[pronut-hiv] Africa Region & Challenging Facts & Opinions on Infant Feeding with Regards to EBF

["Thuts" <maphosat@yahoo.com>]

Dear Colleagues 
 
Compliments of the new season to you all. It is my pleasure and hope that we will all have a successful year towards attainment of all the set goals towards improving Nutrition and Health indicators. It is also imperative to realize that we are 5 years away to the Millennium Development Goals targets. It will also be critical to note that as an African region we are behind in terms of meeting the targets. It will therefore be of great importance to work together in scaling up all the infant feeding programmes as well as prioritize them to make an impact.  
 
We have also done a lot of good things in the region that we need to share and present to the network so as to work within the best practices. While we seek to be all back on track in attaining the set MDGs, it will be imperative to use the World Breastfeeding Trends Initiative and other country monitoring tools to  report and  identify  areas that are still lagging behind. It will be to the advantage of Infants, young children and women to use high impact interventions to improve their survival. It is also noticed that maternal mortality and child mortality has remained high in most of the countries in Africa with a few on the down trend. 
 

Why low Exclusive Breastfeeding?

While the Global Strategy (2002) stated that infants should be exclusively breastfed up to six months and followed by continued breastfeeding and complementary feeding up to 24 months and beyond. It has remained a challenge in the region to attain high proportion of exclusive breastfeeding rates. Replacement feeding is rarely possible in resource-limited settings. Formula feeding is expensive and reliable and consistentsupplies are difficult to maintain in African countries with limited infrastructure for transport and storage. Even when formula is freely provided it may not be culturally acceptable and often puts the mother at risk of having her HIV status disclosed involuntarily to her family and community and of being stigmatized. While challenges have been experienced in the region with regards to code violation breastfeeding has remained a culture in most African countries.  While this has been the case there is strong believe that breastmilk is
 not enough and most mothers end up supplementing with other family foods and water at early infant stage.
 
Currently most countries have therefore been experiencing a dilemma of mixed messages on the recommendations of infant feeding in the context of HIV during the first year of life. This has led to challenges of selecting the best infant feeding options for individual mothersâ hence low exclusive breastfeeding rate. While PMTCT coverage has significantly improved over the years the quality of Infant Feeding Counseling has remained a challenge due financial and human resource capacity specific to infant and young child feeding programmes.  HIV has as well brought a dilemma of orphans and the majority of the women are also likely breastfeeding mothers with HIV and TB co-infection and this triple threat has led to most mothers failing to breastfeed during the time when there are terminal ill. While the orphans do not have the opportunity to get exclusive breastfeeding through wet nursing due to cultural barriers in most African countries.  While we  continue to encourage mothers to continue to breastfeeding regardless of their health conditions this has led to irregular breastfeeding frequencies during the infant's life. Other issues to consider are recurrent disasters and epidemics in the region that are also bound to affect the continuity of breastfeeding in countries like Sudan and Somalia.
 

While other countries have managed to get a high proportion of mothers who are exclusively breastfeeding, it will also be critical in the current year to focus on improving these rates. I might have few questions that you are best placed to answer at country level that include:


 Has HIV brought the dilemma of low exclusive breastfeeding if so what has been done by successful countries with high HIV prevalence to continuously maintain high exclusive BF rates?

  In the context of the new WHO recommendations (2009) on ART cant we ride on and encourage all mothers to exclusively breastfed and for pregnant and lactating mothers to access ART (Further improve coverage)? 

 Are  working mothers contributing a lot on low exclusive breastfeeding rates if so what is the current status of the Ratification of the ILO Convention in individual countries?

 Are Infant Formula Companies aggressively marketing their Infant Formula to mothers without adherence to the Code of marketing of BMS there reducing Breastfeeding rates? (What are countries experiences)

 Are we reaching women, communities on Infant Feeding Messages, are mothers effectively counseled and do we have a high coverage of women that are provided with a counseling session before delivery?

Lets share the answers maybe further research might also needed in some areas
 
WHO guidelines currently recommend exclusive breastfeeding for HIV-infected women for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) for them and their infants. After 6 months, if AFASS is not met, breastfeeding and complementary feeding continues to be the recommended choice until AFASS is met. Clearly there have been several changes with regards to infant feeding recommendations in the context of HIV. Due to weak PMTCT and Infant Feeding counseling programmes as well as lack of access to maternal health services mothers have been receiving information that lacked effective counseling and mentoring through the breastfeeding cycle. (Can this be the main reason why exclusive breastfeeding rates have remained low?
 
Currently most countries have therefore been experiencing a dilemma of mixed messages on the recommendations of infant feeding in the context of HIV during the first year of life. This has led to challenges of selecting the best infant feeding options for individual mothers hence low exclusive breastfeeding rate. While PMTCT coverage has significantly improved over the years the quality of Infant Feeding Counseling has remained a challenge due to financial and human resource capacity specific to infant and young child feeding programmes.

(How far has the integration of Infant Feeding in the context of PMTCT be done in most countries and what has been the main challenges? Into all other programmes IMAI, IMCI). In my view there are also too many projects that are being set up in countries and creating a lot of parallel programmes that can also be brought together and answer to a specific target i.e child.


HIV has as well brought a dilemma of orphans and the majority of the women are also likely breastfeeding mothers with HIV and TB co-infection and this triple threat has led to most mothers failing to breastfeed during the time when there are very ill. Orphans do not have the opportunity to get exclusive breastfeeding through wet nursing due to cultural barriers in mostAfrican countries. While we encourage mothers to continue breastfeeding in spite of their health conditions even with support, this has led to irregular breastfeeding frequencies during the infantâs life. Other issues to consider are recurrent disasters and epidemics in the region that are also bound to affect the continuity of breastfeeding in countries like Sudan and Somalia.

In the region Baby Friendly Hospital Initiative programme got derailed with the advent of HIV and AIDS, so the rates are quite low in most of the countries and but as this is a comprehensive quality programme that can improve exclusive breastfeeding rates especially in countries where health facility based deliveries are high, we will invest energy to revamp it. ÂWhile it is expected that mothers exclusively breastfeed in the first 6 months we cannot overemphasize the fact that ratification of the maternity protection convention and the Code of marketing of BMS is very crucial. Since the majority of the people in Africa are living below the poverty line, the majority of people work in the informal sector. More often this is a vulnerable group that needs to be protected by national legislations. They do not get maternity leave from their work place as well as breastfeeding breaks. While expression is an option to most of these mothers, challenges have  remained in terms of sustainability and feasibility of this method: with regards to storage, water and sanitation issues as well as availability of utilities to ensure that the milk is kept under normal recommended temperatures using the correct methods and utensils to boil, store and feed the child just to mention a fewâ. Industries are also aggressively marketing their products at the expense of the survival of the children. Clearly these conditions make it very difficult for women to exclusively breastfeed and this has also led to high infant and child mortality due to infections like diarrhea and pneumonia in the region.  
 
While I agree that these are critical programmes it whether noting if there are reaching to the community:

What kind of vehicles is being used to get to the community? 
Are they effective in terms of people change through cultural barriers?
Should we also introduce a Community Based Baby Friendly Initiative to improve the quality of service at community level?
What about legislations or country environments, Yes as countries we have been part of the agreement of the Code of Marketing of BMS but why has it taken use to long to ratify it to national law?
 

I would greatly appreciate hearing your views about some of these comments that I have made and I believe they will usher an era of sharing ideas and as well as improving our programming.

Kind Regards 
 
Thulani Maphosa
IBFAN Africa 
Chief Programs Officer