A three-pronged approach can enable positive breastfeeding outcomes

Optimal Breastfeeding can boost maternal and child health worldwide

According to WHO & UNICEF, over 820,000 lives can be saved annually through optimal breastfeeding. Breastfeeding can significantly improve the health of children and mothers resulting in economic benefits equivalent to USD 300 billion worldwide annually.

The optimal breastfeeding practice recommended by WHO is to initiate breastfeeding within one hour of birth, exclusively breastfeed (EBF) for the first six months, followed by breastfeeding and complementary feeding for a minimum of two years thereafter.

India has not scaled its breastfeeding rates as desired
Research has shown breastfeeding rates have not scaled as desired in India (NFHS 4). While institutional deliveries have increased from 40% in 2005-6 to 78% in 2015-16, breastfeeding initiation in the first hour is still low at 48.5%, with EBF rates for the first six months at 55%. These numbers point to a missed opportunity to enable breastfeeding at birth and sustain those practices effectively thereafter.

In public hospitals, the front-line workers (FLWs), doctors and nurses are expected to provide information and support on breastfeeding. However, inadequate staffing, low awareness and incentivisation for other activities over breastfeeding play a role in why this is not prioritised. In the private sector, where regulation is limited, there is low awareness and limited incentives for doctors and nurses, who are the key caregivers to mothers. Many caregivers encourage mothers struggling with breastfeeding to lean towards formula food.

Why are breastfeeding rates low?
Considering breastfeeding is a natural process, we assume that it comes naturally to every mother. However, issues range from incorrect latching, doubts on milk sufficiency, lip and tongue ties, delayed onset of milk (which require individual counseling) to mastitis and breast abscess (which require medical intervention and sometimes, surgery). Predominantly, lack of timely awareness and sustained support mean that mothers are ill-equipped to address such issues and this can ultimately, lower their confidence to breastfeed.

A three-pronged approach is required to address these barriers:
1. Awareness generation to ensure that families have the right information
• Counselling should start early (during pregnancy) and be extended to the family, especially the primary support system (spouse, mother, siblings, mother-in-law) to ensure a supportive and encouraging environment.
• Ensure adequate and frequent training to all who impart breastfeeding counselling (including frontline workers, doctors and nurses). Training should also be a part of the curriculum for medical and nursing students.

2. Skilled counselling to overcome barriers and enable appropriate behaviour
• Invest in dedicated skilled lactation counsellors for breastfeeding counselling at a public district hospital level. A cost-benefit analysis (EPW ) has shown that it will strengthen the government’s agenda on breastfeeding and promote best practices.
• Invest in sustainable models of skilled counselling in private facilities that focuses on demand creation along with ensuring a pool of trained counsellors.
• Boost private and public partnerships to address availability and quality of care by filling gaps in the public sector through appropriate incentivisation

3. Peer support groups to sustain the behaviour for the desired period
There is strong evidence to show how support groups improve breastfeeding rates. It is important that such groups work with families, as they play a significant role in busting myths and stigmas and stopping mothers from abandoning breastfeeding. . We need to:
• Institutionalise and sustain peer and mother support groups in the public sector by working closely with frontline workers and communities
• Strengthen and replicate successful existing peer networks and use them to accelerate breastfeeding outcomes in the private sector through enabling the right partnerships

It is critical these strategies all work in tandem to achieve favourable outcomes.

Finally, it is the choice of the mother
In India, we see a gap between intent and implementation. Strengthening policy, enabling working parents, increased funding and rigorous monitoring are critical enablers in reducing these gaps. In addition, catalysing the private sector to focus on innovation and demand-led models to increase breastfeeding rates are important, especially as the private sector starts to play a larger role in healthcare.

The choice to breastfeed lies with the mother. What the ecosystem should ensure is that her choice is backed by the right information and the necessary emotional and medical support throughout her breastfeeding journey.

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An edited version of this article was published in BW Wellbeing World to mark World Breastfeeding Week.

Talk to us: impact@sattva.co.in

Breaking Breastfeeding Barriers for Working Women

Breaking Breastfeeding Barriers for Working Women

India needs stronger legislation, better maternity policies and quality childcare, to enable women employees in the formal and informal sectors to achieve positive breastfeeding outcomes

India has set a target for an exclusive breastfeeding rate of 69 percent by 2025. A big part of this puzzle will be to enable working women to breastfeed.

Overall, India ranks 78 in the World Breastfeeding Trends initiative (WBTi), of 97 countries that participated. Only 48 percent of children initiate breastfeeding within the hour and only 55 percent follow exclusive breastfeeding for six months.

The target can be met only if we address barriers that working women face through legislation. Essentially, this means creating mother-baby proximity for the first six months to allow for exclusive breastfeeding without wage loss and facilities to pump, store and feed expressed milk once work is resumed by the mother.

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While there are some big wins for women in the formal workforce, the legislation can be further strengthened.

In India, the revised maternity bill accounts for six months of paid maternity leave for up to two children. However, the burden of wage payment during this time lies solely with the employer; experts say that this could be counterproductive and discourage organisations from employing women. In 2017-18 alone, about 11-18 lakh jobs were lost because of this. In addition, enforcement of legislation for contract workers need to be strengthened.

Here’s how the legislation can be strengthened:

– Provide incentives to employers such as underwriting part of the wage payment, tax breaks, or even introduce employee taxes to encourage employers to continue to hire more women • Create appropriate paternity leave provisions to ensure spouse support that is especially critical in establishing breastfeeding

– Sharpen guidelines on workplace enablement to include providing appropriate pumping equipment and having a designated pumping spaces in addition to providing nursing breaks

Workplaces need to sensitise all employees such that they can encourage breastfeeding mothers. They must also create mechanisms for mothers to seek out the right information and support through connecting peer groups and breastfeeding support organisations.

Large corporate governance must ensure that this applies to workers across across their value chain, including contract workers across SMEs and MSMEs .

The maternity act does not apply to the informal sector, which is estimated to be over 80 percent of the women workforce. Informal workers are also forced to return to work early because of poor economic conditions. A recent study on childcare practices of mothers working in the informal sector by Indian Institute for Human Settlements (IIHS) showed how close to 50 percent of the women surveyed returned to work within three months of birth, and only 21 percent of the total women continued to exclusively breastfeed.

Informal workers require convergence across maternity schemes and better childcare facilities to enable positive breastfeeding outcomes.

A critical need for informal women workers is wage protection. Today, schemes that support maternity benefits for informal workers at both a central and state level are inadequate:

– Informal workers are entitled to only Rs 5,000 as a fixed benefit from the government for their first child under the scheme PMMVY (Pradhan Mantri Matru Vandana Yojna).
– There are also some state schemes (such as in Tamil Nadu and Odisha) that provide financial incentives that are higher; however, they are few and far in between.
– Nowhere are these financial benefits linked to wages.

Secondly, implementation is weak: only about 3.2 million women have benefited under PMMVY till August 2018, in spite of over 25 million births in that time as found by an RTI request.

Thirdly, as women in the informal sector are forced to return to work—in many cases before six months—there is a need for effective childcare. Childcare legislation in India is very limited. Recently, the funding from the central government on the National Creche Scheme has been drastically reduced, in a blow for informal workers.

Going forward

There needs to be a strong focus in bringing convergence around maternity schemes for informal workers addressing key current gaps, such as linking financial benefits to wages and allowing for the fluidity of informal work (no fixed employer, multiple job changes, etc) and ensuring that the schemes complement each other. This also means ensuring adequate childcare through the public health system for women from whenever they resume work (even earlier than six months).

For example, anganwadis can be equipped with breast pumps and storage facilities to help mothers express and store breast milk. Finally, Self Help Groups (SHGs), which have successfully organised several million informal workers, should be enabled as vehicles to create solutions and engage and lobby with the government to ensure adequate legislation—a wonderful example is the SEWA Sangini programme that has created a sustainable model of childcare for informal workers and had big wins through engaging and working with the government.

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This article was originally published in Forbes to mark World Breastfeeding Week.

Talk to us: impact@sattva.co.in

PRALAY CHAKRABARTI

Pralay is a Principal with Sattva’s Transformation Advisory and Portfolio Services. He has 15+ years of management consulting and corporate strategy experience across multiple sectors. He has led multi-country complex transformation initiatives. These have been across impacting organisation strategy, process, people, and culture that needed strategy formulation and deep change management expertise.

Pralay holds an MBA from Indian Institute of Management, Kozhikode.

Tailored Healthcare Solutions for Tribal Women

Tailored Healthcare Solutions for Tribal Women

16-year old Nirmala weighed 43 kgs and had a haemoglobin level of 5.8 when she was eight months pregnant. Hers was a “high-risk pregnancy”, and after much coaxing over multiple visits by the on-ground health worker she agreed to travel 4 kilometres (2.5 miles) on foot and 11 kilometres (6.8 miles) in a bullock-cart to the nearest hospital for her delivery. She is now the mother of a healthy six-month old boy.

She was lucky; more than half of the maternal deaths in India are among the 8.6% tribal population . Less than 15% of tribal women meet the recommended protocol of ante-natal care . Across the continuum of care, tribal women have poorer access to adequate maternal and child health services than their counterparts elsewhere in India. By increasing access to quality maternal health services and emphasising on two important social determinants of maternal health – literacy and age of marriage – India has succeeded reducing maternal mortality by 77% in the last 19 years.

However, the last leg is the toughest. How do we reach the most marginalised women in remote villages to ensure safe deliveries for them?

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There is no data on health, healthcare and finances specific to the 104 million strong tribal population in India, and the budgetary plans and allocations for the tribal population remain buried under “rural healthcare”. Alarmingly, there are no existing institutional mechanisms to even gather or generate such data!

The challenges and needs of the tribal population are unique and need to be addressed differently. Tribal populations suffer from the “triple disease burden”: infections and communicable diseases, non-communicable diseases such as cancer and diabetes, and mental illnesses . The nutritional parameters are poorer: anaemia among tribal women is 38% higher than it is in the non-SC-ST population in India4 and the Infant Mortality Rate (IMR) among tribal children is 20% higher than the national average.

Continued disproportionate health outcomes indicate the need for a different approach to address the maternal health challenges in these communities. To paraphrase American writer and activist Audre Lorde, “it is not our differences that separate us, but our inability to accept and acknowledge them”.

Maternal health services for tribal women need to be tailored to their needs, instead of being replicated naively from modern health practices or relying on monetary incentives to motivate health-seeking behaviour. To improve maternal health outcomes, we need to adopt a three-pronged strategy: provide last-mile access to care, leverage technology to provide better quality care, and increase utilisation of services provided by being more culturally sensitive and building trust in the community.

Solutions to combat poor maternal healthcare Last mile access can be improved through effective community-based care, adequate ante-natal counselling, and provision of emergency transportation services. The Government of Madhya Pradesh, along with UNICEF, piloted a 24×7 Free Referral Transport system for pregnant women (home to facility, inter-facility and drop back) which contributed to the increase in institutional delivery from 47% to 83% in Madhya Pradesh over a five-year period.

We also need to preserve and build beneficial traditional practices by integrating last-mile health workers into the system and focus on safer deliveries – at home or in a health centre.

There is tremendous scope to leverage technology to improve health outcomes. Mobile applications can help identify and track high-risk pregnancies, increase on-ground reach by incentivising field workers, and strengthen the referral chain to make patient data accessible. Tech solutions can conduct point-of-care diagnostic tests, improve the performance of field workers by providing training support and work as job-aids to guide them through complex tasks. Telemedicine centres and electronic medical records also hold great promise.

Through our research, we learnt that tribal communities view pregnancy and childbirth as a natural phenomenon that does not warrant external interventions. Doctors in white coats and sterile, whitewashed, multi-storeyed hospital buildings are viewed as intimidating. Respecting tribal culture and community beliefs, the Society for Education, Action and Research in Community Health (SEARCH) has built a tribal-friendly hospital in Gadchiroli . The clinics are modelled on a typical tribal home with mud flooring and thatched roofs. Outpatient departments feature large, tree-lined open spaces for patients to wait and mingle. To overcome access barriers, the state of Jharkhand established Sahiyya Help Desks in District Hospitals and Community Health Centres to help patients navigate complex, often culturally alien and unfriendly health facilities. Anecdotal evidence suggests that these desks significantly reduce the fear of being misunderstood on account of language and socio-cultural differences and improve awareness of entitlements and services, grievance redressal, and feedback regarding services.

To drive community behaviour change, we need to go beyond acknowledging the distinctiveness of the tribal population and learn to understand their culture and beliefs. We must eschew the cookie-cutter approach that seems to characterise many proposed solutions to this challenge. Tailoring interventions to the needs of tribal people will promote health-seeking attitudes, improve the overall nutritional status and enable better integration. This will facilitate better outcomes for mothers and children.

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This article was originally published in Impact Magazine and can be accessed here.

You can find more Insights from Sattva here.

To talk to us for collaborations or partnerships, you can write to us: impact@sattva.co.in

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i.Name changed to protect identity
ii.India’s maternal mortality rate is 167 per 100,000 live births- Census 2011 data
iii.Tribal Health Expert Committee Report
iv.NHFS-3 data
v.SEARCH website: http://searchforhealth.ngo/tribal-friendly-hospital/

Parvathy Ramanathan

Parvathy leads the Transformation Advisory Services portfolio at Sattva, where we focus on enabling ambitious organisations achieve their highest impact. In addition, she also leads Sattva’s technology CSR Programme Management product – SHIFT.

Parvathy has worked extensively in both the US and India at the intersection of systemic transformation and technology, in sectors including Government, Healthcare and Education.

Parvathy is an entrepreneurial leader, now focused on solving urgent problems in the development sector, leveraging over 18 years of global experiences in strategy, marketing, product innovation, services delivery and business development. She has launched, generated and managed global revenue streams across products and services. Her leadership roles range from Accel-Partners funded Big Data Analytics start- up to Fortune-500 firms like Amazon, IQVIA and McGraw-Hill. Her experience spans sectors including Government, Healthcare, Financial Services, Education and Retail.

Parvathy has an MBA from the Kellogg School of Management and a Bachelors in Engineering from RAIT, Mumbai University.

Shaivi Chandavarkar

Shaivi is a Senior Consultant based in our Mumbai office. She works in CSR Advisory and is currently focused on a project to build the paediatric liver transplants ecosystem in India and the tribal maternal health space. She brings with her a diversity of experience in strategy consulting, project management, business development and marketing communications in healthcare projects.

Prior to Sattva, Shaivi worked in healthcare consulting with IQVIA in Singapore, was the Medical Project Lead for a multi-specialty hospital in Mumbai – Namaha Healthcare (voted #1 Emerging Hospital in India by TOI in 2017) and worked in healthcare communication with DDB Remedy. She is also the founder of a non-profit Swasyah, to conduct camps to identify undiagnosed patients and direct them to appropriate health care.

Shaivi is a physical therapist by training from Seth GS Medical College and KEM Hospital, Mumbai. She also has an MA in Economics from SNDT University and an MBA from INSEAD.

Bobbymon George

Bobbymon heads Assessments in Sattva and is based in our Bangalore office.

He has delivered evaluation assignments across sectors and with key CSR accounts such as ABG, JPMorgan, ACC, Philips, L&T Infotech, L&T Financial Services, Dell and Fidelity. He comes with over 13 years of experience in the development sector, across programme design, implementation and Monitoring and Evaluation. He has led Programme Delivery, Curriculum Development, setting up Monitoring & Evaluation frame works and tools in non-profits.

He is also a master facilitator/trainer in Life Skills.

Garima Goel

Garima is part of the Transformative Advisory team in Delhi, working with Kaivalya Education Foundation (KEF) on the District Transformation Product for 25 districts.

Before Sattva she co-founded a sanitation enterprise called “Project Raahat” which is working in the field of urban sanitation in partnership with the government and is currently operational in 3 states. She represented India and Raahat in London and become ‘Enactus World Champion 2017’, chosen among 36 countries. She has also worked with MPs under the MPLAD programme and ran projects in their adopted villages regarding menstrual hygiene and community development. At Sattva she has worked with Central Square Foundation in landscaping the EdTech industry on a programme to drive efficacy and advocacy for country wide implementation by the government. She is committed to inculcating a bottom up method in development solutions to make them community driven.

Garima did her Bachelors of Management Studies from Shaheed Sukhdev College of Business Studies, with a major in Finance.

Atul Sukumar

Atul helps design, build and implement consulting projects as part of the Consulting Services team in Delhi.

Previously, his experience includes extensive research and analysis on problems of economic policy, education, healthcare, and energy. He has worked as a Data Analyst with the McKinsey Center for Government, a global hub for research, collaboration and innovation in government productivity and performance. He has also worked in consulting organisations, publishing companies, law firms and election campaigns. He is committed to bringing best practices from the private sector to impact public efficiency and effectiveness.

Atul is a liberal arts graduate of the University of Miami.

Mohana Rajan

Mohana Rajan is part of the Consulting Services team in Mumbai.

Prior to Sattva she has worked in the corporate as well as development sectors and as a Legislative Assistant to Mr. Jyotiraditya Scindia. She has worked with Foundations, Philanthropists, Corporate CSR and Non-profits in the areas of skill development, healthcare and children with special needs. She is passionate about gender equality and is keen to look into innovative models that can emulate corporate success in the development sector.

Mohana is a mechanical engineer from NITK Surathkal and a graduate of IIM Bangalore.