Vaatsalya- Kanani-2007-hospital based nutrition communication
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Transcript of Vaatsalya- Kanani-2007-hospital based nutrition communication
!""#$"%&"!""#$"%&"!""#$"%&"!""#$"%&"…
A Hospital Based Nutrition Health Communication Program
A Report of the Interim Assessment of the Program
At Maharani Shantadevi Hospital
By Shubhada Kanani and Smita Maniar
A Program by:
Aarogya Center for Health-Nutrition Education and Health Promotion
January, 2005
Vaatsalya, Aarogya 2005 1
!!!!""#$"%&"""#$"%&"""#$"%&"""#$"%&"…
A Hospital Based Nutrition Health Communication Program
A Report of the Interim Assessment of the Program At Maharani Shantadevi Hospital
By
Shubhada Kanani and Smita Maniar
Counseling Team: Smita Maniar
Vaijayanti Deshpande Vibha Shah
A Program by:
Aarogya Center for Health-Nutrition Education and Health Promotion
January, 2005
Vaatsalya, Aarogya 2005 2
Acknowledgements
We appreciate the support of the Maharani Shantadevi Hospital for giving the permission to carry out the Vaatsalya program in their hospital. We acknowledge the continued support given by Dr. Athale. Dr. Bhide, Dr. Ambardar, Ms. Madhavi (Dietician), Mrs. Kiranben (Administration) and Dr. Deepti (Medical Officer of FWC) and other staff of FWC during the program. We are appreciative of the support of the Trust Board members of the MSH hospital who value our services and extend co-operation as needed. We appreciate the continued support of our counselors, Ms. Vaijanthi Deshpande and Ms. Vibha Shah who regularly and effectively conducted the Vaatsalya counseling sessions and also carefully documented the qualitative and quantitative data. We also thank our Computer Assistant Ms. Sunita for data entry and preliminary analysis of the data. Dr. Shubhada Kanani Smita Maniar Director, Aarogya Program Coordinator, Aarogya
Vaatsalya, Aarogya 2005 3
Glossary of Terms
Anda Egg Bataka Potato Bataka-pauwa A snack made from potato and rice flakes Bhaji Green Leafy Vegetables Bhat Cooked rice Bhinda Ladyfinger Cha Tea Chamchi Spoon Chanadal Split Bengal gram Chikoo Sapota Dal A liquid pulse preparation Darakh Grapes Doodh-kela Mixture of milk and banana Dudh Milk Fulevar Cauliflower Gehu wheat Ghee Saturated fat Ghutti A herbal medication Guvar Cluster beans Kadhi A fluid made of sour buttermilk and bengal gram flour Kathol Pulses Kela Banana Keri Mango Khichadi Pressure cooked mixture of rice and pulse Kodri A kind of millet Palak Spinach Pattervel-na-pan Colocasia leaves Phal Fruits Roti Unleavened bread Sakhis Friends Suva A type of green leafy vegetable Tandalja A type of green leafy vegetable Upma A porridge-type snack made of semolina Valor Broad beans Vatki Bowl Vavding A herbal medication
Vaatsalya, Aarogya 2005 4
INTRODUCTION For several decades now, the high prevalence of maternal mortality especially among
pregnant and lactating women; low birth weight (LBW); and infant mortality continue to
jeopardize the survival and quality of life of our women and children. The box below
gives the disturbing scenario.
Although under the Reproductive and Child Health (RCH) program of the Government,
the preventive and curative reproductive health and nutrition needs are met to some
extent, the quality of the services provided leaves much to be desired.
Pregnancy and lactation care remains unsatisfactory with poor coverage; lack of
attention to nutrition and virtually absent counseling of the women. Newborn care and
infant feeding also requires attention. Improper feeding practices increase the risk of
neonatal and infant mortality and morbidity. It is a known fact that the peaking of stunting
and underweight during the period of 6 to 24 months (especially the 2nd year of life) is
largely due to faulty breastfeeding and complementary feeding practices, aggravated by
infections and poor health care.
The Challenge due to Rapid Urbanization
The problem of rapid urbanization (especially in States such as Gujarat) is throwing up
newer challenges, especially the growth of the slum population. The State of Gujarat has
always been one of the most urbanized with 37.9 % of its population in urban areas. In
Vadodara city, the total slum population in the Municipal Corporation limits is 8.21% of
the total population of the city. The increasing number of slum dwellers calls for
expansion and improvement of the existing urban basic services.
Some discouraging data
o Pregnant women are 40 times more likely to die in India due to pregnancy or childbirth compared to women in a developed country.
o Above 80% of women are anemic during pregnancy and breastfeeding periods o One in every three infants is born weak; with low birth weight. o Many of them die before their first birthday. o Those who survive do not grow normally. o Children under two years do not get even 50% of the required food intake
because parents do not know what to feed and how much, how often.
Vaatsalya, Aarogya 2005 5
Role of Health Institutions: Urban Hospitals as Institutions of Change
It is believed that health institutions catering to pregnant and lactating women through
antenatal (ANC) and postnatal (PNC) care can play an important role in reducing
maternal undernutrition through adequate ANC services. Qualitative improvement of the
existing ANC services in these institutions has the potential to reduce the LBW and
improve the neonatal feeding practices, which would definitely have a positive impact on
neonatal mortality and morbidity. Further, PNC would not only focus on the much
neglected lactating mother, but also help promote desirable neonatal-infant feeding and
care practices, so vital to reduce the prevalence of stunting and underweight in our
country.
These institutions can act as health promoters rather than just providing curative and
rehabilitative services to the community. The World Health Organization had, in 2002,
mooted the concept of “Health Promoting Hospitals” and provided guidelines for
enabling hospitals to become institutions of change.
Maternity Hospitals in Vadodara city In Vadodara city, maternity hospitals (especially those run by charitable not-for-profit
institutions) and government run teaching hospitals draw a large number of poor women
for pregnancy care and delivery of newborn from the slums and nearby rural areas.
Women hope for better quality care here. Approximately 4000-5000 deliveries take place
in a year in each of these hospitals where above 50% of the women are from low socio-
economic groups. The primary aim of these hospitals is to give adequate curative and
rehabilitative care. Due to the large in-flow of the women in these hospitals and pressing
medical care needs, adequate attention is not given to counseling and communication of
messages to address common health-nutrition related antenatal-postnatal problems
such as poor dietary practices during pregnancy and lactation; poor weight gain during
pregnancy; irregular iron supplementation; lack of utilization of contraceptive methods
during lactation.
The pregnant and lactating women visiting these hospitals lack awareness regarding
appropriate nutrition-health care for themselves and also of their newborns and infants
such as feeding colostrum; exclusive breastfeeding till 6 months of age and so on. Thus,
strengthening health-nutrition counseling and communication as an integral part of
Vaatsalya, Aarogya 2005 6
hospital care will greatly help in improving the nutritional status and health profile of the
women with beneficial effects on the health and nutritional status of the newborns and
the infants as well. This will particularly help the low income group families especially the
uneducated or less educated.
Nutrition-Health Communication for Behaviour Change Qualitative improvement of hospitals includes strengthening of the nutrition- health
education component in terms of improving the communication strategies for behavior
change. Strengthening of the existing ANC services, especially in terms of effective
Nutrition-Health Communication for Behavior Change (NHCBC) can go a long way in
improving the nutritional profile of pregnant women. This in turn would be expected to
have a beneficial effect on the birth weight of the newborn. Secondly, once the woman
has delivered her child at the hospital, the 3-4 days that she is in the ward is an
opportunity for empowering her and her attending relatives with valuable knowledge
regarding newborn feeding and care, especially breast feeding and complementary
feeding practices, hygiene and prevention of infections, management of common
childhood illnesses.
However, the reality is different. In the crowded out-patient department (OPD) and the
wards, the focus is on immediate needs like managing morbidities in women and taking
care of a large number of deliveries. The shortage of staff and inadequate sensitization
of the service providers regarding women’s needs make it very challenging and difficult
to introduce and carry out counseling and nutrition-health communication services in
hospitals. This is more so for areas considered less important or dispensable, such as
advising adequately regarding maternal and child feeding and preventive health care.
And yet, counseling and communication towards favorable change in nutrition-health
practices is critical in these hospitals, more so because many of them in urban and semi-
urban areas cater to the low-income families, who have traveled distances in the hope of
getting better quality care compared to those available to them locally.
The !""#$"%&"!""#$"%&"!""#$"%&"!""#$"%&" Program of Aarogya Trust Aarogya, Center for Health-Nutrition Education and Health Promotion, a registered non-
government organization (NGO) has initiated a program '!""#$"%&"� (Vaatsalya means
affection) based on Nutrition-Health Communication for Behavior Change (NHCBC) in
Vaatsalya, Aarogya 2005 7
two urban hospitals catering to low and middle socio-economic groups. The objective of
the program is to improve antenatal care; postnatal care; newborn and infant care
practices through a focus on behavior change communication.
The specific aim of this program is to educate pregnant and lactating women and their
families to improve home based nutrition-health practices. It also aims to educate nurses
and ayahs of the hospital who in turn will educate the women on antenatal-postnatal
care and infant care practices as part of their routine work. Appropriate communication
strategies occupy an important place in this program.
The !""#$"%&" program was initiated in 2002 in Kalpana-Uma Hospital (KUH). The
strategy included weekly sessions with pregnant women and their family members
wherein they were encouraged to practice certain key behaviors that will improve their
own health; and the birth weight and health of their newborn and later, in infancy. Follow-
up sessions were held to reinforce the messages. Simple and clear flash cards were
used. Follow-up was also done in the wards post-delivery. Further, the nurses and
aayahs were sensitized regarding the key practices related to postnatal care and infant
feeding through periodic training workshops. These nurses and aayahs spread the
nutrition-health messages among the pregnant women and their families while taking
care of routine hospital activities.
After encouraging experiences in KUH, !""#$"%&" is being implemented in three phases
at the Maharani Shantadevi Hospital (MSH), another hospital in the city catering to large
number of pregnant and lactating women and infants from low and lower- middle income
groups. The phases of the program are:
Phase I: Situational Analysis: assessing the current situation as regards birth weight
profile, and beliefs-practices of mothers related to nutrition.
Phase II: Designing and implementing Nutrition-Health Communication for Behavior
Change strategies, in partnership with the hospital staff.
Phase III: Process and Impact Evaluation of the Program – assessing the approaches
which work and the constraints and challenges of a hospital setting; as well impact of the
NHCBC approach on practices of women and their families.
The detailed description of these phases follows.
Vaatsalya, Aarogya 2005 8
PHASE I: SITUATIONAL ANALYSIS Before beginning the program in the Maharani Shantadevi Hospital (MSH) in the year
2004, a rapid appraisal was conducted to understand the situation as regards the
prevalence of low birth weight (LBW) and the existing knowledge, attitude and practices
of pregnant and lactating women and their families as regards nutrition of women as well
as the infants. The hospital keeps a database of all the births in the hospital including
birth weight of the newborn, sex of the newborn, age of women, parity, time of
enrollment for antenatal care (ANC) and regularity of ANC visits, expected due date and
date of delivery.
Sample and Tools used for Situational Analysis A systematic random sample of 746 records from the last three years i.e. 2001-2003
was taken, approximately 250 records from each year. Data analysis was done using
Epi-Info–604d package. Mean birth weight and prevalence of low birth weight (LBW)
was estimated of the overall sample as well as by year. Further, effect of age of women,
parity and time of enrolment (early or late) for ANC checkups on the mean birth weight
and prevalence of LBW was also studied.
For assessing knowledge and practices regarding antenatal, postnatal care and infant
feeding practices, semi-structured interviews (SSIs) were conducted with the mothers of
the newborns who were admitted in the wards. Ten women were interviewed using the
questionnaire given in Annexure 1. Since data emerging were similar, more interviews
were not considered necessary. The qualitative and quantitative data obtained through
these interviews were analyzed. Verbatim statements of the women were retained to
illustrate their perceptions.
In-depth interviews were conducted with key personnel in the hospital and frequent visits
were made to understand and observe the system of providing health-nutrition care to
pregnant and lactating women in the hospital. The administrative superintendent, chief
medical officer, the gynecologists, the nutritionists, the pediatricians, the head nurses
and nurses attending to newborn were interviewed. The hospital has a Family Welfare
Center (FWC) run by the Vadodara Municipal Corporation on its premises. The Medical
Vaatsalya, Aarogya 2005 9
Officer, Lady Health Volunteer and Family Health Workers of the center were also
interviewed to understand their role in antenatal, postnatal and infant care.
Birth Weight of Newborns The mean birth weight of the newborns was 2.718 kg (Range: 1.000 kg to 4.150 kg;
Median: 2.750 kg.) and was significantly (p<0.01) higher among boys (2.772 kg) as
compared to that of girls (2.674 kg). There were no marked differences in the birth
weights year wise. Considering the age of mothers, it was found that the mean birth
weight of babies born to women less than 20 years was significantly (p<0.001) lower
than the mean birth weight of babies born to older women (≥ 20y). Moreover, the mean
birth weight of babies born to women delivering for the first time was significantly
(p<0.001) lower than those delivering for the second or third or more time (Figure 1).
This was probably because many women delivering for the first time were less than 20
years of age.
Figure 1: Mean birth weight of newborns according to parity of the women
The prevalence of low birth weight (LBW) was found to be 26.3% being higher among
girls. Further, prevalence of LBW was also significantly high (p<0.001) for women less
than 20 years of age (Figure 2). Considering the parity, the prevalence of LBW was
higher in primiparous women as compared to others, but this difference was not
significant statistically.
2.675 2.804 2.757
00.5
1
1.52
2.53
3.54
First Second Third or moreParity of mothers
Mea
n B
irth
Wei
ght(k
g)
Vaatsalya, Aarogya 2005 10
Figure 2: Percent low birth weight of newborns according to age of mothers
Knowledge and Practices of Pregnant and Lactating Women
� Nutrition during Pregnancy Majority of the women consumed at least three meals a day during pregnancy. They
either took cereal-vegetable or cereal-pulse combination in each meal. The women
mentioned that they increased food intake during pregnancy. However, their daily meal
pattern indicated that their food intake was less than adequate. Milk and fruit
consumption was regular. Consumption of green leafy vegetables and pulses/ legumes
was not regular.
Majority of the women reported consuming one iron tablet daily from second or third
trimester of pregnancy. They were aware that iron supplementation provides strength
and increases blood.
� Weight Gain and Rest during Pregnancy
Weight monitoring was regularly done and the women were aware that their weight was
increasing regularly during pregnancy. They also mentioned that the purpose of weight
monitoring was to indicate the growth and weight of the fetus and their own health
status. To quote…
o Balak nu poshan barabar thaye chhe ke nahi te khabar pade” (We come to know
whether the child is getting adequate nutrition).
o “Balak no vikas khabar pade” (We come to know the growth of the child).
45.4
23.2 22.9
0
10
20
30
40
50
<20 y 20-30 y >30 y
Age of the women
Perc
enta
ge L
BW
Vaatsalya, Aarogya 2005 11
Majority of the women reported that they rested in the afternoon during pregnancy.
However, they were not aware of benefits of taking rest during pregnancy.
� Nutrition during Lactation Women reported increase in their food intake during lactation. They were aware that
increasing food intake during lactation would increase breast milk and hence improve
the health of the baby. However, only a few women mentioned the benefit of increasing
food intake to their own health.
Various myths were prevalent regarding foods to be avoided during lactation. Some of
them avoided vegetables such as ladyfinger, cluster beans and colocasia leaves. It was
believed that they cause cough in the child. Some women avoided sour foods,
particularly, lemon, curd, buttermilk and kadhi. This was more so among women who
had stitches due to caesarian section delivery, as it was believed that sour foods prevent
healing of the stitches.
Majority of the women were not aware about iron supplementation during lactation. Most
of them believed that iron supplementation should be only during pregnancy. However,
they mentioned that if prescribed by the doctors they would consume iron tablets during
lactation.
� Breastfeeding Majority of the women had fed colostrum to their newborns and had initiated
breastfeeding as soon as possible after birth. Less than half of the women interviewed
were aware that infants should be exclusively breast fed till 6 months. There were some
women who believed that breastfeeding should be continued till 9 months-1½ years
without giving any complementary foods. Some women were delivering for the first time,
hence were not aware that till what age should the infant be exclusively breast fed.
When asked regarding breastfeeding the infant during illness, half of the women said
that they would continue breastfeeding during illness. Some women mentioned that they
would consult the doctor and then breastfeed during illness.
Vaatsalya, Aarogya 2005 12
� Complementary Feeding Majority of the women were not
aware of the age of initiation of
complementary foods. Further,
they were also not aware of the
quantity of complementary
foods to be fed to infants 6-12
months old. The women
mentioned that first foods
initiated as complementary
foods were dal-water, tea-
biscuit, dal-rice. The statements indicating their lack of awareness is mentioned in the
Box 1.
Services provided by the hospital to pregnant and lactating women The overall system that emerged from the interviews with key personnel of the hospital
and observations made during frequent visits to the hospital is highlighted below.
� The pregnant women who are registered in the hospital visit the nutritionist usually
twice before delivery. They are counseled in the local language (i.e. Gujarati or
Marathi) regarding diet during pregnancy, keeping in view the socio-cultural
background. Counseling of at least 10-12 pregnant women is done per day. Personal
queries of the women are also addressed. Specific and ‘doable’ messages are given
regarding nutrition during pregnancy. Since the hospital is a “Baby Friendly hospital”,
it was reported that a lot of IEC material is used for counseling women on
breastfeeding practices such as initiation as soon as possible, colostrum feeding and
avoiding prelacteals; especially during the last trimester of pregnancy.
� Hemoglobin (Hb) and other blood parameters are checked of the pregnant women at
the time of registration. Antenatal visits are quite frequent and regular: once a month
in first and second trimester and once fortnightly in last trimester. During the visits
the gynecologists and supporting nursing staff monitor the weight; regularly do
antenatal check-ups; and prescribe iron and calcium supplementation. Records are
kept for each antenatal visit.
� The hospital has a Family Welfare Center (FWC) of Vadodara Municipal Corporation,
which provides Tetanus Toxoid vaccination and iron tablets to the pregnant women.
Box 1: Voices of women regarding Complementary Feeding
o “6 mahine, ½-1chamchi dal-bhat aapvana.” o (When the child is 6 months old, ½ -1 spoon
dal-rice should be fed) o “Cha-dudh aapvana. Khavay etalu khay” o (Should give tea, top milk. Child will eat as
much as he/she wants) o “Balak bhukhyu thaye etele aapiye” o (We give when child feels hungry)
Vaatsalya, Aarogya 2005 13
The BCG vaccination of all the children born in the hospital is also taken care of by
the FWC. Further, the lactating women regularly visit the FWC for other vaccines to
be given to their children as well as for services related to family planning.
� After delivery, the pediatricians and the nurses of the baby room give information on
avoiding prelacteals, colostrum feeding and early initiation of breastfeeding. The
women’s stay at hospital post delivery is 2-3 days for normal delivery and 4-5 days
for women undergoing caesarian section deliveries.
� The postnatal visits of women are generally within a week or 15 days. The lactating
women definitely come at 1-month post delivery during which free-check up is
available to the infant. Women also come regularly for BCG immunizations
(scheduled on fixed days of the month) and other immunization of their infants at the
FWC as mentioned earlier.
The doctors and the hospital staff were quite cooperative in providing all the information
needed to decide the strategy for implementation of the program.
Conclusions based on Situational Analysis The situational analysis was very informative as regards knowing the nutritional status of
the women and the infants; assessing their current knowledge and practices,
understanding the current services of the hospital for pregnant and lactating women,
especially the role of the nutritionist, the doctors, nurses, FWC and other staff. It was
found that nutritional care and advice during antenatal period and early neonatal and
breastfeeding practices are already being addressed at the hospital in the OPD and the
wards through the hospital’s nutritionist.
Hence, it was decided that the !""#$"%&" program would focus on the postnatal and
infancy period so as to complement the ANC counseling already been given. The
!""#$"%&" program would support the services currently given at the hospital and
importantly, increase awareness and encourage behavior change among lactating
women and their families with regard to their own nutrition and the nutrition-health of
their infants. It would ensure that the messages are gender-sensitive and encourage
family support of the women.
The details of the implementation of the program are described in the next section.
Vaatsalya, Aarogya 2005 14
PHASE II: IMPLEMENTATION OF THE PROGRAM Apart from reviewing the existing situation, an appropriate need-based and feasible
strategy should be first planned and then implemented, for any program to have a
measurable impact on nutrition-health related behaviors and ultimately on the health and
nutritional status of its beneficiaries. On the basis of the situational analysis as said
earlier, it was decided that the !""#$"%&" program would focus on postnatal nutrition and
infant care. The program is gender sensitive and hence nutrition of lactating woman is
stressed upon for her own sake and not simply because she is breastfeeding.
Behavior change is possible if the communication is focused on highly critical behaviors.
Hence, a list of critical behaviors regarding postnatal nutrition, breastfeeding and
complementary feeding was prepared. These behaviors were selected based on the
following criteria.
o The behaviors, which are recommended and those which have been well documented to have impact on the health-nutritional status of lactating women and infants.
o The behaviors, which are feasible or possible to be practiced by the women.
A sample of these behaviors is given in Box 2 on next page.
A counseling guide has been developed which includes the following components:
o Message containing critical behaviors;
o the motivating factors to accept encourage acceptance of the behaviors and
o the possible resistances that the women might face while practicing the behaviors
(Annexure 2).
It has been established that behavior change is not possible unless supported by the
family members. Hence, a list of supportive behaviors for the family members such as
mothers or mothers-in-law or husband of the lactating women is also included it in the
counseling guide. Counseling of the family members would encourage them to support
the lactating women to practice the recommended behaviors.
Vaatsalya, Aarogya 2005 15
Detailed plans of the communication session for both the initial and the follow-up visits
have been designed. These session plans help the counselors to be focused during the
sessions. The question guides needed to elicit information on the perceptions and
practices of the women - both at the time of initial and follow up visits - have been
included to record the qualitative and quantitative information obtained. Annexure 3
gives a sample of the data recording sheet of quantitative variables. The qualitative
information is recorded as field notes.
The Overall Strategy The overall strategy (Figure 3) which aims at improving maternal nutrition during
lactation and infant feeding includes…
� Bi-weekly counseling session in the ward and Out Patient Department (OPD)
with lactating women and their family members to make women aware of critical
behaviors regarding postnatal nutrition and infant feeding; and to encourage
them to practice these behaviors.
Box 2: The Behaviors Emphasized during Communication Sessions with Lactating Women and their Family Members- An Example Postnatal Nutrition o Increase quantity and improve quality of food intake during lactation
� One extra food item daily e.g. 1 roti or 1 vatki dal-bhat or 1 vatki kathol or 1 vatki upma or bataka-pauwa
� Include daily one fruit (any seasonal fruit) � Include 1 vatki bhaji daily in your diet. � Drink adequate amount of water/ liquids.
o Consume daily 1 iron-folate tablet after meals � Lactating women should consume iron tablets for at least three months after delivery. � Later, consume at least one tablet per week till menopause.
Breastfeeding o Exclusive breast feeding up to 6 months without water or any other fluid
� Breastfeed 8-12 times during the day. � Do not give prelacteals or any other fluids i.e. ghutti, honey, gripe water, herbs. � Do not give water. � Do not give top milk or top foods.
o Empty one breast fully before switching to the other. o Breast-feed the infant during illness of either mother or infant
Vaatsalya, Aarogya 2005 16
Figure 3: Nutrition-Health Communication for Behavior Change The Overall Strategy
Lactating Women and Family members counseled
VISIT 1: INITIAL VISIT
In Wards In OPD of the hospital
(Women admitted after delivery) (Women visiting the pediatrician or FWC for immunization of infant)
VISIT 2: FOLLOW UP VISIT
In OPD of the hospital (Women visiting the pediatrician or FWC for immunization of infant)
VISIT 3 OR MORE: FOLLOW UP VISIT
In OPD of the hospital (Women visiting the pediatrician or FWC for immunization of infant)
� Follow-up sessions with the same women and their family members within 2-4
months after the first session to reinforce critical infant feeding messages and to
record whether women could change their behaviors.
Attempts are being made to counsel the women at least twice. Almost one-third of the
women have paid 2 visits to !""#$"%&" and about 5-10% of the women visited three or
more times. Counseling is carried out by a pair of !""#$"%&" sakhis. One of them
counsels the women and the other records information obtained.
Emphasis on Communication � Focussed Message: During the counseling sessions, the counseling guide is used to
emphasize critical specific messages (Annexure 2). In the sessions the benefits of
each behavior that the women are asked to practice are highlighted and their
Vaatsalya, Aarogya 2005 17
resistence (anxieties, beliefs), if any, are addressed. Although all the behaviors in
the list are important, counseling is focused on most relevant behaviors during each
session. For example, during our sessions with the lactating women admitted in the
wards immediately after delivery, the behaviors regarding postnatal nutrition and
breastfeeding are focused upon and not of complementary feeding. The behaviors
related to complementary feeding are emphasized during the subsequent
communication session in the OPD when the women come for postnatal checkup or
immunization of their infants.
� Including primary and secondary audience in counseling: Realising the importance of
family support, the family members are also a part of the counseling process and are
informed of the various ways in which they could support the women to practice the
critical behaviours.
� Use of visuals: The counselors use colorful and relevant flashcards to emphasize
key aspects of each critical behavior. The pictorial representations of the behaviors
help in catching attention of women and help them to remember the messages later
at home.
� Multiple channels: It is known that the messages should be given through various
channels and be reinforced to be effective. In this hospital, the pediatrician, the
nutritionists and !""#$"%&" team members continuously reinforce the critical infant
feeding messages along with messages related to the postnatal care.
� Take home messages: Aarogya has developed a guidebook entitled ‘Healthy
Mother, Healthy Child: A Nutrition Guidebook for the Mother and the Child’, in the
local language, Gujarati. This is distributed among the women who are counseled in
the wards or the OPD for the first time. This guidebook is not only a tool to transmit
consistent and uniform messages among women counseled under the !""#$"%&"
program, but also serves as a motivator and a reminder to the women to practice
the behaviors at home. � Documentation of the Program: The counselors record the qualitative and
quantitative information pertaining to the perceptions and practices of the women
obtained during each session with the women on simple formats.
o Qualitative data: The information obtained from the field notes taken during the
sessions are categorized in broad themes and sub-themes based on the
behaviors addressed during the counseling. These are then summarized in the
form of a report. Weekly or fortnightly session reports thus prepared include
Vaatsalya, Aarogya 2005 18
mainly qualitative information obtained regarding postnatal nutrition and infant
feeding practices. Separate reports are prepared for women counseled in wards
and OPD; as well as for Visit 1 sessions and Visit 2 sessions. The reports
document our progress and inform us about the changes in the awareness and
practices of women after our counseling.
o Quantitative data: The quantitative information recorded on the data sheets is
coded and entered into the computer using statistical package EpiInfo-6.04d.
These data are analyzed periodically to evaluate the impact of the program.
Thus, the counseling process is continuously evaluated and modified as required. The
changes made in the process are also documented in the reports. Periodic review
meetings are organized for the counselors and recorders with senior nutritionists and
communication experts to discuss the progress, communication process and revise if
needed.
The periodic reports on documented qualitative and quantitative information also help to
inform the hospital authorities about the progress of the program – the benefits of the
program to the beneficiaries and the support received from them to implement the
program.
RESULTS OF THE INTERIM EVALUATION OF !""#$"%&"!""#$"%&"!""#$"%&"!""#$"%&"((((
While on an ongoing journey, it is desirable to pause, assess, analyse and reflect on the
activities undertaken and the direction ahead. With this view, we undertook an interim
assessment of the Vaatsalaya program for the year 2004, which consisted of analysis of
perceptions of women during Visit 1 and impact of our counseling as assessed in visit 2.
The Initial Visit (Visit 1) of the Women…..
Profile of the Participants During the year, 643 women were counseled (295 women in wards and 348 women in
OPD) for the first time (Visit 1). Majority of the women enrolled in the program had
delivered for the first time (62%). Some of them had delivered for the second time (32%)
Vaatsalya, Aarogya 2005 19
and very few for the third time or more. Further, majority of the women (95%) had
normal deliveries.
Almost equal number of boys and girls were represented as indicated in the Table 1.
Majority of the infants of the women counseled were in the age group of 0-5 months.
Table 1: Profile of the Women !""#$"%&"((Beneficiaries and their Infants
Parameter OPD(N=348)
Ward(N=295)
Total (N=643)
n % n % n % Number of Women
Parity of the women I II III or more
206 123 19
59.2 35.3 5.5
190 82 23
64.4 27.8 7.8
396 205 42
61.6 31.9 6.5
Type of delivery Full term Pre-term
328 20
94.3 5.7
281 14
95.3 4.7
609 34
94.7 5.3
Number of Infants OPD
(N=348) Ward
(N=295) Total
(N=643) n % n % n %Sex of infants Boys Girls
196 152
56.3 43.7
156 139
52.9 47.1
352 291
54.7 45.3
Age group 0-5 months 6-12 months
288 60
82.8 17.2
295 0
100.0
0
583 60
90.6 9.4
The women counseled at !""#$"%&"((were mainly accompanied by their mothers (37%).
Some women were accompanied by their husbands or the mothers-in-law or sisters-in-
law. In the OPD, the women are mainly directed by the staff of the FWC to visit the
!""#$"%&" counseling center; the pediatrician of the hospital directs the others.
Vaatsalya, Aarogya 2005 20
Anthropometric Measurements of the Infants
� Birth weights of the infants The current weight of the infants at the time of enrolment in !""#$"%&" was recorded
and also their birthweights (as mentioned in the baby card) were recorded. In all,
anthropometric data of 591 infants was available out of the 643 enrolled. As shown in
Table 2, the mean birth weight of the infants enrolled was 2.60 kg. The birthweight of
the girls was significantly (p<0.01) lower than of boys.
Table 2: Mean Birthweight of the Infants Enrolled
Mean Birth Weight ±±±± SE T-value Sex of the child Boys (N=324) 2.83 ± 0.02 2.77 S**
Girls (N=267)
2.74 ± 0.01 Total 2.60 ± 0.23 NS: Non-significant, S*: Significant at p<0.05, S**: Significant at p<0.01, S***: Significant at p<0.001
� Prevalence of Low Birth Weight As Table 3 indicates that the prevalence of low birth weight (LBW) among the infants
enrolled was 19%. The prevalence of LBW was significantly (p<0.05) higher among girls
as compared to boys. Among those enrolled in OPD and ward, the prevalence of LBW
was similar (19%). The prevalence of LBW had no correlation with the parity of the
mother.
Table 3: Prevalence of Low Birth Weight (LBW) Among Infants Enrolled
Parameter Normal Weight Low Birth Weight M-H-Chi-square value
n % n % Sex of the child Boy (N=324) 274 84.6 50 15.4 5.7 S* Girl (N=267) 205 76.8 62 23.2 Place of counseling OPD (N=339) 204 81.1 64 18.9 0.0 NS Ward (N=252) 275 81.0 48 19.0 Parity First Child (N=358) 283 79.1 75 20.9 2.36 NS Two or more children (N=233)
196 84.1 37 15.9
Total (N=591) 479 81.0 112 19.0
Vaatsalya, Aarogya 2005 21
� Weight of the Infants at Enrolment Table 4 shows the mean weights of the infants at the time of enrolment. As expected,
infants enrolled in the OPD had significantly (p<0.001) higher mean weight as compared
to those enrolled in the wards, the reason being those enrolled in OPD were older than
those enrolled in wards. The infants were enrolled in wards within 2-4 days after
delivery. Comparing the sex of the infants, the mean weight of girls was significantly
(p<0.01) lower than that of boys, perhaps because their birth weight was lower to begin
with.
Table 4: Mean Weight of the Children at Visit 1 (at enrollment)
Mean Weight ±±±± SE T-value Sex of the child Boys (N=324) 3.93± 0.12 2.6 S** Girls (N=267) 3.55± 0.09 Place of counseling OPD (N=339) 4.50± 0.11
13.3 S*** Ward (N=252) 2.79± 0.03
Total (N=591) 3.75±0.07 NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S***: Significant at p<0.001
� Prevalence of Underweight at Enrolment About one-tenth of the infants enrolled (Visit 1) were underweight (Weight for Age Z-
score-WAZ- <-2.0 SD) with the highest prevalence among 6-11 months old (20%). The
prevalence of underweight was not significantly different among the two age groups;
among the boys and the girls; or among those enrolled in OPD and in ward (Table 5).
Table 5: Percent Children Underweight* at Visit 1 (at enrollment)
Parameter Normal Weight Underweight M-H-Chi square Value
n % n %
Age group of infants 0-5 months (N=535) 476 89.0 59 11.0 3.60NS 6-11 months (N=56) 45 80.4 11 19.6 Sex of the child Boys (N=324) 286 88.3 38 11.7 1.01NS
Vaatsalya, Aarogya 2005 22
Parameter Normal Weight Underweight M-H-Chi square Value
n % n %
Girls (N=267) 235 88.0 32 12.0 Place of counseling OPD (N=339) 297 87.6 42 12.4 0.23NS Ward (N=252) 224 88.9 28 11.1 Parity First child (N=358) 314 87.7 44 12.3 0.17NS Two or more children (N=233)
207 88.8 26 11.2
Prevalence of LBW LBW (N=112) 55 49.1 57 50.9 201.46S3 Normal Birth weight (N=479)
Total (N=591) 521 88.2 70 11.8 *Normal weight = ≥ -2.00 WAZ; Underweight= <-2.0 WAZ NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S3: Significant at p<0.001 As indicated in Table 5, the prevalence of underweight infants was also compared with
parity respect to and LBW. The prevalence of underweight was not affected by the parity
of the mothers. The mothers with more than one child had mostly two children. Half of
the infants who were LBW babies were underweight; significantly highter (p<0.001) as
compared to the infants born with normal weight. Overall, about one-tenth of the infants
were underweight at the time of enrollment.
Considering the IAP classification (Table 6), the prevalence of underweight was about
one-third (28%) among the infants enrolled in the program. Further, there was no
significant difference in the prevalence of underweight (≤80% NCHS Standard) among
the two age groups; and among the boys and the girls enrolled. Overall, considering the
IAP classification the prevalence of underweight at the time of enrollment; was higher
than as compared to the percentage of underweight considering <-2.0 WAZ.
Vaatsalya, Aarogya 2005 23
Table 6: Percent Children Underweight* at Visit 1 (At Enrollment)
Parameter Normal Weight Underweight M-H-Chi square Value
n % n %
Age group of infants 0-5 months (N=535) 386 72.1 149 27.9 0.01NS 6-11 months (N=56) 40 71.4 16 28.6 Sex of the child Boys (N=324) 239 73.8 85 26.2 1.01NS Girls (N=267) 187 70.0 80 30.0
Total (N=591) 426 72.1 165 27.9 *Normal weight = > 80% of NCHS Standard; Underweight= ≤ 80% of NCHS Standard. NS: Non-significant; S*: Significant at p<0.05; S**: Significant at p<0.01 S***: Significant at p<0.001 Perceptions and Practices of the Women at the time of Visit 1 (At Enrollment)
o Nutrition During Lactation � Quantity of Food Intake during Lactation A majority of the women (67%) had increased their food intake during lactation (Table 7). The women stated that during lactation they consume more food as compared to
usual intake, or intake during pregnancy.
o “Pregnancy ma khati hati tevu vadhare khau chhu.” (I am consuming more as I
used to consume in pregnancy.)
o “Pahela karta vadhare khau chhu.” (I consume more food than before.)
The main reason stated for increasing food intake was to increase breast milk
production.
o “Jo chokru dhavashe etle vadhare khau to padshejne” (Since child will be
breastfeeding, naturally we have to eat more.)
o “Main jyada khaungi to hi mujhe jyada dudh aayega na!” (If I consume more then
only my breast milk will increase.)
Vaatsalya, Aarogya 2005 24
Table 7: Practices regarding Quantity of Food intake during Lactation
Food intake during lactation as compared to normal status
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %Has increased 232 66.7 200 67.8 432 67.2 Has decreased 31 8.9 17 5.8 48 7.5 Remained the same 83 23.9 71 24.1 154 24.0 No response/ No idea 2 0.6 7 2.4 9 1.4 The elderly female family members of women also mentioned that the women should
consume more mainly for increasing breast milk production. To quote a mother-in-law
and a mother of lactating women….
o “Chokrane dhavan aapvanu to khorak vadharvanoj ne.” (Since the child has to be
breastfed, food intake should be increased.)
o “Haave toh be pet thaya – baba nu pet ane manu pet. Etle vadhare khavanu.”
(Now, two stomachs have to be filled – child’s stomach and mother’s stomach.
So, food intake should be increased.)
Further, some women believed that they should increase food intake for better growth
and development of their infants.
o “Chokrane sari rite poshavanu hoi to vadharej khau pade ne!” (If we want to
provide adequate nourishment to our child, we have to eat more!)
Some women mentioned that since they were breastfeeding their appetite had
increased, hence they eat more.
o “Pushkal Khate. Breast feeding karavate mhanun bhuk pan khup lagte.” (I eat
a lot. Since I am breasting, my appetite has increased.)
About one-fourth of the women did not increase or decrease their food intake during
lactation as indicated in Table 7. Many of these women were overweight even after 2-3
months post delivery, hence they felt that if they increased food intake their weight would
further increase.
o “Charbi vadhare chhe etle nathi khati” (Since I am fat I do not eat more.)
The family members of these women also corroborated that the women do not increase
food intake due to weight consciousness. To quote…
Vaatsalya, Aarogya 2005 25
o “Jadi thayi jay etele nathi vadharti” (She [lactating woman] does not eat as she
believes that she would become fat.)
Another reason given for not increasing food intake was excessive breast milk
production leading to discomfort to mother and the child could not suckle.
o “Jyada nahi khati kyonki jyada khane se jyada dudh banata hai aur ye to pi nahi pati
pressure ki vajah se. Gathiya ban jati hai.” (I don’t consume more since increased
food intake lead to increase milk production and due to pressure she cannot suckle
properly. Hence, lumps get formed.)
o “Hu vadhare khau, to dudh bahu bharai jay ane chhati tight thai jay. Pacchi chhokra
ne dhavta na phave ne? Etale limited j khavanu.” (If I eat more, breast milk
accumulates and breasts become tight. Then, how can the child suckle? Hence
should eat only limited food.)
Some women also believed that excessive food intake would make the infant fall ill.
o “Chokru bimar pade, hu vadhare khau to.” (If I eat more, child would fall ill.)
o “Main jyada khaungi to bache ko julab nahi hoga?” (If I consume more food, won’t
the child suffer from diarrhea?)
Among the women who were visited in wards immediately after delivery, the food intake
had not increased due to various reasons. These included…
♣ Recently delivered hence due to pain of delivery their food intake had not increased.
o “Kachi suvavad chhe, etle hamna vadhare na khavay.”(As I have recently
delivered, I cannot eat more at present.)
♣ Caesarian section delivery hence light diet in the needed initial days after delivery.
o “Caeser hai to jyada kha nahi sakti.” (Since it was cesarian section delivery, I
cannot eat more.)
o “Khavatu nathi, tankane lidhe dukhe chhe.” (I cannot eat, as due to stitches it
pains a lot.)
♣ Dislike towards food made in the hospital.
� “Dawakhana nu khavanu bhavtu nathi, etle ochhu khavay chhe.” (I do not like the
food served in hospital, so I consume less.)
Vaatsalya, Aarogya 2005 26
♣ Indigestion and heaviness in stomach.
o “Vadhare khau, to pet bhare thai jay.” (If I eat more, I feel heaviness in the
stomach.)
o “Apacho thai jaye chhe etele khati nathi vadhare.” (I do not eat more as it leads
to indigestion.)
A few women (8%) had decreased their food intake mainly due to lack of appetite,
nausea and lack of time or attention towards their own health.
o “Bhukh nathi lagti. Khavatu nathi” (I do not feel hungry. I cannot eat.)
o “Vadhare khavanu man nathi mantu.” (I donot feel like eating more.)
o “Vadhare nathi khavatu, ubka ave chhe.” (Due to nausea I cannot eat more.)
o “Marathi potani kalgi, khorak ma dhyan nathi rahetu, etle mane thay chee ke maru
dudh ochu aavechhe” (I cannot take care of myself and my diet so I feel my milk
production has decreased.)
o “Time nahi hai isliye. Ghar me koi nahi hai to ye sone ke bad gharka kam karti hu.” (I do not get time. There is nobody in the house, so when my child sleeps I do the
household work.)
On the other hand, a few women were uncertain whether to increase or decrease food
intake during lactation. They wondered whether increasing food intake increases breast
milk production.
o “Kya ye sach hai ki hum jyada khayenge to jyada dudh aayega?”(Is it true that if we
consume more food, then milk output will be more?)
When the women and their family members were informed during the counseling that
food intake should be increased during lactation and that it is beneficial for both the
mother and the child, they were grateful to receive the information.
o “Paheli pregnancy me maine jayda nahi khaya tha, to dudh hi nahi aaya. Achha hai
apne yeh samjaya.” (During my earlier pregnancy, I had not consumed more hence
breast milk was not produced. It’s good that you explained this.)
Similarly, to quote a family member….
o “Saru thayu tame vadhare khavanu samjavyu, te to vajan vadhi jay, etle vadhare
khatij nathi.” (It is good that you [the counselor] have explained about increasing diet
during lactation, she is worried that her weight will increase hence she does not eat
more food)
Vaatsalya, Aarogya 2005 27
� Quality of Food Intake during Lactation About one-half of the women mentioned that they would avoid certain food items during
lactation (Table 8).
Table 8: Myths regarding Food Intake during Lactations
Will avoid certain foods during lactation
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %Yes 166 47.7 132 44.7 298 46.3 No 118 33.9 105 35.6 223 34.7 No response/ No idea 64 18.4 58 19.7 122 19.0 The women mainly avoid certain vegetables such as lady finger (bhinda), runner beans
(valore), cluster beans (guvarsing) , cauliflower (fulevar), potatoes (bataka), other beans
(papdi) , colocassia leaves (pattarvelna paan) or amaranth leaves (tandaljo). They
believed that these vegetables cause diarrhea, gastric trouble, indigestion and varadh (a
form of chest infection that causes severe cough) in the child. To quote…
o “Gawar, valor thi chokra ne gas thai jaye.” (Consuming cluster beans causes gas in
the child’s stomach.)
o “Bataka thi gas thay” (Potatoes causes gas/flatulence.)
o “Tandalja ni bhaji khay toh balak ne varadh thay.” (If tandalja is consumed, child
suffers from severe cough.)
o “Mu fulevar khadhi toh baba ne aakhi raat jhada thaya.” (When I ate cauliflower, my
child suffered from loose motions the whole night.)
These beliefs regarding various vegetables were also prevalent among the family
members of the women, especially elderly female family members. To quote..
o “Hari sabjiya agar ma khati hai to bachhe ko varadh ho jati hai. Isliye khali suva ki
sabji deti hu.” (If lactating woman consumes green leafy vegetables, her child will
suffer from diarrhea. Hence I give only Shepu leaves to her.) o “Pana na bhajia haju na pache, etle na aapiye.” (Lactating woman cannot digest
Pana na bhajia [a fried snack made from Bengal gram flour and collocasia leaves] ,
so we don’t give.)
Vaatsalya, Aarogya 2005 28
Some women avoided sour foods such as curds and food items prepared from sour
curds. They believed that consuming sour foods causes pus in the stitches taken post
delivery; and it causes cold and cough in the child. A few women were not aware of the
reason for avoiding sour foods; they avoided themsince elders in the family do not allow
them to consume them.
o “Khatash nahi khavanu, sasu kahe chhe” (I do not eat sour foods because mother-in-
law says so.)
o “Bade log dahi kadhi detej nahi hai bache ko shardi hoti hai.” (Elders do give curd
and kadhi [a fluid preparation made from sour curd and bengalgram flour], it causes
cold to the child.)
o “Operation chhe etele khatu nahi khavanu.” (Since I have got operated [C-section
delivery], I do not consume sour foods.)
Further, due to caesarian section delivery various foods were avoided such as rice,
ghee, and fried foods. These are believed to be harmful. The women did not know what
the adverse effects were.
o “Caesarian me tala aur ghee nahi khate” (Due to caesarian section delivery, fried
foods and ghee [clarified butter] are avoided.)
o “Operation karyu chhe, etle bhat nathi khati.” (Since I have undergone caesarian, I
do not consume rice.)
The above responses were mainly from women admitted in the wards. Whether they
continue avoiding these foods after discharge from hospital is not known; even the
women themselves were not aware what they would eat and what they would avoid after
going home from the hospital.
o “Ghare jaine mummy je aapshe te khaish etele mane khabar nathi ke badhu khavay
ke nahi.” (After going home, I would eat whatever my mother serves me so I do not
what I can eat and what I cannot.)
Various fruits were also avoided such as grapes (draksh), sapota (chiku) and banana
(kela). The women avoid these mainly since the elders do not allow them to eat them. A
few women mentioned that these fruits are considered ‘cold’ and cause cough-cold in
the child.
Vaatsalya, Aarogya 2005 29
o “Mara sasu mane darakh na didhi. Mane khaber chhe ke badhu khavay pan khava
de to ne!” (My mother-in-law did not allow me to eat grapes. I know everything can
be eaten but I was not allowed to eat.) o Gharwale kahe chhe ke fruits nahi khavanu, thandu pache.” (Family members say
that fruits shouldn’t be consumed, they are ‘cold’.) o “Thandi chije jaise kela khau to bacha chhinkta hai.” (If I consume ‘cold’ items such
as banana then the child sneezes.)
A few women avoided mangoes, as they are believed them to be ‘hot’ and cause
diarrhea in infant.
o Garma-garam chij, keri- khane se bachhe ko nuksan karata hai.” (Consumption of
‘hot’ foods such as mangoes harms the child.)
o “Aam khane se loose motions hote hai.” (Consuming mangoes causes loose motions
in the child.)
Some women avoided certain pulses and legumes such as bengal gram, bengal gram
dal and red gram dal. These were also believed to cause indigestion, flatulence and
diarrhea in the child.
o “Dal thi jhada thay. Roj na khavay.” (Pulses cause diarrhea. It should not be
consumed daily.)
o “Chanadal digest thavama bhare chhe hoon touch pan karti nathi. Mane bik laage
chhe kai chokrine thai jase.” (Bengal gram dal is difficult to digest, so I don’t even
touch it. I am scared that it will harm my daughter.)
The female family members of the women also believed that these dals should be
avoided.
o “Tuver ni dal na apiye. Balak ne pet ma dukhe.” (Red gram dal is not being served to
the lactating women. Child suffers from stomachache.)
Some women avoided wheat and rice. The main reason for avoiding rice was that it was
believed to cause indigestion and wheat was avoided since it was believed to cause
stomachache in the mother or the child. Further, some women consumed only soft foods
especially a type of millet boiled in water (kodri) for 1-2 months after delivery. They
believed that consuming soft foods helps to make the flow of breast milk easier and
hence it is easier for the child to breastfeed. The elderly family members also mentioned
Vaatsalya, Aarogya 2005 30
that they do not allow lactating women to consume any ‘hard’ food items and serve only
‘soft’ foods.
o “Badha kahe chhe ke bhat nade ane gas kare, etale kodri khau chhu.” (People say
that rice is harmful and can cause gastric trouble, hence I consume kodri [a type of
millet])
o “Gehu khane se pet me dard hota hai. Chikna hota hai na isliye.” (Since wheat is
sticky, if I consume wheat, my stomach pains.)
Many women believed that if they have a boy child, a lot of foods would be harmful but if
they have a girl child nothing would be harmful. Hence, certain foods are avoided only
when the women has delivered a boy child.
o “Beti hai to sab kuch kha sakte hai, lekin beta hai our gehu khaye to bete ko nahi
pachta.” (I can eat everything if I have a girl child but since I have a boy child I
cannot consume wheat as my son cannot digest it.)
o “Babo chhe etale bhinda-gawar nade, baby hoi to evu badhu khavay” (Lady finger
and cluster beans can harm the baby boy, but if the child is female, I can consume
these foods.)
o “Mane chokri chhe to hu badhuj khau chhu. Pan chokro hoi to nade.” (I have a girl
child so I consume everything but these could be harmful for male child.)
Further, some women had no idea whether to consume all food items or avoid certain
food items. They believed whatever their elders say. Some of them asked the
counselors during the sessions whether they could consume various foods items,
especially the non-vegetarian food items.
o “Anda kha sakte hai?” (Can I eat eggs?)
o Non-veg khay to chale ne?” (Is it okay if I consume non-vegetarian items?)
Some women and their husbands mentioned that due to pressure from elderly family
members they avoid certain foods
o Iski ichha to hoti hai par bade log kahete hai to maanana padata hai.” (She [lactating
woman] feels like eating everything but since elders ask to avoid certain foods we
have to obey.)
In contrast, some women (35%) and their family members did not believe that anything
should be avoided. They consumed all the food items during lactation.
Vaatsalya, Aarogya 2005 31
o “Vadahre sari quality no khorak etele vadhare dal, bhaji, phal evu badhu khavanu.”
(Improved quality of food means more pulses, leafy vegetables, fruits -everything
should be consumed during lactation.)
o “Hari sabjiya aur non-veg. khati hoon.” (I consume green leafy vegetables and non-
vegetarian items.)
They believed that if the lactating women consume all the food items, their children
would get adapted to consuming everything and would learn to digest everything.
o “Suvavad ma je khaye badha chokra bi khaye, etele badhu khavanu.” (Things which
the women eats during lactation, all those things the children would also eat so
everything should be consumed.)
o “Badhuj khavdavavanu, etle balak ne kai nade nahi.” (Everything should be served to
the lactating women, so that child is not affected.)
o “Sava mahina sudhimaj matane badhu thodu thodu khavdavi devanu, balak ne
badhu pachi jay.” (Within one and half months after delivery, the lactating woman
should be served everything so that the child can digest everything later.)
Many women’s doubts were clarified during the first visit counseling session and hence
they agreed to eat everything and to not keep any restrictions during lactation.
o “Abhi aapne bataya na to sab khaungi” (Since you [counselor] informedme just now,
I will now eat everything.)
� Iron Supplementation during Lactation The consumption of iron tablets during lactation varied among the women enrolled in
the program. As shown in Table 9, about half the women (44%) consumed iron tablets
daily for about 1-3 months post delivery and the remaining (45%) did not consume.
Table 9: Iron Supplementation during Lactation
Consumed or will consume IFA once daily for 1-3 months
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %Yes 202 58.0 79 26.8 281 43.7 No 131 37.6 156 52.9 287 44.6 No idea 15 4.3 60 20.3 75 11.7
Vaatsalya, Aarogya 2005 32
The women, who consumed iron tablets, were generally prescribed these tablets post-
delivery.
o “Jitni likh ke di thi utni sab li.” (I have consumed the quantity prescribed by the
doctor.)
o Delivery pachi tran mahina kidhi chhe levani.” (Doctor told me to take for 3 months
after delivery.) o “Delivery ke time jo goli dete the wohi continue karne ko kaha hai.” (I have been
asked to continue the same tablet that I used to take in pregnancy.) o “Tran mahina sudhi lidhi.” (I have consumed till 3 months)
Some women avoided despite being prescribed due to various reasons as mentioned
below.
o “Main iron ki goli khati hu to bache ko jyada sandas hota hai, isliye ab goli nahi leti
hu to sandas kam ho gaya.” (If I consume IFA then child passes more stools. Hence,
I have discontinued the tablet and hence number of stools has reduced.)
o “Iron ni goli lau to mane constipation thay chhe, etale bandh kari didhi.” (If I
consume iron tablets I suffer from constipation so I have stopped consuming.) o “Mazhi sasu mhante ki balala goli garam padate mhanun phekun dilya.” (My mother-
in-law says the tablets are ‘hot’ for the baby, hence threw them away.)
o “Iron ni goli nathi lidhi karan ke mane vomitaj thia jaye.” (I have not consumed iron
tablet because as soon as I take I vomit.)
o “Lakhi aapi hati pan galati nahi to nahi lidhi.” (Even though prescribed, I cannot
swallow so I did not consume.)
o “Ayurvedic doctor ne kidu chhe ki iron tablet levani nahi, balak ne kabajiyat chhe
etele” (Ayurvedic doctor has asked not consume tablets, since the child has
constipation.)
On the other hand, some women were not prescribed and were not aware that iron
supplementation is essential during lactation. They mentioned that if the doctor
prescribes they would consume.
o “Doctor kehshe to leshu” (If doctor advises we will take.)
o “Delivery ke bad koi goli likhkehi nahi di.” (After delivery no tablet has been
prescribed.)
Vaatsalya, Aarogya 2005 33
o Feeding Infants 0-5 months � Initiation of Water to the Infant About one-half of the women were not aware regarding age of initiation of water to the
infants (Table 10); and a majority of these women (62%) were the ones in the wards
post-delivery. This was perhaps because most of the women were delivering for the first
time.
o “Bahu khaber nathi, pan char-panch mahine tipu pani pivdavishu.” (I don’t know
much, but I will give little after 4-5 months.]
o “Pahelahi bacha hai to pata nahi hai.” (Since this is my first child, I don’t know.)
Table 10: Age of Initiation of Water to the Infants
Age of initiation of water
OPD (N=348)
Ward (N=295)
Total (N=643)
n % n % n % < 3 months 22 6.3 19 6.4 41 6.4 3-5 months 131 37.6 58 19.7 189 29.4 6-8 months 68 19.5 31 10.5 99 15.4 >8 months 11 3.2 5 1.7 16 2.5 No idea / No response 116 33.3 182 61.7 298 46.3
About one third of the women- and their family members- visiting the OPD, mentioned
that water should be initiated around 3-5 months of age, mainly because...
♣ Child’s throat becomes dry.
o “Sab bolte hai bache ko paani pilane ka, nahi toh ooska gala sukh jayega.”
(Everybody says that water should be fed to the child otherwise his throat will
become dry.)
♣ Child becomes thirsty especially in summer.
o “Garmi hai na to paani pilane ka.” (Since weather is hot, water should be given.)
o Unalama galu sukai etle divas ma 2-3 chamchi pani aapvu paade” (In summer,
child’s throat becomes dry hence water should be given (2-3 spoons) during the
day.)
♣ Elderly family members insist on water.
o “Doctor kidu chhe ki chh mahina sudhi balak ne pani nahi aapavanu. Pan mari
sasu mantij nahi ne. Sada tran mahina na balak ne pani aapva chalu kari didhu.
Vaatsalya, Aarogya 2005 34
Tame mara husband ne samzao to e mari sasu ne kaheshe.” (Doctor had told me
that don’t give water up to six months. But my mother-in-law just does not listen.
She started feeding water at 3½ months of age. You please explain to my
husband so that he tells my mother-in-law.) o Mere sasune char mahine ke bad pani dene ko bola. Mujhe pata tha 6 mahine ke
bad dene ka.” (My mother-in-law asked me to give water after 4 months. I knew
that it should be given after 6 months.) ♣ Initiated water along with allopathy medicines during illness.
o “Jhada thayela tyare, ukaline powder nu pani pivdavelu atu.” (When my baby
was suffering from diarrhea, powder (ORS) was mixed in boiled water and given
to the him.) o “Be divas balak ne urine nathi thai etle doctor re thodu thodu pani pivdavanu
kidhu chhe.” (Since child had not urinated for 2 days, the doctor advised to feed
little water to the child.)
♣ Initiated water along with certain herbal juices and syrups believed to improve
digestion by the child.
o “Dabur ghutti boiled water ke sath de sakte hai.” (We can give Dabur ghutti with
boiled water.)
Some women were aware that water should be initiated around 6 months and that infant
should be exclusively breastfed till then. The doctors and nutritionists of the hospital had
informed them and also some of them had also read this in newspapers or magazines.
A few mentioned that they had heard it on radio and television programs.
o “Doctor ne bola hai ki chh mahine tak pani nahi deneka.” (Doctor has advised me
not to initiate water till 6 months.)
o “Jyar sudhi feeding chalu chhe tyar sudhi pani na aapavu joiye. Jyare upar nu
khavanu chalu karu tyare pani aapavanu chalu karvanu.” (As long as only
breastfeeding is continued, water is not given. When top foods are initiated, at that
time water should be given)
o “Newspaper, Magazine ma vanchyu chhe ke chha mahina sudhi pani pan nahi
aapavanu.” (I have read in newspapers and magazines that till six months, not even
water should be fed.)
Vaatsalya, Aarogya 2005 35
� Feeding ‘Hind’ Milk As indicated in the Table 11, majority of the women (78%) were not aware about
feeding nutrient-dense ‘hind’ milk. Most of them fed for a few minutes from both the
breasts during each feed and generally were not aware that they should empty one
breast and then feed from the other.
Table 11: Practices regarding Feeding ‘Hind’ Milk
Feeding ‘Hind’ Milk: Emptying one breast fully before offering the other
OPD (N=348)
Ward (N=295)
Total (N=643)
n % n % n % Yes 72 20.7 43 14.6 115 17.9 No 265 76.1 239 81.0 504 78.4 No idea/ No response 11 3.2 13 4.4 24 3.7 Most of the women and family members also believed that if child is fed from only one
breast at a time, the other breast will harden and lumps would be formed.
o “Do baju se thoda thoda deti hu.” (I feed little from both breasts.)
o “Ek baju ni chhati khali thava daiye, to biji baju nu dudh jami ne vasi na thai jay?” (If
I empty one breast, then won’t the milk from the other breast accumulate and
become stale?)
o “Banne bajuthij aapvanu, nahi to gantho padi jay.” (Breastfeeding should be done
from both breasts at each feed, otherwise lumps will be formed.) o “Ek baju chati chadi gai hoy to banne baju levanu evu baa kahe chhe.” (My
grandmother advises to feed baby from both breasts, if milk has accumulated too
much in the breasts.)
Some women mainly used one breast for feeding due to various reasons. Some women
had problems in one breast such as ‘inverted nipple’ and ‘less development of one
breast’ and hence perceived that milk flow from that breast was less.
o “Ek baju nipple ma problem chhe etele occhu dudh aave chhe to ek baju thi puru
nathi thatu.” (I have problem in one nipple so milk flow is less hence it is not
sufficient.)
Vaatsalya, Aarogya 2005 36
o “Be tran mahina thi khali jamani bajuj piye chhe dudh, biji baju ochu aave chhe.”
(Since 2-3 months the child sucks only from the right breast, milk flow from the other
breast has decreased.)
o “Mane pahela thi ekaj baju aapvanu phave chhe, biji baju jaray phavtuj nathi.”
(Right from the beginning I feel comfortable feeding from one breast only and am
not comfortable feeding from the other breast.)
A few women also stated that despite trying many times their infants insist on suckling
from only one breast. They were not able to find the reason behind such behavior.
o “Ha ekaj bajuni pito dusari kadun ka pit nahi kalat nahi.” (He sucks only from one
breast. I don’t understand why he doesn’t sucks from the other.)
o “Chhokru ek bajuj dhave chhe, ene biji baju letaj nathi phavtu.” (Child suckles only
from one breast; he cannot suckle from another breast.)
A few women believed that their milk flow is less, hence to satisfy the hunger of the
child, they had to feed from both breast at each feed.
o “Bahu dudh nahi aavtu etele ek vakhat thodi thodi vare banne baju aapu chhu.”
(Since milk flow is less, I breastfeed for a few minutes from both breast at each
feed.)
A few mentioned signs such as crying of the baby and less weight of the baby as
indicators of less milk flow from the breasts.
o “Sasu bolti hai ki woh rota hai to usko tumhara dudh kam padata hoga, abhi mujhe
bhi ye lagta hai.” (My mother-in-law says that child cries because your milk may not
be sufficient and now I also feel the same.)
o “Mujhe lagta hai mera dudh sufficient nahi aa raha kyanki iska vajan abhi badha
nahi hai.” (I feel my breast milk is not sufficient because child’s weight is not
increasing.)
About one-fifth of the women were feeding ‘hind’ milk but were not aware of its benefits.
A few of them were advised by the doctor to do so.
o “Ek vaar ek baaju thi ane biji vaar biji baaju thi” (Once from one side and other time
from the other side)
o “Doctor ne bola hai vaisa hi karti hu. Ek baju pura pilake phir dusari baju pilati hu.” (I
am following the advice of the doctor. I breastfeed from one breast completely and
then feed from another breast.)
Vaatsalya, Aarogya 2005 37
� Breastfeeding during Illness of Infant Three-fourth of the women stated that they would continue breastfeeding the infant
during his or her illness (Table 12).
Table 12: Beliefs of Women regarding Breastfeeding
during Infant’s Illness
Breastfeeding during infant’s illness
OPD (N=348)
Ward (N=295)
Total (N=643)
n % n % n % Yes 274 78.7 207 70.2 481 74.8 No 10 2.9 19 6.4 29 4.5 No idea/ No response 64 18.4 69 23.4 133 20.7
A majority of them felt that since the child is not fed anything else apart from breast
milk; breastfeeding should be continued. Some women also mentioned that since child
needs nourishment even during illness, breastfeeding should be continued. In some
cases, the infants had already suffered from diarrhea, cough, cold, fever and other
minor illnesses; and they had continued to breastfeed at that time; hence they were
aware about it. Their verbatim statements are mentioned below.
� “Daat aave tyare jhada thai gaya hata pan hu to dhavan aapti hati.” (As teeth were
erupting, child had diarrhea but I had continued to breastfeed.)
� “Chokra ne jhada thai toh tenu sharir dhovai jai etele ma nu dudh vare ghadiye
aapvuj pade ne!” (When child suffers from diarrhea his body becomes dehydrated,
hence breast milk should be fed frequently.)
� “Balala dudhatun immune power milate na mhanun dudh tar dyaylach have
aajarpant.” (Child gets immunity through breast milk; hence breast milk must be
given during illness.)
The family members also felt that breastfeeding should be continued during illness. To
quote…
� “Mandu hoi, toye chhokra ne bhukh to lagej ne ! Dhavan na apiye to biju shu
aapiye!” (Even if the child is ill, he feels hungry! If breast milk is not given, what else
can we give!)
� “Dhavanj apvu pade, nahi to manda chokra ne ashakti aavi jay.” (Breast milk should
be fed otherwise ill child would become weak.)
Vaatsalya, Aarogya 2005 38
However, about one-fifth of the women were not aware whether to continue
breastfeeding during illness of the child. They mentioned that when their child will fall ill,
they will consult the doctor and then breastfeed.
� Breastfeeding during Illness of Mother Table 13 shows that most of the women (42%) mentioned they would continue to
breastfeed their children during their own illness. On the other hand, about one-third felt
that breastfeeding should be stopped if the mother is ill.
Table 13: Beliefs of Women regarding Breastfeeding during Mother’s Illness
Breast feeding during mother’s illness
OPD (N=348)
Ward (N=295)
Total (N=643)
n % n % n % � Yes 162 46.6 108 36.6 270 42.0 � No 78 22.4 94 31.9 172 26.7 � No idea/ No response 108 31.0 93 31.5 201 31.3 The main reason for continuing to breastfeed during illness of mother stated was that
since there is no alternative the infant is exclusively breastfed.
� Upar nu kasu aapvanu nahi to dudh to aapvuj pade ne.” (Since top food is not
allowed, breast milk should be fed.)
� “Dudh tar dyaylach have tyashivay tar kahi shakya nahi.” (Breast milk has to be
given, since there is no other alternative.)
Further, the women mentioned that during illnesses such as fever, cough, cold and
headache they would continue to breastfeed. These illnesses require minor medication
such as crocin which is not harmful. However, they were not sure whether to continue
feeding if they suffer from diarrhea, malaria, jaundice or more severe illnesses. They
stated that in such cases they would consult the doctor and then breastfeed their infants.
� “Dhavan chalu hoi to crocin chale pan biji goli hoye to nai aapvanu.” (During
lactation, crocin can be consumed, but if another tablet is consumed then
breastfeeding should be discontinued.)
Vaatsalya, Aarogya 2005 39
� “Khasi thayeli tyare dava chalu hati to doctor ne puchayu to emne kidu chhe ke
dhavan chalu rakhi shakay.” (I was consuming tablets when I had cough hence
asked doctor and he said breastfeeding could be continued.)
� “Bukhar aaya to chalu rakhenge dusari koi bimarihoi toh doctor jo bolenge woh
karenge.” (If I have fever, I will continue breastfeeding but if I have other illness I will
follow doctor’s advice.)
The women who believed that breastfeeding should be discontinued during their own
illness felt that the infant would be affected by the disease and would suffer from the
same disease if breastfed at that time.
� “Jo hu dhavdau to chokra ne maro tav lagi jay.” ( If I breastfeed, child will catch my
fever.)
� “Main bimar hungi aur feeding karaungi to bacha bimar ho jayega na!” (If I
breastfeed the child when I am sick then the child will also fall sick!) � “Hu mandi thavu to mara sharir na jivjantu balak na pet ma jay etele dhavan bandh
karvu” (If I fall sick the germs of my body will transmit to the stomach of the child.
Hence, breastfeeding should be discontinued.) Their family members also believed in this.
� “Ene taav aave to balak ne lage ne” (If mother has fever, child will get it)
A few women believed that the adverse effect of the medication would affect the health
of the infant.
� Hu dava lau, te chokra ne nuksan na kare, etle dhavan nahi apu.” (If I consume
medicines, it will harm the child. Hence, I won’t breast feed.)
Further, they believed that when mother is ill, top milk or fluids or foods could be given to
the infants. In such cases, generally women give either cow’s milk or dairy milk. A few
women dilute the top milk and feed the infants.
� “Hu maandi padu to upar nu kasu aapu.” (If I fall ill then I will give some top food.)
� “Jo hu mandi padu to balak ne feeding nahi karau, pan mug nu pani ke bahar nu
dudh thodu aapish.” (If I fall ill, I will not breastfeed the child but will give a little green
gram dal water or top milk.)
� “Maari bimarima to sachavavuj pade ne balakne, etele patlu dudh aapvanu” (During
my illness, child has to taken care of; hence thin top milk should be given.)
Vaatsalya, Aarogya 2005 40
About one-third of the women mentioned that they would consult the doctor and do as
per his or her advice.
� “Doctor ni salahthij karvu joiye.” (We would do according to doctor’s advice.)
� “Doctor ne puchi ne dhavan aapu mu bimar padu tyare.” (If I am ill, I will breastfeed
the child after consulting the doctor.)
o Feeding Infants 6-12 months � Initiation of top milk to the Infant Table 14 indicates that about one-half of the women were not aware of the age of
initiation of top milk. They mentioned that they would either consult the doctor or the
elders in the family regarding when to initiate top milk. � “Atyare to maruj dudh aapu chhu, biju kashuj nahi.” (Presently I feed only breast
milk, nothing else.)
� “Doctor ne aju kidu nathi kyarthi aapaye.” (Doctor has not advised so far as to when
to initiate top milk.)
� “Ghar na log kahe evu karu.” (I do whatever my family members say.)
Table 14: Age of Initiation of Feeding Top Milk to Infants
Age of initiation of top milk
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %� < 3 months 20 5.7 3 1.0 23 3.6 � 3-5 months 51 14.7 46 15.6 97 15.1 � 6-8 months 83 23.9 57 19.3 140 21.8 � >8 months 34 9.8 39 13.2 73 11.4 � No idea / No response 160 46.0 150 50.8 310 48.2
Some women (15%) had initiated top milk at 3-5 months of age due to various reasons.
♣ Decreased breast milk and less weight- for-age of the infant.
� “Bache ka weight kam hai na isliye khas jo kam weight vale bachon keliye aata hai
woh dudh deti hu” (Weight of the child is less hence, I am feeding that top milk which
is specially made for low-weight children.)
Vaatsalya, Aarogya 2005 41
♣ Women working outside home.
� “Hoon job karu chhu etle, doctore kidu chhe ke upar nu dudh aapi shakay.” (Since I
am working, doctor has allowed me to give top milk.)
� “Hoon job karu chhu to tran mahina thi dudh aapavanu chalu kari didhu.” (Since I
am working, I have started giving top milk from 3 months of age.) ♣ Twin children hence insufficient breast milk to sustain both of them.
� “Julve aslya mule doctoranni pahela pasunaj varache dudh dyayla sangitale aahe.”
(As I have twins, doctor has advised to initiate top milk since birth.) On the other hand, some women (11%) mentioned that they would initiate top milk as
late as 9 months or 1 year or even later. They believed that top milk should be given only
when infants stops breastfeeding or when breast milk is not sufficient for the infant.
� “Ma nu dudh aave tyar sudhi upar nu dudh nahi aapavanu.” (As long as breast milk
is produced, top milk should not be initiated.)
� “Bachha dhavan chhode ga tab dungi – 1½ varas pachhi.” (I will give top milk when
the child will stop breastfeeding – at about 1½ year.)
� “Dhavan nahi aave thyarthi upar no dudh aapvanu.” (When breast milk stops
flowing, top milk should be given.) � “Ma nu dudh aave tyar sudhi shu kam baharnu dudh aapvani jarur pade!” (As long
as breast milk is produced, where is the need to feed top milk!)
Although about one-fifth of the women mentioned that they would initiate top milk at
around 6-8 months of age, only a few among these were aware that complementary
foods should be initiated along with top milk at this age.
� Initiation of Fluids (other than top milk) to the Infants
As in the case of top milk, a majority of the women were not aware about the correct age
of initiation of top fluids. About one-third of the women (Table 15) mentioned that fluids
such as dal-water, rice-water, juices and soups should be initiated after 6 months.
� “Chha mahine se dal, chawal ka pani de sakte hai, sirf itna pata hai, aur kuchh nahi
janti.” (From 6 months, dal-rice water can be given. I know only this much and
nothing else.) � “Pravahi chha mahina pacchi aapiye” (Fluids are given after 6 months)
Vaatsalya, Aarogya 2005 42
Some women mentioned that they would initiate fluids when the child starts sitting. � “Jab baith sakega tab dal, chawal ka pani chalu karne ka.” (When the child starts
sitting then dal and rice water should be started.)
� “Basayala laglya var pravahi padarth va naram khorak chalu kariar.” (When the child
sits on his/her own, I will initiate fluids and soft foods.)
Table 15: Age of Initiation of Feeding Top Fluids to Infants
Age of initiation of top fluids
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %� < 3 months 2 0.6 3 1.0 5 0.8 � 3-5 months 93 26.7 73 24.7 166 25.8 � 6-8 months 118 33.9 92 31.2 210 32.7 � >8 months 28 8.0 16 5.4 44 6.8 � No idea / No response 107 30.7 111 37.6 218 33.9 In contrast, about one-fourth of the women had initiated fluids at 3-5 months or believed
that fluids should be initiated at 3-5 months. They mentioned that it is the trend to initiate
top foods early these days and to stop breastfeeding early.
� “Chothe mahine se fluids aur mashed fruits dena chalu kiya.” (From the fourth
month, I initiated fluids and mashed fruits.)
� “Aajkal to badha vahelu aapva mande chhe etele char mahine aapish.” (Nowadays,
everyone gives quite early so I will give after 4 months.)
� “Mag nu pani ane bhat nu pani patlu karine, char mahine apiye.” (Diluted green gram
water, and rice water should be given after 4 months.) A few women had experienced that initiating fluids early reduces breast milk production.
Since the infants take fluids, they suckle less and hence breast milk production
decreases.
� “Dal nu pani pivdavavanu sharu karyu, pachhi dhavan ochhu thai gayu chhe.”
(Breast milk flow has been decreased after the initiation of dal-water.)
About one-third of the women (a higher percentage from the wards) were not aware as
to when they should initiate top fluids to their infants. They asked the counselors about it.
Vaatsalya, Aarogya 2005 43
� Initiation of Complementary foods to the Infants
As shown in Table 16, a majority of the women (40%) did not know the age of initiation
of complementary foods; some giving a reason that they had delivered for the first time,
hence they were not aware about complementary feeding. Many women counseled in
the OPD, had infants 1-3 months of age and hence they were not much concerned or
interested in complementary feeding. Similarly, the women visited in the wards had just
delivered, and they were still struggling to breastfeed their newborns; therefore showed
little interest in complementary feeding advice. They mentioned that when the time
comes they would either ask their elders or the doctors regarding complementary
feeding.
���� “Pahili vel aahe na mhanun kahi mahiti nahi.” (As it is for the first time, I don’t know
anything.)
���� “Mujhe kuchh nahi pata, saans hai na sab kahene ke liye.” (I don’t know. My mother-
in-law is there to tell me everything.)
���� ““Doctor kahe tyare aapish.” (I will give soft food to the child when doctor advises.)
Some women asked the counselors to inform them regarding the complementary
feeding. They stated that they would feed their infants as per the counselor’s advice.
� “Ketlu aapavanu, kyare aapvanu tamej kaho. Amne khabar nathi.” (You [counselor]
advise us about how much and when to give soft foods. We do not know.)
� “Tame kaho tyare aapu balak ne khorak” (We will initiate whenever you [counselor]
say.)
Table 16: Perceptions and Practices regarding
Complementary Feeding to Infants
Parameter
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %Age of initiation of complementary foods
� 3-5 months 16 4.6 14 4.7 30 4.7 � 6-8 months 94 27.0 72 24.4 166 25.8 � >8 months 102 29.3 89 30.2 191 29.7 � No idea / No response 136 39.1 120 40.7 256 39.8 Quantity of complementary foods to be fed at 6-8 months
� 1-2 teaspoons 87 25.0 81 27.5 168 26.1
Vaatsalya, Aarogya 2005 44
Parameter
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %� ½ -1 katorie 60 17.2 37 12.5 97 15.1 � As much as child eats 28 8.0 39 13.2 67 10.4 � No idea / No response 173 49.7 138 46.8 311 48.4 Frequency of feeding complementary foods per day at 6-8 months
� Once 28 8.0 15 5.1 43 6.7 � 2-3 times 98 28.2 128 43.4 226 35.1 � 4 or more times 31 8.9 6 2.0 37 5.8 � On demand 12 3.4 11 3.7 23 3.6 � No idea / No response 179 51.4 135 45.8 314 48.8 Some women mentioned that they usually initiate when the child starts sitting or walking
or when the child has teeth.
� “Chaltu thay tyare khichadi chalu karvanu.” (Khichadi should be initiated when the
child starts walking.) � “Pahela liquid start karvanu pachi dat aave tyare khichdi jevu aapvanu.” (Initially
liquids should be fed, then when the child has teeth items like Khichadi should be
given.)
Many women (30%) mentioned that they would initiate complementary foods after 8
months or even after 1 year.
���� “Das mahine se naram khorak aapvanu chalu karvanu.” (From 10 month, soft food
should be initiated.)
���� “Do saal tak sirf maka dudh aur uparka dudh hi dete hai. Kuchh khilate nahi hai.” (Till
the child is two years old only mother’s milk and top milk should be given. We do not
give any food.)
���� “Ek varshya nanter sagle chalu karayche.” (After one year, everything [food] should
be initiated.)
Which foods initiated? Most of the women mentioned that they will initiate with either biscuits, cerelac or fruits.
� “Shuru me toh biscuit dene ka.” (Initially [at around 8 months] biscuit should be
given.) ���� “Sat-aath mahina thi biscuit khavdavish.” (I will give biscuits from 7th or 8th month.)
Vaatsalya, Aarogya 2005 45
���� “Ghar ka khana toh tikha hota hai, kaise khilaye bacheko?” (Home made food is
spicy, how can we feed it to the child?”)
Many believed that home-made foods such roti should be initiated after 1-2 years of age.
� “Be time dudh ne biscuit aapu chhu. Roti to balak ne bhare pade ne.” (I am feeding
milk and biscuit two times a day. Roti will be heavy to digest for the child.)
���� “Anaj to ek saal tak nahi khilaneka.” (We do not feed cereals till 1 year.)
���� “Roti galama atki jaay ane pachvama bhare hoi ne etale ek varas pachhi aapish.”
(Since roti gets stuck in the throat, I will give only after 1 year of age.)
Table 16 shows that about one-half of the women were not aware of the amount of
complementary food to be fed to infants at 6-8 months. One-fourth mentioned extremely
inadequate amounts; about 1-2 teaspoons of soft foods should be given.
� “Taste alag laage to 1-2 chamachi le chhe.” (If the child finds it tasty, he eats 1-2
spoons.)
� Khali ek be danaj balak ne chatadavu chhu.” (I feed only 1-2 grains to the child.)
� “Chh mahina nu balak ne 1-2 chamchi be var aapay.” (A 6 months old child should
be fed 1-2 spoons two times a day))
Only a few mentioned that they feed the child as much as he or she wants and do not
encourage or force the infants to eat more.
� “Balak jetlu khay etelu aapvanu.” (Food should be given as much as the child eats.) � “Balachya bhookpromane tyala khau ghalayche.” (Feed the child as per his appetite) A few stated that the infant should be given limited quantity and should not be fed too
much.
� “Bahu khavdavanu nahi chokrane, bodu thay jaye.” (Should not give more to the
child, otherwise becomes dumb.)
Similarly, most of the women were not aware of the frequency of feeding
complementary foods to infants. Some women fed only once, some fed twice whereas
some fed as many times as the infant demanded.
� “Khay eteli vaar khavdavanu.” (Feed whenever child wants to eat.)
Vaatsalya, Aarogya 2005 46
� “Ek be chamchi, ek-be vaar divas ma aapiye” (We give soft foods 1-2 spoons 1-2
times per day) � Ekaj time uprno khorak aapu. Khatoj nathi ne, khali upar nu dudh piye chhe.” (Only
once I feed the child. He does not eat anything and only consumes top milk)
� “Ek baar cerelac dene ka.” (Cerelac should be fed once in a day.)
However, a few women did feed a relatively more amounts of foods and more frequently.
They also fed food routinely prepared in the house to the children.
� “Ek vaar osaman, pachi thodo pocho khorak evi rite aapvanu roje” (Once dal-water,
then some soft food, should be given daily.) � “Be var cerelac, be var dudh aapu. Roti no tukdo ke khichdi – Ame jamta hoiye tyare
khavu hoi to khay.” ( I give cerelac and milk twice a day. While we eat, a piece of roti
or Khichadi is given to the child, he eats if he wants to.)
� “Mung bhat savare ne sanjhe aapu.” (I feed green gram dal and rice in the morning
and in the evening.) However, most of the women enrolled were not aware of the amount and frequency of
complementary foods required to be fed to infants in the age group of 6-8 months; and
later.
� Initiation of Fruits and Vegetables to the Infants
Most of the women (46%) were not aware of the age at which infants should be given
fruits and vegetables (Table 17).
Table 17: Age of Initiation of Feeding Fruits and Vegetables to Infants
Age of initiation of fruits and vegetables
OPD(N=348)
Ward(N=295)
Total(N=643)
n % n % n %� < 3 months - - 2 0.7 2 0.3 � 3-5 months 23 6.6 21 7.1 44 6.8 � 6-8 months 69 19.8 55 18.6 124 19.3 � >8 months 100 28.7 75 25.4 175 27.2 � No idea / No response 156 44.8 142 48.1 298 46.3
A few women mentioned that they would ask the doctor or the elders.
Vaatsalya, Aarogya 2005 47
���� “Doctor ne puchi ne shakbhaji ne fruit aapu.” (I will give fruits and vegetables after
asking the doctor.)
���� “Amne khabar nahoti etle shakbhaji vahelu na apyu, have thodu aapu chhu.” (We did
not know that vegetables can also be given at an early stage, now I give it little.)
About one-fifth of the women were aware that fruits and vegetable should be initiated
when complementary foods are initiated at around 6 months of age. They also
mentioned that initially juices or soups are given and then soft fruits and boiled
vegetables should be initiated.
���� “Khichadi vagera chalu karne ke sath hi vegetables dete hai.” (We give vegetables
when we start giving khichadi.)
���� “Phalancha juice 7 mahinyan nanter pajayacha ani phal naram karun 8-9 mahinya
nanter dyayche” (Fruit juices should be given after 7 months and whole soft fruits
after 8-9 months.)
���� Palak, suva ni bhaji bhat ma nakhi mixture ma kadhi ne balak ne aapu chhu.” (I grind
spinach and other leafy vegetables along with rice and serve the mixture to the
infant.) ���� “Dal chawal chalu karne ke sath hi fruits aur vegetables dete hai.” (We initiate fruits
and vegetables when we initiate rice-dal.)
However, there were some women who believed that the infants cannot consume
vegetables at 6 months. They believed that fruits and vegetables should be initiated only
after 8 months or even later.
���� “Dasma mahine dant ave pachhi aa badhu thodu thodu aapi shakay.” (At 10th month,
when the teeth erupts, these foods can be initiated in small quantity.)
���� “Fal ane shakbhaji to varas pachhij aapu.” (I will initiate fruits and vegetable only
after 1 year.) ���� “Subji garam padti hai to voh bada ho jaye tabhi denge.” (Vegetables are ‘hot’ so we
will give when the child grows up.)
Some women avoided giving certain fruits such as banana as was believed to be ‘cold’
and cause cough-cold to the child. Similarly, some women avoided certain vegetables
such as potato as they are believed to cause indigestion and flatulence.
Vaatsalya, Aarogya 2005 48
� “Kela ane drakshto balak ne thanda pade. Dudh ni sathe kela na aapiye.” (Banana
and grapes are “cold” for the child. We do not give banana with milk.) � “Sasu kahe chhe ki bataka nahi aapvanu ene pachse nahi.” (My mother-in-law says
that potato should not be given to the child, as he will not be able to digest it.)
A majority of the women were thus not sure regarding feeding of fruits and vegetables to
their infants.
Vaatsalya, Aarogya 2005 49
PHASE III: INTERIM ASSESSMENT OF PROGRESS OF !""#$"%&"!""#$"%&"!""#$"%&"!""#$"%&"((((
Periodic assessment of any program is essential to inform about the impact of a program
as well as to inform about the key changes required to improve its effectiveness. The
periodic assessment should involve both, the impact and the process of implementation.
As mentioned earlier, the objective of the !""#$"%&" program in MSH is to bring about
positive changes in awareness and practices of women and their families with regard to
postnatal and infant care. The impact assessment will help us to determine the changes
in knowledge and practices of the women after the counseling sessions as compared to
pre-counseling. The assessment will help us understand the changes required in the
strategy to improve the effectiveness of the program. These results are presented in the
following section.
Impact Assessment As mentioned earlier, the pair of !""#$"%&" sakhis (counselor and recorder) collects
information on data recording sheets of the weight of the infants and also the knowledge
and practices of the women during both the initial visit (Visit 1) and follow-up visit (Visit
2). The information recorded on data sheets was coded and entered into the computer.
The data was analyzed to understand the impact of counseling on the behaviors and
practices of the women.
At the time of the assessment, 120 women had visited for follow-up out of 643 women
enrolled in the program during the year. Of these 120 women, 68 women were
counseled in the OPD and 52 women in the wards during the initial visit. One-third of the
women came for follow-up visit on their own. The remaining two-third women were sent
for follow up by the pediatrician or staff of Family Welfare Center. Pre-post analysis was
done of the changes in knowledge and practices of the women with regard to postnatal
and infant care. Further, qualitative information obtained from the weekly counseling
session reports of the follow up visits were analyzed to inform about the changes in the
beliefs of the women after counseling as compared to pre-counseling.
Vaatsalya, Aarogya 2005 50
Anthropometric Profile of the Infants after Counseling In MSH, each child born in the hospital is given a baby-card wherein at every visit of the
child to the hospital- date of the visit, weight and height of the child, immunization
schedule of the child, history of morbidities and other such information is recorded. The
weight of the infant at the time of the visit was noted by the !""#$"%&" sakhis. The
weight profile of the infants enrolled and the change in the prevalence of malnurtrition
among the enrolled infants was analyzed.
� Prevalence of Underweight after Counseling Considering Weight-for-Age Z-score, the prevalence of underweight at Visit 2 was more
or less similar among the two younger age groups (0-5 months and 6-11 months) as
presented in Table 18. The prevalence was high among the 12-23 months old, however
since the number was less nothing conclusive can be said regarding the change.
Table 18: Percent Children Underweight* at Visit 2
Parameter Normal Weight Underweight
n % n % Age group of infants � 0-5 months (N=73) 71 97.3 2 2.7 � 6-11 months (N=41) 40 97.6 1 2.4 � 12-23 months (N=6) 4 66.7 2 33.3 Sex of the child � Boys (N=66) 64 97.0 2 3.0 � Girls (N=54) 51 94.4 3 5.6 Place of counseling � OPD (N=68) 63 92.7 5 7.3 � Ward (N=52) 52 100.0 0 0 Total (N=120) 115 95.8 5 4.2 *Normal weight = ≥ -2.00 WAZ; Underweight= <-2.0 WAZ
The overall prevalence of underweight was 4%; being mainly among those counseled in
the OPD as compared to those counseled in the wards. The prevalence of underweight
was slightly higher among girls, but not statistically significant.
Considering the IAP classification (Table 19), the prevalence of underweight was among
one-tenth of the infants counseled. The sex of the infants did not affect the prevalence of
underweight. It was interesting to note that as compared to Weight-for-Age Z-score
Vaatsalya, Aarogya 2005 51
classification, the prevalence of underweight was more than double considering the IAP
classification.
Table 19: Percent Children Underweight* at Visit 2
Parameter Normal Weight Underweight n % n %
Age group of infants � 0-5 months (N=73) 63 86.3 10 13.7 � 6-11 months (N=41) 39 95.1 2 4.9 � 12-23 months (N=6) 4 66.7 2 33.3 Sex of the child � Boys (N=66) 59 89.4 7 10.6 � Girls (N=54) 47 87.0 7 13.0 Total (N=120) 106 88.3 14 11.7 *Normal weight = > 80% of NCHS Standard; Underweight= ≤ 80% of NCHS Standard.
Change in Prevalence of Underweight after Counseling Table 20 compares the prevalence of underweight at Visit 1 (at
enrollment) and Visit 2 (Follow-up). The prevalence of underweight
decreased at Visit 2 as compared to Visit 1. However, due to small
numbers the change is not statistically significant. Among the two age-
groups; and among both boys and girls the prevalence of underweight has
decreased. This could be partly attributed to the positive practices adopted
by the women as regards infant care.
Table 20: Prevalence of Underweight at Visit 1 and Visit 2
Parameter Visit 1 Visit 2 Normal Under-
weight Normal Under-
weight Age group at Visit 1 � 0-5 months % 94.6 5.4 97.8 2.2 n 88 5 91 2 N 93 93 93 93 � 6-11 months % 72.7 27.3 82.0 18.0 n 8 3 9 2 N 11 11 11 11
Vaatsalya, Aarogya 2005 52
Parameter Visit 1 Visit 2 Normal Under-
weight Normal Under-
weight Sex of the child � Boys % 94.5 5.5 96.4 3.6 n 52 3 53 2 N 55 55 55 55 � Girls % 89.8 10.2 95.9 4.1 n 44 5 47 2 N 49 49 49 49 Place of Counseling � OPD % 92.2 7.8 93.8 6.2 n 59 5 60 4 N 64 64 64 64 � Ward % 92.5 7.5 100 0 n 37 3 40 0 N 40 40 40 40 Total % 92.3 7.7 96.2 3.8 n 96 8 100 4 N 104 104 104 104 * Normal = >=-2.00 Weight for Age Z-score; Underweight= <-2.00 Weight for Age Z-score
Perceptions and Practices of the Women after Counseling
o Nutrition During Lactation � Quantity of Food Intake during Lactation ���� Table 21 shows that the percentage of women who increased their food intake
during lactation was similar during Visit 1 and Visit 2. Those women who had kept
the food intake the same as usual during lactation, did not increase their food intake
even after counseling.
Table 21: Change in Quantity of Food intake During Lactation
Parameter OPD (N=68) WARD (N=52) TOTAL (N=120)
Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Compared to usual diet, food intake during lactation
� Has increased
49 72.1 47 69.1 39 75.0 41 78.8 88 73.3 88 73.3
� Has decreased
6 8.8 4 5.9 2 3.8 2 3.8 8 6.7 6 5.0
� Remained the Same
13 19.1 17 25.0 11 21.2 9 17.3 24 20.0 26 21.7
Vaatsalya, Aarogya 2005 53
The main reason for not increasing food intake was that these women had stopped
breastfeeding and hence they did not feel the need to increase their food intake.
� “Haave to balak upar nu badhuj khay chhe etale dhavan occhu thai gayu chhe to
marathi vadhare nathi khavatu.” (Now the child has started eating everything, hence
breast feeding has decreased and so I cannot eat more.)
Despite counseling, a few women were not able to increase their food intake mainly due
to the following reasons.
♣ Excessive work load, lack of time and negligence towards their own health.
���� “Do bache hai to khane ke liye time nahi milta.” (Since I have two children, I do not
get time to eat.)
���� “Sarsrima kam vadhare chhe to thaki jau ane khorak vadhare na lai shaku.” (I have
more work at the in-law’s place, which makes me feel tired, and so I cannot eat
more.
♣ Belief that lactating women should consume only soft-foods or less food for easier
flow of breast milk for 2-3 months after delivery.
� “Dhilo khorak khaiye to sarkhu dudh aave.” (Soft-foods should be consumed so that
breast milk flows properly.)
� “Kodari vadhare khavani, rotli gheewali khavani pan dharai ne nahi khavanu. Occhu
khavanu toh dhavan barabar aave.” (I eat more Kodri, chapatti with ghee, but should
not it more. One should eat less so that breast milk flow is proper.)
♣ Less food intake due to weight consciousness
� “Vadhare na khau. Vajan vadhi jay.” (I will not eat more. My weight will increase.)
Thus, although the women increase their food intake they mainly do so for increased
milk production and not for their own health.
� Quality of Food Intake during Lactation It was encouraging to note that after counseling a majority of the women (73%) had
stopped avoiding foods that they earlier avoided after counseling (Table 22). Before
counseling many (68%) women avoided certain foods whereas after counseling only
one-fourth of the women continued to avoid certain foods during lactation. This change
was statistically significant (p<0.001). There was a significant change among both the
women counseled in the wards and the OPD. Thus, the quality of food intake of the
women improved.
Vaatsalya, Aarogya 2005 54
The main reason for this change was increased awareness due to counseling sessions
and clarification of doubts regarding harmful effects of certain foods during counseling.
To quote the women…
� Gharna gharda kaheta hata etale pahela bhinda, gawar nahoti khati. Tame kidhu
etale have to badhuj khau chhu. Kasu nahi thayu balakne.” (I did not eat ladyfinger,
cluster beans earlier since my elders told me. Now I eat everything since you [the
counselor] told me. Nothing happened to the child.)
� “Pahela bhinda nohti khati, haave khau chu.” (Earlier I used to avoid lady finger, now
I eat.)
Table 22: Change in Awareness regarding Nutrition during Lactation
Parameter OPD (N=68) WARD (N=52) TOTAL (N=120)
Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Any foods avoided or will avoid during lactation � Yes 50 73.5 22 32.4 31 59.6 9 17.3 81 67.5 31 25.8� No - - 46 67.6 41 78.8 - - 87 72.5� No idea 18 26.5 - - 21 40.4 2 3.8 39 32.5 2 1.7 Note: Chi-squares comparing percentages of women who avoided food items at Visit 1 and Visit2 are highly significant (p<0.001) for OPD, ward and total sample.
Some elderly family members had also changed their beliefs and had started serving
food to lactating women without any restrictions. To quote a mother-in-law…
���� “Tame kidhu etale have badhu aapava mandyu.” (Since you [the counselor] advised
us, I have started giving everything to her [lactating woman].)
However, about one-fourth of the women continue to avoid certain foods such as pulses
and certain vegetables like cluster beans, lady finger, red gram tender, double beans
and potato. These are believed to cause flatulence or diarrhea in the infant and some
women believe that it causes pus in the stitches taken during delivery. Fruits such as
banana, grapes are believed to cause severe cough and cold in the infant.
���� “Bhinda thi balak ne varadh thaye, evu kahe chhe etele bik laage chhe, nathi khati.
(People say that if I consume lady finger, child would suffer from whooping cough,
hence I am scared and avoid eating it.)
Vaatsalya, Aarogya 2005 55
���� “Main kela khati hu to bache ko shardi hoti hai.” (If I eat banana the child gets
cough.)
���� “Hu chana ni dal khau to balak ne jhada thai jay.” (If I consume Bengal gram dal,
child suffers from diarrhea.)
The family members also insist that the women avoid these foods as it is believed to be
harmful to the women and their infants.
� “Sasu na paade chhe, etele haaji sudhi nathi khati valore ane papdi.” (My mother-in-
law does not allow me to eat double beans and runner beans so I have not yet
consumed them.)
Some women continue to avoid sour foods such as curds and preparations made from
curd, tamarind, tomatoes and other sour foods. They believe that sour foods cause pus
formation in stitches taken after delivery.
���� “Khatash khay to tanka pake.” (If I consume sour foods, pus will be formed in the
stitches.) A few women avoided milk mainly due to personal dislike. A few women did not
consume rice as traditionally it is not consumed few months post delivery.
It was observed that these restrictions were kept for initial 1-2 months after delivery,
only a few women continue these restrictions as long as they breastfeed. The women
follow the advice of the elders considering them to be experienced and since certain
practices are traditionally followed.
In brief, food avoidance continued though there was a decrease in percentage of women
following them.
� Iron supplementation during Lactation
Table 23 shows that a higher percentage of women (65%) started consuming iron
tablets as compared to before counseling (52%). This difference was significant
(p<0.05). Many women mentioned that they had started consuming iron tablets due to
the information and guidance given during counseling.
���� “Aapne samjhaya thana isliye family welfare se leke aai hu.” (Since you explained it
to me I brought it from family welfare center).
���� “Tame kidhu hatu etele lav chhu roje. (Since you [counselor] advised me I take
daily.)
���� “Aapan ne takat male ne.” (It should be taken as it gives us strength.)
Vaatsalya, Aarogya 2005 56
Table 23: Change in Iron Supplementation during Lactation
Parameter
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Consumed or will consume IFA once daily during lactation � Yes 44 64.7 42 61.8 18 34.6 36 69.2 62 51.7 78 65.0� No 21 30.9 25 36.8 21 40.4 13 25.0 42 35.0 38 31.7� No idea 3 4.4 1 1.5 13 25.0 3 5.8 16 13.3 4 3.3 Note: Chi-square comparing percentages of women who consumed iron tablets at Visit 1 and Visit2 was not significant for OPD; but was significant for ward (p<0.001) and total sample (p<0.05).
A significantly higher percentage (p<0.001) of women counseled in the wards started
consuming iron tablets as compared to those counseled in the OPD (Figure 4). Some
of the women counseled in the OPD had stopped taking iron tablets after taking them
continuously for 3-4 months.
Figure 4: Percentage of Lactating Women Consuming IFA during Visit 1 and Visit 2
Some women (32%) do not consume iron tablets despite counseling. The main reasons
behind not consuming iron tablets were nausea, vomiting, reluctance to swallow tablets,
negligence towards own health and doctors had not prescribed.
� “Goli thi mane ubka aave etale levati nathi.” (On consuming the tablets I suffer from
nausea so I cannot take them.)
64.7
34.6
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Vaatsalya, Aarogya 2005 57
� “Doctore lakhi nathi aapi etele mane khaber nathi.” (Doctor has not prescribed so I
don’t know.)
� “Lakhi aapi hati pan haaji kharidi nathi.” (It was prescribed but so far I have not
purchased.)
� “Tahme kidhu hatu pan mane kantalo aave chhe goli galvano.” (You [counselor] had
told me but I feel too lazy to swallow tablets.)
A few women (3%) could not recall the messages given by the counselor and
mentioned that they were not aware that iron supplementation is essential during
lactation. When the counselor informed them again about the benefits they mentioned
that they would either purchase iron tablets or collect from the FWC and take them
regularly. Their husbands and mothers also supported them. To quote a husband of a
lactating women….
� “Tahme naam lakhi aapone, toh hamna laine teh chalu kari deshe.” (Why don’t you
[counselor] tell me the name of the tablet; I will purchase just now and she [lactating
woman] will start taking them.)
We however did not prescribe iron-folate tablets but referred them to the doctor or
Family Welfare Center.
o Feeding Infants 0-5 months � Initiation of Water to the Infant About one-half of the women (57%) were aware that infants should be given water only
after six months (Table 24) at Visit 2. The awareness had increased as compared to
Visit 1 (23%). At Visit 1, many women (42%) were not aware when to initiate water;
whereas at Visit 2 only a few women (5%) could not recall that the age of initiation of
water is after 6 months.
Vaatsalya, Aarogya 2005 58
Table 24: Change in Awareness regarding Age of Initiation of Water to Infants
Age of
initiation of water
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� < 3 months 3 4.4 4 5.9 2 3.8 2 3.8 5 4.2 6 5.0 � 3-5 months 24 35.3 23 33.8 9 17.3 14 26.9 33 27.5 37 30.8� 6-8 months 20 29.4 35 51.5 7 13.5 33 63.5 27 22.5 68 56.7� >8 months 3 4.4 2 2.9 2 3.8 1 1.9 5 4.2 3 2.5 � No idea 18 26.5 4 5.9 32 61.5 2 3.8 50 41.7 6 5.0
Note: Chi-squares comparing percentages of women who mentioned that water should be initiated at the age of 6-8 months at Visit 1 and Visit2 are significant for OPD (p<0.01); and ward and total sample (p<0.001). This difference in awareness was highly significant (p<0.001) more so among women
who were counseled in wards as compared to those counseled in OPD as shown in
Figure 5.
Figure 5: Percentage Change in Awareness of Age of Initiation of Water to Infants
Many women mentioned that counseling helped increase their awareness.
���� “Mane badhu yaad chhe tame kidhu hatu te etale chh mahinathi pachhij paani
aapish.” (I remember everything you [counselor] told me hence we will give water
only after 6 months.)
���� “Tahme kidhu haatu etale chatha mahina paachi aapish.” (Since you [counselor] told
me I will give water only after 6 months.)
29.4
13.5
51.5
63.5
0
10
20
30
40
50
60
70
OPD WARD% o
f Wom
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at W
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sh
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be
Initi
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afte
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mon
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VISIT 1VISIT 2
Vaatsalya, Aarogya 2005 59
���� “Aapne kaha tha isliye ise bund bhi paani nahi diya.” (Since you [counselor] advised
me I have not given even a drop of water to my child so far.) (3 month old infant)
Some women mentioned that the doctors also advise that water should be inititated only
after 6 months of age.
� “Chhatha mahina thi paani aapvaanu doctore kidhu chhe.” (Doctor has told us that
we should give water from 6th month.)
However, about a third (31%) believed that water should be initiated around 3-5 months
of age at Visit 2. The major reasons given were…
♣ Child becomes thirsty due to hot weather.
� “Garmi haati etele char mahine pani pivdavyu.” (Since it is hot we gave water
from 4th month.)
♣ Elders in the family insist that child becomes thirsty.
� “Mara gharwala nathi sambhalta. Paani char mahinathi aapava mandavanu
kahechhe.” (My family members do not listen and insist that I give water at 4
months.)
♣ Some doctors and certain magazines and booklets mention that water and fluids
should be initiated at 4-5 months.
� “Chopadi ma lakhyuj chhe ne te pramane char mahinathi aapish.” (It is written in
the book to give water at 4 months hence I will give accordingly.)
� Feeding ‘Hind’ Milk
As indicated in the Table 25, a significantly higher percentage of women were feeding
‘hind’ milk at Visit 2 as compared to Visit 1 (p<0.001), both among those counseled in
wards and in OPD.
Table 25: Change in Practices regarding Breastfeeding
Feeding Hind Milk
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� Yes 11 16.2 53 77.9 7 13.5 36 69.2 18 15.0 89 74.2� No 52 76.5 15 22.1 44 84.6 16 30.8 96 80.0 31 25.8� No idea 5 7.4 - - 1 1.9 - - 6 5.0 - - Note: Chi-squares comparing percentages of women who fed ‘hind’ milk at Visit 1 and Visit2 are highly significant for OPD and total sample (p<0.001).
Vaatsalya, Aarogya 2005 60
Before counseling, women were not aware about the benefits of ‘hind’ milk and hence
only 15% of the women emptied one breast and then fed from the other. On the other
hand, after counseling 74% of the women fed ‘hind’ milk.
As indicated in the Figure 6, the increase in awareness was similar in women counseled
in OPD and ward.
Figure 6: Percentage Change in Awareness regarding Feeding ‘Hind’ Milk
In the women’s own words…..
� “Ek baju khali thay pacchi biji baaju.” (I feed from the other side only after emptying
from one side.)
� “Ek baaju pura pilake, bhookh raahe toh dusari baju, nahi toh phir dusri time pilaneka
dusari baju.” (I feed till breast empties and if child is still hungry feed from other
breast or else feed from the other breast in the next feed.)
� “Hu to chhati khali karinej pivadau chhu. Tame nahotu kidhu.” (I empty the breast
and then feed from other. Didn’t you [counselor] tell me this!)
About one-fourth of the women continue feeding from both breast despite being aware of
the benefits of ‘hind’ milk as they faced problems such as engorgement or soreness of
breast and child refusing to continue feeding from one breast for too long.
� “Biji baju bharai jaye chhe etele hu to banne bajuj aapu chhu.” (The other breast
becomes overfull hence I feed from both breasts.)
16.2 13.5
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Vaatsalya, Aarogya 2005 61
� “Ek baju khali hone tak baccha wait nahi karta, to dusari baju se dena hi padta hai.”
(My child does not wait till one breast is empty, hence I have to feed from other
breast.)
A few women believed that child’s hunger would not be satisfied if fed from one breast
only at each feed.
� “Santosh thay ne balaak ne etele banne baaju thi thodi-thodi vaar aapu chhu.” (To
satisfy the child, I breastfeed from both breast little at a time.)
� “Ek baaju thi aapu toh enu pet naa bharay ne!” (If I feed from only one side, his
stomach will not become full!)
Further, a few women believed that if the child is fed from one breast at each feed, the
shape of the breast would change and both breast would become unequal in size.
� “Be baju pivadau chhu, nahi to chhati nani moti thai jaye ne.” (I feed from both
breasts otherwise one breast would become small and the other big.)
� Breastfeeding during Illness of Infant Almost all women (97%) were aware at Visit 2 that breastfeeding should be continued
during illness of the infant and were also aware of its benefits. Before counseling, about
one fourth of the women were not sure whether to continue breastfeeding during illness
of the infant (Table 26).
Many women mentioned that the counseling session helped to increase their awareness
and also since there is no alternative food that could be given to infants less than 6
months breastfeeding should be continued.
� “Tahme kidhu haatu te badhu yaad chhe. Bimari maa pan dhavan aapay.” (I
remember what you [counselor] had told me. Even in illness breast milk can be
given.)
� “Bimarima balak ne shakti male ne etale dudh to aapavanuj.” (The ill child would get
strength hence breastfeeding should be continued during his illness.
� “Dudh to aapavuj pade ne, biju shu aapi shakay?” (Ill child had to be breastfed, what
else can be given?)
Vaatsalya, Aarogya 2005 62
Table 26: Change in Perceptions regarding Breastfeeding during Illness of Infant
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Breast feeding during infant’s illness
� Yes 55 80.9 65 95.6 36 69.2 52 100.0 91 75.8 117 97.5� No - - - - 1 1.9 - - 1 0.8 - - � No idea 13 19.1 3 4.4 15 28.8 - - 28 23.3 3 2.5 Note: All chi-square values comparing percentages of women breastfeeding during infant’s illness for OPD, ward and total sample (Visit 1 versus Visit 2) are significant (p-value<0.01). A few women mentioned that the doctors had informed them to continue breastfeeding
when their infants had suffered from illnesses such as cough, cold, fever, diarrhea and
jaundice, in the past.
� “Babo nahno hato tyare jaundice thayo hato tyare doctare dudhaj pivdavanu kahyu
hatu.” (When my son was young he suffered from jaundice and the doctor had
advised to only breastfeed.)
Figure 7 clearly shows the increase in awareness among women after counseling
regarding continuing breastfeeding during illness of infant.
Figure 7: Percentage Change in Awareness regarding continuing Breastfeeding during Infant’s Illness
75.8
97.5
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20
40
60
80
100
120
Continuing Breastfeeding duringInfant's Illness
% o
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espo
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VISIT 1VISIT 2
Vaatsalya, Aarogya 2005 63
� Breastfeeding during Illness of Mother As the Table 27 shows as compared to Visit 1, a significantly higher percentage (above
90%) of women at Visit 2 (p<0.001) were aware that breastfeeding should be continued
during their own illness. At Visit 1, a little less than half of the lactating women (42%)
stated that they had no idea whether to continue breastfeeding the infants during their
own illness.
Table 27: Change in Perceptions regarding Breastfeeding during Illness of Mother
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Breast feeding during mother’s illness
� Yes 31 45.6 64 94.1 13 25.0 48 92.3 44 36.7 112 93.3� No 9 13.2 1 1.5 17 32.7 2 3.8 26 21.7 3 2.5 � No idea 28 41.2 3 4.4 22 42.3 2 3.8 50 41.7 5 4.2 Note: All chi-square values comparing percentages of women breastfeeding during their own illness for OPD, ward and total sample (Visit 1 versus Visit 2) are highly significant (p-value<0.001). Many women mentioned that earlier they used to believe that breastfeeding during their
illness would transfer the illness to the infant or the infant would be adversely affected by
the medication they take during illness. After the counseling session, wherein they were
informed that in general illnesses and medication do not affect the infant, they were
relieved to be informed that breastfeeding could be continued.
���� “Pahele confusion tha meri bimari me dudh pilau ki nahi par ab to koi confusion
nahi.” (Formerly I was confused whether to breastfeed during my illness but now
there is no confusion.)
���� “Dhavan toh aapi shakay. Tahmej kidhu hatu ne!” (Breast milk can be fed during
mother’s illness. You [counselor] only told this!)
Many women also mentioned that since there is no alternative for young children (less
than 6 months) breastfeeding should be continued.
A few women and their family members continue to be skeptical about breastfeeding
infants during mother’s illness. Despite counseling and reassurance by the doctors, they
are still scared to feed their infants during their own illness. They fed lemon-juice, sugar-
syrup or top-milk in such cases.
Vaatsalya, Aarogya 2005 64
� “Maaro taav ane laagi jay toh? Sasu paan naa paade.” (What if the child catches my
fever? Mother-in-law also refuses to let me breastfeed.)
These women and their family members were once again reassured that breastfeeding
would not transmit illness such as fever, cough, and cold from mother to child; and the
breastfeeding should be continued during these illnesses.
o Feeding Infants 6-12 months � Initiation of Top milk to the Infant Table 28 indicates that 42% more women were aware that top milk should be initiated at
around 6-8 months, after counseling. This increase was highly significant (p<0.001).
Earlier many of these women were not aware of the age of initiation of top milk.
According to them their awareness had increased due to counseling and due to advice
given by the pediatrician of the hospital.
Table 28: Change in Awareness regarding
Age of Initiation of Top Milk
Age of initiation of
top milk
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� < 3 months 4 5.9 3 4.4 - - 1 1.9 4 3.3 4 3.3 � 3-5 months 4 5.9 6 8.8 5 9.6 4 7.7 9 7.5 10 8.3 � 6-8 months 14 20.6 38 55.9 7 13.5 33 63.5 21 17.5 71 59.2� >8 months 7 10.3 10 14.7 6 11.5 5 9.6 13 10.8 15 12.5� No idea 39 57.4 11 16.2 34 65.4 9 17.3 73 60.8 20 16.7Note: Chi-squares comparing percentages of women who believed that top-milk should be initiated at 6-8 months at Visit 1 and Visit 2 are highly significant for OPD, ward and total sample (p-value<0.001).
The women also mentioned that although they initiate top milk around 6 months of age,
infants do not like it and hence do not drink it much. A few women mentioned that
despite adding sugar and other flavors, the infants did not prefer to drink top milk.
Women usually give top milk in bottle although some do give in either sipper or a small
glass.
� “Upar nu dudh satma mahinathi chalu karyu chhe, pan te nathi piti.” (I have initiated
top milk since 7th month, but she does not like it.”
� “Dudh sharu karyu chhe pan e toh pitoj nathi.” (I have initiated top milk but he just
refuses to drink it.)
Vaatsalya, Aarogya 2005 65
A few women (11%) had initiated top milk between 2-5 months of age due to various
reasons. A few mentioned that top milk was initiated since the weight of the infant was
not increasing. Some of them mentioned that they had initiated because they felt that the
breast milk is insufficient after 3-4 months. A few added various herbs to the top milk at
an early age and gave to the infant believing that this herbal flavored milk gives warmth
to the infant. These beliefs were mainly of the elderly female family members and the
lactating women simply followed the advice of the elderly female members.
� “Sasu ae kidhu ke vavding valu dudh aapvanu etele ane shardi na thay, ane pachhi
jaay.” (My mother-in-law told me to give Vavding [a herb] with milk, as it protects
infant from cold and also helps in digestion.)
� “Kesar vaalu dudh thi garmavo male, dhandi naa laage.” (Milk flavored with saffron
gives warmth, infant does not feel cold.)
A few women were working; hence they could not continue to exclusively breastfeed
their infants till 6 months.
� “Hoon job karu chhu etele mein tran mahina thi dudh chalu kari didhu.” (Since I am
working I started giving top milk from 3 months of age.)
On the other hand, a few women and their family members continued to believe that top
milk should not be initiated as long as breast milk is produced. A few women had
experienced that feeding top milk caused diarrhea and hence they had discontinued it.
� “Jya sudhi dhavdavu chhu tya sudhi uparnu dudh nahi aapu.” (I will not feed top milk
as long as I am breastfeeding.)
� “Upar na dudhthi to jhada thay etale maruj aapu.” (Top milk causes diarrhea to the
infant, so I give my milk only.)
� Initiation of Fluids (other than top milk) to the Infants As in the case of top milk, many women (39%) were not aware before counseling
regarding the age of initiation of fluids. At visit 2, 61% of the women were aware that
fluids should be initiated around 6-8 months (Table 29); for example, thick daal, raab,
fruit juice.) This difference was highly significant (p<0.001).
Vaatsalya, Aarogya 2005 66
Table 29: Change in Awareness regarding Age of Initiation of Fluids other than top milk
Age of
initiation of fluids
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� < 3 months - - - - 1 1.9 - - 1 0.8 - - � 3-5 months 17 25.0 15 22.1 11 21.2 3 5.8 28 23.3 18 15.0� 6-8 months 24 35.3 38 55.9 13 25.0 35 67.3 37 30.8 73 60.8� >8 months 3 4.4 12 17.6 4 7.7 6 11.5 7 5.8 18 15.0� No idea 24 35.3 3 4.4 23 44.2 8 15.4 47 39.2 11 9.2 Note: Chi-squares comparing percentages of women who believed that fluids should be initiated at 6-8 months at Visit 1 and Visit 2 are significant for total sample; and for OPD (p<0.05) and ward (p<0.001).
According to the women, their awareness had increased due to counseling, advice given
by pediatricians and also through information obtained from certain newspapers/
magazines, or informative booklets given by !""#$"%&" team members.
� “Maane yaad chhe tahme kidhu haatu ke chh mahina paachi chalu karvanu.” (I
remember that you [counselor] had told me that fluids should be initiated after 6
months.)
� “Chopadi ma lakhyuj chhe ne etale vanchi ne aapish.” (I will read what is written in
the booklet and give accordingly.)
As in the case of top milk, some women (15%) mentioned that they would initiate fluids
after 8 months as they believed that the infants will not be able to digest top fluids. A few
women and family members mentioned that even though they had initiated, the infant
does not accept it and hence had discontinued giving.
� “Dal nu pani aapyu pan pitij nahoti.” (I gave dal-water but she refuses to drink.)
Despite counseling, a few women (9%) were not aware when to initiate fluids and they
mentioned that when they feel the need to initiate they will consult the pediatrician and
would do as per his advice.
� Initiation of Complementary Foods (CF) to the Infants Table 30 shows that as compared to pre-counseling, a higher percentage of women
(13% more) were aware that soft-foods should be intiated around 6-8 months of age.
This difference was significant statistically (p<0.05). About half had earlier no idea about
age of initiating CF before counseling.
Vaatsalya, Aarogya 2005 67
The women could recall the messages given by the counselors. To quote…
� “Tame kidhu chhe ne chh mahina pachhi galelo khorak aapavanu. Evuj aapu.” (You
[counselor] had told that soft foods should be given after six months. I will do
accordingly.]
� “Chh mahina pachhi pahela pani jevo khorak aapyo ane pachi pocho khorak –
bhat,khichadi evu badhu aapyu.” (After six months initially I gave fluids and then
soft foods such as rice, khichadi and other items.)
Table 30: Change in Awareness regarding
Age of Initiation of Complementary Foods (CF)
Age of initiation of
CF
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� 3-5 months 2 2.9 1 1.5 1 1.9 2 3.8 3 2.5 3 2.5 � 6-8 months 16 23.5 25 36.8 12 23.1 19 36.5 28 23.3 44 36.7� >8 months 16 23.5 37 54.4 11 21.2 21 40.4 27 22.5 58 48.3� No idea 34 50.0 5 7.4 28 53.8 10 19.2 62 51.7 15 12.5Note: Chi-squares comparing percentages of women who believed that CF should be initiated at 6-8 months at Visit 1 and Visit 2 are not significant for OPD and ward. However, it is significant for total sample (p-value<0.05).
Many women and their family members believed that the infants should be fed soft
foods only after 8 months – at around 9-10 months (Figure 8), mainly because infants
less than 8 months do not have teeth and cannot digest foods.
Figure 8: Change in Awareness among Women regarding Age of Initiation of Complementary Foods (CF)
23.3 22.5
36.7
48.3
0
10
20
30
40
50
60
6-8 months After 8 months% o
f Wom
en a
war
e ab
out a
ge o
f In
itiat
ion
of C
F
VISIT 1VISIT 2
Vaatsalya, Aarogya 2005 68
Some of them mentioned that their infants were not able to swallow food and throw up if
soft foods are fed. A few mentioned that until the infant learns to sit properly they would
not feed soft foods.
� “Khorak toh gala ma atki jay chhe.” (Soft foods get stuck in the throat of the
infant.)
� “Ene to khali dudhaj bhave. Biju kashu khatoj nathi.” (He only likes milk. He does
not eat anything else.)
� “Chhokru baista shikhe pachhij khava devay ne.” (When child starts sitting, then
only food should be given.)
Regarding quantity of complementary foods to be fed to the infants, a majority at Visit 1
had mentioned very inadequate quantities (1-2 tsp.). At Visit 2, a significantly higher
(p<0.001) percentage of women (41% more) were aware that at each feed at least ½ -1
katorie of soft foods should be served to the infants at around 6-8 months of age (Table 31).
Table 31: Change in Awareness regarding Quantity and Frequency of CF
Parameter
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
Quantity of complementary foods to be fed at 6-8 months � 1-2
teaspoons 8 11.8 17 25.0 7 13.5 11 21.2 15 12.5 28 23.3
� ½ -1 katori 15 22.1 26 38.2 7 13.5 23 44.2 22 18.3 49 40.8� As much as
child eats 3 4.4 9 13.2 6 11.5 5 9.6 9 7.5 14 11.7
� No idea 42 61.8 16 23.5 32 61.5 13 25.0 74 61.7 29 24.2Frequency of feeding complementary foods per day at 6-8 months � Once 5 7.4 8 11.8 4 7.7 4 7.7 9 7.5 12 10.0� 2-3 times 12 17.6 25 36.8 16 30.8 22 42.3 28 23.3 47 39.2� 4 or more
times 8 11.8 19 27.9 1 1.9 13 25.0 9 7.5 32 26.7
� On demand 2 2.9 1 1.5 - - 2 3.8 2 1.7 3 2.5 � No idea 41 603 15 22.1 31 59.6 11 21.2 72 60.0 26 21.7Note: 1.The Chi-square comparing percentages of women who believed that ½- 1 Katorie of CF should be served at Visit 1 and Visit 2 is significant for OPD (p<0.05) and highly significant for ward and total sample (p<0.001). 2. The Chi-square comparing percentages of women who believed that CF should be given at least 2-3 times per day is significant for OPD (p<0.05); and total sample (p<0.01); but not significant for ward.
Vaatsalya, Aarogya 2005 69
The change was higher among those counseled in the wards as compared to those
counseled in the OPD.
� “Tahme kidhu tu em ek vakhatma 1 vatki aapu chhu.” (As you had informed me, I
give one katorie at each feed.)
However, a few women continued to believe that initially at around 6-8 months the
infants should be given about only 1-2 teaspoons of food at each feed. The main reason
was that the infants do not have teeth and hence cannot digest more than a few
teaspoons of food.
Figure 9 shows the change in awareness regarding quantity of complementary foods to
be served to the infants after 6 months of age.
Figure 9: Change in Awareness among Women regarding Quantity of Complementary Foods (CF) given to Infants
About one-fourth of the women continued to be ignorant as to the amount of CF to be
given. As they were counseled when their infants were about 1-2 months old, it is
possible that they did not pay much attention at that time to messages given related to
CF.
� “Ketlu aapvanu te khabar nathi, 6 mahinano thashe pacchi doctor ne puchchishu.” (I
do not know how much of CF should be given, when my child becomes 6 months old,
I will ask the doctor.)
18.3
7.5
40.8
11.7
05
1015202530354045
1/2 - 1 Katorie As much as child wants
% o
f Wom
en a
war
e re
gard
ing
Qua
ntity
of C
F to
be
serv
ed
VISIT 1VISIT 2
Vaatsalya, Aarogya 2005 70
When asked ‘how many times should an infant 6-8 months old be given CF’; a
significantly higher percentage of women were aware at Visit 2 that CF should be given
at least 2-3 times during the day to the infants with continued breastfeeding (Table 31). � “Sanje ne savare ek-ek vaar khavadau. Vache fruit ke dudh aapvanu.”
(Complementary foods should be fed once in the morning and once in the evening. In
between fruits and top milk should be given.)
� “Be vaar jamavana jevu aapu pachi divas ma 2-3 vaar juice fruit evu badhu aapu.”
(Two times food should be given and then 2-3 times juices or fruits or such items
should be given.)
On the other hand, about one-tenth of the women continued to believe that the infants
should be fed CF only once a day at 6-7 months of age. Further, some of them fed as
and when the child demanded or child cried.
A few women mentioned that they feed 1-2 teaspoons of foods many times during the
day. Hence, they were unable to give an estimate of how much quantity and how
frequently are infants fed complementary foods.
� “Thodu-thodu aakho divas khaya kaare.” (He eats little many times during the day.)
These women were informed that they should regularize the meal timings and quantity
of complementary foods given to their infants.
� Initiation of Fruits and Vegetables to the Infants As indicated in Table 32, majority of the women (43%) were aware that fruits and
vegetables should be initiated at 6-8 months of age at Visit 2 as compared to Visit 1
(22%). This difference was highly significant (p<0.001).
Table 32: Change in Awareness regarding Age of Initiation of Feeding Fruits and Vegetables to Infants
Age of initiation of fruits and
vegetables
OPD (N=68) WARD (N=52) TOTAL (N=120)Visit 1 Visit 2 Visit 1 Visit 2 Visit 1 Visit 2n % n % n % n % n % n %
� 3-5 months 2 2.9 3 4.4 1 1.9 2 3.8 3 2.5 5 4.2 � 6-8 months 19 27.9 30 44.1 7 13.5 21 40.4 26 21.7 51 42.5� >8 months 16 23.5 21 30.9 13 25.0 10 19.2 29 24.2 31 25.8� No idea 31 45.6 14 20.6 31 59.6 19 36.5 62 51.7 33 27.5Note: The Chi-square comparing percentages of women who believed that fruits and vegetables should be given at 6-8 months is significant for OPD (p<0.05); ward (p<0.01) and total sample (p<0.001).
Vaatsalya, Aarogya 2005 71
Initially, they believed that since the infants do not have teeth, fruits and vegetables
cannot be given. When counseled, they started mixing boiled vegetables with cereal-
pulse mixes; and also started giving soft- mashed fruits to the infants.
About one fourth of the women continued to believe that fruits and vegetables should be
initiated after 8 months. Further, about one-fourth were not aware when to initiate fruits
and vegetables; they were unable to recall despite being counseled. These were mainly
women who were counseled when their infants were 1-2 months old; hence they
perhaps did not pay much attention to counseling regarding complementary feeding.
A few women and their family members continued to believe that unless the child has
teeth, fruits and vegetables cannot be initiated. They believed that they would get stuck
in the throat. Certain fruits such banana and grapes were avoided despite counseling
due to the perception that these fruits cause cough and cold.
Overall, some women could not recall the messages pertaining to complementary
feeding. A likely reason is that when they were counseled they had either just delivered;
or had infants less than 3 months of age; hence during counseling they only paid
attention to messages related to breastfeeding as these were of immediate interest to
them. Further, some women were helpless as regards following the recommendations
given during counseling as they were pressurized by their mothers-in-law to follow
traditional behaviours and not follow the advice given by pediatrician or the counselors.
On the other hand, some family members agreed to change their previous beliefs and
accepted the recommended behaviours.
Vaatsalya, Aarogya 2005 72
Process Evaluation The !""#$"%&" program at MSH involves bi-weekly counseling sessions with the
lactating women and their family members in the hospital wards immediately after
delivery or in the OPD where women visit for postnatal checkup or for immunization /
pediatric check-up of their infants. After the first visit, every attempt is made to have
follow-up counseling sessions with the women in the OPD (one or two months later).
Trained nutritionists conduct the counseling sessions. During the sessions, counseling
guide, session plans and visual flash cards are used to focus on critical behaviours or
messages related to postnatal and infant nutrition-care as discussed earlier.
Simultaneously, records are maintained of each session especially the perceptions and
practices of the lactating women and their family members during each visit. The
counseling sessions and recording are periodically supervised and monitored. Further,
fortnightly or monthly review meetings are held with senior experienced members of the
team to review the progress of the program and make appropriate changes to further
improve its impact. This continuous assessment process, and the changes made in the
counseling based on this assessment is ongoing. This is the major strength of the
!""#$"%&" program.
The major highlights of the process evaluation and the corresponding modifications
made during the year are presented in a matrix in Annexure 4.
There is continuous modification in the counseling strategy, the message focus, the
visuals used and the recording system of the !""#$"%&" program based on the
observations of the sessions done periodically. The ultimate aim of the program is to
satisfy the client’s need for information and bring about change in behaviours. To quote
a woman…
� “Saaru chhe tahme aa badhu samjhavo chho. Amne toh kai khabarj nathi. Tahme
kidhu em karishu.” (It is good that you are informing us all this. We did not know
anything. We would do as who have advised.)
Vaatsalya, Aarogya 2005 73
Factors Facilitating and Obstructing Behavior Change: The Motivators and The Inhibitors
The !""#$"%&" Program of Aarogya Trust at the Maharani Shantadevi Hospital is an
ongoing program to improve the postnatal and infant nutrition and care practices of the
lactating women and their family members.This program review assessed the progress
of !""#$"%&"(and lessons learnt. In the year 2004, 643 women along with their family
members were reached through this program. Of these, 120 women came for follow-up
till the time of this report.
The twice-weekly counseling sessions carried out in the wards and OPD of the hospital
to impart nutrition and care messages by a pair of Vaatsalya sakhis has brought about a
positive change in several perceptions and practices of the lactating women and their
family members as regards nutrition care.
The highlights of perceptions and practices which changed; and the extent of change
seen from pre-to-post counseling as determined through quantitative assessment of
women’s responses at Visit 1 (pre-counseling) and Visit 2 (post-counseling), are
presented in this section.
Further, during the counseling sessions with the women, varied responses were
obtained indicating the motivating factors enabling positive behaviours and the
constraints preventing the desired behavior change. These responses were categorized
and the interesting insights obtained from the women and their family members are
presented in tabular form.
The symbol ‘+’ indicates frequency of responses, where:
+++ = majority of informants (above 50%)
++ = some informants (30-50%)
+ = few informants (less than 30 %).
A: Lactating Women’s Nutrition Quantity of Food Intake Figure 10 indicates that though food intake of lactating women in terms of quantity eaten
did not change in a majority, qualitative improvements appeared to have occurred in
terms of less food restrictions.
Vaatsalya, Aarogya 2005 74
Figure 10: Change in Behaviors regarding Nutrition during Lactation
As shown in Table 33, the motivators for increasing food intake in lactation remained
more or less the same in Visits 1 and 2 (majority of the women were already eating more
than usual). However, due to counseling the various constraints mentioned to increase
food intake reduced.
Table 33: Key Responses of the Women and Family members regarding
Quantity of Food Intake during Lactation during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
� Increased food intake (+++) The Motivators � For increased milk production (+++) � Increased appetite (++) � For proper growth and development of the
child (+) � To provide good nourishment of the child (+) � Food intake remained same or decreased
food intake (++) The Inhibitors � Caesarian section delivery (+) � Recently delivered (+) � Illness of women (+) � Does not like hospital food (+) � Loss of appetite (+) � Weight consciousness (+) � Excess work load and negligence towards
own health (+) � Reduced breastfeeding as initiated
� Increased food intake (+++) The Motivators � For increased milk production (+++) � Increased appetite (++) � For proper growth and development of the
child (+) � Motivation from counselors (+) � Food intake remained same or decreased food
intake (+) The Inhibitors � Loss of appetite (+) � Weight consciousness (+) � Reduced breastfeeding as initiated
complementary food (+)
73.3 67.573.3
25.8
0
20
40
60
80
100
Food Intake Increased Certain Foods Avoided
Nutrition During Lactation
% o
f Lac
tatin
g W
omen
Visit 1Visit 2
Vaatsalya, Aarogya 2005 75
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
complementary foods (+) � Lack of awareness (+) � Indigestion due to more intake (+) � Affects child (‘bhar pade’) and leads to
diarrhea(+) � Excess intake causes excess milk production
which causes discomfort to women (+) � Seasonal effect (+)
Certain Myths regarding Food Intake during Lactation Similarly, many reasons stated by the women and their family members regarding
avoiding certain food items during lactation also reduced after counseling (Table 34).
They agreed to consume the food items previously avoided and appreciated the
counseling.
Table 34: Key Responses of the Women and Family members regarding Quality of Food Intake during Lactation during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Consuming various food groups without any
restrictions due to lactation (+) The Motivators � To maintain own health (+) � For better growth and development of the child
(+) � The child gets better adjusted to the foods if all
foods consumed right from the beginning (+) � Avoiding certain food items (+++) The Inhibitors � Various beliefs mainly affecting child’s health
and own health (+++) � Lack of awareness (++) � Religious reasons (++) � Insistence of family members (++) � Difference due to gender of the child (+)
� Consuming various food groups without any restrictions due to lactation (++)
The Motivators � Counseling (++) � Support of family members (+) � To maintain own health (+) � Avoiding certain food items (++) The Inhibitors � Insistence of family members (++) � Various beliefs mainly affecting child’s
health (+) � Cannot digest certain food items (+) � Religious reasons (+)
It was interesting to note the various reasons mentioned to avoid certain food items. The
main food items avoided were vegetables, pulses and legumes as indicated in the matrix
below. During counseling, it was explained that these foods do not affect the women or
the infants adversely. Food per se has no adverse effect on the health of the mother or
child. However, they were cautioned that in case they are sensitive to certain foods (for
Vaatsalya, Aarogya 2005 76
example, food allergies) or for other medical reasons are advised to avoid them, they
should consult their physician and follow the instructions. A few items avoided due to
religious reasons continued to be avoided such as jaggery, asaefoetida, tea and so on.
Food Item Reasons for avoiding by Mother Effect on Mother Effect on child
� Vegetables Cluster beans (+++) Indigestion Varadh (Severe cough) Ladies finger (+++) Varadh (Severe cough)or
diarrhea Field beans, brinjal (++) Gastric trouble Potato(++), sweet potato (+) Gastric trouble Colocasia leaves (++) Stomachache Stomachache Tandalja (Amarnath leaves) (+)
Varadh (Severe cough)
Green leafy vegetables (+) Green stools Pumpkin (+) Heavy to digest Heavy to digest � Pulses and Legumes Pulses (++) Stomach ache, flatulence,
diarrhea Stomach ache, flatulence, diarrhea
Green peas (+) Stomach hardens Black gram dal (+) Pus formation in stitches. Red gram dal (+) Reduces milk production Varadh (Severe cough) Banana, grapes (++) Cold / cough Bengal gram dal / flour (++) Flatulence Flatulence � Cereals Rice (++) Flatulence Corn (+) Flatulence, stomachache Flatulence, stomachache � Milk and Milk Products Milk (+) Sticky stools or Cough / cold Sour things (curd, lemon tamarind) (++)
Pus formation in stitches
Cold water, ice creams (+) Flatulence Cough / cold � Fruits & other foods Guava, Bor (Zizyphus) (+) Stomachache Salt, turmeric (+) Pus formation in child’s ears. Spicy, oily foods (+) Acidity Asafoetida (+) Religious reasons Jaggery (+) Religious reasons Non-vegetarian foods (+) Heavy to digest Heavy to digest
Vaatsalya, Aarogya 2005 77
IFA Supplementation during Lactation Figure 11 shows that there was a 13% increase in proportion of women taking IFA
tablets during initial months of lactation. However, the duration of taking tablets varied.
Some women consumed for 2 months and some for more than 4 months.
Figure 11: Change in Behaviors regarding IFA supplementation during Lactation
The women and their family members gave various reasons for consuming iron tablets
and the constraints for not consuming iron tablets (Table 35). The major reasons given
for not consuming iron tablets during lactation was lack of awareness; and that it was not
prescribed by the doctor. On counseling, the women and their family members went
back to the doctors for prescription or collected tablets from FWC and started iron
supplementation.
Table 35: Key Responses of the Women and Family members regarding Iron Supplementation during Lactation during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Consuming daily one IFA tablet at least for
3 months after delivery (+) The Motivators � Doctor’ advice (+) The Inhibitors � Not aware (+++) � Not prescribed by the doctor (+++) � IFA tablets are believed to be ‘hot’ (+) � Causes constipation, nausea (+) � Irregular consumption due to negligence (+) � Consumed in pregnancy so do not consume
now (+)
� Consuming daily one IFA tablet at least for 3 months after delivery (++)
The Motivators � Counseling (+) � Doctor’s advice (++) (Women ask for IFA
prescription). The Inhibitors � Not prescribed by the doctor (+) � First stock of IFA purchased completed and
not bought more tablets (+) � Irregular consumption due to negligence (+)
51.765
020406080
100
IFA Suplementation% o
f Lac
tatin
g W
omen
Visit 1Visit 2
Vaatsalya, Aarogya 2005 78
B: Breastfeeding Practices The breastfeeding practices improved remarkably after counseling (Figure 12). Many
women adopted the practice of exclusive breastfeeding till 6 months, feeding ‘hind’ milk
to their infants and continuing breastfeeding during illness of the infant or mother, which
they were not doing earlier.
Figure 12: Change in Perceptions regarding Breastfeeding
Table 36 gives the highlights underlying initiation of water. After counseling, the family
members realized that it is very important to exclusively breastfeed (EBF) infants till 6
months of age and hence agreed to delaying initiation of water. However, a few women
who perceived ‘insufficient breast milk production’ or since they go to work outside, had
initiated water (and top foods) despite counseling. A few family members continued to
believe that infants need water after 3 months especially in summer season. The baby
card given from the hospital also mentioned initiation of fluids at 4-5 months of age.
These were printed with earlier recommendations. Due to the efforts of the !""#$"%&"(
team members and the hospital pediatricians, the instructions on baby card were edited
and new baby cards were printed, recommending EBF till 6 months.
22.515
75.8
36.7
56.7
74.2
97.5 93.3
0
20
40
60
80
100
120
Initiation of Waterafter 6 months
Feeding 'Hind'Milk
Continuing BFduring Infant's
Ilness
Continuing BFduring Mother's
illness
% o
f Lac
tatin
g W
omen
Visit 1Visit 2
Vaatsalya, Aarogya 2005 79
Table 36: Key Responses of the Women and Family members regarding Initiation of Water during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Initiation of water at 6 months (+) The Motivators � Doctor’s advise (++) � Information from newspaper/magazines (+)
� Initiation of water at 6 months (++) The Motivators � Counseling increased awareness (++) � Doctors’ advise. (++)
� Initiation of water before 6 months (++) The Inhibitors � Because of summer season (++) � Family insistence (++) � Water necessary for child’s digestion (+) � Not aware that it is harmful (++) � Initiated during child’s illness e.g. diarrhea (+) � Information printed on the baby card (+)
� Initiation of water before 6 months (+) The Inhibitors � Summer season (+) � Family insistence (+) � Doctor’s advise (+) � Information printed on the baby card (+)
Similarly, mainly due to lack of awareness and insistence by family members, some
women did not feed ‘hind’ milk to their infants. After counseling the women and their
family members, most of them started feeding ‘hind’ milk. However, a few women
continued to feed from both breasts at each feed as they were troubled due to
engorgement of breast and dripping of breast milk from the other breast (Table 37).
Table 37: Key Responses of the Women and Family members regarding Feeding ‘hind’ milk during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Feeding hind milk (+) The Motivators � Doctor’s advise (+)
� Feeding ‘hind’ milk (++) The Motivators � Counseling (++) � Doctor’s advise (+)
� Not feeding ‘hind’ milk (+++) The Inhibitors � Family insistence. (++) � Fear of change in breast size (++) � Not aware regarding ‘hind’ milk (++) � Problem with one breast (+) � Child does not suckle at only one breast
(+) � Dripping of breast milk from another
breast or engorgement of breast (+) � Insufficient milk for child from one
breast (+) � Milk flow less from one breast (+)
� Not feeding ‘hind’ milk (++) The Inhibitors � Family insistence. (+) � Problem with one breast. (+) � Not convenient to feed ‘hind’ milk due to
engorgement, soreness and dripping from other breast (+)
� Child does not suckle at only one breast(+) � Milk flow less from one breast (+)
Vaatsalya, Aarogya 2005 80
As Figure 12 earlier indicates, continuing breastfeeding during illness (of child or
mother) showed an increase in Visit 2 and this improvement was more marked for
breastfeeding the child when mother is ill.
Table 38 gives the summary of responses of women and their family members
regarding reasons underlying continuing breastfeeding during illness of the infant. There
were various beliefs regarding breastfeeding during illness of the infant. As many women
were simply not aware that they should continue breastfeeding during illness of the
infant, the counseling clarified their doubts and they were informed that in illnesses such
as fever, cough-cold, diarrhea, and so on; breastfeeding should be continued. A few
family members continued to believe that diarrhea and cough-cold are caused due to
breastfeeding especially when the mother consumes certain food items as mentioned
earlier.
Table 38: Key Responses of the Women and Family members regarding
Breastfeeding during Illness of Infant during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
� Breastfeeding continued during illness of child (++)
The Motivators � No other alternative to breast milk (++) � Breastfeeding gives strength to the child
and helps in recovery. (+) � Doctors’ advise. (+)
� Breastfeeding continued during illness of child (+++)
The Motivators � Counseling (++) � Doctors’ advise. (+)
� Breastfeeding (BF) not continued during illness of child (+)
The Inhibitors � Not aware (++) � Private practitioners’ (doctor, ayurvedic or
other faith healer) advise (+) � Breast milk makes the illness worse (+) � Sick child cannot digest breast milk (+) � Advise from family members (+)
� Breastfeeding not continued during illness of child (+)
The Inhibitors � Private practitioners’ (doctor, ayurvedic or
other faith healer) advise (+) � Advise from family members (+) � Illness such as diarrhea (+)
A greater percentage of women discontinued breastfeeding during their own illness as
compared to illness of their infants, and this changed after counseling. Earlier, they
believed that breastfeeding will lead to illness being transferred to their children, but then
their doubts were clarified during counseling and hence their perceptions and practices
in this regard improved. However, a few women and their family members continued to
Vaatsalya, Aarogya 2005 81
fear that their illness will be transfered to their infants and hence did not breastfeed
during their own illness (Table 39).
Table 39: Key Responses of the Women and Family members regarding Breastfeeding during Illness of Mother during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Breastfeeding continued during illness of
mother (++) The Motivators � No other alternative to breast milk (++) � Breast milk does not harm the child (+) � Doctor’s advise (+)
� Breast feeding continued during illness of mother (+++)
The Motivators � Counseling (++) � Breast milk does not harm the child (++) � Doctor’s advise. (+)
� Breastfeeding discontinued during illness of mother (+)
The Inhibitors � Fear of transferring mother’s illness through
breast milk (++) � Adverse effect of mother’s medication. (+) � Family resistances as they believed that
mother’s medication has adverse effect on child, mother’s illness get transferred to the child and since years they discontinue during illness (++)
� Breastfeeding discontinued during illness of mother (+)
The Inhibitors � Fear of transferring mother’s illness
through breast milk. (+) � Family resistances as they believe that
mother’s medication has adverse effect on child, mother’s illness get transferred to the child and since years they discontinue during illness (+)
C: Complementary Feeding Practices Complementary feeding (CF) practices improved mainly in terms of initiation of fluids
and foods at the right age of around 6 months and decrease in too early initiation of top
milk and other fluids (Figure 13).
Figure 13: Change in Awareness regarding Age of Initiation of Top Milk and Other Fluids
17.5
30.8
59.2 60.8
0102030405060708090
100
Initiation of Top milk after 6months
Initiation of Other fluids after6 months
% o
f Lac
tatin
g W
omen
Visit 1Visit 2
Vaatsalya, Aarogya 2005 82
Initiation of top milk Table 40 gives the summary reasons related to CF practices. The reasons for initiating
top milk at an early age were addressed and hence after counseling top milk was
initiated at 6 months or later. Further, some of the reasons cited earlier such as inverted
nipples, engorgement of breasts, were temporary and once these problems were solved
they stopped giving top milk to their infants.
Some of the women and their family members believed that as long as breastfeeding is
continued top milk should not be initiated. A few women and their family members
continued to believe this even after counseling and hence did not make efforts to initiate
top milk even among infants 9-10 months of age.
Table 40: Key Responses of the Women and Family members regarding Initiation of Top milk during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
� Initiation of top milk at 6 months (+) The Motivators � Top milk is essential for proper growth of
the child (+) � Early Initiation of top milk around 3-4
months (++) The Inhibitors � Insufficient breast milk (+) � Twin children (+) � Engorgement of breast or Inverted nipples
(+) � Family insistence (+) � Child needs top milk after 4 months with
breast milk for proper growth (+) � To satisfy child’s hunger as breast milk
decreases after 3-4 months (+) � Women working outside home (+) � Indicated in the baby check-up card (+) � Late Initiation of top milk at 7 months
or later (++) The Inhibitors � Child can digest top milk only after 7
months (+) � As long as breast milk is sufficient, top
milk should not be initiated (+) � Child dislikes top milk (+)
� Initiation of top milk at 6 months (++) The Motivators � Counseling (++) � Early Initiation of top milk around 3-4
months (+) The Inhibitors � Insufficient breast milk (+) � Mother working out (+) � Twin children (+)
� Late initiation of top milk at 7 months or later (+)
The Inhibitors � As long as breast milk is sufficient, top milk
should not be initiated (+)
Vaatsalya, Aarogya 2005 83
Initiation of other fluids The major reasons cited for early initiation of fluids was insistence by family members,
insufficient breast milk and due to mention of this in the baby card (Table 41). As long as
the baby card was not revised the women continued to follow instructions given in it.
Many women were influenced by counseling and agreed to initiate only after 6 months of
age of the infants. A few women continued to believe that as long breast milk is
produced there is no need to initiate top fluids since the infant will not be able to digest
them. A few women especially those counseled in wards could not recall the messages
related to complementary feeding, probably since at that time they did not pay attention
since they were more concerned regarding breastfeeding.
Table 41: Key Responses of the Women and Family members regarding Initiation of Fluids other than top milk during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Initiation of fluids at 6 months (+) The Motivators � Doctors’advise (+) � 2nd delivery hence aware of this (+) � Early Initiation of fluids at 3-4 months
(++) The Inhibitors � Insistence from family members,
neighbours (+) � Breast milk alone insufficient after 4-5
months (+) � Indicated on baby card (+) � Needed for growth of the child (+)
� Late initiation of fluids at or after 7
months (++) The Inhibitors � Child does not accept (+) � Lack of awareness (++)
� Initiation of fluids at 6 months (++) The Motivators � Counseling (++) � Doctors’advise (+) � Early Initiation of fluids at 3-4 months (+) The Inhibitors � Indicated in the baby check-up card (+)
� Late initiation of fluids at or after 7 months (+)
The Inhibitors � Child is too young to digest (+) � Less attention of women during to this
message counseling and hence not aware. (+)
Initiation of soft foods Before counseling a majority of the women and their family members believed that soft
foods should be initiated after 7-8 months of age as the child cannot diges foods; and
soft foods should be given only after child starts sitting or his/her teeth erupt. Further,
Vaatsalya, Aarogya 2005 84
increase in the quantity and frequency of soft foods fed in the crucial period of 6-8
months also was reported after counseling (Figure 14). There was also improvement as
regards quality of complementary feeding especifically initiation of fruits and vegetables
among infants at 6-8 months.
Figure 14: Change in Awareness regarding Complementary Feeding
Counseling played a major role in changing their beliefs and they agreed to initated after
6 months of age and not wait till teeth erupted (Table 42).
Table 42: Key Responses of the Women and Family members regarding Initiation of Soft foods during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Initiation of soft foods at 6 months (+) The Motivators � For proper growth of the child (+) � Late initiation of soft foods after 7
months (++) The Inhibitors � Insistence from family members,
neighbours as they believe that soft foods should be initiated when child starts sitting and child cannot digest before 7 months (+)
� Child does not accept (+) � Child cannot digest (+) � After teeth eruption (+)
� Initiation of soft foods at 6 months (++)
The Motivators � Counseling (++) � Late initiation of soft foods after 7
months (+) The Inhibitors � Child cannot swallow (+) � When child learns to sit (+) � Less attention of women during
counseling (+)
23.318.3
23.3 21.7
36.7 40.8 39.2 42.5
0102030405060708090
100
Initiation of Softfoods after
months
Giving atleast 1/2-1 Katorie at each
feed
Giving atleast 2-3feeds per day
Initiating Fruitsand Vegetablesafter 6 months
% o
f Lac
tatin
g W
omen
Visit 1Visit 2
Vaatsalya, Aarogya 2005 85
Quantity and Frequency of Complementary Feeding A majority of the women earlier believed that at 6 months only 1-2 teaspoons of food
should be given to the infant at each meal. They believed that a little at a time should be
given as the infant will not be able to digest more food. A few believed that infant should
be fed as much as he/she wants. During counseling, it was emphasized that the infant
needs more food (1/2-1 Katorie at one sitting) and that s/he should be encouraged to eat
more. Adequate amount of CF at each meal is required for proper growth and
development of the infant (Table 43).
Table 43: Key Responses of the Women and Family members regarding
Quantity and Frequency of Complementary Feeding during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) Quantity of soft foods given to infants at 6-8 months� ½ katori –1 katori of complementary foods
given per meal (+) The Motivators � Aware of this since second child (+)
� 1-2 teaspoons of complementary foods given
per meal to infant after 6 months (++) The Inhibitors � Child cannot consume more than 1-2
teapoons of soft foods (++) � Child cannot digest more food (++) � Insistence from elderly family members
who believe that infant can be fed only little at a time (+)
� Child should be fed as much as s/he demands (+)
� To develop taste of soft food (+)
� ½ katori – 1 katori per meal of complementary foods given to infant after 6 months (++)
The Motivators � Counseling (++) � Aware of this since second child (+) � 1-2 teaspoons of complementary foods
given per meal to infant after 6 months (++)
The Inhibitors � Child cannot consume more than 1-2
teapoons of soft foods(+)
Frequency of Feeding soft foods to infants at 6-8 months � Feeding complementary foods 3-4 times/day
(+) The Motivators � For growth and development of the child
(+) � Feeding complementary foods only once or
twice day (++) The Inhibitors � Child cannot digest (+) � Child does not accept more (+) � Child like breast feeding more (+)
� Feeding complementary foods 3-4 times/day (++)
The Motivators � For growth and development of the
child (+) � Counseling (+) � Feeding complementary foods only once
or twice day (+) The Inhibitors � Child cannot digest (+) � Child does not accept more (+)
Vaatsalya, Aarogya 2005 86
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
� Give as per the family meal pattern (+) � Insistence by family members who believe
it is sufficient for the infant (++)
� Insistence by family members who believe it is sufficient for the infant as child is still breastfeeding (+)
At Visit 1, a majority of the women fed CF only once or twice a day. They believed that
the infants cannot digest more than that or cannot accept more than that. Further, many
family members believed that breast milk alone is sufficient for the infant till about 9-10
months of age (Table 43). When they were informed about the requirement of the
infants and the need of CF for physical and mental growth of the infant, they agreed to
increase the frequency of CF given at 6-8 months.
Initiation of Fruits and Vegetables As in the case of soft foods, many women and their family members believed that fruits
and vegetables should be initiated after teeth erupt. Contrastingly, a few women initiated
fruit juices and vegetable soups at a tender age of 4-5 months. At visit 2, the women
mentioned that they were aware that soft fruits and boiled mashed vegetables should be
initiated at 6 months; and that this is necessary for maintaining the health of the infants
(Table 44).
Table 44: Key Responses of the Women and Family members regarding Inititation of Fruits and Vegetables during Visit 1 and Visit 2
Responses of the Women and Family members Counseled in Ward and OPD
Pre-Counseling (Visit 1) Post Counseling (Visit 2) � Initiation of fruits and vegetables at 6 months
(+) The Motivators � Fruit juices and soups gives strength to the
child (+) � Early initiation of fruits and vegetables (only
juices and soups) at 4-5 months (++) The Inhibitors � Fruit juices and soups has good nutritive value
(+) � Insistence from family members as they are
eager to begin (++)
� Initiation of soft fruits and boiled soft vegetables at 6 months (++)
The Motivators � Counseling (+) � Good for health of child (+)
Vaatsalya, Aarogya 2005 87
Responses of the Women and Family members Counseled in Ward and OPD Pre-Counseling (Visit 1) Post Counseling (Visit 2)
� Late initiation of fruits and vegetables after 8-9 months or later (+)
The Inhibitors � Given when teeth erupt (++) � Various beliefs that certain fruits and
vegetables have adverse effect on health (+)
� Late initiation of fruits and vegetables after 8-9 months or later (+)
The Inhibitors � Given when teeth erupt(++) � Various beliefs that certain fruits and
vegetables have adverse effect on health (+)
Overall, the responses gave rich insights into the underlying factors and cultural beliefs
which influence infant feeding behavious and helped us to modify our counseling guide
based on this information. We also understood why some behaviors improved and why
some did not.
An unexpected and encouraging observation was that there was a decrease in the
prevalence of underweight (WAZ<-2.0) to 2.8% as compared to 5.4% at enrolment,
among infants 0-5 months of age. Similarly, among infants 6-11 months, the prevalence
of underweight decreased to 3.3% from a high prevalence of 27.3% at enrolment. The
prevalence of underweight had decreased more among girls (6.1%) as compared to
boys (1.9%). This impact clearly points out to the benefits of our complementary feeding
messages.
Overall, considering that just one contact was made, the counseling brought about
unexpected and encouraging improvements in reported practices of benefit to both,
mother and infant.
Vaatsalya, Aarogya 2005 88
CONCLUSION When we began the Vaatsalya Program, we were convinced that with a systematic
approach to nutrition communication and with patience and persistence, and keeping
behavior change as the goal, we will be able to implement an effective, need-based
program in a hospital setting. However, we had our doubts regarding the extent of
change possible with just one or two contacts with women and their families in crowded
OPDs and busy wards. Nevertheless, we took the plunge but made sure that all the
necessary formative research; dialogue with hospital authorities and the required
planning to prepare a well thought out communication strategy, (with appropriate
messages and visuals) had been accomplished first.
The results and positive impact (as regards improving lactation care and infant-feeding
and care practices) have surpassed our expectations. In just one (at the most two)
contacts lasting for about 15 minutes on average, we were able to bring about
remarkable increases in awareness and positive impact on practices, which the results
section has demonstrated.
As also seen from the data, the factors motivating behavior change were primarily the
following:
♦ The counseling itself and the attention to effective communication. It sounds
too simple, but it is true: often the lack of desirable behaviour is simply
because people who need information often do not get it in an appropriate
manner.
♦ When message recipients become aware of the benefits of the desired
practices and the harmful effects of the undesirable practices, they are more
willing to change. This means that adequate attention to message content is
important.
♦ Family support facilitated the change process. Thus, counseling just the
primary caregiver is not enough; the whole family needs to be involved and
sensitized.
♦ Experience of motherhood – those who already had a child seemed aware;
(though many said they did not know of these messages).
♦ Hospital support and reinforcement of similar messages by the doctors.
Vaatsalya, Aarogya 2005 89
It was expected that inhibitors of change will also continue to play a role and prevent
some women/their families from practising the desired behaviours; and our efforts will
continue to address this resistance/anxieties towards change. We are confident that with
time, even a brief contact in a hospital setting- if appropriate and effective- can lead to
change in a large proportion of women and their families who avail of maternity care
services. Our experiences indicate that non-government organizations can forge
partnerships with hospitals for positive change towards good nutrition and health of
women, newborns and infants.
Vaatsalya, Aarogya 2005 90
ANNEXURE 1 Question Guide to understand perceptions and practices of the women
regarding Antenatal, Postnatal and Infant Nutrition Background Information: Name of the woman: Place of Residence: Urban/ Rural Type of Delivery: Date of the Interview: Name of the Interviewer: Question Guide
� Nutrition during Pregnancy and Lactation 1. Can you describe your routine diet during pregnancy? 2. Did you change the quantity of your food intake during pregnancy? (Probe for
Increase, decrease or same) a) Increase b) Decrease c) Same
3. After you go home from the hospital, will you change the quantity of your food intake?
d) Increase e) Decrease f) Same
4. Will you avoid any food items after you go home (during first 6 months of breastfeeding?
5. Do you think it is important to increase food intake during pregnancy and lactation? 6. How many times in a week did you consume the following foods during pregnancy?
(Probe for reason if not consuming) a) Fruits (seasonal)
� Tomato/Lemon � Papaya/Mango � Others
b) Green leafy vegetables � Methi ni bhaji � Shepu / Palak � Others
c) Pulses and legumes � Chana/Chaula � Masoor/ Muth � Vatana (dry)
d) Milk/ Curd/ Buttermilk e) Bajra (rotla) f) Meat/ Fish/ Poultry
7. What is the importance of consuming fruits and green leafy vegetables during pregnancy and lactation?
Vaatsalya, Aarogya 2005 91
8. How many IFA tablets did you consume during pregnancy? (Probe: Daily/Weekly for how many months)
9. Will you continue consuming IFA tablets when you go home? If yes, for how long? 10. What are the benefits of consuming IFA tablets during pregnancy and lactation? 11. Did you take rest during the day during pregnancy (min. ½ hour)?
a) Yes b) No c) Other (e.g. state if rest advised due to medical reasons)
12. Do you think a pregnant woman should take rest in a day? (Probe for reasons for ‘Yes’ and ‘No’)
13. How much was your weight gain during pregnancy? 14. Was your weight monitored regularly (Probe: once a month)? 15. Why do you think one should monitor the weight gain during pregnancy? � Breastfeeding and Complementary Feeding 16. Did you feed colostrum to your child?
a) Yes b) No c) Other
17. What is the importance of colostrum for the newborn? 18. Did you start breastfeeding the child within 1 hour of birth? (Probe for reasons for
‘Yes’ and ‘No’ responses) 19. Till what age, will you exclusively breastfeed your child? (Probe and note if they will
exclusively breastfeed with or without water) 20. Do you think it is desirable to exclusively breastfeed till six months? (Not even
giving water) 21. At what age, is it desirable to introduce top milk? Why? 22. At what age, is it desirable to introduce top foods? Why? 23. How much quantity of food should a 6-8 month old receive in a day? 24. By 12 months, how much should the child consume? 25. During illness, will you
a) Increase breastfeeding your child b) Decrease breastfeeding your child c) Breastfeed same as before
26. During illness, will you a) Increase breastfeeding your child b) Decrease breastfeeding your child c) Breastfeed same as before
27. For a 6-12 month old child, what are foods which are beneficial? Why? 28. For a 6-12 month old child, what are foods which are harmful? Why?
Vaatsalya, Aarogya 2005 93
ANNEXURE 2 A section of the counseling guide
Behavior Change Communication Strategy (CMRS Strategy)Behavior Change Communication Strategy (CMRS Strategy)Behavior Change Communication Strategy (CMRS Strategy)Behavior Change Communication Strategy (CMRS Strategy) Post-natal Care
Message Code
Message for Behavior CCCChange
for Mother
MMMMotivating Factors
Expected RRRResistance and Overcoming It
Family SSSSupport (H: Husband; MIL: Mother-in-Law)
P1 Increase quantity of food; and quality of food. • One extra food
item daily e.g. 1 roti or 1 vatki dal-bhat or 1 vatki kathol or 1 vatki upma or bataka-pauwa
• Include daily one fruit (any seasonal fruit)
• Include 1 vatki bhaji daily in your diet.
• Drink adequate amount of water/ liquids.
• Gives mother energy to take care of the baby and make up for losses during delivery.
• Breast milk output will be sufficient.
• Weight and Health is maintained
• Gives immunity against diseases. Hence, able to take care of the baby well.
� Do not get time to think about myself
• It is important to maintain weight and one’s own health so that you can work normally, feel well, and can take care of the health of the child and the family.
� I cannot eat more .It is not
possible to eat more. • Then eat small frequent
meals which are nutritious. It is essential to recover losses of the delivery and pregnancy; and to maintain health during breastfeeding period.
♦ Encourage mothers to eat one helping more. It is important that mothers take care of their own health and not just health of child. Breast milk quantity and quality improves if mothers take proper food.
♦ Bring fruits, green leafy vegetables from market frequently; and prepare nutritious snacks.
♦ Keep aside fruits, nutritious snaks and extra food for frequent small meals.
♦ Remind them to consume the above.
Vaatsalya, Aarogya 2005 94
ANNEXURE 3 DATA RECORDING SHEET-Visit 1: A sample !""#$"%&"�(Maharani Shantadevi Hospital
Knowledge and Practices of Lactating Women before Counseling- Visit 1 DATA RECORDING SHEET-Visit 1
Dates: Place: OPD/ WARD Variable
Label Responses of the women regarding each message1
W1 W2 W3 W4 W5 W6
Regt. No. FL1 Food intake during lactation
♦ Increased ♦ Decreased ♦ Same ♦ No idea/ No response
FAV1 Any foods avoided during lactation
♦ Yes ♦ No ♦ No idea/ No response
IFA1 Consuming/ Consumed IFA during lactation
♦ Regular- daily for 1-3 months
♦ Irregular ♦ No ♦ No idea/ No response
IW1 Age of initiation of water ♦ 0–2 mths ♦ 3–5 mths ♦ 6 mths ♦ 7-8 months ♦ No idea / No response
FHM1 Feeding Hind Milk 2 ♦ Yes ♦ No ♦ No idea / No response
BFILCH1 BF during child’s illness ♦ Yes
♦ No
♦ No idea / No response
1 Tick (√) in the columns as per responses given by the women. 2 Yes = Emptying one breast & then feeding from other. No = Feeding from both breasts for 1-2 minutes or little from both breasts
Vaatsalya, Aarogya 2005 95
ANNEXURE 4 Continuous Program Improvements
((((Observations Modifications in the program
based on the observations Process related: ♦ The nurses assisting the pediatricians
and the staff members of FWC quite often forget to direct women to !""#$"%&" counseling center
♦ The !""#$"%&" sakhis themselves directed the women waiting outside the OPD of pediatrician and the FWC to the !""#$"%&" counseling center.
♦ The FWC had fixed days of each month
for BCG vaccination i.e. 10th, 20th and 30th of each month. Many lactating women along with their neonates visited the hospital on these days
♦ To enroll more women in the !""#$"%&" program, the counseling session in the OPD were also held on these BCG vaccination days over and above the bi-weekly sessions.
♦ Some women visited the !""#$"%&" center for the second time within a month of the Visit 1. This did not allow the women to have adequate time to practice the behaviors. Also at the time of the Visit 2 the counselors did not have any indication of the date of the Visit 1.
♦ Similarly, when women came to visit for the third time, the counselors did not have any indication how many times the women are counseled and when.
♦ It was decided to note down the date of Visit 1 and the registration number of the women as per !""#$"%&" records on the last page of the child record booklet. The women always carry this booklet when they visit the hospital so it is easy for the !""#$"%&" sakhis to decide whether the women needs the Visit 2 session.
♦ The counselor also noted the Visit 2 and Visit 3 dates on the child record booklet. This informed them without going through their own record books about the counseling session with the women.
♦ Some women forgot certain messages when they went home and hence requested for some sort of reminders or informative brochures. Although most women were not very educated, they could read the local language Gujarati
♦ Informative and colorful booklet was designed and printed which had the same messages as given by the !""#$"%&" counselors and had similar pictures as in the flash cards used by counselors. This served as a good reinforcement tool. Family members could use it to inform women if needed.
Message related: ♦ The pediatricians and the booklet for
recording the weight and vaccination schedule of the children registered at the hospital (child-record booklet) recommended that fluids should be initiated at 4-6 months of age.
♦ Due to continued follow-up by !""#$"%&" team members, the booklets were revised and reprinted by the hospital. Also the pediatrician supported current recommendations of ‘exclusive breast- feeding till 6 months of age of the infant’.
♦ During formative research, certain critical messages related to neonatal feeding such as initiation of breastfeeding within
♦ The message related to avoiding prelacteals and herbal fluids before 6 months of age of the infant was added in
Vaatsalya, Aarogya 2005 96
Observations Modifications in the program based on the observations
½-1 hour after delivery, feeding colostrum and avoiding prelacteals were emphasized by the pediatricians, gyneacologists and nutritionists of the hospital. Hence these were not included in the Vaatsalya counseling strategy. However during Visit 1, many women mentioned prelacteal feeding such as honey and ghee as well as feeding herbal fluids such as gripe water within 1-3 months of infant’s age.
the counseling session of the !""#$"%&" program.
♦ Initially !""#$"%&" strategy included details messages related to complementary feeding. For example, feeding at least ½-1 katorie per meal; feeding 3-4 times a day. However, the women having infants less than 3 months of age did not pay attention to these messages.
♦ The counseling strategy was revised and modified in such a way that there were different messages for women with younger infants (1-3 months) and women with older infants (4-12 months). The messages focus more on breastfeeding for mothers with younger infants and more on complementary feeding for mothers with older infants.
♦ Many women visiting the !""#$"%&" center had twins. They had many queries regarding breastfeeding both the infants.
♦ A special message regarding breastfeeding twins was added for mothers having twins.
Recording related: ♦ Initially the perceptions and practices of
the women counseled were noted as field notes. Later on to code and enter the information in to the computer used to be difficult.
♦ For making recording and data entry easier, each message was given a variable name and data entry sheets, which included all the messages given by the counselors along with the probable answers or options. The counselors record the options given by each woman on the data sheets.
♦ Data entry was difficult since options or answers given by the women were ticked in the data sheets. The data entry operator had to enter the suitable code in the computer corresponding to that answer or option ticked.
♦ The data sheets were revised to include the codes of the answers or options for each of the message or variable. The recorder recorded the codes in the data sheet according to the response of the women. This helped in data entry later on.
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