According to the WHO Global Data Bank on Infant and Young Child Feeding, 98% of babies in Bangladesh are breastfed and the average age of weaning is 33 months. Dig even deeper and you’ll see that 95% of one year olds are still being breastfed as are 91% of two year olds.
Westerners who look at those statistics generally have one of two reactions:
Wow…that is amazing. We have so much to learn from them on creating a society that is supportive of breastfeeding.
Of course the breastfeeding rates are so high. Women are forced to breastfeed because they can’t afford formula and babies whose moms don’t breastfeed end up dying. Just look at the infant mortality rate.
Which of those reactions is the correct one? From what I’ve seen, it is probably a bit of both.
Last month, I had the life changing opportunity to go to Bangladesh with Save the Children Canada. I was invited to visit their mother and child health and nutrition programs (MaMoni), as well as some of their education programs.
The program staff seemed almost bewildered when we persisted on asking over and over again what happens when a mother is unable to breastfeed or when a baby is unable to latch on. The mother would be transferred to a medical facility, where the breastfeeding problem would be assessed and corrected, they said. But this is so rare, that it didn’t really register on their radar as a major issue to be dealt with, like it is in North America where so few women meet their own breastfeeding goals.
The Booby Traps
With such high breastfeeding success rates in Bangladesh, does that mean there are no booby traps? No, in fact there are a few…
- Perceived low supply: When the MaMoni project was rolled out in some regions in Bangladesh, they found that a lot of moms were introducing solids early because they thought they had insufficient milk — low supply. Because moms thought that they didn’t have enough milk, they introduced solids too early, which did lead to lower supply and insufficient nutrition for their babies because the nutrition the babies were getting from the solids wasn’t comparable to what they were getting from breastmilk. They had to teach mothers to follow good breastfeeding practices (e.g. initiating breastfeeding within one hour of birth, nursing on demand, etc.) and then trust their own bodies to make the milk that their babies needed and to wait until six months to introduce other foods.
- Mother-in-law factor: I spoke to one woman who was breastfeeding her seven month old. She said breastfeeding was going well. I asked if she had introduced any other foods yet. She said that she hadn’t and when I asked why not, she said that her mother-in-law didn’t think it was time yet. The mother-in-law plays a very strong role in decision making in some of these homes, so even new mothers who have been educated on ideal breastfeeding practices come up against resistance in their own homes as a result. With the younger generation being better educated about breastfeeding through the MaMoni project, hopefully this is something that will be phased out within 10 to 20 years.
- Which foods to introduce: Food is often scarce for families in Bangladesh. When there isn’t enough food to go around, it is often the mother and the infant who go without or who are left with less nutritious foods (e.g. only rice instead of rice, vegetable and animal protein). Mothers have to be taught the importance of giving animal protein and other foods that are rich in nutrients to their infants and toddlers once they have started solids. Exclusive breastfeeding is critical for the first six months, but after that it is important to ensure the baby gets a variety of foods from the family table and not just simple grains. Nutrition during the first 1000 days is critical to that child’s health and success in life.
- When to wean: Part of the breastfeeding education program in Bangladesh involves repeating over and over again the message that babies should be breastfed exclusively for six months with continued breastfeeding for two years. I mentioned above that the average age of weaning in Bangladesh is 33 months. Given that the natural age of weaning from an anthropological perspective is around 4.2 years (with a range of 2.5 years to 7 years), I was concerned that these mothers were being taught that they had to wean at two years, which would be both earlier than they traditionally did and earlier than the anthropologically natural weaning age. The official language used in breastfeeding policies reads that breastfeeding should continue for up to two years or beyond, but when I spoke to mothers about weaning they said that they weaned at age two. I asked if that was initiated by the baby or by the mother and they said it was mother-led.
There has been a lot of success in addressing these booby traps in the areas that the MaMoni project and other initiatives have been implemented. In fact, the rate of exclusive breastfeeding for six months increased from 43% in 2007 to 64% in 2012 (by comparison, in Canada and the United States it hovers at around 15%). So how do they do it?
Breastfeeding Education in the MaMoni Project
Given the high infant and child malnutrition rates in Bangladesh (41% of children under 5 are stunted), one of the main priorities of the MaMoni project is to improve breastfeeding practices. Although almost all women breastfeed, they want to ensure that they are doing it in a way that ensures the highest level of success for the mother and the infant.
There are a number of ways that they do this:
- They speak to the mother about breastfeeding during her pregnancy
- They teach the mother about appropriate breastfeeding techniques and positioning through group meetings, pamphlets and one-on-one visits with new mothers
- They visit and check-in with the mother regularly to see how things are going and to provide any additional support that is needed
The support is provided through health professionals at the local health center, such as the birth center and walk-in clinic that I wrote about on my blog. It is also provided through community volunteers who are given training in breastfeeding and infant care and nutrition. These volunteers go into the homes of new mothers to give them additional hands-on support. On top of that, there are community action groups that discuss any health and nutrition problems in the community and work together to come up with solutions and to educate people. The pride that the health workers and volunteers have in the work that they are doing is inspiring. They know what a huge difference they are making in the health of their own communities.
Formula Marketing and WHO Code Violations
People who are familiar with the history of the WHO Code of Marketing of Breastmilk Substitutes will know that formula companies have a horrible history of predatory formula marketing practices in developing countries that has resulted in many, many baby deaths due to malnutrition or infection from dirty water.
In the past, WHO Code violations have been a big problem in Bangladesh. In 1997, Joanna Moorhead wrote about the way that formula companies were trying to undermine the work of breastfeeding campaigners in the country. In a country that previously had healthy breastfed babies, hospitals were suddenly full of infants who were dying from diarrhea because they were being fed formula made with dirty water instead of being breastfed. This type of thing didn’t happen before formula companies started marketing aggressively in the country.
The aggressive marketing is often directed at health care providers, who are given “information” about formula and often end up suggesting it to new mothers who are having trouble with breastfeeding instead of getting them breastfeeding support. “Just try formula” ends up being the answer, instead of addressing the breastfeeding problem.
Whether that is the case or not depends greatly on the region and who is active there. In cities like Dhaka, women are more likely to come across a formula pushing doctor and be able to buy formula in stores. In rural villages, like some of the ones I visited, the health professionals would never suggest formula and it isn’t even available in local stores or affordable to those families. The formula companies are smart enough not to chase after dollars that are not there.
In Dhaka, I went into a typical supermarket and checked out the formula containers. There were no glaring WHO Code violations (like the promotions and pictures of happy formula drinking babies on the cans that we see here in North America). There was some plain packaging (which was encouraging to see) and some that seemed to be skirting ever so slightly on the edge of the WHO Code (e.g. instead of a prohibited picture of a baby, they would put a picture of a baby’s stuffed animal).
Reading Moorhead’s article and speaking to Save the Children and MaMoni project staff in Bangladesh, it was obvious that there is a constant underground battle between the breastfeeding advocacy of non-governmental organizations and the government and the underhanded secretive tactics used by formula companies to try to influence health professionals and increase their indirect access to moms.
Where to from here?
In countries like Bangladesh, breastfeeding continues to be an important life or death issue for infants. While we know a lot about the health benefits of breastfeeding in North American and the risks of not breastfeeding, most babies are not at risk of death if their mother doesn’t breastfeed. In Bangladesh and many other developing countries, there is nothing more critical for infant survival than ensuring moms are able to exclusively breastfeed for six months.
That means that despite a 98% breastfeeding rate, there is still work to be done. Work to maintain that rate as the country’s wealth increases and the formula companies continue to be more aggressive and work to ensure the best possible breastfeeding practices so that every mom can successfully nurse her baby.
Annie has been blogging about the art and science of parenting on the PhD in Parenting Blog since May 2008. She is a social, political and consumer advocate on issues of importance to parents, women and children. She uses her blog as a platform to create awareness and to advocate for change, calling out the government, corporations, media and sometimes other bloggers for positions, policies and actions that threaten the rights and well-being of parents and their children.