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6.00 am: Sona breastfeeds her 4-month-old infant as she stirs tea in an aluminium vessel. While doing so, she keeps a close watch on her other children, a two-year-old boy and a six-year-old girl, busy playing with plastic toys.
7.30 am: After washing clothes and utensils, the infant is breastfed again even as Sona rolls out rotlas and prepares sabzi that the family will carry to the worksite.
8.30 am to 12.00 pm: the child is breastfed thrice: the first time, Sona breastfeeds the infant, cradled in her right arm, while walking with a cement sack (approximately weighing 50 kgs) on her head. The other two times, she uses the five-minute breaks in between the loading and unloading of cement that makeshift lifts ply from the ground floor to the third floor. If the infant wails in hunger out of turn, as if on cue, the oldest child offers her biscuits mashed in water or a lick from a juice bottle. This pattern continues for the rest of Sona’s work hours.
It is only during lunch break and at night on completion of all other household chores that the mother has an opportunity to spend more time with her infant and the other children.”
– (Abridged description from an ongoing study on breastfeeding practices among women in construction work).
Sona is well aware of the need to exclusively breastfeed her infant. It is the information that she has received repeatedly, at the anganwadi centre as well as in the hospital after childbirth. The common misconception around poor breastfeeding rates in India is that there is a lack of awareness. But it isn’t poor messaging around healthcare or outreach that is to blame.
Sona’s case is representative of the experience of a vast majority of women engaged in the informal economy – as street vendors, domestic workers, construction workers, waste pickers, among others – who lack access to basic maternity protection.
Promoting exclusive breastfeeding
In the past decade, there has been a concentrated campaign to promote exclusive breastfeeding (EBF) with an aim to counter the abysmally low rates of EBF in the country. In 2015-16, according to the National Family Health Survey-4 (NFHS), less than 55% of infants were exclusively breastfed up to six months of age. While there has been some improvement since then, vast regional variations continue to exist.
The World Health Organisation (WHO) recommends EBF – i.e. giving an infant only breast milk with no other added food or water for the first six months of life – as it provides ideal and adequate nutrition to infants, protects them from immunological infections and is critical to achieve optimal growth, development and health. For poorer households, the cost of not breastfeeding can be very steep. Infants that are not EBF are likely to be undernourished and fall ill more frequently, in turn increasing health expenditure and loss of time for paid work.
And yet, for Sona and others like her, EBF is an impracticable concept, one that is impossible to follow in the context of competing time demands for paid work, household chores and other caregiving responsibilities. The conditions at the workplace – long hours of work, no regular breaks, physically arduous tasks – reduce women’s ability to breastfeed on time and an adequate number of times. Sona’s daily routine, part of which is described at the beginning of this piece, indicates the little time she has to breastfeed her infant. This experience is shared by a majority of working women in the country that do not have access to social protection, especially maternity protection.
India’s Maternity Benefits Act, often touted as being progressive, entitles women in the formal workforce to 26 weeks of maternity leave and full wage compensation by the employer. However, this leaves behind a majority of women, especially those who are engaged in informal work where the employer-employee relationship is difficult to establish. Consequently, women are forced to return to work immediately after childbirth, sometimes as early as two to three weeks after delivery as they cannot forgo paid work, which is critical for the sustenance of their family.
While the Pradhan Mantri Matru Vandana Yojana (PMMVY), a scheme under the National Food Security Act, provides a conditional cash transfer to pregnant and lactating mothers as partial compensation for wage-loss during childbirth and initial months of breastfeeding, it remains inaccessible to most women and is also grossly insufficient.
First, the PMMVY supports the women only for the first childbirth automatically reducing its coverage; second, women find it challenging to fulfil the many conditionalities (including completion of pre-natal care, child immunisation, regular child growth monitoring and six months EBF) imposed by the cash transfer scheme; third, the cash transfer amount of only Rs 5,000 across six months is too little for women who earn approximately Rs 9,000 a month, which is the minimum wage across several sectors of work.
The assumption that the primary identity of a woman with a child is that of a mother, not that of a worker is the greatest pitfall of the PMMVY and other initiatives focused on breastfeeding. Consequently, it disregards the fact that EBF is economically costly for women as it is time-intensive and an un-substitutable form of care.
Provisions that are equivalent to what women in formal workspaces receive or a universal maternity entitlement programme is critical for women in the informal economy, which constitutes about 90% of the female labour force in this country.
Perhaps, the ongoing World Breastfeeding Week (WBW), celebrated in the first week of August each year to commemorate the Innocenti Declaration aiming to ‘Protect, Promote and Support Breastfeeding,’ is a good time to reflect on some of these serious concerns.
Divya Ravindranath is a researcher based at the Indian Institute for Human Settlements. Her work focuses on maternal and child health in the context of informal work.