Matter of choice

The nine months of pregnancy is the right time to start thinking about how to feed a baby

While breastfeeding is considered to provide more nutrition and protection, women must be given information about the choices and support for their decisions.

About 26 million babies are born in India every year and yet too few women make informed decisions on feeding their babies. The Government of India’s new programmes to reduce maternal and infant mortality, which includes antenatal counseling, can make a big difference saving the lives of thousands of children and their mothers.

A recent survey conducted by the Facebook group Breastfeeding Support for Indian Mothers showed that more than 50% of women who delivered in private hospitals were introduced to infant formula at birth and out of these in two thirds cases, it was given without their consent. Women are often told to feed their babies formula thinking that they do not produce enough milk. This perception is largely due to either because of lack of skills of health workers working with these women or myths propagated by baby food industry.

Use of any kind of infant formula during infancy is related to increased risk of infections like diarrhea and respiratory disorders in newborn babies. To reduce such risks World Health Organisation advises that: “In situations where infants are not breastfed, caregivers, particularly of infants at high risk, should be regularly alerted that [powdered infant formula] is not a sterile product and can be contaminated with pathogens that can cause serious illness; they should be provided with information that can reduce the risk”.

The government’s routine health package of an antenatal check includes counseling on breastfeeding with the aim of having all women breastfeed. But the recent NFHS 4 data shows that only 41.6% are breastfed within the first hour of birth and only 54.9% infants are exclusively breastfed. That means half the country’s infants are given artificial feeding, of which formula is quite common. According to a Euromonitor Report, 10,847 tonnes of standard infant formula or milk powder for the age group of zero to six months was sold in India in 2012. This means that India sells about 27 million containers of 400 gms every year. Going by the estimated growth of formula industry in 2022, this figure will be 32.7 million.

The latest National Family Health Survey shows that about 80% of all the births in the country take place in medical institutions and a little more than 50% in public institutions. This implies that about 30% occur in private institutions. It is at these private institutions that many infants are given powdered infant formula without heed to the WHO’s guidelines on acceptable medical reasons for giving substitutes. The WHO recommends that once constituted infant formula should be consumed immediately and not after a couple of hours. Prepared feeds provide ideal conditions for bacteria to grow, especially when kept at room temperature. Feeds that are prepared for use later must be refrigerated and discarded if not used within 24 hours.

Disseminating information

Pregnancy, especially the second and third trimester, is the opportune time when women can be given information between the choices of breastfeeding and formula feeding.

The recent Pradhan Mantri Surakshit Matritva Abhiyan announced by Prime Minister Narendra Modi aims at reducing maternal and infant mortality rates through safe pregnancies and safe deliveries. This initiative is the perfectly channel through which to introduce a “baby or infant feeding decision during pregnancy” programme. This would include skilled counseling support that continues into birthing and later.

Most women who give up breastfeeding usually do so due to psychological factors that interfere with success of breastfeeding not because of biological or physiological factors.

A mother who decides to breastfeed needs to be supported both mentally and physically. The efforts should start from the antenatal period by counseling her on the breastfeeding benefits to her and her baby. There needs to be counseling to build a woman’s confidence so that she can breastfeeding without any hindrance and support for the woman if a problem should arise. Reassurance during pregnancy is essential because a woman has a lot on her mind at this time.

Some women face difficulties in allowing infants to attach to to the nipple as well as breast conditions like breast engorgement, inverted nipples and mastitis. While there problems are entirely preventable and require only some practical help, they often become reasons for introducing formula feeding after birth. Counseling families and creating a positive family environment is also crucial to this process.

Support for formula-feeding mothers

A mother who decides to formula feed needs more support so that she is aware and prepared for the risks it entails. She must be provided information on how sterile or not infant formula is, the time it takes for contamination of formula, nutritional quality and content, and short- and long-term health implications. She should also be told to follow the WHO guidelines on how to prepare formula for bottle-feeding at home such that it is safe for the newborn.

Women should have the option of feeding their babies as they choose but before they make that choice they should be fully aware of the options. It is also essential that everyone respect this choice and women be supported to implement that their decisions.

The Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and its amendment in 2003 recommends providing unbiased information on both breastfeeding and formula feeding. The Act also suggests that all the educational material, whether audio or visual, dealing with prenatal or postnatal care include clear information on benefits and superiority of breastfeeding, preparation for and the continuance of breastfeeding for at least six months, the harmful effects on breastfeeding due to the partial adoption of bottle feeding, the difficulties in reverting to breastfeeding of infants after a period of feeding by infant substitutes, the financial and social implications in making use of infant milk substitute and feeding bottles and the health hazards of improper use of infant milk substitutes and feeding bottles.

Women can be given all this information in just one counseling session under the Pradhan Mantri Surakshit Matritva Abhiyan. This may be done through face-to-face counseling and through reading materials. Keeping safety of infant health as the primary outcome, this sessions should be followed by a decision-making session to help a woman choose between breastfeeding and formula feeding. The decision can be recorded and passed on the health facility where she is going to give birth to her baby.

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

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