An integrated nutrition and health program package on IYCN improves breastfeeding but not complementary feeding and nutritional status in rural northern India: A quasi-experimental randomized longitudinal study

Abstract

Background: Undernutrition below two years of age remains a major public health problem in India. We conducted an evaluation of an integrated nutrition and health program that aimed to improve nutritional status of young children by improving breast and complementary feeding practices over that offered by the Government of India's standard nutrition and health care program.

Methods: In Uttar Pradesh state, through multi-stage cluster random sampling, 81 villages in an intervention district and 84 villages in a comparison district were selected. A cohort of 957 third trimester pregnant women identified during house-to-house surveys was enrolled and, following childbirth, mother-child dyads were followed every three months from birth to 18 months of age. The primary outcomes were improvements in weight-for-age and length-for-age z scores, with improved breastfeeding and complementary feeding practices as intermediate outcomes.

Findings: Optimal breastfeeding practices were higher among women in intervention than comparison areas, including initiating breastfeeding within one hour of delivery (17.4% vs. 2.7%, p<0.001), feeding colostrum (34.7% vs. 8.4%, p<0.001), avoiding pre-lacteals (19.6% vs. 2.1%, p<0.001) and exclusively breastfeeding up to 6 months (24.1% vs. 15.3%, p = 0.001). However, differences were few and mixed between study arms with respect to complementary feeding practices. The mean weight-for-age z-score was higher at 9 months (-2.1 vs. -2.4, p = 0.0026) and the prevalence of underweight status was lower at 12 months (58.5% vs. 69.3%, p = 0.047) among intervention children. The prevalence of stunting was similar between study arms at all ages. Coefficients to show the differences between the intervention and comparison districts (0.13 cm/mo) suggested significant faster linear growth among intervention district infants at earlier ages (0-5 months).

Interpretation: Mothers participating in the intervention district were more likely to follow optimal breast, although not complementary feeding practices. The program modestly improved linear growth in earlier age and weight gain in late infancy. Comprehensive nutrition and health interventions are complex; the implementation strategies need careful examination to improve feeding practices and thus impact growth.

Trial registration: The trial was registered with ClinicalTrials.gov, NCT00198835.

Conflict of interest statement

Competing Interests: UK and DNC managed the intervention but had no direct involvement in the evaluation. All other authors had no conflict of interest.

Figures

Fig 1. Flow chart of subject selection and follow-up*.

* Still births, died, migrated are cumulative numbers ℗ Purposively selected blocks based on geographical location due to cohort nature of the study ® Random selection of sectors and AWCs → Single arrow demonstrates permanent removal from the subsequent visits due to death or migration ↔ Double arrow shows refusal or ‘not available’ and may or may not be a part of subsequent visits ‘Not available’ were not at home at the time of scheduled visits. They were visited twice for two subsequent weeks after first scheduled visit before assigning this status for the visit.

Fig 2. Locations of Barabanki (green) and Unnao (yellow) study districts in Uttar Pradesh (pink).

Lightly shaded states show locations of CARE-India’s INHP II programs.

Fig 3. Complementary feeding practice outcomes from 9 to 18 months of age based on 24-hour recalls collected at different ages.

* Statistical testing result comparing intervention and comparison districts by chi square for contingency presentations, with r-1 x c-1 degrees of freedom where r = number of comparison groups (r = 2) and c = number of strata for each comparison (c = x), significant at: *p1 Reported consumption of at least 300gm of solid or semi-solid food at 9 mo and at least 400gm of food at 12, 15 and 18 mo visits 2 Reported consumption of solid or semi-solid food at least 3 or more times at 9 mo and at least 4 or more times at 12, 15 and 18 mo visits 3 Estimated on the basis of reported consumption of 3 or more food groups 4 Estimated on the basis of reported consumption using all the three indicators of age-appropriate complementary feeding, i.e., frequency and variety

Fig 4. Variety of complementary food being consumed based on 24-hour recall at different ages.

1 Statistical testing result comparing intervention and comparison districts by chi square for contingency presentations, with r-1 x c-1 degrees of freedom where r = number of comparison groups (r = 2) and c = number of strata for each comparison (c = x), significant at: *p<0.05. **p<0.01 and ***p<0.001.