BREASTFEEDING: PRIVILEGE OR NORM?

Rosemary* fascinated me to no end when I met her. She was a huge personality rolled up in a small 5’ 2” frame, with excessive energy and a throaty laughter. She dutifully brought her younger sister to the ante-natal clinic and sat in through the consultation, echoing all the instructions given like clockwork.

She had a full-time job, with a little one at home but she took a day off from work to be there for her little sister through the pregnancy. She had literally raised her since she was sixteen when they had lost their parents. Stacy*, the younger sister, was a complete contrast. She was tall, slim even in pregnancy, fashion-conscious and quite reserved. She was completely absorbed in her career and it was even amazing that she had taken time out to be a mom. Having lived with HIV since birth, she had surmounted crazy hurdles to get where she was.

One day, Stacy came home and announced to Rosemary that she was pregnant. For someone who wasn’t even dating, this was surprising. She explained that she had decided to have a baby and 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.

Rosemary was no stranger to her sister’s unexpected decisions and she fully embraced the new status with pomp. 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 and by 9.15a.m., a healthy baby girl had been delivered.

This was where the unusual events set in. Throughout ante-natal care, we took a lot of time to discuss the feeding options for the baby after delivery. Stacy had an 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 mommy to baby. She could also opt for alternative feeding, which would then mean six weeks of anti-retroviral medication for the baby and exclusive formula feeding for six months before introduction of complementary feeds.

Alternative feeding confers greater protection but is not popular in the developing world due to the costs. It has not been encouraged among the general population for fear of the cost of formula (which may result in over-dilution of the formula 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 for this cohorts of babies quite successfully. The risk of infection is weighed against the risk of diarrheal diseases and malnutrition.

However, Stacy and Rosemary had already explored further. They brought the suggestion to us at the clinic and after undertaking due diligence, supported them in their choice. So when the little one was wheeled out of theatre to the nursery, Rosemary walked beside her incubator, entered the nursery, washed up, changed into the mothers’ gown and sat down to breastfeed her niece.

When Stacy recovered from anesthesia and was able to meet her daughter, it was a special moment between the three. She held and cuddled her baby but her sister fed the little one. She would do this exclusively for six months before adding anything else.

As her own baby was five months old, the new baby missed out on colostrum but the two would co-share the breast for as long as they pleased, just like twins would. Rosemary, despite her diminutive size, 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 mom and baby were in the ward, Rosemary arrived by seven, breastfed the baby and brought with her 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. She brought a whole new meaning to the World Health Organization recommendation for breastfeeding which outlines the following:

• Initiate breastfeeding within the first hour of life
• Exclusively breastfeed the baby without any additional food or drink, not even water
• Breastfeeding on demand; as often as the baby wants
• Do not use bottles, teats or pacifiers

The only recommendation not met was the last one.

Despite the WHO guidelines for breastfeeding and the amount of dedication put in support breastfeeding, the changing demographics of mothers in Kenya have resulted in these guidelines being an impossibility for some. More and more mothers are becoming the sole breadwinners of their homes, hence do not have the luxury of sitting at home to breastfeed the baby on demand and avoid bottles as stipulated. Very few employers have provided nursing crèches at work. The irony is that the very nurses and lactation specialists who work to promote breastfeeding have no facilities in their own workplaces in the hospital for expressing and storing of the milk!

On the reverse side of the coin is that the very practice of breastfeeding advocacy has created casualties of its own. The advocates of breastfeeding 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 to 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 from their houses by five to queue outside the factories to make enough to buy food for the other children in the house and many many more.

This special category of mothers are struggling to do what they have been told is in the best interest of their babies, against a romanticized 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 where 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!