Dismal breastfeeding rates hampering infant health

It is that time of year: posters are printed about the benefits of breastfeeding, well-baby contests are held and bonnie, breastfed babies are paraded as pictures of health. World Breastfeeding Week (August 1 to 7), with its Olympian theme of “Going for the Gold’ this year had been a hectic seven days with media messages and campaigns around the country.

However, the lack of a policy framework to promote breastfeeding, the powerful supplementary foods lobby, the lack of support for mothers and health workers under-prepared in human lactation, have meant that the seven-day long push loses steam as the year rolls around.

The National Family Health Survey - 3, published in late 2006, said only 24.5 percent of new mothers initiated breastfeeding in the hour after birth, 46.4 percent breastfed exclusively the first six months and a slightly more encouraging 56.7 percent nursed beyond six months with the introduction of complementary food. But nearly half of under 5 children were underweight.

The survey mentions these numbers in the same breath as a 57 in 1,000 live birth infant mortality rate compared to 44 in 1,000 live births of sub-Saharan Africa. An important developmental parameter, IMR continues to stay high despite the two-decade long campaign to bring it down.

It is not just the affluent, working women who have problems. Stay at home mothers who have been wrongly guided by their families and women from even second-tier cities, where breastfeeding rates are higher, end up calling for help.

• Decommissioning the diaper • HDI rankings: Poor and unhealthy The solution, according to World Health Organisation is as simple as it is natural. Early initiation of breastfeeding, it says, within an hour after birth could bring the IMR down by 22 percent. A January 2008 series on Infant Mortality and Malnutrition that was published in medical journal Lancet said nearly 77 per cent (1.06 million) child deaths attributable to suboptimal breastfeeding are due to non-exclusive breastfeeding during 0-6 months of life.

Breastfeeding promotion alone contributes to 11.6 per cent reduction in IMR if coverage of promotion is 99 per cent through one-to-one and group counseling, and can avert 21.9 million Disability Adjusted Life Years at 3 years. With such staggering statistics lined up, the country needs to give breastfeeding an impetus. The solution is simple: promote breastfeeding by committing money and resources.

Unenforced law and misinformation

If the benefits were this palpable, breastfeeding rates themselves are dismal. A study done by Breastfeeding Promotion Network of India (BPNI), headquartered in New Delhi, suggests the main stumbling block is the lack of support for mothers from the family, society, medical fraternity and also their work places. Mothers are often asked to throw away immune-property-rich colostrum or the first milk. Older women in the family, who dictate infant feeding practices for new mothers, cite inadequate breastmilk supply and encourage mothers to switch to infant milk substitutes.

Coupled with the aggressive promotion of these substitutes through surrogate advertisements, breastfeeding rates continue to be low. Surprisingly, it is not the law that is deficient, but its implementation and formation of support structures.

According to Dr Arun Gupta, BPNI National Coordinator, the country has an excellent law in the form of The Infant Milk Substitute, Feeding Bottles and Infant Food (Regulation of Production, Supply and Distribution) Act, 1992. The Act while not banning the products under its scope, regulates marketing of breast milk substitutes, which the Act calls infant milk substitutes, to children under the age of two, clearly in consonance with the World Health Organisation recommendation of breastfeeding till 2 years.

“The IMS Act aims to curtail misinformation and misdirected education of pregnant women and mothers of infants about breastfeeding, and prohibits contact between industry and pregnant women or mothers of infants. Instead of just regulating the baby food industry, the Act also mandates creating awareness among pregnant women and lactating mothers about the benefits of breastfeeding. When read with other laws like The Maternity Benefit Act, the law could adequately serve to increase breastfeeding,” Dr Gupta says.

Apart from benefits to the mother and child, economic value of breastfeeding is quite high. According to 1998 BPNI estimate, the value of breast milk and breastfeeding to this country of 24.4 million annual births, based on the national breastfeeding patterns over a 2-year lactation period, was around three times the national education budget then.

Using available data on lactating mothers, frequency of nursing per day in both the exclusively breastfed group and those who had introduced complementary food, the researchers indicated Indian mothers produced an estimated total of 3944 million litres of breast milk. If this milk were to be replaced by infant milk substitutes it would cost $3 billion.

Little wonder then that the Infant Milk Substitutes manufacturers have been trying to subvert the IMS Act. Surrogate advertising and sponsored medical conferences were the norm till BPNI took on Food Products Major, Nestle, in 1994. Nestle products Cerelac and Lactogen were found to be violating provisions for advertising, labelling and sponsoring medical events. While BPNI had filed a case in the Court of Metropolitan Magistrate, Delhi, in 14 years the chargesheet is yet to be filed.

Nestle was put in the dock for promoting introduction of complementary food Cerelac in the 4th month (after three months) while, at that point, the Act proscribed marketing such food to those below 4 months and advertising Cerelac. Nestle’s Infant Milk Substitute Lactogen was also found to violate labelling rules, says Dr Gupta.

All that Nestle has done in the last 14 years is to intimidate and delay court proceedings. The company had also filed a writ petition challenging the key provisions of the Act, questioning its constitutional validity and seeking a stay on the case, stating it is impossible to comply with the IMS Act. But since then all their product labelling has complied with the Act,” says Dr Gupta.

BPNI, however, is still trying to push the case in the court. However, says Dr Gupta, the evidences that were filed with the court have gone missing and the case is getting even more delayed. “The Act empowers four NGOs, including BPNI to prosecute erring companies, in addition to Health officers. But the government has done little in the way of budgetary allocation or legal support system. Though we have initiated the case, it is the State which is prosecuting Nestle. It is therefore very important to establish a good coordination between the government and NGO arm to implement this Act.”

In the face of strong lobby, the government has failed to meet the targets had set itself for the 10th five year plan ending 2007 vis-a-vis breastfeeding (50 per cent initiating breastfeeding, 70 per cent exclusive breastfeeding for 6 months and 75 per cent complementary foods with breastfeeding till two years). And to the activists in BPNI, it is clearly the case of lack of information, of support, lack of skills among health workers in an institutional delivery and finally social taboos devaluing breastfeeding.

The activists are none too happy with the budgetary allocation for or implementation of the National Guidelines for Infant and Young Child Nutrition that the Department of Women and Children formulated. While the document proposes use of locally prepared food, the Ministry is now pushing packaged, fortified food caving into the pressure from the industry. Contracting reduction of malnutrition to private players would only jeopardise the mission, they say.

Another aspect of breastfeeding support is mother-to-mother groups. The efforts have been sketchy and are often NGO-driven in both urban and rural India; their success depending more on the commitment of their leaders. But there are positive examples too.

Positive stories and the fightback

While it seems like so much is going wrong with breastfeeding, positive stories emerge from urban and rural areas. In Mumbai, people like Kavita Mukhi, a former beneficiary of the international lactation movement La Leche League (LLL), have donned the role of a leader to help women overcome their breastfeeding difficulties.

Breastfeeding is a learned skill, she says, adding however many find they have learned it the wrong way in the hospitals. “In the first place, the mother and babies are exposed to pain killers at birth and the feeding does not start off immediately; in some cases, only as late as 3 days. To compensate, the staff give formula or water in a bottle and send breastfeeding downhill by causing nipple confusion. C-sections are very common and mothers are often not helped to establish breastfeeding immediately. When they return home, they are exposed to more taboos and misinformation and many seek help as late as 5 months after delivery,” Mukhi says.

Listing out the benefits, Mukhi avers breastfeeding offers health as well as emotional benefits to infants and mothers. The baby gets protected against allergies, bonding between mother and child contributes to reduction in postpartum depression, gives mother a rest from the reproductive cycle through lactational amenorrhoea, which has many benefits: no anaemia, fatigue, protects against breast cancer, makes baby feel secure, and gives the baby the safest and the perfect food for full development as nature intended.

The women she works with have braved clogged ducts, mastitis and babies that are too lazy to suckle at the breast due to nipple confusion, only to want to continue breastfeeding. “I am surprised at the numbers (of women) that look online for breastfeeding help when help should be available to mothers at hospitals,” she says. Talking to mothers over phone and visiting them in their homes in Mumbai, Mukhi and LLL volunteers right the wrongs.

It is not just the affluent, working Mumbaikars who have problems and come to her for help. Stay at home mothers who have been wrongly guided by their families and women from even second-tier cities, where breastfeeding rates are higher, end up calling for help, she said adding the disinformation is now reaching rural India.

It is exactly in these still urbanising parts of the country that another set of women are helping mothers. The 10,500-strong Village Health Nurses (VHN) and Auxiliary Nurse Midwives (ANM) in Tamilnadu working alongside the Anganwadi workers under the Integrated Child Nutrition Scheme are struggling to promote optimal mother, infant and young child nutrition.

“Our greatest challenge has been in trying to convince women that the colostrum produced on days 1, 2 and 3 after delivery have immunological properties and should be given to children, instead of being thrown away as milk gone bad. We also need to break social taboos like women not nursing in the presence of elders in the family and fad diets that are nutritionally poor,” says S Gomathy, President Tamilnadu Government Sugathara Seviliyar Sangam.

The recent focus on breastfeeding has meant the staff are trained in detecting poor breastfeeding practices like a bad latch, bad positioning, poor weight gain in babies and help women optimally breastfeed and introduce complementary foods. “We have been asked to push Kangaroo care (where the mother and child get a lot of skin-to-skin contact) in newborns. We often have to come up with creative solutions that will work in a paternalistic society where such practices would be precluded,” she says of her work-a-day in Achirapakkam village (near Chennai).

Workplace changes needed for returning mothers

However, with agriculture taking a backseat and growing ubranisation has meant most of the efforts of health workers get diluted. Daily wage earners, be it agricultural labourers or construction workers, traditionally take their children to work place and breastfeed on demand. Increasing contractualisation of labour has meant employment practices that are not mother - and child-friendly.

“All the work we do in getting women to provide nutritionally the best food goes waste because mothers have to return to work to supplement family income. The supervisors forbid women from taking nursing breaks or from bringing infants to worksite. Having to provide the extra income, mothers often abandon exclusive breastfeeding by three months so that they can return to workforce,” says Gomathi.

This phenomenon is equally seen in urban organised sectors. Employers be it the state or private institutions often do not offer a maternity leave with benefits in excess of the minimum 6 weeks prescribed under the Maternity Benefits Act 1961. While the maternity leave available under this law varies from state to state with Haryana and Punjab providing for 6 months, others like Tamilnadu give 135 days or 3 months’ leave. There is a long-standing demand that Act be amended to extend the minimum leave to 6 months and implement it uniformly in the country, says Professor K Shanmugavelayutham, Convenor of Chennai-based TN-FORCES.

Experience elsewhere have shown that security net measures for women like long paid maternity leave have helped women breastfeed exclusively and longer. In Norway, approximately 97 per cent of women breastfeed when leaving hospital, 80 per cent are breastfeeding at 3 months and 20 per cent beyond 12 months, reports the World Health Organisation. The government’s family policies ensured that women are entitled to a maternity leave of 42 weeks with full pay or 52 weeks with 80 percent of the salary and nursing breaks of at least 1 hour on their return to work.

While India too has a legal provision for nursing breaks, this remains more in paper. Under Sec 11 of the Act, every woman delivered of a child who returns to duty after such delivery shall, in addition to the interval for rest allowed to her, be allowed in the course of her daily work two breaks of the prescribed duration for nursing the child until the child attains the age of fifteen months. “For this to be possible, all offices should have creches and day-care facilities. Often women are forced to give up on their maternity privileges in the increasingly corporatised and contractualised work place. And the one who pays the price is the infant,” says Shamugavelayutham.

These are the setbacks to breastfeeding that BPNI plans on tackling working with the central government and with the Planning Commission. The network wants the government to recognise breastfeeding as food security for infants and recognise 0 - 6 months as entities in planning. Optimal feeding of infants and young children should be declared a part of poverty reduction and adequate funds provided in central and state plans to promote breastfeeding.