Only 38% of children less than six months of age in the developing world are exclusively breastfed.(2) This very low rate in the uptake of a practice that contributes to the health and well-being of both the child and the mother is of utmost public health importance and requires urgent intervention. According to the United Nations Children’s Fund (UNICEF) “breastfed children have at least six times greater chance of survival in the early months than non-breastfed children.”(3) The potential impact of exclusive breastfeeding (EBF)(4) is especially important in developing countries which are characterised by a high burden of disease and low access to clean water and adequate sanitation.(5) It is said that promoting EBF is the most effective child health intervention currently feasible for implementation in low-income populations that cannot afford or sustain the use of safe infant formula.(6) This paper, part 2 of a two-part series, discusses the health implications of the attitudes towards and practices of exclusive breastfeeding, highlighted in part 1 of the series. The World Health Organisation (WHO)/UNICEF Global Strategy for Infant and Young Child Feeding (IYCF), designed and implemented to support and encourage optimal breastfeeding practices, is discussed. Finally, recommendations for the successful implementation of the strategy are presented. Health implications of the attitudes and practices of exclusive breastfeeding Poor practices of and attitudes toward exclusive breastfeeding have been reported to be among the major reasons for poor health outcomes among children, particularly in developing countries. The six causes of 90% of under-five child mortality worldwide – acute respiratory infections, diarrhoea, measles, malaria, HIV and AIDS and neonatal conditions – are easily preventable.(7) The highest levels of under-five mortality continue to be found in sub-Saharan Africa, where one in eight children die before the age of five (129 deaths per 1 000 live births) – nearly twice the average in developing regions overall and around 18 times the average in developed regions.(8) Diarrhoea, malaria and pneumonia are responsible for more than half the deaths of children under five in sub-Saharan Africa.(9) Breastfeeding strengthens children’s immunity, ensures child health and survival, and reduces their vulnerability to these diseases. Scientific evidence has shown that breastfeeding could lead to a 13% reduction in deaths of children under five, if infants were exclusively breastfed for six months and continued to be breastfed for up to one year.(10) Scientific evidence has proved that poor breastfeeding practices among HIV positive women increase the risk of HIV transmission to infants. Infant feeding is estimated to be responsible for 5-20% of the burden of HIV transmission from mother to child.(11) However, without breast milk, the reduction in the number of infants infected with HIV in sub-Saharan Africa, through the provision of a nutritionally adequate and safe diet, is challenging given the high levels of poverty that the region experiences. HIV positive mothers who can afford acceptable, sustainable and safe replacement feeding are advised to avoid breastfeeding altogether. However, this is not feasible for many women in sub-Saharan Africa, and the best alternative is for them to breastfeed exclusively. According to UNICEF, “exclusive breastfeeding for the first six months is associated with a 3-4 fold lower risk of HIV transmission as compared to mixed feeding,” as other liquids and foods given to the baby alongside breast milk can damage or irritate the infant’s already delicate and permeable intestinal wall and allow the virus to be transmitted more easily.(12) However, as observed from the review of literature, women in sub-Saharan Africa are more likely to mix feed. In an attempt to promote optimal breastfeeding practices, most countries in Sub-Saharan Africa have adopted the WHO/UNICEF Global Strategy for Infant and Young Child Feeding (IYCF). The strategy was approved in 2002 and sets the standards for global action in support of optimal breastfeeding, complementary feeding and related child nutrition and health. The strategy calls for action in the following areas: “All Governments should develop and implement a comprehensive policy on infant and young child feeding, in the context of national policies for nutrition, child and reproductive health, and poverty reduction. All mothers should have access to skilled support to initiate and sustain exclusive breastfeeding for 6 months and ensure the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond. Health workers should be empowered to provide effective feeding counselling and their services be extended in the community by trained lay or peer counsellors. Governments should review progress in national implementation of the International Code of Marketing of Breast milk Substitutes, and consider new legislation or additional measures as needed to protect families from adverse commercial influences. Governments should enact imaginative legislation protecting the breastfeeding rights of working women and establishing means for its enforcement in accordance with international labour standards.”(13) In the context of a renewed determination to address the poor uptake of optimal breastfeeding practices in a holistic manner, countries in Africa have since revised their health policies to incorporate the IYCF action areas. At present, over 30 countries in Africa, including Angola, Botswana, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe, have developed national IYCF strategies with implementation plans.(14) These IYCF strategies have been incorporated in various maternal, new-born and child policies and programmes. For instance, in Malawi in 2005, the Government developed a road map to accelerate the attainment of the United Nations Millennium Development Goals (MDGs) related to maternal and new-born health. This road map focuses on interventions to reduce maternal and child deaths. Recognising that a large number of infant deaths are attributed to the poor uptake of EBF and the introduction of mixed feeding within the first 48 hours after birth, the road map focuses on interventions such as counselling mothers on infant feeding, mothers initiating breastfeeding within half an hour after delivery, sustaining EBF for six months and ensuring the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond.(15) Likewise, Zambia, with one of the highest rates of under-five and infant mortality in Africa (119 and 70 deaths per 1 000 live births respectively),(16) developed a road map (2010 – 2015) to accelerate the reduction of maternal, new-born and child mortality rates sufficiently in order to attain the maternal and infant health MDGs by 2015. The roadmap emphasizes the importance of optimal feeding practices and highlights key intervention areas.(17) The development and implementation of Zambia’s national IYCF strategies have contributed towards improvement in the coverage of some key breastfeeding interventions, such as exclusive breastfeeding rates, the enactment of the ‘International Code on the Marketing of Breast Milk Substitutes’ into national laws, and increased capacity building of health workers to provide effective feeding counselling.(18) The implementation of the IYCF strategies has not been without challenges, however. These challenges include: delays in and the long duration of the process, mainly due to bureaucratic bottlenecks; the lack of high political motivation to drive implementation; ineffective communication to the target population; cultural practices concerning the role of mothers-in-law, grandmothers and fathers in infant feeding that hinder optimal feeding practices; nursing and medical schools not teaching adequate counselling skills; high staff turnover, particularly among healthcare staff; and low and unrealistic budget allocations that both governments and partners commit to child survival in general.(19) Recommendations One of the major challenges that most countries encounter in achieving their IYCF goals, is funding. More funds must be allocated to IYCF activities to reduce infant and child deaths through improved breastfeeding and appropriate complementary feeding practices. In addition, commitment from ministries of health is crucial for the successful development and implementation of IYCF strategies and interventions. Furthermore, health providers need to be better trained to provide counselling services. There is also great need to create awareness of optimal breastfeeding practices. Conclusion It is of utmost public health importance that optimal breastfeeding practices are practised throughout the word in order to promote the growth, survival and health of children. The promotion and acceptance of practices, such as exclusive breastfeeding, are especially important in developing countries with high levels of poverty, and which are characterised by a high burden of disease and low access to clean water and adequate sanitation. The WHO/UNICEF Global Strategy for Infant and Young Child Feeding has had positive effects on promoting optimal child feeding practices in some African countries. While great strides have been made in the promotion and uptake of optimal breastfeeding practices through the implementation o IYCF interventions, as in Zambia for example, challenges remain. Both increased funding and greater commitment from ministries of health are required for the successful development and implementation of IYCF strategies and interventions. Such funding and commitment is essential in the quest to meet the chid and maternal health related MDGs in Africa by the looming 2015 deadline. Click here to read Part 1 Written by Rita Magawa (1) NOTES: (1)Contact Rita Magawa through Consultancy Africa Intelligence’s Public Health Unit ( public.health@consultancyafrica). (2)‘Breastfeeding: Impact on child survival and global situation,’ United Nations Childrens Fund, January 2005, unicef.org. (3) ‘Nutrition: Breastfeeding’, UNICEF website, unicef.org. (4) See part 1 of this series for a definition of exclusive breastfeeding. (5) ‘Breastfeeding: Impact on child survival and global situation’, United Nations Childrens Fund, January 2005, unicef.org. (6) Jones, G., et al., 2003. How many child deaths can we prevent this year? Lancet, 362, pp. 65-71. (7) ‘Towards the UN MDG Review Summit 2010: Recommendations to the EU’, CONCORD, March 2010, bond.org.uk. (8) ‘The Millennium Development Goals Report’, United Nations, 2011, un.org. (9) Ibid. (10) Jones, G., et al., 2003. How many child deaths can we prevent this year? Lancet, 362, pp. 65-71. (11) De Cock, K.M., et al., 2000. Prevention of mother-to-child HIV transmission in resource-poor countries. Journal of the American Medical Association, 283, pp. 1175-1185. (12) ‘HIV and infant feeding’, UNICEF website, unicef.org; Kumwenda, N.I., Hoowever, R.D. and Mofenson, L.M., 2008. Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission. New England Journal of Medicine, 359, pp. 119-129. (13) ‘Global strategy for infant and young child feeding’, World Health Organisation, 2003, who.int. (14) Sagoe-Moses, C.S, et al., ‘Implementation of the global strategy on infant and young child feeding at national level in the African region: Challenges and way forward’, WHO The African Health Observatory, aho.afro.who.int. (15) ‘Road map for accelerating the reduction of maternal and neonatal mortality and morbidity in Malawi’, Ministry of Health, Republic of Malawi, October 2005, unicef.org. (16) ‘Zambia demographic and health survey 2007’, Central Statistics Office (CSO) and Macro International Inc, 2009, measuredhs. (17) ‘Road map for accelerating the attainment of the Millennium Development goals related to maternal, newborn and child health in Zambia’, Ministry of Health, Republic of Zambia, 2010. (18) Sagoe-Moses, C.S, et al., ‘Implementation of the global strategy on infant and young child feeding at national level in the African region: Challenges and way forward’, WHO The African Health Observatory, aho.afro.who.int. (19) Ibid. Edited by: Consultancy Africa Intelligence CAI
Posted on: Sun, 28 Dec 2014 14:15:01 +0000
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