lactation blues
The great decision

The breast-feeding practices in Pakistan, over the years have either been stagnant or showing a decline. Various, social, cultural, health services and nutritional interventions have been suggested and implemented. However, there seems to be not a significant change; the blame is always put on the media and its abuse by artificial milk producing companies. This in a way may be justified.  But, perhaps we need to step back and reflect on the basic physiology, the ‘lactation reflex’ and factors influencing interruption of this process.  This blog is an attempt to draw some attention, on how the mothers’ mental health problems may be an important factor in decline of breast feeding trends varying from its early initiation, exclusive breast milk and then continuing it for at least 6 months.

The dilemma of breast feeding management commences initially due to the artificial divide between the ‘birth attendants’ (of any level of expertise) and the care-giver of newborn/infant (varying from LHW, doctor) later.  Both disciplines have their varying compartmentalized approaches as well as messages; above all both focus separately & exclusively on mothers and newborn/infant respectively. The dilemma gets further compounded when we tend to underestimate the basic lactation reflex and look for quick fixes based on various pre-determined but mainly medicalized and sometime socio-cultural factors.

Pakistan ranks highest among the prevalence of Post-Partum Depression (PPD); figures vary from 28% to 63% have been quoted among various studies.  Interestingly studies demonstrate that breastfeeding can protect depression, however, this association may be in the other direction, i.e PPD may lead or be associated with poor lactation and breast-feeding decline. The causality in either direction is still not clear but in terms of logical thinking the PPD has pre-disposing factors and keeping in mind the lactation reflex and arc, one can imagine that a mentally disturbed mother would experience interferences in the stimulus for lactation. This get furthers complicated when various ‘advisors’ at home and care providers load her with different messages and remedies. The baby gets more irritated and hungry all leading to the declaration that “mother is just simply not producing milk” and an easier decision by all to move on to bottle feeding and related alternatives.

We always cherish in conducting research and big seminars on breast feeding issues and its remedies, but have we ever thought of addressing the issue of PPD, which I believe is easy to screen and detect, and hopefully mange, also. Unfortunately, in our society, seeking an advice for mental health and its related experts is akin to declaring oneself as “mad” or mentally sick. Alternatively, the elders and husband label this situation (PPD) as being normal.  Its high time that we think out of the box and also look into this important dimension, rather than prescribing and promoting recopies for breast feeding, with apparently no significant changes.

Thinking out of box – Malnutrition fiasco

Public Health Professionals

“Insanity is doing the same thing, over and over again, but expecting different results.”

We, in Pakistan, are at least doing same things consistently with ‘malnutrition’; we do the survey, cry over the high rates, bully the government and come with same interventions (but with newer names). And then after few years, we repeat the cycle. In my lifetime, I have been quoting the famous 1976-77 survey and then so on; the latest is being undertaken or may be completed. We, all do the academic luxury by presenting it in 4-5 star hotels, presenting and writing the papers and beefing our CV, in addition to monetary benefits.

I don’t have any hesitation to admit that the only exam I failed was for my Diploma in Child Health (DCH) and the examiner was actually the teacher of my teacher (Prof.  Billoo) and just because I could’nt satisfy the examiner about management of malnutrition in a child; her exact words were “you can’t do a Pediatric practice without proper understanding & management of malnutrition”.  This is also true on a larger scale for Public Health practitioners for managing the malnutrition at a community/district/provincial levels.

Perhaps we all need to appreciate many dimensions related to malnutrition and its management.

  1. There can be a whole spectrum or pathway to malnutrition, starting from normal to at risk, getting into developing obvious signs of complications.
  2. There is a biological dimension & illness-malnutrition nexus.
  3. The social norms, taboos, maldistribution within family/society.
  4. A number of influencing &/or contributing factors other than just food insecurity and poverty.
  5. What intervention, how, by whom and how the malnutrition is being managed
  6. What percentage of time is being contributed to managing malnutrition by mothers, workers, doctors, nurse, hospitals?
  7. Are we doing enough with whatever resources we have got? How many success stories do we have on a small scale and how many have many have been scaled up.
  8. Is there a strong political will and commitment or is it just restricted to policies, strategies, big reports and a big push by the bi-laterals or multi-laterals (donors).
  9. Above all what are we focusing; on promoting good nutrition, preventing malnutrition or managing malnutrition.

As a “hopeful-pessimist” (or sarcastic), I don’t expect large and longer-term investment by respective provincial and even federal governments, except for knee-jerk responses or project-oriented (max for 5 years) by donors and lenders. Unfortunately, it appears that we act too late when the malnutrition (wasting or stunting has developed); the worst part is both are difficult to manage and need higher-cost.  Even disturbing ritual related to malnutrition is mis-interpretation & abuse of “growth chart” when it is used to pick up malnutrition and send the data at a higher level to be fed (in computer) and reported; neither instant action is taken by community health worker nor the manager except to put it in the report and present as needed. As big “nutrition advocates” we join the bandwagon of ‘multi-sectoral’ approach without appreciating the fact that at the end the malnutrition has to be managed by a health worker working at some level—from a community to hospital.

So do we keep on doing the same…… Let us think out of the box!!. Let us go back to basic of Public Health.

  • Why can’t we put our efforts on “positive-deviant” approach and understanding why in the same community some children are still healthy.
  • Why not put our efforts on maintaining the good nutrition of a child (and for that matter her mother’s).
  • Why not pick a child when the growth on “growth-chart” starts faltering rather than wait to let him/her slip into malnutrition? It is much easier and less costly to adopt this approach for promoting good nutrition.
  • Why can’t mother herself and mothers in a community be taught to handle nutritional status of their children by using social media and digital technology?
  • Why not address adolescent girls before their marriage rather than giving iron and nutrients at the time of pregnancy.
  • Above all, whatever we keep on doing, if we don’t address rapidly expanding the population, we will just keep on adding more malnourished children in our community.

Well, one can say, these all are being done!  However, I would contest that based on my observations, discussion and some actual work. For those having some academic flavour, please refer to my few papers (through the web) related to risk approach, P in GMP, undernutrition in squatter areas, intermittent growth monitoring, on rickets etc.  Even if all or something has been done, it must be a time-bound, projectized and small-scale approach.  Of course, more inputs are needed for discussions and actions.