Transcript PMTCT - Infant Feeding The Botswana Experience

PMTCT - Infant Feeding
The Botswana Experience
WABA-UNICEF Colloquium
HIV and Infant feeding
September 20-21st 2002
Dr. Chewe Luo
UNICEF, East and Southern African Regional
office
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
Acknowledgement
Food and Nutrition Unit , Family Health Division
Ministry of Health Botswana
PMTCT Technical Advisory Group Botswana
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
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
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
Needs Assessment ... cont’d
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
Needs Assessment…cont’d
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
Needs Assessment …cont’d
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
Needs Assessment….cont’d
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
Needs Assessment …cont’d
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
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
Concensus…..cont’d
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
Concensus…cont’d
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
Consensus…cont’d
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
Consensus….cont’d
4. Regulation on Marketing of Breast Milk
Substitute
 A multi-sectoral committee drafted the
Botswana’s code of marketing of breast milk
substitute
 Regulation on marketing of breastmilk substitute
being finalized by the Attorney General’s 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
Consensus…cont’d
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
Lessons Learnt
 Health worker’s 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
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
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,
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