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Breastfeeding in India is disrupted as mothers and babies are separated in the pandemic
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- Breastfeeding in India is disrupted as mothers and babies are separated in the pandemic
Feature Baby Health and Covid BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3316 (Published 25 August 2020) Cite this as: BMJ 2020;370:m3316
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- Neha Bhatt, freelance journalist
- New Delhi, India
- nehabhatt70{at}gmail.
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India’s efforts to promote breastfeeding are threatened by covid-19, as misguided fears of infection see newborns separated from mothers and formula milk promoted. Neha Bhatt reports
In mid-April, Arun Gupta came across a string of photographs on social media that sent alarm bells ringing in his head. The photographs1 showed police officers, state administrators, and representatives of non-profit organisations such as the Ladli Foundation Trust distributing infant formula, including the Nestle products Lactogen and Cerelac, as part of pandemic relief efforts during India’s lockdown.2
“Infant milk substitutes were being donated to poor mothers and babies in Delhi, West Bengal, Jharkhand, and other states,” says Gupta. As a paediatrician and the central coordinator of the Breastfeeding Promotion Network of India (BPNI), he is appointed by the government to monitor the implementation of the Infant Milk Substitutes Act of 1992 (IMS Act), which he helped to formulate.
The act prohibits distribution and promotion of infant milk substitutes for children under the age of 2.
Over the following few days Gupta filed an “action alert”—a public notification issued on the BPNI website and to the media—urging the central government to tell state authorities to stop acceptance and distribution of infant formula in pandemic relief. He also sent letters to the Ministry of Health and Family Welfare and the National Disaster Management Authority, highlighting the separation of mothers and babies in suspected and confirmed covid-19 cases in hospitals and asking for a committee to investigate formula companies that exploit the pandemic for commercial gain.
In response,3 the minister said that doctors may take the decision to separate on a case-by-case basis depending on the clinical condition of the mother and newborn, although the minister did not specify what guidance this was based on. The health ministry has also sought a response from the Federation of Obstetric and Gynaecological Societies of India and the Indian Academy of Paediatrics, regarding webinars sponsored by formula manufacturing companies that violate the IMS Act.
Nestle India has denied any wrongdoing. A spokesperson said in an email to The BMJ, “We have not donated any infant milk substitute or infant food, to any individual, organization or local authority. We are always fully compliant with the IMS Act 1992 and we also have very stringent internal guidelines in place for this.” The Ladli Foundation Trust, meanwhile, tweeted that it had stopped distributing formula milk after BPNI highlighted the issue.
Voice of experts
A report published in May by the World Health Organization, Unicef, and the non-profit International Baby Food Action Network warned that the fear of covid-19 transmission was overshadowing the importance of breastfeeding, as aggressive marketing by formula companies exploited such fears and sowed misinformation to sell breastmilk substitutes.4 Gupta claims that he and other research colleagues have seen advertising increase drastically since April.
In India, for example, brands such as Danone, which manufactures the infant milk Aptamil, have increased their marketing, particularly online and on social media.
As part of a Danone marketing campaign called Voice of Experts,5 a video instructs mothers who test positive for covid-19 to stay six feet away from their baby and not to feed directly. This goes against WHO’s latest recommendations that mothers who test positive for covid-19 should be allowed to stay in the same room as their babies, breastfeed them directly, and have skin-to-skin contact with them while wearing a mask. A Danone spokesperson tells The BMJ that the company supports WHO’s recommendations and that the views expressed by medical experts in the campaign “are their own.”
Gupta fears that these messages and the habits they introduce at a time of high anxiety may cause longlasting damage to breastfeeding rates while adding a further purchasing burden on families whose incomes are already squeezed. “It takes years to take breastfeeding rates up by even 1%,” he says. “In the last 10 years the breastfeeding rate in India has gone up by 5%6 thanks to the IMS Act, Maternity Benefits Act [amended in 2017 to extend paid leave to 26 weeks], and the government’s Mother’s Absolute Affection campaign to promote breastfeeding through counselling services.
7 The covid crisis could set us back many years.”
Worldwide, breastfeeding rates have dropped by 40-50% in some hospitals during the pandemic.8 Before the pandemic only 41% of babies in India breastfed within an hour of being born, a number that has slid lower during the pandemic. The reasons are numerous, but chief among them is the widespread separation of mother and baby at birth because of confusion over guidelines and deep fear.
In April recommendations from the Indian Council of Medical Research endorsed separation based on guidelines from the US Centers for Disease Control and Prevention. In contrast, WHO revised its guidelines to state that the benefits of breastfeeding outweighed any risks of covid-19 infection.9
Recent research, such as a study published in the Lancet, has concurred with WHO’s stance.10 But translating fresh research into action has been difficult in maternity wards, where anxiety is high.
Anxiety on the maternity ward
Several doctors have told The BMJ that breastfeeding has become stigmatised during the pandemic.
Many families in city hospitals, for example, naturally worry when a mother tests positive for covid-19 and are adamant that the baby be kept in another ward or taken home.
Shacchee Khare Baweja, a lactation consultant in Delhi, says that hospitals are short staffed, at a time when we need more health workers to support breastfeeding. There is little family support, she says, as well as “the difficulty of helping mothers breastfeed from a distance, while wearing [personal protective] gear.”
Maternal anxiety is also high. When Nikita Wable’s family of four in Mumbai, including her 5 month old baby, tested positive for covid-19 in June, she was struck by panic. After a night of separation from her baby she went back to rooming with her. “There is so much hype and fear around the disease. The paediatrician advised me to keep feeding my baby, which calmed me down. But not everyone gets that support,” she says.
“After I posted my story on the network Breastfeeding Support for Indian Mothers to help others who may be in a similar situation, I received several calls from mothers who didn’t know what to do, as they were being asked by the city municipal authority to separate themselves from their babies,” Wable tells The BMJ.
“The babies were not being tested. The problem is that there are no fixed parameters, especially for new parents.”
Doctors are also concerned about newborns’ immunity to the novel coronavirus if they are not allowed to breastfeed. Megha Consul, a paediatrician based in Gurugram, says, “We are opening the doors to all manner of [health issues] if we don’t breastfeed en masse.”
Dwindling support
Even in the best of times, successfully establishing breastfeeding is a challenge. During a health crisis the existing problems are amplified.
“Access to the support mechanism for mothers has reduced drastically,” says Aparna Hegde, head of ARMMAN, a non-profit organisation that works on maternal and child health. “Resources in rural areas, such as the Anganwadi [rural maternal and child health centres], are closed at the moment. ASHAs [accredited social health activists, India’s equivalent of health visitors] have also been pulled away to focus on covid-19 related problems.
”
With a growing gap in support systems, and elders in the family often disapproving of mothers breastfeeding while covid-19 positive or even suspected of infection, many mothers with access to the internet are turning to online communities. Adhunika Prakash, founder of the Facebook group Breastfeeding Support for Indian Mothers, which has over 126 000 members, started noticing a steady rise in covid related posts by mothers who were distressed at being asked to isolate away from their nursing children.
“I decided it was time to start a campaign and, through videos and infographics, create awareness on how to safely breastfeed during this time and how separation was unnecessary,” she tells The BMJ. Prakash says that she has also noticed a rise in caesarean sections to reduce childbirth risks during the pandemic, which can entail delayed breastfeeding and increased formula feeding.
Among the mothers Prakash has personally coached is Sahaana Balachandran, a tax manager in Bengaluru.
She says, “Talking to her helped me understand how to tandem feed my 22 month old son, who tested positive for covid-19 and stopped eating solids, and my 4 month old baby [who tested negative, along with Balachandran]. I learnt how to sanitise myself before I went to feed my younger son.” Continuing to breastfeed and pushing back against misplaced fear is what helped her older son to recover from covid-19, she believes.
New efforts
The big question, then, is how to promote and protect breastfeeding at a time when it is buried under layers of urgent health matters and misinformation. “A key initiative involves sensitisation of officials to frontline functionaries [such as community health workers] on covid-19, infant feeding, and the IMS Act,” Gayatri Singh, Unicef’s child development specialist and India head of nutrition, told a webinar on breastfeeding during the pandemic, held in June.
Sadly, not many government administrators or non-profit organisations in India are even aware of the IMS Act, says Gupta.
He’s pinning his hopes on new efforts, such as BPNI’s mobile app Stanpan Suraksha (“breastfeeding protection”), launched during World Breastfeeding Week on 1-7 August, which he says will provide access to skilled counselling support for breastfeeding women.
BPNI and many government and non-profit health organisations have also increased the number of in-person workshops for lactating mothers, while maintaining social distancing. And volunteer lactation consultants, such as the women at Breastfeeding Support for Indian Mothers, are offering one-to-one virtual consultations to help women overcome the difficulties of feeding during the pandemic.
Health workers, meanwhile, are also taking matters into their own hands. Doctors in Mumbai have been conducting online training in safe breastfeeding for Anganwadi supervisors in the rural parts of the wider Maharashtra state, running a helpline for mothers with questions on breastfeeding during the pandemic, and creating a series of tutorials for new mothers.
Footnotes
Clarification: We have amended the section titled “Voice of experts” to make it clear that the 40-50% decrease in breastfeeding rates was only in some hospitals.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned, not peer reviewed.
This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.
https://bmj.com/coronavirus/usage
References
- ↵
Parida M. Twitter. 18 Apr 2020. https://twitter.com/manuparida1/status/1251420799287754754.
- ↵
Gupta A. Exploitation of covid-19 pandemic by baby food or feeding companies. 19 Jun 2020.
- ↵
Ram T. Letter to A Gupta. 23 Apr 2020.
- ↵
World Health Organization. Countries failing to stop harmful marketing of breast-milk substitutes, warn WHO and Unicef. 27 May 2020. https://www.who.int/news-room/detail/27-05-2020-countries-failing-to-stop-harmful-marketing-of-breast-milk-substitutes-warn-who-and-unicef.
- ↵
Danone. Voice of experts. https://www.danone.in/voice-of-experts/.
- ↵
Kaul R. World Breastfeeding Week: more women are breastfeeding in India than before. Hindustan Times 2017 Aug 4. https://www.hindustantimes.com/health/world-breastfeeding-week-more-women-are-breastfeeding-in-india-than-before/story-ImAqfQp4EEt0iOwONjSguL.html.
- ↵
- MAA (Mothers’ Absolute Affection) Programme for Infant and Young Child Feeding
. https://www.nhp.gov.in/maa-(mothers%E2%80%99-absolute-affection)-programme-for-infant-and-young-child-feeding_pg.
.jpg)
- ↵
Welsh T. NGOs defend breastfeeding as covid-19 misinformation rages. Devex. 9 Jun 2020. https://www.devex.com/news/ngos-defend-breastfeeding-as-covid-19-misinformation-rages-97440.
- ↵
World Health Organization. Breastfeeding and covid-19. 23 Jun 2020. https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19.
- ↵
Salvatore CM, Han JY, Acker KP, et al. Neonatal management and outcomes during the covid-19 pandemic: an observation cohort study. Lancet Child Adolesc Health 2020;S2352-4642(20)30235-2. https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30235-2/fulltext.
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von 2Breastfeeding in Switzerland: myths and reality
Katrin Berger (right) and Margrit Hagen: certified breastfeeding specialists at the University Hospital Bern (Universitätsspital Bern / Inselspital). swissinfo.chApproximately 95% of mothers breastfeed their babies. However, the process of breastfeeding itself is still surrounded by numerous prejudices. It is rare that a woman who has given birth has not heard such expressions in her address: "you do not have enough milk", "after breastfeeding your breasts will lose shape" or "a good mother is only one who breastfeeds her child." swissinfo.ch spoke to two Swiss experts specializing in breastfeeding issues and concerns.
This content was published on February 06, 2019 - 11:00Patricia Islas (Patricia Islas)
Katrin Berger and Margrit Hagen are board certified and certified breastfeeding specialists consulting women at the gynecological department of the University Hospital Bern (Frauenklinik des Universitätsspitals Bern / Inselspital).
In addition, they are also midwives with more than 30 years of professional experience, and therefore know first-hand about the feelings, thoughts and concerns of mothers who are faced with the peculiarities of the organization of the process and nutrition of newborns.
Show more
It was on the basis of their experience that Swiss medical institutions were awarded the certification labels "Clinic where babies are welcome" ( Baby Freundliche SpitälerExternal link ). The criteria for awarding such a kind of "quality label" are guided by the recommendations formulated by the World Health Organization ( WHOExternal link ) and the UNESCO Children's Fund (UNICEFExternal link). Today, a total of 27 clinics in Switzerland have been awarded this label.
swissinfo.ch: How is Switzerland following the UN recommendations to promote breastfeeding?
Kathrin Berger: Before 95%External link mothers are now breastfeeding newborns in their very first days of life.
In 1992, UNICEF and WHO developed a regulation for the Baby Freundliche Spitäler (Baby Freundliche Spitäler) certification label. In Switzerland, this idea fell on fertile ground. On the one hand, of course, not all medical institutions with a maternity ward aim to obtain such certification at all costs - primarily because of the costs (it costs up to 10,000 Swiss francs to obtain such certification).
Nevertheless, most of these structures try to follow - and follow in practice - the UN recommendations called "Ten Steps to Successful Breastfeeding". In addition, the statutory health insurance funds in Switzerland pay for three consultations of breastfeeding specialists, which also positively affects the situation in which breastfeeding as such is in the country.
swissinfo.ch: How long do people breastfeed on average in Switzerland?
Margriet Hagen: According to the studyExternal link published in 2014, breastfeeding is approximately 31 weeks.
In Switzerland, as in other industrialized countries, more educated mothers breastfeed their babies for longer. In developing countries, we see an inverse relationship.
swissinfo.ch: Why is breastfeeding advice needed in Switzerland?
KB: Society has changed! Previously, knowledge about breastfeeding was passed on in the family, among the sisters. The attitude to this issue among representatives of different generations was not as noticeable as it is now. Today we are all individualists! It is becoming increasingly rare to see breastfeeding mothers in public places. Women are increasingly seeking professional advice because breastfeeding is a process that needs to be learned and takes time.
swissinfo.ch: Are there any “frequently asked questions” women have during these consultations?
MH: Yes, persistent questions include breastfeeding pain, sore nipples, breast problems, breast infections, fear of too much or too little milk, partial breastfeeding, weaning , feeding rhythm, manual or mechanical pumping.
swissinfo.ch: Women often ask on social media to recommend a “good” lactation consultant! Who or what exactly are they looking for?
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KB: Women seek answers to questions related to their individual needs or concerns. Most importantly, they are looking for a consultant who would not force them to feed. A good consultant will always support a mother who does not want to breastfeed her baby. At its core, our counseling communication is about respecting the will of the woman while taking into account the needs of the child, strengthening their mutual relationship and contributing to the well-being of the woman.
We also always point out that life is complicated and there can be no black and white solutions, that there are always some intermediate possibilities and options. Ultimately, it is about providing correct information on a case-by-case basis so that each mother can make an informed decision, ignoring rumors, myths and clichés.
swissinfo.ch: So there are still myths and rumors about breastfeeding in Switzerland?
MH: Of course there are! Some families still tell "tales" that can upset or frighten the new mother. For example, that she has bad milk, and therefore the child loses weight, which means that the mother must transfer him to artificial feeding. Or here's another myth - the breasts will lose their shape after feeding and sag.
Many women also believe that the ability to breastfeed is hereditary. They say, "My mom couldn't breastfeed, so I can't." Certain anatomical features can really become an obstacle, but this can be solved. Some women also feel that they should stop breastfeeding if they have a breast infection or are taking medication. In both cases this is not true.
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swissinfo.ch: What is the scientific and public interest in breastfeeding?
KB: Previously, science was not interested in this.
The first information about breastfeeding came from veterinary medicine in general. For example, how to treat breast infections. Thus, the first results appeared, which could then be applied in the field of human treatment. Today there is research, education and training going on, but there is a lack of interest in many areas of society to see and promote breastfeeding as a social investment rather than a burden.
swissinfo.ch: Since 2014, there have been legal provisions in Switzerland allowing breastfeeding during working hours without loss of earnings.
MH: Yes, this possibility exists on paper, but in practice it is still in its infancy in Switzerland. Even breastfeeding in public places was somehow forgotten.
Today, it is still widely believed that the image of an uncovered chest is a sexual symbol, but not a source of life or food. The rejection of breastfeeding always occurs when society persists in defending antiquated, inflexible structures while promoting personal independence.
In general, a woman cannot imagine that she will be at work pumping milk to feed her baby later, or that she will discuss the issue of breastfeeding with her superiors when she returns to work after parental leave.
swissinfo.ch: Have we forgotten about breast function like nutrition?
KB: Breastfeeding has always been an intimate affair, even though we now assume that women play a very different role in public life than they used to. What is the value of breastfeeding in the eyes of society? It is no longer considered something natural and harmonious, inherent in our biological species.
We believe that the process of public perception of the female breast has lost some very important elements. We would really like people to realize again that breast milk is the very first food of every person. And that women could spend more time with their children, and not just the first 14 weeks they are entitled to as part of maternity leave.
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Indian doctor dedicated her life to women's health
Geeta and her husband came to Sir Jamsetji Jijebhoy Hospital over 15 years ago driven by the desire to have children. Since they were both HIV-positive, the doctors advised them not to have a child, so they went to busy Mumbai, India, to Rekha Daver, hoping to find some kind of solution.
Rekha Daver is a doctor in charge of the gynecology department at a public hospital. Under her leadership, the hospital has become a referral center for HIV-positive pregnant women, who are often denied admission to other health facilities.
“Back then I couldn't guarantee that their baby would be healthy, but I signed Gita into our antiretroviral therapy program,” recalls Rekha Daver.
Subsequently, Gita's husband also signed up for the program. Less than a year later, Gita gave birth to a girl in the hospital.
“They never missed an appointment, and when they finally had a daughter who tested negative for HIV, you should have seen their happiness,” says the doctor. The couple, now together with their grown-up daughter, still visit Rekha Daver, which she is very happy about. “This is more than just preventing mother-to-child transmission of HIV, it is an opportunity for two adults to live normal lives.”
Few people know more about the emergence of a new life than Dr. Daver. Since 2000, her team has delivered more than a thousand HIV-positive women. And lately, they have had reason to rejoice: within two years, one hundred women using the new three-drug regimen had healthy babies.
Sarita Jadav, UNESCO New Delhi Coordinator for HIV and School Health Education, speaks highly of Rekha Daver's work: “Maternal and child health is one of her main goals in life.
She has dedicated over 37 years to helping disadvantaged women." Ms. Jadav draws particular attention to the fact that Dr. Daver studied and worked in the US and was able to obtain a residence permit, but still chose to return to India, work in a public hospital and teach medical students.
“We all admire her relentless drive to make a difference and save lives,” says Sarita Jadav.
Rekha Daver notes the importance of counseling services: “When a woman is HIV-positive and her husband is not, such couples experience significant pressure from society, much more than couples in which the man is infected and the woman is healthy. Our team is working to spread the word about safer sex and family planning.” Dr. Daver says she owes her extensive knowledge of women's health to her work at the Human Reproductive Health Research Center and the Indian Council of Medical Research.
She has made helping women a central part of her career. Since childhood, Rekha Daver knew that she wanted to become a doctor, and thought to go to study as a surgeon, but growing up in a small town, she realized that she wanted to help women, which means that she could be more useful if she became an obstetrician or gynecologist.
After graduating from a medical college in India, the girl went to the USA, where she studied for three years at the Texas Medical Center in Houston. When she decided to return to India, her husband Dr. Gustad (whom they had met in medical school) and their two children went with her.
In 1990, Rekha Daver began working at Sir Jamsetji Jijebhoy Hospital and it was there that she realized how many women in India were living with HIV.
“I knew there was no cure for this disease, and perhaps the best thing I could do was to prevent HIV transmission, especially from mother to child.”
After reviewing programs in Thailand and Uganda, Dr. Daver and her team began antiretroviral treatment for HIV-positive pregnant women. Without taking antiretroviral drugs, 33–45% of women living with HIV have HIV-infected babies. The Sir Jamsetji Jijebhoy Hospital became a testing ground where Dr. Daver trained other doctors who came from all over India.
Now, with the success of programs to prevent mother-to-child transmission of HIV, Dr.
