baseline study on iycf

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AGA KHAN FOUNDATION

DECEMBER 2012 STATUS OF INFANT AND YOUNG CHILD FEEDING

PRACTICES IN 3 DISTRICTS OF BIHAR – A BASELINE STUDY

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Table of Contents EXECUTIVE SUMMARY ............................................................................................................... 3

INTRODUCTION ........................................................................................................................ 10

REVIEW OF LITERATURE ........................................................................................................... 13

MATERIAL & METHODS ........................................................................................................... 18

OBSERVATIONS ........................................................................................................................ 26

DISCUSSION .............................................................................................................................. 92

List of Annexures .................................................................................................................... 105

Annex 1: Project Organogram .................................................................................................... i

Annex 2: Conceptual Framework of the Project........................................................................ ii

Annex 3: Monitoring Indicators of the Project ......................................................................... iii

Annex 4: Cluster Sampling – Detailed methodology ................................................................. v

Annex 5: Data Collection Tools (English version)....................................................................... x

Annex 6: Data Collection Tools (translated into Hindi) ............................................................ xi

LIST OF TABLES: ........................................................................................................................ xii

LIST OF FIGURES: ...................................................................................................................... xv

BIBLIOGRAPHY ........................................................................................................................ xvi

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ABBREVIATIONS & ACRONYMS

AI Agragami India

AKF Aga Khan Foundation

AKRSP, I Aga Khan Rural Support Programme, India

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

AWW Anganwadi Worker

BCC Behaviour Change Communication

BF Breastfeeding

CBR Crude Birth Rate

CC Cluster Coordinator

CF Complementary feeding

DFID: Department for International Development

DLHS District Level Health Survey

EBF Exclusive breastfeeding

IP Implementing Partner

IYCF Infant and Young Child Feeding

KAP Knowledge Attitude Practice

MIS Management Information System

NFHS National Family Health Survey

PAHO Pan American Health Organisation

PC Project Coordinator

PE Peer Educator

PPH Postpartum haemorrhage

PPS Probability Proportionate to Size

SC Scheduled caste

SPMU State Project Management Unit

UP Uttar Pradesh

VHSND Village Health Sanitation and Nutrition Day

WBTi World Breastfeeding Trends Initiative

WHO World Health Organisation

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EXECUTIVE SUMMARY

The Aga Khan Foundation (AKF) has initiated a project in three districts1 of Bihar, India,

which aims to improve the uptake of optimal Infant and Young Child Feeding (IYCF) practices

by the mothers and care-givers of children under-two years of age. The project is supported

by the Department of International Development (DFID), and AKF is working in collaboration

with three other implementing partners2. The project will use multiple behaviour change

communication (BCC) tools and techniques which are expected to improve the knowledge

of pregnant women and breastfeeding mothers regarding IYCF. This change, along with

individualised support to mothers by project functionaries will ultimately result in improved

IYCF practices by the mothers and care-givers.

Under the approved project design, the BCC activities are being undertaken by project

specific personnel in order to ensure that large numbers are reached out to with IYCF

specific messages. However, such a model also means that sustainability of project efforts

following withdrawal of funding will be a genuine challenge. This issue has been addressed

in the project design itself, by including activities for the training and mentoring of existing

facility and community based health and nutrition functionaries3 on counselling for IYCF.

These service providers are thus the secondary target population of the project.

In order to monitor the progress of the project on a regular basis, as well as evaluate its

potential success (or the lack thereof) at the end of the project, a monitoring conceptual

framework (Annex 2), along with project specific monitoring indicators (Annex 3) were

drawn up. The three tenets of IYCF, namely, a) early and timely initiation of breastfeeding

within an hour of birth, b) exclusive breastfeeding for six months, and c) introduction of age

appropriate complementary feeding at six months along with continued breastfeeding for

two years and beyond are the key outcome indicators that will be tracked. Other

“immediate” (output) level indicators are related to the knowledge of mothers and service

1 The three Project districts are i) Muzaffarpur, ii) Samastipur, and iii) Sitamarhi

2 The four implementing partners are: i) Aga Khan Foundation, India (AKF, I), ii)Agragami, India, iii) CHARM, and

iv) Aga Khan Rural Support Programme, India (AKRSP, I) 3 The facility based service providers include ANMs and Mamtas, whereas the community-based service

providers include AWWs and ASHAs.

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providers on IYCF issues as well as the performance of the service providers in relation to

IYCF counselling.

Tracking progress against these indicators required “baseline” or starting levels, which were

preferably specific to the project. While national and sub-national surveys such as the

National Family Health Survey (NFHS) and District Levels Health Survey (DLHS) provided

information on the broad IYCF related impact and outcome indicators, these surveys, as

expected, did not carry any information on the output level indicators. Also, even the “most

recent” of these surveys (i.e., DLHS-3) was based on data at least four years prior to the

start of the project. In addition, the project requires different sampling methodology and

specific formulation of indicators tailored to the project objectives and that was at slight

variance with the large scale surveys. In order to address these issues, the project team

decided to conduct a project specific baseline survey with the following objectives:

1. To assess the: a) knowledge level and, b) actual practice regarding the following

amongst mothers:

Initiation of Breastfeeding

Exclusive Breastfeeding (EBF)

Introduction of Complementary Feeding (CF)

Age appropriate Complementary Feeding

To assess the: a) knowledge level on IYCF issues and b) on-the-job performance of

health/nutrition functionaries on IYCF and the activities related to BCC .

The respondents were broadly classified as a) Pregnant women and mothers of young

infants and b) service providers. The sub-categories of these respondents were as under:

A. Women

i) Women in the last trimester of pregnancy

ii) Mothers with a child less than 7 days of age

iii) Mothers with a child 3-4 months of age

iv) Mothers with a child 6-7 months of age

v) Mothers with a child 12-13 months of age

B. Health and nutrition workers (service providers)

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i) Community based health and nutrition functionaries (i.e. Accredited Social

Health Activists (ASHAs) and Anganwadi Workers (AWWs))

ii) Facility based health functionaries (i.e. Auxiliary Nurse Midwives (ANMs) and

Mamtas)

AKF had conducted a formative research in October 2011 to understand the barriers to and

facilitating factors in the community for following the recommended IYCF practices. This

understanding was used to develop the data collection tools for this survey (Annex 5 and

Annex 6).

Multi-stage cluster sampling methodology was chosen to select the Panchayats in the

project areas, from which the required number of women respondents were chosen (Annex

4). The project monitoring requires that output and outcome indicators related to the

primary beneficiaries (pregnant women and mothers) be disaggregated at the district and

implementing partner level. This allows comparisons of these baseline results with future

reporting in the project through the regular monitoring system. District level reporting of

progress is required to share results with the local government in the district as well as with

DFID. Implementing partner level tracking is required for the purpose of internal project

monitoring. Therefore, for most indicators related to data from women, the report presents

both district and implementing partner specific disaggregated data.

To ensure than even the disaggregated data is within acceptable confidence levels, a sample

size of 384 women from each respondent category was required to be interviewed by each

implementing partner. Therefore, except for the second category of respondents (namely

mothers of children less than 7 days of age), the survey captures responses from 1536

women from each category. For the second category, only 1498 women could be

interviewed from the selected Panchayats due to its relatively smaller ‘universe’. From the

other broad category of respondents, a total of 400 service providers were interviewed (i.e.

194 facility based and 206 community-based providers).

Overall on the IYCF behaviour related (outcome level) indicators, the current study shows an

improvement over the DLHS-3 (2007-08) findings (1). DLHS-3 showed that in 2007-08, 16.2%

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of the mothers in Bihar had initiated breastfeeding within the mandated first hour after

birth. In comparison, the present study shows a slight increase of 1.2 percentage points to

reach 17.4% for the overall project area. This increase is even more significant when

compared district by district because in DLHS-3 the three project districts fared worse than

the state average on this indicator. Samastipur showed the highest net increase of 5.4

percentage points on the indicator on early initiation of breastfeeding.

Similarly, exclusive breastfeeding rates (for the first 6 months) increased in the last few

years from 11.8% under DLHS-3 in 2007-08 to 15.2% under the current study. Once again,

Sitamarhi shows the steepest increase from 0.3% to 13.5% - a difference of 13.2 percentage

points.

Complementary feeding showed mixed results. Regarding timely introduction of

complementary foods, the project level results in the present study are about 12 percentage

points above the Bihar level results under DLHS-3 (that is, an increase from 61.4% in DLHS-3

to 73.4% in the present study). However, the disaggregated data presents a slightly different

picture. Under DLHS-3, the districts Muzaffarpur and Samastipur reported better results on

this indicator than the state average. When those district level DLHS results are compared to

the present study, one sees a decline in timely introduction of complementary feeding in

these districts. The major reason here is probably the stark difference in definition of the

two indicators. The project indicator tracks children only in the 7th month of life, as

compared to the DLHS indicator on complementary feeding which captures children 6-9

months of age. It is obvious that the probability of a child being initiated to complementary

feeding increases with increasing age. On the other hand, the DLHS indicator specifically

asks about the introduction of semi-solid foods in the child’s diet, whereas the current study

asks for “any other foods other than breast-milk”. Thus the commonly given animal milk

would not be counted as complementary food under the DLHS indicator, but has been

counted as complementary food in the current study.

While the median age for introduction of complementary feeding was a little over six

months, it was found that about 10% of the mothers had not started their child on

complementary foods even by the age of one year. This extremely delayed complementary

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feeding gives an insight into one of the reasons behind high malnutrition rates of young

children in Bihar.

As far as age appropriateness of complementary feeding is concerned, even those who had

started their children on complementary foods were found to be feeding their children less

frequently than required and in far less quantities than needed for a child of that age. There

was hardly any increase in the mean number of meals per day given to a child 6-7 months of

age (2.8 times a day), and that given to a 12-13 month old child (2.9 times per day)4.

Moreover, it was not clear what was counted as a “meal”. Though it was difficult to

accurately assess and compare the quantity of food against an “ideal” age related quantity,

the rather rough assessment revealed that the quantity of food offered was inadequate. A

study of the food diversity of complementary foods, as measured in terms of food groups

showed that cereals and pulses were the most common components of a child’s meal.

Relatively few mothers gave their children fruits and vegetables, and even fewer offered the

child non-vegetarian food (i.e., meat, fish, poultry and eggs). The choice of food items is a

reflection of the common adult diet in India as well as the relatively poor economic

condition of the population in the project areas, which could be one of the major reasons

behind the absence of relatively expensive items such as fruits, meats and eggs from the

child’s plate.

Most KAP studies like the present study reveal that the proportion of respondents who have

the correct knowledge is often greater than the proportion acting upon that knowledge. In

this study too, while 23.2% women knew the correct time of initiation of breastfeeding, only

17.4% actually put it into practice. Similarly, while 22.2% of the mothers said that 6 months

was the ideal duration for exclusive breastfeeding, only 15.2% actually practiced the same.

For introduction of complementary foods, 22% of the mothers stated 6 months as the ideal

time for this. However, only 11.2% intended to practise this in the case of their own child.

But, as mentioned above, 73.4% of the mothers had already started giving the child food

other than breast-milk by the age of 6 months.

4 According to the WHO PAHO guidelines a child 6-8 months of age should be given complementary foods 2-3

times a day (minimum 2) while a child over a year should be fed 3-4 times in a day (minimum 3). This is in addition to snacks which should be given 1-2 times a day.

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The service providers interviewed in this survey have counselling on IYCF as an important

part of their job description. In order to be the behaviour change agents for mothers and

care-givers these providers need to not only have the correct knowledge on optimal IYCF

practices, but should also be conducting counselling sessions. Of all the service provider

cadres, the Mamtas were found to be the weakest in IYCF-related knowledge.

Overall, about three fourths of the service providers knew the correct timing for initiation of

breastfeeding. However, for the Mamtas, this proportion was only 41.9% and only 51% for

the ASHAs. This has serious implications because these two cadres are most likely to be

present with the mother at the time of institutional delivery.

Similarly, while 73.3% of the service providers could cite the correct duration of exclusive

breastfeeding, only 67.5% understood the correct meaning of exclusive breastfeeding. 14%

felt that offering water to the baby does not compromise the exclusivity of breastfeeding.

Even here, the ASHAs and the Mamtas performed the worse with only about 48% of each

cadre able to define exclusive breastfeeding.

Only 57% of the providers could cite the recommended age for introduction of

complementary feeding. Another 24.3% mentioned 7 months. This high percentage could

be because of the prevalent practice in the community of referring to age in “running”

months rather than completed months. So “after 6 completed months” would be referred

to as “in the 7th month” and might have been recorded as such by the interviewers.

Though IYCF counselling is an integral component of the job description of all these cadres,

only 86.5% of the workers knew/ acknowledged the same when directly asked whether

counselling on IYCF was part of their job description. An even lesser 80.8% actually claimed

to counsel women and care-givers on IYCF issues. However, when asked whether they had

conducted any group meetings or undertaken any home visits on IYCF in the previous three

months, only 31.7% and 34.7% respectively admitted doing so. This clearly reflects that

counselling on IYCF is not a priority for the service providers.

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Thus, the baseline study shows that there is much room for improvement in both the

knowledge and practice of the pregnant women and mothers of young children, as well as

the service providers. It is hoped that the project activities which focus on both of these

categories as primary and secondary beneficiaries respectively will bring about the much

needed change in uptake of recommended IYCF behaviours.

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Chapter 1

INTRODUCTION It is widely recognised that among all the individual public health interventions5 meant to

reduce neonatal, infant and child mortality, improving IYCF practices is likely to have a high

impact. A universal (100 percent) uptake of ideal IYCF norms across the population is

expected to reduce neonatal and infant mortality by about 15 percent (2).

AKF, supported by DFID, is implementing a health project that aims to reduce neonatal and

infant mortality by improving breastfeeding and complementary feeding practices of

mothers of children under two-years of age in the three districts of Muzaffarpur, Samastipur

and Sitamarhi in Bihar through effective behaviour change communication (BCC) efforts.

There are four implementing partners in this project who are responsible for carrying out

BCC activities in a population of about 1.1 million each. The distribution of the population by

district and implementing partner is described in Table 1.

Table 1: District and Implementing partner wise distribution of project population

Muzaffarpur Samastipur Sitamarhi TOTAL

Aga Khan Foundation (AKF) 1,129,487 1,129,487

Aga Khan Rural Support

Programme (AKRSP,I) 520,448 527,313 1,047,761

Agragami India (AI) 1,324,298 1,324,298

CHARM 1,110,558 1,110,558

TOTAL 1,649,935 1,851,611 1,110,558 4,612,104

The project mainly works through dedicated Peer Educators6 (PEs) – one peer educator for a

population of about 9,000. The PEs will be responsible for imparting information related to

optimal IYCF practices through group meetings and through home visits for young infants

5 Common interventions include improving immunization coverage rates, standard treatment of Artificial

Respiratory Infections (ARI) and diarrhea, use of insecticide treated bed-nets for malaria prevention etc. 6 A Peer Educator (PE) is a woman between 21-40 years of age with basic reading and writing skills, and

preferably married and residing in the community she is expected to serve. Her key tasks involve counseling the women, families and community on IYCF issues and helping mothers and care-givers resolve issues related to the same through inter-personal counseling sessions.

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and for individual problem solving for an estimated 10 percent of the mothers through

home visits.

A group of four PEs is supervised by a Cluster Coordinator7 (CC). [A detailed project

organogram can be found as Annex 1 at the end of the document]. The PEs and CCs are also

expected to mentor government health and nutrition functionaries by ensuring their

presence at PE led group meetings and home visits as well as through formal class-room-

based orientation sessions in order to improve their knowledge regarding recommended

IYCF practices as well as inter-personal and group counselling skills. It is hoped that such

mentoring will help them carry our IYCF home visits, group meetings and inter-personal

counselling sessions for sharing IYCF messages both at the community and household levels

as well at the facility level8. This is important to ensure sustainability of efforts beyond the

project time-frame.

As with all BCC efforts, the project activities are expected to bring about an improvement in

the knowledge levels (output) of the primary beneficiaries (mothers of children under two)

as well as the secondary target population (health and nutrition functionaries) before

resulting in a change in practice (outcome). Hence, the project’s monitoring plan includes

regular tracking of indicators that measure knowledge and practice levels of mothers and

health functionaries. The project’s conceptual framework and the monitoring indicators are

available in Annex 2 and Annex 3.

In October 2011, prior to the approval of this grant, AKF conducted a formative research to

understand the barriers and facilitating factors for the uptake of recommended IYCF

behaviours in the targeted communities. This research provided the team with adequate

qualitative information to draw up a technical communication plan, but the absence of a

valid baseline for these indicators was a problem that needed resolution. While DLHS 3 data

was used as the baseline to set tentative milestones and targets at the proposal

7 A Cluster Coordinator (CC) is person (preference given to women) who is between 21-40 years of age and has

passed the 12th

grade. Her main responsibility is to support and supervise the work of four PEs, as well as mentor the government health and nutrition functionaries. CCs with also work with the Project Coordinators for district level advocacy on IYCF issues. 8 Facility level counseling on IYCF is required at the time of delivery to ensure early and timely initiation of

breastfeeding, within one hour of birth.

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development stage, it was soon realised that DLHS 3 could not serve as a “true” baseline for

the project. This was because:

- Data collection for DLHS 3 was conducted in 2007-08. Therefore the data is more

than four years older than the actual project time-frame.

- The indicators used in DLHS do not match the project monitoring indicators (for

example, the denominator in DLHS 3 is mothers of children under-3, whereas for the

project monitoring purposes, the denominator varies with the indicator in question).

- DLHS does not collect information on output (knowledge level) indicators either at

the community level or for the health and nutrition functionaries.

- DLHS does not collect information on IYCF counselling related practices of health and

nutrition functionaries.

Objectives:

Given the above-mentioned limitations of the DLHS-3 data, the Project conducted an

independent cross-sectional baseline survey with the following objectives:

1. To assess the: a) knowledge level and, b) actual practice regarding the following among

mothers:


Exclusive Breastfeeding (EBF)

Introduction of Complementary Feeding (CF)

Age Appropriate Complementary Feeding

2. To assess the: a) knowledge level on IYCF issues and b) on-the-job performance of

health/nutrition functionaries on IYCF and the activities related to BCC.

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Chapter 2

REVIEW OF LITERATURE

The Global Strategy for Infant and Young Child Feeding was adopted by the World Health

Assembly in May 2002, and accepted by the UNICEF executive board in September 2002 (3).

It was meant to revitalise world attention to the impact that feeding practices have on the

nutritional status, growth and development, health, and thus the very survival of infants and

young children (4).

The three key tenets of optimal IYCF behaviours are:

- Early and timely initiation of breastfeeding within an hour of birth

- Exclusive breastfeeding for the first six months.

- Introduction of age appropriate complementary feeding at six months of age along

with continued breastfeeding for two years and beyond.

Early and Timely Initiation of Breastfeeding

WHO recommends that breastfeeding should be initiated within an hour of birth. In order to

facilitate this, it proposes that all activities that involve separation of the mother from the

baby (such as weighing or bathing) be delayed till after the first hour. This will allow the

mother and the newborn to have uninterrupted skin-to-skin contact until the first

breastfeed (5). Two recent studies, one in Ghana and the other in Nepal have shown an

increased risk of neonatal mortality of 2.4 and 1.4 times respectively if initiation of

breastfeeding was delayed beyond the first 24 hours (5). In the Ghana study, late initiation

(beyond 24 hours) was associated with a 2.6 fold increase in infection-specific neonatal

mortality, whereas no such association was observed between timing of initiation of

breastfeeding and non-infection neonatal deaths. The increasing risk of mortality with delay

in initiation of breastfeeding is shown in Table 2 below.

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Table 2: Delayed initiation of breastfeeding increases neonatal mortality (6)

The plausible biological pathways through which early initiation helps in reduction of

neonatal morality include: a) provision of immune factors present in colostrum; b)

protection against exposure to infectious pathogens (potentially present in pre-lacteal feeds

and breast-milk substitutes); c) optimal maturation of the gut and immune system; d)

protection against hypothermia; and e) facilitating sustained breastfeeding (5).

In India, the rates of early initiation of breastfeeding within an hour of birth have shown a

major increase over the past few years, from 23.4% as found in NFHS-3 (7) of 2005-06, to

40.5% in DLHS-3 (1). However, a relatively recent study conducted in Bareilly district of Uttar

Pradesh (UP) in India revealed that while only 22% of the mothers of children 0-11 months

of age had initiated breastfeeding within the recommended one-hour of birth, another

21.2% delayed it beyond the first 24 hours (8). It must be noted that compared to the

national and sub-national surveys, this was a very small and localised study, the results of

which may not be comparable to the situation in the state, let alone at the national level.

Exclusive breastfeeding

Breastfeeding confers many benefits to the child, including prevention of infections,

allergies and asthma in childhood, to protection from adult diseases such as diabetes and

hypertension (3). The Ghana and Nepal studies also showed that exclusive breastfeeding

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resulted in a reduction in mortality irrespective and independent of the timing of initiation

of breastfeeding (5). Breastfeeding results in optimal physical and mental growth and

development of the child. Breastfeeding also saves the family and thus the community and

the nation a lot of money, be it through reduced expenses on infant milk substitutes or on

treatment of a sick child. It also confers benefits to the mother such as protection from

osteoporosis and breast-cancer, as well as delaying the return of fertility post child-birth (3).

The Lancet series on child survival identified breastfeeding as the single most important

intervention that could prevent 13-16 percent of all childhood deaths (2).

Breastfeeding the child is almost a norm in countries like India. The recent World

Breastfeeding Trends Initiative (WBTi) report, published by IBFAN in 2012, reveals that the

average (median) duration of breastfeeding in India is close to 30 months (9). However,

continued breastfeeding differs from exclusive breastfeeding. Unlike the rise in early

initiation rates, the proportion of children under 6 months of age who were exclusively

breastfed in the 24 hours preceding the survey remained almost constant at 46.8% in DLHS-

3 (1) from 46.3% in NFHS-3 (7). While these appear to be relatively high rates, DLHS-3 also

shows that only 26.2% of the children 6-35 months of age were exclusively breastfed for at

least 6 months. The difference between the two results relates the proportion of mothers

who discontinue exclusive breastfeeding before the age of 6 months. The Bareilly study

reported that as high as 77.2% of the children were exclusively breastfed, though it is

unclear from the article for how long the baby has been exclusively breastfed (8). Studies

have shown that the most common cause cited by the mother to give supplementary feeds

along with breastfeed is her perception that she does not have enough breast-milk (10).

Complementary feeding:

The Lancet series on child survival states that adequate complementary feeding from 6-23

months could save an additional 6 percent of child deaths (beyond those saved due to

exclusive breastfeeding) (2).

According to the PAHO (WHO) guidelines (11) on complementary feeding, a 6-8 month old

child should be given food (other than breast-milk) 2-3 times a day, while the frequency

should be increased for 12-23 month old child to 3-4 times a day. In addition to this, the

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child should be offered snacks9 about 1-2 times in a day. These recommendations are based

on assumptions related to the average amount of breast-milk taken by children of these

ages, based on which it is stated that babies 6-8 months of age require 200 Kcal, 9-11

months 300 Kcal and 12-23 months 550 Kcal of energy per day from complementary foods.

With some more assumptions related to the calorie density of common complementary

foods (viz. 1.07 to 1.46 Kcals per gram of food) these calorie requirements translate into the

following quantities of daily complementary foods for the children in different age groups:

- 6-8 months: 137 to 187 grams / day



The national surveys have defined complementary feeding as the introduction of semi-solid

or solid foods into a child’s diet in addition to breast-milk. According to this definition,

NFHS-3 found that complementary feeding had been initiated for 55.8% of the Indian

children in the age group 6-9 months (7). This showed an insignificant increase to 56.5% in

DLHS-3 (1). The WBTi 2012 report quotes this figure at 57.1% (9). However, the source of

data for this multi-country report is not known. The Bareilly study found that about one

fourth of the mothers had initiated complementary feeding of their children before the

recommended age of 6 months. Another 43% started the same between 6-9 months of age,

whereas about a third had delayed it beyond 9 months (8). Thus according to this small

study, over two thirds of the children 6-9 months of age were receiving complementary

foods, which is about 10 percentage points higher than the national surveys.

No studies that assessed the age appropriateness of complementary feeding were found for

this review. This could be because there is no standard agreed upon definition for this that

takes into account various aspects of complementary feeding, including, but not limited to,

the frequency, quantity and variety of foods offered to the child. Additionally, measuring all

these aspects reliably through the commonly used interview technique is difficult, and is a

practical impediment for data collection for the indicator on age appropriateness of

complementary feeding.

9 “Snacks” are defined as foods eaten between meals-usually self-fed, convenient and easy to prepare.

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Role of service providers:

Several studies in India and across the globe have demonstrated that it is possible to achieve

high rates of exclusive breastfeeding, but this is possible only through education and

counselling (3). This is because increasing exclusive breastfeeding and complementary

feeding require behaviour change and it is a process that can be achieved through

appropriate knowledge and skill transfer. It is not the same as the delivery of some

vaccinations and health protection. It needs inputs from service providers as well as support

from the families of lactating women. For example, lack of exclusive breastfeeding is mostly

due to the feeling of “not enough milk” in the mothers, and needs to be addressed by

building their confidence through counselling (3).

Despite the glaring need, the status of community-based support systems for pregnant and

breastfeeding mothers is poor in India. According to World Breastfeeding Tends Initiative

(WBTi 2012) (9), India scored a low 5 out of 10 on this index type indicator, which covers

issues such as whether or not the community-based service providers are trained in

counselling skills for IYCF. The glaring gap in this area can be better understood when one

looks at neighbouring countries like Sri Lanka and Maldives, which scored 9 on this indicator.

Another related indicator gauges the status of information support on IYCF in the country,

by looking into existence of a comprehensive multi-media plan at the national level for

dissemination of IYCF information, and whether the information shared is technically sound

and based on international guidelines. India scored a 6 of the maximum 10 points under this

indicator. Once again neighbouring Sri Lanka and Pakistan scored a much higher 9 points,

while some African countries like Malawi, Kenya and Gambia scored a perfect 10 for this

indicator.

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Chapter 3

MATERIAL & METHODS

Study Design:

This is a cross-sectional survey design.

Period of data collection:

Data was collected from the women respondents from 19th September to 15th October

2012, and from the service providers from 20th September to 29th October 2012.

Study area:

The survey was conducted in select blocks of three districts of Bihar where the Project is

being implemented - Muzaffarpur, Samastipur and Sitamarhi. As mentioned in Chapter 1

(Table 1), the activities in these three districts are being implemented by four project

partners - AKF(I), AKRSP(I), Agragami (India) and CHARM.

Respondents’ selection criteria:

In line with the objectives, data was collected from broadly two respondent categories,

namely pregnant women and mothers of young infants, and health and nutrition

functionaries. These categories were further subdivided depending on the denominator of

the indicator in question. Thus, the various respondent categories were:

A. Women



iii) Mothers with a child 3-4 months10 of age

iv) Mothers with a child 6-7 months11 of age

v) Mothers with a child 12-13 months12 of age

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“child 3-4 months of age” refers to the child who has completed 3 months, but not 4 months on the date of the survey, i.e. the 4

th month after birth.

11 “child 6-7 months of age” refers to the child who has completed 6 months, but not 7 months on the date of

the survey, i.e. the 7th

month after birth. 12

“child 12-13 months of age” refers to the child who has completed 12 months, but not 13 months on the date of the survey, i.e. the 12

th month after birth.

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B. Health and nutrition workers (service providers)

i) Community based health and nutrition functionaries (i.e., ASHAs and AWWs)

ii) Facility based health functionaries (i.e., ANMs and Mamtas)

Sample size:

In order to calculate sample size, a tentative “prevalence” level of various indicators was

required. While DLHS-3 provides levels for some indicators, for reasons mentioned above in

Chapter 1, they were not considered reliable enough for calculating the sample, size. Thus,

the prevalence level of 50 percent was assumed for all indicators in order to arrive at the

maximum sample size.

Sample size = (1.96)2pq

d2

where,

p = Current prevalence level (viz. 50% or 0.5)

q = 1 - p (viz. 1 - 0.5 = 0.5)

d = Allowable error (set at 5% or 0.05 for the women respondents, and 7% or 0.07 for

the health and nutrition functionaries13)

Using this formula, the sample size for each category of women respondents was calculated

to be 384, while that for the workers was calculated to be 196 (rounded off to 200).

It was also decided that while the data collected from the women would be disaggregated

and reported at both the implementing partner and district levels, the data for the workers

would be reported at the overall project level only. This meant that each implementing

partner would have to individually reach out to the “complete sample size”, i.e., 384 women

from each respondent category for data collection. However, they would need to collect

data from only 50 (that is 200/4) respondents for each category of workers.

13

The allowable error for the health and nutrition functionaries is kept slightly higher than for the women / mothers in order to reduce the sample size, while keeping in mind that the workers are not the primary target population of the project.

20

Sampling methodology:

Multi–stage cluster sampling with probability proportionate to size (PPS) was used for

selection of respondents owing to the large geographical area to be covered and also

because of the absence of a list with the complete universe of respondents.

Each implementing partner selected 64 clusters using this methodology. Six women from

each respondent category were interviewed from each cluster, thus making a total of 384

(i.e., 64x6) women in each category.

In the first stage of sample selection, all the administrative blocks covered by an

implementing partner were listed and variable numbers of clusters were allocated to each

block using the PPS methodology. In the second stage, the clusters allotted to each block

were further divided and allocated to various Panchayats in those blocks, again using the

PPS methodology. Thus, the panchayat was the last geo-administrative unit to which cluster

positioning was done.

As there are number of revenue villages located in a Panchayat (4 to 5) which may be spread

across a relatively large geographical distance, the interviewers started with the revenue

village with the largest population in order to cover the maximum number of respondents

from the minimum possible area. In instances where the interviewers were unable to find

the required number of respondents in the first (largest) revenue village, they moved to the

one with the second highest population and so on. In some cases the required sample of

one category was reached earlier than the others. In such cases, only the “leftover” sample,

if any, was covered from the smaller revenue villages.

The second sub-category of women (mothers with children aged less than 7 days) had the

smallest possible “universe” as the age time-frame captured in this category is only 7 days

compared to a month for all other categories. Despite almost universal coverage,

interviewers were unable to find the requisite number of mothers in this sub-category in

some of the clusters.

21

The detailed cluster selection methodology is provided in Annex 4.

Survey Instruments:

Six types of survey instruments were created, one for each respondent category of women,

and a common form for all the service providers. As detailed in Table 3, for the women, the

focus of the questionnaire was on the knowledge, intention and/or practice of the IYCF

behaviour relevant to that particular age group. For the service providers, the survey

instrument had questions to assess their knowledge on all IYCF recommendations, as well as

on-the-job performance related to BCC for increasing uptake of recommended behaviours

by women.

Table 3: Issues assessed through the various survey instruments. Respondent category Issues assessed through survey instrument

Women in the last trimester of pregnancy

Knowledge regarding

- Initiation of breastfeeding

- Pre-lacteal feeds

- Colostrum

Intention to

- Breastfeed the baby

Mothers with a child less than 7 days of age

Knowledge regarding

- Advantages of breastfeeding

- Duration of exclusive breastfeeding.

Practice related to

- Initiation of breastfeeding

- Pre-lacteal feeds

- Exclusive breastfeeding

- Keeping the baby warm.

Intention to

- Exclusively breastfeed the baby

22

Mothers with a child 3-4 months of age

Knowledge regarding

- Duration and advantages of exclusive

breastfeeding.

Practice related to


Intention to

- Continue exclusive breastfeeding

- Introduce complementary foods


Knowledge regarding

- Duration of exclusive breastfeeding.

- Diarrhoea management

Practice related to


- Continuation of breastfeeding

- Introduction of complementary foods

- Age appropriate complementary feeding

Intention to

- Continue breastfeeding

- Introduce complementary foods (if not

done already)


Practice related to

- Continuation of breastfeeding

- Introduction of complementary foods

- Age appropriate complementary feeding

Intention to

- Introduce complementary foods (if not

done already)

23

Health and Nutrition functionaries (i.e.

ASHAs, AWWs, ANMs and Mamtas)

Knowledge regarding

- Initiation of breastfeeding.

- Pre-lacteal feeds

- Colostrum feeding

- Keeping the baby warm


- Introduction of and age appropriate

complementary feeding

On the job performance related issues

- Training on IYCF

- Counselling women on IYCF.

The first draft of the tools were prepared in English and shared with the State Project team

for review. Multiple rounds of review and revisions resulted in the final tool. These were

then translated into the local language (Hindi). The team reviewed the translated versions

again to ensure that meaning was not lost during the translation process. The translated

tools were also pre-tested in the field before going to the printers.

The final English versions of the data collection tools are attached as Annex 5 . The

translated (Hindi) version of the data collection tools can be found in Annex 6.

Interviewers:

The PEs, CCs and Project Coordinators (PCs) were the designated interviewers for the

baseline survey. While the PEs and CCs collected data from the women respondents, the

PCs interacted with the service providers. Following technical training on IYCF, 227 PEs, 108

CCs and all 8 PCS were oriented to the data collection tools as well as the process of

respondent selection after reaching the sample panchayat.

While in the field, the interviewers faced many problems in data collection, such as

- Limited numbers of mothers with a child less than 7 days of age (due to relatively

few number of deliveries taking place in the months of data collection).

24

- Interviewing the second category of respondents, as they had just delivered a few

days back, and were tired because of the effort during delivery and time needed for

child-care.

- Interference during the interview by other care-givers such as fathers and

grandmothers, who often responded instead of the mother.

Data entry and analysis:

For quick data entry, the State Project Management Unit (SPMU) created a template in MS

Excel. The MIS assistants, one each with the four implementing partners, were responsible

for data entry. They, along with the PCs and Project Managers were trained by the SPMU.

The complete data set in Excel was reviewed by the SPMU and discordant information,

wherever present, was reviewed. Some “uniform” data entry errors14 were revised for the

complete data set.

Data analysis was done through simple frequency tables. Data collected from the women

respondents was disaggregated by both district and IP to assess for intra-project differences

in baseline, if any, and later assist in internal project monitoring.

Quality assurance:

Quality was ensured at various stages of the survey.

- Multiple reviews and revisions of the tool, including its translated version and its

pilot testing ensured that the tool was designed to capture the required information.

- Training of interviewers ensured homogeneity in data collection methodologies. For

example, some questions required the interviewer to only list spontaneous answers,

whereas a few others required the interviewer to prompt the respondent. All of

these were not only specified in the questionnaire but also specifically explained to

the interviewers during training.

- The CCs and Project Coordinators from the implementing partners accompanied the

PEs during data collection. The SPMU also visited the field on a random basis to

ensure valid data collection.

14

At places, data entry operators had filled in no. of days in the “no. of months” column and vice versa. At other places, they had filled in the actual number of times a baby was fed rather than the designated numerical code for the same.

25

- All forms were checked at the end of each day to ensure completeness of

information.

- Excel sheet forms had in-built mechanisms to prevent data entry errors, such as

allowing entry of only pre-defined options for many questions.

- Training of data entry operators (MIS assistants) reduced errors and ensured

homogeneity in data entry.

- Following data entry, a random back-check of 10 percent forms was done to ensure

that the data entered in the excel sheet matched the data present in the forms, thus

capturing inadvertent data entry errors.

- Repeat data entry was done for those fields were “uniform” data entry errors (see

above under “Data entry and analysis”) were found.

26

Chapter 4

OBSERVATIONS

SECTION A: WOMEN

Respondent Profile:

As stated in Chapter 3, the women respondents were categorised into five groups

depending on the stage of their pregnancy or the age of the index child. These were:



iii) Mothers with a child 3-4 months of age

iv) Mothers with a child 6-7 months of age

v) Mothers with a child 12-13 months of age

In order to ensure a confidence level of 95% even when the data is disaggregated at the IP

level, 384 women were to be interviewed from each of these respondent groups by each IP.

As two of the three districts - Muzaffarpur and Samastipur - in the Project are managed by

two IPs each, the sample size for these two districts exceeds the 384 mark. The final

respondent tally is shown in Table 4

Table 4: District and Implementing Partner wise distribution of women respondents of categories (i), (iii), (iv) and (v).

Implementing Partner

District AKF (I) Agragami CHARM AKRSP (I) TOTAL

Muzaffarpur 384 - - 174 558

Samastipur 384 - 210 594

Sitamarhi - - 384 - 384

TOTAL 384 384 384 384 1536

For the second category, i.e., women with a child less than 7 days old, owing to a relatively

smaller “universe” the ideal sample size for this category was not reached by two IPs. As can

be seen from

27

Table 5, while AKRSP (I) could enrol 372 of the required 384 women in this category, AKF (I)

could manage to find only 358 respondents in this category from the Panchayats chosen

under cluster sampling.

Table 5: District and Implementing Partner wise distribution of women respondents

of category (ii) i.e., those with a child less than 7 days of age.




Samastipur - 384 - 206 590

Sitamarhi - - 384 - 384

TOTAL 358 384 384 372 1498

Thus, a total of 7642 women respondents were interviewed across three districts and four

implementing partners. The overall distribution is given in Table 6

Table 6: District and Implementing Partner wise distribution of all the women respondents



Muzaffarpur 1894 - - 862 2756

Samastipur - 1920 - 1046 2966

Sitamarhi - - 1920 - 1920

TOTAL 1894 1920 1920 1908 7642

Figure 1 shows that about 51 % of women respondents all belonged to the marginalised

population. Of these, almost 36% were women from scheduled castes, while another 15%

were Muslims. There was insignificant variation in this distribution among the various

respondent categories.

28

Figure 1: Caste and religion-wise distribution of women respondents (overall).

However, there existed notable variation in the proportion and mix of marginalised

population across districts and implementing partners. As can be seen from that found in

Samastipur (10%)

Table 7 , the proportion of SC women respondents in Sitamarhi is only 25% compared to

about 39% and 40% in Muzaffarpur and Samastipur respectively. On the contrary, the

proportion of Muslim respondents in Sitamarhi (23%) is more than double of that found in

Samastipur (10%)

Table 7: Caste and religion wise distribution of women respondents across districts

Caste/Religion Others

Marginalised groups TOTAL

District SC Muslim Total marginalised

Muzaffarpur 1245

(45.2)

1077

(39.1)

434

(15.7)

1511

(54.8) 2756

Samastipur 1471

(49.6)

1192

(40.2)

303

(10.2)

1495

(50.4) 2966

49%

36%

15%

Others SC Muslim

29

Sitamarhi 998

(52.0)

483

(25.2)

439

(22.9)

922

(48.0) 1920

TOTAL 3714

(48.6)

2752

(36.0)

1176

(15.4)

3928

(51.4) 7642

Numbers in parentheses indicate percentages of the row totals, rounded off to the first decimal.

Similarly, Table 8 shows that there is a much larger proportion of women respondents from

marginalised groups in AKRSP (I) areas (60.5%) compared to the others. Agragami, with only

45% of respondent women from the marginalised groups, has the least proportion of such

respondents. Specifically, there is a wide variation in the respondents belonging to the

scheduled castes between the various IPs, with AKRSP (I) once again having the highest

proportion at 47%, which is almost double the 25% found among the respondents from

areas managed by CHARM.

Table 8: Caste and religion wise distribution of women respondents across Implementing partners

Caste/Religion

Others

Marginalised groups

TOTAL Implementing partner SC Muslim

Total

marginalised

AKF 906

(47.8)

644

(34.0)

344

(18.2)

988

(52.2) 1894

Agragami 1056

(55.0)

731

(38.1)

133

(6.9)

864

(45.0) 1920

CHARM 998

(52.0)

483

(25.2)

439

(22.9)

922

(48.0) 1920

AKRSP( I) 754

(39.5)

894

(46.9)

260

(13.6)

1154

(60.5) 1908

TOTAL 3714

(48.6)

2752

(36.0)

1176

(15.4)

3928

(51.4) 7642

Numbers in parentheses indicate percentages of the row totals, rounded off to the first decimal.

30

The women were asked questions about their knowledge, intention and practice (as

applicable according to the stage of pregnancy or age of their child) regarding IYCF

behaviours. The findings are presented below. They have been categorised based on the

three tenets of IYCF, namely Initiation of breastfeeding, exclusive breastfeeding and


Initiation of Breastfeeding:

a) Timing of initiation of breastfeeding:

Women in the third trimester of pregnancy were asked when, according to them, should

breastfeeding be initiated following birth of the baby. Table 9 and Table 10 show that of

the 1536 respondents in this category across the projects, less than one-fourth could

give the correct answer i.e. breastfeeding should be initiated within an hour of birth.

About one-third (32%) said that it should be initiated within the first 6 hours of birth.

Of the three districts, women from Sitamarhi fared the worst with respect to their

knowledge on this issue with just 19% knowing the appropriate response (Table 9).

Alarmingly, more than half of the women in Samastipur felt that the correct time to

initiate breastfeeding was after the first 24 hours of birth, with 33% saying between 1-3

days and another 19% stating after 3 days.

On the contrary, 70% of the women respondents from Muzaffarpur felt that

breastfeeding should be initiated within the first 6 hours, with 28% giving the correct

response.

Table 9: Knowledge of women in the third trimester of pregnancy about ideal time for initiation of breastfeeding - disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Knowledge regarding timing

of initiation of BF

Immediately, within one hour of birth

157

(28.1)

126

(21.2)

73

(19.0)

356

(23.2)

Same day between 1 - 6 hours after birth

236

(42.3)

185

(31.2)

65

(16.9)

486

(31.6)

31

Same day (6-24 hours after birth)

41

(7.4)

118

(19.9)

26

(6.8)

185

(12.0)

1-3 days 54

(9.7)

77

(13.0)

128

(33.3)

259

(16.9)

After 3 days 6

(1.2)

29

(4.9)

72

(18.8)

107

(7.0)

Never 1

(0.2)

2

(0.3)

0

(0.0)

3

(0.2)

Others / No response 63

(11.3)

57

(9.6)

20

(5.2)

140

(9.1)

TOTAL 558 594 384 1536

Numbers in parentheses indicate percentages of the column totals, rounded off to the first decimal.

As Sitamarhi district is managed by CHARM, when the indicator related to knowledge of

women regarding the ideal time for initiating breastfeeding was disaggregated by

implementing partner (Table 10), CHARM fared the worst of all the four partners. Similarly,

AKF which works in Muzaffarpur reported relatively good results on this indicator, with 75%

of the women stating the time frame for breastfeeding initiation within the first 6 hours of

birth, of which 27% gave the correct response of “within 1 hour of birth”.

Table 10: Knowledge of women in the third trimester of pregnancy about ideal time for initiation of breastfeeding - disaggregated by implementing partners

Implementing partner

AKF Agragami CHARM AKRSP,I TOTAL Knowledge regarding timing

of initiation of BF


104 (27.1)

75 (19.5)

73 (19.0)

104 (27.1)

356

(23.2)


184 (47.9)

100 (26.0)

65 (16.9)

137 (35.7)

486

(31.6)


23 (6.0)

73 (19.0)

26 (6.8)

63 (16.4)

185

(12.0)

32

1-3 days 28

(7.3) 62

(16.2) 128

(33.3) 41

(10.7)

259

(16.9)

After 3 days 3

(0.8) 28

(7.3) 72

(18.8) 4

(1.0)

107

(7.0)

Never 0

(0.0) 0

(0.0) 0

(0.0) 3

(0.8)

3

(0.2)

Others / No response 42

(10.9) 46

(12.0) 20

(5.2) 32

(8.3)

140

(9.1)

TOTAL 384 384 384 384 1536


Women who had delivered recently i.e., mothers with a child less than 7 days of age were

asked about the actual practice related to initiation of breastfeeding. Table 11

(disaggregation by district) and Table 12 (disaggregation by IP) show that just 17% of the

women had initiated breastfeeding within the recommended one hour after birth. Another

38% had initiated within the first 6 hours.

As can be seen from Table 11, the inter-district variation in findings on the actual practice of

women related to initiation of breastfeeding are similar to knowledge on this issue, with

women from Sitamarhi faring far worse than in the other two districts. However, it must be

noted here for Sitamarhi that while only 36% of the pregnant women had cited a time

within the first 6 hours for initiation of breastfeeding, there was an improvement in actual

practice, and a significantly larger proportion of women (48%) had initiated breastfeeding

within 6 hours of birth.

In comparison, Muzaffarpur had the best report on this indicator from all three districts,

with 67% of the women having initiated breastfeeding within the first 6 hours, and 19%

within the recommended first hour of birth.

33

Table 11: Time of initiation of breastfeeding by women with a child less than 7 days of age – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Practice regarding timing of

initiation of BF


101 (19.3)

96 (16.3)

64 (16.7)

261 (17.4)


252 (48.1)

192 (32.5)

119 (31.0)

563 (37.6)


99 (18.9)

129 (21.9)

40 (10.4)

268 (17.9)

1-3 days 54

(10.3) 98

(16.6) 95

(27.7) 247

(16.5)

After 3 days 15

(2.9) 54

(9.2) 60

(15.6) 129 (8.6)

Never 1

(0.2) 9

(1.5) 4

(1.0) 14

(0.9)

Others 2

(0.4) 12

(2.0) 2

(0.5) 16

(1.1)

TOTAL 524 590 384 1498


Table 12 shows that the inter-district differences in practice are replicated across

implementing partners too, depending upon the district(s) they manage. Practice of women

in AKF areas was closer to the recommended behaviour for initiation than for other

implementing partners.

Table 12: Time of initiation of breastfeeding by women with a child less than 7 days of age – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL Practice regarding timing of

initiation of BF


67 (18.7)

61 (15.9)

64 (16.7)

69 (18.6)

261 (17.4)


185 (51.7)

93 (24.2)

119 (31.0)

166 (44.6)

563 (37.6)


65 (18.2)

86 (22.4)

40 (10.4)

77 (20.7)

268 (17.9)

34

1-3 days 29

(8.1) 80

(20.8) 95

(27.7) 43

(11.6) 247

(16.5)

After 3 days 11

(3.1) 50

(13.0) 60

(15.6) 8

(2.2) 129 (8.6)

Never 0

(0.0) 6

(1.6) 4

(1.0) 4

(1.0) 14

(0.9)

Others 1

(0.3) 8

(2.1) 2

(0.5) 5

(1.3) 16

(1.1)

TOTAL 358 384 384 372 1498


Comparing the knowledge on and actual practice of initiation of breastfeeding (Figure 2),

there is a slight drop in the percentage (about 6 percentage points) of who know the “ideal

time” to those who were able to adopt it into actual practice. However, the overall

proportion of women who initiated breastfeeding within the first six hours is comparable to

the 55% of women in the third trimester who had stated the same. Overall, about 1% of the

women with children less than 7 days of age had not initiated breastfeeding until the time

of the survey. The reason for the same was not explored as part of this survey.

35

Figure 2: Comparison between knowledge and practice of initiation of breastfeeding after delivery

Exclusive breastfeeding:

Women in three of the five categories were asked questions related to exclusive

breastfeeding (EBF) viz. mothers with children less than 7 days of age, between 3-4 months

of age and between 6-7 months. While all three categories were asked questions related to

their knowledge about the advantages and/or the ideal duration of exclusive breastfeeding,

they were also asked about their actual practice and/or intention about exclusive

breastfeeding.

a) Knowledge regarding exclusive breastfeeding

Mothers of a child less than a week old as well as those with a child 3-4 months of age were

asked to enumerate some advantages of exclusive breastfeeding. Overall, about one-third

of the women interviewed were unable to mention even a single advantage of

breastfeeding (Table 13, Table 14, Table 15 and Table 16). On an average, the women with

a child less than 7 days of age could list down 1.5 advantages, whereas those with a 3-4

months’ old child mentioned about 1.3 advantages.

23.2

31.6

12

16.9

7

0.2

9.1

17.4

37.6

17.9 16.5

8.6

0.9 1.1

0

5

10

15

20

25

30

35

40

Immediately, within one

hour of birth

Same day between 1 - 6

hours after birth

Same day (6-24 hours after

birth)

1-3 days After 3 days Never Others/No response

Knowledge (N=1536) Practice (N=1498)

36

Women from Sitamarhi fared the worst on this indicator (Table 13 and Table 15). Almost

half the women from both the respondent categories (mothers with a child less than 7 days

and mothers with a child 3-4 months) could not cite even a single advantage. Compared to

this, only 27% and 19% of the women respondents in these two categories from

Muzaffarpur were found this lacking in breastfeeding related knowledge.

Table 13: Knowledge of women with a child less than 7 days of age about advantages of

exclusive breastfeeding – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL No. of advantages of BF cited

Zero 142

(27.1) 117

(19.8) 181

(47.1) 440

(29.4)

One 145

(27.7) 243

(41.2) 109

(28.4) 497

(33.2)

Two 125

(23.9) 104

(17.6) 48

(12.5) 277

(18.5)

Three 61

(11.6) 81

(13.7) 16

(4.2) 158

(10.5)

Four 32

(6.1) 28

(4.7) 9

(2.3) 69

(4.6)

Five 6

(1.1) 11

(1.9) 2

(0.5) 19

(1.3)

More than five 13

(2.5) 6

(1.0) 19

(5.0) 38

(2.5)

TOTAL 524 590 384 1498


37

Table 14: Knowledge of women with a child less than 7 days of age about advantages of exclusive breastfeeding – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL No. of advantages of EBF

cited

Zero 113

(31.6) 101

(26.3) 181

(47.1) 45

(12.1) 440

(29.4)

One 111

(31.0) 173

(45.1) 109

(28.4) 104

(28.0) 497

(33.2)

Two 74

(20.7) 57

(14.8) 48

(12.5) 98

(26.3) 277

(18.5)

Three 38

(10.6) 32

(8.3) 16

(4.2) 72

(14.4) 158

(10.5)

Four 16

(4.5) 14

(3.6) 9

(2.3) 30

(8.1) 69

(4.6)

Five 1

(0.3) 4

(1.0) 2

(0.5) 12

(3.2) 19

(1.3)

More than five 5

(1.4) 3

(0.8) 19

(5.0) 11

(3.0) 38

(2.5)

TOTAL 358 384 384 372 1498


Table 15: Knowledge of women with a child 3-4 months of age about advantages of

exclusive breastfeeding – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL No. of advantages of EBF

cited

Zero 106

(19.0) 167

(28.1) 207

(53.9) 480

(31.3)

One 213

(38.2) 231

(38.9) 116

(30.2) 560

(36.5)

Two 151

(27.1) 120

(20.2) 34

(8.9) 305

(19.9)

Three 70

(12.5) 50

(8.4) 14

(3.6) 134 (8.7)

More than three 18

(3.2) 26

(4.4) 13

(3.4) 57

(3.7)

TOTAL 558 594 384 1536


38

Table 16: Knowledge of women with a child 3-4 months of age about advantages of exclusive breastfeeding – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL No. of advantages of BF cited

Zero 97

(25.3) 120

(31.3) 207

(53.9) 56

(14.6) 480

(31.3)

One 159

(41.4) 182

(47.4) 116

(30.2) 103

(26.8) 560

(36.5)

Two 86

(22.4) 52

(13.5) 34

(8.9) 133

(34.6) 305

(19.9)

Three 35

(9.1) 18

(4.7) 14

(3.6) 67

(17.4) 134 (8.7)

More than three 7

(1.8) 12

(3.1) 13

(3.4) 25

(6.5) 57

(3.7)

TOTAL 384 384 384 384 1536


As can be seen from Table 17, close to half (48%) of the women respondents listed

appropriate physical and mental development of the child as the advantages of exclusive

breastfeeding that they were aware of. Slightly more than one-fourth (27.5%) said that

mother’s milk was the best and complete food for the child for the first 6 months. Relatively

fewer women were aware of the protective effect of breast-milk against common childhood

diseases such as diarrhoea (14.4%) and pneumonia (7.8%). It is interesting to note, that few

even listed the economic benefits of breastfeeding such as it being “free” (when compared

to other infant milk substitutes), savings due to no expenditure for fuel, and even money

saved due to reduced illness and therefore medical expenses for the child.

Less than 3% of the women mentioned the contraceptive benefit of exclusive breastfeeding.

39

Table 17: Knowledge of women (across two respondent categories) about advantages of exclusive breastfeeding

Women’s respondent category Mothers of children less

than 7 days of age

(N=1498)

Mothers of children 3-4

months of age

(N=1536)

TOTAL

(N=3034)

Advantages of exclusive

breastfeeding

BF helps in mental and physical development of child

699 (46.7)

757 (49.3)

1456

(48.0)

Mother's milk is the best and complete diet for the baby for the first six months

348 (23.2)

487 (31.7)

835 (27.5)

EBF protects against diarrhoea 205 (13.7)

233 (15.2)

438 (14.4)

EBF protects against pneumonia 111 (7.4)

127 (8.3)

238 (7.8)

BF helps in mother-child bonding* 201 (13.4)

N/A* 201^ (6.6)

Breast-milk is free and so saves money*

236 (15.8)

N/A* 236^ (7.8)

Breast-milk is always available and so saves time*

132 (8.8)

N/A* 132^ (4.4)

BF does not require water and fuel for cleaning utensils and boiling milk and so saves money*

62 (4.1)

N/A* 62^ (2.0)

BF reduces incidence of disease in child and so saves money spent on treatment*

136 (9.1)

N/A* 136^ (4.5)

Lactational amenorrhoea reduces maternal anaemia and also works as a contraceptive.

30 (2.0)

57 (3.7)

87 (2.9)

BF protects the mother from breast cancer

36 (2.4)

84 (5.5)

120 (4.0)

Others 75 (5.0)

94 (6.1)

169 (5.6)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal. Percentages do not add up to hundred as multiple options were allowed as responses. * These options were not given in schedule III (for mothers with a child 3-4 months of age). ^ These are not “true” totals as there was no corresponding option in schedule III (for mothers with a child 3-4 months of age). Hence the percentages also need to be interpreted in that light.

40

Women with children less than a week old and those with a child 6-7 months of age were

asked about what, in their opinion, was the ideal duration of exclusive breastfeeding (not

even water). As can be seen from Table 18, slightly more than half the women gave a

response stating the actual number of months. Figure 3 gives a detailed break-up of the

numerical responses and shows that about 22% of all respondents (23% of women with

children under 7 days and 21% of women with an older child), across the two categories

gave the correct response, i.e. 6 months. About 18% gave a response less than 6 months,

while 11% stated durations of more than 6 months. The graph also shows a slight “peaking”

of responses at 7 months, and at 12 and 24 months. The median15 number of months stated

as the ideal duration of breastfeeding across both the respondent categories was 6 months.

Table 18: Responses of women (across two respondent categories) about the ideal duration of exclusive breastfeeding

Women’s respondent

category

Mothers of

children less

than 7 days of

age

Mothers of

children 6 - 7

months of

age

TOTAL Ideal duration of exclusive

breastfeeding

Numerical response 745

(49.7) 792

(51.6) 1537 (50.7)

Non-numerical response / No response

753 (50.3)

744 (48.4)

1497 (49.3)

TOTAL 1498 1536

3034

15

The median was chosen as the measure of central tendency for this indicator as, despite have a greater number of women giving a response less than 6 months, as compared to those who gave a response more than 6 months, the “outlier” figures of more than 12 months (like 24 months, 36 months etc.) were driving the arithmetic mean on the higher side. The arithmetic mean for the mothers with a child less than 7 days was 6.3 months, while that for the mothers of children 6-7 months of age was 6.5 months.

41

Figure 3: Knowledge of women (across two respondent categories) about the ideal duration (in months) of exclusive breastfeeding

Note: The y-axis of the graph has deliberately been shortened to reflect only 6 percentage points to highlight the “peaking” at some months. This also means that the two tall bars at 6 months (for more 23.2% and 21.2% each) are not shown fully in the graph.

About 50% of the women did not give a numerical response to the question about duration

of exclusive breastfeeding. As shown in Table 19, some of them (about 18%) gave a

“qualitative” response, while about a third of all women did not give any response (or said

that they did not know) at all to the question about the ideal duration of breastfeeding.

Amongst the qualitative responses, about 9% each said that the duration of exclusive

breastfeeding depended on either the child’s requirements (hunger) or on the mother’s

ability to produce sufficient milk.

3.1

3.4

4.5

3.2

2.3

23

.3

2.1

1.3

0.9

0.4

0.1

2.5

0.1

0

0

0.4

0

1.7

0

0 0.1

0 0.1

0.1

2.2

2.9

4.4

5.1

4.0

21

.2

2.7

2.0

1.2

0.3

0.1

2.8

0.1

0.1

0.1

0.4

0.1

1.3

0.2

0.1

0.1

0.1

0.1

0.2

0

1

2

3

4

5

6 1

mo

nth

2 m

on

ths

3 m

on

ths

4 m

on

ths

5 m

on

ths

6 m

on

ths

7 m

on

ths

8 m

on

ths

9 m

on

ths

10

mo

nth

s

11

mo

nth

s

12

mo

nth

s

15

mo

nth

s

16

mo

nth

s

17

mo

nth

s

18

mo

nth

s

22

mo

nth

s

24

mo

nth

s

25

mo

nth

s

26

mo

nth

s

30

mo

nth

s

32

mo

nth

s

34

mo

nth

s

36

mo

nth

s

Pce

rce

nta

ge

Mothers of children less than 7 days of age (N=1498)

Mothers of children 6 - 7 months of age (N=1536)

42

Table 19: Knowledge of women (across two respondent categories) about the ideal duration (qualitative response) of exclusive breastfeeding


category

Mothers of

children less

than 7 days of

age

(N=1498)

Mothers of

children 6 - 7

months of

age

(N=1536)

TOTAL

(N=3034)

Ideal duration of exclusive

breastfeeding

Depends on child’s requirements

148 (9.9)

122 (7.9)

270 (8.9)

Depends on mothers’ capacity to produce sufficient milk for child

116 (7.7)

141 (9.2)

257 (8.5)

Others 0

(0.0) 8

(0.5) 8

(0.26)

Do not know / no response 489

(32.6) 473

(30.8) 962

(31.7)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal.

b) Practice regarding Exclusive breastfeeding

Mothers of children less than 7 days of age as well as those with a child 3-4 months of age

were asked if they had started feeding the child anything other than breast-milk. This was

an indirect means of assessing the exclusivity of breastfeeding at this age, as formative

research had shown that women do not understand “exclusive breastfeeding” and find it

difficult to differentiate between exclusive breastfeeding and breastfeeding per se.

Even in the first week after birth, about 40% of the mothers had started giving the child

foods other than breast-milk. Table 20 shows a wide inter-district variation. While more

than 82% of the mothers in Muzaffarpur were exclusively breastfeeding their newborns less

than 7 days of age, only about half as many (44%) were doing so in Samastipur. Table 21

shows a similar variation among implementing partners. About 87% mothers in AKF areas

were exclusively feeding their babies in the early neonatal period, compared to only 36% in

Agragami areas.

43

Table 20: Practice of giving foods to the child other than breast-milk, by mothers of a child less than 7 days of age – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Practice regarding feeding

anything other than BM

Yes 94

(17.9) 333

(56.4) 162

(42.2) 589

(39.3)

No (Exclusive Breastfeeding) 430

(82.1) 257

(43.6) 222

(57.8) 909

(60.7)

TOTAL 524 590 384 1498


Table 21: Practice of giving foods to the child other than breast-milk, by mothers of a child less than 7 days of age – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL Practice regarding giving

foods other than BM

Yes 48

(13.4) 245

(63.8) 162

(42.2) 134

(36.0) 589

(39.3)


(86.6) 139

(36.2) 222

(57.8) 238

(64.0) 909

(60.7)

TOTAL 358 384 384 372 1498


Table 22 and Table 23 show that by 3-4 months, this proportion had increased and more

than two-thirds of the mothers had started the child on foods other than breast-milk. Thus,

only about 32% of the mothers were exclusively breastfeeding in the 4th month after

delivery.

Of the three districts, Samastipur showed the poorest result on this indicator with just about

20% of the mothers exclusively breastfeeding their 3 month old child. Sitamarhi had the

best results with over 50% of the mothers practicing exclusive breastfeeding. (Table 22)

44

Table 22: Practice of giving foods to the child other than breast-milk, by mothers of a child 3-4 months of age – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Practice regarding feeding

anything other than BM

Yes 382

(68.5) 475

(80.0) 190

(49.5) 1047 (68.2)


(31.5) 117

(19.7) 194

(50.5) 487

(31.7)

No response 0

(0.0) 2

(0.3) 0

(0.0) 2

(0.1)

TOTAL 558 594 384 1536


Similarly, disaggregation of data by IP (Table 23) shows that in CHARM areas, more than half

women with a child 3-4 months of age breastfeeding their children exclusively. However,

only 15% of the women in Agragami project areas were found to be exclusively

breastfeeding their 3 month old babies.

Table 23: Practice of giving foods to the child other than breast-milk, by mothers of a child

3-4 months of age – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL Practice regarding giving

foods other than BM

Yes 252

(65.6) 325

(84.6) 190

(49.5) 280

(72.9) 1047 (68.2)


(34.4) 59

(15.4) 194

(50.5) 102

(26.6) 487

(31.7)

No response 0

(0.0) 0

(0.0) 0 (0)

2 (0.5)

2 (0.1)

TOTAL 384 384 384 384 1536


While less than 2% of the 1536 women respondents with a child 6-7 months of age admitted

to never having breastfed their child, another 4% or so had discontinued breastfeeding at

the time of the survey. This means that an overwhelming 94.6% were breastfeeding their 6-

7 month olds at the time of the survey (not shown in tables 24 and 25 below).

45

Women respondents in this category revealed that only 15% had breastfed their children

exclusively (not even water) for at least 6 months (Figure 4). Of this, while 12% had

practiced exclusive breastfeeding for 6 months, another 3% were continuing with practice

way into the 7th month. The disturbing finding was that about 14% of the women had not

maintained the exclusivity of breastfeeding for even a day, and about 40% for about a

month or less.

The mean duration of exclusive breastfeeding for this group was 2.67 months (or 2 months and 20 days).

Figure 4: Duration of exclusive breastfeeding as informed by mothers with a child 6-7

months of age

Disaggregation of this data by district, as depicted in Table 24, shows mixed results. While

Sitamarhi had the lowest proportion of women (8%) who had not maintained exclusivity

for even a single day, and Samastipur the highest (20%) on this negative indicator, Sitamarhi

also had the lowest proportion of women (13.5%) who had exclusively breastfed for at least

6 months. In contrast Muzaffarpur had the best results on this indicator, with nearly 18% of

the women having exclusively breastfed their children for at least 6 months. This is also

reflected in the average duration of exclusive breastfeeding, which is the highest for

Muzaffarpur (3.1 months) followed by Sitamarhi (2.5 months) with Samastipur the last at

2.36 months.

14.3

12.4

3 2.9

7.4

9.1

11.1

13.3

11.3 12.3

2.9

0

2

4

6

8

10

12

14

16

Not even for

1 day

Less than 1 week

Less than 2 weeks

Less than 3 weeks

About 1 month

About 2 months

About 3 months

About 4 months

5 months

6 months

7 months

Pe

rce

nta

ge

46

Table 24: Duration of exclusive breastfeeding as informed by mothers with a child 6-7 months of age – disaggregated by districts.

District

Muzaffarpur Samastipur Sitamarhi TOTAL Duration of Exclusive

Breastfeeding

Not even for 1 day 68

(12.2) 120

(20.2) 32

(8.3) 220

(14.3)

Less than 1 week 51

(9.1) 79

(13.3) 60

(15.6) 190

(12.4)

Less than 2 weeks 10

(1.8) 11

(1.9) 25

(6.5) 46

(3.0)

Less than 3 weeks 7

(1.3) 19

(3.2) 18

(4.7) 44

(2.9)

About 1 month 25

(4.5) 47

(7.9) 42

(10.9) 114 (7.4)

About 2 months 51

(9.1) 54

(9.1) 35

(9.1) 140 (9.1)

About 3 months 77

(13.8) 65

(10.9) 29

(7.6) 171

(11.1)

About 4 months 93

(16.7) 65

(10.9) 46

(12.0) 204

(13.3)

5 months 78

(14.0) 51

(8.6) 45

(11.7) 174

(11.3)

6 months 88

(15.8) 64

(10.8) 37

(9.6) 189

(12.3)

7 months 10

(1.8) 19

(3.2) 15

(3.9) 44

(2.9)

TOTAL 558 594 384 1536


Disaggregating this data by implementing partner (Table 25), one sees that women in AKF

areas are the closest to the recommended practice. Not only do they have the least

proportion of women (7%) who had never exclusively breastfed their child, they also have

the highest proportion of women (19%) who have exclusively breastfed their child for at

least 6 months. The mean duration of exclusive breastfeeding for Muzaffarpur is 3.4

months, which is greater by more than a month when compared to the AKRSP average of

2.4 months (not shown in table).

47

Table 25: Duration of exclusive breastfeeding as informed by mothers with a child 6-7 months of age – disaggregated by implementing partners.


AKF Agragami CHARM AKRSP,I TOTAL Duration of Exclusive

Breastfeeding

Not even for 1 day 28

(7.3) 64

(16.7) 32

(8.3) 96

(25.0) 220

(14.3)

Less than 1 week 34

(8.9) 42

(10.9) 60

(15.6) 54

(14.1) 190

(12.4)

Less than 2 weeks 7

(1.8) 7

(1.8) 25

(6.5) 7

(1.8) 46

(3.0)

Less than 3 weeks 2

(0.5) 16

(4.2) 18

(4.7) 8

(2.1) 44

(2.9)

About 1 month 20

(5.2) 36

(9.4) 42

(10.9) 16

(4.2) 114 (7.4)

About 2 months 35

(9.1) 46

(12.0) 35

(9.1) 24

(6.3) 140 (9.1)

About 3 months 55

(14.3) 47

(12.2) 29

(7.6) 40

(10.4) 171

(11.1)

About 4 months 71

(18.5) 40

(10.4) 46

(12.0) 47

(12.2) 204

(13.3)

5 months 58

(15.1) 35

(9.1) 45

(11.7) 36

(9.4) 174

(11.3)

6 months 64

(16.7) 39

(10.2) 37

(9.6) 49

(12.8) 189

(12.3)

7 months 10

(2.6) 12

(3.1) 15

(3.9) 7

(1.8) 44

(2.9)

TOTAL 358 384 384 372 1536

Numbers in parentheses indicate percentages of the column totals, rounded off to the first decimal. All the mothers from different respondent categories, who had not breastfed their children

for the recommended duration of six months, were asked about the reason for introducing

food substances other than breast-milk in their child’s diet at the early age. Table 26 shows

that the commonest reason for topping up breast-milk with other food substances, cited by

close to 50% of the mothers who had not exclusively breastfed their child for the

recommended 6 months was the mothers’ perception that their child was hungry. A similar

reason was the mother’s perception of insufficient milk. It may be noted that this

perception seems to increase with the age of the child (though it is difficult to analyse for

the presence of a “real trend” in just three readings). Family traditions and social pressures

were also cited in about a third of such cases.

48

Table 26: Reasons given by women across three respondent categories for introducing food substances other than breast-milk in the child’s diet before 6 months of age.


category Mothers of children less

than 7 days of age

(N=589)

Mothers of children 3-4 months of

age (N=1047)

Mothers of children 6 - 7

months of age (N=1303)

Reason for introducing foods

other than breast-milk at

early age

Child is hungry 282

(47.9) 567

(54.2) 708

(54.3)

Child is thirsty 174

(29.5) 403

(38.5) 585

(44.9)

Family members advice/my knowledge

172 (29.2)

302 (28.8)

258 (19.8)

Culture / tradition 56

(9.5) 73

(7.0) 51

(3.9)

No Milk / Less milk 96

(16.3) 266

(25.4) 340

(26.1)

Due to pain in breast 27

(4.6) 44

(4.2) 68

(5.2)

Child is unable to suck 83

(14.1) 40

(3.8) 56

(4.3)

Doctor recommended -

44 (4.2)

87 (6.7)

Child is not growing - -

39 (3.0)

Others 23

(3.9) -

14 (1.1)

Percentages do not add up to hundred as multiple options were allowed as responses.

Complementary feeding:

a) Introduction of complementary feeding

Mothers of children 3-4 months of age were asked a generic question about the ideal time

for introduction of complementary foods in order to assess their knowledge on this issue.

They were also asked another question specifically to understand their intention of

introducing complementary foods in their child’s diet. In both the questions, women could

give responses in actual months and/or as a “qualitative” response such as “when the child

starts teething”.

49

Slightly more than 60% of the women gave a response in actual months when asked about

their knowledge on timing of introduction of complementary feeding, while a slightly less

proportion (53%) gave a numerical response when sharing their intention in relation to their

own child.

As can be seen from the blue bars in Figure 5, only one fifth (21%) of the respondents with

children 3-4 months of age were aware about the correct time for initiation of

complementary feeding, viz. 6 months. Another 13% mentioned 7 months as the ideal age.

Contrary to popular belief that women are confused with the “mixed” messaging16 on

duration of exclusive breastfeeding and therefore initiation of complementary feeding too,

less than 2% of the women stated 4 months as the ideal time for introducing

complementary foods. On an average17, the women stated 8 months as the ideal time for

introduction of complementary foods.

The intention of the women regarding introduction of complementary foods in their own

child’s diet differed when compared to their knowledge on this issue. As the red bars in

Figure 5 show, slightly more than one-tenth (11%) of the women actually intended to start

complementary feeding at 6 months for their child, which is almost half of those who said

that 6 months was the ideal time in response to the generic question. Another 8% stated 7

months. In contrast, 13% of the women said that they intend to start complementary

feeding at 12 months of age, while only 8% had stated that as the ideal age for

complementary feeding. The average18 age at which women with a child 3-4 months of age

at the time of the survey intended to introduce complementary foods in the child’s diet was

9.6 months.

16

The earlier international / UN guidance on breastfeeding recommended 4 months as the ideal duration for exclusive breastfeeding, which was later changed to 4-6 months. Current guidance recommends exclusive breastfeeding till 6 months of age, with introduction of complementary food at 6 months of age. 17

The “average” here refers to the arithmetic mean, which was calculated to be 8.0 months. The median reading for this question was 7 months. 18

The “average” here refers to the arithmetic mean, which was calculated to be 9.6 months. The median reading for this question was 8 months.

50

Figure 5: Knowledge and intention of mothers with a child 3-4 months of age regarding the age / time for introduction of complementary feeding

As mentioned above, many women also gave qualitative responses (non-numerical) to these

two questions, sometimes along with a numerical response, which are described in Table

27. 13% of the women respondents said that the ideal age to start complementary feeding

is when the child is “ready”, while another 7% described this “readiness” as the child

grabbing food. Another 12% linked it to the (in) sufficiency of breast-milk as understood

from hunger cues by the child even after breastfeeding. About 12% of women did not give

any response (either numerical or qualitative) to each of these questions.

As far as their own child was concerned, more than one-fourth (26%) of the women said

that they would wait for the child to be “ready” or grab food spontaneously as a signal to

introduce complementary foods. Another 13% said that they would begin complementary

feeding when they felt that their milk was insufficient.

0.2

0.4

0.5

1.6

1.8

21

12

.8

5.7

4.5

1.2

0.2

8.2

0.2

0.1

0.1

0.1

0.8

1

0.1

0.1

0.1

0.2

0.3

1.3

1

11

.3

8.4

4.6

5.6

2.1

0.3

12

.5

0.5

0.1

0.7

0.3

2.2

1.9

0 0.1

0

5

10

15

20

25

Knowledge of mothers – generic (N=1536) Intention of mothers for own child (N=1536)

51

Table 27: Knowledge and intention of mothers with a child 3-4 months of age regarding the age / time for introduction of complementary feeding

Timing for introduction of


(qualitative responses)

Knowledge of

mothers –

generic

(N=1536)

Intention of

mothers for

own child

(N=1536)

When the child is “ready” 204

(13.3) 266

(17.3)

When the child is hungry even after breast-milk

177 (11.5)

205 (13.4)

When the child starts teething 58

(3.8) 66

(4.3)

When the child grabs food 110 (7.2)

139 (9.1)

Don’t know 178

(11.6) 179

(11.7)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal. Percentages do not add up to hundred as not all women gave “qualitative” responses and also because multiple options were allowed as responses.

IYCF norms state that complementary feeding should be initiated when the child completes

6 months of age. In order to assess how close to this norm the actual practice was in the

project areas, mothers of children aged 6-7 months and 12-13 months were asked whether

they had initiated complementary feeding (described as giving any foods other than breast-

milk) for their child. Mothers of children 12-13 months were also asked about the actual age

of the child when they started complementary feeding.

As can be seen from Table 28, about three-fourths of children 6-7 months of age had

already started receiving foods other than breast-milk. This rose to over 90% by the time the

children turned a year old. However, the corollary of these figures is that about one in ten

children were on breast-milk only even at the age of 1 year, pointing towards grossly

insufficient nutritional intake.

52

Table 28: Status of introduction of complementary feeding for children 6-7 months of age and 12-13 months of age.


category Mothers of

children 6 - 7

months of age

Mothers of

children 12-13

months of age Introduction of

complementary foods

Yes 1127 (73.4)

1390 (90.5)

No 402

(26.2) 146 (9.5)

No response 7

(0.5) 0

(0.0)

TOTAL 1536 1536


When these rates were disaggregated by districts, it was seen that Sitamarhi had the best

result in this indicator with 82% of the mothers of 6-7 month olds stating that they had

initiated foods other than breast-milk for their child (Table 29). This was as low as 68.5% in

Muzaffarpur. However, this difference reduced by the time the children reached 12 months

of age, with all three districts showing complementary feeding rates close to 90% at that age

(Table 30).

Table 29: Status of introduction of complementary feeding for children 6-7 months of age

– disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Introduction of

complementary foods

Yes 382

(68.5) 430

(72.4) 315

(82.0) 1127 (73.4)

No 175

(31.4) 159

(26.8) 68

(17.7) 402

(26.2)

No response 1

(0.2) 5

(0.8) 1

(0.3) 7

(0.5)

TOTAL 558 594 384

1536


53

Table 30: Status of introduction of complementary feeding for children 12-13 months of age – disaggregated by districts

District

Muzaffarpur Samastipur Sitamarhi TOTAL Introduction of

complementary foods

Yes 506

(90.7) 545

(91.8) 339

(88.3) 1390 (90.5)

No 52

(9.3) 49

(8.2) 45

(11.7) 146 (9.5)

TOTAL 558 594 384 1536


Comparing the same across implementing partners, the difference is even starker. While

84% of the mothers of children aged 6-7 months have initiated complementary feeding for

their child, only 60% of the 6-7 month old children in AKRSP,I areas are receiving

complementary foods – a difference of over 24 percentage points (Table 31). However, as

with the inter-district variation, this difference reduces to non-significant19 levels when the

children turn a year old (Table 32)

Table 31: Status of introduction of complementary feeding for children 6-7 months of age

– disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL Introduction of

complementary foods

Yes 259

(67.5) 323

(84.1) 315

(82.0) 230

(59.9) 1127 (73.4)

No 124

(32.3) 57

(14.8) 68

(17.7) 153

(39.8) 402

(26.2)

No response 1

(0.3) 4

(1.0) 1

(0.3) 1

(0.3) 7

(0.5)

TOTAL 384 384 384 384 1536


19

The words “non-significant” do not carry the usual statistical meaning here. It refers to the significance in differences from a Project management perspective.

54

Table 32: Status of introduction of complementary feeding for children 12-13 months of age – disaggregated by implementing partners


AKF Agragami CHARM AKRSP,I TOTAL Introduction of

complementary foods

Yes 358

(93.2) 356

(92.7) 339

(88.3) 337

(87.8) 1390 (90.5)

No 26

(6.8) 28

(7.3) 45

(11.7) 47

(12.2) 146 (9.5)

TOTAL 384 384 384 384 1536


In order to understand the practice related to the actual timing of introduction of

complementary foods, mothers of children 12-13 months of age, who claimed to have

started the child on foods other than breast-milk, were asked when they added non-breast-

milk food items to their child’s diet. Figure 6 and Table 33 give detailed and disaggregated

(by district and implementing partner respectively) distributions of the age at which

mothers of 12-13 month olds introduced complementary foods.

It can be seen that more than one-fourth (26%) of the others report that they introduced

complementary foods before the child turned 6 months of age, with some (6%) having

started foods other than breast-milk as early as when the child was 1 month of age. Only

16% of the mothers introduced the foods at the recommended age of 6 months. Across

districts 12-13% of the women did not remember when they started the child on

complementary foods (Figure 6), while this figure varied from about 10% for AKF to 16% for

Agragami (Table 33)

55

Figure 6: Distribution of age at which complementary food was introduced (for children currently 12-13 months of age) – disaggregated by districts

Table 33: Distribution of age at which complementary food was introduced (for children

currently 12-13 months of age) – disaggregated by implementing partners Implementing partner

AKF Agragami CHARM AKRSP,I TOTAL Age of child at introduction of

complementary foods

1 month 11

(3.1) 33

(9.3) 27

(8.0) 14

(4.2) 85

(6.1)

2 months 14

(3.9) 37

(10.4) 12

(3.5) 17

(5.0) 80

(5.8)

3 months 8

(2.2) 36

(10.1) 20

(5.9) 26

(7.7) 90

(6.5)

4 months 9

(2.5) 19

(5.3) 18

(5.3) 12

(3.6) 58

(4.2)

0 2 4 6 8 10 12 14 16 18 20

1 month

2 months

3 months

4 months

5 months

6 months

7 months

8 months

9 months

10 months

11 months

12 months

Do not remember

Percentage

Muzaffarpur (N=506) Samastipur (N=545) Sitamarhi (N=339) TOTAL (N=1390)

56

5 months 9

(2.5) 16

(4.5) 14

(4.1) 15

(4.5) 54

(3.9)

6 months 73

(20.4) 56

(15.7) 40

(11.8) 49

(14.5) 218

(15.7)

7 months 52

(14.5) 31

(8.7) 29

(8.6) 63

(18.7) 175

(12.6)

8 months 44

(12.3) 29

(8.1) 46

(13.6) 34

(10.1) 153

(11.0)

9 months 43

(12.0) 13

(3.7) 49

(14.5) 29

(8.6) 134 (9.6)

10 months 25

(7.0) 15

(4.2) 25

(7.4) 17

(5.0) 82

(5.9)

11 months 14

(3.9) 6

(1.7) 7

(2.1) 7

(2.1) 34

(2.4)

12 months 22

(6.1) 8

(2.2) 8

(2.4) 11

(3.3) 49

(3.5)

Do not remember 34

(9.5) 57

(16.0) 44

(13.0) 43

(12.8) 178

(12.8)

TOTAL 358 356 339 337 1390


From the responses received, the mean age at which complementary feeding was started by

mothers of children 12-13 months of age was calculated. As shown in Table 34, the mean

age for introduction of complementary feeding across the project was 6.4 months. While

mothers from Muzaffarpur started complementary feeding relatively late at an average of 7

months, mothers from Samastipur stated more than a month earlier at 5.8 months.

Similarly, there was a difference of two months in the average age for complementary

introduction between Agragami areas (5.3 months) and AKF areas (7.3 months)

57

Table 34: Average age of child (in months) at introduction of complementary feeding – for a child currently 12-13 months of age

Average20 age of child (in

months) at introduction of complementary feeding

District wise

Muzaffarpur (n=444) 7.0

Samastipur (n=473) 5.8

Sitamarhi (n=295) 6.5

Implementing partner wise

AKF (n=324) 7.3

Agragami (n=299) 5.3

CHARM (n=295) 6.5

AKRSP, I (n=294) 6.4

OVERALL (n=1212) 6.4

The 402 and 146 mothers of children 6-7 months and 12-13 months respectively, who had

not initiated complementary feeding, were asked about the time when they intended to

initiate complementary feeding with their child. 267 (66%) and 49 (34%) women

respectively from the two groups gave their responses in actual months, the average of

which is shown in Table 35. While women with children 6-7 months of age, who had not

introduced complementary foods in their child’s diet at the time of the survey intended to

do so when the child is between 9 to 10 months, the mothers with older children preferred

to wait until about 16 months of age. However, it must be emphasised here that these

averages need to be interpreted with caution owing to the relatively few respondents in

each sub-category. For example, in the case of women with 12-13 month old child in

Agragami areas, the average has been calculated from responses of only 5 women.

20

The “average” refers to the arithmetic mean of all the responses (in months), wherein the denominator is the mothers who had initiated complementary feeding and had given a numeric response (i.e. did not say “do not remember”). This denominator is specified as “n” against the district or implementing partner.

58

Table 35: Average age at which mothers of children 6-7 months and 12-13 months of age, who have not initiated complementary feeding, intent to do so

Average age of the child (in months) at which mothers intend to initiate complementary feeding

Mothers of children 6 - 7 months of age Mothers of children 12-13 months of age

District wise

Muzaffarpur (n= 115) 9.4 16.1 Muzaffarpur (n= 19)

Samastipur (n= 102) 9.6 16.3 Samastipur (n= 11)

Sitamarhi (n= 50) 9.7 16.1 Sitamarhi (n= 19)


AKF (n= 91) 9.2 15.4 AKF (n= 15)

Agragami (n= 32) 11.1 19.8 Agragami (n= 5)

CHARM (n=50) 9.7 16.1 CHARM (n = 19)

AKRSP, I (n= 94) 9.2 15.5 AKRSP, I (n= 10)

OVERALL (n= 267) 9.5 16.1 OVERALL (n= 49)

Mere introduction of complementary foods at the right age is not sufficient to ensure that

the dietary requirements of a child are met. In order to assess the “age appropriateness” of

complementary feeding, one needs to look into various other aspects of complementary

feeding such as the frequency of meals offered to the child, the quantity given to the child

per meal and of course the variety of foods offered in order to ensure a balanced diet. For

the children aged 6-7 months and 12-13 months who had been started on complementary

foods, questions related to each of these aspects were asked. In order to avoid recall bias,

they were asked these questions with reference to the previous 24 hours. Their responses

to these factors are presented one by one in the sections below.

b) Frequency of complementary feeding

The ideal frequency of complementary feeding varies according to the age of the child. With

reference to the PAHO (WHO) guidelines of complementary feeding, the minimum required

frequency of complementary feeding for a child 6-8 months is twice a day, with 1-2 snacks21

in between. Similarly, the minimum frequency for older age groups like 12-24 months is 3

21 “Snacks” are defined as foods eaten between meals - usually self-fed, convenient and easy to prepare, such

as a piece of fruit, bread or chapatti with nut paste etc. (PAHO)

59

times in a day (See Chapter 2 – Review of Literature for more details). However, as it is

difficult to decipher from the survey answers whether the frequency mentioned includes a

snack or only “full meals”, the minimum frequency can be taken to be 3 in 24 hours for 6-8

month olds and 4 for the older children.

As can be seen from Table 36, about a third of the mothers with 6-7 month olds who had

initiated complementary feeding could not / did not give a response about the number of

times they had given complementary foods to their child in the past 24 hours. This

proportion was only 18% for the mothers of 12-13 year olds. It must be mentioned here that

the question and response options were such that they did not allow the actual number of

meals to be mentioned, but grouped them together. Hence, when a response 3-4 times is

marked, it is difficult to say whether the child was given 3 or 4 meals in a day. Hence the

group 3-4 times in a day was taken as meeting the “minimum” frequency for both the age

groups of children. Using this understanding, only 35% of the 6-7 month olds received the

minimum of three meals / snacks, whereas 55% of the older children (12-13 months)

received the required number of meals/snacks. About 9% and 11% of the women (mothers

of 6-7 month olds and 12-13 months olds respectively) reported feeding their children five

or more meals in the 24 hours prior to the survey.

Table 36: Distribution of frequency of complementary feeding in the past 24 hours – for children aged 6-7 months and 12-13 months

Women’s respondent category

Mothers of children 6 - 7 months of age

Mothers of children 12-13 months of age

Frequency of complementary feeding in past 24 hours

1 to 2 times 395

(35.0) 519

(37.3)

3 to 4 times 300

(26.6) 468

(33.7)

5 times 49

(4.3) 77

(5.4)

more than 5 times 49

(4.3) 80

(5.8)

Do not know / no response 334

(29.6) 246

(17.7)

TOTAL 1127 1390


60

As can be seen from Table 37, there was not much difference in the average frequency of

complementary feeding in the 24 hours before the survey, between the two age groups of

children. While the 6-7 month olds were given 2.8 meals / snacks on an average, the

average for the 12-13 month olds was 2.9.

For the 6-7 months old children, there was not much inter-district variation in averages.

However, disaggregating data based on implementing partners revealed distinctly higher

average (3.3) in this age group in the AKRSP,I areas.

It is also interesting to note that while there is an overall project level increase in the

frequency of feeding while moving from 6-7 month to 12-13 month olds, AKRSP, I shows a

drop from 3.3 times/ day to just 2.9 times, along with Agragami which shows a drop from its

already lower than average level of 2.6 times to just 2.4 times / day, making it the lowest in

this age group.

Table 37: Average frequency of complementary feeding in the past 24 hours – for children aged 6-7 months and 12-13 months

Average22 frequency (no. of times food was given) of complementary feeding in past 24 hours


District wise

Muzaffarpur (n=282) 2.7 2.9 Muzaffarpur (n=416)

Samastipur (n=314) 2.8 2.6 Samastipur (n=482)

Sitamarhi (n=197) 2.7 3.3 Sitamarhi (n=246)


AKF (n=178) 2.4 2.9 AKF (n=269)

Agragami (n=225) 2.6 2.4 Agragami (n=295)

CHARM (n=197) 2.7 3.3 CHARM (n =246)

22

The average / arithmetic mean has been calculated by taking the mid-point of the class interval (such as 1.5 for the class interval 1-2 times), and multiplying it by the respondents, and summing it up across all numerical categories to get the numerator. For the interval “more than 5 times”, “6” was taken as the multiplying factor. The denominator was the total number of women who gave a response, and is specified as “n” against the district or implementing partner.

61

AKRSP, I (n=193) 3.3 2.9 AKRSP, I (n=334)

OVERALL (n=793) 2.8 2.9 OVERALL (n=1144)

c) Quantity of complementary foods

The women respondents were asked to assess the quantity of food offered to the child in

the past 24 hours. The interviewers showed them “standard” katoris23 of 150 ml and spoons

(10 ml) to understand the quantity of food offered. The number of katoris and/or spoons

were added together and multiplied by 150 or 10 as the case may be to arrive at a quantity

(volume) of food for the day. However, it is difficult to assess the weight of the food in

grams as different foods in the same volume weigh differently depending on their density.

Figure 7 shows that the a large proportion of mothers of 6-7 month and 12-13month olds

(56% and 67% respectively) had given 600 ml or less food to their children in the 24 hours

preceding the survey. 42% and 26% of the two categories respectively, could not / did not

specify the quality of food they gave to their child in the past 24 hours (not shown in chart).

For the 6-7 months old children, the minimum quantity that was mentioned was 10 ml (1

spoonful) mentioned by 2 mothers, while the maximum was 1200 ml, reported by 4

mothers. Even for the 12-13 months old children, the minimum quantity specified by two

mothers was also 10 ml, whereas the maximum was 1850 ml, mentioned by one mother.

23

“Katori” is a bowl used to serve liquid / semi-solid foods.

62

Figure 7: Distribution of quantity of complementary food eaten by the child in the past 24 hours – for children aged 6-7 months and 12-13 months

On the whole, the average quantity of complementary food increased from 278 ml for the

6-7 month old children to 349 ml for the older age group (as seen in Table 38, and also as

the difference between the red and blue ribbons in Figure 7. The maximum increase of 137

ml was seen in Sitamarhi district / CHARM area. It is surprising, that Agragami actually

recorded a dip in quantity from 405 ml to 394 ml between these two age groups. This could

be linked to the reduction in average frequency of complementary feeding as seen in Table

37 above.

0

5

10

15

20

25

30 1

- 2

00

ml

20

1 –

40

0 m

l

40

1 –

60

0 m

l

60

1 –

80

0 m

l

80

1 –

10

00

ml

10

01

– 1

20

0 m

l

12

01

– 1

40

0 m

l

14

01

– 1

60

0 m

l

16

01

– 1

80

0 m

l

18

00

an

d a

bo

ve

Mothers of children 6 - 7 months of age (N=1127)

Mothers of children 12-13 months of age (N=1390)

63

Table 38: Average quantity of complementary food eaten by the child in the past 24 hours – for children aged 6-7 months and 12-13 months

Average24 quantity (in ml) of complementary feeding in past 24 hours


District wise

Muzaffarpur (n=246) 189 287 Muzaffarpur (n=376)

Samastipur (n=270) 334 350 Samastipur (n=454)

Sitamarhi (n=143) 326 463 Sitamarhi (n=199)


AKF (n=153) 170 276 AKF (n=244)

Agragami (n=177) 405 394 Agragami (n=267)

CHARM (n=143) 326 463 CHARM (n =199)

AKRSP, I (n=186) 211 295 AKRSP, I (n=319)

OVERALL (n=659) 278 349 OVERALL (n=1029)

d) Variety of complementary foods

Mothers were asked to specify the types of liquid / semi-solid and solid foods (only in the

case of 12-13 month old children) that they were offering to the child.

Animal milk was the most common liquid food other than breast-milk that was offered to

children in both age groups, though it was more common in the younger age group (66%)

than with the older children (46%). Commercially available infant foods were the next

common food variant (35% and 42%). This included pre-mixed preparation like Cerelac, and

also biscuits. Even though a biscuit per se does not fall into the category of semi-solid food,

the way it is offered to the child (softened and mashed in milk or water) puts it in this

category, and therefore suitable even for the younger children. Home made preparations

like halwa25 or porridge were also offered by a substantial proportion of women. However

fruits and fruit juices found few takers in this category.

24

The “average” refers to the arithmetic mean of all the responses (in ml), wherein the denominator is the mothers who had initiated complementary feeding and had given response (or did not say “do not remember”). This denominator is specified as n against the district or implementing partner. 25

“Halwa” is sweet pudding made by roasting semolina or wheat (usually) in oil and adding sugar and water to make it into a paste like consistency. Any other grain/pulse powder may also be used.

64

Table 39: Distribution of the variety of liquid or semi-solid complementary foods eaten by the child in past 24 hours – for children aged 6-7 months and 12-13 months.


category Mothers of

children 6 - 7 months of age

(n=1127)

Mothers of children 12-13 months of age

(n=1390) Variety of liquid or semi-solid

complementary foods

Animal Milk 745

(66.1) 644

(46.3)

Powdered milk 194

(17.2) 173

(12.4)

Any commercially available infant and young child food

395 (35.1)

582 (41.9)

Halwa or porridge (semi-solid) 260

(23.1) 481

(34.6)

Any Seasonal fruit or fruit juice

44 (3.9)

98 (7.1)

Others 122

(10.8) 67

(4.8)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off

to the first decimal.


Figure 8 shows that almost all (95%) the mothers of 12-13 month old children who had

initiated complementary foods had included cereals (rice, roti, which is made of wheat) in

their child’s diet in the past 24 hours. A third (35%) of them had offered dhal (pulses,

legumes), while another quarter had also added tuberous food (potato) to the child’s diet.

This is in line with the regular Indian meal. Very few had given the child fruits (10%), meats

and fish (8%) or even eggs (7%).

65

Figure 8: Distribution of the variety of solid complementary foods (split as food groups) eaten by children aged 12-13 months in past 24 hours


As can be seen from Table 40, about 44% of the mothers had offered food from three or

more food groups. Only 24% had offered food from a single food category (usually cereals

only). On an average, mothers had offered foods from slightly less than 3 (2.8) food groups.

Mothers from areas managed by CHARM (Sitamarhi) fared the best on this indicator by

giving foods from 3.4 food groups on an average (Table 41).

Table 40: No. of food groups from which the 12-13 months old child ate food in the past 24 hours

No. of food groups for complementary

foods (solids) in last 24 hours Mothers of children 12-13 months of age

One category 331

(23.8)

Two categories 405

(29.1)

Three categories 275

(19.8)

0 10 20 30 40 50 60 70 80 90 100

Eggs

Meat, fish, poultry etc.

Others

Yellow and Orange Fruits

Other Fruits and Vegetables

Oilseeds, Ghee

Green leafy vegetables

Sugar

Dairy Products

Roots and tubers

Pulses and Sprouted grains

Cereals (Rice, Roti etc.)

Percentage

66

Four categories 147

(10.6)

Five categories 78

(5.6)

More than five categories 112 (8.1)

No response 42

(3.0)

TOTAL 1390


Table 41: Average number of food groups from which the 12-13 months old child ate food in the past 24 hours

Average no. of food groups given as

complementary food in last 24 hours

District wise

Muzaffarpur (n=496) 2.9

Samastipur (n=527) 2.4

Sitamarhi (n=325) 3.4


AKF (n=353) 2.9

Agragami (n=341) 2.2

CHARM (n=325) 3.4

AKRSP, I (n=329) 2.8

OVERALL (n=1348) 2.8

e) Age appropriate complementary feeding

While there is no universally accepted definition of “appropriate complementary feeding”

(depending on age), a simple one was created for monitoring under the current project. This

Project specific definition applies only to the children in the 12-13 month age group, and is

based on the PAHO guidelines of complementary feeding (11). Children in the age group 12-

13 months were said to be receiving appropriate complementary feeding if:

i) The child had started receiving foods other than breast-milk.

67

ii) The child had received complementary food at least 3 times in the previous 24

hours26.

iii) The child had received at least 375 ml of complementary food in the past 24

hours27.

Using this definition, as seen in Table 42, Table 42 overall about one-fifth of the children aged 12-13 months of age were receiving

complementary foods appropriate for their age. This proportion was the highest for

Sitamarhi at almost 25%, while only 15% of the children in Muzaffarpur were being fed

appropriately. Disaggregating the same data by implementing partners, children in AKF

areas were the least likely (11%) to be given adequate complementary foods, while about

one-fourth of the children in CHARM areas were being given the required amount of food.

Table 42: Status of age appropriate complementary feeding for children 12-13 months of age


District

AKF

(N=384)

Agragami

(N=384)

CHARM

(N=384)

AKRSP,I

(N=384)

TOTAL

(N=1536)

Muzaffarpur (N=558) 84

(15.1)

Samastipur (N=594) 126

(21.2)

Sitamarhi (N=384) 94

(24.5)

TOTAL (N=1536) 43

(11.2)

74

(19.3)

94

(24.5)

93

(24.2)

304

(19.8)

26

Mothers who gave no response to the question on frequency of complementary feeding the past 24 hours were also counted in the numerator. 27

Mothers who gave no response to the question on quantity of complementary feeding the past 24 hours were NOT counted in the numerator.

68

SECTION B: SERVICE PROVIDERS

The health and nutrition functionaries working within the government system are the

secondary target groups of the project. Those cadres whose job entails counselling women

and families about IYCF were chosen for the project (and hence for this baseline study, too).

While the project based PEs are the primary people responsible for carrying out BCC

activities, in order to ensure sustainability of communication and counselling efforts under

the project, it is important to ensure that the existing cadre of workers are geared up to

fully take on this responsibility after the end of the project.

The PEs and CCs are tasked with mentoring the service providers for this role. The success

(or lack thereof) of these efforts will be measured by change in a) knowledge of service

providers on IYCF issues, and b) change in performance of service providers related to IYCF

counselling. Therefore, this survey attempts to assess the current status of the service

provides on both these elements.

Respondent profile:

Four hundred service providers were interviewed. Of these, slightly less than half (194) were

facility based providers (ANMs28 and Mamtas29) whereas the others were community-base

providers (AWWs 30 and ASHAs 31 ). Table 43 gives a detailed break-down of all the

respondents by cadre. Very few Mamtas (only 31) could be interviewed due to the relatively

few in service. Also, even though both the AWWs and ASHAs are to be positioned at one per

28

ANMs are Auxiliary Nurse Midwives who, after a formal training for 18-months, are placed at health sub-centres catering to a population of about 5000. ANMs are responsible for conducting MCH and immunization related outreach activities. In recent times, the government of India is training ANMs as skilled birth attendants following which they are expected to conduct deliveries at the facility where they are posted. 29

Mamtas are nurse-aides posted by the government of Bihar at delivery rooms of primary health centres to support the doctor or nurse conducting the delivery and act as a birth companion for the woman in labour. Mamtas are literate, but do not receive any formal training in health care. 30

AWWs are Anganwadi workers who are responsible for the nutrition and pre-school education of children under six years of age. They run a pre-school facility for a population of about 1000 people. AWWs receive a job-training for 30 days after recruitment. 31

ASHAs are “honorary” link workers recruited by the department of health – one for a population of about 1000. The honorarium paid to ASHAs comes in the form of incentives for certain pre-defined tasks, one of which is encouraging a pregnant woman for an institutional delivery accompanying her to a health facility.

69

1000 population, the posts for many ASHAs are vacant, and hence a relatively fewer number

were available in the chosen areas for interviewing.

Table 43: Cadre wise distribution of the service provider respondents

Service provider category No. (proportion) of respondents

Facility based providers ANM 163

(40.8) 194

(48.5) Mamta 31 (7.8)

Community-based

provider

AWW 110 (27.5)

206

(51.5) ASHA 96 (24.0)

TOTAL 400

Numbers in parentheses indicate percentages of the column total, rounded off to the first decimal. Table 44, Table 45 and Table 46 show that while all implementing partners interviewed 100

service providers each, the distribution by cadre is relatively inconsistent. While AKF and

CHARM managed to select 50 each of the facility-based and community-based providers,

AKRSP interviewed more facility based providers than community-based (58 vs. 42), while

the situation with Agragami was the reverse, with only 36 facility-based providers and 64

community-based. The main reason for this difference is that at some places, the

government functionaries, refused to answer the survey questions in the absence of a

formal government order instructing them to do the same.

Table 44: District and Implementing Partner wise distribution of all the service providers


District AKF Agragami CHARM AKRSP,I TOTAL


Samastipur - 100 - 50 150

Sitamarhi - - 100 - 100

TOTAL 100 100 100 100 400

70

Table 45: District and Implementing Partner wise distribution of all facility based service providers (ANMs & Mamtas)





Sitamarhi - - 50 - 50

TOTAL 50 36 50 58 194

Table 46: District and Implementing Partner wise distribution of all community based service providers (AWWs & ASHAs)





Sitamarhi - - 50 - 50

TOTAL 50 64 50 42 206

Knowledge:

a) Initiation of breastfeeding

Overall, about three fourths of all service providers knew that breastfeeding should be

initiated within an hour of the child’s birth. However, breaking down the data by cadre

(Table 47) shows that the while most of the ANMs (93%) were aware of the correct

recommendation, only 42% and 51% of the Mamtas and ASHAs respectively knew the

correct answer. Mamtas and ASHAs are the two cadres who have the greatest chance of

being present with the woman at the time of delivery (see Chapter 5, for further discussion).

Table 47: Knowledge of service providers about timing of initiation of breastfeeding

Service Provider Facility- based

service providers

Community-based

service providers TOTAL

Timing of initiation of BF ANM Mamta AWW ASHA


151 (92.6)

13 (41.9)

85 (77.3)

49 (51.0)

298 (74.5)

71

164 (84.5)

134 (65.0)


9 (5.5)

14 (45.2)

20 (18.2)

35 (36.5) 78

(19.5) 23 (11.9)

55 (26.7)


2 (1.2)

4 (12.9)

2 (1.8)

7 (7.3) 15

(3.8) 6 (3.1)

9 (4.4)

1-3 days

0 (0.0)

0 (0.0)

2 (1.8)

5 (5.2) 7

(1.8) 0 (0.0)

7 (3.4)

Never

0 (0.0)

0 (0.0)

1 (0.9)

0 (0.0) 1

(0.3) 0 (0.0)

1 (0.5)

No response

1 (0.6)

0 (0.0)

0 (0.0)

0 (0.0) 1

(0.3) 1 (0.5)

0 (0.0)

TOTAL 163 31 110 96

400 194 206

Numbers in parentheses indicate percentages of the column total, rounded off to the first decimal.

Those who cited “within 1 hour of birth” as the ideal time for initiating breastfeeding, were

asked to list the advantages of early and timely initiation of breastfeeding (Table 48). More

than 80% of the service providers quoted improvement in the immune status of the child

due to colostrum as the most common advantage of early initiation. Keeping the baby’s

body warm due to the mother’s body heat was the next common response (33%), while

reduction in the incidence of postpartum haemorrhage (PPH) was the third at 24%. Very few

service providers (16% of this sub-set and 12% overall) knew that initiating breastfeeding on

time actually reduces the incidence of breastfeeding problems later, thus helping the

mother to continue breastfeeding and maintain the exclusivity of breastfeeding for longer

durations.

72

Table 48: Knowledge of service providers about the advantages of early and timely initiation of breastfeeding

Service Provider

Facility- based

service providers

(n=164)

Community-based

service providers

(n=134)

TOTAL

Advantages of timely

initiation of BF

ANM

(n=151)

Mamta

(n=13)

AWW

(n=85)

ASHA

(n=49)

Closeness to mother’s body keeps the baby warm

57 (37.7)

7 (53.9)

16 (18.8)

19 (38.8) 99

(33.2) 64 (39.0)

35 (26.1)

BF causes faster uterine contraction and reduces the incidence of PPH

42 (27.8)

2 (15.4)

13 (15.3)

14 (28.6) 71

(23.8) 44 (26.8)

27 (20.1)

Early and timely initiation of BF reduces the incidence of BF related problems.

23 (15.2)

2 (15.4)

14 (16.5)

9 (18.4) 48

(16.1) 25 (15.2)

23 (17.2)

Colostrum feeding improves the immunity of the baby

124 (82.1)

10 (76.9)

73 (85.9)

29 (59.2) 236

(79.2) 134 (81.7)

102 (76.1)

Others

10 (6.6)

0 (0.0)

6 (7.1)

3 (6.1) 19

(6.4) 10 (6.1)

9 (6.7)

Numbers in parentheses indicate percentages of the column total, rounded off to the

first decimal.

b) Exclusive breastfeeding

In order to promote exclusive breastfeeding, it is important for the service providers to

understand what it means and differentiate EBF from related practices such as predominant

breastfeeding etc.

As can be seen from Table 49, overall slightly more than two thirds (67.5%) of the service

providers were aware that exclusive breastfeeding refers to giving the child nothing other

than breast-milk, not even water. Another 14% felt that giving water based on child’s need

73

(thirst) also qualified as exclusive breastfeeding. About 13% of the service providers could

not give a response.

Breaking down the information by cadre, ASHAs and Mamtas fared the worst with less than

50% knowing the correct answer. Also about a fourth (23%) of the Mamtas did not respond

to this question.

Table 49: Knowledge of service providers about the definition of exclusive breastfeeding


service providers

Community-based


Definition of Exclusive

breastfeeding ANM Mamta AWW ASHA

Only mother’s milk fed to the child, not even water.

133 (81.6)

15 (48.4)

76 (69.1)

46 (47.9) 270

(67.5) 148 (76.3)

122 (59.2)

Mother’s milk fed to the child, with water as and when required

6 (3.7)

7 (22.6)

17 (15.5)

26 (27.1) 56

(14.0) 13 (6.7)

43 (20.9)

Largely on mother’s milk, may be supplemented by other milk / liquids

4 (2.5)

1 (3.2)

2 (1.8)

7 (7.3) 14

(3.5) 5 (2.6)

9 (4.4)

Other

2 (1.2)

1 (3.2)

2 (1.8)

2 (2.1) 7

(1.8) 3 (1.5)

4 (1.9)

Don’t know/no response

18 (11.0)

7 (22.6)

13 (11.8)

15 (15.6) 53

(13.3) 25 (12.9)

28 (13.6)

TOTAL 163 31 110 96

400 194 206


About three fourths (73%) of the service providers knew that exclusive breastfeeding should

be continued for 6 months (Table 50). Less than 7% of the respondents quoted a time frame

for exclusive breastfeeding that was less than 6 months, with the minimum being one

74

month, which was cited by 3 service providers. On the other hand, the maximum duration

mentioned as the duration of exclusive breastfeeding was 36 months.

Table 50: Knowledge of service providers about the ideal duration (in months) of exclusive

breastfeeding


service providers

Community-based


Duration of EBF ANM Mamta AWW ASHA

Less than 6 months

11 (6.7)

3 (9.7)

4 (3.6)

8 (8.3) 26

(6.5) 14 (7.2)

12 (5.8)

6 months

140 (85.9)

9 (29.0)

87 (79.1)

57 (59.4) 293

(73.3) 149 (76.8)

144 (69.9)

7-12 months

4 (2.5)

6 (19.4)

5 (4.5)

11 (11.5) 26

(6.5) 10 (5.2)

16 (7.8)

More than 12 months

3 (1.8)

2 (6.5)

2 (1.8)

3 (3.1) 10

(2.5) 5 (2.6)

5 (2.4)

No numeric response

5 (3.1)

11 (35.5)

12 (10.9)

17 (17.7) 45

(11.3) 16 (8.2)

29 (14.1)

TOTAL 163 31 110 96

400 194 206


About 11% of the service providers did not give a numeric response to the question about

the ideal duration of exclusive breastfeeding. Table 51 shows that 78% of these respondents

(or about 9% overall) felt that ideal duration of exclusive breastfeeding should be based on

the ability of the mother to produce “sufficient” milk to satisfy the needs of the child.

75

Table 51: Knowledge of service providers about the duration of exclusive breastfeeding (qualitative responses)

Service Provider

Facility- based

service providers

(N=194)

Community-based

service providers

(N=206)

TOTAL

(N=400)

Duration of EBF (qualitative

responses)

ANM

(N=163)

Mamta

(N=31)

AWW

(N=110)

ASHA

(N=96)

Till the mother produces sufficient milk

3 (1.8)

8 (25.8)

10 (9.1)

14 (14.6) 35

(8.8) 11 (5.7)

24 (11.7)

Others

1 (0.6)

0 (0.0)

0 (0.0)

2 (2.1) 3

(0.8) 1 (0.5)

2 (1.0)

No response

1 (0.6)

3 (9.7)

2 (1.8)

1 (1.0) 7

(1.8) 4 (2.1)

3 (1.5)

TOTAL 5 11 12 17

45 16 29

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal.

On an average, the service providers stated 6.7 months as the ideal duration of exclusive

breastfeeding. The average is on the higher side to certain very high “outlier” responses like

36 months. Owing to the relatively fewer numbers of Mamtas and ASHAs knowing the

correct answer of 6 months, the average duration for exclusive breastfeeding as stated by

these two cadres is much higher at 8.6 and 7.0 months respectively.

As ideally the duration of ideal breastfeeding coincides with the age for introduction of

complementary feeding, an attempt was also made to compare the two indicators in the

same table. Table 52 shows that on an average, the age for introducing complementary

feeding is slightly earlier than for exclusive breastfeeding. The difference is particularly stark

in the responses from Mamtas where on an average, the age to introduce complementary

feeding is 1.6 months prior to the duration of exclusive breastfeeding, once again indicating

their lack of understanding of the concept of exclusive breastfeeding.

76

Table 52: Knowledge of service providers - average duration of exclusive breastfeeding and age for introduction of complementary feeding


service providers

Community-based


Average ANM Mamta AWW ASHA

Duration of exclusive breastfeeding (in months)

6.4 8.6 6.5 7.0 6.7

6.6 6.7

Age for introduction of Complementary feeding (in months)

6.2 7.0 6.5 6.7 6.5

6.4 6.6

Service providers were also asked about the advantages of exclusive breastfeeding. Their

responses are listed in Table 53. The most common advantage cited by the respondents was

that breast-milk helps in the physical and mental growth and development of the child.

About a third knew about its protective effect against diarrhoea, whereas relatively fewer

numbers (22%) could list protection from ARI/pneumonia as one of its advantages. The

advantages to the mother, such as the contraceptive effect of lactational amenorrhoea or

the protective effect of breastfeeding against development of breast-cancer in the mother,

could be quoted by very few (14%) respondents.

Overall, the Mamtas had the least knowledge on this subject, and the proportion of

respondents citing each of the listed advantages was less than the average for all the

specified advantages. On an average, each health worker cited about 1.8 advantages of

exclusive breastfeeding. While this average was as high as 2.1 for the ANMs, it was only 1.1

for the Mamtas.

Table 53: Knowledge of service providers about the advantages of exclusive breastfeeding

Service Provider

Facility- based

service providers

(n=194)

Community-based

service providers

(n=206)

TOTAL

Advantages of EBF ANM

(n=163)

Mamta

(n=31)

AWW

(n=110)

ASHA

(n=96)

BF helps in mental and physical development of

106 (65.0)

15 (48.4)

62 (56.4)

52 (54.2)

235 (58.8)

77

child 121 (62.4)

114 (55.3)

Mother's milk is the best and complete diet for the baby for the first six months

72 (44.2)

7 (22.6)

42 (38.2)

39 (40.6) 160

(40.0) 79 (40.7)

81 (39.3)

EBF protects against diarrhoea

59 (36.2)

6 (19.4)

35 (31.8)

30 (31.3) 130

(32.5) 65 (33.5)

65 (31.6)

EBF protects against pneumonia

47 (28.8)

4 (12.9)

20 (18.2)

17 (17.7) 88

(22.0) 51 (26.3)

37 (18.0)

Lactational amenorrhoea reduces maternal anaemia and also works as a contraceptive.

33 (20.2)

1 (3.2)

11 (10.0)

12 (12.5) 57

(14.3) 34 (17.5)

23 (11.2)

BF protects the mother from breast cancer

29 (17.8)

1 (3.2)

15 (13.6)

5 (5.2) 50

(12.5) 30 (15.5)

20 (9.7)

Others

19 (11.7)

5 (16.1)

9 (8.2)

8 (8.3)

41 (10.3)

24

(12.4)

17

(8.3)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal. Percentages do not add up to 100 as multiple options were allowed. c) Complementary feeding

As can be seen from Table 54, about 93% of the respondents gave a numerical response (in

months), when asked about the ideal age to introduce complementary foods to the child

diet. 57% of the service providers knew about the correct time for introduction of

complementary foods (6 months). Another one fourth (24%) said 7 months. This data must

be interpreted in light of the way age is thought of (and calculated) by a large proportion of

the Indian population, that is, in “running months”. Thus, a child who has completed 6

months is now into her 7th (running) month. Thus, a substantive proportion of the

respondents who responded 7 months could actually be referring to 6 completed months.

78

Once again, the Mamtas showed the worst knowledge on this front with only about one-

third (32%) of the respondents giving the correct response. In contrast, two-thirds (67%) of

the ANMs gave the correct answer.

Table 54: Knowledge of service providers about the ideal timing (in months) for introduction of complementary foods


service providers

Community-based



complementary foods ANM Mamta AWW ASHA

Less than 6 months

9 (5.5)

3 (9.7)

0 (0.0)

3 (3.1) 15

(3.8) 12 (6.2)

3 (1.5)

6 months

109 (66.9)

10 (32.3)

62 (56.4)

47 (49.0) 228

(57.0) 119 (61.3)

109 (52.9)

7 months

36 (22.1)

6 (19.4)

32 (29.1)

23 (24.0) 97

(24.3) 42 (21.6)

55 (26.7)

More than 7 months

7 (4.3)

9 (29.0)

6 (5.5)

9 (9.4) 31

(7.8) 16 (8.2)

15 (7.3)

No numeric response

2 (1.2)

3 (9.7)

10 (9.1)

14 (14.6) 29

(7.3) 5 (2.6)

24 (11.7)

TOTAL 163 31 110 96

400 194 206

Numbers in parentheses indicate percentages of the column total, rounded off to the first

decimal.

Some service providers added a qualitative response to the numeric response given above,

and some gave multiple qualitative responses about the ideal timing for introduction of

complementary feeding. These are described in Table 55. One sees that even some service

providers felt that foods other than breast-milk should be introduced only when the supply

79

of mother’s milk is unable to meet the demands of the child, which could be reflected either

as a child’s hunger even after breastfeeding or in less than optimum growth of the child.

Table 55: Knowledge of service providers about the ideal timing for introduction of

complementary foods (qualitative responses)

Service Provider

Facility- based

service providers

(N=194)

Community-based

service providers

(N=206)

TOTAL

(N=400)


Complementary foods

(qualitative responses)

ANM

(N=163)

Mamta

(N=31)

AWW

(N=110)

ASHA

(N=96)

When the child is ready to eat

1 (0.6)

2 (6.5)

9 (8.2)

5 (5.2) 17

(4.3) 3 (1.5)

14 (6.8)

When only mother’s milk does not satisfy child’s hunger

3 (1.8)

2 (6.5)

1 (0.9)

11 (11.5) 17

(4.3) 5 (2.6)

12 (5.8)

When child’s development is not optimum or s/he is moving towards under-nutrition

0 (0.0)

0 (0.0)

1 (0.9)

0 (0.0) 1

(0.3) 0 (0.0)

1 (0.5)

No response

1 (0.6)

1 (3.2)

0 (0.0)

1 (1.0)

3 (0.8)

2

(1.0) 1

(0.5)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off

to the first decimal.

Percentages do not add up to 100 as multiple options were allowed.

Service providers were asked how often in 24 hours a child should be given complementary

food. They were asked to share their responses for three age groups – 6-9 months, 9-12

months and 12-24 months. The detailed distribution of the responses, categorised by age,

are given in Table 56.

For the age groups 6-9 months and 9-12 months, about a third of the respondents (35%)

mentioned giving the child complementary foods 3-4 times in a day. For the older age group

80

(12-24 months), more than 5 times in a day was by far the most common response quoted

by over half the service providers.

About 10-11% of the respondents did not give a response to this question.

Table 56: Knowledge of service providers about the frequency of complementary feeding in 24 hours, depending on the age of the child

Child’s age group

Frequency of

complementary feeding in

24 hours

6-9

months

9-12

months

12-24

months

1-2 times 81

(20.3) 14

(3.5) 7

(1.8)

3-4 times 138

(34.5) 141

(35.3) 76

(19.0)

5 times 54

(13.5) 74

(18.5) 63

(15.8)

More than 5 times 85

(21.3) 132

(33.0) 210

(52.5)

No response 42

(10.5) 39

(9.8) 44

(11.0)

TOTAL 400 400 400


Calculating an average of the responses given by various cadres for the different age groups

(Table 57), shows that according to the service providers, the average number of

complementary meals per day increases, from 3.9 for the 6-9 month old children to 4.6 and

then to 5.2 for the children aged 9-12 and 12-24 months respectively. It is also interesting to

note the relative lack of inter-cadre difference on this indicator.

81

Table 57: Knowledge of service providers – average32 frequency (no. of times in 24 hours) of complementary feeding, depending on the age of the child


service providers

Community-based


Age group of the child ANM Mamta AWW ASHA

6-9 months 3.7 3.7 4.0 4.0

3.9 3.7 4.0

9-12 months 4.6 4.7 4.8 4.6

4.6 4.6 4.7

12-24 months 5.1 5.1 5.4 5.2

5.2 5.1 5.3

As with the frequency of feeding, a look at Table 58 shows that in the service providers’

opinion, the quantity of food offered as complementary food to the child in 24 hours should

also keep on increasing with age. They were asked to express the desired quantity as

number of cups (of 150 ml each) and/or number of spoons (of 10 ml each) to be given to the

child per day. The number of cups and/or spoons was multiplied by the average cup/spoon

capacity and added together to arrive at the total quantity for a day.

For the 6-9 month old age group, 60% of the respondents quoted food quantities less than

400 ml per day. For the 6-9 month age group, a similar percentage (57%) mentioned

quantities in the 201-600 grams per day quantity range. For the oldest age group of 12-24

years, the quantity range covered by 58% of the respondents was 401 to 1000 grams. The

relatively larger range in this age group may be attributed to the larger age range this is

associated with.

About 10% of the service provider respondents did not give a response about the

appropriate quantity of complementary food for one or more of these age groups.

32

The average / arithmetic mean has been calculated by taking the mid-point of the class interval (such as 1.5 for the class interval 1-2 times), and multiplying it by the respondents, and summing it up across all numerical categories to get the numerator. For the interval “more than 5 times”, 6 was taken as the multiplying factor. The denominator was the total number of service providers who gave a response.

82

Table 58: Knowledge of service providers about the quantity of complementary feeding in 24 hours, depending on the age of the child

Child’s age group

Quantity of complementary feeding

in 24 hours

6-9

months

9-12

months

12-24

months

1 - 200 ml 142

(35.5) 36

(9.0) 11

(2.8)

201 - 400 ml 94

(23.5) 80

(20.0) 33

(8.3)

401 - 600 ml 86

(21.5) 149

(37.3) 117

(29.3)

601 - 800 ml 19

(4.8) 27

(6.8) 59

(14.8)

801 - 1000 ml 14

(3.5) 35

(8.8) 57

(14.3)

1001 - 1200 ml 5

(1.3) 20

(5.0) 41

(10.3)

1201 - 1400 ml 1

(0.3) 4

(1.0) 10

(2.5)

1401 - 1600 ml 1

(0.3) 7

(1.8) 15

(3.8)

1601 - 1800 ml - 2

(0.5) 9

(2.3)

1801 - 2000 ml - 1

(0.3) 6

(1.5)

2201 - 2400 ml - - 1

(0.3)

2401 - 2600 ml - - 3

(0.8)

No response 38

(9.5) 39

(9.8) 38

(9.5)

TOTAL 400 400 400


83

Calculating the average quantity too (Table 59) one also sees a gradual increase across age

groups, from 344ml for the 6-9 months old age group to 566 ml for 9-12 months and 803 ml

for 12-24 months. Once again, the difference across cadres is not significant.

Table 59: Knowledge of service providers – average quantity (in ml) of complementary

feeding in 24 hours, depending on the age of the child


service providers

Community-based


Age group of the child ANM Mamta AWW ASHA

6-9 months 345 382 340 338

344 350 339

9-12 months 545 604 582 569

566 555 576

12-24 months 773 875 804 829

803 789 815

When asked about the variety of foods that should be offered to the children in the

different age groups as complementary foods, cereals was the most common answer given

by 82-87% of the respondents across age groups, followed by pulses (Table 60). The

proportion of respondents who chose a particular food group to be included in the child’s

diet increases with increasing age of the child. For example, while only 20% of the service

providers said that green leafy vegetables should form part of a the complementary diet of

a 6-9 month old, this increased to 28% for children aged 9-12 month old and further to 39%

for children over a year.

Thus, the number of food groups in the “appropriate diet” as envisaged by the service

providers kept in increasing with age of the child. While services providers listed about 2.6

and 3.3 food groups on average for children 6-9 months and 9-12 months of age, this

increased dramatically to 4.6 food groups for the oldest group of children (not shown in the

table).

84

Table 60: Knowledge of service providers about the variety of foods to be given to the child for complementary feeding, depending on the age of the child

Child’s age group

Variety (food groups) for


6-9

months

9-12

months

12-24

months

Cereals (Rice, Roti etc.) 327

(81.8) 344

(86.0) 349

(87.3)

Roots and tubers 45

(11.3) 68

(17.0) 98

(24.5)

Green leafy vegetables 79

(19.8) 111

(27.8) 156

(39.0)

Yellow and Orange Fruits 64

(16.0) 110

(27.5) 114

(28.5)

Sugar 62

(15.5) 90

(22.5) 106

(26.5)

Oilseeds, Ghee 48

(12.0) 72

(18.0) 102

(25.5)

Other Fruits and Vegetables 34

(8.5) 76

(19.0) 158

(39.5)

Dairy Products 103

(25.8) 162

(40.5) 195

(48.8)

Pulses and Sprouted grains 230

(57.5) 206

(51.5) 254

(63.5)

Meat, fish poultry etc. 14

(3.5) 37

(9.3) 173

(43.3)

Eggs 10

(2.5) 31

(7.8) 137

(34.3)

Others 12

(3.0) 1

(0.3) 3

(0.8)

Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off to the first decimal. Percentages do not add up to 100 as multiple options were allowed.

85

Performance of service providers:

There are many factors33 that influence the performance of a worker34. Clarity in job roles is

one of them. As has been mentioned before, counselling women and families on IYCF is an

integral part of the job description of all the cadres of workers interviewed as part of this

survey. However, whether the workers themselves recognised IYCF counselling as a

component of their job was assessed, and the results of the same are shown in

Table 61. About 87% of the service providers agreed that IYCF counselling is an integral part

of the work that was expected of them. Although there was not much variation between the

various cadres of service providers it ranged from about 91% for the ANMs to 83% for the

AWWs.

Table 61: Opinion of service providers whether counselling on IYCF is a part of their job description


service providers

Community-based


Counselling on IYCF part of

job description ANM Mamta AWW ASHA

Yes

148 (90.8)

26 (83.9)

91 (82.7)

81 (84.4) 346

(86.5) 174 (89.7)

172 (83.5)

No

10 (6.1)

5 (16.1)

18 (16.3)

14 (14.6) 47

(11.8) 15 (7.7)

32 (15.5)

No response

5 (3.1)

0 (0.0)

1 (0.9)

1 (1.0) 7

(1.8) 5 (2.6)

2 (7.5)

TOTAL 163 31 110 96 400

33

Factors influencing the performance of a worker include 1) Job clarity, 2) Possession of knowledge and skills, 3) Availability of equipment and supplies, 4) Access to supportive supervision, and 5) Motivation through rewards and recognition.

34 Performance improvement: Stages, steps & tools. Introduction to Performance Improvement.

http://www.intrahealth.org/sst/intro.html#subsection2

http://www.intrahealth.org/sst/intro.html#subsection2

86

194 206


However, when it came to acting on this element of their job description, one can see a mild

dip in Table 62, wherein only 81% acknowledged that they actually counsel women and

care-givers on IYCF issues. Once again, the ANMs seemed to perform better than the other

cadres with 89% of them self-reporting that they counselled on IYCF. In contrast only 74% of

the ASHAs admitted to actually complying with this element in their job description. ASHAs

are also the cadre that saw the maximum reduction of over 10% percentage points from the

acceptance in their job description to actually performing on the same.

Table 62: Performance of service providers on IYCF counselling


service providers

Community-based


Counselling on IYCF done ANM Mamta AWW ASHA

Yes

145 (89.0)

23 (74.2)

84 (76.4)

71 (74.0) 323

(80.8) 168 (86.6)

155 (75.2)

No

14 (8.6)

8 (25.8)

16 (14.5)

19 (19.8) 57

(14.3) 22 (11.3)

35 (17.0)

No response

4 (2.5)

0 (0.0)

10 (9.1)

6 (6.3) 20

(5.0) 4 (2.1)

16 (7.8)

TOTAL 163 31 110 96

400 194 206


There are three main routes through which the service providers can provide counselling on

IYCF-related issue – group meetings, home-visits and one-on-one counselling at the time of

delivery. While ANMs, AWWs and ASHAs, are all mandated to conduct group meetings and

undertake home visits, the Mamtas, being posted at a health facility get the opportunity to

counsel women when the woman come to deliver at a health facility. The ANMs also get a

87

similar opportunity if they are posted at a health facility where deliveries are taking place.

Thus ANMs are the only cadre of worker that can counsel through all the three routes.

A comparison of Table 62 and Table 63 shows that while about 90% of the ANMs and 75%

each of the AWWs and ASHAs claim to counsel women and care-givers on IYCF issues, only

28% of the ANMs, 45% of the AWWs and 23% of the ASHAs have conducted any IYCF-

related group meetings in the three months prior to the survey. Similarly, Table 64 shows

that a relatively similar number, that is 27% of the ANMs, 43% of the AWWs and 39% of the

ASHAs, have undertaken any home visits to discuss IYCF issues in the past three months.

Table 63: Performance of service providers related to conducting group meetings in the past 3 months to discuss IYCF issues.


service providers

Community-based


Group meetings conducted ANM Mamta AWW ASHA

Yes

46 (28.2)

N/A 49

(44.5) 22

(22.9) 117 (31.7) 46

(28.2) 71

(34.5)

No

117 (71.8)

N/A 61

(55.5) 74

(77.1) 252 (68.3) 117

(71.8) 135

(65.5)

TOTAL 163 N/A 110 96

369 163 206


Table 64: Performance of service providers related to undertaking home visits in past 3 months to discuss IYCF issues.

88


service providers

Community-based


Home visits undertaken ANM Mamta AWW ASHA

Yes

44 (27.0)

N/A 47

(42.7) 37

(38.5) 128 (34.7) 44

(27.0) 84

(40.8)

No

119 (73.0)

N/A 63

(57.3) 59

(61.5) 241 (65.3) 119

(73.0) 122

(59.2)

TOTAL 163 N/A 110 96

369 163 206


Of those who did conduct group meetings indicated that they had conducted about 7 such

meetings on an average in the past 3 months (Table 65). The ANMs gave the highest

response of about 12 meetings (or about 4 per month), whereas the AWWs and ASHAs

mentioned almost 4 and 3 meetings respectively, that is only about 1 per month. The

average attendance at each of these meetings was about 20 participants and this remained

relatively consistent across service provider cadres.

The average number of home visits was significantly higher at about 24 home visits or 8

home visits per month. There was not much difference in the average number of home

visits across various cadres of service providers.

Table 65: Average number of group meetings and home visits conducted by service providers in past 3 months


service providers

Community-based


Average35 no. of ANM Mamta AWW ASHA

Group meetings conducted in past 3 months

12.3 N/A 3.8 2.9 7.0

12.3 3.5

Women who attended a 20.8 N/A 19.3 19.5 19.9

35

The “average” here refers to the arithmetic mean. The denominator takes into account only those health workers who said that they conduct group meetings or undertake home visits (as the case may be).

89

group meeting 20.8 19.3

Home visits undertaken in past 3 months

22.4 N/A 24.8 23.5 23.6

22.4 24.2

The third important platform for counselling women on IYCF behaviours is at the health

facility when the woman has just delivered. Of the two facility-based cadres, only 18% of the

ANMs said that they were posted at facilities where deliveries were taking place. This

proportion was much higher for Mamtas (74%). Even of those who were posted at facilities

conducting deliveries, not all had attended a minimum of one delivery in the three months

preceding this survey. The ones who counselled women on early and timely initiation and/or

exclusive breastfeeding were even fewer. Only 9.2% of the ANMs had counselled the

women on each of the two issues of early initiation and exclusive breastfeeding. Similarly

while 71% of the Mamtas had counselled women on timely initiation, only 55% claimed to

have counselled the mother of exclusive breastfeeding.

The centres where deliveries were being conducted saw an average (median) of 74

deliveries in the preceding three months. Of these, on an average, only 45 women were

counselled on each of the two IYCF messages. It must be mentioned here that these

numbers were not cross-checked against the facility records. With a reporting time frame of

three months prior to the survey, these suffer from a potential recall bias.

Table 66: Performance of service providers related to counselling postpartum mothers on IYCF issues in past 3 months.

Service Provider ANM

(N=163)

Mamta

(N=31)

TOTAL

(N=194)

No. (%)

of ANM

Average 36

number of

deliveries

No. (%)

of

Mamtas

Average 36

number of

deliveries

No. (%)

of Health

Workers

Average 36

number of

deliveries

Deliveries (in last 3 months) taking place in facility where health worker is posted

29 (17.8)

25 23

(74.2) 195

52 (26.8)

74

36

The “average” here refers to the median, as the arithmetic mean is on the higher side due to outlier readings. Also, this median is only more those health workers who have given a response of one or more deliveries. Health workers who have not given any response, or whose response is “zero” have been excluded from calculation of the median.

90

Deliveries (in last 3 months) attended by health worker

20 (12.3)

11 22

(71.0) 88

42 (21.6)

54

Deliveries (in last 3 months) where mother counselled on initiation of breastfeeding

15 (9.2)

11 22

(71.0) 84

42 (21.6)

45

Deliveries (in last 3 months) where mother counselled on exclusive breastfeeding

15 (9.2)

19 17

(54.8) 52

32 (16.5)

45

Overall, 32% of the “eligible”37 providers conducted group meetings, 35% conducted home

visits, 22% counselled postpartum women on timely initiation, and another 16.5% on

exclusive breastfeeding in the three months preceding the survey. Table 67 shows that

overall, only 47% of the service providers have counselled women on IYCF behaviours using

at least one of the three platforms. This percentage, which reflects their self-reported

practice in the past quarter, is about 34 percentage points less than the 81% who claim to

counsel women and families on IYCF. This being a quantitative survey, there is no data on

the other means, if any, used by the service providers, especially the community-based

providers (AWWs and ASHAs), in order to fulfil this component of their job requirement.

Table 67: Overall performance of service providers related to counselling on IYCF issues in past 3 months


service providers

Community-based


Counselling sessions 38

undertaken ANM Mamta AWW ASHA

Yes

65 (39.9)

22 (71.0)

57 (51.8)

42 (43.8) 186

(46.5) 87 (44.8)

99 (48.1)

No 98

(60.1) 9

(29.0) 53

(48.2) 54

(56.3) 214

(53.5)

37

“Eligible” means that for the purpose of calculating the proportions of workers who are counseling women, only those providers whose job description specifies the same have been taken into account. For example, Mamtas are not expected to conduct group meetings or home visits and have therefore been removed from the denominator there. Similarly, only the facility-based providers namely ANMs and Mamtas have been counted for facility-based postpartum counseling. 38

“Counseling sessions” refer to a) group meetings conducted to discuss IYCF issues, OR b) home visits undertaken to discuss IYCF issues, OR c) counseling on initiation of breastfeeding provided to a postpartum mother at a health facility, OR d) counseling on exclusive breastfeeding provided to a postpartum mother at a health facility

91

107 (55.2)

107 (51.9)

TOTAL 163 31 110 96

400 194 206

92

Chapter 5

DISCUSSION

In order to ensure optimal health and development of a child the World Health Organisation

(WHO) and UNICEF recommend the following practices related to Infant and Young Child

Nutrition.

- Initiating breastfeeding within an hour of birth

- Exclusive breastfeeding (not even water) to the child for the first six months

- Introduction of age appropriate complementary feeding at six (completed) months

of age, along with continuation of breastfeeding for two years and beyond.

This DFID supported project aims to improve these IYCF related practices in selected blocks

of three districts - Muzaffarpur, Samastipur and Sitamarhi - of Bihar through BCC

interventions, such as PE-led group meetings and home visits on this topics. The field level

interventions are being led by four implementing partners. In order to assess the

effectiveness of project efforts and its impact on the knowledge and practices of the

mothers and care-givers, a monitoring and evaluation plan was designed and indicators

defined under the same. (Annex 2 and Annex 3). This study was conducted to assess the

“baseline” levels of these indicators, i.e. before the initiation of the grass-root level

communication efforts. Most of the indicators have been disaggregated by both district and

implementing partner, as the same would be followed throughout the life of the project for

monitoring purposes. While the district level data is required for sharing with the donor as

well as with the district authorities, the IP specific data is important from internal project

management purposes.

While the mothers (and care-givers) of children under two years of age are the primary

target population of the project, the facility-based and community-based service providers

whose job involves counselling women on IYCF, are the secondary target population of the

project. It is envisaged that continuous mentoring by the project staff (PEs and CCs) will help

improve the knowledge of the service providers on IYCF-related issues, and also improve

their performance insofar as conducting counselling sessions is concerned.

93

Thus, the discussion in this chapter will be under two broad sub-heads

Pregnant women and mothers

Service providers

PREGNANT WOMEN and MOTHERS

Women in different stages of life (with reference to pregnancy and child-bearing) were

interviewed for this survey. As can be seen from Table 4 and Table 5, a total of 7642 women

were interviewed across five respondent groups. While there were 1536 women each in this

sample who were in their third trimester of pregnancy, or with a child in the age group 3-4

months or 6-7 months or 12-13 months, the interviewers could find only 1498 women in the

sampled Panchayats, who had a child less than a week old. The questions asked to these

different respondent categories were in congruence to their life stage.


As can be seen from Table 9 and Table 10, only 23% of the pregnant women in their third

trimester could give the correct answer about the right time to initiate breastfeeding.

However, only 17% of the women with a child less than 7 days of age actually initiated

breastfeeding within an hour of delivery, thus showing a gap between knowledge and actual

practice (Table 11 and Table 12). This is comparable to the 16.2% reported by DLHS-3 for

Bihar in 2007-08. However, a comparison of the district level figures shows substantively

higher levels (a difference of 4-6 percentage points) in the current study compared to DLHS-

3.

Table 68: Comparison of breastfeeding initiation rates between DLHS-3 and present study

DLHS 3

(2007-08)

Present baseline

study

(2012)

Difference

(percentage

points)

Overall (Bihar / Project) 16.2 17.4 1.2

Muzaffarpur 15.5 19.3 3.8

Samastipur 10.9 16.3 5.4

Sitamarhi 12.5 16.7 4.2

94

Despite the difference between knowledge and practice for initiation of breastfeeding

within the recommended 1 hour of birth, it is interesting to note that this difference ceases

to exist if one considers the period of first 6 hours after birth instead of just the first hour. In

the current study 55% of the pregnant women quoted an ideal time for initiation within 6

hours of birth, and a similar 55% of the mothers actually initiated breastfeeding within 6

hours. Putting the data on knowledge and practice for the two time-frames (within 1 hour

and within 6 hours of birth) together, it could mean that due to various socio-cultural and

medical reasons women are not able to follow up on their intentions of feeding the baby

within 1 hour, but are able to do so within 6 hours of birth. In fact, linking these findings to

the formative research conducted in October 2011, one can infer that practices such as

bathing / cleaning the baby or performing certain religious rituals might be the cause that

delayed initiation beyond the recommended first hour and despite correct knowledge and

positive intention on the mother’s end.

The formative research also showed that many women delay breastfeeding until they feel

spontaneous let-down of “white” milk. This could be the reason behind 25% of the women

delaying breastfeeding beyond 24 hours (Table 11 and Table 12). It is also probable that the

1% who did not initiate breastfeeding at all did not have such a spontaneous let-down and

therefore did not even try to put the child to the breast.

Exclusive Breastfeeding

Women were asked about the advantages of exclusive breastfeeding. It was clear that

women were unable to differentiate between the advantages of breastfeeding in general

vis-à-vis exclusive breastfeeding specifically. While the most common advantage mentioned

by the women was that breast-milk helps in the physical growth and mental development of

the child (Table 17), about 25% to 30% of the respondents could not cite even a single

advantage (Table 13 to Table 16), reflecting a relatively poor status of knowledge on this

front. However, the responses to this question should not be taken as an “absolute

indicator” of lack of knowledge. This is because in this question, the interviewers were

asked to list spontaneous responses and not prompt the women with options. Therefore, it

is probable that some women knew of more advantages than they could list spontaneously.

95

For example, it is well known that women are aware of the contraceptive benefit of

lactational amenorrhoea. In fact, studies on family planning have found that women actually

rely on this contraceptive effect of this amenorrhoea for longer than the recommended six

months. However, only 2% and 3.7% of the women with children less than seven days and

3-4 months of age respectively, could spontaneously list lactational amenorrhoea and its

contraceptive effect as an advantage of exclusive breastfeeding.

Figure 3 shows that less than one-fourth of the women across two respondent groups knew

the ideal duration of exclusive breastfeeding. It is a common apprehension among

communication experts that changes in the recommended duration of exclusive

breastfeeding over the past two decades or so, from 4 months to 4-6 months to 6 months,

have created confusion in the minds of the service providers as well as the mothers and care

givers on this issue. However, data from the present study does not show any evidence (in

the form of peaking of responses at 4 months, or 5 months) to support this apprehension.

On a different note, even though the question regarding the mothers’ knowledge on the

duration of exclusive breastfeeding clearly specified “only breast-milk, not even water”, it

was clear that not only are women unclear about the concept of exclusive breastfeeding,

they are also unable to differentiate it from continued breastfeeding. This was a clear

finding in the formative research and is also reflected in the present study through

responses that go beyond 12 months (to as high as 36 months), coupled with a “peaking” of

responses seen at 12 months and 24 months. It is highly improbable that any woman really

believes that only her milk will be sufficient for the baby’s needs for beyond 12 months.

Hence, these “outlier” and “unreasonable” responses seem to reflect a lack of clarity in the

mothers about the meaning of exclusive breastfeeding.

Another notable finding was that about half the respondents were unable to state any

particular age as the duration for exclusive breastfeeding. Instead, they related the same to

“sufficiency” of their breast-milk, one of the judges of which was hunger cues from the child

(Table 19). This correlates very well with the formative research where it was found that

mothers do not understand the concept of optimal growth and development. In a food

scarce environment like most of the project area, the basic purpose of food / feeding

96

(including breastfeeding) is to satisfy the hunger of the person in question, which in this

case is the child.

As with initiation of breastfeeding, there was a gap between knowledge and practice of

exclusive breastfeeding. As mentioned before, about 22% of the mothers knew that the

ideal duration for exclusive breastfeeding is six months. However, when mothers with a

child 6-7 months of age were questioned about when they had introduced food substances

other than breast-milk for their child (thus breaking the exclusivity of breastfeeding), only

15% admitted to have exclusively breastfed their child for at least six months (Table 24). In

fact, only 31% of the children 3-4 months were being exclusively breastfed, showing that the

exclusivity of breastfeeding is broken at a much earlier age. The mean duration for exclusive

breastfeeding was slightly over two and half months.

However, despite the seemingly low rates for exclusive breastfeeding, Table 69 shows

significantly higher percentages in the current survey compared to DLHS-3 rates of exclusive

breastfeeding for at least six months. While the overall difference is 3.4 percentage points,

the change is the starkest in Sitamarhi district where exclusive breastfeeding seems to have

increased from a mere 0.3% in 2007-08 to 13.5% in 2012. It must be noted here that the two

indicators are not identical because while the denominator in the present study is only

(mothers of) children in the age group 6-7 months, the denominator for DLHS is 6-35

months. Thus the chances of a “recall bias” are much higher in the DLHS study.

Table 69: Comparison of exclusive breastfeeding rates between DLHS-3 and present study

DLHS 3

(2007-08)

Present baseline

study

(2012)

Difference

(percentage

points)

Overall (Bihar / Project) 11.8 15.2 3.4

Muzaffarpur 5.2 17.6 12.4

Samastipur 5.6 14.0 8.4

Sitamarhi 0.3 13.5 13.2

97

Complementary Feeding

Growth faltering is known to begin at the age of six months, which coincides with the

recommended age for introduction of complementary foods. Literature suggests various

reasons for this, including delayed introduction of complementary foods, inadequate

quantity of complementary foods given to the child, etc. Micronutrient deficiency disorders,

especially iron deficiency anaemia also begin to manifest at this age owing to a diet that is

not balanced in terms of coverage of all macro and micronutrients.

Complementary feeding is not an easy issue to study owing to its various dimensions. For

complementary feeding to be age appropriate, the child must be not only be introduced to

the foods at the right age, but the consistency (from semi solid to solid with increasing age)

and quantity of food, the frequency of feeding, the variety of food items (covering all major

food groups) needs to be ensured. The present study attempted to cover all these aspects.

Women with children 3-4 months of age, that is those who had not yet reached the

recommended age for introduction of complementary feeding, were assessed on their

knowledge and intention related to complementary feeding. Figure 5 shows that only 21%

of the mothers knew that they should introduce complementary feeding for their children

at six months of age. Another 13% mentioned seven months. This is important to note,

because in the Indian, many people refer to the child’s age in “running” months (or years).

Thus a child who has completed 6 months of age, will be referred to as “in the 7th (running)

month” by the mother, and perhaps noted as such by the interviewer. Thus a substantive

proportion of the women answering seven months, would actually mean six completed

months.

Curiously, when asked about their intention to introduce complementary feeding in their

own child’s diet, one sees a shift in the graph to the right. Only 11% and 8% responded six

and seven months of age respectively. The difference is also seen in the mean age. Whereas

the mean age for knowledge on introduction of complementary feeding was eight months,

the mean age for intention for their own child was 9.6 months, a difference of over one and

half months, which can have a significant impact on the growth and development of the

child. One can understand this apparent dichotomy by correlating these with the formative

98

research. As mentioned before, hunger and not optimal growth (or heath) was the primary

factor that led to decisions on IYCF. As can also be seen from the present study, a

substantive proportion of the mothers would wait for cues from the child indicating breast-

milk insufficiency (compared to child’s needs) before starting the chid on other foods. The

formative research also showed that most mothers pride themselves on having “sufficient”

milk, and those who cannot breastfeed their child for long durations are often thought to be

lacking. Thus, this apparent delay in introduction of complementary feeding for their own

child is a reflection of the mother’s pride and confidence in her capacity to produce enough

milk to satisfy her child for periods longer than “normal” (which was reflected as their

knowledge).

However, when it came to actually introducing complementary foods, about 73% of the

mothers of children 6-7 months of age had already started giving their child foods other

than breast-milk. This percentage increased to over 90% by the time the child turned 12

months old (Table 28). While the table below shows a variable increase / decrease in

complementary feeding rates across the districts, it must be pointed out once again that the

project indicator and the DLHS indicator are not exactly comparable. Apart from a different

denominator, namely 6-9 months in the case of DLHS and 6-7 months only for the present

study, the numerator is variable too. The DLHS indicator specifically asks about introduction

of semi-solid foods along with breast-milk. The question for this study asked the mother if

they have started the child on anything other than breast-milk. This “other” food substance

could be animal milk, which would not be covered in definition of the DLHS indicator.

Table 70: Comparison of complementary feeding rates between DLHS-3 and present study

DLHS 3

(2007-08)

Present baseline

study

(2012)

Difference

(percentage

points)

Overall (Bihar / Project) 61.4 73.4 +12.0

Muzaffarpur 87.2 68.5 -18.7

Samastipur 82.8 72.4 -10.4

Sitamarhi 77.4 82.0 + 4.6

99

Even though the mean age for introducing complementary foods was 6.4 months (close to

the recommended age), the fact that about 10% of the mothers had not started giving the

child complementary foods at even 12 months of age points towards gross delay in the

same for a substantive proportion of the children, and reflects one of the most important

reasons of childhood malnutrition in Bihar.

As mentioned before, a mere introduction of complementary foods at the right age is not

sufficient to ensure appropriate feeding. The frequency, quantity and variety of foods given

is equally, if not more, important. However, national / sub-national surveys such as NFHS

and DLHS, which seek information on multiple health related issues of which IYCF is just one

small element, cannot afford to go into an in-depth assessment of age –appropriateness of


A child aged 6-7 months is just introduced to complementary foods, and as such includes

children who are just a few days over 6 months of age. The project team felt that it is too

early in the complementary feeding cycle to assess the “appropriateness” of

complementary feeding for this age group. However, at 12-13 months, complementary

feeding should be firmly established, and one can assess the various elements against

international guidelines.

According to the WHO PAHO guidelines a child 6-8 months of age should be given

complementary foods 2-3 times a day (minimum 2) while a child over a year should be fed

3-4 times in a day (minimum 3). This is in addition to snacks which should be given 1-2 times

a day.

The data collection tools of the current study club the frequency of complementary feeding

into the following bands - “1-2 times”, “3-4 times”, “5 times” and “more than 5 times” in 24

hours. Hence, even if one considers twice a day as the minimum required frequency of

feeding for a 6-7 month old child, the analysis is not possible with the tool as the category

“1-2 times” could mean just once, too. Hence it is difficult to assess how many children in

this age category were given food in the required frequency.

100

However, for the older age group, if one counts all those mothers who said that they had

fed their children 3-4 times or more in the past 24 hours, one sees that 45% of those who

had started complementary feeding, (or 41% of all respondents in that age group) gave their

child the minimum required frequency of complementary foods (Table 36). In fact, Table 37

shows that there is hardly any increase in the average frequency39 of complementary

feeding for a 6-7 month old child and a 12-13 month old child. Moreover, high frequencies

such as five and above also causes one to question what exactly is being counted as a

“meal” for the child. The formative research had revealed that mothers did not give regular

and timely meals to their child. Once again, their cue for giving food to the child was any

signs of hunger or the child demanding food. There was no “responsive feeding”, and

mothers hardly ever checked how much the child had eaten nor did they ensure that the

child ate sufficient quantities at one meal. Smaller quantities at a meal also meant that the

child ate relatively more frequently.

PAHO guidelines also specify the approximate quantities of food that should be given to a

child of certain ages. These quantities have been derived from the calorie requirement of a

child from foods other than breast milk. For example, a child aged 6-8 months needs an

additional 200 Kcal/day (137-187 grams40 of food) which increases to 550 Kcal/day (378-515

grams of food) for a 12-23 month old child. It must be noted that in the current survey, only

volume of food has been calculated and not weight. Also, as the exact type of food (and

therefore the calorie density) was not known, it is difficult to state whether the calorie

requirement was met. Nonetheless, based on the assumption that whatever food was being

referred to was of the required calorie density and that each ml (volume) can be translated

into a gram (weight) of food, one sees that on an average, 278 ml (grams) of food were

offered to a child 6-7 months of age, which is more than the recommended quantity.

However, as the child ages, this average increases to only 349, which is significantly lower

than the minimum required in this age group of 12-13 months (Table 38). Considering the

calorie requirement from complementary food almost triples from the age of 6 months to

12 months, but this is not matched by a significant increase in food quantities, once again,

this gives an insight into the reason behind the rampant child under-nutrition in Bihar.

39

These average frequencies are for only those children for whom complementary feeding has been initiated. 40

These food quantities are based on the assumption that the calorie density of the food is 1.07 to 1.46 Kcal/gram.

101

The variety of foods offered to the child, as seen in Figure 8, is a reflection of the traditional

Indian adult meal. Most of the carbohydrate requirement is met by cereals (rice, roti), which

not only form the staple food but are also relatively cheap. Cereals being carbohydrate rich

are also filling, and satisfy hunger more easily (with lesser quantity) than other food groups.

This is followed by pulses (dhals). Similarly, the relatively less reporting of powdered milk,

and other commercially packed infant foods (Table 39) also point towards the effect of

economic situation of the community in the choice of complementary food for the child.

Even during the formative research, respondents had shared that only the mothers from

affluent families gave ready commercially packed infant pre-mixes to their children,

whereas the others relied on the food available at home for the rest of the family members.

The poor inclusion of fruits, vegetables and non-vegetarian items in the diet explain the

micronutrient deficiencies in the children, especially the high rates of anaemia in this age

group.

SERVICE PROVIDERS

Four hundred service providers were interviewed for this study. About half (194) were

facility-based providers namely ANMs and Mamtas, while the other half (206) were

community-based providers namely AWWs and ANMs. With only 31 respondents, Mamtas

was the smallest sample in this group.

As counselling women and care givers on IYCF issues is an important component of the job

responsibility of all these workers, it is of utmost important that they have the correct

knowledge on the recommended behaviours so that they can transmit the correct message

to the community.

While overall about 75% of the service providers knew the correct time for initiation of

breastfeeding, only 42% of the Mamtas could give the correct response (Table 47). This is

particularly worrisome as the very purpose of employing Mamtas in health centres is to act

as a birth companion for the women at the time of delivery and give them correct advice

related to breastfeeding and newborn care. Similarly, the primary role of ASHAs is as a link

102

worker and community mobiliser. Needless to say, giving correct health messages is an

important aspect of their work. As ASHAs are incentivised to accompany women to a health

facility for delivery, they too, like the Mamtas, are in a unique position to offer

breastfeeding advice. However, like the Mamtas, very few ASHAs (51%) knew the ideal time

for initiation of breastfeeding.

On the other hand, it is encouraging to note that over 90% of the ANMs gave the correct

response. The Government of India is now promoting the training of ANMs as Skilled Birth

Attendants, and converting sub-centres into accredited facilities for conducting deliveries.

With an increasing proportion of ANMs now conducting deliveries, correct information

about the time for initiation of breastfeeding is very important.

A relatively smaller proportion of service providers (67.5%) knew the correct meaning of

exclusive breastfeeding (Table 49). Once again, the Mamtas fared the worst, with less than

50% giving the correct response. Also only 29% knew the correct duration of exclusive

breastfeeding (Table 50). While Mamtas do not go to the field or interact with women after

they are discharged from the health facility following delivery, they are expected to counsel

women about exclusive breastfeeding at the time of discharge. Incorrect advice at this stage

would lead to the woman following the wrong practice which could have a detrimental

impact on the child’s health.

Similarly, ASHAs are expected to pay a visit to the recently delivered mother on the 3rd and

7th days following delivery. The purpose of these visits is related to early detection of

postpartum and newborn complications, if any, as well as giving advice on newborn care to

the mother, including breastfeeding. With less than half of the ASHAs knowing the correct

meaning of exclusive breastfeeding, and only 60% stating six months as the duration of

exclusive breastfeeding, the quality of counselling that they offer on this issue comes under

scrutiny. The fact that as about 6% of the Mamtas and 3% of the ASHAs cited durations over

12 months also reflects their lack of understanding of the concept of exclusive

breastfeeding, and probably they are confusing the same with continued breastfeeding.

103

Regarding complementary feeding (Table 54), 57% of the service providers gave the correct

response regarding the age for introduction of complementary foods in the child’s diet.

Another 24% answered seven months. As with the mothers, this too might be because of

the local practice of counting the child’s age in “running moths”. Therefore a response “7th

month onwards” which in reality means six completed months might have been marked by

the interviewer as seven months.

The average recommended frequency of complementary feeding in 24 hours proposed by

the service providers is not only higher than the “standard” frequency suggested by PAHO,

but almost double of what is being practiced by the mothers. The same is the case with the

quantity and variety of food to be given to the child. This means that either the women are

not being counselled about complementary feeding, or the quality of counselling is

extremely poor and details regarding frequency, quantity and variety of complementary

foods are either missed out during counselling sessions or explained ineffectively.

The mere acquisition of correct information on recommended IYCF practices by service

providers is not sufficient to ensure that the same is transmitted to the mothers, families

and communities. The service providers need to engage people in counselling sessions

(either as a group or in on-on-one sessions) to enable this. Even though counselling on IYCF

is an integral part of the job descriptions of all these workers, the task will be done only if

they recognise this responsibility as such.

Table 61 shows that a substantive proportion (87%) of service providers acknowledge that

counselling on IYCF is part of their duties. While there is not much to differentiate between

the various cadres, it was surprising to note that the AWWs had the least proportion on this

indicator, even though the focus of AWW’s work is nutrition. The probable reason for this

could be that the AWW sees herself as a provider of supplementary nutrition for the older

pre-school children (3-6 years), with little focus on newborns and young children.

Even though 81% of the service providers said that they counsel women and care-givers on

IYCF practices, only 32% and 35% respectively conduct group meetings and/or undertake

home visits. Another 22% and 17% counsel women after delivery on timely initiation of

104

breastfeeding and exclusive breastfeeding respectively. Overall, only 46.5% acknowledge

having used any/all of these methods for counselling women and care-givers in the three

months preceding the survey. It is not clear from the survey what other methods of

counselling the service providers were referring to, if any.

Table 65 shows that the average number of group meetings conducted by the ANMs in the

past three months is significantly higher than for the AWWs or ASHAs. This could probably

be because VHNDs are the most common platform for holding a group meeting. The

population served by an AWW or ASHA is 1000, and is most likely to attend only one VHND

in a month. However, the ANM covers a substantially larger area and multiple villages, and

thus attends almost four times the VHNDs attends by AWWs and ASHAs, which is reflected

in the increased number of group meetings too.

RECOMMENDATIONS

Apart from serving as a starting point for the project’s monitoring efforts, the findings of the

baseline study have important implications on the project activities.

1. The study has revealed distinct gaps in the knowledge of service providers on IYCF

related issues. The training content for the government frontline functionaries will

therefore focus on these deficiencies, and ensure that the service providers have the

appropriate knowledge related to IYCF.

2. Following DLHS-3 in 2007-2008, this is the first relatively large scale study that provides

data on the status of IYCF behaviors in the three project districts. This data will be of

enormous importance in advocating with the local government to improve and promote

programmatic focus on IYCF issues.

3. In view of the significant inter-district and inter-implementing partner differences in

most indicator levels, it is important that the efforts of the implementing partner teams

be compared with their respective baselines and not with each other or with the overall

project target, even though the latter (overall project target) is what has been

mentioned in the project log-frame and is what will be reported to DFID.

105

List of Annexures

1. Project Organogram 2. Conceptual Framework of the Project 3. Monitoring Indicators of the Project 4. Cluster Sampling – Detailed Methodology 5. Data Collection Tools (English Version) 6. Data Collection Tools (Translated into Hindi)

i

Annex 1: Project Organogram

ii

Annex 2: Conceptual Framework of the Project

Progress in project activities and outputs will be tracked through regular project monitoring. Outcomes will be tracked through an internal tracking study and will also be validated through an external end-line survey The project will not be measuring the impact level indicators

Impacts Outcomes Outputs

Early initiation of breastfeeding within an hour of birth

Exclusive breastfeeding of infants for the first 6 months of age.

Age appropriate complementary feeding given to the child beyond six months of age, with continuation of breastfeeding

Decreased neonatal mortality

Decreased infant mortality

1. Improved knowledge of mothers and care-givers regarding IYCF practices

2. Improved knowledge and performance of health and nutrition functionaries (in the context of IYCF counseling)

3. Appropriate policy and programmatic improvements (in the context of IYCF BCC efforts)

Building the knowledge and skills of mothers and care givers

Selection of Peer educators (PEs)

Technical training of PEs

Formation of mothers’ groups (cohort wise)

Dissemination of IYCF related information through group meetings and home visits (for young infant)

Problem solving through home visits

Baby shows

BF week

Building capacity of health and nutrition workers

Orientation of community based health and nutrition functionaries.

Mentoring of field level functionaries (AWWs, ASHAs, TBAs) through combined presence with PEs at group meetings and home visits

Training of facility level health functionaries (ANM, Staff nurses, Mamtas) by CCs.

Advocacy to scale up efforts

Sharing monitoring data trends with district level officials of three districts

Advocacy with professional associations (IAP, IMA, BOGS etc.) using data

Advocacy with neighboring districts and state government to scale up efforts.

Project Activities

iii

Annex 3: Monitoring Indicators of the Project

Output 3 Process Indicators 3.1 No. of district level meetings in three project

districts at which project monitoring data was shared

3.2 No. of advocacy events conducted with professional organizations / associations

3.3 No. of advocacy events conduct with the state or other district authorities

Output indicators

3.4 No. of policy / programme improvements with reference to BCC efforts for improving IYCF practices

Output 1 Process Indicators

1.1 No. of PEs selected and retained 1.2 No. of PEs trained 1.3 No. of mothers’ groups enrolled in the project 1.4 Average No. of mothers' groups meetings held

per PE in a month 1.5 Proportion of mothers who have a problem in

following optimal IYCF practices 1.6 Average no. of home visits conducted per PE in

a month 1.7 Proportion of mothers who have a problem in

following optimal IYCF practices who were paid at least one visit in the previous quarter

Output indicators

1.8 Proportion of women in the last trimester of pregnancy who can cite the ideal time for initiation of breastfeeding

1.9 Proportion of mothers with a child aged 3-4 months old who can cite three advantages of exclusive breastfeeding.

Output 2 Process Indicators

2.1 Proportion of mothers’ group meetings where a community-based health / nutrition functionary (AWW, ASHA, TBA) was also present

2.2 Proportion of PE led home visits to mothers where a community based health / nutrition functionary ( AWW, ASHA, TBA) was also present

2.3 No. of facility based functionaries (staff nurses/ Mamtas) who have been trained in IYCF counselling by CCs.

Output indicators

2.4 Proportion of community based health / nutrition functionaries (AWW, ASHA, TBA) who have the correct knowledge regarding optimal IYCF practices

2.5 Proportion of community based health / nutrition functionaries ( AWW, ASHA, TBA) who have conducted group meetings and home visits related to IYCF counselling in the past 3 months

2.6 Proportion of facility based health functionaries (ANMs, SNs, Mamtas) who have correct knowledge regarding early initiation / optimal IYCF practices.

iv

Outcome indicators

4.1 Proportion of mothers with newborns less than 7 days old who report having breastfed their newborns within one hour of birth 4.2 Proportion of mothers with a child 3-4 months of age who have exclusively breastfed their child in the past 24 hours. 4.3 Proportion of mothers with a child 6-7 months of age who have exclusively breastfed their child for at least six months 4.4 Proportion of mothers with a child 6-7 months of age who have initiated age appropriate complementary feeding for their child on/after 6 months of age. 4.5 Proportion of mothers with a child aged 12-13 months who are giving age appropriate complementary feeding for their child

v

Annex 4: Cluster Sampling – Detailed methodology The following sample selection methodology was shared with and used by the SPMU to

randomly select the Panchayats and the respondents from within the Panchayats. The text

also carries within it the reasoning for choosing the Panchayat as the last geo-administrative

unit of cluster location.

For the baseline survey, we will use multi-stage cluster sampling, probability proportionate

to size (PPS) methodology where the number of clusters we need to sample in a particular

geographical / administrative unit will be decided based on the population size of the same.

This means, geographical / administrative unit with larger population will have a greater

chance of being selected into the sample and/or will have a greater number of cluster

situated in it.

As population size forms the basis for cluster selection, it is obvious that we can decide the

number of cluster only till the last administrative / geographical unit for which we have

population figures available (while it is preferable to have the latest population figures, even

previous census figures will do, as we have to look at proportions, and we can assume that

these population would have grown with a similar growth rate). Based on our discussions, it

is clear that we have population for the block, then down to the panchayats in each block,

and to the revenue villages in each panchayat. Hence, it is possible that the revenue village

be selected as the last administrative unit for positioning the cluster. Which unit we decide

as the last possible unit will depend on the population of that unit and the number of

potential respondents in each cluster.

Deciding on the “last level” of geo-administrative unit for choosing as “location” for

cluster.

Going by the types of respondents we need to reach out to, we realise that the one with the

smallest “universe” will be “Mothers with a child less than 7 days of age” as it covers only a

7-day life span. All other categories cover a 1 month life span, and will naturally have a

larger number (about 4 times) of potential respondents who we can reach out to.

vi

Going by the population data from 2001 census, the average population of a panchayat is

8827, while that of a revenue village is 2268.

“Average”

Panchayat

“Average”

Revenue village

Average population (2001 census) 8827 2268

Average population (calculated) in 2012 using 25%

decadal growth (or “straight-lined” 2.5% annual

growth rate).

11254 2891

Births per annum (CBR 29/1000) 326 84

Births per month 27 7

Births in last 7 days 6.3 1.6

Now if we choose the revenue village as the last unit for cluster location, we will get on an

average only 1.6 women with a child less than 7 days per revenue village. As 384 such

women have to be interviewed per IP, this means that 384/1.6=240 revenue villages/

clusters need to be reached which could be spread across many / all panchayats. Thus,

choosing a revenue village as the last administrative unit defeats the very purpose of cluster

sampling.

Hence, it is suggested that a panchayat be taken as the unit for deciding the number (and

location) of clusters. As on an average about 6.3 women with children less than 7 days of

age would be present per panchayat, we would need to select 384/6.3 = 61 panchayats /

clusters. Rounding off figures, 384/6=64 clusters per IP.

Detailed methodology for cluster (Panchayat) selection

Here is the step by step methodology for selection. All these steps need to be followed

separately for each IP. It is recommended that the SPMU conduct this paper exercise of

cluster selection and hand-over the list of selected panchayats to the IP leads. This will

minimise error in sample selection.

vii

A) Selecting number of clusters in each block

1. List all the blocks covered by the IP alphabetically. Against each write the 2001/2011

population estimation (whichever year is chosen, it should be same for all the

blocks). Also write the cumulative population against each row. For example,

Block Population Cum Population

A 250,000 250,000

B 150,000 400,000

C 400,000 800,000

D 125,000 925,000

E 75,000 10,00,000

2. Divide the total population of all these blocks by the number of clusters, i.e. 64. This

is the Sampling interval. For example, if the total population is 10,00,000 (which is

the last cumulative figure), then the sampling interval is 10,00,000 / 64 = 15,625.

3. Choose any random number between one and the sampling interval. You may

randomly draw out a currency note from your wallet, and use the last 4 or 5

(depending on the sampling interval) to choose this random number. Look at the

cumulative population figures and see where this number falls. This is the position of

your first cluster. For example, the number on the currency note chosen randomly

for this example was numbered “824090”. The last 5 digits are 24,090, which is

more than the sampling interval in the example. Hence we should choose the last 4

digits, which is 4090. 4090 falls well within the 250,000 population of block A.

4. Add the sampling interval to this random number to decide the location of the

second cluster. That is 4090+15,625= 19715. This will give you the location of the

second cluster. In this case, this too falls within the first block.

viii

5. Now add another sampling interval to the previous figure to give you the location of

the third cluster. That is 19715+15,625 = 35,340 and so on.

6. In the case of blocks, as the number of blocks is less, and the number of clusters is

high, this process of placing 64 blocks this way will take a relatively long time. One

can use a mathematical formula for this.

If X is the number of clusters to be placed in the first block, then

Population of first block (approx) = random number + X*Sampling interval

Therefore X = (Population of first block – random number) / Sampling interval

For example, for deciding number of clusters in block A =

(250,000-4090)/15625 = 15.7

As we cannot have “incomplete/partial” clusters, only 15 clusters will be covered in

block A and the 16th cluster will fall under block B.

For Block B, we need to take the cumulative population.

(400,000-4090)/15625 = 25.3

This means 25 clusters. Of these 15 clusters have been covered under block A, this

leaving us with 25-15=10 clusters for block B (remember, the 400,000 was the

cumulative population for Block A & B. Therefore the 25 clusters are also cumulative.

Continue this for all 5 blocks.

B) Selection of Panchayats and the number of clusters therein.

1. The process is similar to block selection.

2. For each block, list the panchayats alphabetically, with their populations and

cumulative populations.

3. Remember, in this case, the number of clusters is not the complete 64, but the

number allotted to that block through the process under section A above. For block

A, we have to divide the total population of all the panchayats by 15, which is the

number of clusters falling in that block.

4. The rest of the process is same.

ix

5. As the number of panchayats in each block will, in all probability, be more than the

number of clusters, it means that many panchayats will not have any cluster

allocated to it. In case of larger panchayats, there may be more than one cluster

allocated to it. Hence step # 6 described above for blocks will NOT be helpful / apply

here.

C) Choosing households within a cluster

Ideally, one should stand in a middle of a cluster, randomly choose a direction, and start

walking in that direction and pick out households which meet our criteria.

However, in this case, the geographical spread even within a cluster will be relatively

vast and spread across revenue villages. Hence it is suggested that the interviewer start

with the largest revenue village, and search for households with potential respondents.

Once a village is over, she should move on to the next largest village in that very

panchayat. This also meets the requirements of PPS

Remember, we need 6 respondents (of each category) per cluster (see calculation above

for number of clusters). Once the PE (data collector) reaches that number, she should

stop collecting information for that particular respondent category.

It must be noted that owing to smaller available numbers for the second category (i.e.

women with a child less than 7 days old), PEs might have to move to a new village within

the panchayat for only that category, even though data collection for other categories

might be over.

It is also possible, that by the end of it, we may fall short of the 384 women per IP for

this category. Do NOT add a new panchayat area to make up for the reduced numbers,

as it will destroy the “randomness” of the sampling methodology. We will do with a

higher confidence interval for this indicator at the analysis stage if required.

x

Annex 5: Data Collection Tools (English version)

Tool for Mothers - English

Tools for Service Providers- English

xi

Annex 6: Data Collection Tools (translated into Hindi)

Tools for Mothers- Hindi

Tool for Service Providers Hindi

xii

LIST OF TABLES: TABLE 1: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF PROJECT POPULATION ............................................... 10 TABLE 2: DELAYED INITIATION OF BREASTFEEDING INCREASES NEONATAL MORTALITY (6) ......................................................... 14 TABLE 3: ISSUES ASSESSED THROUGH THE VARIOUS SURVEY INSTRUMENTS. ........................................................................... 21 TABLE 4: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF WOMEN RESPONDENTS ............................................. 26 TABLE 5: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF WOMEN RESPONDENTS ............................................. 27 TABLE 6: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF ALL THE WOMEN RESPONDENTS .................................. 27 TABLE 7: CASTE AND RELIGION WISE DISTRIBUTION OF WOMEN RESPONDENTS ACROSS DISTRICTS .............................................. 28 TABLE 8: CASTE AND RELIGION WISE DISTRIBUTION OF WOMEN RESPONDENTS ...................................................................... 29 TABLE 9: KNOWLEDGE OF WOMEN IN THE THIRD TRIMESTER OF PREGNANCY ABOUT IDEAL TIME FOR INITIATION OF BREASTFEEDING -

DISAGGREGATED BY DISTRICTS ............................................................................................................................. 30 TABLE 10: KNOWLEDGE OF WOMEN IN THE THIRD TRIMESTER OF PREGNANCY ABOUT IDEAL TIME FOR INITIATION OF BREASTFEEDING -

DISAGGREGATED BY IMPLEMENTING PARTNERS ....................................................................................................... 31 TABLE 11: TIME OF INITIATION OF BREASTFEEDING BY WOMEN WITH A CHILD LESS THAN 7 DAYS OF AGE – DISAGGREGATED BY

DISTRICTS ........................................................................................................................................................ 33 TABLE 12: TIME OF INITIATION OF BREASTFEEDING BY WOMEN WITH A CHILD LESS THAN 7 DAYS OF AGE – DISAGGREGATED BY

IMPLEMENTING PARTNERS .................................................................................................................................. 33 TABLE 13: KNOWLEDGE OF WOMEN WITH A CHILD LESS THAN 7 DAYS OF AGE ABOUT ADVANTAGES OF EXCLUSIVE BREASTFEEDING –

DISAGGREGATED BY DISTRICTS ............................................................................................................................. 36 TABLE 14: KNOWLEDGE OF WOMEN WITH A CHILD LESS THAN 7 DAYS OF AGE ABOUT ADVANTAGES OF EXCLUSIVE BREASTFEEDING –

DISAGGREGATED BY IMPLEMENTING PARTNERS ....................................................................................................... 37 TABLE 15: KNOWLEDGE OF WOMEN WITH A CHILD 3-4 MONTHS OF AGE ABOUT ADVANTAGES OF EXCLUSIVE BREASTFEEDING –

DISAGGREGATED BY DISTRICTS ............................................................................................................................. 37 TABLE 16: KNOWLEDGE OF WOMEN WITH A CHILD 3-4 MONTHS OF AGE ABOUT ADVANTAGES OF EXCLUSIVE BREASTFEEDING –

DISAGGREGATED BY IMPLEMENTING PARTNERS ....................................................................................................... 38 TABLE 17: KNOWLEDGE OF WOMEN (ACROSS TWO RESPONDENT CATEGORIES) ABOUT ADVANTAGES OF EXCLUSIVE BREASTFEEDING 39 TABLE 18: RESPONSES OF WOMEN (ACROSS TWO RESPONDENT CATEGORIES) ABOUT THE IDEAL DURATION OF EXCLUSIVE

BREASTFEEDING ................................................................................................................................................ 40 TABLE 19: KNOWLEDGE OF WOMEN (ACROSS TWO RESPONDENT CATEGORIES) ABOUT THE IDEAL DURATION (QUALITATIVE RESPONSE)

OF EXCLUSIVE BREASTFEEDING ............................................................................................................................. 42 TABLE 20: PRACTICE OF GIVING FOODS TO THE CHILD OTHER THAN BREAST-MILK, BY MOTHERS OF A CHILD LESS THAN 7 DAYS OF AGE –

DISAGGREGATED BY DISTRICTS ............................................................................................................................. 43 TABLE 21: PRACTICE OF GIVING FOODS TO THE CHILD OTHER THAN BREAST-MILK, BY MOTHERS OF A CHILD LESS THAN 7 DAYS OF AGE –

DISAGGREGATED BY IMPLEMENTING PARTNERS ....................................................................................................... 43 TABLE 22: PRACTICE OF GIVING FOODS TO THE CHILD OTHER THAN BREAST-MILK, BY MOTHERS OF A CHILD 3-4 MONTHS OF AGE –

DISAGGREGATED BY DISTRICTS ............................................................................................................................. 44 TABLE 23: PRACTICE OF GIVING FOODS TO THE CHILD OTHER THAN BREAST-MILK, BY MOTHERS OF A CHILD 3-4 MONTHS OF AGE –

DISAGGREGATED BY IMPLEMENTING PARTNERS ....................................................................................................... 44 TABLE 24: DURATION OF EXCLUSIVE BREASTFEEDING AS INFORMED BY MOTHERS WITH A CHILD 6-7 MONTHS OF AGE –

DISAGGREGATED BY DISTRICTS. ............................................................................................................................ 46 TABLE 25: DURATION OF EXCLUSIVE BREASTFEEDING AS INFORMED BY MOTHERS WITH A CHILD 6-7 MONTHS OF AGE –

DISAGGREGATED BY IMPLEMENTING PARTNERS. ...................................................................................................... 47 TABLE 26: REASONS GIVEN BY WOMEN ACROSS THREE RESPONDENT CATEGORIES FOR INTRODUCING FOOD SUBSTANCES OTHER THAN

BREAST-MILK IN THE CHILD’S DIET BEFORE 6 MONTHS OF AGE. ................................................................................... 48 TABLE 27: KNOWLEDGE AND INTENTION OF MOTHERS WITH A CHILD 3-4 MONTHS OF AGE REGARDING THE AGE / TIME FOR

INTRODUCTION OF COMPLEMENTARY FEEDING ........................................................................................................ 51 TABLE 28: STATUS OF INTRODUCTION OF COMPLEMENTARY FEEDING FOR CHILDREN 6-7 MONTHS OF AGE AND 12-13 MONTHS OF

AGE. ............................................................................................................................................................... 52 TABLE 29: STATUS OF INTRODUCTION OF COMPLEMENTARY FEEDING FOR CHILDREN 6-7 MONTHS OF AGE – DISAGGREGATED BY

DISTRICTS ........................................................................................................................................................ 52 TABLE 30: STATUS OF INTRODUCTION OF COMPLEMENTARY FEEDING FOR CHILDREN 12-13 MONTHS OF AGE – DISAGGREGATED BY

DISTRICTS ........................................................................................................................................................ 53 TABLE 31: STATUS OF INTRODUCTION OF COMPLEMENTARY FEEDING FOR CHILDREN 6-7 MONTHS OF AGE – DISAGGREGATED BY

IMPLEMENTING PARTNERS .................................................................................................................................. 53 TABLE 32: STATUS OF INTRODUCTION OF COMPLEMENTARY FEEDING FOR CHILDREN 12-13 MONTHS OF AGE – DISAGGREGATED BY

IMPLEMENTING PARTNERS .................................................................................................................................. 54

xiii

TABLE 33: DISTRIBUTION OF AGE AT WHICH COMPLEMENTARY FOOD WAS INTRODUCED (FOR CHILDREN CURRENTLY 12-13 MONTHS

OF AGE) – DISAGGREGATED BY IMPLEMENTING PARTNERS ......................................................................................... 55 TABLE 34: AVERAGE AGE OF CHILD (IN MONTHS) AT INTRODUCTION OF COMPLEMENTARY FEEDING – FOR A CHILD CURRENTLY 12-13

MONTHS OF AGE ............................................................................................................................................... 57 TABLE 35: AVERAGE AGE AT WHICH MOTHERS OF CHILDREN 6-7 MONTHS AND 12-13 MONTHS OF AGE, WHO HAVE NOT INITIATED

COMPLEMENTARY FEEDING, INTENT TO DO SO ........................................................................................................ 58 TABLE 36: DISTRIBUTION OF FREQUENCY OF COMPLEMENTARY FEEDING IN THE PAST 24 HOURS – FOR CHILDREN AGED 6-7 MONTHS

AND 12-13 MONTHS ......................................................................................................................................... 59 TABLE 37: AVERAGE FREQUENCY OF COMPLEMENTARY FEEDING IN THE PAST 24 HOURS – FOR CHILDREN AGED 6-7 MONTHS AND 12-

13 MONTHS ..................................................................................................................................................... 60 TABLE 38: AVERAGE QUANTITY OF COMPLEMENTARY FOOD EATEN BY THE CHILD IN THE PAST 24 HOURS – FOR CHILDREN AGED 6-7

MONTHS AND 12-13 MONTHS ............................................................................................................................ 63 TABLE 39: DISTRIBUTION OF THE VARIETY OF LIQUID OR SEMI-SOLID COMPLEMENTARY FOODS EATEN BY THE CHILD IN PAST 24 HOURS

– FOR CHILDREN AGED 6-7 MONTHS AND 12-13 MONTHS. ....................................................................................... 64 TABLE 40: NO. OF FOOD GROUPS FROM WHICH THE 12-13 MONTHS OLD CHILD ATE FOOD IN THE PAST 24 HOURS ...................... 65 TABLE 41: AVERAGE NUMBER OF FOOD GROUPS FROM WHICH THE 12-13 MONTHS OLD CHILD ATE FOOD IN THE PAST 24 HOURS ... 66 TABLE 42: STATUS OF AGE APPROPRIATE COMPLEMENTARY FEEDING FOR CHILDREN 12-13 MONTHS OF AGE .............................. 67 TABLE 43: CADRE WISE DISTRIBUTION OF THE SERVICE PROVIDER RESPONDENTS .................................................................... 69 TABLE 44: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF ALL THE SERVICE PROVIDERS ..................................... 69 TABLE 45: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF ALL FACILITY BASED SERVICE PROVIDERS (ANMS &

MAMTAS) ....................................................................................................................................................... 70 TABLE 46: DISTRICT AND IMPLEMENTING PARTNER WISE DISTRIBUTION OF ALL COMMUNITY BASED SERVICE PROVIDERS (AWWS &

ASHAS) .......................................................................................................................................................... 70 TABLE 47: KNOWLEDGE OF SERVICE PROVIDERS ABOUT TIMING OF INITIATION OF BREASTFEEDING ............................................ 70 TABLE 48: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE ADVANTAGES OF EARLY AND TIMELY INITIATION OF BREASTFEEDING ..... 72 TABLE 49: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE DEFINITION OF EXCLUSIVE BREASTFEEDING ...................................... 73 TABLE 50: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE IDEAL DURATION (IN MONTHS) OF EXCLUSIVE BREASTFEEDING............. 74 TABLE 51: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE DURATION OF EXCLUSIVE BREASTFEEDING (QUALITATIVE RESPONSES) ... 75 TABLE 52: KNOWLEDGE OF SERVICE PROVIDERS - AVERAGE DURATION OF EXCLUSIVE BREASTFEEDING AND AGE FOR INTRODUCTION OF

COMPLEMENTARY FEEDING ................................................................................................................................. 76 TABLE 53: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE ADVANTAGES OF EXCLUSIVE BREASTFEEDING ................................... 76 TABLE 54: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE IDEAL TIMING (IN MONTHS) FOR INTRODUCTION OF COMPLEMENTARY

FOODS ............................................................................................................................................................ 78 TABLE 55: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE IDEAL TIMING FOR INTRODUCTION OF COMPLEMENTARY FOODS

(QUALITATIVE RESPONSES) .................................................................................................................................. 79 TABLE 56: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE FREQUENCY OF COMPLEMENTARY FEEDING IN 24 HOURS, DEPENDING ON

THE AGE OF THE CHILD........................................................................................................................................ 80 TABLE 57: KNOWLEDGE OF SERVICE PROVIDERS – AVERAGE FREQUENCY (NO. OF TIMES IN 24 HOURS) OF COMPLEMENTARY FEEDING,

DEPENDING ON THE AGE OF THE CHILD .................................................................................................................. 81 TABLE 58: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE QUANTITY OF COMPLEMENTARY FEEDING IN 24 HOURS, DEPENDING ON

THE AGE OF THE CHILD........................................................................................................................................ 82 TABLE 59: KNOWLEDGE OF SERVICE PROVIDERS – AVERAGE QUANTITY (IN ML) OF COMPLEMENTARY FEEDING IN 24 HOURS,

DEPENDING ON THE AGE OF THE CHILD .................................................................................................................. 83 TABLE 60: KNOWLEDGE OF SERVICE PROVIDERS ABOUT THE VARIETY OF FOODS TO BE GIVEN TO THE CHILD FOR COMPLEMENTARY

FEEDING, DEPENDING ON THE AGE OF THE CHILD ..................................................................................................... 84 TABLE 61: OPINION OF SERVICE PROVIDERS WHETHER COUNSELLING ON IYCF IS A PART OF THEIR JOB DESCRIPTION ..................... 85 TABLE 62: PERFORMANCE OF SERVICE PROVIDERS ON IYCF COUNSELLING ............................................................................ 86 TABLE 63: PERFORMANCE OF SERVICE PROVIDERS RELATED TO CONDUCTING GROUP MEETINGS IN THE PAST 3 MONTHS TO DISCUSS

IYCF ISSUES. .................................................................................................................................................... 87 TABLE 64: PERFORMANCE OF SERVICE PROVIDERS RELATED TO UNDERTAKING HOME VISITS IN PAST 3 MONTHS TO DISCUSS IYCF

ISSUES. ........................................................................................................................................................... 87 TABLE 65: AVERAGE NUMBER OF GROUP MEETINGS AND HOME VISITS CONDUCTED BY SERVICE PROVIDERS IN PAST 3 MONTHS ....... 88 TABLE 66: PERFORMANCE OF SERVICE PROVIDERS RELATED TO COUNSELLING POSTPARTUM MOTHERS ON IYCF ISSUES IN PAST 3

MONTHS. ........................................................................................................................................................ 89 TABLE 67: OVERALL PERFORMANCE OF SERVICE PROVIDERS RELATED TO COUNSELLING ON IYCF ISSUES IN PAST 3 MONTHS ........... 90 TABLE 68: COMPARISON OF BREASTFEEDING INITIATION RATES BETWEEN DLHS-3 AND PRESENT STUDY .................................... 93 TABLE 69: COMPARISON OF EXCLUSIVE BREASTFEEDING RATES BETWEEN DLHS-3 AND PRESENT STUDY ..................................... 96

xiv

TABLE 70: COMPARISON OF COMPLEMENTARY FEEDING RATES BETWEEN DLHS-3 AND PRESENT STUDY ..................................... 98

xv

LIST OF FIGURES: FIGURE 1: CASTE AND RELIGION-WISE DISTRIBUTION OF WOMEN RESPONDENTS (OVERALL). .................................................... 27 FIGURE 2: COMPARISON BETWEEN KNOWLEDGE AND PRACTICE OF INITIATION OF BREASTFEEDING AFTER DELIVERY ....................... 35 FIGURE 3: KNOWLEDGE OF WOMEN (ACROSS TWO RESPONDENT CATEGORIES) ABOUT THE IDEAL DURATION (IN MONTHS) OF

EXCLUSIVE BREASTFEEDING ......................................................................................................................... 41 FIGURE 4: DURATION OF EXCLUSIVE BREASTFEEDING AS INFORMED BY MOTHERS WITH A CHILD 6-7 MONTHS OF AGE.................... 45 FIGURE 5: KNOWLEDGE AND INTENTION OF MOTHERS WITH A CHILD 3-4 MONTHS OF AGE REGARDING THE AGE / TIME FOR

INTRODUCTION OF COMPLEMENTARY FEEDING ................................................................................................ 50 FIGURE 6: DISTRIBUTION OF AGE AT WHICH COMPLEMENTARY FOOD WAS INTRODUCED (FOR CHILDREN CURRENTLY 12-13 MONTHS

OF AGE) – DISAGGREGATED BY DISTRICTS ....................................................................................................... 55 FIGURE 7: DISTRIBUTION OF QUANTITY OF COMPLEMENTARY FOOD EATEN BY THE CHILD IN THE PAST 24 HOURS – FOR CHILDREN AGED

6-7 MONTHS AND 12-13 MONTHS .............................................................................................................. 62 FIGURE 8: DISTRIBUTION OF THE VARIETY OF SOLID COMPLEMENTARY FOODS (SPLIT AS FOOD GROUPS) EATEN BY CHILDREN AGED 12-

13 MONTHS IN PAST 24 HOURS ................................................................................................................... 65

xvi

BIBLIOGRAPHY 1. District Level Household Survey - 3. IIPS. s.l. : Ministry of Health and Family Welfare, Government of India, 2007-08. 2. G Jones, et al. How many child deaths can we prevent this year? Lancet. 2003, Vol. 362, pg 65-71. 3. Gupta, Arun. Infant and Young Child Feeding - An "Optimal" Approach. Economic and Political weekly. 2006, August 26. 4. World Health Organisation. Global Strategy for Infant and Young Child Feeding. Geneva : WHO, 2003. ISBN 92 4 156221 8. 5. Alive and Thrive. Impact of early initiation of exclusive breastfeeding on newborn deaths. Insight - A&T Technical Brief. Washington : www.aliveandthrive.org, January 2010. 1. 6. Lutter, Dr. Chessa. Early Initiation of Breastfeeding - the key to survival and beyond. Family and Community Health, Healthy Life Course Project. s.l. : Pan American Health Organisation. 7. National Family Health Survey - 3. Mumbai : IIPS, 2005-06. 8. Mahmood SE, Srivastava A, Shrotriya VP, Mishra P. Infant feeding practices in rural population of north India. J Fam Community Med. 2012, Vol. 19, Pg 130-35. 9. Gupta A, Holla R, Dadhich JP, Bhatt B. World Breastfeeding Trends Initiative - Are our babies falling through the gaps? Delhi : IBFAN-Asia, 2012. ISBN: 978-81-88950-36-2. 10. JP Dadhich, et al. Managemet of breastfeeding. s.l. : National Neonatology Forum. 11. Dewey, Kathryn. Guiding Principles for Complementary Feeding of the Breastfed Child. Division of Health Promotion and Protection, Pan American Health Organisation. Washington DC : PAHO, 2002.

baseline study on iycf

Government & Nonprofit

x annex

world health organisation

project organogram

young child feeding

list of annexures

list of tables

list of figures

status of infant