Feasibility Study of IMNCI Guidelines on Effective Breastfeeding in a Rural Area of North India

Children younger than 3 years old commonly suffer from fever (27% prevalence in the previous 2-week period) acute respiratory infections (17%) diarrhoea (13%) and malnutrition (43%) - and often a combination of these conditions. During the mid-1990s the World Health Organization (WHO) in collaboration with UNICEF and many other agencies institutions and individuals responded to this challenge by developing a strategy known as Integrated Management of Childhood Illness (IMCI). Due to high neonatal mortality and morbidity in the country the Government of India revised the strategy to be called Integrated Management of Neonatal and Childhood Illness (IMNCI). This strategy addresses various aspects of nutrition immunization and other important elements of disease prevention and health promotion in addition to early detection and prompt management of cited childhood illnesses. Great emphasis was given on effective breast-feeding in IMNCI guidelines. The present study was planned with the objective of implementing IMNCI guidelines of effective breastfeeding as an intervention and comparing the results in pre- and post-intervention period in rural areas. (excerpt)


Materials and Methods
The study was conducted in a rural health and training centre covering the villages Kheri and Kakrali by School of Public Health, Department of Community Medicine, PGIMER, Chandigarh, India, from February to June 2005. Mothers with children aged <2 years and those breastfeeding their babies at the time of study were included. The data collection instrument was a pre-tested proforma, which was designed using the standard IMNCI breastfeeding guidelines. (3) Data collection was done by a doctor (a postgraduate in community medicine), who was trained in IMNCI. The Þ rst part of the proforma dealt with general socio-demographic information about the mother including age, literacy level, caste, occupation, parity, etc. The second part of the proforma was used to record observations pertaining to the position of baby and its attachment with mother while breastfeeding. The awareness of the mother regarding breastfeeding time and interruptions during feeding was also assessed. Other responses like tiredness after breastfeeding, frequency of feeding, complaints in breasts were also noted.
After recording the pre-intervention observations related to position and attachment of the baby while breastfeeding, a demonstration of correct breastfeeding practices was made to mothers as per IMNCI guidelines. IMNCI chart booklet was used to illustrate correct and wrong breastfeeding practices. Post-intervention observations were done after a gap of 10-15 days using the same proforma. Data were analyzed using Epi Info 2000 statistical software. The paired t-test was used to test differences in observations between pre-and postintervention periods. The differences were considered to be statistically signiÞ cant at the 5% level.

Results
Out of 32 mothers (14 from Kakrali village and 18 from Kheri village) with children aged <24 months, 31 mothers were breastfeeding their babies and included in the study. The purpose of the Þ rst home visit was to record pre-intervention observations while breastfeeding. For recording post-intervention observations, we contacted 25 mothers in our second visit after a gap of 10 days, 5 mothers in our third visit after a gap of 15 days, and 2 mothers could not be contacted. The response rate was 93.5%. The socio-demographic proÞ le of mothers shows that they were between 20 and 35 years; 42% were married for 1-3 years; 32% were primiparous; 22% were illiterate; 64% of mothers had infants of age <6 months. All the mothers were homemakers.
Pre-and post-intervention observations related to position and attachment of the baby while breastfeeding are shown in Table 1. It was observed that following intervention, a signiÞ cant number of mothers (82.8%) were keeping the baby close to them, and another signiÞ cant observation (89.7%) was that the baby's neck was found to be straight or slightly bent backwards while breastfeeding. A signiÞ cant number of babies were suckling deep and well in the post-intervention period. However, no signiÞ cant change was observed in correction of these when all criteria were combined.
Mothers had significantly shown improvement in breastfeeding time per session. As a post-intervention observation, it was noted that a signiÞ cant number (21.4%) of mothers reported getting tired after breastfeeding. A reason given for this was holding the baby with both hands, and some mothers experienced back pain. It was observed that, with the increase in parity up to 3, the number of mothers adopting correct position and attachment increased in the post-intervention period. After a parity of >3, this number declined. As the age of baby may inß uence breastfeeding practice, out of 20 mothers with babies under 6 months, 8 mothers (40%) had shown correct position following intervention as compared to 27% (3/11) mothers with babies over 6 months. Similarly, with respect to attachment, 50% (10) of mothers with babies under 6 months had shown improvement following intervention as compared to 18% (2/11) mothers with babies over 6 months. However, the association observed between parity, age of baby, literacy of mothers and effective breastfeeding was not signiÞ cant statistically.

Discussion
Many studies have documented the usefulness of mother's milk, but literature is scanty regarding the prevalence of breastfeeding practices. (4) To our knowledge, there was no study to document the cultural acceptability of breastfeeding techniques to rural Indian women. This study is the Þ rst of its kind in this region. There are reports available on the overall impact on infant mortality rate as a result of implementation of IMNCI strategy in many developing countries. (5) However, the impact of IMNCI guidelines on effective breastfeeding has not been studied. In this study, the IMNCI guidelines of breastfeeding helped mothers in bringing the babies close to them and turned towards them. By adopting these two techniques, the attachment of the baby, especially suckling, signiÞ cantly improved. Since the baby was suckling deep and well, it could suck for long, as was evident from increased feeding time after the intervention. However, no signiÞ cant improvement was observed in supporting the baby with both hands because of the menace of house ß ies; as a result supporting the baby with both hands was impractical as one hand was needed to drive the ß ies away. North Indian women usually wear the salwaar kameej. To feed the baby, the mother had to lift her kameej to her chest and hold it with her one hand. Moreover, back pain as a result of supporting the baby with both hands prevented some mothers from using this particular technique while breastfeeding. In such situations, recommending breastfeeding as per the IMNCI guidelines becomes difÞ cult. It is concluded that although IMNCI guidelines of breastfeeding are a useful tool for effective breastfeeding in rural areas, socio-cultural barriers should be taken care of while designing these guidelines, which are to be implemented in developing countries like India.