Breast milk is best

Every year World Breastfeeding Week is celebrated across the globe from August 1 to August 7 with the aim of encouraging breastfeeding and improving the health of babies.

This year’s theme was, ‘Empower parents, Enable Breastfeeding’ which aimed to make parents aware of the benefits of exclusive breastfeeding for six months for the infant and the mother.

Sri Lanka was a pioneer in promoting exclusive breastfeeding from the inception even before the setting up of the baby-friendly hospital initiative in 1991, which has been a great success story in the country.

Considering the importance of maintaining and improving the initiative that was set up many years ago, The College of Community Physicians chose the subject ‘Baby-Friendly Hospital Initiative, 25 years on…Can we be complacent?’ as the Dr. F.A. Wickramasinghe oration that was delivered by Dr. Dhammika Rowel, Consultant Physician, working in UNICEF’s Sri Lanka office.


Dr. Dhammika Rowel, Consultant Physician

The objectives of the oration were to celebrate achievements in breastfeeding in Sri Lanka as it is one of the areas where Sri Lanka could proudly claim to be among the global best with the contribution of many important players along the way and with no political influence. We need to thank all those who did not succumb to the threats of the milk powder infant formula industry and took many bold decisions when breastfeeding was the unpopular choice, to document the customisation of the baby-friendly hospital initiative in Sri Lanka and emphasise the need to sustain these achievements.

From the beginning of the 20th century, billion dollar businesses were made on formula milk for children, around the world of which Sri Lanka was a part. In her oration, Dr. Rowel illustrated how it was different in the ancient past when breastfeeding was revered, taking examples from historical and religious individuals.

In Luke Chapter 22, Verse 27, in the Bible, it is mentioned that after Jesus spoke to a crowd, a woman amongst them shouted out, “Blessed is the womb that bore you, and the breasts at which you nursed!” In Classical Greece, the milk of a Greek goddess was thought to confer immortality to those who drank it. According to Greek mythology, it was Hera’s breast milk that made Hercules invincible.​

There is an outstandingly beautiful woodcarving of a baby being breastfed on a pillar at the Ambekke Devale, which is from the 14th century.

Dr. Rowel, explaining about wet nursing, went on to say that in addition to your child, wet nursing, which is breastfeeding another’s child, was a widespread practice before the introduction of the feeding bottle and infant formula. An example from history is how Prince Siddhartha was fed by many wet nurses headed by Maha Prajapathi Gothami after the death of his mother.

Wet nursing created strong community bonds in addition to providing nutrition for infants. This practice unfortunately disappeared with the advent of powdered milk introduced from the West.

The fact remains that mammalian milk is specific to its species when feeding the young – human milk for the infant, cow milk for the calf and goat milk for the kid. Once the young are weaned off mammary milk, what follows is a normal diet. It is the mammalian biological character and natural law. There is no substitute for human milk to feed an infant. The only instance is to employ a wet nurse if a mother is unable to breastfeed. It is a practice that comes down through generations in human societies recognising the fact that animal milk has no substitute.

According to Dr. Rowel, from the beginning of the 29th century, food industries have been marketing suitable substitutes for breast milk. The requirement for breast milk substitutes grew even faster with the Industrial Revolution in the 1930s and 1940s as more women entered the workforce. Breast milk substitutes were identified as a mark of the liberation of women. Communities soon lost memories and skills to support breastfeeding and the social models of artificial feeding became the norm. Once it was established in many industrialised countries, these practices soon spread across the world into less-developed countries.

The renowned Jamaican-born British Pediatrician and Epidemiologist Dr. Cicely Williams, during her work, observed that the mortality of newborns was extremely high. Further inquiry into the matter revealed that companies were employing women dressed as nurses, to go to houses and convince new mothers that formula milk was a preferable replacement for their own milk, a practice which was illegal in Europe at the time. In 1939, Dr. Williams in an address to the Singapore Rotary Club on a topic called ‘Milk and Murder’, said, “Misguided propaganda on infant feeding should be punished as the most miserable form of sedition, and these deaths should be regarded as murders.”

The WHO and UNICEF for many years emphasised the importance of breastfeeding, and of reviving the practice where it is in decline to improve the health and nutrition of infants and young children. ​In 1981, at the 34th World Health Assembly, the international code of marketing of infant formula and other products used as breast milk substitutes was adopted by 118 votes for and one against.

But the international code alone was not enough to reinstate the breastfeeding culture in the world. “In 1990, at a gathering representing 30 countries, the Innocenti Declaration on protection, promotion and support of breastfeeding was adopted and later endorsed by the 45th World Health Assembly and the executive board of the UNICEF,” Dr. Rowel explained.

In August 1990, government policymakers, the WHO, the UNICEF and other organisations got together and signed the Innocenti Declaration, which aimed to protect, promote and support breastfeeding. Commemorating the Innocenti Declaration ever since, World Breastfeeding Week has been celebrated every year from August 1 to 7. The initiative encourages breastfeeding and spreads awareness on how mother’s milk helps improve the health of newborns around the world and makes their immune system stronger.

Dr. Rowel explained that the second operational target of the declaration was to ensure that every facility providing maternity services fully practises the 10 steps for successful breastfeeding that were inaugurated by the WHO and the UNICEF in 1991 in Ankara, Turkey, to incentivise maternity facilities in order to adopt the 10 steps, to abide by the breastfeeding code and also to recognise those that do so by introducing a baby-friendly hospital initiative (BFHI) designated methodology of

* having a written breastfeeding policy that is routinely communicated to all healthcare staff;

* training all healthcare staff in skills necessary to implement this policy;

* informing all pregnant women about the benefits and management of breastfeeding;

* helping mothers to initiate breastfeeding within half an hour of birth;

* showing mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;

* not giving newborn infants any food or drink other than breast milk unless medically indicated;

* practising of rooming-in which is allowing mothers and infants to remain together 24 hours a day;

* encouraging breastfeeding on demand;

* not giving any artificial teats or pacifiers; and

* fostering the establishment of breastfeeding support groups and referring mothers to them on discharging from the hospital or clinic.

Subsequently, many high-level policy documents reiterated the importance of implementing the BFHI and the ‘The Global Strategy on Infant and Young Children Feeding’ of the WHO and the UNICEF in 2003, and the second international conference on nutrition in 2014 recommended that countries should implement policies, programmes and actions to practise the BFHI.

Dr. Rowel recalled that the BFHI was introduced to Sri Lanka in June 1992, at the De Soysa Maternity Hospital for Women at a ceremony held in the current car park of the hospital with the patronage of Hema Premadasa who was the First Lady at the time, with Renuka Herath who was the Health Minister and Dr. Hiranthi Wijemanne from the UNICEF. She also mentioned that she was privileged to witness the event on that day as an intern house officer at the same hospital.

This initiative was fortunate to have strong political backing as well as full support of the medical fraternity. At the time, 84 hospitals around the country were declared as Baby-Friendly Hospitals.

On the 25th anniversary of the Baby-Friendly Hospital Initiative, a congress was held in Geneva to celebrate achievements in improving quality of care for breastfeeding mothers, examine the current status of the BFHI in the world, to discuss new guidance on country implementation of the 10 steps and to form or strengthen regional networks to improve country programmes for maternity facilities.

“During this appraisal, it was highlighted how Sri Lanka had faired excellently by confirming a strong breastfeeding culture in the country. Exclusive breastfeeding up to the completion of four months of the infants had steadily increased from 19 percent in 1993 to 83 percent in 2006. It is also noteworthy that indicators have increased in all sectors in the country and more significantly in the estate sector. In comparison with other countries in the South-East Asian Region, Sri Lanka had the best breastfeeding indicators. The current policy is that exclusive breastfeeding should be practised up to the completion of six months and the story remains the same,” explained Dr. Rowel.

These impressive breastfeeding indicators enabled Sri Lanka to be number one in the World Breastfeeding Trends Initiative (WBTi) assessments conducted by the International Baby Food Action Network (IBFAN) once in four years.

Research has indicated that breastfeeding annually reduces over 800,000 infant deaths around the world. It also prevents diseases in babies and longer breastfeeding is associated with higher performance on intelligence tests and better academic performance. Thus, there is an economic case also for investing in breastfeeding.

In adhering to the 10 steps in the BFHI process, the country integrated them into national policies and strategies for maternal and newborn care.

The National Nutrition Policy of 2010 states that “all infants should be exclusively breastfed for up to complete six months and breastfeeding should be continued with adequate complementary feeding up to two years or beyond.” The breastfeeding policy as addressed in the Maternal and Child Health Policy of 2012 is to ‘Protect, promote and support breastfeeding practices with special emphasis on delivery settings.’ The policy environment in the country that covers the breastfeeding is strong.

In 1993, an 18-hour course for health staff was introduced that included a module on the importance of ‘mother-friendly care’, which was further revised into a 20-hour package in 2009.

In this matter, the country was never divided. It was on September 17, 1981, that the Cabinet memorandum for the Sri Lanka Code for the Promotion of Breastfeeding and Marketing of Breast Milk SubstitutesandRelated Productswas submitted to the Cabinet by no less a person than former President J.R. Jayewardene who was the Plan Implementation Minister. The code was formulated by a five-member subcommittee comprising of Professor Priyani Soysa, Dr. Brighty de Mel, Dr. A.E.F. Jayasinghe, T. Kandasamy and Dr. A.C.A. Shuaib. The relevant provisions for the marketing and advertising of infant foods were gazetted under the Consumer Protection Act in 1983. There is evidence that active measures were taken to increase awareness about the code among health staff and the public. Through the collaboration of Sarvodaya, this code was even converted into a reader-friendly cartoon for easy understanding of the public.

Dr. Rowel further warned that it is the responsibility of all to maintain the momentum of this important and established practice in Sri Lanka.

Euromonitor International, one of the world-leading independent provider of strategic market research has shown that baby food industry sales were worth US$ 58 billion, out of which US$ 45 billion was from formula milk sales. It is predicted to grow to US$ 70 billion by 2019 and according to this report, Sri Lanka would be one of the top 20 markets in the future.

This prediction is due to the fact that Sri Lanka is one of the fastest-growing and promising economies in Asia and the country has one of the lowest average import duties in South Asia with an expanding middle-class with a potential to be influenced by market trends.

“Research conducted in the Kandy district showed that 25 percent of mothers had been recommended to use feeds other than breast milk by healthcare workers within the first six months when they should have exclusively breastfed and these recommendations had not been for medically-accepted reasons,” Dr. Rowel said.

“It is scary, the danger is imminent. We have to overcome this situation by strengthening the legal status of the code and challenging current market strategies. Further, innovative technologies such as mobile applications should be available to collect and report violations instantly, enabling quick action. Twenty-five years on we have many accomplishments, but the price of undue complacency can be high affecting the health of our infants,” Dr. Rowel said.​



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