Vaatsalya- Kanani-2007-hospital based nutrition communication

!""#$"%&"‌ !""#$"%&" A Hospital Based Nutrition Health Communication Program

A Report of the Interim Assessment of the Program At Maharani Shantadevi Hospital By Shubhada Kanani and Smita Maniar A Program by:

Aarogya Center for Health-Nutrition Education and Health Promotion

January, 2005

!""#$"%&"‌ ""#$"%&" A Hospital Based Nutrition Health Communication Program

A Report of the Interim Assessment of the Program At Maharani Shantadevi Hospital By Shubhada Kanani and Smita Maniar

Counseling Team:

Smita Maniar Vaijayanti Deshpande Vibha Shah A Program by:

Aarogya Center for Health-Nutrition Education and Health Promotion

January, 2005

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Acknowledgements We appreciate the support of the Maharani Shantadevi Hospital for giving the permission to carry out the Vaatsalya program in their hospital. We acknowledge the continued support given by Dr. Athale. Dr. Bhide, Dr. Ambardar, Ms. Madhavi (Dietician), Mrs. Kiranben (Administration) and Dr. Deepti (Medical Officer of FWC) and other staff of FWC during the program. We are appreciative of the support of the Trust Board members of the MSH hospital who value our services and extend co-operation as needed.

We appreciate the continued support of our counselors, Ms. Vaijanthi Deshpande and Ms. Vibha Shah who regularly and effectively conducted the Vaatsalya counseling sessions and also carefully documented the qualitative and quantitative data. We also thank our Computer Assistant Ms. Sunita for data entry and preliminary analysis of the data.

Dr. Shubhada Kanani

Smita Maniar

Director, Aarogya

Program Coordinator, Aarogya

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Glossary of Terms Anda Bataka Bataka-pauwa Bhaji

Bhat Bhinda Cha Chamchi Chanadal Chikoo Dal Darakh Doodh-kela

Dudh Fulevar Gehu Ghee Ghutti

Guvar Kadhi Kathol

Kela Keri Khichadi Kodri Palak Pattervel-na-pan Phal Roti Sakhis Suva Tandalja Upma

Valor Vatki Vavding

Egg Potato A snack made from potato and rice flakes Green Leafy Vegetables Cooked rice Ladyfinger Tea Spoon Split Bengal gram Sapota A liquid pulse preparation Grapes Mixture of milk and banana Milk Cauliflower wheat Saturated fat A herbal medication Cluster beans A fluid made of sour buttermilk and bengal gram flour Pulses Banana Mango Pressure cooked mixture of rice and pulse A kind of millet Spinach Colocasia leaves Fruits Unleavened bread Friends A type of green leafy vegetable A type of green leafy vegetable A porridge-type snack made of semolina Broad beans Bowl A herbal medication

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INTRODUCTION For several decades now, the high prevalence of maternal mortality especially among pregnant and lactating women; low birth weight (LBW); and infant mortality continue to jeopardize the survival and quality of life of our women and children. The box below gives the disturbing scenario.

Some discouraging data o o o o o o

Pregnant women are 40 times more likely to die in India due to pregnancy or childbirth compared to women in a developed country.

Above 80% of women are anemic during pregnancy and breastfeeding periods One in every three infants is born weak; with low birth weight.

Many of them die before their first birthday.

Those who survive do not grow normally.

Children under two years do not get even 50% of the required food intake because parents do not know what to feed and how much, how often.

Although under the Reproductive and Child Health (RCH) program of the Government, the preventive and curative reproductive health and nutrition needs are met to some extent, the quality of the services provided leaves much to be desired.

Pregnancy and lactation care remains unsatisfactory with poor coverage; lack of attention to nutrition and virtually absent counseling of the women. Newborn care and infant feeding also requires attention. Improper feeding practices increase the risk of neonatal and infant mortality and morbidity. It is a known fact that the peaking of stunting and underweight during the period of 6 to 24 months (especially the 2nd year of life) is largely due to faulty breastfeeding and complementary feeding practices, aggravated by infections and poor health care.

The Challenge due to Rapid Urbanization The problem of rapid urbanization (especially in States such as Gujarat) is throwing up newer challenges, especially the growth of the slum population. The State of Gujarat has always been one of the most urbanized with 37.9 % of its population in urban areas. In Vadodara city, the total slum population in the Municipal Corporation limits is 8.21% of the total population of the city. The increasing number of slum dwellers calls for expansion and improvement of the existing urban basic services.

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Role of Health Institutions: Urban Hospitals as Institutions of Change It is believed that health institutions catering to pregnant and lactating women through antenatal (ANC) and postnatal (PNC) care can play an important role in reducing maternal undernutrition through adequate ANC services. Qualitative improvement of the existing ANC services in these institutions has the potential to reduce the LBW and improve the neonatal feeding practices, which would definitely have a positive impact on neonatal mortality and morbidity. Further, PNC would not only focus on the much neglected lactating mother, but also help promote desirable neonatal-infant feeding and care practices, so vital to reduce the prevalence of stunting and underweight in our country.

These institutions can act as health promoters rather than just providing curative and rehabilitative services to the community. The World Health Organization had, in 2002, mooted the concept of “Health Promoting Hospitals� and provided guidelines for enabling hospitals to become institutions of change.

Maternity Hospitals in Vadodara city In Vadodara city, maternity hospitals (especially those run by charitable not-for-profit institutions) and government run teaching hospitals draw a large number of poor women for pregnancy care and delivery of newborn from the slums and nearby rural areas.

Women hope for better quality care here. Approximately 4000-5000 deliveries take place in a year in each of these hospitals where above 50% of the women are from low socioeconomic groups. The primary aim of these hospitals is to give adequate curative and rehabilitative care. Due to the large in-flow of the women in these hospitals and pressing medical care needs, adequate attention is not given to counseling and communication of messages to address common health-nutrition related antenatal-postnatal problems such as poor dietary practices during pregnancy and lactation; poor weight gain during pregnancy; irregular iron supplementation; lack of utilization of contraceptive methods during lactation.

The pregnant and lactating women visiting these hospitals lack awareness regarding appropriate nutrition-health care for themselves and also of their newborns and infants such as feeding colostrum; exclusive breastfeeding till 6 months of age and so on. Thus, strengthening health-nutrition counseling and communication as an integral part of

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hospital care will greatly help in improving the nutritional status and health profile of the women with beneficial effects on the health and nutritional status of the newborns and the infants as well. This will particularly help the low income group families especially the uneducated or less educated.

Nutrition-Health Communication for Behaviour Change Qualitative improvement of hospitals includes strengthening of the nutrition- health education component in terms of improving the communication strategies for behavior change. Strengthening of the existing ANC services, especially in terms of effective Nutrition-Health Communication for Behavior Change (NHCBC) can go a long way in improving the nutritional profile of pregnant women. This in turn would be expected to have a beneficial effect on the birth weight of the newborn. Secondly, once the woman has delivered her child at the hospital,

the 3-4 days that she is in the ward is an

opportunity for empowering her and her attending relatives with valuable knowledge regarding newborn feeding and care, especially breast feeding and complementary feeding practices, hygiene and prevention of infections, management of common childhood illnesses.

However, the reality is different. In the crowded out-patient department (OPD) and the wards, the focus is on immediate needs like managing morbidities in women and taking care of a large number of deliveries. The shortage of staff and inadequate sensitization of the service providers regarding women’s needs make it very challenging and difficult to introduce and carry out counseling and nutrition-health communication services in hospitals. This is more so for areas considered less important or dispensable, such as advising adequately regarding maternal and child feeding and preventive health care.

And yet, counseling and communication towards favorable change in nutrition-health practices is critical in these hospitals, more so because many of them in urban and semiurban areas cater to the low-income families, who have traveled distances in the hope of getting better quality care compared to those available to them locally.

The !""#$"%&" Program of Aarogya Trust Aarogya, Center for Health-Nutrition Education and Health Promotion, a registered nongovernment organization (NGO) has initiated a program '!""#$"%&"

(Vaatsalya means

affection) based on Nutrition-Health Communication for Behavior Change (NHCBC) in

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two urban hospitals catering to low and middle socio-economic groups. The objective of the program is to improve antenatal care; postnatal care; newborn and infant care practices through a focus on behavior change communication.

The specific aim of this program is to educate pregnant and lactating women and their families to improve home based nutrition-health practices. It also aims to educate nurses and ayahs of the hospital who in turn will educate the women on antenatal-postnatal care and infant care practices as part of their routine work. Appropriate communication strategies occupy an important place in this program.

The !""#$"%&"

program was initiated in 2002 in Kalpana-Uma Hospital (KUH). The

strategy included weekly sessions with pregnant women and their family members wherein they were encouraged to practice certain key behaviors that will improve their own health; and the birth weight and health of their newborn and later, in infancy. Followup sessions were held to reinforce the messages. Simple and clear flash cards were used. Follow-up was also done in the wards post-delivery. Further, the nurses and aayahs were sensitized regarding the key practices related to postnatal care and infant feeding through periodic training workshops. These nurses and aayahs spread the nutrition-health messages among the pregnant women and their families while taking care of routine hospital activities.

After encouraging experiences in KUH, !""#$"%&" is being implemented in three phases at the Maharani Shantadevi Hospital (MSH), another hospital in the city catering to large number of pregnant and lactating women and infants from low and lower- middle income groups. The phases of the program are: Phase I: Situational Analysis: assessing the current situation as regards birth weight profile, and beliefs-practices of mothers related to nutrition.

Phase II: Designing and implementing Nutrition-Health Communication for Behavior Change strategies, in partnership with the hospital staff.

Phase III: Process and Impact Evaluation of the Program – assessing the approaches which work and the constraints and challenges of a hospital setting; as well impact of the NHCBC approach on practices of women and their families.

The detailed description of these phases follows.

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PHASE I: SITUATIONAL ANALYSIS Before beginning the program in the Maharani Shantadevi Hospital (MSH) in the year 2004, a rapid appraisal was conducted to understand the situation as regards the prevalence of low birth weight (LBW) and the existing knowledge, attitude and practices of pregnant and lactating women and their families as regards nutrition of women as well as the infants. The hospital keeps a database of all the births in the hospital including birth weight of the newborn, sex of the newborn, age of women, parity, time of enrollment for antenatal care (ANC) and regularity of ANC visits, expected due date and date of delivery.

Sample and Tools used for Situational Analysis A systematic random sample of 746 records from the last three years i.e. 2001-2003 was taken, approximately 250 records from each year. Data analysis was done using Epi-Info–604d package. Mean birth weight and prevalence of low birth weight (LBW) was estimated of the overall sample as well as by year. Further, effect of age of women, parity and time of enrolment (early or late) for ANC checkups on the mean birth weight and prevalence of LBW was also studied.

For assessing knowledge and practices regarding antenatal, postnatal care and infant feeding practices, semi-structured interviews (SSIs) were conducted with the mothers of the newborns who were admitted in the wards. Ten women were interviewed using the questionnaire given in Annexure 1. Since data emerging were similar, more interviews were not considered necessary. The qualitative and quantitative data obtained through these interviews were analyzed. Verbatim statements of the women were retained to illustrate their perceptions.

In-depth interviews were conducted with key personnel in the hospital and frequent visits were made to understand and observe the system of providing health-nutrition care to pregnant and lactating women in the hospital. The administrative superintendent, chief medical officer, the gynecologists, the nutritionists, the pediatricians, the head nurses and nurses attending to newborn were interviewed. The hospital has a Family Welfare Center (FWC) run by the Vadodara Municipal Corporation on its premises. The Medical

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Officer, Lady Health Volunteer and Family Health Workers of the center were also interviewed to understand their role in antenatal, postnatal and infant care.

Birth Weight of Newborns The mean birth weight of the newborns was 2.718 kg (Range: 1.000 kg to 4.150 kg; Median: 2.750 kg.) and was significantly (p<0.01) higher among boys (2.772 kg) as compared to that of girls (2.674 kg). There were no marked differences in the birth weights year wise. Considering the age of mothers, it was found that the mean birth weight of babies born to women less than 20 years was significantly (p<0.001) lower than the mean birth weight of babies born to older women (â&#x2030;Ľ 20y). Moreover, the mean birth weight of babies born to women delivering for the first time was significantly (p<0.001) lower than those delivering for the second or third or more time (Figure 1).

This was probably because many women delivering for the first time were less than 20 years of age.

Figure 1: Mean birth weight of newborns according to parity of the women

Mean Birth Weight(kg)

4 3.5 3

2.675

2.804

2.757

First

Second Parity of mothers

Third or more

2.5 2 1.5 1 0.5 0

The prevalence of low birth weight (LBW) was found to be 26.3% being higher among girls. Further, prevalence of LBW was also significantly high (p<0.001) for women less than 20 years of age (Figure 2). Considering the parity, the prevalence of LBW was higher in primiparous women as compared to others, but this difference was not significant statistically.

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Figure 2: Percent low birth weight of newborns according to age of mothers

Percentage LBW

50

45.4

40 30

23.2

22.9

20-30 y

>30 y

20 10 0 <20 y

Age of the women

Knowledge and Practices of Pregnant and Lactating Women Nutrition during Pregnancy Majority of the women consumed at least three meals a day during pregnancy. They either took cereal-vegetable or cereal-pulse combination in each meal. The women mentioned that they increased food intake during pregnancy. However, their daily meal pattern indicated that their food intake was less than adequate. Milk and fruit consumption was regular. Consumption of green leafy vegetables and pulses/ legumes was not regular.

Majority of the women reported consuming one iron tablet daily from second or third trimester of pregnancy. They were aware that iron supplementation provides strength and increases blood.

Weight Gain and Rest during Pregnancy Weight monitoring was regularly done and the women were aware that their weight was increasing regularly during pregnancy. They also mentioned that the purpose of weight monitoring was to indicate the growth and weight of the fetus and their own health status. To quote… o

Balak nu poshan barabar thaye chhe ke nahi te khabar pade” (We come to know whether the child is getting adequate nutrition).

o

“Balak no vikas khabar pade” (We come to know the growth of the child).

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Majority of the women reported that they rested in the afternoon during pregnancy.

However, they were not aware of benefits of taking rest during pregnancy.

Nutrition during Lactation Women reported increase in their food intake during lactation. They were aware that increasing food intake during lactation would increase breast milk and hence improve the health of the baby. However, only a few women mentioned the benefit of increasing food intake to their own health.

Various myths were prevalent regarding foods to be avoided during lactation. Some of them avoided vegetables such as ladyfinger, cluster beans and colocasia leaves. It was believed that they cause cough in the child.

Some women avoided sour foods,

particularly, lemon, curd, buttermilk and kadhi. This was more so among women who had stitches due to caesarian section delivery, as it was believed that sour foods prevent healing of the stitches.

Majority of the women were not aware about iron supplementation during lactation. Most of them believed that iron supplementation should be only during pregnancy. However, they mentioned that if prescribed by the doctors they would consume iron tablets during lactation.

Breastfeeding Majority of the women had fed colostrum to their newborns and had initiated breastfeeding as soon as possible after birth. Less than half of the women interviewed were aware that infants should be exclusively breast fed till 6 months. There were some women who believed that breastfeeding should be continued till 9 months-1½ years without giving any complementary foods. Some women were delivering for the first time, hence were not aware that till what age should the infant be exclusively breast fed.

When asked regarding breastfeeding the infant during illness, half of the women said that they would continue breastfeeding during illness. Some women mentioned that they would consult the doctor and then breastfeed during illness.

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Complementary Feeding Majority of the women were not aware of the age of initiation of complementary foods. Further, they were also not aware of the quantity

of

complementary

foods to be fed to infants 6-12 months

old.

mentioned initiated foods

The

that as

were

women

first

foods

complementary dal-water,

Box 1: Voices of women regarding Complementary Feeding o “6 mahine, ½-1chamchi dal-bhat aapvana.” o (When the child is 6 months old, ½ -1 spoon dal-rice should be fed) o “Cha-dudh aapvana. Khavay etalu khay” o (Should give tea, top milk. Child will eat as much as he/she wants) o “Balak bhukhyu thaye etele aapiye” o (We give when child feels hungry)

tea-

biscuit, dal-rice. The statements indicating their lack of awareness is mentioned in the Box 1.

Services provided by the hospital to pregnant and lactating women The overall system that emerged from the interviews with key personnel of the hospital and observations made during frequent visits to the hospital is highlighted below.

The pregnant women who are registered in the hospital visit the nutritionist usually twice before delivery. They are counseled in the local language (i.e. Gujarati or Marathi) regarding diet during pregnancy, keeping in view the socio-cultural background. Counseling of at least 10-12 pregnant women is done per day. Personal queries of the women are also addressed. Specific and ‘doable’ messages are given regarding nutrition during pregnancy. Since the hospital is a “Baby Friendly hospital”, it was reported that a lot of IEC material is used for counseling women on breastfeeding practices such as initiation as soon as possible, colostrum feeding and avoiding prelacteals; especially during the last trimester of pregnancy.

Hemoglobin (Hb) and other blood parameters are checked of the pregnant women at the time of registration. Antenatal visits are quite frequent and regular: once a month in first and second trimester and once fortnightly in last trimester. During the visits the gynecologists and supporting nursing staff monitor the weight; regularly do antenatal check-ups; and prescribe iron and calcium supplementation. Records are kept for each antenatal visit.

The hospital has a Family Welfare Center (FWC) of Vadodara Municipal Corporation, which provides Tetanus Toxoid vaccination and iron tablets to the pregnant women.

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The BCG vaccination of all the children born in the hospital is also taken care of by the FWC. Further, the lactating women regularly visit the FWC for other vaccines to be given to their children as well as for services related to family planning.

After delivery, the pediatricians and the nurses of the baby room give information on avoiding prelacteals, colostrum feeding and early initiation of breastfeeding. The womenâ&#x20AC;&#x2122;s stay at hospital post delivery is 2-3 days for normal delivery and 4-5 days for women undergoing caesarian section deliveries.

The postnatal visits of women are generally within a week or 15 days. The lactating women definitely come at 1-month post delivery during which free-check up is available to the infant. Women also come regularly for BCG immunizations (scheduled on fixed days of the month) and other immunization of their infants at the FWC as mentioned earlier.

The doctors and the hospital staff were quite cooperative in providing all the information needed to decide the strategy for implementation of the program.

Conclusions based on Situational Analysis The situational analysis was very informative as regards knowing the nutritional status of the women and the infants; assessing their current knowledge and practices, understanding the current services of the hospital for pregnant and lactating women, especially the role of the nutritionist, the doctors, nurses, FWC and other staff. It was found that nutritional care and advice during antenatal period and early neonatal and breastfeeding practices are already being addressed at the hospital in the OPD and the wards through the hospitalâ&#x20AC;&#x2122;s nutritionist.

Hence, it was decided that the !""#$"%&" program would focus on the postnatal and infancy period so as to complement the ANC counseling already been given. The !""#$"%&" program would support the services currently given at the hospital and importantly, increase awareness and encourage behavior change among lactating women and their families with regard to their own nutrition and the nutrition-health of their infants. It would ensure that the messages are gender-sensitive and encourage family support of the women.

The details of the implementation of the program are described in the next section.

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PHASE II: IMPLEMENTATION OF THE PROGRAM Apart from reviewing the existing situation, an appropriate need-based and feasible strategy should be first planned and then implemented, for any program to have a measurable impact on nutrition-health related behaviors and ultimately on the health and nutritional status of its beneficiaries. On the basis of the situational analysis as said earlier, it was decided that the !""#$"%&" program would focus on postnatal nutrition and infant care. The program is gender sensitive and hence nutrition of lactating woman is stressed upon for her own sake and not simply because she is breastfeeding.

Behavior change is possible if the communication is focused on highly critical behaviors.

Hence, a list of critical behaviors regarding postnatal nutrition, breastfeeding and complementary feeding was prepared. These behaviors were selected based on the following criteria.

o o

The behaviors, which are recommended and those which have been well documented to have impact on the health-nutritional status of lactating women and infants.

The behaviors, which are feasible or possible to be practiced by the women.

A sample of these behaviors is given in Box 2 on next page.

A counseling guide has been developed which includes the following components:

o Message containing critical behaviors; o the motivating factors to accept encourage acceptance of the behaviors and o the possible resistances that the women might face while practicing the behaviors (Annexure 2).

It has been established that behavior change is not possible unless supported by the family members. Hence, a list of supportive behaviors for the family members such as mothers or mothers-in-law or husband of the lactating women is also included it in the counseling guide. Counseling of the family members would encourage them to support the lactating women to practice the recommended behaviors.

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Box 2: The Behaviors Emphasized during Communication Sessions with Lactating Women and their Family Members- An Example Postnatal Nutrition o Increase quantity and improve quality of food intake during lactation One extra food item daily e.g. 1 roti or 1 vatki dal-bhat or 1 vatki kathol or 1 vatki upma or bataka-pauwa Include daily one fruit (any seasonal fruit) Include 1 vatki bhaji daily in your diet.

Drink adequate amount of water/ liquids. o Consume daily 1 iron-folate tablet after meals Lactating women should consume iron tablets for at least three months after delivery.

Later, consume at least one tablet per week till menopause.

Breastfeeding o Exclusive breast feeding up to 6 months without water or any other fluid Breastfeed 8-12 times during the day.

Do not give prelacteals or any other fluids i.e. ghutti, honey, gripe water, herbs.

Do not give water.

Do not give top milk or top foods. o Empty one breast fully before switching to the other. o Breast-feed the infant during illness of either mother or infant

Detailed plans of the communication session for both the initial and the follow-up visits have been designed. These session plans help the counselors to be focused during the sessions. The question guides needed to elicit information on the perceptions and practices of the women - both at the time of initial and follow up visits - have been included to record the qualitative and quantitative information obtained. Annexure 3 gives a sample of the data recording sheet of quantitative variables. The qualitative information is recorded as field notes.

The Overall Strategy The overall strategy (Figure 3) which aims at improving maternal nutrition during lactation and infant feeding includesâ&#x20AC;Ś Bi-weekly counseling session in the ward and Out Patient Department (OPD) with lactating women and their family members to make women aware of critical behaviors regarding postnatal nutrition and infant feeding; and to encourage them to practice these behaviors.

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Follow-up sessions with the same women and their family members within 2-4 months after the first session to reinforce critical infant feeding messages and to record whether women could change their behaviors.

Attempts are being made to counsel the women at least twice. Almost one-third of the women have paid 2 visits to !""#$"%&" and about 5-10% of the women visited three or more times. Counseling is carried out by a pair of !""#$"%&" sakhis. One of them counsels the women and the other records information obtained.

Figure 3: Nutrition-Health Communication for Behavior Change The Overall Strategy Lactating Women and Family members counseled VISIT 1: INITIAL VISIT

In Wards (Women admitted after delivery)

In OPD of the hospital (Women visiting the pediatrician or FWC for immunization of infant)

VISIT 2: FOLLOW UP VISIT

In OPD of the hospital (Women visiting the pediatrician or FWC for immunization of infant) VISIT 3 OR MORE: FOLLOW UP VISIT In OPD of the hospital (Women visiting the pediatrician or FWC for immunization of infant)

Emphasis on Communication Focussed Message: During the counseling sessions, the counseling guide is used to emphasize critical specific messages (Annexure 2). In the sessions the benefits of each behavior that the women are asked to practice are highlighted and their

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resistence (anxieties, beliefs), if any, are addressed. Although all the behaviors in the list are important, counseling is focused on most relevant behaviors during each session. For example, during our sessions with the lactating women admitted in the wards immediately after delivery, the behaviors regarding postnatal nutrition and breastfeeding are focused upon and not of complementary feeding. The behaviors related to complementary feeding are emphasized during the subsequent communication session in the OPD when the women come for postnatal checkup or immunization of their infants.

Including primary and secondary audience in counseling: Realising the importance of family support, the family members are also a part of the counseling process and are informed of the various ways in which they could support the women to practice the critical behaviours.

Use of visuals: The counselors use colorful and relevant flashcards to emphasize key aspects of each critical behavior. The pictorial representations of the behaviors help in catching attention of women and help them to remember the messages later at home.

Multiple channels: It is known that the messages should be given through various channels and be reinforced to be effective. In this hospital, the pediatrician, the nutritionists and !""#$"%&" team members continuously reinforce the critical infant feeding messages along with messages related to the postnatal care.

Take home messages: Aarogya has developed a guidebook entitled â&#x20AC;&#x2DC;Healthy Mother, Healthy Child: A Nutrition Guidebook for the Mother and the Childâ&#x20AC;&#x2122;, in the local language, Gujarati. This is distributed among the women who are counseled in the wards or the OPD for the first time. This guidebook is not only a tool to transmit consistent and uniform messages among women counseled under the !""#$"%&" program, but also serves as a motivator and a reminder to the women to practice the behaviors at home.

Documentation of the Program: The counselors record the qualitative and quantitative information pertaining to the perceptions and practices of the women obtained during each session with the women on simple formats.

o Qualitative data: The information obtained from the field notes taken during the sessions are categorized in broad themes and sub-themes based on the behaviors addressed during the counseling. These are then summarized in the form of a report. Weekly or fortnightly session reports thus prepared include

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mainly qualitative information obtained regarding postnatal nutrition and infant feeding practices. Separate reports are prepared for women counseled in wards and OPD; as well as for Visit 1 sessions and Visit 2 sessions. The reports document our progress and inform us about the changes in the awareness and practices of women after our counseling.

o Quantitative data: The quantitative information recorded on the data sheets is coded and entered into the computer using statistical package EpiInfo-6.04d.

These data are analyzed periodically to evaluate the impact of the program.

Thus, the counseling process is continuously evaluated and modified as required. The changes made in the process are also documented in the reports. Periodic review meetings are organized for the counselors and recorders with senior nutritionists and communication experts to discuss the progress, communication process and revise if needed.

The periodic reports on documented qualitative and quantitative information also help to inform the hospital authorities about the progress of the program â&#x20AC;&#x201C; the benefits of the program to the beneficiaries and the support received from them to implement the program.

RESULTS OF THE INTERIM EVALUATION OF !""#$"%&"( !""#$"%&"( While on an ongoing journey, it is desirable to pause, assess, analyse and reflect on the activities undertaken and the direction ahead. With this view, we undertook an interim assessment of the Vaatsalaya program for the year 2004, which consisted of analysis of perceptions of women during Visit 1 and impact of our counseling as assessed in visit 2.

The Initial Visit (Visit 1) of the Womenâ&#x20AC;Ś..

Profile of the Participants During the year, 643 women were counseled (295 women in wards and 348 women in OPD) for the first time (Visit 1). Majority of the women enrolled in the program had delivered for the first time (62%). Some of them had delivered for the second time (32%)

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and very few for the third time or more. Further, majority of the women (95%) had normal deliveries.

Almost equal number of boys and girls were represented as indicated in the Table 1.

Majority of the infants of the women counseled were in the age group of 0-5 months.

Table 1: Profile of the Women !""#$"%&"((Beneficiaries and their Infants Parameter

Parity of the women I II III or more Type of delivery Full term Pre-term

OPD (N=348)

Ward (N=295)

n

%

206 123 19

59.2 35.3 5.5

328 20

94.3 5.7

OPD (N=348) Sex of infants Boys Girls Age group 0-5 months 6-12 months

n % Number of Women 190 82 23

64.4 27.8 7.8

281 95.3 14 4.7 Number of Infants Ward (N=295) n %

n

%

196 152

56.3 43.7

156 139

288 60

82.8 17.2

295 0

Total (N=643) n

%

396 205 42

61.6 31.9 6.5

609 34

94.7 5.3

Total (N=643) n

%

52.9 47.1

352 291

54.7 45.3

100.0 0

583 60

90.6 9.4

The women counseled at !""#$"%&"((were mainly accompanied by their mothers (37%).

Some women were accompanied by their husbands or the mothers-in-law or sisters-inlaw. In the OPD, the women are mainly directed by the staff of the FWC to visit the !""#$"%&" counseling center; the pediatrician of the hospital directs the others.

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Anthropometric Measurements of the Infants Birth weights of the infants The current weight of the infants at the time of enrolment in !""#$"%&" was recorded and also their birthweights (as mentioned in the baby card) were recorded. In all, anthropometric data of 591 infants was available out of the 643 enrolled. As shown in Table 2, the mean birth weight of the infants enrolled was 2.60 kg. The birthweight of the girls was significantly (p<0.01) lower than of boys.

Table 2: Mean Birthweight of the Infants Enrolled Mean Birth Weight ± SE

T-value

Sex of the child Boys (N=324) Girls (N=267)

2.83 ± 0.02 2.74 ± 0.01

2.77 S**

Total

2.60 ± 0.23

NS: Non-significant, S*: Significant at p<0.05, S**: Significant at p<0.01, S***: Significant at p<0.001

Prevalence of Low Birth Weight As Table 3 indicates that the prevalence of low birth weight (LBW) among the infants enrolled was 19%. The prevalence of LBW was significantly (p<0.05) higher among girls as compared to boys. Among those enrolled in OPD and ward, the prevalence of LBW was similar (19%). The prevalence of LBW had no correlation with the parity of the mother.

Table 3: Prevalence of Low Birth Weight (LBW) Among Infants Enrolled Parameter

Sex of the child Boy (N=324) Girl (N=267) Place of counseling OPD (N=339) Ward (N=252) Parity First Child (N=358) Two or more children (N=233) Total (N=591)

Vaatsalya, Aarogya 2005

Normal Weight

Low Birth Weight

M-H-Chisquare value

n

%

n

%

274 205

84.6 76.8

50 62

15.4 23.2

5.7 S*

204 275

81.1 81.0

64 48

18.9 19.0

0.0 NS

283 196

79.1 84.1

75 37

20.9 15.9

2.36 NS

479

81.0

112

19.0

20

Weight of the Infants at Enrolment Table 4 shows the mean weights of the infants at the time of enrolment. As expected, infants enrolled in the OPD had significantly (p<0.001) higher mean weight as compared to those enrolled in the wards, the reason being those enrolled in OPD were older than those enrolled in wards. The infants were enrolled in wards within 2-4 days after delivery. Comparing the sex of the infants, the mean weight of girls was significantly (p<0.01) lower than that of boys, perhaps because their birth weight was lower to begin with.

Table 4: Mean Weight of the Children at Visit 1 (at enrollment) Mean Weight ± SE

T-value

Sex of the child Boys (N=324) Girls (N=267)

3.93± 0.12 3.55± 0.09

2.6 S**

Place of counseling OPD (N=339) Ward (N=252)

4.50± 0.11 2.79± 0.03

Total (N=591)

3.75±0.07

13.3 S***

NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S***: Significant at p<0.001

Prevalence of Underweight at Enrolment About one-tenth of the infants enrolled (Visit 1) were underweight (Weight for Age Zscore-WAZ- <-2.0 SD) with the highest prevalence among 6-11 months old (20%). The prevalence of underweight was not significantly different among the two age groups; among the boys and the girls; or among those enrolled in OPD and in ward (Table 5).

Table 5: Percent Children Underweight* at Visit 1 (at enrollment) Parameter

Age group of infants 0-5 months (N=535) 6-11 months (N=56) Sex of the child Boys (N=324) Vaatsalya, Aarogya 2005

Normal Weight n %

Underweight n %

M-H-Chi square Value

476 45

89.0 80.4

59 11

11.0 19.6

3.60NS

286

88.3

38

11.7

1.01NS 21

Parameter

Normal Weight n %

Underweight n %

M-H-Chi square Value

Girls (N=267) 235 88.0 32 12.0 Place of counseling OPD (N=339) 297 87.6 42 12.4 0.23NS Ward (N=252) 224 88.9 28 11.1 Parity First child (N=358) 314 87.7 44 12.3 0.17NS Two or more children 207 88.8 26 11.2 (N=233) Prevalence of LBW LBW (N=112) 55 49.1 57 50.9 201.46S3 Normal Birth weight (N=479) Total (N=591) 521 88.2 70 11.8 *Normal weight = â&#x2030;Ľ -2.00 WAZ; Underweight= <-2.0 WAZ NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S3: Significant at p<0.001 As indicated in Table 5, the prevalence of underweight infants was also compared with parity respect to and LBW. The prevalence of underweight was not affected by the parity of the mothers. The mothers with more than one child had mostly two children. Half of the infants who were LBW babies were underweight; significantly highter (p<0.001) as compared to the infants born with normal weight. Overall, about one-tenth of the infants were underweight at the time of enrollment.

Considering the IAP classification (Table 6), the prevalence of underweight was about one-third (28%) among the infants enrolled in the program. Further, there was no significant difference in the prevalence of underweight (â&#x2030;¤80% NCHS Standard) among the two age groups; and among the boys and the girls enrolled. Overall, considering the IAP classification the prevalence of underweight at the time of enrollment; was higher than as compared to the percentage of underweight considering <-2.0 WAZ.

Vaatsalya, Aarogya 2005

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Table 6: Percent Children Underweight* at Visit 1 (At Enrollment) Parameter

Normal Weight n %

Underweight n %

M-H-Chi square Value

Age group of infants 0-5 months (N=535) 6-11 months (N=56) Sex of the child Boys (N=324) Girls (N=267)

386 40

72.1 71.4

149 16

27.9 28.6

0.01NS

239 187

73.8 70.0

85 80

26.2 30.0

1.01NS

Total (N=591)

426

72.1

165

27.9

*Normal weight = > 80% of NCHS Standard; Underweight= ≤ 80% of NCHS Standard.

NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S***: Significant at p<0.001

Perceptions and Practices of the Women at the time of Visit 1 (At Enrollment) o Nutrition During Lactation Quantity of Food Intake during Lactation A majority of the women (67%) had increased their food intake during lactation (Table 7). The women stated that during lactation they consume more food as compared to usual intake, or intake during pregnancy.

o “Pregnancy ma khati hati tevu vadhare khau chhu.” (I am consuming more as I used to consume in pregnancy.)

o “Pahela karta vadhare khau chhu.” (I consume more food than before.)

The main reason stated for increasing food intake was to increase breast milk production. o

“Jo chokru dhavashe etle vadhare khau to padshejne” (Since child will be breastfeeding, naturally we have to eat more.)

o

“Main jyada khaungi to hi mujhe jyada dudh aayega na!” (If I consume more then only my breast milk will increase.)

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Table 7: Practices regarding Quantity of Food intake during Lactation

Food intake during lactation as compared to normal status Has increased Has decreased Remained the same No response/ No idea

OPD (N=348) n % 232 66.7 31 8.9 83 23.9 2 0.6

Ward (N=295) n % 200 67.8 17 5.8 71 24.1 7 2.4

Total (N=643) n % 432 67.2 48 7.5 154 24.0 9 1.4

The elderly female family members of women also mentioned that the women should consume more mainly for increasing breast milk production. To quote a mother-in-law and a mother of lactating women…. o

“Chokrane dhavan aapvanu to khorak vadharvanoj ne.” (Since the child has to be breastfed, food intake should be increased.)

o

“Haave toh be pet thaya – baba nu pet ane manu pet. Etle vadhare khavanu.”

(Now, two stomachs have to be filled – child’s stomach and mother’s stomach.

So, food intake should be increased.)

Further, some women believed that they should increase food intake for better growth and development of their infants. o

“Chokrane sari rite poshavanu hoi to vadharej khau pade ne!” (If we want to provide adequate nourishment to our child, we have to eat more!)

Some women mentioned that since they were breastfeeding their appetite had increased, hence they eat more. o

“Pushkal Khate. Breast feeding karavate mhanun bhuk pan khup lagte.” (I eat a lot. Since I am breasting, my appetite has increased.)

About one-fourth of the women did not increase or decrease their food intake during lactation as indicated in Table 7. Many of these women were overweight even after 2-3 months post delivery, hence they felt that if they increased food intake their weight would further increase. o

“Charbi vadhare chhe etle nathi khati” (Since I am fat I do not eat more.)

The family members of these women also corroborated that the women do not increase food intake due to weight consciousness. To quote…

Vaatsalya, Aarogya 2005

24

o

“Jadi thayi jay etele nathi vadharti” (She [lactating woman] does not eat as she believes that she would become fat.)

Another reason given for not increasing food intake was excessive breast milk production leading to discomfort to mother and the child could not suckle. o

“Jyada nahi khati kyonki jyada khane se jyada dudh banata hai aur ye to pi nahi pati pressure ki vajah se. Gathiya ban jati hai.” (I don’t consume more since increased food intake lead to increase milk production and due to pressure she cannot suckle properly. Hence, lumps get formed.)

o

“Hu vadhare khau, to dudh bahu bharai jay ane chhati tight thai jay. Pacchi chhokra ne dhavta na phave ne? Etale limited j khavanu.” (If I eat more, breast milk accumulates and breasts become tight. Then, how can the child suckle? Hence should eat only limited food.)

Some women also believed that excessive food intake would make the infant fall ill. o

“Chokru bimar pade, hu vadhare khau to.” (If I eat more, child would fall ill.)

o

“Main jyada khaungi to bache ko julab nahi hoga?” (If I consume more food, won’t the child suffer from diarrhea?)

Among the women who were visited in wards immediately after delivery, the food intake had not increased due to various reasons. These included…

♣ Recently delivered hence due to pain of delivery their food intake had not increased. o

“Kachi suvavad chhe, etle hamna vadhare na khavay.”(As I have recently delivered, I cannot eat more at present.)

♣ Caesarian section delivery hence light diet in the needed initial days after delivery. o

“Caeser hai to jyada kha nahi sakti.” (Since it was cesarian section delivery, I cannot eat more.)

o

“Khavatu nathi, tankane lidhe dukhe chhe.” (I cannot eat, as due to stitches it pains a lot.)

♣ Dislike towards food made in the hospital.

“Dawakhana nu khavanu bhavtu nathi, etle ochhu khavay chhe.” (I do not like the food served in hospital, so I consume less.)

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25

♣ Indigestion and heaviness in stomach. o

“Vadhare khau, to pet bhare thai jay.” (If I eat more, I feel heaviness in the stomach.)

o

“Apacho thai jaye chhe etele khati nathi vadhare.” (I do not eat more as it leads to indigestion.)

A few women (8%) had decreased their food intake mainly due to lack of appetite, nausea and lack of time or attention towards their own health. o

“Bhukh nathi lagti. Khavatu nathi” (I do not feel hungry. I cannot eat.)

o

“Vadhare khavanu man nathi mantu.” (I donot feel like eating more.)

o

“Vadhare nathi khavatu, ubka ave chhe.” (Due to nausea I cannot eat more.)

o

“Marathi potani kalgi, khorak ma dhyan nathi rahetu, etle mane thay chee ke maru dudh ochu aavechhe” (I cannot take care of myself and my diet so I feel my milk production has decreased.)

o

“Time nahi hai isliye. Ghar me koi nahi hai to ye sone ke bad gharka kam karti hu.” (I do not get time. There is nobody in the house, so when my child sleeps I do the household work.)

On the other hand, a few women were uncertain whether to increase or decrease food intake during lactation. They wondered whether increasing food intake increases breast milk production. o

“Kya ye sach hai ki hum jyada khayenge to jyada dudh aayega?”(Is it true that if we consume more food, then milk output will be more?)

When the women and their family members were informed during the counseling that food intake should be increased during lactation and that it is beneficial for both the mother and the child, they were grateful to receive the information. o

“Paheli pregnancy me maine jayda nahi khaya tha, to dudh hi nahi aaya. Achha hai apne yeh samjaya.” (During my earlier pregnancy, I had not consumed more hence breast milk was not produced. It’s good that you explained this.)

Similarly, to quote a family member…. o

“Saru thayu tame vadhare khavanu samjavyu, te to vajan vadhi jay, etle vadhare khatij nathi.” (It is good that you [the counselor] have explained about increasing diet during lactation, she is worried that her weight will increase hence she does not eat more food)

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26

Quality of Food Intake during Lactation About one-half of the women mentioned that they would avoid certain food items during lactation (Table 8).

Table 8: Myths regarding Food Intake during Lactations

Will avoid certain foods during lactation Yes No No response/ No idea

OPD (N=348) n % 166 47.7 118 33.9 64 18.4

Ward (N=295) n % 132 44.7 105 35.6 58 19.7

Total (N=643) n % 298 46.3 223 34.7 122 19.0

The women mainly avoid certain vegetables such as lady finger (bhinda), runner beans (valore), cluster beans (guvarsing) , cauliflower (fulevar), potatoes (bataka), other beans (papdi) , colocassia leaves (pattarvelna paan) or amaranth leaves (tandaljo). They believed that these vegetables cause diarrhea, gastric trouble, indigestion and varadh (a form of chest infection that causes severe cough) in the child. To quote… o

“Gawar, valor thi chokra ne gas thai jaye.” (Consuming cluster beans causes gas in the child’s stomach.)

o

“Bataka thi gas thay” (Potatoes causes gas/flatulence.)

o

“Tandalja ni bhaji khay toh balak ne varadh thay.” (If tandalja is consumed, child suffers from severe cough.)

o

“Mu fulevar khadhi toh baba ne aakhi raat jhada thaya.” (When I ate cauliflower, my child suffered from loose motions the whole night.)

These beliefs regarding various vegetables were also prevalent among the family members of the women, especially elderly female family members. To quote.. o

“Hari sabjiya agar ma khati hai to bachhe ko varadh ho jati hai. Isliye khali suva ki sabji deti hu.” (If lactating woman consumes green leafy vegetables, her child will suffer from diarrhea. Hence I give only Shepu leaves to her.)

o

“Pana na bhajia haju na pache, etle na aapiye.” (Lactating woman cannot digest Pana na bhajia [a fried snack made from Bengal gram flour and collocasia leaves] , so we don’t give.)

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27

Some women avoided sour foods such as curds and food items prepared from sour curds. They believed that consuming sour foods causes pus in the stitches taken post delivery; and it causes cold and cough in the child. A few women were not aware of the reason for avoiding sour foods; they avoided themsince elders in the family do not allow them to consume them. o

“Khatash nahi khavanu, sasu kahe chhe” (I do not eat sour foods because mother-inlaw says so.)

o

“Bade log dahi kadhi detej nahi hai bache ko shardi hoti hai.” (Elders do give curd and kadhi [a fluid preparation made from sour curd and bengalgram flour], it causes cold to the child.)

o

“Operation chhe etele khatu nahi khavanu.” (Since I have got operated [C-section delivery], I do not consume sour foods.)

Further, due to caesarian section delivery various foods were avoided such as rice, ghee, and fried foods. These are believed to be harmful. The women did not know what the adverse effects were. o

“Caesarian me tala aur ghee nahi khate” (Due to caesarian section delivery, fried foods and ghee [clarified butter] are avoided.)

o

“Operation karyu chhe, etle bhat nathi khati.” (Since I have undergone caesarian, I do not consume rice.)

The above responses were mainly from women admitted in the wards. Whether they continue avoiding these foods after discharge from hospital is not known; even the women themselves were not aware what they would eat and what they would avoid after going home from the hospital. o

“Ghare jaine mummy je aapshe te khaish etele mane khabar nathi ke badhu khavay ke nahi.” (After going home, I would eat whatever my mother serves me so I do not what I can eat and what I cannot.)

Various fruits were also avoided such as grapes (draksh), sapota (chiku) and banana (kela). The women avoid these mainly since the elders do not allow them to eat them. A few women mentioned that these fruits are considered ‘cold’ and cause cough-cold in the child.

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28

o

“Mara sasu mane darakh na didhi. Mane khaber chhe ke badhu khavay pan khava de to ne!” (My mother-in-law did not allow me to eat grapes. I know everything can be eaten but I was not allowed to eat.)

o

Gharwale kahe chhe ke fruits nahi khavanu, thandu pache.” (Family members say that fruits shouldn’t be consumed, they are ‘cold’.)

o

“Thandi chije jaise kela khau to bacha chhinkta hai.” (If I consume ‘cold’ items such as banana then the child sneezes.)

A few women avoided mangoes, as they are believed them to be ‘hot’ and cause diarrhea in infant. o

Garma-garam chij, keri- khane se bachhe ko nuksan karata hai.” (Consumption of ‘hot’ foods such as mangoes harms the child.)

o “Aam khane se loose motions hote hai.” (Consuming mangoes causes loose motions in the child.)

Some women avoided certain pulses and legumes such as bengal gram, bengal gram dal and red gram dal. These were also believed to cause indigestion, flatulence and diarrhea in the child. o

“Dal thi jhada thay. Roj na khavay.” (Pulses cause diarrhea. It should not be consumed daily.)

o

“Chanadal digest thavama bhare chhe hoon touch pan karti nathi. Mane bik laage chhe kai chokrine thai jase.” (Bengal gram dal is difficult to digest, so I don’t even touch it. I am scared that it will harm my daughter.)

The female family members of the women also believed that these dals should be avoided. o

“Tuver ni dal na apiye. Balak ne pet ma dukhe.” (Red gram dal is not being served to the lactating women. Child suffers from stomachache.)

Some women avoided wheat and rice. The main reason for avoiding rice was that it was believed to cause indigestion and wheat was avoided since it was believed to cause stomachache in the mother or the child. Further, some women consumed only soft foods especially a type of millet boiled in water (kodri) for 1-2 months after delivery. They believed that consuming soft foods helps to make the flow of breast milk easier and hence it is easier for the child to breastfeed. The elderly family members also mentioned

Vaatsalya, Aarogya 2005

29

that they do not allow lactating women to consume any ‘hard’ food items and serve only ‘soft’ foods. o

“Badha kahe chhe ke bhat nade ane gas kare, etale kodri khau chhu.” (People say that rice is harmful and can cause gastric trouble, hence I consume kodri [a type of millet])

o

“Gehu khane se pet me dard hota hai. Chikna hota hai na isliye.” (Since wheat is sticky, if I consume wheat, my stomach pains.)

Many women believed that if they have a boy child, a lot of foods would be harmful but if they have a girl child nothing would be harmful. Hence, certain foods are avoided only when the women has delivered a boy child. o

“Beti hai to sab kuch kha sakte hai, lekin beta hai our gehu khaye to bete ko nahi pachta.” (I can eat everything if I have a girl child but since I have a boy child I cannot consume wheat as my son cannot digest it.)

o

“Babo chhe etale bhinda-gawar nade, baby hoi to evu badhu khavay” (Lady finger and cluster beans can harm the baby boy, but if the child is female, I can consume these foods.)

o

“Mane chokri chhe to hu badhuj khau chhu. Pan chokro hoi to nade.” (I have a girl child so I consume everything but these could be harmful for male child.)

Further, some women had no idea whether to consume all food items or avoid certain food items. They believed whatever their elders say. Some of them asked the counselors during the sessions whether they could consume various foods items, especially the non-vegetarian food items. o

“Anda kha sakte hai?” (Can I eat eggs?)

o

Non-veg khay to chale ne?” (Is it okay if I consume non-vegetarian items?)

Some women and their husbands mentioned that due to pressure from elderly family members they avoid certain foods o

Iski ichha to hoti hai par bade log kahete hai to maanana padata hai.” (She [lactating woman] feels like eating everything but since elders ask to avoid certain foods we have to obey.)

In contrast, some women (35%) and their family members did not believe that anything should be avoided. They consumed all the food items during lactation.

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o

“Vadahre sari quality no khorak etele vadhare dal, bhaji, phal evu badhu khavanu.”

(Improved quality of food means more pulses, leafy vegetables, fruits -everything should be consumed during lactation.)

o

“Hari sabjiya aur non-veg. khati hoon.” (I consume green leafy vegetables and nonvegetarian items.)

They believed that if the lactating women consume all the food items, their children would get adapted to consuming everything and would learn to digest everything. o

“Suvavad ma je khaye badha chokra bi khaye, etele badhu khavanu.” (Things which the women eats during lactation, all those things the children would also eat so everything should be consumed.)

o

“Badhuj khavdavavanu, etle balak ne kai nade nahi.” (Everything should be served to the lactating women, so that child is not affected.)

o

“Sava mahina sudhimaj matane badhu thodu thodu khavdavi devanu, balak ne badhu pachi jay.” (Within one and half months after delivery, the lactating woman should be served everything so that the child can digest everything later.)

Many women’s doubts were clarified during the first visit counseling session and hence they agreed to eat everything and to not keep any restrictions during lactation. o

“Abhi aapne bataya na to sab khaungi” (Since you [counselor] informedme just now, I will now eat everything.)

Iron Supplementation during Lactation The consumption of iron tablets during lactation varied among the women enrolled in the program. As shown in Table 9, about half the women (44%) consumed iron tablets daily for about 1-3 months post delivery and the remaining (45%) did not consume.

Table 9: Iron Supplementation during Lactation Consumed or will consume IFA once daily for 1-3 months Yes No No idea

Vaatsalya, Aarogya 2005

OPD (N=348) n % 202 58.0 131 37.6 15 4.3

Ward (N=295) n % 79 26.8 156 52.9 60 20.3

Total (N=643) n % 281 43.7 287 44.6 75 11.7

31

The women, who consumed iron tablets, were generally prescribed these tablets postdelivery. o

“Jitni likh ke di thi utni sab li.” (I have consumed the quantity prescribed by the doctor.)

o

Delivery pachi tran mahina kidhi chhe levani.” (Doctor told me to take for 3 months after delivery.)

o

“Delivery ke time jo goli dete the wohi continue karne ko kaha hai.” (I have been asked to continue the same tablet that I used to take in pregnancy.)

o

“Tran mahina sudhi lidhi.” (I have consumed till 3 months)

Some women avoided despite being prescribed due to various reasons as mentioned below. o

“Main iron ki goli khati hu to bache ko jyada sandas hota hai, isliye ab goli nahi leti hu to sandas kam ho gaya.” (If I consume IFA then child passes more stools. Hence, I have discontinued the tablet and hence number of stools has reduced.)

o

“Iron ni goli lau to mane constipation thay chhe, etale bandh kari didhi.” (If I consume iron tablets I suffer from constipation so I have stopped consuming.)

o

“Mazhi sasu mhante ki balala goli garam padate mhanun phekun dilya.” (My motherin-law says the tablets are ‘hot’ for the baby, hence threw them away.)

o

“Iron ni goli nathi lidhi karan ke mane vomitaj thia jaye.” (I have not consumed iron tablet because as soon as I take I vomit.)

o

“Lakhi aapi hati pan galati nahi to nahi lidhi.” (Even though prescribed, I cannot swallow so I did not consume.)

o

“Ayurvedic doctor ne kidu chhe ki iron tablet levani nahi, balak ne kabajiyat chhe etele” (Ayurvedic doctor has asked not consume tablets, since the child has constipation.)

On the other hand, some women were not prescribed and were not aware that iron supplementation is essential during lactation. They mentioned that if the doctor prescribes they would consume. o

“Doctor kehshe to leshu” (If doctor advises we will take.)

o

“Delivery ke bad koi goli likhkehi nahi di.” (After delivery no tablet has been prescribed.)

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o Feeding Infants 0-5 months Initiation of Water to the Infant About one-half of the women were not aware regarding age of initiation of water to the infants (Table 10); and a majority of these women (62%) were the ones in the wards post-delivery. This was perhaps because most of the women were delivering for the first time. o

“Bahu khaber nathi, pan char-panch mahine tipu pani pivdavishu.” (I don’t know much, but I will give little after 4-5 months.]

o

“Pahelahi bacha hai to pata nahi hai.” (Since this is my first child, I don’t know.)

Table 10: Age of Initiation of Water to the Infants Age of initiation of water < 3 months 3-5 months 6-8 months >8 months No idea / No response

OPD (N=348) n % 22 131 68 11 116

6.3 37.6 19.5 3.2 33.3

Ward (N=295) n % 19 58 31 5 182

6.4 19.7 10.5 1.7 61.7

Total (N=643) n % 41 189 99 16 298

6.4 29.4 15.4 2.5 46.3

About one third of the women- and their family members- visiting the OPD, mentioned that water should be initiated around 3-5 months of age, mainly because...

♣ Child’s throat becomes dry. o

“Sab bolte hai bache ko paani pilane ka, nahi toh ooska gala sukh jayega.”

(Everybody says that water should be fed to the child otherwise his throat will become dry.)

♣ Child becomes thirsty especially in summer. o

“Garmi hai na to paani pilane ka.” (Since weather is hot, water should be given.)

o

Unalama galu sukai etle divas ma 2-3 chamchi pani aapvu paade” (In summer, child’s throat becomes dry hence water should be given (2-3 spoons) during the day.)

♣ Elderly family members insist on water. o

“Doctor kidu chhe ki chh mahina sudhi balak ne pani nahi aapavanu. Pan mari sasu mantij nahi ne. Sada tran mahina na balak ne pani aapva chalu kari didhu.

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Tame mara husband ne samzao to e mari sasu ne kaheshe.” (Doctor had told me that don’t give water up to six months. But my mother-in-law just does not listen.

She started feeding water at 3½ months of age. You please explain to my husband so that he tells my mother-in-law.) o

Mere sasune char mahine ke bad pani dene ko bola. Mujhe pata tha 6 mahine ke bad dene ka.” (My mother-in-law asked me to give water after 4 months. I knew that it should be given after 6 months.)

♣ Initiated water along with allopathy medicines during illness. o

“Jhada thayela tyare, ukaline powder nu pani pivdavelu atu.” (When my baby was suffering from diarrhea, powder (ORS) was mixed in boiled water and given to the him.)

o

“Be divas balak ne urine nathi thai etle doctor re thodu thodu pani pivdavanu kidhu chhe.” (Since child had not urinated for 2 days, the doctor advised to feed little water to the child.)

♣ Initiated water along with certain herbal juices and syrups believed to improve digestion by the child. o

“Dabur ghutti boiled water ke sath de sakte hai.” (We can give Dabur ghutti with boiled water.)

Some women were aware that water should be initiated around 6 months and that infant should be exclusively breastfed till then. The doctors and nutritionists of the hospital had informed them and also some of them had also read this in newspapers or magazines.

A few mentioned that they had heard it on radio and television programs. o

“Doctor ne bola hai ki chh mahine tak pani nahi deneka.” (Doctor has advised me not to initiate water till 6 months.)

o

“Jyar sudhi feeding chalu chhe tyar sudhi pani na aapavu joiye. Jyare upar nu khavanu chalu karu tyare pani aapavanu chalu karvanu.” (As long as only breastfeeding is continued, water is not given. When top foods are initiated, at that time water should be given)

o

“Newspaper, Magazine ma vanchyu chhe ke chha mahina sudhi pani pan nahi aapavanu.” (I have read in newspapers and magazines that till six months, not even water should be fed.)

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Feeding ‘Hind’ Milk As indicated in the Table 11, majority of the women (78%) were not aware about feeding nutrient-dense ‘hind’ milk. Most of them fed for a few minutes from both the breasts during each feed and generally were not aware that they should empty one breast and then feed from the other.

Table 11: Practices regarding Feeding ‘Hind’ Milk Feeding ‘Hind’ Milk: Emptying one breast fully before offering the other Yes No No idea/ No response

OPD (N=348) n % 72 265 11

20.7 76.1 3.2

Ward (N=295) n % 43 239 13

14.6 81.0 4.4

Total (N=643) n % 115 504 24

17.9 78.4 3.7

Most of the women and family members also believed that if child is fed from only one breast at a time, the other breast will harden and lumps would be formed. o

“Do baju se thoda thoda deti hu.” (I feed little from both breasts.)

o

“Ek baju ni chhati khali thava daiye, to biji baju nu dudh jami ne vasi na thai jay?” (If I empty one breast, then won’t the milk from the other breast accumulate and become stale?)

o

“Banne bajuthij aapvanu, nahi to gantho padi jay.”

(Breastfeeding should be done

from both breasts at each feed, otherwise lumps will be formed.) o

“Ek baju chati chadi gai hoy to banne baju levanu evu baa kahe chhe.” (My grandmother advises to feed baby from both breasts, if milk has accumulated too much in the breasts.)

Some women mainly used one breast for feeding due to various reasons. Some women had problems in one breast such as ‘inverted nipple’ and ‘less development of one breast’ and hence perceived that milk flow from that breast was less. o

“Ek baju nipple ma problem chhe etele occhu dudh aave chhe to ek baju thi puru nathi thatu.” (I have problem in one nipple so milk flow is less hence it is not sufficient.)

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35

o

“Be tran mahina thi khali jamani bajuj piye chhe dudh, biji baju ochu aave chhe.”

(Since 2-3 months the child sucks only from the right breast, milk flow from the other breast has decreased.)

o

“Mane pahela thi ekaj baju aapvanu phave chhe, biji baju jaray phavtuj nathi.”

(Right from the beginning I feel comfortable feeding from one breast only and am not comfortable feeding from the other breast.)

A few women also stated that despite trying many times their infants insist on suckling from only one breast. They were not able to find the reason behind such behavior. o

“Ha ekaj bajuni pito dusari kadun ka pit nahi kalat nahi.” (He sucks only from one breast. I don’t understand why he doesn’t sucks from the other.)

o

“Chhokru ek bajuj dhave chhe, ene biji baju letaj nathi phavtu.” (Child suckles only from one breast; he cannot suckle from another breast.)

A few women believed that their milk flow is less, hence to satisfy the hunger of the child, they had to feed from both breast at each feed. o

“Bahu dudh nahi aavtu etele ek vakhat thodi thodi vare banne baju aapu chhu.”

(Since milk flow is less, I breastfeed for a few minutes from both breast at each feed.)

A few mentioned signs such as crying of the baby and less weight of the baby as indicators of less milk flow from the breasts. o

“Sasu bolti hai ki woh rota hai to usko tumhara dudh kam padata hoga, abhi mujhe bhi ye lagta hai.” (My mother-in-law says that child cries because your milk may not be sufficient and now I also feel the same.)

o

“Mujhe lagta hai mera dudh sufficient nahi aa raha kyanki iska vajan abhi badha nahi hai.” (I feel my breast milk is not sufficient because child’s weight is not increasing.)

About one-fifth of the women were feeding ‘hind’ milk but were not aware of its benefits.

A few of them were advised by the doctor to do so. o

“Ek vaar ek baaju thi ane biji vaar biji baaju thi” (Once from one side and other time from the other side)

o

“Doctor ne bola hai vaisa hi karti hu. Ek baju pura pilake phir dusari baju pilati hu.” (I am following the advice of the doctor. I breastfeed from one breast completely and then feed from another breast.)

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Breastfeeding during Illness of Infant Three-fourth of the women stated that they would continue breastfeeding the infant during his or her illness (Table 12).

Table 12: Beliefs of Women regarding Breastfeeding during Infant’s Illness

Breastfeeding during infant’s illness Yes No No idea/ No response

OPD (N=348) n % 274 10 64

78.7 2.9 18.4

Ward (N=295) n % 207 19 69

70.2 6.4 23.4

Total (N=643) n % 481 29 133

74.8 4.5 20.7

A majority of them felt that since the child is not fed anything else apart from breast milk; breastfeeding should be continued. Some women also mentioned that since child needs nourishment even during illness, breastfeeding should be continued. In some cases, the infants had already suffered from diarrhea, cough, cold, fever and other minor illnesses; and they had continued to breastfeed at that time; hence they were aware about it. Their verbatim statements are mentioned below.

“Daat aave tyare jhada thai gaya hata pan hu to dhavan aapti hati.” (As teeth were erupting, child had diarrhea but I had continued to breastfeed.)

“Chokra ne jhada thai toh tenu sharir dhovai jai etele ma nu dudh vare ghadiye aapvuj pade ne!” (When child suffers from diarrhea his body becomes dehydrated, hence breast milk should be fed frequently.)

“Balala dudhatun immune power milate na mhanun dudh tar dyaylach have aajarpant.” (Child gets immunity through breast milk; hence breast milk must be given during illness.)

The family members also felt that breastfeeding should be continued during illness. To quote…

“Mandu hoi, toye chhokra ne bhukh to lagej ne ! Dhavan na apiye to biju shu aapiye!” (Even if the child is ill, he feels hungry! If breast milk is not given, what else can we give!)

“Dhavanj apvu pade, nahi to manda chokra ne ashakti aavi jay.” (Breast milk should be fed otherwise ill child would become weak.)

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However, about one-fifth of the women were not aware whether to continue breastfeeding during illness of the child. They mentioned that when their child will fall ill, they will consult the doctor and then breastfeed.

Breastfeeding during Illness of Mother Table 13 shows that most of the women (42%) mentioned they would continue to breastfeed their children during their own illness. On the other hand, about one-third felt that breastfeeding should be stopped if the mother is ill.

Table 13: Beliefs of Women regarding Breastfeeding during Mother’s Illness

Breast feeding during mother’s illness

Yes No No idea/ No response

OPD (N=348) n % 162 78 108

46.6 22.4 31.0

Ward (N=295) n % 108 94 93

36.6 31.9 31.5

Total (N=643) n % 270 172 201

42.0 26.7 31.3

The main reason for continuing to breastfeed during illness of mother stated was that since there is no alternative the infant is exclusively breastfed.

Upar nu kasu aapvanu nahi to dudh to aapvuj pade ne.” (Since top food is not allowed, breast milk should be fed.)

“Dudh tar dyaylach have tyashivay tar kahi shakya nahi.” (Breast milk has to be given, since there is no other alternative.)

Further, the women mentioned that during illnesses such as fever, cough, cold and headache they would continue to breastfeed. These illnesses require minor medication such as crocin which is not harmful. However, they were not sure whether to continue feeding if they suffer from diarrhea, malaria, jaundice or more severe illnesses. They stated that in such cases they would consult the doctor and then breastfeed their infants.

“Dhavan chalu hoi to crocin chale pan biji goli hoye to nai aapvanu.” (During lactation, crocin can be consumed, but if another tablet is consumed then breastfeeding should be discontinued.)

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“Khasi thayeli tyare dava chalu hati to doctor ne puchayu to emne kidu chhe ke dhavan chalu rakhi shakay.” (I was consuming tablets when I had cough hence asked doctor and he said breastfeeding could be continued.)

“Bukhar aaya to chalu rakhenge dusari koi bimarihoi toh doctor jo bolenge woh karenge.” (If I have fever, I will continue breastfeeding but if I have other illness I will follow doctor’s advice.)

The women who believed that breastfeeding should be discontinued during their own illness felt that the infant would be affected by the disease and would suffer from the same disease if breastfed at that time.

“Jo hu dhavdau to chokra ne maro tav lagi jay.” ( If I breastfeed, child will catch my fever.)

“Main bimar hungi aur feeding karaungi to bacha bimar ho jayega na!” (If I breastfeed the child when I am sick then the child will also fall sick!)

“Hu mandi thavu to mara sharir na jivjantu balak na pet ma jay etele dhavan bandh karvu” (If I fall sick the germs of my body will transmit to the stomach of the child.

Hence, breastfeeding should be discontinued.)

Their family members also believed in this.

“Ene taav aave to balak ne lage ne” (If mother has fever, child will get it)

A few women believed that the adverse effect of the medication would affect the health of the infant.

Hu dava lau, te chokra ne nuksan na kare, etle dhavan nahi apu.” (If I consume medicines, it will harm the child. Hence, I won’t breast feed.)

Further, they believed that when mother is ill, top milk or fluids or foods could be given to the infants. In such cases, generally women give either cow’s milk or dairy milk. A few women dilute the top milk and feed the infants.

“Hu maandi padu to upar nu kasu aapu.” (If I fall ill then I will give some top food.)

“Jo hu mandi padu to balak ne feeding nahi karau, pan mug nu pani ke bahar nu dudh thodu aapish.” (If I fall ill, I will not breastfeed the child but will give a little green gram dal water or top milk.)

“Maari bimarima to sachavavuj pade ne balakne, etele patlu dudh aapvanu” (During my illness, child has to taken care of; hence thin top milk should be given.)

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About one-third of the women mentioned that they would consult the doctor and do as per his or her advice.

“Doctor ni salahthij karvu joiye.” (We would do according to doctor’s advice.)

“Doctor ne puchi ne dhavan aapu mu bimar padu tyare.” (If I am ill, I will breastfeed the child after consulting the doctor.)

o Feeding Infants 6-12 months Initiation of top milk to the Infant Table 14 indicates that about one-half of the women were not aware of the age of initiation of top milk. They mentioned that they would either consult the doctor or the elders in the family regarding when to initiate top milk.

“Atyare to maruj dudh aapu chhu, biju kashuj nahi.” (Presently I feed only breast milk, nothing else.)

“Doctor ne aju kidu nathi kyarthi aapaye.” (Doctor has not advised so far as to when to initiate top milk.)

“Ghar na log kahe evu karu.” (I do whatever my family members say.)

Table 14: Age of Initiation of Feeding Top Milk to Infants

Age of initiation of top milk

< 3 months 3-5 months 6-8 months >8 months No idea / No response

OPD (N=348) n % 20 5.7 51 14.7 83 23.9 34 9.8 160 46.0

Ward (N=295) n % 3 1.0 46 15.6 57 19.3 39 13.2 150 50.8

Total (N=643) n % 23 3.6 97 15.1 140 21.8 73 11.4 310 48.2

Some women (15%) had initiated top milk at 3-5 months of age due to various reasons.

♣ Decreased breast milk and less weight- for-age of the infant.

“Bache ka weight kam hai na isliye khas jo kam weight vale bachon keliye aata hai woh dudh deti hu” (Weight of the child is less hence, I am feeding that top milk which is specially made for low-weight children.)

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♣ Women working outside home.

“Hoon job karu chhu etle, doctore kidu chhe ke upar nu dudh aapi shakay.” (Since I am working, doctor has allowed me to give top milk.)

“Hoon job karu chhu to tran mahina thi dudh aapavanu chalu kari didhu.” (Since I am working, I have started giving top milk from 3 months of age.)

♣ Twin children hence insufficient breast milk to sustain both of them.

“Julve aslya mule doctoranni pahela pasunaj varache dudh dyayla sangitale aahe.”

(As I have twins, doctor has advised to initiate top milk since birth.)

On the other hand, some women (11%) mentioned that they would initiate top milk as late as 9 months or 1 year or even later. They believed that top milk should be given only when infants stops breastfeeding or when breast milk is not sufficient for the infant.

“Ma nu dudh aave tyar sudhi upar nu dudh nahi aapavanu.” (As long as breast milk is produced, top milk should not be initiated.)

“Bachha dhavan chhode ga tab dungi – 1½ varas pachhi.” (I will give top milk when the child will stop breastfeeding – at about 1½ year.)

“Dhavan nahi aave thyarthi upar no dudh aapvanu.” (When breast milk stops flowing, top milk should be given.)

“Ma nu dudh aave tyar sudhi shu kam baharnu dudh aapvani jarur pade!” (As long as breast milk is produced, where is the need to feed top milk!)

Although about one-fifth of the women mentioned that they would initiate top milk at around 6-8 months of age, only a few among these were aware that complementary foods should be initiated along with top milk at this age.

Initiation of Fluids (other than top milk) to the Infants As in the case of top milk, a majority of the women were not aware about the correct age of initiation of top fluids. About one-third of the women (Table 15) mentioned that fluids such as dal-water, rice-water, juices and soups should be initiated after 6 months.

“Chha mahine se dal, chawal ka pani de sakte hai, sirf itna pata hai, aur kuchh nahi janti.” (From 6 months, dal-rice water can be given. I know only this much and nothing else.)

“Pravahi chha mahina pacchi aapiye” (Fluids are given after 6 months)

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Some women mentioned that they would initiate fluids when the child starts sitting.

“Jab baith sakega tab dal, chawal ka pani chalu karne ka.” (When the child starts sitting then dal and rice water should be started.)

“Basayala laglya var pravahi padarth va naram khorak chalu kariar.” (When the child sits on his/her own, I will initiate fluids and soft foods.)

Table 15: Age of Initiation of Feeding Top Fluids to Infants

Age of initiation of top fluids

< 3 months 3-5 months 6-8 months >8 months No idea / No response

OPD (N=348) n % 2 0.6 93 26.7 118 33.9 28 8.0 107 30.7

Ward (N=295) n % 3 1.0 73 24.7 92 31.2 16 5.4 111 37.6

Total (N=643) n % 5 0.8 166 25.8 210 32.7 44 6.8 218 33.9

In contrast, about one-fourth of the women had initiated fluids at 3-5 months or believed that fluids should be initiated at 3-5 months. They mentioned that it is the trend to initiate top foods early these days and to stop breastfeeding early.

“Chothe mahine se fluids aur mashed fruits dena chalu kiya.” (From the fourth month, I initiated fluids and mashed fruits.)

“Aajkal to badha vahelu aapva mande chhe etele char mahine aapish.” (Nowadays, everyone gives quite early so I will give after 4 months.)

“Mag nu pani ane bhat nu pani patlu karine, char mahine apiye.” (Diluted green gram water, and rice water should be given after 4 months.)

A few women had experienced that initiating fluids early reduces breast milk production.

Since the infants take fluids, they suckle less and hence breast milk production decreases.

“Dal nu pani pivdavavanu sharu karyu, pachhi dhavan ochhu thai gayu chhe.”

(Breast milk flow has been decreased after the initiation of dal-water.)

About one-third of the women (a higher percentage from the wards) were not aware as to when they should initiate top fluids to their infants. They asked the counselors about it.

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Initiation of Complementary foods to the Infants As shown in Table 16, a majority of the women (40%) did not know the age of initiation of complementary foods; some giving a reason that they had delivered for the first time, hence they were not aware about complementary feeding. Many women counseled in the OPD, had infants 1-3 months of age and hence they were not much concerned or interested in complementary feeding. Similarly, the women visited in the wards had just delivered, and they were still struggling to breastfeed their newborns; therefore showed little interest in complementary feeding advice. They mentioned that when the time comes they would either ask their elders or the doctors regarding complementary feeding.

“Pahili vel aahe na mhanun kahi mahiti nahi.” (As it is for the first time, I don’t know anything.)

“Mujhe kuchh nahi pata, saans hai na sab kahene ke liye.” (I don’t know. My motherin-law is there to tell me everything.)

““Doctor kahe tyare aapish.” (I will give soft food to the child when doctor advises.)

Some women asked the counselors to inform them regarding the complementary feeding. They stated that they would feed their infants as per the counselor’s advice.

“Ketlu aapavanu, kyare aapvanu tamej kaho. Amne khabar nathi.” (You [counselor] advise us about how much and when to give soft foods. We do not know.)

“Tame kaho tyare aapu balak ne khorak” (We will initiate whenever you [counselor] say.)

Table 16: Perceptions and Practices regarding Complementary Feeding to Infants

Parameter Age of initiation of complementary foods 3-5 months 6-8 months >8 months No idea / No response Quantity of complementary foods to be fed at 6-8 months 1-2 teaspoons Vaatsalya, Aarogya 2005

OPD (N=348) n %

Ward (N=295) n %

Total (N=643) n %

16 94 102 136

4.6 27.0 29.3 39.1

14 72 89 120

4.7 24.4 30.2 40.7

30 166 191 256

4.7 25.8 29.7 39.8

87

25.0

81

27.5

168

26.1 43

Parameter ½ -1 katorie As much as child eats No idea / No response Frequency of feeding complementary foods per day at 6-8 months Once 2-3 times 4 or more times On demand No idea / No response

OPD (N=348) n % 60 17.2 28 8.0 173 49.7

Ward (N=295) n % 37 12.5 39 13.2 138 46.8

Total (N=643) n % 97 15.1 67 10.4 311 48.4

28 98 31 12 179

15 128 6 11 135

43 226 37 23 314

8.0 28.2 8.9 3.4 51.4

5.1 43.4 2.0 3.7 45.8

6.7 35.1 5.8 3.6 48.8

Some women mentioned that they usually initiate when the child starts sitting or walking or when the child has teeth.

“Chaltu thay tyare khichadi chalu karvanu.” (Khichadi should be initiated when the child starts walking.)

“Pahela liquid start karvanu pachi dat aave tyare khichdi jevu aapvanu.” (Initially liquids should be fed, then when the child has teeth items like Khichadi should be given.)

Many women (30%) mentioned that they would initiate complementary foods after 8 months or even after 1 year.

“Das mahine se naram khorak aapvanu chalu karvanu.” (From 10 month, soft food should be initiated.)

“Do saal tak sirf maka dudh aur uparka dudh hi dete hai. Kuchh khilate nahi hai.” (Till the child is two years old only mother’s milk and top milk should be given. We do not give any food.)

“Ek varshya nanter sagle chalu karayche.” (After one year, everything [food] should be initiated.)

Which foods initiated?

Most of the women mentioned that they will initiate with either biscuits, cerelac or fruits.

“Shuru me toh biscuit dene ka.” (Initially [at around 8 months] biscuit should be given.)

“Sat-aath mahina thi biscuit khavdavish.” (I will give biscuits from 7th or 8th month.)

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“Ghar ka khana toh tikha hota hai, kaise khilaye bacheko?” (Home made food is spicy, how can we feed it to the child?”)

Many believed that home-made foods such roti should be initiated after 1-2 years of age.

“Be time dudh ne biscuit aapu chhu. Roti to balak ne bhare pade ne.” (I am feeding milk and biscuit two times a day. Roti will be heavy to digest for the child.)

“Anaj to ek saal tak nahi khilaneka.” (We do not feed cereals till 1 year.)

“Roti galama atki jaay ane pachvama bhare hoi ne etale ek varas pachhi aapish.”

(Since roti gets stuck in the throat, I will give only after 1 year of age.)

Table 16 shows that about one-half of the women were not aware of the amount of complementary food to be fed to infants at 6-8 months. One-fourth mentioned extremely inadequate amounts; about 1-2 teaspoons of soft foods should be given.

“Taste alag laage to 1-2 chamachi le chhe.” (If the child finds it tasty, he eats 1-2 spoons.)

Khali ek be danaj balak ne chatadavu chhu.” (I feed only 1-2 grains to the child.)

“Chh mahina nu balak ne 1-2 chamchi be var aapay.” (A 6 months old child should be fed 1-2 spoons two times a day))

Only a few mentioned that they feed the child as much as he or she wants and do not encourage or force the infants to eat more.

“Balak jetlu khay etelu aapvanu.” (Food should be given as much as the child eats.)

“Balachya bhookpromane tyala khau ghalayche.” (Feed the child as per his appetite)

A few stated that the infant should be given limited quantity and should not be fed too much.

“Bahu khavdavanu nahi chokrane, bodu thay jaye.” (Should not give more to the child, otherwise becomes dumb.)

Similarly, most of the women were not aware of the frequency of feeding complementary foods to infants. Some women fed only once, some fed twice whereas some fed as many times as the infant demanded.

“Khay eteli vaar khavdavanu.” (Feed whenever child wants to eat.)

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“Ek be chamchi, ek-be vaar divas ma aapiye” (We give soft foods 1-2 spoons 1-2 times per day)

Ekaj time uprno khorak aapu. Khatoj nathi ne, khali upar nu dudh piye chhe.” (Only once I feed the child. He does not eat anything and only consumes top milk)

“Ek baar cerelac dene ka.” (Cerelac should be fed once in a day.)

However, a few women did feed a relatively more amounts of foods and more frequently.

They also fed food routinely prepared in the house to the children.

“Ek vaar osaman, pachi thodo pocho khorak evi rite aapvanu roje” (Once dal-water, then some soft food, should be given daily.)

“Be var cerelac, be var dudh aapu. Roti no tukdo ke khichdi – Ame jamta hoiye tyare khavu hoi to khay.” ( I give cerelac and milk twice a day. While we eat, a piece of roti or Khichadi is given to the child, he eats if he wants to.)

“Mung bhat savare ne sanjhe aapu.” (I feed green gram dal and rice in the morning and in the evening.)

However, most of the women enrolled were not aware of the amount and frequency of complementary foods required to be fed to infants in the age group of 6-8 months; and later.

Initiation of Fruits and Vegetables to the Infants Most of the women (46%) were not aware of the age at which infants should be given fruits and vegetables (Table 17).

Table 17: Age of Initiation of Feeding Fruits and Vegetables to Infants

Age of initiation of fruits and vegetables < 3 months 3-5 months 6-8 months >8 months No idea / No response

OPD (N=348) n % 23 6.6 69 19.8 100 28.7 156 44.8

Ward (N=295) n % 2 0.7 21 7.1 55 18.6 75 25.4 142 48.1

Total (N=643) n % 2 0.3 44 6.8 124 19.3 175 27.2 298 46.3

A few women mentioned that they would ask the doctor or the elders.

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“Doctor ne puchi ne shakbhaji ne fruit aapu.” (I will give fruits and vegetables after asking the doctor.)

“Amne khabar nahoti etle shakbhaji vahelu na apyu, have thodu aapu chhu.” (We did not know that vegetables can also be given at an early stage, now I give it little.)

About one-fifth of the women were aware that fruits and vegetable should be initiated when complementary foods are initiated at around 6 months of age. They also mentioned that initially juices or soups are given and then soft fruits and boiled vegetables should be initiated.

“Khichadi vagera chalu karne ke sath hi vegetables dete hai.” (We give vegetables when we start giving khichadi.)

“Phalancha juice 7 mahinyan nanter pajayacha ani phal naram karun 8-9 mahinya nanter dyayche” (Fruit juices should be given after 7 months and whole soft fruits after 8-9 months.)

Palak, suva ni bhaji bhat ma nakhi mixture ma kadhi ne balak ne aapu chhu.” (I grind spinach and other leafy vegetables along with rice and serve the mixture to the infant.)

“Dal chawal chalu karne ke sath hi fruits aur vegetables dete hai.” (We initiate fruits and vegetables when we initiate rice-dal.)

However, there were some women who believed that the infants cannot consume vegetables at 6 months. They believed that fruits and vegetables should be initiated only after 8 months or even later.

“Dasma mahine dant ave pachhi aa badhu thodu thodu aapi shakay.” (At 10th month, when the teeth erupts, these foods can be initiated in small quantity.)

“Fal ane shakbhaji to varas pachhij aapu.” (I will initiate fruits and vegetable only after 1 year.)

“Subji garam padti hai to voh bada ho jaye tabhi denge.” (Vegetables are ‘hot’ so we will give when the child grows up.)

Some women avoided giving certain fruits such as banana as was believed to be ‘cold’ and cause cough-cold to the child. Similarly, some women avoided certain vegetables such as potato as they are believed to cause indigestion and flatulence.

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“Kela ane drakshto balak ne thanda pade. Dudh ni sathe kela na aapiye.” (Banana and grapes are “cold” for the child. We do not give banana with milk.)

“Sasu kahe chhe ki bataka nahi aapvanu ene pachse nahi.” (My mother-in-law says that potato should not be given to the child, as he will not be able to digest it.)

A majority of the women were thus not sure regarding feeding of fruits and vegetables to their infants.

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PHASE III: INTERIM ASSESSMENT OF PROGRESS OF !""#$"%&"( !""#$"%&"( Periodic assessment of any program is essential to inform about the impact of a program as well as to inform about the key changes required to improve its effectiveness. The periodic assessment should involve both, the impact and the process of implementation.

As mentioned earlier, the objective of the !""#$"%&" program in MSH is to bring about positive changes in awareness and practices of women and their families with regard to postnatal and infant care. The impact assessment will help us to determine the changes in knowledge and practices of the women after the counseling sessions as compared to pre-counseling. The assessment will help us understand the changes required in the strategy to improve the effectiveness of the program. These results are presented in the following section.

Impact Assessment As mentioned earlier, the pair of !""#$"%&" sakhis (counselor and recorder) collects information on data recording sheets of the weight of the infants and also the knowledge and practices of the women during both the initial visit (Visit 1) and follow-up visit (Visit 2). The information recorded on data sheets was coded and entered into the computer.

The data was analyzed to understand the impact of counseling on the behaviors and practices of the women.

At the time of the assessment, 120 women had visited for follow-up out of 643 women enrolled in the program during the year.

Of these 120 women, 68 women were

counseled in the OPD and 52 women in the wards during the initial visit. One-third of the women came for follow-up visit on their own. The remaining two-third women were sent for follow up by the pediatrician or staff of Family Welfare Center. Pre-post analysis was done of the changes in knowledge and practices of the women with regard to postnatal and infant care. Further, qualitative information obtained from the weekly counseling session reports of the follow up visits were analyzed to inform about the changes in the beliefs of the women after counseling as compared to pre-counseling.

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49

Anthropometric Profile of the Infants after Counseling In MSH, each child born in the hospital is given a baby-card wherein at every visit of the child to the hospital- date of the visit, weight and height of the child, immunization schedule of the child, history of morbidities and other such information is recorded. The weight of the infant at the time of the visit was noted by the !""#$"%&" sakhis. The weight profile of the infants enrolled and the change in the prevalence of malnurtrition among the enrolled infants was analyzed.

Prevalence of Underweight after Counseling Considering Weight-for-Age Z-score, the prevalence of underweight at Visit 2 was more or less similar among the two younger age groups (0-5 months and 6-11 months) as presented in Table 18. The prevalence was high among the 12-23 months old, however since the number was less nothing conclusive can be said regarding the change.

Table 18: Percent Children Underweight* at Visit 2 Parameter

Age group of infants 0-5 months (N=73) 6-11 months (N=41) 12-23 months (N=6) Sex of the child Boys (N=66) Girls (N=54) Place of counseling OPD (N=68) Ward (N=52) Total (N=120)

Normal Weight n %

Underweight n %

71 40 4

97.3 97.6 66.7

2 1 2

2.7 2.4 33.3

64 51

97.0 94.4

2 3

3.0 5.6

63 52 115

92.7 100.0 95.8

5 0 5

7.3 0 4.2

*Normal weight = â&#x2030;Ľ -2.00 WAZ; Underweight= <-2.0 WAZ The overall prevalence of underweight was 4%; being mainly among those counseled in the OPD as compared to those counseled in the wards. The prevalence of underweight was slightly higher among girls, but not statistically significant.

Considering the IAP classification (Table 19), the prevalence of underweight was among one-tenth of the infants counseled. The sex of the infants did not affect the prevalence of underweight. It was interesting to note that as compared to Weight-for-Age Z-score

Vaatsalya, Aarogya 2005

50

classification, the prevalence of underweight was more than double considering the IAP classification.

Table 19: Percent Children Underweight* at Visit 2 Parameter Age group of infants 0-5 months (N=73) 6-11 months (N=41) 12-23 months (N=6) Sex of the child Boys (N=66) Girls (N=54) Total (N=120)

Normal Weight n %

Underweight n %

63 39 4

86.3 95.1 66.7

10 2 2

13.7 4.9 33.3

59 47 106

89.4 87.0 88.3

7 7 14

10.6 13.0 11.7

*Normal weight = > 80% of NCHS Standard; Underweight= â&#x2030;¤ 80% of NCHS Standard.

Change in Prevalence of Underweight after Counseling Table 20 compares the prevalence of underweight at Visit 1 (at enrollment) and Visit 2 (Follow-up). The prevalence of underweight decreased at Visit 2 as compared to Visit 1. However, due to small numbers the change is not statistically significant. Among the two agegroups; and among both boys and girls the prevalence of underweight has decreased. This could be partly attributed to the positive practices adopted by the women as regards infant care.

Table 20: Prevalence of Underweight at Visit 1 and Visit 2 Parameter

Age group at Visit 1 % 0-5 months n N 6-11 months % n N

Vaatsalya, Aarogya 2005

Visit 1 Normal Underweight 94.6 88 93 72.7 8 11

5.4 5 93 27.3 3 11

Visit 2 Normal Underweight 97.8 91 93 82.0 9 11

2.2 2 93 18.0 2 11

51

Parameter

Visit 1 Normal Underweight

Visit 2 Normal Underweight

Sex of the child Boys

% 94.5 5.5 96.4 3.6 n 52 3 53 2 N 55 55 55 55 % 89.8 10.2 95.9 4.1 Girls n 44 5 47 2 N 49 49 49 49 Place of Counseling % 92.2 7.8 93.8 6.2 OPD n 59 5 60 4 N 64 64 64 64 % 92.5 7.5 100 0 Ward n 37 3 40 0 N 40 40 40 40 Total % 92.3 7.7 96.2 3.8 n 96 8 100 4 N 104 104 104 104 * Normal = >=-2.00 Weight for Age Z-score; Underweight= <-2.00 Weight for Age Z-score

Perceptions and Practices of the Women after Counseling o Nutrition During Lactation Quantity of Food Intake during Lactation

Table 21 shows that the percentage of women who increased their food intake during lactation was similar during Visit 1 and Visit 2. Those women who had kept the food intake the same as usual during lactation, did not increase their food intake even after counseling.

Table 21: Change in Quantity of Food intake During Lactation OPD (N=68) WARD (N=52) TOTAL (N=120) Parameter Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % Compared to usual diet, food intake during lactation

Has increased Has decreased Remained the Same

49

72.1

47

69.1

39

75.0

41

78.8

88

73.3

88

73.3

6

8.8

4

5.9

2

3.8

2

3.8

8

6.7

6

5.0

13

19.1

17

25.0

11

21.2

9

17.3

24

20.0

26

21.7

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The main reason for not increasing food intake was that these women had stopped breastfeeding and hence they did not feel the need to increase their food intake.

“Haave to balak upar nu badhuj khay chhe etale dhavan occhu thai gayu chhe

to

marathi vadhare nathi khavatu.” (Now the child has started eating everything, hence breast feeding has decreased and so I cannot eat more.)

Despite counseling, a few women were not able to increase their food intake mainly due to the following reasons.

♣ Excessive work load, lack of time and negligence towards their own health.

“Do bache hai to khane ke liye time nahi milta.” (Since I have two children, I do not get time to eat.)

“Sarsrima kam vadhare chhe to thaki jau ane khorak vadhare na lai shaku.” (I have more work at the in-law’s place, which makes me feel tired, and so I cannot eat more.

♣ Belief that lactating women should consume only soft-foods or less food for easier flow of breast milk for 2-3 months after delivery.

“Dhilo khorak khaiye to sarkhu dudh aave.” (Soft-foods should be consumed so that breast milk flows properly.)

“Kodari vadhare khavani, rotli gheewali khavani pan dharai ne nahi khavanu. Occhu khavanu toh dhavan barabar aave.” (I eat more Kodri, chapatti with ghee, but should not it more. One should eat less so that breast milk flow is proper.)

♣ Less food intake due to weight consciousness

“Vadhare na khau. Vajan vadhi jay.” (I will not eat more. My weight will increase.)

Thus, although the women increase their food intake they mainly do so for increased milk production and not for their own health.

Quality of Food Intake during Lactation It was encouraging to note that after counseling a majority of the women (73%) had stopped avoiding foods that they earlier avoided after counseling (Table 22). Before counseling many (68%) women avoided certain foods whereas after counseling only one-fourth of the women continued to avoid certain foods during lactation. This change was statistically significant (p<0.001). There was a significant change among both the women counseled in the wards and the OPD. Thus, the quality of food intake of the women improved.

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The main reason for this change was increased awareness due to counseling sessions and clarification of doubts regarding harmful effects of certain foods during counseling.

To quote the women…

Gharna gharda kaheta hata etale pahela bhinda, gawar nahoti khati. Tame kidhu etale have to badhuj khau chhu. Kasu nahi thayu balakne.” (I did not eat ladyfinger, cluster beans earlier since my elders told me. Now I eat everything since you [the counselor] told me. Nothing happened to the child.)

“Pahela bhinda nohti khati, haave khau chu.” (Earlier I used to avoid lady finger, now I eat.)

Table 22: Change in Awareness regarding Nutrition during Lactation OPD (N=68) WARD (N=52) Parameter Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % Any foods avoided or will avoid during lactation

TOTAL (N=120) Visit 1 Visit 2 n % n %

Yes 50 73.5 22 32.4 31 59.6 9 17.3 81 67.5 31 25.8 No 46 67.6 41 78.8 87 72.5 No idea 18 26.5 21 40.4 2 3.8 39 32.5 2 1.7 Note: Chi-squares comparing percentages of women who avoided food items at Visit 1 and Visit2 are highly significant (p<0.001) for OPD, ward and total sample.

Some elderly family members had also changed their beliefs and had started serving food to lactating women without any restrictions. To quote a mother-in-law…

“Tame kidhu etale have badhu aapava mandyu.” (Since you [the counselor] advised us, I have started giving everything to her [lactating woman].)

However, about one-fourth of the women continue to avoid certain foods such as pulses and certain vegetables like cluster beans, lady finger, red gram tender, double beans and potato. These are believed to cause flatulence or diarrhea in the infant and some women believe that it causes pus in the stitches taken during delivery. Fruits such as banana, grapes are believed to cause severe cough and cold in the infant.

“Bhinda thi balak ne varadh thaye, evu kahe chhe etele bik laage chhe, nathi khati.

(People say that if I consume lady finger, child would suffer from whooping cough, hence I am scared and avoid eating it.)

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“Main kela khati hu to bache ko shardi hoti hai.” (If I eat banana the child gets cough.)

“Hu chana ni dal khau to balak ne jhada thai jay.” (If I consume Bengal gram dal, child suffers from diarrhea.)

The family members also insist that the women avoid these foods as it is believed to be harmful to the women and their infants.

“Sasu na paade chhe, etele haaji sudhi nathi khati valore ane papdi.” (My mother-inlaw does not allow me to eat double beans and runner beans so I have not yet consumed them.)

Some women continue to avoid sour foods such as curds and preparations made from curd, tamarind, tomatoes and other sour foods. They believe that sour foods cause pus formation in stitches taken after delivery.

“Khatash khay to tanka pake.” (If I consume sour foods, pus will be formed in the stitches.)

A few women avoided milk mainly due to personal dislike. A few women did not consume rice as traditionally it is not consumed few months post delivery.

It was observed that these restrictions were kept for initial 1-2 months after delivery, only a few women continue these restrictions as long as they breastfeed. The women follow the advice of the elders considering them to be experienced and since certain practices are traditionally followed.

In brief, food avoidance continued though there was a decrease in percentage of women following them.

Iron supplementation during Lactation Table 23 shows that a higher percentage of women (65%) started consuming iron tablets as compared to before counseling (52%). This difference was significant (p<0.05). Many women mentioned that they had started consuming iron tablets due to the information and guidance given during counseling.

“Aapne samjhaya thana isliye family welfare se leke aai hu.” (Since you explained it to me I brought it from family welfare center).

“Tame kidhu hatu etele lav chhu roje. (Since you [counselor] advised me I take daily.)

“Aapan ne takat male ne.” (It should be taken as it gives us strength.)

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Table 23: Change in Iron Supplementation during Lactation

OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % Consumed or will consume IFA once daily during lactation Parameter

Yes 44 64.7 42 61.8 18 34.6 36 69.2 62 51.7 78 65.0 No 21 30.9 25 36.8 21 40.4 13 25.0 42 35.0 38 31.7 No idea 3 4.4 1 1.5 13 25.0 3 5.8 16 13.3 4 3.3 Note: Chi-square comparing percentages of women who consumed iron tablets at Visit 1 and Visit2 was not significant for OPD; but was significant for ward (p<0.001) and total sample (p<0.05).

A significantly higher percentage (p<0.001) of women counseled in the wards started consuming iron tablets as compared to those counseled in the OPD (Figure 4). Some of the women counseled in the OPD had stopped taking iron tablets after taking them continuously for 3-4 months.

Percentage of Women consuming IFA during Lactation

Figure 4: Percentage of Lactating Women Consuming IFA during Visit 1 and Visit 2 80 70

64.7

69.2 61.8

60 50 34.6

40

VISIT 1 VISIT 2

30 20 10 0 OPD

WARD

Some women (32%) do not consume iron tablets despite counseling. The main reasons behind not consuming iron tablets were nausea, vomiting, reluctance to swallow tablets, negligence towards own health and doctors had not prescribed.

â&#x20AC;&#x153;Goli thi mane ubka aave etale levati nathi.â&#x20AC;? (On consuming the tablets I suffer from nausea so I cannot take them.)

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“Doctore lakhi nathi aapi etele mane khaber nathi.” (Doctor has not prescribed so I don’t know.)

“Lakhi aapi hati pan haaji kharidi nathi.” (It was prescribed but so far I have not purchased.)

“Tahme kidhu hatu pan mane kantalo aave chhe goli galvano.” (You [counselor] had told me but I feel too lazy to swallow tablets.)

A few women (3%) could not recall the messages given by the counselor and mentioned that they were not aware that iron supplementation is essential during lactation. When the counselor informed them again about the benefits they mentioned that they would either purchase iron tablets or collect from the FWC and take them regularly. Their husbands and mothers also supported them. To quote a husband of a lactating women….

“Tahme naam lakhi aapone, toh hamna laine teh chalu kari deshe.” (Why don’t you [counselor] tell me the name of the tablet; I will purchase just now and she [lactating woman] will start taking them.)

We however did not prescribe iron-folate tablets but referred them to the doctor or Family Welfare Center.

o Feeding Infants 0-5 months Initiation of Water to the Infant About one-half of the women (57%) were aware that infants should be given water only after six months (Table 24) at Visit 2. The awareness had increased as compared to Visit 1 (23%). At Visit 1, many women (42%) were not aware when to initiate water; whereas at Visit 2 only a few women (5%) could not recall that the age of initiation of water is after 6 months.

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Table 24: Change in Awareness regarding Age of Initiation of Water to Infants Age of initiation of water

OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % < 3 months 3 4.4 4 5.9 2 3.8 2 3.8 5 4.2 6 5.0 3-5 months 24 35.3 23 33.8 9 17.3 14 26.9 33 27.5 37 30.8 6-8 months 20 29.4 35 51.5 7 13.5 33 63.5 27 22.5 68 56.7 >8 months 3 4.4 2 2.9 2 3.8 1 1.9 5 4.2 3 2.5 No idea 18 26.5 4 5.9 32 61.5 2 3.8 50 41.7 6 5.0

Note: Chi-squares comparing percentages of women who mentioned that water should be initiated at the age of 6-8 months at Visit 1 and Visit2 are significant for OPD (p<0.01); and ward and total sample (p<0.001).

This difference in awareness was highly significant (p<0.001) more so among women who were counseled in wards as compared to those counseled in OPD as shown in Figure 5.

% of Women aware that Water should be Initiated after 6 months

Figure 5: Percentage Change in Awareness of Age of Initiation of Water to Infants 70

63.5

60

51.5

50 40 30

VISIT 1

29.4

20

VISIT 2 13.5

10 0 OPD

WARD

Many women mentioned that counseling helped increase their awareness.

“Mane badhu yaad chhe tame kidhu hatu te etale chh mahinathi pachhij paani aapish.” (I remember everything you [counselor] told me hence we will give water only after 6 months.)

“Tahme kidhu haatu etale chatha mahina paachi aapish.” (Since you [counselor] told me I will give water only after 6 months.)

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“Aapne kaha tha isliye ise bund bhi paani nahi diya.” (Since you [counselor] advised me I have not given even a drop of water to my child so far.) (3 month old infant)

Some women mentioned that the doctors also advise that water should be inititated only after 6 months of age.

“Chhatha mahina thi paani aapvaanu doctore kidhu chhe.” (Doctor has told us that we should give water from 6th month.)

However, about a third (31%) believed that water should be initiated around 3-5 months of age at Visit 2. The major reasons given were…

♣ Child becomes thirsty due to hot weather.

“Garmi haati etele char mahine pani pivdavyu.” (Since it is hot we gave water from 4th month.)

♣ Elders in the family insist that child becomes thirsty.

“Mara gharwala nathi sambhalta. Paani char mahinathi aapava mandavanu kahechhe.” (My family members do not listen and insist that I give water at 4 months.)

♣ Some doctors and certain magazines and booklets mention that water and fluids should be initiated at 4-5 months.

“Chopadi ma lakhyuj chhe ne te pramane char mahinathi aapish.” (It is written in the book to give water at 4 months hence I will give accordingly.)

Feeding ‘Hind’ Milk As indicated in the Table 25, a significantly higher percentage of women were feeding ‘hind’ milk at Visit 2 as compared to Visit 1 (p<0.001), both among those counseled in wards and in OPD.

Table 25: Change in Practices regarding Breastfeeding

Feeding Hind Milk Yes No No idea

OPD (N=68) WARD (N=52) Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % 11 16.2 53 77.9 7 13.5 36 69.2 52 76.5 15 22.1 44 84.6 16 30.8 5 7.4 1 1.9 -

TOTAL (N=120) Visit 1 Visit 2 n % n % 18 15.0 89 74.2 96 80.0 31 25.8 6 5.0 -

Note: Chi-squares comparing percentages of women who fed ‘hind’ milk at Visit 1 and Visit2 are highly significant for OPD and total sample (p<0.001).

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Before counseling, women were not aware about the benefits of ‘hind’ milk and hence only 15% of the women emptied one breast and then fed from the other. On the other hand, after counseling 74% of the women fed ‘hind’ milk.

As indicated in the Figure 6, the increase in awareness was similar in women counseled in OPD and ward.

% of Women aware about Feeding 'Hind' Milk

Figure 6: Percentage Change in Awareness regarding Feeding ‘Hind’ Milk

90 80 70 60 50 40 30 20 10 0

77.9 69.2

VISIT 1 VISIT 2 16.2

13.5

OPD

WARD

In the women’s own words…..

“Ek baju khali thay pacchi biji baaju.” (I feed from the other side only after emptying from one side.)

“Ek baaju pura pilake, bhookh raahe toh dusari baju, nahi toh phir dusri time pilaneka dusari baju.” (I feed till breast empties and if child is still hungry feed from other breast or else feed from the other breast in the next feed.)

“Hu to chhati khali karinej pivadau chhu. Tame nahotu kidhu.” (I empty the breast and then feed from other. Didn’t you [counselor] tell me this!)

About one-fourth of the women continue feeding from both breast despite being aware of the benefits of ‘hind’ milk as they faced problems such as engorgement or soreness of breast and child refusing to continue feeding from one breast for too long.

“Biji baju bharai jaye chhe etele hu to banne bajuj aapu chhu.” (The other breast becomes overfull hence I feed from both breasts.)

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“Ek baju khali hone tak baccha wait nahi karta, to dusari baju se dena hi padta hai.”

(My child does not wait till one breast is empty, hence I have to feed from other breast.)

A few women believed that child’s hunger would not be satisfied if fed from one breast only at each feed.

“Santosh thay ne balaak ne etele banne baaju thi thodi-thodi vaar aapu chhu.” (To satisfy the child, I breastfeed from both breast little at a time.)

“Ek baaju thi aapu toh enu pet naa bharay ne!” (If I feed from only one side, his stomach will not become full!)

Further, a few women believed that if the child is fed from one breast at each feed, the shape of the breast would change and both breast would become unequal in size.

“Be baju pivadau chhu, nahi to chhati nani moti thai jaye ne.” (I feed from both breasts otherwise one breast would become small and the other big.)

Breastfeeding during Illness of Infant Almost all women (97%) were aware at Visit 2 that breastfeeding should be continued during illness of the infant and were also aware of its benefits. Before counseling, about one fourth of the women were not sure whether to continue breastfeeding during illness of the infant (Table 26).

Many women mentioned that the counseling session helped to increase their awareness and also since there is no alternative food that could be given to infants less than 6 months breastfeeding should be continued.

“Tahme kidhu haatu te badhu yaad chhe. Bimari maa pan dhavan aapay.” (I remember what you [counselor] had told me. Even in illness breast milk can be given.)

“Bimarima balak ne shakti male ne etale dudh to aapavanuj.” (The ill child would get strength hence breastfeeding should be continued during his illness.

“Dudh to aapavuj pade ne, biju shu aapi shakay?” (Ill child had to be breastfed, what else can be given?)

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Table 26: Change in Perceptions regarding Breastfeeding during Illness of Infant OPD (N=68) WARD (N=52) Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % Breast feeding during infant’s illness

Yes No No idea

TOTAL (N=120) Visit 1 Visit 2 n % n %

55 80.9 65 95.6 36 69.2 52 100.0 91 75.8 117 97.5 1 1.9 1 0.8 13 19.1 3 4.4 15 28.8 28 23.3 3 2.5

Note: All chi-square values comparing percentages of women breastfeeding during infant’s illness for OPD, ward and total sample (Visit 1 versus Visit 2) are significant (pvalue<0.01).

A few women mentioned that the doctors had informed them to continue breastfeeding when their infants had suffered from illnesses such as cough, cold, fever, diarrhea and jaundice, in the past.

“Babo nahno hato tyare jaundice thayo hato tyare doctare dudhaj pivdavanu kahyu hatu.” (When my son was young he suffered from jaundice and the doctor had advised to only breastfeed.)

Figure 7 clearly shows the increase in awareness among women after counseling regarding continuing breastfeeding during illness of infant.

% of Women responding

Figure 7: Percentage Change in Awareness regarding continuing Breastfeeding during Infant’s Illness 120 97.5

100 75.8

80

VISIT 1

60

VISIT 2

40 20 0 Continuing Breastfeeding during Infant's Illness

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Breastfeeding during Illness of Mother As the Table 27 shows as compared to Visit 1, a significantly higher percentage (above 90%) of women at Visit 2 (p<0.001) were aware that breastfeeding should be continued during their own illness. At Visit 1, a little less than half of the lactating women (42%) stated that they had no idea whether to continue breastfeeding the infants during their own illness.

Table 27: Change in Perceptions regarding Breastfeeding during Illness of Mother OPD (N=68) WARD (N=52) Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % Breast feeding during mother’s illness

TOTAL (N=120) Visit 1 Visit 2 n % n %

44 36.7 112 93.3 26 21.7 3 2.5 50 41.7 5 4.2

Yes No No idea

31 45.6 64 94.1 13 25.0 48 9 13.2 1 1.5 17 32.7 2 28 41.2 3 4.4 22 42.3 2

92.3 3.8 3.8

Note: All chi-square values comparing percentages of women breastfeeding during their own illness for OPD, ward and total sample (Visit 1 versus Visit 2) are highly significant (p-value<0.001).

Many women mentioned that earlier they used to believe that breastfeeding during their illness would transfer the illness to the infant or the infant would be adversely affected by the medication they take during illness. After the counseling session, wherein they were informed that in general illnesses and medication do not affect the infant, they were relieved to be informed that breastfeeding could be continued.

“Pahele confusion tha meri bimari me dudh pilau ki nahi par ab to koi confusion nahi.” (Formerly I was confused whether to breastfeed during my illness but now there is no confusion.)

“Dhavan toh aapi shakay. Tahmej kidhu hatu ne!” (Breast milk can be fed during mother’s illness. You [counselor] only told this!)

Many women also mentioned that since there is no alternative for young children (less than 6 months) breastfeeding should be continued.

A few women and their family members continue to be skeptical about breastfeeding infants during mother’s illness. Despite counseling and reassurance by the doctors, they are still scared to feed their infants during their own illness. They fed lemon-juice, sugarsyrup or top-milk in such cases.

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“Maaro taav ane laagi jay toh? Sasu paan naa paade.” (What if the child catches my fever? Mother-in-law also refuses to let me breastfeed.)

These women and their family members were once again reassured that breastfeeding would not transmit illness such as fever, cough, and cold from mother to child; and the breastfeeding should be continued during these illnesses.

o

Feeding Infants 6-12 months

Initiation of Top milk to the Infant Table 28 indicates that 42% more women were aware that top milk should be initiated at around 6-8 months, after counseling. This increase was highly significant (p<0.001).

Earlier many of these women were not aware of the age of initiation of top milk.

According to them their awareness had increased due to counseling and due to advice given by the pediatrician of the hospital.

Table 28: Change in Awareness regarding Age of Initiation of Top Milk Age of initiation of top milk

OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % 4 5.9 3 4.4 1 1.9 4 3.3 4 3.3 4 5.9 6 8.8 5 9.6 4 7.7 9 7.5 10 8.3 14 20.6 38 55.9 7 13.5 33 63.5 21 17.5 71 59.2 7 10.3 10 14.7 6 11.5 5 9.6 13 10.8 15 12.5 39 57.4 11 16.2 34 65.4 9 17.3 73 60.8 20 16.7

< 3 months 3-5 months 6-8 months >8 months No idea Note: Chi-squares comparing percentages of women who believed that top-milk should be initiated at 6-8 months at Visit 1 and Visit 2 are highly significant for OPD, ward and total sample (p-value<0.001).

The women also mentioned that although they initiate top milk around 6 months of age, infants do not like it and hence do not drink it much. A few women mentioned that despite adding sugar and other flavors, the infants did not prefer to drink top milk.

Women usually give top milk in bottle although some do give in either sipper or a small glass.

“Upar nu dudh satma mahinathi chalu karyu chhe, pan te nathi piti.” (I have initiated top milk since 7th month, but she does not like it.”

“Dudh sharu karyu chhe pan e toh pitoj nathi.” (I have initiated top milk but he just refuses to drink it.)

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A few women (11%) had initiated top milk between 2-5 months of age due to various reasons. A few mentioned that top milk was initiated since the weight of the infant was not increasing. Some of them mentioned that they had initiated because they felt that the breast milk is insufficient after 3-4 months. A few added various herbs to the top milk at an early age and gave to the infant believing that this herbal flavored milk gives warmth to the infant. These beliefs were mainly of the elderly female family members and the lactating women simply followed the advice of the elderly female members.

“Sasu ae kidhu ke vavding valu dudh aapvanu etele ane shardi na thay, ane pachhi jaay.” (My mother-in-law told me to give Vavding [a herb] with milk, as it protects infant from cold and also helps in digestion.)

“Kesar vaalu dudh thi garmavo male, dhandi naa laage.” (Milk flavored with saffron gives warmth, infant does not feel cold.)

A few women were working; hence they could not continue to exclusively breastfeed their infants till 6 months.

“Hoon job karu chhu etele mein tran mahina thi dudh chalu kari didhu.” (Since I am working I started giving top milk from 3 months of age.)

On the other hand, a few women and their family members continued to believe that top milk should not be initiated as long as breast milk is produced. A few women had experienced that feeding top milk caused diarrhea and hence they had discontinued it.

“Jya sudhi dhavdavu chhu tya sudhi uparnu dudh nahi aapu.” (I will not feed top milk as long as I am breastfeeding.)

“Upar na dudhthi to jhada thay etale maruj aapu.” (Top milk causes diarrhea to the infant, so I give my milk only.)

Initiation of Fluids (other than top milk) to the Infants As in the case of top milk, many women (39%) were not aware before counseling regarding the age of initiation of fluids. At visit 2, 61% of the women were aware that fluids should be initiated around 6-8 months (Table 29); for example, thick daal, raab, fruit juice.) This difference was highly significant (p<0.001).

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Table 29: Change in Awareness regarding Age of Initiation of Fluids other than top milk Age of initiation of fluids

OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % 1 1.9 1 0.8 17 25.0 15 22.1 11 21.2 3 5.8 28 23.3 18 15.0 24 35.3 38 55.9 13 25.0 35 67.3 37 30.8 73 60.8 3 4.4 12 17.6 4 7.7 6 11.5 7 5.8 18 15.0 24 35.3 3 4.4 23 44.2 8 15.4 47 39.2 11 9.2

< 3 months 3-5 months 6-8 months >8 months No idea Note: Chi-squares comparing percentages of women who believed that fluids should be initiated at 6-8 months at Visit 1 and Visit 2 are significant for total sample; and for OPD (p<0.05) and ward (p<0.001).

According to the women, their awareness had increased due to counseling, advice given by pediatricians and also through information obtained from certain newspapers/ magazines, or informative booklets given by !""#$"%&" team members.

“Maane yaad chhe tahme kidhu haatu ke chh mahina paachi chalu karvanu.” (I remember that you [counselor] had told me that fluids should be initiated after 6 months.)

“Chopadi ma lakhyuj chhe ne etale vanchi ne aapish.” (I will read what is written in the booklet and give accordingly.)

As in the case of top milk, some women (15%) mentioned that they would initiate fluids after 8 months as they believed that the infants will not be able to digest top fluids. A few women and family members mentioned that even though they had initiated, the infant does not accept it and hence had discontinued giving.

“Dal nu pani aapyu pan pitij nahoti.” (I gave dal-water but she refuses to drink.)

Despite counseling, a few women (9%) were not aware when to initiate fluids and they mentioned that when they feel the need to initiate they will consult the pediatrician and would do as per his advice.

Initiation of Complementary Foods (CF) to the Infants Table 30 shows that as compared to pre-counseling, a higher percentage of women (13% more) were aware that soft-foods should be intiated around 6-8 months of age.

This difference was significant statistically (p<0.05). About half had earlier no idea about age of initiating CF before counseling.

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The women could recall the messages given by the counselors. To quote…

“Tame kidhu chhe ne chh mahina pachhi galelo khorak aapavanu. Evuj aapu.” (You [counselor] had told that soft foods should be given after six months. I will do accordingly.]

“Chh mahina pachhi pahela pani jevo khorak aapyo ane pachi pocho khorak – bhat,khichadi evu badhu aapyu.” (After six months initially I gave fluids and then soft foods such as rice, khichadi and other items.)

Table 30: Change in Awareness regarding Age of Initiation of Complementary Foods (CF) Age of initiation of CF

OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % 2 2.9 1 1.5 1 1.9 2 3.8 3 2.5 3 2.5 16 23.5 25 36.8 12 23.1 19 36.5 28 23.3 44 36.7 16 23.5 37 54.4 11 21.2 21 40.4 27 22.5 58 48.3 34 50.0 5 7.4 28 53.8 10 19.2 62 51.7 15 12.5

3-5 months 6-8 months >8 months No idea Note: Chi-squares comparing percentages of women who believed that CF should be initiated at 6-8 months at Visit 1 and Visit 2 are not significant for OPD and ward.

However, it is significant for total sample (p-value<0.05).

Many women and their family members believed that the infants should be fed soft foods only after 8 months – at around 9-10 months (Figure 8), mainly because infants less than 8 months do not have teeth and cannot digest foods.

% of Women aware about age of Initiation of CF

Figure 8: Change in Awareness among Women regarding Age of Initiation of Complementary Foods (CF) 60 48.3

50 36.7

40 30

VISIT 1 23.3

22.5

VISIT 2

20 10 0

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6-8 months

After 8 months

67

Some of them mentioned that their infants were not able to swallow food and throw up if soft foods are fed. A few mentioned that until the infant learns to sit properly they would not feed soft foods.

“Khorak toh gala ma atki jay chhe.” (Soft foods get stuck in the throat of the infant.)

“Ene to khali dudhaj bhave. Biju kashu khatoj nathi.” (He only likes milk. He does not eat anything else.)

“Chhokru baista shikhe pachhij khava devay ne.” (When child starts sitting, then only food should be given.)

Regarding quantity of complementary foods to be fed to the infants, a majority at Visit 1 had mentioned very inadequate quantities (1-2 tsp.). At Visit 2, a significantly higher (p<0.001) percentage of women (41% more) were aware that at each feed at least ½ -1 katorie of soft foods should be served to the infants at around 6-8 months of age (Table 31).

Table 31: Change in Awareness regarding Quantity and Frequency of CF OPD (N=68) WARD (N=52) TOTAL (N=120) Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 n % n % n % n % n % n % Quantity of complementary foods to be fed at 6-8 months Parameter

1-2 teaspoons ½ -1 katori As much as child eats No idea

8

11.8 17 25.0

7

13.5 11 21.2 15 12.5 28 23.3

15 22.1 26 38.2 3 4.4 9 13.2

7 6

13.5 23 44.2 22 18.3 49 40.8 11.5 5 9.6 9 7.5 14 11.7

42 61.8 16 23.5 32 61.5 13 25.0 74 61.7 29 24.2 Frequency of feeding complementary foods per day at 6-8 months

Once 2-3 times 4 or more times On demand No idea

5 7.4 8 11.8 4 7.7 4 7.7 9 7.5 12 10.0 12 17.6 25 36.8 16 30.8 22 42.3 28 23.3 47 39.2 8 11.8 19 27.9 1 1.9 13 25.0 9 7.5 32 26.7 2 41

2.9 603

1 1.5 2 3.8 2 1.7 3 2.5 15 22.1 31 59.6 11 21.2 72 60.0 26 21.7

Note: 1.The Chi-square comparing percentages of women who believed that ½- 1 Katorie of CF should be served at Visit 1 and Visit 2 is significant for OPD (p<0.05) and highly significant for ward and total sample (p<0.001).

2. The Chi-square comparing percentages of women who believed that CF should be given at least 2-3 times per day is significant for OPD (p<0.05); and total sample (p<0.01); but not significant for ward.

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The change was higher among those counseled in the wards as compared to those counseled in the OPD.

“Tahme kidhu tu em ek vakhatma 1 vatki aapu chhu.” (As you had informed me, I give one katorie at each feed.)

However, a few women continued to believe that initially at around 6-8 months the infants should be given about only 1-2 teaspoons of food at each feed. The main reason was that the infants do not have teeth and hence cannot digest more than a few teaspoons of food.

Figure 9 shows the change in awareness regarding quantity of complementary foods to be served to the infants after 6 months of age.

Figure 9: Change in Awareness among Women regarding Quantity

% of Women aware regarding Quantity of CF to be served

of Complementary Foods (CF) given to Infants 45 40 35 30 25 20 15 10 5 0

40.8

VISIT 1

18.3

VISIT 2 11.7 7.5

1/2 - 1 Katorie

As much as child wants

About one-fourth of the women continued to be ignorant as to the amount of CF to be given. As they were counseled when their infants were about 1-2 months old, it is possible that they did not pay much attention at that time to messages given related to CF.

“Ketlu aapvanu te khabar nathi, 6 mahinano thashe pacchi doctor ne puchchishu.” (I do not know how much of CF should be given, when my child becomes 6 months old, I will ask the doctor.)

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When asked ‘how many times should an infant 6-8 months old be given CF’; a significantly higher percentage of women were aware at Visit 2 that CF should be given at least 2-3 times during the day to the infants with continued breastfeeding (Table 31).

“Sanje ne savare ek-ek vaar khavadau. Vache fruit ke dudh aapvanu.”

(Complementary foods should be fed once in the morning and once in the evening. In between fruits and top milk should be given.)

“Be vaar jamavana jevu aapu pachi divas ma 2-3 vaar juice fruit evu badhu aapu.”

(Two times food should be given and then 2-3 times juices or fruits or such items should be given.)

On the other hand, about one-tenth of the women continued to believe that the infants should be fed CF only once a day at 6-7 months of age. Further, some of them fed as and when the child demanded or child cried.

A few women mentioned that they feed 1-2 teaspoons of foods many times during the day. Hence, they were unable to give an estimate of how much quantity and how frequently are infants fed complementary foods.

“Thodu-thodu aakho divas khaya kaare.” (He eats little many times during the day.)

These women were informed that they should regularize the meal timings and quantity of complementary foods given to their infants.

Initiation of Fruits and Vegetables to the Infants As indicated in Table 32, majority of the women (43%) were aware that fruits and vegetables should be initiated at 6-8 months of age at Visit 2 as compared to Visit 1 (22%). This difference was highly significant (p<0.001).

Table 32: Change in Awareness regarding Age of Initiation of Feeding Fruits and Vegetables to Infants Age of OPD (N=68) WARD (N=52) TOTAL (N=120) initiation of Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2 fruits and n % n % n % n % n % n % vegetables 3-5 months 2 2.9 3 4.4 1 1.9 2 3.8 3 2.5 5 4.2 6-8 months 19 27.9 30 44.1 7 13.5 21 40.4 26 21.7 51 42.5 >8 months 16 23.5 21 30.9 13 25.0 10 19.2 29 24.2 31 25.8 No idea 31 45.6 14 20.6 31 59.6 19 36.5 62 51.7 33 27.5 Note: The Chi-square comparing percentages of women who believed that fruits and vegetables should be given at 6-8 months is significant for OPD (p<0.05); ward (p<0.01) and total sample (p<0.001).

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Initially, they believed that since the infants do not have teeth, fruits and vegetables cannot be given. When counseled, they started mixing boiled vegetables with cerealpulse mixes; and also started giving soft- mashed fruits to the infants.

About one fourth of the women continued to believe that fruits and vegetables should be initiated after 8 months. Further, about one-fourth were not aware when to initiate fruits and vegetables; they were unable to recall despite being counseled. These were mainly women who were counseled when their infants were 1-2 months old; hence they perhaps did not pay much attention to counseling regarding complementary feeding.

A few women and their family members continued to believe that unless the child has teeth, fruits and vegetables cannot be initiated. They believed that they would get stuck in the throat. Certain fruits such banana and grapes were avoided despite counseling due to the perception that these fruits cause cough and cold.

Overall, some women could not recall the messages pertaining to complementary feeding. A likely reason is that when they were counseled they had either just delivered; or had infants less than 3 months of age; hence during counseling they only paid attention to messages related to breastfeeding as these were of immediate interest to them. Further, some women were helpless as regards following the recommendations given during counseling as they were pressurized by their mothers-in-law to follow traditional behaviours and not follow the advice given by pediatrician or the counselors.

On the other hand, some family members agreed to change their previous beliefs and accepted the recommended behaviours.

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Process Evaluation The !""#$"%&" program at MSH involves bi-weekly counseling sessions with the lactating women and their family members in the hospital wards immediately after delivery or in the OPD where women visit for postnatal checkup or for immunization / pediatric check-up of their infants. After the first visit, every attempt is made to have follow-up counseling sessions with the women in the OPD (one or two months later).

Trained nutritionists conduct the counseling sessions. During the sessions, counseling guide, session plans and visual flash cards are used to focus on critical behaviours or messages related to postnatal and infant nutrition-care as discussed earlier.

Simultaneously, records are maintained of each session especially the perceptions and practices of the lactating women and their family members during each visit. The counseling sessions and recording are periodically supervised and monitored. Further, fortnightly or monthly review meetings are held with senior experienced members of the team to review the progress of the program and make appropriate changes to further improve its impact. This continuous assessment process, and the changes made in the counseling based on this assessment is ongoing. This is the major strength of the !""#$"%&" program.

The major highlights of the process evaluation and the corresponding modifications made during the year are presented in a matrix in Annexure 4.

There is continuous modification in the counseling strategy, the message focus, the visuals used and the recording system of the !""#$"%&" program based on the observations of the sessions done periodically. The ultimate aim of the program is to satisfy the client’s need for information and bring about change in behaviours. To quote a woman…

“Saaru chhe tahme aa badhu samjhavo chho. Amne toh kai khabarj nathi. Tahme kidhu em karishu.” (It is good that you are informing us all this. We did not know anything. We would do as who have advised.)

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Factors Facilitating and Obstructing Behavior Change: The Motivators and The Inhibitors The !""#$"%&" Program of Aarogya Trust at the Maharani Shantadevi Hospital is an ongoing program to improve the postnatal and infant nutrition and care practices of the lactating women and their family members.This program review assessed the progress of !""#$"%&"( and lessons learnt. In the year 2004, 643 women along with their family members were reached through this program. Of these, 120 women came for follow-up till the time of this report.

The twice-weekly counseling sessions carried out in the wards and OPD of the hospital to impart nutrition and care messages by a pair of Vaatsalya sakhis has brought about a positive change in several perceptions and practices of the lactating women and their family members as regards nutrition care.

The highlights of perceptions and practices which changed; and the extent of change seen from pre-to-post counseling as determined through quantitative assessment of women’s responses at Visit 1 (pre-counseling) and Visit 2 (post-counseling), are presented in this section.

Further, during the counseling sessions with the women, varied responses were obtained indicating the motivating factors enabling positive behaviours and the constraints preventing the desired behavior change. These responses were categorized and the interesting insights obtained from the women and their family members are presented in tabular form.

The symbol ‘+’ indicates frequency of responses, where: +++

= majority of informants (above 50%)

++

= some informants (30-50%)

+

= few informants (less than 30 %).

A: Lactating Women’s Nutrition Quantity of Food Intake Figure 10 indicates that though food intake of lactating women in terms of quantity eaten did not change in a majority, qualitative improvements appeared to have occurred in terms of less food restrictions.

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% of Lactating Women

Figure 10: Change in Behaviors regarding Nutrition during Lactation 100 73.3

80

73.3

67.5

60

Visit 1

40

25.8

Visit 2

20 0 Food Intake Increased

Certain Foods Avoided

Nutrition During Lactation

As shown in Table 33, the motivators for increasing food intake in lactation remained more or less the same in Visits 1 and 2 (majority of the women were already eating more than usual). However, due to counseling the various constraints mentioned to increase food intake reduced.

Table 33: Key Responses of the Women and Family members regarding Quantity of Food Intake during Lactation during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Increased food intake (+++) The Motivators For increased milk production (+++) Increased appetite (++) For proper growth and development of the child (+) To provide good nourishment of the child (+)

Food intake remained same or decreased food intake (++) The Inhibitors Caesarian section delivery (+) Recently delivered (+) Illness of women (+) Does not like hospital food (+) Loss of appetite (+) Weight consciousness (+) Excess work load and negligence towards own health (+) Reduced breastfeeding as initiated

Vaatsalya, Aarogya 2005

Increased food intake (+++) The Motivators For increased milk production (+++) Increased appetite (++) For proper growth and development of the child (+) Motivation from counselors (+) Food intake remained same or decreased food intake (+) The Inhibitors Loss of appetite (+) Weight consciousness (+) Reduced breastfeeding as initiated complementary food (+)

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Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)

complementary foods (+) Lack of awareness (+) Indigestion due to more intake (+) Affects child (‘bhar pade’) and leads to diarrhea(+) Excess intake causes excess milk production which causes discomfort to women (+) Seasonal effect (+) Certain Myths regarding Food Intake during Lactation Similarly, many reasons stated by the women and their family members regarding avoiding certain food items during lactation also reduced after counseling (Table 34).

They agreed to consume the food items previously avoided and appreciated the counseling.

Table 34: Key Responses of the Women and Family members regarding Quality of Food Intake during Lactation during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Consuming various food groups without any Consuming various food groups without restrictions due to lactation (+) any restrictions due to lactation (++) The Motivators The Motivators To maintain own health (+) Counseling (++) For better growth and development of the child Support of family members (+) (+) To maintain own health (+) The child gets better adjusted to the foods if all foods consumed right from the beginning (+) Avoiding certain food items (++) The Inhibitors Avoiding certain food items (+++) Insistence of family members (++) The Inhibitors Various beliefs mainly affecting child’s Various beliefs mainly affecting child’s health health (+) and own health (+++) Cannot digest certain food items (+) Lack of awareness (++) Religious reasons (+) Religious reasons (++) Insistence of family members (++) Difference due to gender of the child (+) It was interesting to note the various reasons mentioned to avoid certain food items. The main food items avoided were vegetables, pulses and legumes as indicated in the matrix below. During counseling, it was explained that these foods do not affect the women or the infants adversely. Food per se has no adverse effect on the health of the mother or child. However, they were cautioned that in case they are sensitive to certain foods (for

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75

example, food allergies) or for other medical reasons are advised to avoid them, they should consult their physician and follow the instructions. A few items avoided due to religious reasons continued to be avoided such as jaggery, asaefoetida, tea and so on.

Food Item Vegetables Cluster beans (+++) Ladies finger (+++) Field beans, brinjal (++) Potato(++), sweet potato (+) Colocasia leaves (++) Tandalja (Amarnath leaves) (+) Green leafy vegetables (+) Pumpkin (+) Pulses and Legumes Pulses (++) Green peas (+) Black gram dal (+) Red gram dal (+) Banana, grapes (++) Bengal gram dal / flour (++) Cereals Rice (++) Corn (+) Milk and Milk Products Milk (+) Sour things (curd, lemon tamarind) (++) Cold water, ice creams (+) Fruits & other foods Guava, Bor (Zizyphus) (+) Salt, turmeric (+) Spicy, oily foods (+) Asafoetida (+) Jaggery (+) Non-vegetarian foods (+)

Vaatsalya, Aarogya 2005

Reasons for avoiding by Mother Effect on Mother Effect on child Indigestion

Varadh (Severe cough) Varadh (Severe cough)or diarrhea

Gastric trouble Stomachache

Heavy to digest

Gastric trouble Stomachache Varadh (Severe cough) Green stools Heavy to digest

Stomach ache, flatulence, Stomach ache, flatulence, diarrhea diarrhea Stomach hardens Pus formation in stitches.

Reduces milk production Varadh (Severe cough) Cold / cough Flatulence Flatulence Flatulence Flatulence, stomachache

Flatulence, stomachache Sticky stools or Cough / cold

Pus formation in stitches Flatulence

Cough / cold Stomachache Pus formation in childâ&#x20AC;&#x2122;s ears.

Acidity Religious reasons Religious reasons Heavy to digest

Heavy to digest

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IFA Supplementation during Lactation Figure 11 shows that there was a 13% increase in proportion of women taking IFA tablets during initial months of lactation. However, the duration of taking tablets varied.

Some women consumed for 2 months and some for more than 4 months.

% of Lactating Wom en

Figure 11: Change in Behaviors regarding IFA supplementation during Lactation 100 80

65 51.7

60

Visit 1 Visit 2

40 20 0 IFA Suplem entation

The women and their family members gave various reasons for consuming iron tablets and the constraints for not consuming iron tablets (Table 35). The major reasons given for not consuming iron tablets during lactation was lack of awareness; and that it was not prescribed by the doctor. On counseling, the women and their family members went back to the doctors for prescription or collected tablets from FWC and started iron supplementation.

Table 35: Key Responses of the Women and Family members regarding Iron Supplementation during Lactation during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)

Consuming daily one IFA tablet at least for Consuming daily one IFA tablet at least for 3 months after delivery (+) 3 months after delivery (++) The Motivators The Motivators Doctor’ advice (+)

Counseling (+) The Inhibitors

Doctor’s advice (++) (Women ask for IFA Not aware (+++) prescription).

Not prescribed by the doctor (+++) The Inhibitors IFA tablets are believed to be ‘hot’ (+) Not prescribed by the doctor (+) Causes constipation, nausea (+) Irregular consumption due to negligence (+) First stock of IFA purchased completed and not bought more tablets (+) Consumed in pregnancy so do not consume Irregular consumption due to negligence (+) now (+)

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B: Breastfeeding Practices The breastfeeding practices improved remarkably after counseling (Figure 12). Many women adopted the practice of exclusive breastfeeding till 6 months, feeding ‘hind’ milk to their infants and continuing breastfeeding during illness of the infant or mother, which they were not doing earlier.

Figure 12: Change in Perceptions regarding Breastfeeding Visit 1

% of Lactating Women

120 97.5

100 74.2

80

93.3

Visit 2

75.8

56.7

60

36.7

40 22.5 15

20 0 Initiation of Water after 6 m onths

Feeding 'Hind' Milk

Continuing BF during Infant's Ilness

Continuing BF during Mother's illness

Table 36 gives the highlights underlying initiation of water. After counseling, the family members realized that it is very important to exclusively breastfeed (EBF) infants till 6 months of age and hence agreed to delaying initiation of water. However, a few women who perceived ‘insufficient breast milk production’ or since they go to work outside, had initiated water (and top foods) despite counseling. A few family members continued to believe that infants need water after 3 months especially in summer season. The baby card given from the hospital also mentioned initiation of fluids at 4-5 months of age.

These were printed with earlier recommendations. Due to the efforts of the !""#$"%&"( team members and the hospital pediatricians, the instructions on baby card were edited and new baby cards were printed, recommending EBF till 6 months.

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Table 36: Key Responses of the Women and Family members regarding Initiation of Water during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Initiation of water at 6 months (+) The Motivators Doctor’s advise (++) Information from newspaper/magazines (+)

Post Counseling (Visit 2) Initiation of water at 6 months (++) The Motivators Counseling increased awareness (++) Doctors’ advise. (++)

Initiation of water before 6 months (++) The Inhibitors Because of summer season (++) Family insistence (++) Water necessary for child’s digestion (+) Not aware that it is harmful (++) Initiated during child’s illness e.g. diarrhea (+) Information printed on the baby card (+)

Initiation of water before 6 months (+) The Inhibitors Summer season (+) Family insistence (+) Doctor’s advise (+) Information printed on the baby card (+)

Similarly, mainly due to lack of awareness and insistence by family members, some women did not feed ‘hind’ milk to their infants. After counseling the women and their family members, most of them started feeding ‘hind’ milk. However, a few women continued to feed from both breasts at each feed as they were troubled due to engorgement of breast and dripping of breast milk from the other breast (Table 37).

Table 37: Key Responses of the Women and Family members regarding Feeding ‘hind’ milk during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Feeding hind milk (+) The Motivators Doctor’s advise (+)

Feeding ‘hind’ milk (++) The Motivators Counseling (++) Doctor’s advise (+) Not feeding ‘hind’ milk (+++) Not feeding ‘hind’ milk (++) The Inhibitors The Inhibitors Family insistence. (++) Family insistence. (+) Fear of change in breast size (++) Problem with one breast. (+) Not aware regarding ‘hind’ milk (++) Not convenient to feed ‘hind’ milk due to Problem with one breast (+) engorgement, soreness and dripping from Child does not suckle at only one breast other breast (+) (+) Child does not suckle at only one breast(+) Dripping of breast milk from another Milk flow less from one breast (+) breast or engorgement of breast (+) Insufficient milk for child from one breast (+) Milk flow less from one breast (+)

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As Figure 12 earlier indicates, continuing breastfeeding during illness (of child or mother) showed an increase in Visit 2 and this improvement was more marked for breastfeeding the child when mother is ill.

Table 38 gives the summary of responses of women and their family members regarding reasons underlying continuing breastfeeding during illness of the infant. There were various beliefs regarding breastfeeding during illness of the infant. As many women were simply not aware that they should continue breastfeeding during illness of the infant, the counseling clarified their doubts and they were informed that in illnesses such as fever, cough-cold, diarrhea, and so on; breastfeeding should be continued. A few family members continued to believe that diarrhea and cough-cold are caused due to breastfeeding especially when the mother consumes certain food items as mentioned earlier.

Table 38: Key Responses of the Women and Family members regarding Breastfeeding during Illness of Infant during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)

Breastfeeding continued during illness of child (++) The Motivators No other alternative to breast milk (++) Breastfeeding gives strength to the child and helps in recovery. (+) Doctors’ advise. (+) Breastfeeding (BF) not continued during illness of child (+) The Inhibitors Not aware (++) Private practitioners’ (doctor, ayurvedic or other faith healer) advise (+) Breast milk makes the illness worse (+) Sick child cannot digest breast milk (+) Advise from family members (+)

Breastfeeding continued during illness of child (+++) The Motivators Counseling (++) Doctors’ advise. (+)

Breastfeeding not continued during illness of child (+) The Inhibitors Private practitioners’ (doctor, ayurvedic or other faith healer) advise (+) Advise from family members (+) Illness such as diarrhea (+)

A greater percentage of women discontinued breastfeeding during their own illness as compared to illness of their infants, and this changed after counseling. Earlier, they believed that breastfeeding will lead to illness being transferred to their children, but then their doubts were clarified during counseling and hence their perceptions and practices in this regard improved. However, a few women and their family members continued to

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fear that their illness will be transfered to their infants and hence did not breastfeed during their own illness (Table 39).

Table 39: Key Responses of the Women and Family members regarding Breastfeeding during Illness of Mother during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Breastfeeding continued during illness of Breast feeding continued during illness of mother (++) mother (+++) The Motivators The Motivators No other alternative to breast milk (++) Counseling (++) Breast milk does not harm the child (+) Breast milk does not harm the child (++) Doctor’s advise (+) Doctor’s advise. (+) Breastfeeding discontinued during illness Breastfeeding discontinued during illness of mother (+) of mother (+) The Inhibitors The Inhibitors Fear of transferring mother’s illness through Fear of transferring mother’s illness breast milk (++) through breast milk. (+) Adverse effect of mother’s medication. (+) Family resistances as they believe that Family resistances as they believed that mother’s medication has adverse effect on mother’s medication has adverse effect on child, mother’s illness get transferred to child, mother’s illness get transferred to the the child and since years they discontinue child and since years they discontinue during during illness (+) illness (++)

C: Complementary Feeding Practices Complementary feeding (CF) practices improved mainly in terms of initiation of fluids and foods at the right age of around 6 months and decrease in too early initiation of top milk and other fluids (Figure 13).

% of Lactating Women

Figure 13: Change in Awareness regarding Age of Initiation of Top Milk and Other Fluids

100 90 80 70 60 50 40 30 20 10 0

60.8

59.2

Visit 1 Visit 2

30.8 17.5

Initiation of Top m ilk after 6 m onths

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Initiation of Other fluids after 6 m onths

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Initiation of top milk Table 40 gives the summary reasons related to CF practices. The reasons for initiating top milk at an early age were addressed and hence after counseling top milk was initiated at 6 months or later. Further, some of the reasons cited earlier such as inverted nipples, engorgement of breasts, were temporary and once these problems were solved they stopped giving top milk to their infants.

Some of the women and their family members believed that as long as breastfeeding is continued top milk should not be initiated. A few women and their family members continued to believe this even after counseling and hence did not make efforts to initiate top milk even among infants 9-10 months of age.

Table 40: Key Responses of the Women and Family members regarding Initiation of Top milk during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Initiation of top milk at 6 months (+) Initiation of top milk at 6 months (++) The Motivators The Motivators Top milk is essential for proper growth of Counseling (++) the child (+) Early Initiation of top milk around 3-4 Early Initiation of top milk around 3-4 months (+) months (++) The Inhibitors The Inhibitors Insufficient breast milk (+) Insufficient breast milk (+) Mother working out (+) Twin children (+) Twin children (+) Engorgement of breast or Inverted nipples (+) Family insistence (+) Late initiation of top milk at 7 months or Child needs top milk after 4 months with later (+) breast milk for proper growth (+) The Inhibitors To satisfy childâ&#x20AC;&#x2122;s hunger as breast milk As long as breast milk is sufficient, top milk decreases after 3-4 months (+) should not be initiated (+) Women working outside home (+) Indicated in the baby check-up card (+)

Late Initiation of top milk at 7 months or later (++) The Inhibitors Child can digest top milk only after 7 months (+) As long as breast milk is sufficient, top milk should not be initiated (+) Child dislikes top milk (+)

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Initiation of other fluids The major reasons cited for early initiation of fluids was insistence by family members, insufficient breast milk and due to mention of this in the baby card (Table 41). As long as the baby card was not revised the women continued to follow instructions given in it.

Many women were influenced by counseling and agreed to initiate only after 6 months of age of the infants. A few women continued to believe that as long breast milk is produced there is no need to initiate top fluids since the infant will not be able to digest them. A few women especially those counseled in wards could not recall the messages related to complementary feeding, probably since at that time they did not pay attention since they were more concerned regarding breastfeeding.

Table 41: Key Responses of the Women and Family members regarding Initiation of Fluids other than top milk during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Initiation of fluids at 6 months (+) The Motivators Doctorsâ&#x20AC;&#x2122;advise (+) 2nd delivery hence aware of this (+)

Initiation of fluids at 6 months (++) The Motivators Counseling (++) Doctorsâ&#x20AC;&#x2122;advise (+)

Early Initiation of fluids at 3-4 months (+) The Inhibitors Indicated in the baby check-up card (+)

Early Initiation of fluids at 3-4 months (++) The Inhibitors Insistence from family members, neighbours (+) Breast milk alone insufficient after 4-5 months (+) Indicated on baby card (+) Needed for growth of the child (+)

Late initiation of fluids at or after 7 months (+) Late initiation of fluids at or after 7 The Inhibitors months (++) Child is too young to digest (+) The Inhibitors Less attention of women during to this Child does not accept (+) message counseling and hence not aware.

Lack of awareness (++) (+)

Initiation of soft foods Before counseling a majority of the women and their family members believed that soft foods should be initiated after 7-8 months of age as the child cannot diges foods; and soft foods should be given only after child starts sitting or his/her teeth erupt. Further,

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increase in the quantity and frequency of soft foods fed in the crucial period of 6-8 months also was reported after counseling (Figure 14). There was also improvement as regards quality of complementary feeding especifically initiation of fruits and vegetables among infants at 6-8 months.

% of Lactating Women

Figure 14: Change in Awareness regarding Complementary Feeding

100 90 80 70 60 50 40 30 20 10 0

Visit 1 Visit 2

40.8

36.7 23.3

18.3

42.5

39.2 23.3

21.7

Initiation of Soft Giving atleast 1/2- Giving atleast 2-3 Initiating Fruits feeds per day and Vegetables 1 Katorie at each foods after after 6 m onths feed m onths

Counseling played a major role in changing their beliefs and they agreed to initated after 6 months of age and not wait till teeth erupted (Table 42).

Table 42: Key Responses of the Women and Family members regarding Initiation of Soft foods during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Initiation of soft foods at 6 months (+) Initiation of soft foods at 6 months The Motivators (++) For proper growth of the child (+) The Motivators Counseling (++) Late initiation of soft foods after 7 months (++) Late initiation of soft foods after 7 The Inhibitors months (+) Insistence from family members, The Inhibitors neighbours as they believe that soft foods Child cannot swallow (+) should be initiated when child starts sitting When child learns to sit (+) and child cannot digest before 7 months (+) Less attention of women during Child does not accept (+) counseling (+) Child cannot digest (+) After teeth eruption (+)

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Quantity and Frequency of Complementary Feeding A majority of the women earlier believed that at 6 months only 1-2 teaspoons of food should be given to the infant at each meal. They believed that a little at a time should be given as the infant will not be able to digest more food. A few believed that infant should be fed as much as he/she wants. During counseling, it was emphasized that the infant needs more food (1/2-1 Katorie at one sitting) and that s/he should be encouraged to eat more. Adequate amount of CF at each meal is required for proper growth and development of the infant (Table 43).

Table 43: Key Responses of the Women and Family members regarding Quantity and Frequency of Complementary Feeding during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Quantity of soft foods given to infants at 6-8 months ½ katori –1 katori of complementary foods ½ katori – 1 katori per meal of given per meal (+) complementary foods given to infant The Motivators after 6 months (++) Aware of this since second child (+) The Motivators Counseling (++) 1-2 teaspoons of complementary foods given Aware of this since second child (+) per meal to infant after 6 months (++) The Inhibitors 1-2 teaspoons of complementary foods Child cannot consume more than 1-2 given per meal to infant after 6 months teapoons of soft foods (++) (++) Child cannot digest more food (++) The Inhibitors Insistence from elderly family members Child cannot consume more than 1-2 who believe that infant can be fed only teapoons of soft foods(+) little at a time (+) Child should be fed as much as s/he demands (+) To develop taste of soft food (+) Frequency of Feeding soft foods to infants at 6-8 months Feeding complementary foods 3-4 times/day Feeding complementary foods 3-4 (+) times/day (++) The Motivators The Motivators For growth and development of the child For growth and development of the (+) child (+) Counseling (+) Feeding complementary foods only once or twice day (++) Feeding complementary foods only once The Inhibitors or twice day (+) Child cannot digest (+) The Inhibitors Child does not accept more (+) Child cannot digest (+) Child like breast feeding more (+) Child does not accept more (+)

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Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Give as per the family meal pattern (+) Insistence by family members who Insistence by family members who believe believe it is sufficient for the infant as it is sufficient for the infant (++) child is still breastfeeding (+) At Visit 1, a majority of the women fed CF only once or twice a day. They believed that the infants cannot digest more than that or cannot accept more than that. Further, many family members believed that breast milk alone is sufficient for the infant till about 9-10 months of age (Table 43). When they were informed about the requirement of the infants and the need of CF for physical and mental growth of the infant, they agreed to increase the frequency of CF given at 6-8 months.

Initiation of Fruits and Vegetables As in the case of soft foods, many women and their family members believed that fruits and vegetables should be initiated after teeth erupt. Contrastingly, a few women initiated fruit juices and vegetable soups at a tender age of 4-5 months. At visit 2, the women mentioned that they were aware that soft fruits and boiled mashed vegetables should be initiated at 6 months; and that this is necessary for maintaining the health of the infants (Table 44).

Table 44: Key Responses of the Women and Family members regarding Inititation of Fruits and Vegetables during Visit 1 and Visit 2 Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Initiation of fruits and vegetables at 6 months Initiation of soft fruits and boiled soft (+) vegetables at 6 months (++) The Motivators The Motivators Fruit juices and soups gives strength to the Counseling (+) child (+) Good for health of child (+)

Early initiation of fruits and vegetables (only juices and soups) at 4-5 months (++) The Inhibitors Fruit juices and soups has good nutritive value (+) Insistence from family members as they are eager to begin (++)

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Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2) Late initiation of fruits and vegetables after 8- Late initiation of fruits and vegetables 9 months or later (+) after 8-9 months or later (+) The Inhibitors The Inhibitors Given when teeth erupt (++) Given when teeth erupt(++) Various beliefs that certain fruits and Various beliefs that certain fruits and vegetables have adverse effect on health (+) vegetables have adverse effect on health (+) Overall, the responses gave rich insights into the underlying factors and cultural beliefs which influence infant feeding behavious and helped us to modify our counseling guide based on this information. We also understood why some behaviors improved and why some did not.

An unexpected and encouraging observation was that there was a decrease in the prevalence of underweight (WAZ<-2.0) to 2.8% as compared to 5.4% at enrolment, among infants 0-5 months of age. Similarly, among infants 6-11 months, the prevalence of underweight decreased to 3.3% from a high prevalence of 27.3% at enrolment. The prevalence of underweight had decreased more among girls (6.1%) as compared to boys (1.9%). This impact clearly points out to the benefits of our complementary feeding messages.

Overall, considering that just one contact was made, the counseling brought about unexpected and encouraging improvements in reported practices of benefit to both, mother and infant.

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CONCLUSION When we began the Vaatsalya Program, we were convinced that with a systematic approach to nutrition communication and with patience and persistence, and keeping behavior change as the goal, we will be able to implement an effective, need-based program in a hospital setting. However, we had our doubts regarding the extent of change possible with just one or two contacts with women and their families in crowded OPDs and busy wards. Nevertheless, we took the plunge but made sure that all the necessary formative research; dialogue with hospital authorities and the required planning to prepare a well thought out communication strategy, (with appropriate messages and visuals) had been accomplished first.

The results and positive impact (as regards improving lactation care and infant-feeding and care practices) have surpassed our expectations. In just one (at the most two) contacts lasting for about 15 minutes on average, we were able to bring about remarkable increases in awareness and positive impact on practices, which the results section has demonstrated.

As also seen from the data, the factors motivating behavior change were primarily the following:

♦

The counseling itself and the attention to effective communication. It sounds too simple, but it is true: often the lack of desirable behaviour is simply because people who need information often do not get it in an appropriate manner.

♦

When message recipients become aware of the benefits of the desired practices and the harmful effects of the undesirable practices, they are more willing to change. This means that adequate attention to message content is important.

♦

Family support facilitated the change process. Thus, counseling just the primary caregiver is not enough; the whole family needs to be involved and sensitized.

♦

Experience of motherhood – those who already had a child seemed aware; (though many said they did not know of these messages).

♦

Hospital support and reinforcement of similar messages by the doctors.

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It was expected that inhibitors of change will also continue to play a role and prevent some women/their families from practising the desired behaviours; and our efforts will continue to address this resistance/anxieties towards change. We are confident that with time, even a brief contact in a hospital setting- if appropriate and effective- can lead to change in a large proportion of women and their families who avail of maternity care services.

Our experiences indicate that non-government organizations can forge

partnerships with hospitals for positive change towards good nutrition and health of women, newborns and infants.

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ANNEXURE 1 Question Guide to understand perceptions and practices of the women regarding Antenatal, Postnatal and Infant Nutrition Background Information: Name of the woman: Place of Residence: Urban/ Rural Type of Delivery: Date of the Interview: Name of the Interviewer: Question Guide Nutrition during Pregnancy and Lactation 1. Can you describe your routine diet during pregnancy?

2. Did you change the quantity of your food intake during pregnancy? (Probe for Increase, decrease or same) a) Increase b) Decrease c) Same 3. After you go home from the hospital, will you change the quantity of your food intake? d) Increase e) Decrease f) Same 4. Will you avoid any food items after you go home (during first 6 months of breastfeeding?

5. Do you think it is important to increase food intake during pregnancy and lactation?

6. How many times in a week did you consume the following foods during pregnancy?

(Probe for reason if not consuming) a) Fruits (seasonal) Tomato/Lemon Papaya/Mango Others b) Green leafy vegetables Methi ni bhaji Shepu / Palak Others c) Pulses and legumes Chana/Chaula Masoor/ Muth Vatana (dry) d) Milk/ Curd/ Buttermilk e) Bajra (rotla) f) Meat/ Fish/ Poultry 7. What is the importance of consuming fruits and green leafy vegetables during pregnancy and lactation?

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8. How many IFA tablets did you consume during pregnancy? (Probe: Daily/Weekly for how many months) 9. Will you continue consuming IFA tablets when you go home? If yes, for how long?

10. What are the benefits of consuming IFA tablets during pregnancy and lactation?

11. Did you take rest during the day during pregnancy (min. ½ hour)? a) Yes b) No c) Other (e.g. state if rest advised due to medical reasons) 12. Do you think a pregnant woman should take rest in a day? (Probe for reasons for ‘Yes’ and ‘No’) 13. How much was your weight gain during pregnancy?

14. Was your weight monitored regularly (Probe: once a month)?

15. Why do you think one should monitor the weight gain during pregnancy?

Breastfeeding and Complementary Feeding 16. Did you feed colostrum to your child? a) Yes b) No c) Other 17. What is the importance of colostrum for the newborn?

18. Did you start breastfeeding the child within 1 hour of birth? (Probe for reasons for ‘Yes’ and ‘No’ responses) 19. Till what age, will you exclusively breastfeed your child? (Probe and note if they will exclusively breastfeed with or without water) 20. Do you think it is desirable to exclusively breastfeed till six months? (Not even giving water) 21. At what age, is it desirable to introduce top milk? Why? 22. At what age, is it desirable to introduce top foods? Why? 23. How much quantity of food should a 6-8 month old receive in a day?

24. By 12 months, how much should the child consume?

25. During illness, will you a) Increase breastfeeding your child b) Decrease breastfeeding your child c) Breastfeed same as before 26. During illness, will you a) Increase breastfeeding your child b) Decrease breastfeeding your child c) Breastfeed same as before 27. For a 6-12 month old child, what are foods which are beneficial? Why? 28. For a 6-12 month old child, what are foods which are harmful? Why?

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ANNEXURE 2 A section of the counseling guide Behavior Change Communication Strategy (CMRS Strategy) Post-natal Care

Message Code

P1

Message for Behavior Change for Mother

Increase quantity of • food; and quality of food.

•

• • •

One extra food item daily e.g. 1 roti or 1 vatki dal-bhat or 1 vatki • kathol or 1 vatki upma or bataka• pauwa Include daily one fruit (any seasonal • fruit) Include 1 vatki bhaji daily in your diet.

Drink adequate amount of water/ liquids.

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Motivating

Expected Resistance and Overcoming It

Factors Gives mother energy to take care of the baby and make up for losses during delivery.

Breast milk output will be sufficient.

Weight and Health is maintained Gives immunity against diseases.

Hence, able to take care of the baby well.

•

•

Family Support (H: Husband; MIL: Mother-in-Law)

Do not get time to think ♦ about myself It is important to maintain weight and one’s own health so that you can work normally, feel well, and can take care of the health of the child and the family. ♦ I cannot eat more .It is not possible to eat more.

Then eat small frequent meals which are nutritious.

It is essential to recover losses of the delivery and pregnancy; and to maintain health during breastfeeding period.

93

♦ ♦

Encourage mothers to eat one helping more. It is important that mothers take care of their own health and not just health of child. Breast milk quantity and quality improves if mothers take proper food.

Bring fruits, green leafy vegetables from market frequently; and prepare nutritious snacks.

Keep aside fruits, nutritious snaks and extra food for frequent small meals.

Remind them to consume the above.

ANNEXURE 3 DATA RECORDING SHEET-Visit 1: A sample

!""#$"%&" (Maharani Shantadevi Hospital Knowledge and Practices of Lactating Women before Counseling- Visit 1 DATA RECORDING SHEET-Visit 1 Dates: Place: OPD/ WARD Variable Label FL1

FAV1

IFA1

IW1

FHM1

BFILCH1

Responses of the women regarding each message1 Regt. No. Food intake during lactation ♦ Increased ♦ Decreased ♦ Same ♦ No idea/ No response

W1

W2

W3

W4

W5

W6

Any foods avoided during lactation ♦ Yes ♦ No ♦ No idea/ No response Consuming/ Consumed IFA during lactation ♦ Regular- daily for 1-3 months ♦ Irregular ♦ No ♦ No idea/ No response Age of initiation of water ♦ 0–2 mths ♦ 3–5 mths ♦ 6 mths ♦ 7-8 months ♦ No idea / No response Feeding Hind Milk 2 ♦ Yes ♦ No ♦ No idea / No response BF during child’s illness ♦ Yes ♦

No

♦

No idea / No response

1

Tick (√) in the columns as per responses given by the women.

Yes = Emptying one breast & then feeding from other. No = Feeding from both breasts for 1-2 minutes or little from both breasts

2

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Observations

ANNEXURE 4 Continuous Program Improvements ( Modifications in the program based on the observations

Process related: ♦ The nurses assisting the pediatricians ♦ The and the staff members of FWC quite often forget to direct women to !""#$"%&" counseling center

!""#$"%&" sakhis themselves directed the women waiting outside the OPD of pediatrician and the FWC to the !""#$"%&" counseling center.

♦ The FWC had fixed days of each month ♦ To enroll more women in the !""#$"%&"

for BCG vaccination i.e. 10th, 20th and program, the counseling session in the 30th of each month. Many lactating OPD were also held on these BCG women along with their neonates visited vaccination days over and above the bithe hospital on these days weekly sessions. ♦ Some women visited the !""#$"%&" ♦ It was decided to note down the date of Visit 1 and the registration number of the center for the second time within a women as per !""#$"%&" records on the month of the Visit 1. This did not allow last page of the child record booklet. The the women to have adequate time to women always carry this booklet when practice the behaviors. Also at the time they visit the hospital so it is easy for the of the Visit 2 the counselors did not have any indication of the date of the Visit 1. !""#$"%&" sakhis to decide whether the women needs the Visit 2 session. ♦ Similarly, when women came to visit for the third time, the counselors did not ♦ The counselor also noted the Visit 2 and have any indication how many times the Visit 3 dates on the child record booklet. women are counseled and when.

This informed them without going through their own record books about the counseling session with the women. ♦ Some women forgot certain messages ♦ Informative and colorful booklet was when they went home and hence designed and printed which had the requested for some sort of reminders or same messages as given by the informative brochures. Although most !""#$"%&" counselors and had similar women were not very educated, they pictures as in the flash cards used by could read the local language Gujarati counselors. This served as a good reinforcement tool. Family members could use it to inform women if needed.

Message related: ♦ The pediatricians and the booklet for ♦ Due to continued follow-up by !""#$"%&" recording the weight and vaccination team members, the booklets were schedule of the children registered at the revised and reprinted by the hospital. hospital (child-record booklet) Also the pediatrician supported current recommended that fluids should be recommendations of ‘exclusive breastinitiated at 4-6 months of age. feeding till 6 months of age of the infant’. ♦ During formative research, certain critical ♦ The message related to avoiding messages related to neonatal feeding prelacteals and herbal fluids before 6 such as initiation of breastfeeding within months of age of the infant was added in

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Observations

Modifications in the program based on the observations

½-1 hour after delivery, feeding the counseling session of the !""#$"%&" colostrum and avoiding prelacteals were program. emphasized by the pediatricians, gyneacologists and nutritionists of the hospital. Hence these were not included in the Vaatsalya counseling strategy.

However during Visit 1, many women mentioned prelacteal feeding such as honey and ghee as well as feeding herbal fluids such as gripe water within 1-3 months of infant’s age. ♦ Initially !""#$"%&" strategy included ♦ The counseling strategy was revised and modified in such a way that there were details messages related to different messages for women with complementary feeding. For example, younger infants (1-3 months) and women feeding at least ½-1 katorie per meal; with older infants (4-12 months). The feeding 3-4 times a day. However, the messages focus more on breastfeeding women having infants less than 3 for mothers with younger infants and months of age did not pay attention to more on complementary feeding for these messages. mothers with older infants. special message regarding ♦ Many women visiting the !""#$"%&" ♦ A breastfeeding twins was added for center had twins. They had many mothers having twins. queries regarding breastfeeding both the infants.

Recording related: ♦ Initially the perceptions and practices of ♦ For making recording and data entry the women counseled were noted as easier, each message was given a field notes. Later on to code and enter variable name and data entry sheets, the information in to the computer used which included all the messages given to be difficult. by the counselors along with the probable answers or options. The counselors record the options given by each woman on the data sheets. ♦ Data entry was difficult since options or ♦ The data sheets were revised to include answers given by the women were the codes of the answers or options for ticked in the data sheets. The data entry each of the message or variable. The operator had to enter the suitable code recorder recorded the codes in the data in the computer corresponding to that sheet according to the response of the answer or option ticked. women. This helped in data entry later on.

(

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