WWS Policy Task Force

Child and Maternal Health in Developing Countries

Drs. Karl and Sally Le Roux

STRATEGIES TO PROMOTE AND SUPPORT

EXCLUSIVE BREASTFEEDING IN SOUTH AFRICA

Nicolas Trad
January 5th, 2015

Honor Statement
This paper represents my own work in accordance with University regulations.

 DEFINITIONS

Exclusive breastfeeding Feeding infants only breast milk and no other foods or liquids;
(EBF) recommended for the first 6 months of life by WHO

Mixed feeding Feeding infants any other foods and/or liquids (e.g. formula milk)
together with breast milk; also known as combined feeding or
partial breastfeeding

Complementary foods Foods and liquids other than breast milk introduced into the childs
diet; recommended by WHO after 6 months to supplement breast
milk and meet childrens evolving nutritional needs

ARV Anti-retroviral drugs

BFHI Baby-friendly Hospital Initiative; launched in 1991 by WHO and

UNICEF to promote and support breastfeeding in hospitals

CHW Community health worker

PMTCT Prevention of mother-to-child transmission of HIV

 BRIEFING PAPER

South Africa has one of the lowest rates of exclusive breastfeeding (EBF) in the world, with only
8% of women exclusively feeding their infants breast milk during the first 6 months of life.
Malnutrition, diarrhea, and acute respiratory infections such as pneumonia remain the leading
causes of death for children under five in South Africa. These problems are compounded by low
rates of breastfeeding, as it has been shown that optimal breastfeeding practices (6 months of
EBF and continued breastfeeding with the addition of appropriate complementary foods until 2
years of age or beyond) protect children against a host of infectious diseases and entail a variety
of health benefits for the mother as well. Formula feeding in South Africa, particularly in rural
areas, where clean water and electricity are neither widely available nor reliable, can present
serious risks to the health of children. Promotion and support of EBF should therefore become a
fundamental health objective for the South African government, regional entities, and NGOs
operating in South Africa.

Understanding the underlying factors that explain why rates of EBF are so low in South Africa
will help unlock policy recommendations. In the 1990s and early 2000s, the HIV epidemic
precipitated an overarching focus on preventing mother-to-child transmission (PMTCT) of HIV,
leading the South African government to offer free formula milk to seropositive mothers. The
policy contributed to lower rates of EBF among both HIV-positive and HIV-negative mothers,
increasing infants vulnerability to disease. While the policy was reversed in 2011 as the South
African government refocused on reducing child mortality, rates of EBF have remained
abysmally low. Sociocultural attitudes and views on breastfeeding also help explain why so few
women exclusively breastfeed. Many women in South Africa perceive breast milk as insufficient
nourishment for their children. Others face significant family pressures, especially from
grandmothers and partners, to supplement breast milk with formula milk. Despite evidence
showing that EBF reduces transmission of HIV relative to alternatives such as mixed feeding,
HIV-positive mothers are understandably reluctant to risk infecting their children. The continued
marketing of breast milk substitutes and the difficulty of breastfeeding after returning to work
further contribute to the low prevalence of EBF.

Other countries have shown that concerted national strategies to actively promote optimal
breastfeeding behavior can result in substantial increases in rates of EBF. Governments from
Latin America (Brazil, Bolivia), to Asia (Bangladesh) to Africa (Ghana, Madagascar) have
achieved significant changes in attitudes by combining media campaigns with community-based
counseling programs. South Africa can reach similar results with sensible adjustments to national
and regional policies. Mothers and their relatives (e.g. husbands, grandmothers) should be
targeted through the mass media with concise and consistent messages that emphasize the
benefits of EBF and address local perceptions of breastfeeding. South Africa should continue its
crackdown against breast milk substitute marketing and should expand existing maternity leave
protections to encourage women to breastfeed for 6 months. Awareness of the benefits of EBF
and practical counseling skills should become a core competency for health workers who interact
with mothers at every stage of care, and communities should be mobilized to provide support and
encouragement to breastfeeding mothers.

Challenges to implementing these policies do exist, but they are not insurmountable. South
Africas stagnant economy and budget woes could present financial and political roadblocks to
pursuing these strategies, but studies have shown that EBF promotion is a cost-effective
intervention and that savings associated with ending the provision of free formula milk and
reduced child morbidity would more than compensate for the price of a national campaign.
Convincing HIV-positive women to exclusively breastfeed their children will remain a
challenge, but near universal coverage of ARVs and the reduced risks of transmission through
EBF should largely put those concerns to rest. Finally, care must be taken to prevent stigmatizing
women who decide not to breastfeed their children.

By themselves, these policies do not constitute a magic bullet solution to the lamentable state
of child health in South Africa. Exclusive breastfeeding nevertheless remains the single most
effective preventative intervention in reducing child mortality, with the potential to save tens of
thousands of lives every year without the need to deploy expensive technologies. South Africa
should follow the lead of other countries in Sub-Saharan Africa and the world in ensuring that all
mothers have the requisite knowledge, counseling and support to appropriately breastfeed their
children.

 TABLE OF CONTENTS

INTRODUCTION 1

THE BENEFITS OF EXCLUSIVE BREASTFEEDING 2

Benefits for the child
Benefits for the mother
HIV transmission and EBF
The risks of formula feeding in South Africa

WHY ARE RATES OF EXCLUSIVE BREASTFEEDING SO LOW? 6

Government policy
Tradition and sociocultural beliefs
The HIV epidemic
Difficulties with breastfeeding
Challenges of working mothers
Continued marketing of breast milk substitutes

REVIEW OF EBF PROMOTION PROGRAMS IN OTHER COUNTRIES 10

Horizontal integration of EBF promotion
Harnessing mass media
Training health professionals to support EBF

POLICY RECOMMENDATIONS 13
Launching an education and awareness campaign
Expanding maternity leave
Preventing breast milk substitute marketing
Ensuring women obtain proper counseling
Mobilizing communities

IMPLEMENTATION CHALLENGES 18
Financial considerations
Continuing concerns about HIV transmission
Preventing stigmatization of women who decide against EBF

CONCLUSION 20

INTRODUCTION

While substantial progress has been made in reducing under-5 mortality in South Africa

since 2003, the current rate of 41 deaths per 1,000 live births (1) is nevertheless more than

double the 2015 target put forth in the Millennium Development Goals and higher than most

other middle-income countries. The Sustainable Development Goals (2), by comparison, call for

a reduction to less than 25 deaths per 1,000 live births in all countries by 2030. While some of

the blame can be attributed to increased morbidity and death as a result of the HIV epidemic, low

rates of exclusive breastfeeding (EBF) have significantly contributed to South Africas high rate

of child mortality (3). With only 8% of infants exclusively breastfed until they reach 6 months,

South Africa has one of the lowest rates of EBF in Sub-Saharan Africa and in the world (4).

Countries such as Malawi, Rwanda and Burundi have achieved rates of EBF in excess of 65%

even as South Africa lags behind (4). Currently, the predominant mode of feeding consists of

supplementing breast milk with some combination of formula milk, solids and herbal

preparations, despite the fact that mixed feeding is associated with increased mortality and

morbidity and higher rates of mother-to-child transmission (MTCT) of HIV (5).

Exclusive breastfeeding is associated with lower rates of child mortality primarily

because breast milk acts as a rich source of nourishment and a potent natural booster of the

infants immune system, providing significant protection against infectious diseases such as

pneumonia and diarrhea, which are the major killers of children under 5 (4). Based on this

evidence, WHO and UNICEF recommend that mothers initiate breastfeeding within one hour of

birth and exclusively breastfeed infants for the first 6 months of life. After 6 months, children

should receive safe and nutritious complementary foods in order to meet evolving needs, with

continued breastfeeding up to 2 years of age or beyond (6). WHO recommends that HIV-positive

mothers also exclusively breastfeed for 6 months and continue partial breastfeeding for one year

(7), because EBF is associated with a lower risk of postnatal HIV transmission than mixed

feeding due to the infants strengthened immune system (5). According to WHO guidelines,

HIV-positive mothers who choose to give commercial infant formula to their children should do

so only if they have access to clean running water, are willing to regularly and exclusively

formula feed for the first 6 months, and have reliable access to child health services (7). In South

Africas urban slums and rural areas, these conditions can scarcely be met because water is

unsafe and inaccessible, electricity is often unavailable, and living conditions are not conducive

to safe and regular formula feeding. While some breastfeeding is better than none for HIV-

negative women, formula presents a risk because it can weaken the childs immune protections

and cause the supply of breast milk to decrease. For HIV-positive women specifically, mixed

feeding presents an added danger because it increases the risk of transmission.

Despite clear evidence supporting EBF as the optimal feeding practice for children of

both HIV-positive and HIV-negative mothers, studies suggest that 35-50% of women in South

Africa discontinue breastfeeding altogether before 3 months after birth, and that it is common

practice to introduce complementary food for infants as young as 6 weeks old (8). This despite a

2003 study that identified EBF in the first 6 months as the single most effective intervention in

reducing child mortality, one that could prevent 13% of child deaths if adopted by 90% of

mothers (9). Supporting and promoting EBF in the first 6 months would therefore go a long way

toward meeting South Africas international commitments to reducing the burden of child health.

THE BENEFITS OF EXCLUSIVE BREASTFEEDING

BENEFITS FOR THE CHILD | As mentioned above, the risk of dying is substantially lower for

children who are exclusively breastfed as compared to children who are given mixed feeding or

only formula milk. The Lancets 2008 Series on Maternal and Child Undernutrition found that

children who were exclusively breastfed for the first 6 months were 14 times less likely to die

than children who were not breastfed at all, and 3 times less likely to die than children who were

partially breastfed (10). In another study conducted in KwaZulu-Natal, one of South Africas

poorest provinces and the epicenter of the countrys HIV epidemic, cumulative mortality at 3

months for exclusively breastfed children was estimated at 6.1% versus 15.1% for children who

were not breastfed (5), despite the fact that mothers who exclusively breastfed were of lower

socioeconomic status. EBF has a profound impact on child survival, providing a range of

developmental, cognitive, nutritional and protective elements which formula feeding does not.

Breast milk provides all the necessary nutrients, minerals and vitamins that an infant

requires to grow for the first 6 months; no additional foods or liquids (including water) are

necessary (4). In addition to providing adequate nutrition, breast milk transfers essential

antibodies, sugars and proteins from the mother to the child, building protection against

infectious diseases such as pneumonia and diarrhea (4). In fact, children who are not breastfed

are 15 times more likely to die from pneumonia and 11 times more likely to die of diarrhea than

children who are given only breast milk for the first 6 months (11). The mothers first milk-

colostrum- acts as the childs first vaccination and is considered the most potent natural immune

booster known to science (4). Colostrum strengthens and protects the intestinal lining, acts as a

laxative by helping the baby pass its early stools, and its thick consistency teaches infants how to

breathe and swallow simultaneously. Breastfeeding has also been associated with increased

cognitive development, with studies showing that breastfed children tend to score significantly

higher on behavior and intelligence tests than formula-fed children (12). Finally, breastfeeding

reduces the risk of chronic diseases such as asthma, diabetes, obesity and cardiovascular diseases

later in life (4). Promoting EBF therefore has the potential to produce substantial savings in

health care costs, even decades after a child is born.

BENEFITS FOR THE MOTHER | Breastfeeding also benefits the mother in a variety of ways, a

dimension that is often overlooked. Beyond the benefits of strong mother-baby bonding, the

babys suckling releases a hormone called oxytocin into the womans bloodstream, causing

contractions in the uterus that reduce the risk of postpartum hemorrhage, which is the leading

cause of death after delivery (4). Breastfeeding can also reduce the risk of breast and ovarian

cancer, and some studies suggest that breastfeeding as little as 6 months during a womans

reproductive lifetime could reduce the risk of breast cancer by up to 25% (4). Because

breastfeeding can cause menstrual periods to stop for several months, it acts to space

pregnancies, which is beneficial for mothers and children. Pregnancies that are spaced too close

to one another are associated with higher risks of preterm birth, lower birth weight, and placental

complications; the mothers stores of iron and essential nutrients have often not recovered in

time to feed a new baby (4). Finally, breastfeeding allows mothers to expend up to 500 calories

per day, helping them lose weight after pregnancies and thereby reducing the risk of

cardiovascular disease (4).

HIV TRANSMISSION AND EBF | In the context of South Africas high prevalence of HIV, the

fear of transmitting HIV through breast milk has complicated efforts to promote EBF. In 2001,

the South African government began providing free formula milk for children of HIV-positive

mothers until 6 months as part of its PMTCT program (13). While the policy has since been

reversed, the program speaks to the broader difficulty of balancing the risks of HIV transmission

for breastfed children against the increased risks of death from pneumonia and diarrhea in

children who are not breastfed. Seropositive women have three options: exclusive formula

feeding (EFF), mixed feeding (MF) or exclusive breastfeeding (EBF). EFF is advantageous in

that the risk of MTCT transmission is essentially eliminated, but the increased risk of death from

pneumonia, diarrhea and other infectious diseases more than offset the benefits, especially in

South Africa and other low and middle-income countries, where many households do not have

regular access to clean water. The data show that EBF is associated with substantially lower risks

of HIV transmission than MF, because foods and liquids ingested by the baby before 6 months

can damage the intestinal lining, allowing the virus to spread more easily. A study conducted in

KwaZulu-Natal in South Africa in 2007 following infants (HIV-negative at birth) born to HIV-

positive mothers confirms this: compared with exclusively breastfed children, the risk of HIV

transmission was 11 times higher for children who were given breast milk and solids and twice

as high for children who were given breast milk and formula (5). Of all possible feeding

practices, EBF is therefore unique in its ability to reduce both the probability of postnatal HIV

transmission and the risk of contracting deadly infectious diseases. Taking into account near

universal coverage of anti-retroviral drugs (ARVs) in South Africa, the risk of MTCT via

exclusive breastfeeding falls below 2% (14).

THE RISKS OF FORMULA FEEDING IN SOUTH AFRICA | Due to persisting urban-rural

inequities and high levels of poverty and unemployment, it is nearly impossible for most South

African women to meet WHOs criteria for formula feeding. Formula feeding in rural areas and

in peri-urban shantytowns can pose serious risks to the infants health, as water supplies can be

contaminated and unreliable. A 2007 study (15) that analyzed the contents of feeding bottles

prepared by HIV-positive mothers as part of South Africas PMTCT program point to the risks

of relying on formula feeding. 67% of bottles prepared at the PMTCT clinic and 81% of bottles

prepared at home were contaminated with fecal bacteria, while 57% of all milk samples were

contaminated with E. coli. Additionally, 28% of bottles prepared at the clinic and 47% of bottles

prepared at home were over-diluted, putting infants at risk of undernutrition (15). These statistics

confirm the difficulty of safely preparing replacement feeds, a meticulous process that involves

measuring, preparing, storing and cleaning, even in contexts where adequate counseling is

provided. The difficulty is compounded in rural areas, where only 11% of residents have access

to piped water, and 56% have access to electricity for cooking (16). Even when women rely on

publicly provided formula milk, supplies are frequently unreliable, making it difficult to sustain

formula feeding (17).

WHY ARE RATES OF EXCLUSIVE BREASTFEEDING SO LOW?

GOVERNMENT POLICY | In 2001, the South African government began implementing a

comprehensive PMTCT program (13). As part of the policy, HIV-positive women who chose not

to breastfeed were regularly provided free formula milk for 6 months at public health facilities. A

report evaluating the effectiveness of South Africas PMTCT program raised significant

concerns with the policy (13). First, group information sessions geared toward all mothers and

conducted prior to testing for HIV included advice on formula feeding, thereby undermining

EBF even for mothers who were not HIV-positive (13). Second, mothers who received formula

milk tended to receive more postpartum care than mothers who opted to exclusively breastfeed

their children (partly because they needed to visit health clinics in order to receive formula

supplies), perversely incentivizing mothers to choose formula feeding over breast milk (13).

Third, concerns were raised regarding the possibility that the promotion of formula feeding for

HIV-infected mothers could spill over into the broader population, leading uninfected mothers

to use formula as well (13). Indeed, many women understandably perceived the governments

provision of formula supplies for HIV-positive mothers as an implicit endorsement of

replacement feeding as a superior practice to breastfeeding. A study in neighboring Botswana

found significant decreases in breastfeeding among HIV-negative women who attended PMTCT

sites compared to women in the broader population (18). While South Africa discontinued

providing free formula milk to HIV-positive mothers in 2011, mixed signals from the

government and the policy reversal continue to have lasting effects on perceptions of

breastfeeding among South African women.

TRADITION AND SOCIOCULTURAL BELIEFS | Cultural beliefs play an important role in

shaping womens views on breastfeeding. Many women in South Africa and across the world

view breast milk as insufficient energy for their babies and feel that they are unable to produce

adequate amounts of breast milk (8). When children cry, it is often assumed that they are

unsatisfied with breast milk. Mothers in South African households must often conform to the

choices of matriarchs (often the babys grandmother) or patriarchs (husbands or grandfathers).

Grandmothers often pressure their daughters into supplementing breast milk with formula milk

and partners sometimes buy formula upon birth as a sign of support for mothers (19). Formula

milk is perceived by some as more inclusive because it allows fathers and grandparents to

participate in feeding infants, helping to relieve the mother by sharing the burden of caring for

the child (20). Younger mothers are particularly vulnerable to influence from other members of

the household because resisting family pressures requires high levels of self-confidence and

knowledge about EBF (21). Despite widespread appreciation for the benefits afforded by

breastfeeding, many do not understand how supplementing breast milk with formula milk or

other complementary foods can decrease the supply of breast milk or pose risks to the childs

health (especially in children of HIV-positive mothers). Giving muthi and other herbal

preparations for medicinal purposes is fairly popular in South Africa: in a peri-urban settlement

of Cape Town called Langa, 56% of infants received muthi before reaching 1 month, ostensibly

to resolve colic-like symptoms (8). Finally, many men and women in South Africa believe that

having sexual intercourse during lactation spoils or poisons breast milk, posing health risks to the

child and exposing parents to charges of immorality from elder members of the community (19).

THE HIV EPIDEMIC | The HIV epidemic substantially complicates the breastfeeding picture.

Because breast milk can transmit the virus to children, many HIV-positive women are

understandably reluctant to breastfeed their children. HIV-positive mothers face greater

challenges, family pressures and confusion in deciding whether to exclusively breastfeed. Faced

with competing pressure from male figures, grandmothers, and health workers, HIV-positive

mothers often struggle to preserve their decision-making autonomy. Many HIV-positive women

decide not to disclose their HIV status to family members and friends because they fear being

stigmatized, making it more difficult to explain to others why they are so reluctant to introduce

formula or additional foods into the childs diet (22). Misinformation and lack of education- a

problem that has been compounded by ever-changing guidelines and continually evolving

research- has also served to undermine EBF in HIV-positive mothers.

DIFFICULTIES WITH BREASTFEEDING | Practical difficulties with breastfeeding can interfere

with the exclusivity and duration of breastfeeding. Difficulties often occur within the first few

weeks and mostly affect women who are breastfeeding for the first time, those who are

supplementing their breast milk with other foods or liquids, and those who have received a

lower-than-recommended number of antenatal and postnatal counseling consultations. Bleeding

or cracked nipples, mastitis, abscesses and oozing of pus from the nipple or breast are all

potential complications that can lead women to begin weaning their babies before the

recommended 2 years (23). Professor Anna Coutsoudis of the University of KwaZulu-Natal says

that many health care providers lack the skills needed to offer adequate support to breastfeeding

mothers, so when problems arise- cracked nipples, babies wont suck and babies dont seem

satisfied- the mothers get bad advice. Then when they become discouraged, they are told to stop

breastfeeding altogether (14). Indeed, counseling and support are associated with a lower

prevalence of problems with breastfeeding (23), because women who have regular access to

skilled health workers have the opportunity to learn why it is better to feed on demand and

regularly in order to prevent engorgement and how to properly attach the infant at the breast.

CHALLENGES FOR WORKING MOTHERS | Despite South Africas relatively progressive

policies on maternal rights, women are given a total of 3 months with their infants, posing

difficulties for working women who decide to exclusively breastfeed for 6 months (mothers are

guaranteed 4 months of maternal leave, starting 1 month before their due date) (24). Unlike

government workers, women working in the private sector are not guaranteed full pay from their

employers during maternity leave, a factor which can discourage mothers from taking extended

time away from their jobs. Furthermore, mothers often see returning to work as incompatible

with EBF because reducing the frequency of breastfeeding tends to lower the supply of breast

milk. This is especially true in workplaces where women are often not guaranteed a private,

hygienic space to express breast milk with a pump nor facilities to store breast milk (14).

CONTINUED MARKETING OF BREAST MILK SUBSTITUTES | Another obstacle to EBF

pertains to the continued marketing of breast milk substitutes (BMS), which often falsely suggest

to mothers that formula is equally- if not more- nutritious for the baby as breast milk. Studies in

countries such as the Philippines have shown that BMS marketing is very effective in enticing

mothers to use formula, and that women were more likely to discontinue breastfeeding or begin

mixed feeding if they recalled advertising messages (25). South Africa took a step in the right

direction by passing legislation against the marketing of formula milk in 2012, but the law has

been poorly executed. A UNICEF survey found that multiple companies were violating the rules

with impunity, because the lack of monitoring mechanisms made the legislation effectively

unenforceable (26). Some formula companies have skirted the regulations by advertising

growing up milk or follow-on formula products as compatible with EBF (20). Some mothers

are still given free or discounted formula, and many health professionals persist in

recommending formula to mothers (26). Characterizations of infant feeding in mainstream print

and visual media have continued to portray breastfeeding as a practice of poor, rural women,

whereas attractive, inspirational images of formula feeding are featured prominently in

popular media, from movies to soap operas to parenting magazines (20). In sum, BMS

advertising in South Africa has created a social and cultural environment across generations that

is more supportive of formula than science would suggest is appropriate.

REVIEW OF EBF PROMOTION PROGRAMS IN OTHER COUNTRIES

HORIZONTAL INTEGRATION OF EBF PROMOTION | Historically, many health campaigns have

failed to meet expectations because of the costs associated with the development and scaling up

of novel technologies and drugs. As many countries have shown, however, it is possible to

rapidly and sustainably increase optimal breastfeeding behavior among mothers by leveraging

existing technologies and integrating EBF promotion within broader nutrition, family planning

and child survival programs as well as relevant non-health programs. In Ghana, Bolivia, and

Madagascar, this horizontal approach to EBF promotion was successfully implemented

nationwide, producing rapid and tangible increases in rates of EBF. In all three countries, a

program called LINKAGES (27) promoted EBF by adopting a four-pronged strategy. First,

NGOs, womens groups, and governments at the national and local levels coalesced around a

common agenda and agreed to diffuse clear and consistent messages to mothers about the

benefits of EBF. Second, community health workers (CHWs), volunteers, and NGO staff were

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equipped with the negotiating and counseling skills necessary to support EBF. Trainees engaged

in discussion of key messages and participated in demonstration and role-play to gain practical

knowledge. Third, the importance of behavioral change was communicated through newspapers,

radio and television, and renowned public figures helped to disseminate these messages as well.

Finally, actors at the local levels organized regular events to mobilize their communities and

increase awareness surrounding the health benefits of EBF. These events included healthy baby

contests, songs promoting breastfeeding, group counseling events and health fairs.

This combined approach allowed LINKAGES to reach sizable populations (1 million in

Bolivia, 3.5 million in Ghana and 6 million in Madagascar) and achieve impressive results (27).

Over a period of 3 to 4 years, initiation of breastfeeding within an hour of birth increased from

56% to 74% in Bolivia, 32% to 40% in Ghana, and 34% to 78% in Madagascar (27). The

percentage of children exclusively breastfed for the first 6 months also increased significantly,

rising from 54% to 65% in Bolivia, 68% to 79% in Ghana, and 46% to 68% in Madagascar (27).

Measured improvements in breastfeeding practices were seen as early as 9 months after program

launches. These results attest to both the flexibility and efficacy of adopting an integrated,

comprehensive approach to breastfeeding promotion. By relying on a mix of programs and

encouraging relevant actors to disseminate consistent messages, the program proved flexible

enough to achieve positive results in African and Latin American countries with different

sociocultural, economic and political circumstances.

HARNESSING MASS MEDIA | The breadth and increasing reach of mediums of communication

in households across the world (i.e. written press, television, radio, cellular phones, etc.)

facilitate the diffusion of messages aimed at encouraging behavioral change. Mass media

therefore provides a potent avenue to communicate messages aimed at promoting optimal

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breastfeeding practices to women, even those living in marginalized areas. Beginning in 1980,

Brazil launched a concerted national campaign to encourage mothers to breastfeed, diffusing

messages through 100 TV channels, 600 radio stations, water and electricity bills, bank

statements and newspapers (4). After conducting a baseline survey of the attitudes and feeding

practices of Brazilian women, a media strategy was carefully crafted to answer mothers specific

psychological anxieties and concerns. Actresses, prominent sportsmen, and radio personalities

were used to reassure mothers and their husbands that breastfeeding is the optimal way to feed

infants (28). The messages reached millions, and rates of EBF rose from 3.6% to over 40% (4).

More recently, Bangladesh launched a similar education and awareness campaign aimed at

creating a supportive environment for breastfeeding through TV and radio stations. Six

commercials were aired, addressing the role of fathers, stressing the importance of timely

initiation of breastfeeding, and countering the misguided perception that breast milk is an

insufficient source of energy for the child. As a result, rates of EBF rose from 43% to 65% in

program areas (4). As these countries have shown, communicating the benefits of EBF through a

multitude of mediums and channels is an effective way to catalyze large-scale behavioral change.

TRAINING HEALTH PROFESSIONALS TO SUPPORT EBF | In hospitals, maternity facilities, and

during home visits, health care personnel play a major role in influencing mothers infant feeding

practices. As a result, many EBF promotion programs across the developing world have focused

on strengthening health professionals ability to accurately communicate the benefits of EBF and

provide skilled breastfeeding counseling for mothers. Most training programs have relied on the

guidelines and educational material of the Baby Friendly Hospital Initiative (BFHI), launched in

1991 by the WHO and UNICEF and formally endorsed by South Africa in 2011. To be certified

as baby friendly, hospitals must train staff with the necessary skills to adhere to a written

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breastfeeding policy, communicate to women the benefits of EBF, assist mothers in initiating

breastfeeding within an of birth, and practice rooming-in in order to keep infants near their

mothers (29). Studies in Belarus (30), Brazil (31) (32), and South Africa (33) have demonstrated

that implementing BFHI has a measurable impact on optimal breastfeeding behavior, resulting in

higher rates of EBF and timely initiation of breastfeeding.

Some analyses (31) (34), however, suggest that a strategy that relies exclusively on

training hospital staff and implementing BFHI is insufficient in itself to ensure that gains in

optimal breastfeeding behavior are sustained for 6 months. Complementing hospital-based

breastfeeding counseling with home visits by lay community counselors or CHWs is a proven

and effective way to sustain higher rates of EBF after women are discharged from the hospital.

In Brazil, women who delivered in baby friendly hospitals and received 10 postnatal visits

were significantly more likely to exclusively breastfeed their children at 6 months than women

who delivered in the same hospitals without later receiving home visits (34). Studies in Mexico

(35) and Bangladesh (36) have also shown that, regardless of hospital counseling, a combination

of antenatal and postnatal home visits leads to major increases in rates of EBF: in Mexico City,

67% of women who received 6 home visits exclusively breastfed at 3 months compared to 12%

of women who did not receive any visits (35); in Dhaka, 70% of women who received 15 visits

exclusively breastfed at 5 months compared to only 6% in the control group (36). Integrating

hospital-based counseling with antenatal and postnatal home visits is therefore essential to

ensuring that women exclusively breastfeed their children for 6 months.

POLICY RECOMMENDATIONS
AT THE NATIONAL LEVEL

LAUNCHING AN EDUCATION & AWARENESS CAMPAIGN | Given the successes of media-

driven strategies aimed at promoting EBF in countries such as Bangladesh and Brazil, South

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Africa should launch a concerted national campaign to raise awareness of the benefits of EBF.

Consistent, straightforward, and captivating messages should be broadcast through targeted

media platforms such as television, radio, social media, newspapers, tabloids, and cellphones.

The campaign should concisely and convincingly convey the biological benefits of EBF, the

positive role that fathers and grandmothers can play in supporting breastfeeding mothers, and the

importance of initiating breastfeeding within an hour of birth. Common myths and sociocultural

beliefs that impede optimal breastfeeding behavior should be countered. To the extent possible,

voices of authority and renowned public figures- male and female- could be recruited to lend

credence to the campaign. In order for gains to prove durable, the drive to promote EBF through

media platforms should have wide geographic reach and should follow a sustained and

prolonged timeline. A strategy that harnesses the mass media and takes advantage of South

Africas high level of mobile phone penetration will effectively convey to mothers that EBF is

safe, nutritious, sufficient and immunologically advantageous. It will also equip women who are

vulnerable to influence by members of their households with the necessary confidence and

evidence to withstand family pressures. Mothers who wish to exclusively breastfeed their

children will be able to point to the governments explicit endorsement of the practice. Finally,

as more mothers begin exclusively breastfeeding, it is plausible that they might encourage their

friends and neighbors to do the same by giving them practical advice and sharing their personal

experience, a snowball effect that would amplify the messages conveyed through the media.

EXPANDING MATERNITY LEAVE | Facilitating the continuation of breastfeeding by providing a

safe and supportive environment for working mothers should be a fundamental component of

any EBF promotion strategy. Labor laws should be amended to ensure that all women in the

private sector are paid for the first 4 months of leave (starting one month prior to birth), and an

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additional 3 months of unpaid leave should be offered so that women have the option to

breastfeed their children for 6 months. With regard to women working in the informal sector,

appropriate legal recourse should be made available in order to allow mothers working in

unregulated enterprises to demand maternity leave as well. The government should also work

with different stakeholders (i.e. employers and trade unions) to clarify protections afforded to

mothers under existing law. For example, women should be made aware that they are entitled to

express and store breast milk in private, hygienic places in their workplaces.

PREVENTING BREAST MILK SUBSTITUTE MARKETING | In order to counter BMS marketing

and make clear to mothers the harmful consequences of formula feeding, I recommend that

South Africa prohibit formula companies from placing brand names, promotional messages and

pictures on products. Additionally, South Africas Department of Health should require

prominent health warnings on all breast milk substitute packaging and related products,

highlighting the increased vulnerability of formula fed children to diseases such as pneumonia

and diarrhea and emphasizing that formula milk does not contain all the nutrients and antibodies

found in breast milk. While South Africa passed a law in 2012 prohibiting BMS, more must be

done to ensure the law is appropriately enforced. Specifically, standard and stringent penalties

must be imposed on companies and individuals that violate the law, and government watchdogs

should be specifically designated to verify compliance and monitor the marketing practices of

BMS companies. The government should provide avenues for its citizens to report violations by

mail, telephone or the Internet, and it must also increase dialogue with hospitals and clinics to

ensure that women are not presented with promotional material or free samples of formula milk

within the health care system.

15


Finally, South Africa should explore whether making formula milk available only by

prescription would be a feasible and effective to encourage mothers to exclusively breastfeed.

While Iran has already taken this step, there has been very little analysis regarding the effects

and perceptions of this policy. Restricting the availability of formula milk to women who truly

require it would send a clear signal that breast is best, and it would allow health professionals

to directly answer the concerns of mothers who experience complications or have reservations

with breastfeeding. In order to have a greater understanding of these issues, South Africa should

implement a pilot program at the provincial level over 5 to 10 years in order to study womens

responses to the policy. After the pilot program concludes, a task force should evaluate its results

in order to make a determination as to whether the policy should be adopted nationwide.

POLICY RECOMMENDATIONS
AT THE REGIONAL & LOCAL LEVELS

ENSURING WOMEN OBTAIN PROPER COUNSELING | A nationwide strategy of mass

communication will produce lasting changes in breastfeeding behavior only if the health

professionals who interact with mothers reinforce messages in support of EBF. EBF counseling

and support should therefore become a core competency for health professionals (physicians,

nurses, primary care nurses, midwives, CHWs) at all levels of the health care system, from local

clinics to district hospitals. While an increasing number of hospitals in South Africa have begun

to adopt baby friendly policies with the support of the Department of Health, many others have

yet to implement the 10 steps necessary to obtain BFHI certification or to integrate BFHI

curriculum in health worker training programs (33). South Africa should provide logistical and

financial support to hospitals to train health professionals in providing consistent and accurate

information regarding the benefits of EBF and helpful assistance to help mothers initiate

breastfeeding. In order to encourage adoption of baby friendly standards, South Africa should

16


amend national regulations for health facilities to include BFHI standards and designate a BFHI

coordination group tasked with certifying hospitals that are baby friendly, regularly assessing

progress, and providing impetus and logistical support for hospitals transitioning to baby

friendly status. Additionally, every hospital should staff its maternity ward with lactation

consultants who can help women initiate breastfeeding within the first hour of life, impart

practical skills and advice, and communicate the importance and health benefits of EBF for the

first 6 months. Sustaining gains in EBF rates for the recommended 6 months will also require

expanding the tasks of existing CHWs to include EBF counseling and support. CHW training

curricula should integrate the 20-hour BFHI breastfeeding training program (29), and the CHW

program should be strengthened to ensure that all women receive antenatal and postnatal

breastfeeding guidance during home visits and in their local clinics.

MOBILIZING COMMUNITIES | The South African Department of Health should engage actors at

the local level- NGOs, nutrition advocates, municipalities, womens rights organizations, child

support groups, etc.- to harmonize messages related to breastfeeding, share educational and

promotional material, and encourage community-level mobilization activities. Emulating the

LINKAGES program adopted by Ghana, Madagascar and Bolivia, municipalities should work

with NGOs and other relevant stakeholders to fuel enthusiasm for breastfeeding in communities

by reaching women through healthy baby contests, breastfeeding promotion songs, and health

fairs or festivals to celebrate breastfeeding and promote EBF. In order to ensure women have the

adequate support to continue breastfeeding, communities should also be encouraged to

collaborate with womens organizations to create mother-to-mother peer support groups,

providing women the opportunity to share their thoughts, advice, and personal experiences with

breastfeeding. A systematic review found that integrating peer support groups in breastfeeding

17


promotion programs is an effective way to provide continuous breastfeeding support throughout

the postnatal period (37), and another study showed that infant feeding buddies helped HIV-

positive women in South Africa sustain safe infant feeding practices (38). Community activities

that celebrate and advocate EBF by engaging a diverse set of committed partners on the ground

are central to increasing engagement with mothers and their relatives at the local level.

IMPLEMENTATION CHALLENGES

FINANCIAL CONSIDERATIONS | Despite South Africas reputation as a promising emerging

economy, recent economic and fiscal trends could complicate the implementation of policies to

promote and support EBF. Economic growth has slowed to an anemic 1% and persistent deficits

have caused a near doubling of the public debt as measured against the size of the economy,

resulting in credit downgrades and loss of investor confidence (39). Some may argue that South

Africas current fiscal trajectory is not politically conducive to increased spending on media

campaigns, enforcement mechanisms, extended maternity leave and the training of health

professionals. There are two factors, however, that should encourage policymakers to make a

long-term financial investment in EBF promotion. First, implementing the aforementioned

recommendations will necessitate only accessible, inexpensive technologies and sensible

adjustments to existing legislation and training curricula. Second, durable health gains associated

with EBF provide an important opportunity to trim health spending in the long-term by reducing

the prevalence of preventable diseases such as pneumonia and diarrhea. A recent analysis (40) in

South Africa weighing the costs of promoting EBF and providing ARVs against the costs of

promoting exclusive formula feeding found that actively supporting breastfeeding is the least

costly strategy in both the urban and rural settings despite the costs of treating HIV infection.

The cost-effectiveness of EBF promotion was attributed to the high cost of providing formula

18


milk and savings due to the lower morbidity of breastfed children (40). While this study may not

apply specifically to the above recommendations, it confirms that long-term savings attributable

to better breastfeeding practices may help to mitigate the immediate costs of promoting EBF.

CONTINUING CONCERNS ABOUT HIV TRANSMISSION | Stubbornly high rates of HIV in

South Africa may represent another obstacle to convincing HIV-positive mothers to exclusively

breastfeed their children. Fostering a change in attitude for women who are hesitant to breastfeed

their children for fear of transmitting HIV will require constant and consistent messages

communicated through mediums of mass communication and by health professionals. Ensuring

that HIV-positive mothers understand EBF is the safest and surest way to reduce the risk of

postnatal transmission in the South African context should therefore be a fundamental objective

of any promotion campaign. More importantly, South Africa has already made important strides

toward mitigating concerns related to HIV transmission by dramatically increasing access to

ARVs, testing nearly 100% of pregnant women for HIV, and reducing MTCT to 2.7% in 2011

(41). Additionally, the government updated its guidelines in 2014 to provide for the immediate

initiation of lifelong ART for all HIV-positive women who are pregnant, breastfeeding or within

1 year post-partum, regardless of CD4 cell count (41). The guidelines also call for increased

HIV-testing of mothers and infants, as well as initiation of ARV prophylaxis for all HIV-exposed

infants immediately after birth (41). In the long-term, these steps will help foster a climate

conducive to EBF in South Africa by reducing the fear of postnatal HIV transmission.

PREVENTING STIGMATIZING OF WOMEN WHO DECIDE AGAINST EBF | As other countries

have shown, a substantial proportion of women continue to opt for mixed feeding regardless of

the success achieved by EBF promotion campaigns. When communicating the benefits of EBF,

training health professionals and mobilizing communities, it is therefore crucial to avoid

19


stigmatizing women who decide against exclusively breastfeeding their children. Attaching a

stigma to women who do not exclusively breastfeed could potentially lead to unsafe and

surreptitious preparation of formula, inaccurate reporting and assessments of feeding practices,

and avoidance of breastfeeding peers or health professionals who encourage EBF. The

consequences of stigma could be wide-ranging, indirectly harming infants health and

marginalizing women in the same way that HIV-related stigma complicates disclosure of HIV

status, testing, and adherence to ARVs. For these reasons, a philosophy of informed consent and

decision-making should undergird policies to promote EBF. While making clear that EBF is the

recommended and safest feeding option, health care professionals should share accurate

information and expert support so that women can make responsible feeding decisions for their

children. As more women become informed in the long-term, the benefits of EBF, especially in

the South African context, should prove compelling enough to convince most mothers that

exclusively breastfeeding for the first 6 months is the healthiest option for their child.

CONCLUSION

In order to sustainably change attitudes toward breastfeeding, South Africa will need a

coordinated national strategy and strong partnerships with employers, NGOs, health

professionals and local governments. Attaining higher rates of EBF is a goal that requires a

fundamental change in societal perceptions of breastfeeding and individual feeding behavior. As

shown in Brazil and Bangladesh, a communication strategy that harnesses mass media can

achieve wide-scale changes in feeding behavior among women by disseminating messages

extolling the benefits of EBF and dispelling the myths surrounding breastfeeding. Enforcing and

strengthening the ban on breast milk substitute marketing will complement those efforts by

ensuring mothers receive the right message about EBF. Strengthening the capacity of health

20


personnel to provide breastfeeding counseling and ensuring that hospitals are equipped to be

baby friendly will help translate and reinforce those messages on the ground during mothers

interactions with hospitals and clinics. Community mobilization events, extended maternity

leave, mother-to-mother support groups and skilled CHWs providing home-based counseling can

help ensure that positive changes in feeding behavior are sustainably maintained outside of the

health care system. These policy prescriptions will be maximally effective if they are

implemented together, providing uninterrupted support for breastfeeding women at every level

(national government, municipalities, hospitals, clinics, NGOs, etc.) and every stage (pregnancy,

birth, and the postnatal period).

Promoting EBF is perhaps the most potent and cost-effective tool in South Africas

armamentarium of health interventions. Because rates of EBF are currently so low, the gains that

can be achieved by increasing optimal breastfeeding behavior have the potential to reshape the

state of child health in South Africa by significantly decreasing child mortality and the

prevalence of preventable diseases such as diarrhea and pneumonia. Far from being incompatible

with the goal of reducing the burden of HIV, as some mistakenly assume, EBF has the potential

to further decrease MTCT by making clear to mothers the dangers of mixed feeding. Finally,

promoting EBF does not require developing or acquiring expensive new technologies, and

breastfeeding itself is free, locally sourced, and specifically tailored to the babys immunological

and energy needs. The Sustainable Development Goals, published this year, call on every

country to eliminate preventable deaths of newborns and children and reduce under-5 mortality

to at least a low as 25 per 1,000 live births (2), which is appreciably lower than South Africas

current rate. A comprehensive national program to promote EBF is perhaps the most

straightforward and proven way to reach those ambitious goals and meet South Africas

international promises.

21


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