Infant & Young Child Feeding Policy

Change:

The Experience of KZN Department of Health

Child Health Priorities Conference

Bloemfontein

4 December 2014

Lenore Spies: Nutrition Programme Manager

This presentation is provided on the South African Child Health

Priorities Website as presented at the 5th Child Health Priorities

Conference except that potential patient identifying content has

been removed except where part of corporate content. The

association takes no responsibility for the content of the

presentation.

KZN Infant and Young Child

Feeding Journey….

Following the December 2009 publication of

the WHO / UNICEF guidelines on an HIV and

Infant Feeding: KZN DoH in January 2011 took

the bold step ahead of National DoH to stop the

issuing of free infant formula to HIV exposed

infants… Why? How?

Estimated percentage of preventable death for

different interventions

3 Reference: How many child deaths can we

prevent this year? Lancet, 2003

Estimated under 5 deaths prevented

Preventive intervention Number of deaths (x103)

Proportion of all

deaths

Breastfeeding 1301 13% Complementary feeding 587 6%

Zinc 459 5%

Clean delivery 411 4%

Hib vaccine 403 4%

Water, sanitation, hygiene 326 3%

Antenatal steroids 264 3%

Newborn temperature management 227 2%

Vitamin A 225 2%

Tetanus toxoid 161 2%

Nevirapine and replacement feeding 150 2%

Measles vaccine 103 1%

Antimalarial intermittent preventive treatment in pregnancy 22 <1%

Under-5 Deaths Prevented Through

Achievement of Universal Coverage With

Individual Interventions

Jones G et al., Lancet 2003

5

Source: : UN Inter-agency Group for Child Mortality Estimation,2010 6

* 46

56

1721

IMR U5MR

Brazil

1990 2009

* 48

62

43

62

IMR U5MR

South Africa

1990 2009

Sources : DHS 1986, 1991 & 1996; SOWC 2009

Sources : DHS 1998, 2003

10.4 11.7

1.2 1.4

7 8.3

1998 2003

% Exclusive breastfeeding practice in South Africa

0-3 months

4-6 months

<6 months

Trend EBF < 6mo

3.7 5.8

40.3

0.5 3

12.8

2.5 4.8

29.2

40

1986 1991 1996 2003-2008

% Exclusive breastfeeding practice in Brazil

0-3 months

4-6 months

<6 months

Trend EBF < 6mo

Mortality trend in selected countries

Thank You

KZN scenario • SA National Study Preparation of Infant Formulae in Hospitals,2008

Infant formula from sealed tins tested positive for pathogens

vast majority of samples tested positive after preparation:

inadequate hygiene in feed preparation

• Issuing formula contributed to mixed feeding

• Mothers often lacked adequate resources

• HIV incidence 39,5% (Antenatal Seroprevalence Survey, 2009)

• > 50% child deaths were related to HIV

• Diarrhea & Pneumonia: 2 leading causes of death in children <5yrs

• Formula was associated with being HIV positive i.e. stigma

• Health facilities/Companies ran out of stock

• Prevention of postnatal MTCT came at the cost of excess deaths in HIV uninfected infants

• Needed to consider overall outcome i.e. how many HIV infections can be prevented as well as how many infants survive – i.e. HIV-free survival

• Revised WHO IYCF guideline (December, 2009)

– Exclusive breast feeding with ARV treatment/ prophylaxis

– Exclusive formula feeding for 6 months and continued for up to 24 months

• In addition, the new WHO guideline also recommended that national /sub-national health authorities opt for & promote a single infant feeding strategy; that would most likely give infants in the region the greatest chance of HIV-free survival

The IYCF Paradox

Main Causes of Deaths in

Children under 5 years (Saving Children, 2011)

ARI, 29%

Diarrhoea, 21%

Septicaemia, 16%

TB, 7%

Meningitis, 6%

34% were

malnourished

Preparatory work

• Advocacy begun in 2008

• Many of the studies mentioned were conducted

in SA and in KZN specifically e.g. Kesho Bora

• KZN participated in the WHO meeting ahead of

the release of the Guidelines in December 2009

• Successful PMTCT programme – Impact

Assessment (2007) following introduction of

Dual Therapy

Revised IYCF strategy

• 20th of April 2010: KZN-DOH Head of Department approved

implementation of IYCF policy revision for implementation with

effect from 1 January 2011

Exclusive breast feeding for 6 months with ARV intervention

This included a decision to stop issuing of free infant formula to mothers in

the PMTCT programme

Phased out approach

• 2 Indicators added to DHIS in April 2011

– Early breastfeeding initiation (1 hour of birth)

– Exclusive breastfeeding at 14 weeks

• Advocacy processes documented by UNICEF

Progress with implementation • District Management Advocacy

• NGO Partners Meetings for Policy Support

• Training (District & PHC trainers; Doctors; Nurses;

Lay counselors)

• Communication Strategy/Consultant (Media Brief;

Materials; Radio; District Community Dialogues)

• Provincial Health Portfolio Committee presentation

• Accelerated Plan for Implementation of MNCWH &

Nutrition Interventions at Community Level

KZN Framework for Accelerating Community-based Maternal,

Neonatal, Child and Women’s Health and Nutrition Interventions

Successes

• Extensive period of advocacy and consultation

• Management support from MEC & HOD level

• All lay councilors trained (entry point to programme)

• Partnering with Programme Managers (MCWH)

• Inputs from partners (UNICEF; WHO; UKZN-Paediatrics;

20 000+; Zoe Life; Children Rights; Africa Centre)

• Strong provincial support processes e.g. MBFI,

Breastfeeding Week Activities, budget allocation

(supplementation for lactating mothers; Radio messaging

and Outside Broadcasts)

CHALLENGES

• Limited training of Professional Nurses

• Limited advocacy at community level

• Inadequate emphasis on M & E

• Documentation of process

• “Not a National Policy” (National Policy

implemented April 2012- Tswane Declaration)

• National Support visits on PMTCT new guidelines

not in line with KZN new Policy

Progress – MBFI on track for 2015

– Provincial Guidelines on Human Milk Banking approved in 2012

targeting NICUs

– 5 established provincial HBMB in 4 districts

– Creating a Breast feeding Culture: Communication Strategy (IEC,

Radio & Print, National Breastfeeding Week)

– Capacity Building for Breastfeeding at all levels within the Health

Care system ( CCGs- Nompilo Report, UKZN 2014)

– Employment of Nutrition Advisors at All PHC facilities

– Nutrition Indicators included in Provincial Annual Performance

Plan

Infant feeding patterns in KZN at 14

weeks (2012 Impact Assessment)

Exclusive breastfeeding rates- 34,3%

Predominant breastfeeding- 2,4%

Exclusive formulafeeding- 6,7%

Mixed feeding- 56,6%

Barriers to Exclusive Breastfeeding in the first 6

months of life (Community Engagements 2013)

• Misperceptions regarding infants’ satiety, optimal nutrition &

weight gain in infants

Some mothers felt that infants did not get full on breast milk

alone

Some also cited poor milk supply and difficulty expressing milk

• Influence of community & elder family members, especially

grandmothers

• Issues of practicality when mothers were scholars or employed

away from home

51 137

32 831

25 789

18 214 16 606

0

10 000

20 000

30 000

40 000

50 000

60 000

2009 2010 2011 2012 2013

Diarrhoea with dehydration under 5 years - new ambulatory

26%

57.50%

69.10%

82.90% 81.60%

34%

63%

49.10% 49.90% 49.80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2011/12 FY 2012/13 FY 2013/14 FY 2014/15 Q1 2014/15 Q2

Infant Feeding Practices in KZN Province 2011 – 2014 (Q1 & Q2) (DHIS)

Proportion of babies having early initiation of breastfeeding Infant Exclusively breastfed at Hep B 3rd dose

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

2008/2009 2009/2010 2010/2011 2011/2012 2012/13 2013/14

Underweight for age rate under 5 years (%)

Underweight for age rate under 5 years (%)

2013/2014 Annual HOD Report

83% 84%

76%

84%

76%

71%

90% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14

MBFI Accreditated Facilities KZN 2006 - 2014

MBFI Accreditated Facilities

21.10%

18.00%

26.90% 25.90%

10.35% 9.30%

8.20%

3.60% 3.70% 4.50%

3.80%

1.50%

7.70%

4.80%

17.50%

18.90%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

1999 NFCS 2005 NFCS-FB SANHANES-1 Boys SANHANES-1 Girls

Anthropometric Status of Children in South Africa

Stunting Underweight Wasting Overweight/Obesity (2-5 years)

Anthropometric Status of KwaZulu-

Natal Children

16.0%

1.0%

4.0%

7.0%

19.0%

9.0%

4.0% 4.0%

15.1%

1.3%

5.0% 6.3%

13.5%

2.4% 3.4%

15.1% 14.4%

1.5%

20.3%

0%

5%

10%

15%

20%

25%

Stunting Wasting Underweight Overweight / Obesity

1994 – SAVACG Survey 1999- NFCS 2005 NFCS Fortification Baseline SANHANES-1 Boys SANHANES-1 Girls

KIBS – KwaZulu-Natal Initiative for

Breastfeeding Support • Commence May 2014; Complete March 2017

• Aims to: • improve breastfeeding rates,

• encourage continued breastfeeding

• improve neonatal morbidity and mortality in KwaZulu-Natal Province.

• Four key objectives: 1. Strengthen the provision of human milk banking

2. Strengthen support and promotion of breastfeeding in health institutions

3. Increase acceptability of breastfeeding and human milk banking at community level

4. Monitor and evaluate the effect of the project interventions on infant feeding practices in KZN

Ongoing Strategies to improve IYCF

• Extension of MBFI to CHCs & PHCs

• Establishment of Breast Milk Banks

• Media messaging (including social media)

• Expanding health facility support-lactation advisors

• Mentoring and support for health care workers (Quality Assurance/Quality Improvement)

• Pila Mntwana Centres & OSS War rooms

• Complementary feeding

• Home based micronutrient powders

Conclusions

• At third of mothers in KZN successfully exclusively breast

feed for the first 14 weeks

• There is an unacceptably high rate of mixed feeding of

infants under six months of age

• Implementation of the revised IYCF policy has been well

received in KZN

• Improved uptake is likely to positively impact infant

morbidity and mortality in the Province

Acknowledgements

• Premier, MEC & HOD - leadership

• Provincial Nutrition Team-commitment and

dedication

• Provincial MCWH Directorate -holding our

hands

• District Teams – Implementation

• UNICEF- unwavering support

THANK YOU