tag:theconversation.com,2011:/us/topics/exclusive-breastfeeding-22193/articlesExclusive breastfeeding – The Conversation2023-03-23T12:42:19Ztag:theconversation.com,2011:article/2010852023-03-23T12:42:19Z2023-03-23T12:42:19ZInfant formula shortages forced some parents to feed their babies in less healthy ways<figure><img src="https://images.theconversation.com/files/515955/original/file-20230316-2480-ieroj6.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5267%2C3500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Babies still need to eat even when formula is hard to come by.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/shelves-are-empty-as-natalia-restrepo-a-member-of-la-news-photo/1240791802">Joseph Prezioso/AFP via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>One third of families who relied on formula to feed their babies during the COVID-19 pandemic were forced by severe infant formula shortages to <a href="https://doi.org/10.1111/mcn.13498">resort to suboptimal feeding practices</a> that can harm infant health, according to our research published in the journal Maternal and Child Nutrition.</p>
<p>Infant formula shortages left <a href="https://www.kff.org/medicaid/issue-brief/key-characteristics-of-infants-and-implications-of-the-recent-formula-shortage/">70% of U.S. store shelves bare</a> in May 2022, with 10 states reporting out-of-stock rates of <a href="https://news.bloomberglaw.com/health-law-and-business/us-baby-formula-shortages-hit-74-despite-biden-action">90% or greater</a>.</p>
<p><a href="https://scholar.google.com/citations?user=hI28SJIAAAAJ&hl=en&oi=ao">As psychology</a> <a href="https://jessicamarinocom.wordpress.com">researchers</a> who study breastfeeding, this situation left us concerned for the safety of infant nutrition. With two <a href="https://scholar.google.com/citations?user=mrwyVwIAAAAJ&hl=en&oi=ao">colleagues who focus</a> <a href="https://scholar.google.com/citations?user=NChgQR4AAAAJ&hl=en">on public health</a>, we conducted an online survey of over 300 infant caregivers in the U.S. to understand how many families had trouble obtaining infant formula and what they fed their babies when they did.</p>
<p><iframe id="dxSI9" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/dxSI9/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Considering the scope of the formula shortages, we were not surprised that 31% of the formula-feeding families we surveyed reported challenges obtaining infant formula, the most common being that it was sold out and they had to travel to more than one store.</p>
<p>But their babies still needed to eat. Being unable to get their hands on infant formula pushed caregivers to potentially unhealthy or even dangerous stopgaps. For example, 11% of the formula-feeding families surveyed said they practiced “formula-stretching” – diluting infant formula with extra water to make formula supplies last longer, which provides a baby with less nutrition in each bottle.</p>
<p>Furthermore, 10% of formula-feeding families reported substituting cereal for infant formula in bottles, 8% prepared smaller bottles and 6% skipped formula feedings for their infants, which all provide infants with less nutritious meals.</p>
<p>Exclusively breastfeeding families were insulated against these supply disruptions. Almost half of breastfeeding families surveyed reported that COVID-19 lockdowns actually allowed them time to increase their milk supply. </p>
<h2>Why it matters</h2>
<p>Our study suggests that the waves of formula shortages from 2020 to 2022 in the U.S. were more than just an inconvenience for parents. Instead, this study is the first to document that formula shortages likely had real and widespread adverse impacts on infant nutrition, given that a large proportion of parents surveyed resorted to feeding their baby in ways that can harm infant health.</p>
<p>For instance, studies have shown that adding extra water to “stretch” formula can result in infant <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">malnutrition, growth and cognitive delays</a> and even <a href="https://doi.org/10.1542/peds.100.6.e4">seizures and death</a> in extreme cases. Adding cereal to bottles increases the risk of <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">choking-related deaths</a> and <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">severe constipation</a>. Moreover, feeding infants age-inappropriate foods can have lifelong consequences for <a href="https://doi.org/10.1111/nure.12102">cognitive development</a> and <a href="https://doi.org/10.1093/ajcn/87.6.1852">growth</a>, leading to a higher <a href="https://doi.org/10.1159/000351486">risk for chronic illnesses</a> like obesity and cardiovascular disease.</p>
<p>Given that <a href="https://www.cdc.gov/breastfeeding/data/reportcard.htm">approximately 75% of infants</a> in the U.S. are fed with infant formula in the first six months of life, formula shortages could put roughly 2.7 million babies each year at risk for suboptimal feeding practices.</p>
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<span class="caption">President Biden met with baby formula manufacturers in June 2022 to discuss shortages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-joe-biden-meets-virtually-with-baby-formula-news-photo/1400488773">Kevin Dietsch/Getty Images</a></span>
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<h2>What’s next</h2>
<p>A perfect storm of formula recalls, ingredient shortages and shipping delays <a href="https://theconversation.com/whats-causing-the-us-baby-formula-shortage-and-how-to-make-sure-it-doesnt-happen-again-182929">contributed to COVID-19-related formula shortages</a> in the U.S. Although President Joe Biden’s administration has taken some steps to <a href="https://highways.dot.gov/newsroom/biden-administration-announces-new-protect-formula-program-73-billion-bipartisan">improve distribution infrastructure</a>, the U.S. does not currently have infant nutrition disaster plans in place beyond <a href="https://www.hhs.gov/formula/index.html">common-sense recommendations for individuals</a>.</p>
<p>Unfortunately, <a href="https://theconversation.com/breastfeeding-can-help-tackle-climate-crisis-but-its-on-governments-not-mums-to-save-the-world-124676">climate change will likely increase the risk</a> of formula-supply disruptions over the next century because of the <a href="https://e360.yale.edu/features/how-climate-change-is-disrupting-the-global-supply-chain">increased frequency of natural disasters</a>.</p>
<p>The best way to protect infant nutrition from supply chain issues is to promote and support breastfeeding, which provides optimal infant nutrition and insulates infants from those disruptions. Since <a href="https://www.healthgrades.com/right-care/pregnancy/9-reasons-you-may-not-be-able-to-breastfeed">not all babies can be breastfed</a>, though, governmental policies could help prevent and address acute formula shortages and ensure equitable formula access for all.</p><img src="https://counter.theconversation.com/content/201085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many families in the US encountered empty shelves when they went in search of infant formula during COVID-19.Jessica A. Marino, Doctoral Student in Health Psychology, University of California, MercedJennifer Hahn-Holbrook, Assistant Professor of Psychology, University of California, MercedLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657892021-11-10T15:16:33Z2021-11-10T15:16:33ZWhy are babies going hungry in a food-rich nation like Canada?<figure><img src="https://images.theconversation.com/files/431095/original/file-20211109-17-1nj4al0.jpg?ixlib=rb-1.1.0&rect=22%2C8%2C1894%2C1218&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Whether they breastfeed or use formula, food insecure mothers are struggling to feed their babies. </span> <span class="attribution"><span class="source">(Hessam Nabavi/Unsplash)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/why-are-babies-going-hungry-in-a-food-rich-nation-like-canada" width="100%" height="400"></iframe>
<p>Jean, a 24-year-old mother of two, said: “People don’t think there’s hungry kids out there [in Canada].” She would like us to know “there definitely is.” </p>
<p>More than <a href="https://proof.utoronto.ca/food-insecurity/">1.2 million children in Canada live in food-insecure households</a>, including babies of the families as well. In Nunavut, that number is higher than any other part of Canada. Many of the children in food insecure families go hungry: parents often need to cut the size of meals, or skips meals altogether. </p>
<p>The first 1,000 days of a baby’s life is the <a href="https://doi.org/10.1002/ajhb.22952">most important time for growth and development</a>. There are special and <a href="https://www.canada.ca/en/health-canada/services/publications/food-nutrition/prenatal-nutrition-guidelines-health-professionals-iron-contributes-healthy-pregnancy-2009.html">costly nutritional needs for both mother and baby such as increased iron and folic acid for mothers</a>, <a href="https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months.html">vitamin D for breastfed babies, and commercial formula for those not breastfed</a>. But for many, this is also a time of diminished incomes. </p>
<p>People have often said to me that even the most undernourished women can successfully breastfeed and that the real cause of infant food insecurity too much access to infant formula. This misses the point I’m making.</p>
<p>At the heart of infant <a href="https://doi.org/10.2752/175174415X14101814953927">food insecurity in Canada is poverty and food access, which disrupts maternal eating and infant feeding habits</a> regardless of how and what babies are fed. </p>
<p>To really understand infant food insecurity, one needs to listen to mothers. While researching my book, <a href="https://www.ubcpress.ca/out-of-milk"><em>Out of Milk: Infant Food Insecurity in a Rich Nation</em></a>, I spoke to many mothers, those who were breastfeeding and those who had opted to use formula. Their stories reveal how poverty and food insecurity are disrupting their eating and infant feeding habits. I recount some of their stories here; all of the following names are pseudonyms.</p>
<h2>The breastfeeding paradox</h2>
<p>When breastfeeding works, it is praised by the mothers we spoke with as the ideal healthy and secure food system. Some mothers said they were drawn to breastfeeding because of health benefits and the high cost of food. Lorraine explained: “There is no risk of cross-contamination, it’s there, it’s ready, it’s the right amount, it’s the perfect food.” </p>
<p>Erica said: “You know your baby is never going to go hungry. You don’t have to worry about where you’re going to get food and where the money is going to come from.” </p>
<p>Yet the most food-insecure mothers stop breastfeeding after one or two months. Some never start. For them, breastfeeding is a non-sustainable food system. This is referred to as the “<a href="https://doi.org/10.2752/175174415X14101814953927">breastfeeding paradox</a>.” It means that those that can least afford to stop breastfeeding <a href="https://doi.org/10.1503/cmaj.170880">are actually more likely to do so</a>. </p>
<p>The reasons include the struggles of daily living: lack of practical support, insufficient public services and poverty brought on by inadequate income supports. A mother’s own lack of food is at the root — and like any food system, the system breaks down when producers are not supported.</p>
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<a href="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&rect=75%2C117%2C5543%2C3622&q=45&auto=format&w=1000&fit=clip"><img alt="A woman browses infant formula at a grocery store." src="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&rect=75%2C117%2C5543%2C3622&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Mothers least able to afford infant formula are more likely to rely on it to feed their babies.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Mary said: “I don’t know if what I was producing was really enough, nutrient-wise, if it was … healthy enough for him, giving him what he needed. Plus, in order to be able to produce milk, the mother needs to be food secure, and you don’t have that all the time. You still have to buy food for yourself to keep yourself healthy and the price of fruits and vegetables and proper meat is really high.”</p>
<p>Another mother, Sally, challenged the idea that breastfeeding is free, saying: “It might be cheaper than formula feeding but it still costs.” </p>
<h2>Inadequate access to formula</h2>
<p>When breastfeeding fails and infant formula is not affordable, the outcomes are tragic. </p>
<p>Unlike <a href="https://www.fns.usda.gov/wic/about-wic">other developed countries</a>, Canada has no government-provided infant formula for low-income mothers. The reasons are, at a minimum, twofold: One, there are concerns that <a href="https://www.phac-aspc.gc.ca/hp-ps/dca-dea/publications/pdf/ppsb-ppsam-eng.pdf">supplying free formula will affect infant feeding choices</a>; and two, Canada doesn’t use food as a form of welfare benefits for anyone.</p>
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<a href="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman feeds a baby with a milk bottle." src="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Without income supports, struggling mothers resort to using watered-down formula and buying it second-hand online.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>This, on top of a failed social safety net, leaves families struggling to feed their babies with limited options. Parents can look to food banks, <a href="https://doi.org/10.15353/cfs-rcea.v5i1.230">but infant formula may not be consistently available, if at all</a>. Reasons for its scarcity are embedded in the nature of food charity, which is marked by inconsistent donations, and more specifically, beliefs in Canada and elsewhere that <a href="https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2019/05/Provision-of-formula-milk-at-food-banks-Unicef-UK-Baby-Friendly-Initiative.pdf">formula provision in food banks may put breastfeeding and babies at risk</a>. </p>
<p>When we allow food insecurity to disrupt breastfeeding, or make formula inaccessible with the intent to protect breastfeeding, it punishes already struggling mothers.</p>
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<img alt="" src="https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://theconversation.com/ca/podcasts">Click here to listen to Don’t Call Me Resilient</a></span>
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<p>Unsurprisingly, <a href="https://globalnews.ca/news/4864964/baby-formula-under-lock-and-key-as-thefts-rise-say-winnipeg-retailers/">infant formula is now one of the most shoplifted items</a>, leading some retailers to keep it locked-up. </p>
<p>Desperate mothers are <a href="https://www.ubcpress.ca/out-of-milk">turning to online platforms</a> like Facebook Marketplace and Kijiji to get second-hand formula, which is sometimes already opened.</p>
<p>Heather said: “You take what you can get. It is a matter of being able to feed the baby at all.… We sold stuff. Stole stuff. Stole it to sell it and stole formula from the store. Whatever we had to do to feed them we did it — I am not proud of it but my kids are still alive.” </p>
<p>Mothers sometimes resort to watering-down formula to make it last longer and introduce solids and other liquids early when there is no formula to be found. These survival tactics show the lengths families must go to find food.</p>
<h2>A nutritious diet is expensive</h2>
<p>Most low-income families with babies who receive federal maternity benefits or income assistance cannot afford a basic nutritious diet. If they tried, according to <a href="https://doi.org/10.17269/s41997-020-00306-5">our research</a>, they would likely be short hundreds of dollars each month, whether they breastfeed or use formula. </p>
<p>According to many mothers, no matter where you live in the world, poverty and food insecurity is a threat to maternal and infant health. The consensus among mothers we spoke with say the solutions lie in their economic security. </p>
<p>Yes, breastfeeding is a robust physiological system and malnourished mothers can breastfeed. But we need real upstream policy solutions that ensure mothers and their babies don’t go hungry in the first place. Canada needs adequate social welfare that protects sustainable breastfeeding and ensures that non-breastfed babies have access to food. </p>
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<p class="fine-print"><em><span>Lesley Frank receives funding from the Social Science and Humanities Research Council, Research Nova Scotia, and Acadia University. She is affiliated with the Canadian Centre for Policy Alternatives - Nova Scotia as a Research Associate and Steering Committee member of Campaign 2000. </span></em></p>With the high cost of infant formula, food-insecure mothers who cannot breastfeed are struggling to feed their babies.Lesley Frank, Tier II Canada Research Chair in Food, Health, and Social Justice, Acadia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1668532021-09-16T14:33:43Z2021-09-16T14:33:43ZBreastfeeding trends show most developing countries may miss global nutrition targets<figure><img src="https://images.theconversation.com/files/419959/original/file-20210908-22-8w3xm0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exclusive breastfeeding in the first six months makes more difference to a baby's health and survival than any other intervention.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Exclusive breastfeeding, the practice of giving only breast milk (no other food or water), is the ideal for an infant’s first six months. Breast milk <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_1">contains all the essential nutrients</a> an infant needs at this stage.</p>
<p>Research has illuminated the longer-term health benefits of exclusive breastfeeding for the mother and child. These benefits include <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_1">reducing the risk of overweight and obesity</a> in childhood and adolescence and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929058/">certain noncommunicable diseases later in life</a> and enhancing human capital in adulthood. Additionally, breastfeeding <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930884/">reduces the risk</a> of breast and ovarian cancers, type 2 diabetes and high blood pressure among mothers. </p>
<p>These are just a few of the benefits of exclusive breastfeeding. Overall, it makes <a href="https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding">more difference to a baby’s health and survival than any other intervention</a>. That’s the reason why the World Health Organisation (WHO) includes it as a <a href="https://globalhandwashing.org/resources/whounicef-global-action-plan-for-pneumonia-and-diarrhoea-gappd">proven protective intervention</a> in the Global Action Plan for Pneumonia and Diarrhoea.</p>
<p>The WHO initially set a global target of 50% prevalence of exclusive breastfeeding <a href="https://apps.who.int/nutrition/publications/globaltargets2025_policybrief_breastfeeding/en/index.html">by 2025</a>. Recently it was updated to at least <a href="https://www.who.int/nutrition/global-target-2025/discussion-paper-extension-targets-2030.pdf?ua=1">70% prevalence by 2030</a>. It means that every member country is expected to achieve an exclusive breastfeeding prevalence of at least 70% by the end of 2030. </p>
<p>Previous research has shown that the proportion of exclusively breastfed children <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30752-2/fulltext">remains low</a> in many lower and middle-income countries, however. </p>
<p>As part of the <a href="http://www.healthdata.org/gbd/2019">Global Burden of Disease study</a>, my colleagues and I recently <a href="https://www.nature.com/articles/s41562-021-01108-6">published</a> our analysis of data covering two decades (2000-2018) from 94 low- and middle-income countries. We examined the trends and prevalence of exclusive breastfeeding and projected the performance of countries in relation to WHO targets. This type of analysis can help countries formulate the necessary policies and interventions to promote breastfeeding practices.</p>
<h2>Findings from our study</h2>
<p>Total prevalence of exclusive breastfeeding increased (27% to 39%) across all countries during the study period (2000-2018). But we found significant variations between countries and within regions. This suggests intra-regional inequalities that need attention from leaders.</p>
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Read more:
<a href="https://theconversation.com/malnutrition-among-children-is-rife-in-nigeria-what-must-be-done-164496">Malnutrition among children is rife in Nigeria. What must be done</a>
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<p>Countries included in the study made substantial progress. For example, 57 of the 94 countries had an aggregate exclusive breastfeeding practice level of less than 30% in half of their basic administrative units (referred to in this study as provinces) in 2000. But by 2018, exclusive breastfeeding prevalence in some of these countries (8) rose closer to 50%, with at least 45% exclusive breastfeeding levels in most provinces. Similarly, 34 countries had at least one province recording more than a 45% increase in exclusive breastfeeding prevalence by the end of 2018.</p>
<p>Of the African countries, Chad and Somalia had the highest rates of annualised decline in exclusive breastfeeding practices during the study period. </p>
<h2>Progress towards the 70% target</h2>
<p>To estimate future prevalence, we assumed that current trends would continue. We first projected based on the initial target of 25% by 2025, followed by the updated target of at least 70% by 2030. In general, exclusive breastfeeding practices across the countries are expected to increase from 39% in 2018 to 43% by 2025. The practice level will increase to 45% by the end of the new targeted period of 2030. Although this is positive progress, it falls short of the 70% goal. </p>
<p>Our analysis projected six countries – Burundi, Cambodia, Lesotho, Peru, Rwanda and Sierra Leone – to meet 70% of exclusive breastfeeding prevalence by 2030. Eighty-eight of 94 countries are unlikely to meet the global nutrition target on exclusive breastfeeding by 2030. Only three countries (Burundi, Lesotho and Rwanda) are predicted to meet this target in all their sub-national level units (provinces and districts). </p>
<h2>Reasons for low rates of exclusive breastfeeding</h2>
<p>Several reasons may account for the poor performance of countries towards the goal. They include but are not limited to:</p>
<ul>
<li><p>manipulative <a href="https://journals.sagepub.com/doi/10.1177/0379572115602174">marketing or promotion</a> of breast-milk substitutes</p></li>
<li><p>lack of <a href="https://gh.bmj.com/content/3/5/e001032.abstract">workplace support</a> for optimal breastfeeding practices </p></li>
<li><p>lack of attendance at <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/addressing-barriers-to-exclusive-breastfeeding-in-low-and-middleincome-countries-a-systematic-review-and-programmatic-implications/53EBA65F5D58D16E3E4D32E0FCFA938B">antenatal care</a></p></li>
<li><p>lack of skilled <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/addressing-barriers-to-exclusive-breastfeeding-in-low-and-middleincome-countries-a-systematic-review-and-programmatic-implications/53EBA65F5D58D16E3E4D32E0FCFA938B">lactation support or breastfeeding counselling</a> in health facilities </p></li>
<li><p>societal or cultural <a href="https://www.cambridge.org/core/journals/public-health-nutrition/article/addressing-barriers-to-exclusive-breastfeeding-in-low-and-middleincome-countries-a-systematic-review-and-programmatic-implications/53EBA65F5D58D16E3E4D32E0FCFA938B">beliefs</a> favouring mixed feeding.</p></li>
</ul>
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Read more:
<a href="https://theconversation.com/whats-missing-in-south-africas-strategy-to-get-breastfeeding-levels-up-165548">What's missing in South Africa's strategy to get breastfeeding levels up</a>
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<h2>Way forward</h2>
<p>Breastfeeding requires a lot of effort from mothers and support from wider networks, including their families, communities, workplaces, health systems and government leadership. </p>
<p>Advocacy at global, national and sub-national levels is critical and must be pursued by national and sub-national governments. For example, the global breastfeeding <a href="https://www.k4health.org/toolkits/breastfeeding-advocacy-toolkit">advocacy toolkit</a> outlines seven key policy actions to increase breastfeeding practices. These include:</p>
<ul>
<li><p>increasing funding to support exclusive breastfeeding and continued breastfeeding up to 2 years</p></li>
<li><p>fully adopting and monitoring the International Code of Marketing of Breast-Milk Substitutes</p></li>
<li><p>enacting workplace breastfeeding policies and paid family leave</p></li>
<li><p>implementing the baby-friendly hospitals’ ten steps to successful breastfeeding</p></li>
<li><p>improving access to skilled breastfeeding counselling in health facilities </p></li>
<li><p>strengthening links between health facilities and communities to support breastfeeding</p></li>
<li><p>strengthening monitoring systems to track progress. </p></li>
</ul>
<p>These documented strategies can aid policy-makers in monitoring the success of breastfeeding policy and programme investments.</p>
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Read more:
<a href="https://theconversation.com/community-initiative-keeps-kenyan-women-breastfeeding-exclusively-for-longer-165177">Community initiative keeps Kenyan women breastfeeding exclusively for longer</a>
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<p>In conclusion, our study found that only six of the 94 low and middle income countries are on course to meet the WHO target of at least 70% exclusive breastfeeding prevalence by 2030. That means that 94% of the countries included in our study are unlikely to meet the target. This projected poor performance calls for deliberate efforts to promote exclusive breastfeeding for better child health and well-being. Robust policy interventions may still make it possible for some of these low and middle income states to achieve the target by 2030.</p><img src="https://counter.theconversation.com/content/166853/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The original research of this paper was supported by Bill & Melinda Gates Foundation grant (OPP1132415) to the Institute of Health Metrics and Evaluation, University of Washington, USA. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Bill & Melinda Gates Foundation.
The author of the present paper, Dr Dickson Amugsi, who works with the African Population and Health Research Center has no conflict of interest to declare.
</span></em></p>Prevalence of exclusive breastfeeding has increased across all countries but few are likely to meet the 2030 goal of 70%.Dr Dickson Amugsi, Associate Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1655482021-08-10T15:34:56Z2021-08-10T15:34:56ZWhat’s missing in South Africa’s strategy to get breastfeeding levels up<figure><img src="https://images.theconversation.com/files/414796/original/file-20210805-23-wmksjl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Jose Luis Pelaez Inc/GettyImages</span></span></figcaption></figure><p>This year marks the 40th anniversary of the <a href="https://www.who.int/nutrition/publications/code_english.pdf">International Code for the Marketing of Breastmilk Substitutes</a>. This was a landmark policy framework designed to stop commercial interests from discouraging breastfeeding and hence endangering the health and nutrition of the world’s infants and young children. </p>
<p>It was driven by <a href="https://pediatrics.aappublications.org/content/100/6/1035">research</a> <a href="https://pubmed.ncbi.nlm.nih.gov/26869575/">that showed</a> human milk can meet all the nutritional needs of an infant during the first <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">six months of life</a>. </p>
<p>In line with the code South Africa published <a href="https://www.gov.za/sites/default/files/gcis_document/201409/35100rg9700gon184.pdf">regulations</a> on infant formula in 2012. These stipulated a set of requirements in relation to product formulation, packaging and labelling, including clear and visible instructions for formula feeds. The regulations also prohibited direct marketing to the mothers, including rebates, marked down prices and free gifts and gadgets to incentivise sales. </p>
<p>But South Africa still falls short of its breastfeeding target. The country failed to reach the ambitious exclusive breastfeeding target of <a href="https://extranet.who.int/nutrition/gina/en/node/7994">75% by 2017</a>. By 2016 only <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=211">32% of babies</a> were being exclusively breastfed. </p>
<p>Formula is still widely accepted in <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-021-01441-2">South Africa</a>.
But feeding babies formula is <a href="https://pubmed.ncbi.nlm.nih.gov/27174145/">associated with</a> increased child illness like middle ear infection, allergies and diarrhoea. On top of this, the proper use of infant formula is nearly impossible in settings with no clean running water and a lack of fuel to sterilise feeding utensils and boil water for the formula. </p>
<p>Also, in low-income households the use of infant formula is a higher economic burden. In South Africa, adequate amounts of formula for an infant under six months cost more per month than the <a href="https://theconversation.com/south-africa-can-and-should-top-up-child-support-grants-to-avoid-a-humanitarian-crisis-135222">child support grant</a>. </p>
<p>To increase breastfeeding rates South Africa must enforce the regulations around the marketing of infant formula. It must also do more to support mothers to breastfeed. </p>
<h2>Breastfeeding and infant formula</h2>
<p>Exclusive breastfeeding is defined as providing no other food or drink, not even water, except breastmilk (including expressed breastmilk or breastmilk from a wet nurse) for the first six months of life. It does allow for the infant to receive oral rehydration solution, drops and syrups (vitamins, minerals and medicines). </p>
<p>WHO <a href="https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/">recommendations</a> encourage continued breastfeeding up to two years or beyond with the introduction of appropriate nutrient-dense foods at age six months when complementary feeding is appropriate. </p>
<p>But the infant formula industry remains a powerful force. The top five companies are Nestlé, Danone, Mead Johnson, Abbott and FrieslandCampina. Combined they represent <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">over 60%</a> of the global market.</p>
<p>Manufacturers began to advertise directly to physicians in the early 20th century as formulas <a href="https://pubmed.ncbi.nlm.nih.gov/11160571/">evolved</a> supported by research. By 1929, the American Medical Association formed the Committee on Foods to approve the safety and quality of formula composition. By the 1940s and 1950s, physicians and consumers regarded the use of formula as an accepted, popular, and safe substitute for breastmilk. Consequently, breastfeeding rates in the US steadily declined until the <a href="https://www.contemporarypediatrics.com/view/concise-history-infant-formula-twists-and-turns-included">1970s</a>. </p>
<p>At about the same time the aggressive marketing of infant formula in suboptimal conditions in Africa led to <a href="https://www.who.int/nutrition/publications/code_english.pdf">letters</a> of concern to WHO and to UNICEF as child mortality numbers increased. This resulted in a raft of reports about the effects Nestlé’s marketing strategy on developing countries. They included the <a href="https://newint.org/issues/1973/08/01">New Internationalist’s Baby Food Tragedy issue in 1973</a>, <a href="https://waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf">War on Want’s “Baby Killer” by Mike Muller in 1974</a>, and the <a href="https://collections.nlm.nih.gov/catalog/nlm:nlmuid-8100588A-vid">Bottle Babies documentary in 1975</a>.</p>
<p>The reports caused global outrage and an <a href="https://www.nestle.com/ask-nestle/our-company/answers/nestle-boycott">international boycott</a> of Nestlé products.</p>
<p>Nevertheless, the industry continues to <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">invest heavily</a> in marketing. One of the consequences of some of the campaigns is that it sows doubt in mothers’ confidence in breastfeeding. An example is a <a href="http://www.babymilkaction.org/archives/8683">campaign</a> funded by Nestlé through the Paediatric Society of Rio Grande do Sul in Brazil. </p>
<p>Research also <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w">shows</a> that infant formula campaigns use emotional appeals, such as tapping into concerns mothers might have about their babies crying or being hungry or not sleeping. </p>
<p>Social media has made it <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w">even easier for the infant formula companies</a> to pose as the friend and supporter of parents. It is also providing companies with a rich stream of personal data with which they hone and target their campaigns. </p>
<p>In addition, the industry has designed a set of formula products to <a href="https://www.girafood.com/wp-content/uploads/2018/09/GIRA_ChinaDairy_GlobalInfantFormulaProductsMarketEN_June2018.pdf">displace breastfeeding</a>: starter formula from 0-6 months, follow-on formulas from 6-12 months and growing-up milks from 12 months. </p>
<p>But breastfeeding is the perfect food for the healthy growth and development of infants and young children. Low breastfeeding rates lead to <a href="https://pubmed.ncbi.nlm.nih.gov/26869575/">increased mortality and morbidity</a>. South Africa’s low breastfeeding rates underlie the increase in child malnutrition which is reflected in increased stunting and obesity rates. </p>
<p>More than a <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2020/CG2020_CC_child%20nutrition.pdf">quarter (27%)</a> of the country’s children are stunted. </p>
<h2>Beyond regulating</h2>
<p>South Africa, like a number of other countries, has taken steps to regulate the marketing of infant formula. But many individuals and organisations don’t recognise the regulations. Some even <a href="https://health-e.org.za/2021/08/02/npos-slam-governments-handling-of-infant-formula-donations/">challenged the government</a> for trying to enforce the rules. This points to the lack of awareness and the understanding of the regulations. It also points to a gap in monitoring and enforcement. </p>
<p>But regulating the marketing of infant formula is only the first step towards improving breastfeeding rates in the country.</p>
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<strong>
Read more:
<a href="https://theconversation.com/why-many-south-african-mothers-give-up-breastfeeding-their-babies-so-soon-145557">Why many South African mothers give up breastfeeding their babies so soon</a>
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<p>Other important steps include: upskilling health professionals on the regulations to protect mothers from the inappropriate promotion of infant formula; engaging the media on the inappropriate marketing and promotion of infant formula; and building an environment in communities that supports mothers to breastfeed.</p><img src="https://counter.theconversation.com/content/165548/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten is the Chairperson of the Child Health Priorities Association and the Nutrition Lead for the South African Civil Society for Women's, Adolescents' and Children's Health (SACSoWACH).</span></em></p>South Africa needs to ensure regulations on formula foods for babies are enforced.Chantell Witten, Lecturer, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1651772021-07-30T07:52:29Z2021-07-30T07:52:29ZCommunity initiative keeps Kenyan women breastfeeding exclusively for longer<figure><img src="https://images.theconversation.com/files/413704/original/file-20210729-17-k25vm4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenyan women march towards a restaurant after a female client was allegedly thrown out for breastfeeding and not covering up. </span> <span class="attribution"><span class="source">Photo credit should read SIMON MAINA/AFP via Getty Images</span></span></figcaption></figure><p>Exclusive breastfeeding in the first six months, as recommended by the <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_1">World Health Organisation</a>, is vital for child growth and survival. Exclusive breastfeeding means that the infant receives only breast milk. This is because breast milk has adequate amounts of nutrients and water required for healthy growth as well as immune factors required for the development of the infants immune system in the first 4-6 months of life.</p>
<p>Other benefits of breastfeeding include protection against common childhood illnesses such as diarrhoea and pneumonia, and infant death. Scaling up exclusive breastfeeding can prevent <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf">823,000 child deaths every year</a>, and protect against <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01024-7.pdf">overweight and diabetes</a>.</p>
<p>There are benefits for <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01024-7.pdf">mothers too</a>. It’s been shown to reduce risks of breast and ovarian cancer, improve the spacing between births and reduce the risk of diabetes.</p>
<p>Kenya has made great efforts to increase the number of women breastfeeding their babies. Exclusive breastfeeding rates have increased over the years from 32% in 2008 to 61% in <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">2014</a>, which is higher than the the current <a href="https://apps.who.int/iris/bitstream/handle/10665/326049/WHO-NMH-NHD-19.22-eng.pdf?sequence=1&isAllowed=y">global average</a> of 43%. </p>
<p>But Kenya’s exclusive breastfeeding rates vary with age. For example, the percentage of children exclusively breastfed decreases sharply from 84% of infants age 0-1 month to 63% of infants age 2-3 months and, further, to 42% of infants <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">age 4-5 months</a>. </p>
<p>In a bid to address these patterns, the Kenyan government has put a number of initiatives in place to promote exclusive breastfeeding during the first six months of a baby’s life. </p>
<p>One is the <a href="https://www.who.int/elena/titles/bbc/implementation_bfhi/en/">baby friendly hospital initiative</a>. Launched in 1991, it aims to scale up 10 interventions in maternity facilities to support successful breastfeeding. The initiative has been effective in promoting exclusive breastfeeding during the <a href="https://onlinelibrary.wiley.com/doi/10.1111/mcn.12294">first weeks</a>, but not as effective in sustaining it through to the recommended six months. </p>
<p>This highlighted the need to scale up the promotion of breastfeeding in communities, which led to the baby friendly community initiative. This equips primary healthcare workers and community health volunteers with skills to help mothers breastfeed and feed their infants and young children. It also empowers other family and community members to support breastfeeding mothers.</p>
<p>The intervention is important particularly in regions such as Africa where 60% of women give birth at <a href="https://www.who.int/pmnch/media/publications/aonsectionIII_3.pdf?ua=1#:%7E:text=Yet%20almost%2060%20percent%20of,care%20do%20not%20receive%20it.">home</a>. </p>
<p>We conducted <a href="https://pubmed.ncbi.nlm.nih.gov/33528102/">a study</a> to assess the effectiveness of the baby friendly community initiative in Koibatek, a rural area in the Rift valley region of Kenya where mothers exclusively breastfeed for an average of <a href="https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf">three months</a>. </p>
<h2>What we found</h2>
<p>The study was conducted in 13 community units in Koibatek sub-county. Pregnant women aged 15-49 years were recruited and followed up until their children were at least six months old. Mothers in the intervention group received standard maternal, infant and young child nutrition counselling and support from trained community health volunteers, health professionals, community mother support groups and mother to mother support groups. Those in the control group received standard counselling only, consisting of messages on infant and young child nutrition. No maternal and child nutrition related support was given to the mothers in the control group. Data on breastfeeding practices were collected.</p>
<p>A total of 823 pregnant women were recruited. Compared with mothers in the control group, the 351 mothers in the intervention group were three times more likely to exclusively breastfeed for six months and for a longer time (19 days longer). </p>
<p>The intervention used minimal resources because it was implemented within the existing health system by community health volunteers who were instrumental in providing information on maternal infant and young child nutrition. </p>
<p>They were required to visit mothers in their homes and provide support through community mother support groups and mother to mother support groups. </p>
<p>The mother to mother support groups consisted of 9-15 pregnant, lactating women and in some cases fathers and grandmothers. The group met monthly to discuss issues around pregnancy and young child feeding and nutrition. Community health volunteers and a lead mother, who acted as the leader of the group, facilitated the meetings.</p>
<p>The community mother support group included a nutritionist, community health volunteers, a local administrator, a community leader and a lead mother. The role of the support group was to oversee, plan and execute community meetings on the baby friendly community initiative; mobilise all community members to participate in its activities; support community health extension workers and nutritionists in monitoring and documenting monthly activities at the community level; and to monitor and document the maternal, infant and young child nutrition activities monthly.</p>
<h2>Next steps</h2>
<p>We believe our findings show that supporting mothers in their communities has the potential to increase exclusive breastfeeding for longer. </p>
<p>This is because the help women get in their communities addresses some key reasons that have been identified for the drop off in women breastfeeding exclusively in the first six months. These are:</p>
<ul>
<li><p>Lack of information/knowledge on the importance of breastfeeding</p></li>
<li><p>Advice and cultural beliefs and practices which negatively impact breastfeeding</p></li>
<li><p>Poor breastfeeding positioning and latching</p></li>
<li><p>Inadequate breastfeeding support</p></li>
</ul>
<p>Our findings showed that supporting breastfeeding in communities, and providing information, led to a significant increase in exclusive breastfeeding rates. We concluded from our findings that the baby friendly community initiative has the potential to improve exclusive breastfeeding rates in similar settings. It should be scaled up in Kenya and extended to other African countries.</p><img src="https://counter.theconversation.com/content/165177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Antonina Mutoro works for the African Population and Health Research Center. She is affiliated with the University of Glasgow, United Kingdom</span></em></p><p class="fine-print"><em><span>Elizabeth Kimani-Murage works for the African Population and Health Research Center (APHRC). She receives funding from the Wellcome Trust, USAID, NIH. She is affiliated with Brown University, USA. </span></em></p>Provision of breastfeeding support and information within the community can lead to a significant increase in exclusive breastfeeding rates.Antonina Mutoro, Postdoctoral Research Scientist, African Population and Health Research CenterElizabeth Kimani-Murage, Senior Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1455572020-10-05T15:06:01Z2020-10-05T15:06:01ZWhy many South African mothers give up breastfeeding their babies so soon<figure><img src="https://images.theconversation.com/files/361569/original/file-20201005-24-1w4e9gf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A lot is still uncertain about breastfeeding practices in South Africa.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Breast milk plays a vital role in reducing child mortality. It has all the nutrients a baby needs in the first six months of life and its health benefits extend into adulthood. This is why organisations, like UNICEF and the World Health Organisation (WHO), recommend <a href="https://www.who.int/elena/titles/exclusive_breastfeeding/en/">exclusive breastfeeding</a> – no other food or drink, not even water – for infants in this period. </p>
<p>Globally, numerous <a href="https://www.who.int/bulletin/volumes/91/6/12-109363/en/">policies and programmes</a> have been put in place to promote and support breastfeeding. South Africa has also been promoting exclusive breastfeeding. But the country has one of the <a href="https://www.nature.com/articles/s41591-019-0525-0">lowest</a> rates of exclusive breastfeeding in Africa and globally.</p>
<p>Within the country, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6799928/#:%7E:text=In%202011%2C%20South%20Africa%20committed,2011%20to%2032%25%20by%202016.">rate</a> varies substantially. There have been remarkable improvements in some age groups. In 2003, only 11.2% of babies were breastfeeding exclusively in the first month of life. By 2016, that number had jumped to 44%. But, at five months, only 31.6% of babies were being exclusively breastfed. </p>
<p>These patterns were echoed in my <a href="https://link.springer.com/epdf/10.1186/s13006-020-00320-w?sharing_token=DQiu5G7OcEt-gvfz_FOTKW_BpE1tBhCbnbw3BuzI2RMVNeuGNqr5t7js5_IpkDN6vYhu6wCty9qZhtTFDgALHUYROUrv7xKEd1T0YdA_7mIgeGyvRYttjmDKzKuDWzKfa-7MkTal6UdDkDoBsZjDMe0e6Dif3dLQQNpxMvfvSzU%3D">doctoral study</a> conducted in the Tlokwe sub-district – an area with nine primary healthcare clinics and a district hospital – in South Africa’s North West province. I examined the rate and reasons of exclusive breastfeeding discontinuation among a particular group of mothers. </p>
<p>It’s important to understand why mothers, despite the decades of breastfeeding promotion campaigns, still do not optimally breastfeed their infants. Understanding the reasons can inform policy and interventions to make it easier to give babies the best start in life. </p>
<h2>Breastfeeding practices</h2>
<p>The Tlokwe sub-district is like many low-income neighbourhoods in South Africa. It’s burdened with high unemployment, poor living conditions, high levels of violence and crime and low levels of social capital. Most households in setting like this are headed by women and have multiple children. The men are often drawn to cities for better employment opportunities. I followed a cohort of 178 breastfeeding mothers with infants from age 14 days to 24 weeks.</p>
<p>In my study, exclusive breastfeeding rates decreased from 34% at 4-8 weeks to a mere 9.7% by weeks 20-24. Over the same period, mixed feeding with infant formula increased from 17% to 50.1%, and food feeding from 3.1% to 54.2%. These numbers mirror the <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=215">national trends</a>.</p>
<p>A lot is still uncertain about breastfeeding practices in South Africa. But my research suggests that womens’ decisions around breastfeeding are shaped by a host of personal, social, economic and cultural factors. These often get in the way of the mother’s intentions to breastfeed her infant as recommended. This is especially true for women living in poverty.</p>
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<a href="https://theconversation.com/how-health-workers-have-adapted-to-south-africas-breastfeeding-policy-99688">How health workers have adapted to South Africa's breastfeeding policy</a>
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<p>Of all the factors that determine women’s decisions on breastfeeding, the most dominant one – in my study, at least – was the stress that mothers endure in difficult home environments. </p>
<p>Many South African women face daily challenges of poverty – no food, rent to pay, children to put through school. </p>
<p>One <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860892/#:%7E:text=Most%20women%20initiated%20breastfeeding%3A%2091.6,those%20with%20severe%20food%20insecurity">study</a> found that a major concern and source of stress for breastfeeding mothers was the lack of food in the home. In 2017, <a href="http://www.statssa.gov.za/publications/P0211/P02113rdQuarter2019.pdf">almost 20%</a> of South African households had inadequate or severely inadequate access to food. The North West province – where I did my study – had the highest proportion of food insecure households at 63%.</p>
<p>Under such trying conditions, women often have to care for children alone. Studies have <a href="https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-017-0135-8">found</a> that most new mothers live with their families of origin rather than their partners or spouses. And these families have their own struggles with poverty. </p>
<p>This elevates stress. Family stress and the lack of food and money take a toll on a mother’s mental health. I used the <a href="https://journals.co.za/content/ajpherd/20/sup-1/EJC162286">Edinburg Postnatal Depression Scale</a> to measure mothers’ mental health and found that nearly 45% had clinical signs of distress. This rate is higher than found in previous studies of mental health among HIV-positive mothers. </p>
<p>Around <a href="https://www.who.int/mental_health/maternal-child/maternal_mental_health/en/#:%7E:text=Worldwide%20about%2010%25%20of%20pregnant,and%2019.8%25%20after%20child%20birth">13%</a> of mothers in developing countries experience clinical depression after childbirth – a condition also known as postpartum or postnatal depression. Women with high levels of postpartum depression are more likely to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492376/">stop breastfeeding</a> within three months. </p>
<p>In my study, mothers feared that the stress they experienced could be passed on to their infants through breastfeeding. Mothers are reluctant to pass on their stress and distress to their infants. Their decision to seek alternative feeding is a protective action to spare their infants their negative stress.</p>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901002/">shows</a> that stress in mothers increases corticosteroids in breast milk. This validates mothers’ concern for their infants and the negative impact of stress.</p>
<p>My qualitative data showed that many mothers had difficult and strained relationships in the home and experienced a hostile social environment towards breastfeeding. Mothers expressed discomfort and shame about breastfeeding in public spaces and places.</p>
<p>There are additional factors that influence breastfeeding choices. These include the mother’s breastfeeding knowledge, and breastfeeding support from health professionals. Mothers knew about the health benefits of breastfeeding for their infants. But surprisingly, baby cues were often interpreted and internalised as negative responses to their breast milk. These cues included the baby crying, the baby breastfeeding frequently, and the baby not sleeping for long periods. Often these aspects of baby care and breastfeeding were not discussed at the health facilities. </p>
<p>The infant <a href="https://www.huffpost.com/entry/baby-formula-industry-has-a-long-history-of-undermining-breastfeeding-moms_n_5b44bf07e4b07aea75446989">formula industry</a> markets infant formula as a superior response to the crying baby, the “hungry baby” and the difficult sleeper. These were some of the reasons that mothers switched to infant formula. </p>
<p>Guidance from family, relatives and health professionals is also likely to shape the decision to continue – or discontinue – with breastfeeding. </p>
<h2>Recommendations</h2>
<p>Most mothers deliver their babies in a health facility where exclusive breastfeeding is recommended and encouraged. But the fact that mixed feeding is the norm suggests that mothers are confronted with environments that make it hard for them to follow this advice. </p>
<p>My findings suggest that breastfeeding information and education is reaching mothers, which mothers value and want to breastfeed.</p>
<p>But telling a mother that breastfeeding is good for the baby does not address the challenge of household food insecurity, internalised misconceptions about breast milk production, and difficult family relations. These barriers inhibit optimal breastfeeding practices and demand broader society engagement on supporting women and their child care responsibilities.</p>
<p>Breastfeeding support programmes narrowly focused on the health and social benefits of breastfeeding need to take a broader approach. Child nutrition can’t be addressed without addressing the challenges that women, and mothers in particular, face.</p><img src="https://counter.theconversation.com/content/145557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Breastfeeding support programmes need to engage more with the challenges that mothers face.Chantell Witten, Lecturer, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/996882018-07-12T14:42:54Z2018-07-12T14:42:54ZHow health workers have adapted to South Africa’s breastfeeding policy<figure><img src="https://images.theconversation.com/files/227432/original/file-20180712-27036-908fah.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In the past 20 years there has been a massive global push for mothers to exclusively breastfeed their newborns for the first six months of their lives. The <a href="http://www.who.int/pmnch/media/news/2016/breastfeeding_brief.pdf">science</a> suggests this is a good way to improve their children’s later development. </p>
<p>There has also been a large body of research on the effects of formula milk, and other replacement foods, on the health of babies during their first six months. A great deal shows that they have <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862005000600009&script=sci_arttext">negative effects</a>. </p>
<p>But for many years HIV positive mothers were <a href="http://apps.who.int/iris/handle/10665/78393">advised</a> to either exclusively breastfeed their babies, or only feed them formula. They could choose which they preferred – but not a mixture of the two.</p>
<p>This was very confusing for many mothers. Many fell back on mixed feeding. They started using both approaches as the same time – sometimes breastfeeding their babies, sometimes using commercial formula or other replacement liquids and foods. </p>
<p>In South Africa this practise was <a href="https://journals.co.za/content/healthr/2016/1/EJC189314?TRACK=RSS">very common</a> – <a href="https://journals.co.za/content/healthr/2016/1/EJC189314?TRACK=RSS">close to 90%</a> of the country’s babies were mixed fed in the early 2000s.</p>
<p>In 2010 this changed. The World Health Organisation took a stand and <a href="http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/">recommended</a> that governments should make a choice between the two options. They either had to encourage HIV positive mothers to exclusively breastfeed <em>or</em> to exclusively formula feed. They shouldn’t do both. </p>
<p>These guidelines prompted South Africa to end its free formula programme in public facilities. Instead, it <a href="https://nutritionconfidence.wordpress.com/tag/tshwane-declaration-of-support-for-breastfeeding-in-south-africa/">promoted exclusive breastfeeding</a> for all mothers. This meant that frontline health workers, including nurses and clinic staff, had to change they way they counselled mothers about feeding practises. </p>
<p>Seven years after the new policy was introduced we wanted to find out how well frontline workers had adjusted. Did they understand the new policy and its purpose? And did it make a difference to breastfeeding rates? </p>
<p>Our <a href="https://doi.org/10.1186/s13006-018-0164-y">findings</a> were surprising. When it came to HIV positive mothers, the frontline workers encouraged them to breastfeed their babies exclusively.</p>
<p>But when it came to HIV negative mothers, the workers didn’t highlight the importance of exclusive breastfeeding, nor did they discourage mothers from mixed feeding.</p>
<p>Our study suggests that South Africa could improve exclusive breastfeeding rates. The rate has improved in recent years – by <a href="https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf">2016</a> 32% of mothers were exclusively breastfeeding their babies. But there’s still a great deal of room for improvement. Kenya, for example, has achieved a rate of <a href="https://theconversation.com/how-a-breastfeeding-initiative-in-rural-kenya-changed-attitudes-78852">over 60%</a>.</p>
<p>The onus is with the South African government to engage health workers about the benefits of exclusive breastfeeding for babies born to HIV positive as well as HIV negative mothers. They need to provide clear communication tools and counselling skills that can help health workers address the barriers mothers face.</p>
<h2>Reliant on advice</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/19323863">Studies</a> have shown that new mothers rely heavily on the advice they get from health workers about infant feeding. </p>
<p>Mothers who get <a href="https://www.ncbi.nlm.nih.gov/pubmed/29026431">confusing or misleading advice</a> from health workers are less likely to exclusively breastfeed, or to do so for a shorter time. On the other hand, those who receive clear, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16028656">positive messages</a> about exclusive breastfeeding from their health workers are more likely to breastfeed. </p>
<p>That’s why our study focused on health workers. We interviewed frontline health workers from four community health clinics in Soweto. They included nurses, ward-based outreach team members and staff seconded from non-governmental organisations. Each of them had counselled mothers about baby feeding before and after the policy change. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227178/original/file-20180711-27021-m53s0q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some mothers were breastfeeding their babies but not exclusively, they were using formula.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Few health workers understood the scientific rationale of the policy to promote exclusive breastfeeding. Many were under the impression that the formula programme had been stopped due to costs and most hadn’t been trained on the new policy. </p>
<p>The health workers believed that breastmilk was best for babies and were able to rattle off the nutritional benefits and other advantages such as allowing the mother and the baby to bond and the fact that it was cheaper. </p>
<p>But there were differences in the way they responded to HIV positive and negative mothers. They advised all mothers to breastfeed their babies. But they spent more time educating HIV positive mothers about the importance of exclusive breastfeeding rather than HIV negative mothers. The subtext was that mixed feeding was mostly a HIV related risk.</p>
<p>When they spoke to HIV negative mothers they spent more time warning them about HIV and advising them how to protect themselves. They did not emphasise the benefits of exclusively breastfeeding. </p>
<h2>What next?</h2>
<p>There are still structural barriers around exclusive breastfeeding that need attention. This includes maternity leave policies that fall short of the six month exclusive breastfeeding period, an absence of public and workplace spaces for breastfeeding and the idea that exclusive breastfeeding is only for HIV-exposed babies. On top of this, mixed feeding remains a cultural norm in many communities.</p>
<p>On the bright side, exclusive breastfeeding rates are increasing in South Africa and health workers have an important role to play in explaining the health and development benefits of exclusive breastfeeding for all babies. </p>
<p>South Africa’s health department should provide health workers with updated information on the benefits of exclusive breastfeeding and the risks of mixed feeding. This needs to include pre-tested materials that can be placed in public spaces like clinics.</p>
<p>In addition, they should continuously provide interactive content on the health workers’ cellphones through platforms like <a href="http://www.health.gov.za/index.php/mom-connect#nurseconnect">NurseConnect</a> which they could access during consultations. </p>
<p>Health workers also need training on how to navigate between health education and counselling that empowers mothers. To get the best outcome for both mother and baby, a single directive from above is less likely to result in behaviour change than a two-way conversation about overcoming barriers.</p><img src="https://counter.theconversation.com/content/99688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara Nieuwoudt is a Consortium for Advanced Research Training in Africa (CARTA) PhD fellow. CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100029), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) (Grant No: 107768/Z/15/Z) and the UK government. The statements made and views expressed are solely the responsibility of the fellow.</span></em></p>Health workers promote exclusive breastfeeding to HIV positive mothers more than they do to mothers who are negative.Sara Jewett Nieuwoudt, Lecturer, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/806942017-07-19T18:21:57Z2017-07-19T18:21:57ZSouth Africa has made giant strides in breastfeeding. But it’s still taboo in public places<figure><img src="https://images.theconversation.com/files/178791/original/file-20170719-13586-12wkscb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Reuters/Adrees Latif</span></span></figcaption></figure><p>South Africa has a long history of promoting breastfeeding as an important part of promoting child health in the country. </p>
<p>Even during the height of <a href="https://www.ncbi.nlm.nih.gov/pubmed/3696214">apartheid</a>, the health fraternity acknowledged the need to keep breastfeeding at the forefront of children’s development. The first breastfeeding campaign was launched in <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Malan%20A%5BAuthor%5D&cauthor=true&cauthor_uid=3696214">October 1987</a>. Several other initiatives were launched in the years that followed. These have led to significant improved breastfeeding rates in the country. </p>
<p>The current government has been very active in protecting, promoting and supporting breastfeeding through an array of policies, programmes and legislation to improve the breastfeeding environment in South Africa. The country has some of the most progressive legislation to protect the breastfeeding from inappropriate marketing of breastmilk substitutes.</p>
<p>But South Africa hasn’t managed to clear the last hurdle – attitudes towards breastfeeding in public. Thirty years after breastfeeding was first championed, mothers can’t breastfeed in public without <a href="https://www.all4women.co.za/369211/lifestyle/inspiring/i-was-told-not-to-breastfeed-in-public">provoking angry responses</a>. On several occasions mothers have been humiliated and <a href="http://www.parent24.com/Baby/Breastfeeding/sa-mom-discriminated-for-breastfeeding-on-kulula-flight-20160728">stigmatised</a>. </p>
<p>In recent years, several countries have put legislation in place to protect breastfeeding at <a href="https://www.theguardian.com/world/2015/mar/19/brazil-law-breastfeeding-mothers-fine-sao-paulo">work and in public spaces</a>. For example, in Brazilian city Sao Paulo, businesses or organisations that prevent women from breastfeeding in public are fined. Others, like Vietnam, have invested in communication and education strategies to <a href="http://www.who.int/features/2016/Viet-Nam-breastfeeding-campaign/en/">improve breastfeeding culture</a>. The result is that women can breastfeed in public places without being victimised.</p>
<p>South African health authorities educate the public about breastfeeding. But without supportive legislation and strong behaviour change communication, breastfeeding in public will never be normalised. </p>
<h2>Breastfeeding successes</h2>
<p>Seven years ago the government made positive <a href="http://www.sajcn.co.za/index.php/SAJCN/article/view/586">policy changes towards breastfeeding</a> to encourage exclusive breastfeeding. Since then it has made several additional and significant policy shifts to promote and support longer duration of breastfeeding to 24 months, among HIV-negative and HIV-positive mothers. </p>
<p>In 2012 the health department stopped providing free infant formula to HIV positive mothers. This reversed an earlier policy that promoted the use of infant formula – an approach that had been pursued because of the transmission of HIV from mothers to children <a href="http://www.sahivsoc.org/FileUpload/Infant_feeding_FAQ_July_2011.pdf">through breastmilk</a>.</p>
<p>The reversal on formula milk approach was accompanied by a massive rollout of life-long anti-retrovirals for pregnant mothers. This makes breastfeeding in the context of HIV safer and lowers the risk of mother to child transmission of HIV through breastfeeding.</p>
<p>In the same year the department also <a href="http://webcache.googleusercontent.com/search?q=cache:Zgj5uXp_VosJ:www.health.gov.za/index.php/shortcodes/2015-03-29-10-42-47/2015-04-30-09-10-23/2015-04-30-09-11-35/category/207-regulations-labelling-and-advertising%3Fdownload%3D742:r991-guidelines-to-industry-and-health-care-personnel-may2014-1+&cd=1&hl=en&ct=clnk&gl=za">passed regulations</a>
that prohibit the marketing and promotion of products that undermined and displaced breastfeeding, like infant formula.</p>
<p>This was followed by a revised infant and young child feeding policy in line with the <a href="http://www.ennonline.net/whoguidelineshivandinfantfeeding2010">World Health Organisation’s recommendations</a> that countries have one public health infant feeding policy. </p>
<p>South Africa has also had phenomenal success in establishing human milk banking. In addition, more than 70% of public health facilities have been accredited as Mother-Baby-Friendly. These facilities are trained and offer a level of service that protects, promotes and supports breastfeeding with immediate initiation of breastfeeding, practice of skin-to-skin and rooming-in to keep mothers and babies together.</p>
<p>These facilities discourage bottle feeding and teach mothers cup feeding and how to express breastmilk for when they are not with their babies. All these practices improve breastfeeding and the mother’s milk supply.</p>
<h2>Breastfeeding practises</h2>
<p>But public breastfeeding is still frowned upon. Part of the problem seems to be that initiatives to promote breastfeeding have been restricted to the health system. </p>
<p>There is very little promotion and conversation in other sectors such as education, social development and in the justice system.
Evidence from other countries show that breastfeeding improves if the interventions are delivered through a <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01044-2/abstract">multi-pronged approach</a>. Where there have been successes, governments have ensured that breastfeeding is supported in and by:</p>
<ul>
<li><p>the health system and the services that are offered, </p></li>
<li><p>the family and community, and</p></li>
<li><p>the workplace</p></li>
</ul>
<p>While South Africa has <a href="http://www.labour.gov.za/DOL/legislation/codes-of-good-ractise/Basic%20Conditions%20of%20Employment/code-of-good-practice-on-pregnancy">provisions</a> under the Basic Conditions of Employment Act, very few employers have made effort to protect or support mothers in their work environment. </p>
<p>Last year, the Department of Health unveiled its National Breastfeeding Campaign which is built around the question: </p>
<blockquote>
<p>Why do communities not support mothers to breastfeed? </p>
</blockquote>
<p>This is an important question because it goes to the heart of the challenge South Africa still faces. Society remains averse to mothers breastfeeding their babies in public spaces, even though breastmilk is universally recognised as being a lifesaving <a href="http://www.savethechildren.org.uk/resources/online-library/superfood-babies">super food for babies</a>.</p>
<p>If breastfeeding is part of our African culture, why are people offended and disturbed when a mother breastfeeds her baby? If it is part of the natural order of loving and caring for children, why do people shame, humiliate and stigmatise breastfeeding mothers?</p>
<p>But it’s not enough for the health department to pose the question. Collectively, we need to come up with answers, and take action. </p>
<p>South Africa can take a lead from <a href="https://www.ncbi.nlm.nih.gov/pubmed/27780198">Vietnam and Bangladesh</a> who have benefited enormously from large-scale interventions. Both countries have combined intensive inter-personal counselling with mass media campaigns. </p>
<p>South Africa has antenatal care counselling for mothers at clinics but has not yet invested in the promotion of breastfeeding. Such campaigns are not unfamiliar in the country. It has done exceptionally well in campaigns such as <a href="https://www.arrivealive.co.za/">Arrive Alive</a> and the <a href="http://www.knowmystatus.org/">HIV know your status</a> campaign .</p>
<p>But until the resistance of communities towards breastfeeding is fully understood, there will not be a shift in embracing it and South Africa will continue to carry the high burden of infant death and disease.</p><img src="https://counter.theconversation.com/content/80694/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chantell Witten is affiliated with the South African Civil Society for Women's. Adolescents' and Children's Health (SACSoWACH)</span></em></p>South African health authorities educate the public about breastfeeding but without supportive legislation and strong communication, it will never be normalised.Chantell Witten, Lecturer and PhD candidate, North-West UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/703112017-01-16T15:17:06Z2017-01-16T15:17:06ZUncovering the deeper secrets of every mother’s breast milk<figure><img src="https://images.theconversation.com/files/152677/original/image-20170113-11183-13176yw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Investigating the make up and composition of breast milk has been a critical part of understanding how newborn babies <a href="http://www.sciencedirect.com/science/article/pii/S0140673615010247">build their immune systems</a> and ward off disease later in life. </p>
<p>Initially it was thought that breast milk did not contain bacteria except when a mother had an infection. But more recent <a href="http://www.sciencedirect.com/science/article/pii/S0022347603006140">studies</a> have shown that breast milk has millions of microbes (bacteria, viruses and fungi) that are critical to preventing babies from suffering diseases and other acute infections later in life. These include ear infections, meningitis, urinary tract infection, asthma, type 1 diabetes and obesity. To develop their immune systems babies need an optimal slew of bacteria to colonise their gut.</p>
<p>Previous research has shown that the bacterial makeup in breast milk is unique to every mother – like a <a href="http://www.sciencedirect.com/science/article/pii/S1744165X16300178">fingerprint</a>. Several factors affect the composition of this bacterial community. These include the mothor’s diet and well-being (stress, for example, has a major impact), the age at which she has a baby, her geographic location, the mode of delivery of the baby, as well as her use of antibiotics or probiotics. </p>
<p>We set out to delve deeper by looking at the bacterial composition of mothers’ milk in different countries – China, South Africa, Spain and Finland. Our aim was to identify the impact of four different geographical locations: Asia, Africa, and North and South Europe on breast milk composition. We focused on the microbiome – the microorganisms in a particular environment – as well as the fatty acid composition of the mother’s milk. We also looked at the impact of the mode of delivery on breast milk.</p>
<p>We <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5061857/">found</a> that the collection of bacteria in the breast milk of the women we studied varied between countries. This, as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3472256/">other studies</a> have suggested, may be due to what they ate. </p>
<p>We also confirmed <a href="http://ajcn.nutrition.org/content/96/3/544.full">previous findings</a> from studies in Finland and Spain that there’s a link between the mode of delivery and milk microbiome. But we found that the impact differed depending on the country. </p>
<p>These different bacterial collections are, in turn, passed onto babies through breast milk.</p>
<p>Our findings add to the body of growing knowledge about breast milk and opens the door to a more granular understanding of its bacterial composition. This is important as it could identify additional benefits to breast feeding which in turn could help efforts to increase the number of women who breastfeed. </p>
<p>Global health bodies strongly recommend that babies be breastfed exclusively until they are six months old. This is based on research that shows that breast feeding is best for babies. </p>
<p>Yet only 38% of all babies in the world are fed for half a year. The effect on their health has been extensively studied. For example <a href="https://www.unicef.org/nutrition/index_24824.html">research</a> shows that in developing countries babies who are not breastfed are 14.4 times more likely to die in the first months of life from diseases such as diarrhoea and pneumonia than babies who are breastfed.</p>
<h2>Cultivating bacteria</h2>
<p>Bacteria start to be transferred from mother to baby in the womb. This continues during the actual birthing process and then after birth through breast milk when millions of microbes are send into the baby’s gut every day. </p>
<p>This is important because breast milk bacteria play several roles in the baby’s gut. They:</p>
<ul>
<li><p>reduce the incidence and severity of infections; </p></li>
<li><p>improve the intestinal barrier function by increasing the amount of mucous that acts as a shield;</p></li>
<li><p>“teach” the immune system, showing it good bacteria from the bad;</p></li>
<li><p>produce anti-inflammatory substances which keeps the gut alive and thriving; and</p></li>
<li><p>burn energy, determines how much fat the baby stores and breaks down sugars and proteins.</p></li>
</ul>
<h2>Differences</h2>
<p>Our study confirmed <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3472256/">earlier research</a> that the bacterial makeup of a mother’s milk is affected by a number of factors. These include:</p>
<ul>
<li><p>the mode of delivery of the baby, </p></li>
<li><p>a mother’s diet and well-being,</p></li>
<li><p>the environment, and</p></li>
<li><p>geographic location.</p></li>
</ul>
<p>When it comes to the mode of delivery of the baby we found that it had an impact on the microbiome in the mother’s milk. But this differed between countries.</p>
<p>Previously it has been suggested that the <a href="http://ajcn.nutrition.org/content/96/3/544.full.pdf+html">hormones released during labour</a> can influence the bacterial community in breast milk. Where elective cesarean section is the delivery mode – that is when a mother has a cesarean section before going into labour – these labour hormones are not released and therefore no alteration of the breast milk bacterial community is observed. </p>
<p>Our research confirmed earlier findings that the <a href="https://theconversation.com/malnutrition-stunting-and-the-importance-of-a-childs-first-1000-days-43379">well-being of the mother</a> is also of utmost importance. For example, a good diet and regular exercise, even before she falls pregnant.</p>
<p>In our study, diets differed. For example in Finland, the diet is rich in oily fish which is high in omega-3 fatty acids. The Spanish use olive oil, whereas the Finnish use Canola oil and South Africans use sunflower oil. These differences have a significant affect on the microbiome.</p>
<h2>What next?</h2>
<p>Breast feeding rates need to increase to meet the <a href="http://worldbreastfeedingweek.org/pdf/wbw2016-toolkit.pdf">sustainable development goals</a> which strive to reduce maternal and infant deaths. </p>
<p>Our research on the breast milk microbiome and its core role in infant health is an attempt to improve infant health by providing additional information on these bacteria. Primary health caregivers, nurses and midwives, partners and mothers all need to be equipped with as much information as possible about its positive attributes so that the prolonged benefits of breast feeding can be shared with mothers, and the practice initiated immediately.</p><img src="https://counter.theconversation.com/content/70311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elloise du Toit receives funding from the National Research Foundation. </span></em></p>The bacteria in a mother’s breast milk are important because it helps develop a baby’s gut. Research shows this bacteria are different depending on where mothers live and what they eat.Elloise du Toit, Medical Microbiologist, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/557782016-03-08T04:38:59Z2016-03-08T04:38:59ZBetter maternity leave laws are needed to protect African mothers<figure><img src="https://images.theconversation.com/files/114069/original/image-20160307-31281-9w7kjk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Employers should provide an enabling environment at work for women to continue breastfeeding their infants.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Maternity leave for women in developing countries is still a massive problem, with many women in informal sectors not receiving adequate cover.</p>
<p><a href="http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_242617.pdf">More than 70%</a> of working women do not enjoy the full benefits of maternity leave. Only 330 million women – or 28% of working women – are fully protected, meaning they get time off and full pay. About 80% of those without adequate maternity protection are in Africa and Asia.</p>
<p>When women do not enjoy full maternity benefits, their health – and that of their children – may be affected.</p>
<p><a href="http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_242617.pdf">Discrimination</a> against women around maternity leave is pervasive throughout the world, according to the International Labour Organisation. And even where legislation does exist, ensuring it is effectively implemented remains a challenge. </p>
<p>The organisation recommends 14 weeks’ maternity leave, with six weeks of compulsory postnatal leave for women in countries that have signed the <a href="http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C183">Maternity Protection Convention</a>. At least 167 of the organisation’s member nations have passed some form of <a href="http://mprp.itcilo.org/allegati/en/m12.pdf">legislation</a> on maternity protection. But not all countries fully implement or enforce these laws. </p>
<p>In Kenya, for example, laws provide women in formal employment with three months of maternity leave, but in some instances this is not adhered to. And casually employed women are not entitled to maternity leave, according to <a href="http://onlinelibrary.wiley.com/doi/10.1111/mcn.12161/epdf">research</a> conducted by the African Population and Health Research Centre in Kenya. These women have to juggle staying home shortly after delivery to rest and <a href="http://aphrc.org/workplace-support-for-breastfeeding-mothers/">breastfeed</a> their babies with returning to work. </p>
<p>Even where women are entitled to maternity leave, some organisations do not adhere to the regulations and women are asked to work from home during maternity leave or return to work prematurely. Few workplaces provide appropriate policies and an enabling environment for women to combine work with breastfeeding successfully once they return from maternity leave.</p>
<h2>Maternity leave laws across the globe</h2>
<p>Legislating maternity leave is important because it transposes universally accepted principles into national laws and sets minimum national and subnational standards. The content of the legislation is determined individually by countries. </p>
<p>For example, in South Africa, domestic workers are eligible for maternity benefits because they are covered by the basic labour laws of the country. Domestic workers have the right to paid leave, overtime payments, severance pay, notice of dismissal and a written contract with their employer. </p>
<p>The Brazilian constitution grants women 120 days of maternity leave without prejudice to jobs or wages.</p>
<p>In Gabon, a pregnant woman can ask the labour inspector to examine the work she is doing before she goes on maternity leave to ensure that it is not too strenuous for her. If it is found to be dangerous, she may ask to be moved to a different position without loss of pay until three months after she returns from maternity leave. </p>
<p>The International Labour Organisation notes that its maternity leave convention applies to all employed women, including those in atypical forms of dependent work, including part-time, casual or seasonal jobs. But the organisation admits that few countries have included such a wide scope in their national legislation. </p>
<p>In reality, the percentage of women covered by the law is often quite low. Several <a href="http://mprp.itcilo.org/allegati/en/m12.pdf">sectors</a> are either excluded or poorly protected. These include:</p>
<ul>
<li><p>the private sector compared with the public sector;</p></li>
<li><p>rural workers compared with urban ones;</p></li>
<li><p>agricultural, informal economy, domestic or homeworkers;</p></li>
<li><p>migrant workers;</p></li>
<li><p>part-time, casual or temporary workers;</p></li>
<li><p>workers in small enterprises or those in family undertakings; and</p></li>
<li><p>self-employed, independent workers.</p></li>
</ul>
<h2>Why maternity leave is important</h2>
<p>Maternity leave allows mothers to breastfeed adequately, and to rest and recover from nine months of pregnancy and subsequent delivery. Research shows that the longer a mother stays on maternity leave, the more likely she is to breastfeed exclusively or <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf">breastfeed at all</a>.</p>
<p>Breastfeeding is critical to good nurturing. It has enormous short- and long-term <a href="http://apps.who.int/iris/bitstream/10665/43623/1/9789241595230_eng.pdf">benefits</a>. These include:</p>
<ul>
<li><p>reduced infections and deaths among infants; </p></li>
<li><p>improved mental and physical development; and </p></li>
<li><p>improved <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)70002-1/abstract">intellectual performance</a>, educational achievement and earning ability in adulthood. </p></li>
</ul>
<p>Breastfeeding improves mothers’ <a href="http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(15)70002-1.pdf">post-partum recovery</a>. It also reduces the risk of non-communicable diseases such as <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01024-7.pdf">diabetes</a>, cancer and depression, and improves birth spacing. </p>
<p>But adverse work conditions mean many mothers stop exclusive breastfeeding before six months or any breastfeeding before two years, counter to World Health Organisation <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf">recommendations</a>.</p>
<h2>Improving economic activity</h2>
<p>A woman should be given the chance to exercise her right to choose both good nurture for her baby and productivity for herself. </p>
<p>Women should be supported to successfully combine work with breastfeeding so they do not have to choose one over the other. This may include safeguarding the three months’ maternity leave provided for in international labour legislation. But it should include the option of providing longer maternity leave of up to six months. </p>
<p>This would cover the World Health Organisation’s recommended six months of exclusive breastfeeding. And employers should provide an enabling environment at work for women to continue breastfeeding. </p>
<p>It is also important to consider those categories not entitled to maternity leave in many national labour laws. </p>
<p>Protecting maternity leave is not only important for the well-being of the mother and her baby; it is important for the whole society. It is the first step towards optimal child development, health and survival. It will also <a href="https://blogs.unicef.org/blog/why-nutrition-and-breastfeeding-are-crucial-to-sustainable-development/">help achieve</a> the <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a> and the realisation of the <a href="http://www.unfpa.org/demographic-dividend">demographic dividend</a>. Importantly, it also has an effect on women’s economic productivity.</p><img src="https://counter.theconversation.com/content/55778/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Kimani-Murage receives funding from the Wellcome Trust, NIH/USAID, Unicef, Transform Nutrition.</span></em></p>Only 28% of working women across the globe are fully protected by maternity laws that provide for time off work with full pay.Elizabeth Kimani-Murage, Research Scientist at the African Population and Health Research Center and Adjunct Assistant Professor, Brown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/540312016-02-29T04:24:57Z2016-02-29T04:24:57ZHow traditional practices in Nigeria can put a stop to an increase in allergies<figure><img src="https://images.theconversation.com/files/113033/original/image-20160226-26669-1254rqw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Reuters/Kim Kyung-Hoon </span></span></figcaption></figure><p>Doctors in parts of Nigeria have reportedly seen an <a href="http://www.punchng.com/your-perfume-may-give-you-allergies/">increase</a> in patients treated for allergies.</p>
<p>This may be partly as a result of Nigerian societies adopting Westernised lifestyles and substituting traditional options for more modern choices. The allergy increase is due to their lifestyle choices preventing them from being exposed to the good micro-organisms that prevent allergies.</p>
<p>Nigeria is not unique. <a href="http://www.nature.com/nri/journal/v15/n5/full/nri3830.html">Research</a> shows that allergic diseases have been increasing in both developed and developing countries as a result of rising living standards and the adoption of western lifestyles. </p>
<p>The World Health Organisation suggests that <a href="http://www.who.int/mediacentre/factsheets/fs307/en/">more than 235 million</a> people worldwide suffer from atopic dermatitis, allergic rhinitis and allergic asthma. </p>
<p>Although not being exposed to good bacteria early in life is one possible cause of the increase in allergies, Western lifestyle factors such as exposure to pollution and tobacco smoke are also to blame. </p>
<p>Reducing the time mothers’ breastfeed and/or cutting it out completely could also contribute to the increased incidence of allergic diseases.</p>
<p>In Nigeria, some cultures recommend extended breastfeeding to help babies develop strong immune systems. But there are also several other indigenous child-rearing practices that have traditionally helped babies beef up their immune systems and ward off allergies. These are viable options that should be promoted locally. They include:</p>
<ul>
<li><p>natural delivery;</p></li>
<li><p>weaning babies off breast milk with pap and soya milk; and</p></li>
<li><p>surrounding the new mother with family members.</p></li>
</ul>
<h2>A balanced immune system</h2>
<p>A child’s immune system <a href="http://onlinelibrary.wiley.com/doi/10.1002/bdrb.20170/full#fig1">starts developing</a> in its mother’s womb and continues until it turns two. This is thought to be a critical developmental window as it can alter the risk for children developing allergic diseases.</p>
<p>To prevent allergies and other related immune mediated disorders, there is a need for a diverse microbial community and a balanced immune <a href="http://onlinelibrary.wiley.com/enhanced/doi/10.1002/bdrb.21116/">system</a>. Microbial communities are groupings of “good” bacteria that live in different parts of the body, including the skin, gastrointestinal and genital tracts. This good bacteria helps in the efficient development of the immune system. </p>
<p>In the first two years of a baby’s life, there is a need to encounter and interact with as much of this good bacteria as possible. One of the most efficient ways for this bacteria to be transferred is through normal delivery. As the baby goes through the genital tract, it accesses this bacteria. </p>
<p>However, during a Cesarean section birthing process, there is limited transfer of this good bacteria to the child. </p>
<p>Another process of transferring these good bacteria to the baby is through breastfeeding. The child gets to interact with the bacteria on the mother’s skin. Therefore, as the baby develops and encounters different bacteria populations, the bacteria community becomes more diverse.</p>
<p>This helps the immune system develop and become tolerant of innocuous substances – and subsequently prevents the development of most allergic diseases. </p>
<p>There are several traditional practises in Nigerian societies that aid this process.</p>
<h2>Breastfeeding</h2>
<p>In some Nigerian societies, cultural and tradition practices are performed until a child turns two. Some of these practices have immunological basis as they contribute to the immune system developing efficiently. </p>
<p>For example, mothers from the Efik and Ibibio culture in southern Nigeria breastfeed their children until they are <a href="http://irmbrjournal.com/papers/1367572222.pdf">one year old</a>.</p>
<p>Coincidentally, this is similar to the World Health Organisation’s <a href="http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/">recommendation</a> to breastfeed infants until they are two. Breast milk contains several immune modulating components which help in effectively developing a child’s immune system. </p>
<p>It also helps expose the child to preformed antibodies which helps to prevent diseases in the early stages of their immune system developing. By this stage, their immune systems have not yet developed the full capability of combating infectious diseases. </p>
<h2>A locally produced weaning meal</h2>
<p>Another immune boosting mechanism in some Nigerian cultures is weaning babies off breast milk with pap. The Yoruba people call it “ogi baba/koko” while the Igbo people call it “akamu” and Hausas call it “Kwunu zaaki”.</p>
<p>Pap is a semi-solid food made from fermentation of cereals and legumes – maize, guinea corn, millet and sorghum. Pap helps diversify the microbial community that the baby develops from the starter cultures it has got during the delivery process and breastfeeding. </p>
<p>Scientists have <a href="http://www.pnas.org/content/107/33/14691.full">shown</a> that these locally produced meals help to calibrate the immune and metabolic functions which decrease the risk of immune-mediated diseases including allergies. As a result of the pap, the baby has a natural supply of probiotics that help develop a microbial community for the immune system. </p>
<p>In the Yoruba community, lactating mothers are also encouraged to take pap as it improves their production of breast milk. This cultural practice also has potential immune benefits. <a href="http://scialert.net/abstract/?doi=jm.2007.247.253">Studies</a> have shown that locally prepared pap contains naturally present probiotic supplements. This may lead to them having higher levels of anti-inflammatory molecules in their breast milk which offers their babies reduced risks against allergy and other diseases. </p>
<p>There is also a social practice in which the new mother is encouraged to keep the company of other family members immediately after birth. <a href="http://dx.doi.org/10.12968/ajmw.2013.7.1.39">Research</a> suggests that this reduces the risk of postnatal depression in new mothers. But it also provides a window for the child to have early encounters with a wider range of microbial communities.</p>
<p>Promoting some indigenous cultural practices is important as it would aid the effective development of children’s immune systems and reduce susceptibility to allergic conditions.</p><img src="https://counter.theconversation.com/content/54031/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyebola Oyesola does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Several indigenous child-rearing practices have helped babies develop strong immune systems to ward off allergies. These should be actively promoted.Oyebola Oyesola, PhD candidate in Immunology and Infectious DIsease, Cornell UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/516862015-12-08T04:18:36Z2015-12-08T04:18:36ZWhat’s needed in the final push to eliminate new cases of HIV in children<figure><img src="https://images.theconversation.com/files/104622/original/image-20151207-2975-1yi1gle.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The successful prevention of mother to child transmission programmes means nearly all HIV-infected pregnant women should get anti-retroviral treatment to protect their babies.</span> <span class="attribution"><a class="source" href="http://www.africaknows.com/">Joshua Wanyama/Africa Knows</a></span></figcaption></figure><p>The prevention of HIV from mothers to children has been the most successful HIV prevention programme in South Africa and across the <a href="http://www.unicef.org/gambia/Towards_an_AIDS-free_generation_-_Children_and_AIDS-Sixth_Stocktaking_Report_2013.pdf">globe</a>. </p>
<p>When the programme was started in 2002, transmission of HIV from mothers to children was as high as 40%. Estimates are that the current transmission rate when women stop breastfeeding is around 5% and about <a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742014000300034&script=sci_arttext&tlng=en">2%</a> of children exposed to HIV are infected by the time they reach six weeks old.</p>
<p>Despite these tremendous gains, certain areas need attention to reduce the burden of paediatric HIV. Around <a href="http://www.unicef.org/gambia/Towards_an_AIDS-free_generation_-_Children_and_AIDS-Sixth_Stocktaking_Report_2013.pdf">360 000</a> children under 14 years live with HIV in South Africa. Of these children only 50% access anti-retroviral treatment.</p>
<p>The gaps in the programmes relate to mothers, babies, children and teenagers and explain the remaining challenges with South Africa’s HIV prevention strategy around children.</p>
<h2>Delayed treatment for mothers</h2>
<p>There are three main problems around mothers:</p>
<ul>
<li><p>pregnant women are booked into anti-retroviral programmes late, </p></li>
<li><p>new mothers drop off these programmes, and </p></li>
<li><p>misconceptions around exclusive breastfeeding. </p></li>
</ul>
<p>Considering the success of prevention of mother to child transmission programmes, nearly all HIV-infected pregnant women should be initiated onto anti-retroviral treatment. But in 2013/4, only <a href="http://indicators.hst.org.za/uploads/files/DHB0708.pdf">81%</a> of those needing treatment accessed it. </p>
<p>Many women access HIV testing at their first antenatal care visit. But those who become HIV-infected during their pregnancy must be diagnosed with a retest later. This test is not always repeated. </p>
<p>For HIV-infected women not yet diagnosed or on anti-retrovirals, each week without prophylaxis increases the risk of infecting the baby, particularly if the woman is newly infected and has a high viral load. They are more likely to transmit HIV to their babies in-utero, during delivery or through breastfeeding.</p>
<p>After birth, new mothers drop off the anti-retroviral treatment, attending fewer clinic visits. Some struggle to maintain clinic visits on return to work. Others believe they don’t need treatment when they stop breastfeeding. The South African government’s guidelines recommend lifelong anti-retroviral treatment for all women starting in pregnancy or during <a href="http://www.kznhealth.gov.za/family/HIV-Guidelines-Jan2015.pdf">breastfeeding</a>.</p>
<p>Lastly, there are lingering misconceptions around breastfeeding. Several <a href="http://linkinghub.elsevier.com/retrieve/articleSelectPrefsTemp?Redirect=http%3A%2F%2Fwww.thelancet.com%2Fretrieve%2Fpii%2FS0140673612603213&key=039de0287f4434e05c49702da47e2ace92cb7214">studies</a> show when both mother and baby are on anti-retrovirals in the first few weeks after birth, the benefits of breastfeeding far outweigh the risks of HIV transmission. Some parents and healthcare workers are still concerned about the HIV risk in breastfeeding infants. </p>
<h2>Getting babies early treatment</h2>
<p>South Africa has excellent HIV testing <a href="http://www.kznhealth.gov.za/family/HIV-Guidelines-Jan2015.pdf">guidelines</a> for HIV-exposed babies. In babies who get prolonged nevirapine prophylaxis, a viral test to detect viral material, rather than a rapid HIV test, is done at birth and then again at 10 and 16 week clinic visits. A final antibody test - the rapid HIV test - is done at 18 months. A final test is done six weeks after breastfeeding stops, or if the infant is symptomatic.</p>
<p>We <a href="http://www.scielo.org.za/scielo.php?pid=S0256-95742015000900025&script=sci_arttext&tlng=en">argue</a> that the an extra HIV test should be done at the nine month measles immunisation visit, which is well attended. If an HIV rapid screening test was done here and the baby tested positive a viral test would be done, replacing the post-feeding viral test which is usually poorly done as there is no fixed time for it. </p>
<p>This would mean babies are diagnosed with HIV before they are one. The first 12 months are known to be the highest risk period for mortality and morbidity if anti-retrovirals are not started. </p>
<p>Traditionally, HIV treatment for children under one has had to be doctor initiated. This needs to change so that HIV-infected children are diagnosed by nurses and given treatment before they fall ill. This is especially true for children from rural and under-resourced areas where doctors specialising in paediatric HIV are not readily available.</p>
<h2>Targeting HIV in childhood</h2>
<p>In the past few years, HIV testing guidelines have been substantially tightened for children under 18 months old. At the beginning of the epidemic, these testing guidelines were less rigorous and testing was frequently aimed at sick children. </p>
<p>But some children only become obviously ill late in childhood or in early to mid-teens. Often these youngsters have low CD4 counts and are very ill when they get help. This is precious time that’s being wasted. Several programmes address this including the Paediatric Adolescent Scale-up Programme. It aims to increase testing in children and teenagers and access to anti-retroviral treatment, ensuring quality care. </p>
<p>Infants and children require a lifetime of anti-retroviral treatment. Our goal should be for them to have the same life expectancy as their uninfected peers. To achieve this, their treatment regimens must be carefully managed. There should be an emphasis on excellent adherence, a simple regimen and as few side effects as possible.</p>
<h2>The special challenge of adolescence</h2>
<p>HIV-infected teenagers are considered a <a href="http://www.jiasociety.org/index.php/jias/article/view/18579">high-risk group</a> because they fail to adhere to their treatment programmes. It can take time for an immunological or clinical deterioration to become apparent. These feelings of wellness are often the reason they abandon treatment. </p>
<p>Adherence difficulties are also driven by clinical, emotional and social factors that teenagers experience. These are exacerbated by the HIV infection because issues of sexuality and social exploration become more complex. </p>
<p>Poor adherence to treatment results in an increase in their viral load. They also become resistant to treatment.</p>
<p>Children growing up with HIV and newly infected teenagers need additional support. A youth friendly approach is needed to deal with issues that affect adherence. This includes:</p>
<ul>
<li><p>access to sexual and reproductive health care, </p></li>
<li><p>mental healthcare screening and treatment, </p></li>
<li><p>exploration of violence and orphanhood, and </p></li>
<li><p>social and financial difficulties.</p></li>
</ul>
<p>The end goal is for these HIV infected teens to transition to adult care with good clinical and mental health outcomes.</p><img src="https://counter.theconversation.com/content/51686/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lee Fairlie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s programmes preventing HIV transmission from mothers to children have been hugely successful. But there are still gaps that need to be filled.Lee Fairlie, Director: Child & Adolescent Health at the Wits Reproductive Health and HIV Institute, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/499212015-10-30T04:20:01Z2015-10-30T04:20:01ZLessons other countries can learn from Kenya’s ambitious nutrition plan<figure><img src="https://images.theconversation.com/files/100239/original/image-20151029-15358-s0odhi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenya's nutrition plan has resulted in dramatic improvements in its nutrition targets. </span> <span class="attribution"><span class="source">Reuters/Mohamed Nureldin Abdallah </span></span></figcaption></figure><p>One in every three people globally suffers from malnutrition. And nearly half of all countries in the world face multiple serious burdens of malnutrition such as poor child growth, micronutrient deficiency and overweight adults, according to the <a href="http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/129443/filename/129654.pdf">2015 Global Nutrition Report</a>. </p>
<p>Three years after the World Health Assembly set the 2025 goals to improve undernutrition, countries across the globe have scaled up their programs to address malnutrition. The 2015 nutrition report reveals this is not nearly enough to meet the assembly’s targets.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=650&fit=crop&dpr=1 600w, https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=650&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=650&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=817&fit=crop&dpr=1 754w, https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=817&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/100174/original/image-20151029-15338-92ahs4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=817&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">WHO</span></span>
</figcaption>
</figure>
<p>The targets are to:</p>
<ul>
<li><p>reduce stunting in children under the age of five by 40%;</p></li>
<li><p>reduce anaemia in women of reproductive age by 50%;</p></li>
<li><p>reduce low birth weights by 30%;</p></li>
<li><p>reduce and maintain childhood wasting to 5%;</p></li>
<li><p>improve exclusive breastfeeding to 50%; and </p></li>
<li><p>ensure there is no increase in overweight children. </p></li>
</ul>
<p>Out of 74 countries that were analysed for the report, Kenya is the only country that is on track to meet all five targets by 2025. This is mainly based on its achievements in the last few years.</p>
<p>Kenya has reduced stunting to 26%. Its low birth weights are down to 5.6% and it has improved exclusive breastfeeding to 61.4%. Childhood wasting and obesity both sit at 4% and anaemia in women of reproductive age has been reduced to 25%.</p>
<p>Of the remaining 73 countries, only four others – Colombia, Ghana, Vanuatu and Vietnam – are on course for four targets.</p>
<p>So what is Kenya doing right, and how can it continue with its progress?</p>
<h2>A bold plan</h2>
<p>Kenya’s <a href="http://bit.ly/1G8RVz8">National Nutrition Action Plan 2012-2017</a> has been central to it combating malnutrition. There are several elements that have led to the strategy being successfully implemented. </p>
<p><strong>Strong government leadership and co-ordination</strong></p>
<p>A Nutrition Interagency Co-ordinating Committee, which was formed and is chaired by the government’s head of nutrition, has resulted in well-co-ordinated structures that implement actions around nutrition. Within these structures, all the stakeholders both inside and outside the government have clear roles and responsibilities. </p>
<p>The committee includes a network of government ministries: Health, Education, Agriculture, Planning, Labour as well as United Nations agencies, civil society, academic and research institutions, the private sector and multilateral and bilateral donors.</p>
<p>A budget of US$687 million (KES70 billion) was drawn, and the Kenyan government committed a total of US$58 million (KES6 billion) of public funds to the five-year plan.</p>
<p>Kenya has also forged international partnerships to boost the plan. Since 2012 it has been part of the global <a href="http://scalingupnutrition.org/">Scaling Up Nutrition</a> movement. The movement is made up of 55 countries committed to improving their nutrition figures. This has helped to develop an approach that works across sectors to implement nutrition-specific and nutrition-sensitive interventions and strategies. </p>
<p><strong>Support from donors</strong></p>
<p>Kenya’s network of development partners, which include the UN system and bilateral donors such as the European Union, the US, Japanese and UK governments and the World Bank, are all making commitments to support the national nutrition initiative. </p>
<p><strong>Good monitoring and research</strong></p>
<p>And to measure progress around the nutrition indicators, Kenya has incorporated strong monitoring and research and information management and sharing. It has guided how the nutrition plan is implemented and overseen by a nutrition information working group in the health ministry.</p>
<p><strong>Improved human resources for health</strong></p>
<p>The government and its implementation partners have increasingly enhanced the capacity of the healthcare staff. They support nutrition counselling by training healthcare workers on high-impact nutrition interventions such as importance of infant and young child feeding.</p>
<h2>The impact of policy changes</h2>
<p>The <a href="http://bit.ly/1G8RVz8">National Nutrition Plan</a> is part of a roadmap to success, called <a href="http://www.vision2030.go.ke/index.php/vision">Kenya Vision 2030</a>. Along with the nutrition plan, it draws on other strategies and policies:</p>
<ul>
<li><p>the maternal infant and young child nutrition 2012-2017 strategy; and </p></li>
<li><p>The <a href="http://bit.ly/1NsvuqF">Food and Nutrition Security Policy</a>.</p></li>
</ul>
<p>The infant nutrition strategy makes sure high-impact, cost-effective nutrition interventions like promoting breastfeeding and other maternal, infant and young child nutrition practices are implemented at health facilities in communities.</p>
<p>Along with Kenya’s newly promulgated <a href="http://www.lcil.cam.ac.uk/sites/default/files/LCIL/documents/transitions/Kenya_19_2010_Constitution.pdf">constitution</a>, the roadmap has brought positive changes to improve the Kenyan people’s health status.</p>
<p>One of these changes is a free maternity policy, which encourages more deliveries at health facilities. This has increased the number of babies born with a trained attendant at a facility from 43% in 2008 to 61% in 2014, based on the recent <a href="http://bit.ly/1ONxyws">national survey</a>. </p>
<p>Birthing at a facility results in care for the mother and baby after birth before going home. Mothers are taught how to adequately breastfeed and are counselled on family planning and babies get the required vaccinations.</p>
<p>Another change is the recently enacted <a href="https://extranet.who.int/nutrition/gina/sites/default/files/KEN%202012%20Thre%20Breast%20Milk%20Substitutes%20Regulation%20and%20Control%20Bill,%202012%20Arrangement%20of%20Clauses_0.pdf">Breast Milk Substitutes (Regulation and Control) Act</a>. The act protects, promotes and supports breastfeeding. Better breastfeeding practices leads to better child growth, development and survival.</p>
<h2>What next?</h2>
<p>Kenya is on track to achieve these highly ambitious but critically important global nutrition <a href="http://bit.ly/1KcGicQ">targets</a>. But more needs to be done.</p>
<p>Despite the strong commitment by the Kenyan government to raise close to 10% of the budget to implement the national nutrition plan, more government resources are critical to ensure success.</p>
<p>Although co-ordination is strong, there are still some gaps that need to be addressed, particularly around convening powers. To address these, discussions are underway to establish a Multi-sectoral Food Security and Nutrition Secretariat and a Nutrition Technical Committee. The secretariat would fall under the office of the oresident while the technical committee under the cabinet secretary for health.</p>
<p>A systematic investigation of the success factors is needed to ensure the entire country is on track to achieve these targets. But the championing of optimal nutrition is universal. </p>
<p>With sustained investment, sustainable progress towards our goal as a nation to ensure a high quality of life for everyone – beginning with the first day of their lives can be achieved.</p>
<p>As Kenya marks National Nutrition Week, promoting good nutrition as a human right, the Kenyan government must increase its support to the national nutrition plan to ensure that every child born in Kenya has a healthy start. </p>
<hr>
<p><em>Betty Samburu, programme manager at the maternal infant and young child nutrition programme within the Kenyan Ministry of Health; Marjorie Voleje from UNICEF and SUN Movement and nutritionist Grace Gitau also contributed to this article.</em></p><img src="https://counter.theconversation.com/content/49921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Kimani-Murage previously received funding from the Wellcome Trust and is currently funded by PEER Health and Transform Nutrition. She works for the African Population and Health Research Center. She is affiliated with the Global Nutrition Report, Brown University and Glasgow University. </span></em></p>Over the last three years Kenya has seen marked improvements in its nutrition-related targets as a result of a national nutrition plan it has implemented.Elizabeth Kimani-Murage, Senior Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.