When life's chaos gets in the way of breastfeeding

They say breastfeeding is the most natural thing; the most beautiful journey. Photos have been taken and the most endearing paintings drawn to show it all. At the clinic, they tell you its benefits and it all makes sense. It all sounds rosy. After all, what could go wrong?

For Mercy Mutuma, the rosy part ended all too soon. As a casual worker, who is always on the move, exclusive breastfeeding seems like a luxury she cannot afford.

Her biggest concern is how to make ends meet. The single mother of two, who also runs a grocery, can barely afford a meal a day for her family and with this comes concerns about nutrition for her and her baby. “I often go without food and this affects my milk flow. I had to introduce porridge to my baby when she was three months old as I did not have breastmilk,” she tells HealthyNation at her grocery stall in Nairobi’s Muthurwa market.

WHO and Unicef recommend breastfeeding within an hour of birth, exclusive breastfeeding for six months and continued breastfeeding with appropriate complementary feedings until children are two years old, for optimal growth and development.

Globally, nearly two out of three infants are not exclusively breastfed for the recommended six months, a rate that has remained steady for the past two decades.

PUBLIC TOILET

Ms Mutuma managed to breastfeed her first baby exclusively for six months since her husband was supporting her and could provide for the family. However, the couple separated when she was pregnant with the second child. Despite her willingness to continue breastfeeding exclusively for six months, her job would not allow it.

“Every time I go to the clinic, they tell me I have to feed the baby only on breast milk, but I can’t. I don’t have enough milk,” says Ms Mutuma, who admitted she did not reveal to the nurses she had started weaning the baby. “I got the lessons on optimal maternal and child nutrition and the importance of exclusive breastfeeding for six months, but I am unable to do so.”

Ms Mutuma represents thousands of mothers in needy situations who despite wanting to breastfeed exclusively for six months, are unable to do so because of various reasons.

For working mums, finding a calm, private area to express breast milk is often hard. Sometimes getting a place to breastfeed, especially in crowded spaces such as malls, airports or hospitals, is impossible.

Ms Leah Wangari (below), a working mother, found solace in a public toilet — the public room you want to leave as soon as you get in. But it is in the privacy of these walls, in a restaurant in Nakuru, that Ms Wangari, armed with her breast pump, went to express breast milk. “This was the easiest and most accessible place. I could not do it anywhere else to avoid the prying and judgmental eyes of people who would not understand what I was doing,” she tells HealthyNation.

Her action breathes life to sentiments shared by Dr James Nyikal, a paediatrician and former director of medical services, who in 2016 said: “Toilets and restrooms cannot be the dining areas for our babies.”

But, this was the only option for Ms Wangari. “The place was not clean, but I had to express the milk to relieve my engorged breast. I couldn’t wait to get home, sterilise the pump and express milk for my firstborn son who was then four months old,” she says.

MYTHS AND MISCONCEPTIONS
That was in 2017, but the memories of that day are still fresh in her mind. Ms Wangari says motherhood is particularly “hard for working mothers”, a factor WHO attributed to a decline in exclusive breastfeeding.
She considers herself lucky that her current employer has a room dedicated to breastfeeding mothers.
“I do not take it for granted as many women in the country don’t have this. There is a breastfeeding/expressing room on the third floor, just past our Executive Director's office. It has a comfortable seat and a small freezer to store the milk,” the mother of two shares.
So much is her commitment to the six-month rule that whenever she travels, she ensures she leaves behind enough breastmilk.
Research shows that such facilities for breastfeeding or pumping and storing breastmilk, paid maternity leave policies, as well as on-site childcare, offer additional support to mothers working outside the home. Otherwise, their children would have been denied the option of exclusively breastfeeding for the first six months.
A study done in six counties by World Vision, looking into challenges among Kenyan women around this natural practice, revealed work as a barrier to optimal breastfeeding and that it cut across social classes. Other challenges include poor nutrition for a mother, myths and misconceptions, health issues and lack of social and professional support groups.
In 2017, Buuri MP Boniface Kinoti Gatobu made a proposal to raise maternity leave from three to six months.
Marked globally on August 1 to 7, the theme of this year's World Breastfeeding Week is "Empowering parents: Enable breastfeeding", which is aimed at promoting community and societal support for parents and empowering them to realise their breastfeeding goals.

FEEDING STATIONS
The Kenya Women Teachers Association (Kewota) last week called on the government to set up breastfeeding centres. Ms Benta Opande, Kewota CEO, said this would allow women to take their children to school in the company of caregivers.

The lack of such a space nearly cost her job. “I requested a colleague to stand in and invigilate a chemistry exam for me as I went back to my house to breastfeed my baby. I had left without permission from the head teacher. My colleague, however, stepped out to go to the washroom, leaving the laboratory assistant in charge, albeit briefly. But the head teacher walked in and I was interdicted,” says Ms Opande.

Nevertheless, exclusive breastfeeding in the country has seen an improvement from 2003 where it was at 13 per cent to 32 per cent in 2009 and 61 per cent in 2014, shows the Kenya Demographic Health Survey. This is attributed to two programmes set up by the government: the Baby-Friendly Hospital Initiative and the Baby-Friendly Community Initiative. One promotes breastfeeding in hospitals at the time of delivery and the other breastfeeding in the community.

The global prevalence of exclusive breastfeeding increased from 36 per cent in 2000 to 43 per cent in 2015.
The Health Act 2017 makes it mandatory for employers to provide feeding stations for nursing mothers in the workplaces. Many establishments are now providing space, but the public sector still lags behind.

In the private sector, companies such as Safaricom, malls such as Two Rivers and Sarit Centre in Nairobi have lactation stations and nurseries where babies are cared for during working hours, which also makes it convenient for shoppers.

To prevent breast engorgement and maintain milk supply, Ms Josephine Karoki, a lactation expert, advises nursing mothers to express milk continually. She recommends cowpeas, spinach and cereals to increase milk production.

For mothers whose babies have refused to breastfeed, she advises them to still find ways of bonding with them. “Breastfeeding can be awkward, uncomfortable and unproductive in the beginning, but persistently putting the baby on the breast will stimulate milk flow,” says Ms Karoki. “Ensure you maintain the same schedule of breastfeeding. The best ways to increase milk supply is to keep nursing your little one. Your baby suckling at your breast as many times as possible is better than any other method to help your body produce more milk.”

Ms Gladys Mugambi, head of Nutrition and Dietetics at the Ministry of Health, urges women to join lactating support groups and consult an expert to address breastfeeding challenges.

Human breast milk, also known as white gold, is a matter of life and death for babies as it not only protects them from cognitive impairment, but also strengthens immunity. A drop of milk contains around one million white blood cells, which protect babies from infections and keep obesity at bay.

STORMED HOTEL

Failure to breastfeed, according to the Cost of Not Breastfeeding tool, has led to the deaths of about 595,379 babies of between six and 59 months from diarrhoea and pneumonia. A majority of the deaths were reported in Sub-Saharan Africa and lower-middle-income countries.

The findings of the global tool, published on June 24, 2019, in the Health Policy and Planning Journal, further show mothers also benefit from breastfeeding. It is estimated to avert close to 100,000 deaths from breast and ovarian cancers and type II diabetes annually, and reduces the risk of post-delivery bleeding and depression. It is also associated with a natural method of birth control (98 per cent protection in the first six months after birth).

Notably, the HIV epidemic led to a series of different recommendations on whether or not to exclusively breastfeed. For instance, in 1997, WHO advised HIV-infected mothers to avoid breastfeeding to prevent mother-to-child transmission if replacement feeding could be practised safely.

However, several studies in the early 2000s reported lower HIV transmission risk among exclusively breastfed infants compared with those who were mixed-fed (that is, breastfed and given solid foods or infant formula). In 2010, new guidelines advised exclusive breastfeeding for children of HIV-infected women on antiretroviral therapy. This recommendation was reiterated in 2016.

In May 2018, a restaurant was caught up in a storm after its staff was claimed to have ordered a woman to breastfeed her baby in a washroom. Protesters stormed the hotel and the management apologised.

The incident prompted the Nairobi County government to promise to establish breastfeeding zones in bus stops and rest areas among other public places. These breastfeeding zones are yet to be actualised.

The situation is not any better in Nairobi County offices, which still lack lactation stations to date.

Attempts by the HealthyNation to get a response or status update from the county’s Health minister Mohammed Dagane were futile as he did not answer calls or respond to text messages.

According to Maternal, Young Infants and Children Nutrition Programme Head Caroline Kathiari, only Nandi County has so far ensured breastfeeding mothers are supported at their places of work. "So far, only the Nandi County government has fully complied with the provisions of Section 72 of the 2017 Health Act and has put up lactation stations and rooms for its workers. We are still in talks with other counties to encourage them to make life easier for breastfeeding mothers at their workplaces. Their response has been encouraging and we expect more of them to comply going forward," she said.

Additional reporting by Aggrey Omboki