iuns 20 th international congress of nutrition, granada. september 15-20, 2013

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


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


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


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


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


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


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


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


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


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


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


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


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?


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


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)


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


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


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


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!


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?


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

iuns 20 th international congress of nutrition, granada. september 15-20, 2013

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