File photo: About 1 600 mothers and their babies gather in the Good Hope Centre in Cape Town hoping to set a Guiness Record in August. Among them was Nokubonga Nomshwaka, with her two-month-old twins Zweli and Zwelani. Picture: Neil Baynes

Johannesburg - On paper, the groundbreaking document that Health Minister Aaron Motsoaledi signed last August promised to be a turning point for poverty-stricken babies: it would save them by putting them on their mothers’ breasts.

But for exclusive breast-feeding advocates such as Chantell Witten, the ideals of the Tshwane Declaration of Support for Breast-Feeding are not being met and the numerous hurdles surrounding exclusive breast-feeding that many of the country’s women face persist.

“There are a whole range of barriers to women exclusively breast-feeding,” remarks Witten, a nutrition specialist at Unicef.

“We haven’t unpacked what those are and we haven’t developed interventions to address these barriers. The policy environment has changed and we’ve made huge strides, but translating policy into action and implementing programmes haven’t changed.”

The exclusive breast-feeding strategy hopes to save the lives of thousands of babies, particularly those whose mothers are infected with HIV and who are impoverished, in the crucial first six months of life, and encourages breast-feeding until the age of two.

But arguably the strategy’s most controversial position is the outlawing of the provision of free formula to HIV-positive mothers in state-run hospitals and clinics – unless certified by a doctor. According to the Health Department, all provinces had removed free formula from their stockrooms by September.

HIV is transmitted in breast milk, but exclusive breast-feeding for the first six months of a child’s life, given with antiretroviral medicine such as nevirapine, cuts the risk of HIV transmission to below two percent.

Breast milk supports the immune system of infants, protecting them from two of the biggest baby killers – diarrhoea and pneumonia. Experts point out that children who are not breast-fed are six times more likely to die from an illness such as diarrhoea.

Breast-fed babies are better protected against infections such as allergies and ear infections and are at much lower risk of malnutrition, while their mothers benefit with a reduced risk of developing breast and ovarian cancer.

For a country with the lowest exclusive breast-feeding rate in the world – hovering at a measly eight percent – the declaration commits resources to promoting exclusive breast-feeding and providing support for workplace breast-feeding.

The Tshwane Declaration committed to addressing the policy and legislative framework, the education of health workers and improvement of hospital practices as well as creating an enabling workplace environment.

And given SA’s ranking among 12 countries across the globe with the highest child mortality, Motsoaledi argued last year that it was vital that the country “reposition, protect and support” breast-feeding.

But efforts have been “piecemeal”, Witten points out.

“Our staff have come across moms stockpiling formula before they go back to work. They can’t afford to buy adequate formula and are underfeeding their children.

“The other issue is that moms are leaving their babies with caregivers and these kids are exposed to inappropriate feeding practices – like the feeding of porridge at two months. That’s the irony.”

Nationwide, there is a need for a training package for the health care sector and to override the bias of nurses, for example, towards formula.

“We had a case recently where a hospital would not accept expressed breast milk… It’s difficult for nurses to disassociate their own experiences and perspectives. They’re still sending mixed messages to women,” says Witten.

“After delivery, they should be getting the baby on the breast. But that’s not happening. Women are not initiated in breast-feeding and when they get home from delivery a few hours later, there is no support.

“Baby is crying and the family are saying ‘Give baby something’. What does the mother do? She turns to the easiest thing: formula. We haven’t seen a change in the health system communicating the breast-feeding strategy.”

Experts point out that free formula feeding, which the government adopted as policy to prevent babies from potentially becoming infected with HIV, caused child deaths to continue. Research has shown that the breast-fed babies of HIV-positive mothers who are also fed formula and other solids in the first six months of their lives run a greater risk of HIV infection because formula damages the sensitive lining of their intestines, through which HIV can pass.

But concerns over the declaration’s intentions focus on the ability of HIV-positive mothers to adhere to infant ARV regimens and the potential for nevirapine shortages in the public health sector.

“Babies delivered to HIV-positive mothers are not always adequately covered by nevirapine – at household level, we know mothers are not giving it to their children every day. But how many babies are dying from diarrhoea and pneumonia compared to getting infected [with HIV] ? Do the sums,” says Witten.

Worldwide, where the correct facilities are in place for safe infant feeding – clean water, sanitation, electricity and access to healthcare – formula feeding should be the only option for HIV-positive mothers.

Professor Haroon Saloojee, of the department of community paediatrics at Wits University, has remained a critic of the removal of free formula. He believes there are 20 000 mothers countrywide who can safely feed, but who are denied the potential of having an HIV-uninfected child.

Also, he says, ensuring that 300 000 well but HIV-exposed infants receive a daily dose of nevirapine and breast milk alone, is a huge challenge, which escalates the risk of HIV infection.

He tells the Saturday Star he has not heard “complimentary” evidence of the exclusive breast-feeding push and remains concerned. His unit is starting a Gauteng study into this.

Earlier this year, the Department of Health published new draft baby feeding regulations to forbid formula manufacturers from “aggressively marketing” their products to mothers and sponsoring meals and professional development courses for health-care practitioners.

Getting these regulations published into law is vital, says Anna Coutsoudis, a professor in the department of paediatrics and child health at the University of KwaZulu-Natal.

She says the lives of many of the 66 000 children a year who die in SA could be saved through breast-feeding promotion.

“We’ve been doing enough of the traditional way of promoting breast-feeding through education materials and posters and have been very good with training community health workers, particularly in KwaZulu-Natal, where we’ve really gone all-out to provide training courses to doctors and nurses.”

Marketing efforts must now dispel the notion that breast-feeding is associated with poverty.

“Until you change the perceptions about breast-feeding and make it the lifestyle of choice… poor people will always aspire to do what the rich are doing. People aspire to have something like formula – and will do everything in their power to get it.

“It’s aspirational – like getting a cellphone – and is a mark of modernity. But it’s sad, they are being sold a lie. The inconvenient truth is that they are actually harming their babies.

“We need punchy marketing – the same way formula companies market themselves – and we have to target the upper middle class and get the big private medical aids on board. We’ve got to appeal to people’s aspirational and health desires.

“If you look at all the pros and cons, the thing that can give a child the best chance of what we call HIV-free survival is breast-feeding.

“That so many kids are dying is ridiculous. We know we can save children through proper exclusive breast-feeding,” adds Coutsoudis.

Some NGOs have “not embraced the new policy” because of fears over HIV transmission.

“While they are not discouraging it, they’re not encouraging and supporting women to actively breastfeed. We haven’t had community mobilisation and advocacy to make community movers and shakers come on board to promote exclusive breast-feeding,” says Witten.

But Dr Ashraf Grimwood, the chief executive of Kheth’Impilo (an HIV Aids NGO) operating in KwaZulu-Natal, the Eastern Cape, Western Cape and Mpumalanga, says more women are reaping the benefits of exclusive breast-feeding.

Of the 40 000 women it cared for last year, 40 percent were HIV-positive. It is the NGO’s support, which treats “mothers like VIPs”, that is paying off.

“All advantages of exclusive breast-feeding are discussed and include protection against infections, lower risk of developing illness, less risk of diarrhoeal disease, increased bonding of mother and child, it’s readily available and no other feeding is needed for the first six months.”

Grimwood points out, though, that government policies need to be flexible.

“We see all sites promoting exclusive breast-feeding, which is great.

“We’ve not seen change in the six-week incidence of HIV and we continue to see a decline (in transmission). We expect most women are exclusively breast-feeding.

“But there’s also the fact that clinics are not providing any formula and this is a dilemma. Whenever there is such a hard and fast rule, what happens to those kids whose mothers die in labour, or shortly after?

“The exclusivity needs to be able to accommodate those different scenarios we find in our complex communities.

“There is a need for ongoing research. How are our adolescent mothers and working mothers coping, or the moms with lots of kids?”

Grimwood points out that misconceptions, barriers and poor practices do persist.

“Mothers would promise to breastfeed exclusively and when community health care workers visit the homes, they would find bottle-feeding happening with breast-feeding. Working mothers find it difficult or too tedious to express breast milk.

“There’s the influence of community members or grannies who insist baby needs more food as they assume baby is not gaining weight. There are also preconceived ideas about HIV and breast-feeding.”

Witten believes it’s health care workers who have a “serious responsibility” to the country’s mothers.

“Given all the rubbish and misinformation around breast-feeding in the past, it’s health care workers who must help give moms courage and determination to breast-feed. It starts off at hospital where mothers are set up for failure and believe they won’t cope with breast-feeding. Our mothers need encouragement.”

What the national Health Department says

“All provinces have phased out the issuing of free formula,” explains Lynn Moeng, director of nutrition.

“KwaZulu-Natal was the first a year earlier and the Western Cape used a different approach. The first focused on promoting breast-feeding as a norm in the province.

“At a time when formula was issued freely, in the Western Cape almost 100 percent of the moms were encouraged to formula feed. At the moment within six months they are down to 50 percent of mothers choosing formula feeding and, in some facilities, only 25 percent choose formula feeding, due to the education on benefits of breast-feeding.”

The issuing of formula continued until last month to all the infants who were initiated in April.

“The policy did not encourage abrupt stopping. Some facilities needed time to put systems in place to implement the new policy, ensuring that mothers were well educated.

“To implement the new policy, hospitals had to put systems in place to address new challenges. Most of these are being addressed as they emerge. There may be incidences where health workers may fear breast milk may be switched if not clearly marked and stored in the same refrigerator, especially if the mom is not admitted. These are genuine precautionary measures that health facilities should consider.”

Moeng says that health authorities are providing training courses in all provinces to improve the skills of health care providers.

“To date more than 5 000 community health workers have been trained and their training has a strong infant feeding component. Developmental partners have been assisting with training and community dialogues.

“The [Department of Public Service and Administration] has just released a guideline towards the development of workplace crèches. More engagement is needed with the Department of Labour and unions to address the needs of employees outside government.”

The national Department of Health has established a breast-feeding room for mothers.

“This is a first step in ensuring that we lead by example. Regulations relating to infant and young child nutrition were developed and are awaiting final approval. Milk banks are being established, including lodger facilities for breast-feeding mothers in hospitals, as part of the Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa.

“In the past few months there have been radio messages promoting breast-feeding. In August, there was a breast-feeding festival in Cape Town. These are all efforts by the government and partners to increase exclusive breast-feeding rates.

“During World Breast-feeding Week [events] the key message was to educate women on how to combine work and breast-feeding, this can be achieved with adequate support. We believe for most mothers this is feasible. Breast-feeding promotion to ensure improved child survival needs commitment from various stakeholders, including employers, in different settings.”- Saturday Star