PMTCT - Infant Feeding The Botswana Experience

1
PMTCT - Infant Feeding The Botswana Experience

• WABA-UNICEF Colloquium
• HIV and Infant feeding
• September 20-21st 2002
• Dr. Chewe LuoUNICEF, East and Southern African
  Regional office

2
Infant and Young Child Feeding and PMTCT
The Botswana Experience

• Background
• Needs Assessment and Analysis on IYCF Botswana
• The Infant Feeding Study
• Consensus on KEY IYCF components for accelerated
  action
• Lessons Learned
• Conclusion

3
Acknowledgement

• Food and Nutrition Unit , Family Health Division
  Ministry of Health Botswana
• PMTCT Technical Advisory Group Botswana

4
Background

• Reducing the risk of HIV transmission through
  Breastfeeding (BF) is one of the strategies of
  Botswana PMTCT
• Mothers enrolled in the PMTCT programme and their
  families are offered infant feeding (IF)
  counselling and supported in their choices
• Current IF guideline recommends HIV positive
  mothers be counselled on infant feeding and
  encourages exclusive formula feeding using cups.
• The GOB provides free infant formula to all HIV
  positive mothers for 12 months

5
Background cont.

• HIV positive mothers who choose to breastfeed
  are counselled to do so up to 6 months followed
  by safe transition to replacement feeding
• For HIV negative mothers and for those who do not
  know status exclusive breastfeeding is promoted
• A third of HIV positive mothers enrolled in the
  programme choose to breastfeed
• Stigma and socio-cultural resistance to formula
  feeding are major constraints
• The objective of the IYCF component of the PMTCT
  programme is to reduce the risk of HIV
  transmission through BF and to avoid morbidity
  and mortality related to replacement feeding

6
Needs Assessment and Analysis in IYCF - The
Infant Feeding Study

• Aims of the study
• To provide information that will contribute
  towards child survival in Botswana through
  appropriate infant feeding practices in the HIV
  epidemic
• To inform policy and provide recommendations on
  infant feeding practices to improve child
  survival in the country

7
Needs Assessment ... contd

• Methods Used
• A facility based study was conducted using a
  cross sectional questionnaire
• A total of 40 sites (urban and rural) were
  visited
• Non-PMTCT sites
• ? 186 mothers with infants 0-6mths
• ? 97 mothers with infants 7-12 mths
• ? 48 health workers
• PMTCT sites
• ? 317 mothers with infants 0-6 mths
• ? 159 mothers with infants 7-12mths
• ? 90 health workers
• ? 59 mothers on postnatal wards

8
Needs Assessmentcontd

• Summary of findings
• Adherence to EFF amongst HIV-infected women who
  choose to FF is seemingly good (89),
• EBF rates among HIV-infected women who choose to
  BF is poor (31)
• EBF rates among uninfected women at PMTCT sites
  is significantly lower than in mothers at
  non-PMTCT sites
• Theremight significant spillover of FF practices
  amongst uninfected mothers at PMTCT sites
• Complementary feeding practices are generally
  poor at all sites

9
Needs Assessment contd

• Summary
• Initial counselling perceived as satisfactory
• many women received only one session
• 35-58 received demonstration of FF preparation
• Little follow-up support, especially for BF
• CF advice is sub-optimal in all groups (57-71)
• Very little advice offered on abrupt cessation
• Early vs. later cessation of BF associated with
  engorgement (50), mastitis( 38) and criticisms
  / difficulties with family (37.5)
  Education(54-72) and water (100 urban 86 in
  rural) sanitation( 94 urban and 80 rural)
  favourable
• Most mothers are dependants

10
Needs Assessment.contd

• Summary
• FF preparation and storage poor (esp. uninfected)
• FF predominantly given by bottle
• Mothers experienced several logistic difficulties
• Ran out of FF
• Lack of privacy when dispensed FF at clinic
• Most would prefer larger tins of FF and labelled
  brands
• PMTCT trained staff knowledge regarding HIV and
  infant feeding generally poor ( only 2 hrs
  training during the 2wks PMTCT counseling course)
• But positive attitude and comfortable counselling
• shortage of staff in the clinics

11
Needs Assessment contd

• Recommendations from the study
• Improve staff knowledge on IYCF and develop their
  skills on IF counseling in the context of HIV
• Strengthen support for all Infant Feeding
  postnatals - reactivate BMFHI
• Strengthen monitoring on spill over effect,
  morbidity and mortality, repeat study in HF -
  undertake sub-study using community based
  sampling
• Increase community awareness on HIV/AIDS and on
  appropriate IFP and community support groups -
  lay counselors and FWE
• Review IF policy and approach to support breast
  feeding
• Regulate code of marketing of breast milk
  substitute

12
Consensus on key IYCF components for accelerated
action

• In partnership with WHO the UNICEF - CO prepared
  a technical paper for discussion with Minister of
  Health where UNICEF agreed to provide technical
  and financial assistance to a five pronged
  strategy on IYCF
• accelerate process of legislation regulations for
  Marketing of breast milk substitutes
• Development of an Infant Feeding Policy
• Training of health workers on HIV and IF
• Reactivation of the BMFHI
• Community mobilization for community capacity
  development for action
• UNICEF CO supported by Regional Office, New York
  and Copenhagen, mobilized technical and financial
  resources

13
Concensus..contd

• 1. Training
• WHO/UNICEF breastfeeding/HIV infant feeding
  counseling training manuals adapted to suit
  Botswana
• Strengthened capacity of a national institute to
  carry out training of trainers on IYCF
• 133 trainers from national and district levels
  underwent a two weeks training on IYCF
• District level trainers developed strategies and
  district plan of action
• District health managers to be trained to guide
  and support training in the districts
• First district training to start 8 of September
  2002 to be used as pilot where master trainers
  and other district trainers participate to refine
  methodology and logistics

14
Concensuscontd

• 2. Policy on IYCF
• Multi-sectoral committee established to develop
  policy on IYCF chaired by the PS
• Technical support mobilized from UNICEF NY and
  ESARO and IBFAN
• First draft developed and shared with relevant
  stakeholder - the document being finalized - Oct.
  2002
• Policy document to be presented to Parliament for
  endorsement before end of the year

15
Consensuscontd

• 3. Reactivation of BMFHI
• Reassessment of already certified BMFHI
  facilities
• Minister of Health launched reactivation of the
  BMFHI
• Decision to review the Ten Steps to successful
  breast feeding and the BFHI Assessment tools -
  to optimal infant feeding
• All PMTCT health facilities to be mother and baby
  friendly

16
Consensus.contd

• 4. Regulation on Marketing of Breast Milk
  Substitute
• A multi-sectoral committee drafted the Botswanas
  code of marketing of breast milk substitute
• Regulation on marketing of breastmilk substitute
  being finalized by the Attorney Generals Office
• National trainers from the Food Control unit and
  the Attorney Generals office trained on Code
  monitoring
• Advocacy and training on code monitoring to be
  initiated soon

17
Consensuscontd

• 5. Community Mobilization for CCD
• Training of Lay counselors and family Welfare
  educators on IYCF agreed up on
• Interaction at community level initiated in two
  districts more need to be done
• Work in progress with support from Regional
  Office to define community level strategy
  including capacity building at national and
  district levels

18
Lessons Learnt

• Health workers training is a resource intense
  activity
• Need to move fast in line with accelerated
  expansion
• Training of lay counselors and FWEs should
  include IF to strengthen community level support
• Advocacy and community education and mobilization
  is essential for community capacity development
• Reduction of stigma to address low uptake is a
  challenge
• Need to be alert to subtle marketing strategies
  by BMS manufacturers
• IYCF policy and regulation need to be in place
  and widely disseminated to provide legal support

19
Lessons Learned

• Involvement of male, other family members and the
  community key element to support mothers in their
  IF choices
• Cost of formula a major concern for
  sustainability
• Global review of the Ten Steps and Assessment
  Tools to reflect optimal infant feeding urgently
  needed
• Spillover effect - a serious concern with nation
  wide impact with the rollout plan
• Abrupt cessation with safe transition not well
  known by HWs should be specifically addressed
• Mixed feeding - especially with those who choose
  to BF need critical attention
• Streamlining infant formula tendering process in
  the context of the code of marketing of breast
  milk substitute is urgent
• Community based study is needed to better
  understand IFP

20
Conclusion

• Effective IYCF programme must include
• Advocacy to mobilize political commitment and
  other level support
• A clear and practical policy
• Health workers knowledge, attitude, and skills
  must be up to date,
• A functioning BMFHI in all facilities with
  maternity services,
• Regulation on the Code,
• A good supply procurement, management and
  logistics system
• Community mobilization for community capacity
  development
• Adequate and continued financial resources,

21
Conclusion

• IF choice should be based on sustainability of
  strategy
• Intervention should be culturally acceptable and
  nutritionally sound
• Replacement feeding must be individualised
  according to specific situation of the
  mother/family
• Botswana is likely to implement optimal IYCF
  programme