Choosing between breastfeeding and formula feeding

On this page we cover the following:

  • Considering the risk of HIV transmission
  • Health benefits of breast milk
  • Cultural expectations towards feeding
  • Things not going as planned
  • Preferring formula feeding

Over 800 pregnancies occur in women with HIV annually in the UK, with very low rates of passing HIV onto their babies (0.22%). Transmission risk via exclusive breastfeeding is greatly reduced by antiretroviral therapy (ARTs) but is not zero (see resources for more details.

The women we spoke to frequently described weighing up the risk of HIV transmission through breastfeeding with the health benefits of breastmilk. Please also read about women’s actual experiences of breastfeeding and formula feeding. Kay said that she wanted to breastfeed, but for others, like April, the risk of HIV transmission was too worrying. The one unifying theme for all women was that they wanted to do what is best for their baby.

Considering the risk of HIV transmission

The risk of transmitting HIV through breastfeeding is very low if you have an undetectable viral load (viral load less than 50). For mothers with detectable viral loads (more than 50), breastfeeding is usually strongly discouraged due to the increased risk of HIV transmission.

Among the women with spoke with, the decision to breastfeed or formula feed was often influenced by a combination of conversations they had had with their medical teams, their thoughts about risk and risk-taking in general, and their personal circumstances. They had received varied levels of advice and information from their medical teams, and it was not straightforward: some felt well informed by their HIV clinic while others did not; some felt supported by their midwives and paediatricians while others did not.

Women’s perceptions of the risk of passing HIV through breastmilk differed, and some recalled being told inaccurate or incomplete information by their medical team. For example, Sasha was told outdated information that the risk was 2% (2 HIV transmissions per 100 breastfeeding babies) and felt it was too “high a number” to even consider breastfeeding. The most up-date figure for HIV transmission via breastmilk for women on HIV treatment from before conception and all though pregnancy and delivery, with an undetectable viral load throughout, is less than one in a thousand (<1/1000) (PROMISE TRIAL, 2016).

Meanwhile, Sandra and Emily knew the risk of HIV transmission via breastmilk was very low but still wanted to formula feed to remove all risk entirely.

Emily spoke with her partner and family before making the decision.

I discussed it with my partner and then my family back home, I came to conclusion that for the safety of the baby I will not breastfeed, I will not breastfeed, I will bottle feed and then they said that they have a, a charity that they give, give baby food to people in my condition so I was also very glad to hear about that so that helped.

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Amina had been diagnosed during her pregnancy, just a few weeks before she spoke to us. She was worried that her viral load might change throughout the day without her knowing. In fact, she also did not believe it was possible to safely breastfeed (no matter what anybody said) and felt that by her having HIV “a line had been crossed.” She also felt reassured by seeing other babies in her family growing up healthy on formula milk.

Amina did not want to take the risk of transmitting HIV by breastfeeding and has seen healthy formula fed babies within her family.

Like if I think of it in a spiritual way or like away from science way it’s like milk, I produce milk to be a nutritious and food for my child. If there is a possibility that that could be tainted or not give the child, the nutrients, or alongside giving the nutrients give something else, it’s not a risk that I personally would want to take. And they say, the doctors say, you know, there are safe ways of doing it, in my head, if the lines have been crossed, I can’t see how they can undo it, if you know what I mean, but, obviously, if there is a way, the doctors can show me that there’s a no, that there’s a good gap between risk and or the point of risk, then I may consider it but right now, living in London, having access to formula and these kind of things like a lot of my nieces and nephews none of them were breastfed and I don’t think it was because their mother was HIV, just because she preferred not to and they’re healthy babies, they’re not small and that, babies look healthy so I don’t see why I should possibly put my child at risk.

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Formula feeding was often seen as a way of being certain the baby wouldn’t contract HIV. This was especially felt by mothers who recalled the past when even having babies was a huge risk for women and birthing parents with HIV. Formula feeding allowed mothers like Sasha, who has three children, to feel she’d done “everything in her power” to make sure her babies “haven’t got it.” Others like Pauline worried that breastfeeding would be a source of ongoing anxiety about the possibility of transmission. Meanwhile, Maya’s choice to formula feed was informed by the trauma of having a sibling pass away from HIV-related complications and having a miscarriage before her pregnancy. For her and her partner, formula feeding was the preferred way to have a “very healthy baby in every shape, way, or form”.

Other mothers considered the transmission rate less concerning as long as their HIV remained undetectable. For example, Marella and Kay (pregnant at the time) planned to breastfeed because of the very low risk of transmission. Kay wanted to breastfeed because she had read that breastfeeding could help prevent post-partum depression. In her view, the impact of being emotionally detached from her baby would be more harmful than the “very miniscule” risk of transmission. Eriife had already breastfed her older child, and with the support of her HIV doctor, she felt confident breastfeeding again. She felt that if there was any risk to the baby, she would have formula fed.

Health benefits of breast milk

In the UK, outside of the context of HIV, breastfeeding is general encouraged by maternity teams. Among the mothers we spoke to, several, but not all, felt strongly that breast milk was the healthiest option for babies. The process of breastfeeding was also very highly valued as a way of bonding with a newborn. Several of the mothers we spoke with, such as Eriife and Gracelove, felt that breastmilk was a better option for babies’ nutrition, compared to formula milk.

Holly planned to breastfeed after seeing a relative’s baby put on weight quickly from breast milk.

It has changed yeah because a family member had just given birth to a healthy lovely little baby and she breastfed and, I don’t know, they just chunk up real quick and it does make them look really healthy and a bit more robust and I think the fear, the fear of maybe your first child because you’ve never had one before and you don’t wanna drop it [laughs] I don’t know there’s something about giving it lots of breast milk at least for the first part of their life just so that they chunk out nice and quick and you’re giving them all your immune stuff so I do want to breastfeed now but I was thinking initially again just for a month but then if I remain undetectable I might go further with that, realistically I probably will.

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Marella (pregnant at the time) reflected that her first child was often sick, and she wondered if this was related to being formula fed. A couple of mothers felt that they hadn’t bonded as closely to older children that they had formula fed, and that in the future they would prefer to breastfeed.

We also spoke with women who felt that formula feeding still produced healthy and robust babies. They often drew on themselves, their other children, or people they knew as examples of babies who were formula fed and grew up without any health issues.

Swelihle preferred to use formula to avoid waking up at night for feeds.

Not getting up at night, I didn’t not want to wake up at night. I just want to sleep. So, if I breastfeed the baby would be there milking all the time, just how I am. Feeding isn’t giving me much of a problem, I bottle feed her. If she’s full she just sleeps the whole night.

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A few women who had formula fed also told us that it was possible to bond well with their baby,  for example by having lots of skin-skin contact, cuddling, making eye contact, talking and singing.

When women felt very strongly that breast milk was the better option, if they were unable to breastfeed for some reason, such as Rachel and Camille, they felt very guilty and heartbroken. For both of them, their babies had some health problems and needed to stay in hospital. Both were told that they were not producing enough milk and advised by the hospital staff to give up breastfeeding. Camille felt she didn’t get the support she had needed.

Camille wanted to breastfeed to bond with her baby and provide the best possible nutrition.

Because I know that obviously in terms of the nutritional value it’s better than cow’s milk, isn’t it, naturally that’s how it’s supposed to be. So, I wouldn’t have wanted anything else than to give the baby what I know nutritionally is 100% better and not only that the bond, you know, between me and the baby, you know, even just the few times I connecting to each other, you know. So it was, it was a bit emotional for me, you know, that it didn’t happen.

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We also spoke to two fathers about their thoughts on infant feeding. Stephan’s partner, Holly, is pregnant with their first child. Edward’s wife, Marella, is pregnant with their second child; they also have a two-year-old son. Both couples are considering breastfeeding.

Stephen, Holly’s partner, was interested in the benefits of breastfeeding for babies’ immune systems.

There’s a lot of, so yeah you’ve got the colostrum in the first like three or four days of breastfeeding which is kind of like sure to sort of like boost the immune system, lowers the risk of adult diabetes and obesity and a whole list of things.

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Kay found the logistics of breastfeeding easier when Covid-19 made it possible for her to work from home.

Covid because of the way that it had been changing structures around work arrangements was actually something I thought about when it came to keeping like going through with the pregnancy because it actually felt like an opportune time just given that I’m like such a professionally orientated person so it’s maybe one of the few times in my life where I was like complete location flexibility which also would translate to feeding because the women that I talked to, a lot of women ended up giving up when they were working because it was just so difficult to do, breast feeding and work in a professional job were you had to be in an office, like 9 to 5.

Just like basic things like if you were breast feeding and trying to interact with like larger society would probably feel like pretty uncomfortable and/or embarrassing, so yeah. So, it’s like the working from home definitely makes it easier to capacitate breastfeeding.

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Cultural and familial expectations towards infant feeding

Many women we spoke to discussed how the norms within their families and cultures influenced their choice of feeding option. See also Experiences of formula feeding and Social Identity, belonging, stigma and discrimination. Amina, Emily and LeaSuwanna felt that breastfeeding was expected of them based on the emphasis on breastfeeding in their respective Asian, African and Caribbean cultures. Meanwhile, Diablos had grown up in an African country at a time when mothers with HIV were advised not to breastfeed, and this influenced her choice to use formula. Nowadays, the World Health Organisation recommends that all mothers taking HIV medication should breastfeed, especially in high HIV prevalence areas and where access to safe drinking water may not be possible. This differs from the BHIVA guidelines which are followed in the UK.

For Puleng, who has southern African heritage, breastfeeding “culturally is a big thing,” and not being able to breastfeed felt like missing out. This was also the case for Eriife, originally from east Africa.

Eriife grew up seeing mothers around her breastfeeding and considered it “something natural to do”.

Why was that important to be able to breastfeed?

That’s all I’ve ever seen to be honest. I think yeah, I think it’s more subconsciously breastfeeding that’s all I’ve ever seen from aunties, cousins, family, that’s all I’ve ever seen so it kind of, it kind of for me is something natural to do and also of course the benefits that you get from that I was told, especially by my family, like cousins that have had children and stuff, they really advocated for breastfeeding, they fed, although they fed their babies till like they were past one which I don’t think I would, I’m going to do] yes, no the benefits of, you know, the babies milk, the especially the first six months of breastfeeding it was just better than bottle.

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For some women, the choice to formula feed was met with questions from their families or non-HIV medical staff. Emily and Amy found it stressful when family and friends, not aware of their HIV status, wanted to know why they were not breastfeeding.

Amy’s baby is of African heritage and suspected her partner’s family would ask her why she was not breastfeeding (played by an actor).

It’s a very natural thing to just want to feed the baby and obviously in the African community you need to breastfeed so it was preparing myself for the questions of “why aren’t you breastfeeding”, “why are you formula feeding”, and having a story ready that was my big like thing of having a story to just shut everybody up and leave me alone kind of thing because obviously we’re not gonna be talking about the diagnosis with the family and stuff like that. I remember the build up to having the baby I was panicking about those questions, and they do like to question you a lot yeah.

Regardless of my feelings of wanting to breast feed I, I couldn’t outweigh that risk potentially to her. It was kind of a non-decision really it’s just one that’s kind of automatically, obviously if I was in a position where I was in the country where I didn’t have access to clean things and I couldn’t formula feed safely that’s a different conversation but I, yeah I didn’t feel like it was a choice, it was like just wrap your head around it and get on with it kind of thing.

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Nozipho and Biola’s partners were not aware of their HIV status. In fact, the reason why Biola chose to breastfeed was to avoid suspicion about her HIV status. A few women recalled their time in hospital, when healthcare staff who did not know their HIV status and/or decision to formula feed, questioned them about why they were not breastfeeding. Needing to repeatedly explain their situation was exhausting and upsetting.

Emma was sad not to breastfeed but decided she didn’t want to take any risks. She felt judged by staff who kept pressuring her about breastfeeding.

I was sad because I wanted to breastfeed again but then I thought well it’s my choice and I don’t want to give any risk at all to my baby. Plenty of people bottle feed the only thing I will say is in a hospital there was a lot of nurses and doctors kept pressuring me into: “why aren’t you breastfeeding, why aren’t you breastfeeding, breastfeeding is best” and I had to explain to them over and over again why I couldn’t. Which was quite hard actually because they kind of judge you almost for not trying and then until they realise why you couldn’t. But you feel bad enough anyway not being able to do it without that added pressure.

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Although there may be different expectations across cultures, some women of African and Asian heritage felt that formula feeding was becoming more socially acceptable and common. This was especially true for the women in their 20s and early 30s.

Amina thinks formula feeding is becoming normal now and that women have a range of reasons not to breastfeed.

I think in the UK, I think we’ve got formula and access to formula, and I think formula is good enough. Yeah, women are not choosing to breastfeeding, because they’re not, I don’t know why they don’t, but anyway, maybe they don’t want to be attached to the baby all night or I don’t know. Or I don’t know, does it make your boobs saggier than if you didn’t breastfeed? Probably not but yeah, I think it’s normal now to choose not to breastfeed maybe they’re not around as much to make that happen because they’re working, that kind of thing.

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Things not going as planned

When Nozipho was experiencing problems with lactating, the medical team asked to give her baby formula. She agreed because she thought it was a “one off” and she would be able to breastfeed later. The 2020 BHIVA recommended exclusive breastfeeding, and so this initial mix-up meant that she no longer had the option to breastfeed.

Similarly, when Camille’s baby developed jaundice, her healthcare practitioners felt she did not have enough breastmilk supply and asked her to stop breastfeeding. She felt she wasn’t supported as she should have been and found it extra difficult when her breasts filled with milk shortly after her baby was started on formula milk.

The UK guidelines were updated in 2022 to clarify that mixed feeding with formula milk (baby receiving breastmilk and formula milk) is safe in certain situations and with the support of your HIV medical team.

Tina had twins and they were premature, so she did not feel able to breastfeed but she’s pleased that the new guidelines give mothers more choice.

Sure so yeah the current guidelines are, well the research rather is based on full term babies and the safety is based on purely breastfeeding for six months and not combination feeding and our twins were born at 31 weeks, so very early and there’s two of them. So, the fact that the safety data isn’t there for premature babies yet and the fact there’s two of them I just felt that solely breastfeeding would be very difficult, I know some people manage but I think, you know, the number that manage to exclusively breastfeed multiple babies is much lower than a singleton and the safety data isn’t there for premature babies. So I spoke to my consultant and chatted it through with her and we decided that, well I decided ultimately that, you know, safety first sort of thing so decided not to. But luckily where I am the NICU (Neonatal Intensive Care Unit) because they were in intensive care for eight weeks, well the special care baby unit for eight weeks, they have access to a breastmilk bank so they had donor breastmilk for the first sort of three weeks which was great and then went onto the premature baby formula.

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Preferring formula feeding

Women such as Danai and Maya commented that formula feeding allowed the sharing of feeding responsibilities with their partners. Sherry didn’t like breastfeeding and had only breastfed her older children for a short period of time, even though she was not HIV positive at that time. She did not mind that the UK guidelines encourage formula feeding and felt that being formula fed was “not gonna make any difference” to the baby and that breastfeeding wasn’t necessary for a baby to thrive.

Sherry did not breastfeed her three older children who are completely healthy and so the guidelines did not affect her decision to formula feed this time as well.

Because I have three children before this and I never bother about breastfeeding and they, they all come out well. They’re not sick, they don’t have any pain at all. I don’t take them to hospital, they don’t even have colds, they hardly have cold. They’re very strong, So, anybody out there that is thinking that because of their status they won’t, they won’t breastfeed this child and they get sick and worried about, no, no, no you don’t need that, you don’t just need that. All you need to do is focus on your baby, how to look after your baby best breast milk is good, very good but when you don’t have it, you don’t have it.

It’s good, I can say it’s good but when I said ‘it’s not gonna affect your child’ and all those things, and yet things can happen, mistakes can happen. Anyway, you know, that mistakes can happen, don’t just go it if there is another way to go around it, you understand? Breastfeeding is not, is not doing everything. The baby, there are children that, the mother that gave birth to them died. There’s things- that’s ways to go round this, what that the government said yes, if you want to do it, do it, it all depends on you. But for me, I don’t want any things, any single thing that would come from me to my child, no. No that does not mean, if I don’t feed my child that does not mean that I don’t love him. I love him so much, you can’t love my child more than I do. Any sensible woman, any sensible mum that has senses that is intact. Nobody on earth that will love her child more than the lady that gave birth – the mother, you know what I mean so they can’t lie about it, if I breastfeed this child, its fine if you can’t do it.

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Most of the women we spoke to were offered free formula milk. Danai said she would have considered breastfeeding if she didn’t receive free formula milk. The thought of needing monthly blood tests for their baby also put some women off breastfeeding.

Maya and her partner did not worry about formula feeding.

Yeah, we decided to formula feed straight away because we just thought there is, in our head we just said we just didn’t want to impose any risk, if there doesn’t need to be it like. Again, because I’ve come from a big family, one of my sisters she breastfed her first child, but then her second child it didn’t work so well, so she couldn’t breastfeed. It just wasn’t working with her body and producing the milk and everything that was happening. It caused so much more of a headache if she had chosen to formula feed her children. So again, like I know that within the formula, still got enough for your child even though that everyone says you know, breast milk’s the best milk.

But there is loads of people that do choose formula and I’ve had other friends that have had babies and again their choice is to formula, and their children have come out fine so that made me feel a lot better that you know, do everything like.

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Marella (currently pregnant) and her husband, Edward, formula fed their eldest child and planned to breastfeed this time.

Edward enjoyed being able to bond through formula feeding their first child, but is fully supportive of his wife’s decision to breastfeed their second child when the baby is born (played by an actor).

One of the things I enjoyed the first-time round was that we could it put less pressure on just one partner to feed the child and for me as the male of a child I thought it was important for me to find at least some way to try and bond with the child when they were younger, so giving the opportunity to bottle feed early doors was quite, was quite helpful. Obviously when it came round to the second one knowing that as my thought process the first time probably took me a little while to be fully convinced I was very much lead by my partner actually saying that it was something that, that she really wanted to try and it didn’t take a huge amount of convincing for me but, you know, it’s one of those things, normally the decision is hers, you know, we make most decisions combined, that sort of decision is hers and if she wants to, she wants to go down that route then I can only fully support it.

And I think, I think what it was, again the impressions that I’ve got from my partner is that we, that she really wants the, again also the nutritional side of it but for her I think it’s the bonding side of it that’s really important this time and I don’t feel that that was lacking the first time round possibly but maybe it will help even more so this time.

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