Protection of breastfeeding in Papua New Guinea

Protection of breastfeeding in Papua New Guinea
Hanny Friesen,1 John Vince,2 Peniel Boas,3 & Robert Danaya4
In Papua New Guinea the bottle-feeding of babies has been increasing, predominantly among unemployed women of
low educational status. Many women are unaware of their legal right to have breaks at work for the purpose of
breastfeeding, and a high proportion of workplaces have no facilities for mothers who wish to breastfeed their
children. Thelawsonthefeedingofinfantsshouldbeupdated andimplemented,andaneffortisneededtoexplainthe
benefits of breastfeeding and the rights of working mothers.
Voir page 273 le reÂsume en francËais. En la paÂgina 274 figura un resumen en espanÄol.
Paediatricians, nutritionists and other health personnel working in Papua New Guinea during the early
1970s were aware of the devastating effects of bottlefeeding on children's health, as well as of the often
questionable practices employed in the marketing of
breast-milk substitutes (1). In hospitals there was
clear evidence of increasing morbidity and mortality
from diarrhoeal diseases. Among women leaving
hospitalafterdeliveryinPortMoresbytheproportion
feeding their babies artificially rose from 6% in 1964
to22%in1974(2).In1976asurveyconductedinfive
suburbs of the city indicated that a third of babies
were fed artificially and that 69% of this proportion
were malnourished. By contrast, only 26% of
breastfed children were in this condition (3).
Papua New Guinea's Baby Feed Supplies
(Control) Act 1977 states that feeding bottles may
be obtained only from registered pharmacists on
presentation of a prescription written by a registered
health worker. A health worker who prescribes a
bottle must be satisfied that bottle-feeding is in the
baby's best interest and must take steps to ensure that
the mother or guardian is fully conversant with the
technique and has the means necessary to bottle-feed
safely. In addition the Act prohibits the advertising of
breast-milk substitutes. Four years later, international
guidelines on the marketing of breast-milk substitutes were issued (4).
In 1979 a survey in four of the five suburbs
covered in 1976 revealed that only 11% of babies
were being artificially fed, indicating that the
legislation had had a beneficial effect in the short
term (5). In 1984 an amendment to the Act added
baby cups with perforated spouts to the feeding
bottles, teats and dummies on the list of proscribed
articles (6).
Concern justified
1 Senior Lecturer in Child Health, Department of Clinical Sciences,
University of Papua New Guinea, P.O. Box 5623, Boroko, N.C.D.,
Papua New Guinea.
2 Professor of Child Health, Department of Clinical Sciences, University
of Papua New Guinea.
3 Medical student in the Division of Paediatrics, Department of Clinical
Sciences, Faculty of Medicine, University of Papua New Guinea.
4 Senior Specialist Medical Offcer, Paediatrics, Department of Health,
Port Moresby, Papua New Guinea.
Correspondence should be addressed to Ms Friesen
(tel: 6751 324 8451; fax: 6751 325 4935;
e-mail: [email protected]).
Reprint No.
Current policy favours exclusive breastfeeding for
thefirst4±6monthsofababy'slife,nobottle-feeding
in maternity or paediatric facilities and active
discouragement of such feeding (7). Papua New
Guinea subscribes to the Maternity Protection
Convention, whereby breastfeeding breaks are
allowed for working mothers. Nevertheless, the
Paediatric Society of Papua New Guinea became
concerned that exclusive breastfeeding was declining
and therefore undertook a multicentre-based infant
feeding survey in 1995.
A pretested, standardized questionnaire was
used to obtain socioeconomic data and information
on infant feeding practices in seven base and
provincial hospitals, two urban clinics and two
settlements in the National Capital District. Unselected mothers and guardians of 1822 children
below two years of age who attended the children's
outpatient clinics were interviewed. The Epi Info 5
package was used for data entry and analysis, and
proportions were compared by means of the chisquare test. Nearly half the interviews were conducted in the National Capital District, the others in
six other provinces. Eighty percent of the children
were 12 months of age or below and slightly over half
were males. Breast-milk substitutes or other fluids
were given to 1133 children; 66% were fed by cup
and spoon, while 32% of the mothers used a bottle or
a baby cup with a spout for the following main
reasons:
± mother employed;
± baby adopted;
± breast milk inadequate/breast problems;
± pregnancy;
± twins;
± convenience.
Bulletin of the World Health Organization, 1999, 77 (3)
# World Health Organization 1999
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271
Policy and Practice
Information on the manner in which bottles
were obtained was available for 325 of the 364 bottlefed children. Just over a third of the mothers had
obtained a bottle from a pharmacy on presenting a
prescription from a health worker, most often a
private practitioner. Just over half the mothers had
bought a bottle in a store or pharmacy without
prescription, and the others had been given one by a
relative or friend.
The pattern of ways in which bottles were
obtained varied with the reasons given for using
them. Thus, of the mothers in paid employment
almost two-thirds acquired a bottle on prescription,
whereas this was true of only a tenth of those who
used a bottle for convenience (see figure).
Fig.1.
Reasons for bottle-feeding and ways in which bottles
were obtained
Bottle-feeding was common in all the provincial centres where the survey was conducted, the
highest prevalence being 35% in Western Highlands
Province. In Madang Province and in the highland
provinces most bottles were bought in stores or
pharmacies without prescription.
Influence of education and
employment
Of the 500 mothers without formal education, 13%
were using a bottle or baby cup; of the 706 mothers
witheducationuptograde6,15%weredoingso.The
corresponding values for 344 mothers educated to
grades7±10,24whohadreceivedvocationaltraining,
and 210 who had received tertiary education, were
28%, 33% and 42% respectively.
Of the 253 mothers in paid employment, 55%
were bottle-feeding, whereas of the 1519 without
suchemploymentonly14%weredoingso.However,
a breakdown of the educational levels of the latter
group suggested that employment was more important than educational level in determining
whetherbottle-feedingwaspractised.Althoughthere
272
was a relatively large amount of bottle-feeding by the
more highly educated women and women in paid
employment, the absolute numbers were small and
bottles were used predominantly by unemployed
women with only primary education or no formal
education at all.
Information about breastfeeding had been
received by65% of themothersfrom healthworkers,
and 64% knew that using a cup and spoon was the
best way to feed children artificially. Of the mothers
who had been advised by health workers, 14%
thought that bottle-feeding was the best method of
giving drinks to babies. Of the 1139 mothers who
knew that feeding by means of a cup and spoon was
better than bottle-feeding, 16% nevertheless continued using bottles. Of the mothers who were
bottle-feeding, 72% knew that the practice could
cause diarrhoea.
Although employment was one of the main
reasons why mothers bottle-fed their babies, almost
two-thirds of working mothers were unaware that
they were legally entitled to two half-hour breastfeeding breaks daily. The existence of child-minding
facilities in workplaces was reported by under 5% of
the interviewees.
The importance of breastfeeding is now widely
recognized (8). Even though the number of HIVinfected women is rapidly increasing in Papua New
Guinea the benefits of breastfeeding outweigh the
risk of HIV transmission via breast milk. The policy
of encouraging breast-feeding remains valid. Unfortunately, the survey indicates that, notwithstanding the legislation, bottle-feeding is being practised to
a greater extent than was anticipated. Merely having
legislation in place is not enough: clearly, it has to be
enforced.
The baby-feeding practices of mothers in paid
employment and those who have benefited from
higher education merit special attention because
these women are likely to be influential in their
families and communities. The survey shows the
prevalence of bottle-feeding among mothers in paid
employment to be four times higher than among
other mothers; a positive but weaker correlation
exists between bottle-feeding and the educational
status of mothers. It therefore seems particularly
important to facilitate breastfeeding for working
mothers.
Following the survey, the Paediatric Society of
Papua New Guinea passed resolutions requesting:
± enforcement of the Baby Feed Supplies (Control)
Act;
± amendment of the Act to limit the prescription of
proscribed articles to registered medical practitioners;
± revision of fines imposed for offences against the
Act, and removal of trade licences for persistent
offenders;
± enforcement of ILO rules on paid maternity leave
and the provision of breastfeeding breaks and
facilities for breastfeeding in workplaces;
Bulletin of the World Health Organization, 1999, 77 (3)
Protection of breastfeeding in Papua New Guinea
± organization of health education campaigns
focusing on appropriate feeding practices.
Subsequent discussions between Society delegates and the Department of Health have paved the
way for implementation of these resolutions.
The survey was conducted among women
attending urban health facilities,andits resultscannot
be regarded as representative of the rural population.
Although the level of bottle-feeding in the urban
population is still relatively low there is a clear need
for rigorous implementation of the law, coupled with
education on the dangers of bottle-feeding and the
benefits of breastfeeding, especially among educated
and working mothers. Efforts should be made to
secure the help of private practitioners in the
promotion of breastfeeding and the discouragement
of bottle-feeding, since educated and working
women are increasingly using their services rather
than those of paediatricians in the public sector.
In the matter of breastfeeding, as in other areas of
health education, female health workers should be
encouraged to lead by example.
Following the 1977 legislation there was,
perhaps, a feeling among health workers that the
problem of bottle-feeding had been solved. The
survey has shown this not to be so. Persons working
intheareaofchild healthshouldcontinue topressfor
the updating and implementation of the laws and
policies on infant feeding. n
Acknowledgements
The authors thank D. Mokela, G. Ogle, P. Asuo,
A. Kemiki, W. Lagani, T. Rongap, M. Varughese,
W. Saweri and staff in the hospitals for assisting with
the organization of the survey and the interviews.
Re
 sume
Â
De
 fense de l'allaitement maternel en Papouasie-Nouvelle-Guine
Âe
En Papouasie-Nouvelle-GuineÂe, les politiques d'alimentation des nourrissons preÂconisent l'allaitement maternel
exclusif pendant 4 aÁ 6 mois. Dans les materniteÂs et les
services de peÂdiatrie, on deÂcourage vivement l'utilisation
du biberon conformeÂment aÁ l'initiative des hoÃpitaux
«amis des beÂbeÂs». En 1977, la loi sur le controÃle des
articles pour l'alimentation des enfants, qui stipulait que
les biberons ne pouvaient eÃtre obtenus chez les
pharmaciens agreÂeÂs que sur preÂsentation d'une prescription reÂdigeÂe par un agent de sante agreÂeÂ, a eÂteÂ
accepteÂe. En 1994, la SocieÂte de PeÂdiatrie de PapouasieNouvelle-GuineÂe s'est inquieÂteÂe de ce qui semblait eÃtre
une progression de l'allaitement artificiel et une
diminution de l'allaitement maternel exclusif. Il en est
reÂsulte une enqueÃte meneÂe dans 7 hoÃpitaux de base et
de province, au moyen d'un questionnaire standardiseÂ,
visant aÁ obtenir des donneÂes d'ordre socio-eÂconomique
et des informations sur les pratiques utiliseÂes pour
l'alimentation des nourrissons. On a interrogeÂ
1822 meÁres ou personnes s'occupant d'enfants de
moins de deux ans, choisies au hasard. Mille cent trentetrois enfants recevaient des substituts du lait maternel ou
d'autres liquides; 32% des meÁres utilisaient un biberon
ou une tasse pour beÂbeÂ, alors que 66% des enfants
eÂtaient nourris aÁ la cuilleÁre. Les principales raisons
invoqueÂes pour justifier l'utilisation du biberon ou d'une
tasse pour beÂbe eÂtaient le fait que la meÁre travaillait, que
lebeÂbe avaiteÂte adopteÂ,que lameÁren'avaitpasassezde
lait, et que c'eÂtait plus commode. On a su comment la
meÁre s'eÂtait procure les biberons pour 325 des
364 enfants nourris ainsi. Un peu plus du tiers d'entre
elles avaient obtenu un biberon en pharmacie sur
preÂsentation d'une ordonnance d'un praticien priveÂ. Un
peu plus de la moitie d'entre elles avaient achete un
biberon ou une tasse pour beÂbe dans un magasin ou une
pharmacie sans ordonnance et les autres les avaient
Bulletin of the World Health Organization, 1999, 77 (3)
recËus d'une parente ou d'une amie. Parmi les meÁres qui
avaient un travail reÂmuneÂreÂ, preÁs des deux tiers avaient
obtenu un biberon sur ordonnance alors que seules 10%
de celles qui utilisaient un biberon pour plus de
commodite avaient pu en obtenir une.
Sur les 500 meÁres n'ayant recËu aucune instruction,
13% utilisaient un biberon ou une tasse pour beÂbeÂ; sur
les 706 qui avaient beÂneÂficie d'une instruction primaire,
15% en utilisaient. Enfin, sur les 344 meÁres ayant eÂteÂ
jusqu'aÁ la fin du colleÁge, les 24 ayant beÂneÂficie d'une
formation professionnelle et les 210 ayant poursuivi des
eÂtudes apreÁs le baccalaureÂat, ces chiffres eÂtaient
respectivement de 28%, 33% et 42%. S'il est vrai
qu'on a observe une freÂquence relativement eÂleveÂe de
l'alimentation des beÂbeÂs au biberon chez les femmes
ayant fait des eÂtudes supeÂrieures et chez celles qui
occupaient un emploi reÂmuneÂreÂ, elles eÂtaient peu
nombreuses en nombre absolu et les biberons ont eÂteÂ
principalement utiliseÂs par les femmes sans emploi
n'ayant recËu qu'une instruction primaire ou pas
d'instruction du tout.
Les reÂsultats de l'enqueÃte indiquent que, malgre la
loi, les beÂbeÂs sont beaucoup plus souvent nourris au
biberon qu'on ne pouvait s'y attendre. Il ne suffit donc
pas simplementd'avoir une loi, encorefaut-ill'appliquer.
Les habitudes d'alimentation des nourrissons des meÁres
qui occupent des emplois reÂmuneÂreÂs et de celles qui ont
fait des eÂtudes supeÂrieures meÂritent une attention
particulieÁre, car ces femmes sont celles qui vont avoir
de l'influence au sein de leur famille et de leur
communauteÂ. Il faut s'efforcer de s'adjoindre l'aide des
praticiens priveÂs pour promouvoir l'allaitement au sein et
deÂconseiller l'allaitement artificiel, puisque c'est aÁ eux
quecesfemmesfontdeplusenplussouventappeletnon
aux peÂdiatres du secteur public.
273
Policy and Practice
Resumen
Proteccio
 n de la lactancia natural en Papua Nueva Guinea
Las polõÂticas de nutricioÂn del lactante aplicadas en Papua
Nueva Guinea fomentan la lactancia natural exclusiva
hasta los 4±6 meses. El uso del biberoÂn es activamente
desaconsejadoenlosserviciosdematernidadypediatrõÂa,
en consonancia con la Iniciativa «Hospitales amigos del
ninÄo». En 1977 se aprobo la Ley (de Control) de los
Suministros de Alimentos Infantiles, que establece que
soÂlo se pueden obtener biberones de farmaceÂuticos
colegiados, previa presentacioÂn de una receta firmada
por un agente de salud autorizado. En 1994 la Sociedad
de PediatrõÂa de Papua Nueva Guinea empezo a
preocuparse por el aparente aumento del uso del
biberoÂn y la paralela disminucioÂn de la lactancia natural
exclusiva. Ello llevo a realizar una encuesta en siete
hospitales de base y provinciales mediante un cuestionario normalizado disenÄado para obtener datos socioeconoÂmicos e informacioÂn sobre las praÂcticas de
alimentacioÂn de los lactantes. Se entrevisto a madres y
custodios no seleccionados de 1822 ninÄos menores de
dos anÄos. De ellos, 1133 recibõÂan sucedaÂneos de la leche
maternayotroslõÂquidos;el32% delasmadresutilizaban
biberoÂn o una tacita con boquilla, y el 66% de los ninÄos
eran alimentados con taza y cuchara. Entre las
principales razones para usar el biberoÂn o tacita se
senÄalo que la madre trabajaba, que el ninÄo habõÂa sido
adoptado, que la madre no producõÂa suficiente leche y
que resultaba maÂs coÂmodo. En 325 de los 364 casos en
que se alimentaba a los lactantes con biberoÂn se
consiguio informacioÂn sobre la manera de obtener ese
producto. Poco maÂs de la tercera parte de las madres
habõÂan conseguido el bibero n en una farmacia
presentando una receta firmada por un meÂdico privado.
Algo maÂs de la mitad de las madres habõÂan comprado el
biberoÂn o tacita en una tienda o farmacia sin receta, y las
demaÂs lo habõÂan recibido de un pariente o amigo. Entre
las mujeres que tenõÂan un trabajo remunerado, casi las
dos terceras partes habõÂan adquirido el biberoÂn con
receta, cosa que soÂlo habõÂan hecho un 10% de las que
empleaban el biberoÂn por comodidad.
De las 500 mujeres sin estudios escolares, el 13%
empleaban un biberoÂn o tacita; de las 706 madres con
alguÂn tipo de estudios primarios, el 15% hacõÂan lo
propio. Las cifras correspondientes a las 344 madres con
alguÂn tipo de estudios secundarios, las 24 que habõÂan
recibido formacioÂn profesional y las 210 con estudios
terciarios eran del 28%, 33% y 42%, respectivamente.
Aunque seobservo unafrecuenciarelativamenteelevada
del uso del biberoÂn entre las mujeres con maÂs instruccioÂn
y las mujeres con un trabajo remunerado, las cifras
absolutas eran bajas, y quienes usaban el biberoÂn eran
fundamentalmentemujeressintrabajoquetenõÂansoÂlo,o
ni siquiera, estudios primarios.
Los resultados de la encuesta muestran que, pese
a las medidas legislativas, el uso del biberoÂn es una
praÂctica maÂs extendida de lo que se creõÂa. La mera
legislacioÂn en vigor no es suficiente, pues es necesario
vigilar su aplicacioÂn. Las praÂcticas de alimentacioÂn del
lactante entre las madres con trabajos remunerados y las
de mayor nivel de educacioÂn merecen especial atencioÂn,
pues esas mujeres pueden influir en sus familias y
comunidades. Hay que intentar lograr la ayuda de los
meÂdicos privados para promover la lactancia materna y
desaconsejar el uso del biberoÂn, dado que las mujeres
con instruccioÂn y las que tienen trabajos remunerados
recurren cada vez maÂs a ellos en lugar de a los pediatras
del sector puÂblico.
References
1.
2.
3
.
4.
5.
. The baby killer: a War on Want investigation into the
promotion and sale of powdered baby milks in the Third World.
London, War on Want, 1979.
. Every baby deserves the breast. Nutrition and
development, 1975, : 29±34.
. Port Moresby Infant Feeding Survey.
Papua New Guinea medical journal, 1977, (4): 175±179.
International Code of Marketing of Breast-Milk Substitutes.
Geneva, World Health Organization, 1981.
. Port Moresby Infant Feeding Survey
1979. Papua New Guinea medical journal, 1980, (2): 92±96.
Chetley A
Biddulph J
1
Lambert J, Bashford J
20
6. Baby Feed Supplies (Control) (Amendment) Act 1984. The
Independent State of Papua New Guinea Government Gazette
(1985): 53.
7. Papua New Guinea national policy on infant feeding practices.
Waigani, Department of Health, 1994.
8. Infant and young child nutrition (progress and evaluation report,
and status of implementation of the International Code of
Marketing of Breast-Milk Substitutes). Geneva, World Health
Organization, 1991 (unpublished document WHO/EB89/28).
Benjamin A, Biddulph J
23
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