Baseline Study on IYCF

i
AGA KHAN FOUNDATION
DECEMBER 2012
STATUS OF INFANT AND YOUNG CHILD FEEDING
PRACTICES IN 3 DISTRICTS OF BIHAR –
A BASELINE STUDY

1
Table of Contents
EXECUTIVE SUMMARY...............................................................................................................3
INTRODUCTION........................................................................................................................10
REVIEW OF LITERATURE...........................................................................................................13
MATERIAL & METHODS ...........................................................................................................18
OBSERVATIONS ........................................................................................................................26
DISCUSSION..............................................................................................................................92
List of Annexures....................................................................................................................105
Annex 1: Project Organogram ....................................................................................................i
Annex 2: Conceptual Framework of the Project........................................................................ii
Annex 3: Monitoring Indicators of the Project.........................................................................iii
Annex 4: Cluster Sampling – Detailed methodology .................................................................v
Annex 5: Data Collection Tools (English version).......................................................................x
Annex 6: Data Collection Tools (translated into Hindi) ............................................................ xi
LIST OF TABLES:........................................................................................................................ xii
LIST OF FIGURES:...................................................................................................................... xv
BIBLIOGRAPHY ........................................................................................................................ xvi

2
ABBREVIATIONS & ACRONYMS
AI Agragami India
AKF Aga Khan Foundation
AKRSP, I Aga Khan Rural Support Programme, India
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWW Anganwadi Worker
BCC Behaviour Change Communication
BF Breastfeeding
CBR Crude Birth Rate
CC Cluster Coordinator
CF Complementary feeding
DFID: Department for International Development
DLHS District Level Health Survey
EBF Exclusive breastfeeding
IP Implementing Partner
IYCF Infant and Young Child Feeding
KAP Knowledge Attitude Practice
MIS Management Information System
NFHS National Family Health Survey
PAHO Pan American Health Organisation
PC Project Coordinator
PE Peer Educator
PPH Postpartum haemorrhage
PPS Probability Proportionate to Size
SC Scheduled caste
SPMU State Project Management Unit
UP Uttar Pradesh
VHSND Village Health Sanitation and Nutrition Day
WBTi World Breastfeeding Trends Initiative
WHO World Health Organisation

3
EXECUTIVE SUMMARY
The Aga Khan Foundation (AKF) has initiated a project in three districts1
of Bihar, India,
which aims to improve the uptake of optimal Infant and Young Child Feeding (IYCF) practices
by the mothers and care-givers of children under-two years of age. The project is supported
by the Department of International Development (DFID), and AKF is working in collaboration
with three other implementing partners2
. The project will use multiple behaviour change
communication (BCC) tools and techniques which are expected to improve the knowledge
of pregnant women and breastfeeding mothers regarding IYCF. This change, along with
individualised support to mothers by project functionaries will ultimately result in improved
IYCF practices by the mothers and care-givers.
Under the approved project design, the BCC activities are being undertaken by project
specific personnel in order to ensure that large numbers are reached out to with IYCF
specific messages. However, such a model also means that sustainability of project efforts
following withdrawal of funding will be a genuine challenge. This issue has been addressed
in the project design itself, by including activities for the training and mentoring of existing
facility and community based health and nutrition functionaries3
on counselling for IYCF.
These service providers are thus the secondary target population of the project.
In order to monitor the progress of the project on a regular basis, as well as evaluate its
potential success (or the lack thereof) at the end of the project, a monitoring conceptual
framework (Annex 2), along with project specific monitoring indicators (Annex 3) were
drawn up. The three tenets of IYCF, namely, a) early and timely initiation of breastfeeding
within an hour of birth, b) exclusive breastfeeding for six months, and c) introduction of age
appropriate complementary feeding at six months along with continued breastfeeding for
two years and beyond are the key outcome indicators that will be tracked. Other
“immediate” (output) level indicators are related to the knowledge of mothers and service
1
The three Project districts are i) Muzaffarpur, ii) Samastipur, and iii) Sitamarhi
2
The four implementing partners are: i) Aga Khan Foundation, India (AKF, I), ii)Agragami, India, iii) CHARM, and
iv) Aga Khan Rural Support Programme, India (AKRSP, I)
3
The facility based service providers include ANMs and Mamtas, whereas the community-based service
providers include AWWs and ASHAs.

4
providers on IYCF issues as well as the performance of the service providers in relation to
IYCF counselling.
Tracking progress against these indicators required “baseline” or starting levels, which were
preferably specific to the project. While national and sub-national surveys such as the
National Family Health Survey (NFHS) and District Levels Health Survey (DLHS) provided
information on the broad IYCF related impact and outcome indicators, these surveys, as
expected, did not carry any information on the output level indicators. Also, even the “most
recent” of these surveys (i.e., DLHS-3) was based on data at least four years prior to the
start of the project. In addition, the project requires different sampling methodology and
specific formulation of indicators tailored to the project objectives and that was at slight
variance with the large scale surveys. In order to address these issues, the project team
decided to conduct a project specific baseline survey with the following objectives:
1. To assess the: a) knowledge level and, b) actual practice regarding the following
amongst mothers:
 Initiation of Breastfeeding
 Exclusive Breastfeeding (EBF)
 Introduction of Complementary Feeding (CF)
 Age appropriate Complementary Feeding
To assess the: a) knowledge level on IYCF issues and b) on-the-job performance of
health/nutrition functionaries on IYCF and the activities related to BCC .
The respondents were broadly classified as a) Pregnant women and mothers of young
infants and b) service providers. The sub-categories of these respondents were as under:
A. Women
i) Women in the last trimester of pregnancy
ii) Mothers with a child less than 7 days of age
iii) Mothers with a child 3-4 months of age
iv) Mothers with a child 6-7 months of age
v) Mothers with a child 12-13 months of age
B. Health and nutrition workers (service providers)

5
i) Community based health and nutrition functionaries (i.e. Accredited Social
Health Activists (ASHAs) and Anganwadi Workers (AWWs))
ii) Facility based health functionaries (i.e. Auxiliary Nurse Midwives (ANMs) and
Mamtas)
AKF had conducted a formative research in October 2011 to understand the barriers to and
facilitating factors in the community for following the recommended IYCF practices. This
understanding was used to develop the data collection tools for this survey (Annex 5 and
Annex 6).
Multi-stage cluster sampling methodology was chosen to select the Panchayats in the
project areas, from which the required number of women respondents were chosen (Annex
4). The project monitoring requires that output and outcome indicators related to the
primary beneficiaries (pregnant women and mothers) be disaggregated at the district and
implementing partner level. This allows comparisons of these baseline results with future
reporting in the project through the regular monitoring system. District level reporting of
progress is required to share results with the local government in the district as well as with
DFID. Implementing partner level tracking is required for the purpose of internal project
monitoring. Therefore, for most indicators related to data from women, the report presents
both district and implementing partner specific disaggregated data.
To ensure than even the disaggregated data is within acceptable confidence levels, a sample
size of 384 women from each respondent category was required to be interviewed by each
implementing partner. Therefore, except for the second category of respondents (namely
mothers of children less than 7 days of age), the survey captures responses from 1536
women from each category. For the second category, only 1498 women could be
interviewed from the selected Panchayats due to its relatively smaller ‘universe’. From the
other broad category of respondents, a total of 400 service providers were interviewed (i.e.
194 facility based and 206 community-based providers).
Overall on the IYCF behaviour related (outcome level) indicators, the current study shows an
improvement over the DLHS-3 (2007-08) findings (1). DLHS-3 showed that in 2007-08, 16.2%

6
of the mothers in Bihar had initiated breastfeeding within the mandated first hour after
birth. In comparison, the present study shows a slight increase of 1.2 percentage points to
reach 17.4% for the overall project area. This increase is even more significant when
compared district by district because in DLHS-3 the three project districts fared worse than
the state average on this indicator. Samastipur showed the highest net increase of 5.4
percentage points on the indicator on early initiation of breastfeeding.
Similarly, exclusive breastfeeding rates (for the first 6 months) increased in the last few
years from 11.8% under DLHS-3 in 2007-08 to 15.2% under the current study. Once again,
Sitamarhi shows the steepest increase from 0.3% to 13.5% - a difference of 13.2 percentage
points.
Complementary feeding showed mixed results. Regarding timely introduction of
complementary foods, the project level results in the present study are about 12 percentage
points above the Bihar level results under DLHS-3 (that is, an increase from 61.4% in DLHS-3
to 73.4% in the present study). However, the disaggregated data presents a slightly different
picture. Under DLHS-3, the districts Muzaffarpur and Samastipur reported better results on
this indicator than the state average. When those district level DLHS results are compared to
the present study, one sees a decline in timely introduction of complementary feeding in
these districts. The major reason here is probably the stark difference in definition of the
two indicators. The project indicator tracks children only in the 7th
month of life, as
compared to the DLHS indicator on complementary feeding which captures children 6-9
months of age. It is obvious that the probability of a child being initiated to complementary
feeding increases with increasing age. On the other hand, the DLHS indicator specifically
asks about the introduction of semi-solid foods in the child’s diet, whereas the current study
asks for “any other foods other than breast-milk”. Thus the commonly given animal milk
would not be counted as complementary food under the DLHS indicator, but has been
counted as complementary food in the current study.
While the median age for introduction of complementary feeding was a little over six
months, it was found that about 10% of the mothers had not started their child on
complementary foods even by the age of one year. This extremely delayed complementary

7
feeding gives an insight into one of the reasons behind high malnutrition rates of young
children in Bihar.
As far as age appropriateness of complementary feeding is concerned, even those who had
started their children on complementary foods were found to be feeding their children less
frequently than required and in far less quantities than needed for a child of that age. There
was hardly any increase in the mean number of meals per day given to a child 6-7 months of
age (2.8 times a day), and that given to a 12-13 month old child (2.9 times per day)4
.
Moreover, it was not clear what was counted as a “meal”. Though it was difficult to
accurately assess and compare the quantity of food against an “ideal” age related quantity,
the rather rough assessment revealed that the quantity of food offered was inadequate. A
study of the food diversity of complementary foods, as measured in terms of food groups
showed that cereals and pulses were the most common components of a child’s meal.
Relatively few mothers gave their children fruits and vegetables, and even fewer offered the
child non-vegetarian food (i.e., meat, fish, poultry and eggs). The choice of food items is a
reflection of the common adult diet in India as well as the relatively poor economic
condition of the population in the project areas, which could be one of the major reasons
behind the absence of relatively expensive items such as fruits, meats and eggs from the
child’s plate.
Most KAP studies like the present study reveal that the proportion of respondents who have
the correct knowledge is often greater than the proportion acting upon that knowledge. In
this study too, while 23.2% women knew the correct time of initiation of breastfeeding, only
17.4% actually put it into practice. Similarly, while 22.2% of the mothers said that 6 months
was the ideal duration for exclusive breastfeeding, only 15.2% actually practiced the same.
For introduction of complementary foods, 22% of the mothers stated 6 months as the ideal
time for this. However, only 11.2% intended to practise this in the case of their own child.
But, as mentioned above, 73.4% of the mothers had already started giving the child food
other than breast-milk by the age of 6 months.
4
According to the WHO PAHO guidelines a child 6-8 months of age should be given complementary foods 2-3
times a day (minimum 2) while a child over a year should be fed 3-4 times in a day (minimum 3). This is in
addition to snacks which should be given 1-2 times a day.

8
The service providers interviewed in this survey have counselling on IYCF as an important
part of their job description. In order to be the behaviour change agents for mothers and
care-givers these providers need to not only have the correct knowledge on optimal IYCF
practices, but should also be conducting counselling sessions. Of all the service provider
cadres, the Mamtas were found to be the weakest in IYCF-related knowledge.
Overall, about three fourths of the service providers knew the correct timing for initiation of
breastfeeding. However, for the Mamtas, this proportion was only 41.9% and only 51% for
the ASHAs. This has serious implications because these two cadres are most likely to be
present with the mother at the time of institutional delivery.
Similarly, while 73.3% of the service providers could cite the correct duration of exclusive
breastfeeding, only 67.5% understood the correct meaning of exclusive breastfeeding. 14%
felt that offering water to the baby does not compromise the exclusivity of breastfeeding.
Even here, the ASHAs and the Mamtas performed the worse with only about 48% of each
cadre able to define exclusive breastfeeding.
Only 57% of the providers could cite the recommended age for introduction of
complementary feeding. Another 24.3% mentioned 7 months. This high percentage could
be because of the prevalent practice in the community of referring to age in “running”
months rather than completed months. So “after 6 completed months” would be referred
to as “in the 7th
month” and might have been recorded as such by the interviewers.
Though IYCF counselling is an integral component of the job description of all these cadres,
only 86.5% of the workers knew/ acknowledged the same when directly asked whether
counselling on IYCF was part of their job description. An even lesser 80.8% actually claimed
to counsel women and care-givers on IYCF issues. However, when asked whether they had
conducted any group meetings or undertaken any home visits on IYCF in the previous three
months, only 31.7% and 34.7% respectively admitted doing so. This clearly reflects that
counselling on IYCF is not a priority for the service providers.

9
Thus, the baseline study shows that there is much room for improvement in both the
knowledge and practice of the pregnant women and mothers of young children, as well as
the service providers. It is hoped that the project activities which focus on both of these
categories as primary and secondary beneficiaries respectively will bring about the much
needed change in uptake of recommended IYCF behaviours.

10
Chapter 1
INTRODUCTION
It is widely recognised that among all the individual public health interventions5
meant to
reduce neonatal, infant and child mortality, improving IYCF practices is likely to have a high
impact. A universal (100 percent) uptake of ideal IYCF norms across the population is
expected to reduce neonatal and infant mortality by about 15 percent (2).
AKF, supported by DFID, is implementing a health project that aims to reduce neonatal and
infant mortality by improving breastfeeding and complementary feeding practices of
mothers of children under two-years of age in the three districts of Muzaffarpur, Samastipur
and Sitamarhi in Bihar through effective behaviour change communication (BCC) efforts.
There are four implementing partners in this project who are responsible for carrying out
BCC activities in a population of about 1.1 million each. The distribution of the population by
district and implementing partner is described in Table 1.
Table 1: District and Implementing partner wise distribution of project population
Muzaffarpur Samastipur Sitamarhi TOTAL
Aga Khan Foundation (AKF) 1,129,487 1,129,487
Aga Khan Rural Support
Programme (AKRSP,I)
520,448 527,313 1,047,761
Agragami India (AI) 1,324,298 1,324,298
CHARM 1,110,558 1,110,558
TOTAL 1,649,935 1,851,611 1,110,558 4,612,104
The project mainly works through dedicated Peer Educators6
(PEs) – one peer educator for a
population of about 9,000. The PEs will be responsible for imparting information related to
optimal IYCF practices through group meetings and through home visits for young infants
5
Common interventions include improving immunization coverage rates, standard treatment of Artificial
Respiratory Infections (ARI) and diarrhea, use of insecticide treated bed-nets for malaria prevention etc.
6
A Peer Educator (PE) is a woman between 21-40 years of age with basic reading and writing skills, and
preferably married and residing in the community she is expected to serve. Her key tasks involve counseling
the women, families and community on IYCF issues and helping mothers and care-givers resolve issues related
to the same through inter-personal counseling sessions.

11
and for individual problem solving for an estimated 10 percent of the mothers through
home visits.
A group of four PEs is supervised by a Cluster Coordinator7
(CC). [A detailed project
organogram can be found as Annex 1 at the end of the document]. The PEs and CCs are also
expected to mentor government health and nutrition functionaries by ensuring their
presence at PE led group meetings and home visits as well as through formal class-room-
based orientation sessions in order to improve their knowledge regarding recommended
IYCF practices as well as inter-personal and group counselling skills. It is hoped that such
mentoring will help them carry our IYCF home visits, group meetings and inter-personal
counselling sessions for sharing IYCF messages both at the community and household levels
as well at the facility level8
. This is important to ensure sustainability of efforts beyond the
project time-frame.
As with all BCC efforts, the project activities are expected to bring about an improvement in
the knowledge levels (output) of the primary beneficiaries (mothers of children under two)
as well as the secondary target population (health and nutrition functionaries) before
resulting in a change in practice (outcome). Hence, the project’s monitoring plan includes
regular tracking of indicators that measure knowledge and practice levels of mothers and
health functionaries. The project’s conceptual framework and the monitoring indicators are
available in Annex 2 and Annex 3.
In October 2011, prior to the approval of this grant, AKF conducted a formative research to
understand the barriers and facilitating factors for the uptake of recommended IYCF
behaviours in the targeted communities. This research provided the team with adequate
qualitative information to draw up a technical communication plan, but the absence of a
valid baseline for these indicators was a problem that needed resolution. While DLHS 3 data
was used as the baseline to set tentative milestones and targets at the proposal
7
A Cluster Coordinator (CC) is person (preference given to women) who is between 21-40 years of age and has
passed the 12
th
grade. Her main responsibility is to support and supervise the work of four PEs, as well as
mentor the government health and nutrition functionaries. CCs with also work with the Project Coordinators
for district level advocacy on IYCF issues.
8
Facility level counseling on IYCF is required at the time of delivery to ensure early and timely initiation of
breastfeeding, within one hour of birth.

12
development stage, it was soon realised that DLHS 3 could not serve as a “true” baseline for
the project. This was because:
- Data collection for DLHS 3 was conducted in 2007-08. Therefore the data is more
than four years older than the actual project time-frame.
- The indicators used in DLHS do not match the project monitoring indicators (for
example, the denominator in DLHS 3 is mothers of children under-3, whereas for the
project monitoring purposes, the denominator varies with the indicator in question).
- DLHS does not collect information on output (knowledge level) indicators either at
the community level or for the health and nutrition functionaries.
- DLHS does not collect information on IYCF counselling related practices of health and
nutrition functionaries.
Objectives:
Given the above-mentioned limitations of the DLHS-3 data, the Project conducted an
independent cross-sectional baseline survey with the following objectives:
1. To assess the: a) knowledge level and, b) actual practice regarding the following among
mothers:
 Initiation of Breastfeeding
 Exclusive Breastfeeding (EBF)
 Introduction of Complementary Feeding (CF)
 Age Appropriate Complementary Feeding
2. To assess the: a) knowledge level on IYCF issues and b) on-the-job performance of
health/nutrition functionaries on IYCF and the activities related to BCC.

13
Chapter 2
REVIEW OF LITERATURE
The Global Strategy for Infant and Young Child Feeding was adopted by the World Health
Assembly in May 2002, and accepted by the UNICEF executive board in September 2002 (3).
It was meant to revitalise world attention to the impact that feeding practices have on the
nutritional status, growth and development, health, and thus the very survival of infants and
young children (4).
The three key tenets of optimal IYCF behaviours are:
- Early and timely initiation of breastfeeding within an hour of birth
- Exclusive breastfeeding for the first six months.
- Introduction of age appropriate complementary feeding at six months of age along
with continued breastfeeding for two years and beyond.
Early and Timely Initiation of Breastfeeding
WHO recommends that breastfeeding should be initiated within an hour of birth. In order to
facilitate this, it proposes that all activities that involve separation of the mother from the
baby (such as weighing or bathing) be delayed till after the first hour. This will allow the
mother and the newborn to have uninterrupted skin-to-skin contact until the first
breastfeed (5). Two recent studies, one in Ghana and the other in Nepal have shown an
increased risk of neonatal mortality of 2.4 and 1.4 times respectively if initiation of
breastfeeding was delayed beyond the first 24 hours (5). In the Ghana study, late initiation
(beyond 24 hours) was associated with a 2.6 fold increase in infection-specific neonatal
mortality, whereas no such association was observed between timing of initiation of
breastfeeding and non-infection neonatal deaths. The increasing risk of mortality with delay
in initiation of breastfeeding is shown in Table 2 below.

14
Table 2: Delayed initiation of breastfeeding increases neonatal mortality (6)
The plausible biological pathways through which early initiation helps in reduction of
neonatal morality include: a) provision of immune factors present in colostrum; b)
protection against exposure to infectious pathogens (potentially present in pre-lacteal feeds
and breast-milk substitutes); c) optimal maturation of the gut and immune system; d)
protection against hypothermia; and e) facilitating sustained breastfeeding (5).
In India, the rates of early initiation of breastfeeding within an hour of birth have shown a
major increase over the past few years, from 23.4% as found in NFHS-3 (7) of 2005-06, to
40.5% in DLHS-3 (1). However, a relatively recent study conducted in Bareilly district of Uttar
Pradesh (UP) in India revealed that while only 22% of the mothers of children 0-11 months
of age had initiated breastfeeding within the recommended one-hour of birth, another
21.2% delayed it beyond the first 24 hours (8). It must be noted that compared to the
national and sub-national surveys, this was a very small and localised study, the results of
which may not be comparable to the situation in the state, let alone at the national level.
Exclusive breastfeeding
Breastfeeding confers many benefits to the child, including prevention of infections,
allergies and asthma in childhood, to protection from adult diseases such as diabetes and
hypertension (3). The Ghana and Nepal studies also showed that exclusive breastfeeding

15
resulted in a reduction in mortality irrespective and independent of the timing of initiation
of breastfeeding (5). Breastfeeding results in optimal physical and mental growth and
development of the child. Breastfeeding also saves the family and thus the community and
the nation a lot of money, be it through reduced expenses on infant milk substitutes or on
treatment of a sick child. It also confers benefits to the mother such as protection from
osteoporosis and breast-cancer, as well as delaying the return of fertility post child-birth (3).
The Lancet series on child survival identified breastfeeding as the single most important
intervention that could prevent 13-16 percent of all childhood deaths (2).
Breastfeeding the child is almost a norm in countries like India. The recent World
Breastfeeding Trends Initiative (WBTi) report, published by IBFAN in 2012, reveals that the
average (median) duration of breastfeeding in India is close to 30 months (9). However,
continued breastfeeding differs from exclusive breastfeeding. Unlike the rise in early
initiation rates, the proportion of children under 6 months of age who were exclusively
breastfed in the 24 hours preceding the survey remained almost constant at 46.8% in DLHS-
3 (1) from 46.3% in NFHS-3 (7). While these appear to be relatively high rates, DLHS-3 also
shows that only 26.2% of the children 6-35 months of age were exclusively breastfed for at
least 6 months. The difference between the two results relates the proportion of mothers
who discontinue exclusive breastfeeding before the age of 6 months. The Bareilly study
reported that as high as 77.2% of the children were exclusively breastfed, though it is
unclear from the article for how long the baby has been exclusively breastfed (8). Studies
have shown that the most common cause cited by the mother to give supplementary feeds
along with breastfeed is her perception that she does not have enough breast-milk (10).
Complementary feeding:
The Lancet series on child survival states that adequate complementary feeding from 6-23
months could save an additional 6 percent of child deaths (beyond those saved due to
exclusive breastfeeding) (2).
According to the PAHO (WHO) guidelines (11) on complementary feeding, a 6-8 month old
child should be given food (other than breast-milk) 2-3 times a day, while the frequency
should be increased for 12-23 month old child to 3-4 times a day. In addition to this, the

16
child should be offered snacks9
about 1-2 times in a day. These recommendations are based
on assumptions related to the average amount of breast-milk taken by children of these
ages, based on which it is stated that babies 6-8 months of age require 200 Kcal, 9-11
months 300 Kcal and 12-23 months 550 Kcal of energy per day from complementary foods.
With some more assumptions related to the calorie density of common complementary
foods (viz. 1.07 to 1.46 Kcals per gram of food) these calorie requirements translate into the
following quantities of daily complementary foods for the children in different age groups:
- 6-8 months: 137 to 187 grams / day
The national surveys have defined complementary feeding as the introduction of semi-solid
or solid foods into a child’s diet in addition to breast-milk. According to this definition,
NFHS-3 found that complementary feeding had been initiated for 55.8% of the Indian
children in the age group 6-9 months (7). This showed an insignificant increase to 56.5% in
DLHS-3 (1). The WBTi 2012 report quotes this figure at 57.1% (9). However, the source of
data for this multi-country report is not known. The Bareilly study found that about one
fourth of the mothers had initiated complementary feeding of their children before the
recommended age of 6 months. Another 43% started the same between 6-9 months of age,
whereas about a third had delayed it beyond 9 months (8). Thus according to this small
study, over two thirds of the children 6-9 months of age were receiving complementary
foods, which is about 10 percentage points higher than the national surveys.
No studies that assessed the age appropriateness of complementary feeding were found for
this review. This could be because there is no standard agreed upon definition for this that
takes into account various aspects of complementary feeding, including, but not limited to,
the frequency, quantity and variety of foods offered to the child. Additionally, measuring all
these aspects reliably through the commonly used interview technique is difficult, and is a
practical impediment for data collection for the indicator on age appropriateness of
complementary feeding.
9
“Snacks” are defined as foods eaten between meals-usually self-fed, convenient and easy to prepare.

17
Role of service providers:
Several studies in India and across the globe have demonstrated that it is possible to achieve
high rates of exclusive breastfeeding, but this is possible only through education and
counselling (3). This is because increasing exclusive breastfeeding and complementary
feeding require behaviour change and it is a process that can be achieved through
appropriate knowledge and skill transfer. It is not the same as the delivery of some
vaccinations and health protection. It needs inputs from service providers as well as support
from the families of lactating women. For example, lack of exclusive breastfeeding is mostly
due to the feeling of “not enough milk” in the mothers, and needs to be addressed by
building their confidence through counselling (3).
Despite the glaring need, the status of community-based support systems for pregnant and
breastfeeding mothers is poor in India. According to World Breastfeeding Tends Initiative
(WBTi 2012) (9), India scored a low 5 out of 10 on this index type indicator, which covers
issues such as whether or not the community-based service providers are trained in
counselling skills for IYCF. The glaring gap in this area can be better understood when one
looks at neighbouring countries like Sri Lanka and Maldives, which scored 9 on this indicator.
Another related indicator gauges the status of information support on IYCF in the country,
by looking into existence of a comprehensive multi-media plan at the national level for
dissemination of IYCF information, and whether the information shared is technically sound
and based on international guidelines. India scored a 6 of the maximum 10 points under this
indicator. Once again neighbouring Sri Lanka and Pakistan scored a much higher 9 points,
while some African countries like Malawi, Kenya and Gambia scored a perfect 10 for this
indicator.

18
Chapter 3
MATERIAL & METHODS
Study Design:
This is a cross-sectional survey design.
Period of data collection:
Data was collected from the women respondents from 19th
September to 15th
October
2012, and from the service providers from 20th
September to 29th
October 2012.
Study area:
The survey was conducted in select blocks of three districts of Bihar where the Project is
being implemented - Muzaffarpur, Samastipur and Sitamarhi. As mentioned in Chapter 1
(Table 1), the activities in these three districts are being implemented by four project
partners - AKF(I), AKRSP(I), Agragami (India) and CHARM.
Respondents’ selection criteria:
In line with the objectives, data was collected from broadly two respondent categories,
namely pregnant women and mothers of young infants, and health and nutrition
functionaries. These categories were further subdivided depending on the denominator of
the indicator in question. Thus, the various respondent categories were:
A. Women
iii) Mothers with a child 3-4 months10
of age
iv) Mothers with a child 6-7 months11
of age
v) Mothers with a child 12-13 months12
of age
10
“child 3-4 months of age” refers to the child who has completed 3 months, but not 4 months on the date of
the survey, i.e. the 4
th
month after birth.
11
“child 6-7 months of age” refers to the child who has completed 6 months, but not 7 months on the date of
the survey, i.e. the 7
th
month after birth.
12
“child 12-13 months of age” refers to the child who has completed 12 months, but not 13 months on the
date of the survey, i.e. the 12
th
month after birth.

19
B. Health and nutrition workers (service providers)
i) Community based health and nutrition functionaries (i.e., ASHAs and AWWs)
ii) Facility based health functionaries (i.e., ANMs and Mamtas)
Sample size:
In order to calculate sample size, a tentative “prevalence” level of various indicators was
required. While DLHS-3 provides levels for some indicators, for reasons mentioned above in
Chapter 1, they were not considered reliable enough for calculating the sample, size. Thus,
the prevalence level of 50 percent was assumed for all indicators in order to arrive at the
maximum sample size.
Sample size = (1.96)2
pq
d2
where,
p = Current prevalence level (viz. 50% or 0.5)
q = 1 - p (viz. 1 - 0.5 = 0.5)
d = Allowable error (set at 5% or 0.05 for the women respondents, and 7% or 0.07 for
the health and nutrition functionaries13
)
Using this formula, the sample size for each category of women respondents was calculated
to be 384, while that for the workers was calculated to be 196 (rounded off to 200).
It was also decided that while the data collected from the women would be disaggregated
and reported at both the implementing partner and district levels, the data for the workers
would be reported at the overall project level only. This meant that each implementing
partner would have to individually reach out to the “complete sample size”, i.e., 384 women
from each respondent category for data collection. However, they would need to collect
data from only 50 (that is 200/4) respondents for each category of workers.
13
The allowable error for the health and nutrition functionaries is kept slightly higher than for the women /
mothers in order to reduce the sample size, while keeping in mind that the workers are not the primary target
population of the project.

20
Sampling methodology:
Multi–stage cluster sampling with probability proportionate to size (PPS) was used for
selection of respondents owing to the large geographical area to be covered and also
because of the absence of a list with the complete universe of respondents.
Each implementing partner selected 64 clusters using this methodology. Six women from
each respondent category were interviewed from each cluster, thus making a total of 384
(i.e., 64x6) women in each category.
In the first stage of sample selection, all the administrative blocks covered by an
implementing partner were listed and variable numbers of clusters were allocated to each
block using the PPS methodology. In the second stage, the clusters allotted to each block
were further divided and allocated to various Panchayats in those blocks, again using the
PPS methodology. Thus, the panchayat was the last geo-administrative unit to which cluster
positioning was done.
As there are number of revenue villages located in a Panchayat (4 to 5) which may be spread
across a relatively large geographical distance, the interviewers started with the revenue
village with the largest population in order to cover the maximum number of respondents
from the minimum possible area. In instances where the interviewers were unable to find
the required number of respondents in the first (largest) revenue village, they moved to the
one with the second highest population and so on. In some cases the required sample of
one category was reached earlier than the others. In such cases, only the “leftover” sample,
if any, was covered from the smaller revenue villages.
The second sub-category of women (mothers with children aged less than 7 days) had the
smallest possible “universe” as the age time-frame captured in this category is only 7 days
compared to a month for all other categories. Despite almost universal coverage,
interviewers were unable to find the requisite number of mothers in this sub-category in
some of the clusters.

21
The detailed cluster selection methodology is provided in Annex 4.
Survey Instruments:
Six types of survey instruments were created, one for each respondent category of women,
and a common form for all the service providers. As detailed in Table 3, for the women, the
focus of the questionnaire was on the knowledge, intention and/or practice of the IYCF
behaviour relevant to that particular age group. For the service providers, the survey
instrument had questions to assess their knowledge on all IYCF recommendations, as well as
on-the-job performance related to BCC for increasing uptake of recommended behaviours
by women.
Table 3: Issues assessed through the various survey instruments.
Respondent category Issues assessed through survey instrument
Women in the last trimester of pregnancy
Knowledge regarding
- Initiation of breastfeeding
- Pre-lacteal feeds
- Colostrum
Intention to
- Breastfeed the baby
Mothers with a child less than 7 days of age
Knowledge regarding
- Advantages of breastfeeding
- Duration of exclusive breastfeeding.
Practice related to
- Initiation of breastfeeding
- Pre-lacteal feeds
- Exclusive breastfeeding
- Keeping the baby warm.
Intention to
- Exclusively breastfeed the baby

22
Mothers with a child 3-4 months of age
Knowledge regarding
- Duration and advantages of exclusive
breastfeeding.
Practice related to
Intention to
- Continue exclusive breastfeeding
- Introduce complementary foods
Knowledge regarding
- Duration of exclusive breastfeeding.
- Diarrhoea management
Practice related to
- Continuation of breastfeeding
- Introduction of complementary foods
- Age appropriate complementary feeding
Intention to
- Continue breastfeeding
- Introduce complementary foods (if not
done already)
Practice related to
- Continuation of breastfeeding
- Introduction of complementary foods
- Age appropriate complementary feeding
Intention to
- Introduce complementary foods (if not
done already)

23
Health and Nutrition functionaries (i.e.
ASHAs, AWWs, ANMs and Mamtas)
Knowledge regarding
- Initiation of breastfeeding.
- Pre-lacteal feeds
- Colostrum feeding
- Keeping the baby warm
- Introduction of and age appropriate
complementary feeding
On the job performance related issues
- Training on IYCF
- Counselling women on IYCF.
The first draft of the tools were prepared in English and shared with the State Project team
for review. Multiple rounds of review and revisions resulted in the final tool. These were
then translated into the local language (Hindi). The team reviewed the translated versions
again to ensure that meaning was not lost during the translation process. The translated
tools were also pre-tested in the field before going to the printers.
The final English versions of the data collection tools are attached as Annex 5 . The
translated (Hindi) version of the data collection tools can be found in Annex 6.
Interviewers:
The PEs, CCs and Project Coordinators (PCs) were the designated interviewers for the
baseline survey. While the PEs and CCs collected data from the women respondents, the
PCs interacted with the service providers. Following technical training on IYCF, 227 PEs, 108
CCs and all 8 PCS were oriented to the data collection tools as well as the process of
respondent selection after reaching the sample panchayat.
While in the field, the interviewers faced many problems in data collection, such as
- Limited numbers of mothers with a child less than 7 days of age (due to relatively
few number of deliveries taking place in the months of data collection).

24
- Interviewing the second category of respondents, as they had just delivered a few
days back, and were tired because of the effort during delivery and time needed for
child-care.
- Interference during the interview by other care-givers such as fathers and
grandmothers, who often responded instead of the mother.
Data entry and analysis:
For quick data entry, the State Project Management Unit (SPMU) created a template in MS
Excel. The MIS assistants, one each with the four implementing partners, were responsible
for data entry. They, along with the PCs and Project Managers were trained by the SPMU.
The complete data set in Excel was reviewed by the SPMU and discordant information,
wherever present, was reviewed. Some “uniform” data entry errors14
were revised for the
complete data set.
Data analysis was done through simple frequency tables. Data collected from the women
respondents was disaggregated by both district and IP to assess for intra-project differences
in baseline, if any, and later assist in internal project monitoring.
Quality assurance:
Quality was ensured at various stages of the survey.
- Multiple reviews and revisions of the tool, including its translated version and its
pilot testing ensured that the tool was designed to capture the required information.
- Training of interviewers ensured homogeneity in data collection methodologies. For
example, some questions required the interviewer to only list spontaneous answers,
whereas a few others required the interviewer to prompt the respondent. All of
these were not only specified in the questionnaire but also specifically explained to
the interviewers during training.
- The CCs and Project Coordinators from the implementing partners accompanied the
PEs during data collection. The SPMU also visited the field on a random basis to
ensure valid data collection.
14
At places, data entry operators had filled in no. of days in the “no. of months” column and vice versa. At
other places, they had filled in the actual number of times a baby was fed rather than the designated
numerical code for the same.

25
- All forms were checked at the end of each day to ensure completeness of
information.
- Excel sheet forms had in-built mechanisms to prevent data entry errors, such as
allowing entry of only pre-defined options for many questions.
- Training of data entry operators (MIS assistants) reduced errors and ensured
homogeneity in data entry.
- Following data entry, a random back-check of 10 percent forms was done to ensure
that the data entered in the excel sheet matched the data present in the forms, thus
capturing inadvertent data entry errors.
- Repeat data entry was done for those fields were “uniform” data entry errors (see
above under “Data entry and analysis”) were found.

26
Chapter 4
OBSERVATIONS
SECTION A: WOMEN
Respondent Profile:
As stated in Chapter 3, the women respondents were categorised into five groups
depending on the stage of their pregnancy or the age of the index child. These were:
iii) Mothers with a child 3-4 months of age
iv) Mothers with a child 6-7 months of age
v) Mothers with a child 12-13 months of age
In order to ensure a confidence level of 95% even when the data is disaggregated at the IP
level, 384 women were to be interviewed from each of these respondent groups by each IP.
As two of the three districts - Muzaffarpur and Samastipur - in the Project are managed by
two IPs each, the sample size for these two districts exceeds the 384 mark. The final
respondent tally is shown in Table 4
Table 4: District and Implementing Partner wise distribution of women respondents
of categories (i), (iii), (iv) and (v).
Implementing Partner
District
AKF (I) Agragami CHARM AKRSP (I) TOTAL
Muzaffarpur 384 - - 174 558
Samastipur 384 - 210 594
Sitamarhi - - 384 - 384
TOTAL 384 384 384 384 1536
For the second category, i.e., women with a child less than 7 days old, owing to a relatively
smaller “universe” the ideal sample size for this category was not reached by two IPs. As can
be seen from

27
Table 5, while AKRSP (I) could enrol 372 of the required 384 women in this category, AKF (I)
could manage to find only 358 respondents in this category from the Panchayats chosen
under cluster sampling.
Table 5: District and Implementing Partner wise distribution of women respondents
of category (ii) i.e., those with a child less than 7 days of age.
District
Muzaffarpur 358 - - 166 524
Samastipur - 384 - 206 590
Sitamarhi - - 384 - 384
TOTAL 358 384 384 372 1498
Thus, a total of 7642 women respondents were interviewed across three districts and four
implementing partners. The overall distribution is given in Table 6
Table 6: District and Implementing Partner wise distribution of all the women respondents
District
Muzaffarpur 1894 - - 862 2756
Samastipur - 1920 - 1046 2966
Sitamarhi - - 1920 - 1920
TOTAL 1894 1920 1920 1908 7642
Figure 1 shows that about 51 % of women respondents all belonged to the marginalised
population. Of these, almost 36% were women from scheduled castes, while another 15%
were Muslims. There was insignificant variation in this distribution among the various
respondent categories.

28
Figure 1: Caste and religion-wise distribution of women respondents (overall).
However, there existed notable variation in the proportion and mix of marginalised
population across districts and implementing partners. As can be seen from that found in
Samastipur (10%)
Table 7 , the proportion of SC women respondents in Sitamarhi is only 25% compared to
about 39% and 40% in Muzaffarpur and Samastipur respectively. On the contrary, the
proportion of Muslim respondents in Sitamarhi (23%) is more than double of that found in
Samastipur (10%)
Table 7: Caste and religion wise distribution of women respondents across districts
Caste/Religion
Others
Marginalised groups
TOTAL
District SC Muslim Total marginalised
Muzaffarpur
1245
(45.2)
1077
(39.1)
434
(15.7)
1511
(54.8)
2756
Samastipur
1471
(49.6)
1192
(40.2)
303
(10.2)
1495
(50.4)
2966
49%
36%
15%
Others SC Muslim

29
Sitamarhi
998
(52.0)
483
(25.2)
439
(22.9)
922
(48.0)
1920
TOTAL
3714
(48.6)
2752
(36.0)
1176
(15.4)
3928
(51.4)
7642
Numbers in parentheses indicate percentages of the row totals, rounded off to the first
decimal.
Similarly, Table 8 shows that there is a much larger proportion of women respondents from
marginalised groups in AKRSP (I) areas (60.5%) compared to the others. Agragami, with only
45% of respondent women from the marginalised groups, has the least proportion of such
respondents. Specifically, there is a wide variation in the respondents belonging to the
scheduled castes between the various IPs, with AKRSP (I) once again having the highest
proportion at 47%, which is almost double the 25% found among the respondents from
areas managed by CHARM.
Table 8: Caste and religion wise distribution of women respondents across
Implementing partners
Caste/Religion
Others
Marginalised groups
TOTAL
Implementing partner SC Muslim
Total
marginalised
AKF
906
(47.8)
644
(34.0)
344
(18.2)
988
(52.2)
1894
Agragami
1056
(55.0)
731
(38.1)
133
(6.9)
864
(45.0)
1920
CHARM
998
(52.0)
483
(25.2)
439
(22.9)
922
(48.0)
1920
AKRSP( I)
754
(39.5)
894
(46.9)
260
(13.6)
1154
(60.5)
1908
TOTAL
3714
(48.6)
2752
(36.0)
1176
(15.4)
3928
(51.4)
7642
Numbers in parentheses indicate percentages of the row totals, rounded off to the first
decimal.

30
The women were asked questions about their knowledge, intention and practice (as
applicable according to the stage of pregnancy or age of their child) regarding IYCF
behaviours. The findings are presented below. They have been categorised based on the
three tenets of IYCF, namely Initiation of breastfeeding, exclusive breastfeeding and
complementary feeding.
Initiation of Breastfeeding:
a) Timing of initiation of breastfeeding:
Women in the third trimester of pregnancy were asked when, according to them, should
breastfeeding be initiated following birth of the baby. Table 9 and Table 10 show that of
the 1536 respondents in this category across the projects, less than one-fourth could
give the correct answer i.e. breastfeeding should be initiated within an hour of birth.
About one-third (32%) said that it should be initiated within the first 6 hours of birth.
Of the three districts, women from Sitamarhi fared the worst with respect to their
knowledge on this issue with just 19% knowing the appropriate response (Table 9).
Alarmingly, more than half of the women in Samastipur felt that the correct time to
initiate breastfeeding was after the first 24 hours of birth, with 33% saying between 1-3
days and another 19% stating after 3 days.
On the contrary, 70% of the women respondents from Muzaffarpur felt that
breastfeeding should be initiated within the first 6 hours, with 28% giving the correct
response.
Table 9: Knowledge of women in the third trimester of pregnancy about ideal time for
initiation of breastfeeding - disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALKnowledge regarding timing
of initiation of BF
Immediately, within one hour
of birth
157
(28.1)
126
(21.2)
73
(19.0)
356
(23.2)
Same day between 1 - 6
hours after birth
236
(42.3)
185
(31.2)
65
(16.9)
486
(31.6)

31
Same day (6-24 hours after
birth)
41
(7.4)
118
(19.9)
26
(6.8)
185
(12.0)
1-3 days
54
(9.7)
77
(13.0)
128
(33.3)
259
(16.9)
After 3 days
6
(1.2)
29
(4.9)
72
(18.8)
107
(7.0)
Never
1
(0.2)
2
(0.3)
0
(0.0)
3
(0.2)
Others / No response
63
(11.3)
57
(9.6)
20
(5.2)
140
(9.1)
TOTAL 558 594 384 1536
Numbers in parentheses indicate percentages of the column totals, rounded off to the first
decimal.
As Sitamarhi district is managed by CHARM, when the indicator related to knowledge of
women regarding the ideal time for initiating breastfeeding was disaggregated by
implementing partner (Table 10), CHARM fared the worst of all the four partners. Similarly,
AKF which works in Muzaffarpur reported relatively good results on this indicator, with 75%
of the women stating the time frame for breastfeeding initiation within the first 6 hours of
birth, of which 27% gave the correct response of “within 1 hour of birth”.
Table 10: Knowledge of women in the third trimester of pregnancy about ideal time for
initiation of breastfeeding - disaggregated by implementing partners
Implementing partner
AKF Agragami CHARM AKRSP,I TOTALKnowledge regarding timing
of initiation of BF
of birth
104
(27.1)
75
(19.5)
73
(19.0)
104
(27.1)
356
(23.2)
hours after birth
184
(47.9)
100
(26.0)
65
(16.9)
137
(35.7)
486
(31.6)
birth)
23
(6.0)
73
(19.0)
26
(6.8)
63
(16.4)
185
(12.0)

32
1-3 days
28
(7.3)
62
(16.2)
128
(33.3)
41
(10.7)
259
(16.9)
After 3 days
3
(0.8)
28
(7.3)
72
(18.8)
4
(1.0)
107
(7.0)
Never
0
(0.0)
0
(0.0)
0
(0.0)
3
(0.8)
3
(0.2)
Others / No response
42
(10.9)
46
(12.0)
20
(5.2)
32
(8.3)
140
(9.1)
TOTAL 384 384 384 384 1536
decimal.
Women who had delivered recently i.e., mothers with a child less than 7 days of age were
asked about the actual practice related to initiation of breastfeeding. Table 11
(disaggregation by district) and Table 12 (disaggregation by IP) show that just 17% of the
women had initiated breastfeeding within the recommended one hour after birth. Another
38% had initiated within the first 6 hours.
As can be seen from Table 11, the inter-district variation in findings on the actual practice of
women related to initiation of breastfeeding are similar to knowledge on this issue, with
women from Sitamarhi faring far worse than in the other two districts. However, it must be
noted here for Sitamarhi that while only 36% of the pregnant women had cited a time
within the first 6 hours for initiation of breastfeeding, there was an improvement in actual
practice, and a significantly larger proportion of women (48%) had initiated breastfeeding
within 6 hours of birth.
In comparison, Muzaffarpur had the best report on this indicator from all three districts,
with 67% of the women having initiated breastfeeding within the first 6 hours, and 19%
within the recommended first hour of birth.

33
Table 11: Time of initiation of breastfeeding by women with a child less than 7 days of age
– disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALPractice regarding timing of
initiation of BF
of birth
101
(19.3)
96
(16.3)
64
(16.7)
261
(17.4)
hours after birth
252
(48.1)
192
(32.5)
119
(31.0)
563
(37.6)
birth)
99
(18.9)
129
(21.9)
40
(10.4)
268
(17.9)
1-3 days
54
(10.3)
98
(16.6)
95
(27.7)
247
(16.5)
After 3 days
15
(2.9)
54
(9.2)
60
(15.6)
129
(8.6)
Never
1
(0.2)
9
(1.5)
4
(1.0)
14
(0.9)
Others
2
(0.4)
12
(2.0)
2
(0.5)
16
(1.1)
TOTAL 524 590 384 1498
decimal.
Table 12 shows that the inter-district differences in practice are replicated across
implementing partners too, depending upon the district(s) they manage. Practice of women
in AKF areas was closer to the recommended behaviour for initiation than for other
implementing partners.
Table 12: Time of initiation of breastfeeding by women with a child less than 7 days of age
– disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALPractice regarding timing of
initiation of BF
of birth
67
(18.7)
61
(15.9)
64
(16.7)
69
(18.6)
261
(17.4)
hours after birth
185
(51.7)
93
(24.2)
119
(31.0)
166
(44.6)
563
(37.6)
birth)
65
(18.2)
86
(22.4)
40
(10.4)
77
(20.7)
268
(17.9)

34
1-3 days
29
(8.1)
80
(20.8)
95
(27.7)
43
(11.6)
247
(16.5)
After 3 days
11
(3.1)
50
(13.0)
60
(15.6)
8
(2.2)
129
(8.6)
Never
0
(0.0)
6
(1.6)
4
(1.0)
4
(1.0)
14
(0.9)
Others
1
(0.3)
8
(2.1)
2
(0.5)
5
(1.3)
16
(1.1)
TOTAL 358 384 384 372 1498
decimal.
Comparing the knowledge on and actual practice of initiation of breastfeeding (Figure 2),
there is a slight drop in the percentage (about 6 percentage points) of who know the “ideal
time” to those who were able to adopt it into actual practice. However, the overall
proportion of women who initiated breastfeeding within the first six hours is comparable to
the 55% of women in the third trimester who had stated the same. Overall, about 1% of the
women with children less than 7 days of age had not initiated breastfeeding until the time
of the survey. The reason for the same was not explored as part of this survey.

35
Figure 2: Comparison between knowledge and practice of initiation of breastfeeding after
delivery
Exclusive breastfeeding:
Women in three of the five categories were asked questions related to exclusive
breastfeeding (EBF) viz. mothers with children less than 7 days of age, between 3-4 months
of age and between 6-7 months. While all three categories were asked questions related to
their knowledge about the advantages and/or the ideal duration of exclusive breastfeeding,
they were also asked about their actual practice and/or intention about exclusive
breastfeeding.
a) Knowledge regarding exclusive breastfeeding
Mothers of a child less than a week old as well as those with a child 3-4 months of age were
asked to enumerate some advantages of exclusive breastfeeding. Overall, about one-third
of the women interviewed were unable to mention even a single advantage of
breastfeeding (Table 13, Table 14, Table 15 and Table 16). On an average, the women with
a child less than 7 days of age could list down 1.5 advantages, whereas those with a 3-4
months’ old child mentioned about 1.3 advantages.
23.2
31.6
12
16.9
7
0.2
9.1
17.4
37.6
17.9
16.5
8.6
0.9 1.1
0
5
10
15
20
25
30
35
40
Immediately,
within one
hour of birth
Same day
between 1 - 6
hours after
birth
Same day (6-24
hours after
birth)
1-3 days After 3 days Never Others/No
response
Knowledge (N=1536) Practice (N=1498)

36
Women from Sitamarhi fared the worst on this indicator (Table 13 and Table 15). Almost
half the women from both the respondent categories (mothers with a child less than 7 days
and mothers with a child 3-4 months) could not cite even a single advantage. Compared to
this, only 27% and 19% of the women respondents in these two categories from
Muzaffarpur were found this lacking in breastfeeding related knowledge.
Table 13: Knowledge of women with a child less than 7 days of age about advantages of
exclusive breastfeeding – disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALNo. of advantages of BF cited
Zero
142
(27.1)
117
(19.8)
181
(47.1)
440
(29.4)
One
145
(27.7)
243
(41.2)
109
(28.4)
497
(33.2)
Two
125
(23.9)
104
(17.6)
48
(12.5)
277
(18.5)
Three
61
(11.6)
81
(13.7)
16
(4.2)
158
(10.5)
Four
32
(6.1)
28
(4.7)
9
(2.3)
69
(4.6)
Five
6
(1.1)
11
(1.9)
2
(0.5)
19
(1.3)
More than five
13
(2.5)
6
(1.0)
19
(5.0)
38
(2.5)
TOTAL 524 590 384 1498
decimal.

37
Table 14: Knowledge of women with a child less than 7 days of age about advantages of
exclusive breastfeeding – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALNo. of advantages of EBF
cited
Zero
113
(31.6)
101
(26.3)
181
(47.1)
45
(12.1)
440
(29.4)
One
111
(31.0)
173
(45.1)
109
(28.4)
104
(28.0)
497
(33.2)
Two
74
(20.7)
57
(14.8)
48
(12.5)
98
(26.3)
277
(18.5)
Three
38
(10.6)
32
(8.3)
16
(4.2)
72
(14.4)
158
(10.5)
Four
16
(4.5)
14
(3.6)
9
(2.3)
30
(8.1)
69
(4.6)
Five
1
(0.3)
4
(1.0)
2
(0.5)
12
(3.2)
19
(1.3)
More than five
5
(1.4)
3
(0.8)
19
(5.0)
11
(3.0)
38
(2.5)
TOTAL 358 384 384 372 1498
decimal.
Table 15: Knowledge of women with a child 3-4 months of age about advantages of
exclusive breastfeeding – disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTAL
No. of advantages of EBF
cited
Zero
106
(19.0)
167
(28.1)
207
(53.9)
480
(31.3)
One
213
(38.2)
231
(38.9)
116
(30.2)
560
(36.5)
Two
151
(27.1)
120
(20.2)
34
(8.9)
305
(19.9)
Three
70
(12.5)
50
(8.4)
14
(3.6)
134
(8.7)
More than three
18
(3.2)
26
(4.4)
13
(3.4)
57
(3.7)
TOTAL 558 594 384 1536
decimal.

38
Table 16: Knowledge of women with a child 3-4 months of age about advantages of
exclusive breastfeeding – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALNo. of advantages of BF cited
Zero
97
(25.3)
120
(31.3)
207
(53.9)
56
(14.6)
480
(31.3)
One
159
(41.4)
182
(47.4)
116
(30.2)
103
(26.8)
560
(36.5)
Two
86
(22.4)
52
(13.5)
34
(8.9)
133
(34.6)
305
(19.9)
Three
35
(9.1)
18
(4.7)
14
(3.6)
67
(17.4)
134
(8.7)
More than three
7
(1.8)
12
(3.1)
13
(3.4)
25
(6.5)
57
(3.7)
TOTAL 384 384 384 384 1536
decimal.
As can be seen from Table 17, close to half (48%) of the women respondents listed
appropriate physical and mental development of the child as the advantages of exclusive
breastfeeding that they were aware of. Slightly more than one-fourth (27.5%) said that
mother’s milk was the best and complete food for the child for the first 6 months. Relatively
fewer women were aware of the protective effect of breast-milk against common childhood
diseases such as diarrhoea (14.4%) and pneumonia (7.8%). It is interesting to note, that few
even listed the economic benefits of breastfeeding such as it being “free” (when compared
to other infant milk substitutes), savings due to no expenditure for fuel, and even money
saved due to reduced illness and therefore medical expenses for the child.
Less than 3% of the women mentioned the contraceptive benefit of exclusive breastfeeding.

39
Table 17: Knowledge of women (across two respondent categories) about advantages of
exclusive breastfeeding
Women’s respondent category Mothers of
children less
than 7 days of
age
(N=1498)
Mothers of
children 3-4
months of age
(N=1536)
TOTAL
(N=3034)
Advantages of exclusive
breastfeeding
BF helps in mental and physical
development of child
699
(46.7)
757
(49.3)
1456
(48.0)
Mother's milk is the best and
complete diet for the baby for the
first six months
348
(23.2)
487
(31.7)
835
(27.5)
EBF protects against diarrhoea 205
(13.7)
233
(15.2)
438
(14.4)
EBF protects against pneumonia 111
(7.4)
127
(8.3)
238
(7.8)
BF helps in mother-child bonding* 201
(13.4)
N/A* 201^
(6.6)
Breast-milk is free and so saves
money*
236
(15.8)
N/A* 236^
(7.8)
Breast-milk is always available and so
saves time*
132
(8.8)
N/A* 132^
(4.4)
BF does not require water and fuel
for cleaning utensils and boiling milk
and so saves money*
62
(4.1)
N/A* 62^
(2.0)
BF reduces incidence of disease in
child and so saves money spent on
treatment*
136
(9.1)
N/A* 136^
(4.5)
Lactational amenorrhoea reduces
maternal anaemia and also works as
a contraceptive.
30
(2.0)
57
(3.7)
87
(2.9)
BF protects the mother from breast
cancer
36
(2.4)
84
(5.5)
120
(4.0)
Others 75
(5.0)
94
(6.1)
169
(5.6)
Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off
to the first decimal.
Percentages do not add up to hundred as multiple options were allowed as responses.
* These options were not given in schedule III (for mothers with a child 3-4 months of age).
^ These are not “true” totals as there was no corresponding option in schedule III (for mothers with a
child 3-4 months of age). Hence the percentages also need to be interpreted in that light.

40
Women with children less than a week old and those with a child 6-7 months of age were
asked about what, in their opinion, was the ideal duration of exclusive breastfeeding (not
even water). As can be seen from Table 18, slightly more than half the women gave a
response stating the actual number of months. Figure 3 gives a detailed break-up of the
numerical responses and shows that about 22% of all respondents (23% of women with
children under 7 days and 21% of women with an older child), across the two categories
gave the correct response, i.e. 6 months. About 18% gave a response less than 6 months,
while 11% stated durations of more than 6 months. The graph also shows a slight “peaking”
of responses at 7 months, and at 12 and 24 months. The median15
number of months stated
as the ideal duration of breastfeeding across both the respondent categories was 6 months.
Table 18: Responses of women (across two respondent categories) about the ideal
duration of exclusive breastfeeding
Women’s respondent
category
Mothers of
children less
than 7 days of
age
Mothers of
children 6 - 7
months of
age
TOTAL
Ideal duration of exclusive
breastfeeding
Numerical response
745
(49.7)
792
(51.6)
1537
(50.7)
Non-numerical response / No
response
753
(50.3)
744
(48.4)
1497
(49.3)
TOTAL 1498 1536 3034
15
The median was chosen as the measure of central tendency for this indicator as, despite have a greater
number of women giving a response less than 6 months, as compared to those who gave a response more
than 6 months, the “outlier” figures of more than 12 months (like 24 months, 36 months etc.) were driving the
arithmetic mean on the higher side. The arithmetic mean for the mothers with a child less than 7 days was 6.3
months, while that for the mothers of children 6-7 months of age was 6.5 months.

41
Figure 3: Knowledge of women (across two respondent categories) about the ideal
duration (in months) of exclusive breastfeeding
Note: The y-axis of the graph has deliberately been shortened to reflect only 6 percentage
points to highlight the “peaking” at some months. This also means that the two tall bars at 6
months (for more 23.2% and 21.2% each) are not shown fully in the graph.
About 50% of the women did not give a numerical response to the question about duration
of exclusive breastfeeding. As shown in Table 19, some of them (about 18%) gave a
“qualitative” response, while about a third of all women did not give any response (or said
that they did not know) at all to the question about the ideal duration of breastfeeding.
Amongst the qualitative responses, about 9% each said that the duration of exclusive
breastfeeding depended on either the child’s requirements (hunger) or on the mother’s
ability to produce sufficient milk.
3.1
3.4
4.5
3.2
2.3
23.3
2.1
1.3
0.9
0.4
0.1
2.5
0.1
0
0
0.4
0
1.7
0
0
0.1
0
0.1
0.1
2.2
2.9
4.4
5.1
4.0
21.2
2.7
2.0
1.2
0.3
0.1
2.8
0.1
0.1
0.1
0.4
0.1
1.3
0.2
0.1
0.1
0.1
0.1
0.2
0
1
2
3
4
5
6
1month
2months
3months
4months
5months
6months
7months
8months
9months
10months
11months
12months
15months
16months
17months
18months
22months
24months
25months
26months
30months
32months
34months
36months
Pcercentage
Mothers of children less than 7 days of age (N=1498)
Mothers of children 6 - 7 months of age (N=1536)

42
Table 19: Knowledge of women (across two respondent categories) about the ideal
duration (qualitative response) of exclusive breastfeeding
category
Mothers of
children less
than 7 days of
age
(N=1498)
Mothers of
children 6 - 7
months of
age
(N=1536)
TOTAL
(N=3034)
Ideal duration of exclusive
breastfeeding
Depends on child’s
requirements
148
(9.9)
122
(7.9)
270
(8.9)
Depends on mothers’ capacity
to produce sufficient milk for
child
116
(7.7)
141
(9.2)
257
(8.5)
Others
0
(0.0)
8
(0.5)
8
(0.26)
Do not know / no response
489
(32.6)
473
(30.8)
962
(31.7)
Numbers in parentheses indicate percentages of the “N” on top of the column, rounded
off to the first decimal.
b) Practice regarding Exclusive breastfeeding
Mothers of children less than 7 days of age as well as those with a child 3-4 months of age
were asked if they had started feeding the child anything other than breast-milk. This was
an indirect means of assessing the exclusivity of breastfeeding at this age, as formative
research had shown that women do not understand “exclusive breastfeeding” and find it
difficult to differentiate between exclusive breastfeeding and breastfeeding per se.
Even in the first week after birth, about 40% of the mothers had started giving the child
foods other than breast-milk. Table 20 shows a wide inter-district variation. While more
than 82% of the mothers in Muzaffarpur were exclusively breastfeeding their newborns less
than 7 days of age, only about half as many (44%) were doing so in Samastipur. Table 21
shows a similar variation among implementing partners. About 87% mothers in AKF areas
were exclusively feeding their babies in the early neonatal period, compared to only 36% in
Agragami areas.

43
Table 20: Practice of giving foods to the child other than breast-milk, by mothers of a child
less than 7 days of age – disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALPractice regarding feeding
anything other than BM
Yes
94
(17.9)
333
(56.4)
162
(42.2)
589
(39.3)
No (Exclusive Breastfeeding)
430
(82.1)
257
(43.6)
222
(57.8)
909
(60.7)
TOTAL 524 590 384 1498
decimal.
less than 7 days of age – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALPractice regarding giving
foods other than BM
Yes
48
(13.4)
245
(63.8)
162
(42.2)
134
(36.0)
589
(39.3)
310
(86.6)
139
(36.2)
222
(57.8)
238
(64.0)
909
(60.7)
TOTAL 358 384 384 372 1498
decimal.
Table 22 and Table 23 show that by 3-4 months, this proportion had increased and more
than two-thirds of the mothers had started the child on foods other than breast-milk. Thus,
only about 32% of the mothers were exclusively breastfeeding in the 4th
month after
delivery.
Of the three districts, Samastipur showed the poorest result on this indicator with just about
20% of the mothers exclusively breastfeeding their 3 month old child. Sitamarhi had the
best results with over 50% of the mothers practicing exclusive breastfeeding. (Table 22)

44
3-4 months of age – disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALPractice regarding feeding
anything other than BM
Yes
382
(68.5)
475
(80.0)
190
(49.5)
1047
(68.2)
176
(31.5)
117
(19.7)
194
(50.5)
487
(31.7)
No response
0
(0.0)
2
(0.3)
0
(0.0)
2
(0.1)
TOTAL 558 594 384 1536
decimal.
Similarly, disaggregation of data by IP (Table 23) shows that in CHARM areas, more than half
women with a child 3-4 months of age breastfeeding their children exclusively. However,
only 15% of the women in Agragami project areas were found to be exclusively
breastfeeding their 3 month old babies.
3-4 months of age – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALPractice regarding giving
foods other than BM
Yes
252
(65.6)
325
(84.6)
190
(49.5)
280
(72.9)
1047
(68.2)
132
(34.4)
59
(15.4)
194
(50.5)
102
(26.6)
487
(31.7)
No response
0
(0.0)
0
(0.0)
0 (0)
2
(0.5)
2
(0.1)
TOTAL 384 384 384 384 1536
decimal.
While less than 2% of the 1536 women respondents with a child 6-7 months of age admitted
to never having breastfed their child, another 4% or so had discontinued breastfeeding at
the time of the survey. This means that an overwhelming 94.6% were breastfeeding their 6-
7 month olds at the time of the survey (not shown in tables 24 and 25 below).

45
Women respondents in this category revealed that only 15% had breastfed their children
exclusively (not even water) for at least 6 months (Figure 4). Of this, while 12% had
practiced exclusive breastfeeding for 6 months, another 3% were continuing with practice
way into the 7th
month. The disturbing finding was that about 14% of the women had not
maintained the exclusivity of breastfeeding for even a day, and about 40% for about a
month or less.
The mean duration of exclusive breastfeeding for this group was 2.67 months (or 2 months
and 20 days).
Figure 4: Duration of exclusive breastfeeding as informed by mothers with a child 6-7
months of age
Disaggregation of this data by district, as depicted in Table 24, shows mixed results. While
Sitamarhi had the lowest proportion of women (8%) who had not maintained exclusivity
for even a single day, and Samastipur the highest (20%) on this negative indicator, Sitamarhi
also had the lowest proportion of women (13.5%) who had exclusively breastfed for at least
6 months. In contrast Muzaffarpur had the best results on this indicator, with nearly 18% of
the women having exclusively breastfed their children for at least 6 months. This is also
reflected in the average duration of exclusive breastfeeding, which is the highest for
Muzaffarpur (3.1 months) followed by Sitamarhi (2.5 months) with Samastipur the last at
2.36 months.
14.3
12.4
3 2.9
7.4
9.1
11.1
13.3
11.3
12.3
2.9
0
2
4
6
8
10
12
14
16
Not
even for
1 day
Less
than 1
week
Less
than 2
weeks
Less
than 3
weeks
About 1
month
About 2
months
About 3
months
About 4
months
5
months
6
months
7
months
Percentage

46
Table 24: Duration of exclusive breastfeeding as informed by mothers with a child 6-7
months of age – disaggregated by districts.
District
Muzaffarpur Samastipur Sitamarhi TOTALDuration of Exclusive
Breastfeeding
Not even for 1 day
68
(12.2)
120
(20.2)
32
(8.3)
220
(14.3)
Less than 1 week
51
(9.1)
79
(13.3)
60
(15.6)
190
(12.4)
Less than 2 weeks
10
(1.8)
11
(1.9)
25
(6.5)
46
(3.0)
Less than 3 weeks
7
(1.3)
19
(3.2)
18
(4.7)
44
(2.9)
About 1 month
25
(4.5)
47
(7.9)
42
(10.9)
114
(7.4)
About 2 months
51
(9.1)
54
(9.1)
35
(9.1)
140
(9.1)
About 3 months
77
(13.8)
65
(10.9)
29
(7.6)
171
(11.1)
About 4 months
93
(16.7)
65
(10.9)
46
(12.0)
204
(13.3)
5 months
78
(14.0)
51
(8.6)
45
(11.7)
174
(11.3)
6 months
88
(15.8)
64
(10.8)
37
(9.6)
189
(12.3)
7 months
10
(1.8)
19
(3.2)
15
(3.9)
44
(2.9)
TOTAL 558 594 384 1536
decimal.
Disaggregating this data by implementing partner (Table 25), one sees that women in AKF
areas are the closest to the recommended practice. Not only do they have the least
proportion of women (7%) who had never exclusively breastfed their child, they also have
the highest proportion of women (19%) who have exclusively breastfed their child for at
least 6 months. The mean duration of exclusive breastfeeding for Muzaffarpur is 3.4
months, which is greater by more than a month when compared to the AKRSP average of
2.4 months (not shown in table).

47
Table 25: Duration of exclusive breastfeeding as informed by mothers with a child 6-7
months of age – disaggregated by implementing partners.
AKF Agragami CHARM AKRSP,I TOTALDuration of Exclusive
Breastfeeding
Not even for 1 day
28
(7.3)
64
(16.7)
32
(8.3)
96
(25.0)
220
(14.3)
Less than 1 week
34
(8.9)
42
(10.9)
60
(15.6)
54
(14.1)
190
(12.4)
Less than 2 weeks
7
(1.8)
7
(1.8)
25
(6.5)
7
(1.8)
46
(3.0)
Less than 3 weeks
2
(0.5)
16
(4.2)
18
(4.7)
8
(2.1)
44
(2.9)
About 1 month
20
(5.2)
36
(9.4)
42
(10.9)
16
(4.2)
114
(7.4)
About 2 months
35
(9.1)
46
(12.0)
35
(9.1)
24
(6.3)
140
(9.1)
About 3 months
55
(14.3)
47
(12.2)
29
(7.6)
40
(10.4)
171
(11.1)
About 4 months
71
(18.5)
40
(10.4)
46
(12.0)
47
(12.2)
204
(13.3)
5 months
58
(15.1)
35
(9.1)
45
(11.7)
36
(9.4)
174
(11.3)
6 months
64
(16.7)
39
(10.2)
37
(9.6)
49
(12.8)
189
(12.3)
7 months
10
(2.6)
12
(3.1)
15
(3.9)
7
(1.8)
44
(2.9)
TOTAL 358 384 384 372 1536
decimal.
All the mothers from different respondent categories, who had not breastfed their children
for the recommended duration of six months, were asked about the reason for introducing
food substances other than breast-milk in their child’s diet at the early age. Table 26 shows
that the commonest reason for topping up breast-milk with other food substances, cited by
close to 50% of the mothers who had not exclusively breastfed their child for the
recommended 6 months was the mothers’ perception that their child was hungry. A similar
reason was the mother’s perception of insufficient milk. It may be noted that this
perception seems to increase with the age of the child (though it is difficult to analyse for
the presence of a “real trend” in just three readings). Family traditions and social pressures
were also cited in about a third of such cases.

48
Table 26: Reasons given by women across three respondent categories for introducing
food substances other than breast-milk in the child’s diet before 6 months of age.
category Mothers of
children less
than 7 days of
age
(N=589)
Mothers of
children 3-4
months of
age
(N=1047)
Mothers of
children 6 - 7
months of age
(N=1303)
Reason for introducing foods
other than breast-milk at
early age
Child is hungry
282
(47.9)
567
(54.2)
708
(54.3)
Child is thirsty
174
(29.5)
403
(38.5)
585
(44.9)
Family members advice/my
knowledge
172
(29.2)
302
(28.8)
258
(19.8)
Culture / tradition
56
(9.5)
73
(7.0)
51
(3.9)
No Milk / Less milk
96
(16.3)
266
(25.4)
340
(26.1)
Due to pain in breast
27
(4.6)
44
(4.2)
68
(5.2)
Child is unable to suck
83
(14.1)
40
(3.8)
56
(4.3)
Doctor recommended
-
44
(4.2)
87
(6.7)
Child is not growing
- -
39
(3.0)
Others
23
(3.9)
-
14
(1.1)
Percentages do not add up to hundred as multiple options were allowed as responses.
Complementary feeding:
a) Introduction of complementary feeding
Mothers of children 3-4 months of age were asked a generic question about the ideal time
for introduction of complementary foods in order to assess their knowledge on this issue.
They were also asked another question specifically to understand their intention of
introducing complementary foods in their child’s diet. In both the questions, women could
give responses in actual months and/or as a “qualitative” response such as “when the child
starts teething”.

49
Slightly more than 60% of the women gave a response in actual months when asked about
their knowledge on timing of introduction of complementary feeding, while a slightly less
proportion (53%) gave a numerical response when sharing their intention in relation to their
own child.
As can be seen from the blue bars in Figure 5, only one fifth (21%) of the respondents with
children 3-4 months of age were aware about the correct time for initiation of
complementary feeding, viz. 6 months. Another 13% mentioned 7 months as the ideal age.
Contrary to popular belief that women are confused with the “mixed” messaging16
on
duration of exclusive breastfeeding and therefore initiation of complementary feeding too,
less than 2% of the women stated 4 months as the ideal time for introducing
complementary foods. On an average17
, the women stated 8 months as the ideal time for
introduction of complementary foods.
The intention of the women regarding introduction of complementary foods in their own
child’s diet differed when compared to their knowledge on this issue. As the red bars in
Figure 5 show, slightly more than one-tenth (11%) of the women actually intended to start
complementary feeding at 6 months for their child, which is almost half of those who said
that 6 months was the ideal time in response to the generic question. Another 8% stated 7
months. In contrast, 13% of the women said that they intend to start complementary
feeding at 12 months of age, while only 8% had stated that as the ideal age for
complementary feeding. The average18
age at which women with a child 3-4 months of age
at the time of the survey intended to introduce complementary foods in the child’s diet was
9.6 months.
16
The earlier international / UN guidance on breastfeeding recommended 4 months as the ideal duration for
exclusive breastfeeding, which was later changed to 4-6 months. Current guidance recommends exclusive
breastfeeding till 6 months of age, with introduction of complementary food at 6 months of age.
17
The “average” here refers to the arithmetic mean, which was calculated to be 8.0 months. The median
reading for this question was 7 months.
18
The “average” here refers to the arithmetic mean, which was calculated to be 9.6 months. The median
reading for this question was 8 months.

50
Figure 5: Knowledge and intention of mothers with a child 3-4 months of age regarding
the age / time for introduction of complementary feeding
As mentioned above, many women also gave qualitative responses (non-numerical) to these
two questions, sometimes along with a numerical response, which are described in Table
27. 13% of the women respondents said that the ideal age to start complementary feeding
is when the child is “ready”, while another 7% described this “readiness” as the child
grabbing food. Another 12% linked it to the (in) sufficiency of breast-milk as understood
from hunger cues by the child even after breastfeeding. About 12% of women did not give
any response (either numerical or qualitative) to each of these questions.
As far as their own child was concerned, more than one-fourth (26%) of the women said
that they would wait for the child to be “ready” or grab food spontaneously as a signal to
introduce complementary foods. Another 13% said that they would begin complementary
feeding when they felt that their milk was insufficient.
0.2
0.4
0.5
1.6
1.8
21
12.8
5.7
4.5
1.2
0.2
8.2
0.2
0.1
0.1
0.1
0.8
1
0.1
0.1
0.1
0.2
0.3
1.3
1
11.3
8.4
4.6
5.6
2.1
0.3
12.5
0.5
0.1
0.7
0.3
2.2
1.9
0
0.1
0
5
10
15
20
25
Knowledge of mothers – generic (N=1536) Intention of mothers for own child (N=1536)

51
Table 27: Knowledge and intention of mothers with a child 3-4 months of age regarding
the age / time for introduction of complementary feeding
Timing for introduction of
(qualitative responses)
Knowledge of
mothers –
generic
(N=1536)
Intention of
mothers for
own child
(N=1536)
When the child is “ready”
204
(13.3)
266
(17.3)
When the child is hungry even
after breast-milk
177
(11.5)
205
(13.4)
When the child starts teething
58
(3.8)
66
(4.3)
When the child grabs food
110
(7.2)
139
(9.1)
Don’t know
178
(11.6)
179
(11.7)
Numbers in parentheses indicate percentages of the “N” on top of the column, rounded off
to the first decimal.
Percentages do not add up to hundred as not all women gave “qualitative” responses and
also because multiple options were allowed as responses.
IYCF norms state that complementary feeding should be initiated when the child completes
6 months of age. In order to assess how close to this norm the actual practice was in the
project areas, mothers of children aged 6-7 months and 12-13 months were asked whether
they had initiated complementary feeding (described as giving any foods other than breast-
milk) for their child. Mothers of children 12-13 months were also asked about the actual age
of the child when they started complementary feeding.
As can be seen from Table 28, about three-fourths of children 6-7 months of age had
already started receiving foods other than breast-milk. This rose to over 90% by the time the
children turned a year old. However, the corollary of these figures is that about one in ten
children were on breast-milk only even at the age of 1 year, pointing towards grossly
insufficient nutritional intake.

52
Table 28: Status of introduction of complementary feeding for children 6-7 months of age
and 12-13 months of age.
category
Mothers of
children 6 - 7
months of age
Mothers of
children 12-13
months of age
Introduction of
complementary foods
Yes
1127
(73.4)
1390
(90.5)
No
402
(26.2)
146
(9.5)
No response
7
(0.5)
0
(0.0)
TOTAL 1536 1536
decimal.
When these rates were disaggregated by districts, it was seen that Sitamarhi had the best
result in this indicator with 82% of the mothers of 6-7 month olds stating that they had
initiated foods other than breast-milk for their child (Table 29). This was as low as 68.5% in
Muzaffarpur. However, this difference reduced by the time the children reached 12 months
of age, with all three districts showing complementary feeding rates close to 90% at that age
(Table 30).
– disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALIntroduction of
complementary foods
Yes
382
(68.5)
430
(72.4)
315
(82.0)
1127
(73.4)
No
175
(31.4)
159
(26.8)
68
(17.7)
402
(26.2)
No response
1
(0.2)
5
(0.8)
1
(0.3)
7
(0.5)
TOTAL 558 594 384 1536
decimal.

53
Table 30: Status of introduction of complementary feeding for children 12-13 months of
age – disaggregated by districts
District
Muzaffarpur Samastipur Sitamarhi TOTALIntroduction of
complementary foods
Yes
506
(90.7)
545
(91.8)
339
(88.3)
1390
(90.5)
No
52
(9.3)
49
(8.2)
45
(11.7)
146
(9.5)
TOTAL 558 594 384 1536
decimal.
Comparing the same across implementing partners, the difference is even starker. While
84% of the mothers of children aged 6-7 months have initiated complementary feeding for
their child, only 60% of the 6-7 month old children in AKRSP,I areas are receiving
complementary foods – a difference of over 24 percentage points (Table 31). However, as
with the inter-district variation, this difference reduces to non-significant19
levels when the
children turn a year old (Table 32)
– disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALIntroduction of
complementary foods
Yes
259
(67.5)
323
(84.1)
315
(82.0)
230
(59.9)
1127
(73.4)
No
124
(32.3)
57
(14.8)
68
(17.7)
153
(39.8)
402
(26.2)
No response
1
(0.3)
4
(1.0)
1
(0.3)
1
(0.3)
7
(0.5)
TOTAL 384 384 384 384 1536
decimal.
19
The words “non-significant” do not carry the usual statistical meaning here. It refers to the significance in
differences from a Project management perspective.

54
Table 32: Status of introduction of complementary feeding for children 12-13 months of
age – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALIntroduction of
complementary foods
Yes
358
(93.2)
356
(92.7)
339
(88.3)
337
(87.8)
1390
(90.5)
No
26
(6.8)
28
(7.3)
45
(11.7)
47
(12.2)
146
(9.5)
TOTAL 384 384 384 384 1536
decimal.
In order to understand the practice related to the actual timing of introduction of
complementary foods, mothers of children 12-13 months of age, who claimed to have
started the child on foods other than breast-milk, were asked when they added non-breast-
milk food items to their child’s diet. Figure 6 and Table 33 give detailed and disaggregated
(by district and implementing partner respectively) distributions of the age at which
mothers of 12-13 month olds introduced complementary foods.
It can be seen that more than one-fourth (26%) of the others report that they introduced
complementary foods before the child turned 6 months of age, with some (6%) having
started foods other than breast-milk as early as when the child was 1 month of age. Only
16% of the mothers introduced the foods at the recommended age of 6 months. Across
districts 12-13% of the women did not remember when they started the child on
complementary foods (Figure 6), while this figure varied from about 10% for AKF to 16% for
Agragami (Table 33)

55
Figure 6: Distribution of age at which complementary food was introduced (for children
currently 12-13 months of age) – disaggregated by districts
Table 33: Distribution of age at which complementary food was introduced (for children
currently 12-13 months of age) – disaggregated by implementing partners
AKF Agragami CHARM AKRSP,I TOTALAge of child at introduction of
complementary foods
1 month
11
(3.1)
33
(9.3)
27
(8.0)
14
(4.2)
85
(6.1)
2 months
14
(3.9)
37
(10.4)
12
(3.5)
17
(5.0)
80
(5.8)
3 months
8
(2.2)
36
(10.1)
20
(5.9)
26
(7.7)
90
(6.5)
4 months
9
(2.5)
19
(5.3)
18
(5.3)
12
(3.6)
58
(4.2)
0 2 4 6 8 10 12 14 16 18 20
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
11 months
12 months
Do not remember
Percentage
Muzaffarpur (N=506) Samastipur (N=545) Sitamarhi (N=339) TOTAL (N=1390)

56
5 months
9
(2.5)
16
(4.5)
14
(4.1)
15
(4.5)
54
(3.9)
6 months
73
(20.4)
56
(15.7)
40
(11.8)
49
(14.5)
218
(15.7)
7 months
52
(14.5)
31
(8.7)
29
(8.6)
63
(18.7)
175
(12.6)
8 months
44
(12.3)
29
(8.1)
46
(13.6)
34
(10.1)
153
(11.0)
9 months
43
(12.0)
13
(3.7)
49
(14.5)
29
(8.6)
134
(9.6)
10 months
25
(7.0)
15
(4.2)
25
(7.4)
17
(5.0)
82
(5.9)
11 months
14
(3.9)
6
(1.7)
7
(2.1)
7
(2.1)
34
(2.4)
12 months
22
(6.1)
8
(2.2)
8
(2.4)
11
(3.3)
49
(3.5)
Do not remember
34
(9.5)
57
(16.0)
44
(13.0)
43
(12.8)
178
(12.8)
TOTAL 358 356 339 337 1390
decimal.
From the responses received, the mean age at which complementary feeding was started by
mothers of children 12-13 months of age was calculated. As shown in Table 34, the mean
age for introduction of complementary feeding across the project was 6.4 months. While
mothers from Muzaffarpur started complementary feeding relatively late at an average of 7
months, mothers from Samastipur stated more than a month earlier at 5.8 months.
Similarly, there was a difference of two months in the average age for complementary
introduction between Agragami areas (5.3 months) and AKF areas (7.3 months)

57
Table 34: Average age of child (in months) at introduction of complementary feeding – for
a child currently 12-13 months of age
Average20
age of child (in
months) at introduction of
District wise
Muzaffarpur (n=444) 7.0
Samastipur (n=473) 5.8
Sitamarhi (n=295) 6.5
Implementing partner wise
AKF (n=324) 7.3
Agragami (n=299) 5.3
CHARM (n=295) 6.5
AKRSP, I (n=294) 6.4
OVERALL (n=1212) 6.4
The 402 and 146 mothers of children 6-7 months and 12-13 months respectively, who had
not initiated complementary feeding, were asked about the time when they intended to
initiate complementary feeding with their child. 267 (66%) and 49 (34%) women
respectively from the two groups gave their responses in actual months, the average of
which is shown in Table 35. While women with children 6-7 months of age, who had not
introduced complementary foods in their child’s diet at the time of the survey intended to
do so when the child is between 9 to 10 months, the mothers with older children preferred
to wait until about 16 months of age. However, it must be emphasised here that these
averages need to be interpreted with caution owing to the relatively few respondents in
each sub-category. For example, in the case of women with 12-13 month old child in
Agragami areas, the average has been calculated from responses of only 5 women.
20
The “average” refers to the arithmetic mean of all the responses (in months), wherein the denominator is
the mothers who had initiated complementary feeding and had given a numeric response (i.e. did not say “do
not remember”). This denominator is specified as “n” against the district or implementing partner.

58
Table 35: Average age at which mothers of children 6-7 months and 12-13 months of age,
who have not initiated complementary feeding, intent to do so
Average age of the child (in months) at which mothers intend to initiate
Mothers of children 6 - 7 months of age Mothers of children 12-13 months of age
District wise
Muzaffarpur (n= 115) 9.4 16.1 Muzaffarpur (n= 19)
Samastipur (n= 102) 9.6 16.3 Samastipur (n= 11)
Sitamarhi (n= 50) 9.7 16.1 Sitamarhi (n= 19)
AKF (n= 91) 9.2 15.4 AKF (n= 15)
Agragami (n= 32) 11.1 19.8 Agragami (n= 5)
CHARM (n=50) 9.7 16.1 CHARM (n = 19)
AKRSP, I (n= 94) 9.2 15.5 AKRSP, I (n= 10)
OVERALL (n= 267) 9.5 16.1 OVERALL (n= 49)
Mere introduction of complementary foods at the right age is not sufficient to ensure that
the dietary requirements of a child are met. In order to assess the “age appropriateness” of
complementary feeding, one needs to look into various other aspects of complementary
feeding such as the frequency of meals offered to the child, the quantity given to the child
per meal and of course the variety of foods offered in order to ensure a balanced diet. For
the children aged 6-7 months and 12-13 months who had been started on complementary
foods, questions related to each of these aspects were asked. In order to avoid recall bias,
they were asked these questions with reference to the previous 24 hours. Their responses
to these factors are presented one by one in the sections below.
b) Frequency of complementary feeding
The ideal frequency of complementary feeding varies according to the age of the child. With
reference to the PAHO (WHO) guidelines of complementary feeding, the minimum required
frequency of complementary feeding for a child 6-8 months is twice a day, with 1-2 snacks21
in between. Similarly, the minimum frequency for older age groups like 12-24 months is 3
21
“Snacks” are defined as foods eaten between meals - usually self-fed, convenient and easy to prepare, such
as a piece of fruit, bread or chapatti with nut paste etc. (PAHO)

59
times in a day (See Chapter 2 – Review of Literature for more details). However, as it is
difficult to decipher from the survey answers whether the frequency mentioned includes a
snack or only “full meals”, the minimum frequency can be taken to be 3 in 24 hours for 6-8
month olds and 4 for the older children.
As can be seen from Table 36, about a third of the mothers with 6-7 month olds who had
initiated complementary feeding could not / did not give a response about the number of
times they had given complementary foods to their child in the past 24 hours. This
proportion was only 18% for the mothers of 12-13 year olds. It must be mentioned here that
the question and response options were such that they did not allow the actual number of
meals to be mentioned, but grouped them together. Hence, when a response 3-4 times is
marked, it is difficult to say whether the child was given 3 or 4 meals in a day. Hence the
group 3-4 times in a day was taken as meeting the “minimum” frequency for both the age
groups of children. Using this understanding, only 35% of the 6-7 month olds received the
minimum of three meals / snacks, whereas 55% of the older children (12-13 months)
received the required number of meals/snacks. About 9% and 11% of the women (mothers
of 6-7 month olds and 12-13 months olds respectively) reported feeding their children five
or more meals in the 24 hours prior to the survey.
Table 36: Distribution of frequency of complementary feeding in the past 24 hours – for
children aged 6-7 months and 12-13 months
category
Mothers of
children 6 - 7
months of age
Mothers of
children 12-13
months of age
Frequency of complementary
feeding in past 24 hours
1 to 2 times
395
(35.0)
519
(37.3)
3 to 4 times
300
(26.6)
468
(33.7)
5 times
49
(4.3)
77
(5.4)
more than 5 times
49
(4.3)
80
(5.8)
Do not know / no response
334
(29.6)
246
(17.7)
TOTAL 1127 1390
decimal.

60
As can be seen from Table 37, there was not much difference in the average frequency of
complementary feeding in the 24 hours before the survey, between the two age groups of
children. While the 6-7 month olds were given 2.8 meals / snacks on an average, the
average for the 12-13 month olds was 2.9.
For the 6-7 months old children, there was not much inter-district variation in averages.
However, disaggregating data based on implementing partners revealed distinctly higher
average (3.3) in this age group in the AKRSP,I areas.
It is also interesting to note that while there is an overall project level increase in the
frequency of feeding while moving from 6-7 month to 12-13 month olds, AKRSP, I shows a
drop from 3.3 times/ day to just 2.9 times, along with Agragami which shows a drop from its
already lower than average level of 2.6 times to just 2.4 times / day, making it the lowest in
this age group.
Table 37: Average frequency of complementary feeding in the past 24 hours – for children
aged 6-7 months and 12-13 months
Average22
frequency (no. of times food was given) of complementary feeding in past
24 hours
Mothers of children 6 - 7 months of age Mothers of children 12-13 months of age
District wise
Muzaffarpur (n=282) 2.7 2.9 Muzaffarpur (n=416)
Samastipur (n=314) 2.8 2.6 Samastipur (n=482)
Sitamarhi (n=197) 2.7 3.3 Sitamarhi (n=246)
AKF (n=178) 2.4 2.9 AKF (n=269)
Agragami (n=225) 2.6 2.4 Agragami (n=295)
CHARM (n=197) 2.7 3.3 CHARM (n =246)
22
The average / arithmetic mean has been calculated by taking the mid-point of the class interval (such as 1.5
for the class interval 1-2 times), and multiplying it by the respondents, and summing it up across all numerical
categories to get the numerator. For the interval “more than 5 times”, “6” was taken as the multiplying factor.
The denominator was the total number of women who gave a response, and is specified as “n” against the
district or implementing partner.

Baseline Study on IYCF

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (11)

Similar to Baseline Study on IYCF

Similar to Baseline Study on IYCF (20)

More from Abhishek Singh

More from Abhishek Singh (9)

Recently uploaded

Recently uploaded (20)

Baseline Study on IYCF