author information

Authors and Affiliations

  1. Yale University School of Public Health, New Haven, CT, 06510, USA

    Debbie Vitalis, Mireya Vilar-Compte & Rafael Pérez-Escamilla

  2. Yale University, Cushing/Whitney Medical Library, 333 Cedar St., New Haven, CT, 06510, USA

    Kate Nyhan

Authors
  1. Debbie Vitalis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mireya Vilar-Compte
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kate Nyhan
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rafael Pérez-Escamilla
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

RPE and DV conceived the idea for this research. KN designed the database search strategies and conducted all searches. DV and MVC conducted record reviews and data extraction. DV led the writing of the manuscript. MVC and RPE provided critical feedback and helped shape the analysis and manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Debbie Vitalis.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vitalis, D., Vilar-Compte, M., Nyhan, K. et al. Breastfeeding inequities in South Africa: Can enforcement of the WHO Code help address them? – A systematic scoping review. Int J Equity Health 20, 114 (2021). https://doi.org/10.1186/s12939-021-01441-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12939-021-01441-2

Keywords

  • Breastfeeding
  • The WHO code for Marketing of Breastmilk Substitutes
  • HIV
  • Infant feeding
  • Infant feeding guidelines
  • South Africa

International Journal for Equity in Health

ISSN: 1475-9276

Contact us