Breastfeeding Key To Infant And Child Survival
Promoting something as simple as breastfeeding can reduce infant mortality by 11.6 per cent. But though India has among the worst infant and child mortality figures in the world, 75 per cent of the nation’s children are not breastfed from birth and over 50 per cent are not exclusively breastfed.
Breastfeeding Week, which comes and goes August, gets little attention from the media or public in India. This, in a nation with a high infant mortality rate of 57 per 1000 live births and an under-five mortality rate of 74.3 per cent (National Family Health Survey-3, 2005-06).
According to The Lancet series on maternal and child undernutrition, 2008, breastfeeding promotion alone contributes to an 11.6 per cent reduction in IMR (if coverage of promotion is 99 per cent) and can avert 21.9 million Disability Adjusted Life Years (DALYs) in 3 years. (DALYs combine years of life lost due to premature death and years of life lived with disabilities into a single indicator allowing assessment of the total loss of health from different causes. One DALY can be considered as approximately one lost year of “healthy” life. The impact of early initiation and exclusive breastfeeding on infant and child survival, therefore, is too enormous to ignore. The Lancet states that new research points out that even if all other nutrition risks were addressed, a substantial number of child deaths still require interventions related to breastfeeding practices.
But the low figures for early initiation of breastfeeding in India is
a matter of concern. Early initiation of breastfeeding is not seen in over 75 per cent of the nation’s children and over 50 per cent of children are not exclusively breastfed (NFHS-3).
Promotion of exclusive breastfeeding (no other milk, food, drinks, or water) within six months of birth and continued breastfeeding for 6-11 months is the single most effective intervention and can reduce under-five mortality by 13 per cent, according to child survival data published in The Lancet (2003). It notes that infants aged 05 months
who are not breastfed have a significantly greater risk of dying from diarrhoea and pneumonia compared to infants who are exclusively breastfed.
Infections in the newborn, diarrhoea and pneumonia, are largely responsible for child deaths from the time of birth till the end of the fourth year. Starting breastfeeding early (within half an hour of birth), and exclusively breastfeeding the infant for the first six months, are critical for a child’s survival.
Twenty million out of about 26 million babies born in India do not get exclusive breastfeeding by the time they are six months old. Dr Arun Gupta, national coordinator of Breastfeeding Promotion Network of India (BPNI), says this issue is not given the kind of importance it warrants because most of those entrusted with implementing nutrition programmes are under the impression that India is a “breastfeeding nation”. He adds that despite the fact that Prime Minister Manmohan Singh announced on August 15, 2008, that child malnutrition in India has to be eliminated, and mentioned the need for breastfeeding infants, little is done to actively promote the same. According to a deputy technical adviser of the Food and Nutrition Board, nutrition advocacy is a major activity and breastfeeding is a component under nutrition in the Integrated Child Development Services (ICDS) programme, but there is no separate allocation for breastfeeding.
“Breastfeeding can be promoted just by generating awareness and providing support to women and mothers. The expense involved is much less than what the government proposes to spend on other areas,” Dr Gupta notes.
Sub-optimal breastfeeding among urban poor
Breastfeeding gets little support overall, caught as it is between low priority accorded to it by the Food and Nutrition Department and the concerted efforts of baby food manufacturers to promote formula feeds despite the Infant Milk Substitutes Act 1992 (which prohibits the promotion of infant foods, infant milk substitutes and feeding bottles), and the focus on immunisation in infant and child survival progammes. Health activists say that breastfeeding is not a priority at the policy level, which translates into relative inaction by community health workers in rural and urban areas. Non-profit organisations, too, seldom give it the importance it deserves. “They very often only pay lip service to breastfeeding,” says a community social mobiliser. The worst affected are vulnerable women like those among the urban poor.
urban poverty is estimated at 28 per cent, according to the interim report of a committee directed by the Planning Commission, as against the previous estimate of 26 per cent. The urban poor live mostly in unlisted slums in cities and towns, marked by poor living conditions and access to healthcare, and weak social support systems. Infant mortality is at 54.6 per 1000, as per disaggregated NFHS-3 data analysed by the Urban Health Resource Centre (UHRC), an organisation that works on health issues of the urban poor.
The prevalent belief that women who are economically better off opt out of breastfeeding and poor women are more likely to practise it, is not substantiated by statistics: only 27.3 per cent mothers among the urban poor initiated breastfeeding within an hour of birth (compared to over 31 per cent for urban non-poor women), and more than half the babies born to urban poor women are were exclusively breastfed for six months.
Women working in the construction industry are a particularly vulnerable segment. The National Sample Survey 1999-2000 puts the number of construction workers at 20 million while Mobile Creches, an NGO that runs crèches and day care centres for children at construction sites, estimates this figure at 30 million workers, of which over 30 per cent are women. Conservative estimates
of women workers put the number of children at sites at 10 million and 300,000 children in Delhi alone, the NGO’s website states.
Construction workers usually get back to work two months after giving birth, and in the absence of family or community support, are unable to spare the time for breastfeeding. According to Mridula Bajaj, executive director, Mobile Creches, women employed in the construction sector are entitled to maternity benefits like paid leave, but since the bulk of the woman labour force is seasonal migrants, they do not avail of these benefits. While most women would get back to work at the earliest after delivering a child, and place the child in a day care centre, the
emerging trend is that most of these centres are far away from the construction site. “Ensuring exclusive breastfeeding is difficult because when the women leave their babies in the centre, they are unable to come back to feed them. Again, there is a lot of movement within the sector as the labour force moves to different locations based on demand,” Bajaj notes.
Women working as domestic help and in factories too face hindrances in ensuring exclusive breastfeeding for their babies. Nearly 94 per cent of the country’s workforce is in the unorganised sector, and few employers, be they households or companies, are willing to ensure that laws relating to breastfeeding are enforced. This, coupled with not enough political will for promoting breastfeeding, negatively impacts this critical component of neonatal and infant health.
Misconceptions and obstacles
The urban poor, who mostly reside in temporary settlements and unlisted slums, have no social reinforcements. With weak community linkages and a near absence of awareness promotion on breastfeeding, socio-cultural beliefs and misconceptions that impede breastfeeding prevail.
A combination of factors is responsible for poor early initiation of breastfeeding among them. Lack of awareness and misconceptions about colostrum (the yellowish fluid which has protective substances that protect against infectious diseases and promote growth), for instance, results in it being discarded. Also, very often, early initiation of breastfeeding is substituted with prelacteals like ghutti (a herbal concoction) or honey, as immediate breastfeeding is believed to cause indigestion.
Shameem, who lives in Chandbagh, a slum in north-east Delhi, says most women do not know that breastfeeding is important. She herself did not receive any information in this regard. Very little information is passed on by health workers to mothers, so usually women with four to five children are approached for advice as they are considered “experienced.” But these women themselves are not aware of the importance of breastfeeding, she says.
Mrityunjay Kumar, project co-ordinator at one of the Gender Resource Centres (GRC) in north- east Delhi, says that even community workers don’t know about the importance of breastfeeding. Early initiation of breastfeeding is affected because immediately after delivery, time is taken up in paying bills. Further, local nursing homes near poor urban habitations typically do not prioritise early initiation of breastfeeding.
Women from slums point to the pressure on many urban poor women to maintain their figures; there is a misconception that breastfeeding would ruin their figures. They are living in an urban but poor environment that is strikingly different from the rural areas many hail from, says Sudhir Rai, programme support consultant, Urban Health Resource Centre. With not enough awareness, misleading sources of information at times, the media obsession with bodies and the women’s desire to fit into this milieu, it is not surprising that the practice of breastfeeding early and exclusively, is ignored.
Most urban poor women working in the informal sector are unable to take time out to feed their babies. Those working as construction workers or
domestic help are seldom allowed time to feed their infants. Rai adds that the work of urban poor women, especially construction workers, is physically demanding and they are unable to address their own nutritional requirements.
Gaps in translating guidelines into action
Improving exclusive breastfeeding is critical in preventing undernourishment and diarrhoea among children and the National Guidelines for Infant and Young Child Feeding highlight this. But in urban poor settlements and slums, breastfeeding is not practised to optimal levels. In a scenario where the country posts malnourishment figures that are on a par with some nations in sub-Saharan Africa (42 per cent of children below five years of age in India are undernourished and for urban poor children, the figure is 49 per cent according to NFHS-3), this needs urgent attention.
Not enough is being done to promote breastfeeding through interpersonal channels and the mass media. NS De Silva, president of the 62nd World Health Assembly and Minister of Healthcare and Nutrition, Government of Sri Lanka, said that in Sri Lanka, with the campaign for promoting exclusive breastfeeding, the rate of breastfeeding now stands at 78 per cent. He was speaking in response to the petition submitted by International Baby Food Action Network’s ‘One Million Campaign: Support Women to Breastfeed’. The campaign (http://www.onemillioncampaign.org/en/Details_Petitions.aspx) demands concrete support systems for breastfeeding women to increase the coverage of early and exclusive breastfeeding.
Scant attention is paid to training with regard to breastfeeding. “People think, what is the training required to ensure breastfeeding? When actually, there are so many aspects involved like counselling, correct practices, infections or mastitis, breastfeeding for HV-positive women, among
others,” says Dr Gupta.
Monitoring and evaluation is another weakness in service delivery and not enough data is available. Dr Gupta says that in some areas, anganwadi workers and health workers such as ANMs and ASHAs/USHAs, monitor breastfeeding but as this is not yet in the guidelines of a national programme, the extent to which it is practised depends on the priority accorded to it by state governments.
Efforts towards recognising breastfeeding as a core intervention in infant survival and incorporating it in the 11th Plan have also not fructified; the intervention suffers from the absence of a budgetary allocation and thereby specific focus.
Public health authorities are calling for breastfeeding and complementary feeding promotion to be the key strategies to reduce the burden of under-nutrition, stunting and diseases, and prevent lifestyle diseases in adulthood, says Dr Gupta, who is also regional coordinator of IBFAN Asia.
He has urged the World Health Assembly to adopt a resolution in 2010 to deal with four key issues.
To prepare a specific plan of action on infant feeding which is budgeted and coordinated in the same way as action plans for immunisation.
To ensure the end of promotion of baby milks and foods intended for children under two years in a time-bound manner, i.e., by 2015.
To end partnerships in the area of infant and young child feeding and nutrition with commercial sector corporations that present conflicts of interests.
To create support and maternity entitlements for women both in the formal and informal sectors so that mothers and babies can stay close to each other for at least six months.
Dr Gupta says intense focus is required to promote breastfeeding for which a budgetary allocation and initiating a national programme would be necessary. Behaviour change communication through trained women at basti-level for breastfeeding support would be
effective in promoting breastfeeding and dispelling myths. In urban areas, the USHA could be effective in interpersonal communication, says Mridula Bajaj of Mobile Creches, and in this regard, the Gender Resource Centre is a very good model to see that the available schemes take off.
In the absence of legislation to cover informal sector workers, the available laws like having creche services at work sites would support the practice of breastfeeding, but they would need strict enforcement, she adds.
Intersectoral convergence between the Ministries of Health and Family Welfare and Women and Child Development and the Food and Nutrition Department, is critical but ground-level activities also need to be promoted by anganwadi workers and USHAs, says Dr Gupta.
He adds that training of healthcare professionals, ICDS staff, and USHAs with regard to breastfeeding, and ensuring support to women in this regard by dispelling misconceptions and fears, is essential. Having conducted training programmes in urban areas including with doctors from government hospitals, Dr Gupta believes that with the rollout of the proposed National Urban Health Mission, the issue would get more focused. Controlling indirect promotional activities by manufacturers of baby food would also help breastfeeding promotion, he adds.
Sudhir Rai of UHRC says special breastfeeding promotion camps would be a good means to generate awareness and prioritise breastfeeding. Dissemination of effective and sustained messages through television and radio about the importance of breastfeeding, dispelling misconceptions about colostrum, and explaining the role breastfeeding plays in child health, would also give the issue a boost. This was reaffirmed by women from slums spoken to, who noted that television messages and advertisements helped increase their information on the subject.
Monitoring and evaluation components need to be built into all major infant and young child feeding programme activities and collection of data concerning feeding practices integrated into national nutritional surveillance and health monitoring systems or surveys. Monitoring or management information system data should be collected systematically and considered by programme managers as part of the management and planning process. Unless breastfeeding is included in the guidelines at the Central level, state governments will not act on it, Dr Gupta says.
Dr Gupta is emphatic that eradication of child malnutrition should be considered as important a priority as climate change, and the same kind of interest needs to be created about it. Breastfeeding must be considered a national priority, he says, offering the example of Bhutan where he helped develop a strategy for promoting breastfeeding. “Policymakers were listening there,” he says.
Poor urban women are often considered better-off than their rural counterparts, but they have extreme vulnerabilities that are least understood and render their children weak and undernourished. Urban health experts hope that the National Urban Health Mission will address their concerns and emphasise that breastfeeding is critical.
By Deepanjali Bhas