Action needed to address worrying decline in breastfeeding

Vandy Kang, a 31-year-old grocery vendor and mother to two young children, knows that breastmilk is key to giving her kids the best start in life.

“Firstly, the children's eyes, brain and general immune system are built stronger and healthier, shielding them from viruses and diseases,” she says. “And when they grow up, they tend to be smarter in studying and living their life.”

Vandy lives with her three-year-old daughter and six-month-old son in Ratanakiri, a heavily forested border province known for its lush forests and remote indigenous communities. Like most in her community, she depends on income from agriculture, her and her husband having made the journey several years ago from Battambang to Ratanakiri to set up a cashew farm. After COVID-19 hit, borders closed and the price farmers could fetch for their harvest dropped significantly, families were forced to find other means of income or take on debt to ensure they had enough money to feed their family.

Many mothers in remote and hard-to-reach communities like those in Ratanakiri miss the opportunity to interact with health workers, yet Vandy says she depended on her local clinic, Poy Health Centre, to take care of her children’s health despite their financial struggles. When she fell pregnant during the height of the pandemic, she never missed any antenatal appointment and kept up with her daughter’s regular immunizations. This is also where she learned about how important breastmilk is in preventing illnesses and boosting brain development in newborn babies, and that it is the best and only nutrition they need in their first six months of life.

By carefully following the advice of the clinic, including how to breastfeed correctly with proper hygiene and only adding solid food after the baby turns six months, she says her children are healthy and rarely get sick compared to their peers in the villages.

“Life was hard during COVID,” she says. “Still, we survived, and now we are thriving once again.”

Breastfeeding, initiated within the first hour of birth, provided exclusively for six months, and continued up to two years or beyond alongside safe and appropriate complementary foods, is considered one of the most powerful practices for promoting child wellbeing. It improves child survival, protects against life-threatening and chronic illnesses, and promotes healthy growth and early child development.

Breastfeeding also supports healthy brain development and has been linked to higher performance in intelligence tests among children and adolescents across all income levels. It has been estimated that improving breastfeeding rates around the world could save the lives of more than 820,000 children under the age of five every year.

While most mothers in Cambodia choose to breastfeed their newborns, research has shown that the prevalence of exclusive breastfeeding until the baby is six months old, the standard recommended by UNICEF and the World Health Organization (WHO), has been steadily decreasing in the country over the past decade. This is despite the huge progress made between 2000 and 2010 in increasing these figures. The Cambodia Demographic and Health Survey (CDHS) found that exclusive breastfeeding declined from 73.5% in 2010 to 65% in 2014, most prominently in urban areas, and only 37% of children were continuously breastfed until age two as recommended by WHO. In 2021 these numbers dropped even further, with only 51% of children exclusively breastfed in the first five months of life.

The sharp decline has been attributed to a number of factors, including aggressive marketing campaigns for breastmilk substitutes and the weak implementation of national legislation to regulate the practice, women having to return to their workplace soon after the baby is born, as well as a lack of knowledge on the benefits of breastfeeding. One study found that many mothers and family caregivers, especially in urban areas, believe that formula milk is better if the mother’s own diet is not good enough, which is not true.

“The reversal of these positive trends is particularly concerning as children under six months who are only partially breastfed have an increased risk of mortality, especially from diarrhea,” says Selamawit Negash, UNICEF Cambodia nutrition specialist, who also emphasised the huge benefits of breastmilk in preventing illness in breastfeeding mothers, including ovarian and breast cancer, heart disease and type 2 diabetes, as well as its significant role in contributing to the development of a country as a whole.

“Breastfeeding is one of the most important interventions for not only child survival and development but maternal health too. The economic impact is also high as children will be less sick so the pressure on healthcare services will be reduced. Most importantly, breastfed babies are more likely to fulfill their full potential at later stages in life through learning better in school and being more productive in adulthood. It really is the best gift a mother can give to her child.”

UNICEF is supporting the Ministry of Health, the Council for Agricultural and Rural Development and other partners to decrease child malnutrition through promoting and protecting infant and young child feeding practices. A large part of this work involves conducting outreach and social and behaviour communication change (SBCC) campaigns to advocate for and support mothers in breastfeeding within one hour of birth, and exclusively breastfeeding for the first six months of life and up to two years with safe complementary foods.

A recent SBCC capacity assessment has identified ongoing gaps in running successful SBCC activities to promote optimal maternal, infant, and young child feeding practices. The results of the assessment will be used to design evidence-based capacity building materials as well as a home-based kit for mothers to refer to. Ongoing support for outreach activities in five northeastern provinces is also helping health workers to deliver essential health services, including individual counselling as well as group nutrition and health education in hard-to-reach areas.

UNICEF also advocates for increased maternity leave and breastfeeding friendly workplaces and to support revised legislation that clarifies and updates the regulations around the selling and marketing of substitute milk products.

Recognising the ongoing challenges, Negash says to strengthen the protection of breastfeeding and regain the progress that has been lost is a shared responsibility between all members of society.

"UNICEF, government and other partners need to join hands in three areas,” she says. “The first one is continuing to promote counselling support, especially for young mothers, on the benefit of breastfeeding and on the harm of using breastmilk substitutes. The second is national legislation must be properly enforced to protect mothers from that commercial pressure. Thirdly, mothers need an enabling environment, including family support, the support of their employers and the support of the government, so that they can comfortably breastfeed in the workplace and can stay at home for longer before returning to work. If these three things come together, the breastfeeding situation will definitely improve.”

Vandy too recognises the ongoing need in her community to educate mothers on the importance of breastfeeding alongside addressing other health challenges, explaining that many parents still rely on traditional healers when their children become ill. In remote areas with poor sanitation and hygiene practices, breastmilk is considered the safest, no-cost and most environmentally friendly solution for protecting children against infection.

“Many children of my neighbours tend to fall sick very often,” she says. “I have observed that this is because some parents misunderstand health practices. Sometimes, they are too busy to look after their baby and they don't breastfeed properly and adequately.”

Vandy now hopes a pre-school will be built in her community so that her daughter can study without needing to travel to another village. Knowing the benefits of breastmilk last a lifetime, she is confident her children are on the path to a happy and healthy future.