EXCLUSIVE BREASTFEEDING IN INDIA: TRENDS AND DATA GAPS

Globally, only 38 percent of infants aged 0 to 6 months are exclusively breastfed. Recent analyses indicate that suboptimal breastfeeding practices, including non-exclusive breastfeeding, contribute to 11.6 percent of mortality in children under 5 years of age. This was equivalent to about 804,000 child deaths in 2011 (WHO/UNICEF). In 2012, the World Health Assembly (WHA) unanimously endorsed a set of six global nutrition targets, including an increase in exclusive breastfeeding (EBF) rates, to be achieved by 2025 to improve maternal, infant and young child nutrition across the world.

A recent report by POSHAN, provides an overview of national trends and of state-level variability in nutrition outcomes, determinants, and intervention coverage in India. Our analysis of the EBF trends shows that, over the last decade, the percentage of infants (under 6 months of age) who were exclusively breastfed in India increased from 46.4 percent to 54.9 percent. The national average, however, conceals variability across states. Prevalence of exclusive breastfeeding ranges from 35.8 percent in Meghalaya, to 77.2 percent in Chhattisgarh. Despite this variability in levels, what is encouraging is that most states saw substantial increases in EBF, with Goa leading with a 43.2 percentage point increase. Only six states (Uttar Pradesh, West Bengal, Chhattisgarh, Karnataka, Arunachal Pradesh and Kerala) showed a decline in the prevalence of EBF; Uttar Pradesh had the maximum decline of -9.7 percentage points.

The disaggregated district-level data from the NFHS-4 highlight that about one third of all the districts have EBF levels that are higher than 60 percent. The top ten districts with the highest levels of EBF belong to Chhattisgarh, Madhya Pradesh, Assam, Maharashtra, Andhra Pradesh and Rajasthan, with Mandsaur (MP), leading with 95.1 percent. Seven out of the bottom ten districts with the lowest EBF rates belong to Uttar Pradesh.

A key data challenge around EBF is that for one-third of the districts, EBF prevalence cannot be calculated because of small survey sample sizes for the 0-5 month age group, which is a sub-sample of the larger NFHS-4 survey sample for each district. Most of these districts are in South India, and the data challenges are likely driven by a combination of lower fertility and smaller population sizes in these districts. Not knowing the levels of EBF in these districts, however, can hamper effective actions.

Strategies to support exclusive breastfeeding should therefore address the multiple factors that contribute to exclusive breastfeeding including lack of knowledge and awareness, lack of support and time within the household, insufficient support from the health and nutrition programmes, maternity leave and/or maternity benefits,  formula marketing, monitoring of the code of marketing of breastmilk substitutes, and more. The limited availability of disaggregated data on EBF at the district-level makes it challenging to understand the relative contributions of these multiple factors to EBF at a district-level. This, in turn, makes it difficult to design locally-relevant strategies to address the most salient drivers of EBF at a local level or to monitor the trends over time.

In summary:

• The positive trend in EBF in India and in most states is promising and provides a much-needed impetus for more concerted action on an area of nutrition where success seems possible.
• States such as Chhattisgarh, Manipur and Tripura should sustain policy actions to ensure that EBF levels do not decline.
• States such as Meghalaya, Uttar Pradesh and Nagaland need to revitalize attention to EBF, examine state-specific constraints and develop state-specific strategies to address these constraints to support improvements in EBF.
• States such as Goa, Himachal Pradesh and Madhya Pradesh should strive to achieve further improvements in EBF with the ongoing efforts.
• Future surveys may need to consider over-sampling women with children in the 0-5 month age group to deliver better local estimates of EBF.

Written by Esha Sarswat and Purnima Menon, IFPRI.