Dr Tony Westwood draws attention to a major role-player in the fight against gastroenteritis: breast-feeding.
Now is the summer of our diarrhoea. As I write, hospitals across the Western Cape are dealing with the annual influx of dehydrated babies who have developed infective diarrhoea, or gastroenteritis. Many of them are malnourished; many will become malnourished as a result of the diarrhoea. Thanks to the hard work of our public health system, few of these babies die, even when they are severely malnourished. But many are put at severe risk.
Is this annual surge of dehydrated babies inevitable? Is diarrhoea an unavoidable feature of a young child’s life? The answer is an unequivocal “no”.
With acceptable water supply and sanitation for all having become a prominent political issue in the province, few can be unaware of their role in preventing gastroenteritis. Everything must be done to ensure that young children (whose numbers in Cape Town have risen by nearly 50 percent in the last 10 years, mostly in the poorest communities) have what is required for a hygienic environment.
The role of immunisation (especially against rotavirus that causes about a third of cases of childhood gastroenteritis) in preventing severe childhood illnesses is established and accepted by almost all.
I wish to draw attention to a third major role-player in the fight against gastroenteritis: breast-feeding. In doing so, I will highlight the roles of political class warriors from the Premier to Andile Lili, government departments, business moguls, the corner shop and backyard enterprises in commerce, and Joe, Josephine and Jongile citizen in promoting this life-saving “natural remedy”.
Prevention is better than cure. Breast-feeding turns out to be both preventive and curative for gastroenteritis. We should all be involved in its promotion, protection and support. A breast-fed baby is 26 times less likely to contract gastroenteritis than a formula-fed baby, especially if the latter obtains the milk from a bottle and teat. Even a partially breast-fed infant is better protected from gastroenteritis than one who only gets formula. Breast milk protects the gut; formula doesn’t.
Breast milk is sterile and promotes healthy bacteria in the gut; formula-feeding, especially with a bottle and teat, raises the risk of pathogenic bacteria being fed to a relatively unprotected gut, especially where clean water and fuel for heating are hard to obtain. Breast milk is free; formula and all that is required to deliver it safely is expensive. Breast milk promotes healing of the damaged gut.
Central to any debate on breast-feeding is the woman who produces the milk. Whether to breast-feed her baby or not has to be her choice. You cannot lead a determinedly reluctant breast-feeder to produce breast milk; physiology is against it.
The commonest reasons for the lack of intention to breast-feed at all or for more than a very short time vary by society, but usually prominent among these are lack of knowledge and insufficient understanding, lack of family and societal support, unplanned pregnancy and the wish to return to employment. All are amenable to societal responses that promote the choice to breast-feed.
This province’s young, vulnerable women require a society that promotes their right to security, education (including education on sex, reproduction and breast-feeding) and sexual and reproductive health. Young women will then be better prepared for pregnancy and more likely to undertake and sustain breast-feeding.
Pregnancy care itself is largely the domain of health services where promotion of breast-feeding should be given, but in fact, such promotion is not an inevitable part of antenatal care. Knowledge of breast-feeding is often woefully lacking, even among health care workers, and there is much to be done to educate society about this natural activity. Nurturing the woman who is to nurture through breast-feeding – at home, in our health services, in our workplaces and in general society – will restore some of the naturalness of breast-feeding that we have lost.
There is good evidence that support groups promote and protect breast-feeding. How many churches, mosques and other community groups include supporting breast-feeding in their outreach activities? Do other community services in our Social Development and Health Departments prioritise, promote and support such groups?
Real men support breast-feeding; fathers, uncles, brothers, nephews and grandfathers can step up to the plate on the domestic front while the mother is breast-feeding and getting necessary rest. A word of support and encouragement can go a long way to assist the breast-feeding woman.
Two facets of a woman’s return to work after a pregnancy are worth highlighting with respect to breast-feeding. First, the need to earn must be balanced against the costs of not being with the baby after the first two to three months of life: childcare, transport, increased infections secondary to cross-infection in many day-care environments, especially in the many informal crèches in our most at-risk communities. In addition, there is the cost of formula with its attendant risk of infections; this “formula factor” must be added if the woman has not been wisely counselled that breast-feeding can be sustained – the second facet to be considered with respect to employment.
Owing to the bad press “mixed feeding” (not breast milk alone) has had in the context of HIV without antiretroviral medication, many women give up breast-feeding altogether when anticipating the return to work. “Any breast-feeding is better than no breast-feeding” must be the clear message across this province. If employers are supportive and refrigeration is available at work and at home, 24 hours of breast milk a day can be achieved through the use of expressed breast milk – a reachable ideal.
What about breast-feeding and HIV? Dr Max Kroon of Mowbray Maternity Hospital and I rehearsed this issue in the pages of the Cape Times at the time of the Premier’s Wellness Summit (in which breast-feeding had a prominent part) in November 2011. In short, in an era of antiretroviral therapy, in a large majority of cases breast-feeding is the best and safest feeding method on offer.
Unfortunately, labour laws that protect breast-feeding are insufficient. Four months of maternity leave do not match up with the evidence that six months of exclusive breast-feeding is best for babies. Maternity leave only applies to women in permanent posts. The “casualisation” of labour (whatever its causes) is thus inimical to breast-feeding. Nothing (except the bottom line) prevents a business granting maternity (and paternity) leave to temporary workers.
Imagine if the Western Cape Parliament passed a law enabling losses related to maternity leave to be written off against corporate social responsibility budgets. Another helpful law would be one that ensured that businesses above a certain size provided childcare facilities. At present there is nothing preventing all provincial government departments from implementing such facilities. And what about our business community introducing, in addition to their BEE score cards, an annual BBEE (Best Breast-feeding Enabling Environment) prize? It is been amply demonstrated that, beyond preventing gastroenteritis, breast-feeding is an investment (in rand) in society’s future. Our laws and practices must reflect this.
By 14 weeks of age – a mere three months old – fewer than 20 percent of the province’s children are breast-feeding adequately. On a world scale this is appallingly low. Our children are being left vulnerable to malnutrition and diarrhoea.
A societal response is required. There is good evidence from Brazil and other countries that a multifaceted response, led by government, supported by commerce and involving all communities, can in a short time turn 20 percent to more than 80 percent. The benefits accrue not only to the children now, but to them and society as they grow up to adulthood and produce the next generation.
Who will take the lead?