Motherhood is a beautiful, complicated, and life-changing event that I experienced fifteen years ago when my daughter came into this world (albeit three weeks early). Sindhushree, who we lovingly call Sana, was born by a lower segment caesarean section. After getting a fleeting glance at her without my glasses, my daughter was quickly shuffled off to the Neonatal Intensive Care Unit due to my gestational diabetes status. Despite requests from my family and myself, I was not allowed to breastfeed my baby within the first hour of birth. The next few days passed in a blur without any counselling. An inverted nipple on one side and a cracked one on the other made breastfeeding difficult and painful. However, and contrary to many opinions, things eased out over the next few days, and I am happy and proud that I continued breastfeeding for the following two years.

Clearly, breastfeeding practices, with all its surrounding beliefs and socio-cultural barriers that dictate incorrect practices, can lead to a complex interplay. As we bust myths and bridge barriers, it is crucial to understand why breastfeeding is important, and why it needs to be initiated early. There is ample evidence from large trials conducted in India, Ghana and Tanzania, which reported that initiation of breastfeeding in the first hour of birth was associated with a 44 percent lower risk of neonatal mortality.¹

India’s figure of only close to 50 percent newborns being breastfed within the first hour of birth² reinforces the fact that more needs to be done. Despite provisions defined internationally, especially by the Baby-friendly Hospital Initiative, which many hospitals are accredited to, there is a clear failure to enact these best practices.

The practice of inclusion of a birth companion for the woman in labour, coupled with the ‘zero separation’ policy − which mandates the newborn be put between the breast immediately after delivery to maintain skin-to-skin care for the first few hours after birth − has surely been a critical first step towards the ‘right start’ of life. However, a long journey is still underway.

With more than 80 percent of deliveries in India being institutional, Indian health systems, whether public or private, need to gear up for a more rigorous performance and help new mothers navigate the maze of birthing and childcare with better outcomes. The need is not just to build capacities of healthcare staff, but also the intent to have good practices. An authorized body to regulate these practices, especially in the private sector, could lead the way.

Exclusive breastfeeding (EBF) for the first six months of life presents another challenge with sociocultural and familial pressures adding to the pressure being put on mothers. Between imparting domestic chores and pitching in to augment the family income, scant attention is paid to the mother. Though India has achieved the World Health Assembly Breastfeeding Target with 58 percent of mothers exclusively breastfeeding their newborns,³ is that enough and are we cognizant of the larger picture?

During my visits to review our programs I have come across mothers, who had delivered just two weeks before, slogging it out in the fields or resorting to a feeding bottle as breastfeeding seemed more time-consuming. And all this was only because there was some other more urgent work pending to attend. A more humane approach to birthing and empathizing with the woman is much needed. Families need to ask – does she need help? Could a secondary caregiver share her load?

Focusing on family participatory care, the provision of 26 weeks of maternity leave by the Government of India is a possible answer. This paid leave post-partum to ensure EBF has been welcomed by mothers, especially in the formal sector. However, the informal sector is where the real numbers lie, and such measures need to be factored in there too.

At Nutrition International we have dedicatedly advocated with governments and health system teams – both public and private – on aspects of maternal and child nutrition. From building the capacity of frontline workers (FLWs) to counselling communities to bring about change, our efforts have added up. We are proud to see that continued breastfeeding for 6- to 23-month-old children has increased significantly in our intervention areas with more than 90 percent of new mothers practicing it.⁴

Unfortunately, a darker reality is that such gains are being challenged by COVID-19. Invariably, time for promotion and counselling for breastfeeding has been affected as FLWs, who were the chief counsellors for breastfeeding, are playing the dual role of COVID-19 surveyors on top of their routine activities. An analysis of government data reported for March to April 2020 reveals that institutional births have decreased by almost 40 percent as compared to last year.⁵ During the pandemic, it is important to counter misinformation and continue to promote breastfeeding and the message that there is insufficient evidence to support that COVID-19 can be transmitted through breastmilk.⁶ Such trying times can only be dealt with innovative methods like telemedicine that FLWs are now adopting to offset minimum interactions, yet provide the necessary support to encourage breastfeeding.

Even beyond the pandemic, appropriate home-based infant and young child nutrition practices and the need for creating a more empathetic birthing experience with dignity, respect and quality must be widely publicized. My personal experience of motherhood taught me to appreciate the challenges of being a new mother while coping with childbirth and its varied complexities. And I can say that an enabling environment can truly help − it renewed my passion to continue working towards strengthening health systems.

References
¹Debes, A. K., Kohli, A., Walker, N., Edmond, K., & Mullany, L. C. (2013). Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC public health, 13(S3), S19.
²Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS) National Report. New Delhi.
³Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS) National Report. New Delhi.
⁴Nutrition International. 2020. Nutrition Intervention Monitoring Survey (2019-20) (Internal document).
⁵Ruchir Kumar, Ritesh Mishra and Rajesh Kumar Singh. During Covid-19 lockdown, births at clinics plummet by 40%. https://www.hindustantimes.com/india-news/during-lockdown-births-at-clinics-plummet-by-40/story-D1DzxlaZhGswBRtHbeXwjN.html (accessed on June 8, 2020)
⁶World Health Organization. (‎2020)‎. Breastfeeding and COVID-19: scientific brief, 23 June 2020. World Health Organization. https://apps.who.int/iris/handle/10665/332639.

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