scale-up of human milk banking in kzn -...
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SCALE-UP OF HUMAN MILK BANKING IN KZN: 2000 - 2016
Every child gets a chance
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CONTENTS01Introduction
History of human milk banking in KZN
From community to healthfacilities
The journey to the Tshwane Declaration
The significance of the Tshwane Declaration
Protecting, promoting and supporting breastfeeding
Scaling up of human milk banks
Human milk banks in KwaZulu-Natal
Key Successes
Issues to flag
The journey continues
Acknowledgements
02
06
08
10
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“From the experience of
impacting one orphan’s life,
we realised more babies
could be saved if we
could facilitate more mothers
to donate their excess breastmilk”
Prof Anna Coutsoudis
INTRODUCTION
Breastfeeding provides the optimal nutrition for growing infants and is globally considered a pillar of child survival because of its protective effects.1
The KwaZulu-Natal Department of Health, as part of the Global Strategy2 and its
strategic Plans3, includes programming to protect, promote and support breast-
feeding at all levels of the healthcare system. One aspect of this strategy is the
establishment of human milk banks to ensure a steady supply of breastmilk for
at-risk infants.
Mother’s own milk is the best option but in some cases mother’s own milk is not
available and the next preferred option is pasteurised donor human milk. A human
milk bank is a service established to screen and recruit breastmilk donors, collect
donated milk, and then process, screen, store and distribute the milk to vulnerable
infants.4 These vulnerable infants may be orphaned, premature or low birth weight
and the mother at that stage has insufficient milk or is unable to supply breastmilk.
A human milk bank’s sustainability relies heavily on the prioritization of breastfeeding
promotion to ensure the recruitment and support of mothers to donate their
excess breastmilk. The presence of a milk bank in a hospital is known to improve
breastfeeding practices.5
This document tells the story of the journey from one small community milk bank
for orphans to a human milk bank system in the province of KwaZulu-Natal (KZN).
1 World Health Organization Collaborative Study Team on the Role of Breastfeeding in the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. The Lancet. 2000;355(9202):451–455.2 United Nations Global Strategy for women’s and children’s health and nutrition 2017-2022.3 National Department of Health South Africa’s National Strategic Plan for Maternal, Newborn, Child and Women’s health (MNCWH) and nutrition 2017-2022.4 PATH A global implementation framework strengthening Human Milk Banking (2013: version 1)5 Arslanoglu S, Moro GE, Bellù R, et al. Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. Journal of Perinatal Medicine. 2013;41(2):129–131. 01
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““Never doubt that a small
group of thoughtful, committed
citizens can change the
world; indeed, it’s the only
thing that ever has.” Margaret Mead
HISTORY OF HUMAN MILK BANKING IN KZNThroughout history women (called wet nurses) have breastfed or provided breastmilk for babies whose own mothers have been unable to breastfeed them.
After the industrial revolution, due to a variety of socio-economic factors, there was
a sharp decline in the number of wet nurses. This need gave rise to the concept
of human milk banking and the first milk bank was established in Vienna, Austria,
in 1909. Many other western countries followed suit and established successful
human milk banks. Subsequently, with the aggressive marketing of infant formula
over many decades and the onset of HIV, these milk banks were closed down.
Since the late 1990s KwaZulu-Natal has been at the epicentre of the HIV pandemic
in South Africa, with the highest HIV prevalence in the country. As a result,
thousands of infants were either being abandoned when their mothers discovered
they were living with HIV or orphaned when their mothers died of HIV/AIDS.6 Prof
Anna Coutsoudis (Department of Paediatrics at the University of KwaZulu-Natal
(UKZN)) established a transitional home for these infants in November 2000. This
home was called iThemba Lethu (www.ithembalethu.org) which means “I have a
destiny” in isiZulu.
The first baby received into
iThemba Lethu’s care was
desperately ill. Prof Coutsoudis
knew - from her own research
and findings from around the
world - that if this baby was
given breastmilk his life could be
saved. A mother in the community
was willing to donate her excess
03026 Dorrington R E, Bradshaw D and Budlender D. HIV/AIDS profile of the provinces of South Africa – indicators for 2002. Centre for Actuarial Research, Medical Research Council and the Actuarial Society of South Africa. 2002.
and within a few days of receiving the donor milk he
showed remarkable recovery. Prof Coutsoudis realised
that if one baby could benefit in this way then so could
many more. The dream to have a human milk bank at
iThemba Lethu was birthed.
Prof Coutsoudis contacted the UNICEF Nutrition Officer at that time, Joan Matji and shared her dream of having a human milk bank at iThemba Lethu.
After discussions with her UNICEF colleagues, UNICEF
offered a small amount of money which could be used
as seed money. That seed money was used to establish
the iThemba Lethu community human milk bank.
In 2001 a pasteuriser was donated to iThemba Lethu human milk bank.
This pasteuriser was a huge success and once again
Prof Coutsoudis knew that if this could be done in one
orphanage it could be done elsewhere. Once more she
contacted UNICEF and they provided money to set up 2
additional human milk bank sites, one in the Western
Cape and one in Gauteng. These two human milk
bank sites have grown significantly from those early
days and are today Milk Matters (www. milkmatters.
org) based at Mowbray Maternity Hospital, in Cape
Town and the South African Breastmilk Reserve in
Gauteng (SABR)(www.sabr.org.za).
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Over the years there were many lessons to be learnt about milk banking.
The United Kingdom Association for Milk Banking (UKAMB) and the Human Milk
Banking Association of North America (HMBANA) were very supportive in sharing
their knowledge and guidelines to support the iThemba Lethu milk bank.
News spread around South Africa
about the success of iThemba
Lethu and many more human
milk banks were set up around
the country. In 2008 a group
of researchers and healthcare
professionals involved in human
milk banking formed the Human
Milk Banking Association of South
Africa (HMBASA) (www.hmbasa.
org.za) to encourage South African
human milk banks to maintain
the highest standards of safety.
Guidelines for human milk banking
were developed, based on those
used by UKAMB and HMBANA.
One person’s passion had led to the successful planting and replanting of the UNICEF seed money. Today, through the vision of the KZN Nutrition Department, many human milk banks - with the potential to save hundreds of lives - have been established in public hospitals in KZN.
04 05
Zibuyile Seme, the District Nutrition Co-ordinator and Sebenzile Simelane, HMB Co-ordinator at the installation of the Dundee Human Milk Bank
Ms SNN Nyawo (EN: Human Milk Bank) and Ms N Zulu (Lay counsellor: Human Milk Bank) putting human milk into the pasteuriser at Lower Umfolozi Regional War Memorial Hospital.
Donated human milk is pasteurised and stored in freezers until needed
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“UNICEF acknowledges
that human milk banks can
play a role in providing an
alternative feeding option
to newborns and infants,
when the best option,
breastmilk from their own mother, is not
available for a shorter or
longer period of time.”
UNICEF position
on human milk banks 22 June 2016
FROM COMMUNITY TO HEALTH FACILITIESIn 2008 Prof Miriam Adhikari, a neonatologist based at King Edward VIII Hospital, Durban, heard about the success of the human milk bank at iThemba Lethu and decided to implement a human milk bank at King Edward VIII Hospital.
Funding was received from the Carl and Emily Fuchs Foundation to set up a milk
bank. The implementation of the milk bank resulted in publications highlighting
local research around human milk banking.7,8 Initially the human milk bank used
the flash-heating method to pasteurise the donated breastmilk.8 Flash-heating
pasteurises donor milk by rapid
heating of the milk to 72°C for
15 seconds. Flash-heating the
breastmilk inactivates HIV and thus
provides the baby with breastmilk
that is free of HIV, is nutritious
and immunologically beneficial.9
This method of flash-heating did
not have adequate temperature
monitoring so research was done
on how to improve this method
to ensure appropriate quality
assurance.
Program for Appropriate Technology in Health (PATH) and The University of
Washington, Seattle collaborated with HMBASA to adapt an affordable system
to monitor human milk pasteurisation via a temperature probe connected to an
Android phone. This system was named FoneAstra.
In 2012 use of this system was piloted at King Edward VIII Hospital and Mahatma
Gandhi Memorial Hospital. With the success of these 2 milk banks, additional
7 Coutsoudis I., Petrites A., Coutsoudis A. Acceptability of donated breast milk in a resource limited South African setting. International Breastfeeding Journal 2011, 6:3 http://www.internationalbreastfeedingjournal.com/content/6/1/38 Coutsoudis I., Adhikari M., Nair N., et al. Feasibility and safety of setting up a donor breastmilk bank in a neonatal prem unit in a resource limited setting: An observational, longitudinal cohort study. BMC Public Health 2011, 11:356 http://www.biomedcentral.com/1471-2458/11/3569http://www.ucdmc.ucdavis.edu/welcome/features/20070620_flashheated_breastmilk/
funding was received to implement more milk banks.
This is described further in this document.
0706
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THE JOURNEY TO THE TSHWANE DECLARATIONPrior to the rollout of comprehensive Prevention of Mother-to-Child Transmission
(PMTCT) treatment interventions, many mothers living with HIV had faced a stark
choice: to breastfeed their babies, and risk passing on HIV through their breastmilk;
or to formula feed, and risk their infants dying from diarrhoea, pneumonia and
malnutrition because they are deprived of the nourishment, natural immunity and
protection of breastmilk.
From 2005 to 2008 the Kesho Bora study was conducted in five sites in Africa.
One of these sites was in KwaZulu-Natal. The purpose of the study was to assess
whether the risk of HIV transmission during breastfeeding could be safely reduced
by providing a combination of three Anti-retroviral drugs (ARVs). The findings from
this study showed that triple-ARV regimen cuts HIV infections in infants by 43% and
a 54% reduction in the risk of HIV transmission during breastfeeding.10
The Director of Nutrition at
the KwaZulu-Natal Provincial
Department of Health, together
with public health scientists at
UKZN, started the process of
motivating for the revision of the
Provincial Infant and Young Child
Feeding (IYCF) policy to stop the
supply of free formula for mothers
on the PMTCT programme. This
was supported by the Provincial
Head of Department (HOD) and
the Members of the Executive
Council (MEC) but was also met
with opposition at some levels.
Those involved in motivating for
the stopping of formula knew
from evidence based research11,12
that this bold change in policy would ultimately result in saving the lives of many
thousands of infants.
“The KwaZulu-Natal Department of Health has made great strides in increasing the survival of our infants and young children in the Province. One of the evidence-based strategies employed was to improve the breastfeeding rates of mothers to 45% at 14 weeks (2015) primarily through consistent messaging regarding breastfeeding for all mothers irrespective of their HIV status.”
Ms Lenore Spies, Director: Integrated Nutrition Programme, KZN Department of Health.
Preparation for this change was done at a Provincial and District level with
aggressive advocacy, partnership, financial commitment and political will. On 20
April, 2010 the amended provincial IYCF policy was released. The most significant
changes were that mothers living with HIV would be encouraged to exclusively
breastfeed for 6 months and receive ARVs to lower the chance of HIV transmission
(and their babies would receive prophylaxis); and free formula would no longer be
issued to mothers on the PMTCT programme.
Extensive updated training on the new IYCF policy was provided to all levels of staff
across the province. A communication strategy was implemented to ensure the
effective communication of exclusive breastfeeding with ARVs for mothers living
with HIV. The IYCF policy was integrated into other existing Provincial Department
of Health strategies.
The biggest challenge at this stage was that the stopping of free formula was not
yet a National Department of Health policy. Many questions were raised by civil
society, academics and health professionals on this change in policy. The National
Department of Health requested a National Breastfeeding Consultative Meeting in
August 2011 to discuss these many issues. This meeting resulted in the Tshwane
Declaration of support for breastfeeding in South Africa.13
10 World Health Organization 2011 Department of Reproductive Health and Research Policy brief on Kesho Bora Study. Preventing mother-to-child transmission of HIV during breastfeeding. (WHO/RHR/11.01) http://www.who.int/reproduc- tivehealth/topics/rtis/mtct/en/index.html11 Coutsoudis A, Goga AE, Rollins N, et al. Free formula milk for infants of HIV-infected women: blessing or curse? Health Policy and Planning 2002; 17(2): 154-160.12 Coutsoudis A, Coovadia HM, Wilfert CM. HIV, infant feeding and more perils for poor people: new WHO guidelines encourage review of formula milk policies. Bull WHO 2008; 86: 210-214.13 National Department of Health, 2011. Tshwane Declaration of support for breastfeeding in South Africa. South African Journal of Clinical Nutrition, 24 (4):214. 0908
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THE SIGNIFICANCE OF THE TSHWANE DECLARATION The National Breastfeeding Consultative Meeting was attended by international support partners, healthcare workers that included the leadership within the Department of Health, non-governmental organisations, academics, traditional leaders, traditional health practitioners and civil society.
The objective of this meeting was to build consensus on policy and programme
changes to protect, promote and support breastfeeding in the context of HIV
and AIDS.
This consultative meeting was a very significant milestone for the future of breast-
feeding and human milk banking in South Africa.
Some of the strategic decisions made at this meeting included:
1. The South African National Department of Health (NDOH) resolved to actively
protect, promote and support exclusive breastfeeding.
2. Adopting the 2010 WHO guidelines on HIV and Infant Feeding, recommending
that all mothers living with HIV should breastfeed their infants and receive ARVs
to prevent HIV transmission.
3. Finalising and adopting into legislation the national regulations on the
International Code of Marketing of Breastmilk Substitutes.
4. Review of legislation regarding maternity leave and maternity protection, and
an enabling workplace that protects, promotes and supports breastfeeding.
5. To promote and support human milk banks as an effective approach to reduce
early neonatal and post-natal morbidity and mortality for babies who cannot
breastfeed.
6. Implementation of the Baby Friendly Hospital Initiative (BFHI) and Kangaroo
Mother Care
Since 2011 the KwaZulu-Natal Department of Health
has strategically and systematically implemented each
of the recommendations from the Tshwane Declaration.
The strategies that had the biggest impact on child survival
were implemented immediately, preparing a platform to
implement the remaining interventions concurrently.
““Over and
over again,
research has
shown that
breastfeeding
is the most
effective
child survival
strategy”Dr Aaron Motsoaledi,
Minister of Health of South Africa
1110
Dr Aaron Motsoaledi, Minister of Health of South Africa
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1. HIV and Infant Feeding guidelines: In 2010 the revised HIV and Infant Feeding
guidelines were implemented to ensure all mothers living with HIV would
exclusively breastfeed for the first 6 months, with the provision of ARVs for the
mother and infant while breastfeeding.
2. As of 1 January 2011 a phased out approach for the stopping of routine issue of free formula within the context of HIV was implemented.
3. Mother and Baby Friendly Initiative: In 2011 the Baby Friendly Hospital Initiative
(BFHI) was rebranded the Mother and Baby Friendly Initiative (MBFI) to include
the mother and to ensure the initiative also extended into the community.
Extensive training and mentorship was provided across the Province to ensure
that health facilities reached the required standards for MBFI accreditation.
To date 54 health facilities in KwaZulu-Natal have been MBFI accredited.
Since 2012 Ilembe District has consistently maintained their MBFI accreditation
regionally and at all 3 district hospitals.
4. Foodstuffs, Cosmetics and Disinfectants Act, 1972: Regulations of foodstuffs for infants and young children (R991): In 2012 the International Code of Marketing
of Breastmilk Substitutes (the Code) was legislated under the Foodstuffs,
Cosmetics and Disinfectants Act, 1972(R991). The Code is stringently enforced
and the KwaZulu-Natal Provincial Department of Health has monthly meetings
with relevant companies to ensure Code and Regulations R991 compliance.
In addition to this, the provincial office is supported by nutrition and dietetic
team members who monitor implementation of the Code and Regulations R991.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%FY 2006/07
83% 84% 84%
90% 91%94% 94%
76% 76%71%
FY 2007/08 FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2014/15
PROTECTING,PROMOTING AND SUPPORTING BREASTFEEDINGAs an ongoing strategy, in 2011 the KwaZulu-Natal Provincial Department of Health recommitted to protect, promote and support breastfeeding.
There were key interventions that needed to be put in place. Many of these
interventions were interlinked and the interventions with the bigger impact on child
survival were prioritized for implementation. These interventions were:
1312Protect, Promote and Support Breastfeeding
KZN DOH MBFI accredited sites 2006 – 2016
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Violations are reported to the provincial office for further communication to the
Deputy-Director General for Health in the National Department of Health.
Violations relate to the retail market but also include marketing and promoting
of designated products such as infant formula, bottles and teats on social
media and in mass media advertisements.
5. National Infant and Young Child Policy in the context of HIV: In 2013 the
updated National Infant and Young Child Policy was implemented. Extensive
training was provided in KZN to ensure all healthcare workers were
communicating and implementing the same messages.
6. Workplace feeding rooms and community support: The KZN Department of
Nutrition under the auspices of the
Office of the Premier is planning
interventions for the set-up of
feeding rooms for staff within
public sector workplaces.
7. Implementation Research: The Province has partnered with
various bodies to conduct research.
8. Breastfeeding advocacy and communication: Breastfeeding
advocacy is ongoing. World
Breastfeeding Week is celebrated
globally, each year, during the first
week of August. It is a key annual event in facilities and communities
in KwaZulu-Natal. Districts link with other government departments and
developmental partners, and community support is mobilised. One such
successful event was held in 2016 in the uMzinyathi District. The district had
active participation from the subdistrict team, clinics, the community caregiver
corps and the community.
9. Human milk banks: Human milk banks could not be implemented at facilities
until there was a culture of breastfeeding amongst facility staff and the general
public. In 2012 the Department of Health began negotiations to establish the
KwaZulu-Natal Initiative for Breastfeeding Support (KIBS) project.
“The Human Milk Banks are of significant benefit to mothers and babies as human milk is donated for vulnerable and sick babies who cannot access their mothers’ own milk. This reduces early neonatal and postnatal morbidity and mortality for babies and is part of the Child Survival Strategy for the Department.”
2016 BUDGET VOTE SPEECH by KZN Health MEC, Dr
Sibongiseni Dhlomo at the KwaZulu-Natal Provincial
Legislature
““The
KwaZulu-Natal
Department
of Health has
made great
strides in
increasing
the survival of
our infants
and young
children in the
Province.”Ms Lenore Spies,
Director: Integrated Nutrition Programme,
KZN Department of Health.
15
Dr Sibongiseni Dhlomo (MEC KZN) officially opening the human milk bank at Lower Umfolozi Regional War Memorial Hospital.
14
Stanger Hospital’s human milk bank Community Awareness Event
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SCALING UP OF HUMAN MILK BANKS During Breastfeeding Week in 2014, the KIBS project was launched. The aim of the project was to improve breastfeeding rates, encourage continued breastfeeding and reduce neonatal morbidity and mortality in the KwaZulu-Natal Province. The objectives of the project were:
1. To strengthen the provision of human milk banking to increase access to human
milk for sick and small neonates
2. To strengthen the support and promotion of breastfeeding in health institutions
3. To develop and implement an advocacy and communication campaign that
included community engagement
4. To monitor and evaluate the effect of the project interventions on infant feeding
practices in KwaZulu-Natal
Key factors that contributed to the introduction and successful scale-up of human
milk banks were:
Provincial government leadership
Established policy framework
Comprehensive advocacy within the Department of Health
Relationships with partners
Capacity development for breastfeeding support
Training of milk bank teams
Community awareness
Provincial government leadership
The Provincial Department of Health had done extensive work laying the foundation
for protecting, promoting and supporting breastfeeding. The scale-up of milk banks
could only be implemented once this foundation had been laid.
The first step was the development of the
“Guidelines for the Establishment of Human Milk
Banks in the KwaZulu-Natal Province.”
The strategy adopted for the scale-up of the milk
banks was to implement a central human milk
bank in each of the 11 districts of KwaZulu-Natal
at a regional or tertiary hospital, with satellite
human milk banks in surrounding hospitals.
Established policy framework
Following the 2011 Tshwane Declaration, the
National Implementation Framework highlighted
the role human milk banking would play in
improving breastfeeding rates. However, there
was no existing policy framework for this. One
had to be created. The KwaZulu-Natal Provincial
Department of Health consulted with HMBASA,
taking the lead to draft the Provincial guidelines
for the implementation of human milk banks
following consultation with key stakeholders.
Once the Human Milk Bank Guidelines were completed the Department of Health began
the process of compiling the human milk bank implementation framework. The framework
described how the implementation would proceed to achieve the scale-up of human milk
banks.
Comprehensive advocacy within the Department of Health
Prior to the implementation of the human milk banks, there was a programme of advocacy
(sharing and ensuring the vision and objectives for the milk banks was known) aimed at all
levels of management at the Provincial Department of Health. This ensured that human milk
banking would be integrated into and supported by all programmes at a provincial level.
The Provincial Department of Health communicated with the District Health Management
Teams on the scale-up of human milk banks. The Provincial and District Health Management
Teams assisted in identifying hospitals that would benefit from having a human milk bank.
These Provincial and District teams communicated with the hospital management on the
proposed implementation of a human milk bank. Meetings were held with each of the
hospitals’ management teams to discuss the benefits of a human milk bank and the financial
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and physical steps necessary for successful implementation. Once there was
support and buy in from the hospital management, site visits were conducted
and the hospitals were provided with training, support and mentorship on the
implementation of milk banks.
Community advocacy was done via community awareness events.
Relationship with partners
Funding for the KIBS project was received from ELMA Philanthropies. A project
steering committee was established and this was chaired by the KwaZulu-Natal
Department of Health. The project coordinator was the Centre for Rural Health (CRH)
and technical assistance was provided by the UKZN Department of Paediatrics.
The UKZN Department of Paediatrics assisted with the development of the training
manuals and also provided the training and mentorship on the management of
milk banking at the hospitals. Standard operating procedures, registers, forms and
teaching tools were also developed for use in the milk banks.
Communication specialists, Community Media Trust, were contracted to develop
and implement a communication plan for the project. This plan consisted of:
• Branding of the project. The project was
branded “Made my Mom” and all materials
and promotional gifts handed out at
community events and training were
branded with the Made by Mom logo.
• Creation of a video documentary about milk
banking which could be shown to health
care workers and the community. This video
was filmed at Stanger Hospital human milk bank and in the local clinic and
community. The video documentary is in English and isiZulu and is
available to be viewed on a computer, cell phone, tablet or TV
• Video Public Service Announcements (PSAs) advocating breastfeeding that
could be used on the TV or shown in health facilities
• Radio Public Service Announcements (PSAs) and Radio Dramas advocating
breastfeeding that could be used on the radio or played in health facilities
as part of advocacy
• Development of pamphlets providing mothers with information on human
milk banking
In parallel with - and complementing - the KIBS project, PATH assisted with the
implementation of satellite human milk banks in five district hospitals in KwaZulu-
Natal. A satellite human milk bank aims to make donated human milk available
for the clients in the district hospital. While its role is only to provide donated
human milk for its own clients and not to support other facilities, surplus donated
breastmilk may be sent to the central milk bank for pasteurisation and for storage
where available. The implementation of a human milk bank at this level aims to
support and promote breastfeeding and sensitize the community to the role that
breastfeeding plays in child survival.
Mixed Media, a company specialising in communication with drama, was
subcontracted by HMBASA for the PATH project to strategise, create and develop a
range of communications resources that included video and radio PSAs. A pivotal
component was a set of 6 dramas
integrating human milk banking
into the breastfeeding messages.
They were performed at community
events, at the milk bank training and
during Breastfeeding Week at the
hospitals. These dramas are available
in English and isiZulu (as a script
book and videos) for hospital staff
and community members to perform
independently.
18 19
Prof Anna Coutsoudis (UKZN), Nompumelelo Nxumalo (CRH), Ronel Sorgenfrei (DOH), Lenore Spies (DOH), Chirstiane Horwood (CRH), Glen Naidoo (CRH), Sharmila Rugbeer (CRH) missing, Anne Magege (ELMA)
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Capacity expansion for breastfeeding support
Breastfeeding is the cornerstone of effective human milk banks.14 To ensure this
foundation was in place, the Department of Health reskilled enrolled nurses as
lactation advisors and placed them in each of the hospitals in the province with a
maternity unit. The lactation advisors were trained by the Centre for Rural Health
and received mentorship from lactation mentors as a component of the KIBS project.
The lactation advisors provide one-on-one support by demonstrating practical
lactation management information and skills to newly delivered mothers in the
postnatal ward to ensure early initiation of breastfeeding. The nutrition advisors
based at Primary Health Care clinics continue to advise mothers on breastfeeding
following discharge.
Training of facility milk bank teams
The hospital management assisted with identifying multidisciplinary human milk
bank teams within the hospital. These teams comprised of a neonatologist or
paediatrician, operational manager from the nursery, dietitians, laboratory manger,
infection control and the staff working hands-on in the human milk bank. Each
team member had a key role and responsibility which ensured team - rather than
a single person’s - accountability for the operation of the milk bank. The human milk
bank training was provided for all members of the milk bank team. The training
was done on site at the hospital and, where necessary, practical sessions were
conducted in the human milk bank. Separate training on the use of the pasteuriser
was provided by the pasteuriser service providers.
Prof Anna Coutsoudis(UKZN) providing human milk bank training at Bethesda Hospital
Community awareness
Community awareness was an integral part of each of the human milk bank
community launch events. These events were held in community halls and
both district and hospital public relations officers played a central role in their
coordination. The hospitals were provided with Made by Mom posters and leaflets
to advertise the events. At the event, the halls were decorated with the Made by
Mom banners and bunting and staff were given Made by Mom t-shirts. The event
programme included the breastfeeding dramas written for the human milk bank
project, testimonies from donor mothers and recipients, educational talks around
human milk banking by the hospital staff and even musical items where audiences
were encouraged to join in the singing and dancing. After the educational talk
about human milk banking, a quiz was held and promotional Made by Mom
gifts such as umbrellas, cooler bags, baby beanies, bags, mugs and pens were
handed out as prizes.
Human milk bank community awareness in Empangeni
20 2114 PATH. A global implementation framework strengthening Human Milk Banking. 2013
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HUMAN MILK BANKS IN KWAZULU-NATALIn 2014, the KwaZulu-Natal Provincial Department of Health partnered with PATH
and HMBASA to implement 5 satellite human milk banks at Addington, RK Khan,
GJ Crookes, Murchison and Mahatma Gandhi Memorial hospitals. The sites also
received human milk bank training, mentorship and were provided with an updated
version of the FoneAstra system
In 2015 the human milk banks in hospitals that had been established prior to KIBS,
received updated training. These hospitals were Newcastle, Edendale, Stanger and
Lower Umfolozi War Memorial Regional Hospitals. In 2016 Port Shepstone, King
Edward, Bethesda, Ladysmith and Dundee Hospitals received human milk bank
training and subsequently human milk banks were established. Christ the King
Hospital, Prince Mshiyeni Memorial Hospital, Nkonjeni and Grey’s Hospitals will
receive training in 2017.
The Department of Health worked very closely with the hospitals in facilitating the
process of the hospitals purchasing equipment for the milk banks.
The implementation of the human milk banks has ensured that every child will have
access to breastmilk. From January 2015 up until September 2016, 660 mothers
in KwaZulu-Natal have donated their excess breastmilk. 1 076 295 ml of donor
human milk has been pasteurised and this has provided donor milk for over 711
vulnerable infants.
HUMAN MILK DONOR STATS
KZN HUMAN MILK BANKS
22 23
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““The Human
Milk Banks
are of
significant
benefit to
mothers and
babies as
human milk is
donated for
vulnerable and
sick babies
who cannot
access their
mothers’
own milk.” Dr Sibongiseni
Dhlomo, KZN HEALTH MEC
Prof Anna Coutsoudis was awarded the GSK/Save the Children Health Innovation
Award in 2015 to adapt the FoneAstra for use in community human milk banks
and rural hospitals. This resulted in the development in 2016 of a lower cost system
called the PiAstra.
Dr Victoria Mubaiwa (DOH), Professor Anna Coutsoudis (UKZN) and Ms Lenore Spies (DOH) receiving GSK award
“The world has evolved greatly with the advancement of technology, science, innovations and information. It is indeed encouraging to see the Nutrition programme taking advantage of these advancements to make breastmilk available to babies who otherwise would not have had access to breastmilk, thus giving them the best shot at growth and development from an early age. Breastmilk remains the best form of feeding for babies, no matter how advanced we can be in the era of information and communication technology advancements.”
Dr Victoria Mubaiwa (KZN Provinical Department of Health Acting Chief Director: Strategic
Health Programmes and Director of MCWH.)
24 25
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KEY SUCCESSES Districts
• Ownership by the District Health Teams for the
implementation and support of the human milk
banks has ensured their success in the hospitals
and district
• Ongoing quality improvement and quality
assurance audits by the district teams ensures the
standard and quality of human milk banking is
maintained
• Coordination of learning sessions with the human
milk bank teams at a district level provides an
environment for updates, communication and
learning
Hospitals
• The hospital management team supported the
implementation of the human milk banks and
understood the important role the human milk bank
could have in the hospital with saving lives
and decreasing infant mortality and morbidity
• Milk banking was integrated into the newborn
care package
• Even though there were challenges and a
shortage of staff at some facilities, the staff
supported the implementation of the milk banks
because they were convinced of the benefits of
breastmilk for all babies
• Advocacy was targeted at all hospital staff prior to
the implementation of the human milk banks
• Each hospital identified human milk bank teams
who were responsible for the implementation of
the human milk bank. Each team member had a
key role and responsibility and this prevented the
entire activity becoming the responsibility of one
person.
Baby X was born at 28 weeks gestation weighing just 1,230kg. Mom was critically ill after delivery and was transferred to ICU where she was placed on a ventilator. Baby X had respiratory distress syndrome and was transferred to the Neonatal ICU. The mother really wanted to breastfeed her baby so the family consented to Baby X receiving donor human milk. The milk bank at this hospital had just opened and over the period of a month they were able to provide Baby X with over 16 000ml of donor breastmilk while the mother was on a ventilator. This milk was received from 9 different donor mothers who also had babies in the Neonatal ICU. They were donating their excess milk. Mom and Baby X were discharged and at their 4 month check-up baby weighed 3.9kg.
From Port Shepstone Hospital Human Milk Bank
26 27
The milk banking activities and expected outcomes were included in job
descriptions, Key Result Areas (KRAs) and Key Performance Areas (KPAs)
of team members
The foundation to protect, promote and support breastfeeding was
established over many years to ensure that a breastfeeding culture is
normalized within the Province
Milk banking was integrated into the breastfeeding strategy
Advocacy involving the Provincial management structure ensured the
support and integration of human milk banking into all provincial and
district level programmes
The relationship and support from partners was key to the success of the
breastfeeding strategy. This support was comprised of strategic planning,
research, training, material development and implementation. These
partners were, amongst others, NDOH,UNICEF, HMBASA, UKZN, ELMA
Philanthropies and PATH
The Provincial Department of Health human milk bank guidelines and
documents were adapted by the
team
Establishment of systems for
human milk bank reporting
as well as monitoring and
evaluation
The documenting of the process
of the scale-up of human milk
banks was a key part of the KIBS
project to ensure the story could
be shared with other districts,
provinces and countries. To date
the KZN milk bank materials
have been shared with the
National Department of Health,
and the Department of Health
in Ethiopia, India, Kenya and the
Eastern Cape.
•
•
•
•
•
•
•
•
Province
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These teams comprised of a
neonatologist or paediatrician, operational
manager for the nursery, dietitians,
laboratory manager, infection control nurse
and the staff allocated to work in the milk
bank. Hospitals were given the flexibility to
identify who would work in the milk
bank, with various hospitals assigning either
professional nurses, enrolled nurses or
enrolled nurse aids
• The hospital milk bank teams benchmarked
their progress against those from
other hospitals, shared lessons learnt and
collaborated to overcome challenges
• Laboratory services were part of the human
milk bank teams to ensure communication
and updates on post pasteurisation testing
• Some hospital human milk bank staff set
up social media (WhatsApp) communication
groups with other milk bank staff to provide
additional support and communication
• Staff were initially surprised by the number
of donors and the amount of donor human
milk they received. They had had concerns
about donations within a high HIV
prevalence setting
• It did not take long for hospital staff to recruit
donors and to fill their freezers with
pasteurised donor milk. This encouraged the staff to persevere with their efforts to
maintain and sustain the milk banks
• If a hospital human milk bank had excess milk or was short on stock, the milk banks
were willing to share milk within and across districts
• Scepticism toward donor milk changed when staff witnessed the success of the milk
banks, ensuring every baby had access to human milk
• Breastfeeding promotion provided advocacy for human milk banking which was in
line with the mother and baby friendly initiative of the hospitals
• The hospitals ensured that the concerns raised around milk banking from staff
members, mothers and families were addressed to prevent any barriers to
implementation of the milk banking system
• Concerns from different cultural, traditional and religious groups were
addressed and, where necessary, relevant communication was provided
• Community awareness around milk banking was conducted before setting
up a milk bank in a hospital. As a result, communities were more willing to
donate (and receive) excess breastmilk.
Community
• Sustainability and ownership of the community milk banks is attributed to
the awareness raised on how a human milk bank can provide for vulnerable
infants from the community
• Marketing of the human milk banks in the community is successfully done by
word of mouth
• The community milk banks have been able to successfully recruit donors
who provide large amounts of donor milk
28 29
Donor mother sharing her story at eThekwini community awareness event
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ISSUES TO FLAG
• In some rural areas the tribal authority needed to be consulted before the
implementation of the human milk bank
• Some hospitals were initially reluctant to take ownership of the human milk bank
because of already over-burdened staff
• The support and implementation of the human milk banks has increased the
workload of some already overburdened team members because no additional
staff were allocated to the human milk bank
• Strategies to ensure advocacy of breastfeeding and human milk banking,
targeted at all levels of staff at facilities, need to be implemented, assessed and
or revised
• Regular, consistent awareness campaigns are needed in hospitals and the
community to recruit new donors and ensure a regular supply of donor milk to
sustain the human milk banks
• Challenges with lack of support from the service providers providing pasteurisers
used in the human milk bank
• Extra support from all levels of the health system is needed to ensure human
milk banks keep up with the demand
• A small number of mothers declined to donate when they were informed there
was no remuneration in return for donating their breastmilk
3130
““Breastmilk
remains the best
form of feeding
for babies, no
matter how
advanced we can
be in the era of
information and
communication
technology
advancements.” Dr Victoria Mubaiwa
KZN Provinical Department of Health Acting Chief Director:
Strategic Health Programmes and
Director of MCWH.
Ms. L Simamane, Donor Mom, with her baby at the Stanger Hospital human milk bank community event.
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THE JOURNEY CONTINUESThe Tshwane Declaration was released in 2011 and since then the KwaZulu-Natal Department of Health has taken great strides to achieve those goals. As expected there are still areas that need support and strengthening as we continue to expand the service. Those areas are:
• Ensuring wherever possible that all babies have access to their own
mothers’ milk and that breastfeeding is continually protected, promoted
and supported.
• Ongoing breastfeeding support for mothers including post-discharge from
delivery site
• Establishment of Breastfeeding support groups.15
• Community health workers / members conduct home visits to mothers
following discharge and continue with support visits until breastfeeding has
been established.16
• Quality assurance and audits conducted at human milk bank sites to
ensure the safety of donor human milk.
• Bi-annual human milk bank learning sessions including all milk banks in the
Province for support and to discuss and identify best practises and quality
improvement packages.
• Ongoing research of point-of-care testing of post-pasteurisation samples to
lower costs, lower the chance of contamination and to minimise time delays
in sending post-pasteurisation samples to the laboratory.
• Human milk banking awareness and advocacy aimed at primary healthcare
clinic staff and community caregivers.
• Setting up human milk bank depots for receiving donated human milk in
communities and the transfer of the milk to central milk banks for
pasteurising.
• Devising a safe transport system for the transfer of unpasteurised and
pasteurised human milk between facilities.
It is our desire that the efforts we are currently engaged in would result, in the near future, in working mothers being provided with adequate maternity leave to ensure exclusive breastfeeding and enabling workplaces that facilitate the storage of expressed milk for continued breastfeeding; that scholars and teenage mums receive the additional support necessary to ensure their babies are breastfed and ultimately, that we experience a decreased need for milk banks as more mothers breastfeed their babies.
15 Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? The Lancet 2016, Vol 387: 491-504162011 KwaZulu-Natal Department of Health Provincial guidelines for the implementation of the three streams of PHC re-engineering 32 33
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ACKNOWLEDGEMENTS
The success of the scale-up thus far has encouraged all involved in milk banking
to continue to be bold and pioneering into the future, to never give up hope and to
appreciate the contribution of every person, team and organisation with whom we
collaborate.
The KwaZulu-Natal Department of Health sees the scale-up of human milk banking
as a continuous, ongoing process to save the lives of the most vulnerable in our midst.
The KwaZulu-Natal Department of Health would like to thank all stakeholders for the
successful scale-up of human milk banking in KwaZulu-Natal - so that every child gets
a chance.
Photo credits: Community Media Trust, Conway Photography, Mary-Lou Mitchell, Mixed Media, PATH and Josh Reid Media and the Zululand Observer.
34
“Human Milk Banks make two major contributions to our services:
1. They fulfill an immediate need in supporting the early and appropriate feeding of extremely vulnerable newborn babies which has the spinoff of less neonatal sepsis and necrotizing entero-colitis (NEC); and2. In the longer term they foster the creation of an environment that recognises and supports breastfeeding as a major child survival strategy. I believe that this is a critical need in our hospitals as many of our medical and nursing staff do not fully appreciate the importance of breastfeeding and mothers who see formula feeds in hospitals receive a mixed message that formula feeding is an acceptable alternative to breastmilk.”
Dr Neil H. McKerrow, Head: Paediatrics and Child Health,Maternal, Child and Women’s Health KZN Dept of Health
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