Between experts and experience: Compassionate advocacy and support for exclusive breastfeeding

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Image credit: Nigeria Health Watch

These are some of the reasons Nigerian mothers give for why they are unable to exclusively breastfeed their babies in the first six months after giving birth. To experts, some of these reasons may seem like excuses, but with Nigeria’s exclusive breastfeeding (EBF) rates as low as 28%, this is far below the global goal of 50% by 2025. It is clear that Nigeria’s strategies to increase EBF rates are not be working. There are some very rare conditions that prevent a baby from being breastfeed. Yet, as Nigeria joins the rest of the world to commemorate World Breastfeeding Week 2019, our advocacy should focus on providing support to Nigerian mothers who are not exclusively breastfeeding. We must understand their reasons and put greater effort into helping them understand the incredible benefits to them and their babies from exclusively breastfeeding for 6 months.

Personal breastfeeding experiences
My challenges with breastfeeding started minutes after giving birth; my newborn had been handed to me to breastfeed and I was feeling a little like superwoman after a health worker came into the room and commended me on how well my daughter had latched on. My mother had given me several practical lessons about the right positions to achieve optimum latch, so the absence of these lessons from health workers at the hospital was not as glaring for me as it may be for others. My baby fed on both breasts for about 45 minutes each and she fell asleep.

Image credit: Nigeria Health Watch

I felt great, despite the delivery pain, until two hours later when my happy bubble burst. A nurse came in, examined me thoroughly and said those dreaded words; “Hmm… your breastmilk isn’t coming out yet. Your baby needs to eat so you will need to buy baby formula downstairs… and feed the baby every three hours until your breastmilk comes. Keep putting the baby to breast every two hours.” For me, that opening statement was so devastating that I took it to mean that I’d never be able to exclusively breastfeed my baby.

Agnes, a first-time mother, also shared how health workers at the facility where she gave birth told her to get baby formula, as she wasn’t producing enough milk. “They said my breast milk wasn’t coming out and I should get formula for her, so she wouldn’t get too weak because she had been stressed out already. They are the experts at the hospital; they should know better, so I didn’t argue.”

It seems a woman’s breastfeeding journey is sometimes inhibited at the health facility by the advice given to them by health workers. Martha, a 31-year-old first-time mother who gave birth to her baby in a public hospital shared how rough the journey was for her. She said she didn’t know how to breastfeed and nobody at the health facility told her what to do. She struggled till she got home and used her instincts and the internet to learn how to breastfeed. These are basic lessons that should be taught repeatedly at antenatal classes, culminating in the ultimate hands-on, one-on-one practical experience when a woman finally gives birth.

A huge burden rests on antenatal and after-delivery health workers to boost exclusive breastfeeding rates in Nigeria. Image credit: Nigeria Health Watch

A call to refocus breastfeeding advocacy on health workers
When a woman is not able to breastfeed, what is the appropriate protocol health workers should follow? Comrade Olubunmi Aiyedun, past president of the National Association of Paediatric Nurses suggests following the Breast Milk Substitutes (BMS) code. “The BMS code is a policy that protects, promotes and supports early initiation of exclusive breastfeeding. Using infant formula in the ward by a health care professional is against the code. Health workers are not to advertise, recommend or use breastmilk milk substitutes except on rare, dire occasions where it is well prescribed. Health care professionals are abusing the code, that is why a woman will tell you I’m not lactating, and the next thing is to give infant formula. That is against the code,” she said.

The proportion of exclusively breastfed children sharply decreases with age from birth to the second, third month and towards the sixth month of life. Aiyedun believes that the popular culture of giving water to babies under six months also stops many women from exclusively breastfeeding. Children who are given water do not breastfeed as much and this lack of demand on the breast results in the reduction of milk production, so the longer a woman goes without breastfeeding the less she thinks she can.

Image credit: Nigeria Health Watch

Apart from being nutritionally inadequate, substitutes — such as formula, other kinds of milk, or porridge — can be contaminated, exposing infants to the risk of illness and a higher risk of death. Introducing breastmilk substitutes before the age of 6 months can also discourage breastfeeding, which should be continued to at least 2 years of age. The 2018 National Nutrition and Health Survey notes that an exclusively breastfed child is 14 times less likely to die in the first six months than a non-breastfed child, and breastfeeding drastically reduces deaths from Acute Respiratory Infection (ARI) and diarrhoea, two major child killers.

There is an urgent need to refocus exclusive breastfeeding advocacy on health workers, outlining what is expected of them under the code.

Comrade Aiyedun provides three steps health workers should take when a mother’s breastmilk does not come in immediately: ‘The first step should be psychotherapy; talk to the mom to identify and resolve emotional issues, trauma and stress she might be going through; the next useful step is administering a warm massage, starting from the back of the woman’s head, down to the shoulders, back and chest. This immediately relaxes the woman, often putting her to sleep and boosting milk flow; finally, the health worker must teach good positioning so the mother can achieve good lactation. Both health worker and mother need to be patient during this process. The more the baby is put to breast, the better the milk will flow,” she said.

Image credit: Nigeria Health Watch

The need for accurate information for breastfeeding mothers
When a woman believes she is not producing enough milk or she has difficulties breastfeeding, she often turns to informal sources for information. For my friends Bolu, Agnes, Martha and Lawunmi, the internet, older women and fellow mothers were their first go-to for information about breastfeeding. Pap, coconut water, oatmeal, lactation cookies, palm wine were some of the solutions proffered to them. Lawunmi lamented; “I drank palm wine, I drank coconut water, I drank pap! My aunt came from Lagos with a truckload of pap and told me to keep taking it for my breast milk to come. I am telling you, I suffered! And at the end of the day nothing happened, it wasn’t until I started using a breast pump that my milk started coming out.”
 
Lactation cookies and other foods that supposedly increase breast milk supply are known as galactogogues. Galactogogues should never replace professional medical evaluation and counselling on modifiable factors that affect milk production. We need more professionals specifically trained to handle lactation issues. Lactation consultants in Nigeria are very few and far between. If there are specialised lactation professionals who can address immediate and long-term breastfeeding issues of women, many myths will be debunked, and exclusive breastfeeding rates will increase in Nigeria. Babymigo is attempting to help bridge that gap by providing an inventory of lactation specialists. Although the list is sparsely populated and lactation consultants on the inventory are primarily in Lagos, it is a helpful step which needs to be broadened.

NGO’s like Alive & Thrive and the Wellbeing Foundation have done extensive work to support women in breastfeeding exclusively in Nigeria. This has been through programmes which include the training of midwives to support mothers in the early initiation of breastfeeding once they give birth and encouraging optimal breastfeeding practices. Alive & Thrive looked at the economic impact of not breastfeeding and developed a cost of breastfeeding tool that showed in Nigeria over 10 million cases of diarrhoea and pneumonia could be avoided in children who are not breastfed and $22 million could be saved in healthcare costs if children were breastfed. Government support is needed in budgetary allocation to support breastfeeding policies and programmes.

I exclusively breastfed, and thankfully my lovely princess did not fall ill, she was not susceptible to any of the common infant illnesses and is developing excellently. From my experience, it is crucial that partners, employers, and health workers understand the incredible toll that exclusive breastfeeding has on women. To effectively advocate for exclusive breastfeeding, all stakeholders must realise that breastfeeding, though natural, is not as simple as opening a tap. Mothers need to be prepared and taught by skilled health workers about what to expect and how to breastfeed.

Image credit: Nigeria Health Watch

Just as health worker support and training plays a major role in ensuring that mothers start off exclusively breastfeeding, partner support is just as crucial in ensuring that mothers continue exclusive breastfeeding. It is the responsibility of partners and the wider support network that mothers have, to ensure that as they try to exclusively breastfeed, that they are not dehydrated and are able to maintain a healthy diet and remain stress-free. In addition, employers need to ensure family-friendly policies are in place, because without workplace support, exclusive breastfeeding will remain a challenge for working mothers who return to work within the first six months of giving birth.

Mothers who exclusively breastfeed are heroes and should be treated as such. Those who want to, but are struggling should be gently encouraged and supported. New mothers who have doubts about breastfeeding should be accurately sensitised to understand the benefits to their children’s health. As Ruth, another first-time mother noted, “I chose to exclusively breastfeed my children so that they won’t have to treat any infection. I realized that most of those who fed their baby with formula had to treat one infection or the other. So rather than visit the hospital, I will pay the price to breastfeed.”

Are you a breastfeeding mother or is your partner breastfeeding? Are you a health worker who attends to breastfeeding mothers? What are your challenges and successes? Share your story with us during World Breastfeeding Week! Use the hashtag #WorldBreastfeedingWeek and tag us on social media!

Discussion2 Comments

  1. This article is timely and truly health workers need to take the responsibility of keeping themselves informed. I once witnessed a ‘well meaning’ nurse torture a mother in the name of helping her hand express herbreastmilk. Something that should otherwise be a painless process. The mother was motivated to breastfeed but had to give up and give her baby formula. All because the one person who was meant to be the repository of information for her atleast was ignorant. The same goes for treatment of other challenges like inverted nipples.
    There is also the issue of bullying of mothers in some health facilities all in the name of enforcing half baked on ill informed attempts at enforcing the Baby Friendly initiative. I encourage everyone to educate themselves on the correct thing to do, health workers and patients alike without waiting for instruction from external parties. Unicef and global health media have so many free resources as videos etc online.

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