According to the World Health Organization (WHO), more than 800,000 infants can be saved, if optimally breastfed. Children who are breastfed have lower incidence of infectious disease, less morbidity, gastrointestinal issues and less risk of obesity in later life. The mothers who breastfeed have less chances of breast cancer, reduced rates of ovarian cancer. Only 64 per cent of the infants are exclusively breastfed (EBF) with rural areas having higher proportion of EBF by merely five per cent as per the Fifth National Family Health Survey (NFHS-5). In spite of umpteen advantages of breast milk on child health, maternal health and environment advantages (with zero ecological print), formula milk is winning over breastfeeding, globally. Transition from breastfeeding to Commercial Milk Formula (CMF) / Formula milk (FM) is a matter of public concern. Studies show low socio-economic status have higher proportion of EBF. Though rural areas have high proportion of pregnant women practicing EBF as compared to urban mothers, CMF is becoming a common choice gradually in the rural areas of many developing countries.
The major challenge observed among mothers which leads to switching to FM is perceived breast milk insufficiency. Most women have full ability to produce milk to feed an infant except in 10-15 per cent cases where, due to some medical reason, milk production is low/absent. Poor Latching and stress also contribute to decreased levels of EBF in countries, but are easily manageable with proper strategies. On the pretext of addressing hunger and satiety among infants, they are readily fed with FM making their stomach full and heavy. Once habitual of consuming FM, the child refuses breast milk and does not attempt to suck. This leads to a drastic decrease in milk production, as there is no further demand for milk. Mothers are coerced by kith and kin into thinking that FM is better than their breast milk as the child is less irritable, calmer and having sound sleep, notwithstanding that this saviour is actually an enemy in disguise. Lack of safe spaces for breastfeeding or expressing milk in workplaces, or facilities to store breast milk, mean that breastfeeding is not a viable option for many women outside homes. This further creates an easy way for formula milk, as it can be fed anywhere in a so-called ‘dignified manner’.
Another challenge is that FM is gaining popularity. It is capturing the market on the basis of false promises of being ‘nutrient rich’. A survey on FM nutrition claims was conducted in 15 countries with high, middle and low income groups. Companies claim that long chain polyunsaturated fatty acids in formula milk are involved in the development of the brain, eyes and the nervous system. However, recent studies have failed to substantiate the association. Statements by FM companies such as prebiotics, probiotics, and synbiotics lead to strengthening and supporting a healthy immune system do not have strong substantiation in scientific literature. Unproven claims of enhanced brain development and improved intelligence are also stated by CMF companies. The FM industry cashes in on parents’ fears and concerns at a vulnerable time. On the pretext of providing a wholesome breast milk substitute in the presence of low breast milk supply, a multimillion industry is flourishing by claiming to settle infant behaviours such as crying, fussiness, and poor night-time sleep, which are indeed part of normal development of a baby.
The multidimensional baby friendly hospital initiative of WHO, which involves the health system and community, has been adopted by many countries to increase EBF. Many developing as well as developed countries have experienced improvement in BF in the last few years. While Burkina Faso created mother-to-mother support groups to improve BF, The United States increased the BF through counseling and encouraging hospitals to be ‘baby friendly’.
This public health issue would require inter-sectoral policies including education, health and labour to improve the current scenario. First and foremost, the government needs to understand that proximity between mother and baby is indispensable for milk production. In many hospitals, mothers and babies are kept separately for a long duration, where FM is given to babies. This window itself starts pushing babies towards milk substitutes. Implementing ‘Kangaroo Mother care’ (where skin-to-skin contact is established between mother and newborn immediately after birth) and initiating feeding mother’s milk to the infant within one hour of birth strictly in public and private facilities might be fruitful in this context. In addition to this, laws regarding paid maternity should be reformed. Maternity leave is very much correlated with the prevalence and duration of BF. Inadequate paid leave forces many mothers to return to work soon after childbirth. Half of the remuneration can be given in developing countries to women on maternity leave but some amount of financial security is required for them in order to nurture the future generation. The children of women working in the informal sector suffer more owing to nil financial security after childbirth. Provision of supplementary feeding should be accompanied by financial support for lactating mothers working in the unorganised sector. It is high time the government starts a scheme to cover these lactating mothers.
Another strategy for improving EBF is breastfeeding preparedness. While in rural area, this can be achieved through Accredited Social Health Activist (ASHA) / Auxiliary Nursing Midwives (ANM), mother peer groups can also be formed to transfer the knowledge to ease the process of BF for new mothers. In urban areas, government/private hospitals can have booklets or breastfeeding counseling sessions by skilled personnel in the last trimester of pregnancy. Post natal follow up on BF is essential for support and can be extended for at least a month. The Union Ministry for Ayurveda, Unani, Siddha and Homeopathy may also contribute by sharing knowledge on natural galactogues or diet on increasing milk production. The department of health, in collaboration with the education department, can spread awareness in schools and colleges, especially in rural areas where school going girls become mothers. Village health and sanitation days might also serve as point of contact where community members (partners, family) can be sensitized by ASHA/ANMs/medical officers on support needed by mothers to breastfeed. The community needs to understand that physical, nutritional and emotional support are essential for mothers to have adequate milk supply.
Last but not the least, creating a conducive environment where breastfeeding in public is culturally unacceptable, is critical. Creating spaces which can serve as feeding rooms in inter-state bus terminals, airport, govt. offices, railway stations might provide lactating mothers with a sense of safety to breastfeed their babies. We don’t criticise use of FM by mothers, per se. It can be a saviour among HIV mothers and mothers / infants with serious health issues but increasing dependency on FM is an alarming situation.
Vani Kandpal is Consultant at Division of Reproductive, Child Health & Nutrition, Indian Council of Medical Research, New Delhi
Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth