Best to breastfeed

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In conjunction with World Breastfeeding Week celebrated this month, we look at how far the Baby- Friendly Hospital Initiative (BFHI) has come in Penang.

It was looking to be one of the more unusual interviews I would do. Sitting in my living room and armed with the usual pen and paper, I had an extra “accessory” that I couldn’t avoid: a one-month-old baby in my lap.

The experience was slightly harrowing as my phone was due to ring at any moment with an interviewee on the line, and my newborn son was nursing on my right side. He’s usually quiet and unfussy when feeding but I’m unfortunately righthanded, which may pose problems if I need to write at the same time.

Fortunately, I was due to speak to someone who completely understood.

Children of the formula generation

Dr Afif Bahardin, the state Health Committee executive councillor, was a practising medical doctor before the last general election, but he also has “street cred” in this area as both his children are proudly, exclusively breastfed.

“There are still cultural and societal pressures that discourage breastfeeding among mothers in our country,” explains Afif. “We have had a generation during which formula milk feeding started. As a result, many among this older generation have been trained to discourage breastfeeding among their children and grandchildren. These are some of the cultural pressures that have been passed down to us,” he says, adding that aside from fierce rivalry from infant formula, a habit of using cow’s milk and goat’s milk as alternatives has further reduced the number of breastfeeding mums.

On top of all that, breastfeeding in itself is not an easy process, especially for working mothers.

“In my experience, a lot of mothers say that they can’t produce enough milk or that their babies are not ‘fat enough’ drinking just breast milk. Breastfeeding is also an activity that needs a psychological stimulus for the milk to flow, and mothers who are not able to be with their babies all of the time may find it challenging. All in all, a lot of mothers are not well-equipped with proper knowledge,” Afif explains.

Nursing on the go poses its own set of problems, and many commercial venues like department stores and malls do not provide conducive enough environments for mothers to breastfeed, he adds.

All this, Afif says, contributes to many mothers opting for infant formula to feed their children.

In fact, the third National Health and Morbidity Survey (NHMS III) from 2006, widely regarded as the country's most comprehensive study on the national rate of breastfeeding, notes that only 14.5% of mothers succeeded in exclusively breastfeeding their babies for the first six months – which is the minimum recommendation that the World Health Organization (WHO) promotes to achieve optimal growth, development and health. This, the study notes, is the case despite the proportion of women who have breastfed reaching 94.7%, which is a 6.1% increase from the 1996 NHMS II.

Lactation educator Tay Pai Lim giving a few pointers to a mother.

Baby-friendly institutions

Despite the challenges, there have been strong efforts made to increase the rate of breastfeeding in Malaysia. In 1998, the country became the third in the world, after Sweden and Oman, to have all its public hospitals accredited under the Baby-Friendly Hospital Initiative (BFHI) – a WHO and Unicef effort to implement practices that protect, promote and support breastfeeding on a global scale.

Private hospitals, however, have severely lagged behind with a mere eight establishments out of over 200 in the country receiving this certification as of 2012. Of this very short list, Penang can boast of housing only one: Penang Adventist Hospital (PAH), which celebrates its 10th anniversary of BFHI accreditation this year.

PAH lactation educator Tay Pai Lim recalls the bumpy ride towards getting BFHI-certified: “Looking at all the benefits breastfeeding can bring, our resident consultant paediatrician and neonatologist Dr Pong Kwai Meng first came up with the suggestion to seek BFHI accreditation. This was brought up to the hospital’s top management and discussed in meetings and, eventually, a steering committee was formed,” says Tay. “We then went to the Ministry of Health (MOH) to ask for the BFHI guidelines and invited them to come and give us training and advice on how to obtain accreditation.” The hospital was introduced to the 10 Steps required to officially turn PAH baby-friendly.

“When we first started BFHI policies, rooming-in was the most difficult,” admits Tay. “The hospital needed to make physical changes that needed a significant amount of funds. As babies would be in the rooms with the mothers, we needed to install CCTVs and a security door to ensure their safety. The nurses, too, experienced a lot of stress and worry having all the babies out of the nursery,” Tay says.

But that was not the extent to which rooming-in was problematic. For deliveries, mothers generally stay two nights in the hospital and, especially in private institutions, often fork out quite a bit of money for the entire episode. “Some patients and their families think, ‘I’m paying the hospital, why is the mother taking care of the baby?’ In actual fact, rooming-in is for the benefit of both mothers and babies, not the hospital,” Tay explains. “It promotes breastfeeding and also provides mothers the opportunity to observe good practices and ask questions before they go home,” she says, adding that after a decade of accreditation (which includes MOH audits every three years), rooming-in still remains the most challenging criterion of being BFHI-accredited.

Penang Adventist Hospital's breastfeeding room.

Tay believes that the additional BFHI criteria have helped raise breastfeeding rates at the hospital.

Beyond BFHI

While WHO and Unicef have formulated the basic 10 steps to successful breastfeeding, each country is open to developing extra BFHI criteria according to their needs.

Tay says that the Malaysian MOH has added three steps to which BFHI establishments must adhere: “Step 11 is a code of ethics involving infant formula in which we don’t provide any free samples or offer infant formula at discounted rates. This is to discourage the easy use of formula.

“Step 12 is mother-friendly care where we promote as natural a labour process as possible. This includes allowing mothers to eat and drink as well as move around in early labour and select their delivery position. We also try to avoid invasive procedures such as unnecessary caesareans and induction of labour unless medically indicated. All this is to try and limit possible complications or trauma to the mother and to keep her energy up and enable her to respond to the baby’s needs immediately after birth,” she says.

Finally, Step 13 details issues surrounding HIV-positive mothers and infant feeding. “With proper treatment and a caesarean delivery, the chance of infants contracting HIV from their mothers is actually only two per cent. However, this risk significantly increases if the mother breastfeeds. Through Step 13, we provide counselling to HIV-positive mothers on the risks of them breastfeeding and, in these cases, offer formula as a second option,” Tay says.

The full 13 steps may be a bit daunting initially, but Tay believes that they have helped in raising breastfeeding rates among mothers at the hospital. “We’ve conducted our own internal survey of 407 mothers that delivered here and found that 46.7% of them successfully breastfed their babies for more than six months. A total of 40% breastfed for less than that, with the remaining percentage falling under missing data,” she says.

She adds that initially, the hospital was concern that the strict BFHI policies would reduce their clientele, but thankfully, the opposite has turned out to be true. “In general, mothers are happy with a place that can support their breastfeeding efforts. We’ve also had a lot of Penang-based mothers who come to us to deliver their second or third babies after failing to fully breastfeed their earlier children. We’re happy that we’ve managed to achieve higher breastfeeding rates because, through this, we believe we get healthier babies and less sick children coming in for treatment.

“In the end, the long-term benefits are well worth the effort.”



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