Before Sim Ark gave birth to her second child, she didn't think much about what a workplace needed to accommodate a new mother.
Now that she's a working mother rather than a stay-at-home mom as she was with her first child, Sim Ark knows.
"I want to have a daycare facility right in my workplace so that I can visit my baby while working," said Sim Ark, 29, who works at the You Li International factory in Bavet city, in Cambodia's Svay Rieng province.
Three months after giving birth to her son Ham Ya Oudom, after many calls from factory administrators, Sim Ark returned to work. She didn't want to risk losing her job.
Her absence from home during the day meant the baby switched from breastfeeding to bottle-fed meals of infant formula. At night, he switched back to breast milk unless Sim Ark found herself working overtime, which she says causes her milk to dry up.
Everyone in Sim Ark's house — Phing Tithya, her husband, 29; Sim Lat, her sister, 40; and So Yam, her mother, 80 — knows how to mix breast-milk substitute (BMS) with boiled water or bottled mineral water to feed Ham Ya Oudom, a healthy, hungry baby who is happy except when he wakes up. Then, unless one of his adults carries him on a walk around the house or the village, he cries.
Although Sim Ark and other garment workers would like to be able to breastfeed their children until they are at least 6 months old, as doctors recommend, they don't know how to raise the issue with their employers.
"I'm not sure how it look like if we had [a daycare facility in a factory]. Maybe a family member could come and help [in the facility] to look after the baby," Sim Ark said, only to add, "then nobody would be available to do the work at home."
The change in Ham Ya Oudom's routine when his mother returned to work helps explain why the rate of breastfeeding is declining in Cambodia, a change that worries child development experts.
In 2010, 74% of Cambodia's infants younger than 6 months were breastfed. By 2014, the most recent year available, Cambodia had gone from having one of the highest rates of breastfeeding to a middling 65%, according to the latest available government data confirmed by UNICEF.
It is "a drastic decline," said Cristian Munduate, a UNICEF representative in Cambodia, who described breastfeeding as "the best practice for a child during its first 6 months of life — the first natural vaccine that a child receives."
Appropriate breastfeeding practices could prevent an estimated 823,000 child deaths every year worldwide, according to UNICEF, and breastfeeding contributes to improved cognitive development, school achievement and future earning potential, according to research published in the medical journal The Lancet.
The current rate of breastfeeding is estimated to cost about $1 million a year in treating children with diarrhea and pneumonia and mothers with type II diabetes, according to a report by Alive & Thrive, a global initiative to ensure mother and infant health. Breastfeeding alleviates all three conditions.
The Alive & Thrive report suggests Cambodia stands to lose $83 million a year because of future cognitive losses associated with inadequate breastfeeding.
Law vs. reality
Several factors contributed to Cambodia's declining rate of breastfeeding. Among them, according to UNICEF, are the lack of peer and government support for breastfeeding, the difficulty of juggling infant care with a job, and the aggressive marketing of infant formula.
With about 2.4 million women ages 15 to 34 participating in the country's labor force, Cambodia has a law guaranteeing many women the opportunity to breastfeed, Munduate said.
Yet law and reality have yet to mesh, as Lim Buyheak, 35, a Ph.D. candidate in clinical psychology at Vietnam National University, knows.
She has breastfed her daughter Heng Vichetsoma since she was born five months ago. She bought an electronic breast milk pumping kit for $145 and attempted to use it to pump and store her breast milk. Pumping turned out to be so difficult, she gave up. She now works on her thesis from home just to be able to breastfeed her daughter.
With like-minded young mothers, Lim Buyheak formed a Facebook group in November. It now has about 160 members who promote breastfeeding and support each other.
"When I breastfeed in public, I feel like I am odd," Lim Buyheak told VOA by phone. "For instance, when I was at the AEON, everyone takes out feeding bottles to feed the baby, and I hold my shirt to the side to breastfeed" at the upscale Phnom Penh shopping mall.
"At first, I felt a little bit shy as well," she said. "Now I feel very good to have support from my friends."
Sim Ark and Phing Tithya, a baker in Sneang village, Svay Ta Yean commune, have two boys: Ham Yarith is 5 years old, and Ham Ya Oudom is 5 months old.
Sim Ark's unmarried sister Sim Lat cares for the boys while their parents work.
Although Sim Ark's factory allows postpartum mothers one hour a day for breastfeeding, her job is 20 kilometers from home, a 30-minute motor scooter ride away. She's not alone in leaving her children with relatives.
In another household, Ouk Sokha, 58, sings lullabies to lull her 10-week-old grandson to sleep. Ouk Sokha has tended 11 grandchildren over the past eight years as her five daughters and one son have left their babies with her along with cans of baby formula and feeding bottles.
"I want my daughter to have the opportunity to earn money," Ouk Sokha said. "If she had to breastfeed, there was no way she could go to work."
As a young mother, Ouk Sokha breastfed each baby while working in the family's rice fields.
"In my generation, we all breastfed," she said. "Feeding [their infants] with baby formula is more preferable now."
Rocking the baby's bamboo cradle, Ouk Sokha said she fed her grandson five bottles of formula per day.
On average, the 10-week-old baby consumes seven cans of infant formula per month. Each can costs about $12. The minimum wage for garment workers is $182 per month.
The breast-milk substitute (BMS) industry is global and growing, in part because of marketing in developing countries such as Cambodia that undermines efforts to improve breastfeeding, according to UNICEF. In 2014, global BMS sales reached about $44.8 billion. By the end of 2019, sales are expected to have increased to $70.6 billion, according to the World Health Organization (WHO).
In Cambodia, a report published in July by Helen Keller International (HKI) and World Vision International (WVI) found "92% of breast-milk substitute labels contained text that idealized the use of BMS or discouraged or undermined breastfeeding," violating the government's decree to promote infant exclusive breastfeeding. The report investigated 66 stores across five provinces in Cambodia.
"These products are often marketed with misleading claims about improving young children's IQ and immune systems or that they are essential for healthy growth," Mary Champeny, a nutrition researcher from Helen Keller International, said in an email.
The World Health Assembly adopted the International Code of Marketing Breast-milk Substitutes in 1981 "to protect and promote breastfeeding, through the provision of adequate information on appropriate infant feeding and the regulation of the marketing of breast-milk substitutes, bottles and teats."
Yet according to a study Champeny co-authored, only 36.1% of Cambodian infants from birth to 5 months were exclusively breastfed, and 12.5% of children 20 to 23 months of age were still breastfed. Consumption of BMS was high, occurring among 43.1% of children zero to 5 months and 29.3% of children 6 to 23 months old.
Unlike their mothers and grandmothers who gave birth at home, Cambodian women today are more likely to deliver their babies in a health facility.
Consequently, the health system plays a significant role in supporting breastfeeding and serves as a critical source of breastfeeding advice.
Doctors such as Sot Sam Aun, 30, at Samaki Roumdoul Referral Hospital in Svay Rieng, where about 20 women go for delivery service every month, said women receive counseling to avoid BMS unless they cannot produce milk because of health issues or "are getting busy."
However, BMS companies make presentations once or twice a year to midwives who work in the hospital and are often closer to the young mothers than doctors.
"But we know that their marketing contradicts the [health] ministry's guidelines, which emphasize the benefits of breastfeeding," said Sot Sam Aun, so the BMS presentations "are not allowed to be held inside the hospital."
Although Cambodia prohibits the promotion of BMS in a hospital or health center, the Facebook page for Nutrilatt Cambodia shows mothers receiving BMS at high-end private clinics in Cambodia.
Nutrilatt Cambodia Managing Director Tim Sovannara said gifts of BMS to new mothers are "preparation" for those times when a mother cannot breastfeed because for whatever reason. "It is just a present for the delivery," he said. "We did not force them to use it."