The Challenge of Breastfeeding Sensitisation

Nikhil Srivastav ( is with the Research Institute for Compassionate Economics (r.i.c.e).
1 March 2018

Mothers’ Absolute Affection, the nationwide programme to improve breastfeeding, attempts to achieve the same by incentivising frontline health workers to create awareness on the issue. However, a pilot study shows that hiring breastfeeding consultants at the district hospital level is not only more economically feasible, but also results in improved breastfeeding rates. 

In August 2016, the Government of India launched Mothers’ Absolute Affection (MAA), a nationwide programme to promote breastfeeding. For each of the 685 districts in India, Rs 4,30,000 has been earmarked per year, to create awareness through mass media and interpersonal communication. The programme ambitiously plans to train and incentivise Accredited Social Health Activists (ASHAs) to promote breastfeeding. 

Through monetary rewards, it also plans to rope in Auxiliary Nurse Midwives (ANMs) and doctors at the delivery points in hospitals. MAA in its current form intends to provide Rs 300 as an annual stipend for ASHAs, along with a budget of Rs 50,000 for a one-day sensitisation of ANMs, nurses, and doctors in the district. Another Rs 10,000 has been earmarked as for ANMs, nurses, and doctors in district hospitals (MHFW 2016: 12).

The government’s intention to promote breastfeeding deserves praise, but to achieve this goal, the programme will need to be substantially redesigned. It is well known that health workers in villages, that is, ASHAs and ANMs, as well as doctors in hospitals fail to provide counselling-related services to people. Moreover, the programme’s budget may be too small to achieve any meaningful improvements in breastfeeding rates. 

Therefore, in addition to MAA, the government should run a parallel programme by hiring dedicated breastfeeding and newborn care consultants at each district hospital. This article will look at the importance and necessity of such a programme.

Institutional Deliveries and Breastfeeding Rates

Breastfeeding is indeed an important public policy issue in India. Findings from the Demographic and Health Survey (DHS) for India, conducted in 2005–06, indicate that 30% of 7-month-old children were underweight. This indicates, among other causes, the inadequate adherence to early initiation of breastfeeding and exclusive breastfeeding during the first six months of an infant’s life. 

Health surveys show less improvement in the breastfeeding rates than in the rate of institutional deliveries. Between the National Family Health Survey (NFHS)-2 in 1998–99 and the NFHS-4 in 2015–16, the rate of institutional deliveries increased by 52.9 percentage points. But for the same time period, the rates of early initiation of breastfeeding and exclusive breastfeeding showed dismal improvements of just 8.1 and 25.7 percentage points respectively. 

Source: All four rounds of the NFHS

Absence of Breastfeeding Counselling

While providing breastfeeding and newborn care, education has always been part of a health worker’s written job description (MHFW 2011); in practice, health workers rarely counsel new mothers. Frontline health workers mostly perform those services that they get paid for, for instance, immunisation. Since breastfeeding counselling and newborn care services have little or no monetary returns, they are mostly abandoned. 

According to the Rapid Survey of Children (RSOC), conducted by the Ministry of Women and Child Development, only 31% of the women were visited by an ASHA at home during pregnancy, only 23% were advised to deliver in a hospital by an ASHA, and only 51% reported that they were visited by an ASHA, AWW, or ANM after delivery (MWCD 2016 a; 2016 b). There may be several reasons responsible for this: public hospitals usually function way over their capacity, and front-line workers lack supervision and support (Gopalan Mohanty et al  2012).

In the case of doctors, the situation is no different. Because they are overburdened and disproportionately prioritise clinical treatments over primary care, they spend very little time with patients and hardly adhere to treatment guidelines (Das and Hammer 2004). This further reduces or leaves no time for offering newborn care-related and breastfeeding advice. 

Considering that the cost for getting doctors and front-line health workers to prioritise breastfeeding counselling is much greater than the current funding available with a programme like MAA, expecting the programme to be successful by itself would be impractical.

Hiring Dedicated Breastfeeding Consultants

The government guidelines issued for MAA earmark a total Rs 3,20,000 towards payments of incentives to the ASHA workers in each of the 685 districts in India. On average, each district has 1,066 ASHA workers in India, but most districts in disadvantaged states such as Uttar Pradesh and Bihar have a significantly higher number of ASHAs per district (MHFW 2016: 12). 

This means that such districts with a greater number of ASHAs might face difficulties in compensating ASHAs for this additional role. Furthermore, for the districts with the average number of ASHAs, even if the entire amount earmarked for the ASHA were to go straight into her pocket, assuming zero monitoring and implementation cost, each ASHA would still receive only Rs 300 per year. 

Therefore, even in the best case scenario, where there are enough funds to pay every ASHA in the district, the monetary incentive for the health workers is very small when compared to the amount of work that is being expected from them. 

Contrary to this, hiring one breastfeeding consultant in each of the district hospitals would require a similar budget and would ensure a full-time dedicated staff for promotion of breastfeeding in hospitals.

Pilot Programme on Breastfeeding Consultation

I was part of a team piloting a breastfeeding consultation programme in a district hospital in Uttar Pradesh. The pilot programme was not only feasible to monitor, it also showed a significant impact. 

Of the 1,236 women, who were first-time mothers and who were visited by a lactation consultant, 74% did not have a good latch on the first try, causing delays and hardships for breastfeeding. After one counselling session, almost a third of the women were able to correct the position of the child for a good latch, allowing the newborn to feed and encouraging the mother to continue breastfeeding.

Promoting breastfeeding in the hospitals is important because when a mother does not feed her baby for the first few days of life, she may have an inadequate milk supply during the later days. Also, many mothers stop breastfeeding after complaining of an inadequate milk supply (Aruldas et al 2010). This forces them to supplement an infant’s feed with something other than breastmilk, which ultimately makes infants more susceptible to the poor disease environment around them. 

To be sure, proposing a breastfeeding promotion programme at the district hospital level would mean admitting that the programme is making no efforts to reach those babies born in other clinics and private hospitals. But realistically, crafting and ensuring the implementation of a policy for promoting breastfeeding at every private hospital will not be feasible with the limited funds available. 

The miniscule funding available would not even be enough to monitor a district-wide programme, let alone implement one and motivate thousands of private hospital staff to participate in these new duties. Recognising that this will not happen in the current setting is the only responsible use of this resource.

While it is true that not all deliveries take place at public district hospitals, a large fraction of births do occur there. In fact, data from the fourth round of the NFHS-4, conducted during 2015¬¬–2016, reveals that 23% of all births in the country take place at such hospitals. Moreover, 46% of all births that happen in a government institution happen here. This has created an opportunity for improving child health outcomes by providing a single point newborn-care consultation to new mothers. 

Moreover, monitoring a consultant in the hospital is much easier, and more practically feasible than monitoring front-line health workers in the villages. In hospitals, the consultant will be surrounded by several higher officials, whereas private hospitals and informal delivery points in the villages are mostly independent, and are rarely monitored by government officials. 

Breastfeeding Counselling in District Hospitals is the Best Intervention

Provision of breastfeeding counselling to all mothers, including those who deliver babies in villages and at private hospitals, is an important long-term policy goal. If it were feasible with the current funding, then of course, attempting to reach every infant would be ideal. 

However, with such a small budget allocation, it is absurdly infeasible. On the other hand, hiring, training, and monitoring breastfeeding consultants at district hospitals is more feasible and the programme is likely to have a much wider reach.

Policy decisions should be made based on a critical cost and benefit analysis of a programme, which in this case suggests that hiring a dedicated breastfeeding and newborn care consultant at each district hospital will strengthen the government’s agenda of promoting breastfeeding, without compromising the limited funds available for many other equally important social security programmes. 

Nikhil Srivastav ( is with the Research Institute for Compassionate Economics (r.i.c.e).
1 March 2018