On 4 April, Shilpa Bharadwaj was admitted to a government hospital in Sanagneri Gate, Jaipur, as soon as she experienced the first twinge of labour pain. Later that day, she delivered a healthy boy. Twelve hours later, she died of complications. Her family, wracked with grief, had to turn its attention to the more pressing issue of the newborn’s immediate nutritional needs.

A July 2018 report, Capture The Moment, by Unicef and the World Health Organisation (WHO), says delaying breastfeeding after birth can be life threatening. A 2016 Unicef-WHO report (Nurturing The Health And Wealth Of Nations: The Investment Case For Breastfeeding) notes that India, along with Indonesia, China, Mexico and Nigeria, accounts for more than 236,000 child deaths every year due to inadequate breastfeeding.

Bharadwaj’s family, aware of the importance of breastfeeding, was worried the infant might turn into one such statistic.

“That’s when a common friend introduced us to an employee of the Mahatma Gandhi Hospital, who informed us of the Amrit Milk Bank, started by a local not-for-profit organization called the Inaya Foundation and the hospital together. We could get bottles of pasteurized donor human milk there," says Gaurav Bharadwaj, Shilpa’s brother-in-law. The family sent Gaurav to collect bottles from the bank on Tonk Road, on the outskirts of Jaipur. The doctor recommended at least 10 bottles a day for the newborn—with one bottle of 30ml milk every 2 hours. The hospital gave around 25 bottles. “It is because we suffered a tragedy that we learnt of the existence of such services. It has been life-saving for the baby," says Gaurav.

There are many like them who have just discovered such banks exist. Some of these are tucked away in the by-lanes of Jaipur, others are attached to medical colleges, such as the Institute of Child Health and Hospital for Children (ICH) in Egmore, Chennai. According to a landscape study, to be published next month by PATH—a global not-for-profit working to accelerate health equity—there are 60-plus such banks across the country, in both public and private hospitals. This number was just 14 in 2014, and 30 in 2016.

Experts believe many more are needed, given that India has one of the largest number of low birth weight babies in the world,with significant mortality and morbidity rates. According to a 2016 report in data journalism portal IndiaSpend, as many as 700,000 newborns die in India each year—29 per 1,000 births—due to low birth weight and preterm deliveries. “Feeding these (low birth weight) babies with breast milk can significantly reduce the risk of infections," states a chapter on “Infant And Young Child Feeding" in a 2014 report published by the Indian Academy of Pediatrics.Besides stating facts, both known and revelatory, the report urges the government, health experts and civil society to join hands to propagate the concept of banking human milk.

“If mother’s own milk is unavailable or insufficient, the next best option is to use pasteurized donor human milk," states the chapter. Ruchika Chugh Sachdeva, deputy director (maternal, new born, child health and nutrition) at the PATH India Country Program, concurs, adding that while many mothers resort to formula feeds, its benefits are nothing compared to donor breast milk. “In preterm babies, the organs are still developing. So, they are able to absorb and accept pasteurized donor milk better," she says.

Sachdeva says breastfeeding could prevent 160,000 under-5 deaths in India. PATH has supported the Union government and technical leaders in formulating the “National Guidelines on Lactation Management Centers in Public Health Facilities", launched in July 2017, to ensure access to milk for all babies by supporting scale up of milk banks in different states.

So, who makes for an ideal donor? According to PATH, any lactating woman who is in good health, and has enough milk after feeding her own baby satisfactorily, would be an ideal donor. However, any woman who uses illegal drugs, takes over 2 ounces of alcohol or its equivalent, or three caffeinated drinks per day, or has tested positive for HIV, hepatitis B and C, and syphilis, is taking radioactive drugs, and has received a blood transfusion in the past 12 months, would not be eligible.

Creating these categories and the stringent set of rules and regulations is only half the job. Convincing mothers to be active milk donors is another matter altogether. According to Unicef, India ranks lowest in breastfeeding practices among South Asian countries—with only 41% of newborns breastfed within an hour of birth and less than 55% of children under six months exclusively breastfed.

Unicef India mentions mothers, both in high- and low-income countries, face challenges such as poor healthcare and nutrition. Sometimes, families end up giving babies honey or sugared water as their first oral feed, referred to as prelacteal feed. An August 2018 IndiaSpend report says 41.5% of the children in Uttar Pradesh were given prelacteal feed, the highest in the country, followed by Uttarakhand (39.1%) and Punjab (32.1%). Across the country, 21.1% of the children got prelacteal feed.

Milk banks have a dedicated set of counsellors to answer such queries about lactation management and convince new mothers about the benefits of donating milk. At the Amrit Milk Bank, counsellor Mamta Choudhry, 33, can be seen responding to the queries of seven-eight donor mothers. In an adjoining room, which has five electrical and manual pumps each, some new mothers are busy expressing milk. Their babies are in the neonatal ICU (Nicu), unable to take their feed, so they can donate excess milk.

View Full Image Nitisha Sharma of the Inaya Foundation with milk donors at the Amrit Milk Bank.

It has taken Amrit, set up in 2016 at the Mahatma Gandhi Hospital, time to convince both doctors and patients about the benefits of milk banking. “One of the frequently asked queries is: ‘God knows what you will do with the milk. Will you sell it commercially?’" says Choudhry. The team takes them around the facility to show just what happens to the milk.

A majority of the donors hail from neighbouring villages in Sanganer as well as Jaipur. You will often find Nitisha Sharma, founder of the Inaya Foundation, which runs the bank, sitting with the mothers—who donate on a voluntary basis—connecting stories from myths and legends with the need to donate milk. “We tell them historical stories in local Rajasthani dialects of Panna Dhai (nurse to Udai Singh II) as an example. The team has made a lot of recordings of previous donors, so that is shown to them. It needs to be emphasized that their donation will give a jeevan daan (gift of life) to the babies, as breast milk is most important for a strong immune system," she says.

It has taken the banks a while to wean mothers off the tendency to give prelacteal feed to their babies and encourage them to reach out to banks. Choudhry has witnessed some horror stories in the labour room at the Mahatma Gandhi Hospital, where she used to work as a nurse until 2016. “Some mothers would not let us know they were not producing sufficient milk, owing to fears of ostracization and ridicule from the family. They would feed the newborn tea which would come for them," she says.

The team at the Amaara Human Milk Bank, a not-for-profit located at La Femme Fortis in south Delhi’s Greater Kailash-II, is trying to convince donors through social media events, flyers and counselling. Founded in 2016, Amaara was the first-of-its kind public milk bank in the National Capital Region.

View Full Image The Comprehensive Lactation Management Centre at the Lokmanya Tilak Municipal Medical College and General Hospital in Mumbai.





The team realized that the best way to convince donors is to make the process easy and convenient. “So we started, for the first time in India, a home collection service. Any new mother who is getting excess milk can express the milk at home and put it in the freezer," says Raghuram Mallaiah, director and head, neonatology, La Femme Fortis, and co-founder, Breast Milk Foundation. A team from the hospital will come to her house with an ice box and collect the bottle.

The donor does have to undergo a series of blood and screening tests to make sure she meets the eligibility criteria and is free of infection. “These tests too are conducted at home, free of cost," says Dr Mallaiah. The bank offers counselling on ways to sterilize bottles and ensure a hygienic sample, as well as the optimum temperature milk should be stored at.

Disha Batra, who stays in Delhi’s Sultanpur Farms and runs a digital marketing agency and a concierge company, became one of the donors at Amaara last year. “I would pump milk fresh for my daughter and keep storing the excess in the freezer. Breast milk is called liquid gold and is so precious to a mother. And here I had this stock of milk which was not getting used. And I didn’t know what to do with it," says Batra, whose daughter is now 19 months.

One day, while waiting for an appointment with Dr Mallaiah, she chanced upon a flyer for the breast milk bank. “And after tests and checks, I started collecting the surplus milk. I would call the hospital and a person would come with a box for collection. It was really convenient," says Batra, who donated milk four-five times, close to 75-80 ounces each time.

“Every ounce matters. A lot of people associated with my agency or on social media weren’t even aware that such a service existed. But now the awareness is slowly seeping in," she says.

Whether it is Amaara or the Amrit Milk Bank, the founding teams first visited Mumbai’s Sion area. For, this is where the Lokmanya Tilak Municipal Medical College and General Hospital is located—the first hospital in India to set up a human milk bank in 1989. It was started by Armida Fernandez, then head of the department of neonatology, after the hospital started losing its babies in the Nicu due to diarrhoea and infections after feeding them formula.

“She decided to do away with formula feed completely, and also emphasized that mother’s milk is best for the baby. And if that is not available, the next best option is another mother’s milk, made safe by pasteurization," says Jayashree Mondkar, dean and professor, department of neonatology, who was an associate professor when the milk bank started. Soon, the hospital began to see a rise in the recovery rate of newborn babies.

Though it stands as an example for new milk banks, the one in Sion has had its own share of challenges. It started with generous initial funding from the Taj group of hotels. Soon, however, the team was struggling with a large neonatal unit—8,000-10,000 deliveries a year at a given point—and bare minimum staff.

“The Taj group made it easy initially by financing the bank and staff for three years. But after that, it became the prerogative of the BMC (Brihanmumbai municipal corporation) to maintain the staff. And to convince them to fill positions for the bank was really tough. It was far easier to convince women to become donors as they were eager to help. Also, we got lactation counsellors to make them understand that the more milk they expressed, the better the supply will be, both for their babies and the ones that they are helping," says Dr Fernandez, who went on to establish SNEHA, which works for women and child healthcare and nutrition.

Initially, Sion was one of its kind. Dr Fernandez spent years convincing hospitals like KEM to organize a human milk bank. In the past five years, however, she has noticed a rise in the number of breast milk banks. “Maybe because there is sufficient research to convince the medical fraternity about the superiority of banked human milk over animal and formula feed. As a result, milk banks have increased the world over and India has joined in as well. These banks are necessary in hospitals with a large number of deliveries, and especially if they have neonatal intensive care units," she says.

Demand, however, continues to far outstrip supply. “When we started the bank, the demand was for 1,500ml per day but we were able to collect only 1,000-1,200ml," says C.N. Kamalarathnam, head of neonatology at Chennai’s ICH. Though it started in 2014 with donated deep freezers and pumps, it was upgraded as a model bank in Tamil Nadu in August 2015. “After years of counselling, we have managed to collect 250 litres of milk annually over the past two years, and we still need more. We are unable to spare milk for other hospitals," he says. Donor milk is also collected to be given to abandoned babies left in the hospital’s care.

Milk bank services are generally free. Amaara charges a minimal ₹200 a bottle from non-BPL (below poverty line) card owners to generate money for the facility. Its team prefers to hand over the milk to hospitals and neonatologists, rather than patients, to prevent misuse.

The Amrit Milk Bank, which has served 1,200 infants, is inundated with requests for milk from public and private hospitals such as Cocoon, Narayana Hospital and Rungta in Jaipur. “We get requisitions from as far as Delhi, which we are unable to fulfil as the milk can’t travel well that distance. But patients come in from Delhi, saying we have had a baby after 10 years or 16 years, and this milk saved his or her life," says Choudhry. The biggest achievement for the bank, perhaps, is that the use of formula feed has been stopped completely in the wards of Mahatma Gandhi Hospital. “The next step is to help babies in orphanages with donated breast milk," says Sharma.

MILK CULTURE

There was a time when milk banks around the country had varied practices. But organizations such as PATH are helping standardize technical and operational guidelines, while also helping hospitals to create infrastructure for storage and processing.

Today, there is a certain uniformity in the kind of equipment and services offered by milk banks, though there’s a long way to go. Each bank has a series of breast pumps—mechanical and electrical—to help donor mothers express milk. Once the milk comes in, it undergoes a milk culture, with the report coming in three days. The milk is heated to 62.5 degrees Celsius for 30 minutes in a pasteurizer or a water bath shaker, after which it is cooled to 25 degrees Celsius for 10 minutes. It is cooled further to 4 degrees Celsius and stored in the deep freezer.

According to international guidelines, the milk can be stored for 180 days. Banks also do a post-bacteria test before giving the milk to the baby.

“Also," says Dr Raghuram Mallaiah, “ours is the only bank (Amaara Human Milk Bank) to have a breast milk analyser. We check the protein and fat content for each bottle that is pasteurized. These qualities are very important when it comes to feeding premature babies. Each bottle is then sealed, with a label put on it."

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