If ever there was a slowpoke law in Pakistan, it is the one made for Pakistani newborns and babies, whose very survival rests on it — the Protection of Breastfeeding and Young Child Nutrition Act, 2002.

Had this law been enforced in letter and spirit, and had the little ones been exclusively breastfed (EBF), 15 per cent, or nearly 53,000 deaths of under five babies can be averted annually.

— Data from Unicef

Globally fewer babies are dying today than two decades ago. Still, close to 7 million under five of years die from preventable causes. Of those who die, half are newborns. Immediate breastfeeding (within an hour after birth) can significantly reduce neonatal mortality. The importance of breastfeeding can be underscored by the fact that it can prevent over 800,000 deaths (13 per cent of all deaths) in children under five in the developing world.

— Data from Unicef

How many more babies will have to die before life is breathed into the law which exists, but is gathering dust due to political apathy?

It took Pakistan more than 20 years to legislate and promulgate the Protection of Breastfeeding and Young Child Nutrition Act 2002 after it voted in favour of adopting the International Code of Marketing of Breast-milk Substitutes during the World Health Assembly back in May 1981.

Seven more years elapsed before the rules were notified in 2009; another four years passed when it notified the Infant Feeding Board in October 2013 to monitor implementation of the 2002 Ordinance.

It took Pakistan more than 20 years to legislate and promulgate the Protection of Breastfeeding and Young Child Nutrition Act 2002. — Photo by author.

Today when all the provinces have passed their own breastfeeding and nutrition laws (health became a provincial subject after the passage of the 18th constitutional amendment in 2010), one would think that child rights activists would be celebrating the triumph in showing commercial breast milk substitutes in the industry the door.

Alas nothing could be further from the truth.

Experts say breast milk substitute companies continue to flout the law and continue to market their ware inappropriately. "The baby food industry continues to misinform people about the wonders of the formula milk and infant cereal products," says Dr D S Akram, a renowned pediatrician who heads the Health Education and Literacy Programme (Help) that provides primary healthcare to marginalised populations in Pakistan.

Take a look: Board to back mother-feed law

A survey "SuperFood for Babies: How overcoming barriers to breastfeeding will save children's lives" carried out by Save The Children in 2013 found that a third of all available information relating to infant feeding was sponsored by commercial companies. It also discovered that there was misleading information and that there was promotion of bottle-feeding in some ways, in clear violation of the code.

Dr Sania Nishtar, founder and president of healthcare reform NGO — Heartfile — finds the breastfeeding trends in Pakistan quite discouraging. Using the Pakistan and Demographic Health Survey of 2012-2013, as a yardstick, she says the rate of EBF was just 37.7pc.

Dr Tabish Hazir, head of pediatrics at the Children's Hospital of Pakistan Institute Of Medical sciences (Pims) Pakistan, adds that this was "a marginal increase from 37pc in 2006-07" lowest among South Asia.

The low rate of breastfeeding is illustrative of the health profile of Pakistan. A country with an exploding population (it is the 6th most populous country in the world and if things remain the same, Pakistan's population would exceed to 300m by 2050) has an infant mortality rate of 78 deaths per 1,000 live births whereas the mortality rate of children under five years old is 89 deaths per 1,000 live births. The maternal mortality rate of 276 deaths per 100,000 live births is also far too high as is the high burden of communicable diseases in children.

The report published by Save the Children states that in a developing world such as ours, if a mother continues breastfeeding for six months, the infant is 15 times less likely to die from killer diseases such as pneumonia and diarrhea. And if the baby receives colostrum (the mother's first milk) within an hour of birth, it immediately triggers the baby's immune systems, making him or her three times more likely to survive.

At the same time, Pakistan had the highest rate of bottle feeding in the entire region. The bottle feeding rates increased from 32.1pc in 2006-07 to 41pc in 2012-13 which makes it clear where our priorities lie.

On the other hand, in Bangladesh the rate of exclusive breastfeeding for six months is 64pc and in Nepal it is 70pc.

"Commercial interests have heavily influenced societal attitudes in that regard," points out Nishtar.

This week from August 1 to 7, as the world celebrates breastfeeding, there is little for child rights activists to cheer about. Global food and formula milk industry have clearly won the battle — their business expanded from $25 billion in 2012 to $38bn in 2015 with a majority of profit-making happening through countries like Vietnam, Thailand, the Philippines and Pakistan.

Medical fraternity blames itself for the booming baby food industry

The various data collected from all across Pakistan points clearly that babies born in a health facility are more likely to be bottle fed. Hospitals, says Hazir, are the perfect places for big formula milk companies to advertise with health practitioners backing their nefarious business.

"I blame the health practitioners, the health practitioners and the health practitioners alone for the low rate of breastfeeding in Pakistan," he says, adding that until the medical fraternity did not "clean up" its "own backyard", it should not blame anybody else for the mischief.

He says often the baby food industry use health professionals to endorse their products and in return are offered goodies and junkets. "A couple of years back, at an international conference in Greece, there were close to 160 pediatricians from Pakistan invited by one baby food company!"

Why don't moms breastfeed?

According to a 2012 survey, "Determinants if suboptimal breastfeeding practices in Pakistan", while 95pc of mothers interviewed in Karachi considered breast milk best for their baby, this did not translate into practice.

One reason could be that healthcare workers do not counsel mothers about the importance of EBF.

According to Dr DS Akram, new mothers who deliver in a health facility are rarely informed about how to breastfeed, are hardly ever discouraged from bottle feeding or formula, are not informed about demand feed (that the baby will get hungry more often than a bottle fed baby and why and that frequent suckling early on helps produce more milk).

In addition, Hazir says there was little on infant and young child feeding in a medical college syllabus. "In a survey carried out in a medical college in Karachi, 80pc of the students did not know what EBF was," he points out.

According to World Health Organisation's (WHO) definition: “Exclusive Breastfeeding is defined as only breastfeeding and no additional food, water or other fluids for the first six months of life.”

Danish believes that training for improved breastfeeding should not just be limited to doctors alone but should also include training lady health workers, skilled birth attendants, community midwives for improved breastfeeding counseling.

"Creation of baby-friendly health facilities would be another important step towards promoting EBF," he adds.

Hazir, a sought-after doctor not only among the rich and famous, also sees a large majority of the less affluent. "The young moms I see in the evening are very different from the ones I see in the daytime," he admits and therein lay the paradox and the contradiction of the 2012 survey report on breastfeeding that he led.

"The former are educated and the affluent and extremely motivated and committed and have this huge desire to exclusively breastfeed their baby." And then there is this deluge of tired, sleep-deprived, working moms whom he sees during the day.

"They are poor, not well educated or aware, have too many kids, and are working. They are not aware of the dangers of the bottle, and the workplace is not geared for a mother who needs to feed a newborn every couple of hours." he says.

At the same time, the 2012 survey found that rates of bottle feeding were higher among women who were more educated which proved that educational status did not necessarily mean greater awareness.

But to Hazir, this could have had a "trickledown" effect as these women are role models to those who are less privileged. "When a domestic help sees her employer feeding her baby formula in a bottle, she thinks this would be best for her baby too and would emulate," he says.

The survey further found that babies of women who went for more than four antenatal checkups and who delivered in a facility had a higher bottle feeding rate.

The study surmised it could be lack of training of health-care workers in breast-feeding counselling and it could also be that the health care practitioners were blinded by attractive marketing strategies of manufacturers of formula milk.

Need for behavioural change

The survey proved that legislation and law will only go so far.

According to Nishtar, along with a providing an enabling environment for new moms to breastfeed, there is a need for behavioural change through health promotions. "We need to go beyond the bland and ineffective public service announcements approach," she says.

Promoting breastfeeding means providing the mother and child with an enabling environment to do so. — Photo by author

But health promotions through behavioural change is a very complex science and is grounded in research, she says, adding: "The communication strategy developed based on that evidence must then be packaged in a creative yet hard hitting manner, to make the greatest impact, to the group that needs to be targeted.

"Merely placing a huge billboard with a public service message on a main boulevard is not going to help; you need to find the hotspots and take the message there."

According to Nishtar, for promoting breastfeeding there has never been an "effective campaign" probably because it's a practice that has always been taken for granted. "Sometimes simple things with the greatest of dividends are taken for granted," she muses.

Promoting breastfeeding means providing the mother and child with an enabling environment to do so.
And that would mean taking some "statutory measures" to make a workplace mother-friendly. "These can include looking into the duration of paid maternity leave, breastfeeding breaks, nursing room facility, flexible working hours, and promoting the culture of creches," she says.

However, she says Pakistan was great at making "gold standard" laws but when it came to implementation, it was extremely weak. "And even if there are these great laws, neither the woman nor her boss are aware."

Along with working mothers, there are thousands others who work in the informal, even seasonal or part-time economy. They, too, need strong family and community support to be able to work as well as breastfeed the baby.

The theme of this year’s World Breastfeeding Week (Aug 1 to 7) is ‘Women and work – Let’s make it work’ and this ties in well with Nishtar's emphasis for better support systems and policies to enable working mothers to breastfeed.

But for the breastfeeding to become "fashionable" she says there is a need to create role models. "We need to make breastfeeding glamourous."

"Whether working or not, all new mothers need complete support like motivation to continue to breastfeed, give them less housework, responsibilities and a stress-free environment," adds Akram.

World Breastfeeding Week (WBW) is an annual celebration which is held every year from 1 to 7 August.

Zofeen T. Ebrahim is an independent journalist based in Karachi.