When he heard that a hospital in Karachi was going to set up a milk bank for babies, the news was a “huge relief” for Mohammad Munawwar.
Because his wife was very ill and their premature son Ayan was in hospital, the 52-year-old father had to collect milk five or six times a day from various female relatives who were breastfeeding their own babies.
His joy was short-lived; last month the bank closed before a single ounce could be deposited after complaints from Muslim clerics. Doctors who had worked at the bank for more than 12 months share Munawwar’s disappointment.
“We have been working on the bank for a year and have been in intensive discussions with the religious clergy of Jamia Darul Uloom Karachi for the past eight months,” said Dr Jamal Raza, executive director of the Sindh Institute of Child Health and Neonatology (SICHN), which established Pakistan’s first milk bank in partnership with UNICEF.
He said the scholars had raised several concerns, all of which had been addressed and after the seminary finally gave the green light, the bank opened on June 12.
But the seminary has since withdrawn fatwa of consent, stating that the hospital would find it not only “difficult but almost impossible” to adhere to the strict conditions set by the institution’s clergy.
“The aim of the doctors who wanted to set up the breast milk bank may be in good faith, but we agree with Jamia Darul Uloom Karachi and do not think it should be encouraged,” said Hafiz Muhammad Tahir Mehmood Ashrafi, chairman of the Pakistan Ulema Council, though he declined to elaborate.
The complexity arises from the bond of kinship. In Islam, if a baby is nursed by a woman who is not the biological mother, any future marriage between that baby and one of the woman’s own children is forbidden.
The concern is further heightened by the fact that donors at the 750 milk banks in nearly 70 countries are anonymous and milk from different sources can be combined.
However, Raza said that would not have been a problem. “The original fatwa allowed us to mix a maximum of three to five breast milks, but we plan to limit it to one mother donating to one child at a time.”
Dr Azra Pechuho, Minister of Health for Sindh Province, said: “When there is a well-developed digital identification system in Pakistan, it is not difficult to track which child has been fed milk by which woman.”
She said the state should not miss this opportunity to “save the lives of premature babies because of this problem, which is clearly solvable.”
Ayan is not the only baby whose survival is at risk, said Dr. Hassan Jabbar, who works in the 52-bed neonatal unit. The unit holds an average of five to eight premature babies, who stay until they are strong enough to go home. A baby born at 26 weeks, for example, stays an average of six weeks.
“It’s the same story that keeps repeating itself and it’s very painful,” Jabbar said. “I just saw a one-kilo baby whose mother died during childbirth; how do we feed him?”
Bottle feeding is not a substitute, he said. “I am absolutely against bottle feeding babies, it means they have to go through more complications. People say ventilators are important in (intensive care); I say breast milk is more important. A ventilator costs 7.5 million rupees (£4,000); breast milk is free.”
Leading paediatrician Dr DS Akram said breast milk protects babies in a way that formula does not. “Premature babies have very underdeveloped protection against bacteria in their gut. If they are formula fed, they are at high risk of developing a serious gut infection called necrotising enterocolitis, which has a very high mortality rate.”
Therefore, Pechuho said, “if we want our premature babies to survive, we must have breast milk banks in all our obstetric and pediatric hospitals.”
Of the nearly 15 million babies born prematurely each year in the world, nearly 1 million die from complications.
According to the Pakistan Demographic and Health Council Survey 2018The country’s neonatal mortality rate is 42 per 1,000 live births, one of the highest in the world.
“A premature baby cannot latch on, cannot suck, and cannot swallow. He has to be fed through a tube,” said Dr Syed Rehan Ali of SICHN’s neonatal intensive care unit. He added: “The milk bank was a way to reduce our dismal neonatal mortality rate.”
Last week, Pechuho told lawmakers in the Sindh Assembly that she will call on the Council for Islamic Ideology to help make the initiative “Sharia-compliant”.
Ayan is now a month old and is bottle-fed. “He has gained weight and looks good,” Munawwar said. But cost is now a concern. “A can of milk costs Rs 2,600 and it runs out in six days,” he said. “I have three other children and no steady job,” he added.
Doctors say bottle feeding is not without its risks in places where few follow safe practices of sterilizing bottles and teats or are able to ensure that the water used for mixing is clean. “Mothers from lower socioeconomic groups often reduce the ratio of milk powder to water to make it last longer, to save money,” Akram said.
Despite laws that promote breastfeeding, Akram said the relentless marketing of formula continues and has had an impact. It is now illegal for breast milk replacement companies to approach health care facilities and for health care professionals to promote their products.
Only 48% of Pakistani mothers exclusively breastfeed their babies, lower than in Bangladesh (65%) and India (64%). In Sri Lanka, 82% of women breastfeed their babies for the first six months.
The clerics did not respond to requests for comment.