Working with Government Systems to Improve Exclusive Breastfeeding Practices in Urban Informal Settlements of India
In urban Maharashtra, a highly industrialized state in India, exclusive breastfeeding rates are low, around 50%. Increasing rates of exclusive breastfeeding is an effective strategy for preventing diarrhea, a leading cause of poor nutritional status and death among infants. Researchers at the Mumbai-based non-profit Society for Nutrition, Education & Health Action (SNEHA) recently published results of a study aimed at improving exclusive breastfeeding practices in informal settlements in Mumbai. We examined factors associated with practicing exclusive breastfeeding and whether its practice is associated with pregnant mothers’ enrollment in a community-based program to tackle child malnutrition.
The community-based program for prevention and treatment of acute malnutrition operated for nearly five years in Dharavi, a large and vulnerable settlement in Mumbai. The program was implemented in partnership with the Government of India’s Integrated Child Development Services, covering 300 childcare or anganwadi centers and an estimated population of 300,000. The program’s primary activities included monthly growth monitoring, home-based counseling for pregnant women and caregivers and referrals to public health care facilities. A mixed-methods evaluation of the program found that the program had successfully reduced wasting (weight-for-height) prevalence among children under the age of three, in large part due to the continuous presence of trusted and informed community health workers (CHWs).
Activities for pregnant women and children up to six months of age
Throughout the intervention, CHWs employed by SNEHA continually identified new pregnancies, new migrant pregnant women and missed pregnancies (as some women did not disclose their pregnancies until their second trimester). They also tracked newly married couples and couples with a single child who might be considering having a child. During the home visits, the CHWs encouraged pregnant women to register for delivery and access early antenatal care. They provided information on the possible danger signs during pregnancy for which they should seek immediate medical care.
The CHWs counseled women on preparation for institutional delivery, appropriate postnatal care, the importance of iron and folic acid for the baby’s growth and on a nutritious diet and rest. A critical component of the counseling was to discuss the importance of breastfeeding practices such as initiation of breastfeeding within one hour of delivery, the benefits of colostrum, exclusive breastfeeding and avoidance of any prelacteal feeds. These educational visits continued from pregnancy through the birth of the child until the child was six months old.
The CHWs also counseled lactating mothers on correct positioning, common challenges and remedies related to breastfeeding. The home visits allowed CHWs to respond to mothers’ breastfeeding concerns in a timely manner. Approximately 11% of mothers reported a problem with breastfeeding, with the majority reporting an issue of “low milk supply.” Each CHW was trained with specific strategies to manage issues and facilitate exclusive breastfeeding. In addition to home visits, SNEHA CHWs organized group meetings and culturally relevant community events for pregnant women for social support and health education.
Factors associated with exclusive breastfeeding
Endline evaluation data showed that 64.4% of 888 mothers with children under age six months of age were exclusively breastfeeding. Infants less than three months of age had much higher rates of exclusive breastfeeding (75.3%) compared to infants aged five to three months (52.7%). About a third of mothers gave prelacteal liquids in the first days following birth and had lower levels of exclusive breastfeeding (54.7%) as compared to mothers who did not give any prelacteal feeds (70%). Giving birth in a public facility was associated with higher rates (71.7%) of breastfeeding as compared to mothers who had given birth in private facilities (55%). Having a normal weight-for-height status and participating in the SNEHA program were positively associated with exclusive breastfeeding.
Benefits of early enrollment
In the study, we also examined our program surveillance data to explore whether counseling pregnant women helped improve exclusive breastfeeding practices. Mothers were significantly more likely to report exclusively breastfeeding if they had enrolled in the program while pregnant. Caregivers benefited from receiving counseling services earlier and more frequently: Mothers enrolled during antenatal care received an average of nine home visits from a SNEHA CHW, and mothers enrolled after a new birth received an average of five home visits. This study provides evidence in support of antenatal intervention in child nutrition programs and serves as example of how this can be done in partnership with existing government partners.
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Photo Credit: Suraj Katra/SNEHA