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When Sushma Sahu gave birth to her first son six years ago in a village in Uttar Pradesh, India’s most populous state, her mother-in-law asked the local Hindu priest to recommend an auspicious time to start breastfeeding the baby. The priest set a time on the infant’s third day of life. In the meantime, the newborn would be fed with honey and water then cow’s milk. “My first time, I didn’t know anything,” says Sahu. “I trusted my mother-in-law and whatever she was saying.”
But three years later when Sahu gave birth to her second child, a daughter, the nurse in the primary health care centre told her to start breastfeeding immediately, as recommended by the World Health Organisation to ensure newborns get their mother’s first milk (known as colostrum). Colostrum is rich in protective antibodies, vitamin A and proteins, and is only produced in the first few days after childbirth. Sahu did as the nurse suggested. “I also felt like breastfeeding, so when the nurse told me, I didn’t really wait for anybody,” she says.
Now Sahu is one of a small group of Indian mothers who are trying to persuade others to breastfeed their newborns straight after birth and to provide skin-to-skin contact to help keep them warm. The women are part of a year-old experiment aimed at reducing Uttar Pradesh’s persistently high rates of infant mortality.
The project, led by the Community Empowerment Lab, a research organisation, has involved mothers like Sahu being trained as “life coaches” and then paid to advise women during their pregnancies and in the first month after their babies are born. The aim is to entice women to change their pre- and post-partum practices — including adopting early breastfeeding and skin-to-skin contact, which together are known as “kangaroo mother care” — and measurably cut newborn deaths.
“People don’t need messages, they don’t need information — they need a friend they can trust,” says Vishwajeet Kumar, founder of the Community Empowerment Lab. “If you go and tell them something, it doesn’t change anything. You need to work with them. There is no shortcut to these things — you need to navigate, negotiate. You need to nudge.”
Public health professionals believe simple practices such as kangaroo mother care could help reduce India’s high infant mortality rate: 700,000 newborns die within a month every year. In the state of Uttar Pradesh alone, 240,000 newborns die each year — about the same number of deaths as were caused by the 2004 Indian Ocean tsunami.
Kangaroo mother care was originally developed in Colombia nearly four decades ago, when doctors in an overcrowded, poorly equipped hospital found the practice could help save premature or low-birthweight babies who might otherwise have been put in incubators — had these been available.
In 2003 and 2004, impressed by the success of these simple techniques, Dr Kumar and his colleagues carried out a study to see whether they could be used to reduce infant mortality in rural Uttar Pradesh, where most women were having their babies at home, loyal to traditional practices for the care and handling of newborns.
The results were clear: the study showed that infant mortality in Indian villages could be reduced by 54 per cent if new mothers adopted early breastfeeding and held their babies close for long periods of time. The impact was especially significant for premature or low-birthweight babies, who are at the greatest risk. “This is the most powerful intervention we know of,” Dr Kumar says.
Gary Darmstadt, associate dean for maternal and child health at Stanford University School of Medicine in the US, acknowledges the global benefits: “A lot of great evidence has been gathered on the impact of kangaroo care on preterm, low-birthweight babies. The mortality reduction in that population is 40-50 per cent,” he says.
maternal deaths per 100,000 live births in India
But despite the weight of such evidence, Indian public health experts have struggled to figure out how to persuade more rural women to adopt techniques that are at odds with traditional methods of babycare, as well as the demands of rural life, where daughters-in-law are expected to do much of the heavy work for large extended families, including preparing food, tending to livestock and crops, and fetching water.
“If you want to be able to provide this care to the baby, you have to think about the broader elements of the system you are trying to make that happen in,” says Dr Darmstadt. “If the system is not supportive of the practice, it’s very difficult for the mother to provide that care.”
deaths of children under five per 1,000 live births in India
Nearly 70 per cent of Indian babies are now born in some form of health centre — a dramatic shift from a decade ago, when most babies were born at home. Nurses in India’s overstretched and understaffed primary healthcare centres might briefly advise women, but they have little capacity for sustained intervention, or to override the wishes of powerful mothers-in-law attached to old ideas. Many women are sent home from clinics — or simply leave — within an hour or two of giving birth, often before breastfeeding their babies.
Traditional newborn care practices are rooted in Hindu notions of ritual purity and impurity, which affect how both mothers and babies are treated immediately after birth. In Hindu societies, a woman’s menstrual blood is considered impure, as are the blood and fluids associated with childbirth.
In Uttar Pradesh, new mothers are kept in confinement for up to 40 days after childbirth and newborns are vigorously scrubbed — sometimes in cold mud — to purify them, which can lead to hypothermia. Colostrum is traditionally seen as dirty and harmful for the baby. As of 2014, fewer than a quarter of newborns in Uttar Pradesh were breastfed within an hour of birth.
Dr Kumar’s idea — now being tested in a small-scale pilot study — is to see whether his “life coaches” can change these practices. The coaches, all mothers themselves, and mostly college graduates, make pre- and postnatal visits to prepare mothers-to-be for birth and its aftermath, to try to inspire the women and their families to adopt new practices.
“We try to identify women in the village that [mothers] can look up to,” says Dr Kumar. Each coach in the pilot study has been responsible for 600 families. They try to engage with every pregnant woman in their area, making a series of three prenatal visits followed by three visits in the month after the birth, including on the day the baby is born. Currently there are only 10 coaches, but the preliminary results — measured against a control group in an area with no intervention — are encouraging. The initiative will soon be scaled up to 100 or 150 coaches, Dr Kumar says.
In their meetings with pregnant women, the coaches share videos on a tablet device and describe their own experiences of childbirth and caring for their babies. In each household, they determine which family members will dictate newborn care practices and try to find out how new babies have been cared for in the recent past. “They try to figure out who is making decisions and get some sense of what family [childcare] practices are,” says Aarti Kumar, the co-founder of the group.
In September, Annapoorna Verma, a 30-year-old coach, called on Akhteri Bhano, who was already back at home in her village of Bhaunsi, hours after giving birth to her third child at the community health care centre in Shivgarh 12km away. Verma weighed both mother and baby and took their temperatures. She then showed Bhano how to hold the baby skin-to-skin to keep him warm in the dark, damp interior room where Bhano was to spend at least a week recovering.
In a nearby village, Sahu was calling on Rukhsana Khatoon, 22, who was in her second trimester. After weighing her and taking her blood pressure, Sahu talked with the young woman and her husband about foetal development. She explained to the couple that Khatoon should eat nutritious, high-protein foods such as eggs, milk and vegetables to help the baby grow.
On her next visit, she says, the talk will turn to postnatal care. Khatoon’s mother-in-law, Islamunisa, says the newborns in their family are traditionally given water and honey and goat’s milk for a few days before breastfeeding begins — villagers believe milk will not arrive until several days after the birth. They also throw the colostrum away in a ritual where it is cast on the ground as an offering to the earth.
“It’s a tradition,” says Islamunisa. “We don’t know why we do it.” But it is a tradition that Sahu will try to change rather than preserve.