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Breastfeeding Promotion in Punjab

Policy Brief No. 02 22nd August 2017

Policy Brief:

There is evidence that breastfeeding is good for the health of infants and young children. In

developing countries, using formula milk and drinks in unhygienic environment rather than

breastfeeding can be a death sentence for children. It is estimated that approximately 1 million

children die each year as a result. ‘Breast is Best’ has been a global slogan for several decades. In

this paper, we discuss what can be done to promote breastfeeding, as a critical part of reducing infant

mortality and boosting children health.

The Benefits of Breastfeeding:

There is substantial evidence of the benefits of breastfeeding on a range of health outcomes. This has

formed the basis for the three breastfeeding goals1:

1. All babies should be put to the breast immediately after birth (known as ‘early initiation’).

2. For the first six months of life, babies should be given only breastmilk and no other foods or liquids (including water) – a practice referred to as exclusive breastfeeding.

3. Breastfeeding should continue for two years.

Breastmilk is designed to meet all the needs of infants for the first six months of life, and continues to

support their health and nutrition beyond six months. The benefits of breastmilk start from birth:

colostrum (the milk produced immediately after birth) is likened to a baby’s first immunization due to

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its anti-infective properties. Problems arise when infants aren’t fed according to these

recommendations because:

An infant’s immune system takes longer to get up and running if it doesn’t get colostrum and breastmilk, that puts the child at a higher risk of getting sick and means they are less able to recover if they do.

Foods and liquids often contain bacteria and other disease-causing pathogens, whereas breastmilk doesn’t. So when infants less than six months old are given other foods, this poses a problem because their immune systems are still immature and they’re less able to fight off illness. These pathogens can end up in foods because of poor hygiene/sanitation or unclean water, and some foods (including infant formula) get contaminated during packaging and storage.

While breastmilk is designed to meet infants’ nutritional needs exactly at all stages of their development, other foods (including infant formula) aren’t. Giving other foods to children less than six months old can put them at risk of malnutrition and mean their brains and bodies don’t develop as they should.

The digestive systems of infants less than six months old aren’t designed to deal with foods or liquids other than breastmilk so the introduction of these too early can cause persistent digestive problems, and can even trigger allergies.

It has been found that, for these reasons, babies who aren’t fed according to recommendations are

significantly more likely to get diarrhoea, gastroenteritis, ear infections and lower respiratory tract

infections2. Children who were breastfed have been shown to perform better at school, to have higher

IQs and, as adults, have been found to be significantly less likely to become obese or develop type 2

diabetes3,4,5.

It has been shown that, in developing countries, babies who aren’t breastfed are significantly more

likely to die. Infants less than six months old who aren’t breastfed are 14 times more likely to die than

those who are breastfed exclusively6.

Why is There a Problem With Breastfeeding?

In very poor communities, the main reasons women aren’t breastfeeding in the best way for their

children, are the demands on women’s time, a lack of skilled support, and cultural beliefs about

feeding infants. Late initiation of breastfeeding is relatively common in these settings and this is

sometimes the result of traditional beliefs, such as, that newborns should be given sugared water or

that colostrum should be discarded. Evidence suggests that cases in which early initiation is delayed

always have decrease continuation rates in future. There’s also an absence of support for helping

mothers to establish breastfeeding. Helping women with positioning the baby to effectively latch-on,

and building confidence in her milk supply, requires one-to-one support both before birth and in the

first weeks after delivery.

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Even in settings where breastfeeding is considered a normal

practice woman will still need support to resolve problems during

lactation (e.g. engorged & cracked nipples, decrease milk

production etc.). This type of support is often lacking in many

developing countries due to lack of trained health staff. In some

cultures, there’s also a perception that breast milk alone cannot

satisfy the needs of infants.

In Urban areas in developing countries, many women are aware of

the benefits of breastfeeding and willing to practice it. There is an increasing trend for women to work

and due to lack of supportive environment in work places, they quit breastfeeding. The undue

publicity of formula milk is also a reason for decline in breastfeeding practices. Finally, breastfeeding

has come to be seen as difficult and women have lost confidence that it’s possible, which in itself is a

major barrier to breastfeeding successfully.

Breastfeeding Trends:

It is alarming to see that Pakistan is a Muslim state (Islam promotes breastfeeding), but still there has been a declining trend in early & exclusive breastfeeding over the years. In South East Asia Pakistan

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has a lowest breastfeeding rates and highest bottle-feeding rates. We need to dig into reasons for decline and rectify them

Exclusive breastfeeding is 16.8% in Punjab according to MICS 2014, but in some districts like

Bahawalpur, Bahawalnagar and Gujranwala, it is 5.6%, 5.8% and 7.3% respectively.

Initiatives Undertaken by Primary & Secondary Healthcare Department, Punjab to Promote Breastfeeding:

Seeing the poor Breastfeeding indicators in the province, Government of Punjab has undertaken

various initiatives. These are under domain of Primary and Secondary Healthcare Department and

Specialized Healthcare and Medical education Department. In communities, LHWs have a major role

in creating awareness and supporting it, whereas Gynecologists and pediatricians have an equally

important role. The targets set by IRMNCH &NP to improve nutrition in province are as follows.

Various Steps taken till date are as follows:

Notification of Breastfeeding Rules -notified and published in the Punjab Gazette on 4th January 2017.

Re-notification of Infant Feeding Board, March 2017.

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2 Meetings of Infant Feeding Board

Meeting with formula companies -in May 2017.

Preparation of Breastfeeding Rules implementation plan

Implementation of Breastfeeding Rules.

Case Studies:

Bangladesh formed a national IYCF alliance with 25 partners, including the Institute of Public Health

Nutrition, government agencies, and NGOs. BRAC, the Bangladesh-based global NGO, ran

interventions in 50 rural sub-districts through its national Essential Health Care program. BRAC

workers regularly visited the homes of pregnant women and mothers with children up to two years

old to provide age-targeted IYCF counseling and encourage other family members to support the

mother’s efforts. The BRAC workers advised community leaders about IYCF and held community

demonstrations. Seven TV spots about good IYCF practices were broadcast nationally. The program

also established a capacity-building program for journalists, and held national and district-level

meetings and workshops for opinion leaders. An IFPRI analysis showed that in intensive intervention

areas, exclusive breastfeeding rates increased from 49 to 88 percent over four years (in areas with less

intensive programs, the effect was less pronounced).

In Ethiopia, breastfeeding rates are higher than in Bangladesh or in Vietnam, but overall IYCF practices

are still poor. A&T provided information and counseling to mothers and caregivers primarily through

the Federal Ministry of Health’s flagship Health Extension Program throughout Ethiopia’s four most

populous regions: Amhara, Oromia, SNNPR, and Tigray, using its large network of female health

extension workers and teams of community health volunteers. They held village gatherings to discuss

breastfeeding and demonstrate how to prepare nutritious complementary foods. A&T also partnered

with various NGOs, faith-based organizations, and women’s associations to launch a radio campaign.

Early initiation of breastfeeding there increased from 67 to 82 percent, while exclusive breastfeeding

rates rose significantly from 72 to 83 percent.

Vietnam is a rapidly industrializing country with low breastfeeding rates. There, A&T worked with the

Ministry of Health, the National Institute of Nutrition, UNICEF and other agencies. Implementing

partner. Save the Children worked with the government to establish 1,032 “social franchises” in clinics,

hospitals, and other health facilities in 15 of the country’s 63 provinces. The franchises provided

individual and group counseling sessions from the third trimester of pregnancy until children turned

two. A&T also worked with partners to strengthen two national policies: the Labor Code, which

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governs paid maternity leave, and the Advertisement Law, which governs the marketing of breast milk

substitutes. A media campaign also promoted behavior change via TV spots, loud speakers, and digital

media. In intensive intervention areas, exclusive breastfeeding rates increased threefold from 19 to

58 percent, less so in non-intensive areas.

Recommended Action to Drive Progress in Increasing Breast Feeding

Investments in health systems are needed to ensure both the sustainable delivery of services to support mothers to breastfeed (during the antenatal period, immediately post-delivery in both hospital and home settings, and postnatally) and the training of health professionals and peer counsellors. Social protection and benefit systems should take special account of the needs of breastfeeding women so they can delay their return to work.

Stringent legislation controlling the marketing of breastmilk substitutes, bottles and teats.

Revival of Baby Friendly Hospitals Initiative.

Involvement of celebrities/public figures for mass awareness.

Easy access to information regarding benefits and problems of breastfeeding

References:

1. World Health Organization (WHO), 2003, Global Strategy for Infant and Young Child Feeding.

2. Ip S et al (2007) Breastfeeding and maternal and infant health outcomes in developed countries. Agency for Healthcare Research and Quality, Evidence Report No. 153.

3. WHO (2007) Evidence on the long-term effects of breastfeeding. WHO, Switzerland.

4. Kramer MS (2008) Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psych, 65, 578-84.

5. WHO (2003) Diet, nutrition and the prevention of chronic disease. WHO Technical Report 916, Geneva, Switzerland.

6. Black RE et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 2008, 371, 243-60.

Prepared By:

Ms. Abida Bashir, Research Associate, PSPU

Dr. Saira Jameel Khan, Nutrition Coordinator, PSPU

Reviewed By:

Muhammad Khan Ranjha, Program Director, PSPU

Dr. Muhammad Nadeem Zaka, Additional Program Director, PSPU