GAIN Interview Cruncher - Nourishing Our Future: Addressing Malnutrition Through Breastfeeding

Geneva, 1 August 2023 - 

The below transcript has been edited for clarity and readability

Wubet Girma: Good day to everyone. Thank you for tuning in to another Interview Cruncher. This time around, in celebration of International Breastfeeding Week, we are focusing on nourishing our future by addressing malnutrition through breastfeeding.
Breastfeeding plays a prominent role in furthering SDGs 2 and 3, which include ending hunger, improving nutrition, and promoting health and well-being. It's one of the critical pathways to reduce under-five mortality. International Breastfeeding Week provides an invaluable opportunity to highlight the essential connections between maternal nutrition, breastfeeding, and the long-term health of both mother and child.

This Interview Cruncher aims to shed light on the critical role of maternal nutrition, in promoting successful breastfeeding and optimal infant nourishment. And to do so, we have three prominent speakers joining us today. I will be introducing them, and they will be sharing their insights around this topic and we will be following that up with a question and answer session.

The full interview is also available on Vimeo here.

Our first speaker is Dr. Sabiha Sultana, who is a Programme Manager at GAIN Bangladesh and she's also joined by Mary Njeri who is a Director for the Global Hunger Response at World Vision International.

And we also have Dr. Anita Gupta joining us who's a national-level expert in breastfeeding-related training.

Dr. Sabiha, if you can address the question, what are the key nutrients that breast milk provides? And how is nature supporting mother and baby through breastfeeding? Thank you.

Dr. Sabiha Sultana: Thank you, Wubet. And it's a great pleasure to meet this fascinating panel.
I'd like to share my insight into how it worked when I first saw that a baby can find, on its own, the mother's breast. I didn't know the reason at that time, but I do now. A baby drinks amniotic fluid during pregnancy and the colostrum - that is the mother's first milk -  smells and tastes just like amniotic fluid. When the mother holds the baby in her arm just after delivery, the baby actually can smell the colostrum and finds a similarity with the amniotic fluid and goes towards the breast.

Still, I find it really amazing. Now come the nutrients, is it only nutrients that the mothers and family members are concerned about? I think their expectation is much more and if anyone can share some of the examples from their experience of what are the expectations of the mother and the family members?

Dr. Anita Gupta: Usually, mothers are not concerned about breastfeeding. She's so tired, she has gone through such an agony of labour pains and the milk is also not there, the breasts are empty.
How can we give the nutrient to the baby from that breast? They think they should be giving something else to the baby from outside, and that can be formula milk or any other milk. So that's their concern mainly rather than giving their breast milk. Thank you.

Dr. Sabiha Sultana: Thank you Dr. Gupta. I find that when the baby is born, the first thing that comes into the mother's mind is that the baby is so small. How I'm going to handle this baby?

Especially for the first, who is experiencing motherhood for the first time, how I'm going to feed him properly? Whether I'll be able to produce sufficient milk or not. Whether the milk that the baby is drinking will provide sufficient nutrition, or as you have mentioned, whether she should go for the formula feed that the people around them are suggesting or just simply just why my belly is still so large? It feels like I have another baby inside me. When is it going to come down, and I will have a natural abdomen?
When all these things are sorted out, I think a mother feels tired. They can sense if they can have a completely good night's sleep after handling all these pressures.

If you think about the nutrition of breast milk, for the first six months, breast milk actually provides all the necessary nutrients to the baby, which is essential for the baby. But after six months, they need some supplementation, as per WHO guidelines.

Breast milk contains sufficient nutrients, for example, carbohydrates, fat, protein, lactulose, vitamins, and minerals, and most importantly like calcium, zinc, magnesium, iron, and omega-3 fatty acids. You also know that people are worried about [it] because babies are frequently affected by GI problems (gastrointestinal) or other lung diseases like acute respiratory infection.

So breast milk not only secretes the nutrient, it also secretes the antibody that the mother's body produces.
I think this is what - more or less - everybody knows, but what is the amazing thing that everyone may not know is that breast milk can actually act as a medicine. It's called the speed backward theory.

Like when a baby gets sick, when the baby's saliva goes back to the mother's milk and that signals to mothers to produce immune-boosting cells and antibodies for the baby for the next batch of breast milk for the baby to drink.

A breastfed baby has less chance of developing common illnesses: obesity, and diabetes, and they have less chance of developing asthma, allergies, lung disease, air disease, sudden infant deaths, et cetera.

So apart from this, there is another natural mechanism, like during lactation, the mother's areola is enlarged and they have a Montgomery gland. It seems like a pimple, but it actually lubricates as a disinfectant that keeps the germs away.
So this is how nature is actually protecting the baby with the natural process.

And the breastfeeding process is actually really exhausting for the mother, so the mother needs to take rest.
And how nature is actually supporting that process, the breast milk actually contains a higher concentration of nucleotide, which is secreted at night time only.

Not at night time only, the concentration is higher at night. So when the baby is fed at night, it makes them sleepy and they have a good sleep.

So if a mother can pump the breast milk and use that high-concentration nucleotide breast milk for another day and someone else can feed, the mother can actually take rest.

And apart from this, a mother can also get benefits from the breastfeeding, it significantly reduces postpartum hemorrhage and allows the uterus to get back to normal size. There is less chance of the development of uterine ovarian breast cancer as well as a low risk of developing diabetes and heart diseases.

I want to conclude with one of the facts: milk actually acts as a living food. It's constantly changing from feed to feed, day to day, month to month based on the nutritional need of the baby and the condition of the mother.
So there is no supplementation or replacement of breast milk and breastfeeding. Thank you all.

Wubet Girma: Thank you so much, Dr. Sabiha. Nature is indeed a miracle, and yet again, as you shared with us, it is evidenced in breastfeeding. 

We will now move on to our second speaker who is Mary Njeri from WorldVision and I will ask Mary to share with us in what ways policy interventions and community initiatives contribute to creating supportive environments that enable breastfeeding mothers to access nutritious food and improve maternal nutrition outcomes.

Mary Njeri: Thank you very much for having me in today's very critical discussion on the topic of breastfeeding. And this comes at a time when women and girls are facing a very huge challenge in access to nutritious food, which is one of the barriers to breastfeeding.
And the reason for this is the ongoing global food and nutrition crisis that is affecting millions of people including mothers and girls. And I want to say that our statistics already show that 69% of girls and women suffer from micronutrient deficiencies. And the latest study by UNICEF shows that the number of acutely malnourished breastfeeding and pregnant mothers has risen by 25% in 12 of the most affected countries by the food crisis.

And so in light of this crisis and the challenges that are affecting women and mothers, my organisation, WorldVision, is implementing a global hunger response and our goal is actually to reduce the acute food insecurity for the most affected communities. And one of the objectives for us to be able to achieve this is by increasing access to preventive and curative health and nutrition services for the most affected and vulnerable groups and this includes pregnant and breastfeeding mothers as well as children under five years. So for us to achieve this objective, we are focusing on policy interventions as well as community initiatives.

And on policy interventions, I would like to say that we are doing a number of things, first knowing that policy interventions create an enabling environment for like, breastfeeding mothers to be able to access nutritious foods and also to improve maternal and nutrition outcomes.

So some of the things we are doing are: first we are partnering with multiple stakeholders and this includes governments, UN agencies, and donors, to export coverage of essential nutrition services through community outreaches. And this provides free services to women at the community level. And actually, we go an extra step of even moving the services from a health facility level to do things like mobile outreaches that go to the nearest, closest to the people most in need so that women are able to get like micronutrients supplementation, screening for malnutrition and things like deworming and other such services.

Secondly, we are promoting social protection for mothers and girls and this we do in all our cash transfer projects ensuring that as we target those people that are most in need in these times of food and nutrition crisis, we ensure that the mothers, these breastfeeding mothers, those that are pregnant, those with children under five years, are among the first to be prioritised for any cash transfer.
And this enables them to use that cash to get nutritious foods for their families. That is, we are using multiple channels to communicate vital information on nutrition and care practises knowing that information and knowledge gaps are also barriers to good maternal and child health. So this is also something we are doing. We use multiple channels sometimes working with community groups such as, what we call, the community health workers, and peer educators to ensure that this information is available even on a door-to-door basis and then to follow up that these mothers are actually using this information to be able to nurture their children well.
In regard to community initiatives, I'd like to give two examples that are very innovative and really working for us in different communities.

The first one was in Sierra Leone, we partnered with Emory University with the Ministry of Health there and worked together to target grandmothers in a project. We identified that grandmothers play a very crucial role in influencing, advising, and also giving care to young mothers before, when they are pregnant, and even after childbirth.
And so we realised that the information they have and their attitude will then also determine how they support these mothers.
So after three years of working with them, ensuring they have the right information on topics such as infant and young child feeding, exclusive breastfeeding, and others, we could already see a turnaround in how they understood and then the change in the application of that information.

For instance, before our partnership, the grandmothers we worked with them, 50% of them believe that children should be given water within six months of birth. But after working with them, we saw this number decrease very much to less than 2%.
And this is very good because they are then able to now promote exclusive breastfeeding and we all know the benefits that this comes for the children. In Kenya, we are using an approach called mother-to-mother care groups that brings together pregnant and breastfeeding mothers and this is a platform for them to learn different information, get knowledge on how to take care of children and have health talks on different topics.

And some of the things we discuss here are like the infant and young child feeding and nutrition. And using this information, then they are able to utilise it at the household level and apply it to their children. And because they're now in a group, this provides a supportive environment for them to share experiences to discuss the challenges they're coming up with and how they can be able to handle them.
And not only that, but we also use these platforms to teach them skills, it can be on cooking, how to best cook the food so that it retains its nutritional value, and also other skills such as how to start small businesses, how to do better farming. And because of this and with the support that comes with it, they're able to grow nutritious foods for their families, to start income-generating activities that can bring an income, and they use that money now to meet the food needs of their households.

So this becomes a platform where they learn, try new things, make an income, and can support their family. So it's holistic and not just looking at one area, but also addressing multiple barriers to breastfeeding.

So you would like to ask why we do this? So at WorldVision, we believe that breastfeeding is a powerful tool in combating malnutrition, reducing under-five mortality, and also promoting child health and nutrition. And we have seen from statistics from the World Health Organisation that optimal breastfeeding can save up to 820,000 lives of children annually.

So we said this is quite something that we need to support as we work on ensuring that children develop to their full potential. And not just saving their lives, but ensuring that they develop their full potential and are able to be productive in their communities, and in their households. And this leads to development in the whole society including their nations.

So thank you for this and I believe that as we continue dialoguing on this show of breastfeeding, we are going to get the speed that we need to support women and address the barriers that affect breastfeeding. Thank you.

Wubet Girma: Thank you so much for that, Mary, and for shedding light on the data. That does say a lot about where we are in terms of child health and wellbeing. And, of course, thank you for sharing the comprehensive programme that you are working on.

I trust the fact that you highlighted and focused on, you know, making information available at all levels, at a community level, at different stakeholders levels is quite critical in terms of issuing that we get the right support and the right decisions and actions are taken.
So we will come back, of course, at the end with some follow-up questions. But for now, let's move on to our third speaker.

Dr. Gupta, so my question to you today is, so if you can tell us about what the key nutrients and dietary considerations for mothers are during the breastfeeding period to ensure optimal nutrition purports them and their infant and how can we assess the growth of the impact?

Furthermore, you can also shed light on how maternal nutrition impacts the quality and composition of breast milk and what implications that has for infant growth, cognitive development, and immune system strength.

Dr. Anita Gupta: Thank you. So today, I'll be talking about how maternal nutrition impacts the baby's growth and development. 
As we all know, the first 1,000 days, it's really a critical window. So these 1,000 days start from the first day of the pregnancy until two years of age. So at this period, the baby is at the greatest vulnerability, which leads to stunting, growth, and development. So, maternal nutrition is the foundation stone for a child's growth and development. 

Fetal growth restriction is one of the leading risks of stunting and contributing to 1/4 of newborn babies' death. It builds a baby's brain and fuels its growth. It improves a child's social readiness and educational achievements, reduces maternal and infant child mortality and morbidity and it also boosts a country's GDP by as much as 12%. And this maternal nutrition only breaks the intergenerational cycle of poverty. 

So much importance is given to maternal nutrition during pregnancy time. But let's see once the mother comes after delivery, and she is into the postnatal period. 

Let's see when the stunting starts: it starts during preconception. So we see that preconception, the stunting starts, and it's apparent at eight weeks of pregnancy, that's the first trimester. And it peaks at 20 weeks of gestation and the weight velocity peaks at 30 weeks, that's the third trimester. And if we don't take care of the mother's nutrition during this period when she's pregnant, she gives birth to low-birth-weight babies. 

And we know that low-birth-weight babies are really vulnerable to death and mortality and morbidities. So it's very important that we take care of the maternal nutrition while she's pregnant and even we should start thinking about the pre-conceptional stage also. So let's see about breastfeeding. So how does maternal nutrition impact the quality and composition of breast milk? It's been seen, and many studies have shown, that a balanced diet for lactating women is essential for providing the psychological needs of the mother as well as for the health of the baby or the infant via the ideal quality and composition of the breast milk contents. 

But still, literature in many studies now show that maternal nutrition status and dietary vitamin and or mineral supplementation mainly influence milk concentration of vitamin A, D, B12, thiamine, riboflavin, pyridoxine, et cetera, iodine, and other minerals. Whereas milk contents of protein, and carbohydrates remain unaltered unless the mother is extremely undernourished. So it's very important that the mother is properly given the micronutrients for the breastfeeding period. 

A study in Latvia on lactating also concluded that macronutrients like fat, proteins, and lactose content in human milk are not affected by maternal diet. A study again says that macronutrient relationship in infant anthropometric measurement by Egypt shows that to improve breast milk composition, one could aim for improving the nutritional balance in lactating women, especially from protein intake. So this is again showing that protein intake has to be good. 

Some say multivitamins or micronutrients have to be good for having good quality maternal milk. Another study also says that the high intake of red meat, cereal, and eggs is associated with higher protein, total dry matter, and energy content in breast milk. So these things do help, the studies are showing. Again, there is another study that says that non-vegetarian, vegetarian, and vegan mothers produce breast milk of comparable nutritive value. So again, there's no difference between a vegetarian and a non-vegetarian diet on breast milk production and quality. But still, the need of the hour is: that more well-designed longitudinal studies about practices that influence human milk compositions are needed. So we can now conclude that if a mother is taking an appropriate balanced diet of all the macronutrients and the micronutrients, she can produce enough milk and offer good quality for her baby. So now we talk about the growth of the baby. 

We all know that breast milk is the best for the growth of the baby, it is tailor-made for her baby. The carbohydrates, proteins and fats, minerals, and vitamins present in breast milk are ideal for the development and growth of the baby. 

Breast milk contains lactose and not sucrose or starch, which is easily digestible by the young baby. And other milk and or milk products contain starch which is not digestible by the baby. And also this high lactose content produces acidic PH in the stomach and which prevents growth of the harmful bacteria, so fewer infections in these babies who are breastfed. Human milk contains an enzyme called lipase which digests fat in the breast milk more completely and thus fat is efficiently used by the baby's body to give better growth to the baby. 

Similarly, breast milk and colostrum contain plenty of vitamin A, which boosts immunity and is also good for the vision or the eyes. Iron present in breast milk is absorbed well so prevents anaemia and the baby till six months. Many formula people have tried to fortify the formula with iron and they claim that the formula has got that much amount of iron as in breast milk, but it's been seen that the absorption is less from the formula milk. 

And secondly, if more amount of iron is added in that, it leads to the growth of harmful bacteria which causes infection in the baby. So this is the best thing that the breast milk gives for the good growth of the baby. If we talk about cognitive development, we all know breastfeeding provides measurable advantages in cognitive development seen in infancy. And persisting! It's been seen that it persists throughout childhood to at least 15 years, with many studies sayings that, and breastfed babies have additional five to eight IQ points higher than the formula breast babies. And this benefits more in low birth weight infants also, which are preterm or low birth. The breast milk contains DHA, which is absorbed well and it is very much essential for myelination of the brain and helps in enhanced cognitive development. 

Again, the formula company wanted to claim that they're fortifying the formula with DHA, but again, the absorption is poor and it's not been utilised properly. Many observational studies have demonstrated nutrients important for neural development are polyunsaturated fatty acids and micronutrients like iron, folate, zinc, et cetera, which are present in breast milk. 

Many studies are coming up saying that longer breastfeeding durations were seen as associated with a mean cognitive score higher than the mean cognitive score of those who were never breastfed. So here are then certain two studies like a follow-up study of three years and a millennium cohort study in the UK. They all say that there is a positive correlation between breastfeeding duration and mental development index, and another study also says that the cognitive scores at the age of 5, 7, 11, and 14 years were really associated with a higher cognitive score depending upon the breastfeeding duration and association. 

Another study by Manuel says, data from 47 preterm infants also say that early breast milk exposure modifies brain connectivity in preterm babies. Another review says the importance of human milk and oligosaccharides in neural development preterm and how they, again, review also focuses importance of human milk and oligosaccharides in neurodevelopment in preterm and how they prevent neonatal complications and thus contribute to increased preterm survival. 
So these oligosaccharides present in breast milk are really helping babies to grow cognitive value as well as their survival is also improved if they are started breastfeeding early exposure is given to them. 

Now we talk about immunity, it's really breastfeeding, we all know it boosts the immunity of the baby. And it's been seen that for the first year, a baby's immune system is not fully developed and so they cannot fight infections as an older child or an adult, so a baby needs to be protected by his mother. And breast milk contains white blood cells, a number of anti-infective factors like immunoglobulins, called secret immunoglobulins, lysozymes, which are secreted within the breast into the milk, and in response to the mother's infection. 

Whether it's a previous infection to the mother or it's a current infection, these antibodies do come to the baby's body and they produce the immunoglobulins antibodies protection to the infection. So let's see what's the mechanism of protection against infection. When the mother gets infected, the white cells in the mother's body make antibodies to protect her and some of these white cells go to her breasts and make antibodies there. And these antibodies are secreted in breast milk to protect the babies. So babies are really protected by these antibodies passed to the breast milk. 

Breast milk is not just a food for babies, it's a living fluid that protects a baby against infection. Colostrum produced for the first few days following birth is particularly rich in antibodies, it's the first immunisation for the baby. Breast milk has probiotic factors also to support the immune system and it also serves as a nutrient source for healthy bacteria in the body called the human microbiomes. 

The healthy microbiomes can play a lifelong role in not only preventing infection but also in decreasing the risk of allergies, asthma, obesity, and other chronic diseases like heart disease, diabetes, et cetera. So the importance of breastfeeding, we cannot deny. Breast milk contains anti-infective proteins like lactoferrin, which binds with iron and prevents the growth of bacteria, and lysosomes also which kill the bacteria as well as antibodies, and immunoglobulins to fight the infection. 

Another important anti-infective factor present in breast milk is the Bifidus factor, which also promotes or inhibits the growth of harmful bacteria. Breast milk has also been containing antiviral and anti-parasitical factors. As we saw in covid-19 also, the viral antibodies were present in the breast milk, which were protecting the dangerous disease the babies. If we talk about the low birth weighted babies, someone says not to start there because they want to gain weight fast. 

But still, it has been seen that breastfeeding prevents many things like hypothermia, hypoglycemia, and other metabolic derangements. It protects from sepsis and necrotizing enterocolitis because of the immunoglobulins, erythropoietin factor, et cetera, in breast milk. It optimises the growth and development of these preterm babies and also reduces the mortality in the preterm. So we must start breastfeeding within one hour as early as possible to come back and get these benefits of breast milk. 

If we have to talk about the healthcare professionals and the role they have in breastfeeding, it was told by Mary also that they are doing some projects. But when are the health professionals required? So they are required during the counseling of the antenatal period when the mother is pregnant, counseling at the time of birth to start breastfeeding within one hour. Then about the checkups, routine opd checkups, immunisation visits. Then again in special circumstances like when she's coming with some breast conditions like mastitis, cracked nipples, so everywhere. 

And the counseling in the community also. Once she goes to the community from the health centres to sustaining exclusive breastfeeding for six months and continuing for two years and more. So everywhere, there's a very important role of healthcare professionals in starting, as well as in continuing breastfeeding for six months and more. We all know the magical first hour is the golden hour and we all know what is the importance of this hour. If we start within one hour, many, many more [hours to come]. It decreases the newborn stress level, improves mother newborn attachment, it encourages breastfeeding also. So it has to be started within one hour and our health professionals should work on these lines. 

Many studies have also shown breastfeeding advice during antenatal care is a very good intervention for promoting breastfeeding. And a Cochrane database study also says that professional breastfeeding support increases initiation as well as exclusive breastfeeding till six months. So first step to initiate and maintain success with breastfeeding is the help of health professionals when the mother is delivering in the institution. 

So why we are not able to do it? Because skilled people are not present in our setup. They don't know how to counsel, they don't know how to help. Then many times, the breastfeeding hospital initiative is not being taken. Hospital practises are not that good where the mother is delivering. So we have to take care of all these things if we want mothers to start breastfeeding and do, and also family support. So family support is also important for initiation as well as for the continuation of breastfeeding along with the health professionals' care and support. 

Now once the mother, has breastfeeding support at the hospital, we have a good breastfeeding hospital initiative, still the professionals should coordinate discharge so that parents and their infants have timely access to ongoing support and care, that is mother support group, the grass root workers, like Anganwadi workers, ASHA, ANM. So we must tell them how to go about it, who will be there to help them. 

So all these health professionals and then again the health professional at the grassroots level should be trained in doing the counseling and helping his mother in her agony. So Ministry of Women and child development programmes for MIYCN. There are many programmes launched like Saksham Anganwadi and Poshan 2.2 period to '21, '22 programme for the MIYCN challenge tackling, then Pradhan Mantri Matru Vandana Yojana in 2017 to support pregnant and lactating mothers with financial support. 

Janani Shishu Suraksha Karyakaram, which was launched in the 2011 year and which gives a mother, entitles the pregnant mother antenatal delivery, complication care, and treatment of sick children for one year, which is absolutely free in public health in India. Then there's a mother's absolute affection programme for the promotion of breastfeeding and complementary feeding. 

So there is a convergence of health as well as the women and child development department at the grass root level in India and where the health and ICDS workers, work together for the nutrition and health of the mother, the education, health checkups, supplementary nutrition, and referral services. Thank you. 

Wubet Girma: Thank you, Dr. Gupta, for that comprehensive insight into the key nutrient and dietary considerations for both the infant and the mother as well as for highlighting the role of health professionals and giving us an overview of supportive regulatory frameworks around this. 

So with that, we move on to the Q&A session. given that you've given us quite comprehensive information, all three panelists, I hope you can take a couple of questions as a follow-up?

I would like to surface one topic which I think we need to cover here as well, and that is the role of employers in terms of creating or contributing to creating a supportive environment for mothers who wish to continue to breastfeed once they're back at the workplace. 

Mary Njeri: Allow me to take it and I believe that the rest of the panelists will, of course, come in. So I know that employers have a key role to ensure that women, first of all, have access to maternity leave once they are pregnant. And I know that there are different periods given by different governments for women to be able to access their leave. 

And so an employer, even while a person is already pregnant and coming to work, should ensure that they have first the time to go to the antenatal care clinics because this is very important for children as we have heard in the different presentations. And also when the time comes for delivery they can go in good times so that they can be able to access a health facility for them to deliver and then they're able to get their full period for maternity with their child so they can have this time for breastfeeding. 

And there should not be any reason why somebody should be recalled like from maternity leave before their time is up. And one other thing they can help is that even have seen employers that even when a person comes back from maternity leave, like the organisation where I work, you're given some additional consideration. 

For instance, where I work, you are given an hour earlier, you can go home earlier one hour so that you can be able either to go for the lunch hour and breastfeed the child, but also that you can either go early in the evening so that you have time with the child. They also provide facilities within the workplace where you are able to express the milk and keep it so that the regular flow of the milk can be there for you and that the child can have this access to this milk even while you are away at work. 

So I'll stop there and let my other panelists come in. 

Dr. Anita Gupta: Thank you so much. I would like to add a few things. Very good, Mary, you have given the insight of the working women help and how employers can help. The only thing is, they [the new mother] can do, instead of a full-time job, they can be switched off to a part-time job. So till they are breastfeeding their babies after the maternity leave, employees can have creches in their workplace the mothers can keep their babies there and they can be given some leave for half an hour for every three to four hours so that they can feed the baby at the same premises. 

That will become easy for the mother to do. Secondly, they can be made part-time workers instead of full-time so that they have to spend only three or four hours and then they can go home. And work from home also can be done in such scenarios permits her work permits. So these things can also be done by the employee if they want mothers to help in breastfeeding. Thank you. 

I want to add just one more point like Mary has already mentioned in detail, what are the steps that we can take in the workplace? I just want to mention that we need to make social behavioural change so that in every sector, everywhere it is incorporated as a kind of behavioural change so that everyone accepts that as it is a very natural thing, not as an extra support or extra benefit given to the women just because of this. 

So I think, if we can change those viewpoints over time, that will really help to create an appropriate environment for promoting breastfeeding. 

Wubet Girma: Indeed. Thank you all so much. That was quite insightful. And I must say it does still feel like this is a privilege that is given to women, whereas it should be the norm for every employer. And maybe moving on to my last couple of questions. This one is a point I believe that comes in different conversations around breastfeeding and I would love to hear your point of view on this. 
How long should a mother breastfeed? And in a way related to that, when should a mother avoid breastfeeding? Are there any counter-indications that you believe should be taken into consideration?

Dr. Anita Gupta: Mother should continue breastfeeding for six months exclusively and what the Ministry of Health and WHO says and she should continue breastfeeding for two years or more if she wants. So that's the period she should continue breastfeeding. And secondly, what are the contraindications and when she is not supposed to breastfeed her? There are only a few contraindications, only one or two which I can say, that is anti-cancerous drugs if a mother is on. But still nowadays, if she's on breast cancer drugs, again, few drugs are coming, which can be given within the time period when the baby is not fed for 24 hours, express the best milk is left. 

But still, we say that if the mother is on anti-cancer drugs as well as if it's in radioactive substances. Otherwise, they have to be a little vigilant if taking any normal drugs, not many contraindications. She has to be vigilant if she's taking anticonvulsants like epileptic drugs or anti-psychotic drugs so that the baby's not getting sedated. Otherwise, with normal drugs, she can continue. And rest, no conditions are there where she has to stop breastfeeding. 

Dr. Sabiha Sultana: Just to add one thing, it's better to discuss with the medical doctor before taking any drug during lactation because some of the drugs actually get secreted in the breast milk. So, one drug has a specific duration than the other. So getting a suggestion from a medical doctor, it's good before taking any medication because is there a number of safe drugs that can be just replaced with the regular drug that is regularly used. So just need a suggestion from an expert. 

Mary Njeri: Thank you so much, Dr. Gupta and Sabiha, for that. I fully agree with the need for the six months of exclusive breastfeeding and then trying to sustain breastfeeding for at least two years more if you can because I have personally seen it really very beneficial when I've done that as a mother and that really propels children in all ways in their development. So it's really something that we should be able to uphold as parents. Thank you. 

Wubet Girma: Thank you all so much for your input and your insights on the different topics. I think we go away with quite a number of critical messages from the conversations we've just had and it's really great to see. Breastfeeding is indeed a powerful tool in combating malnutrition, reducing under-five mortality, and promoting child health and wellbeing as was just presented and highlighted by some of our speakers. 

At the same time, I really appreciate the emphasis that was given to maternal nutrition, which directly influences the quality and composition of breast milk, which is vital for the infant's growth. So the focus on a well-balanced maternal diet is quite a critical point that you have raised. 

Furthermore, as just reflected on, breastfeeding mothers do face challenges, whether it's limited access to nutritious food, whether it's a lack of knowledge or the right information about appropriate dietary choices, or just time constraints. So being cognizant of that, whichever roles we play, whether, as mentioned earlier, whether as a grandmother, or any community member, whether as an employer or any influence in the policy landscape around this is quite critical to kind of have that, the mother's point of view, and the challenges that are faced by the mother around this. 

And definitely, the high-level policy interventions complemented by community-based initiatives do make a difference as it was just shared with us from the examples of the projects that are run by all patients. So really, I'm really thankful to all of you for your time and for kindly sharing your insights on this topic. 

And to our audience, thanks again for joining us at International Breastfeeding Week and tuning into this Interview Cruncher. 
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Views expressed by guests on this webinar are their own and do not necessarily represent our organisation's views.