Post on 12-Apr-2018
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