By: Joan Dippenaar (Technical Advisor: Health Systems Training Institute and Specialist Midwife)
The exclusive breastfeeding (EBF) target for South Africa is that 50% of women should breastfeed the baby exclusively for 6 months by 2025 regardless of their HIV status. In 2016, South Africa reported that 67.3% of infants were initiated onto breastfeeding within 1 hour of birth with an increase of exclusively breastfeeding from 10 –31.6%, the lowest rates on the African continent. The global target is 75%.
In view of the call for shared responsibility the importance of all stakeholders to be involved is recognised. Breastfeeding is a full-time activity and the mother needs support, time and care.
A review of exclusive breastfeeding research articles 1980–2018 showed why progress is slow in South Africa. From the review of 72 articles they found that several provinces were poorly represented in research, and that the influence of families, community and workplace were not looked at. They also thought that the rapid implementation of the breastfeeding global agenda in an unsupportive environment may have caused what they term 'unintended damage.'
So what does the context and supported environment for the SA context look like? Several aspects are briefly highlighted
Socio economic challenges
The Child Health Gauge 2020 focused on food security for children's health in South Africa that does not meet the minimum criteria for acceptable food. The critical period is the need of the baby in the first 1000 days with a focus on the mother's nutrition in pregnancy and lactation and low exclusive breastfeeding rates of children after birth leading to stunting, malnutrition and death. Support is needed to ensure the mother is well-nourished to be able to breastfeed.
Family structure and household income is a major stress as seen by the high rate of single mothers who are often dependent on the family because more than 50% of babies born do not have the biological father's name on the birth certificate. The father of the baby may sometimes also be the primary support to the mother and baby. Men who are part of the family may be unemployed or working far from home. This is critical factor requiring attention in terms of enhancing support to mother and baby.
Patient factors
HIV infections: Young women account for 25% of new HIV infections. Mothers living with HIV (20% pregnancies) should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer but pregnant women living with HIV were less likely to express an intent to breastfeed (71% vs 99%). During the first 6 months postpartum, mothers living with HIV were also less likely to exclusively breastfeed compared to HIV-negative mothers. The factors affecting the EBF of HIV-positive mothers in an Eastern Cape study included employment, low levels of education, and alcohol consumption. School and work commitments were also reasons for discontinuation of EBF (some mothers were teenaged).
Psychological challenges. Research has shown that prolonged breastfeeding has more to do with psychological factors, (such as an optimistic outlook, feeling comfortable with breastfeeding, having faith in breastmilk as a food, expectations of breastfeeding, planned duration of breastfeeding and level of anxiety) than socio economic factors. The psychological condition of women in pregnancy as a stress factor in life is not recognised, considering the young women if single may also work or study.
Staff factors
Competency challenges. One of the main complaints of lactating women is conflicting advice they receive during breastfeeding. To effectively support breastfeeding as the biological norm and respect women's decisions staff should be certified as competent. A competency framework for breastfeeding support in Dublin serves as an example of a standardised approach. It addresses; 1) Awareness level competencies 2) Generalist Competencies and 3). Specialist Competencies. A standardised programme for each level of healthcare worker should certify competency, to ensure safe and effective practice to the community.
Health system factors
Standards of care and scheduled support challenges
Breastfeeding support offered to women with healthy term infants must be structured to increase the duration and exclusivity of breastfeeding. Support may be offered either by professional or lay/peer supporters, or a combination of both.
Characteristics of effective support include:
- Standardised care by trained competent personnel during antenatal or postnatal care,
- ongoing scheduled visits so that women can predict when support will be available
- care should be tailored to the setting and the needs of the population group.
- strategies that rely mainly on face‐to‐face support are more likely to succeed with women practising exclusive breastfeeding.
Ante and postnatal education and support challenges
The Cochrane review (2016) found lack of evidence that ante natal education makes a difference in Exclusive BreastFeeding (EBF). How best can women be supported then? Breastfeeding problems arise when the baby is born and the mother begins breastfeeding. So, postnatal support is critical. Currently health system practices to support women after birth is ineffective. Information is given through the MomConnect platform but women also need an experienced face-to- face clinician to assist with some of the problems. Having a source of support in the community will be effective.
A shared responsibility
When calling on a community to support breastfeeding the next step should engage with the community towards an action plan that can be implemented and measured. Based on the research report that the families, communities and workplaces has an influence, this source can be utilised through the pregnant women and the community involvement in a structured respectful manner for an action plan is to be contextual, finding workable solutions for the community. Actions should be data driven, and inclusive of all stakeholders for a sustainable outcome.
In the Philippines the institution of structural support came in the form of a Republic No 10028 Act, also known as the "Expanded Breastfeeding Promotion Act of 2009." It stipulates the conditions for supporting breastfeeding as "an environment where basic physical, emotional, and psychological needs of mothers and infants" are fulfilled through the practice of rooming-in and breastfeeding, protecting the working women, management of all phases of pregnancy, birth and postnatal care lactation and clean and available lactation stations in public and private places, wet nursing, milk banks, education with inclusion of breastfeeding in all curricula, as well as certification compliance and sanctions for non-compliance. Structure and control could be strategies that assist with meeting the set targets on time.
See the Cochrane site for Breastfeeding round up information.
Ryan-Vig S. 2019 Breastfeeding: a roundup of Cochrane. Evidently Cochrane. Evidence for Maternity Care.https://www.evidentlycochrane.net/breastfeeding-a-round-up-of-cochrane-evidence/
