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NIC-C2 Child Health and Nutrition: Cost-Effective Approaches for Scaling-Up Life-Saving Interventions Infant and young child feeding approaches to getting impact at scale Tina G. Sanghvi, PhD Senior Country Director for Bangladesh Academy for Educational Development (AED) For USAID, March 2010 Reconvening Bangkok Slide 2 Outline Defining the problem Following the evidence Narrowing the focus Finding large-scale platforms Mainstreaming Lessons learned Shahjahanpur Upazila, Bogra District, Dec 09 Slide 3 Problem: When, why, where, how Shrimpton et al. 2001 EBF CF ANC, Delivery, PNC, EPI Nutrition & infection Asia worse off than Africa Slide 4 Interventions Shahjahanpur Upazila, Bogra District, Dec 09 Slide 5 Exclusive BF what does this mean for programs? 14.4 ///// Lancet 2008 Relative risks of specific BF practices: Slide 6 Evidence on BF Interventions Cochrane review, 34 trials with29,385 motherinfant pairs from 14 countries: All forms of extra support increased the duration of breastfeeding. Individual, group counselling by medical, paramedical or CHWs is effective. Teaching mothers simple skills to maximize breastmilk intake Lancet, 2008 Slide 7 Evidence on BF Interventions Mass media campaigns also shown to be effective Community-based strategies for breastfeeding promotion should be integrated with additional health-system support Breastfeeding support in maternities Health contacts (timed & targeted) Lancet, 2008 Slide 8 Focusing down using formative research Initiation < 1 h No pre-/post lacteals EBF to 6 m (BF)+ solids/ss from 6-24 m Frequency CF Quantity CF Quality of foods Hygienic prep, handwashing Responsive feeding Feeding during/after illness Shahjahanpur Upazila, Bogra District, Dec 09 Slide 9 Focusing down - barriers and facilitators Ideal PracticeBarriersFacilitators Early initiation and colostrum + no pre- post- lacteals Birth attendants, families not aware, relatives, doctors, C-section Trained & motivated doctors, CHWs Exclusive BF for 6 months Mothers/families not aware of dangers, milk insufficient, doctors Perception that baby gets enough milk, I can do it Quantity of semi- solids after 6 m as recommended Mothers not aware of what and how, doctors, relatives No special foods needed, easy, child likes and able to eat, fathers, neighbors, CHWs Animal foods/diversity Mothers/family not aware of what and how, cost Easy (family eats the same), child likes, healthy, can increase no. days/week if not daily Encourage & support child to eat Mothers/families not aware of what and how, time Mother understands importance, family helps to feed child/ shares housework Alive & Thrive, 2009 Slide 10 Potential to Improve Practices UrbanRural % Mothers who said HW talked about BF, CF: - During ANC visits - During immunization visits - During sick child visits 9 8 39 7 8 30 Topic covered by health worker % - Only breastmilk before 6 months - Have to feed breastmilk - Continue BF even if baby is sick NOTE: Nothing on CF or BF initiation 18 13 8 29 10 13 Most reliable source of information % - Grandmothers - Doctor - Husband - Friends/neighbor/other -Health worker 20 24 13 12 38 24 10 6 7 Slide 11 Platforms: Scale opportunities BDHS, 2007 BRACs 70,000 community-based volunteers Slide 12 Mainstreaming: How to operationalize ? Char in Sibalay Upazila, Manikganj, Dec 09 Its a marketing & advocacy job wiifm Slide 13 Mainstreaming What? Approach Reach all PW to 2 y children (lists) Counsel mothers in homes, community (BRAC) Link trained health workers with community- based volunteers & workers (BRAC, Govt.) Mobilize family members, opinion leaders (BRAC, Govt.) Monitor quality of counseling Campaign through mass media (Ad company) Slide 14 Mainstreaming What? Implementation Community Worker/Volunteer Training and Support ($$) Home visits (incentives) Community forums (existing) Social mobilization (local advocacy) Health services contacts (advocacy) Mass media ($$, collaborations) Education sector (advocacy) Evaluation: Randomized, control, cross-sectional ($$) Slide 15 Lessons Learned Problem-solving approach (not only messages) Focus on few practices, build confidence of mothers Timing of counseling is key: last trimester of pregnancy,