“Being a doctor, I thought I had good knowledge of lactation and breastfeeding already,” Elsa John, an anaesthetist and a first-time mother in Vellore, told this author. “But nothing prepared me for the doubts that came in the initial days when I had to do it.”
She recalled that a nurse pinched her nipples hard to produce milk. “They repeated this every time there was a shift change, over eight to 10 times,” she recalled. “They also demonstrated, vaguely, a few ways I should hold my baby. None of the information was helpful.”
Stigma surrounding lactation
Exclusively breastfeeding a child for six months is the best way to ensure infants are nourished, according to the World Health Organisation. It is one of the U.N. Sustainable Development Goals for health. But in India, there are many challenges to realising this goal – including an epidemic of shaming and misinformation directed at women.
“The first milk, the colostrum, is thought to be nutrient-rich and full of antibodies good for the child,” Dr. John said. “But nobody ever tells you that it’s just droplets of milk that may not even be visible in the first few days.” When others said there was “no milk”, she said she felt ashamed in an already difficult time.
“I was judged by my paediatrician when I learnt that I had flat nipples and sought help,” S.J., a postgraduate resident in physiology in Vellore, said on condition of anonymity. “Nobody identified this problem in my antenatal period, but once I started having issues, my doctor scolded me for not working on it earlier in my pregnancy.” She added that there is a “severe” lack of counselling options for pregnant women on neonatal care.
In India, “most women are guided by the older women in their families on what to expect during childbirth and how to care for their children,” a public health researcher in rural Maharashtra said. “However, even those older women don’t have a good scientific basis for [their] knowledge.” She wished to remain unnamed.
What is good enough?
In physiological terms, the milk let-down reflex causes a mother to lactate freely when stimulated by her baby’s suckling and oxytocin, a hormone released “when the mother feels bonded to her child,” Dr. S.J. said. The reflex isn’t likely to be stimulated by pinching the nipples, however.
Some suggest natural supplements like galactogogues – plant-based substances that increase milk production. But no studies support their effectiveness. The public health researcher said she was forced by her mother to feed her child some herbs she didn’t know the use of; her background as a health researcher took the backseat to her mother’s “traditional” wisdom. Adverse outcomes could also endanger young mothers’ familial relationships.
Then again, the pressure can also come from within. Helena David, a product marketing manager in Chennai, found that her baby couldn’t latch, after her delivery in the midst of the pandemic. She couldn’t access a lactation counsellor and used a pump to breastfeed. “It felt like I was not doing what was best for my child,” she said.
Under such pressure, women often develop painful cracked nipples and even infection of their breasts, in addition to other problems with inadequate feeding, such as the baby being underweight or having weak immunity, and postpartum depression.
“If your child can pass stools, gain weight, and pass urine regularly, you are probably making enough,” the doctor in Maharashtra said.
Alternative options
A 2018 survey found that almost 70% of mothers have problems with breastfeeding – but “unfortunately there aren’t many nutritious alternatives to breast milk,” Hemant Joshi, a pediatrician in Mumbai who helped bring about the law specifying six months’ maternity leave for India’s working women. “Breastmilk is a nutrition-dense substance with bioactive agents that develop an infant’s gut, immunity as well as brain.”
When a woman can’t adequately breastfeed, however, the child is given cow’s milk, “which tends to be 90% water and sorely lacking in health promoting substances,” Dr. Joshi added. He advises women with the means to “invest in formula feeds,” which are “more nutritious” than cow milk.
“Even the World Health Organisation recommends that cow’s milk or goat’s milk should never be given to infants,” he added.
Formula “can also be used when a mother has … any painful condition of the breast as a bridge until the mother heals,” Dr. John said.
Ms. David said she wishes she had known this when she was struggling with breastfeeding – a sentiment that many women repeated to this writer.
To those who can’t afford formula, Dr. Joshi suggests mothers apply some “semisolid purees of the things that women eat everyday,” like mashed rice or upma, around the child’s mouth. “As soon as the baby realises, he/she will use their tongue to lick it up.”
Human breast milk banks – of which there are some 90 around India – offer another viable alternative.
Struggles are the rule
The need of the hour is lactation counselling for young mothers and their families. Such a counsellor teaches mothers scientifically validated ways to initiate and maintain milk ejection, and other techniques, such as appropriate ways to hold a child while breastfeeding. Studies have found that lactation counselling before and after birth can improve the likelihood of successful breastfeeding.
But if, after all this, a woman is unable to establish a good breastfeeding practice with her child, her families and her immediate social circle must be aware that struggles during breastfeeding are not the exception but the rule. The mother needs to have an environment that prioritises her mental well-being, and helps her seek help when needed and access legitimate alternative feeding options free of guilt, shame, and judgement.
Dr. Christianez Ratna Kiruba is an internal medicine doctor with a passion for patient rights advocacy.
