Upload
prisca
View
51
Download
0
Embed Size (px)
DESCRIPTION
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. - PowerPoint PPT Presentation
Citation preview
IUNS 20th International Congress of Nutrition, Granada. September 15-20, 2013
Factors Contributing to the Dramatic Rise in Exclusive Breastfeeding in Bangladesh
Tina G. Sanghvi PhD, Alive & Thrive Country Programs Director
Panel: Scaling Up Nutrition to Improve Infant and Young Child Feeding
IUNS 20th International Congress of Nutrition, Granada
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
Background
IUNS 20th International Congress of Nutrition, Granada
YearsSource: Bangladesh DHS, 2011
93-94 96-97 99-00 2004 2007 20110
20
40
60
80
100
46 45 46 42 43
64
Perc
enta
ge o
f wom
en re
porti
ng E
BF
Trend in EBF in Bangladesh
IUNS 20th International Congress of Nutrition, Granada
BF Counseling
1984 Ordinance XXXIII on Regulation of Breastmilk Substitutes (Code ) amended 1990
YearsSource: UNICEF Bangladesh Case Study by Luann Martin; DHS Reports
Evolution of national BF policies & programs
200493-94 2011
Bangladesh Breastfeeding Foundation (BBF) advocacy & trg.
Bangladesh Nutrition Programs BINP, NNP … NNS
IYCF Str. Com. Plan
Baby Friendly Hospitals (BFHI) – declined >2001
Maternity Leave 3 --> 4-->6 months
% EBF in national surveys
Social Mob.Scaling up of BF supportnationally through Nutrition /IYCF & Maternal Newborn, Child Health (MNCH)programs
96-97 99-00 2007
Media
IUNS 20th International Congress of Nutrition, Granada
Number of HW trained 2010-2011
2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q40
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
6,630 11,000
13,800
28,000
44,500
Num
ber o
f HW
Cumulative
Source: A&T Monitoring data for the National Alliance, 2013
HW: Health workers, including incentivized volunteers and doctorsTraining: 5-day course; 2.5 days for MNCH
IUNS 20th International Congress of Nutrition, Granada
Number of times Breastfeeding TVCs aired
2010-Q4 2011-Q1 2011-Q2 2011-Q30
100200300400500600700800900
1000
4
349
532
917Cumulative
Sources: Asiatic, Unitrend Media buy records
Num
ber o
f airi
ngs
IUNS 20th International Congress of Nutrition, Granada
Recall of breastfeeding TVC messages
2011
Jul
2011
Aug
2011
Sep
t-N
ov
2011
Sep
t-N
ov
Mothers Sylhet Mothers Manikganj CHW-SS CHW -PK
0
10
20
30
40
50
60
70
80
30
4944
69
28
5044
73TVC BF InitiationTVC EBF 6 m
n=535 n=454 n=251 n=85
Perc
ent
Methods
IUNS 20th International Congress of Nutrition, Granada
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 <6monthsObjectives:• To identify patterns & factors associated with EBF in 2007 and
2011• To determine factors that contributed to improvements in EBF
levels in 2011
IUNS 20th International Congress of Nutrition, Granada
Conceptual framework
Mass media
Infant factors
Householdfactors
Communityfactors
Maternal factors
Facility-based programs
Community-level programs
Policies & laws
Mothers’ knowledge,
beliefs, skills &
environ-ment
Exclusive BF
IUNS 20th International Congress of Nutrition, Granada
Variables testedMaternal factors Age, education, employment status,
age at marriage, height, place of delivery, contact with CHW, contact with HW, C-section, TV viewing, birth interval
Infant factors Age, sex, birth order
Household factors Wealth quintile, oral contraceptive use
Community factors Rural/urban, region
Feeding practices Initiation < 1 h, pre-lacteal feeding
Program exposure Not available
IUNS 20th International Congress of Nutrition, Granada
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)
Results
IUNS 20th International Congress of Nutrition, Granada
EBF across regions of Bangladesh
Barisal Dhaka Khulna Rajshahi+ Sylhet Chittagong All 0
10
20
30
40
50
60
70
80
90
2935
39 41
5157
43
5358
68 6570 69
64
2007 2011
Median duration of EBF increased from 1.8 in 2007 to 3.5 months in 2011
Perc
enta
ge o
f wom
en re
porti
ng E
BF
IUNS 20th International Congress of Nutrition, Granada
EBF across sub-groups Ru
ral
Urba
n
Poor
est
Poor
er
Mid
dle
Rich
er
Rich
est
No
educ
ation
Prim
ary
Seco
ndar
y or
hig
her
Mal
e
Fem
ale
Wealth index Highest education completed
Sex of infant
0
20
40
60
80
100
44 4046
36 3744
57
3646 44
37
50
64 6457
62 6772
6256
6367 64 65
2007 2011
Residence Wealth index Mother’s education Sex of child
Perc
enta
ge o
f wom
en re
porti
ng E
BF
IUNS 20th International Congress of Nutrition, Granada
Infant feeding by age (months)
<2 2-3 4-5 <2 2-3 4-5 <2 2-3 4-5EBF BF + other milk BF + water
0
10
20
30
40
50
60
70
80
90
64
52
2317
2416
10 12 16
84
71
37
913
31
610
17
2007 2011
Perc
enta
ge o
f wom
en re
porti
ng fe
edin
g
-EBF improved in the 4 to 5 month age group also-Did reduced milk use account for the rise in EBF?
IUNS 20th International Congress of Nutrition, Granada
Examples of differences between 2007 & 2011
Variable 2007 (n=505) 2011 (n=786) Change
% n % nAge of infant (mean months) 2.9 505 2.5 786 -0.4
Delivery in a facility 19.0 106 34.1 291 15.2
C-section delivery 10.4 54 20.3 167 9.9
Early initiation <1 hr 41.8 204 47.6 373 5.8
Prelacteal feeding <3 d 54.3 265 35.8 258 -18.5
Secondary education 47.7 247 54.8 443 7.1
Working for pay 15.6 75 5.3 43 -10.3
IUNS 20th International Congress of Nutrition, Granada
Adjusted odds of EBF by sample characteristicsfound to be significant
Variable Category Odds Ratio 95% CI p-valueAge of infant Month 0.55 0.49, 0.60 <0.001
Region, ruralBarisal Ref grp
Chittagong 3.25 1.67, 6.27 <0.001
Rajshahi (& Rangpur) 2.50 1.36, 4.61 0.003
Sylhet 2.94 1.49, 5.80 0.002Location of
delivery, ruralFacility location Ref grp
Home 0.62 0.38, 0.99 0.045
Prelacteal feeding, <3 d
No Ref grpYes 0.55 0.38, 0.73 <0.001
Note: In 2011 younger women were more likely to breastfeed exclusively, however, this change was only marginally significant (p<0.10)
IUNS 20th International Congress of Nutrition, Granada
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
IUNS 20th International Congress of Nutrition, Granada
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
IUNS 20th International Congress of Nutrition, Granada
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
IUNS 20th International Congress of Nutrition, Granada
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– Kaosar Afsana ,Director HNPP– Raisul Haque, Coordinator HNPP (Nutrition)– Morsheda Chowdhury, Coordinator HNPP (MNCH)
• National IYCF Alliance reach & timeline– National IYCF Alliance (GOB/DGHS/IPHN) mapping team– Sumitro Roy & A&T monitoring team– Kuntal Saha, IFPRI/A&T Bangladesh team leader
Thank you!
IUNS 20th International Congress of Nutrition, Granada
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?
IUNS 20th International Congress of Nutrition, Granada
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