Breastfeeding: Protecting the Golden Hour

Aug 18,2021

Breastfeeding

 
The Golden Hour refers to the first 60 minutes after birth, when a baby is placed against its mother’s skin for the first time. Modern medical science tells us that this hour is a critical time for the execution of evidence-based practices – including the initiation of exclusive breastfeeding – that stabilise the health of both mom and baby.1

In fact, research has found that the longer a baby waits to be put to its mother’s breast, the greater the risk of infection or death. Yet globally, only two in five children – 42% – are put to the breast within that first critical hour of life.2

Against this backdrop, the theme for this year’s World Breastfeeding Week is prudent and pertinent – Protect Breastfeeding: A Shared Responsibility. By promoting the correct Golden Hour practices and scaling up breastfeeding, we could prevent 20 000 maternal deaths and 823 000 child deaths annually.3

The 2016 Lancet series on breastfeeding states that breastfeeding support is the most cost-effective children’s health intervention, decreasing child morbidity and mortality. In fact, exclusive breastfeeding, initiated within the first hour of life and continued for at least six months, is considered the “cornerstone of child survival and child health” because it provides essential nutrition and immunisation against a range of infections and life-threatening ailments.3

What’s more, breastfeeding has long-term health benefits. Pertinently, “the protective effect of early breastfeeding [exists] independently of whether or not the children [are] exclusively breastfed”. 2

It’s not surprising that the 2021 World Health Assembly Resolution included a nutrition implementation plan, targeting an increase in the rate of exclusive breastfeeding in the first 6 months, up to at least 50% by 2025. 4

While progress has been made, some populations are not yet meeting their breastfeeding targets. South Africa, for example, falls short of the breastfeeding target. In 2016, only 32% of babies were exclusively breastfed. The target, set by the Department of Health, was a rate of 75% by 2017 5. More than a quarter of children in South Africa are stunted, and experts believe that this may be attributable, in part, to low breastfeeding rates. 6

Across the Eastern and Southern African region (ESAR), the rate of early initiation of breastfeeding varies (see Table 1, below). Studies have established that breastfeeding practices are affected by a range of historical, socioeconomic, cultural and individual factors. 4

Some of these include:

  • Lack of adequate support for mothers (i.e. education/instruction, guidance on breastfeeding, etc.) 4
     
  • Healthcare practices that result in a delay in the initiation of breastfeeding (e.g. in cases of high-risk pregnancy, assisted deliveries, maternal illness, etc.) 2
     
  • Incorrect or outdated breastfeeding practices. For example, poor positioning of baby for feeding, colostrum avoidance, prelacteal supplementation or poor latching of baby. Without the proper instruction, guidance and support, new moms may not get these basics right. 2
     
  • Negative experiences with breastfeeding may be traumatic for new mothers, prompting them to abandon breastfeeding (and making them less likely to try breastfeeding again in the future). 7
     
  • Workplace concerns: To support themselves and their families, many women must return to work very soon after delivering their baby. Yet they face a number of hurdles which make continued breastfeeding impractical, such as insufficient maternity leave (which is found to lead to a four-fold increase in the odds of not establishing breastfeeding or its early cessation); lack of work-time breaks and also lack of on-site breastfeeding (or expressing) rooms. Some employers are not comfortable with breastfeeding or expressing of breastmilk in the workplace (an attitude that is sometimes shared by fellow employees too).  It is believed that more than 60% of working women are informal workers, with no access to employment or maternity protection.  9
     
  • Social and cultural attitudes or norms: Women don’t feel comfortable breastfeeding in public (or at work).  4
     
  • Marketing that discourages breastfeeding: Formula manufacturers have, in the past, relied on marketing practices that positioned formula as the superior nutrition, or the solution for fussy babies, or even as the more sophisticated and convenient option. 4 The International Code of Marketing of Breastmilk Substitutes policy framework aimed to stop commercial interests from discouraging breastfeeding. 6

 

Healthcare practitioners (HCPs) can provide information and support

By observing the ‘Baby-friendly Hospital Initiative’ (BFHI), HCPs can play an active role in protecting breastfeeding by supporting new mothers with sound advice as they initiate breastfeeding. 

feedingThis advice may include explaining:

  • The benefits of breastfeeding:
    • For baby: Colostrum and breastmilk are considered specially personalised nutrition and medicine, delivered at a critical moment. It includes gut bacteria and immune cells from the mother, which builds a healthy microbiome in baby. In addition, breastfeeding prevents up to 54% of all diarrhoea episodes and 32% of all respiratory infections, while also protecting against the development of obesity and Type 2 diabetes later in life.  10
       
    • For mother: Decreases the risk of breast cancer and ovarian cancer, and10 also assists with bonding between mom and infant. 11
       
  • The importance of initiating breastfeeding within the first hour after birth. This ensures that the infant receives colostrum, which contains important antibodies that protect against diseases such as sepsis, pneumonia, diarrhoea and hypothermia. 12

 

  • The lactation process, including a discussion on breast anatomy, the physiology of breast milk production and also the lactation hormones. Also, explain how to express the milk if baby cannot suckle. 13

 

  • The different ways that baby can be positioned at the breast, for easy and effective feeding. Keep in mind that mothers who have been delivered of baby via c-section may find some feeding methods uncomfortable. 12

 

  • The correct latch to ensure optimal feeding of baby (and also prevent discomfort for the mother).12 &13

 

  • The benefits of rooming-in for improving the mother-baby bond, as well as facilitating breastfeeding.

 

  • How to identify baby’s feeding cues (e.g. fists moving to mouth, sucking, turning head to look for breast, etc.) 14 and the benefits of responsive feeding, which involved recognising baby’s signs that they are hungry or satiated, and responding to those signs accordingly. 15 Baby naturally regulates his/her caloric intake; practicing responsive feeding sets the foundation for healthier eating habits later in life, preventing over-eating and obesity. 16

 

  • The benefits of skin-to-skin contact, especially for low-birthweight babies. 17 This contact calms both mother and baby, regulates baby’s temperature and stimulates digestion. It also stimulates the release of hormones that play a role in the breastfeeding process, while enabling colonisation of baby’s skin with bacteria from the mother’s microbiome.  Additionally, it has been found to improve the mother’s milk volume.18

 

  • The importance of avoiding pre-lacteal feeds and unnecessary supplementation that replace colostrum and milk (both of which provide the baby with antibodies that prevent disease).2,3 & 11

 

  • The importance of correct supplemental nutrition, after the first 6 months of exclusive feeding. There is a need for guidance to discourage inappropriate and unnecessary commercially prepared milk drinks for babies and young children. 19

 

Table 1: Rate of early initiation of breastfeeding

(Source: UNICEF, WHO. Capture the Moment – Early initiation of breastfeeding: The best start for every newborn. New York: UNICEF; 2018)

Country

Rate of early initiation of breastfeeding

Year of last estimate

Botswana

40.0%

2007

Burundi

85.0%

2016

Comoros

33.7%

2012

Djibouti

52%

2012

Eritrea

93.1%

2010

Eswatini

48.3%

2014

Ethiopia

73.3%

2016

Kenya

62.2%

2014

Lesotho

65.3%

2014

Madagascar

65.8%

2012

Malawi

76.2%

2015

Mauritius

No data

 

Mozambique

69%

2013

Namibia

71.2%

2013

Rwanda

80.5%

2014

Seychelles

No data

 

Somalia

23.4%

2009

South Africa

61.1%

2003

South Sudan

50.5%

2010

Tanzania

No data

 

Uganda

66.1%

2016

Zambia

65.8%

2013

Zimbabwe

57.6%

2015

 

 

Resources:

 

[1] Neczypor, J. and Holley, S., 2017. Providing Evidence-Based Care During the Golden Hour. Nursing for Women's Health, [online] 21(6), pp.462-472. Available at: <https://nwhjournal.org/article/S1751-4851(17)30281-7/pdf> [Accessed 12 August 2021].

[2] UNICEF, WHO. Capture the Moment – Early initiation of breastfeeding: The best start for every newborn. New York: UNICEF; 2018 [Accessed 12 August 2021].

[3] The Lancet, 2016. Breastfeeding: achieving the new normal. [online] 387, p.404. Available at: <https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00210-5.pdf> [Accessed 12 August 2021].

[4] WHO/UNICEF. Global nutrition targets 2025: breastfeeding policy brief (WHO/NMH/NHD/14.7). Geneva: World Health Organization; 2014.[Accessed 12 August 2021].

[5] Extranet.who.int. 2013. Policy - Roadmap for Nutrition in South Africa | Global database on the Implementation of Nutrition Action (GINA). [online] Available at: < https://extranet.who.int/nutrition/gina/en/node/7994> [Accessed 12 August 2021].

[6] Witten, C., 2021. What's missing in South Africa's strategy to get breastfeeding levels up. [online] Medicalxpress.com. Available at: < https://medicalxpress.com/news/2021-08-south-africa-strategy-breastfeeding.html> [Accessed 12 August 2021].

[7] Nestlé Nutrition Institute, 2021. Understanding Parenting Today 2021 - Hidden Realities in Infant Feeding. [video] Available at: <https://www.youtube.com/watch?v=t3h9g7Ywbgw > [Accessed 12 August 2021].

[8] Rollins, N., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C., Martines, J., Piwoz, E., Richter, L. and Victora, C., 2016. Why invest, and what it will take to improve breastfeeding practices?. The Lancet, [online] 387, pp.491-504. Available at: <https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf> [Accessed 12 August 2021].

[9] Horwood, C., Hinton, R., Haskins, L., Luthuli, S., Mapumulo, S. and Rollins, N., 2021. ‘I can no longer do my work like how I used to’: a mixed methods longitudinal cohort study exploring how informal working mothers balance the requirements of livelihood and safe childcare in South Africa. BMC Women's Health, [online] 21(1). Available at: <https://doi.org/10.1186/s12905-021-01425-y> [Accessed 12 August 2021].

[10] Hajeebhoy, N., 2016. Why invest, and what it will take to improve breastfeeding practices?.

[11] 2002. Essential Newborn Care and Breastfeeding: Training Modules. [ebook] World Health Organisation. Available at: <https://apps.who.int/iris/bitstream/handle/10665/107481/e79227.pdf> [Accessed 12 August 2021].

[12] Ekubay, M., Berhe, A. and Yisma, E., 2018. Initiation of breastfeeding within one hour of birth among mothers with infants younger than or equal to 6 months of age attending public health institutions in Addis Ababa, Ethiopia. International Breastfeeding Journal, [online] 13(1). Available at: <https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-018-0146-0#citeas> [Accessed 12 August 2021].

[13] 2020. Baby-Friendly Hospital Initiative Training Course For Maternity Staff: Participant’s Manual. [ebook] World Health Organization and the United Nations Children’s Fund (UNICEF). Available at: <https://apps.who.int/iris/bitstream/handle/10665/333675/9789240008953-eng.pdf?sequence=1&isAllowed=y> [Accessed 12 August 2021].

[14] WIC Breastfeeding. n.d. Baby's Hunger Cues. [online] Available at: <https://wicbreastfeeding.fns.usda.gov/babys-hunger-cues> [Accessed 13 August 2021].

[15] Chen, T., Chen, Y., Lin, C., Peng, F. and Chien, L., 2020. Responsive Feeding, Infant Growth, and Postpartum Depressive Symptoms during 3 Months Postpartum. Nutrients, [online] 12(6), p.1766. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353384/> [Accessed 13 August 2021].

[16] Brown, D., n.d. Importance of Responsive Feeding. [online] https://kellymom.com/. Available at: <https://kellymom.com/ages/newborn/bf-basics/importance-responsive-feeding/> [Accessed 13 August 2021].

[17] Rollins, N., Minckas, N., Jehan, F., Lodha, R., Raiten, D., Thorne, C., Van de Perre, P., Ververs, M., Walker, N., Bahl, R. and Victora, C., 2021. A public health approach for deciding policy on infant feeding and mother–infant contact in the context of COVID-19. The Lancet Global Health, [online] 9(4), pp.e552-e557. Available at: <https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30538-6/fulltext> [Accessed 12 August 2021].

[18] Baby Friendly Initiative. n.d. Skin-to-skin contact - Baby Friendly Initiative. [online] Available at: <https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/skin-to-skin-contact/> [Accessed 12 August 2021].

[19] Romo‐Palafox, M., Pomeranz, J. and Harris, J., 2020. Infant formula and toddler milk marketing and caregiver's provision to young children. Maternal & Child Nutrition, [online] 16(3). Available at: <https://pubmed.ncbi.nlm.nih.gov/32157807/> [Accessed 12 August 2021].