Introduction
The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, followed by breastfeeding and complementary foods up to two years of age.(1) Breastfeeding is associated with numerous positive benefits as compared to mixed and formula feeding. These benefits include improved neurodevelopmental outcomes, decreased rates of infant mortality and sudden infant death syndrome, and decreased frequency and severity of neonatal and infant infections, particularly necrotizing enterocolitis (NEC).(2) Breastfeeding is a significant challenge in the developing world, and particularly in South Africa. Although initiation rates for breastfeeding in South Africa have improved considerably since 2011 when the State ceased provision of a free six month supply of formula to all Human Immunodeficiency Virus (HIV) positive mothers, rates of exclusive breastfeeding at six months post-partum remain low (6.8–8.3%) in comparison to other countries in Southern Africa, such as Zimabbwe (31%) and the Democratic Republic of Congon (38%).(3–6) As such, mixed feeding is the predominant norm in the South African population population, resulting in significantly increased risk for NEC and other diseases of infancy.(4,6,7)
There are no published data on new mothers’ perceptions of breastfeeding, comfort with existing lactation facilities, level of antenatal and postnatal education on and support of feeding, and attitudes towards milk banks at Chris Hani Baragwanath Academic Hospital (CHBAH). At present no formal lactation facility exists at CHBAH. We aimed to describe mothers’ perceptions of breastfeeding, comfort with existing lactation facilities, and assess attitudes towards milk banks at CHBAH.
Methods
A prospective descriptive study was performed at CHBAH by means of a confidential questionnaire administered to conveniently sampled participants. The questionnaire was administered in English and where necessary, translators were utilized. Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee and voluntary informed consent was obtained from study participants. Questionnaires were distributed to mothers whose children were admitted to the neonatal transitional and intensive care units (TICU, NICU) over a two-week period in September 2017. Data collected included participant demographics, an assessment of participant knowledge of breastfeeding, and assessment of participant attitudes toward existing lactation facilities and breast milk banks. Descriptive statistics were performed using Microsoft Excel®.
Study Site
CHBAH is the third largest hospital in the world, serving a population of 3.5 million people with a maximum capacity of 3600 beds.(8) The neonatal unit at CHBAH is made up of 180 beds, in addition to an 18-bed neonatal intensive care unit.
Results
A total of 64 mothers participated. Median age of respondents was 27 years (range 16–44 years). Majority of participants (66%, 42/64) were HIV negative, unemployed (63%, 40/64), and had two or more children (63%, 40/64). The majority of respondents had two previous pregnancies. Breastfeeding was identified as superior to formula feeding by 97% (62/64) of participants. Most respondents (73%, 47/64) correctly identified only one benefit of breastfeeding. Only 23% (15/64) correctly identified at least two benefits of breastfeeding, and no participants correctly identified all six listed benefits of breastfeeding. Benefits of breast milk as identified by respondents are presented in Figure 1.
Less than half (45%, 29/64) of participants were satisfied with existing lactation facilities at CHBAH.
With respect to education on neonatal feeding, 89% (57/64) of mothers listed both listed both family members and health care workers (nurse, doctor, feeding counsellor, or dietician) as their primary advisors, whilst family members alone were the main source of information for 11% (7/64) of respondents. Summary data on the number of prenatal counselling sessions on feeding are presented in Figure 2.
In the postnatal period, 34% (22/64) of respondents received no counselling on neonatal feeding, and 59% (38/64) received less than 3 counseling sessions.
One third of respondents (21/64) felt unprepared to make the best feeding choice for themselves and their child. Less than half of respondents (44%, 28/64) planned to exclusively breastfeed, with 28% (28/64) planning to exclusively formula feed, and 19% (12/64) planning to mix feed. Nine percent (6/64) of respondents did not indicate their feeding plan.
Most participants (67%, 43/64) had no prior knowledge of human milk banks. This said, 80% (51/64) were willing to donate their own breast milk for use by a milk bank. More than half (58%, 37/64) of the respondents reported being comfortable using milk from milk banks for their children, 28% (18/64) were unwilling to utilize milk from a milk bank, and 13% (8/64) were unsure.
Discussion
The majority of mothers identified exclusive breastfeeding as superior to formula feeding. Whilst this is encouraging, less than half (44%) planned to exclusively breastfeed. This is further tempered by participants’ paucity of knowledge on the benefits of breast milk and breastfeeding. This lack of knowledge may be due to shortcomings in pre- and post-natal counselling on feeding options provided to expectant mothers. We found that one in three respondents reported not receiving antenatal or postnatal counselling on feeding, and that one in 10 respondents relied only on family members as the primary source of advice on feeding practices. Additionally, counselling rates on feeding were worse in the postnatal relative to antenatal periods. Given that expectant mothers in the public sector should attend at least four antenatal visits as per guidelines of the National Department of Health, these findings are concerning.(9) Deficiencies in education on breastfeeding are a worrying finding and may significantly contribute to new mothers’ failure to adopt breastfeeding. Further, and despite most respondents having experienced previous pregnancies and presumably having progressed through the ante- and post-natal care process (including making feeding choices) prior to participation in this study, less than half of respondents planned to exclusively breastfeed. Disconcertingly, one third of respondents reported feeling underequipped to make optimal feeding choices for their children and less than half of respondents planned to exclusively breastfeed. Again, these findings may be due to a lack of appropriate education on optimal feeding practices. Alternative possibilities include mothers’ previous feeding practices, cultural practices that hinder breastfeeding, and economic factors that separate mother and child and prevent breastfeeding. Deficiencies in breastfeeding practices due to inadequate counselling, economic factors, discomfort with existing lactation facilities and previous experience may be addressed through a formalized lactation unit that provides a scheduled breastfeeding education program for all expectant and new mothers and their family members, facilitates the establishment of a breast milk bank, and improvements in existing lactation facilities.
Local studies have identified knowledge gaps, cultural and economic influences, inadequate breastfeeding support, and inconsistent and inadequate education as significant factors negatively influencing rates of breastfeeding.(3,4,6) Methods of improving the rates of breastfeeding and provision of breast milk include antenatal breastfeeding education, breastfeeding support programmes and breastfeeding promotion. At present, facilities for expressing mothers at CHBAH are inadequate due to a lack of privacy, challenges in mothers’ education about breastfeeding, and challenges in milk control. Mothers are required to express milk manually in a corridor in the neonatal unit. This area is not private and there are no dedicated lactation specialists assisting mothers nor is there access to breast pumps. There are no facilities to accommodate mothers that are not staying in the hospital for a medical reason or for the purpose of Kangaroo Mother Care (KMC). As such, these mothers are required to visit the hospital daily in order to express milk for their admitted children. Once milk has been expressed, it is labelled and stored appropriately. For those mothers wishing to donate milk, the necessary steps to sterilise, store and distribute the milk are taken, though volumes are extremely low. Currently donor breast milk is only available for neonates less than 1.5 kg, who are not exposed to HIV and who are less than two weeks of age, and this only for a maximum duration of two weeks. Consequently, many patients at risk of developing necrotising enterocolitis (NEC) do not qualify for access to donor breast milk thus potentially contributing to their morbidity and mortality.
More than two thirds of respondents had not previously heard of breast milk banks, yet 80% of them were willing to donate their milk for utilisation in such a facility. Encouragingly, more than half of respondents were willing to utilise milk from a milk bank if necessary. It is well known that a diet consisting exclusively of human milk reduces the risk of infectious and other diseases of newborns and infants, including NEC, sudden infant death syndrome (SIDS), allergic disease, obesity, and celiac disease.(2) Various studies have demonstrated significant decreases in the rates of NEC with the use of human milk diets, particularly in very low birth weight infants.(2,10,11)
Within the CHBAH community, there is a high prevalence of NEC.(12) Between the months of December 2015 and August 2017, an internal retrospective audit recorded 99 cases of NEC requiring surgical management (that is, external drainage, laparotomy with stoma, laparotomy with primary anastomosis, clip and drop laparotomy, or diagnostic laparotomy) (Unpublished data). Each patient with surgical NEC spent an average of 23 days in the neonatal intensive care unit, with a total of 648 days for all cases. The cost of treating surgical NEC has been calculated at approximately R500 000 per case, resulting in an estimated cost of R50 million for the cases of NEC managed surgically at CHBAH between December 2015 and August 2017.(13) There were 36 mortalities in our cohort of patients translating to a mortality rate of 36 per cent. Given that only four of the patients with surgical NEC underwent primary anastomosis and 11 were definitively managed with external drainage, it follows that the remainder (84) must have had more than one surgical procedure (including relook after clip and drop surgery, or reversal of stoma). These facts establish the immense human, financial and infrastructural burden imposed by NEC and the importance of introducing measures to prevent NEC at our institution. Given the high burden of this potentially preventable disease, low rates of satisfaction with existing lactation facilities, paucity of knowledge on breastfeeding, and low rate of expected breastfeeding we believe that an intervention is required to improve breastfeeding amongst new mothers at CHBAH.
Surgeons for Little Lives (SFLL), a registered Non Profit Company and Public Benefit Organisation operated through the Department of Paediatric Surgery of the University of the Witwatersrand, is in the process of establishing a lactation unit and breast milk bank at CHBAH in conjunction with the South African Breastmilk Reserve (SABR). Such interventions are known to have increased rates of breastfeeding internationally, and it is anticipated that the creation of a lactation unit and breast milk bank at CHBAH will significantly improve education regarding breastfeeding and breastfeeding practices in our environment.(14) In this way, we may decrease the existing burden of and costs associated with the management of preventable neonatal disease. We aim to test this hypothesis once the new facility is operational by reassessing attitudes towards breastfeeding and milk banks, and through a study of medical and surgical NEC experienced at our institution pre- and post- establishment of the lactation unit and breast milk bank.
Limitations
This study has multiple limitations including a small sample size, convenience sampling, responder bias and that it was performed at a single centre. Nevertheless, this study provides valuable information that may assist in designing future robust studies and developing programs to improve knowledge of breastfeeding and human breast milk banks at CHBAH.
Conclusion
The cost, medical, developmental, emotional, and social benefits of exclusive breastfeeding for mother and child are firmly established. Unfortunately, knowledge of breastfeeding and intended breastfeeding practices amongst mothers of neonates admitted at CHBAH are suboptimal. The establishment of a human milk bank and lactation unit at CHBAH is the first step in the journey of improving rates of breast feeding and access to breast milk in the local environment.
Author contributions
PS, NP, TG, AG, KC, PN and JL participated in concept/design, data analysis/interpretation, drafting and critical revision of article, and data collection.
