Child care

No, India is not a ‘breastfeeding nation’. But it badly needs to be one

Caught between unsupportive health workers and an unethical baby food industry, new mothers are being dissuaded from breastfeeding.

India is supposed to be a “breastfeeding nation” but breastfeeding rates in the country do not support this claim. Only about 44% of babies – that is 12 million out of 26 million – begin breastfeeding within one hour of their birth, according to national data sources. The majority are given formula milk, either powdered or liquid, or animal milk.

To understand how new mothers view health services and formula-feeding, the Breastfeeding Support for Indian Mothers, a Facebook group with more than 29,000 members conducted a survey. More than 950 mothers who delivered their babies in private hospitals responded. More than half the respondents said their children were given artificial milk and out of these two-third said that it was without their consent. From the comments of these women, it is evident that health workers often doubted new mothers’ ability to produce milk and undermined their confidence in breastfeeding.

Playing on hormones

It is all about how hormones that control breastfeeding work. Breastmilk is produced by the hormone prolactin, the secretion of which is directly impacted by the amount of suckling by the baby. Breastmilk is ejected from the mother’s breast and into the baby’s mouth during nursing under control of another hormone oxytocin, the production of which is influenced by the mother’s state of mind. More oxytocin is produced when a woman is happy and confident and less if she has doubts, anxiety or is in pain.

Just after a baby is born, the mammary glands produce a form of milk called colostrum. The small quantities of colostrum are sufficient nutrition for the baby but since it is not free-flowing, like the milk that the glands later produce, it is often perceived as less production. The time of production of colostrum is the critical period when the baby is most active to suckle. Not allowing the baby to breastfeed at this time causes problems in breastfeeding later.

The baby food industry started exploiting this hormone mechanism about five decades ago. They made campaigns associating the lack of breastmilk production with guilt such as “if you don’t have enough milk we have the safe alternatives…don’t feel guilty …” Today, in any corner of the world, more than 90% women still make this association. Industry has subtly and systematically undermined women’s confidence, as Gabrielle Palmer’s book The Politics of Breastfeeding: When Breasts are Bad for Business historically captures.

In November 2016, the United Nations Human Rights Commission issued a joint statement on protection, promotion and support of breastfeeding, which noted that “Women who choose to breastfeed often lack the necessary support structures. Gaps in knowledge and skills among healthcare providers often leave women without access to accurate information or support”.

Further, the commission observed that “aggressive and inappropriate promotion of breast-milk substitutes, and other commercially prepared food products for children from 6 to 36 months that compete with breastfeeding, continue to undermine efforts to improve early and exclusive breastfeeding rates and act as barrier for women to exercise their rights. These marketing practices often negatively affect the choice and ability of mothers to breastfeed their infants optimally, and to enjoy the many health benefits breastfeeding provides.”

According to the World Health Organisation, once babies are introduced formula, a return to breastfeeding may not be possible due to diminished breastmilk production. So, if babies are given formula without the consent of their mothers, does that amount to violations of the rights of both mother and child?

What’s needed

When a new mother comes to a health worker and says that she is not producing enough breastmilk, the most common response is to offer treatment with alternatives such as formula. Instead, health workers should investigate the cause of the deficiency and help by showing her the correct of feeding techniques that she may not be aware of and build her confidence to breastfeed. Even new mothers who are anaemic or malnourished lactate and can breastfeed, if given the right health support.

Health workers should be careful not to make a new mother feel guilty, even if she had been using formula – this is a result of bad practice in society and the health system. If a woman makes a choice in favour of artificial feeding having known its risks, health workers should respect her choice and explain to her how safely practice formula feeding.

At the same time, hospitals must have lactation counsellors on their staff to help women feed from the start during colostrum production. In addition, existing maternity staff should be trained to support women at time of birth and breastfeeding. Unless the health system takes this action, artificial feeding will continue to be common practice

The government’s role

Even after 25 years of enacting a law that bans sponsorship of health workers and their associations, the practice continues today. Baby food companies continue to give discount on their products through e-commerce sites, although they have been prohibited to do so. We believe this aggressive promotion contributes to undermining breastfeeding.

The health ministry committed to the new WHO guidelines on ending inappropriate promotion of foods for infants and young children adopted at a the World Health Assembly in 2015. The ministry can take a cue from both this resolution and the United Nations Human Rights Commission Statement to issue a notification to ensure a parent’s consent before a baby is fed formula in a hospital and to end to inappropriate promotion of baby foods and sponsorship in the health systems.

The writer is a paediatrician and founder of the Breastfeeding Promotion Network of India.

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Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

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This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

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SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.