How India is using breastfeeding training to lower infant deaths

In a warmly lit conference room, several dolls dressed in pink, yellow, beige, and neon outfits rest in the arms of attentive trainees. Dr. Rupal Dalal cradles a pink-clad doll against her chest, demonstrating the cross-cradle hold for breastfeeding. Her voice is soft yet steady as she guides the room, filled mostly with primary health care workers, or PHCs, along with a few nurses and pediatricians, who mirror her actions with their own dolls. Outside, the January morning in Sanchi — a town in Madhya Pradesh, a central Indian state plagued by some of the country’s worst maternal and child health indicators — is brisk enough to require jackets. Inside, a four-day training session for 48 local health workers is in full swing. Dalal, a pediatrician with 17 years of experience working with malnourished infants, moves through the room, observing the participants. She offers gentle encouragement, adjusts their techniques, and corrects mistakes with care. The project she leads is rooted in a radically simple idea: Leveraging nutrition to improve maternal and child health outcomes in some of India’s lowest-income, most remote regions. As a part of the project called Health Spoken Tutorial pedagogy, health workers are taught breastfeeding techniques by a team of three master trainers including Dalal. They are also taught about cheap, locally available, and protein-rich food sources with a focus on pregnant and lactating women and children in the first 1,000 days of their lives. Health workers wrap up the training by learning about ways to improve their own diet. “It’s a capacity building of health care workers on nutrition through [a] life-cycle approach,” Dalal told Devex in Sanchi. “Nutrition through life cycle approach is basically appropriate, optimum nutrition required in every phase of life,” she said. Armed with this knowledge, health workers return to their communities and turn malnourished or underweight babies into long and cherubic bundles within months. This training is the kind of initiative the World Health Organization wants countries to invest in as it pushes them to strengthen their PHC and deliver basic but essential health services at the grassroots. So far, this project incubated by the Indian Institute of Technology, or IIT-Bombay, one of India’s premier science and research institutes, has trained over 10,000 health workers across government, private, and nonprofit sectors, the team said. Filling the gaps Around a dozen mothers are asked to sit on sofas kept outside the hospital ward for babies with low birthweight at the Shrimant Madhavrao Scindia District Hospital Vidisha, Sanchi’s nearest government hospital. All the babies here are well below WHO’s recommended birthweight of 3.3 kg. While most are around 2 kg, some weigh as little as 1.2 kg, barely visible in their swaddle. Those attending the training sessions, including pediatricians, said they were taught that WHO standards are based on “western babies” and that Indian ones are smaller and shorter. Around 2.5 kg is how much a healthy Indian baby ought to weigh, they believe. Maternal nutrition is the bedrock of maternal and child health. Improving it reduces pregnancy and birth complications, helps cut both maternal and infant deaths, and improves birthweight for infants, according to WHO. Once the baby is born, getting breastfeeding and nutrition right in the early years for infants cuts the risk of disease, and leads to lower rates of stunting and obesity in the long run. Approaches like these could potentially help India further reduce its maternal and infant deaths, which have been steadily coming down over the years and offer insight to other countries looking to do so. India’s infant mortality rate declined from 39 per 1,000 live births in 2013 to 28 per 1,000 live births in 2020 while its maternal mortality rate declined from 167 per lakh live births in 2014 to 97 per lakh live births in 2020. At the hospital, health workers ask mothers to demonstrate how they currently feed their newborns. Most babies are failing to latch to the mother’s breasts despite earnest attempts by their tired mothers, they notice. The lack of nourishment has turned some babies too weak to even try, and they are showing early signs of slipping away. Through the next four days, the health workers return to the hospital to try to help the mothers with their newly acquired skills, both groups learning more from each other in the process. Latching is a learned behavior and not as instinctive as it is made out to be, said Dalal. This situation needs a little expertise and that is what her training hopes to provide. India is currently off track to meet the Sustainable Development Goals set by the United Nations for reducing neonatal mortality or deaths within the first 28 days of a baby’s life, according to an analysis by US-based nonprofit Population Reference Bureau. This project’s approach is preventive rather than reactive, according to its trainers. It appears to also be in line with WHO’s vision of what health systems ought to do. From pilot project to national impact What started as a pilot project a few years back has now scaled up to several regions in India. The team is currently training around 250 health workers each across seven districts in Madhya Pradesh. The face-to-face training session lasts for four days but guidance will continue for months. Each trained worker will then take on 10 mother-father-child units in their community. Over the next six months, they will track the progress of the mother and the baby, upload the height and weight details of the baby on an app called Cuedwell, and receive guidance from the trainers. The aim is to eventually select 40-50 health workers who demonstrate good results as ‘master trainers’ who can train others. From then on it is up to the local governments to monitor and continue. The Health Spoken Tutorial team at IIT-Bombay also creates training videos in English and several Indian languages that are free to access on YouTube. The use of these videos is not restricted to rural areas where a majority of the training sessions are conducted but the videos are used in several cities. The training itself is a combination of self-driven research, existing techniques, and improvised diet charts tailored to local settings. The funding has come in part from IIT’s alumni, local governments who want their health workers trained, or NGOs who request the training in their areas. Dr. Devaji Patil, adviser to the project, and one of the main trainers said that other countries have to see this program “very, very seriously.” “Here is a model, which is cost-effective, scientific, and actually answers your problem of malnutrition. It actually answers your problem … without going into the realm of peer approval,” he said. Results with basic upskilling Neelam Pal, 26, is a mother of three. When her first two sons were born, they weighed around 2 kg, she said — severely underweight. But this time when Pal was in her eighth month of pregnancy, Anita Kakanya began to speak to her about eating a high-protein diet. Kakanya is a community health worker locally known as an ASHA. She had been freshly trained by Dalal’s team in November last year. Most of the communities Dalal works with eat a low-protein diet. Often it is not the affordability of cheaper options such as curd, dried fish, or eggs but myths that get in the way. Given that Pal was in her third trimester, when the fetus puts on most of its weight, Kakanya managed to catch her at a time when she could make a difference. Following Kakanya’s advice Pal, a vegetarian, began eating more cottage cheese — which is locally called paneer — and consuming two glasses of milk a day to increase her protein consumption. When Devyanshi, Pal’s daughter was born, she weighed 2.7 kg, which was more than what her older brothers weighed at birth but still less than WHO standards. Kakanya then guided Pal through her breastfeeding journey and by the end of her first month, Devyanshi was 4.2 kgs and had caught up on her growth in both weight and height parameters. “I feel less tired this time around,” Pal told Devex at her home in Ratlam. “Compared to my first two pregnancies, my experience this time was smooth.” It was Kakanya’s role as a trained community health worker that was crucial. “I was with her the entire time and I ensured that her breastfeeding was initiated within the first hour of birth,” Kakanya said. The mother’s first milk is yellowish and sticky called colostrum, which protects the baby against infection but often goes to waste. Both this training and WHO emphasize ensuring that the mother receives support to begin breastfeeding right away. Dr. Azhar Ali who is Ratlam’s district program manager in the health department is cautiously optimistic. Around 2,500 babies are identified as being severely malnourished here every year and another 25,000 as being moderately malnourished. True impact will require time and motivation, he said. “The health workers are already burdened with a lot of work. I want us to find a way to provide them with incentives so that they remain motivated to keep doing this work,” he told Devex. But trained health workers in his area have already begun to see results. Ahtesham Ansari was shocked when baby boy Abbas Khan, who was born underweight at 2.42 kg, reached 7.7 kg by the time he was four months old. “I have been a health worker since 1998 but this is the first time I have seen such drastic results. Normally, an underweight baby takes at least six months to gain weight but this baby has already caught up,” she said. Ansari counseled the baby’s mother Salma Khan who is a nonvegetarian to increase milk, eggs, chicken and fish consumption in her diet apart from teaching her the cross-cradle hold technique of breastfeeding. Update, Feb. 7, 2025: This article has been updated to clarify that the Health Spoken Tutorial team is currently training around 250 health workers each across seven districts in Madhya Pradesh.