Even while celebrating its excellent metrics in the area of maternal and child health, one indicator that has always lagged behind in Kerala is breastfeeding, which has a crucial impact on children’s health. The paediatricians’ community in the State is thus elated about the National Family Health Survey (NFHS)-6 (2023-24) findings, for the State seems to have made some gains on the breastfeeding front.

According to NFHS-6, the proportion of infants under six months who are exclusively breastfed in the State has significantly increased from 55.5% in NFHS-5 (2019-20) to 72.7%. Also, the proportion of infants who are initiated early into breastfeeding, within one hour of birth, in Kerala is now 82.3%, up by over 15 points from 66.7% in NFHS-5.

“NFHS-6 data show that breastfeeding gains have not been reported by any States other than Kerala and Sikkim, which indicates that poor breastfeeding is a nationwide phenomenon. It just goes to show that we need to do much more to make mothers more passionate about breastfeeding,” says I. Riaz, the State president of the Indian Academy of Paediatrics (IAP).

How MBFHI helped

A reason for Kerala’s improved performance in encouraging more mothers to exclusively breastfeed for six months has been the Mother and Baby-Friendly Hospital Initiative (MBFHI), a quality improvement and certification programme for hospitals in Kerala, led by the IAP and the State National Health Mission since 2021. It aimed to promote and support breastfeeding and optimal newborn care in maternity facilities.

The MBFHI was an effort to bring WHO-UNICEF’s “Ten Steps to Successful Breastfeeding” and respectful maternity care into routine practice in State’s health facilities. The State also drew up a quality standard certification with 130 check-points for certifying hospitals as mother- and baby-friendly.

Hospitals do lactation counselling from the ante-natal period itself, to educate mothers on the importance of breastfeeding infants exclusively for six months. Hospitals had to appoint lactation consultants and the government also started a lactation counselling certification course to aid this.

C-section impact

Kerala’s low breastfeeding rates are also linked to the high C-section rates — 44% in public and 45% in private hospitals (2024-25 data of DHS), which lead to delays in the early initiation of breastfeeding, probably because post-operative pain limits the mobility of mothers and comfortable positioning for feeding. Also, baby is often kept in the neonatal ICU in the initial hour.

Under the MBFHI initiative, much stress is given on initiation of feeding within an hour of delivery and doctors now encourage feeding on the labour cot itself and Kangaroo nursing.

Often, infant formula (milk substitute for babies) is initiated by the hospital itself. MBFHI-certified hospitals totally discourage infant formula supplementation, unless there are medical reasons involved. Pre-term infants in neonatal ICUs are to be fed on expressed mothers’ milk as far as possible.

Breast milk banks

Another initiative which gave an impetus to breastfeeding was the establishment of breast milk banks in hospitals, so that pre-term or orphaned infants can be provided a nutritional life-line.

Over 50 hospitals in the State, both private and public, have received the MBFHI certification now. “Continuous vigil is required to sustain our gains. MBFHI needs to be revamped and the focus has to be on certifying more hospitals, while re-certifying others,” says K.E. Elizabeth, paediatrician and nutrition expert and the former Superintendent of SAT Hospital.

Some concerns

The State has made gains on the breastfeeding front but there are concerns about infant feeding and nutrition. NFHS-6 also shows that the proportion of children in the 6-23-month age group with “adequate diet” in Kerala is just 26%. “We are absolutely stumped as to why this is happening in Kerala,” says Dr. Elizabeth.

This refers to nutritional adequacy in infants in the 6-23-month age group, who should be given complementary feed, apart from breast milk. It is determined by the WHO’s core indicators in infant and young child feeding (ICYF), including dietary diversity and inclusion of iron-rich food.

“This is an area which needs more attention. Nutritional inadequacy is one reason we still have stunting in 20% of the children under five years,” says Dr. Riaz.