"There are three main factors contributing to South Africa's low breastfeeding rates," says midwife and lactation specialist, Tina Otte. "Employment conditions, cultural and social constraints combined with a lack of education and awareness around child nutrition make it difficult for moms to breastfeed exclusively and for prolonged periods of time."
Over the past decade government has put in place a number of programmes with the aim of improving breastfeeding rates. These include the adoption of the South African Code of Ethics for the Marketing of Breast-Milk Substitutes; the Baby Friendly Hospital Initiative; and the Breast Milk Banking Initiative. The National Health Council has also committed to re-engineering primary healthcare to improve breastfeeding rates.
In a further drive to promote breastfeeding up to 24 months of age, the Department of Health recently published draft regulations on Foodstuffs for Infants and Young Children. This promotes exclusive breastfeeding for the first six months of life, through regulation of the promotion of breast milk substitutes and accessories. It also aims to regulate the use of commercial complementary foods introduced after a baby reaches six months of age.
Currently 49% of babies aged six to nine months are fed a diet of both breast milk and complementary foods in SA with 31% of babies breastfed up to the age of two years.
Otte says because working mothers are only entitled to four months paid maternity leave under the Basic Conditions of Employment Act, it limits their ability to exclusively breastfeed for the first six months. There is also a lack of social support for breastfeeding both in the workplace and in public. Some mothers may also experience health complications after birth which may prevent them from breastfeeding.
"Even within the home, mothers need physical, as well as emotional support when breastfeeding, highlighting the need for family members to understand the importance of breastfeeding," says Otte.
Against this backdrop, the healthcare professional (HCP) plays an integral role in encouraging breastfeeding and educating mothers about its benefits. A majority of mothers rely on advice and information from their HCPs.
The draft regulations propose a restriction on communication between infant food manufacturers and healthcare professionals (HCPs) regarding the various products and ingredient benefits. This may severely limit the HCP's ability to provide moms with the best and most adequate nutritional advice for their babies.
Without access to information, says Otte, mothers may inadvertently include nutritionally inadequate products in their babies' diets such as tea, rice milk, soya milk or whole milk, potentially exacerbating the problem of malnutrition in South Africa. "International case studies suggest that regulations must strike a balance between promoting exclusive and prolonged breastfeeding while allowing moms full access to scientific information on breast milk substitutes via their HCPs if it is to achieve a reduction in malnutrition."
Some programmes where district-based clinical specialist teams composed of a gynaecologist, paediatrician, family physician, anaesthetist, advanced midwife, nurse as well as a paediatric nurse show that breastfeeding can be encouraged by HCPs working together and being brought into the education loop.
"Promoting breastfeeding really starts before pregnancy," says Otte. "Breastfeeding should be actively promoted, encouraged and protected at all times and the continued empowerment of HCPs remains of critical importance."
Otte believes HCPs should be equipped and educated to support mothers with current scientific information relating to breast milk substitutes and complementary foods.
"While appropriate regulation is key to increasing exclusive and prolonged breastfeeding rates in SA, its effectiveness would be significantly enhanced if coupled with active awareness and education programmes on a national basis," says Otte.
Otte points to Madagascar as example. In terms of regulations, the country enacted many of the provisions of the World Health Organisation's (WHO) International Code of Marketing of Breast Milk Substitutes. It also launched a large scale public awareness campaign programme educating mothers about breastfeeding. The campaigned reached 6.3 million people via interpersonal communications, community mobilisation events and local mass media. The results were phenomenal and Madagascar has one of the highest breastfeeding rates in the world, combined with a 61% reduction in its under-five child mortality rate since 1990.
However, despite a significant increase in its breastfeeding rates, Madagascar has one of the highest percentages of stunted children at 49% due to a lack of education about the transition from breast milk to complementary foods.
"When women don't have access to information and are not educated, they may feed their babies unsuitable breastmilk substitutes such as coffee creamers, which are unsuitable from a nutritional point of view," says Otte.
She adds that if a woman decides not to breastfeed her baby, she should be able to access comprehensive and scientific information on infant feeding substitutes via her HCP.
"Mothers obtain information from a variety of sources, including their HCPs, but also from labels, articles and the media," says Otte. "It's important that these sources portray the most up to date information so that mothers are empowered to make the best decisions to promote their babies' good health and nutrition."
