STRATEGIES TO PROMOTE EXCLUSIVE BREASTFEEDING IN SOUTH AFRICA
nicolas trad - 2015
INTRODUCTION
Substantial progress has been made in reducing under-5 mortality in South Africa since 2003. Nevertheless, the current rate of 41 deaths per 1,000 live births is more than double the 2015 target put forth in the Millennium Development Goals and higher than most other middle-income countries. While some of the blame can be attributed to the HIV epidemic, low rates of exclusive breastfeeding (EBF) have contributed significantly to South Africa’s high rate of child mortality.
With only 8% of infants exclusively breastfed until they reach 6 months, South Africa has one of the lowest rates of EBF in Sub-Saharan Africa and in the world. Countries such as Malawi, Rwanda and Burundi have achieved rates of EBF in excess of 65% even as South Africa lags behind. Currently, the predominant mode of feeding consists of supplementing breast milk with some combination of formula milk, solids and herbal preparations, despite the fact that mixed feeding is associated with increased mortality and morbidity and higher rates of mother-to-child transmission of HIV.
With only 8% of infants exclusively breastfed until they reach 6 months, South Africa has one of the lowest rates of EBF in Sub-Saharan Africa and in the world. Countries such as Malawi, Rwanda and Burundi have achieved rates of EBF in excess of 65% even as South Africa lags behind. Currently, the predominant mode of feeding consists of supplementing breast milk with some combination of formula milk, solids and herbal preparations, despite the fact that mixed feeding is associated with increased mortality and morbidity and higher rates of mother-to-child transmission of HIV.
THE BENEFITS OF EXCLUSIVE BREASTFEEDING (EBF)
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BENEFITS FOR THE CHILD
The Lancet’s 2008 Series on Maternal and Child Undernutrition found that children who are exclusively breastfed for 6 months are 14 times less likely to die than children who are not breastfed at all, and 3 times less likely than children who are partially breastfed.
THE RISKS OF FORMULA FEEDING IN SOUTH AFRICA
Due to persisting urban-rural inequities and high levels of poverty and unemployment, it is nearly impossible for most South African women to meet WHO’s criteria for formula feeding. Formula feeding in rural areas and in peri-urban shantytowns can pose serious risks to the infant’s health, as water supplies can be contaminated and unreliable. |
BENEFITS FOR THE MOTHER
Breastfeeding benefits the mother in a variety of ways, a dimension that is often overlooked:
HIV TRANSMISSION AND EBF
EBF is associated with lower risks of transmission than mixed feeding, because foods and liquids ingested before 6 months can damage the intestinal lining, allowing the virus to spread more easily. Exclusive formula feeding, while eliminating the risk of transmission, increases risk of death from pneumonia, diarrhoea and other infectious diseases. Of all possible feeding practices, EBF is unique in its ability to reduce both the probability of postnatal HIV transmission and the risk of contracting deadly infectious diseases. |
WHY ARE RATES OF EBF SO LOW IN SOUTH AFRICA?
Despite evidence supporting EBF as the optimal feeding practice for children of both HIV-positive and HIV-negative mothers, studies suggest that 35-50% of women in South Africa discontinue breastfeeding altogether before 3 months after birth, and that it is common practice to introduce complementary food for infants as young as 6 weeks old. Why?
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PAST GOVERNMENT POLICY
In the 1990s, the HIV epidemic precipitated an overarching focus on preventing mother-to-child transmission (PMTCT) of HIV, leading the South African government to offer free formula milk to seropositive mothers. While the policy was reversed in 2011 as the South African government refocused on reducing child mortality, the policy contributed to lower rates of EBF among both HIV-positive and HIV-negative mothers. THE HIV EPIDEMIC
While exclusive breastfeeding reduces mother-to-child transmission of HIV relative to alternatives such as mixed feeding, HIV-positive mothers remain understandably reluctant to risk infecting their children. CHALLENGES OF WORKING MOTHERS
Unlike government workers, women working in the private sector are not guaranteed full pay from their employers during maternity leave. Mothers often see returning to work as incompatible with EBF because reducing the frequency of breastfeeding tends to lower the supply of breast milk. This is especially true of workplaces where women are often not guaranteed a private, hygienic space to express breast milk with a pump nor facilities to store breast milk. |
SOCIOCULTURAL BELIEFS
Sociocultural attitudes and views on breastfeeding also help explain why so few women exclusively breastfeed. Many women in South Africa perceive breast milk as insufficient nourishment for their children. When children cry, it is often assumed that they are unsatisfied with breast milk. Others face significant family pressures, especially from grandmothers and partners, to supplement breast milk with formula milk. DIFFICULTIES WITH BREASTFEEDING
Practical difficulties with breastfeeding (cracked nipples, mastitis, latching and positioning) can interfere with the exclusivity and duration of breastfeeding. Difficulties often occur within the first few weeks and mostly affect women who are breastfeeding for the first time and those who have received fewer antenatal and postnatal counseling consultations than is recommended. CONTINUED MARKETING OF BREAST MILK SUBSTITUTES
South Africa passed legislation against the marketing of formula milk in 2012, but the law has been poorly executed. A few formula companies have skirted the regulations by advertising ‘growing up milk’ or ‘follow-on formula’ products as compatible with EBF. Some mothers are still given free or discounted formula, and many health professionals persist in recommending formula to mothers. |
POLICY PROPOSALS
AT THE NATIONAL LEVEL
1. EDUCATION AND AWARENESS CAMPAIGN
Given the successes of media-driven strategies aimed at promoting EBF in countries such as Bangladesh and Brazil, South Africa should launch a concerted national campaign to raise awareness of the benefits of EBF. Through targeted media platforms and consistent messaging, the campaign should convey the biological benefits of EBF, the positive role that fathers and grandmothers can play in supporting mothers, and the importance of initiating EBF within an hour of birth. Common beliefs that impede optimal breastfeeding behavior should be countered. To the extent possible, voices of authority and public figures could be recruited to lend credence to the campaign, equipping women who are vulnerable to influence by members of their households with the confidence & evidence to withstand family pressures.
Given the successes of media-driven strategies aimed at promoting EBF in countries such as Bangladesh and Brazil, South Africa should launch a concerted national campaign to raise awareness of the benefits of EBF. Through targeted media platforms and consistent messaging, the campaign should convey the biological benefits of EBF, the positive role that fathers and grandmothers can play in supporting mothers, and the importance of initiating EBF within an hour of birth. Common beliefs that impede optimal breastfeeding behavior should be countered. To the extent possible, voices of authority and public figures could be recruited to lend credence to the campaign, equipping women who are vulnerable to influence by members of their households with the confidence & evidence to withstand family pressures.
2. EXPANDING MATERNITY LEAVE
Facilitating the continuation of breastfeeding by providing a safe and supportive environment for working mothers should be a fundamental component of any EBF promotion strategy. Labor laws should be amended to ensure that women in the private sector are paid for the first 4 months of leave (starting one month prior to birth), and an additional 3 months of unpaid leave should be offered so that women have the option to breastfeed their children for 6 months. The government should also work with different stakeholders (i.e. employers, trade unions) to clarify protections afforded to mothers under existing law. For example, women should be made aware that they are legally entitled to express and store breast milk in private, hygienic places in their workplaces.
Facilitating the continuation of breastfeeding by providing a safe and supportive environment for working mothers should be a fundamental component of any EBF promotion strategy. Labor laws should be amended to ensure that women in the private sector are paid for the first 4 months of leave (starting one month prior to birth), and an additional 3 months of unpaid leave should be offered so that women have the option to breastfeed their children for 6 months. The government should also work with different stakeholders (i.e. employers, trade unions) to clarify protections afforded to mothers under existing law. For example, women should be made aware that they are legally entitled to express and store breast milk in private, hygienic places in their workplaces.
3. PREVENTING BREAST MILK SUBSTITUTE MARKETING
In order to counter BMS marketing and make clear to mothers the harmful consequences of formula feeding, South Africa could prohibit formula companies from placing brand names, promotional messages and pictures on products. Additionally, South Africa’s Department of Health should require prominent health warnings on all breast milk substitute and related products, emphasizing that formula milk does not contain all the nutrients and antibodies found in breast milk. Standard penalties must be imposed on companies that violate the 2012 law banning BMS marketing, and government watchdogs should be designated to verify compliance and monitor marketing practices.
In order to counter BMS marketing and make clear to mothers the harmful consequences of formula feeding, South Africa could prohibit formula companies from placing brand names, promotional messages and pictures on products. Additionally, South Africa’s Department of Health should require prominent health warnings on all breast milk substitute and related products, emphasizing that formula milk does not contain all the nutrients and antibodies found in breast milk. Standard penalties must be imposed on companies that violate the 2012 law banning BMS marketing, and government watchdogs should be designated to verify compliance and monitor marketing practices.
AT THE REGIONAL AND LOCAL LEVEL
1. ENSURING WOMEN OBTAIN PROPER COUNSELING
EBF counseling and support should become a core competency for health professionals at every level of the health care system. While a growing number of hospitals have begun to adopt ‘baby friendly’ policies, others have yet to implement the steps to obtain BFHI certification. To encourage adoption of ‘baby friendly’ standards, South Africa should amend regulations for health facilities to include BFHI standards and designate a BFHI coordination group tasked with certifying hospitals that are ‘baby friendly’ and providing impetus to hospitals transitioning to ‘baby friendly’ status. Hospitals could staff maternity wards with lactation consultants who can help women initiate breastfeeding within the first hour of life, impart practical skills, and communicate the benefits of exclusively breastfeeding for the first 6 months. Finally, CHW curricula should integrate the 20-hour BFHI breastfeeding training program.
EBF counseling and support should become a core competency for health professionals at every level of the health care system. While a growing number of hospitals have begun to adopt ‘baby friendly’ policies, others have yet to implement the steps to obtain BFHI certification. To encourage adoption of ‘baby friendly’ standards, South Africa should amend regulations for health facilities to include BFHI standards and designate a BFHI coordination group tasked with certifying hospitals that are ‘baby friendly’ and providing impetus to hospitals transitioning to ‘baby friendly’ status. Hospitals could staff maternity wards with lactation consultants who can help women initiate breastfeeding within the first hour of life, impart practical skills, and communicate the benefits of exclusively breastfeeding for the first 6 months. Finally, CHW curricula should integrate the 20-hour BFHI breastfeeding training program.
2. MOBILIZING COMMUNITIES
The South African Department of Health should engage actors at the local level - NGOs, nutrition advocates, municipalities, etc. - to harmonize messages related to breastfeeding, share educational and promotional material, and encourage community-level mobilization activities. Emulating the successful LINKAGES program adopted by Ghana, Madagascar and Bolivia, municipalities should work with NGOs and other relevant stakeholders to fuel enthusiasm for breastfeeding in communities by reaching women through ‘healthy baby contests’, breastfeeding promotion songs, and health fairs or festivals to celebrate breastfeeding. In order to ensure women have the adequate support to continue breastfeeding, communities should also encourage mother-to-mother peer support groups, providing women the opportunity to share their thoughts, advice, and personal experiences.
The South African Department of Health should engage actors at the local level - NGOs, nutrition advocates, municipalities, etc. - to harmonize messages related to breastfeeding, share educational and promotional material, and encourage community-level mobilization activities. Emulating the successful LINKAGES program adopted by Ghana, Madagascar and Bolivia, municipalities should work with NGOs and other relevant stakeholders to fuel enthusiasm for breastfeeding in communities by reaching women through ‘healthy baby contests’, breastfeeding promotion songs, and health fairs or festivals to celebrate breastfeeding. In order to ensure women have the adequate support to continue breastfeeding, communities should also encourage mother-to-mother peer support groups, providing women the opportunity to share their thoughts, advice, and personal experiences.
IMPLEMENTATION CHALLENGES
1. FINANCIAL CONSIDERATIONS
Despite South Africa’s reputation as an emerging economy, recent economic and fiscal trends could complicate the implementation of policies to promote and support EBF. Economic growth has slowed to an anemic 1% and persistent deficits have caused a near doubling of the public debt as measured against the size of the economy, resulting in credit downgrades and loss of investor confidence. Some argue that South Africa’s fiscal trajectory is not conducive to spending on media campaigns, extended maternity leave and improved training of health professionals. Two factors, however, should encourage policymakers to make a long-term financial investment in EBF promotion
2. CONTINUING CONCERNS ABOUT HIV TRANSMISSION
Stubbornly high rates of HIV in South Africa may represent another obstacle to convincing HIV-positive mothers to exclusively breastfeed their children. Fostering a change in attitude in seropositive women will require constant and consistent messages communicated through mediums of mass communication and by health professionals. Ensuring that HIV-positive mothers understand EBF is the safest and surest way to reduce the risk of postnatal transmission in the South African context should therefore be a fundamental objective of any promotion campaign. More importantly, South Africa has already made important strides toward mitigating concerns related to HIV transmission by dramatically increasing access to ARVs, testing nearly 100% of pregnant women for HIV, and reducing MTCT to 2.7% in 2011.
3. PREVENTING STIGMATIZING OF WOMEN WHO DECIDE AGAINST EBF
As other countries have shown, a substantial proportion of women continue to opt for mixed feeding regardless of the success achieved by EBF promotion campaigns. When communicating the benefits of EBF, training health professionals and mobilizing communities, it is crucial to avoid stigmatizing women who decide against exclusively breastfeeding their children. Attaching a stigma to women who do not exclusively breastfeed could lead to unsafe and surreptitious preparation of formula, inaccurate reporting, and avoidance of health professionals who encourage EBF. For these reasons, a philosophy of informed consent and decision-making should undergird policies to promote EBF.
Despite South Africa’s reputation as an emerging economy, recent economic and fiscal trends could complicate the implementation of policies to promote and support EBF. Economic growth has slowed to an anemic 1% and persistent deficits have caused a near doubling of the public debt as measured against the size of the economy, resulting in credit downgrades and loss of investor confidence. Some argue that South Africa’s fiscal trajectory is not conducive to spending on media campaigns, extended maternity leave and improved training of health professionals. Two factors, however, should encourage policymakers to make a long-term financial investment in EBF promotion
- Implementing these recommendations requires only accessible, inexpensive technologies and sensible adjustments to existing legislation and training curricula
- Durable health gains associated with EBF provide an important opportunity to trim health spending in the long-term by reducing the prevalence of preventable diseases such as pneumonia and diarrhea. A recent analysis in South Africa weighing the costs of promoting EBF and providing ARVs against the costs of promoting exclusive formula feeding found that ‘actively supporting breastfeeding is the least costly strategy in both the urban and rural settings despite the costs of treating HIV infection’. Long-term savings attributable to better breastfeeding practices may help to mitigate the immediate costs of promoting EBF.
2. CONTINUING CONCERNS ABOUT HIV TRANSMISSION
Stubbornly high rates of HIV in South Africa may represent another obstacle to convincing HIV-positive mothers to exclusively breastfeed their children. Fostering a change in attitude in seropositive women will require constant and consistent messages communicated through mediums of mass communication and by health professionals. Ensuring that HIV-positive mothers understand EBF is the safest and surest way to reduce the risk of postnatal transmission in the South African context should therefore be a fundamental objective of any promotion campaign. More importantly, South Africa has already made important strides toward mitigating concerns related to HIV transmission by dramatically increasing access to ARVs, testing nearly 100% of pregnant women for HIV, and reducing MTCT to 2.7% in 2011.
3. PREVENTING STIGMATIZING OF WOMEN WHO DECIDE AGAINST EBF
As other countries have shown, a substantial proportion of women continue to opt for mixed feeding regardless of the success achieved by EBF promotion campaigns. When communicating the benefits of EBF, training health professionals and mobilizing communities, it is crucial to avoid stigmatizing women who decide against exclusively breastfeeding their children. Attaching a stigma to women who do not exclusively breastfeed could lead to unsafe and surreptitious preparation of formula, inaccurate reporting, and avoidance of health professionals who encourage EBF. For these reasons, a philosophy of informed consent and decision-making should undergird policies to promote EBF.
CONCLUSION
Promoting EBF is perhaps the most potent and cost-effective tool in South Africa’s armamentarium of health interventions. Because rates of EBF are currently so low, the gains that can be achieved by increasing optimal breastfeeding behavior have the potential to reshape the state of child health in South Africa by significantly decreasing child mortality and the prevalence of preventable diseases such as diarrhea and pneumonia. Far from being incompatible with the goal of reducing the burden of HIV, as some mistakenly assume, EBF has the potential to further decrease MTCT by making clear to mothers the dangers of mixed feeding. Finally, promoting EBF does not require developing or acquiring expensive new technologies, and breastfeeding itself is free, locally sourced, and specifically tailored to the baby’s immunological and energy needs.
