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PMTCT - Infant Feeding The Botswana Experience

PMTCT - Infant Feeding The Botswana Experience. WABA-UNICEF Colloquium HIV and Infant feeding September 20-21 st 2002 Dr. Chewe Luo UNICEF, East and Southern African Regional office. Infant and Young Child Feeding and PMTCT: The Botswana Experience. Background

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PMTCT - Infant Feeding The Botswana Experience

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  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 ... 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

  8. Needs Assessment…cont’d Summaryof 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 …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

  10. 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

  11. 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

  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…..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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  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

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