Sarita, 27, could not exclusively breastfeed her sons – now four and eight years old – for the recommended first six months despite having a normal institutional delivery. She works as a domestic help in Rajendra Nagar, Central Delhi. Her husband drives for a ride-hailing platform and does odd jobs like washing cars and serving at weddings to support the family.
“I returned to work within two months of my delivery and had no option but to start infant formula before my sons turned six months. If I did not work, we would not be able to pay rent or meet our living expenses. There are additional costs with every new birth. Besides, my in-laws live with us and are financially dependent on us,” she said.
Sarita is one of the growing number of mothers in India who are unable to exclusively breastfeed (EBF) their infants for the recommended six months.
Lactation management units provide breastfeeding support and donor human milk for premature and unhealthy newborns when mother’s milk is not available. | Photo courtesy: Ramakrishna ji
Why does EBF matter?
EBF is considered one of the most effective interventions to ensure child survival and healthy development. Mother’s milk provides all the nutrients the baby needs during the first six months of life. It contains antibodies that protect against common childhood illnesses like diarrhea and respiratory infections, support healthy growth and brain development, and reduce the risk of malnutrition and infant mortality.
For mothers, breastfeeding helps with recovery after childbirth and reduces the risk of breast and ovarian cancer.
Because it is safe, hygienic and cost-effective, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend starting breastfeeding within an hour of birth and continuing it for the first six months.
As a result, EBF trends are closely monitored in India’s National Family Health Survey (NFHS) as they are important indicators of child health, nutrition and overall public health progress. Low EBF rates may adversely impact child nutrition, increase infections and health care costs, and slow progress in reducing child mortality.
The latest NFHS-6 indicates worrying trends.
Health workers creating awareness on the importance of breastfeeding. | Photo Credit: V Raju
alarming decline
Despite 90.6% of deliveries in the country now being institutionalised, fewer infants are exclusively breastfed during the first six months after birth. Although early initiation of breastfeeding has increased from 41.8% to 50.1% as per NFHS-6 (2023-24), EBF has declined from 63.7% to 55.8% in NFHS-5 over the same period.
NFHS-6 data shows the sharpest decline in exclusive breastfeeding in India’s largest states. In Uttar Pradesh, EBF fell from 59.7% to 34.6%, while in Haryana it fell from 69.5% to 41.2%. Delhi also saw a decline from 64.3% to 54%. A decline was also recorded in Rajasthan and Madhya Pradesh.
In contrast, improvement in EBF rates was recorded in Kerala, Gujarat and West Bengal.
What is also worrying is that, according to the survey, the decline in EBF was observed in both urban and rural India, but was sharper in rural areas, where breastfeeding rates have traditionally been stable.
The data shows that EBF among infants under six months of age in rural areas has fallen from 65.1% to 56.2%. In urban areas it decreased from 59.6% to 54.5%.
a contradiction
What makes this decline particularly shocking is that it comes at a time when India has made significant progress in maternal and child health.
Early breastfeeding has improved, maternity benefits have expanded, and women are more financially and digitally empowered than ever before. NFHS-6 also points to substantial improvement in women empowerment. About 89% of women now participate in major household decisions while a similar number of women operate their own bank accounts. Digital inclusion has expanded rapidly, with Internet usage among women increasing from 33.3% in NFHS-5 to 64.3% in NFHS-6. Yet fewer babies are being exclusively breastfed during the first six months.
“Declining EBF despite these improvements indicates that empowerment alone may not be enough. Increasing economic pressures, informal employment, lack of maternity protection, inadequate workplace support and limited postpartum support are hampering the ability of many mothers to exclusively breastfeed their infants for the recommended first six months,” said pediatrician and public health advocate Arun Gupta, known for his decades-long campaign to promote breastfeeding.
Barriers to EBF
Health experts, particularly in rural India, attribute the decline to increased migration and seasonal labour, early return to agriculture and informal work, changing family structures, erosion of traditional support networks, greater access to packaged foods and formula products, weak postpartum counselling, and increasing cesarean deliveries.
A sharp increase in C-section rates – from 21.5% to 27.2%, which accounts for more than half of all births in private hospitals – has also been cited as a contributing factor.
Breastfeeding advocates say that surgical delivery can make it more challenging to initiate and continue breastfeeding early, especially in the absence of adequate breastfeeding support after delivery.
Anil Bansal, member, Delhi Medical Association, said, “Common medical reasons for not being able to breastfeed exclusively include delayed initiation of breastfeeding after delivery, especially after C-section; perceived or actual low milk supply; lack of breastfeeding counseling and family support; maternal illness or complications; and difficulties faced by premature or low birth weight infants.”
Increasing urbanization, changing lifestyle, inconsistent maternal benefits and marketing of infant formula are leading many families to introduce formula milk or complementary foods earlier than the recommended time.
Experts say cultural practices such as giving water, honey, animal milk or other pre-lacteal feed before six months may also reduce potential EBF benefits.
32 year old Vandana became a mother four years ago. An HR consultant in a private firm, she was unable to exclusively breastfeed her child for the recommended six months.
“After my C-section, despite attempts at skin-to-skin contact, breastfeeding support and frequent feedings, I could not produce enough milk to meet my baby’s nutritional needs. Supplementation became necessary,” she said, adding that early counseling may have helped her case.
Most mothers are aware of the benefits of breastfeeding, but successful breastfeeding often depends on access to maternity leave, family support, counseling and breastfeeding support.
Some hospitals provide pasteurized donor human milk, especially for premature and unwell newborns. | Photo Credit: Handout E-mail
alternative food
When breastfeeding is not possible, WHO recommends infant formula as an alternative. Some hospitals also provide pasteurized donor human milk, especially for premature and unwell newborns. However, public health experts emphasize that formula is meant to be an alternative when breastfeeding cannot be continued, not a replacement for breast milk.
Experts say that raw cow’s milk, goat’s milk and plant-based milk are generally not suitable as main foods for babies under 12 months of age as they do not provide the right balance of nutrients and may be difficult for babies to digest.
policy measures
In India, the government promotes breastfeeding through a combination of health services, counselling, maternity benefits and nutrition programmes, including the Pradhan Mantri Matru Vandana Yojana and integrated child development services. Additionally, comprehensive breastfeeding management centers and breastfeeding management units provide breastfeeding support and donor human milk for premature and unhealthy newborns when mother’s milk is not available.
India also has the Infant Milk Substitutes (IMS) Act, one of the strongest laws in the world that restricts the promotion of infant formula and protects breastfeeding from commercial marketing pressure.
However, Dr Gupta said aggressive marketing of infant formula and alternatives could still undermine breastfeeding and should be strictly regulated. He also said that breastfeeding should begin within an hour of birth and continue with complementary feeding until two years and beyond. “Breastfeeding promotion should be viewed as a public health measure, not just an individual lifestyle choice,” she said.
According to Dr. Gupta, breastfeeding is one of the most cost-effective public health interventions, even though the data highlights the gap between policy success and actual reality.
While India has invested heavily in promoting institutional deliveries, maternity benefits and child nutrition programmes, EBF rates continue to decline. Data suggests that getting mothers safely through labor may be only half the challenge; Ensuring that they have the time, financial security, workplace support and family support needed to exclusively breastfeed for six months is an incomplete task.
A breastfeeding room. | Photo Courtesy: Thangarathinam N
informal sector
Women employed in the organized sector are entitled to 26 weeks of paid maternity leave under the Maternity Benefit Act, 1961, amended in 2017.
Unfortunately, these protections are largely limited to the organized sector. Many women working in the informal sector return to work soon after childbirth.
According to the e-Shram portal, the national database of unorganized workers, more than 16.69 crore women were registered as workers in the unorganized sector by 2025.
Additionally, the periodic labor force survey shows that most working women are self-employed, casual workers, agricultural workers, domestic workers, home-based workers or are employed in small informal enterprises. The Ministry of Labor and Employment has consistently noted that women’s employment is concentrated in the informal economy. As a result, maternity leave, breastfeeding leave, crèche facilities and breastfeeding rooms are out of reach for most working women.
Health experts say this disconnect raises a fundamental policy question: Can India expect mothers to exclusively breastfeed for six months, when most get neither income support nor workplace protections during that period?
Shweta, 25, mother of a five-year-old girl, said that many women working with her in a garment factory in Noida are not able to exclusively breastfeed their children.
“Rising inflation and the fact that we work on contract does not give us the luxury of taking long leave. We are daily wage laborers and are paid according to the amount of work we complete. My husband is an autorickshaw driver. If my husband and I stop working, it becomes difficult to meet household expenses, including rent,” said Shweta, who has decided not to have more children.
“Our aim is to provide the best possible education to our daughter and ensure that she has a better life than us,” he said. He said that no one in his family has completed schooling.
Dr Gupta says there is a need to strengthen maternity benefits and breastfeeding support systems, especially for women working in the informal sector.
According to Dr Bansal, while policies and hospitals can help promote breastfeeding, maintaining EBF for six months largely depends on what happens after the mother leaves the delivery ward.
Dr. Bansal said, “India recommends six months of exclusive breastfeeding and guarantees 26 weeks of paid maternity leave. But this benefit largely applies to women in formal employment. For most women working in agriculture, domestic work, construction and other informal occupations, breastfeeding recommendations often collide with economic reality, and these women, who most need support, are often the least likely to receive it.”
bindu.p@thehindu.co.in
Edited by Vibhuti Bhatnagar
