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Indian Pediatr 2009;46: 11-17 |
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Mainstreaming Early and Exclusive
Breastfeeding for Improving Child Survival |
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J P Dadhich and RK Agarwal*
From S L Jain Hospital, Delhi, India and *R K Hospital,
Udaipur, India.
Correspondence to: Dr JP Dadhich, 23 Canara Apartments, Sector 13, Rohini,
New Delhi 110 085, India. E-mail:
[email protected]
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I ndia is home to
maximum number of under-five deaths and underweight children in the world.
In 2006, for the first time, the number of children in the world dying
before their fifth birthday fell below 10 million, to 9.7 million
annually. South Asia’s contribution to this figure was 3.1 million out of
which 2.1 million deaths occurred in India i.e., 21 percent of the
global burden of under-five deaths. Most of these deaths occur during the
neonatal period. A reduction in the number of deaths among the under-five
children reflects the country’s progress on the fourth Millennium
Development Goal (MDG 4)(1-3).
About 55 million, or one-third of the world’s
underweight children under the age of five years, live in India.
Malnutrition has been estimated to be an underlying cause of up to 50–60
percent of under-five deaths. The number of young underweight children
reflects the country’s progress on the first Millennium Development Goal
(MDG 1), which deals with eradication of extreme poverty and hunger(1,3).
In India, the average annual rate of decline in malnutrition has been
around 0.9% since 1990. Considerably accelerated progress is needed for
India to meet its MDG target of halving the percentage of underweight
children by 2015(2). The World Health Organization (WHO) Global Database
on Child Growth and Malnutrition concludes that the mean weights in
developing countries start to falter at about 3 months of age and decline
rapidly thereafter in infancy(4). Results of the third National Family
Health Survey (NFHS-3) also show that at six months of age 29.5% infants
are already underweight(5). These findings highlight the need for early
life interventions to prevent growth failure and consequent ill effects.
Early breastfeeding within one hour and exclusive
breastfeeding for the first six months are the key interventions to
achieve MDG 1 and MDG 4, which deal with reduction in child malnutrition
and mortality, respectively(3,7). In India, effective implementation of
these interventions is yet to be achieved. NFHS-3 data show that the
initiation of breastfeeding within one hour is only 24.5% while the
exclusive breastfeeding rates in children under six months is only
46.4%(5). Universalizing early and exclusive breastfeeding in the country
will require a national policy and program, along with effective
strategies and necessary budgetary provisions. In the ensuing sections, we
explore the role of early and exclusive breastfeeding as child health
strategies and evidence-based ways to universalize optimal infant and
young child feeding (IYCF) practices.
What are the Global Recommendations for Optimal IYCF
Practices?
The guidelines on the IYCF recommend that infants
should begin breastfeeding within one hour and be exclusively breastfed
for the first six months of life to achieve optimal nutrition, survival,
growth and development. Thereafter, to meet their evolving nutritional
requirements, they should receive appropriate and adequate complementary
feeding along with continued breastfeeding for up to two years of age or
beyond(8,9). Mainstreaming of optimal IYCF, inclusion of breastfeeding
indicators in outcome evaluation, capacity building for effective
improvement in breastfeeding rates, breast-feeding research and building
public awareness on the importance of breastfeeding are crucial parts of
policies and strategies related to child nutrition, health and
development. Child health programs currently do not focus adequately on
improving public awareness of the importance of breastfeeding and on
providing adequate knowledge and counseling skills.
The global community is committed towards accelerating
the achievement of Millennium Development Goals. There is growing
under-standing worldwide to invest in direct interventions for exclusive
breastfeeding rates to go up. The September 2007 "Campaign to Reduce
Maternal and Child Deaths" stressed on two interventions to reduce
neonatal deaths: (i) breastfeeding and (ii) treatment of
sick neonates using antibiotics by trained medical workers(10). The 2006
report of the World Bank also advocates shifting emphasis of nutrition
programs from directly providing food to changing the behaviors of
mothers–to early initiation and exclusive breastfeeding for the first six
months of life and seeking quick treatment for children’s illnesses. The
report emphasizes that the developing countries must increase investment
in nutrition programs for speeding poverty reduction, to achieve high
benefit-cost ratios, and to improve nutrition much faster than reliance on
economic growth alone(11).
In its report "A Practical Plan to Achieve the
Millennium Development Goals" the MDG Task force recommends "Neonatal
Integrated Package" that includes 2 key components: neonatal care and
breastfeeding education. Women to succeed in breastfeeding need accurate
information during pregnancy, assistance and support at the time of birth
for early initiation, counseling to maintain exclusive breastfeeding for
the first 6 months, answers to their questions, solution to their problems
like ‘not enough milk’ and breast problems such as sore nipples, mastitis
and engorgement. Breastfeeding education (in all situations including HIV
infection) providing correct information in simple language by a
well-trained care provider will help prevent problems and help women to
succeed in breastfeeding(12,13).
Evidence in Favour of Breastfeeding as a Child Health
Strategy
Exclusive breastfeeding and child survival
In 2003, Lancet series on child survival(6) and later
Lancet series on newborn survival(14) summarized that 13% to 15% of
under-five deaths in resource poor countries could be prevented through
achievement of 90% coverage with exclusive breastfeeding alone and an
additional 6% deaths could be prevented with appropriate complementary
feeding. Moreover, these interventions are level 1 intervention i.e.
sufficient high-quality evidence of their beneficial effect is
available. It sets a stage for scaling up preventable interventions to
universal level. The recent Lancet series on maternal and child
undernutrition(7) has evaluated the effectiveness of universal coverage of
promotion of breastfeeding strategies as a public health intervention.
Some observations from this review are summarized in the Box.
A global ecological risk assessment(15) concluded that
globally, as many as 1.45 million lives (117 million years of life) are
lost due to sub- optimal breastfeeding in developing countries. This study
further justifies focus on nutrition interventions being mainstreamed.
Another study from Bangladesh (13) described breastfeeding practices and
investigated the influence of exclusive breastfeeding in early infancy on
the risk of infant deaths,
especially those attributable to respiratory infections (ARI) and
diarrhea. It concluded that compared with exclusive breastfeeding in the
first few months of life, partial or no breastfeeding was associated with
a 2.23-fold higher risk of infant deaths resulting from all causes and
2.40- and 3.94-fold higher risk of deaths attributable to ARI and
diarrhea, respectively. The study showed that in the study community, when
exclusive breastfeeding rates at 6 months were increased from 39% to 70 %,
the reduction in the infant mortality rate (IMR) was to the tune of 32% in
a very short span.
Early initiation of breastfeeding prevents neonatal
deaths
A study from Ghana
showed an association between timing of breastfeeding and newborn
survival(16). The study showed that 22% of all neonatal deaths could be
prevented if all women could initiate breastfeeding within one hour of
birth. Further, an epidemiological evidence of a causal association
between early breastfeeding and infection specific mortality in the
newborn infants has also been documented(17). Though it is intuitively
correct, this is the first time a study has demonstrated this with data on
infection specific mortality. The study showed that those newborns in
Ghana, who died of neonatal sepsis had 2.6-fold increase in odds of late
initiation (after day 1) of breastfeeding (adjusted OR 2.61; 95% CI: 1.68,
4.04]. The risk of the infection deaths increased with increasing delay in
initiation of breastfeeding from 1 hour to day 7. Additionally, partial
breastfeeding during first month was associated with risk of death as a
result of infectious disease (adjusted OR: 5.73; 95% CI: 2.75, 11.91)
after adjusting with the effect of early breastfeeding. This means that
programs that focus on early initiation of breastfeeding and exclusive
breast-feeding in the neonatal period can significantly reduce the burden
of infectious disease-related mortality. This is an important addition to
existing scientific evidence on the role of breastfeeding in saving
babies. It calls for focus on preventive approaches in saving newborn
babies and reduce burden on curative health services.
Long-term effects of breastfeeding
Breastfeeding is also linked with childhood
intelligence and adult health. WHO has published a systematic review to
assess the association between breastfeeding and hypertension, diabetes
and related indicators such as serum cholesterol, overweight and
obesity(18). This meta-analysis conclusively establishes protective role
of breastfeeding on obesity, diabetes, hypertension and resultant
cardio-vascular disease later in the life. All effects were statistically
significant, but for some outcomes the magnitude of benefit was modest. A
recent Indian study has found that breastfed babies have significantly
higher total cholesterol and LDL-cholesterol compared to mixed fed babies
in the first 6 months of life with improving HDL-cholesterol /
LDL-cholesterol ratio at 6 months. High cholesterol intake in infancy may
have a beneficial long-term programming effect on synthesis of cholesterol
by down-regulation of hepatic enzymes(18,19).
Exclusive breastfeeding cuts down HIV transmission
Exclusive breastfeeding can cut down HIV transmission
rates from HIV positive women to their offspring by half in comparison
with those who practice mixed feeding. The new intervention cohort study
from South Africa, assessed the HIV-1 transmission risks and survival
associated with exclusive breastfeeding and other types of infant feeding
in HIV positive women. Risk of acquisition of infection at six months of
age via exclusive breastfeeding was 4.04%. Breastfed infants who received
some solids had 11 times higher risk of infection and if other milk or
formula is given along with breastfeeding, the risk could almost
double(20). The study showed that HIV free infant survival was much higher
in exclusively breastfed children at 3 months.
Status of Policies and Plans for Early and Exclusive
Breastfeeding in India
The Global Strategy adopted by the World Health
Assembly (WHA) and the UNICEF Executive Board in the year 2002, calls for
urgent action by all members states to develop, implement, monitor and
evaluate a comprehensive policy and a plan of action on IYCF to achieve a
reduction in child malnutrition and mortality(21). The assessment of the
policies and programs for infant and young child feeding in India
identified several gaps(22), some of which are given below:
• Lack of a national policy for IYCF consistent with
global recommendations
• Lack of a national plan of action or strategy for
IYCF
• Lack of any specific budgetary allocation for IYCF
• A standstill baby friendly hospital (BFHI)
initiative program, waiting for revival
• Inadequate measures for maternity protection
• Inadequate emphasis on IYCF especially skills
training in the pre service education curriculum of health workers
• Inadequate access to counseling services in the
community during pregnancy and postnatal period
• Inadequate policy and program support for infant
feeding counseling for HIV positive mothers
• Lack of a policy that addresses key issues related
to IYCF during emergencies
• Lack of monitoring and evaluation components in the
major IYCF programme activities
Is it feasible to improve breastfeeding rates?
Improving breastfeeding practices requires support at
the family and community levels. A study done by the ‘Infant Feeding Study
Group’ from India concluded that promotion of exclusive breastfeeding
through existing primary healthcare services is feasible, reduces the risk
of diarrhea, and does not lead to growth faltering(23). In this study, the
key input was a 3-day training of frontline workers on IYCF counseling.
Another multicentric study from Bolivia, Ghana and Madagascar(24)
concluded that sizeable improvements in optimal breastfeeding can be
achieved within a relatively rapid time by the programs using a approach
that had partnerships, training, behavior change communication, and
community actions. A study from Uganda, Africa revealed that
training and follow up of peer counselors to support exclusive
breastfeeding in the rural district was feasible. In this study, locally
selected women were trained for five days on breastfeeding counseling
using a structured curriculum. After training they returned to their
communities and started supporting breastfeeding peers. They were able to
identify common breastfeeding problems such as "insufficient breast milk",
sore nipples, breast engorgement, mastitis and poor positioning at the
breast and were able to take action to establish correct positioning of
the baby at the breast(25).
Interventions Required at Country Level
India, which is striving to improve the situation of
child undernutrition and child survival and wish to mainstream and
integrate ‘breastfeeding education’ and support in the child health and
development programs, needs to undertake following actions:
1. National IYCF policy and a national plan
of action: It is necessary to recognize IYCF as a
scientifically proven intervention to improve child nutrition status and
child survival. It needs a comprehensive national policy developed in
consultation with all the stakeholders. It also requires a national plan
of action and adequate budgetary allocations to bridge various
identified gaps in the policy and programs.
2. Child health and development programs:
There is an urgent need to include breastfeeding counseling by
appropriately trained counselors as a preventive intervention in the
programs like Integrated Child Development Services (ICDS) scheme,
National Rural Health Mission (NRHM), Reproductive and Child Health –2
program, and Integrated Management of Neonatal and Childhood Illness
(IMNCI).
3. Community initiatives for supporting
women: Aggressive marketing of baby food by companies can
easily mislead women who don’t have access to accurate information. It
also causes lack of confidence among women to be able to meet the
nutritional demands of their babies. The feeling of ‘not enough milk’
forces many mothers to resort to other milks or foods during the period
of exclusive breastfeeding. The remedy lies in building their
confidence, which is a skillful act. They need support during pregnancy
and childbirth whether they work inside homes or outside. An empathetic
and skilled health worker must support women at the time of birth to
succeed in beginning breastfeeding within an hour of birth and providing
prolonged skin-to-skin contact. They should also have access to
counseling (one to one or group) and support to continue breastfeeding
for the first 6 months. They need answers to their questions and
solution to their problems like sore nipples, mastitis and engorgement.
Women also need counseling for adequate complementary feeding and
continued breastfeeding at completion of 6 months. Finally, if women are
HIV positive, they need counseling for infant feeding options. The
support to the women may be provided at different levels:
(a) At village level, the community based
health workers should impart counseling services after getting
appropriate (at least three days) training in breastfeeding counseling.
Basic curriculum of health workers must also include the breastfeeding
counseling.
(b) At a cluster of 5-10 villages (or maximum
of 30 villages), there should be an IYCF/breastfeeding/lactation support
center managed by woman nurse adequately skilled and trained using a 7
day-course such as the one developed by Breastfeeding Promotion Network
of India (BPNI)(26). The counseling specialist should be able to provide
counseling in all situations including HIV positive mothers.
(c) BFHI should be implemented in all
hospitals. The BFHI program was initiated in our country with great
hopes and expectations, but the implementation of the program lacked a
strong training component. There was no monitoring and reassessment
system in place. The program at the moment is standstill and requires a
revival in line with new international guidelines.
4. Pre-service curriculum strengthening for
doctors and nurses: This will help reduce the need of
in-service training and improve knowledge and skill of doctors and
nurses, which is seriously lacking. BPNI and a technical group of
medical college teachers have developed a teaching module that can be
easily integrated in undergraduate medical education without increasing
the duration of teaching.
5. Protecting breastfeeding: The legislation,
the Infant Milk Substitutes, Feeding Bottles and Infant Foods
(Regulation of Production, Supply and Distribution) Act(27) is in place
for last so many years, but it needs an effective implementation. There
is a need to ensure that the provisions of the Act are widely
disseminated among all stakeholders at all levels in a user-friendly
manner. Monitoring is also needed for effective implementation of IMS
Act. The IMS Act also requires further strengthening in many aspects
including synchronizing it with relevant World Health Assembly
resolutions about sponsorship for health workers and conflict of
interest.
6. Behavior change communication: The
objectives should be to build an enabling environment to support mothers
and families and develop a communication strategy based on an assessment
of local and existing feeding and caring practices with the aim of
promoting positive behavior as per the IYCF guidelines.
7. Maternity benefits: Working mothers
should be supported to achieve successful exclusive breastfeeding by
ensuring effective enforcement of maternity benefit act and provisions
of supportive child care services. There is a dire need to strengthen
the Maternity Benefit Act so as to include maternity leave benefits for
six months for all the working mothers. It includes providing leave or
cash support to ensure babies and mothers stay close and provision of
crèches at work places.
Conclusions
Despite breastfeeding’s numerous recognized advantages,
early and exclusive breastfeeding rates in most states of the India are
low. There are many gaps in policy and programs related to infant and
young child feeding in India. The big challenge is how to mainstream IYCF
counseling and support interventions to help women to succeed both in
early and exclusive breastfeeding. The rationale for supporting a major
program to protect, promote and support breastfeeding action, backed by a
budgetary support, is compelling for our country. Child health and
development policies should urgently address this major concern.
Funding: None
Competing Interests: JDP is working with
Breastfeeding Promotion Network of India (BPNI), an organization with
prime objective of protecting, promoting and supporting breastfeeding.
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