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IUNS 20 th International Congress of Nutrition, Granada. September 15-20, 2013

IUNS 20 th International Congress of Nutrition, Granada. September 15-20, 2013. Panel: Scaling Up Nutrition to Improve Infant and Y oung Child Feeding . Factors Contributing to the Dramatic Rise in Exclusive Breastfeeding in Bangladesh.

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IUNS 20 th International Congress of Nutrition, Granada. September 15-20, 2013

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  1. IUNS 20th International Congress of Nutrition, Granada. September 15-20, 2013 Panel: Scaling Up Nutrition to Improve Infant and Young Child Feeding Factors Contributing to the Dramatic Rise in Exclusive Breastfeeding in Bangladesh Tina G. Sanghvi PhD, Alive & Thrive Country Programs Director

  2. Overview • Question: Can DHS data be utilized to understand national IYCF trends? • Background • Trend in EBF in Bangladesh from 1993-94 to 2011 • National BF program timelines • Methods • Pattern of Exclusive Breastfeeding (EBF) in 2007 and 2011 DHS surveys • Individual & household (HH) characteristics associated with EBF in 2007 and 2011 • Results & Interpretation

  3. Background

  4. Trend in EBF in Bangladesh Percentage of women reporting EBF Years Source: Bangladesh DHS, 2011

  5. Evolution of national BF policies & programs Bangladesh Nutrition Programs BINP, NNP … NNS Media Social Mob. Bangladesh Breastfeeding Foundation (BBF) advocacy & trg. Maternity Leave 3 --> 4-->6 months BF Counseling Scaling up of BF support nationally through Nutrition /IYCF & Maternal Newborn, Child Health (MNCH) programs Baby Friendly Hospitals (BFHI) – declined >2001 IYCF Str. Com. Plan 1984 Ordinance XXXIII on Regulation of BreastmilkSubstitutes (Code ) amended 1990 % EBF in national surveys 96-97 93-94 99-00 2011 2004 2007 Years Source: UNICEF Bangladesh Case Study by Luann Martin; DHS Reports

  6. Number of HW trained 2010-2011 Cumulative Number of HW HW: Health workers, including incentivized volunteers and doctors Training: 5-day course; 2.5 days for MNCH Source: A&T Monitoring data for the National Alliance, 2013

  7. Number of times Breastfeeding TVCs aired Cumulative Number of airings Sources: Asiatic, Unitrend Media buy records

  8. Recall of breastfeeding TVC messages Percent n=454 n=251 n=85 n=535

  9. Methods

  10. DHS 2007 & 2011 Analysis Aims: To understand increased national levels of exclusive breastfeeding; use of DHS data Outcome indicator: 24-hour recall/current status of feeding in infants 1-180 days of age (WHO) Population: Mothers of infants <6months Objectives: • To identify patterns & factors associated with EBF in 2007 and 2011 • To determine factors that contributed to improvements in EBF levels in 2011

  11. Conceptual framework Infant factors Policies & laws Mothers’ knowledge, beliefs, skills & environ-ment Maternal factors Community-level programs Exclusive BF Facility-based programs Household factors Mass media Community factors

  12. Variables tested

  13. Multivariate analysis • An initial set of variables was selected based on our conceptual framework • A logistic regression model run with variables significantly associated (p<0.15) with EBF in the bivariate analysis • Models account for sampling weights and the sampling design. Adjusted percentages and unadjusted n’s are shown • Backward selection was used to remove variables p>0.10 • Factors associated with EBF, changes in the direction of associations, changes in size of the effect from 2007 to 2011, and interactions with other factors (e.g., rural vs. urban)

  14. Results

  15. EBF across regions of Bangladesh Percentage of women reporting EBF Median duration of EBF increased from 1.8 in 2007 to 3.5 months in 2011

  16. EBF across sub-groups Percentage of women reporting EBF Residence Sex of child Mother’s education Wealth index

  17. Infant feeding by age (months) Percentage of women reporting feeding -EBF improved in the 4 to 5 month age group also -Did reduced milk use account for the rise in EBF?

  18. Examples of differences between 2007 & 2011

  19. Adjusted odds of EBF by sample characteristicsfound to be significant

  20. Limitations • EBF - Socially desirable response influenced by: • Interpersonal contacts • Community mobilization & national advocacy • Mass media: high intensity, national coverage • Absence of program exposure indicators • DHS has coverage for others but not IYCF programs • Sample size inadequate for subgroup analyses • Question modified

  21. Summary of results • Factors significantly associated with EBF in both 2007 and 2011: regions (rural areas), younger infant, delivery in a facility in rural areas, no pre-lacteals. • There was a significantly higher proportion of mother/infants in these categories in 2011 (except for regions) • Lack of coverage indicators does not permit firm conclusions about program influences on national indicators

  22. Implications • Program coverage indicators collected at national level e.g. through DHS would facilitate a better understanding of what drives EBF • Global agencies’ inclusion of infant and young child feeding coverage indicators would help scaled up IYCF programs to better assess their progress • Country teams should advocate for the inclusion of these indicators in upcoming DHS and other national surveys • Continue & replicate successful Bangladesh strategy

  23. Acknowledgements • DHS multivariate analysis team • Mackenzie Green, Research Associate FHI 360, NC • Mario Chen, Associate Director of Biostatistics FHI 360, NC • BRAC IYCF interventions & timelines • KaosarAfsana,Director HNPP • RaisulHaque, Coordinator HNPP (Nutrition) • MorshedaChowdhury, Coordinator HNPP (MNCH) • National IYCF Alliance reach & timeline • National IYCF Alliance (GOB/DGHS/IPHN) mapping team • Sumitro Roy & A&T monitoring team • KuntalSaha, IFPRI/A&T Bangladesh team leader

  24. Thank you!

  25. Examples of questions for DHS • Interpersonal coverage • Did any health worker or doctor talk to you about breastfeeding or complementary feeding in the past 3 months? • Mass media coverage • Did you see or hear or read [any, or visually aided] information on TV, radio, newspapers in the past 3 months about the importance of exclusive breastfeeding for six months or how to feed CF to children from 6 to 24 months ? • Coverage during ANC • During your ANC visits did anyone talk to you about when to initiate BF after delivery, or the importance of not feeding anything else except colostrum or breastmilk in the first few days after delivery? • Coverage after delivery/PNC • After delivery did any health worker help you to place your newborn baby on your breast or teach you how to hold the baby for proper breastfeeding, or how to relieve common difficulties? • [5. Exposure to conflicting advice] ?? • Did any health worker or doctor at the time of delivery or at any time in the first 6 months after the child's birth suggest that other milk or formula should [also] be fed to your baby?  

  26. Acronyms • A&T – Alive & Thrive initiative • ANC – Antenatal care • BBF – Bangladesh Breastfeeding Foundation • BFHI - Baby-Friendly Hospital Initiative • BMS – Breastmilk substitutes • BRAC – Name of largest national NGO • CHW – Community health worker • DHS – Demographic and Health Surveys • EHC- Essential health Care program of BRAC • FP – Family planning • HW – Health worker • Manoshi- BRAC’s urban MNCH program • MNCH-Maternal, Newborn and Child Health program • NNP- National Nutrition Program • PNC – Postnatal care

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