It’s been 40 years since the World Health Assembly endorsed the international code for the marketing of breast milk substitutes, and nine years since the R991 regulation came into force to control the undue pressure imposed by the infant formula industry. 

Yet globally, breastfeeding remains suboptimal.

“As we celebrate Women’s Month in South Africa we also join the National Department of Health in a long awareness campaign for protecting, promoting and supporting breastfeeding,” said Motsepe.

In her speech, Motsepe acknowledged 2021’s World Breastfeeding Week theme, Protect Breastfeeding: A Shared Responsibility, as a starting point for the nation to interrogate why a global initiative was launched to protect and support breastfeeding.

According to Dr Owen Kaluwa, the World Health Organization’s representative in South Africa, as a nation we should do better to promote breastfeeding because if we don’t it will become extinct. 

South Africa’s first lady, Dr Tshepo Motsepe, said: ‘As we celebrate Women’s Month in South Africa we also join the national Department of Health in a long awareness campaign for protecting, promoting and supporting breastfeeding.’ (Photo: Gallo Images / Sydney Seshibedi)

“Breastfeeding is central to realising the commitment of the year of action, to transform the way the world tackles the global commitment to eliminate all forms of child malnutrition that include wasting and obesity, but also acts as the baby’s first vaccine, protecting them against common childhood illnesses”, he said.

Poverty and inequality in South Africa are key elements that still need to be addressed in terms of engagement within the breastfeeding community. Rafael Pérez-Escamilla, professor of public health and director of the Maternal Child Health Promotion programme at Yale University, recommended the following to improve breastfeeding outcomes:

• Breastfeeding pre- and in-service training and provision of guidelines on how best to support breastfeeding among women throughout the country, especially healthcare workers or professionals;
• Investing in maternal-child care systems so that at every possible point of contact that is there is an opportunity for breastfeeding to be promoted, supported and protected;
• Unicef to rethink and restructure to improve substantially the promotion of babies born in baby-friendly hospitals in South Africa;
• Invest more in monitoring and evaluation so that implementation and information systems can provide timely feedback;
• Breastfeeding counselling and social support; and
• Robust presence of civil society organisations.

Protecting breastfeeding speaks to the vulnerability of women, their bodies and their role as mothers. This vulnerability is easily abused and taken advantage of when women are not empowered to make informed decisions about their children’s care. 

Professor Linda Richter, developmental psychologist and contributor at the DST-NRF Centre of Excellence in Human Development at the University of the Witwatersrand, notes that often during the first three to four months of the baby’s life they cry a lot because that is how they can best communicate. She says this causes a lot of anxiety for the mothers and families who might assume there is something wrong. The infant formula industry responds to these fears and anxieties by providing multiple sources of information to fill in the gaps in the education and training of health workers about infant development and feeding. A recent example, to which the breastfeeding community reacted very strongly, was the Free Stokvel Mom and Child Forum.

With the impact of Covid-19 on our health and healthcare system, breastfeeding protection and support has been compromised as infants and mothers are separated in hospitals over coronavirus fears. Hospitals also run out of donated breast milk. As a result infant formula proliferates as an option for feeding although it does not match breast milk and the lifetime health benefits of breastfeeding.

How do we protect breastfeeding from being eroded by infant formula marketing?

Julie Mentor of Embrace, a movement for mothers, suggested there should be more conversations around the topic of infants crying, how distressing it is, and an acknowledgement of the effect it has on mothers and families so they don’t fall into the formula trap.

Speaking from the point of view of civil society, Stasa Jordan, executive director at the South African Breastmilk Reserve, suggested a sin tax to make up for the underfunded breastfeeding sector. “Perhaps in the review of the R991 regulation, we should consider not taking marketing budget from pharmaceutical companies but taxing them like how it was done with the cigarette industries,” she says.

Dr Chantell Witten, University of the Free State and nutrition lead for SACSoWACH, said: “as SACSoWACH members we will report on the violations, as we feel that the R991 is slowly becoming part of the mainstream conversation around protecting breastfeeding.”

South Africa is four years away from the United Nations nutrition target of 50% exclusive breastfeeding by 2025. Considering the Covid-19 impact, meeting the target is extremely unlikely unless major changes are made. (Photo: independent.co.uk / Wikipedia)

Unpacking the R991 regulation, Dr Tshimi Lynn Moeng-Mahlangu, health promoter and food control personnel from the Health Department, said: “You will never find regulations that are solid without any loopholes. The gaps may be due to the acts that they are based on that may not be allowing them to regulate certain aspects. Above all there may be issues that when you were regulating were not implemented yet because the industry is innovative.”

According to Mahlangu, the R991 regulation of 2012 is due for an update since it only covers complementary feeding in terms of labelling which makes it hard to pick up some of the violations through the system. She says they are currently relying on the public health workers and civil society to inform them of any violations while they are still strengthening their monitoring tool.

South Africa is four years away from the United Nations nutrition target of 50% exclusive breastfeeding by 2025. Considering the Covid-19 impact, meeting the target is extremely unlikely unless major changes are made.

Unicef and the WHO are calling on the government, health workers and the baby formula industry to prioritise breastfeeding environments for mothers and babies by ensuring the international code of marketing breastfeeding substitutes. DM/MC

The recording of the dialogue can be viewed here.