A Qualitative Analysis of the Barriers and Facilitators for Breastfeeding and Kangaroo Mother Care Among Service Providers,Mothers and Influencers of Neonates Admitted in Two Urban Hospitals in India

Abstract

Background:

Known interventions like breastfeeding and kangaroo mother care (KMC) can avert a large share of infant deaths. Mother Baby Friendly Initiative Plus (MBFI+) is an integrated approach to ensure exclusive human milk diet through promotion of breastfeeding, KMC, and provision of donor human milk (DHM) to vulnerable neonates lacking mothers' own milk.

Materials and Methods:

Qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their knowledge, perceptions, and practices on breastfeeding, KMC, DHM, and human milk banks (HMBs) in 2 facilities in India, one with and another without an operational HMB. This article presents the findings on breastfeeding and KMC.

Results:

Nearly all mothers mentioned that antenatal visits lacked information on breastfeeding. Most were unaware of the recommended duration of exclusive breastfeeding. Most parents knew about the benefits of breast milk and colostrum. Limited staff and privacy in facilities resulted in inadequate breastfeeding and milk expression support to mothers, who found feeding of preterm and low-birth-weight babies challenging. Mothers shared challenges in breastfeeding at home, such as low family support and privacy and burden of household chores. Only those mothers who practiced KMC were aware of its benefits. Few service providers and recipients were comfortable with the practice of wet nursing in the absence of breastfeeding.

Conclusions:

MBFI+ is a promising approach to strengthen breastfeeding and KMC. Quality counseling on breastfeeding and milk expression from antenatal period, increasing awareness and training on KMC for mothers, improving infrastructure, addressing staff shortage, and building capacities of hospital staff on MBFI+ are needed.

Introduction

India contributes to 29% of global newborn deaths (0.76 M).¹ Simple and low-cost measures like breastfeeding and kangaroo mother care (KMC) can avert a large number newborn deaths.¹ In India alone, breastfeeding can prevent 160,000 of these deaths each year.² Recent analyses by the World Breastfeeding Trends Initiative (WBTi) 2018 revealed that India lags in many indicators related to breastfeeding.³ The National Family Health Survey 4 reported institutional deliveries at 78.9%; however, only 41.6% of infants are breastfed within the first hour of birth and 54.9% babies under 6 months of age are exclusively breastfed, indicating a significant gap in access to mothers' own milk (MOM).⁴

Newborns who lack access to MOM for reasons such as mother's illness or death, abandonment, or delay in milk production, require feeding by alternative methods.⁵ Donor human milk (DHM) from human milk banks (HMBs) has been recommended as the next best option for babies lacking access to MOM.⁶

KMC is a natural form of human care that stabilizes body temperature, improves breastfeeding, and prevents infection and other morbidities in newborns.⁷ Early KMC has the potential to save 1.6 million preterm babies in India annually.^8,9 Barriers for uptake of KMC include lack of institutionalization and ownership of KMC in health facilities and inadequate continuum of KMC after discharge.^7,10,11

Building on a comprehensive approach utilized in Brazil to protect, promote, and support breastfeeding, PATH's Mother Baby Friendly Initiative Plus (MBFI+) model is a unique and integrated approach that combines benefits of breastfeeding, KMC, and DHM with the aim of ensuring all infants receive human milk.^5,12 It positions HMBs as centers that provide support for lactation and KMC and collect, screen, process, store, and provide DHM to babies in need. The model has been adapted in India as “Comprehensive Lactation Management Centre” (CLMC) model in the “National Guidelines on Lactation Management Centres in Public Health Facilities.”¹³

As the MBFI+ model is being promoted in India, it was important to understand country-specific insights to create robust evidence for national-level scale-up. A formative research was conducted in 2016 to understand the knowledge, practices, and perceptions on all components of the model—breastfeeding, KMC, and DHM—among service providers and recipients (mothers, fathers, and grandmothers). The findings related to DHM were shared in an earlier article.¹⁴ In this article, we present the findings on knowledge, perceptions, and practices on breastfeeding and KMC among service providers, mothers availing these services, and influencers (fathers and grandmothers) in two health facilities in Mumbai, one with and another without an operational HMB. There are limited studies in this area globally, and less so in India.

Materials and Methods

Two health facilities (Level III with an established HMB and Level II without a HMB) in Mumbai were purposively selected as case studies for the study. The study obtained clearance from the Institutional Ethical Committee of the respective health facilities.

Qualitative research methods were used to collect data. In-depth interview were conducted with nine service providers including HMB in charge, manager, technician, neonatal intensive care unit (NICU) in charge, staff nurses, and lactation counselors. Seven focus group discussions (FGDs) were conducted with 56 service recipients comprising mothers, fathers, and grandmothers of neonates. These were audio recorded after taking informed consent from the participants. Service providers were selected at the facilities who had been providing newborn care services for at least 6 months and who also were aware of HMB policies and functioning. The inclusion criteria of the service recipients are given in Table 1.

Table 1.

Inclusion Criteria for Service Recipients and Key Influencers

Service recipients	Inclusion criteria
Potential human milk donor or recipient	Pregnant women above 18 years of age visiting ANC ward
	Pregnant women who were second para and in the third trimester
	Lactating mothers visiting well-baby clinics with babies younger than 3 months
	Are willing to participate in the interview process
Human milk donors	Mothers above the age of 18 years, admitted to the PNC ward or attending the well-baby clinic and have donated milk at least once in the last 6 months
Human milk donors	Are willing to participate in the interview process
Mothers of baby received DHM	Mothers above 18 years of age whose babies are currently in NICU, or in the premature wards and have received DHM
	Mothers who attend the follow-up OPD and whose babies received DHM during their stay in the hospital
	Are willing to participate in the process
Grandmother of baby received DHM	Grandmother or any elderly woman from the family whose baby is currently in the NICU and has received DHM from the HMB or her daughter-in-law has donated human milk to the HMB
Grandmother of baby received DHM	Are willing to participate in the interview
Father	Fathers above 21 years of age whose babies are admitted in the NICU or the PU
Father	Are willing to participate in the interview

ANC, antenatal care; DHM, donor human milk; HMB, human milk bank; NICU, neonatal intensive care unit; OPD, outpatient department; PNC, postnatal care; PU, preterm unit.

While framing the FGD questionnaire, local cultural and religious sensitivities were considered. All the tools were field tested for validation and modified before beginning the data collection. FGDs were conducted in local languages (Hindi and Marathi) and moderated by a trained moderator assisted by two facilitators. All audio records were transcribed into local languages (Hindi and Marathi) and then translated into English. Transcribed data quality was cross-checked with audio recordings to ensure completeness, accuracy, and quality of the transcription. For each category of participants (service providers, mothers, and influencers), transcripts were coded and analyzed separately for thematic content. The analytical process involved reading and re-reading each transcript and inductively coding “what was being said.” These codes were then compared and contrasted, both within and across data sets, and progressively organized into meaningful categories or emergent themes. In addition, these inductively derived themes were reanalyzed. Representative quotes have been reported.

Results

Breastfeeding knowledge, perceptions, policies, and practices

Service recipients

Knowledge and perceptions of breastfeeding

Most mothers in both facilities were aware that MOM is best for newborns. Most parents agreed that breast milk has optimal nutrition and protective anti-infective substances that prevent childhood illnesses. Mothers opined that breastfeeding plays a significant role in the child's development, facilitates emotional bond between the mother and the baby, and relieves mothers from pain of engorgement. Most parents at both these institutions knew about the benefits of colostrum; few donor mothers opined that the first milk can be infectious and harmful for the baby (Table 2).

Table 2.

Verbatim Quotations on Breastfeeding Knowledge, Perceptions, and Practices

Service recipients	“In my opinion baby should not be given the first milk as it is infectious and harmful.”—FGD, Potential donor mother, Level III
	“Mother's milk is good for the babies' health. It keeps the baby away from the illnesses.”—FGD, donor mother, Level III
	“Once breastfeeding is initiated, milk production starts.”—Potential donor mother, Level II
	“I realized how difficult it was to manage a 3-year-old child for 24 hours when my wife got admitted for her second delivery. I was left to take care of the elder child. I was in tears just satisfying the needs and demands of my elder child. I realized how tough it might be for my wife to handle this everyday.”—FGD with fathers, Level II

FGDs, focus group discussions.

With respect to timing of initiation of breastfeeding, response among mothers varied from—immediately after delivery to within 2–3 hours to the second or third day after delivery.

Mothers had diverse opinions about duration of exclusive breastfeeding, which varied from 3–4 to 6 months. Few said that exclusive breastfeeding should continue after 6 months of age and there was no time limit to breastfeeding.

When asked about their views on exclusive breastfeeding, there was consensus among mothers at the Level III facility that breast milk is best for the baby and the mother as it promotes good health.

Myths and misconceptions on breastfeeding

Mothers believed that consuming bananas, cold water, and sweets can cause cough and cold in the baby. They opined that nonvegetarian food and papaya should be avoided as they generate heat and eating rice after delivery can cause stomach ache. Most mothers and influencers mentioned that a mother should cover herself and the baby while breastfeeding and should not breastfeed in front of others as the baby may fall ill due to evil eye.

Sources of information on breastfeeding

Most respondents received information on breastfeeding only after delivery without any guidance on diet and breastfeeding during the antenatal care (ANC) check-ups. The sources of information included service providers, mass media, information education and communication (IEC) materials, NGOs, family members, and past personal experiences.

Challenges in breastfeeding after discharge

Both donor and recipient mothers shared that it was difficult for women to exclusively breastfeed for 6 months because of lack of help from family members in handling household chores and caring for infants. Most respondents shared that mothers needed support from family members to be able to continue to breastfeed adequately and appropriately.

Mothers believed that hot and fresh meals should be given to improve flow of breast milk. Fathers in both the hospitals expressed willingness to provide all kinds of food to the lactating mothers as per their preferences.

Service providers

Breastfeeding guidelines in facilities

Service providers at both the facilities reported that there were no separate written guidelines on breastfeeding. Most of them followed the “National Guidelines on Infant and Young Feeding Practices.”

Feeding of term babies in facilities

Providers from Level III facility reported that normal term babies were fed immediately after delivery or within half an hour of birth. If mothers are not transferred out of the labor room early, including those who had undergone caesarean section, babies were kept in the postnatal care (PNC) ward and fed DHM until the mother was transferred there (in most cases, after 2 hours). In the Level II facility, the first feed of mother's milk or formula feed was generally initiated after 2–3 hours of birth. Most service providers said that it was difficult for the mother to breastfeed after caesarean section because she was generally unable to sit; the baby was thus given alternative feeds.

Feeding of preterm and sick neonates in facilities

The neonatologist and resident in the NICU at the Level III facility shared that sick full-term babies admitted in the NICU were fed expressed milk of own mother. Those who lacked access to MOM were fed pasteurized DHM or cow's milk. Most mothers (in both facilities) had difficulties with latching and positioning, especially while feeding small-sized babies.

Lactation counselors visited the wards twice or thrice a week and conducted individual and group counseling sessions for mothers of newborns in the NICU, transitional care unit (TCU), preterm unit (PU), or PNC wards. The scope for one-to-one counseling in the PNC wards was limited and all providers agreed that supervision was not optimal because of large number of patients and shortage of staff. Although data were maintained on the number of mothers counseled on breastfeeding, no data were collected on early initiation and exclusive breastfeeding.

Most mothers and influencers said that feeding preterm and low birth weight (LBW) babies was a challenge because of their inability to suck and breastfeed. The facility with the HMB had a protocol to feed babies based on their birth weight. Babies who weighed <2.2 kg were transferred to the NICU. The babies in the NICU were fed the requisite amount of milk under supervision. Those who weighed between 1.5 and 2.2 kg and could not be breastfed but could accept oral feed were given expressed breast milk (EBM) from own mother or DHM from the HMB. Intragastric tube feeds were given to babies who could not accept oral feeds. Ryle's tube feed was given with MOM or DHM for babies who weighed <1.5 kg. Transitioning from Ryle's tube-fed babies to feeding with spoon and bowl, to breastfeeding was a challenge as the chances of drop in baby's blood sugar level is high because breastfeeding was difficult to quantify and monitor. Preterm babies were discharged once they weighed >1,400 g or crossed their birth weight (if >1,400 g at birth) and were successfully breastfeeding with or without supplemental EBM from their own mother.

In the facility without HMB, there was no written protocol to guide the feeding of preterm or LBW babies at NICU. The common practice was to initiate breastfeeding for newborns who had a sucking reflex, else EBM was fed. Preterm formula was also used in case of insufficient breast milk. Mothers and babies were discharged once breastfeeding was initiated. Female family members accompanying the mothers were also counseled to ensure continuity of breastfeeding after discharge. Few respondents from both the facilities opined that formula milk should be given to such babies until mother is able to breastfeed.

Expressed breast milk

Perceptions among mothers

Most recipient mothers at the Level III facility were of the opinion that if milk was not expressed, it will lead to painful engorgement of breasts. Although some potential recipients said that milk was expressed to feed the baby initially when the baby was unable to suck, others said that one should express milk regularly as it leads to more production for one's own baby. Mothers said that they had learnt milk expression techniques from doctors and nurses in the hospitals (Table 3).

Table 3.

Verbatim Quotations on Perceptions and Practices Related to Milk Expression and Top Feeding

Perceptions and practices related to milk expression	“After c-section, mother's milk is expressed, the breast is cleaned before expressing and the milk is given to the baby. I know it as we have also delivered so we know what is to be done.”—FGD, grandmother, Level III
	“When it is the first time the baby does not suck milk properly so the nurse advises to express milk and feed the baby.”—FGD, potential recipient mothers, Level III
	“There is no separate place to express, so when male doctor come my milk flow stops while expressing.”—FGD, Recipient mother, Level III
Top feeding	“Usually cow's milk is given if there is no mother's milk as it is lighter than buffalo's milk.”—FGD, Grandmother, Level III

Practices on EBM

About half the mothers whose babies were in the NICU and PU expressed their breast milk to feed their babies. The doctors shared that expressing breast milk was recommended to mothers with breast engorgement, flat or large nipple, or large breasts. Key challenges in expressing milk included lack of knowledge and skills among mothers about milk expression techniques, lack of privacy and designated places for expression, and inadequate support because of shortage of staff. Some mothers complained about pain while expressing milk that led to fear of expressing, resulting in low milk production and irregular feeding. The Level II facility had a separate feeding room for mothers to breastfeed and express milk.

Lack of family support, mostly because of birth of a girl child, is a source of stress for the mother, which negatively affects milk expression. The lactation counselor further shared the need for having a stress-free environment at the hospital for mothers.

Top feeding practices and perceptions

Most mothers in the PNC wards did not insist on giving any top feed to their newborns. However, some fed honey or cow's milk.

Mothers reported top feeding on account of inadequate lactation in the first 2 days of delivery, breast-related conditions, physical exertion, no previous experience (primigravida mothers), difficulty to breastfeed in tight-fitted clothes, incessant crying by the baby and inability to suckle (Table 3). In some cases, advertisements also influenced mothers to use formula milk over breast milk.

Practices and perceptions on wet nursing

There were two divergent views about wet nursing among the staff at Level III. The pediatrician in charge of HMB and the lactation counselor opined that it was dangerous and should not be encouraged; the senior resident and the lactation nurse considered it to be a good practice. All providers interviewed at the Level II facility expressed positive views on wet nursing. They were of the opinion that wet nursing was beneficial, benefitting two babies at the same time (own baby and the baby without access to MOM). They had concerns about the risk of transmission of infections such as tuberculosis, jaundice, and HIV through wet nursing.

Some parents and grandmothers said that wet nursing was an age old and common practice and that they were comfortable with it. They felt that it was safe if practiced within the family and not by unknown mothers (outside the family or social contacts).

Kangaroo mother care

Knowledge and perceptions about KMC among mothers and influencers

Discussion with mothers and influencers revealed that donor mothers, recipient mothers, fathers, and grandmothers at the Level III facility knew about the practice of keeping the baby in a bag close to the mother's chest. They also knew the benefits of KMC (warmth and support to the baby to aid growth) but did not know the term KMC. Mothers reported feeling uncomfortable in wearing front open gowns for doing KMC (Table 4).

Table 4.

Verbatim Quotations on Knowledge and Perceptions on Kangaroo Mother Care

Service recipients	“Doctor suggested that put the naked baby in bag and then keep the baby on mother's bare chest; but did not know that it is called kangaroo mother care.”—FGD, recipient mother, Level III
	“The child is kept close to mother's chest for a long time to maintain the temperature of the child so that he grows well.”—FGD, fathers, Level III
	“I like KMC as it gives me a chance to keep my baby close to me and show my affection.”—FGD, potential donor mother, Level III

KMC, kangaroo mother care.

None of the respondents at Level II were aware of this practice. When explained, they were hesitant and said that it may not be feasible to practice as the babies were too small to handle. All respondents in both the facilities reported a lack of IEC materials on KMC.

KMC policies and practices in the facility

All respondents at the Level III facility reported that KMC was practiced in the hospital. The senior resident and lactation nurse said that KMC is implemented in the PU. Although it was also advised to mothers of babies admitted in NICU and TCU, challenges of space constraint and high load of sick babies existed. There was little consensus among staff of the Level II facility whether KMC was being practiced there or not. According to some service providers, KMC was not practiced, whereas the senior resident and lactation support nurse mentioned that it was practiced (without the bag). In both the hospitals, the nurses were not formally trained in KMC but had learnt it from the doctors. At the Level III facility, the occupational therapists trained mothers to practice KMC and maintained relevant records. As per the hospital policy, KMC was initiated for stable preterm babies (preferably not on respiratory support) and those on full feed. The duration of KMC was increased or decreased depending on the clinical stability; the senior resident was aware of this policy, but the lactation nurse was not.

There was hesitation among some mothers to practice KMC as they were scared to hold the babies because of their small size. The occupational therapists and staff counseled the mothers every day and provided special bags prepared from baby towels and helped tie the baby close to the mother. The staff mentioned that mothers need to be counseled often to increase the duration of KMC.

The lactation counselor mentioned that mothers are initially scared to handle the babies during KMC, but with support they become more comfortable. Despite the challenges, the staff at the Level III facility agreed that mothers were generally happy to practice KMC as it gave them an opportunity to rest and sleep, while practicing it.

Discussion

The Government of India is focusing on scaling-up breastfeeding, KMC, and provision of DHM as part of the integrated MBFI+/CLMC model that prioritizes access to human milk for all vulnerable babies admitted in Level III facilities. The central tenet of this model is to contribute to breastfeeding and implement strategies to effectively integrate HMB systems within the larger objective to scale-up breastfeeding. A facility-level understanding of the knowledge, attitudes, and practices of service providers and recipients on breastfeeding and KMC will help reveal good practices and gaps to identify appropriate strategies for scaling them up.

This study highlights that counseling support needs to be scaled-up for sustaining optimal infant feeding practices and KMC. Counseling is currently provided in groups; personalized and one-to-one counseling will be more effective. In most cases, women did not receive information on breastfeeding during ANC. A systematic review reported that interventions for supporting breastfeeding from pregnancy to the intrapartum and postnatal period are most effective, compared with interventions for a shorter period.¹⁵ Our study also shows that counseling messages should focus on timing of initiation and duration of exclusive breastfeeding and address myths on breastfeeding, such as the first milk being infectious and food taboos. A study conducted in southern India highlight that myths and disbeliefs related to breast milk and feeding among mothers should be rectified through health education.¹⁶ Messages should also incorporate on issues of frequent and adequate milk expression for sick babies to help sustain milk supply for babies even after discharge.

Although providers reportedly encouraged immediate and exclusive breastfeeding for normal healthy babies at the facility level, it did not translate into optimal breastfeeding practices among mothers primarily on account of suboptimal support because of shortage of lactation staff. Some mothers required timely assistance to help overcome situations, such as difficulties in latching or positioning the babies or pain during breastfeeding or while expressing milk. There is a need to increase the number of lactation counselors as per the load at facilities and strengthen capacities of the current staff through periodic training. Studies conducted in the United States and Croatia have flagged the promising potential of educational interventions in increasing nurses' knowledge about and attitudes to breastfeeding in the NICU.^17,18 A systematic review emphasized on the promotion of skills to enhance the quality of lactation and breastfeeding counseling.¹⁵ In addition, mechanisms like mother's support group need to be implemented.

Every health care facility offering obstetric and newborn care should have feeding guidelines for newborns. These facilities did not have written guidelines. The Baby-Friendly Hospital Initiative (BFHI) friendly expert group recommendation report clearly elucidates the need for policies to be available as written and visual information in the neonatal unit in the language(s) well understood by families and clinical staff.¹⁹

Creating a supportive environment at the hospital and home is necessary as it reduces maternal stress and helps in sustaining exclusive breastfeeding and KMC. This study highlighted the role of influencers in determining breastfeeding practices. Although the medical and paramedical staff were expected to counsel and provide practical guidance for breastfeeding, need for support from family members in the form of taking care of elder siblings, helping in household chores, and caring for the mother emerged as important findings. The scope of counseling should be expanded to include family members who have a critical role to play in ensuring a supportive atmosphere at home for mothers to breastfeed after discharge. A model for family-integrated care in a Canadian NICU resulted in higher breastfeeding incidence, higher infant weight gain, and lower maternal stress at discharge.²⁰ A study in India inferred that translating and adapting principles of family-centered care was feasible and improved the predischarge exclusive breastfeeding rates. Family-centered care empowered and built the capacities of mothers, parents, and attendants that helped in providing continuum of care for high-risk NICU babies at home after discharge.²¹

For feeding vulnerable babies who cannot directly breastfeed, milk expression support at the facility should be augmented. Designated spaces for milk expression, storage, and adequate number of lactation staff is required to teach milk expression techniques to mothers. A review article highlighted that lactation counseling should include demonstration of milk expression by hand or pump.¹⁹ Another study in Italy recorded a positive association between prenatal information about the benefits of breast milk and practical aspects of breast milk expression and longer breastfeeding in preterm infants.²²

The facility with HMB tried to ensure exclusive human milk feeding by increasing expression and providing pasteurized DHM for NICU babies without access to MOM. It also had a robust protocol to guide the feeding of preterm or LBW babies in NICU and higher milk expression rate compared with the facility without the HMB. Previous experience demonstrates that HMBs are most effective when they are implemented as a critical component of breastfeeding and newborn care policies.¹²

Some service providers and recipients supported wet nursing as an effective alternative in the absence of breastfeeding. It is important to raise awareness among them on its harms and healthier alternatives, such as feeding own mother's expressed milk or pasteurized DHM.

The study indicated that there is a need to ensure dedicated space and infrastructure to practice KMC and provide formal training to staff. Evidence shows that clinical staff education and training on their own are unlikely to lead to the successful implementation of KMC and should be accompanied by family awareness on importance of KMC,²³ champions driving the process, multidisciplinary teamwork,^24.25 continuous support from leadership and management,^23–26 and appropriate national and/or institutional policies and operational guidelines.²⁷ Our findings support the need for stronger advocacy and awareness on benefits and techniques of KMC at both service provider and recipient level and monitoring adherence to KMC guidelines.

Conclusion

Scaling-up critical child survival interventions like breastfeeding and KMC require dedicated investments and efforts directed at service providers and recipients as a part of integrated CLMC strategy. Strengthening implementation and monitoring of BFHI standards in facilities, ensuring enough lactation staff for providing early and adequate information and guidance on breastfeeding and milk expression and family support to mothers are important policy and programmatic priorities. More research and advocacy are needed to enhance support for mothers in NICU settings to breastfeed; including better staffing, training, infrastructure, and policies such as rooming in to allow MOM to reach her infants through systems that enable safe storage, collection, and transport of her milk. Assessments are urgently needed to accurately identify the barriers around MOM reaching their infant in NICU settings to inform effective strategies. These are critical to ensure increase in use of MOM in such settings and appropriate use of DHM to be restricted only to infants who truly lack MOM.

India's National Breastfeeding Promotion Program—MAA (Mothers' Absolute Affection),²⁸ the Operational Guidelines for Kangaroo Mother Care and Optimal Feeding for Low Birth Weight Infants,⁷ the Operational Guidelines for Family Participatory Care for Improving Newborn Health guidelines,²⁹ and the National Guidelines on Lactation Management Centers in Public Health Facilities¹³ present multiple policy-level opportunities to enhance breastfeeding and KMC uptake in the country. The CLMC model promoted by the government of India prioritizes breastfeeding and puts HMBs as ancillary support to breastfeeding and KMC. Furthermore, national and regional advocacy is needed to ensure all infants have equitable access to life-saving human milk.

Footnotes

Acknowledgments

This study is the result of the contribution of many people particularly the participants who invested their valuable time to discuss the issues of breastfeeding, kangaroo mother care human milk banking in the health facility and their homes with the study team. The formative study is a result of the joint efforts of Lokmanya Tilak Municipal Medical College (LTMMC) and General Hospital and PATH. While LTMMC led the efforts on implementation of the research, PATH played a key role in providing technical expertise. PATH conceptualized the research design and the protocol, LTMMC provided input and both teams finalized the report and the manuscript. Our special gratitude and acknowledgment is extended to Sudip Mahapatra, Regional Monitoring and Evaluation Specialist, PATH for reviewing the research design and report; and to Cyril Engmann, Global Program Leader, Maternal, Newborn, Child Health & Nutrition, PATH, Seattle, WA, for his valuable input on the manuscript. We extend our thanks to Paramita Kundu for support in writing this article and Manu Bhatia for providing editorial support. This project was funded through a grant from the Margaret A. Cargill Philanthropies to PATH.

Declarations

The study has been approved by LTMMC and Lokmanya Tilak Municipal General Hospital, Staff and Research Society (Reference No. IEC/60/16), and the consent was obtained from all participants.

Disclosure Statement

The authors declare that there is no competing interest.

References

Ministry of Health and Family Welfare, Government of India. India Newborn Action Plan. 2014. https://www.newbornwhocc.org/INAP_Final.pdf (accessed August 15, 2018)

Victoria

, Bahl

, Barros

AJD

, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet, 2016; 387:475–490.

World Breastfeeding Trends Initiative. India Report Card. 2018. www.worldbreastfeedingtrends.org/GenerateReports/reportcard/WBTi-India-Report-Card-2018.pdf (accessed August 25, 2018)

Ministry of Health and Family Welfare, Government of India. National Family Health Survey India IV. http://rchiips.org/NFHS/nfhs4.shtml (accessed January 9, 2019).

Global Breastfeeding Collective. Policy Brief: Ensuring Equitable Access to Human Milk for All Infants: A Comprehensive Approach to Essential Newborn Care. Seattle, WA: PATH, 2017.

Nangia

, Chugh

, Sabharwal

. Human milk banking: An Indian experience. NeoReviews, 2018; 19:4.

Operational Guidelines–Kangaroo Mother Care and Optimal Feeding of Low Birth Weight Infants, 2015, National Health Mission, Government of India.

March of Dimes, PMNCH, Save the Children, et al. Born Too Soon: The Global Action Report on Preterm Birth. Howson

, Kinney

, Lawn

, eds. Geneva: World Health Organization, 2012.

Lawn

, Mwansa-Kambafwile

, Horta

, et al. “Kangaroo mother care” to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol, 2010; 39(Suppl 1):i144–i154.

10.

Vesel

, Bergh

, Kerber

, et al. Kangaroo mother care: A multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth, 2015; 15(Suppl 2):S5.

11.

Engmann

, Wall

, Darmstadt

, et al. Consensus on kangaroo mother care acceleration. Lancet, 2013; 382:e26–e27.

12.

DeMarchis

, Israel-Ballard

, Mansen

, et al. Establishing an integrated human milk banking approach to strengthen newborn care. J Perinatol, 2017; 37:469–474.

13.

Child Health Division, Ministry of Health and Family Welfare, Government of India. National Guidelines on Lactation Management Centres in Public Health Facilities. Available at http://nhm.gov.in/images/pdf/programmes/IYCF/National_Guidelines_Lactation_Management_Centres.pdf (accessed November 16, 2017).

14.

Mondkar

, Chugh

, Shanbhag

, et al. Understanding barriers and facilitators for human milk banking among service providers, mothers and influencers of preterm and sick neonates admitted in health facilities in India. Breastfeed Med, 2018; 13:694–701.

15.

Hannula

, Kaunonen

, Tarkka

. A systematic review of professional support interventions for breastfeeding. J Clin Nurs, 2008; 17:1132–1143.

16.

Veeranki

, Nishimura

, Krupp

, et al. Suboptimal breastfeeding practices among women in rural and low-resource settings: A study of women in rural Mysore, India. Ann Glob Health, 2017; 83:577–583.

17.

Siddell

, Marinelli

, Froman

, et al. Evaluation of an educational intervention on breastfeeding for NICU nurses. J Hum Lact, 2003; 19:293–302.

18.

Zakarija-Grković

, Šegvić

, Bozinovic

, et al. Hospital practices and breastfeeding rates before and after the UNICEF/WHO 20-hour course for maternity staff. J Hum Lact, 2013; 28:389–399.

19.

Nyqvist

, Häggkvist

, Hansen

, et al. Haiek expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations. J Hum Lact, 2013; 29:300–309.

20.

Scott

, Brady-Fryer

, Van Aerde

. Developing nurse/parent relationships in the NICU through negotiated partnership. J Obstet Gynecol Neonatal Nurs, 2010; 39:675–683.

21.

Verma

, Maria

, Pandey

, et al. Family-centered care to complement care of sick newborns: A randomized controlled trial. Indian Pediatr, 2017; 54:455–459.

22.

Dall'Oglio

, Salvaroti

, Bonci

, et al. Breastfeeding promotion in a neonatal intensive care unit: Impact of a new program to a BFHI for high-risk infants. Acta Paediatr, 2007; 96:1626–1631.

23.

Bergh

A-M

, Arsalo

, Malan

, et al. Measuring implementation progress in kangaroo mother care. Acta Paediatr, 2005; 94:1102–1108.

24.

Bergh

A-M

, Van Rooyen

, Pattinson

. “On-site” versus “off-site” facilitation: A randomised trial of outreach strategies for scaling up kangaroo mother care. Hum Resour Health, 2008; 6:13.

25.

Bergh

A-M

, Pattinson

. The development of a conceptual tool for the implementation of kangaroo mother care. Acta Paediatr, 2003; 92:709–714.

26.

Colameo

, Rea

. O Método Mãe Canguru em hospitais públicos do Estado de São Paulo, Brasil: uma análise do processo de implantação [Kangaroo Mother Care in public hospitals in the State of São Paulo, Brazil: An analysis of the implementation process]. Cad Saúde Pública, 2006; 22:597–600.

27.

Bergh

, Charpak

, Ezeonodo

, et al. Education and training in the implementation of kangaroo mother care. S Afr J Child Health, 2012; 6:38–45.

28.

Mothers' Absolute Affection Programme for Promotion of Breastfeeding Operational Guidelines. 2016. Available at http://nhm.gov.in/MAA/Operational_Guidelines.pdf (accessed September 17, 2018 ).

29.

Family Participatory Care for Improving Newborn Health Operational Guidelines for Planning and implementation. Child Health Division Ministry of Health and Family Welfare, Government of India, July, 2017. http://www.nhm.gov.in/images/pdf/programmes/child-health/guidelines/Family_Participatory_Care_for_Improving_Newborn_Health-Operational_guideline.pdf (accessed October 19, 2018)