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
This slide outlines the key steps that need to be put in place to promote and support breastfeeding. Some of them have already been mentioned and some will be discussed in more detail later. The new WHO guidelines call for country’s to make a clear national commitment to protecting and promoting breastfeeding. Social mobilisation to ensure that breastfeeding is regarded as a social norm is also very important as is creation of an enabling environment to support breastfeeding through ensuring that mothers who are working or studying are supported to breastfeed through appropriate legislation and practices. And that systems are in place to understand and to monitor and evaluate breastfeeding practices. Now the health system and health services clearly have a role to play in all of these interventions, but what I am going to focus on today is on what I would argue is the key role for the majority of health care workers which is to provide practical, sustained support for all mothers to initiate and sustain breastfeeding.

5. So how do we think about the health system
So how do we think about the health system. This slide shows a diagram of maternal, newborn and child services which shows how our interventions and programmes need to be combined into a coherent and comprehensive system. It stresses that what we aim to do is to provide a continuum of care both through the lifecycle starting with adolescence, then moving through care during pregnancy, birth, postnatal care and child care. We also need to ensure that the different levels of the health service connect with one another so that there is a continuum of care staring with family and community interventions which can be divided into inter-sectoral interventions and more specific health interventions. Moving through the system we have interventions or services that are provided at PHC or Outpatient facilities, then at district and at more specialised hospitals.
Now in South Africa our main health system efforts to promote breastfeeding as encapsulated in the BFHI has focused very much on initiating breastfeeding immediately after birth, and partly because most newborn in South Africa are found in hospitals, our interventions have focused primarily on hospitals, and have tended to neglect the other parts of the lifecycle, and the other parts of our health system, especially Primary health care and the family and household level.
And I would like to argue today is that we need to look more compre

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
So we need to aim to provide a more comprehensive package of support which aims to provide the right breastfeeding support at the right time for the right group.
So it is presented here, breastfeeding support for every mother needs to begin in the antenatal period and important interventions are to ensure that pregnant women are well cared for and well-nourished. All mothers should also be counselled about exclusive breastfeeding and the benefits thereof. During labour women require physical, emotional and information 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. The right breastfeeding support
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 immediate period after birth is obviously very important for initiation of breastfeeding, and the key interventions to ensure successful initiation of breastfeeding are listed here. The aim is to ensure that all mothers breastfeed within one hour, that mothers and infants are in skin-to-skin contact and that the infant receives the colostrum which is the first milk that the mother produces which is extremely beneficial to the newborn baby. Other key interventions include ensuring that assistance with good attachment and positioning is available to all mothers and that any breast problems are promptly and appropriately treated. Other additional interventions include ensuring that mothers or infants who are ill continue to breastfeed, and that vulnerable newborns receive extra support.
The right breastfeeding support
at the right time to
the right group

8. Counselling on frequent and exclusive breastfeeding
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
But most mothers are discharged from hospital soon after delivery, and we need to ensure that support for initiating and sustaining breastfeeding is provided on an ongoing basis. Important interventions that need to take place during this period include counselling especially first time mothers about the need for frequent and exclusive breastfeeding. Mothers should be observed to ensure that positioning and attachment are good, and problems with breastfeeding should be resolved. There is also a need to ensure that the mother’s health and nutritional needs are addressed and that where necessary the mother and the baby receive the postnatal components of the PMTCT.
During infancy and early childhood mothers need to be supported to continue exclusively breastfed for six months, after which complementary food should be added while the child continues to receive breastmilk. Obviously this support needs to be provided in conjunction with other key child preventive services including PMTCT follow-up where required, in order to ensure that HIV positive mothers are supported to breastfeed as safely as possible.

9. So in essence I am arguing that we need to ensure that support for breastfeeding needs to be embedded within all components and levels of the maternal, newborn and child health service provision.

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.
So having presented an ideal and holistic approach to supporting breastfeeding, we can now look at how we have been doing up until now. As I mentioned previously our main breastfeeding intervention has been the Baby Friendly Initiative. BFHI is a global programme developed and supported by WHO and UNICEF which aims to ensure that mothers are supported to initiate breastfeeding. At the heart of BFHI are the Ten steps for successful breastfeeding which is shown here. So in order to be accredited as baby-friendly hospitals or maternity units need to have a written breastfeeding policy which is routinely communicated to all health care workers, to train health care staff. All pregnant women should be informed about the benefits and management of breastfeeding and should be supported to initiate breastfeeding within half hour of birth. All mothers should be shown how to breastfeed and to maintain lactation even if they should be separated from their infants. Newborn infant should be given no food or drink other than breastmilk. The facilities should practice rooming-in and should encourage breastfeeding on demand. Bottle and dummies should not be used, and critically breastfeeding support groups should be established to support mothers to sustain breastfeeding after discharge. SO overall a comprehensive approach to ensuring that all mothers are supported to initiate breastfeeding.

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
If we look at implementation of the BFHI in South Africa, a review was undertaken in This showed that close to half of facilities which supervise deliveries were accredited as baby friendly and that many other hospitals were working towards accreditation. In accredited facilities approximately three-quarters of women were initiating breastfeeding early, and this was much higher amongst mothers who had received counselling on BF during the antenatal period. However by 10 weeks of age, half of newborn who had been breastfeed were no longer being breastfed. And the reasons that the mothers gave were that they did not have enough milk, that the baby did not want to breastfeed or that they had been advised by a 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
The evaluators looked at each of the steps and the extent to which facilities that were accredited as baby-friendly had been able to sustain the practice. Six of the ten steps had mostly been sustained. However many facilities were struggling to ensure that all training of all staff was maintained. Problems were also experienced with helping mothers to initiate early breastfeeding and to show mothers how to breastfeed, and this was reported as being due to the fact that these steps require individual attention and that staff did not have sufficient time to do this. However the most problematic step related to ensuring community support post-discharge. X

13. BFHI: Strength and weaknesses
Strengths
Weaknesses
Health care workers valued recognition of their efforts to promote breastfeeding and child survival
Poor integration with other newborn programmes (KMC, PMTCT) – resulted in mixed message
Internal monitoring systems were weak
Lack of support after discharge
Overall the review reported that health care workers valued that recognition of their efforts to promote breastfeeding and child survival. However weaknesses included that there was poor integration with other newborn care programme such as kangaroo mother care and PMTCT and this sometimes resulted in mothers receiving mixed messages regarding infant feeding. Systems for internal monitoring as opposed to the external monitoring provided by accreditors was weak, and as mention there was lack of support for mothers post discharge. Critical factors which ensured successful implementation included functional BFHI committees, good management support and no rotation of staff especially nursing staff.
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
So in terms of recommendations, it is clear that the BFHI has achieved a lot but that implementation needs to be strengthened. The BFHI and promotion of breastfeeding should be integrated with other newborn programme such as KMC and care of ill newborns.

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
So what is kangaroo mother care. Complications of preterm birth account for almost half of newborn deaths. KMC which involves the mother or another caregiver securing the newborn baby to her chest so as to ensure skin-to-skin contact. This facilitates keeping the baby warm and has been shown to promote breastfeeding and growth and prevents infection. KMC not only promotes bonding between the mother and infant and allows infants to be discharged from nurseries and hospitals much earlier. A study based on PIPP data also showed that hospitals that introduced 30% reduction in deaths in newborns by almost one third. However despite this many hospitals still do not practice 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
Most hospitals do not provide care for newborn although there is evidence of good practice.

18. Where are the gaps?
This slide shows coverage with a series of key interventions during pregnancy through the postnatal period and then into childhood. What this clearly shows is that the data about coverage as well as the actual coverage of interventions during this period is poor. And yet we know that this is the key period for ensuring that breastfeeding is promoted and supported.

19. Successful community strategies for promoting breastfeeding
Existing community groups
Community mobilisation events
Mass media
Home visits by peer counsellors and CHWs
So having recognised the importance of community support we need to think about the strategies that can be usesd. This publication which looked at Opportunities for Africa’s Newborns identified four key strategies namely using existing community groups, using community mobilisation evens, mass media events and home visits by peer counsellors and CHWs. These interventions will be looked at in more detail in a later presentation, but I would like to talk about the role of CHWS especially in the context of efforts to standardise the role and work of CHWs and to incorporate them as a key component of the health system and service.

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
SO if we look at the process of PHC re-engineering. Establishment of PHC outreach teams is a key component of the PHC re-engineering process. So PHC outreach teams will be responsible for the health of a defined population with each team consisting of both health professional probably a nurse and CHWs. One of the key roles of these teams will be to ensure that mothers and children receive a comprehensive MCH package of services which will include support to all mothers for breastfeeding. So we have a responsibility to ensure that CHWs have the skills an tools required to support breastfeeding, and also that they are not given too many tasks.

21. And we know that we already have many of these tools
And we know that we already have many of these tools. This slide shows the new Road to Health booklet which will be used as the basis for training of CHWs in newborn and child health.

22. And these booklets have a set of very simple messages about infant and young child feeding including Breastfeeding.

23. Likewise CHWS will be taught to teach and support correct positioning and attachment for breastfeeding. These are a set of simple messages from the SA IMCI chartbooklet which is used in PHC facilities when providing care for young children.

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.