Kenya has made significant strides in boosting exclusive breastfeeding, even passing a new law banning the promotion of infant formula. Nevertheless, challenges to safe infant feeding - a major part of prevention of mother-to-child HIV transmission - remain.
The law, passed in September, prohibits the promotion of complementary foods and forbids health workers from accepting gifts from formula manufacturers. It also requires formula packaging to contain "notices, warnings and necessary information with respect to promotion of breastfeeding and proper use of breast milk substitutes".
It is hoped that the law will contribute to the government's push to encourage all mothers to breastfeed exclusively for at least six months. This is particularly important for HIV-positive women - six months of exclusive breastfeeding is associated with a three- to four-fold lower risk of HIV transmission compared to mixed feeding, according to the UN Children's Fund (UNICEF).
Kenya has adopted the UN World Health Organization (WHO) recommendation that HIV-positive mothers should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 24 months of life.
Following prodding by NGOs and the government, a number of local companies - large and small - have started to provide mothers with environments that enable them to exclusively breastfeed.
Breastfeeding-friendly work places
"We have big companies like Safaricom [one of Kenya's largest mobile service providers] and General Motors who have rooms where women can express milk and play areas for young children," said Carole Kariuki, CEO of the Kenya Private Sector Alliance (KEPSA), an umbrella body of more than 180 corporate organizations. "Since we started to encourage them, there has been little resistance, and many more companies are following suit."
But not all women are lucky enough to work with these companies. Between unfriendly work environments and short maternity leave periods - Kenyan law allows for a minimum of three months paid maternity leave - some women are forced to turn to complementary feeding much sooner than they wanted.
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"I found it very hard to do exclusive breastfeeding - my maternity leave ended when my child was just three months; I had to escape from the school where I used to teach to breastfeed her," Betty Awuor, a teacher living with HIV, told IRIN/PlusNews. "[Even if you express] you can't be sure if the person caring for the baby might be giving them other foods while you are away."
"Many mothers have to make a choice between trading off their jobs and staying home to breastfeed. It is a delicate balancing act because they have to put food on the table for their families," Lucy Matu, prevention of mother-to-child transmission technical adviser at Elizabeth Glaser Paediatric AIDS Foundation, told IRIN/PlusNews.
According to Pam Malebe, who heads the Kenya office of the International Baby Food Action Network, there is a need for more employers to provide women with the support they need to continue breastfeeding for six months and beyond.
"We encourage employers to provide women with breastfeeding breaks, flexible working hours, rooms where they can express milk and crèches where they can breastfeed the children at work," she told IRIN/PlusNews. "The publicity on breastfeeding means many people now know the benefits, so we are seeing many companies accommodating women. Exclusive breastfeeding is certainly doable, with support from employers and families."
The country's push for exclusive breastfeeding appears to be working; according to the 2009 Kenya Demographic and Health Survey, 32 percent of babies are exclusively breastfed up to the age of six months, up from just 13 percent in 2003. Experts say the next survey, due in 2013, is likely to show even more growth.
However, most infants are still given complementary food before they hit the six month mark, something that can be partly attributed to misinformation and cultural pressure to provide complementary feeding.
After delivering her baby seven months ago at Oridi Dispensary in Ndhiwa, Diana*, 23 years old and HIV-positive, decided to exclusively breastfeed her child for six months on the advice of health workers. Her husband, also HIV-positive, understood the significance of exclusive breastfeeding. However, convincing her mother in-law, who does not know about the couples' HIV status, was another matter.
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"She was asking why I only gave breast milk to the child yet it was growing and needed other foods as well. The pressure almost made me give up and start mixed feeding, but my husband attended the clinics with me and I had his support," she told IRIN/PlusNews. "It was difficult because I never wanted her to know my HIV status - I didn’t know how she would react to it."
"While HIV-positive mothers who deliver in health facilities are given counselling on infant feeding, when they go back home, it is hard for some of them to follow this because of the advice they receive from people. This affects mainly young mothers with little experience," Justus Ojwang, the district AIDS and sexually transmitted infections coordinator in Ndhiwa, told IRIN/PlusNews.
Experts say the message of exclusive breastfeeding must be disseminated across the board, and not just to specific groups of women. Studies have shown that some women in western Kenya eschew health centre deliveries because they believe it is only necessary for HIV-positive women. Similar misconceptions may affect exclusive breastfeeding rates.
"There is need to ensure there is correct and consistent messaging on infant feeding. Exclusive breastfeeding should be promoted amongst all mothers and not just for HIV-positive ones so that it can reduce the HIV-related stigma associated with it," said EGPAF's Matu.
Health workers say, while they advise women on the right choices, external factors may prevent them from adhering to their guidelines.
"As health workers, we promote exclusive breastfeeding and give counselling on feeding options, but we don't have the capacity to monitor what goes on after mothers leave the facility," Helen Onyango, nursing officer-in-charge of Oridi Dispensary, told IRIN. "Women who disclose their HIV status to family members are more likely to stick their chosen feeding option than those who don't because they can bank on family support."