Breast-feeding practices in South Asia
Breast feeding provides adequate and appropriate nutrients for infant growth and development, protects infants against infections and promotes their survival. For the mother, it offers some protection against pregnancy. In the seventies, that public health specialists recognized the adverse consequences of the growing erosion on the traditional breast-feeding practices on infant health and nutrition especially in developing countries and initiated massive global educational efforts to promote the traditional practice of universal prolonged breast feeding. These efforts have by and large succeeded in most South Asian countries and lactation is now nearly universal. However, efforts to promote exclusive breast-feeding up to six months and introduction of energy dense semi-solid supplements at six months practices which are critical for prevention of undernutrition and morbidity in infants have not been as successful. Consequently, too early introduction of breast milk substitutes and too late introduction of semi-solid complementary feeds are common and are responsible for the rapid increase in the prevalence of undernutrition between 6-24 months.
In the current issue of the IJMR there is an article1 describing the findings from the Bangladesh Health Survey 1999-2000 which showed that (i) breast-feeding was universal in the country; (ii) median duration of full breast feeding (breast milk+water) was 3.7 months; (iii) nearly 70 per cent of mothers introduced milk supplements prior to six months; and (iv) median duration of breast-feeding was over 30 months.
This study reports that the duration of breast-feeding was shorter in urban, educated women, from higher income group families, those who had shorter inter birth interval and availed health facility for delivery care . The authors conclude that these groups would require special attention in the Information Education Communication (IEC) efforts to prolong the duration exclusive as well total duration of breast-feeding.
In India, the National Family Health Survey (NFHS) (1998-99) provides national2 and state level estimates of infant and young child feeding practices and their impact on mother and the child. There are striking similarities in breast-feeding practices reported from Bangladesh and adjoining West Bengal where (ii) breast-feeding was universal; (ii) median duration of full breast-feeding was 2.9 months (urban 2.1 and rural 3.3 months); and (iii) median duration of breast-feeding was over 36 months with 54.8 per cent of women continuing to breast feed their children beyond 3 5 months of age.
Data from NFHS- 2 show that in India, the median duration of full breast-feeding is about 5.3 months and median duration of breast-feeding is 25.4 months. Data from NFHS also showed that duration of breast-feeding was shorter in urban educated women from high income group and those who had delivered in health facility.
As can be expected in a vast and diverse country like India, there are significant differences in breastfeeding practices between states. Andhra Pradesh and Kerala fare the best in term of appropriate duration of exclusive breast-feeding and timely introduction of complementary food. Median duration of full breast-feeding was less than 3 months in Delhi, Goa, Himachal Pradesh, Punjab and West Bengal. In contrast, median duration of full breast-feeding is over six months in Bihar, Madhya Pradesh and Rajasthan. all these data suggest thattoo early introduction of supplements and shorter duration of breast-feeding are more common in states and segments of population who are more educated, have access to health and nutrition care. Advice from health professionals and para professionals regarding appropriate infant feeding practices during the last three decades may be one of the factors responsible for these faulty infant feeding practices.
In the sixties, many paediatric text books recommended introduction of breast milk supplements between 6-12 wk to meet the dietary requirement of rapidly growing infant, especially in undernourished communities. Studies carried out in India3 and other developing countries4 showed that introduction of supplements prior to six months did not improve growth but increased the prevalence of morbidity. In addition, too early introduction of supplements may result in reduction in suckling and consequent reduction in volume of milk production, shorten the duration of lactation and lactation associated infertility5.
The WHO reviewed the global data on infant feeding practices in 1989 and consensus recommendations were incorporated inlnnocenti Declaration (199O)6 which stated that “As a global goal for optimum maternal and child health and nutrition, all women should be enabled to practice exclusive breast-feeding from birth to 4-6 months. Thereafter children should continue to be breast fed while receiving appropriate and adequate complementary food for up to two years of age and beyond”. As lnnocenti Declaration did not clearly indicate 4 or 6 months as the appropriate duration of exclusive breast-feeding, many health professionals preferred to err on the side of caution and advise introduction of supplements by 4 months. This might be responsible for the relatively short duration of full breast-feeding among those who have access to health care.
India’s Reproductive and Child Health (RCH) programme emphasized the need for protecting and promoting exclusive breast-feeding in the first 4-6 months and breast-feeding for 24 months or longer to improve child nutrition and health. There was considerable variation between states in implementation of the initiatives under RCH programme. Kerala with nearly universal access to RCH services ranks as the best state in terms of infant feeding practices and has the lowest levels of undernutrition in children in the country2. However, in the neighbouring state of Tamil Nadu with fairly good access to RCH services, median duration of breast-feeding is the lowest in India (16 months). Effective IEC on benefits of exclusive breast-feeding for 6 months and continued breast-feeding for 24 months or longer are needed to reverse this trend.
In 2000, WHO7 commissioned a systematic review of the global scientific literature, to find out whether 4 or 6 months is the optimal duration of exclusive breast-feeding. Review showed that infants exclusively breast-fed up to six months grew normally and were protected from gastrointestinal infections; exclusive breast-feeding up to six months prolonged post-partum amenorrhoea but resulted in greater weight loss in women. Based on the recommendations of the Expert Consultation, the World Health Assembly in May 2001 resolved that exclusive breast-feeding for the first six months is the most appropriate infant feeding practice8. It was resolved that simultaneously efforts should be made to monitor infant growth and improve maternal nutritional status.
India’s Tenth Five Year Plan9 has emphasized the need to correct faulty infant feeding practices through nutrition education in order to prevent the steep increase in undernutrition in the 6-24 months age group. The Tenth Plan envisages major intervention aimed at the fol lowing:
(i) promotion of exclusive breast-feeding in the first six months;
(ii) nutrition education for the introduction of appropriate low-cost, energy-dense complementary food at six months of age;
(iii) three-monthly monitoring of weight in infancy and childhood; and
(iv) detection of infants with faltering growth and initiating appropriate steps to improve their nutritional status.
It is expected that effective implementation of these interventions will enable the country to achieve by 2007 the following Tenth Plan goals:
(i) enhance exclusive breast-feeding rate for children up to the age of six months from the current rate of 55.2 per cent (as per NFHS-2) to 80 per cent;
(ii) enhance complementary feeding rate at six months from the current level of 33.5 per cent (as per NFHS-2) to 75 per cent; and
(iii) reduce the severe undernutrition by 50 per cent and under-nutrition rates in under three from current level of 47 to 40 per cent.
1. Giashuddin MS, Kabir M. Duration of breast-feeding in Bangladesh. Indian JMedRes 2004; 119 : 267-72.
2. National Family Health Survey-2. Mumbai: International Institute of Population Studies, 2000.
3. Ramachandran P. Lactation – nutrition-fertility interactions. In; Gopalan C, Kaur Suminder, editors. Women and children in.India, New Delhi: Nutrition Foundation of India; 1989 p. 194-223.
4. Weaning: why, where and when, Ballinger A, Rey J, editors. New York: Raven Press; 1987.
5. Kennady KI, RevieraR, McNielly AS. Consensus statement on use of breastfeeding as a family planning method. Contraception 1989; 3 : 477-96.
6. Innocenti Declaration on Protection, Promotion and Support of Breastfeeding. 1 August 1990 Florence, Italy .
7. The optimal duration of exclusive breast feeding-Results of WHO systematic review. Geneva: WHO; April 2001.
8. Infant and young child nutrition resolution 54.2 of the World Health Assembly. Resolutions and Decisions of 54th World Health Assembly; 14-22 May 2001.
9. Tenth Five Year Plan, vol.2, sectoral Policies and Programmes, New Delhi: Planning Commission, Govt of India; 2001.
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