12 August 2008

When breast is best!

Paveethida stores her milk in the breast milk bags. It can be kept in the freezer for 3 months.© UNICEF Thailand/2008/Athit Perawongmetha

Story by Nattha Keenapan

(The story was published in the Bangkok Post on August 12, 2008)

LAMPOON, Thailand -  Like most children her age, four-year-old Donut Wanmuang usually eats snacks after school. But unlike other children, her favorite snack is not meatballs, pork satays or fried potatoes – it is breast milk, fresh from her mother’s breast.

Donut has been breastfeeding since the day she was born. For the first six months of life, it was the only form of nourishment she had.  Today, in addition to eating a variety of other foods, she still regularly breastfeeds along with her one-year-old sister, Noonthip.
“I try my best to breastfeed my children,” said Donut’s mother, Paveethida Wanmuang, a 34-year-old former factory worker who now earns a living as an insurance broker. “I still have plenty of breast milk after all these years and the children still ask for more.”

According to WHO and UNICEF, breast milk is the ideal nourishment – a “super food” – for infants during the first six months of life. It contains all the nutrients, antibodies, hormones and antioxidants that infants need to ward off illnesses and to grow and thrive in childhood. After six months, other foods need to be added to a baby’s diet, but mothers can still breastfeed for up to two years and well beyond as long as they still have milk.

Both UN agencies recommend exclusive breastfeeding for the first six months, meaning that only breast milk should be fed to babies. No other food or liquid – not even water – is needed during this period.

“In the first six months of life, there is nothing more important that a mother can do for her child than exclusively breastfeed,” said Dr. Sopon Mekthon, Deputy Director General of the Department of Health, Ministry of Public Health. “Breast milk is a free and natural gift she should provide to ensure her baby’s health.”

In Lampoon’s Ban Pan village, Paveethida’s neighbors know her as “the breastfeeding guru.” Her house even has a breastfeeding corner where pregnant neighbors often come for information and advice. Paveethida and her in-laws also make home visits to neighbors who recently gave birth in order to demonstrate how to effectively breastfeed their babies.
But Paveethida’s family is not at all typical in Thailand. Only 5.4 per cent – or around 43,000 of the estimated 800,000 babies born in the country each year – are exclusively breastfed for the first six months. This is the lowest exclusive breastfeeding rate in Asia and one of the lowest in the world, according to UNICEF.  In Bangkok, the exclusive breastfeeding rate drops to just 1.1 per cent, the lowest in the country.

“Many parents misunderstand the benefits of a mother’s breast milk compared to infant formula,” said Pornthida Padthong of UNICEF Thailand, who works with the Ministry of Public Health and other organizations in promoting exclusive breastfeeding.  “They think that infant formula is just as good as breast milk, which is far from the truth.  Nothing can compare with the benefits babies get from their mothers’ breast milk.”

The antibodies, hormones, antioxidants, and immunity and growth factors in breast milk cannot be imitated or replaced by infant formula or other substitutes, according to Dr. Kannika Bangsainoi, Assistant Director of the Region 10 Health Promotion Center in Chiang Mai.  Dr. Kannika said breast milk serves to protect infants from diarrhea, allergies and acute respiratory infections by stimulating their immune systems.

”Exclusive breastfeeding really does save lives,” said Dr. Kannika. “It also ensures optimal growth and development for babies and creates an important bond between a mother and her child.” Dr. Kannika noted that breastfeeding also helps protect mothers from breast and ovarian cancers.

Numerous studies have shown that breastfeeding is also very good for babies’ neurological development, and that breast milk can raise a child’s Intelligence Quotient (IQ) by 2-11 points, contributing to higher educational achievement.

A mother breastfeeds her child at the the breastfeeding clinic in Region 10 Health Promotion Centre. © UNICEF Thailand/2008/Athit Perawongmetha

At many hospitals across the country, mothers giving birth receive little or no encouragement to breastfeed from medical staff and no support on proper breastfeeding techniques.  Thailand’s low rate of exclusive breastfeeding is also tied to the country’s rapid socioeconomic development.

Increasing numbers of mothers are working outside the home, which can make it difficult to continue exclusive breastfeeding.

“After I had my first child and had to go back to work, I was worried about how I could continue breastfeeding,” said Paveethida. “Where would I be able to express my breast milk and store it? Would I still have milk after I returned to work?”

After returning to work, Paveethida had to run back and forth to the toilet at every break and during lunchtime in order to express her milk. Nurses at the hospital told her that the more milk she expressed, the more milk she would have for her baby.  Eventually, her supervisor let her use the factory’s first aid room as her “breastfeeding corner”, and made space in a refrigerator for her to store her milk.

“My colleagues thought I was crazy when they saw me rushing back and forth to the toilet at every break,” Paveethida said. “It was hectic but really worth doing, because my child never got sick during the first six months and I never had to take any days off from work.”

A growing number of employers in Lampang are starting to provide mothers support for continuing exclusive breastfeeding. At Indra Ceramic in Lampang Province, one of the country’s largest ceramic factories, pregnant employees are trained about the benefits of exclusive breastfeeding. The company has set up a breastfeeding room, staffed by a nurse who provides advice and help on proper breastfeeding techniques. As a result, the number of working mothers at Indra who exclusively breastfeed was up from 10 per cent in 2006 to 50 per cent in 2007.

Similar exclusive breastfeeding support programmes and facilities have been established by other companies in Lampang, including Big C Supercenter and Quality House.

“Although a mother’s determination to exclusively breastfeed is the most important thing needed to ensure success, support from family, employers, the community and health personnel is also crucial.” Dr Kannika said.

At the Region 10 Health Promotion Centre, groups of new mothers get together every week to share experiences on breastfeeding. Sessions include topics such as “how to deal with grandparents who don’t believe in exclusive breastfeeding,” as well as training from nurses on different breastfeeding techniques. At the hospital’s daycare centre for babies of hospital employees and of mothers from the community, the babies being cared for get their mothers’ expressed breast milk, which is stored in the centre’s refrigerator.

The Region 10 Health Promotion Centre is a certified as a “baby-friendly hospital”, which is a UNICEF- and WHO-supported initiative that began in 1991 to encourage exclusive breastfeeding. At hospitals certified as baby-friendly, new mothers are encouraged and supported to breastfeed from birth, and breast milk substitute products and marketing materials promoting such products are banned.

About 1,000 state-run hospitals are certified as baby-friendly, but many of these hospitals – as well as most private hospitals – do not fully adhere to the prohibitions against the promotion and distribution of breast milk substitute products.
UNICEF’s Pornthida said that one of the biggest challenges in promoting exclusive breastfeeding is the continued aggressive marketing of infant formula and other breast milk substitute products. 

“The infant formula industry puts a huge amount of money into marketing and advertising its products in an attempt to influence mothers to buy them,” Pornthida said. 

According to the Department of Health, the market share for infant formula in Thailand is worth an estimated 24 billion baht (US$ 727 million) a year.  While mothers may get a few free sample cans of infant formula when they give birth, a family will end up paying around baht 30,000 a year to keep using it.

In 1981, the Thai government adopted the International Code of Marketing of Breast-milk Substitutes at the World Health Assembly to protect and promote exclusive breastfeeding. The Code prohibits the advertisement or promotion of infant formulas, breast milk substitutes and bottles and teats to the general public or through the health care system. To date, the Code has been adopted by 181 countries.

But since the Code is only a recommendation and not a regulation, only 28 countries so far have made all of the Code’s provisions into national laws, according to UNICEF. In some countries, such as Iran, the government has taken control of the import and sale of breast milk substitutes. In Iran, formula is available only by prescription, and infant formula brand names, pictures and promotional message are not allowed to be placed on infant formula cans. In India, infant formula cans carry a conspicuous warning about the potential harm that can be done to infants by improper preparation of the formula.

According to International Baby Food Action Network (IBFAN) and the International Code Documentation Centre (ICDC), many of the worst and most frequent violations of the Code occur in Thailand, where infant formula is even promoted and distributed in hospital maternity clinics and maternity wards.

“Infant formula companies are known to supply hospitals with free samples of their product, and these free samples are openly distributed to new mothers in maternity wards,” Pornthida said. “So instead of being encouraged to breastfeed their new babies, these new mothers are being encouraged from the day their babies are born to use the infant formula. This is a blatant violation of the Code.”

Suwat Sitthimongkol, President of the Thailand Pediatric Nutrition Association – an association of infant formula companies – and Assistant Managing Director of Snow Brand Siam Ltd., said infant formula companies provide hospitals free samples for sick infants and for other infants whose mothers are unable to breastfeed due to medical reasons. However, there is no monitoring system in the hospitals to ensure the infant formula is distributed solely for these purposes.

Suwat admitted that violations of the Code do occur in Thailand. But he believed that the exclusive breastfeeding rate will improve in the future due to strong advocacy for exclusive breastfeeding by the government and other organizations.

“We (the infant formula companies) are trying to self-regulate in order to comply with the Code,” Suwat said. “But in reality, I have to admit that sometimes companies do step over the line. But this is not so severe as to undermine the promotion of breastfeeding.”

Pornthida said “voluntary” self-enforcement of the Code by the infant formula industry has not worked in Thailand and that a law is needed to ensure its enforcement through effective monitoring as well as and substantial penalties for violations. 

The Department of Health, together with WHO, UNICEF, the Thai Breastfeeding Center and other partners, recently revised the Thai Code to bring it into line with international standards. The new Thai Code has been approved by the government, but the infant formula industry has so far refused to endorse it.  A monitoring and implementation committee is being established to document violations of the Code. 

“Although we still have a long way to go before the Code becomes law, we have to make it happen in order to ensure that children receive the nutrition they need to reach their full potential, both physically and mentally.” Pornthida said. “Doing this is important not only for the future development of children, but also for the future of Thailand.”

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