For stronger children

Unlike polio eradication and population control, where religious misconceptions are often cited for not achieving the desired goals, health authorities are struggling on ensuring two years breastfeeding despite the fact that it has been made mandatory by religion.

Two-year breastfeeding is the most effective prescription for reducing a person's life-long hospital bill. Global health authorities consider exclusive breastfeeding a cornerstone of child survival and child health because it provides essential, irreplaceable nutrition for a child's growth and development. It also serves as a child's first immunization – providing protection from respiratory infections, diarrhoeal disease, and other potentially life-threatening ailments. It has a protective effect against obesity and certain noncommunicable diseases later in life.

The good news is that the proportion of children who are exclusively breastfed for the first six months of life has gone up to 48.4 percent, which is closer to the World Health Assembly (2012) target of 50 percent. But most indicators related to complementary feeding are declining except the proportion of children receiving an adequately diversified diet.

According to recently released key findings of the National Nutrition Survey (NNS), all complementary feeding indicators are far below acceptable levels: "Only one in seven children (14.2 percent) aged 6–23 months receive a meal with minimum dietary diversity, with at least four different food groups. One in four children (18.2 percent) receives the minimum number of meals a day. Complementary foods that meet the requirements of a minimum acceptable diet to ensure optimal growth and development for children aged 6–23 months are provided to less than one in 20 children (3.6 percent). More children in urban areas receive adequate complementary foods than their peers in rural areas, but rates are critically low in both localities."

Interestingly, so far, the key findings of NNS-2018 do not contain information regarding the percentage of bottle-fed children out of the 51.6 percent non-breastfed children. These statistics are provided in another survey, the Pakistan Demographic Health Survey (PDHS) 2018 released early this year.

The PDHS says that a massive 37 percent of infants under age six months are fed using a bottle, a practice that is discouraged because of the risk of illness to the child. The incidence of bottle-feeding increases with the increase in age, reaching 56 percent by the end of two years.

The Global Breastfeeding Collective, led by Unicef and WHO (World Health Organisation), has identified seven actions needed to enable women to breastfeed, including regulation of marketing of breast-milk substitutes, funding of breastfeeding programmes, maternity protection in the workplace, compliance with the Baby-Friendly Hospital Initiative, access to breastfeeding counseling and training, availability of community support programmes, and consistent monitoring.

The Pakistan government's record on regulating breast milk substitute is dismal, though Pakistan was among the 118 countries which had voted in favour of adopting the International Code of Marketing of Breast Milk Substitutes during the World Health Assembly in May 1981.

In 2002, Pakistan became the 42nd country in the world by enacting the Protection of Breast-Feeding & Child Nutrition Ordinance to regulate baby formula milk; the main thrust of the law was to prohibit commercial practices that may undermine the breastfeeding practice among women. There are penalties for the manufacturers and distributors of formula milk, and health professionals who may be found promoting formula milk at the cost of breastfeeding.

But the law has never taken effect. It took the federal government seven years to draft rules in 2009. The following year, the devolution of the health ministry to provinces again stalled the process. Between 2012 and 2015 all four provinces legislated their respective laws but those laws are still far from enforcement.

Another area is facilitating working women to breastfeed. Pakistan has signed the International Labor Organization's (ILO) Maternity Protection Convention, 2000. The convention says that a woman shall be provided with the right to one or more daily breaks or a daily reduction of hours of work to breastfeed her child.

"The period during which nursing breaks or the reduction of daily hours of work are allowed, their number, the duration of nursing breaks and the procedures for the reduction of daily hours of work shall be determined by national law and practice. These breaks or the reduction of daily hours of work shall be counted as working time and remunerated accordingly," it adds.

Similarly, on the production of a medical certificate or other appropriate certification, as determined by national law and practice, stating the presumed date of childbirth, a woman to whom this convention applies shall be entitled to a period of maternity leave of not less than 14 weeks.

According to the WHO, evidence shows that longer maternity leave is associated with longer duration of exclusive breastfeeding. Unfortunately, no appropriate legislation is done in Pakistan to extend this facility to women.

Breastfeeding can also be used for birth spacing. Two-year breastfeeding can ensure adequate birth spacing, reducing infant and child mortality.

Pakistan's statistics on infant mortality rate are also not favourable. During the five years immediately preceding the PDHS survey, the infant mortality rate was 62 deaths per 1,000 live births. The child mortality rate was 13 deaths per 1,000 children surviving to age 12 months, while the overall under-five mortality rate was 74 deaths per 1,000 live births. Eighty-four percent of all deaths among children under age five in Pakistan take place before a child's first birthday, with 57 percent occurring during the first month of life (42 deaths per 1,000 live births).

The NNS 2018 is the fifth national nutrition survey since 1965, and the first to yield district representative data. A national, province and district representative sample of 76,742 children (aged 0–59 months), 145,847 adolescents (10–19 years) and 145,324 WRA (15–45 years) was selected from 115,600 households.

The so far released provincial data shows that the proportion of children who are exclusively breastfed for the first six months of life is highest in Khyber Pakhtunkhwa (60.7 percent), and lowest in AJK (42.1 percent) and Balochistan (43.9 percent) respectively. In Islamabad the figure is 57.6 percent, Gilgit-Baltistan 54.9 percent, Sindh 52.3 percent, and Punjab 44.3 percent.

For the future course, the WHO suggests that countries already at or near 50 percent exclusive breastfeeding should continue to strive for improvements because of the health and economic benefits of exclusive breastfeeding. In these cases, it suggests a minimum increase of 1.2 percent per year or more.

To achieve this, the WHO also identified the factors for the countries to overcome – inadequate rates of exclusive breastfeeding result from social and cultural, health-system, and commercial factors, as well as poor knowledge about breastfeeding.

These factors include caregiver and societal beliefs favouring mixed feeding (believing an infant needs additional liquids or solids before six months because breast milk alone is not adequate); hospital and healthcare practices and policies that are not supportive of breastfeeding.

In addition, there is lack of adequate skilled support (in health facilities and the community); aggressive promotion of infant formula, milk powder, and other breast-milk substitutes; inadequate maternity and paternity leave legislation and other workplace policies that support a woman's ability to breastfeed when she returns to work; and lack of knowledge on the dangers of not exclusively breastfeeding and of proper breastfeeding techniques among women, their partners, families, healthcare providers and policymakers.

Indeed the government needs a proactive 'province-inclusive' policy to increase the breastfeeding rate to neutralize the heavy diseases burden on the country's health system.

The writer is a freelance contributor.

Email: nadympak@hotmail.com