Bhekisisa recently published a story about breastfeeding babies born to HIV-positive mothers, “Love & other drugs: Men could make all the difference in keeping your baby HIV-free”.
The piece, like so many articles written in South Africa about breastfeeding, makes it sound so simple. Yet, as Bhekisisa noted, the 2012 South African National Health and Nutrition Examination Survey shows that only 7% of South African women manage to breastfeed exclusively for six months, despite the national guidelines.
Why is this disappointing statistic not interrogated any further, other than arguing that breastfeeding figures are low because of insufficient maternity leave?
I’m sure that most women who never make it to the six-month mark with exclusive breastfeeding will agree that it’s a bit more complicated and much harder work than just putting a nipple into a baby’s mouth and expecting them to suck.
Exclusive breastfeeding guidelines prescribe that a baby is fed nothing — not even water — for the first six months of life. When I was pregnant for the first time, I imagined I would breastfeed my baby for at least a year. I figured I would express milk and store it for my very supportive partner to feed her when I returned to work after maternity leave.
That was a dream short-lived.
After delivery, despite my baby latching and feeding well, I suffered from prolonged postpartum bleeding that never quite stopped — even after I consulted a specialist. On most days, it was minor, but on some days the bleeding was so heavy I became dizzy with anaemia.
I could hardly keep myself awake on those days and yet I had to continue breastfeeding. When the bleeding was bad, my breast milk almost dried up because that’s what the body does to compensate for a loss of fluids.
Yet I persevered. I took all the supplements I could get my hands on. I bought a breast pump and pumped in between feeds and at night. I changed my diet.
But still, my baby was not getting enough milk. She was constantly irritable and, at four months old, she was not gaining enough weight.
So I reluctantly gave in and started supplementing her feeds with formula. The change was immediate: her behaviour improved and within weeks she looked healthier.
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By the time I returned to work after five months, she was almost entirely on formula because, when babies get on to the bottle, breast milk supply declines. This happens because the baby is no longer spending as much time on the breast, which is what creates the demand for breast milk — referred to as the “top-up trap” by breastfeeding advocates.
During my second pregnancy, I was less idealistic and decided to pay closer attention to my baby’s needs. The first two months were great; there was no postpartum bleeding and the milk flowed more easily.
My baby gained weight and I was happy.
Then came the heat of a coastal KwaZulu-Natal summer with temperatures as high as 35°C. My clothes were drenched with sweat and it felt as though every glass of water I drank was leaving my body through my skin.
On one particularly bad day, after having spent almost every waking moment with my baby on my breast trying to satisfy her hunger, I became concerned that she might also be dehydrated from perspiring and not getting enough milk. I offered her a small amount of formula in a bottle and she took it in one go.
This was as much a surprise as a relief because breastfed babies don’t usually accept drinking from a bottle immediately. It can take many attempts and a lot of wasted breast milk to get a baby on to bottle-feeding. I know this because it took a long time for my first baby to learn to drink from a bottle even though it was expressed breast milk.
Breast milk is best in an ideal world, of course. And in a perfect world, a person who chooses to breastfeed their baby exclusively would have the freedom to decide how long they want to do it for and, if it were an option, how many times a day or week they would substitute breastfeeding for a bottle of expressed milk.
The foundation of successful breastfeeding requires physical and mental wellbeing and therefore breastfeeding parents should have the emotional, domestic and financial support to be able to nurse their baby for as long as they want.
Should the breastfeeding parent have to return to work, the workplace should be equipped to support lactation by providing clean and secure spaces to express and store breast milk.
South Africa, unfortunately, is far from ideal.
By law, we have the right to four months of maternity leave but labour law doesn’t guarantee this time off is paid leave. Often, maternity leave is taken a few days or even weeks before the baby is born, depending on the mother’s health, which leaves even less time to spend breastfeeding at home. As a result, working women have to start planning their return before their baby is born and often have to resume their jobs while still breastfeeding.
All this can lead to unnecessary stress and anxiety, aggravating risk factors for postpartum depression. There are no national estimates for how many women in South Africa live with postpartum depression but a small 2015 study conducted in the Western Cape found that about half of the 159 new mothers surveyed reported struggling with the condition. The research was published in the African Journal of Primary Health Care & Family Medicine. Previously, an equally small 1999 study in Khayelitsha, published in the British Journal of Psychiatry, found that about a third of mothers surveyed had postpartum depression.
Mothers who experience depression or anxiety are more likely to stop breastfeeding early — this has been shown by numerous studies including 2012 research published in the journal BMC Pregnancy and Childbirth.
I carelessly believed that as a doctor working in a public hospital — which the health department had proudly designated “baby-friendly” — I knew a lot about breastfeeding.
I had even come across a health department pamphlet that almost zealously instructed women to continue breastfeeding in response to any concerns about feeding their baby. I agree that breast milk is the best for babies, but health information that ignores real challenges is misleading and can cause unnecessary stress for new mothers.
Almost all our challenges as a country, whether it’s endemic gender-based violence, poverty or unemployment, have a bearing on how people are able to care for babies and children. Infant nutrition is an integral part of childcare and therefore support for breastfeeding parents should be more holistic and less patronising.
If, as a society, we were to view the current system as dysfunctional and unsupportive, we might be less driven to admonish or shame women who choose to stop breastfeeding and more inclined to ask how we can better help women achieve that six-month mark of exclusive breastfeeding.