It’s a picture that had the internet divided. Actor and poet Gilu Joseph, 28, stares back from the cover of the March issue of the fortnightly Malayalam magazine Grihalaxmi with a radiant look on her face, vermillion in her parted hair and a mangalsutra around her neck. But it is the baby latched at the nipple of her exposed breast that has kicked up a storm. Just a woman’s naked body or empowerment, the internet couldn’t decide.
The picture shot for the magazine’s March issue was part of a campaign to promote breastfeeding. In 2015, the Telugu film Bahubali had a scene where the character of Sivagami (Ramya Krishnan) breastfeeds her two babies as she sits on the throne, in front of her council of ministers. What was different then was that Krishnan had covered herself with her saree. A section now feels that with Joseph’s picture, Grihalaxmi might have gone too far.
The image has also kickstarted a debate about breastfeeding.
Being born in 2018 will be deadly for a million babies who will take their first and last breath on the same day, despite having health conditions that are eminently preventable. Is there a way out of this situation?
It seems the answer was always staring at us in the face: breastfeeding. Global bodies are now pushing for early initiation of breastfeeding, from within the first hour of birth. Time, research suggests, is of the essence.
Most mothers’ breasts will produce a yellow liquid high in antibodies, proteins and fat soon after birth. The nutrient-infused-liquid, called colostrum, is the mother’s first milk and the baby’s first vaccine. Colostrum, according to a growing body of evidence, can make a crucial difference for sickly babies. But the jury’s still out on how crucial.
A recent study published in the Journal of Pediatrics of 4,203 infants born at a health facility in Dar es Salaam, Tanzania, looked at the effects colostrum had on the health of a newborn. “We found lower rates of respiratory infections and vomiting in the first six months of the life of babies who were breastfed within an hour of birth,” said Emily Smith, a research fellow at the department of global health and population at Harvard University’s T.H. Chan School of Public Health, and a coauthor of the study.
Worldwide, 15% of all deaths in the first month occur due to infections and another 6% due to respiratory complications like pneumonia. This study followed up another meta-analysis that looked at early initiation of breastfeeding among infants in India, Ghana and Tanzania, and found evidence that early initiation of breastfeeding could give an infant’s chances of living longer a boost.
A few days ago, Krish Vignarajah, running for the governorship of Maryland, released an ad for her campaign. The 30-second video shows Vignarajah breastfeeding in several shots. The simple act continues to make news and raise eyebrows, never failing to garner eyeballs.
“We see early initiation of breastfeeding as one of the leading missed opportunities,” said France Bégin, senior nutrition advisor for UNICEF, explaining why the fund is focusing on this aspect now. Researchers agree that while one hour is not a timeline set in stone, it is important to understand that the quality of mother’s milk begins changing soon after.
After birth, according to UNICEF, breastmilk is the baby’s first and best protection against illnesses. It is important for healthcare workers to provide enough nutritional counselling to mothers so they can initiate breastfeeding immediately after birth, and continue it exclusively for the first six months of the newborn’s life. But this is not happening.
“The rate of early initiation of breastfeeding is not good even in health facilities where deliveries are conducted by health officials. For those still being conducted at home, more education will help,” Bégin added.
In the Middle East and North Africa region, the rate of early initiation of breastfeeding is 58% when the birth is conducted in the absence of a skilled healthcare worker but falls to 45% in the presence of one.
What’s behind this counterintuitive finding? One explanation could be that often healthcare workers are hard-pressed for time, knowledge or skills, as a result of which they fail to give mothers who struggle to nurse the required support. They may actually make breastfeeding right after birth more challenging by separating newborns from their mothers for washing, assessing or feeding the baby other liquids.
Bégin explained that breastfeeding right after birth helps in maturation of the newborn’s intestine. The skin to skin contact with the mother helps regulate their body temperature and stimulate the production of milk in the mother’s breasts, setting up a healthy trend that can then be continued in the coming months. In many countries, a newborn is first given water and sugar which, researchers say, is nowhere close to the boost colostrum can give the immune system.
Taboos in the way of public health
Cultural taboos and the sexualisation of women’s bodies make it complicated for public health officials to get the message across. Recently, the Bollywood film Padman addressed another taboo, menstruation, as it brought to the screen the story of Arunachalam Muruganantham and his efforts to address the needs of women by producing a low-cost sanitary napkins. It was this taboo associated with a woman’s body that motivated playwright Eve Ensler to write ‘Vagina Monologues’. Ensler suffered from uterine cancer, a form of cancer triggered chiefly by a sexually transmitted virus called the human papillomavirus.
Yet sex and sexually transmitted diseases were not a subject most gynaecologists would broach in the early 1990s, including the one Ensler consulted. Following her successful recovery from cancer, Ensler decided that it was time to help women break free of taboos associated with parts of their bodies. She wrote her play in 1996, touching on rape, childbirth and sex, among other issues associated with a woman’s vagina.
However, over two decades after Ensler’s effort to initiate conversations that aimed to look at a woman’s body beyond a sexual lens, are we ready to look at a woman’s breast for what it is – not an organ of sexual titillation but a part of her body, and the source of the most nutritious food a newborn can get?
Many communities harbour misconceptions about colostrum. In tribal areas of India, for example, a prevailing myth is that colostrum is bad for the baby and is thus allowed to flow out. “Lots of deliveries in rural areas of India still take place at home,” said Rupal Dalal, a paediatrician who works with rural communities and healthcare workers in India, training them in right breastfeeding techniques to reduce malnutrition and infant deaths. “Colostrum in such a setting becomes even more important. We see higher rates of both infection and hypoglycaemia [low sugar] when a baby is not given the first feed right after birth.”
India has the ignominious distinction of being the nation with the highest number of newborn deaths: 24% of all newborn deaths. With a neonatal mortality rate of 25.4 per 1,000 live births, it fares marginally better than Niger at 25.7 and Congo at 28.8. It ranks 12th among the 52 lower middle income countries. India has been placed among a group of ten focus countries with the maximum number of newborn deaths.
According to data from the National Family and Health Survey, less than half the newborns are breastfed in the first hour of birth. Roughly, only one in every two babies is breastfed exclusively for six months.
In February this year, UNICEF kicked off a global campaign, ‘Every Child Alive’, to reduce newborn deaths. In a report, the UN body noted that 7,000 newborns were dying every day. Pakistan is the worst place to be a newborn: one in every 20 babies in the country will die on day one, a mortality rate of 46 of every 1,000 live births.
Why should early initiation of breastfeeding matter? In low-income countries like Rwanda and Nepal, where rates of early initiation of breastfeeding have improved dramatically, newborn mortality has also fallen rapidly.
Early breastfeeding is a fire-fighting method in struggling health systems with little else to offer mothers, a simple, cost-effective way to help babies battle the most common complications. Delaying breastfeeding by 2-23 hours after birth increases the risk of a newborn dying by more than 40%. Delaying it by 24 hours or more increases the risk by almost 80%.
The ignored mother
A growing foetus is constantly sucking food out of a mother’s umbilical cord. A malnourished mother will have an undernourished child. While the logic sounds obvious, the focus of most policies is on the newborn. What then of the mother’s health?
“We have not done our due diligence with respect to maternal nutrition, we can do a better job,” said Daniel Raiten, a program director at the US National Institutes of Health. Pregnancy and childbirth have massive consequences for the mother nutritionally. Right now, the Dietary Guidelines for Americans, used as a reference point worldwide, has zero guidelines for two cohorts: pregnant mother and infants aged 0-2 years. It will be another two years before the US includes nutrition guidelines for the pregnant mother.
With the US setting global health priorities, UNICEF agrees this move will help motivate the rest of the world to follow suit. “Giving mothers just iron and folic acids tablets is not enough and we do recognise that we have definitely ignored the nutrition of the mother,” Bégin said.
Referring to contemporary scientific research about the benefits of starting breastfeeding early, Smith said, “This data tells us that starting breastfeeding early is not just important to ensure that the habit is continued but has independent health benefits of its own.” For us to reach that point though, we need to first look at Gilu Joseph’s picture for what it is – a way of asking women to not be ashamed of their breasts and focus instead on the act of breastfeeding and talk about issues associated with it. Desexualising the act is the first step.
Disha Shetty is a freelance science journalist.