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Arun Gupta
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Information and communication technologies can be used strategically to deliver health services effectively and extensively. What is required is completing the nutrition package of child health and delivering infant feeding counseling to all families as a part of integrated neonatal package.
Infant and young child feeding (IYCF) should be considered a key priority in child health and development programming considering the health and economic benefits linked to this achievement For the effective integration of infant feeding in the existing child health and development programmes, there is a need particularly to reposition the Integrated Child Development Services (ICDS) from food based interventions to feeding based interventions. There is a defined need to reposition the ICDS as a true development programme. Such a process would, however, require additional spending and a high-level, focussed political response.
IYCF needs a serious reappraisal in India. Infant and young child feeding practices in India are far from optimal; according to the National Family Health Survey (NFHS)-2, exclusive breastfeeding rapidly falls form 72 per cent at one month to 20 per cent at six months. Similarly other indicators are also disappointing. Complementary feeding practices are also very poor, only 33 per cent between 6-9 months are given solid mushy foods (NFHS-2). Comparison with NFHS-1 highlights that we are able to stop the decline in breastfeeding. However, achieving the national goals will require massive action and resources. Results from a recently done study from 49 districts (2003)1, with a data of close to 9000 mothers, also show a dismal picture.
It is critical to invest in the early years of life by spending on ensuring optimal infant and young child feeding practices as means to prevent and reduce child malnutrition. Providing Infant and young child feeding counseling as a service to families would be a welcome step in this direction. This can translate our commitments to children and fulfill their rights to highest attainable standards of health through improved nutrition, health and development outcomes. If the government has the intention to achieve the Tenth Five-year Plan goals of infant feeding like increasing exclusive breastfeeding to 80 per cent and adequate complementary feeding to 75 per cent, bold decisions have to be taken both by the ICDS and Reporductive and Child Healthcare (RCH) programmes of government of India. Focus must shift from curative to preventive approaches.
Optimal infant and young child feeding
Optimal infant and young child feeding means that every child gets the best possible start to life through exclusive breastfeeding for the first six months and continued breastfeeding for two years or beyond, along with adequate and appropriate complementary feeding beginning after six months(1) .
After the rapid decline of breastfeeding globally in the 60s, science had to revisit breastfeeding practices during the last three to four decades. This led to a clear evidence that breastfeeding provides ideal and irreplaceable nutrition to the baby, protects it against infections, allergies and asthma, promotes physical, physiological, motor, mental and psycho-social growth and offers protection against obesity and some adult diseases such as diabetes, hypertension, ischemic heart disease and some forms of malignancy.(2) It saves money for the family and the nation, helps fertility control and is eco-friendly(3) . Breastfeeding has also been related to the possible enhancement of cognitive development(4) . There are advantages for the mother; breastfeeding reduces the incidence of post-partum bleeding(5) , leads to faster uterine involution(6) , reduces the risk of breast cancer(7) and ovarian cancer(8) , delays resumption of ovulation and increases child spacing(9) , improves bone re-mineralisation(10) after birth in women with reduction in hip fractures in post menopausal period(11) and finally, it is likely that all the benefits of human milk are not presently known(12)
According to the World Health Organisation (WHO), malnutrition contributes to more than 50 per cent of child deaths and recommends a preventive approach. It also recognises that more than 2/3rd of child deaths are related to poor infant feeding practices. Since most deaths occur within a month of the child being born, therefore, it would be important to offer a universal package of interventions to save newborn babies at the community level through trained healthcare workers. This integrated neonatal package is an intervention recommended by the Millennium Development Goals (MDG) Task Force and includes breastfeeding education. In India, efforts to influence care seeking and healthy infant feeding behaviors have most often been implemented with the intention of saving money or time for the health system, rather than seeking an effective information dissemination of natal information. This may be partly due to the fact that programme managers are not completely aware of the benefits of counseling and education for optimal infant feeding. It is also true that these interventions are harder to implement effectively, and require more organisation, generation of additional resources and highly motivated and skilled staff.
It is important to know that to be effective we should focus on how well these (the intensity and quality of) interventions are implemented rather than what is specifically implemented and by whom. Fortunately, most of the interventions that are needed can be delivered through existing services. However, specific infant feeding components need to be integrated effectively into these services and their overall quality and responsiveness needs to be improved.
Under the National Rural Health Missions just launched Accredited Social Health Activists (ASHA) scheme, accredited social health activists must be properly trained in all areas, but should have at least three days training in infant and young child feeding counselling. This will ensure basic education to impart correct information, help all women to solve not enough milk problem and other common problems related to feeding.
The social health activists refer women to a higher-level for complicated problems like breast infection and abscess. Thus outreach programmes should actually function as Breastfeeding Support Centres (BSC), and one such center each must be available at least for a population of 5000. The Integrated Management of Childhood Illness (IMNCI) being launched under the new RCH programme in almost 125 districts must effectively address the infant feeding skills component including Human Immunodeficiency Virus (HIV). Urban hospitals staff should receive training in counseling on breastfeeding, which can be achieved by a composite 5-6 day training package.
Using communication technology effectively
Communication through the electronic medium can best be used for tracking and reporting the status of child health and development in the country. This medium needs to exploit its strengths in initiating discussion forums on child
health and development: Why it is important and how do we achieve it? News channels can start special series on the status of child development in the country.
Health bulletins on the benefit of breast-feeding can be devised for both the radio and the television medium, for a maximised impact.
Conclusion
Most interventions designed to improve early and exclusive breastfeeding and complementary feeding are a part of community interventions, which are an integral part of the healthcare system. Even those interventions that are implemented outside of the health facilities are affected by what happens within these health facilities, since infant feeding behaviours and mothers perceptions of optimal feeding practices are influenced by their interactions with the healthcare system. There is a multitude of evidence to illustrate that what happens in the healthcare system can in some cases support and in others, undermine the optimal infant feeding practices. It is thus important to provide optimal infant feeding services and support to mothers. More importantly, efforts in health facilities need to be linked with outreach efforts so that interventions effectively reach women. Here information and communication technologies can be used strategically to deliver health services effectively and extensively. What is required is completing the nutrition package of child health and deliver infant feeding counselling to all families as a part of integrated neonatal package.
For programme and policy makers, infant and young child feeding should not be lost in the garb of integration, even WHO recognises it as a main intervention in a recent publication released on World Health Day April 7, 2005; Making every mother and baby count. Better start counting and hold yourself accountable .
Endnotes
1 The Global Strategy for Infant and Young Child feeding. WHO/UNICEF 2003.
2 The Long-term Benefits of having been breast-fed. Fewtrell MS. Current Pediatrics, 2004(14): 97-103.
3 Economic and ecological effects of breastfeeding. Phatak A. J Obstet Gynaecol India 1999; 49: 35-38.
4 Breastfeeding and cognitive development in the first 2 years of life. Soc Sci Med 1988; 26:635-639.
5 A Large Scale Rooming in Programme in a Developing Country. Proceedings of the interagency workshop on Health Care Practices related to breastfeeding. Gonzales, R. Int J Gynecol Obstet April 1990.
6 Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Chua S, Arul Kumaran S, Lim I, et al. Br J Obstet Gynaecol 1994; 101: 804-805.
7 Lactation and a reduced risk of premenopausal breast cancer. Newcomb PA, Storer BE, Longnecker MP, et al. N Eng J Med 1994; 330:81-87.
8 WHO Collaborative study of Neoplasia and Steroid contraceptives. Rosenblatt KA, Thomas DB. Int J Epidemiol 1993; 22:192-197.
9 Contraceptive efficacy of lactational amenorrhea. Kennedy KI, Visness CM. Lancet 1992; 339: 227-230.
10 Influence of breastfeeding and other reproductive factors on bone mass later in life. Metton LJ, Bryant SC, Wahner HW, et al. Osteoporosis Int 1993; 3:76-83.
11 Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. Cumming RG and Klineberg RJ. Int J Epidemiol 1993; 22:684-691.
12 The Economic value of breastfeeding. Almroth S and Greiner T. FAO Food and Nutrition Paper No 11. 1979.
Author: Arun Gupta is the National Coordinator of the Breastfeeding Promotion Network of India.
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