Promoting Breastfeeding at Clinics and Hospitals

Breastfeeding is a cheaper healthier option for feeding an infant.

The young mother's piercing screams of pain quickly gave way to light moans of relief as she gave one final push for her baby to be born.

Still covered in blood and slippery meconium and with the umbilical cord still uncut, the baby was gently placed on the mother's belly and coaxed upwards towards her breast by a midwife. The few seconds-old baby girl began the rooting reflex seeking out the nipple. Within minutes breastfeeding was successfully established.

This age old, yet still miracle experience of natural childbirth and immediate latching on to the breast to feed to place at Murchison Hospital in KwaZulu-Natal, which gained baby friendly status in 2001.

Today, health workers at this hospital are proud of their status and passionate about preaching the positive benefits of breastfeeding. Sister Namlinge Qwesha in the maternity ward says: "I have never seen a mother bottle feeding here except for HIV-positive mothers. These mothers are still nervous about passing on the virus to their babies. All mothers are taught the importance of breastfeeding in the antenatal classes. They are free to choose, they then choose the breast. The HIV-positive mothers often choose the bottle."

Sister Nomalinge Qwesha

Matron of the Murchison Hospital Thandazile Ntleko says the Baby Friendly programme began in 1999 and before this period there were no obvious policies in place to guide the hospital. "We had to have policies to guide us, we had to have a mission statement, orientation programmes and training. We did all this. Training began, those who were trained, trained others. We formed support groups in the community. One of our security guards also went for training. He then began delivering speeches and motivated his wife to breastfeed. It's exciting to see how well our programme has worked and how interested and aware even the males in the hospital have become.

"Companies approached us last year to ask us why we are not ordering infant formula, we told them we were baby-friendly. They came back wanting to give lectures, free samples and posters. We said, no thanks, we are all right.

"Now we are concerned that the Prevention of Mother-to-Child Transmission programme (PMTCT) is bringing back formula. We need to do more counselling, " Ntleko says.

Twenty-three year old Ntombi is an attractive and serene looking HIV-positive mother on the PMTCT programme at Murchison. While bottle-feeding her baby with formula she says, "It's my first baby. I discovered I was HIV-positive when I was pregnant. I think I got it from the father. He didn't tell me that he was HIV-positive. I'm bottle-feeding because I'm scared of giving my baby HIV." However, this was just one woman who was bottle-feeding among many breastfeeding women.

KwaZulu-Natal has become a shining example in the country of taking on breast-feeding with dedication and passion. But the high HIV-positive incidence among young women has presented a serious challenge to health workers.

Penny Campbell, KwaZulu-Natal Health Department

Penny Campbell, KwaZulu-Natal Health Department official says, "The issue is choice for HIV-positive mothers. They should be supported to make a choice that suits their situation best. The problem is the spillover effect into the HIV-negative population. Once other mothers see some mothers getting formula free of charge, they want it too. They say, if they are getting infant formula why can't we."

Another issue, Campbell says, is that once women go back to the community after visiting the clinics they get told by older women that they should mix feed, thinking babies would get the benefit of both breast and formula. But mixed feeding is much more dangerous (for passing on HIV) than exclusive breastfeeding, she says.

Out of 100 pregnant women, 70 will not pass on the virus to their babies through pregnancy, during childbirth or mixed feeding, 30 may. The rate of transmission is 14% through mixed feeding and this can be reduced to 5% if you exclusively breastfeed.

A more general problem, Campbell has observed is that in urban areas bottle-feeding is seen as an attainment of success, a status symbol. Educating the community and raising community support is critical for sustainability of the success of breastfeeding in the province, Campbell says.

Another problem the committed Baby Friendly health workers are experiencing are private doctors, who are "making deals" with infant formula companies.

Doctors and nurses at the Tongaat Community Health Centre, which was awarded Baby Friendly status in the year 2000, say they have seen this happen.

Dr Boodhi Mansingh Roopsingh, medical officer of the health centre committed to the Baby Friendly practices of his staff says that a few private doctors actively encourage the use of formula, they even give it out in their rooms. "Companies market to doctors and doctors then give out to new mothers. There needs to be more education about the benefits of exclusive breastfeeding," he says.

Yes, there needs to be more education generally about the benefits of exclusive breastfeeding, but no health worker or mother at the Tongaat Community Centre needs more convincing or education.

Every mother waiting to be attended to was breastfeeding while all the health workers were blooming with pride about their achievements at the centre.

Sister Cynthia Moonsamy, bouncing with enthusiasm, says: "When I give classes I say to the mothers-to-be 'If you had a choice which car would you prefer to drive, a Toyota or a Mercedes?' They say a Mercedes. I as why, the say because it's a better car. I then tell them it's the same with breast milk and formula feed. You already have the best, the breast, nothing compares to it.

By the time they come into labour, they already know that when the baby is born it will go straight onto the breast without the cord being cut. One mother was so shocked that the baby latched straight away. It's a thrill to watch."

Under her supervision, the health centre is adamant that it would not allow representatives from infant formula feeding companies to enter the premises.

"A representative from an infant formula company pitched up but we told her we are Baby Friendly and she didn't get a chance to show us her products. She didn't pester me after that."

Lalbahadur says she would like the clinic to be part of the roll-out of the PMTCT programme. At present they do not know the HIV status of women. "We are prepared to tell them that they have a choice but if they are positive they should choose either to breastfeed exclusively or formula feed exclusively.

"We are finding that women are generally convinced that breastfeeding is healthier, more economical and convenient. Tongaat is a semi-urban semi-rural area. We find that women from the urban areas think that bottle-feeding is more sophisticated. It's more difficult to convince them, but we keep trying and we are succeeding."

Of equal commitment to Baby Friendly practices is the Gamalakhe Clinic on the south coast of KwaZulu-Natal. This was the first clinic in the province to be declared Baby Friendly, which took place in 1999. It is now part of the roll-out of the PMTCT programme to HIV-positive mothers.

Pretty, 23, sits in the clinic with her three year old who she is still breastfeeding. She says: "I learnt from the clinic about breastfeeding. I tell other women to do it because it's cheap and keeps the baby healthy. Some women say there is not enough milk in the breast but I say to them, it's not true."

Asked if she would have been breast-feeding if she had been HIV-positive, she pauses, thinks, takes a deep breath, then says: "I don't know. Maybe, maybe not."

Sister Namile Sidaki says the training and education never stops. "When we started we were all so ignorant. We were brought up thinking that formula was best. Once we were convinced that breast was best we had to convince the mothers, who were up against their mothers who were telling them something else. We tried to use the issue of cost firstly, of how expensive formula is. Then we went on to the issue of health. The young ones thought it was very "rural" to breastfeed and that it would ruin the shape if the breast. Now they are doing it with pride."

The two biggest problems the clinic is experiencing are the high numbers of teenage pregnancies and the number of HIV-positive mothers. "It's heartbreaking stuff, sometimes I go home crying about it.

I ordered 50 tins of formula for the HIV-positive mothers who might choose to take formula. I still have the same number of tins in the clinic, none of them choose the bottle," Sidaki says proudly. "In fact, here bottle-feeding has almost become a stigma because everyone is talking breast language."

This is the case even though there is such a high HIV-positive incidence at the clinic. From January 2002 to June 2002, 384 women tested for HIV. Of these, 312 were found to be HIV-positive in just this one clinic. This is 34%. Teenage pregnancies were also phenomenally high. Between January 2002 and June 2002, of 1000 women, 280 were teenage pregnancies - between the ages of 12 and 19 years.

With the number of women that die of AIDS and while the number of AIDS orphans growing everyday, the situation has reached crisis proportions. But individual efforts make a difference. Take Professor Anna Coutsoudis.

Professor Anna Coutsoudis

In an innovative initiative in the city of Durban, Coutsoudis from the University of Natal, Department of Paediatrics, started a transit home for AIDS orphans. The home, Itemba Lethu, which means "I have a destiny", also has a milk bank. Women who are HIV-negative and breastfeeding, express milk and then donate it to this breast-milk bank for the little orphaned babies. This breast-milk gets pasteurised, stored in little plastic bags ad then gets fed to the babies. The babies tend to thrive though the milk, get visited by the volunteers who give them love through hugs and then get adopted into loving families.

Coutsoudis is intense about the survival of "her babies" through breast milk. "The Code on the Marketing of Breast-milk Substitutes is vital. South Africa has a voluntary code and therefore can be violated without any consequences. I say pull everything off the shelves, which says four to six months, even first foods. The climate is now ripe for the code because of HIV.

"Mixed feeding is the problem. Who isn't going to accept infant formula if it is given free of charge at the clinics. The government must stop this and do something about the nutrition of mothers instead. When women see health workers giving out infant formula they think it must be healthy, so they take it."

Coutsoudis continue: "The companies marketing their infant formulas are going to have a field day now because of HIV. It's totally undermining breastfeeding.

"It's going to slowly take over with women who are HIV-negative. For me this is the worst problem in the country. This country is poverty-stricken and we can't afford to lose breastfeeding. In the long term there are going to be disastrous consequences."

Given the passion of committed and dedicated people as Coutsoudis and others in KwaZulu-Natal, the province with the highest incidence of HIV/AIDS in the country, it is no wonder that it has become a beacon of light to other provinces in the country. One province in particular, Gauteng, the most urbanised province in the country, has onle one Baby Friendly health facility.

In stark contrast to practices in KwaZulu-Natal is Garankuwa Hospital, one of the largest in the country. The massive hospital is just about 20kms outside Pretoria, one of South Africa's major cities.

Here, many health workers had not even heard of the Code or baby-friendly health initiatives. One of the most common practices at Garankuwa Hospital is to separate mothers from the babies directly after birth, which puts successful breastfeeding into jeopardy.

The rationale is that mothers must have a "rest" after the birth. The babies get taken to a "nursery" where they are often given water because they are "thirsty". When the health workers were asked by a visible distressed Lynne Moeng, a lecturer at the Medical University of South Africa (Medunsa) and consultant to UNICEF on the Code of Marketing Breastmilk Substitutes, why they were not allowing mothers to choose between resting and breastfeeding immediately, the staff looked genuinely surprised.

It was just not the practice of the hospital.

The supervisor of the maternity section, Elizabeth Loate, replied to the question about whether breastfeeding was encouraged: "Well, we have a breastfeeding week in August every year."

And what happens throughout the 12 months of the year, minus one week?

Loate says: "Some breasts are non-secretory. This means that the child must get infant formula for about sex hours after birth. If they don't they will get dehydrated. When mothers have caesareans (and the rate is high at Garankuwa, one in four, in fact it's high in all Gauteng private and public clinics and government hospitals), "they need to rest". The women are hardly given a chance to choose to breast-feed, never mind being actively encouraged to do so. The reality is that 98% of women can breastfeed successfully, the remaining 2% can't normally due to diseases, for example active cancers.

"The mothers get 'drowsy' after birth," one health worker from Garankuwa offers. "This means we look after the baby in the nursery. Night-time is for sleeping for the mother, no matter what, not for feeding. The mothers are tired after being given sedatives, they can't feed. I've seen babies that can't latch onto the breast, so we give them the formula," she says.

"Looking after the baby" for the health workers, often means giving it formula without asking for the mother's permission.

Moeng took the opportunity to do some quick training in a brief period. She told health workers in the maternity section of the hospital very firmly: "Only if the mother asks you to take the baby to the nursery should you do it. Otherwise, keep baby with the mother and put it straight on to the breast. Promoting breastfeeding for one week in a year, Breastfeeding Week, is not enough. It needs to be common practice here everyday."

The health workers listened intently. In many cases it appeared as though this was the first time that they had heard of such a philosophy.

Why is this happening at Garankuwa? According to one health worker at the hospital who was committed to baby friendly practices but had no support to put them into practice, "There is a lack of commitment from the top management. There is no policy in place. There is no training, education and awareness. There is a high turnover of staff. Sometimes after training, health workers move to other departments or leave the hospital so that there is no ongoing sustainability to the baby friendly practices."

Health worker, Margaret Mashego says: "There is no support here for the mothers to breastfeed. The babies are taken away to the nursery. When the mothers say there is no milk, the nurses don't help, they take the babies away and give them infant formula. There needs to be more lactation management here."

Another UNICEF consultant who is presently engaged in Code awareness training of health workers in workshops throughout the country, Jeanne Verster says: "Yes, unfortunately there is a serious lack of training among health care workers in lactation management. When I studied 20 years ago in dietetics, I only got two lectures, a total sum of 80 minutes, on the benefits of breastfeeding."

Verster feels there is a necessity to legalise the Code because there is aggressive marketing of breast milk substitutes that is going on. "History has shown that this undermines breastfeeding," she says.

Last year we were able to retract an advert because it was influencing choices. It showed a baby who was clever because of the infant formula he was drinking. Through this sort of advertising mothers start doubting their ability to breastfeed their babies successfully.

Incorrect information is often given out to mothers, so health workers play an important part. Mothers must not be given mixed messages. They must be given consistent messages, that exclusive breastfeeding is best, for example."

During her Code awareness training, which is on-going at present, Verster says she has "found there is so much ignorance concerning breast-feeding. So many health workers have said to me 'you have opened my eyes'. They were totally unaware that advertising influences the choices we make."

Her experience in the training has shown that health care workers are very confused about HIV and breastfeeding. She says that once the mixed messages stop and once the health workers are very clear on what they want to say, it will be easier for mothers to make informed choices. "These are difficult issues as we are dealing with ethical questions and personal choices. Health care workers need clear guidelines. And more time needs to go into counselling."

About the government's OMTCT programme, Verster says that the ideal is to feed the mother and not the baby but it is easier to feed the baby with formula. "One must bear in mind that the clinics are overworked and understaffed," she says.

Once the Code is legislated, people who work in the field will be able to do the monitoring. They will be able to report violations, she feels. But Verster is hardly pessimistic about where South Africa is at in relation to the Code. She says that not too many countries in the world have legalised the Code, and South Africa is one of the countries at the top trying to do it.

"My big passion is to banish all misconceptions regarding breastfeeding, to re-establish a breastfeeding culture in South Africa of exclusive breastfeeding for the first six months of the child's life and sustained breastfeeding for two years and beyond. I believe this can be done. I also like the "kangaroo mother care" method adopted as a policy in all hospitals," Verster says.

This ideal is hardly a pie-in-the-sky dream if you see what is happening at Cecilia Makiwane Hospital (CMH) in the Eastern Cape.

This baby friendly hospital is practicing and preaching kangaroo mother care to the hilt. The hospital is one of the biggest in the Easter Cape, South Africa's poorest province. It was named after the first black registered nurse, Cecilia Makiwane, which took place in 1908. There are no nurseries at CMH, as rooming-in is the only practice unless the baby is ill or is premature.

Rows of breastfeeding mothers nursed their babies with the help of supportive staff. Bonding between mother and baby was evident as babies swathed in blankets were wrapped around their mothers' bodies in skin-to-skin contact.

There were no sights of bottles or tins of infant formula anywhere but there were signs all over the hospital saying "Kangaroo mother care is warmth, food and love". One sign said "No cots, no nursery, but rooming-in, bedding-in and Kangaroo Mother Care".

How did this happen? Just sit in the red carpeted and meticulously tidy and organised offices of the authoritative chief matron and deputy directory of CMH, Lulama Geleba and you begin to realise how important the values of the top leaders are.

There is a no nonsense approach to what she wants for the hospital and what she knows can be achieved.

"We all speak one language here. This is critical. There are consistent messages to mothers and to staff. Staff are trained to specialise and they remain in that section, we don't constantly move people around on a rotational basis. We believe in Kangaroo Mother Care because babies grow through love and breast milk. You will see this everywhere in the hospital."

The CMH takes training of its staff extremely seriously. It has a programme called Education for Service "where the philosophy of management tallies with the philosophy of care," says Gelebe.

She says, " We have declared formula feeds for baby completely out of fashion, and it is."

The consistency of messages is also filtered down to the HIV programme. The hospital is one of the pilot sites for the PMTCT programme.

"We have a special team to deal with this. The message is simple, mothers have a choice. If you choose to breastfeed, do this exclusively, if you choose to bottle feed, do this exclusively. We have nurses monitoring the programme exclusively.

"Personally, I have a clear sense of what is right and what is wrong. I want to see the correct things happening around me. This way of thinking filters down to the way I do things at the hospital," Gelebe says as she proudly shows us a huge sign at the entrance of the hospital saying: "Baby Friendly".

One cannot help being terribly impressed by the way things are done in theory and practice at CMH. Clearly, the strong and clear policies and philosophies have been highly successful. Every mother in sight was breastfeeding, adopting Kangaroo Mother Care as a common practice. Doctors and nurses, and management are all on the same side. There is specialised and on-going training, and clear, simple and concise messages get conveyed to mothers. The approach works.