The slogan for World Breastfeeding Week, which is being celebrated from August 1 to 7, is “Breastfeeding: Foundation of Life”. This simple yet hard-hitting statement captures the essence of every campaign in support of breastfeeding, which in an ideal world would have been a non-issue, requiring neither sloganeering nor campaigning.
First, a few settled facts before we move on to the controversies. Undernutrition causes 45% of all child deaths and breastfeeding is one of the most significant ways to improve infant survival rates. Breastmilk protects infants from common childhood illnesses such as diarrhoea and pneumonia – the two primary causes of child mortality worldwide. Longer duration of breastfeeding contributes to health and well-being of mothers as well, by reducing risks of breast and ovarian cancer, type II diabetes and postpartum depression.
According to the World Health Organization (WHO), infants exclusively breastfed for the first six months of life are more likely to achieve optimal growth, development and health. It is now equally well-settled that these health benefits are matched by economic returns at family level by reducing dependency on expensive breastmilk substitutes (formula), and at enterprise and national levels by reducing healthcare costs. However, despite these obvious benefits, the culture of breastfeeding is seen to be depleting, especially among working mothers.
Globally, only 36% of infants aged 0-6 months were exclusively breastfed between 2007-2014. In India, as per the National Family Health Survey (NFHS)-4 (2015-16), only 41.6% children under three years were breastfed within one hour of birth while only 54.9% children were exclusively breastfed until six months. While this is a slight improvement over global statistics, it still means that nearly half of our children are not being breastfed as per the WHO guidelines.
A direct correlation to this lies in our shameful infant mortality rate of 34 per 1000 live births with nearly 35% of India’s children under five years being stunted or underweight or both. One would have hoped that these numbers were enough to put in place an unflinching policy to promote breastfeeding. However, recent events at national and international levels have shown that breastfeeding is entangled in a web of political, economic and last of all, health issues, with various competing interests.
Politicking over breastmilk
At the recent UN-affiliated World Health Assembly (WHA) held in Geneva, a resolution seeking to “protect, promote and support breastfeeding” and restricting promotion of food products harmful to young children was sought to be adopted. The latter aspect is particularly important given the aggressive and immoral marketing practices adopted by the infant formula industry at the cost of innocent lives and the health of children. In fact, way back in 1981, the then WHA had adopted an International Code of Marketing of Breast-milk Substitutes (the Code) to proscribe formula industry from marketing its products as superior to breastmilk. However, neither the Code nor the consistent pro-breastfeeding messaging seem to have affected the industry, which is now more than a 50 billion dollar industry.
Despite these concerns, the US delegation at the Geneva WHA, not only opposed the resolution but also threatened other countries with trade and military sanctions to prevent the resolution from being tabled and passed. The Trump administration is alleged to have acted hand in glove with the multi-billion-dollar formula industry. The US delegation however rubbished all allegations while stating that it was only acting on behalf of women who are unable to breastfeed due to malnutrition and poverty, and who might be stigmatised for choosing not to breastfeed for a variety of reasons.
The above instance, apart from highlighting the obvious i.e. the lobbying strength of the formula industry, brings to the fore two other critical issues worth deliberating: one, the right of a mother to choose the manner in which her child should be nourished and two, the rights of a child to an optimal source of nourishment. The policy ramifications of this debate between the rights of a child vis-à-vis that of the mother are significant. If the one and only source of optimal nourishment for infants is recognised to be breastmilk, does this mean that a mother can be obligated or compelled to breastfeed? Does this not usurp the autonomy that the mother has over her body? Should the law dictate that a mother ought to breastfeed, how will this be enforced? Would this not violate her fundamental right to privacy? Is the society right in judging and stigmatising a young mother over her feeding choices? On the other hand, if a child’s right to breastfeed is not recognised, given the life-threatening risks associated with other infant foods, would it not amount to violating the child’s fundamental right to life?
These concerns were partly raised in a 2017 Madras high court order where Justice Kirubakaran sought a clarification from the Centre as to why breastfeeding cannot be declared an infant’s fundamental right under Article 21 of the constitution. While the motive behind the question is commendable, it also showcases a lack of appreciation of various other intertwined issues highlighted above, not to forget the commensurate duty that this would vest not only on the mother but also the state, to ensure that the infant’s right is upheld.
It is thus evident that breastfeeding – a natural and intimate act between a mother and her child – has become a complicated political issue, involving several other stakeholders such as the family, society, governments and businesses, with unfortunately not all acting under benign interests. This interplay of different interests is a subject for in-depth deliberations. However, any outcome of such deliberation should be to recognise the irreplaceable role that a mother has in deciding the manner in which her child is to be fed. Amongst all the stakeholders, the mother is the most affected as well as the most likely party to have the best interests of her child in mind. The role played by other stakeholders should merely be to facilitate the mother to nourish her child – either by way of breastfeeding or formula – as long as her choice is based on credible information and counseling.
Lacunae in law and implementation
This is where the second limb of controversy arises, which highlights the shortcomings of both the government and the society we live in. Even though India is among the very few countries which have adopted the Code into a law (Infant Milk Substitutes, Feeding Bottles and Infant Foods Regulation of Production, Supply and Distribution) Act, 1992), the industry seems to have found a roundabout way of marketing its products through doctors, nurses and midwives, who are trusted sources of information to a new mother.
There have been innumerable reports of young mothers being misled into administering formula to their infants, either under the garb that it is a sufficient/superior source of nourishment or by making them question their ability to breastfeed. It is now well-established that formula can never be a complete replacement for breastmilk and also that ‘insufficient supply’ of breastmilk is mostly a myth. However, many young mothers and families buy into false propaganda thereby depriving the newborns of the best start towards life.
The ill effects of formula are even more worrying given the recent report by the Centre for Science and Environment which has found that popular infant formula in Indian markets have undisclosed genetically modified (GM) ingredients. This unethical and unregulated atmosphere in which these businesses function has disastrous health and environmental consequences. Therefore, it is not enough to merely have strict restrictions on formula advertising, it should also be accompanied by efforts to educate women and families about the potential harm that may be caused to their children.
It is, however, recognised that in some circumstances, a mother may in fact be unable to breastfeed either due to health reasons or due to lack of adequate support system. To cater to such instances, milk banks should be set up across the country. India got its first National Human Milk Bank only in 2017 and has a long way to go before human milk becomes accessible and affordable. Here India can learn from Brazil, which has managed to bring down its infant mortality rate significantly, by investing in around 200 human milk bank centres across the country. However, due care and caution should be exercised before scaling milk banks across India to prevent adulteration and also to ensure adequate storage facilities for breastmilk aka ‘liquid gold’.
Working women and breastfeeding
One would assume that matters are likely to be much more straightforward if women simply chose to breastfeed. However, the challenges are multifold even here, especially for working women. Women constitute only 27% of the Indian workforce with nearly 96% of them being employed in the informal sector. The challenge lies in providing policy and infrastructural support for young working mothers to breastfeed while continuing to be part of the workforce. The Maternity Benefits (Amendment) Act, 2017, applicable only to the formal sector, has made commendable progress in this regard, at least in the letter of the law, by providing for a compulsory 26 weeks paid maternity leave, optional work from home facility and compulsory crèche facility with a minimum of four breaks per day for child care. However, as with any law, the devil is in the detail.
A year since the amendments, ground data show that not only has the law not been implemented, it has in fact backfired by putting women at a great disadvantage. In a recent report titled ‘The Impact of Maternity Benefits on Business and Employment’ by TeamLease, it is estimated that 11-18 lakh women are likely to suffer job loss/or remain out of the workforce due to the cost-intensive maternity benefits provided under law, which places the entire financial burden of implementation on the employers. This is unviable for small and medium-sized businesses. A 2014 International Labor Organization report specifically cautions against making employers solely liable for the cost of maternity benefits for this very reason. The government needs to urgently revisit this issue of financing maternity benefits and shoulder at least part of the expenditure incurred in retaining young mothers.
Further, as an alternative to the cost-intensive crèche facility, the law should give recognition to the practice of expressing and storing breastmilk by working mothers, which can be given to their children while they are away. This requires minimal infrastructure support at workplaces in the form of a clean and private pumping room, along with sufficient breaks for mothers to express and store breastmilk. A few developed countries like the US and the UK have relevant legal provisions to facilitate expressing breastmilk. These measures are necessary to give teeth to the 2017 amendments, without which, as seen until now, it will only remain a token gesture towards women and child rights.
The other challenge is the dearth of infrastructural support to facilitate breastfeeding in public spaces. Even though India does not have any law which punishes breastfeeding in public, it is usually stigmatised due to hyper-sexualisation of a woman’s mammary glands (as seen in the controversy raked by a Kerala magazine which published a cover image of a woman breastfeeding an infant). On the other hand, no effort has been made to provide private nursing rooms in public spaces such as bus stops, malls, railway stations etc. A woman should not be forced to be within the confines of her home in order to breastfeed her child. Accessibility to public spaces and adequate support at workplaces is likely to curb the trend of women choosing not to breastfeed, especially in urban areas.
Given the enormous health, social and economic benefits that breastfeeding assures to every child, it is shameful that governments are not invested enough in promoting breastfeeding. As per the Global Breastfeeding Scorecard, 2017 released by Global Breastfeeding Collective, lead by UNICEF and WHO, India spends an abysmal Rs 10 per child to ensure adherence to breastfeeding guidelines. It is time the government took active measures to one, ensure that every mother has access to credible and complete information about breastfeeding, and two, provide legal, policy and infrastructural support to enable her to breastfeed wherever and for as long as she wants to.
Originally published – https://thewire.in/health/to-increase-rate-of-breastfeeding-in-india-need-for-government-to-step-up-support