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Long-term solution needed to improve estate sector breastfeeding practices: Report

09 Dec 2021

  • Busy mothers urged to use expressed breast milk as opposed to formula feeding
By Ruwan Laknath Jayakody With regard to the use of the practice of expressed breast milk as opposed to formula feeding in the estate sector community, a closely monitored, long-term follow-up with repeated training and surveillance is needed. Expressing milk means squeezing milk out of the breast by hand or with the aid of a breast pump (manual or electric), so that the mother can store it in a sterilised feeding bottle, container, or special storage bag and feed it to the baby later, after defrosting and warming. This requirement was noted in a short report on “Improving the breastfeeding practices in the estate sector of Sri Lanka: A matter that needs urgent intervention”, which was authored by J.C. Ranasinghe (attached to the Kandy National Hospital), A.C. Manawaduge (attached to the Kotmale Medical Officer of Health [MOH] Office), and S.B. Agampodi (attached to the Rajarata University’s Medicine and Allied Sciences Faculty’s Community Medicine Department) and published in the Sri Lanka Journal of Child Health 50 (4) in December 2021. According to the World Breastfeeding Trends Initiative (WBTi), Sri Lanka has achieved the green status in breastfeeding in 2020, becoming the first country to do so with regard to supporting breastfeeding women. As per the Demographic and Health Survey of 2016 by the Department of Census and Statistics (DCS), 82% of infants aged zero to five months are exclusively breastfed and 92% of infants are continued on breastfeeding at one year. Even though it is debatable as to whether these numbers reflect true exclusive breastfeeding rates, these indicators are considered as the best in the world, as per S.B. Agampodi, T.C. Agampodi, and A. de Silva’s “Exclusive breastfeeding in Sri Lanka: Problems of interpreting report rates” and H.E. Ratnayake and D. Rowel’s “Prevalence of exclusive breastfeeding and barriers for its continuation up to six months in the Kandy District”. Notwithstanding these high rates, discrepancies exist in breastfeeding rates in the urban, rural, and estate sectors, as noted in the Demographic and Health Survey of 2016. With regard to the estate sector, suboptimal practices of exclusive breastfeeding are common, in particular due to the early return of mothers to work, the lack of knowledge and management skills of expressed breastfeeding, and other reasons, as explained by U. Senarath, M.J. Dibley, S.S. Godakandage, H. Jayawickrama, A. Wickramasinghe, K.E. Agho, and the South Asia Infant Feeding Research Network (SAIFRN) in the “Determinants of infant and young child feeding practices in Sri Lanka: Secondary data analysis of the Demographic and Health Survey of 2000”. Generally speaking, in order to encourage female workers returning from maternity leave, the estate management provides three months of paid maternity leave, a special allowance after child birth, crèche (a nursery where babies and young children are cared for during the working day) facilities, and the childcare homes system. The Kotmale MOH area serves a population of 67,741, including 1,065 children who are less than two years old. There are about 14 estates in this area and many of the 25 public health midwife (PHM) areas comprise entirely the estate sector population. There is one MOH, three public health instructors (PHIs), 25 PHMs, and about 50 crèche carers who are serving 40 crèche facilities. Some of the PHMs and all crèche carers are trained by the Plantation Human Development Trust while the others are from the government services. While providing routine care in the Kotmale MOH area, Ranasinghe et al. observed that suboptimal feeding practices are very high in this community. They noted that though crèche facilities encourage breastfeeding, the lack of technical skills and equipment to train mothers on expressing breast milk have led to the routine practice of bottle and formula feeding at these centres and also at home. In fact, they pointed out that expressed breast milk has never been used in these facilities and that instead, the babies that are cared for in crèche facilities receive formula (the majority), tea, coriander, cow’s milk, or other preparations, according to both desire and availability. The usual perception, Ranasinghe et al. mentioned, is that it is “difficult to change the behaviour”. Hence, in collaboration with the estate management and the Kotmale MOH, Ranasinghe et al. conducted lectures using audio visuals, practical sessions using dummies, role plays, and street dramas in order to empower PHMs, crèche carers, and mothers on expressing breast milk, storing breast milk, and feeding babies with expressed breast milk. Furthermore, a limited number of breast pumps were also provided through community participation. The strengthening of these practices was done in all 25 PHMs of the area. Thereafter, Ranasinghe et al. evaluated the situation after six months. The records kept by the carers and the MOH staff show that within this period, 36 infants aged less than six months and who should therefore have been exclusively fed on breast milk were taken care of at crèche facilities. The average time of stay at a crèche was six-and-a-half hours. Of these babies, only nine (25%) were exclusively breastfed. Of the remainder, 11 (40.7%) of the infants had received expressed breast milk, showing, therefore, that this behaviour could be introduced to this population, combined with proper training. Nevertheless, while they were in the daycare facility, 21 infants received formula feeds with or without breast milk. During their stay at home, 33 (91.7%) were exclusively breastfed, one (2.8%) was breastfed by another mother, and only two (5.6%) were receiving top-up formula milk. Ranasinghe et al., therefore, concluded that though there was a dramatic improvement in the use of expressed breast milk in the crèche following the said initiative, a significant portion of babies were still on formula feeding. Hence, closely monitored, long-term follow-up with repeated training and surveillance is, they emphasised, required until such time this practice is internalised by the estate community as their own behaviour.

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