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Breastfeeding practice at its low in India

By Ramesh Raja
In Health
March 7, 2016
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breastfeedingIn spite of surge in institutional deliveries, the number of children in India being breastfed in the first hour of birth is less than half. In fact, India ranks lowest among South Asian countries, including Afghanistan, Bangladesh and Sri Lanka in breastfeeding practices, with only 44 per cent women being able to breastfeed their babies within one hour of delivery. Thanks to (poor) existing policies, programs and schemes that have fallen short of meeting the objective of enhancing Infant and Young Child Feeding practices. India is far from reaching its targets on improving infant nutrition, as per the 4th Assessment of India’s Policies and Programmes on Infant and Young Child Feeding. Named “Arrested Development”, the report has been prepared by Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN). The report was released by Nutan Guha Biswas, additional secretary, Ministry of Women and Child Development.

The assessment done as part of the World Breastfeeding Trends Initiative (WBTi) reveals gaps in all ten areas of policies and programs to be implemented for enhancing breastfeeding in India. The report provides an objective assessment on infant and young child feeding (IYCF) policies and programmes as well as practices, with India scoring a total of 78 out of 150 indicating the nation has made little improvements since its last assessment in 2012.

The breakdown of the overall score revealed a major drop during the assessment of indicators 1 (Policy, Program, & Coordination), 2 (Baby-friendly Hospital Initiative), 4 (Maternity protection), 9 (Infant Feeding during Emergencies) and 10 (Mechanisms of Monitoring & Evaluation System).

Reasons for this stagnation include non-converting IYCF guidelines into a policy, non-functioning of the BFHI programme for over a decade, non-review of the maternity benefit laws, neglecting infant feeding in the disaster management programme, infrequency of surveys and the paucity of national data.

Little improvement was seen in the scoring of indicators 3 (Implementation of the International Code of Marketing of Breastmilk Substitutes), 5 (Health & Nutrition Care System), 6 (Mother Support & Community Outreach) and 8 (Infant Feeding & HIV).

According to Dr Arun Gupta, regional coordinator, International Baby Food Action Network (IBFAN) ASIA, and central coordinator, BPNI, “Though there are some welcome advances displayed in India’s current assessment, there are even more missed opportunities to actualize potentially easy gains. These missed opportunities reflect the failure of key decision makers in according issues related to Infant and Young Child Feeding high priority and due attention. The report underlines the need to create an optimal environment towards the health and well-being of all children and their families.”

He further adds, “It is not understandable why only 44 per cent women are able to begin breastfeeding within one hour when more than 75 per cent deliver in institutions as claimed by our Prime Minister during his speech recently at the “Global Call to Action Summit 2015”.

The World breastfeeding Trends Initiative (WBTi) is adapted from the World Health Organization (WHO) tool developed by International Baby Food Action Network (IBFAN) Asia for assessing and monitoring the state of implementation of the Global strategy for Infant and Young Child Feeding. It is currently being implemented in more than 100 nations. The assessment is done on the basis of scores given to the questions answered for each of the defined indicators. Being 15 in number, indicators 1 to 10 deal with IYCF policy and programmes, whereas indicators 11-15 deal with IYCF practices.

Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN) jointly coordinated the India Assessment 2015, between February and June 2015 using the revised WBTi 2014 tool. Typically done every 3 to 5 years, the aim of the survey is to study the impact and trends of various related policy measures.

This round of assessment and analysis for India comes at a time when major cuts have been announced in the social sector budgets related to education, health, and nutrition, including a massive cut in the Integrated Child Development Services scheme. Even though it has been over two years to National Food Security Act, rules are yet to be finalized. The experience of those working at the grass-roots also suggest that problems of implementation of existing schemes and programmes for children are grave and likely to be exacerbated by the budget cuts.

Analysis of the report further reveals that there is still a lot of scope for improvement and India can make significant gains over the next three years if priority is given to addressing indicators currently not performing well.

Given that 44.6 per cent initiate breastfeeding within one hour, 50.5 per cent babies receive complementary foods within 6-8 months whereas 64.9 per cent get exclusive breastfeeding (RSOC 2014 data). Essentially it mean that out of 26 million born in India, 14.5 million children are not able to get optimal feeding practices during the first year of life.

“All these indicators can be improved by simple and doable means not requiring vast investment but better coordination and conscious governance. There is scientific evidence available to support the actions that need to be taken in these indicators given the tools and training materials are readily available,” says Dr Vandana Prasad, national convener, PHRN and former member, NCPCR (National Commission for Protection of Child Rights).

As per the 2012 WBTi report, India scored a total of 74 out of 150 which was much lower than that scored by Afghanistan (99/150), Bangladesh (107.5/150) and Sri Lanka (129/150). The South Asian counties managed to advance much faster because the policy makers prioritized optimum breastfeeding and infant and child feeding, something India has not been able to do so far.

“The assessment report is an opportunity to policy makers and programme managers to raise India’s score by the time the next assessment comes around,” adds Dr Gupta.

Aggressive promotion of baby foods, lack of support to women in the family and at work places, inadequate healthcare support and weak overall policy and programmes were some of the reasons because of which infant and young child feeding practice indicators have not shown a consistent rise. The 2014 report of Euromonitor International has estimated a market worth over 22 billion rupees in India, and one that is growing each year, (Rupees 12,666 to 22,693 million from 2007 to 2012)

“Sales of infant formulas and infant foods are increasing at a rapid pace in India, which is a cause of concern,” says Dr JP Dadhich, national coordinator of BPNI.

The WHO has identified ‘poor infant feeding’ as a risk factor for survival of the child. It also estimates that 53 percent of pneumonia and 55 percent of diarrheal deaths are attributable to poor feeding practices during the first six months of life. Several studies have shown that initiation of breastfeeding within the first hour of birth decreases neonatal deaths by 22 per cent.

Several professionals, civil society groups and international agencies have signed up a Call to Action to Government of India to take actions to bridge the gaps including development of plans of action that are monitored and coordinated, sanctioning budget, reviving the Baby Friendly Hospital Initiative (BFHI), enforcing the IMS Act, and implementing maternity entitlement for all women.

Breastfeeding within first few hours of birth has been acknowledged as an important part of baby’s immunity to various diseases. Ignoring it systematically and promoting baby foods is a crime towards children and the government must intervene by taking necessary steps as that coming generations are healthy and strong.

What Lancet Report tells India?

Dr Arun Gupta

Breastfeeding was reportedly on a decline in 1970s. WhenIndia first measured breastfeeding in 1992 through NFHS -1, it opened our eyes that only about 40 percent women exclusively breastfed their babies and 16 percent initiated breastfeeding within one hour, as recommend by the World Health Organization. Then India enacted a historic legislation, which led to possible check on decline of breastfeeding. It is very timely that India needs to work on the rise of breastfeeding!

The Lancet provides a powerful piece of new evidence, which can be easily understood by the policy makers and economists. It can add 0.6 billion to India’s GNI. That’s like 4300 Crore annually. Breastfeeding rise can lead to increases in Intelligence Quotient (IQ) score of 3 points and adult earning capacity.

Now on health and nutrition.One third of India’s children areundernourished and poverty as it underlying factors. The Lancet has shown it is the highest impact interventions. For India it could reduce 156,000 child deaths, could rapidly bringdown IMR. It can reduce 3,900,000 episodes of diarrhea and 3,436,560 episodes of peumonia, which means reduciing a load on our ailing health system. Even going by a meagre expenditure estimate Rupess 1000 per episode it would save 730 Crore annually. Both these diseases have huge impact on nutrition status of our children.

Coming to non- communicable diseases(NCDs) in India. Annually, breastfeeding could prevent 4915 deaths due to cancer breast and reduce obesity by 26%. It also reduces type 2 diabetes incidence by 35% i.e. 1 out of 3 new cases can be prevented. While India is on the verge of developing a “National Multisectoral Action Plan on Non Communicable Diseases”, should it not be a part of this plan?

Aggressive marketing by milk formula makers remains a big barrier to increase the number of breastfed children. India enacted the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003,which bans promotion of all baby foods under the age of 2. It has successfully led to restriction of sales of milk formula and baby foods. Market analysts have found that from 2008 to 2012 sales of milk formula in India grew from 24,428 to 27,783 Tonnes as compared to China, where it grew from 294,800 to 560,000 Tonnes.

Indian policy makers should not give in to market forces, which are calling for repeal of this law. Health should remain a priority over profits. Rather needs to enforce strictly.

Even as we enter 2016, less than half of India’s infants initiate breastfeeding within an hour, or exclusively breastfed until 6 months, or receive good complementary feeding after six months along with breastfeeding. Very disturbing is the fact more 80 % women deliver in health facilities but only 47% are able to begin breastfeeding within one hour of birth. This is just shameful, health System should immediately respond to this unfortunate situation both in public and private;to plug the gap fast.Why can’t we get a dedicated lacatation counsellor appointed in all health facilities to provide these services? Similarly in the communities peer counsellors can do the job.

For the first two years feeding practices must be set right if meaningful results on child nutrition are to be seen. Labour laws need to befriendly to breastfeeding. Maternity leave of 9 month for all women should be seen as investment in the social capital. For women in unorganized sector, IGMSY should be universal in coverage, and minimum wages be paid for wage loss.

Breastfeeding can make a lasting difference. It has been shown in Bangladesh and Brazil that Breastfeeding has made a rise, provided you invest in the interventions required. That breastfeeding comes free is a myth one has get away with.

Ministers of Finance, Health and Women and Child, Niti Aayog and other sectors have this knowledge in front of them. They have the power to take action. They need to set aside a budget for breastfeeding interventions. A line item in the budget will go a long way for child health and human development.

The writer is a regional coordinator of International Baby Food Action Network (IBFAN) Asia and central coordinator of Breastfeeding Promotion Network of India (BPNI).