Breast crawl as a strategy to ensure more newborns breastfeed within an hour after birth

The Hindu

5 days ago

Earlier this year, I was preparing to give birth. During an antenatal visit to the gynaecologist, my partner and I requested two things: that our newborn do the breast crawl, and we initiate breastfeeding within the 'golden hour' or the first hour of birth (some recommend breastfeeding within 30 minutes). While skin-to-skin contact with the mother and initiating feeding within the first hour is standard practice in most places, including where I delivered– a maternity home in Chetpet, Chennai – breast crawl isn't common. Most parents or parents-to-be are unfamiliar with it.
What is breast crawl?
A newborn will slowly crawl, unassisted, toward the breast while they are skin-to-skin with their mothers. This can take 30 to 60 minutes when uninterrupted. In most cases of normal delivery and in some C-sections, when a baby is on their mother's chest, the breast odour will encourage the baby to move towards the nipple, and the baby will latch for feeding.
This practice of breast crawl and skin-to-skin is recommended and promoted by the Baby Friendly Hospital Initiative (BFHI), supported by the World Health Organisation (WHO) and UNICEF, as well as the Breastfeeding Promotion Network of India (BPNI), a network of organisations and individuals promoting breastfeeding. However, breast crawl is not a part of standard medical or health curriculum, an FAQ prepared by BHFI Maharashtra and UNICEF notes. This World Breastfeeding Week, which is held every year from August 1 to August 7, and is supported by the WHO, let us understand the importance of practices that can initiate breastfeeding within the golden hour.
Also Read: Breastfeeding Week: Dated wisdom, lactation stigma still assail mothers
The importance of the golden hour
Studies show breast crawl and uninterrupted skin-to-skin contact are free and cost-effective interventions to increase the exclusive breastfeeding rate and improve breastfeeding success rates. It regulates a newborn's body temperature, leads to faster and effective achievement of feeding skills, enables the baby to get colostrum as the first feed (colostrum has a high concentration of antibodies), and colonises the baby with safe germs from the mother. It also reduces anxiety among mothers, reduces pain and improves behavioural responses from women during episiotomy suturing.
India has some of the lowest rates of feeding within an hour of birth: only 41.8% babies are breastfed within an hour of their birth as per the National Family Health Survey (NFHS)-5. India ranked 46 out of 76 countries on the Global Breastfeeding Scorecard in 2018.
I learnt of newborn breast crawl from a Lamaze childbirth education workshop and from UNICEF Maharashtra's documentary film on the practice.
'The moment you put the baby on the breast without any interventions, you are pushing the baby towards that goal of initiation (of breastfeeding) within one hour, which is natural,' said Prashant Gangal, paediatrician and training coordinator of the mother support group, BPNI Maharashtra.
He has been a champion of the practice in Maharashtra and documented it in the UNICEF film used for training healthcare workers on breast crawl. BPNI Maharashtra has trained hundreds of healthcare workers in government hospitals with the support of the Maharashtra government and UNICEF.
Tarun Kurian, obstetrician-gynaecologists who handled my pregnancy, and Divya U.S., a lactation and infant feeding specialist, were supportive of our request. It would be their first, they admitted.
After almost a day-long labour, when my daughter was born vaginally, she was placed on my chest. In a few moments, she was calmer and started wiggling her way up on my torso. However, she didn't finish the crawl. But the nursing staff and Ms. Divya helped us initiate breastfeeding within the hour.
Team effort and motivation
'A lot of these things for me, at least, I leave it up to the patient. If the patient is motivated, and it is medically safe, I am willing to do it,' noted Dr Kurian. 'So you need both the gynaecologist and a patient who is motivated to do these things,' he said.
Breast crawl is a team effort: paediatricians, OBGYNs, and nursing staff need to be on the same page, and it can only be attempted if the medical conditions of the baby and mother are suitable for it, he pointed out.
Since then, the hospital has tried the breast crawl in a few more cases with varying levels of success, Ms. Divya said. It may seem new to obstetricians and paediatricians, as it is not covered in their curriculum, Dr Kurian said. While doctors may be hesitant the first few times, once they try it a couple of times and they know it is medically safe they may want to adopt the practice if the patient is also willing and informed, he added.
'As doctors, we prioritise patient safety and think of worst-case scenarios. It is ingrained in us,' Dr. Kurian pointed out. That mindset may prevent more doctors from trying it out. Several other experts said that while breast crawl is ideal, it is not always possible.
Constraints and lack of awareness
Vijaya Krishnan, a certified midwife and a lactation professional, and founder, Sanctum Birth Centre in Hyderabad, advocates for the practice but also notes that not all birthing mothers and babies can achieve it. There are several practical and systemic constraints, such as hospital procedures, as well as a lack of awareness.
Dr. Gangal said some precautions that need to be taken are ensuring both mother and baby are kept warm and that the mother has the support of a partner or nursing staff to prevent the baby from falling. Those who wish to attempt the breast crawl can discuss it during antenatal counselling; however lack of awareness amongst hospital staff to do this appropriately is a huge barrier.
Dr. Krishnan advocated for the practice but is against glorifying it. 'When we glamourise it, they (parents) want the baby to crawl and finish being done in 10 minutes, and that doesn't happen. So then you are just forcing it,' she said. The focus should be to ensure skin-to-skin contact, she explained, and for those who can do the breast crawl, then that's a bonus.
Also Read: 'Breastfeeding a challenge for over 70% of mothers'
Systemic failure
Breast crawl is a far cry in a system where babies aren't getting appropriate skin-to-skin contact immediately after birth, and when one in two babies aren't able to breastfeed within an hour of birth, said Arun Gupta, Director of BPNI. 'I am not discounting the role of crawl, but it may be difficult for every baby in a hospital where thousands of babies are born,' he said. Instead, the practice of uninterrupted skin-to-skin and breastfeeding within an hour of birth should be mandated wherever possible.
According to NFHS-5, skin-to-skin contact immediately after birth is at 76% in India (there's no data on breast crawl). Moreover, what kind of skin-to-skin contact is done, whether it is uninterrupted or not, is also not clear.
'I don't see if (over 76%) babies get skin-to-skin immediately after birth, why only 41% initiate breastfeeding within an hour,' Dr. Gupta said. He reckoned that either there was a discrepancy in the data or the question was misinterpreted by the respondents.
'Skin-to-skin contact and initiation of the first breastfeed should not be separated. They are inseparable,' Dr Gangal said. Skin-to-skin should mean not just touching the baby but until the first feed and for as much as possible within the first hour of birth. He said some hospitals just place the baby in contact with the mother before separating them and call it skin-to-skin.
A missed opportunity?
UNICEF, in a press note, has noted that this is a 'missed opportunity to ensure that all children benefit from early breastfeeding – a life-saving intervention. Children who are not breastfed within one hour of birth have a 33 % higher risk of neonatal mortality.'
In a developing country, skin-to-skin contact and initiation of breastfeeding within an hour is a must, and should be the bare minimum, said Dr. Krishnan. A delay in breastfeeding can lead to issues with lactation and force mothers to turn to formula feeds.
Most babies born in poor families need as much of the immunity that breastmilk and colostrum can provide. They need that first feed from the mother so that they don't have to seek out other formulas and milk banks. She said, 'For poor families, drinking water and sanitation is a big problem. How much will you sterilise a bottle in a typical government hospital?'
The Global Breastfeeding Scorecard notes that breastfeeding acts as a baby's 'first vaccine' by protecting against diseases such as diarrhoea and pneumonia, which helps prevent nearly 6,00,000 child deaths each year. It also benefits the mother, reducing her future risk of breast and ovarian cancers and non-communicable diseases.
Despite nearly 90% deliveries occurring in health facilities, if babies aren't being breastfed within an hour of birth, it is a failure of health systems, Dr. Gupta said.
Hurdles in the current system
According to Dr. Gangal, paediatricians are the first hurdle, as they take the baby away from the mother for assessments. Other experts also said that some assessments can be done while the baby is on the mother. In cases where both mother and child are low-risk, certain tests can be deferred for later as well. However, healthcare staff aren't trained for this.
The second hurdle, he said, is that the hospital staff want to move the mother to the room before initiating the feeding. 'In all of this, the initial firepower of the baby is lost.'
'We're slowly training, talking to paediatricians on how routine care can be done at the breast or on the abdomen while the baby is still skin-to-skin, or certain practices such as weight checks can always be done a little later,' said Ms. Divya.
The increasing number of C-sections and privatisation of healthcare also hinders these efforts, Dr. Gupta added.
C-sections and early initiation issues
Experts point out that the rise in C-section rates prevents the early initiation of breastfeeding. According to UNICEF, C-section rates have continually risen globally over the past decade, and in many countries, early initiation of breastfeeding is significantly lower in newborns delivered by C-section.
The prevalence of C-sections across India increased from 17.2% to 21.5% in the five years leading up to 2021, according to NFHS-5. In the private sector, this was 49.7% in 2021, which is nearly one in two deliveries.
Mothers who deliver by C-section usually face multiple challenges after childbirth, like managing the effects of anaesthesia or recovering from surgery. UNICEF advocates for training birth attendants, putting breastfeeding policies in maternal wards, and involving fathers in breastfeeding to ensure newborns delivered by C-section can be put to the breast within the first hour.
The role of antenatal counselling
Experts said antenatal counselling can also create awareness about skin-to-skin contact and newborn breast crawl, allowing parents to have the option to choose it, if possible. It is also crucial to highlight the importance of breastfeeding within an hour of birth, as well as exclusive breastfeeding for the first six months at this stage.
Dr. Kurian said antenatal counselling is crucial, but gynaecologists have limited time to guide parents if they are not informed and have not done their research. One way to achieve this is to have group counselling or seek the support of lactation consultants and trained doulas who can guide parents-to-be. However for many, this isn't viable either due to economic constraints.
Dr. Gangal who conducts group counselling for mothers from across socio-economic groups said parents-to-be need to sit with and absorb this information ahead of delivery so they can advocate for themselves.
(Mahima Jain is an independent journalist covering the socio-economics of health, gender and environment. [e-mail])