Free, not freely used - A public health miracle

Free, not freely used - A public health miracle

In spite of its easy accessibility and unquestioned value, breastfeeding coverage remains poor. In India, 58.4% children under three, are not breastfed in their first hour after birth according to the National Family Health Survey- 4, 2015-16.

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Unparalleled quality. Easily accessible. Costs practically nothing. Saves lives. How would such a product be received? Would it not be ubiquitous? Popular enough to be genericised like Google, Xerox or Aspirin? In public health, there is one such phenomenon - breastfeeding. It does not distinguish between rich and poor. Even undernourished mothers who may be able to afford only little food, can breastfeed successfully, except in cases of severe malnutrition.

Newborn children should be breastfed in the first hour after birth, and then exclusively for six months. It has rich benefits. Colostrum, the breastmilk produced in the first hour after birth, is rich in nutrients and antibodies. Exclusive breastfeeding protects new-born children against various infections and illnesses that cause child deaths. Universal breastfeeding could save 823,000 lives each year around the world, according to The Lancet. A 2013 World Health Organisation (WHO) study showed that global diarrhoea-related hospitalisation and mortality was lower by 72% and 77% respectively for breastfed infants. Breastfeeding promotes sensory and cognitive development of the child and improves emotional interaction between mother and baby. A study of infants born in Brazil in 1982, published in The Lancet, showed that IQ of children breastfed for 12 months or more, was higher than their peers by 3.7 points. The Lancet's 2016 series on breastfeeding shows that reduced cognitive development due to inadequate breastfeeding costs the global economy $302 billion annually.

In spite of its easy accessibility and unquestioned value, breastfeeding coverage remains poor. In India, 58.4% children under three, are not breastfed in their first hour after birth according to the National Family Health Survey- 4, 2015-16. Over 45% of Indian children are not exclusively breastfed in their first six months.

So, what is limiting the spread of breastfeeding? Social norms and barriers play a role in India. Several communities don't allow breastfeeding till the completion of some rituals in the first three days after birth. In many parts of India, honey is given to neonates in the first two hours after birth. It is also considered auspicious for the new-born to be fed a sweet by an elder family member. In some tribal areas, children are fed water, sugar / salt solution, cow's milk and jaggery ostensibly to resist hunger and clean the tongue. Some communities also administer tea and 'ghutti' (a herbal concoction mixed with water). Assamese communities are known to administer goat milk to new born children. In Kerala, as part of the naming ceremony, children are fed milk using a spoon on the 28th day. In my experience, I have seen infants being fed tobacco to prevent crying. Even if people are aware about the importance of breastfeeding, they don't follow appropriate breastfeeding practices due to faith or practical constraints. Mothers often work long hours in the fields, entrusting babies to siblings or grandparents. Behaviour change is a tough nut to crack.

Breastfeeding's most well-organized opponent is the infant formula milk industry. Save the Children's "Don't Push It" report published earlier this year projected that the global milk formula industry's sales would reach $70.6 billion by 2019, with rapid growth in the developing world. The industry spends $5 billion each year on advertising. Brands aggressively market formula milk as a viable alternative for breastmilk. The industry continues to exert tremendous influence in international relations. Earlier this year, when Ecuador moved a resolution at the WHO favouring breast milk, the New York Times reported that the United States strongly opposed this resolution, threatening trade punishments and withdrawal of military aid. President Trump himself tweeted his administration's belief that women 'need formula milk because of malnutrition and poverty' - an unsubstantiated claim. The good news is that India's Infant Milk Substitutes Act, 1992, which allows for prosecutions when companies violate advertising norms, is seen as an example by the world.

Breastfeeding, especially in public, has also been affected by social taboos. When the Malayalam magazine Grihalakshmi featured a woman breastfeeding a baby, on its cover as part of its "Breastfeed freely" campaign, it sparked a furious debate around the world. The model was trolled aggressively on social media. A necessary public health intervention was reduced to a sexualised gimmick. Whereas, in Australia, for instance, Senator Larissa Walters moved a motion in Parliament while breastfeeding and was warmly received.

Simple actions can make a difference:

  • Awareness: Health facilities must push for early and exclusive breastfeeding. These key messages must be reiterated to mothers, mothers-in-law and other family members when mother and child return home. In rural settings, capacity building of frontline health workers is key, to counter adverse social norms
  • Milk banks: Through human milk banks, lactating mothers can donate surplus breast milk to aid undernourished children without access to adequate breast milk. In 2017, the Government of India set up its first milk bank at Delhi's Lady Hardinge medical college. The Government plans to create a network of human milk banks across India's 661 Sick Newborn Care Units (SNCUs) - a boon for India's mothers and infants
  • Safe spaces: We should create safe spaces for women to breastfeed comfortably in public places such as railway stations, office blocks and malls. In July 2017, the Railways announced plans for designated breastfeeding areas in waiting rooms. In Maharashtra, various health facilities, bus stands, Government buildings etc., have established "Hirkani Kakshas" - dedicated rooms for breastfeeding.
  • Influencers: Public figures play a key role in shaping society's behaviour. In this context, actress Madhuri Dixit-Nene's work with the Union Ministry of Health and Family Welfare, to promote breastfeeding is heartening. Model Lisa Haydon posted a picture of herself breastfeeding, to promote its importance during World Breastfeeding Week last year. Such efforts must be lauded and irresponsible, sexist statements are to be avoided.
My question for businesses is "what do we do to effect behaviour change at scale, for universal adoption of breastfeeding?"

Piyush Mehra is the CEO, Antara Foundation. He has worked in management consulting with Arthur D Little and KPMG.