No. 34 • September 2011

BPNI BULLETINBPNI BULLETINBPNI BULLETINBPNI BULLETINB P N I

Breastfeeding Promotion Network of India

Today there is no doubt that exclusivebreastfeeding for the first six months

and continued breastfeeding for twoyears and beyond is vital for the optimalnourishment and development of infantsand young children. Maternityentitlements, which emerged out of avery valid concern for maternal health,are increasingly recognizing the rights ofmothers and infants to breastfeedoptimally.

The General Conference of theInternational Labour Organisation,convened on 4 June 1952, decided uponthe adoption of certain proposals with

regard to maternity protection; theMaternity Protection Recommendation,1952. The recommendation allowed amaximum period for which any womanshall be entitled to maternity leave to betwelve weeks and wherever practicablenursing breaks should be extended to atotal period of at least one-and-a-halfhours. In 2000, the Maternity ProtectionConvention 183 increased the leave to 14weeks, and further to 18 weeks(Recommendation 191). C 183 and R 191further recognise breastfeeding breaks asa woman's rights, and allow combiningbreastfeeding breaks to shortened work

day; they further guarantee her the rightnot to be dismissed from work because ofbreastfeeding for a period after hermaternity leave. However, both thedocuments allow countries to decide onthe length of maternity leave and numberof breastfeeding breaks.

In India, the rights of working mothers tomaternity benefits were recognized withthe introduction of the Maternity BenefitAct in 1961. The Act extends to the wholeof India and applies to everyestablishment which may be industrial,commercial, agricultural or otherwise. Itprovides maternity leave for twelveweeks; and two breastfeeding breaks ofthe prescribed duration for nursing thechild until the child attains the age offifteen months.

The Act however does not holisticallyaddress the issues regarding the woman'scompulsions to work right up to the laststage of pregnancy and resumption ofwork soon after child birth. Even after 50years since Maternity Benefit Act cameinto existence it has not been effectivelyimplemented for several reasons. Whilegovernment establishments are obligedto follow the law most employers in theprivate sector prefer to either violate it,or bypass it through employment criteriaand procedures. Further, breastfeedingon demand is vital to maintainingexclusivity of breastfeeding, something

Article 42 in the Constitution of India 1949

Provision for just and humane conditions of work and maternity relief

the State shall make provision for securing just and humane

conditions of work and for maternity relief.

Maternity Entitlements in India

an issue of breastfeeding rights

Photo: Satnam Kaur

BPNI Bulletin

that is not possible with just twobreastfeeding breaks.

In 2008, in a major recognition of thefact that the mother and child need to betogether for first six months in order toensure exclusive breastfeeding to theinfant, the Central Government adoptedthe recommendations of the Sixth PayCommission and gave a generousallowance of 180 days of maternity leaveon full pay and in addition paid Child CareLeave for a period of 2 years as part ofmaternal entitlements to its womenemployees; a few state governments havefollowed this precedent. Theseentitlements, however, can be accessedby a miniscule fragment of women.

However, there is till today no legislationguaranteeing maternity entitlements towomen working outside the formal sectorin India. Virtually all of the female non-agricultural labour force of the country isin the unorganised sector, and accountsfor over 95 percent of women workers.

A few schemes have been introduced atdifferent times for different sectors ofwomen as part of maternity entitlements.The National Maternity Benefit Scheme(NMBS) was launched by the Centralgovernment in 2001 to provide nutritionsupport to below poverty line pregnantwomen through one time payment ofRs.500/- prior to delivery to womenabove 19 years of age for two live births.In 2005 the GOI launched JananiSuraksha Yojana (JSY) under the NationalRural Health Mission to provide cashincentive for women to have aninstitutional delivery.

The Dr.Muthulakshmi MaternityAssistance Scheme (DMMAS) in TamilNadu was enhanced from a singlepayment to provide Rs.6000/- spreadover two instalments of 3000/- eachbefore delivery for nutritional supportduring pregnancy and after delivery tocompensate for their loss of income. In2009 the scheme has started paying thecomplete amount in one instalment i.e.after delivery.

In order to provide uniform maternity

entitlements to women in both organisedand unorganised sectors, Government ofIndia launched a new scheme forpregnant and lactating women called the“Indira Gandhi Matritva Sahyog Yojana(IGMSY)” - Conditional Maternity Benefit(CMB) with an aim to improve the healthand nutrition status of pregnant andlactating women as well as to createopportunities for engagement ofpregnant women with Anganwadi centres(AWC) to ensure nutrition and healtheducat ion counse l l ing, growthmonitoring and promotion of optimalinfant and young child feeding practices.A woman are entitled for cash benefits ofRs.4000/ in three instalments per womenbetween the second trimesters till thechild attains the age of 6 months topartly compensate for wage loss towomen during pregnancy and lactationperiod. All Government (Central andState) employees will be excluded fromthe scheme as they are entitled for paidmaternity leave. The scheme would beimplemented through the platform ofICDS scheme and the focal point would beAWC at the village in 52 districts acrossIndia.

However, there are serious flaws in thescheme in spite of the laudable step ofmaking it universal. The IGMSY ignoresthe fact that in India, 56% women deliverbefore the age of 18 years and contributesignificantly to the high incidence ofmaternal mortality. Besides being victimsof social and patriarchal pressures, thesewomen are rarely adequately nourished.

The scheme also disregards the fact thatthe amount of Rs. 4000/- spread over sixmonths, does not compensate the womanfor lost wages, as the minimum wage,

while it varies across states, is on anaverage Rs. 100/- per day. Linkingma t e r n i t y b e n e f i t s t o w a g ecompensation has been the demand ofover 32 civil society organisations andprofessional bodies, activists and healthworkers, through the “Joint StatementCalling for food rights of infants (firstyear of life)”presented to the PrimeMinister in April 2010.

The IGMSY scheme recognizes theimportance of IYCF counseling as well asgrowth monitoring; however it assumesthat supply side provision of counsellingand growth monitoring will happenautomatically, not taking into accountthe current lack of capacity or serviceavailable as of now. As of now only18.2% infants are weighed and nutritioneducation is given to 48.9% mothers.

It would, therefore, be logical to bridgethis service gap by ensuring that workerscapacity exists from block leveldownwards with proper skill training onbreastfeeding and infant and young childfeeding as well as growth monitoring,and faltering.

Though not much work has been done inIndia to research on the critical issueconcerning mother and child care, thereare however data available from otherparts of the world that shows thatinfants' right to breastfeeding andmothers' right to breastfeed can beactualised through creative means ofensuring maternity entitlements towomen. All it requires is political will.

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This newsletter is an attempt

to compile the various

research evidences related to

breastfeeding and Maternity

entitlements/benefits. The

newsletter is a joint effort by

BPNI & IMCH to develop

advocacy documents based on

the research compilation and

disseminate these to all

stakeholders.

BPNI Bulletin

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It is well known that employment and an early return to workafter childbirth are associated with shorter duration of

breastfeeding. Maternity leave, paid or unpaid, has therefore beenput forward as an important ingredient for promoting prolongedbreastfeeding for working mothers. A study from Scotland nowverifies this assumption by showing a direct association betweenthe duration of breastfeeding and the length of maternity leave.This positive effect was seen to be important up to five months.Mothers working part time were also more likely to breastfeedlonger compared to mothers who worked full time. More flexibleworking conditions and more generous employment leave couldthus be an important intervention in order to prolongbreastfeeding among working mothers and should be part ofpublic policy. As also concluded in a study from US thatpostpartum maternity leave may have a positive effect onbreastfeeding among full-time workers, particularly those whohold nonmanagerial positions, lack job flexibility, or experiencepsychosocial distress. Pediatricians should encourage patients totake maternity leave and advocate for extending paid postpartumleave and flexibility in working conditions for breastfeedingwomen.

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According to Payne and Nicholls, to combine breastfeeding andpaid work requires a negotiation of the roles of good mother

and good worker. With the present recommendations of exclusivebreastfeeding for the first six months and partially until the age of2 years in combination with the fact that many mothers return topaid employment within these time periods, how to combine BFand work needs to be highlighted. Payne and Nicholls emphasizethat the strategies used of breastfeeding mothers in theworkplace tend to maintain the marginalization and invisibility ofthe issue. By disciplining themselves to minimize the disruptiveeffects of breastfeeding on their work they manage to fulfill boththe ideals of being a good worker and a good mother at the sametime. This was done by stockpiling breast milk and maintainingmilk supply, which sometimes took a lot of preparations, andplanning, as well as skills. Not only did the mothers disciplinethemselves in this way but did also prepare their babies for theirabsence through bottle feeding training and teaching them to beadaptable. These strategies are however conserving the presentsituation and leaves breastfeeding mothers in the dilemma offulfilling two contradictory expectations. In order to change thispatters, Payne and Nicholls suggest that nurses and midwiveshave the potential to bring about change by educating andsupporting women in relation to breastfeeding. At the same timethey can themselves lead by example by supporting theirbreastfeeding colleagues by demonstrating understanding andarguing for appropriate spaces where breastfeeding mothers mayfeed their babies or extract breastmilk. Furthermore, Payne andNicholls put forward the importance of professional nursingunions that can play a significant role by lobbying governments toprovide paid work breaks for breastfeeding workers.

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Longer Maternity Leave Leads toLonger Breastfeeding Duration

Breastfeeding at Work Needs to beBetter Recognized and Supported

Return to work is a major reason why breast-feeding mothersstop to breastfeed their babies. This has recently been high-

lighted both from low as well as high-income settings. Sasaki etal found in a study of mothers in Phnom Penh, Cambodia thatreturning to work was associated with an almost five-fold risk ofexclusive breastfeeding cessation during the first six monthscompared to mothers who stayed at home during that period. Theauthors call for the promotion and development of better workingconditions and environment for working mothers in order toincrease breast feeding rates.

The same pattern was found in a study by Nawaz et al fromPakistan where almost 20 % of mothers stated that the reason fornot breastfeeding their baby was that they had to work.

Similar results were found in a study from the US where 23 %of study participants stated return to work or school to be themain reason for discontinuing breastfeeding their child.Breastfeeding-friendly policies in the workplace are likely to makea difference, both in high as well as in low-income settings.

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Returning to Work a Major Reason toStop Breastfeeding both in High andLow-income Settings

To practice exclusive breastfeeding is something that requiresdedication and commitment from the mother. That she gets

support from family members and health staff is equally importantsince mothers often face many obstacles to successfullybreastfeed their babies. The balancing of responsibilities for home,family and work in relation to breastfeeding can many times bedifficult. There are evidence that indicate that fathers want to beinvolved to a larger extent in the process of parenthood and thatfathers are many times neglected resource to maintainbreastfeeding practice. In an Australian study, Tohotoa et alfocused on paternal support for breastfeeding and found that“Dads do make a difference”. The fathers in the study were eager tobe a part of parenthood and wanted to be involved. Theirinvolvement was seen as an important factor to promotesuccessful breastfeeding and recognition that breastfeeding is afamily issue benefited everyone. The study points out that whenmothers are sharing the difficulties they encounter with theirpartners, babies will have a better chance of receiving breast milkexclusively for the recommended six months.

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Fathers have an Important Role forContinued Breastfeeding

BPNI Bulletin

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Astudy from the United States shows that feeding the infantdirectly from the breast rather than pumping breast milk is

the most effective strategy for combining breastfeeding andemployment. Most workplace lactation programs encouragepumping breast milk at work. However, direct feeding of the infantfrom the breast during the work day results in longer duration ofbreastfeeding and should be promoted. Mothers who had startedto pump milk and bottle-feed their babies when returning to workwere not likely to change strategy and the intensity and durationof breastfeeding were less in this group. Since many mothers traintheir infants to get used to bottle-feeding before returning towork, information of the possibilities to direct feeding must beprovided in advance. In order to enable mothers to directly feedtheir infants there is a need for on-site day care or other ways tokeep the infant at work, or the possibility of having the babybrought to the work site. Mothers must also be allowed to leavework to go to the infant if direct feeding is to be successful.

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Breastfeeding is well known to be beneficial for mothers andtheir infants. However, working mothers may return to work

early after giving birth for various reasons and if not supported bytheir employers, they can be separated from their babies, havedifficulty expressing and storing milk and thus not be able tomaintain breastfeeding. Workplace programs could help women tocontinue to breastfeed, and by promoting and supporting theprograms, employers may be able to influence the duration ofbreastfeeding (including exclusive breastfeeding) and so improvethe health of mother and baby, but also benefit from less workabsenteeism, high productivity and increased employee moraleand retention. However, a Cochrane review by Abdulwadud andSnow indicates that no randomized-controlled trials to evaluatethe effect of such programs have been performed and that there isa need to further explore this important public health issue.

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The provision of lactation rooms and breast pumping breaks hasbeen shown to have a positive effect on mothers' continued

breastfeeding after returning to work. This is one of theconclusions that can be drawn from a study in a semi-conductorplant in Taiwan. Mothers who were aware of these interventionswere almost seven times more likely to continue breastfeedingtheir babies after returning to work compared to those who didnot know that they had these benefits. This shows on theimportance not only to provide space and time for mothers tobreastfeed, but also to raise awareness that it is possible andacceptable. The Taiwanese study also found that the white-collarworkers of the company were more likely to utilize thebreastfeeding-friendly possibilities provided than their blue-collar colleagues, which emphasizes the need to have a holisticapproach when promoting breastfeeding in the workplace.

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Direct Feeding at Work Most EffectiveStrategy for Combining Breastfeedingand Work

Interventions in the Workplace toSupport Breastfeeding a NeglectedResearch Area

Awareness of Breastfeeding-friendlyMeasures in the Workplace IncreaseContinued Breastfeeding

1. Swaminathan M. “Sixth Pay Commission: Class and Gender Bias” in Economic and PoliticalWeekly 2009; 44: 22-24.

2. Narendra Jena. Gender Dimension of Unorganised Manufacturing Sector in India.Available at http://www.centad.org/Gender%20Dimension%20of%20%20UMS%20in%20India_ed.pdf, accessed on 30th September 2011.

3. Towards Universalization of Maternity Entitlements. An exploratory case study of theDr.Muthulakshmi Maternity Assistance Scheme Tamilnadu. May 2010. Public HealthResource Network in collaboration with M.S.Swaminathan Research Foundation, Chennaiand Tamil Nadu Forum for Crèche and Childcare Services. Available atwww.phrnindia.org/publications_report

4. National Family Health Survey (NFHS-3). India 2005-06. International Institute ofPopulation Sciences. Ministry of Health & Family Welfare, Government of India.

5. Skafida V. Juggling work and motherhood: The Impact of Employment and MaternityLeave on Breastfeeding Duration: A Survival Analysis on Growing Up in Scotland Data.Matern Child Health J 2011 Jan 28 [Epub ahead of print]

6. Guendelman S, Kosa JL, Pearl M, Graham S, Goodman J, Kharrazi M. Juggling work andbreastfeeding: effects of maternity leave and occupational characteristics. Pediatrics 2009Jan;123(1):e38-46.

7. Payne D and Nicholls D.A. Managing breastfeeding and work: a Foucauldian secondaryanalysis, J Adv Nurs. 2010 Aug; 66(8): 1810-8.

8. Sasaki Y, Ali M et al. Predictors of exclusive breast-feeding in early infancy: a survey reportfrom Phnom Penh, Cambodia. J Pediatr Nurs. 2010 Dec; 25(6), 463-9.

9. Nawaz R, Ur Rehman S et al. Factors causing non-breastfeeding in children under sixmonths of age in district Nowshera, Pakistan. J Ayub Med Coll Abbottabad 2009 Oct-Dec;21(4):93-5.

10. Haughton J, Gregorio D and Pérez-Escamilla R. Factors associated with breastfeedingduration among Connecticut Special Supplemental Nutrition Program for Women, Infants,and Children (WIC) participants. J Hum Lact 2010 Aug; 26(3):266-73.

11. Tohotoa J, Maycock B et al. Dads make a difference: an exploratory study of paternal supportfor breastfeeding in Perth, Western Australia. Int Breastfeed J 2009 Nov 29;4:15.

12. Fein, SB, Mandal B and Roe BE. Success of strategies for combining employment andbreastfeeding, Pediatrics 2008 Oct; 122 Suppl 2: S56-62.

13. Abdulwadud OA and Snow ME. Interventions in the workplace to support breastfeedingfor women in employment. Cochrane Database of Systematic Reviews 2007, Issue 3.

14. Chen, YiC, Wu Ya-Chi and Chie Wei-Chu. Effects of work-related factors on thebreastfeeding behavior of working mothers in a Taiwanese semi-conductor manufacturer: across-sectional survey. BMC Public Health 2006 Jun 21; 6:160.

References

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Compiled by:

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Dr. Arun Gupta, Dr. J.P. Dadhich, Dr. Shoba Suri & Radha Holla

Amit Dahiya

The IMCH and BPNI PDC ProjectInternational Maternal and Child Health, Uppsala University,

Sweden and Breastfeeding Promotion Network of India has

come together to work on a partner driven cooperation

project in India. The purpose of this project is to use

evidence-based advocacy (policy advice) to expand the

provision of full maternity entitlements/benefits to all women

(in the selected States) and to provide women with

accurate, unbiased information through skilled counseling

and support. The project will work through situational

analysis of policy and programmes at state and district

levels; and national and state level consultations to develop

call for action.