2. Ensuring child survival and Development by Enhancing Optimal Infant and Young Child Feeding Practices State Advocacy Workshop, Punjab, 29 July 2013 Dr Arun Gupta Regional coordinator, International Baby Food Action Network (IBFAN) Asia, and member Prime Ministers’ Council on India’s Nutrition Challenges

3. Overview Context : Enhancing! And Why !! How to do is the key question Seven Strategies and facilitating factors. BREASTFEEDING GEAR MODEL Actions for Punjab: Immediate, medium and long term

4. The criticality of feeding practices is not just children are vulnerable, this time their brain develops very fast. Years of life Brain development Underweight (-2sd) NFHS-3 Over 60 million 1.7 million die by 5 years, 1.2 million during first year First Year is Critical!

5. National Norms of infant and young child feeding Initiation of breastfeeding within one hour of birth Exclusive breastfeeding for the first six months Timely and appropriate complementary feeding after six months along with continued breastfeeding till 2 years or beyond

6. Punjab Indicators (NFHS 3 - 2005-06)

7. Punjab Indicators DLHS 3 2007-08 Children under 3 years breastfed within one hour of birth44.6 Children age 0-5 months exclusively breastfed 32.4 Children age 6-9 months receiving solid/semi-solid food and breast milk 68.9

8. Deaths attributed to sub-optimal breastfeeding Public Health Nutr. 2006 Sep; 9(6): 673-85 Impact of NOT Following Recommended Norms 7

9. Impact of Following Recommended Norms Subjects who were breastfed experienced lower mean blood pressure and total cholesterol, as well as higher performance in intelligence tests. Prevalence of overweight/obesity and type-2 diabetes was lower among breastfed subjects 8

10. Facilitating factors Evidence based advocacy Political will Legislations to protect from commercial sector, Legislation for Maternity protection Workforce training Implementation at facility and community level Communication campaigns Research Monitoring and evaluation Coordination and multi-sector engagement (Advances in Nutrition 3, 790-800, 2012)

11. 12th Five year Plan, NRHM/ICDS Mission Commitments A comprehensive National Policy backed by resources Yearly Plan of Action National/State Breastfeeding and IYCF committees with nodal officers at state/district levels Enforcement machinery for IMS Act and resources. An empathetic and skilled health worker must support women at the time of birth, Skilled IYCF counselling centres in Health facilities in all district hospitals—and followed at CHC, PHC levels in a phased manner. Well trained workforce having problem solving skills for AWW, ASHA and ANM A network of Resource Centres on IYCF Strong Pre-service curriculum for doctors and nurses

12. Seven strategies How to Enhance Optimal Infant and Young Child Feeding Practices

13. PROTECTION Protecting mothers from Baby food companies, through existing IMS Act 1992/2003 Barrier: Violations of the Act continue

14. When Corporations Break the RULES at will !

15. Scientific Symposium on “Role of Nutrition during Pregnancy and Feeding of the LBW Infants, Organised by Nestle Nutrition Institute, 16 th March, 2013, Ludhiana Posters in A pediatric Clininc in Varanasi Feb’2013

16. Key Actions for Protection Appointing nodal officers at Distt and State through GO. Control over medical and health conferences that attract IMS Act. Awareness seminar for health workers and people

17. Promotion Information, campaigns, advocacy, health workers training and skilled counselling Barriers: Perceived insufficient milk, misinformation, promotion of formula milk

18. What is so critical? For milk ejection 3/4

19. What is promotion about Mothers motivation, building her confidence in her milk supply Perceived insufficient milk is the main reason to adopt artificial feeding Persuasion Support in first 72 hours is critical in health system

20. Key Actions for Promotion Campaigns in Punjabi Infant and young child feeding counselling centres in all health facilities Workforce is trained in skills right up to community level Building State’s capacity to deal with this load, resource centres in medical colleges GO to institutionalize “breastfeeding counselling as a service”

21. Support This means support at all levels of work Barriers: In adequate maternity protection

22. Key Actions for Support Implement the new National Food Security ordinance in its letter and spirit. “Promotion of exclusive breastfeeding for the first six months” 6000 Rs as cash incentive is linked to it. Bring a law to provide six months leave to all employees.( Private, Unorganised)

23. Education, research, monitoring, coordination Pre-service strengthening, Regular data review, qualitative research, review of programmes Barriers: Inadequate attention, lack of context, goals etc

24. Key actions Implement a strong pre-service module in all under graduate courses of doctors and nurses Set up a research committee and fund to carry out operational and other research Coordination mechanisms

26. The breastfeeding gear model for scaling up and sustainability of breastfeeding programs. Exclusive Breastfeeding 0-6 months and BF trends comparing Brazil and Mexico, observing below the program coordination and gear model of execution in these countries Perez- Escamilla et al. Adv. Nutr. 3: 2012. 25

27. Master Gear ! A State Committee with district level representation Coordination mechanisms Master gear fits well with each gear and synchronized at right place It sets the goals Monitors progress of policy and programmes every six months

28. Recommendations for Punjab Set up a state committee chaired by principal secretary HFW, and having all “gears” Assess policy and programmes ( all gears) to document baseline in 2013 and repeat 3-5 years to monitor trends. Launch a Punjab Specific Scheme /Initiative like “Punjab Programme for Protection and Promotion of Breastfeeding ” and monitor it twice a year with clear goals and objectives. Set up a machinery to implement IMS Act, like civil surgeon be nominated by GO.

29. Thank you !!