When he heard a hospital in Karachi was setting up a milk bank for babies, the news was a “huge relief” to Mohammad Munawwar.
With his wife very sick and their premature son Ayan in hospital, the 52-year-old father had had to collect milk five or six times a day from different female relatives who were breastfeeding their own babies.
His elation was short-lived; last month the bank closed before a single ounce could be deposited after complaints from Islamic clerics. Doctors who had been working on the bank for more than 12 months share Munawwar’s disappointment.
“We had been working on the bank [for] a year and had been in intense discussions with the religious clerics from Jamia Darul Uloom Karachi [for] the last eight months,” said Dr Jamal Raza, executive director of the Sindh Institute of Child Health and Neonatology (SICHN), which had established what should have been the first-ever milk bank in Pakistan, in collaboration with Unicef.
He said the scholars had raised several concerns, all of which were addressed, and after finally getting a nod from the seminary, the bank was inaugurated on 12 June.
But the seminary has now withdrawn its fatwa of assent, saying it had new advice that the hospital would find it not only “difficult but almost impossible to adhere to the strict conditions” set down by the institution’s clerics.
“The objective of the doctors who wanted to set up the human milk bank may be in good faith, but we concur with Jamia Darul Uloom Karachi, and do not think it needs to be encouraged,” said Hafiz Muhammad Tahir Mehmood Ashrafi, chair of the Pakistan Ulema Council, though he refused to elaborate.
The complexity arises due to the kinship bond. In Islam, when a baby feeds from a woman who is not the biological mother, any future marriage is forbidden between that baby and any of the woman’s own children.
Further exacerbating the concern is that in the 750 milk banks in nearly 70 countries, donors are anonymous and milk can be combined from several sources.
However, Raza said this would not have been an issue. “The original fatwa allowed us to mix a maximum of three to five mothers’ milk but we intend to keep it to one mother donating to one child at a time.”
Dr Azra Pechuho, health minister for Sindh province said: “When there is a properly developed digital identification system in place in Pakistan, keeping a record of which child got milk from which woman is not difficult.”
She said the state should not let this opportunity of “saving the lives of premature babies lapse because of this issue which is clearly resolvable”.
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 has, on average, between five and eight premature babies, who stay until they are strong enough to go home. A baby born at 26 weeks will stay for an average of six weeks, for instance.
“It’s the same story that keeps repeating and which is very distressing,” said Jabbar. “I just saw a baby weighing a kilogram whose mother died while giving birth; how do we feed him?”
Formula is no substitute he said. “I am totally against feeding babies with formula, it means putting them through even more complications. People say ventilators are important in an [intensive care unit]; I say mother’s milk is even more important. A vent costs 7.5m rupees [£4,000]; human milk is free.”
Leading paediatrician Dr DS Akram said breast milk protects babies in a way formula milk does not. “Premature babies have a very underdeveloped protection against bacteria in their intestines. If fed formula milk, [they] are at high risk of developing a severe gut infection called necrotising enterocolitis, which has a very high death rate.”
That is why, said Pechuho, “If we want our premature babies to survive we have to have human milk banks in all our obstetric and paediatric hospitals.”
Of the almost 15 million babies in the world born prematurely each year, nearly 1 million die due to complications.
According to the Pakistan Demographic and Health Survey 2018, the neonatal mortality rate in the country is 42 per 1,000 live births, one of the highest in the world.
“A premature baby cannot latch, cannot suckle and nor can he swallow, he has to be fed through a tube,” said Dr Syed Rehan Ali of the neonatal intensive care unit at SICHN, adding: “The milk bank was one way of reducing our dismal neonatal mortality rate.”
Last week, Pechuho told lawmakers in the Sindh assembly she will call upon the Council of Islamic Ideology to help make the initiative “Sharia-compliant”.
Now a month old, Ayan is on formula. “He’s gained weight and looks good,” said Munawwar. But cost is now a concern. “A tin of milk costs 2,600 rupees and it is consumed within six days,” he said. “I have three other kids and do not have a regular job,” he added.
Formula milk is not without danger, say doctors, in places where few adhere to safe practices of sterilising bottles and teats or are able to ensure the water used for mixing is clean. “Mothers from lower socioeconomic groups often reduce the proportion of the milk powder to the water for it to last longer, to save the cost,” said Akram.
Despite laws promoting breastfeeding, Akram said the relentless marketing of formula continues and has had an impact. It is now illegal for breastmilk substitute companies to approach healthcare facilities and for health professionals to promote their products.
Just 48% Pakistani mothers exclusively breastfeed their babies, lower than in Bangladesh (65%) and India (64%). In Sri Lanka 82% of women breastfeed their babies in the first six months.
The clerics did not respond to requests for comment.