No, I do not breastfeed my baby,” tells Ujala, a young working mother. Not only is she well-educated but is also aware of what is good for her child. Having a fair idea of the importance of breastfeeding, she exclusively breastfed her baby for three months on her maternity leave but had to switch to formula milk when it was time for her to go back to work. “I had to go back to work due to financial constraints I couldn’t leave my job. I know I am denying my baby the best food that nature has provided but I have no choice,” she laments. The office where she works does not provide any day-care or nursing facilities, though a number of young women work there who could benefit from it.
“Before blaming me for not being a good mother, people should see what circumstances one is living and working in. These very people who blame the mother for not breastfeeding her child do not lift a finger to provide facilities for mothers to nurse their babies, either on work premises or at restaurants and malls,” justifies Ujala.
Mother’s milk is, undoubtedly, the best source of nutrition for the baby. It not only provides all the nutrients, vitamins and minerals an infant need for growth, but also carries antibodies that protect the baby from infections. It also lowers the risk of chronic conditions in later life, such as obesity, high cholesterol, high blood pressure, diabetes, childhood asthma, etc. Studies have also shown that breastfed infants do better on intelligence and behaviour tests into adulthood. It is recommended that the baby should be fed as soon as possible after birth as the initial milk called ‘colostrum’ performs an especially protective function, although due to lack of knowledge many women consider it to be bad milk and discard it.
Despite its benefits, a large number of children in Pakistan are being denied this super food that nature has provided for them. According to the Pakistan Demographic and Health Survey 2017-2018, in Pakistan only 48 per cent of children are exclusively breastfed for the first six months of life; the figures have not much improved since 2006-07 when it was reported as 37 per cent. This is despite WHO’s recommendation that infants be exclusively breastfed till the age of six months, after which breastfeeding should continue along with appropriate complementary food for up to two years of age or beyond. The neonatal mortality rate in Pakistan according to the survey is 42 per 1,000 live births, which is much higher than the target set by the Sustainable Development Goals, i.e. to reduce neonatal mortality to at least as low as 12 per 1,000 live births by 2030. Though all these deaths do not take place only because of poor breastfeeding practices, it is one of the contributing factors.
The question is: why are mothers relying on formula milk? While bottled or formula milk may not be bad in itself but it does not meet the nutritional value of mother’s milk. Regardless, many doctors don’t stress the importance of breastfeeding and may suggest formula because they are under the influence of the infant milk formula manufacturers; who have a great role to play in shaping opinions of mothers as well as doctors.
To encourage breastfeeding as a measure to reduce infant mortality rate, in 1992 the government adopted the Baby Friendly Hospital Initiative (BFHI) which proved to be quite a success. The BFHI is a global effort launched in 1991 by WHO and UNICEF to implement practices that protect, promote and support breastfeeding. Later, in 2002, the federal government through legislature banned the advertising or promotion of infant milk formula within hospital premises as well as on billboards, in newspapers and on TV to protect breastfeeding practice. The companies were also not allowed to give any gifts or free samples to nurses, doctors, etc. Change was brought about due to the legislation but then with the adoption of the 18th Amendment and devolution of health ministry, the provinces had to come up with their separate laws, which they duly did.
The Sindh Protection of Breastfeeding and Child Nutrition Act 2013, makes promotion of formula milk or any such product that encourages bottle-feeding or discourages breastfeeding punishable with imprisonment up to two years and a fine of Rs 50,000 to 500,000 but has no provision to encourage breastfeeding. In 2017, the Punjab Food Authority (PFA) also imposed a complete ban on marketing and sampling of infant formula milk in hospitals.
About the implementation of the law, Dr Mubina Agboatwala, Paediatrician and Chairperson HOPE Foundation, informs, “It is being implemented, especially in government hospitals but not in letter and spirit. Formula manufacturers are not allowed to promote their products in any way in government hospitals. But, unfortunately, there is not much check and balance in private hospitals.”
While there is a ban on promotion of formula milk by the manufacturers, they do so covertly. As pointed out by the paediatrician, they employ several ways to influence the doctors. For instance, they may renovate a doctor’s clinic or sponsor a foreign trip, or provide equipment for the hospital nursery, etc. and in return the doctor feels obliged to promote their product. It was brought to the notice that in many private hospitals, though the doctors tell the mother to breastfeed the baby they also give them a pack of formula milk, in case they want to try. At some point, formula manufacturers used to sponsor paediatric conferences but after the ban they do not do so openly or put up their posters yet they find ways to do so.
“Mothers, even in hospitals, are rarely encouraged to breastfeed or are informed about how to do it,” says Dr Samina Shamim, Professor and Head of Paediatrics Department at the Liaquat National Hospital. “In fact, the gynaecologists, during pregnancy, should prepare and encourage the mother-to-be to breastfeed the baby.”
Many mothers do not feed their babies or stop it soon due to fear that the baby might not be getting enough milk. Paediatricians recommend that mothers who fear this should consult their paediatrician who can check the baby’s health to see if the child is getting enough nutrients. “Mothers also need to be informed that frequent suckling helps produce more milk. For feeding, mother’s position is as important as the child’s. Mother should adopt a proper position to feed and the baby should be held in a way that its chin should rest on the breast,” explains Dr Samina. “Few people know that a mother can produce about one litre milk in a day but due to malnutrition mothers in our country usually produce 600-700 grams. Mothers must maintain good nutrition by taking a balanced diet,” she adds.
Moreover, there are also mothers like Ujala, who stop breastfeeding once they are required to go back to work at the end of the maternity leave which is usually three to four months. UNICEF has approved six months of maternity leave for its employees, which is hardly followed by any other organisation. “Women working in the government sector can avail three months of maternity leave which is usually divided in two parts — one month before the delivery and 60 days after the birth,” highlights Dr Mubina. “In the public sector, too, more or less the same rules are followed, though the government is more lenient and women can take unpaid leave if they so desire.”
In January 2020, the Senate passed the Maternity and Paternity Leave Bill 2018, which makes it mandatory to grant maternity and paternity leave to employees. According to the bill, women will get paid maternity leave of six months on the birth of the first child, four months for the second child and three months for the third child. As per the bill the leave policy will be applicable in both public and private establishments in the federal capital territory.
Women believe that either the mother should be allowed extra leave without pay or someplace be assigned within the offic where mothers can leave the baby with a maid and feed as needed; or mothers be allowed to work flexible hours where she can take a couple of hours off in between to feed the baby; or the mother can work from home where possible.
There are now private organisations that allow the mother to bring her child and leave them with an ayah to look after them. But, unfortunately, there are no clauses in the Act making it mandatory for organisations to provide nursing rooms for their employees, or make it binding for shopping malls, airports and other public places to provide such a facility.
It would help if the laws make it binding for organisations where a certain number of women are employed to have provision for nursery or day-care centre. However, while there has to be some sort of compulsion to give these facilities, there are also chances of drawback — organisations might hesitate in hiring women as they would have to give them maternity leave, nursing time during office hours, assuming they won’t work.
The recent move by the KP government to ban the distribution marketing and sale of formula milk, under the KP Protection of Breastfeeding and Child Nutrition Act 2015, may do some good. This has also instigated the debate whether the use of formula milk is akin to denying the baby his right to mother’s milk or that the mother has a right to choose how she wants to feed the baby. On the contrary, experts believe mere legislation for controlling the promotion of infant milk formula is inadequate. Unless the mother is fully aware of the pros and cons, she can decide to breastfeed her baby and no one would stop her.
“To be breastfed is a child’s right,” emphasises Dr Samina. “No doubt, breast milk is the best food for the baby as animal milk from which formula milk is made has some nutritional deficiency or the other [each species’ milk is fit for that particular species]. But there are mothers who, for certain reasons like post-partum depression or other disease, cannot breastfeed and formula milk becomes an inevitable source of food for the new-born in that case. A mother should be encouraged to breastfeed but we have to understand her situation as well,” she concludes.
*The writer is a freelance journalist.