Breastfeeding should be the norm not a privilege

In spite of her petite frame of 5 feet, 2 inches, Rosemary* had a larger-than-life personality, with bustling energy and throaty laughter. She had a full-time job and a little one at home, but she took a day off to bring her younger sister to the ante-natal clinic, sitting through the consultation and echoing all instructions.

Rosemary was sixteen when their parents died, and she had taken care of her sister Stacy* since then. Stacy was tall and slim, even in pregnancy, fashion-conscious and reserved. Having lived with HIV since birth, she had surmounted crazy hurdles to get where she was.

One day, she came home and announced that she was pregnant. For someone who wasn’t even dating, the news came as a surprise. She said she had engaged the services of a fertility specialist who had successfully taken her through intrauterine insemination using donor sperm from a sperm bank. She was six weeks along and was hoping to have a baby girl.

By the time the baby was born, Stacy had received the highest standard of care to protect her baby from acquiring HIV from the womb and at delivery. The Caesarian section was done on a Friday morning, delivering a healthy baby girl.

Throughout ante-natal care, we took a lot of time to discuss the feeding options for the baby after delivery. Stacy had the option of exclusively breastfeeding her baby for six months, a duration through which her baby would be on anti-retroviral medication to prevent HIV transmission from mummy to baby. She could also opt for alternative feeding, which would mean six weeks of anti-retroviral medication for the baby and exclusive formula feeding for six months before introduction of complementary food.

Alternative feeding confers greater protection but is not popular in the developing world due to the costs involved. It has not been encouraged among the general population for fear of the cost of formula (which may result in over-dilution to stretch a can over a longer period), and difficulty in assuring availability of clean, safe drinking water for constituting the formula. For this reason, exclusive breastfeeding has been promoted quite successfully. The risk of infection is weighed against the risk of diarrhoea and malnutrition.

However, Stacy and Rosemary had a different plan and when they brought it to us, we supported their choice after due diligence. When the little one was wheeled out of theatre to the nursery, Rosemary washed up, changed into the mother’s gown and sat down to breastfeed her niece. Stacy held and cuddled the baby, but her sister fed the little one, and would continue to do so exclusively for six months. Rosemary’s baby was five months old, so Stacy’s baby missed out on colostrum, but the cousins would share the breast as long as they pleased, just like twins. Despite her diminutive size, Rosemary had a great supply of breast milk and had already accumulated a large stock of frozen portions in her freezer for a rainy day.

 For the four days mum and baby were in the ward, Rosemary arrived by 7am, breastfed the baby and brought bottles of freshly expressed milk for the morning. She’d be back in the late afternoon to feed the baby and express enough for the night.

Her consistency and resilience left us all in awe. She did this with so much joy. Yet she did not neglect her own.

***

Let’s not shame mothers who are not able to breastfeed babies as recommended

Despite the World Health Organisation guidelines on breastfeeding and the amount of dedication put in support of breastfeeding, the changing demographics of mothers in Kenya have made it almost impossible to follow these guidelines. More and more mothers are becoming the sole breadwinners and hence do not have the luxury of sitting at home to breastfeed their babies on demand and to avoid bottles as stipulated. Very few employers provide nursing rooms and crèches at work. The irony is that the nurses and lactation specialists who work to promote breastfeeding have no facilities in their own workplace – the hospital – to express and store breast milk! On the flip side, breastfeeding advocacy has come with casualties because breastfeeding advocates carry out their role with a singleness of mind that can intimidate anyone who does not meet the laid-down standards. Not all women have equal potential for lactation. There are those who experience difficulties initiating and sustaining adequate milk for breastfeeding; those who like Stacy, are living with HIV and opt out of breastfeeding; those who do not have a supportive environment at home to enable them devote themselves to breastfeeding; those who must get back to their businesses within a few weeks so as to pay rent; those who must wake up early and leave their houses by 5am to queue outside factories to make enough money to buy food ... and many more. This special category of mothers struggles to do what they have been told is in the best interest of their babies, against a romanticised notion of breastfeeding sustainability. Unfortunately, this is an all too real situation that the guidelines have failed to address. Alongside training lactation specialists to walk the breastfeeding journey with mothers, there must be a concerted effort to incorporate the social aspect raised herein to promote breastfeeding. Let us embrace safe alternatives when it is clear that they are the only option. Otherwise, the end result would be unjust shaming of mothers who are unable comply, making a bad situation even worse!

  Dr Nelly Bosire