Her fifth child is due any day. Nazeer Bibi lives in a shanty part of Qayyumabad, Karachi, and has already decided that she will feed her baby formula milk.
“I work in three houses as a domestic help to support my family. I leave at 8 am after dropping my older children to school and return by 4 pm, and the baby will have to be at home. What option do I have? Besides, dabbay ka doodh (formula milk) makes babies healthier. I want my baby to be healthy like the babies in advertisements.”
Nazeer’s baby will be one of the 62 per cent Pakistani infants who are not exclusively breastfed. Only 38 per cent of infants under the age of six months are exclusively breastfed, according to the Pakistan Demographic and Health Survey (PDHS) 2012-13. The rates are the lowest in South Asia.
The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants, a danger that is not talked about often enough. As the World Breastfeeding Week is celebrated globally from August 1-7, the conversation around breastfeeding needs to be more audible and frequent in Pakistan. But bringing up the topic inevitably initiates parallel discourse regarding how lives of infants are less safer till formula milk is promoted as a choice. “From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health,” says an editorial in medical journal The Lancet.
“Formula milk should only be given when there is a medical reason for it,” says Dr Azra Ahsan, an expert in mother and child health. “The baby gets complete nutrition through breastfeeding. The mother passes on her protective antibodies to prevent common illnesses in the baby. As no water is required to prepare it, unlike how formula milk is prepared, the chances of diarrohea and vomiting are minimised.”
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed. Pakistan has one of the highest infant mortality rates in the region, all the more reason that breastfeeding must be encouraged, especially among the lower income strata.
The PDHS 2012-13 findings also show increase in bottle feeding rates in Pakistan.
“Babies who are born to mothers from the lower income strata are more at danger if they are not exclusively breastfed. The water these mothers use to prepare the formula is unhygienic, and the bottles are not sterilized. Also, formula milk is not cheap. Once they start the baby on it, they start diluting the milk over time so that the formula powder lasts longer; as a result, the baby becomes malnourished,” says Neha Mankani who works as a community health midwife at a hospital in Karachi.
Once the baby is started off on top feed, the unaffording or unaware mother, over time, starts substituting it with unboiled cow’s milk or low quality tea whitening milk powder which is unsuited for an infant. “We can try and convince the mothers but only till they are in the hospital. Also, Community Health Workers (CHWs) have no access to women who deliver at home,” says Mankani, adding that she and her colleagues try to convince mothers to breastfeed.
However, part of the problem could be that healthcare providers are not doing enough to raise awareness. “Healthcare professionals are the main culprits. Instead of advising new mothers to breastfeed, they help perpetuate the trend of using formula milk. They are given incentives by formula milk companies. Research shows that children delivered in hospitals are more frequently formula fed,” says Dr DS Akram, Founder, Health, Education & Literacy Programme (HELP).
The laws protecting the right of the infant to health and nutrition are there. Lawyer Summaiya Zaidi says that the primary focus of laws like the Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is to protect the nutrition of the child and promote breastfeeding as a primary source of nutrition. After the devolution, each province developed its own Acts for the purpose.
“The Sindh 2013 Act stresses that manufacturing, advertising and sale of alternate sources of child nutrition cannot be promoted as better than mothers’ milk or even compared to it. This stresses the primacy of breast milk as the best source of nutrition for a growing baby, and only when the mother is unable to provide the same to her child should alternatives be made available. It basically controls the manufacture and advertising of child nutrition products by placing certain legal limits on promotion of the same,” says Zaidi.
Yet, the tussle between public health experts and forces of consumerism continue. Companies producing or distributing formula milk refused to give any statement regarding how they justify the tempting advertising campaigns.
At the 69th World Health Assembly earlier this year, a resolution welcomed WHO’s guidance on ending the inappropriate promotion of foods for infants and young children. The guidance states that in order to protect, promote and support breastfeeding, the marketing of “follow-up formula” and “growing-up milks should be regulated. This recommendation is in line with the International Code of Marketing of Breastmilk Substitutes.
“The laws are there, but the implementation is a distant dream. Formula companies continue to particularly tantalise urban markets,” says Dr Akram, adding that the government does not seem interested in this cause. Dr Akram and her team run the Baby-friendly Hospital Initiative (BFHI) of WHO and UNICEF successfully in Pakistan for a few years. “When external funding stopped, the government was not interested in investing in it,” she says, adding that companies that produce formula milk mainly target the urban market to tantalise consumers.
“For the poor population in rural areas, breastfeeding is mostly the only available option. The urban social landscape is more challenging when it comes to breastfeeding. More mothers are working mothers; more options for top feed are available here; more people can afford to buy formula milk. Awareness is needed in both rural and urban areas,” says Dr Sara Salman of WHO Sindh.
According to Mankani, despite trying to raise awareness, most mothers follow popular myths. “They feel the baby is healthier if fed formula, owing to the aggressive marketing of formula milk.”
The biggest challenge for exclusive breastfeeding is the perception that mothers are not producing enough milk and should supplement with formula because the baby cries, says Meredith Jackson-deGraffenried, Helen Keller International Country Director for Bangladesh. “This perception is driven by the misunderstanding that if the mother is undernourished and poor, she must be incapable of adequately nourishing her baby.”
“We try to teach these women basics about expressing their own milk and how to store it. Mother’s milk stays fine for up to three days in a refrigerator, and up to six hours at room temperature. It’s an economical and healthier option. But myths are hard to fight,” says Mankani.
Despite proven benefits like the mother who breastfeeds return to her pre-pregnancy state much earlier, and the incidence of breast cancer in women who breastfeed being much lower, as Dr Ahsan says, the myths seem to be winning.
“Socially, breastfeeding proves a challenge as well. There are usually no crèche or nursing rooms at work. That’s one reason working mothers stop breastfeeding,” says Dr Ahsan.