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Aids and maternity in India

 | 
Patrice Cohen
, 
Suniti Solomon

Part 4. Mtct risks factors and practices in India: social sciences perspectives

11. Breast Feeding and Infant Feeding Practices Research in India: A Critical Review

Lakshmi Lingam et Siddhi Mankad

Texte intégral

Introduction

1The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990), drawn up by WHO and UNICEF, was a significant development in the area of maternal and child health. The declaration recommended that breast milk be the first milk given to the infant, that breastfeeding begin as soon as possible after birth and that exclusive breastfeeding be continued until 6 months, following which it can be continued with supplementation until 2 years.

2The importance of breastfeeding lies in the advantages it confers on women and children.

  • Breast milk has immunological and anti-infective properties that shield infants against various diseases. Exclusively breastfed infants have been found to have fewer incidences of diarrhoea and respiratory tract infections.
  • Breast milk contains a mix of nutrients that foster growth for the first few months of life, many of which cannot be replicated by commercial feeds. It is believed that breast milk offers health benefits well into adulthood.
  • As the cheapest mode of infant feeding, it has an economic advantage.
  • Exclusive breastfeeding with high feeding frequency induces a natural infecundity, also known as postpartum amenorrhoea (PPA), that inhibits ovulation or conception, at times even up to two years. PPA protects the infant from being displaced by a new pregnancy and protects the mother from the stress of frequent pregnancies.
  • Studies have also shown that breastfeeding protects women against ovarian and breast cancer.
  • Breastfeeding forges a bond between the mother and child that gives the mother psychological satisfaction and the infant emotional security.

3The stock of evidence on the status of breastfeeding and infant feeding practices in India, obtained by a review of micro-studies and macro-data, reveals the levels of departure from the norms set by the Innocenti Declaration. It is imperative to learn from existing research what we know and do not know about breastfeeding and infant feeding practices. This will provide guidelines for future research and advocacy. The present paper is structured in two parts. The first section unveils the stock evidence. The second and concluding section critically examines the research evidence from a gender perspective.

Stock of Evidence3

Prevalence of Breastfeeding

4There is a near universal prevalence of breastfeeding in India. The NFHS 1 (1995) and 2 (2000) surveys find the prevalence of breastfeeding to be 95 % and 96 % respectively, and evidence from micro-studies on this factor also ranges from 95 to 100 %.

  • 4 Cited by Shrinivasan K in “Has Modernization Increased Fertility in Karnataka, India? Demography In (...)

5However, micro-studies do note differences in prevalence of breastfeeding on the basis of urban-rural location, income, education and employment. Nag (1982)4 observed a higher prevalence of breastfeeding among women in lower income groups, among less educated women and women from rural areas, as compared to women in higher income groups, educated women and those residing in urban areas. Singh, Bhasin, Ingle and Raut (1990) found that breastfeeding was more prevalent among unemployed women, as compared to employed women.

Initiation of Breastfeeding

6Infants are generally not put to the breast immediately after birth. According to NFHS 1, 9.5 % of the women initiate breastfeeding within one hour of birth and 26.3 % within one day. The corresponding NFHS 2 figures are higher at 15.8 % and 37.1 %. Micro-studies find women initiating breastfeeding as early as within two hours and as late as five days after birth. However, these studies observe the majority of women putting the infant to the breast around the second or third day after birth.

7While micro-studies provide no clear trends on factors influencing the initiation of breastfeeding, the NFHS suggests earlier initiation in urban areas, among educated women, women from higher income groups and those delivering at a health facility.

8Delay in initiation of breastfeeding is largely on account of customs and practices of communities or incorrect knowledge, often advanced by medical and paramedical personnel. In some communities, breastfeeding is not initiated before the performance of certain ceremonies. Many women are given to believe that breast milk begins to flow only a couple of days after birth, that the first milk, colostrum, has to be discarded, or that the bowels of the infant contain ‘dirt’ which needs to be cleared before feeding can commence. Deliveries by Caesarean section, where women remain sedated after the delivery or require post-operative care, increases the time that mother and infant are kept apart, as do hospital practices that maintain separate rooming for mother and child and are thereby found to delay the initiation of breastfeeding.

Prelacteal Feeding

9Prelacteal feeds are those given to the infant before breastfeeding is initiated. Common prelacteal feeds include water, honey, glucose water or a herbal preparation called janmaghutti. The practice of giving such feeds is quite high in India and is largely influenced by customs and traditions.

10Most micro-studies find that the prevalence of giving prelacteal feeds is more than 88-90 %. Among findings contrary to this trend are those of Prabhakara et al. (1987) and Nanavati et al. (1994), who observed the majority of their sample giving breast milk as the first feed. The latter study showed the influence of positive reinforcements in a lactation management clinic and provided an insight into how the right interventions can positively affect breastfeeding.

11Age, education, parity, income or urban-rural residence do not show any correlation with the practice of giving prelacteal feeds. Only the type of delivery influences this behaviour, as infants of women delivered by C-section tend to be given prelacteal feeds more often than those born of a normal vaginal delivery.

Colostrum Feeding

12Colostrum is the thick “yellowish” milk produced in the first few days after delivery. It is rich in vitamins and anti-bodies that protect the child against life-threatening infections. Colostrum is essential for infants and, although it is secreted in small amounts, it adequately meets their nutritive needs.

13There is a common belief that colostrum is widely discarded in India. A secondary study by Khan (1990) reported that most infants in India do not receive colostrum. The NFHS 1 and NFHS 2 data state that 63.5 % and 62.8 % of the mothers, respectively, squeeze the first milk from the breast before initiating breastfeeding. However, according to smaller, more localized studies, the range of feeding colostrum covers the entire spectrum, from the entire sample discarding colostrum in some studies, to the entire sample feeding it in some others.

14The macro-perspective as provided by NFHS data finds relatively greater feeding of colostrum in urban areas, among better educated women and women from the higher socio-economic strata, as well as women delivering in health facilities. Micro-studies establish no such clear trends.

15Colostrum feeding is also influenced by beliefs and customs. It is believed that colostrum is unclean or that its removal would ease suckling for the infant. In some communities, the dropping of the initial milk on the “mother earth” is believed to ensure a continuous flow of milk. Alternately, studies note that in certain communities, colostrum feeding, rather than discarding, is the norm.

Exclusive Breastfeeding

16WHO recognizes exclusive breastfeeding when the infant receives only breast milk from his/her mother or a wet nurse, or expressed breast milk and no other liquids, or solids with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicines. WHO guidelines suggest exclusive breastfeeding to be carried on for six months, following which supplements need to be introduced.

17The NFHS 1 and 2 surveys report that in India exclusive breastfeeding is quite common for very young infants, yet at 0-1 months many infants are given water and other supplements. NFHS 1 and 2 find exclusive breastfeeding at the age of six months to be 20.2 % and 19.4 %, respectively. 9 %-10 % children are exclusively breastfed at eight months of age. Micro-studies observe exclusive breastfeeding at less than four months to range from 15 to 92 %.

18There appears to be a higher duration of exclusive breastfeeding in rural areas and among low-income groups. Whereas micro-studies find no clear trend between exclusive breastfeeding and maternal literacy, the NFHS 2 data show a median duration of exclusive breastfeeding among illiterate women to be 2.4 months, as against 1.3 months for women educated until high school and above. NFHS data also find a 2.5 months median duration of exclusive breastfeeding among women employed by others, as compared to 1.3 months for non-working women.

19Earlier “rooming-in” and earlier initiation of breastfeeding may increase the prevalence and duration of exclusive breastfeeding.

20Reasons for the early introduction of supplements and the discontinuation of breastfeeding include lactation failure, the mother’s own assessment of inadequate breast milk, the mother’s need to work, wrong advice from others, and aggressive marketing by commercial milk formula (CMF) and commercial weaning formula (CWF) manufacturers.

Duration of Breastfeeding

21In India, there is a prolonged duration of breastfeeding. The NFHS studies find the median duration to be a little over two years and micro-studies peg the duration of breastfeeding to be at least one year.

22The NFHS-1 and 2 surveys note that more “modernized” mothers (urban women, educated women and those exposed to mass media) breastfeed for a shorter duration. However, working women breastfeed for a longer median duration of 36 months for self-employed women, as against 24.7 months median duration for non-working women. The report notes that working women come disproportionately from rural areas where breastfeeding duration is relatively long.

23The NFHS survey also notes that the median duration of breastfeeding is two months shorter for girls than for boys.

Types of Supplements and Bottle-feeding

24Since the introduction of supplementary feeds and weaning determines the duration of exclusive breastfeeding and the total duration of breastfeeding respectively, it is obvious that the desired time for the introduction of supplementary feeding is at six months and that for weaning is 1½ to two years.

25The type of supplements fed to babies has implications on their health and growth. Generally, supplements include cow or goat milk, juice, pulses, cereals, eggs, fruit, rice, etc. While a large proportion of Indian mothers give their children homemade supplementation and weaning foods, there is an increasing trend towards feeding CMF and CWF, and administering top feeds through the bottle.

26Studies show a far greater use of CMF and CWF among the urban and high-income households than in rural and low-income households. However, aggressive marketing by commercial food manufacturers has enabled its penetration to the low-income and rural markets.

27The concerns of using commercial foods and bottle-feeding, apart from the cost factor, are the possibility of over-dilution and feeding under unhygienic conditions, thereby increasing the risk of malnutrition, morbidity and mortality. Micro-studies observe a higher mortality among artificially fed infants than among breastfed infants.

Contraceptive Effects of Breastfeeding

28Breastfeeding has been accepted as a natural birth-spacing method. Clinical evidence from the world over suggests that breastfeeding has a contraceptive effect under certain conditions, such as feeding frequency.

29The contraceptive effect of breastfeeding is significant since it protects the child from being displaced from the breast by a subsequent sibling and thereby ensures that the child may get the nutritional breast milk for the desired duration. It also guards women from the strain of frequent and immediate pregnancies.

30The period of natural infecundity, or PPA, depends largely on the duration of exclusive breastfeeding since it is influenced by the frequency and intensity of suckling, both of which are reduced when supplement foods are introduced.

Support and Information

31Support and advice extended to the mother during pregnancy and postpartum period is an important factor that influences the breastfeeding practice. Some forms of support may be more powerful, while others more subtle and latent. Support need not always be positive in nature and bring about desired practices, it may often sustain negative breastfeeding practices.

32Lingam (1995) identified the forms and sources of support as follows:

Sources of support

  • Familial support – from the husband, family members and friends.
  • Professional support – from health personnel, breastfeeding support groups, etc.
  • Institutional support – social policy, legislation, baby-friendly hospitals, provision of crèches, housing, and transport by the employer.
  • Indirect support – the media, literature, advocacy, campaigns, etc.

Forms of support

  • Instrumental or material support – such as sharing of domestic work, provision of transport, housing, crèches
  • Emotional and psychological support – by promoting and sustaining positive attitudes toward breastfeeding.
  • Information – regarding the importance and advantages of desirable breastfeeding practices.
  • Social policy – enacting appropriate legislation and assuring its implementation.
  • Organizational support – from employers and from hospital policies that create an environment that promotes and sustains desirable breastfeeding practices.

33Micro-studies observe the influence of support systems on breastfeeding behaviour. For instance, Narayanan’s (1997) study of the impact of women’s multiple roles in the management of breastfeeding found 44 % of the mothers in the sample initiating breastfeeding with the support of relatives. Yet, the family can also be an obstacle to the achievement of desirable breastfeeding practices. Traditions and beliefs relating to the administration of prelacteal feeds, colostrum feeding, duration of breastfeeding, time and type of supplements, etc., passed down through the generations often take precedence over medical knowledge on breastfeeding. Influences by the family based on incorrect knowledge can also result in faulty practices. Kapil et al. (1995) in their study on the use of CWF among scheduled castes in Haryana discovered that 75 % of the mothers began the use of CWF on the advice of family members.

34Similarly, many studies on knowledge, attitudes and practices of medical personnel and paramedical personnel expressed concern at the lack of adequate knowledge of these groups regarding correct breastfeeding behaviour, particularly since they are sources of knowledge on breastfeeding.

35Institutional support for breastfeeding in India comes largely from the Baby-Friendly Hospital Initiative (BFHI), launched by UNICEF/WHO in 1992, and from government legislation. The BFHI requires the formulation of plans at the hospital level that provide the appropriate knowledge to women and the establishment of a favourable environment for breastfeeding. Government legislation includes the Maternity Benefits Act (1961), the Employees State Insurance Act (1948), Factories Act (1948), Plantation Labour Act (1951) (d) & (w), Mines Act (1952), Beedi & Cigar Workers (Condition of Employment) Act (1966), Contract Labour (Regulation & Abolition) Act 1970 and Inter-State Migrant Workers Act (1980), which make different provisions for maternity leave, nursing breaks and/or crèches at the work place. The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, (1992) regulates the production and marketing of infant foods and feeding bottles to prevent unethical marketing of these products. Despite the wide array of legislation, its limited cover and ineffective implementation puts it beyond the reach of most lactating women.

Breastfeeding and HIV/AIDS

36As the prevalence of AIDS increased alarmingly in the 1990s, there has been an increased focus on the risk of transmission of HIV from an infected woman to her child through breast milk. There is no Indian study on the issue, but three important international studies are of significance.

  • Philip’s (1995) meta-analysis of several studies estimated a 14 % incremental risk of HIV-1 transmission in breastfed infants born to HIV-infected mothers.
  • Coutsoudis et al. (1999) found no transmission of the virus with six months exclusive breastfeeding and the highest transmission with mixed feeding.
  • Nduati et al. (2001) observed the same mortality for infants breastfed or formula-fed. Although the research did not aim to study the impact of breastfeeding by HIV-infected women on their own health, they observed in the course of their research that there was a three-fold greater mortality among infected women who breastfed as compared to those that did not breastfeed. While these findings are debated and many view them with caution, this study does highlight the need to focus attention, not only on the health status of the child, but also on that of infected lactating women.

37There is a replacement feeding versus breastfeeding dilemma with respect to breastfeeding by an HIV-infected woman. On the one hand, replacement feeding seems to be the better option as it ensures that the infant is safe from HIV transmission through breast milk. On the other hand, if replacement feeding is not properly carried out, the resulting malnutrition and morbidity increase the risk of infant mortality. Added to this are the costs of replacement feeding and the social stigma attached to women whose HIV status is revealed when they choose not to breastfeed in cultures where it is the norm.

38Based on the findings of research, and being sensitive to individual social circumstances, WHO has advanced certain recommendations on infant feeding for HIV-infected women. It suggests that

  • Exclusive breastfeeding should be protected, promoted and supported for six months. This applies to women who are known not to be infected with HIV and for women whose infection status is unknown;
  • When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended; otherwise, exclusive breastfeeding is recommended during the first months of life;
  • To minimize the risk of HIV transmission, breastfeeding should be discontinued as soon as feasible, taking into account local circumstances, the individual woman’s situation and the risk of replacement feeding (including infections other than HIV and malnutrition);
  • HIV-infected women should have access to information, follow-up clinical care and support, including family planning services and nutritional support.

Critical Review of Research

39The research studies reviewed for this paper encompass different issues and aspects of breastfeeding. The variety of issues covered by the studies is proof of their widespread focus. The studies explore breastfeeding practices in different regions, among different communities, income groups, educational groups, etc. Some are comparative studies, others consider changes in practices over time. Emerging issues like the risk of transmission of HIV through breastfeeding are also debated and studied.

40Though the issues researched are vast and varied, epistemological flaws and an insufficient analysis of issues leave a large void in our understanding.

Epistemological Flaws

41One of the main faults of many research studies relates to the absence of clear definitions. Terms are used without providing their meaning in the context of the study, causing confusion in understanding the findings and making comparisons with similar studies difficult.

42For instance, researchers use the term ‘exclusive breastfeeding’ without appropriately defining it. WHO (1991) defines exclusive breastfeeding as that when “the infant has received only breast milk from his/her mother or a wet nurse, or expressed breast milk and no other liquids, or solids with the exception of drops or syrups consisting of vitamins, mineral supplements, or medicines”. A child may be exclusively breastfed with expressed human milk from his mother, a breast milk donor or from a milk bank. The provision of such clear and explicit definitions enhances the value and utility of a study.

43Another limitation of many studies is the inadequate sample presentation, profiling and analysis. Researchers often mention only the sample size and population from which it is drawn, leaving it to the readers to assume the sample environment, the socio-economic conditions, and the demographic and educational characteristics. Similarly, a ‘community’ is simply presented as a rural community, an urban community, a tribal community or a religious community. Samples are studied as ‘mothers’, ‘poor women’ or ‘educated women’, as if these were homogeneous groups. In the diversity that is India, each community and group has its unique identity, culture and practices. A profile of the sample and community within its sociocultural environment can provide richer data and give a clearer insight into breastfeeding practices.

44Even where sample profiles are drawn, the findings may not be adequately explored in relation to the sample variables.

Insufficient Analyses

45Research on breastfeeding and infant feeding practices in India tends to be conducted with a static approach. The quantitative presentation of data is given precedence over its qualitative analysis. While quantitative data are crucial to understanding the prevalence of certain practices, an enquiry into the causes, the motivation of women to engage in a given behaviour, is essential for forming strategies that attempt to sustain, modify or possibly to replicate the behaviour in other groups.

46The extreme attention given to quantitative analysis may be explained by focusing on the sources of research. In India, breastfeeding research is conducted largely in the medical and demographic fields. While doctors are primarily concerned with child survival, demographers set their sights on population control. Other issues related to breastfeeding do not arrest their attention. For instance, many studies on knowledge, attitudes and practices towards breastfeeding by future mothers question young women on various dimensions related to breastfeeding. One question asks “Is breastfeeding embarrassing outside the house?” and the desired response to this is stated as “No”. In such studies (found in medical journals) doctors, who are men, claim to know what a woman’s experience of breastfeeding should be and attribute this experience universally to all women. Their concern is clearly that women breastfeed at any cost and not their emotional state of mind.

47A qualitative analysis would require the examination of the data from individual women or groups of women with a socio-anthropological perspective. Many breastfeeding practices are attributed to the “beliefs” of the study population. Beliefs evolve within a certain socio-cultural environment. While the environment changes, beliefs that are steeped into tradition may be adamant to change. Examination of the forces that drive breastfeeding behaviour and their flexibility to change will help understand the behaviour within its context and facilitate the formulation of strategies to change it, if required. Let us take the case of not feeding the colostrum because of the belief that it is bad for the infant. If the cause of this belief is merely incorrect knowledge, it can be rectified by providing correct information. If, on the other hand, it is a community practice, then modifying the behaviour would require a different, probably more intense approach.

48Another crucial perspective that tends to be overlooked is the gender perspective. Since breastfeeding is seen exclusively as a woman’s function, researchers are blind to the fact that gender issues are involved therein. The focus of most research is the mother and not the woman. As such, her foremost duty is the care and nurturing of her child. Researchers are not sensitive to women’s multiple roles and social circumstances that may constrain their ability or willingness to breastfeed.

49In the Indian patriarchal social structure, the family takes priority over the individual. Within the household, women occupy a low status and are not empowered to take control of their lives. According to Pandey (1995), the parameters of empowerment are building a positive self-image and confidence, developing the ability to think critically, fostering group cohesion for decision-making and action, ensuring active and equal participation in the process of social change and providing the wherewithal for economic independence.

50It is clear that Indian women do not generally have the decision-making power on critical issues, even when it pertains to their lives. Women have no reproductive choice regarding their fertility, contraception use and the size of their family. Women may be compelled to discontinue breastfeeding a girl child early so as to ensure a quick return to fertility and the hope of the subsequent birth of a son.

51Conflict with in-laws, dowry problems, the need to beget a son, violence, alcoholism, economic constraints, etc. can affect self-confidence, heighten anxiety and cause lactation failure. Studies that examine the cessation of breastfeeding often find lactation failure as a problem, but do not go the one step further to examine whether the lactation failure is on account of physical or psychological problems.

52Self-confidence, participation in decision-making and critical thought also hinge on the availability and access to information. While health infrastructure may be limited, especially in rural areas, women’s access to available infrastructures may also be restricted by their low social status. Lack of education and confinement within the limited space of the household or village also affect their self-confidence.

53Economic independence requires that women have an independent source of income over which they have full control. Economically independent and educated women are not always appreciated in Indian society. It is generally believed that there is a decline in breastfeeding with urbanization, as women “give up” traditional ways of life and take up employment. Lingam (1995) notes that such generalizations carry a hidden ideological baggage that assumes: (1) the sole responsibility of women is the home and childcare, and as a corollary, (2) seeking income-earning work is incompatible with breastfeeding and childcare. These assumptions reveal the insensitivity of researchers to the stock of evidence at the macro- and microlevel that highlight: (a) the crucial significance of women’s income to households, (b) the positive association of women’s education (schooling) and employment to health-seeking behaviour, declines in the infant mortality rate and child survival behaviour, (c) the growing incidence of households headed by women and (d) the steady decline in employment opportunities for men and women.

54The irony in this entire argument is that the initial statement that women give up breastfeeding on account of employment is itself not borne out through research. NFHS data show that the median duration of exclusive breastfeeding and total breastfeeding is higher for working women than for non-working women. Micro-research also does not find women giving up breastfeeding for work. If at all, as shown by Narayanan (1997), breastfeeding is given priority by women and work is sacrificed when there is a conflict situation, even at the cost of financial loss and a subsequent negative health impact.

55The promotion of the belief that breastfeeding and women’s employment are incompatible neglects the need to identify areas that require support so as to enable women to carry out both tasks without financial loss and emotional and health costs. To this end, it is necessary that women are not seen as a homogeneous group, but as individuals in their specific environments of class, community, region, education and employment status type, who need support systems appropriate to the context. Such a strategy can make life, in general, and motherhood, in particular, enriching for women.

56One of the major oversights in research is the total disregard of the role of the man in breastfeeding. While actual breastfeeding is the sole domain of the mother, the father can play a crucial role in supporting the mother, helping her out with other chores and tending to other needs of the baby to allow her to rest. He can accompany her to the doctor and make sure she understands and follows the right practices. Even though Indian men are getting more involved in the birth of their children, research has neglected them. Knowledge, attitude and practice (KAP) studies question future mothers but show no concern about the KAPs of future fathers.

57This one-dimensional approach of research, the neglect of a socio-anthropological and gender enquiry into breastfeeding practices, leads to recommendations that are often unworkable. The favourite recommendation among researchers is to “educate” women to follow desirable practices. Yet, research itself finds that educated women, as well as medical and paramedical personnel engage in or support faulty breastfeeding practices. Even if education is regarded not as formal learning but as the provision of appropriate information, many studies looking at the impact of motivation and provision of information on breastfeeding before birth find that breastfeeding behaviour is sub-optimal. This clearly shows that there are other, more influential forces at play that need to be identified before breastfeeding behaviour can be targeted.

58Where current research has provided insights into the kind of breastfeeding practices prevalent in the country, there is an urgent need to be able to understand the context for the existence of harmful practices, and the factors that impede women’s continuation of breastfeeding. A gender sensitive approach to research to accommodate the development needs of children’s and women’s needs, concerns and problems, will contribute a great deal to the cause. Research must be able to identify, and where possible, provide for affirmative interventions to make breastfeeding an enriching experience for women. Multi-disciplinary studies focusing on all aspects of breastfeeding behaviour are required.

Bibliographie

References

Coutsoudis, A., Pillay, K., Spooner, E. et al., 1999. Influence of infant feeding patterns on early mother-to –child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. Lancet, 354: 47.

Kapil, U., Verma, D., Sachdev, HPS et al., 1995. Use of Milk Based Commercial Weaning Foods Amongst Scheduled Caste Communities in Haryana, Indian Pediatrics, pp. 905-908.

Khan, ME., 1990. Breastfeeding and Weaning Practices in India, Asia Pacific Population Journal, Vol. 5, pp. 71-88.

Lingam, 1995. Support Structures, Empowerment of Women and Breastfeeding, Working note prepared for the National Consultation Meet on ‘Promotion of Breast-feeding: Empowering Women’, NIPCCD, New Delhi.

Nanavati, RN., Mondkar, JA., Fernandez, AR. and Raghavan, KR., 1994. “Lactation Management Clinic - Positive Reinforcement to Hospital Breastfeeding Practices”, Indian Pediatrics, Vol. 31, pp. 1385-1389.

Narayanan, R., 1997. At What Cost? Women’s Multiple Roles and the Management of Breastfeeding, Research Report No. 2, M S Swaminathan Research Foundation.

International Institute for Population Sciences, 1995. National Family and Health Survey 1992-93, Mumbai.

International Institute for Population Sciences, 2000. National Family and Health Survey 1998-99, Mumbai, India, ORC Macro, Maryland, USA.

Nduati, R., Richardson, BA., John, G. et al., 2001. Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial. Lancet 357: 1651-55.

Pandey, D., 1995. Empowerment of women: Participatory Action Research approach. RCWS, SNDT Women’s University, Mumbai.

Philip, S., 1995. Obstetrics: Recent advances. BMJ, 311: 1209-1212.

Prabhakara, GN. et al., 1987. Infant Feeding Patterns in Slums of Bangalore, Indian Pediatrics, Vol. 24, pp. 895-898.

Singh, S., Bhasin, SK., Ingle, GK. and Raut, DK., 1990. Pattern of Breastfeeding Practices in a Rural Community from Haryana, Journal of Tropical Pediatrics, Vol. 36, pp. 334-335.

WHO, 1991. Indicators for assessing breastfeeding practices, WHO/CDD/SER/91.4.

Notes

3 The evidence is drawn from the bibliography prepared by the authors entitled: Breast-Feeding and Infant Feeding Practices in India: A review and Annotated Bibliography of Selected Research. Centre for Health Studies, Tata Institute of Social Sciences, Mumbai, May 2001.

4 Cited by Shrinivasan K in “Has Modernization Increased Fertility in Karnataka, India? Demography India – Vol. 15, July-December 1986.

Auteurs

Reader, Centre for Health Studies, Women’s Studies Unit, Tata Institute of Social Sciences, Deonar, Mumbai, INDIA.

Research Officer, Centre for Health Studies, Women’s Studies Unit, Tata Institute of Social Sciences, Deonar, Mumbai, INDIA.

© Institut Français de Pondichéry, 2004

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