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Being a mother – How breastfeeding can save lives of Pakistan’s infants

breastfeeding pic
By Farahnaz Zahidi

August 7, 2016

The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants

Her fifth child is due any day. Nazeer Bibi lives in a shanty part of Qayyumabad, Karachi, and has already decided that she will feed her baby formula milk.
“I work in three houses as a domestic help to support my family. I leave at 8 am after dropping my older children to school and return by 4 pm, and the baby will have to be at home. What option do I have? Besides, dabbay ka doodh (formula milk) makes babies healthier. I want my baby to be healthy like the babies in advertisements.”
Nazeer’s baby will be one of the 62 per cent Pakistani infants who are not exclusively breastfed. Only 38 per cent of infants under the age of six months are exclusively breastfed, according to the Pakistan Demographic and Health Survey (PDHS) 2012-13. The rates are the lowest in South Asia.
The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants, a danger that is not talked about often enough. As the World Breastfeeding Week is celebrated globally from August 1-7, the conversation around breastfeeding needs to be more audible and frequent in Pakistan. But bringing up the topic inevitably initiates parallel discourse regarding how lives of infants are less safer till formula milk is promoted as a choice. “From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health,” says an editorial in medical journal The Lancet.
“Formula milk should only be given when there is a medical reason for it,” says Dr Azra Ahsan, an expert in mother and child health. “The baby gets complete nutrition through breastfeeding. The mother passes on her protective antibodies to prevent common illnesses in the baby. As no water is required to prepare it, unlike how formula milk is prepared, the chances of diarrohea and vomiting are minimised.”
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed. Pakistan has one of the highest infant mortality rates in the region, all the more reason that breastfeeding must be encouraged, especially among the lower income strata.
The PDHS 2012-13 findings also show increase in bottle feeding rates in Pakistan.
“Babies who are born to mothers from the lower income strata are more at danger if they are not exclusively breastfed. The water these mothers use to prepare the formula is unhygienic, and the bottles are not sterilized. Also, formula milk is not cheap. Once they start the baby on it, they start diluting the milk over time so that the formula powder lasts longer; as a result, the baby becomes malnourished,” says Neha Mankani who works as a community health midwife at a hospital in Karachi.
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed.
Once the baby is started off on top feed, the unaffording or unaware mother, over time, starts substituting it with unboiled cow’s milk or low quality tea whitening milk powder which is unsuited for an infant. “We can try and convince the mothers but only till they are in the hospital. Also, Community Health Workers (CHWs) have no access to women who deliver at home,” says Mankani, adding that she and her colleagues try to convince mothers to breastfeed.
However, part of the problem could be that healthcare providers are not doing enough to raise awareness. “Healthcare professionals are the main culprits. Instead of advising new mothers to breastfeed, they help perpetuate the trend of using formula milk. They are given incentives by formula milk companies. Research shows that children delivered in hospitals are more frequently formula fed,” says Dr DS Akram, Founder, Health, Education & Literacy Programme (HELP).
The laws protecting the right of the infant to health and nutrition are there. Lawyer Summaiya Zaidi says that the primary focus of laws like the Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is to protect the nutrition of the child and promote breastfeeding as a primary source of nutrition. After the devolution, each province developed its own Acts for the purpose.
“The Sindh 2013 Act stresses that manufacturing, advertising and sale of alternate sources of child nutrition cannot be promoted as better than mothers’ milk or even compared to it. This stresses the primacy of breast milk as the best source of nutrition for a growing baby, and only when the mother is unable to provide the same to her child should alternatives be made available. It basically controls the manufacture and advertising of child nutrition products by placing certain legal limits on promotion of the same,” says Zaidi.
Yet, the tussle between public health experts and forces of consumerism continue. Companies producing or distributing formula milk refused to give any statement regarding how they justify the tempting advertising campaigns.
At the 69th World Health Assembly earlier this year, a resolution welcomed WHO’s guidance on ending the inappropriate promotion of foods for infants and young children. The guidance states that in order to protect, promote and support breastfeeding, the marketing of “follow-up formula” and “growing-up milks should be regulated. This recommendation is in line with the International Code of Marketing of Breast-milk Substitutes.
“The laws are there, but the implementation is a distant dream. Formula companies continue to particularly tantalise urban markets,” says Dr Akram, adding that the government does not seem interested in this cause. Dr Akram and her team run the Baby-friendly Hospital Initiative (BFHI) of WHO and UNICEF successfully in Pakistan for a few years. “When external funding stopped, the government was not interested in investing in it,” she says, adding that companies that produce formula milk mainly target the urban market to tantalise consumers.
“For the poor population in rural areas, breastfeeding is mostly the only available option. The urban social landscape is more challenging when it comes to breastfeeding. More mothers are working mothers; more options for top feed are available here; more people can afford to buy formula milk. Awareness is needed in both rural and urban areas,” says Dr Sara Salman of WHO Sindh.
According to Mankani, despite trying to raise awareness, most mothers follow popular myths. “They feel the baby is healthier if fed formula, owing to the aggressive marketing of formula milk.”
The biggest challenge for exclusive breastfeeding is the perception that mothers are not producing enough milk and should supplement with formula because the baby cries, says Meredith Jackson-deGraffenried from Helen Keller International. “This perception is driven by the misunderstanding that if the mother is undernourished and poor, she must be incapable of adequately nourishing her baby.”
“We try to teach these women basics about expressing their own milk and how to store it. Mother’s milk stays fine for up to three days in a refrigerator, and up to six hours at room temperature. It’s an economical and healthier option. But myths are hard to fight,” says Mankani.
Despite proven benefits like the mother who breastfeeds return to her pre-pregnancy state much earlier, and the incidence of breast cancer in women who breastfeed being much lower, as Dr Ahsan says, the myths seem to be winning.
“Socially, breastfeeding proves a challenge as well. There are usually no crèche or nursing rooms at work. That’s one reason working mothers stop breastfeeding,” says Dr Ahsan.

Originally published here: http://tns.thenews.com.pk/mother/#.V6hsuPkrLIX

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How Emotional Neglect Is Turning Too Many Of Pakistan’s Boys Into Criminals

While conflict and terror rise alarmingly around the world, it’s time to ask ourselves: could lives be saved if we got better at raising boys?

http://www.buzzfeed.com/farahnazzahidi/the-neglected-sons-of-pakistan#.jlPyOq14p

Rebecca Hendin / BuzzFeed

Editor’s note: Some names have been changed to protect the identity of people interviewed for this story.

When Zafar was young, he wanted to become a professional footballer. Now, at 38, he recruits young men for his brother, who is one of several warlords in Lyari, a densely populated neighbourhood in Karachi, Pakistan. Lyari is as famous for its talented football players and rich culture as it is infamous for gang warfare and targeted killings.

“I am a victim of this system,” Zafar says, referring to his inability to isolate himself from a life crime. “Time in jail can transform innocent people into criminals.”

Zafar describes himself as non-violent. He spends some of his time managing a confectionery shop as a side-business. “I’m not involved in anything wrong,” he insists. His friends, sitting around him, laugh as a rejection of this claim.

We’re sitting inside journalist Saeed Baloch’s house inside the town. As an active member of the community in Lyari, Baloch has seen many young men stray down violent paths, going on to lead lives of crime and imprisonment. “Neglect leads to boys becoming militant,” he explains.

According to Baloch, as many as 3,000 young Lyari men — many of whom had committed crimes — have been killed in encounters by law enforcement agencies between 2013 and 2015.

March, 2014: Lyari residents protest after gang violence killed 16 people. ASIF HASSAN / Getty Images

Between 2003 and 2015, Pakistan has lost more than 20,000 civilians to acts of terrorism alone, according to the South Asia Terrorism Portal (SATP). The average age of men involved in crime and militancy remains dangerously low. According to Saeed, they often start being recruited when they turn 13.

“Young boys see the good life of gang leaders – their money and power leaves even community elders awestruck,” Baloch says. “When boys have no productive activity, they loiter around. Once they get inducted into a gang, they can never leave.”

Baloch’s 17-year-old daughter Muqaddas is a student of Pre-Medical Intermediate. “Boys are generally non-serious about education and seek other outlets,” she chimes in. “For us girls, education itself is the outlet.”

And gangs are only one of several violent paths that attract Pakistan’s boys. Baloch, and several others I spoke to for this story, said that while resources are spent on fixing the problems that come from neglecting these boys – crime, violence against women, terrorism, gang wars — not enough emphasis is placed on finding solutions to the neglect that leads them down those paths to begin with.

While opportunities for acquiring literacy and education may be available to young men, very few initiatives focus on counseling and mentoring them through adolescence.

“We have already lost too many boys due to negligence, too many chances at a good life missed out on,” says Mossarat Qadeem, a peace activist who works to bring back young men from militancy in Pakistan’s north-western province of Khyber-Pakhtunkhwa (K-P).

According to Mossarat, 35% of the population in Federally Administered Tribal Areas (FATA) are between the ages of 15 to 30 — and they don’t have access to a single university.

“We have no institutions that would help channel the energy of youth,” Mossarat adds. “This has left a huge gap and that gap is being filled by the wrong people.”

April, 2012: Plain-clothed police commandos take positions during an operation against gangs in Lyari. ASIF HASSAN / Getty Images

Mossarat’s organization, PAIMAN, reaches out to conflict-prone districts of K-P and FATA, hoping to counter the impacts of radicalisation and extremism. Mossarat and her team have helped rehabilitate some 1,230 boys since the organization first started in 2004. That’s a drop in the ocean.

There’s a correlation between high proportions of 15 to 29-year-olds in a population and a greater incidence of civil conflict, according to a UNFPA study, which means as the proportion of young people in a society increases, so does their likelihood to get in trouble, unless they’re provided with enough access to educations and honest livelihoods.

And nowhere is this need more dire than in South Asia. India has 356 million, the world’s highest number, of people aged between 10 to 24. Pakistan has 59 million and Bangladesh has 48 million.

“This dividend has turned into a demographic disaster,” says Dr. Farid Midhet, a demographer and director of Jhpiego, which focuses on maternal and reproductive health issues and adolescents, for Pakistan. “In coming decades, this problem will become very serious and possibly uncontrollable in the absence of a good education system for the poor urban and rural boys, an extensive system for vocational training including counseling and social training, social support and social security.”

Rebecca Hendin / BuzzFeed

Who’ll talk to the boys?

According to Baloch, most boys in Pakistan do not receive counseling, even from their own parents. “They simply don’t talk to each other,” he says. “Poverty is so all-consuming and keeps the parents so busy that they cannot focus on keeping their interest for education alive.”

Aman Tech, an initiative of Aman Foundation in Pakistan, is addressing this need. In addition to the hard skills and vocational training it gives to young men, it has made “soft skills” a part of its curriculum. This includes not just grooming and image-building exercises but also communication and social skills.

“When they come to us, it is amazing how out-of-touch with themselves these young men are,” says Mahida Baig, the departmental head of Soft Skills at Aman Tech. She says many young men who come there lack self-awareness and do not know how to encash themselves.

“The biggest reason is that they have not emotionally engaged with their parents, especially their fathers,” Baig says. “It’s just something that is not done in our culture.”

Baig says that when Aman Tech identifies a boy as aggressive, they provide one-on-one counseling. Instructors, who are approachable, act as mentors and guide students who confide in them about relationships and life decisions.

But according to Baig, a central challenge in the counseling process is combating the stereotypes of masculinity that South Asian boys grow up around.

In 2002, Promundo, an NGO focusing on promoting gender justice, launched a program called Program H, which primarily targets men between the ages of 15 to 24, and encourages critical reflection about rigid norms related to manhood. Promundo reports that after participating in their Program H activities, positive changes were seen in these young men. With sensitization that made them rethink gender roles, these boys had better attitudes towards relationships and family planning, participation in domestic work, not indulging in sexually harassment, and not perpetrating domestic violence.

Rebecca Hendin / BuzzFeed

A lop-sided focus on girls?

According to the Pakistan Demographic and Health Survey (PDHS) 2012-2013, only 16% of men have completed more than secondary level of education.

Unlike many of the young men, the girls in Lyari are focused and are better students, says Nadeem Ghazi, a peace activist from the area who works on peace-building through education from the forum of his organization Peace Education Welfare Organization(PEWO). “Girls are more motivated to get an education,” he says. “Boys come under a lot of unhealthy outside influence.”

If boys are a problem, they must be engaged as part of the solution, says Rujuta Teredesai, co-founder and executive director of a social enterprise called Equal Community Foundation (ECF) dedicated to engaging men to end violence and discrimination against women.

According to Teredesai, development projects are focusing on girls because girls are not able to access enough opportunities for education and training. “However, if we exclude boys, we are not addressing some of the root causes; we might be creating a bigger problem.”

Experts say that a lack of focus on young men will actually set back the programs that focus on empowering women.

“All of the gains we have made for women and children can be reversed if we don’t pay attention to what is happening, or not happening, to young men,” says Leith Greenslade, vice chair, MDG Health Alliance and Office of the UN Special Envoy for Financing the Health MDGs. Greenslade says rising numbers of young, uneducated men without job prospects can be distracted by violent, anti-woman ideologies. “These ideologies can lead to civil unrest that can destabilize entire societies. Once the level of violence rises to these levels, we see the gains for women and girls unravel quickly.”

Rebecca Hendin / BuzzFeed

Talking solutions

Teredesai says that work with boys should be done in three major areas: Engaging them as allies, providing them with opportunity to learn about these issues, and catering to their needs.

“None of these approaches can work in isolation,” she says.

And according to Mossarat, the answer to how young men can be mitigated from being recruited into violence and radicalization lies in preventive measures taken before the damage is done.

“We need vigilant communities in society. We need the media to play its role to spread awareness. And we need parents to allow their sons to talk to them about everything,” Mossarat says.

“Because once they get inducted into violence, get radicalized and are caught in that web, it is a tumultuous task to bring them back.”

Is Pakistan Ready For A Male Contraceptive Pill?

http://dawn.com/2012/07/11/is-pakistan-ready-for-a-male-contraceptive-pill/

What is the first thing that the word “contraceptive” brings to your mind, I asked a number of people. “The pill” was a common answer. “And what does the word ‘pill’ bring to your mind”, I persisted. Side-effects, problems having a second child, weight gain: these were the answers. “For whom?” I badgered. Well, for the woman of course, they’d respond with a quizzical look on their faces as if saying “is that even a question?”

Turns out it is! In Airlangga Universitsas in Surabaya, Indonesia, the world’s first non-hormonal contraceptive pill for males (yes, you heard that right) is ready to reach the market shelves, as it is about to enter Phase 3 of human clinical trials. The research is funded by BkkbN, Indonesia’s FP body. Small scale production by a herbal medicine company called Naturoz has begun. Indonesia, the world’s “poster child” when it comes to Family Planning (FP) seems to be coming up with another breakthrough.

Justicia Gendarussa, an innocent looking shrub next door, is what these pills are made of. It is mostly found in Papua, Indonesia. Under the leadership of Prof. Bambang Prijogo, research is on since 1987.

How it works, according to Dr. Bambang, is that it primarily “disturbs the enzyme system of spermatozoa,” affecting its “function, capacity, migration, binding and inhibition.” In layman language, the shrub weakens the ability of the sperm to penetrate an ovum during intercourse.

Once this pill is available world over, would it be a good idea to introduce it in Pakistan, the country that is now the world’s fifth most populous nation, promising to soon become the fourth largest if nothing is done? As this write-up is published on the “World Population Day 2012”, Pakistan’s current population clock is ticking at 180121027 on the 10th of July 2012, (more than a 180 million people) according to the Population Census Organization, Govt. of Pakistan. The Pakistan Demographic and Health Survey (PDHS) 2007 shows that only 30% of married women use any form of contraception.  It would be safe to assume that the percentage of males using contraceptives would be much lower.

Barring condoms and natural methods like Coitus Interruptus (withdrawal method), men mostly are out of the contraceptive game, and even the above two methods are used with a lot of reluctance. Vasectomy, a permanent contraceptive technique, is a no-no for many reasons: it is more invasive, it is not allowed by most religions and it takes away the feeling of being in control from men…the feeling that says “I am virile and I can get my wife pregnant whenever I want”. As for female contraceptives, more mythical and less real side-effects make it a less than ideal choice for people. In a country like Pakistan where the FP decisions are still made by the man of the house and the mother-in-law, particularly in the under-privileged and rural setup where FP is most needed, the eventual result is more children than the family can handle. Eventually, these choices are resulting in more children than Pakistan can possibly handle.

In such a scenario, if the Gendarussa pill were to be introduced in Pakistan, it could be a break through. Free of harmful side-effects, it can be the solution to many problems. But men have their reservations. An unnamed interviewee shared that his wife liked the idea but he is not comfortable with it. “I have two reservations.  Firstly, what if it causes impotency or effects sexual performance? Even if the label says no side effects, this will always be at the back of my mind. Secondly, is it a fool-proof contraceptive method?”
Conspiracy theories and myths regarding contraceptives being introduced as ploys to reduce male virility and fertility in general are common. Seeing the reactions the Polio campaign and iodized salt met in Pakistan, it would not be an easy option for males to accept. It was interesting to note that men interviewed were very scared of the possible side-effects, especially the possible effects on sexual performance or fertility in the long run. However, the pill’s trials indicate quite the opposite. Turns out the Ganderussa pill DOES affect sexual performance by in fact acting as an enhancer, increasing stamina and sexual health. The contraceptive effect is also temporary and reversible once the pill is discontinued.

“My major concern would be that my fertility is not permanently hampered. If there are no side-effects, I have no issues using it, especially when I compare it to using the condom which is not a method of choice for me,” says one interviewee, candidly, who believes that the couple are a team who should decide mutually and work in collaboration. Why then are men not comfortable when presented with this option, I asked. “A lot of times, it is the ego of us males that gets in the way of using contraception. But men should realize that the woman bears the child for nine months, breast feeds and takes care of the children – his children! If she can do that, why can’t he take a simple pill?” he answers, very evidently a more emancipated man, who again chose to stay unnamed.

Women, when asked, were excited about the idea. Somewhere, they felt that now the ball could be in the men’s court, and that the women would not have to be singly responsible for using contraceptives. Yet, they also expressed their apprehensions that their men could not be trusted to take the pill regularly. “If he skips it or lies about taking it, it is me who is going to end up pregnant yet again,” says an unnamed mother of four.

Journalist Sumaira Jajja whose focus is health and development feels introducing such a contraceptive in Pakistan is “a great idea but I don’t see it as an indicator of ‘Gender equality’. Gender sensitive maybe, given that any man willing to take this pill would have to be a man with a responsible attitude towards sex and contraception who would value his partner’s body as more than a ‘baby making machine’.

The idea of a side-effects-free male contraceptive is a promising one. It could cause a positive change in the status quo situation of Pakistan’s FP program. But for changing the status quo, it is the mindset that would have to be changed.