Prakash Chandra Joshi

Last year, during a visit to one of the hilly districts of Karnali Province, I saw a woman at the ward office who was holding her 11-month old daughter on her lap. She had come there to pay her land tax.
While I spoke with her, she told me that she often visited the office for various matters as the head of the family because her husband was in India for work. Carrying a small child on her back and breastfeeding her while waiting in long queues was a tough job for her. She even felt a bit uncomfortable to breastfeed her child in an open space.
I met another woman at one of the districts in Sudur Pashchim Province who has three young children - aged five years, three years and four months living in a joint family. She is responsible for all of the household work starting at 4 a.m. till 10 p.m.

Challenges
Ideally, she should be taking rest and exclusively breastfeeding her youngest child but unfortunately, she hardly gets time to breastfeed the newborn. She feels breastfeeding should usually be a quiet and harmonious moment; an opportunity to sit down and relax a little extra but found it a challenge to include these moments in her day.
These are just a couple of examples of the challenges being faced by women in Nepal in terms of breastfeeding their child. Be it in the household or at public places, young children are deprived of this right.
Child rights and health organizations strongly recommend children should be exclusively breastfed till the first six months and continue breastfeeding with complementary feeding at least until the child turns 2 years or beyond.   
​Breastfeeding is one of the most cost-effective interventions to ensure infant and child health, survival and growth. Breastmilk is a complete meal for infants. It is safe, clean and contains antibodies, which help protect against many common childhood illnesses which reduce child mortality and co-morbidities globally.
Breastmilk provides all the energy and nutrients that the infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year, and up to one third during the second year of life. 
The Breastfed children perform better on intelligence tests, are less likely to be overweight or obese and less prone to diabetes later in life. Women who breastfeed also have a reduced risk of breast and ovarian cancers. Breastfeeding also helps to establish that special bond between a mother and her child.
The benefits of breastfeeding are not limited to health. Because breastfeeding provides the best start in life for infants, they have a better opportunity to reach and fulfil their physical and cognitive potential, which in turn improves their likelihood of becoming productive citizens and thus a contributing to the nation's social and economic capital.
For newborns, every minute counts. Early initiation of breastfeeding - which means breastfeeding a newborn within the first hour of birth - saves lives and provides benefits that last a lifetime. The longer babies need to wait, the greater the risk. A study by Smith Emily R, et al. in 2017 has shown that waiting for two to 23 hours increases their risk of death by 1.3 times. Waiting a day or more increases their risk of death by more than two times.
Having said that, if we look at the work to address this during the past two decades there is some progress, but it is not enough. Looking at the figures from Nepal Demographic and Health Survey (NDHS) 2001 compared with 2016, thanks to the institutional delivery, early initiation of breastfeeding has just risen to 55 per cent from 31 per cent but exclusive breastfeeding has declined from 68 per cent to 66 per cent.
 
Exemplary Indicators
Interestingly, even though other social indicators are not very encouraging, breastfeeding indicators are exemplary in Sudur Pashchim and Karnali Province. The NDHS 2016 shows that 70.7 per cent newborns are breastfed within the first hour of birth in​ the​ Sudur Pashchim Province and 67.6 per cent newborns get this opportunity in ​the ​Karnali Province. In contrast, this rate is the lowest in Province 2. More than half of the children born in Province 2 are fed non-breastmilk items such as honey, water before breastmilk, jeopardizing lives of newborns.
Breastfeeding is not only a woman's job. It's the responsibility of family, society and the nation. Sadly, mothers don't receive family support, institutional support and services to breastfeed their children. For example, the woman mentioned in the second case at the beginning is heavily engaged with household work and could not give enough time for breastfeeding. Family members think that breastfeeding is a mother’s job however with family support, many more mothers would be able to adequately breastfeed and thereby give their child the best possible start to life.
In the first case, the woman is not able to breastfeed her child due to a lack of institutional support like the availability of breastfeeding room or dedicated areas and mother and baby-friendly services at the government offices.
Though many local governments in the country have initiated the establishment of breastfeeding rooms, public places still lack basic infrastructure and minimum standards and much needs to be done on the expansion of such areas whilst meeting the minimum standards.
Besides, each mother should be supported with skilled breastfeeding counselling throughout the first two years of her child's life, and especially at times when she has the most difficulties. Support at the right time can help mothers to continue breastfeeding an d prevent them from stopping too early.
In the context of COVID-19, many women question if they can still breastfeed. To date, breastfeeding is safe for mothers and infants. The Nepal Paediatric Society (NEPAS) Position Statement released in May 2020 says that all healthcare workers should advice regular breastfeeding for all newborns.
Infected mothers should be advised to practice respiratory hygiene, including during feeding and wear a mask when near the child, wash hands thoroughly with soap and water or sanitiser before and after contact with the child and routinely clean and disinfect any surfaces touched.

Intensifying Support
Supporting breastfeeding has a short and long-term impact on the health of society. It is an urgent imperative and we must intensify the support provided to women, while also engage all relevant sectors to take action so that mothers, no matter where they live, or work has the support to breastfeed that they need. As urgent as the COVID-19 crisis and responses are, there is an equally urgent need to protect, promote and support breastfeeding as a life-saving public health intervention that also prevents infections and illnesses in the population at large. ​ ​ 

(Joshi is a nutrition officer at UNICEF Nepal)