Malnutrition in Pakistani children is cause for serious concern. Just consider these numbers from the Pakistan Demographic and Health Survey 2012-13:
Healthcare professionals associated with medical aid charity, Medecins Sans Frontieres (MSF), find that lack of breastfeeding is one of the prime causes for this high level of malnutrition. These observations are based on the NGO's work dealing with malnutrition in Balochistan.
In 2008, MSF began working in the eastern districts of Jaffarbad and Naseerabad in Balochistan, supporting primarily nutrition programmes for children under five years in the District Headquarter Hospital in Dera Murad Jamali, with a network of ATFC mobile clinics and outreach sites.
Each day can be a struggle at these clinics.
Recently, a woman named Farzana raced against time as she rushed to the hospital with her 14-days-old daughter, Razia. The newborn was underweight and malnourished, and had a high fever for five days. By the time Farzana brought her daughter in, it was already too late.
Clinic workers recall a hysteric Farzana struggling to accept that Razia is no more: "I cannot believe my baby is dead. I don't want to let her go."
Unfortunately, such incidents are not a rarity. Here, we look at the heartbreaking stories of other such parents fighting to keep their newborns alive.
Zubaida, a 14-year-old mother who got married before hitting puberty
Zubaida got married before she got her first menstrual cycle. Like many local women, she does not know her exact age. One way of guessing her age is to find out if she got her period at her husband's house or her parents.
"I got my first period one year after I got married; 40 days later I was pregnant with this baby. She is my first child and first pregnancy," she says.
Zubaida's mother-in-law passed away before she came into the family; there is no woman at home to guide her.
"Women in our tribes have to learn how to take care of their babies on their own," she says.
Her mother came and temporarily stayed with her after she gave birth to little Lal Bibi.
"My mother told me that I should feed her formula milk since she is very weak. I do not have milk. I tried breastfeeding her but nothing comes out," she says.
The young woman did whatever her mother told her to do, as per the customs and traditions.
"We live near a pond and we use the water from there for drinking. I prepare formula milk for the baby using the same water."
The MSF nurse examined Zubaida and showed her that she has milk. With some assistance at the hospital, Zubaida was able to feed her child her own milk.
Muradi's 18th pregnancy
Muradi and her husband welcomed little Raiba into this world last year. This was Muradi's 18th pregnancy. Previously, she had miscarried four times, while seven of her newborns — five girls and two boys — died within six months of birth.
Raising these children is not easy. "I do try to breastfeed my babies, but I do not have any breast milk," Muradi says. She feeds the babies goat milk, whenever that is possible. "Most days I cannot feed them at all," she says. "We are very poor."
When asked why she continues to have more babies despite her financial conditions, she says, "Our men believe that a woman's strength is to be pregnant, and have as many children as she can".
Muradi adds that she has finally decided things need to change. "I feel so weak [that] now I have told my husband I don't want to have more babies," she says.
She works on the fields with her husband and has always continued working while pregnant. "One of my miscarriages occurred while I was cutting crops in the field," she says.
Things are better now that her other children are older. While Muradi goes out to work, her older children look after little Raiba. Her eldest daughter is married and has a one-year-old.
'No one taught me how to breastfeed'
Feroza has three children. Her youngest, Salma, has been very weak since birth and is admitted to the nutrition programme. Feroza says her Salma's health is improving ever since she started visiting the mobile clinic.
"My mother passed away when I was young and my mother-in-law lives in another town. No one taught me how to breastfeed. I did whatever I felt was right," she says.
Feroza, like many other women at the clinic, comes from a very poor family. She gives her baby formula milk whenever she can afford to buy it. She says she dilutes the formula milk for every feed, giving Salma half the amount of milk powder for each feed so it lasts long.
There is a misconception amongst many of the women at the clinic here. They believe that initial milk (colostrum) is poisonous and hazardous for the baby. This is in fact not true.
Eunice Wanjiru, a medical team leader of the Dera Murad Jamali project says, "We also observe misconception that colostrum – the first pale yellow milk of mother – is not good for the child. There are also [harmful] practices of giving black tea, herbs, powder milk to newborn babies."
"I don't know why everyone always believed it [colostrum] should be wasted. We are not educated and we rely on our customs that our elders pass on to us," Feroza says.
Zahoor Ahmed, the patriarch with an 'overworked' wife
Ahmed's wife spends majority of her day taking care of their 15-member family. "She cooks and cleans like every woman," he says. She continued with this routine during her recent pregnancy. All this work during that time may be why she had a premature delivery, Ahmed suspects.
Expectedly, upon delivery the baby was very weak.
"We came here because many people told us that this nursery has this glass box (incubator) that can save a premature baby. Also, the doctors and nurses take care of babies so well," he says.
The doctors tell Ahmed that the baby is still critical.
The worried father goes to work everyday while his wife stays at the hospital. He has two other children who stay at home with his brother. "I just wish we could all be back together again, and take this baby home with us soon."
How bad is the breastfeeding resistance situation in Pakistan? Continue reading by clicking the tab below.
In conversation with Eunice Wanjiru, a medical team leader, eastern Balochistan Dera Murad Jamali Project, OCA - MSF Médecins Sans Frontières, Pakistan.
What exactly is malnutrition?
Malnutrition is an imbalance between the body's nutrient requirements versus intake. There are two main categories of malnutrition generally observed in children: Marasmus is a form of severe malnutrition characterised by energy deficiency due to inadequate caloric intake while Kwashiorkor is protein deficiency despite adequate energy intake. In Pakistan, most of children suffer from Marasmus. Malnutrition makes children prone to diseases.
What is situation of malnutrition in Pakistan, and especially in Dera Murad Jamali?
Malnutrition is one of the major child health issues in Pakistan. According to Pakistan Demographic and Health Survey 2012-13, around 45% of children show evidence of chronic malnutrition or stunting and 11% are acutely malnourished requiring urgent treatment. In the districts of Naseerabad and Jaffarabad alone, of a total of around 19,138 children screened on our three locations, 2,259 were severely malnourished. It makes more than 11%. This ratio is alarming, and the concern is that the number is increasing day by day.
What are the core reasons of such high malnutrition?
It is important to note that there is no food insecurity in this area. While food is easily accessible, affordability is a concern. The issue is a combination of cultural, economical and sociological aspects. Low income, lack of access to health facilities, unhygienic practices, health seeking behaviour, unsafe water and especially lack of breastfeeding are some prime causes of such high level of malnutrition in the area.
How important is breastfeeding?
Very important! Medically exclusive breastfeeding is recommended for newborns up to six months of age. Breastmilk is safe; balanced diet, zero contaminated, in right temperature and has anti bodies which help the child's body fight against infection.
The process of breastfeeding also enhances bonding between the mother and child. If a child is not breastfed, his immunity against diseases is compromised, and things such as black tea, herbs, honey, goat or formula milk can never compensate breast milk.
Why is there no culture of proper breastfeeding?
Even if mothers breastfeed their children, it is not proper and enough. There is a lack of awareness on importance of breast milk. Due to large families, children don't get enough care. Women work in the field, therefore the care to children is compromised. We also observe misconception that colostrum – the first pale yellow milk of mother – is not good for the child. There are also practices of giving black tea, herbs, powder milk to newborn babies.
What is MSF doing (core intervention) and what do you want to achieve?
The MSF teams support the inpatient therapeutic feeding for complicated malnourished children, general paediatric ward and neonates, as well as ambulatory therapeutic feeding programme, which provides essential medical care to more than 10,000 children annually.
Our specific objective on malnutrition is improved access to and the provision of quality nutrition support to severely malnourished children and lactating mothers.
What is MSF planning to do in the future, with regards to malnutrition?
It has been observed that many children get malnourished again after treatment. This is because they continue poor health practices. We want to break this vicious circle. Hence, we are also strengthening the preventive component of the project, where through health promotion we are aiming to raise awareness at the community level, so that the issue is addressed from the root cause.