Better Preventive and Curative Health Care

India's health indicators are not improving as fast as other socio-economic indicators. Good healthcare is perceived to be either unavailable or unaffordable. How can we improve healthcare conditions, both curative and preventive, especially relating to women and children?

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How can we improve both the health and the care of expecting mothers?

How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Mon Feb 07, 2011 8:13 am

How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?
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Re: How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Tue Feb 08, 2011 5:35 am

I think its challanging but not impossible. In this case details of Birth Registration may be followed. My thinking is start with some piloting in some urban area and gain some experiences. There is need to strengthen the system of birth registartion in rural area and how it may be ensured. I think at village/block level PHC or dispanciry must be responsible for door to door visit to register them and this this is nopt difficult. After some mid course correction the entire framework may be implemented in rural area too across the country.

Anurag Gupta
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Re: How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Tue Feb 08, 2011 8:13 am

India must be willing to dream big and most importantly be open to ideas based on how other successful nations have done.
The pdfs from the following link shows tiny Abu Dhabi's economic vision for 2030.
Perhaps we can copy some ideas from them. ... ema=PORTAL
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Re: How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Mon Feb 28, 2011 11:14 am

[u]Let me answer this question in a detailed manner, that Government of India should have an objective to ENHANCE OPTIMAL BREASTFEEDING RATES [/u]
What you need is a plan, a budget, coordination, monitoring and evaluation on an ongoing basis!
[/b]Annually 27 million babies are delivered each year in India. 20 million are not able to receive exclusive breastfeeding for the first six months. 13 million do not get good timely and appropriate complementary feeding after six months along with continued breastfeeding. 10th and 11th five year plans of Government of India called for enhancing optimal breastfeeding rates. If India wants to enhance optimal breastfeeding rates,(initiation of breastfeeding within one hour of birth , exclusive breastfeeding for the first six months and timely and appropriate complementary feeding after six months along with continued breastfeeding ), we provide here guidance on how to do it. This we believe is required for two reasons. One India has not seen rise of exclusive breastfeeding for the first six months for last 2 decades and second there is gross lack of understanding on how to do it at the level of programme and policy managers. There is also a kind of belief that it will happen of its own being a natural process, yet there have been efforts so far that claim to ‘promote breastfeeding’ which is different from ‘enhancing breastfeeding rates’. That is fundamental to have the objective right.
What led to a decline in breastfeeding , need to be reversed !
As the modernization spread across the world and economic activity took over all priorities more and more women joined work force. This led to decreasing degree of care of infants as they were away from the mothers and breastfeeding rates declined. Nuclear families, and inadequate protection of women especially during maternity and lactation period made them highly vulnerable. Baby food industry took it as an opportunity and marketed the formula as an alternative using all kind of techniques to woo parents. This led to widespread use of formula and further compounded this decline. Health workers across the world were found lacking in their skills in supporting mothers for breastfeeding when the medicalisation of childbirth became a reality. We will need to make a correction in these three underlying factors in order to enhance breastfeeding rates.
Rate of exclusive breastfeeding for the first six months has shown a very little improvement over the past 2 decades ever since some attempts have been made to do something about it. Reason being that actions taken so far have been ad –hoc , piecemeal and limited to imparting some information to women or families and matters related to support to women in their role for breastfeeding have long been neglected as much the protection of this endangered practice from the commercial baby food manufacturers.
Seven strategies
Enhancing the rates of exclusive breastfeeding for the first six months requires multiple strategies, at least six of them, and all working simultaneously. These include 3 main strategies protection, promotion, support, and additionally 3 support strategies i.e. coordination, information management, and research. 7th is education and training is overarching and fits in to promotion and support as well. We will focus on the first three: protection, promotion and support here because that is the bottom line.
Parliament of India while enacting the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992 clearly expressed its objects and reasons that promotion of breastmilk substitutes is more pervasive than promotion of breastfeeding and it contributes to decline in breastfeeding. It also said that this is a dangerous trend as it leads to disease and malnutrition among children. Commercial baby food manufacturers indulge in aggressive promotion of breastmilk substitutes was noticed by Senator Edward Kennedy , who in the Senate Hearings found that there is a need for marketing code for breastmilk substitutes, and recommended this action to the World Health Organization (WHO). The result was the International Code of Marketing of Breastmilk Substitutes (Code). Government of India followed it and this led to enactment of the IMS Act in 1992, which came into force in 1993. The Act was strengthened further in 2003. Major provision of the Act is to prohibit all kinds of promotion for the milks or foods meant for children under the age two including ban on sponsorship of doctors by the baby food companies. Actions under protection include making health workers aware of their role, ending promotional practices of manufacturers that woo parents to use it, ending free supply of samples to mothers, ending sponsorship of meetings of health workers, ending conflicts of interests in public policy making, and many others. The work requires coordination, human and financial resources.
This is a strategy to reach people with accurate unbiased information as well as all women having access to skilled counselling on breastfeeding. This is mostly not well understood in spite of the fact that Government of India has issues wonderful National Guidelines on infant and young child feeding. Important point of understanding here is that two fascinating hormones control the process of breastmilk production and flow. These are, Prolactin that produces milk in response to the stimulus of suckling, and Oxytocin that helps the milk to flow from the breast to the baby’s mouth. This latter hormone is controlled to a large extent by the state of mind of the mother, especially any fears/doubts about breastfeeding, pain, anxiety etc. which can block the supply, cause breastfeeding problems, and reduce the suckling done by the baby. Four decades back, the baby food lobby, cleverly targeting the psyche of women, created a universal false belief among women that their milk is not enough for their babies. By doing this, the industry created a strong belief that mothers’ milk is just another food for the baby, and their products are equally good so that women all over the world do not feel guilty if their babies did not get enough breastmilk. Today, anywhere in the country, if you ask a question to any woman about feeding of infants, “Why have you adopted artificial feeding?”, invariably, the answer is that she does not have ‘enough breastmilk for the baby’. Advertising also played a significant role in reducing women’s breasts to mere sex symbols. The seeds of doubt that were sowed in women’s minds – that they could not produce enough milk to fully nourish their babies and that artificial milks were better for the infants – persist till today, in spite of overwhelming evidence that breastmilk is the normal food for babies till they are six months old, and after that, babies need to be breastfed for two years and beyond along with home made complementary food in increasing quantities as they grow older.

It is the problem of milk flow that mostly needs to be tackled through promotion. ‘Confidence building measures’ have to be taken through skilled counselling and it is much different from ‘delivering a message’ or delivering polio drops or other vaccine. Action under this included building state/ district capacity to deal with this and also to act as trainers to impart this specialized training skills to workers who talk to mothers. Apart from this changes must to be made in the medical and nursing curriculum, provision of a trained health workers for support at birth and family counsellors for home visits later, in order to provide accurate information and practical support is necessary.
Further it is important to deal with timely and appropriate complementary feeding after six months along with continued breastfeeding, as well as HIV issues and same health worker of the system has to deal with it. How one can do so if they don’t have the skill? In 2010, WHO released revised guidelines on infant feeding in the context of HIV. At the same time, new recommendations were also released on antiretroviral therapy for preventing mother-to-child transmission of HIV. Together, the recommendations provide simple, coherent and feasible guidance to countries for promoting and supporting improved infant feeding by HIV-infected mothers. W.H.O. developed three courses; breastfeeding counselling course in 1993, HIV and Infant feeding in 2000, and complementary feeding in 2002. Total duration of the training is 11 days. WHO also provided a 5- day Infant and young child feeding course for the lay counsellors. The Breastfeeding Promotion Network of India combined these three into one that lasts 7 days, and developed a local course for frontline workers of 3-days duration. This is work requires human and financial resources as well as coordination.
For exclusive breastfeeding rates to go up this strategic action is critical For beginning breastfeeding within one hour you may require only one sector that is health to respond, but to achieve exclusive breastfeeding for the first six months you require multiple sectors like health , nutrition, HIV, disaster management , policy and planning, labour, women’s development etc. to get involved. Ways and means must be found for ALL mothers and babies to stay together day and night for at least six months, to ensure unrestricted access to breastfeeding. Action here is that women in informal work need structured support through legislation, combining work and breastfeeding through provision of Crèches at work place, flexi working hours and creating space where women could express breastmilk are few to mention. Maternity leave of six months should be universal. More breaks for breastfeeding while at work would also be required. These provisions also require coordination, human and financial resources.
Now lets have a look at the other four supporting strategies, which are crucial to support the above 3.
4. Coordination
This means having operational plans with well -identified budgets and backed by coordinated action. This could be done through institutional mechanisms. Each of three strategies described above requires to be coordinated. It is unlikely to succeed and see results without coordination.
5. Research
Establishing a research task force to generate important information around breastfeeding and complementary feeding would make ongoing difference to the work and activities proposed. It should lay emphasis on both qualitative and qualitative research. Policy and programme on breastfeeding /infant and young child feeding should be evaluated every 3-5 years in order to find out gaps and action plans to bridge them should follow. Action required again is funds and coordination.
6. Information management
The strategy should make use of available breastfeeding and complementary feeding data. This should be linked to monitoring of programme a high level enough to make an impact. There should be some one responsible to do this work of analysis and reporting on a regular basis. Action is to fix responsibility of some one to do it and create a space for this.
7. Education and training
As breastfeeding and infant and young child feeding counselling is special skill, it needs to be transferred through training. Education system need to look at the curriculum to address these issues at all level, secondary and higher, technical education as well.
All 7 strategies need funds, coordination and planning. All need to be implemented together if the Government wants to enhance its optimal breastfeeding rates.
The Critical point
The Global Strategy for Infant and Young Child Feeding, endorsed by WHO Member States and the UNICEF Executive Board in 2002, aims to protect, promote and support appropriate infant and young child feeding. The Strategy is the framework for prioritization of research and development work in the area of infant and young child feeding.
This is the crucial to understand –where is the time for women to breastfeed, where is the support, and where is the information that would lead to healthy practice. Women have to work at home for other jobs like preparing food, washing etc. And these three main strategies have to come simultaneously. Now let’s see if she got good information and good support but there comes a misguided element to push formula feeding. What will she do if a health worker promotes the use of formula, she is forced to use suboptimal feeding methods for her baby. All policy makers and programme managers involved in women’s and children’s and children’s issues, child nutrition and health, poverty reduction or rural development – every one needs to understand what is required to enhance exclusive breastfeeding for the first six months. Though food companies continue to contribute to the unnecessary and inappropriate feeding practices of infants that leads to suffering of infants and even deaths, yet countries have lagged behind in action to enhance exclusive breastfeeding for the first six months may be because they face resource crunch, or are under tremendous market pressure, or they have not understood the How.

[color=#FF00BF]It is important to understand what Prof. Abhijit Sen, Member of Planning Commission said recently on the Nutrition and breastfeeding issues,
"...nutrition, which we are hugely lacking, is not simply about food or what you eat, its as much about water, health, most importantly it’s about what happens just after birth, the first one hour, the first two years. The government cannot promise that people will breastfeed their children. But what it should promise is a government support system for a whole aspect of nutrition which it will provide...".
Women need maternity entitlements, leave or wage compensation, adequate food and rest during pregnancy, health education, skilled counselling and support, and work places that are friendly to them as well as having crèches. By having all these you can think of enhancing rates of optimal breastfeeding practices.
W.H.O. conducted a global study that has shown that all children can achieve a remarkably similar growth if they are brought up in an environment that provides breastfeeding as a norm, good feeding practices during first two years, good healthcare and an environment free of smoke. India has adopted these standards, action remains that each child is followed up.

Moving Forward !
This means clearly one has to make a move on all three main strategies i.e. protection, promotion and support of breastfeeding in order to enhance rates of exclusive breastfeeding for the first six months. Most importantly protection from commercial influence if there is need to prioritize.
A report from Lalitpur shows the way how to reach the under 2s.

What you need is additional workers , mentors at block level and a well structured programme for counselling families.
Three key steps to take;
1. Take a look at the current gaps: The tool World Breastfeeding Trends Initiative (WBTi) was used to assess and to find out gaps in policy and programmes of India.
( in 2005 and 2008, it showed no improvement . Time has come to study in 2011. While there have been several commitments made, these need to turn into obligations and infants right to food.
2. Develop a plan with a budget: A clear- cut plan with specific objectives to implement the main three strategies, well -defined budget and high priority given to this intervention can make a difference. Allocation of budget for 0-6 month old baby for food needs is the answer, and can lead to development of a new national scheme for food for infants. (Sonia Gandhi Scheme for Food for Infants (SGSFI)
Simple principle, a mother and baby have to stay together if she were to exclusively breastfeed her baby for the first six moths of life. Now this being a health recommendation and also makes a significant contribution to brain development of the baby, one needed to be serious in pursuing for achieving this standard. Beyond six moths a baby needs solid foods in addition to their mother milk , this is complementary feeding also very critical for nutrition and development.
3. Additional workers and mentors
What India needs is to appoint family counsellors as additional workers responsible for under 2 children who could be given this work. At block level you need to have well trained women in nutrition and training skills, who can act as trainers/mentors for the family counsellors. These women could be at least 5-10 per block depending on number of villages or population size. Funds need to be marked for this purpose as well.

It is not over here ....water , health care and food for the family are three additional needs to prevent undernutrition.

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Re: How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Tue Mar 08, 2011 1:43 am

I think what we have to do is simple.First thing a will to do it and that can happen only when the educators,health care workers,politicians, celebrities themselves are convinced.This is possible by approaching these select in phased manner through those amongst them only,who are already convinced.Once this is done then the way is more simple.We just have to make the Bohr committee recommendations viable in letter and spirit--ensure the multipurpose workers are restricted to their areas of post and visit every home as per the beat pro gramme.They should have no other work except taking care of families allotted to them and use a policy of carrot and stick.The political interference in their postings and transfers should be made a cognizable offence. The preference should be given to local boys and girls to work as MPW's. Even if educated youth is employed for doing the job,it will serve two purposes--one utilizing them for constructive work and second give them employment.
In case governments want they can even train youth from the village itself in line with NAREGA scheme.
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Re: How to reach pregnant and breast feeding mothers, children under two years and prevent under-nutrition?

Postby » Tue Mar 22, 2011 10:42 am

• The polio eradication drive comes to mind. It is a multi-pronged strategy. SMS, hoardings, radio, paper TV every media is involved. One cannot miss the date. Then the vaccine is given at suburban stations, ST stands and many such public places. As if this was not enough health workers go door to door to ensure that the dose is given.
• Similar approach should be adopted to reach every pregnant woman in village and slums. Her health profile should be recorded and required nutritional supplements/medication should be given. In the same manner the new born can be looked after.
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