Responses confirmed that convenience was a consideration when choosing infant feeding methods as this cut down on time, given that many of the households still had no access to safe piped water, sanitation and electricity. This was illustrated by a c9unselor who said,
"The best way is to breast-feed especially if you live in the rural area where there is no clean water".
Chapter Four: Findings
KwaMashu counselors confirmed the inconvenience of the bottle option:
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"Itis not in our culture to bottle-feed and bottle-feed is very expensive and some of the mothers are not working".
In rural areas it was difficult to maintain the bottle-feeding instructions and working leaves no time for preparing formula.
Another counselor said that if she found a person was positive she advised the most appropriate option in view of her place of residence,
"We first ask where they live to establish whether it is safe and possible to formula feed because if the mother lives in rural areas it is not easy to get fresh water so they can not choose to formula feed".
A more controversial view was offered by one respondent, with a more jaundiced view with regard to women's ability to use bottle-feeding in the face of difficulties, it was not the view shared by most:
"What I think, some people are lazy and because first you have to prepare the bottle, for example boil the water and clean the bottle, that all takes time unlike the breast-feeding where you simply take out your breast to feed the baby".
"Bottle-feeding is not recommended" one counselor conceded, but then added that if she (the mother) could sterilise the bottle and manage to bottle-feed the choice was hers. Convenience of bottle-feeding lags way behind that of breast-feeding which is always ready for the baby.
Chapter Four: Findings 96
Advantages and disadvantages of feeding options
The counselors and health care workers had a different perspective on the subject of breast versus bottle. They were influenced by the extent of their knowledge on virus transmission via breast milk and so tended to favour bottle-feeding for the HIV positive mothers. However, they were well aware of the financial constraints faced by most of their clientele and knew that a further expense could not be borne. They were also aware of the difficulties regarding safe water, especially in the rural areas.
"Most babies get oral-thrush, they do not change the nipples in time.
Some do not really boil the bottles and most babies who are formula fed get diarrhoea because they do not get this milk only and mix it with something else like porridge".
It was also found that when a woman was sick or weak she could not manage to breast-feed the child as this was not only physically draining but also practically impossible as illness limited the amount of milk for feeding.
One counselor at an urban clinic responded an explanation that even if a mother is sick, she still counsels her with the same choices as everyone else, she commented,
" Most of the time when a mother has been sick so I tell her that the choice is still hers and nobody else's".
Bottle-feeding had many disadvantages and as mentioned already the main one was the cost. "Many simply do not have the money" was the comment of one person. The problem of money when choosing an option for feeding was mentioned several times, although the formula milk is provided free for a limited time both the women and counselors are aware that when the free milk comes to an end the mother's breast milk will not be available.
Chapter Four: Findings 97
"The big problem is that they are not working and they have no money to buy the milk especially when the formula that is subsidised by the government has come to an end because you are only supplied for six months only".
Another significant disadvantage for bottle-feeding was the cultural proscriptions and what was considered the norm within the Zulu culture, which is for a mother to nurture the child at the breast. Examples of these findings are relayed by several comments,
"Itis not in our culture to bottle-feed.." "In our culture there is discrimination ... "
Itwas found that the lack infrastructure with regard to water and other services played a significant role in restricting bottle-feeding and there were overwhelming responses to confirm this finding. One comment illustrated this concern,
"Most of the mothers can not afford the formula and some live in the rural areas where it is not easy to maintain the bottle-feeding
instructions ...."
Oral thrush was found to occur commonly when there was neglect of bottle
cleanliness. Diarrhoea was also frequently cited as a health hazard. Some other health problems were the danger of bacterial contamination through neglect of washing and sterilising bottles thorougWy and the lack of running water for this purpose. Issues related to mother's milk advantages over that of formula was that the former provided nutrients and therefore natural resistance to common children illnesses. Ignorance was another mentioned difficulty that health care workers posed as a problem and to this end there was this reference:
"Some mothers do not know how to prepare the formula, they do not clean the bottle properly and some live in rural areas where there it is
Chapter Four: Findings
not easy to sterilise the bottles because there is no running water and electricity".
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Advantages for breast-feeding were found to outweigh those of the formula option and to this end concerns about unsafe drinking water, lack of electricity and the high costs of formula food were the most commonly cited problems.
Stigma
Itwas not surprising to find that stigma was also a major problem that posed obstacles for feeding choices of women for their infants. Several of the respondents in this sample explained that mothers were fearful of being stigmatised and therefore opted to breast-feed merely to retain their dignity:
"Itis the stigma for example, if they choose the formula feed they have to come here to collect milk - they leave and people see them with this milk. People know they are positive, and also at their home if they say they are going to breast-feed only, they ask why because they suspect something is wrong with the mother".
"Some, they have not revealed their HIV status to the family and are afraid of the questions that will come when they see her bottle-feed her first born and some just seems lost".
Itwas firmly established by the counselors that in their work with pregnant mothers stigma was rife within the communities and very few women escaped criticism or discrimination if they were perceived to be HIV positive.