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‘Malnutrition will not change unless women exclusively breastfeed’

By Sharmila Joshi

Exclusive breastfeeding for the first six months of life provides comprehensive nutrition and also passes on the mother’s immunity from certain infections. Neonatologist Armida Fernandez, who started the first human milk bank in India, discusses why many women stop breastfeeding, the medical profession’s response, and the community’s role in supporting women

The benefits of breastfeeding are well-known: exclusive breastfeeding for the first six months of life provides comprehensive nutrition and also passes on the mother’s immunity from certain infections. It doesn’t cost any money (though the mother must receive proper nutrition to safeguard her own health, particularly since breastfeeding a baby will extract nutrients such as calcium from the mother). On the other hand, infants on breast milk substitutes can receive substandard nutrition -- this is practically guaranteed among the poor where the substitute may be diluted in order to make the expensive powder last longer. These babies are also at much greater risk of falling ill with – and dying of – diseases transmitted through contaminated water.

Neonatologist Armida Fernandez worked with Mumbai’s municipal and state governments to incorporate breastfeeding promotion in government health services, and later helped set up the Society for Nutrition, Education and Health Care, which collaborates with the municipality to meet the healthcare needs of women and children in slums.

You started the first human milk bank in India, at Sion hospital (the Lokmanya Tilak Municipal General Hospital in Mumbai) in 1989. How is it doing, and have similar banks been established in other hospitals?

The bank is working very well. All babies at Sion hospital are still given only human milk, no formula milk. And human milk banks have started across the city and country -- at JJ, KEM, Nair, in Baroda and in Hyderabad at a private hospital. All of them got in touch with us about how to start a human milk bank. A number of hospitals enquire about how to start such a bank. It does not require too much money, but a lot of commitment which stalls the process in some places.

In the 20-plus years since the bank was started, what changes have you seen in terms of awareness about, and attitudes to, breastfeeding, not only at Sion hospital but generally through your other work as well?

The National Family Health Survey, which is undertaken every four years, shows an increase in early initiation of breastfeeding from 7.8% in 1992-93 to 51.8% in 2005-06. Exclusive breastfeeding in the first six months is 53%. Still, it’s not ideal, the numbers are not high enough, it could be much better. People still have to work hard at promoting breastfeeding. I have realised that more and more mothers want to breastfeed. I train nurses and doctors. And I find that the mothers are very keen. But the support from doctors in private practice is inadequate. It is difficult to make a generalised statement, but the reason why mothers give up, especially those from the higher socio-economic strata, is that they don’t get support from their families and their doctors -- not just the gynaecologist but the paediatrician as well.

What kind of support is missing?

There is a tendency in the hospital to shift the baby to the special care unit for the slightest problem. This separates the mother from the baby and is a source of stress for the baby. Breastfeeding then receives a setback. After discharge from the hospital, the moment there is the slightest problem, for example if the baby is not gaining weight even for a short period of time, the doctors start top milk. With the Mumbai and Maharashtra Breastfeeding Promotion Initiatives (under the Baby-Friendly Hospital Initiative), we covered all the nursing homes and hospitals to promote exclusive breastfeeding, and some hospitals are now baby-friendly.

The baby food industry does not reach mothers in hospitals thanks to the Infant Baby Food Act.

Why do paediatricians have this attitude?

When many paediatricians look at babies, they follow growth curves and try to ensure that the baby is growing well and gaining weight. The moment they find the baby is a few grams less here and there they tell the mother the baby is not gaining weight properly, so start top feed. Support for breastfeeding needs a lot of time, a lot of counselling skills, a lot of effort. But to prescribe top feed is a question of a minute; it’s easy.

On the other hand there are whole teams of paediatricians and hospitals -- one team in particular in north Mumbai -- that have trained mothers to be counsellors. They have a training programme and a support group for mothers where women counsel other mothers, at home, or on the phone. This team is part of the Maharashtra Breastfeeding Promotion Initiative. So in many hospitals across the city, practising paediatricians are indeed baby-friendly.

Are there economic class differentials in terms of awareness and attitudes? For example, are urban middle class women less likely to breastfeed?

In urban India, the poorer women who come to public hospitals would, as a routine, breastfeed. They need support, as I said, to continue and make it exclusive. That has to be put in place. But women from higher socio-economic groups are reading a lot and now many of them do want to exclusively breastfeed their babies. They may finally end up using top feed, but most of the mothers I come across, from all economic classes, want to breastfeed their babies.

One reason mothers from higher income groups who go to private hospitals may not breastfeed is because caesarean section rates have increased tremendously. It is now almost routine. With a normal delivery, the baby is with the mother and the mother is in a position to breastfeed, and the whole process becomes easier. If you have a C-section, you can still breastfeed your baby, but it becomes more difficult because sometimes they separate the baby from the mother, or they may not put the baby to the breast early, or the mother is in pain and may start breastfeeding later. If by then they have started top feed, the whole scene changes.

The other problem is shifting the baby to the intensive care unit and separating the baby from the mother. Once there is separation, breastfeeding becomes difficult unless the hospital supports breastfeeding.

What are some of the social barriers to breastfeeding?

Would you call women working a barrier? No, maybe ‘factor’ is a better word. Many women across all economic classes in urban areas work outside the house, and three to four months down the line they have to get back to work. Working women can continue to breastfeed their babies. Milk can be expressed and stored at room temperature for four to six hours; in the fridge for 24 hours; and in the freezer for longer periods. It’s home milk banking. This advice must be given to the mother. Another social barrier is the absence of family support in a nuclear family.

How does it become difficult for women in nuclear families to breastfeed?

In the past, if the mother had problems the grandmother was there to support and share their experiences, and give the mother the confidence she needs. Now, if the woman is only with her husband there is no one to talk to her about breastfeeding. In a nuclear family, the only support would be hospital staff and the doctor where the baby is taken for follow-up. In my experience, even when we do conduct breastfeeding clinics many mothers don’t come in because unless the practising doctor is convinced about the need for exclusive breastfeeding they do not refer the mother to the clinic.

Does discrimination against women, in terms of their poor access to nutrition, impact their ability to breastfeed?

Malnutrition per se should not impact the ability to breastfeed. Unless the mother is severely malnourished -- then the quality of milk, the proteins, fats, could be affected. But mild malnourishment should not impact the ability to feed. We who promote breastfeeding so vigorously must remember to ensure that the mother gets adequate nutrition. When a mother is breastfeeding she loses calories and these calories need to be supplemented in her diet. The problem amongst the poor is that even if we advise mothers, economic and social factors come in the way of them eating adequately.

What is the status of promotion of breastfeeding in the public health system? Has the focus improved in the last 20 years?

Our nutrition policy definitely lays more emphasis now on breastfeeding. This is mainly due to lobbying by health activists who actively promote breastfeeding and have made sure it happens at the policy level. Students are trained about breastfeeding in medical colleges. With all this effort I would expect early and exclusive breastfeeding numbers to rise swiftly, because there is so much research, so much evidence to show the benefits of breastfeeding. The government has included the promotion and support of breastfeeding in all its health programmes.

How could public health policy and practice further improve in terms of promoting and supporting breastfeeding?

The whole breastfeeding effort should shift from the medical side and it should become a women’s movement. Breastfeeding is natural. So instead of blaming hospitals and doctors, it would be better to empower women, give them knowledge about childbirth and about feeding. Women should know their rights. They should fight to get a normal delivery, and fight those who come in the way of that right. How can we alone in the medical system change the breastfeeding practices of millions of mothers? We need the support of all mothers, an entire women’s movement. And this movement should have strong support groups. Like the La Leche League (started in the US by two women), where women support women in breastfeeding. It’s also a huge community movement in Europe and Australia. Here too, support for breastfeeding should be handed back to where it belongs. This is not a medical issue. If there is a strong community movement, a women’s movement, doctors will make sure there is good reason before prescribing top feed. We need to support breastfeeding practices and take it out of the hands of doctors; they don’t have the time, they may not have the inclination. They are busy treating sick patients. Have breastfeeding counsellors within hospitals, but also have them within communities. We have suggested to the government to do this through the ICDS. Malnutrition is not going to change unless women exclusively breastfeed, and for poor women especially to exclusively be able to breastfeed they need support and counselling services at the right time. These services have to be broadbased, not the purview of hospitals. If you have a sickness you go to the doctor. If you have a problem with breastfeeding, other women, counsellors and the community should support you. This would make a big difference.

(Sharmila Joshi works in the academic field of historical sociology, with an interest in issues related to development, gender, labour and social movements. She has been a journalist, writing for several years on social issues)

Infochange News & Features, July 2012