Breastfeeding in India is disrupted as mothers and babies are separated in the pandemicBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3316 (Published 25 August 2020) Cite this as: BMJ 2020;370:m3316
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.”
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.
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.
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.
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