SCALE-UP OF HUMAN MILK BANKING IN KZN: 2000 - 2016

Every child gets a chance

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

12

16

22

26

31

32

34

“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

““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).

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

“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

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

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

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

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

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

1716

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)

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

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

““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

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

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

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.

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

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.

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“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