1. Presented at the National Breastfeeding Consultative Meeting 22-23 August 2011 by Lynn Moeng

2. Contextual factors  Individual Level- Personal factors  Household Level- family influences and perceptions  Community Level- attitudes and support  Cultural practices and taboos  Knowledge related aspects

4. Generally, women and caregivers believe that breastfeeding is the best way to feed babies and many do choose breastfeeding as the first feeding option The questions is why are breastfeeding practices so poor?

5.  Not enough milk - Preventable  Breast problems - Preventable  Baby or Mother too ill - Can be managed  Baby crying often  Child refuses to breastfeed – many preventable reasons for this.  Fear of HIV transmitting through breastfeeding  Young women believe it is difficult and painful  Going back to work/school - Mothers believe that children should be introduced to other milks and foods before 6 months, in preparation for separation.

8.  Family history and traditions- how other children were fed.  Storing expressed milk at home is a taboo in our culture.  Men not given an opportunity to make decisions on infant feeding. The best they can contribute is purchasing formula.  Influence from grannies  The pressure for young girls who have just delivered babies to go back to school immediately. – the effect of this on the health and survival of these children needs to be investigated.  Preparation for a newborn often includes formula, bottle,teat and self medication eg. Druppels, gripewater and many others.

9.  Link between community structures and the health facility is weak.  Knowledge and skills of community health workers.  Availability and sustainability of support groups  Acceptability of mixed feeding- regarded as the norm.  There are conflicts between cultural norms and information provided by health workers.  Limited utilization of NGO’s to support infant feeding.

11.  Where should women breastfeed- in some environments, restrooms are designated as breastfeeding places- breastfeeding is feeding.  Public places are not breastfeeding friendly  Households are not breastfeeding friendly

12.  Strengthen referral systems from PHC to existing community structures.  Follow-up support just after discharge ( within three days).  How are the postnatal visits used to support breastfeeding.

13.  Breastfeeding management challenges ◦ Supply and demand ◦ Positioning and attachment ◦ Assisting mothers with problems such as flat nipples  Growth spurts ( critical points when frequency of breastfeeding should be increased.  Rates of HIV transmission not well understood  Feasibility of exclusive breastfeeding for six months  Effects of the use of self medication on breastfeeding including drupples that pored in bath water.

14. Tested strategies that can improve breastfeeding practices

15.  Partner involvement  Promoting the culture of cup VS bottle feeding

16.  Assist mothers to position  Ensuring them that is important to breastfeed twins.  Supporting a mother to

17. Adapted from: Haider R, Kabir I, Huttly S, Ashworth A. Training peer counselors to promote and support exclusive breastfeeding in Bangladesh. J Hum Lact, 2002;18(1):7-12. Slide 4.10.5

18. Slide 4.2.5 Step 2: Breastfeeding counselling increases exclusive breastfeeding All differences between intervention and control groups are significant at p<0.001. From: CAH/WHO based on studies by Albernaz, Jayathilaka and Haider. Age: (Albernaz) (Jayathilaka)(Haider) 2 weeks after diarrhoea treatment 4 months3 months

19. Exclusive breastfeeding for 6 months is possible if we have health care workers who support mothers Median duration of exclusive breastfeeding = 159 days Coovadia et al., Lancet 2007

20. From: Morrow A, Guerrereo ML, Shultis J, et al. Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial. Lancet, 1999, 353:1226-31 Slide 4.10.6

21.  Capacity building of CHW  Improve prenatal and post natal education  Involvement of all role players in promoting Breastfeeding  Investment in marketing  Social mobilisation of community  Creating conducive environments for mothers to breastfeed

22. Thank you