A landmark Resolution was passed at the World Health Assembly (WHA) on May 18,2001 at Geneva, issuing a firm call in support of exclusive breastfeeding of infants for first 6 months of age.

The new World Health Assembly Resolution, Infant and Young child nutrition, 54.2 in para. 2 (4) urges Member States to:

 "to strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for 6 months as a public health recommendation, taking into account the findings of the WHO expert consultation on optimal duration of exclusive breastfeeding, and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years of age or beyond, emphasizing channels of social dissemination of these concepts in order to lead communities to adhere to these practices.”

The Resolution also contains important protective clauses regarding baby food industry’s promotional practices such as health claims and Internet advertising and addresses other issues such as human rights.

The Resolution settles a 7-year-old controversy over the two most critical aspects of infant feeding - the optimal duration for exclusive breastfeeding and the marketing of complementary foods for infants. Clarity on these issues will support policies aiming to improve infant health and decrease rates of mortality and morbidity globally.

Brazil,  which is one of the 62 countries that already have a policy on exclusive breastfeeding for six months and led research into breastfeeding, put forward the resolution in May 2000 to the WHA .As many as 50 member states of WHO and 7 International NGOs including International Baby Food Action Network (IBFAN) intervened in the debate in support of the call for 6 months’ exclusive breastfeeding of infants. IBFAN and Save the Children Fund urged WHO to adopt an attitude of caution while dealing with the private sector in which many companies continue to undermine health in pursuit of profits. It is significant that this Resolution was passed on the eve of the 20th Anniversary of the adoption of the International Code of Marketing of Breastmilk Substitutes (The Code). Members of IBFAN from India and several countries were present in the WHA and strongly championed the cause for the adoption of the “6-month exclusive breastfeeding norm”.

IBFAN had also presented at the WHA its latest report on violations of The Code – “Breaking the Rules 2001”. This path- breaking report of 14 countries proved to be “eye opening” for many national delegates. Before the Assembly the International Association of Infant Food Manufacturers (IFM) wrote to member states in an attempt to weaken support for the Resolution. IFM is made up of some of the worst violators of the International Code and subsequent, relevant WHA Resolutions, including Nestlé, Wyeth, Numico (parent company of Nutricia, Milupa, Cow&Gate) and Hipp.

Dr. C. P. Thakur, Union Minister for Health and Family Welfare, speaking in the beginning at the WHA spoke forcefully in favour of supporting the “6 months norm”. At a press briefing upon his return to India, Dr. Thakur said that the technical advisory committee set up by the WHO last year had categorically recommended that exclusive breastfeeding should be allowed for a period of six months. However, companies manufacturing baby foods have been recommending on their labels that the minimum duration of exclusive breastfeeding should be four months. This was with a view to increase their sales. “We contended that the countries should not give in to pressure being exerted by baby food companies and backtrack from the recommendations made by their own experts,'' Dr Thakur said.

The next steps
It is heartening that the accumulating evidence on the benefits of exclusive breastfeeding has at last led to a change in global policy and there is global agreement on this issue. The clear recommendations will allow people to achieve the best practice, as any ambiguity with regard to the optimum duration of exclusive breastfeeding would have had an adverse impact on the breastfeeding promotion movement. Following steps are essential to achieve the objectives of this resolution and should be taken with an urgency.

1. Our national opinion leaders, policy makers, programme mangers in the concerned Departments of the Governments, NGOs, International Organizations, Professional associations, and all others concerned should take steps to effectively revise the national/state policy guidelines on infant feeding.
2. Suitable action should be taken to bring changes to the labels of breastmilk substitutes and infant (cereal) foods.
3. Governments should put into practice a regular monitoring system to monitor the compliance with the International Code for Marketing of Breast-Milk Substitutes, subsequent WHA resolutions and national legislations with the support of WHO, UNICEF and other concerned agencies.
   

Breastfeeding and Lactational Amenorrhea Method (LAM)

The natural birth-spacing effect of breastfeeding has been recognized for many years. Breastfeeding is associated with the suppression of ovarion activity and thus with a variable period of amenorrhea and infertility ⁽¹⁾. The risk of resumption of fertility, and therefore of conception, during lactation is related to infant feeding patterns. Women who breastfeed their infants frequently and who delay the introduction of supplementary feedings tend to remain amenorrheic for a longer period ^(2,3). Fertility, sexuality and contraception⁴ are interrelated aspects of reproduction and breastfeeding affects each of these entities. Population studies regarding the likelihood of becoming pregnant while fully breastfeeding reveals that this risk is extremely small. However, when it does occur, the mother may feel betrayed by her body, particularly if she was told that breastfeeding women do not become pregnant.

A consensus meeting held in Bellagio, Italy in 1988 postulated that full or nearly full breastfeeding during lactational amenorrhea confers 98% protection against pregnancy in the first six months after child birth ( ^5,6). Short and coworkers (⁷⁾ were of the view that the period of lactational amenorrhea rather than the period of breastfeeding should be considered the phase of natural infertility. Reviews of the international literature have shown that between 3 to 10 percent of women conceive during lactational amenorrhea (4). LAM is a modern temporary family planning method that has been developed as a tool to help support both breastfeeding and family planning use. It is based on the natural infertility due to increased level of prolactin. A large prospective longitudinal study in five developing (including in Delhi) and two developed countries was conducted to determine the risk of pregnancy during lactational amenorrhea relative to infant feeding status.The results support the Bellagio Consensus on the use of lactational amenorrhea for family planning and confirm that the lactational amenorrhea method is a viable approach to postpartum contraception ⁽⁸⁾.

1. The woman’s menstrual periods have not resumed- The resumption of menses is an important indicator of a woman’s return to fertility after childbirth. Bleeding during the first two months postpartum is lochial discharge and is not cosidered menstrual bleeding. Menstruation is defined for LAM use as two consecutive days of bleeding, or when a woman perceives that she has had a bleed similar to her menstrual bleed, either of which occurs at least two months postpartum. Once menstruation has resumed, fertility is returning or already has returned. Menses is an absolute indication of the need for another contraceptive method if continued protection is desired ⁽¹⁰⁾.

2. The baby is exclusively breastfed for first six months- Exclusive breastfeeding means that the infant receives only breastmilk from his/ her mother or expressed breastmilk and no other liquids or complementary foods with the exception of undiluted drops or syrups consisting of vitamin and mineral supplements or medicines. Water is not permitted.

3. The baby is less than six months old- After six months of age, the baby should begin receiving complementary foods while continuing to breastfeed two years and beyond. Introduction of water, liquids and foods can reduce the amount of sucking at the breast, triggering hormonal mechanism that causes the ovulation and menses to resume.

Q. 1. Have your menses returned? -NO

Q. 2. Are you supplementing? -NO

Q. 3. Is baby more than six months? -NO

If the answer to all the three questions is NO then the chances of pregnancy is only one to two percent.

When the answer to any of the three questions is YES then the mother’s chance of pregnancy is increased. For continued protection, advice the mother to begin using a complementary family planning method and to continue breastfeeding for the child’s health. (Table 1)

During lactation, the choice of whether to practice contraception and, if so, the choice of method requires different considerations as compared with the same choices during the non lactating state. The family- planning options places nonhormonal methods first, progestin-only method second, and methods containing estrogen a distant third, to be used only when other methods are unavailable⁵

The normal plasma concentration of prolactin is approximately 8ng/ml in women (5ng/ml in men). During the normal menstrual cycle in the nonlactating women, the hypothalamus secretes gonadotropin-releasing hormone (GnRH) in a pulsatile fashion, which in turns triggers a pulsatile release of luteinizing hormone (LH) from the anterior pituitary^4,10,11. The mechanism involved in lactational infertility is partly clear. Presumably, suckling interferes with the normal secretion of Gn RH by the hypothalamus, in turn disrupting normal pulsatile LH secretion. The increased secretion of prolactin is clearly associated with breastfeeding, which has inhibitary effect on anterior pituitary (decreased secretion of LH) and on ovarion function. It appears that the prolactin may produce amenorrhoea by blocking the action of gonadotropins on the ovaries but definitive proof of this hypothesis must await further research. It is furthar reported that 15-20% of women with secondary amenorrhoea have elevated prolactin levels and when prolactin secretion is reduced, normal menstrual cycles and fertility returns¹¹. However, the role of prolactin is uncertain because, some lactating women show normal ovulatory cycles despite high levels of prolactin¹², and because pulsatile GnRH infusion can induce follicular development and ovulation in hyperprolactinemic breastfeeding women¹³. Possibly , the decline in suckling causes both the decrease in prolactin and the improvement in LH pulsation, and the relationship between prolactin and hypothalamic inhibition is only coincidental¹⁴.

A child’s suckling is the stimulus that controls the negative feed back inhibition of normal cycling of the hypothalamic-pituitary-ovarion axis, but accurate measurement or quantification of suckling is difficult ⁴. There is also no universally reliable breastfeeding frequency associated with anovulation, frequent breastfeeding remain an important correlate of lactational infertility^15,16.

Accepted guidelines by WHO and UNICEF and Institute of Reproductive Health in 19949 adopted at Georgetown University is as follow:-

• Breastfeeding can protect against a new pregnancy only if mother is not menstruating i.e. she still has amenorrhea after delivery.

• Exclusive or near exclusive breastfeeding can give good protection for the first six months after delivery.

• After six months of delivery protection against pregnancy is imcomplete even if breast feeding is continued and complimentary feeding is also introduced

• SOME TIME MOTHER CAN CONCEIVE EVEN THOUGH MENSTRUATION HAS NOT STARTED. THIS IS MORE COMMONLY SEEN AFTER SIX MONTHS OF DELIVERY.

• During first six months if some mother wishes to use contraceptive i.e. (in working mothers) it is better to use condoms, diaphragm or IUCD. Hormonal preparations if decided, progesterone containing preparation like provera is recommended as it promotes lactation.

• Estrogen containing preparation or combined pills decrease lactation and hence not recommended. BUT IN CASE OF NO OTHER CONTRACEPTIVE USED IT IS BETTER TO USE EVEN COMBINED PILL THAN NOTHING IS USED .

• No ORAL HORMONAL CONTRACEPTIVE SHOULD BE USED IN FIRST SIX WEEKS AFTER DELIVERY.

GSVM Medical College, Kanpur

IBFAN Regional Training Seminar for South Asia (14-17, November 2000)

The BPNI-IBFAN regional training seminar for South Asia – Healthy Futures: Challenges for the 3rd Millennium - in collaboration with Department of Women and Child Development, Government of India and UNICEF, India, was conducted on 14-17 November 2000 at Himachal Pradesh. This has provided an opportunity for sharing experience, exchange of knowledge and information on infant feeding issues. It has provided improved linkages with various players like NGOs, Governments and health care system within SAARC countries and other participating countries. During the seminar, basic issue of malnutrition, its status and possible solutions towards reduction through improving infant feeding practices were discussed. 40 participants from seven countries of SAARC and four other countries, Saudi Arabia, Philippines, Malaysia and Thailand attended the seminar. The outcome of the seminar was various recommendation for various people like, Governments, NGOs, SAARC countries, human rights institutions. Some of the recommendations are given below:

1. Recommendation for the period of exclusive breastfeeding for first six months, continued breastfeeding for two years and beyond and addition of appropriate and adequate complementary foods when the child is six months old.

2. SAARC secretariat and the SAARC countries to evolve a joint strategy and forge a collective movement at the World Health Assembly, Codex Alimentarius Commission and other international forums to ensure that international standards are made keeping in view the interest and needs of the children of the region.

3. Effective implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly (WHA) Resolutions.

4. To strengthen the Baby Friendly Hospital Initiative (BFHI) programme through high quality training in lactation and breastfeeding management.

5. To strengthen and implement the tools eg. Maternity Protection Act, CRC etc.

6. Awareness about breastfeeding as a human rights issues

7. Call upon all public interest groups to develop a regional cooperation network and to strengthen infant feeding issues.

Informal Consultation to review progress in breastfeeding counselling, Surbaya, Indonesia, (12-15 March, 2001)

WHO-SEARO had organised an informal consultation in Surbaya, Indonesia, from 12-15 March 2001 with the objectives (1) to review the progress in BFC and in other health services to children, (2) to share the tools available to train and evaluate BFC activities, and (3) to plan linkages between IMCI, other health services and BFC. Dr. Arun Gupta, National Coordinator of BPNI and Dr. KP Kushwaha, State Coordinator, UP-BPNI had attended this meeting. The main recommendations for this meeting for our country is,

• Strengthening of BFHI, BFC, IMCI and other programmes through integration and coordination of various players at the centre viz.GOI-Secretary Health, UNICEF, WHO and other concerned ministries.

• Formulations of one programme, integrating all the health services for children.

• Development of evaluation tools for BFC training.

• Integrated training for all important health services for children eg. BFC, IMCI, ECC and ECD and RCH with different levels of training for different health workers and trainers with a minimum of 18 hours training to all health workers in BFC, with due emphasis on the training of terminal health worker.

• Implementation of programmes in every state through existing health care system.

• Country level research on Breastfeeding, morbidity and mortality patterns in children and evaluation of outcomes of different interventions.

Meeting on Maternity Benefits for Working Women (25th May 2001)

Breastfeeding Promotion Network of India (BPNI) organised an interactive session on maternity benefits for working women in the organised and unorganised sector with the journalists on 25th May 2001 at the Indian Womens’ Press Corps, New Delhi.

The main objective of this meeting was to enlist support of journalists especially women journalists, and to discuss how to involve media on the subject as well as to find out how media could help in the provision of maternity benefits to unorganized sector and increase the benefits in the organized sector.

The meeting was inaugurated by the Secretary, National Commission for women, Mrs. Reva Nayyar who congratulated BPNI/WABA/FORCES/ILO/UNICEF for holding this meeting. Twenty people participated in the meeting. There was consensus after the meeting that the media had a positive role to play and they should provide information to mothers of their rights and help in creating awareness among policy makers for provisions of benefits.

Meeting on Infant Feeding Issues - Challenges for Research (26th May 2001)

BPNI held a meeting to discuss Infant feeding issues-Challenges for Research on 26th May 2001 at India International Centre, New Delhi with the purpose to arrive at an agenda on research topics which BPNI should adopt for the next 3-10 years.

About 20 researchers from various organisations and institutions including ICMR attended the meeting. At the end of the meeting research issues performing to three areas, exclusive breastfeeding, complementary feeding and feeding of young children 1-3 years were discussed. It is hoped that the projects will be processed and funding agencies identified for support.

Collaborative Organisations & Activities

Rotary/Inner Wheel Club

BPNI is collaborating with various network/organisation for the cause of promoting the breastfeeding. One of the main collaborator is the Rotary and Inner Wheel Clubs. Dr. A Muthuswami is the nodel person for Rotary & IW Clubs. The main programmes include:

1. All India contest for Innerwheel clubs in india on World Breastfeeding Week celebration. We have announced three cash awards for top three Innerwheel clubs (Rs. 1500, 1000, 750) and one best IW district cash award of Rs. 1000/- (this is the fourth consecutive year).

2. Rain-water harvesting projects for Innerwheel clubs in IWD 298. All the 26 Innerwheel clubs have been motivated to implement a rain water harvest project in a public place. We will reimburse 1/3 of expenditure with the maximum of Rs.1000/ to each club. All the cash awards and rain-water harvesting expenditures have been sponsored by Mrs. Indralekha Muthuswami past IWDM Chairman 298.

White Ribbon Alliance of India (WRAI)

BPNI joined hands with White Ribbon Alliance of India (WRAI) for the work on Safe Motherhood. BPNI representatives participated various meeting on the subject and disseminating these information to its members. BPNI members in Agra participated the Safe Motherhood Programe on 8th March 2001 in Agra.

Study of knowledge of interns on breastfeeding (RMC) Kakinanda (A.P.)

Dr. Sree Karuna Murthy Kolli, Dr. A. Krishnaveni

Postgraduate student in MD, Community Medicine, RMC, Kakinanda

Dr. V. Chandrasekhar

Professor and Head. Dept of Community Medicine,  RMC, Kakinanda

The authors conducted a study to assess the knowledge in essential principles of breastfeeding among interns of Government General Hospital through a pre tested questionnaire in 48 interns. These interns had acquired sufficient basic skills after 6 months of training. After analyzing the questionnaire the results are given below.

Only 85.0% of the Interns are having correct knowledge about exclusive breastfeeding. They know the importance of continuing exclusive breastfeeding for 4-6 months in every child (Fig.1).

Fig. 1: Knowledge about exclusive breastfeeding

• Knowledge about benefits to mother due to breastfeeding – 30.0%

• Awareness about breastfeeding week and its time of celebration – 56.0%

• Awareness about BFHI (Baby Friendly Hospital Initiative) movement – 50.0%

• Awareness about the Act protecting breastfeeding 2.0%

• 73% of Interns felt that breastfeeding is to be continued by HIV+ mothers

Almost all Interns are not aware of the Act protecting breastfeeding. Only 50.0% of the Interns are aware of BFHI. In general the awareness levels in this field are very low among Interns (Fig.2)

Fig. 2: Awareness levels in some important parameters of breastfeeding

Many Interns (55.0%) feel that there is no need for prelacteal feeds to the newborn child. 31.0% have opined that water can be given as prelacteal feed. 13.0% expressed that cow’s milk can be given as a prelacteal feed (Fig.3)

Fig. 3: Knowledge about prelacteal feeds

Majority of the interns (64.0%) are of the opinion that the breast milk must be initiated immediately (1 hour). the rest have express that it can be given at any time between 1-24 hours (Fig.4)

Fig. 4: Knowledge of initiation of breastfeeding

68.0% of Interns have expressed that breastfeeding is to be continued for more than one year (Fig.5)

Fig. 5: Knowledge of duration of breastfeeding

Conclusion: Many Interns at the completion of their professional course are not completely aware about the correct breastfeeding practices. They don’t have correct idea about the timing of initiation of breastfeeding, timing and initiation of supplementary feeding and duration of exclusive breastfeeding. However almost all the House Surgeons are aware about the need to continue breastfeeding during the episodes of diarrhoea. They are also aware of the importance of colostrum and the need for the child to get this milk.

Recommendations: BFHI (Baby Friendly Hospital Initiative) philosophy is yet to reach to all the medical professionals especially those coming out of their professional course and entering into the medical practice. So this BFHI campaign has to be further intensified to reach the entire medical students and interns. The Departments of Pediatrics, Obstetrics, Gynaecology and Community Medicine have a role to play with inter- departmental coordination to propagate this BFHI philosophy to all the young professionals.

BPNI comments: This study has relevance to the question of skilled assistance on breastfeeding available to a woman from a health professional at the time of delivery. If we are able to prepare our medical students well with a strengthened pre service (undergraduate) curriculum, it is likely they will be able to provide the required help to women to succeed in breastfeeding exclusively for the first six months. More such studies would be useful for initiating such action. BPNI also encourages the study on breastfeeding issues at community level.

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