Arj Rizvi’s breastfeeding journey had gotten off to a rocky start. She had just given birth to her first child—a son—and wanted to breastfeed. But after a few weeks of trying, her nipples had grown painfully sore and she was worried about producing enough milk to support her new baby’s growth.
“This is when you get demotivated,” said Rizvi, a 31-year-old auditor from Karachi, Pakistan. “You think the milk is not enough and your child is hungry, and then you start giving formula. I have seen many young mothers in my family who left breastfeeding because of this issue.” Even Rizvi’s mother, who had breastfed her own kids and supported Rizvi’s desire to do the same, urged her to supplement with formula.
While health care practitioners in the West aggressively encourage breastfeeding—sometimes to the detriment of women who struggle to maintain the practice—social norms in Pakistan and elsewhere in South Asia favor bottle-feeding, the product of decades of marketing by makers of infant formula. While some of these companies have changed their practices in response to public pressure, many Pakistanis still view breastfeeding as insufficient nourishment for a growing child—a view encouraged by a medical establishment that is often quick to recommend formula and reinforced by a stunning dearth of trained lactation specialists.
Zohra Kurji is a pediatric nurse at Aga Khan University Hospital in Karachi—and the only practicing lactation consultant in Pakistan certified by the International Board of Lactation Consultant Examiners, the global standard for education in the provision of breastfeeding support. “There was no support from doctors on how to initiate breastfeeding,” she said, recalling her work in the hospital’s neonatal intensive care unit in the early 1990s. “I saw these mothers struggle with tremendous amounts of guilt and frustration.”
When Kurji gave birth to her own twins in 1995, she said she was repeatedly told by physicians and family members that it was impossible to adequately breastfeed her infants without relying on formula. “The awareness of a supply-and-demand system of breastfeeding—the more milk a baby drinks from the breast, the more milk the body makes—did not exist in Pakistan back then,” Kurji says. She gave up after five months.
Her experience reflects a gradual shift in attitudes toward breastfeeding that started taking place in the 1980s. Having prospered in the West by promoting bottle-feeding as the key to women’s liberation, formula-makers began to seek new markets in the countries of the global south. In 1975, 95 percent of infants in Pakistan were being breastfed at 12 months. By 1986, years of campaigning by Western formula-makers helped drive down that percentage to 86 percent. Today, only 38 percent of Pakistani mothers practice exclusive breastfeeding for just six months, despite high rates of stunting—a condition characterized by low height relative to a child’s age, poor cognition, and other developmental delays. Breastfeeding has been shown to be beneficial for cognitive development and long-term protection against chronic disease, research that has led to a surge in breastfeeding in rich countries in recent decades. Currently in the United States, almost 60 percent of infants are breastfeeding at six months. Of the nearly 34,000 board-certified lactation consultants worldwide, more than half are in the United States.
“The women in villages I spoke to used to believe that not giving their babies formula was the worst thing they could ever do,” Kurji said, recalling her early work as a community nurse in rural Sindh province during the 1990s. “Such poor women will do anything to purchase formula, even if it means borrowing money and taking on debts because they believe the only way to have their babies turn out like the beautiful, chubby child they see on the formula boxes is by supplementing with formula milk.” Traditional practices—like feeding infants water, ghee, honey, and herbal tea—and employers’ lack of accommodation for working mothers also discourage the initiation of breastfeeding.
Nida Keshwani, a Karachi-based early childhood educator who knew of the benefits of breastfeeding, gave birth to her son in March. When he wasn’t progressing according to her doctor’s expectations, she was pushed to provide formula.
“The pediatrician felt my baby had lost a lot of weight, so he suggested I feed him formula milk three times for two nights and then come back and see him,” she said. “I kept insisting that I am not OK with formula feeding at all.” It wasn’t until Keshwani herself suggested that there might be a problem with her child latching or with her milk supply that he referred her to a lactation specialist. The next morning, Keshwani met with Kurji.
“Dr. Kurji checked me and taught me how to latch the baby properly to my breast,” Keshwani said. She also learned, for example, that the breast milk that comes toward the end of the feed has the highest fat content and that, by expressing the last few drops of milk, she could help her baby gain weight. “To date I have not given my baby any formula or had to bottle-feed him.” She feels that breastfeeding helped strengthen the bond with her son and brought her peace of mind during one of the most challenging phases of new motherhood.
For new mothers, that external support can make all the difference. Kurji was late in her second pregnancy when she enrolled in the Aga Khan University’s School of Nursing and Midwifery. Her daughter was born on the first day of class, but unlike during her first pregnancy, this time her decision to breastfeed was supported by those around her. The dean of the school encouraged Kurji to bring her newborn to class, even offering her a private room where she could breastfeed.
“I was the first student in the university’s history to bring my baby to class,” Kurji said. “Classmates used to do group assignments with me in the feeding room so I wouldn’t fall behind on my studies. My colleagues were very supportive of my decision to breastfeed, and other students soon started using the room for their own lactating needs.” She went on to breastfeed her daughter for more than two years. A few years later, she traveled to Texas to complete her international certification as a lactation consultant. “You could not take the exam in Pakistan at the time,” she said.
Families and health care practitioners are beginning to recognize the benefits of the practice. In August 2020, Kurji established Pakistan’s first dedicated lactation clinic, at Aga Khan University Hospital, to support mothers who choose to breastfeed. Online networks like Lahore-based LactNation, a breastfeeding advocacy group established in April 2020 that has grown to over 23,000 members on Facebook, are also empowering mothers with the tools and knowledge necessary for them to successfully breastfeed.
But while breastfeeding rates are ticking up in urban areas, women in Pakistan’s villages and rural areas—where children are most at risk of stunted growth and malnourishment in the early years of life—still lack access to accurate information. “The next step for our clinic is to bring more awareness on these issues to the middle and lower classes of Pakistan’s rural populations,” Kurji said. “We have to grow these initiatives … to secondary hospitals and health care facilities working directly with their communities. That’s where the need is greatest.”
In the meantime, more and more women in Karachi are seeking help for their lactation issues. After consulting with Kurji, Rizvi began using a nontoxic nipple ointment she could apply while breastfeeding, expressing her milk by hand, and wearing nipple shields that helped ease her pain. “I was very lucky I had Dr. Kurji to motivate me through this tough time,” Rizvi reflects. “Otherwise, I would have given up breastfeeding my son.”