For most mothers, giving birth is the hardest part of pregnancy. But for Fan Yuk-kuen, the problems began after delivery. Her breasts hurt and she did not understand why. Ms Fan, 27, realised the cause of her discomfort only when a second-time mother explained that her breasts were full of milk. Not knowing what to do, she put up with the pain for a day and a half. Only then did a nurse ask her how she wanted to feed her baby - with a bottle or by suckling the child. When she chose the latter, she was told she could breast-feed, but only at four allotted times in the day. And when she left the private hospital, no one told her she could use pumps to relieve herself and store the milk to feed the baby later. 'Engorged breasts are a sign of pain,' said Dr Linda Brown, chairperson of the Health Care of Women and Childbearing Division at the University of Pennsylvania's School of Nursing, who gave a breast-feeding seminar in Hong Kong. A mother's breasts become filled with milk if she does not use them to feed her newborn child almost immediately and at frequent intervals, she explained. The sight of engorged breasts, she said, was 'the most appalling aspect of my visit here'. Breast-feeding - one of the earliest ways in which a child and mother bond - has not been as widely accepted in Hong Kong as some health professionals would like, despite the nutritional, immunological and psychological benefits to newborns. The situation seems to be improving, however. Surveys, conducted annually at 22 private and public hospitals with maternity wards since 1992, show an increasing number of mothers are breast-feeding their babies by the time they leave hospital. Last year, 45.9 per cent of mothers chose breast-feeding over bottle feeding compared to 32.4 per cent the year before. In 1992, the corresponding rate was 19 per cent. Chee Yuet-oi, project co-ordinator of the Baby Friendly Hospital Initiative Hong Kong Association, says countries such as China, the US and the UK fare slightly better in their breast-feeding rates while Japan, Scandinavia, Germany and Hungary have rates of more than 90 per cent. The association's survey also sought to discover how many 'baby-friendly' points hospitals complied with. (In 1989 the World Health Organisation and the United Nations Children's Fund drew up a simple 10-point plan outlining steps hospitals should take to improve their post-natal care. It suggests initiating breast-feeding within a half-hour of the delivery, allowing mothers and babies to 'room in' together from the moment of birth, and encouraging breast-feeding on demand, rather than on schedule.) 'Of course, [the hospitals] can comply with each point but to what extent is questionable,' said Ms Chee. 'We have had mothers tell us different things than the hospitals indicate. And we have nurses and lactation consultants tell us differently also.' Ms Chee also notes that the surveys give no indication of how many mothers continue breast-feeding after they leave hospital, but she hopes to conduct follow-ups in the future when the association has more resources. 'Ideally, we'd like to see mothers breast-feeding for up to eight weeks.' Her goal is to have the WHO assess hospitals in the territory and officially designate as 'baby friendly' those that meet the standards. 'Once you get one hospital designated, others will get jealous. That's what I'm trying to create - jealousy,' she said. Ms Chee found allies in her promotional work last year, after holding a workshop for breast-feeding mothers. The Hong Kong Breast-feeding Mothers' Association was formed with the help of Vivian Leung Yuet-kan, the group's chairman and a mother of two. Ms Leung now also actively solicits hospitals to help promote breast-feeding. Both women agree that the territory's public and private hospitals are moving in the right direction, although at different rates and with different attitudes. At some private hospitals, breast-feeding is allowed only in a nursery and mothers cannot room-in with their baby, even if they have a private room. When asked why, a labour ward nursing officer at St Paul's Hospital said, 'It is not convenient for us to do this.' 'Public hospitals tend to have policies towards breast-feeding. With private hospitals, it is hit and miss, depending on the doctors and the staff. But they usually go with what mothers want. So, if something goes wrong and the mother doesn't want to breast-feed any more, that is what they will do. They are not as zealous as public hospitals to get mothers breast-feeding. That seems to be the picture in Hong Kong,'said Ms Chee. And although many health professionals agree that mothers should breast-feed their babies as soon as possible after delivery, some hospitals often recommend that they rest for one or two days before doing so. Dr Brown says this makes breast-feeding difficult for mothers, who may suffer from engorged breasts and who may thus be turned off breast-feeding. The sooner the baby can latch on to a mother's nipple, the easier for the mother to empty her breasts of milk. Margaret Yen Yim Wam-fong, assistant director of nursing and domestic services at Matilda Hospital, says having a roughly equal ratio of midwives to mothers helps keep mothers motivated in what she describes as 'a very tough job'. Matilda has earned the respect of many midwives for having achieved a 90 per cent success rate of discharging mothers who breast-feed. Babies are encouraged to suckle on the mother's breast as soon as 30 minutes after they are born. Matilda's nursery is usually empty because mothers are encouraged to feed their babies on demand and hence are roomed-in with their child. Dr Brown stresses the importance of mother and child sharing a room. Otherwise, the mother will have difficulty discerning when her baby needs to be fed. 'If a baby starts crying, it is already too late. A mother has to learn to recognise the cues a baby gives when it wants to be fed,' she said. United Christian Hospital has also joined the breast-feeding crusade. Dr Bill Chan Hin-biu, a consultant paediatrician, says that more than half of the 3,500 new mothers discharged from the public hospital are breast-feeding. The hospital initiated a breast-feeding policy in 1991 and started training its staff to educate mothers better. Before the policy was implemented, only a quarter of mothers leaving the hospital had taken to breast-feeding. Dr Chan says reasons for not breast-feeding differ but he suggests that in Hong Kong, 'some women share small flats with other people and they might think it is inconveniencing others'. Independent midwife Anna Illingworth says that some mothers believe mistakenly that their newborn will not be a 'fat baby' (meaning a healthy baby) if it is breast-fed.