Health Systems Support for Breastfeeding: Successes, challenges and opportunities

1. Health Systems Support for Breastfeeding:Successes, challenges and opportunities Lesley Bamford Child and Youth Health Directorate National Department of Health August 2011

2. WHO Recommendation “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.”

3. SA Infant and Young Child Feeding Policy • Exclusive breastfeeding should be practised during the first six months of life, and breastfeeding should continue up to two years of age or beyond. • Calls for comprehensive support for breastfeeding • Individual rather than a public health approach to feeding choices for HIV positive mothers (includes provision of replacement feeds)

4. Key Actions • Clear national commitment to protecting and promoting breastfeeding • Social mobilization to support breastfeeding as a social norm • Create an enabling environment • Ensure maternity protection for all mothers • Regulate marketing of breastmilk substitutes • Practical, sustained support for mothers to initiate and sustaining breastfeeding • Develop systems to better understand and to monitor and evaluate breastfeeding practices

6. Package of breastfeeding support • During pregnancy: good nutrition (including micronutrient supplementation), counselling on exclusive breastfeeding • During labour: physical, emotional, informational support reduce medical interventions that make the baby drowsy and less likely to initiate breastfeeding The right breastfeeding support at the right time to the right group

7. Immediately after birth: • Early breastfeeding - one hour, colostrum, constant skin-to-skin contact • Assistance with good attachment and positioning • Prompt treatment of breast conditions • Continuation of breastfeeding when mother or infant is ill • Extra support for feeding vulnerable newborns (HIV exposed, LBW infants, teenage mothers) The right breastfeeding support at the right time to the right group

8. Postnatal period • Counselling on frequent and exclusive breastfeeding • Observation for correct positioning and attachment • Resolving breastfeeding problems • Support for the mother’s health and nutrition • PMTCT follow-up where needed Early childhood • Ongoing support to exclusively breastfeed for six months • Introduction of complementary feeds from six months with ongoing breastfeeding • PMTCT follow-up where required

10. Ten steps for Successful Breastfeeding • Have a written breastfeeding policy that is routinely communicated to all health care staff. • Train all health care staff in skills necessary to implement this policy. • Inform all pregnant women about the benefits and management of breastfeeding. • Help mothers initiate breastfeeding within one half-hour of birth. • Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. • Give newborn infants no food or drink other than breastmilk, unless medically indicated. • Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. • Encourage breastfeeding on demand. • Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

11. Review of BFHI implementation • 41% of facilities were accredited as being Baby-friendly • 73% of mothers initiated breastfeeding early • 90% of mothers who received counselling initiated BF early • Half were not breastfeeding at 10 weeks • Not having enough milk • Baby didn’t want to BF • Advice from family member or health worker

12. Ten steps for Successful Breastfeeding • Have a written breastfeeding policy that is routinely communicated to all health care staff. • Train all health care staff in skills necessary to implement this policy. • Inform all pregnant women about the benefits and management of breastfeeding. • Help mothers initiate breastfeeding within one half-hour of birth. • Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. • Give newborn infants no food or drink other than breastmilk, unless medically indicated. • Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. • Encourage breastfeeding on demand. • Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. x x x X

13. BFHI: Strength and weaknesses Strengths Weaknesses Poor integration with other newborn programmes (KMC, PMTCT) – resulted in mixed message Internal monitoring systems were weak Lack of support after discharge • Health care workers valued recognition of their efforts to promote breastfeeding and child survival • Critical success factors • Functional BFHI committees • Good management support • No rotation of staff

14. Recommended Actions • Strengthen implementation • Integrate BFHI into a package of newborn care • Ensure that hospitals support continued breastfeeding – mothers to stay with ill children • Strengthen breastfeeding support at PHC facility and community levels

15. Kangaroo Mother Care • Complications of preterm birth account for 45% of newborn deaths • KMC facilitates skin to skin contact, promotes warmth, breastfeeding and growth and prevents infection • Infants can be discharged from nurseries and hospitals much earlier • 30% reduction in deaths for infants between 1 and 2 kg • BUT many hospitals still do not provide KMC Elize van Rooyen, 2006

16. Limpopo Initiative for Newborn Care (LINC) • Integrated approach to newborn care in hospitals • Integrates programmes: BFHI, PMTCT, KMC, Newborn resuscitation, care of ill newborns • Practical guidelines and approaches that local teams can use to improve newborn outcomes

18. Where are the gaps?

19. Successful community strategies for promoting breastfeeding • Existing community groups • Community mobilisation events • Mass media • Home visits by peer counsellors and CHWs

20. PHC Re-engineering and PHC Outreach teams • Establishment of PHC outreach teams including CHWS • Key roles will be to provide a comprehensive package of MNCH services • Key roles of PHC outreach teams – supporting breastfeeding • Supported by PHC facility services • Ensure that CHWs have skills and tools required to do this – and not too many other tasks

24. Conclusion • The BFHI provides an excellent basis for supporting breastfeeding as part of comprehensive newborn care. • The PHC re-engineering process provides the opportunity to ensure that all mothers are supported to breastfeed their infants as a key component of a package of MNCH health and nutrition services. • The basic interventions, programmes and tools are available. • Action and commitment from many stake-holders will be required • Need to make breastfeeding promotion and support everyone’s business.

25. The right breastfeeding support at the right time to the right group

26. Thank you.