Early and Exclusive Breastfeeding
In India 1.2 million under-fives die every year(SRS 2013) and half of these death occur in the first 28 days of life, a time referred to as the neonatal peroid. Global evidence shows that children who are exclusively breastfed are 14 times more likely to survive the first six months of life than non breastfed children(Black et al., 2008)
Therefore supporting mothers to initiate breastfeeding within one hour of delivery is a high impact child survival intervention. In 2009, 34 per cent of mothers initiated breastfeeding within one hour of birth (CES, 2009). According to NFHS-3 (2005-2006) only 46 per cent of children aged 0-23 mothers are breastfed. According to RSOC (2013-2014), only 44.6 percent of children aged 0-23 months are breastfed immediately within an hour of birth and 64.9 per cent of infants aged 0-5 months are exclusively breastfed. Initiatives to promote (exclusive breastfeeding)EBF are hampered by traditional feeding practices associated with the introduction of water and food supplementation prior to six months. A majority of mothers (70 per cent) perceived that even children less than six months of age would be thirsty especially in summer and therefore they should be fed water.
Many (33 per cent) also believed that their breast milk along would not be sufficient for the child so that fed hin/her animal mild and food (Aruldas er al., 2010). One of the additional challenges faced by stakeholders is conflicting advice from a family member and health staff regarding pre-lacteal feeds, Mothers feel that no milk is coming soon after delivery and their mothers-in-law reinforce that assumption. This leads to delay in early initiation of breastfeeding and giving pre-lacteal feeds. In a study conducted in 4 countries, including 2 sites in India, factors associated with failure to initiate early breastfeeding included nulliparity, caesarian section, low birth weight resuscitation with bag and mask, and failure to place the baby on the mother's chest after delivery (Patel, A. et al 2015)
Early breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal health outcomes. The government of India and international organisation recommend infants to be initiated into breastfeeding within one hour of birth and feed only breast milk for the first six months of the life, with no other food or fluids added, not even water. They also recommend that children continue to breastfeed for two years or beyond while receiving age-appropriate complementary food. Although breastfeeding is natural and may seem instinctive, it is essential to create an enabling environment for to become the norm, Counseling, education and support can increase exclusive breastfeeding rates among children less than six months old by up to 90 percent(The Lancet, 'Evidence-based interventions for improvement of maternal and child nutrition', Page 7, http://www.thelancent.com/journals/lancent/PIIS-0140-6736(13)60996-4/fulltext). Combined individual and group counselling are more effective that individual or group counselling along (Bhu_a et al., 2013)
Under the call to action, population council in partnership with UNICEF and USAID conducted an evidence review to identify key social and behaviouur changes (SBC) strategies and health outcomes supporting child survival in the South Asian region, especially India. More than 7,605 articles on maternal and child health publissed during the last 13 years (2002-2015) were scanned after database searching, and of these, 156 intervention studies were selected for analysis. On handwashing behaviour, a total of 332 articles were identified and screened, 80 abstracts were read, 43 articles were downloaded and reviewed and 20 were selected for a final review. The outcome of the review was report,"Evidence Review on Population Level Social and Behaviour Change in South Asia for Enhancing Child Survival and Development" on which this policy brief is based. In addition, a technical group in UNICEFIndia has enhanced these findings and recommendations with new literature and relecand evidence. 
Policy Recommendations
1. Develop comprehensive and integrated IYCF plans. The plan should be comprehensive, integrated to include a monitoring and evalution system to improve coverage, equity, scale and enhance resource mobilisation for IYCF programmes. Theyy should also focus on fostering strong and broad based partnerships for IYCF programming.
2. Invest very systematicallt in enhancing the communication skills of frontline functionaries and community based organisations (CBOs). Effective promotion of optimal breastfeeding during the first 6 months requires a synergistic reponse to address gaps and ensure an evidence-based comprehensibe package of interventions to be delivered by CHWs. Appropriate knowledge and skills should be imparted to promote optimal breastfeeding and will also help them support mothers.caregivers to optimzally feed there infants/young children, and take care of there own nutritional needs.
3. Fix a minimum number of home visits (Like 10-12) spanning prental to postnatal peroid. Evidence shouws that 15 visits work best. Planning home visits and small group discussion at the right intervals and intensity is required to improve effectiveness. When effects of CHW visits on feeding problems were assessed, only 6 per cent of newborns who receibed home visits bt CHWs within 3 days had feeding difficultiesm compared to 34 per cent of those who did not. As indicated in the literature review, home visits were scheduled starting in the third trumester and continued during the first week postnatally, and thereafter at weeks 2, 4, 8, 16, and 20.
4. Integrate various mutually reinforcing communication components: In additiona to large scale mass communication-based promotional approachm one-on-one counselling and hands-on support to mothers for proper breastfeeding techniques by trained workers should be part of postpartum package, and such support should be made available in the very early days, possibly withon 72 hours to ensure successful initiation of breastfeeding. It is critical to devise comprehensive advocacy strategies, with IYCF interventions prioritised beyond nitrition and health into other programmes such as those related to woment's empowerment. Equally important is designing a comprehensive communication strategy that leads to provision of timely, need-based, and quality counselling and support to communites and networks to indluence behaviours and social norms and reinforcement of IYCF messgages with multiple communication chaneels and innovative approaches.  
5. Supportive supervision: Improve performance and motivation of frontline workers and service providers by enhancing key skills such as interpersonal communication and counselling in household and cmmunity setting through supportive supervision. Supportive supervision helps odentify and correct problems, and proactively improves the quality of service, build key skills and competencies such as counselling on key behaviours and monitors performance. Breastfeeding councelling with eemphasis on the correct technique can improve the EBF rated. 
6. Initation of Breastfeeding on facilities: In recent years, while the percentage of intitutional deliveries has increase significantly, the percentage of infants initiated into Breastfeeding within 1 hour of birth was increased onlu marginally.
The existing public health health infrastructure can be used effectively to improve six month EBF in places whrer the care is given primarily by public health system. Counselling and hands-on support on Breastfeeding techniques bt trained workers within first 3 days of birth, should be part of community based postpartum interventions. 
Literature Reviews: Key Findings
The result of the evidence review indicate that the following interventions could lead to near-universal adherence to exclusive breastfeeding for the first six months.
1. Build capacity of government community health workers to promote EBF through interpersonal communication. In a mapping of training resource packages for community health workers (CHWs), it was found that no training package addressed the range of evidence-based interventions that can be delivered bt CHWs as per World Health Organization guidance. Gaps include weakness in the assessment of competencies of trainees, in supportive supervision, and in impact assessment of packages. In other intervension reviewd qualuty of training being imparted to CHWs was founded to be critical. The trainings focused on demonstrations and role plays, listening to mothers learning about their difficuties assessing the postion and attachment of babies during breastfeed, building mothers confidence, giving support and providing relevant information and practical help when required. Practical training included counselling prenatal and postpartum mothers if newborns less that 5 months of age. The proportion of mothers who breastfed their infants exclusively of six months improved from 19 per cent to 70 per cent when breastfeeding counselling sessions were conducted for public health midwives. [Bhandari er al., (2003:2005); Tran, N. et al., (2014); Kumar et al., (2008)]
2. Implement community based initiatives through government systems - Integrated Child Development Services (ICDS). The results of the review of breastfeeding promotion suggest that facility-based group counselling is more effective that individual counselling. However, this strategy might not reach women who rarely ise health facilities.
The positive unfluence of peer counsellors through mother-to-mother support on initiative, exclusiviy, and during of breastfeeding anong low-income groups, as well as peer suppot, has been proven in many countries around the world, has been proven in many countries around the world.
  • Infrastructure already in palce, hence, easily scalable.
  • Mothly village health and nutrition days are an opportunity to connect with the community.
  • Work woth women's goups anong women in the community through group meetings and interpersonal communication [Intervention by CARE India 2001-06, evaluated in Uttar Pradesh by Baqui et al., 2008, Bhuttan ZA, Ahmed T, Black RE, et al., 2008)]
3. Provide timely counselling to promote breastfeeding practices during the antenatal and postnatal peroid untill the child is 6 month old : As per a study to evaluate the breastfeeding knowlegde of the mother, there was 'good attachment' in 42 per cent of mother-infant opairs and infants were held in correct position by 60 per cent of the mothers. However, additional intervention studies reviewed showed that a total of 15 visits - two in the last trimester of pregnancy, four in the first month (one within 48 hours of delivery, one on day 5, one during days 10-14, and one during days 24-28) and fornightly visits during months 2-5 have high impact in ensuring EBF counselling was given to mothers at home and key family members were included. The literature review suggests that there is a positive correlation between the number of contacts made by the health care provivides and change in breastfeeding practices. [Haider et al., (2000),Kishore M.S. et al. (2009)]
4. Supportive supervision of community health workers (Anganwadi workers (AWW), accredited social health activists (ASHAs) and nurses). As the fundamental link between a community and its health facility, and between the population and the health workers, CHWs can also promote adherence to tratment and follow-up. Community health workers are an important option for investment as part of a comprehensive primary health care system. The literature review reveals that in addition to high quality training, ensuring adequate supervision through mentoring and support in the field, timely supplies and task-based incentives to community health worker were critical to enhance EBF. In the intervention studies, counsellors/CHWs received continous mentoring (Fortnightly to montly) by trained suppervisors. (Bhandari N., Bahl R., Mazumder S., Martines J., Black R.E., Bhan M.K., 2003, Aboubaker, S.(2014))
5. Combination of mother support groups and breastfeeding counsellors works well. In Uttar Prades, a baby friendly community initiative, with mother support groups (AWW+ASHA+community women) and breastfeeding counsellors showed signigicant improvements in infant and young child feeding practices at an average annual cost of USD 1.50 per child. Each women of the support group was respinsible for 30-40 households as her cluster for home visits and counselling. This was reinforced with theme-focused group counselling mettings with eligiable families once every week. A sudy demonstrared significant improvement in Infant and Young Child Feeding (IYCF) practices when pregnent and lactating mothers were supported with skilled counselling. The intervention also effectively increased the initation of breastfeeding within an hour of birth of the baby, exclusive breastfeeding for 6 months, and approprate start of complementary feeding. (Nutrition Moves, How states are Creating Promising Change for Child Nutrition in Indua UNICEF India: Kushwaha, K.P., 2014).
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