Low breastfeeding rates spawn the formation of a breastfeeding support group. Emphasis on mother education and mother-to-mother support.

In the 1970s, breastfeeding in Singapore had fallen to an all-time low. Figures of mothers initiating breastfeeding in 1951 saw 85% of high income mothers and 90% of low income mothers doing so. At three months, 45% of high income mothers and 77% low income mothers were still breastfeeding. By 1971, only 28% of high income mothers, and 51% of low income mothers initiated breastfeeding, and at three months, only 4% of the former, and 5% of the latter were still breastfeeding at all. It was the era of women coming into their own as working women, and working mothers, that sounded such a death knell to breastfeeding.

Prof. Wong Hock Boon, the Professor of Paediatrics in our medical school, studied this disturbing phenomenon in his publication, Breastfeeding in Singapore (1971). As early as 1972, he initiated a correspondence with the La Leche League in the USA, asking for advice and help to start a support group for breastfeeding mothers here. It was not until 1975 that he was in touch with an expatriate lady here, Mrs Illona D. Helmhotz, who had LLLI background, and gave him active assistance to get a group going. Through the newspapers, they asked for interested women to respond. The respondents were a handful of primarily expatriate women, among them a young New Zealand mother married to a Malaysian, Mrs Rosemary Chen, who became the first President of the Singapore Breastfeeding Mothers' Group (SBMG), set up in 1975 as an Advisory Committee under the Consumers' Association of Singapore (CASE). In those days, Prof. Wong highlighted the plight of babies who were allergic to cow's milk, and bottled-fed babies with severe cases of gastroenteritis, who were put on donated breast milk as part of their treatment. He ran human milk banks in the Singapore General Hospital, St. Andrew's Children's Hospital and Alexandra Hospital with milk donated from members of the group. These case studies were to give publicity to the importance of breastfeeding, as so few local mothers were breastfeeding at all then.

SBMG members gave help to mothers through "coffee mornings" in homes, phone counselling, and the sale of printed pamphlets highlighting seven aspects of breastfeeding. These were later amalgamated and expanded to form the main body of our present handbook, "Practical Hints for Breastfeeding." Even in those early years, SBMG organized breastfeeding seminars, baby shows for the public, and participated in exhibitions to share the breastfeeding message. Members donated books towards a library of breastfeeding material, and since then, the SBMG Library has been one of the authoritative resources, and for many years the only resource, for breastfeeding material. In 1977, SBMG President Junnie Tan represented the Group at the International Planned Parenthood Federation's seminar on "Lactation, fertility and the working woman" in Milan, Italy. She was a midwife by training, and the first local President of the Group. In those early years, Dr. Ang Poon Liat and Dr. Maureen Tsakok were closely involved with the Executive Committee. In 1979, Prof. Wong spear-headed the formation of the Sale of Infant Foods Ethics Committee, Singapore (SIFECS). This body aimed to protect and promote breastfeeding by providing guidelines on the appropriate marketing and distribution of breast milk substitutes for up to one year of age. SBMG was, and now BMSG(S) is still an important voice on this regulatory body.

Reaching mothers and training counsellors.

In 1979, the Swedish breastfeeding promotion group, Amningjelpen, took an interest in exploring how they could help promote the cause in Singapore. Maudhe Hedstrom and Britta Hejdenberg visited Singapore for first-hand information. At that time, their group had 700 members, of whom 350 were counselling members. Their Central Administrative Body received a yearly grant of 25,000 Swedish crowns from the Swedish government for their work. They donated some $80,000 to SBMG, the bulk of which was spent in making a film, "The Second Link". Unfortunately, the film was not well made, and did not have much public appeal. Opportunities to educate mums-to-be on the importance of breastfeeding came through invitations to take the breastfeeding segment of antenatal classes in private hospitals like Mount Alvernia, Thomson Medical Centre, and later Gleneagles Hospital. There were occasional opportunities to address mothers in the polyclinics. SBMG also held public talks monthly, often using community centres and libraries as venues. Prof. Wong also invited the Group to speak to fourth or fifth year medical students on their paediatric rotation. Initially, speakers for talks were invariably the well-informed and vocal expatriate members. From the early 1980s, a small number of local mothers began to emerge to gradually take on a bigger role in the running of SBMG. Breastfeeding support in Singapore owes its roots to the expatriate community here in the 1970s, and while it was a very healthy sign that local mothers were slowly coming to the helm, we must never forget the wonderful contribution put in by our expatriate friends.

1981 is important for breastfeeding because the 34^th World Health Assembly adopted the WHO International Code of Marketing of Breast-milk Substitutes. Singapore was one of the signatories. The WHO Code lays down much stricter controls on the infant formula industry compared to our own SIFECS Code, established in 1979. Singapore chose to continue with our own Code, which made hardly a dent in the infant formula industry.

From the beginning, SBMG had been offering breastfeeding counselling by phone to mums in need. Counsellors' numbers were simply printed on the brochures we distributed. It was actually quite disruptive to counsellors' home lives. Counsellors advised from their own experience. We did not have formal Counsellors' Training until 1983, when we put together a simple training package based on the Swedish "Twenty Questions". This was to evolve through the years into the training scheme we use today.

Spreading the breastfeeding message upwards to healthcare professionals, and the entry of Lactation Consultants.

Up to the mid-1980s, SBMG only had platforms to speak to expectant mums, and the occasional lecture to medical students by courtesy of Prof. Wong Hock Boon. The new thrust was to bring the message to nurses, and some doctors, in the government hospitals. It really came about by default. Some time in the early 1980s, Prof. Maureen Tsakok, an obstetrician and the other strong advocate of breastfeeding, invited us to give monthly talks on breastfeeding to KK Hospital mothers. Angela Lee and I gave these talks to dwindling audiences, almost all of whom were Prof. Tsakok's patients. Other doctors simply forgot, or did not bother to send their patients. In 1986 she invited me to go to Singapore General Hospital instead, as she was going to head up the O & G Department there. She wanted to introduce antenatal classes there -the first government hospital to do so. I was able to sit through many planning meetings with the staff, and was able to suggest to the doctors what was hindering breastfeeding - explaining the importance of feeding immediately after birth, among other things. What was common breastfeeding knowledge to our counsellors was clearly new information to them -even ways to manage initial lactation so as to avoid or minimize engorgement.

Before taking the antenatal classes at SGH, we requested an opportunity to address the nursing staff, so that they will give consistent support to the mothers we would prepare through antenatal classes. This was the beginning of an important series of training we called "Nurses' Contribution to Successful Breastfeeding" which SBMG conducted for SGH (1986), and all Maternal and Child Health Clinic nurses (1987). Then in 1988, Toa Payoh Hospital, National University Hospital and later Alexandra Hospital also asked for our help for their antenatal classes. In each case, we addressed the nurses before commencing our antenatal class talks. The burden of these nurses' training sessions fell to myself, Lynette Thomas, Yeo Soo Lan, and later, Bridget Goom. Toa Payoh Hospital was particularly receptive. One doctor there, Dr Noel Leong, was so impressed with the breastfeeding expertise of the Group that he invited us to give extended sessions to their nurses in 1988/89, and some of his doctors were also in attendance.

Exposure to NMAA's Lactation Conference in 1988 was significant to SBMG in a number of ways. In 1989, Yeo Soo Lan, a midwife by training, accepted a position as "Breastfeeding Advisor" in Mount Elizabeth Hospital. It was the first time a local hospital had designated a nurse to attend to the breastfeeding needs of new mothers. SBMG Counsellor Doris Fok, began to explore how she could prepare and sit for the Lactation Consultants' Exam. It was a monumental undertaking, because she did not have medical background. She had only her experience as a Counsellor for SBMG to start her off. Perseverance and determination paid off, and she qualified as a Lactation Consultant and was accredited by the International Lactation Consultants' Association (ILCA). It was a historical milestone that a non-medical SBMG Counsellor should be the first qualified Lactation Consultant for Singapore and Asia in 1992. In 1991, Doris had accepted a position as Lactation Consultant in KK Hospital, our main maternity hospital. During her seven and a half years there, she trained many nurses in KK Hospital and other hospitals, and carried out research in various areas of breastfeeding. She also lectured the medical students on breastfeeding. From this beginning, Singapore now has thirty-two accredited Lactation Consultants in our hospitals and in private practice as at November 2004.

The other important spin-off from the NMAA Conference was the inspiration it gave us to have a fixed line and an answering machine from which to operate our counselling hotline. Up to then, SBMG functioned out of the homes of Committee Members. Only official files were housed at CASE. Everything else - our Library, handbooks, teaching aids, slides and projector -were all stored in our homes. A fixed line became possible when Father Edmund Dunne, who had oversight of a Catholic welfare service, Family Life Society, read of our lack of space in a letter to the press, and offered us use of FLS's small pantry space, where we could put our phone line, and have some overhead storage, and a mailing address. This was to be our "Office" for the next ten years. We also brought back useful knowledge that cabbage leaves were efficacious for dealing with engorgement, and this has since become a standard practice in our breastfeeding management here. With the answering machine, in later years when the hotline roster was well managed, BMSG(S) answered an average of 3,500 calls annually. In 2000, counselling even expanded to include e-counselling, pioneered by Koh Geok Cheng.

KK Hospital leads the breastfeeding way.

In 1990, Dr Noel Leong, who by then was in KK Hospital, saw the importance of promoting breastfeeding in the hospital. I was invited to sit on the Breastfeeding Promotion Committee he initiated, which had the strong support of KK's Director of Nursing, Ms Lee Yoke Lan. To convince the hospital board that there was a necessity to promote breastfeeding, a baseline survey was conducted on mothers returning for their post-natal check-up at six weeks, to see how many were still breastfeeding. The shocking statistic of 2% left no doubt of the need. SBMG was invited to help train the KK nurses, and we took all the maternity ward nurses through our "Nurses' Contribution to Successful Bresastfeeding"in three batches, each comprising three ninety-minute sessions. The trainers were myself, Lynette Thomas and Yeo Soo Lan. The hospital's decision to take on Doris Fok in 1991 as Lactation Consultant was in line with this thrust. From counselling the mother on her first visit, the hospital increasingly put in place more supports to encourage breastfeeding. Seven years down the line, in 1997, KK Hospital conducted a year-long survey to find out how many babies were still breastfed at four months. The finding of 6.3% still feeding at four months was encouraging progress, though it also revealed how much more work lay ahead. KK Hospital has remained the centre where other hospitals send their nurses for lactation training.

Coming out of CASE as Breastfeeding Mothers' Support Group (Singapore)

In 1989, CASE informed us of their intention to restructure, and suggested that the time had come for us to be an independent society. It was a time of floundering and soul-searching for us, as we pondered whether we were ready to go independent - a voluntary, non-profit group with no funding from anywhere to back us. We decided to take the step of faith. We were registered as Breastfeeding Mothers' Support Group (Singapore) - BMSG(S) - on 19 January 1991. Looking back, independence was a great step forward for breastfeeding promotion. It enabled us to move ahead in an unprecedented way. BMSG(S) invited Dr Dixie Tan, former Member of Parliament, and herself a medical doctor with great interest in breastfeeding, to be our Patron. At BMSG(S)'s first Annual General Meeting in August 1991, Lynette Thomas became the first President of BMSG(S). To mark our new status, we organized an Inaugural Seminar for Healthcare Professionals, bringing in three speakers, the late Prof. Derrick Jelliffe, his wife, Prof. Patrice Jelliffe, both from the University of California, USA; and Dr Neil Campbell, Director of Neonatology, Royal Children's Hospital, Melbourne. Dr Mark Belsey, Chief of Maternal and Child Health, of WHO, Switzerland, who was here as a speaker for the FIGO Congress, addressed the Seminar as a fourth speaker. This landmark seminar was the first of several more BMSG(S) organized in succeeding years, to bring breastfeeding expertise into Singapore to address our doctors and nurses. This had never been done before.

1st EXCO of BMSG(S), elected March 1991. Standing (L-R) - Faridah Menion, Selina Gomes, Wong Mei Kwun, Bridget Goom, Lyneet Thomas [President] & Marianne Srinivasan. Front (L-R) - Debbie Woodford, Yeo Soo Lan, Doris Fok & Wan Siew Kwun.

New aspects of BMSG(S) work.

Independence gave us funds from membership subscriptions which we could use for breastfeeding promotion. Membership profile also changed. Our membership now included not only breastfeeding mothers, but husbands, nurses and even doctors who wanted to underline their support for breastfeeding. Farida Menon initiated the setting up of product outlets where we sold our handbooks, breast pumps and other breastfeeding-related products. In more recent years, breastfeeding blouses and tee-shirts, and sarong sling baby carriers have been popular items. These were excellent avenues to meet and counsel mothers who came to buy products. Outlets were run by BMSG(S) counsellors who volunteered their time and space at home for the convenience of mothers. BMSG(S) has maintained up to five outlets at different locations at various times. These outlets also brought in useful income for the Group. The early 1990s was also the period when we had meetings for members and their friends at a zonal level. BMSG(S) also helped train the first batch of counsellors for Joyful Parenting.

President Lynette Thomas speaking at BMSG(S) Inaugural seminar in September 1991

BMSG(S) Booth at Healthy Living - Mums, Babies & Children 1991 Exhibition at IMM Building.

World Breastfeeding Week Seminar in August 1994

An office and part-time staff at last.

For a long time BMSG(S) had discussed and dreamt of an office space of our own, and a part-time staff to relieve the Executive Committee of their heavy workload. Around 1996 the Committee began actively exploring ways to obtain a tax-exempt status, which would help us to fund-raise. BMSG(S) was eventually granted this status in 1997, under the Ministry of Health's "Health Endowment Fund", through the unstinting efforts of Michelle Lam. In 1998, Vice-President Bessie Low actively searched for possible premises. The Singapore Council of Women's Organizations' announcement that they were renovating premises in Waterloo Street for their headquarters gripped us with excitement. There would be some rooms available for lease to interested affiliates. When SCWO first mooted the idea of a headquarters back in 1994/ 1995 and asked if affiliates would be interested, Doris Fok immediately responded that BMSG(S) would be. Her far-sighted response placed us way ahead in the queue of contenders, now that the headquarters was a reality in sight. Fund-raising became our immediate and urgent concern. Two great fund-raising events stand out: the World Breastfeeding Week 1998 Walkathon, chaired by Dr Lucy Leong, and the Chinese Cultural Night in May 2000, sponsored by Mr Sim Wong Hoo at Creative's open-air amphi-theatre. Wong Mei Kwui and Michelle Lam were the prime movers behind this, and Mr Sim generously matched what we raised dollar-for-dollar. These two events, along with all the healthcare professionals' seminars we have organized exemplified the best efforts of BMSG(S) -togetherness, co-operation and wonderful camaraderie in working towards a common goal -Promote Breastfeeding! We had great fun, and forged strong friendships working together. That period from 1998 to 2000, we raised about $107,000, well above the cost of some $53,000 for the office, with a healthy surplus to look for part-time office help, which we finally accomplished in 2001.

International Networking

From the earliest days, SBMG / BMSG(S) representatives have taken the opportunity to participate and learn from international lactation conferences and seminars. These have provided invaluable links with sister groups in other countries. We were particularly active in such representations in the 1990s, joining conferences organized by NMAA, LLLI, IBFAN, as well as various Lactation Consultant associations. Hong Kong's BMSG received help from us in formulating their constitution in the mid-1990s. Today, BMSG(S) is also represented on the international breastfeeding scene by Doris Fok, who is on the International Board of Lactation Consultants Examiners (IBLCE). Such international awareness also plugged us firmly with World Alliance for Breastfeeding Action (WABA), and each year since 1992 we have celebrated World Breastfeeding Week with Seminars for the Public and/or Healthcare Professionals, picnics in public parks, a Walkathon in 1998, Baby Shows in 2001 and 2002, and a Nurse-out March with LLL(S) in 2003.

Profession Wong Hock Boon with President Wan Siew Kwun (2000) and Michelle Lam

Vice-President Jilyn Chew (2000) discussing with IBM staff about office facilities for breastfeeding mums.

Professor Lars Hanson (2002) in consultation with BMSG(S) counsellors.

Reaching Mums in this decade

Bringing the breastfeeding message to parents-to-be took some new directions with the observation that many working mums struggled to maintain their breastfeeding after returning to work. BMSG(S) started a special workshop to teach working mums better management approaches in 1996. By 1998, we also revamped our monthly talk into a series of four workshops dealing with topics from Preparing to Breastfeed, to Introducing Solids. Each series is conducted quarterly.

Members' Activities

BMSG(S) member Stella Leong and her husband initiated the first of several playgroups in 2001, some of which have continued to the present. Koh Geok Cheng tapped members' expertise in 2002 to give talks on interesting child nurture and family-related topics, and even included farm visits. These were well received and enjoyed by many. In 2005, we organized a couple of film shows for families.

One of our judges Dr Koh Poh Kian examing a young contestant for our BMSG(S) 2002 Baby Show.

WBW 2002 Picnic at MacRitchie Reservoir.

WBW 2003 Nurse-out March from SCWO Centre.

International experts brought in to benefit the healthcare profession.

A very key contribution of BMSG(S) to breastfeeding promotion in this last decade has been the increasing inroads made in bringing healthcare professionals into the whole advocacy process. Since our inaugural seminar in 1991, when BMSG(S) brought in Profs. Derrick & Patrice Jelliffe, Dr Neil Campbell and Dr Mark Belsey, other breastfeeding experts brought in through BMSG(S) were Prof. Peter Hartmann (Australia), whose special interest was in the biochemistry of lactation (1995); Dr Marshall Klaus (USA), who studied the importance of touch in infants and the importance of touch to bonding and breastfeeding (1997); Roz Escott (Australia) from IBLCE, who addressed healthcare professionals on the anatomy of the baby's mouth for breastfeeding, and how bottles and pacifiers interfered with this (1999). The year 2000 was significant, when we invited Prof. Lawrence Gartner,University of Chicago (USA), and Sue Cox, Lactation Consultant from Tasmania, Australia to visit. Prof. Gartner's lecture to doctors attracted 105 doctors and some 200 nurses - the largest number of doctors we have managed to bring into a meeting on breastfeeding. Prof. Gartner's expertise on jaundice, and his high international standing in research made this a landmark visit. Hospital visits by both speakers benefited the doctors and nurses further. The most recent expert to visit was Prof. Lars Hanson (Sweden), an eminent immunologist who lectured on the amazing immunological benefits of breast milk and breastfeeding (2002).

Besides lectures to healthcare professionals, BMSG(S) also arranged for many of these experts to address parents at public meetings, and put in television and radio interviews for a number of them, to maximize exposure of their expertise to the public. The most important meetings BMSG(S) initiated along with many of these visits were the "Breastfeeding Consultations". The first was called by BMSG(S) in 1991, where key paediatricians, obstetricians and nursing directors from the main hospitals were invited to a closed-door consultation with our visiting experts. For the first time, hospital personnel were able to trade experiences on the breastfeeding scene in their respective hospitals, and tap the visiting expert for his suggestions. The five or six consultations we have had so far spawned a core group of healthcare professionals committed to the promotion of breastfeeding in their respective spheres. Since 1991, these have been organized and chaired by BMSG(S), until the last one in 2002, when Dr Lim Sok Bee, as Chairperson of the Singapore Breastfeeding Promotion Committee (SBPC), took over the chair.

A new chapter - Healthcare Professionals beginning to move Breastfeeding Advocacy

The Breastfeeding Consultation in 2000 with Prof Lawrence Gartner and Sue Cox was a turning point. Most of the Asian countries around us have a national committee spear-heading breastfeeding promotion. After 25 years, this was still done only at a mother-support group level in Singapore. Prof. Gartner recommended that Singapore form a national committee if we were to significantly impact the breastfeeding rates here. Following from the August 2000 consultation, BMSG(S) again initiated a meeting in January 2001, this time including representatives from related professional doctors' and nurses' associations, along with the hospital representatives and mother-support groups. The upshot of this historic meeting was a consensus among those present that a national committee was needed, and the Singapore Breastfeeding Promotion Committee was born, with Dr Lim Sok Bee, from KK Hospital's Neonatal Department as Chairman. The morning of the same day, a delegation from BMSG(S) met with Dr Lam Sian Lian, head of the Institute of Health, soon-to-be the Health Promotion Board, to share with her the proposed plans for a national breastfeeding committee. We mooted the need for a national breastfeeding survey, as Singapore had no comprehensive breastfeeding statistic to date. Dr Lam immediately undertook for Health Promotion Board to carry out such a survey, which was duly done in 2001, with SBPC representatives in every hospital lending enthusiastic support. The results of this national survey were made public in early 2005. In November 2003, SBPC was registered as a society, under the new name, Association for Breastfeeding Advocacy (Singapore) - ABAS. BMSG(S) continues to serve as secretariat for ABAS, and we still form the backbone for ABAS at this time. We can look forward to the day when doctors will increasingly come to the fore in this advocacy movement, and move breastfeeding to much greater heights than we can reach from the grassroots as a mother-support movement.

All in all, breastfeeding has come a long and painstaking way in thirty years in Singapore, but there is still a long way to go to see that all babies in Singapore come into their birthright to be nurtured on mothers' milk.

Wan Siew Kwun
Past President, BMSG(S)
March 2005

References

BMSG(S) Minutes and AGM Reports
Keeping Abreast, 1992-2005
SBMG Minutes and AGM Reports
Wan Siew Kwun, Current Trends in Breastfeeding in Singapore, Consumers' Bulletin, Feb. 1982
Wan Siew Kwun, BMSG(S) - a Report and History, Keeping Abreast, January 1992.
Wan Siew Kwun, The State of Breastfeeding in Singapore, Aug. 2000
Wong Hock Boon, Breast Feeding in Singapore, 1971.