As we move towards achieving the Sustainable Development Goals 2030, of ending hunger and well being of everyone, two ideas are suggested to strengthen services at block level, and second a plan for reduction of inadequately breastfeeding.
The comprehensive national nutrition survey (CNNS) reveals that one out of three children under the age of 5 years is underweight and 2% are overweight. The double burden of malnutrition is evident. These children, either don’t get to eat enough foods or what they eat is unhealthy. Food for babies below 2 years means mainly breast milk for the first six months, and addition of a diverse diet with four or more food groups after 6 months to 2 years. A roadmap for the prevention of the double burden of malnutrition will have to address it through prevention strategies. Solutions that are preventative in nature could achieve a greater and sustainable improvement. Improved feeding practices and healthcare can minimise the disease burden and prevent incidence of malnutrition, both under nutrition and over nutrition. For example, according to WHO, increased breastfeeding, adequate and quality complementary feeding after six months can reduce wasting and stunting. And an international study estimates that inadequate breastfeeding in India results in 100,000 preventable child deaths (mainly due to diarrhoea and pneumonia), 34.7 million cases of diarrhoea, 2.4 million cases of pneumonia, and 40,382 cases of obesity. The health impact on mothers translates into more than 7,000 cases of breast cancer, 1,700 of ovarian cancer and 87,000 of Type 2 diabetes.
Poshan Abhiyaan, India’s premier effort to reduce malnutrition could consider including two big ideas essentially preventive in nature.
STRENGTHENING THREE SERVICES AT BLOCK LEVEL
While the convergent action plan is impressive, as a principle we must reach all pregnant and lactating women and under-2 children with the services they need to succeed in improving their nutrition. Additional services to be included here are discussed below.
1. Face-to-face breastfeeding counselling for every pregnant and lactating woman: The WHO recommends face-to-face counselling on breastfeeding and complementary feeding, and a counselling session is a must during pregnancy, and about six times up to six months after birth. Our research showed that antenatal counselling on breastfeeding is a rarity. Indicator percentage “of pregnant women in the 3rd trimester who received dedicated counselling session on Feeding Decisions” may be added. ANM in the community and Nurse/doctor in the health facility may be responsible for this under MOHFW.
2. Dietary assessment and counselling for
individual children at 6-24 months: “Dietary diversity is a proxy for nutrient adequacy of the diet. Insufficient dietary diversity and meal frequency play a key role in nutritional deficiencies among infants and young children, leading to increased risks of childhood morbidity and mortality” CNNS Government Of India 2018.
When babies don’t get to eat enough diverse foods or what they eat is unhealthy, it can be due to two reasons. One, the family may not know what and when to give, and the other could be family is unable to purchase. The current supplementary food scheme can hardly provide dietary diversity with such low budgets. Having the diet assessment done for every baby may require additional foods/fruits/eggs/milk etc. In addition educating families on harmful impact of highly processed and high sugar foods is required to prevent over nutrition.
3. Growth tracking: Monitoring the growth of individual child is the key to detect early faltering. Additional indicator may be “% of children 0-3 years who faltered on the growth curve during previous month”.
The idea is to strengthen these three services at the block level. This may be done through having four dedicated skilled lactation and nutrition counsellors technically capable of analysis and advice on growth faltering and educating people on under and over nutrition, and assist in securing additional diverse foods if required. They would be directly responsible for about 150 babies born each month in a block, assisted by ASHA, ANM and AWW, whom they mentor and provide referral support as well. This action may require additional recurring and non-recurring budget of about Rs 20 lakh per block.
That brings me to the second big idea.
PLAN FOR REDUCTION OF INADEQUATELY BREASTFEEDING
India lacks a plan to increase rates of early, exclusive breastfeeding or continued breastfeeding, and why India should have such a plan, these are the reasons.
1. Low Infant Feeding (IF) score of all states: The Minister of Health and Family Welfare in August 2019 released the IF Score based on NFHS-data. It varied between 3.1 to 7.7 out of 10 for all states and UTs. None achieved above 80%. Our analysis shows that increase in IF score is associated with lowering of infant mortality and it is a statistically significant effect with a p-value of 0.03758 through a linear regression modelling.
2. Mere numbers: The plan will benefit 2.6 crore children born each year. Out of these, 1.3 crore experience inadequate breastfeeding and more than 2 crore inadequate complementary feeding at 6 months to 24 months.
3. Reducing disease and deaths: As mentioned above the plan offers a huge opportunity for reduction in disease burden and deaths of children. How young babies are fed is critical to a child’s survival, health, nutrition and development—not because children are vulnerable at this age but their brain almost entirely develops during the first 2 years.
4. Rampant use of commercial milk in health facilities: India enacted the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 (IMS Act), recognising that the use of breast milk substitutes could negatively impact health and nutrition of infants. This law is very weak on implementation. It prohibits any promotion of baby foods. Food companies continue to illegally sponsor research and meetings of the health workers, thereby influencing their behaviour towards the common use of infant formula for babies, especially babies born by Caesarean section.
5. Inadequate policy and programmes: India looks so inadequate on policies and programmes that help in removing barriers women face in feeding babies. Deficits include inadequate coordination and budget allocation, weak support to women in public and private health facilities, continued aggressive promotion of commercial baby foods and inadequate structural support to women at both formal and informal work places. Five consecutive reports show that progress is slow ever since 2005.
These are compelling reasons to have a plan that addresses national and state actions to strengthen services in health facilities. Its elements could include appointment of “authorised officers” by law at the district level, awareness for health workers and people, monitoring of the compliance with the IMS Act, and an annual report. In the health facilities/delivery points, appointment of dedicated skilled lactation counsellor as recommended by Government of India’s guidelines will help minimise the use of unnecessary infant formula and help mothers even with Cesarean section to achieve early breastfeeding. These actions may require additional funding of about Rs 436 crore for recruitment as well as skilled training. This is a missing piece in the existing POSHAN Abhiyaan. The plan could also address that PMMVY scheme covers every child born that may also need additional funding. This plan has the potential to reduce inadequate breastfeeding in India.
The current operational guidance for convergent action plan of Poshan Abhiyaan has provisions for additional interventions and a focus on under-2s and these two ideas can fit in.
The challenge is that policymakers, especially the planners and finance people, understand such additional needs. This could become a game changer for India. Of course it would require additional funding and an alternative vision to achieve this. The Prime Minister of India could lead this pragmatic action and policy managers pay attention to it.
Dr Arun Gupta, a pediatrician with more than four decades of experience, coordinates the work of South Asia for International Baby Food Action Network (IBFAN), the 1998 Right Livelihood laureate. He is the central coordinator of Breastfeeding Promotion Network of India (BPNI), a 28-year-old organisation. He is the convener of the Nutrition Advocacy in Public Interest (NAPi), a national think tank. Formerly, he was member of the PM’s Council on India’s Nutrition Challenges.