BREASTFEEDING IN SOUTH AFRICA Social and Cultural Aspects and Strategies for Promotion

Die voordele van borsvoeding word toenemend dwarsdeur die wêreld in wetenskaplike literatuur beklemtoon. Tydens swangerskap spreek meeste vroue ook die wens uit om te borsvoed. Daar moet vasgestel word wat vroue beinvloed om nie te borsvoed nie, of om borsvoeding vroeg in die postpartum tydperk te staak. Faktore wat borsvoeding beinvloed is ekonomiese faktore; advertensie en kommersiële druk: die voorbeeld van die hoër sosio-ekonomiese groep; veranderde waardes en statussimbole; wedywerende ideologië; te min melk; kulturele voorkeur aan vet babas; beskikbaarheid van ondersteuning; invloed van gesondheidsvoorligting; hospitaalbeleid; gebrek aan hulp in die eerste kritieke dae en gebrek aan selfvertroue. Daar is ’n tendens weg van borsvoeding af met ernstige gesondheidsimplikasies en ons het derhalwe ’n verantwoordelikheid om borsvoeding te bevorder. Strategieë wat aangevoer word is onder meer navorsing; hulp vir die werkende vrou; beperkinge op die bevordering van melkformules; voorligting; opleiding van gesondheidspersoneel; veranderings in hospitaalroetines; ’n nasionale projek om borsvoeding te bevorder en 'n ondersteuningstelsel in subekonomiese gebiede.


INTRODUCTION
Every week from 5-10 new scientific papers on the topic of breast-feed ing are published (Jelliffe. 1983).Many of these emphasise the ad vantages of human milk over modi fied cow's milk.The increasing evi dence highlights the nutritional ad vantages, the immunological bene fits, the enhanced bonding between mother and infant, and the childspacing advantages of breast-feed ing.In developing countries these advantages can prove to be lifesaving.
Although infant mortality figures for South Africa (especially Afri cans) are difficult to obtain, a review of statistics available from Local Authorities in the W estern Cape shows that two of the major causes of death are gastro-enteritis and respiratory infections.The inci dence of these infections is far lower among breast-fed infants.Ex perts agree that breast-feeding alone could have a significant effect on the infant mortality rate.Any perceived trends away from breast feeding, especially in sub-economic areas cause great consternation, and often provoke the question, Why aren't these women breastfeed ing' ?
Many studies have focused on when the mother makes her deci sion about how to feed her baby.It is interesting how many women ex press the wish, during the preg nancy to breast-feed.In a recent survey (Carter, 1984) the investiga tors found that 98,3% of pregnant women interviewed at Maternity Obstetric Units in Cape Town said they wanted to breast-feed their babies.Marina Petropulos of Fair Lady magazine, who receives ap p ro x im ately 1 000 le tte rs each month with questions on infant feeding, says that she is often struck by the strength o f womens' wishing to breast-feed.
W hat happens to this desire to breast-feed?An interesting study c o n d u c te d a m o n g u r b a n Z u lu mothers revealed that 72% of the infants had commenced formula feeding at between one and five weeks of age.(Ross, Loening, Van Middlekoop, 1983).Obviously it is necessary to examine what happens between the time the desire to breast-feed is expressed during the pregnancy, and the subsequent infant feeding, to determine why women do not initiate breast-feed ing, or stop feeding early in the postpartum period.

FACTORS INFLUENCING BREAST-FEEDING Economic factors
Economic factors are perhaps the most important ones influencing a woman's decisions about breast feeding.We need to consider the costs of breast-feeding.The first is the price of extra food for the lactating mother.Increasing the food intake of the mother need not be a problem if there are inexpensive, locally produced, nutritious foods.It is likely that in most areas this would be less expensive than the modified milk needed to replace the breast milk.
Furthermore it has been noted that malnourished mothers do lac tate adequately.In ongoing re search comparing lactation among Gambian and English women, Whitehead and associates have found that all produce similar amounts of milk.On the question o f w h e th e r th e m a ln o u r is h e d mother's milk has lower levels of nutrients, W hitehead reports the principal constituents -protein, carbohydrate, and fa t -are well protected even on a very low plane o f nutrition (Whitehead, 1983).Supplementing the m other's diet in this instance, although it made no significant difference in her breast milk, did increase her energy level, and general state of health.

This paper was presented at the
It does appear then, that feeding the mother is more cost-effective than providing modified milk for the infant, especially in sub-economic areas.
The second, more important economic question is, if breast feeding means losing work, can a woman afford to do it?It is clear that many South African women must work (whether they earn the sole income for the family, or a sup plemental income).Can these women breast-feed, and for what length of time?
An examination of M aternity Rights and benefits is necessary.Protection from dismissal is not guaranteed in South Africa.Bar bara Klugman found that all the countries investigated in the E uro pean Industrial Relations Review and Report provide this protection (K lu g m an , 1983).F u rth e rm o re Botswana, Lesotho, and Swaziland also guarantee re-instatem ent (In ternational Distributive Trade In Southern Africa, 1982).
The fact that this protection does not exist in South Africa has impli cations for breast-feeding because a woman may need to be looking for another job during the time when she is meant to be on maternity leave.The only guaranteed benefit she has is a m aternity leave of one month before and two months after birth, with 45% of income provided by the Unemployment Insurance Fund (if certain requirem ents are met).Many working women, for a variety of reasons, are not eligible for this.Even those who are, always have the fear that there will be no equivalent job for them at the end of their leave.Poor working women in South Africa face m ajor ob stacles if they wish to breast-feed.
It is essential however, to point out that many women are not breast-feeding for reasons other than economic ones.A num ber of surveys in South Africa have ad dressed this issue.In surveys administered at two child welfare clinics in Heideveld and M anenberg (subeconomic residential areas of Cape Town) 80% o f the mothers were not working at the time o f the interview, and o f these, 55% were wholly bottle feeding.(Power, Wolloughby, De W aal, 1979).
Only 22% of m others attending a KwaMashu clinic were introducing supplementary foods because they were returning to work (Ross, Van M iddelkoop, Khoza, 1983).In a Black urban area (Zulu speakers) it was found that Eighteen per cent o f the mothers gave their return to work as a reason, but there was often a gap o f several weeks between introducing formula-feeding and actually returning to work.(Ross, Van M iddelkoop, Loening, 1983).
These statistics make it clear that we must look for other explanations for a decline in breast-feeding in ad dition to the economic ones.

Advertising codes
Much emphasis has been placed on the effect that advertising and com mercial pressures have in persuad ing women to bottle-feed.A t pres ent each company which manufac tures a modified milk has a Code which is intended to provide guide lines for promotional activities.Some of the companies adhere to the W .H .O .Code.All of the codes prohibit direct advertising to the public.There is no m ethod of en forcement by outside sources, so whether the companies adhere to them is questionable.It is possible that the companies m onitor each o th e r 's p ro m o tio n a l a c tiv itie s.Some observers feel that the com panies are at times competing not only for the m arket, but for an image of ethical conduct where pro motion is concerned.
It does seem plausible that pro motional activities vary geographi cally.For instance, it would be very unlikely that questionable prom o tional practices would occur in Cape Town, where a Breast-feeding Liaison Group, the Breast-feeding Association, and La Leche League are active.However, in other areas where there are no groups particu larly interested in breast-feeding, promotions and advertising may continue unquestioned.

Indirect advertising
Since direct advertising theoreti cally does not exist, it is im portant to look at other means of indirect advertising and prom otion.A l though the companies themselves refrain from advertising to the con sumer, it is permissible for the dis tributors of the products to ad vertise them.Superm arkets and chemists compete for the m arket, and offer certain modified milks at reduced prices.
They often advertise these specials in newspapers, and they have special displays in the stores.These special prices may have the effect of convincing pregnant or lactating mothers that they should try the product.The danger is, of course, that they perhaps do not realise that their own breast milk supply will diminish when modified milks are introduced.In situations where there is not enough money to purchase these products continu ously, or when uncontaminated water is not available, the problems multiply.
O ther indirect forms of advertis ing include the literature available from modified milk producers.These always recommend breast feeding as the preferred m ethod of feeding, but also obviously present their own line of products.These materials are always very colourful and appealing.The babies are fat and healthy looking, and the mothers are neat and attractive.L ay o r g a n i s a ti o n s p r o m o tin g b r e a s t -f e e d i n g , f o r f in a n c ia l reasons, cannot produce pamphlets and literature with a form at as ap pealing as that offered by the m odi fied milk m anufacturers.
Given a choice, m others would probably opt for the more attractive booklet, which may give question able advice about breast-feeding, and may omit information about the effect of supplementing on the breast milk supply.Also, there are times when accurate breast-feeding information is not available in the form of a pam phlet for the m other, so the modified milk producers fill the gap with their literature.Sales representatives of the for mula producers are sometimes per mitted to speak to groups of mothers in clinic situations.Health education talks.It is questionable w h e th e r th ese re p re s e n ta tiv e s supply accurate information about breast-feeding, when their primary job is to promote their product.A paediatrician in Natal comments: They will come at a time when the nurses are very busy and ask if they would like them to give a health talk to the mothers.It is unusual fo r the sister to deny them that opportunity, since they rarely can fin d time and material fo r their health education obligations.The representatives will then advise the mothers to breast feed but should they have insuffi cient milk then their product is just as good.Hence the vast majority o f mothers fin d that they have insuffi cient milk.
P o te n tia lly m ore d an g e ro u s forms of promotion are the free samples which may be available for women through hospitals, doctors, or clinics.There has been much controversy about the effect free bottles and samples have on the lac tation performance of women.Some studies indicate that a woman receiving these samples is much more likely to stop breast-feeding earlier than a woman who has not been offered them.If a woman is unaware of the supply and demand function of breast-feeding, she might use the samples, not realising the effect this would have on her own milk supply.In subeconomic areas this can be particularly prob lematic.

Promotion by shop owner
A nother form of promotion is that which is done informally by the owner of the shop or cafe.Many people have rem arked on the var iety and number of modified milks which are available in all areas.In Cape Town at Crossroads every little shop is well stocked with these products.It would be very interest ing and revealing to investigate the sales, and the involvement of the cafe owner in those sales.It is quite clearly very easy for the proprietor to recommend a particular type of formula to a prospective buyer, it is in his best interest to do so.
A survey conducted by Ross, Loening, and Van Middelkoop to find the sources of information con cerning infant foods, concluded that the storekeeper is most frequently cited (Ross, et al., 1983).It would appear then that the cafe owners, who have more access to poor mothers than health care providers do, may be doing much more harm than all other forms of promotion.
One should be somewhat cau tious about overemphasising the effect of advertising on women's choices.By placing full blame on advertisers we assume that there are no other influences in a woman's life.Anthropologist Judy Johnston comments, the idea doesn't make anthropological sense.
The potency ascribed to advertising would suggest that mothers around the world are poised waiting to be told what to do and what they want and, in the interim, are living lives o f no reality, no culture, (Johnston, cited in Edson, 1979).Dana Raph ael, a social anthropologist who has done a great deal of lactation re search agrees with this and adds that between the advertising mes sage and the response to it numer ous intervening variables mediate behaviour (Raphael, 1982).

The trend-setting elite
We must recognise that with in creasing industrialisation and com mercial pressures poor women seek to imitate wealthier women, and may therefore follow their lead in infant feeding practices.In 1982 the World Health Organization pre sented the results of an extensive survey of information readily avail able on breast-feeding prevalence.
Figure 1 compares prevalence be tween developing and developed countries, and prevalence within regions.It is clear that the elite lead the trends, whether it is toward bottle or breast.

Changing values and status symbols
In creasin g com m ercialism c o n vinces us that anything purchased for a high price must be valuable.Sheila Kitzinger, childbirth educa tor and social anthropologist com ments, Commercial pressures in Western society persuade many women that doing the best they can for their babies means spending money on them, and since artificial milk involves expenditure they be lieve bottle feeding must be superior to breastfeeding (Kritzinger, 1979).
The author was surprised when speaking to women in a clinic in Langa, a Black township outside Cape Town, to find that even those mothers who were breast-feeding, were supplementing with the most expensive processed baby cereals.
They seemed to feel that what was best for baby had to be bought, and could not be provided by nature.

Obviously breast-feeding education needs to stress what is best for baby, not what is cheapest.
Competing ideologies: rural/ urban, traditional/modern Among many peoples there has always been a traditional pattern of early supplem entation of breast milk.The native foods which are in troduced are prepared in a form ac ceptable to the small infant.This p ra c tic e , in c o m b in a tio n with breast-feeding works well for seve ral reasons.Breast milk helps to protect the baby from the harmful effects of contam inated water which may be used to prepare the food, and it also improves the availability of nutrients in other foods the baby eats.In a society where mixed feed ing begins early it does not neces sarily have an adverse effect on the breast milk supply because by the time mixed feeding starts the supply is well established.
However, introducing anything which reduces the suckling time at the breast (including dummies) also reduces the milk supply.In this in stance the substitution of a cow's milk product and a bottle before the m other's own supply has been well established results in a diminished breast milk supply which necessi tates more frequent use of the sub stitute.This snowballing effect may result in lactation decline or failure.In this instance, as with others, it is the combination of traditional prac tices with modern conveniences which may lead to a decline in breast-feeding.
Cultural prescriptions have a role to play in a woman's decisions about infant feeding.For example, among the Xhosa speaking people it is reported that there is a pre scription against sexual intercourse after the birth of a baby, during the period of lactation (information collected during intervies with women in Crossroads, Cape Town, 1981).Yet it is also said that these are things o f the past.A Black nurs ing sister in Cape Town comments, How can a woman whose husband is a migrant labourer refuse to have intercourse when he returns home?She must, because otherwise she might lose him to the women in the city.If this is the case, would a woman bottle feed in order to resume relations with her husband?Research on the effect of socio logical factors, such as migrant labour, on lactation patterns would be useful.Some people believe that there is a proscription prohibiting suckling immediately after birth.A num ber of nursing sisters in Cape Town report that Africans believe that co lostrum is poison.This seems highly unlikely, since it would mean find ing other sources of nutrition, or other women to breast-feed for the first two to five days.
Monica H unter's Reaction to Conquest, the result of her field work among the Pondo, mentions a twelve-hour wait after the birth, during which the baby was given water, and an infusion of plants (H unter, 1936).It is possible that there is some similar practice today among some groups but it is quite likely that it is a short period of time before the infant goes to the breast.In South Africa there is much con jecture about how everyone else does it.W ithout reliable anthropo logical data, these reports can only remain conjectures.

Not enough milk
Many studies have focused on why women stop breast-feeding.The most frequently given reason for stopping is not enough m ilk.The statistics in table 1 indicate the per centages of m others who give this reason for discontinuing breast feeding.
It is interesting to note that this seems to be a world-wide phenom enon -all of the literature re viewed on this subject suggests that not enough milk is most frequently cited as the reason for introducing other foods.In order to better understand this, it is necessary to look at the draught or let-down reflex of breast-feeding.
The release of the horm one pro lactin results in the production of breast milk.However this milk is only accessible to the infant if the hormone oxytocin is released.This results in ejection of the milk.This mechanism is called the let-down reflex, but it is im portant to note that, This key neuroendocrine reflex differs from other breast-feeding re flexes in that it is psychosomatic.Its function makes the difference be tween making milk and giving milk.(Jelliffe and Jelliffe, 1978).This is critical to this discussion because there are many distracting, distres sing situations which will inhibit this all important mechanism.
Geissler's work among low and middle socio-economic class women in Iran prom pted this statem ent.It has not been sufficiently appreciated in the past that environmental psy chosocial stress can have an effect on lactation performance.Such stress is occasioned by poverty and unem ployment, by poor housing and crime, by illegitimacy and fam ily in stability, and by cultural confusion and uncertainty, and is probably manifested through the effect o f an xiety on the let-down reflex.(Geissler, et al. 1975).
The applicability to the South African situation is obvious -we have ample evidence of all those conditions listed above.In these cir cumstances not enough milk may mean I 'm very worried about other things, how can I relax and breast feed?

Cultural bias for fat babies
There exists a cultural bias toward fat babies which is also involved in the trend away from breast-feeding.Bottle-fed babies, by gaining weight quickly, are also more likely to gain the approval of relatives, friends, nursing sisters, and doctors.The mother herself may want her baby to be fat.A breast-feeding counsellor who had worked with Malawian, Zim babwean, and South African Black women told me that this com pari son between fat formula-fed babies and their thinner breast-fed coun terparts was the biggest problem she encountered in promoting breast-feeding.
U nder these circumstances the mother may think her m ilk is too weak, or that it is drying up.The re sulting anxiety may result in a loss of confidence in her ability to feed her baby, and further problems with the let-down reflex.If she per ceives that her breast milk is the problem, switching to bottle-feeding may be the solution.

Presence or absence of support
The immediate social environment of the mother is also very important to the success or failure of breast feeding.The presence or absence of a doula or supportive person, as de fined by Raphael in Breast-feeding: the tender gift (Raphael, 1973) is one such factor in the social en vironment.Raphael's survey of the postpartum period in 278 cultures found that almost all of these socie ties have a support network for the new mother to cushion her during the critical stage which Raphael calls matrescence: that time when a woman first takes on the responsibi lities o f motherhood.
The doula takes on other respon sibilities, enabling the new m other to relax and enjoy her baby.W ith out the supportive help, the milk ejection reflex may be inhibited, or may fail.The loss of the extended family household in South Africa means fewer doulas.Migrant la bour, forced removals, and any other sociological factors which result in the absence of support (both physical and emotional) may be implicated in trends away from breast-feeding.

Influence of health education
It is of course necessary to look at health education.There are many different authorities who have an opportunity to discuss breast-feed ing with pregnant women and mothers in the clinic situation.There is the clinic staff itself.State Health Nutrition Advisors, Family Planning Advisors, City Council Health Education Officer, the Vol untary Sterilization Group, the Cape Nutrition Education Unit, and any other volunteers, such as members of the Breast-feeding A s sociation.It is only very recently that an attempt was made to bring these various groups together to discuss what kind of education was being done and where.Health edu cation for pregnant and new mothers has not been a co-ordi nated effort.
In Sister Carter's survey, referred to earlier, it was found that many mothers had not had any health education talks at all, and others had only had an opportunity to hear a portion of a talk (Carter, 1984).It is also possible that some women hear the same talks several times.Without overall co-ordination of this education, there are many gaps, and there may be duplication of services.Lies Hoogendoorn, the Community Health sister in the Child Health Unit and co-ordinator of the B re a st-fe e d in g L iaison Group, feels that this fragmentation o f services is a major problem.
However, even a well controlled, and co-ordinated health education programme for breast-feeding is not necessarily the solution to the pro blem.Ross, Loening, and Van Mid delkoop compared the breast-feed ing practices of a group of urban Black mothers who had two halfhour sessions of education on the advantages of breast-feeding and practical advice, with a control group which had no education.The result showed that the m others who had the health education actually introduced formula feeds before the controls did, even though they scored better on a breast-feeding test which was administered to both groups.
The authors comment 'Health education is frequently carried out without any systematic analysis o f the factors likely to lead to the de sired health change, and the results o f educational attempts are rarely evaluated to see if changes in behavi our do in fact occur.They conclude that there are other environmental factors which must be contributory factors (Ross, et al.. 1983).

Hospital policies
Another important consideration is the hospital policies which may in terfere with a successful breast feeding start.There is now conside rable evidence that certain drugs administered during labour cross the placenta.These drugs may affect the baby's willingness to suckle immediately after the de livery.It is quite clear that the opti mum start for breast-feeding is an undrugged labour, and immediate contact for mother and infant.There should be an opportunity for the baby to suckle at this time, since the sucking drive is strongest im mediately after birth (if there have been no drugs administered during labour).
Bottles, whether they contain water or formula, interfere with lac tation because they reduce the hunger or thirst which would moti vate the baby to suckle the uieast.Also the baby becomes accustomed to a bottle, from which liquids flow with little effort.This is very differ ent from the action of breastfeeding which requires that the baby draw the nipple and areola into his mouth, and suckle.Patterning on the bottle teat rather than the mothers nipple may cause fixing problems.
The influence that the opportu nity for bonding between mother and baby has on breast-feeding has been shown in a number of studies internationally.Mothers who have the opportunity for early close con tact with their babies are more likely to initiate breast-feeding, and more likely to continue for a longer time than those who do not.Ross reports that babies breast-fed im mediately were significantly more likely to be fully breast-fed fo r a longer period o f time than those suckled later on the day o f birth (Ross et al., 1983).In Oxford, Sloper and associates found that simple modification of hospital practices, along with orientation of sisters and health visitors, had sig nificant beneficial effects on inci dence and duration of breast-feed ing (Sloper et al, 1977).

Absence of help during first few critical days
The first few days following the birth are critical as well.For at risk deliveries in hospital there is usually a two day period when the woman remains in hospital.With a staff which is interested in encouraging breastfeeding, this woman may have some help with those first feeds.
Flowever, the majority of women delivering in rural or urban areas, in hospital or M aternity Obstetric Unit, are discharged several hours after the birth.They may or may not have had an opportunity to suckle their baby.Not only do many of these women have to resume their responsibilities at home, but they do not have the benefit of someone to speak to if their breasts are engorged, or their nipples are sore.
Theoretically they should be vis ited by M OU staff the first day after they return home.It is said theoreti cally, because the M OUs are often very busy.M atron Squire of Groote Schuur comments, Staff numbers are fewer, and the demands are greater.Delivering the babies must obviously have priority over home visits.
So who is available to help the woman at home who is struggling with various problems in addition to trying to establish lactation?Ross, Loening, and Van Middelkoop comment: Withdrawal o f home nursing services from the Black community and apparent lack o f support fo r breast-feeding from other fam ily members make the mother very vulnerable to the temp tation to reach fo r the easy alterna tive at the first sign o f difficulty.(Ross, et al. 1983)

Confidence in ability to breast-feed
There is a pattern which emerges from this discussion.It can perhaps be seen as a wom an's lack of confi dence in her ability to produce an adequate amount of breast milk for her baby.Those factors m entioned above produce feelings of anxiety, doubt, and fear which suppress the reflexes necessary for successful breast-feeding.Any strategy aimed at improving breast-feeding preva lance and duration, must attempt to provide conditions in which women feel confident about their lactation performance.

NEED FOR OBJECTIVITY
When considering infant feeding practices in circumstances of pov erty it is necessary to try to remain objective about breast-feeding.The main concern is not the prevalence and duration of breast-feeding, but rather the health of the infant, m other, and other family members.
Peter Hakim of the Institute of Human Nutrition at Columbia Uni versity wrote, It is hard fo r people working in the area o f health and nutrition to accept the notion that lo w -in co m e w om en w ho reject breast-feeding are acting in their own and their fam ilies' best interests particularly since that choice often turns out so prejudicial to the objec tives we seek (Hakim , 1979).
An understanding of the full complexity of factors influencing women's choices would help us to understand how and why in some instances the bottle feeding of an infant may better serve the interests of a woman's family.The primary task then is to fin d ways to make breast-milk substitutes available to those who really need them, without implicitly or explicitly promoting their use fo r the whole population (Baer, 1981).

STRATEGIES FOR PROMOTION OF BREASTFEEDING
Although there is little published research on breast-feeding in South Africa, it is clear from existing data that the rural/urban differences in breast-feeding prevalence noted in ternationally hold for South Africa as well (Ross, et al, 1983).It is also clear that there is a trend away from breast-feeding among poor women in urban situations (Power, et al, 1979);W atson, 1979;Ross, et al, 1983).In view of this, it is believed we have a responsibility to promote breast-feeding.

Need for research
The need for more research cannot be overemphasised.National plan ning for breast-feeding prom otion is impossible without a thorough going analysis of the determ inants of infant feeding decisions.This has not been attem pted in South Africa.Superficial surveys and questionnaires may help to deter mine breast-feeding prevalence and duration in a particular area.More information is needed on the exact time women are introducing bot tles.This could help us to deter mine whether there is a critical time when the m other has no help or support.However, surveys alone are inadequate.We need to ask women why they stopped, and what they thought might have helped them to succeed.
The Human Lactation Centre has completed interesting investigations in lactation by focusing on the lives of the women they were studying.E lev en social a n th ro p o lo g is ts , funded by Aid for International D e velopment worked in their respec tive field sites investigating infant feeding practices (Raphael, 1977).Participant observation proved to be a much more reliable means of data gathering than surveys or ques tionnaires.Women tend to say what they believe the investigator wants to hear.In this instance, some women called themselves breastfeeders but daily observations re vealed that they breast-fed only during mornings and evenings, and other foods were given by caretak ers throughout the day.It was only by observing women in their homes that a researcher could construct a true picture of feeding practices (Raphael, 1982).Programme de signs based on the kind of informa tion gleaned from this type of re search would have much more ap plicability and acceptability in the communities where they are imple mented.
A n th ro p o lo g ic a l re se a c h p r o vides useful information about traditional practices and how they have changed with the introduction of W esternized medicine.It has been recognised that many tradi tional practices bring comfort to very large numbers of people.
Health or medical intervention which ignores these practices runs the risk of being completely unac ceptable to the community it serves.To say that people are not respond ing to health education or interven tion because they are ignorant is in fact a confession of ignorance on the part of the speaker who is ignor ant of the social and cultural factors involved in decisions about health care.
It is also important to recognise that traditional practices are not fixed and unchanging.The introduction of hospitals and clinics adds more options for people in rural situ ations.Marion H eap, a social anthropologist at U .C.T. reports that in rural villages in Lesotho women usually deliver in hospital, but return home very soon after wards and are confined to their home (with the newborn) for the first three months.This is an example of how the traditional practices combine with the modern, according to the situation.

This flexibility allows for timely intervention by professional health workers if they could only appreci
ate what their appropriate role might be within the structure o f their com munity (R.H.O.Bannerman, 1982).It is the responsibility of those who provide modern health care to be aware of traditional prac tices, and rather than deny them , recognise their function.Craig and Albino, who work with urban Zulu mothers write, I f the health care fa cilities are to be patronized and the comm unity's health needs are to be met, recognition o f the apparent co existence o f acceptance o f Western medicine and beliefs in traditional health care seem important (Craig, et al., 1983).
It is obvious that we cannot stop promoting breast-feeding while we are waiting for the results of defini tive studies.Therefore strategies are suggested which have achieved suc cess in other countries, and could be investigated for applicability in South Africa.

Help for working women
Legislative changes to promote breast-feeding might include pro tection from dismissal during ma ternity leave and nursing breaks for lactating women.
The Commercial, Catering and Allied Workers Union of South Africa has an excellent maternity agreement.Any woman who has worked for twelve m onths or more qualifies for a twelve-month leave with a guarantee of re-employment in a position of similar status with pension fund benefits intact and m edical aid ben efits a v a ilab le throughout the leave if contribu tions are paid.Also, she may apply for an extension beyond that pe riod.(Health Information Centre, n.d.)This provides ample flexibility for those mothers who wish to breast-feed.
Sympathetic employers could en courage breast-feeding in various ways.Providing crêches for breast fed infants to permit mothers to feed throughout the day is one possibility.Due to the long dis tances many women must travel and the length of the working day, this is not usually a viable alterna tive.However, when a woman lives close to her work, permission to return home periodically for feed ing would be an encouragement.Employers could also permit wo men to express breast milk during breaks, refrigerate it, and take it home to be given to their baby while they are working.
Nursing breaks for lactating mothers have been legislated in Botswana, Lesotho, Zimbabwe, and Papua New Guinea, (Inter n a tio n a l D istrib u tiv e T rad e in Southern Africa, 1982).In certain work situations this could work in South Africa.
In addition to these measures, providing education about, and mo tivation for breast-feeding (through industrial nurses) would encourage breast-feeding.

Restrictions on modified milk promotion
Strict control of the distribution of modified milk is another strategy which has been used with some suc cess.In Papua New Guinea a health workers prescription is necessary for the purchase of a feeding bottle.Ghana and Jamaica restrict the im port of infant formula, and Algeria has nationalised its importation.
O ther countries seek to control the use by enforcing the World Health Organization code (Baer, 1981).Currently there are three countries which have the Code in effect as law.In a survey of 114 countries (South Africa was not in cluded), 13 had government con trols on distribution and marketing.I l l of the countries have, or are pre paring codes.Some of these are vol untary codes prepared by industry, others are government prepared codes (IBFAN, 1984).This issue can be a very contro versial one.Some experts argue vo ciferously that banning advertising and promotion is essential.A smaller minority would advocate even stronger measures, such as those implemented in Papua New Guinea.Others argue that thou sands of infants would perish if modified milks were not as easily available as they are.
The author believes that a policy of negotiation and engagement with the proprietary products indus try would be useful.However, for the purposes of enforcement a code which is legislated is preferable.The Departm ent of Health and Welfare has proposed a new code for South Africa, which is currently under study.In order to be effective this code must: control promotional activities, prohibit free samples, ex clude sales representatives from clinics, prohibit all advertising and incorporate some means of enforce ment.

Breast-feeding education
A co-ordinated programme for breastfeeding education would be very advantageous.Lay organis ations which promote breast-feed ing in liaison with other bodies in volved in breast-feeding education could produce literature and sug gested programmes.In this way a more unified approach to breast feeding would result.
Slide/tape programmes are an ef fective way to reach women waiting in clinics.The Breast-feeding Asso ciation and Divisional Council have produced one for Xhosa speaking mothers.This is being used in Cape Town, but is also available for hos pitals and clinics upcountry.
However, breast-feeding educa tion should ideally begin long before pregnancy.It should be in cluded in school curriculums as part of a family life unit or a nutrition unit.Furtherm ore, every effort should be made to interest com munity organisations such as church groups, youth groups, and wom en's groups.Using networks which al ready exist in communities ensures acceptability.The recent efforts of Sister Ray Carter to co-ordinate various education efforts is a major step forward.
Continued liaison between the Departm ent of Health and Welfare and all other groups promoting breast-feeding could alleviate the fragmentation which now plagues breast-feeding education.
A note on content of education is necessary.Too often breast-feeding education consists of a list of advan tages of breast-feeding only.It is necessary to dispel some of the myths surrounding breast-feeding and to provide some practical point ers as well.
A morning at a Divisional Coun cil clinic in Langa discussing feeding with mothers of babies under six months revealed some problem areas.A simple explanation of the supply/demand function of breast feeding is necessary to dispel the myth that allowing the breasts to rest will help to increase the milk supply.The effect that introducing any other food has on the breast milk supply needs attention.Some knowledge of the let-down reflex could help mothers to understand how stress affects their breast-feeding.These more practical points should be an integral part of breast feeding talks.

Teaching the teachers
The health care delivery system would also benefit by a co-ordinated effort to provide education on practical aspects of breast-feed ing management.In recent years there has been more emphasis on breast-feeding education for doc tors and nurses in training.The physiology of lactation is covered, but what is also required is some practical application of the theory, some hands-on experience.Some enterprising medical school and midwifery lecturers have made pro visions for this, but this needs to be part of the curriculum for everyone involved with m others and babies.
Furtherm ore, even if we reach those in training now, that is not enough.There are hundreds of practising nurses and doctors who do not know enough about lactation to be able to help mothers.Lay or ganisations who counsel breast feeding m others have countless calls from women who have been given no support or encourage ment, or worse, have actually been given advice which is detrim ental to successful breast-feeding.
Obviously retraining is necessary.This could be accomplished through videos or slide/tape programmes on the practical management of breast feeding.Continuing education in the form of special conferences and/or seminars on breast-feeding would also help to solve the prob lem.Once again the D epartm ent of Health and Welfare could be the co-ordinating body.With the help of lay organisations and the Breast feeding Liaison G roup, accurate and complete information could be assembled and distributed to doc tors and nurses.

Changes in hospital routines
If the initiation of breast-feeding is a priority, a close examination of any hospital practices which inter fere with a m other's access to her baby is necessary.Hospital admi nistrators should be urged to inves tigate ways to prom ote breast-feed ing.Some suggestions are: • rooming-in for m others and babies • no water and milk feeds • in-service training for staff, cov ering motivation for breast-feed ing and helping m others with ini tial feeds.

National breast-feeding promotion
Strategies to improve hospital pro cedures for breast-feeding mothers have become perm anent fixtures of health care in countries throughout the world.In 1981 29 countries had undertaken breast-feeding prom o tion campaigns which involved these kinds of changes (Baer,

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Offering advice, support, and help, at this critical time could help to fill the gap left by the scarcity of health visitors.
Several m edical p ra c titio n e rs who are active proponents of breast-feeding have indicated an interest in a pilot study to deter mine the efficacy of such a pro gramme, with surveys administered before and after to determine breast-feeding prevalence and dura tion.In view of the success of this type of support in many areas of the world, perhaps the time is right to initiate this type of intervention in areas of South Africa where breast feeding is declining.

CONCLUSION
Women in poverty clearly have fewer options.Considering the seemingly impossible circumstances in which they find themselves, it is quite amazing that breast-feeding can succeed.Without attention to those circumstances which make breast-feeding impossible or diffi cult, nation-wide campaigns and promotions will treat the symptoms and not the cause.
Conference of the Second Carnegie Inquiry into Poverty and De velopment in Southern Africa held from 13-19 April 1984 at the Univer sity of Cape Town.

FIGURE
FIGURE 1. Breast-feeding prevalence between developing and developed countries (WHO, 1982) h i g h PO RTE

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The

TABLE 1 Percentage of women who gave not enough milk as reason for discontinuing breast-feeding in three studies
(Jacobs, unpublished statistics, 1979) However, few attem pts have been made to tailor these courses to the communities they are intended to reach.Dr Marion Jacobs, a lec turer in Pediatrics at the UCT Medical School has suggested that a new approach might be to use exist ing training programmes to create a new teaching course which would be more acceptable.M others who have breast-fed and are interested in promoting it could do this course.Their responsibility would be to visit all mothers in their immediate vicinity who have just returned home from the hospital or MOU.Advances in International Mater nal and Child Health.Oxford.Oxford University Press.C arter, D.L. (1984) A survey o f nutrition education in the maternity units of Groote Schuur Hospital, unpublished, submitted for Carnegie Inquiry.Chetley, A. (1984) O ur campaign has just begun Ideas Forum No. 14. Published by International Baby Food Action N et work.Craig, A .P .;Albino.R.C. (1983) Urban Zulu mothers' views on the health care of their infants.South African Medical Jour nal.Vol.63 No. 15, p. 571.Geissler, C.; Galloway, D .H .;M orgen, S.; Kennedy, B. (1975) Lactation adequacy, pre and post-natal nutritional status and serum hormonal levels in Iranian women of low and middle socio-economic status.Federation Proceedings, Volume 4. Hakim, P. (1979) Programmes to encourage breastfeeding in the developing coun tries.IN Breast-feeding and fo o d policy in a hungry world.Dana Raphael, editor.New York: Academic Press.
Health Information Center (n.d.)M ater nity rights, information for negotiations.Unpublished.