Breastfeeding in Pakistan is almost universal. The data for this study indicate that around 91 per cent of the children under five at the time of the survey were ever breastfed. The figure is identical to the value obtained in the Pakistan Demographic and Health Survey,
1990-91, which recorded 91 per cent of all infants ever breastfed in the major cities and 94 per cent in the rest of the country (Ahmed and Ayub, 1992:149). The practice of breastfeeding is fairly consistent throughout Pakistan with negligible differences by region. This is supported by the Pakistan Contraceptive Prevalence Survey, 1984-85 report according to which 98 per cent of women in Pakistan breastfed their children (Population Welfare Division, 1986), and the Pakistan Fertility Survey report, with a figure of 95 per cent (Population Planning Council, 1976). However, the length of breastfeeding depends on various factors and varies between an average of six months and over twelve months. Twenty-four per cent of the children were still being breastfed at the time of the survey with 14 per cent being breastfed for a period of one week to five months. About 23 per cent of the children were reported to have been breastfed for six to 12 months. The remaining children were said to have been breastfed for more than 12 months.
Multiple responses were obtained when the mother was asked to state why the child was not breastfed or the reason for stopping breastfeeding. As stated by the mothers, 29 per cent of the children were either not breastfed or were weaned prematurely because the mother or the baby was too ill or weak to continue breastfeeding, there was insufficient milk or a nipple problem or the baby simply refused the breast. In about 5 per cent of the cases, the mothers reported that the child had died. The other important reason for discontinuing breastfeeding was the next conception, and 29 per cent of the children belonged to mothers who reported having put the index child on other milk in preparation for the next birth, while around 13 per cent of the children were said to have reached weaning age and no longer required mother’s milk (Appendix table B6.4).
There are further explanations of the variation in the length of breastfeeding. One of the more religious respondents who had breastfed her babies for well over twelve months said it was incumbent upon the mother to breastfeed the child, and according to Islam (as
interpreted), a woman should fully breastfeed the male child for at least 18 months and a female child for 22 months. Another respondent who had never been to a school had other reasons for not breastfeeding any of the six sons she had borne. She explained that during and after every pregnancy she remained so sick that she thought if she breastfed any of the babies the illness would be transferred to them. All she gave them was cow ’s milk.
Breastfeeding, however, is the most convenient mode of feeding the child. Although a large number of the women stay at home, the traditional acceptance of feeding the child wherever and whenever it is necessary adds to the convenience. It is also the most reliable source of food for the baby, especially in the light of economic constraints, availability and accessibility of other sources. Whatever the reasons, breastfeeding in a traditional society like Pakistan is very much a cultural norm.
Age at weaning is another important factor which can gravely affect the health of the child. Early or late weaning can create a gap during which a child can suffer from malnutrition. Although breastmilk is nutritionally ideal for the infant, owing to a variety of immunoglobulins secreted into breastmilk which protect the child from a variety of pathogenic viral and bacterial organisms (Huffman and Lamphere, 1984; Jelliffe and Jelliffe, 1989), supplementary feeding should begin between the ages of four and six months (Winikoff, 1982). The introduction of supplementary feeding before four months may increase diarrhoea caused by contaminated supplementary food and is not considered to be necessary for breastfed infants, whereas a late introduction of solid foods after six months may deprive the infant of the nutrition needed and may lower its defences to some of the common childhood diseases (Wray, 1978; WHO, 1981; UNICEF, 1985: 101).
The data show that 52 per cent of the children were weaned between the ages of one month and five months and 33 per cent were given other food after six months. Of the 24 per cent of children who were still being breastfed, 9 per cent were reported to be given some solids along with breastmilk. Generally, breastmilk is initially supplemented, in most cases, with cow ’s milk. Gradually, other supplementary food like banana, boiled rice and others which are considered soft are introduced in small quantities. Forty-five per cent of the children were given cow ’s milk along with other food compared to only 11 per cent of children being given formula milk in combination with other food. The other 29 per cent of the children were only given breastmilk and when weaned were given solid food, not supplemented with milk (Appendix table B6.4). Those children who were given cow ’s milk were at a high risk of infection as cow’s milk is generally diluted with unclean water, and certain properties in the cow ’s milk may cause indigestion leading to infection, particularly gastro-intestinal infection (Hull and Johnston, 1981: 65)
When the child is weaned, one of the most widespread practices is to put a piece of roti (bread) in the child’s hand so that while other family members are busy eating, the child can suck or nibble on the piece without being a nuisance. The child plays with it, and may drop it on the ground and then put it back in its mouth. Giving unboiled water to the weaned child is also common. Usually if an adult is drinking water, it is not uncommon to let the child have water from the same source. As seen in a few households, when the mother bottle-feeds the child, the feeding bottle is often left exposed to the environment and is an easy prey for house-flies and other insects. After a while, the mother puts the same bottle back in the child’s mouth. This also holds true for other food.
During the post-weaning period, the child usually eats whatever is cooked for the family.
roti— is generally given with tea. Tea is essential at breakfast and people drink it several times a day, especially after meals. This routine imparts the habit to children who, sooner rather than later, completely stop drinking milk and have tea instead.
During each day of the survey fieldwork, it was noticeable that many children would buy fruit from a nearby vendor and eat it unwashed. Children were also seen munching on unwrapped lollies, sweet-meats, rice-cakes and other items bought from the vendors. If the food was dropped, the child simply picked it up and ate it. The same habit was probably practised at home too. One of the respondents who had never been to school and had borne nine children did not consider such practices to be harmful to the health of the child. Expressing her views about child behaviour she said:
Children are children; whenever they feel hungry they eat; even if you tell them not to, they grab something from the kitchen; it is even harder to tell them they can’t purchase food from the vendors; there is nothing much you can do with the children, except let them have their way.
There were others, however, who had different perceptions and were determined to train their children differently. These mothers were more particular about the kind of food allowed to the child. For example, many mothers expressed their concern that tea was not healthy
Figure 6.3 Per cent distribution of children by incidence of diarrhoea and fever by treatment and advice sought
I Treatment
100 T A dvice
Diarrhoea Fever
Source: Child Health Survey, Rawalpindi, 1992.
for the child and therefore, the child was trained to have milk only. A rather strict discipline at home also inculcated the habit of having meals on time. Buying eatables from outside was a treat for the children. I observed that many of these mothers were careful not to leave the child squatting on the floor while eating; they fed the child before the rest of the family had their meal. Such practices ensured the m other’s personal attention and care.