Infant and Young Child Feeding Programme ReviewsReviews

•10-country case study on large scale community based•10-country case study on large scale community based breastfeeding programmes, 2007

6 t IYCF i 2008•6-country IYCF review, 2008

IYCN Unit, Nutrition Section, UNICEF HeadquartersOctober 2009

1

Overview of presentationOverview of presentation

1 Some data on exclusive breastfeeding1. Some data on exclusive breastfeeding

2. Learning from Large-scale Community-based g g yProgrammess to Improve Breastfeeding(AED/UNICEF/USAID/WHO, 2007)• 10-country case studies: Benin, Bolivia, Cambodia, 0 y , , C ,

Ethiopia, Ghana, Honduras, India, Madagascar, Mali, and Nepal

3 IYCF Programme Review3. IYCF Programme Review (UNICEF/AED, 2008)• 6-country case studies: Bangladesh, Benin ,

th Phili i S i L k U d U b ki tthe Philippines, Sri Lanka, Uganda, Uzbekistan

2

Exclusive breastfeeding, global data from g, garound 1996-2006

50

41

33 32

44

32 32

3635

40

45

2724

3232 32

25

2020

25

30

around 1996

1010

15

20

around 2006

0

5

South Asia East Asia/Pacific excl China

Sub Saharan Africa

Middle East and North Africa

CEE/CIS Developing countries

3Source: UNICEF , global database

Significant increases in exclusive breastfeeding in 16 countries (>20 percentage points):

67

76

70

80

4347 48

54

60 6164

67

50

60

70

19

3338

2326

34 36 37 38 4043

30

40

3 36

16 16

8 710 11 11

712

19 17

0

10

20

0

4

baseline

most recent dataSource: UNICEF Global Database 2009

Countries with significant declines in EBF ( )(>10 percentage points)

7780

90

7774

63

5047 4444

53

50

60

70

80

44

36 35

19 1914

44

32 31

2317 1520

30

40

50

14

6 7 84

0

10

5

Baseline Most recent data

Source: UNICEF Global Database 2009

1. Learning from Large-scale Community-based Programs to Improve Breastfeeding

(AED/UNICEF/USAID/WHO, 2008)

• Desk review in 2007 of large scale breastfeeding programs in 10 countries: Benin, Bolivia, Cambodia, Ethiopia, Ghana, Honduras, India, Madagascar, Mali, and Nepal.

• Purpose: – to share experiences and lessons from community-based

approaches to improve breastfeeding practices so that others canapproaches to improve breastfeeding practices so that others can use the information to strengthen existing programs and design new ones

– Can inform those planning to scale up current activities and can encourage poor performing countries as well. e cou age poo pe o g cou t es as e

• Diversity in programmatic approaches, partnerships and results• Varying levels of progress in exclusive breastfeeding (30% to

70%) i i t t d li i6

70%) – some increasing, some stagnant, some declining

Trends in Exclusive Breastfeeding Rates in the Ten Countries: mixed results

80

Source: UNICEF Global Database 2009

60

70

40

50

20

30

0

10

7

Community-based breastfeeding promotion and support should feature as part of a national plan

It should be based on a comprehensive strategy:It should be based on a comprehensive strategy:1. Policy level, including nutrition and IYCF policy, national

Code of Marketing of Breast-milk Substitutes, maternity protection legislation

2. Health services: strengthening the capacity of health services to support appropriate IYCF at all MCH contactsservices to support appropriate IYCF at all MCH contacts

3. Community: strengthening community-based support for IYCF at scale

4. Integration: integrating activities into existing programs and initiatives

5 C i ti f b h i d i l h8

5. Communication for behaviour and social change6. Monitoring and evaluation

Strong links across all levels

National… up-dated & consistent

national strategies, guidelines & messages

Regional •Planners•Donors•AcademiaThe media

guidelines & messages used by government,

professional associations, and NGOs

•District MOH Team•NGOs

Districts

•The media… harmonized

training for service providers (both in-

Health workers

NGOs•Hospital Administration

Health Facilities community support

service & pre-service)

Communities( & families)

Health workers• Public • Private

•Community workers•Community Leaders

… community support

… saturate mothers, families and communities

with a core message

9

( & families) •Community Leaders•Existing Women’s Groups•Male involvement

with a core message through multiple

communication channelsSource: LINKAGES

Key FindingsKey Findings

1 Th it ff i di bl f1. The community offers indispensable resources for breastfeeding promotion and support, and these resources need continual mentoring and

tencouragement.

2. Multiple program frameworks offer opportunities for2. Multiple program frameworks offer opportunities for community-based breastfeeding promotion and support.

10

Key FindingsKey Findings

3. Breastfeeding practices can change over a relatively short period and need continued reinforcement to be sustained.

4. Effective communication and advocacy are vital to set policy priorities influence community normsset policy priorities, influence community norms, and improve household practices.

11

Key Findings cont’d5. More attention needs to be given during

training of community health workers to

Key Findings cont d

training of community health workers to interpersonal counseling skills.

6. Partnerships, leadership, proof of concept, and f ilit t l b tresources facilitate program scale up - but:

• gains in BF achieved during intensive pilot activities can be a challenge to achieve during a scale up as a part of l it b d ith lti llarge community-based programmes with multiple elements.

7. Monitoring and evaluation is critical to measure id tif f l d f lprogress, identify successful and unsuccessful

strategies, and make appropriate program adjustments.

12

j

Cambodia – from 11% to 60% EBF in 5 years.

Timing of the survey and phrasing of some questions could partially

13

g y p g q p yaccount for differences. Even if these factors are taken into account, major improvements in feeding practices were achieved

Cambodia – Success FactorsComprehensive policy and investment plan for IYCF, including:

– CommunicationT i i f h lth k– Training of health workers

– Pre-service curriculum development– Support for the BFHI and Baby Friendly Community Initiative

Lessons learned: – Community-based activities, nationwide media campaigns, and

coordinated messages with emphasis on “not giving water to the g p g gchild” set a strong foundation for positive behaviour change.

– Integration of breastfeeding promotion into multiple programme frameworks (reproductive health, IMCI, PMTCT)Comprehensive nutrition training created multiple opportunities to– Comprehensive nutrition training created multiple opportunities to reach women and their children.

– Extended participation and involvement of many different partners contributed to increased reach and scale.

14

Why is EBF in some countries ystagnating or declining?

– low coverage of activities, – a non-comprehensive approach,

overburdened community workers– overburdened community workers, – lack of focus by national nutrition program on IYCF,– Lack of, or poor implementation, of appropriate

policies/legislation– inadequate training, esp. a lack of focus on problem

solving, and communication and counseling skills,solving, and communication and counseling skills,– weak health system capacities and links with CHW, – no performance monitoring, supporting supervision

15

– communication not focused, comprehensive, coverage- and particular behavior oriented

Summary: 10-country case study y y ythe review demonstrates: 1) the importance of community-) p y

based activities for achieving scale,

2) the role of the community as2) the role of the community as partners, not recipients, and

3) the feasibility of improving ti th hpractices through a

comprehensive approach that involves partnerships at many l l it b ildi b h ilevels, capacity building, behavior change communication, and the creation of an enabling

16

environment.

2. IYCF programme review, 2008p g ,

• Review recommended •Examined nationalduring mid term review of UNICEF’s Medium Term Strategic Plan (2006 2013)

Examined national efforts to improve IYCF (primarily breastfeeding) i 6 t iStrategic Plan (2006-2013)

Purpose:• To understand the factors

in 6 countries:

•Bangladesh that influenced breastfeeding practices and learn from the experience of these

i

•Benin •the Philippines •Sri Lankacountries.

• To identify main lessons learned for future

i

Sri Lanka •Uganda•Uzbekistan

programming. 17

EBF trends in the 6 countriesEBF trends in the 6 countries

7680

100

45 46 42 43 3844

37 34

53 5763 60

40

60

nths

(%)

10

2517

2.49

26

0

20

sive

BF

0-5

mon

0

Bangladesh Benin Philippines Sri Lanka Uganda Uzbekistan

Exc

lus

18

Country and Year

Factors influencing breastfeeding rates in the 6 countriesrates in the 6 countries

• International leadership• Enabling environment• Results orientation and

coveragecoverage• Coordination• IYCF champions• Community outreach• Community outreach• Timing and frequency of

caregiver contacts with health workers

• Use of multiple channels of communicationcommunication

19

Lessons learned: national levelLessons learned: national level1. Diverse set of partners2. Continuous, effective

leadership3 Pl i t hi l3. Planning to achieve scale

at the outset4. Evidence-based de ce based

advocacy5. Widespread

di i ti f li idissemination of policies6. Effective national Code

legislationlegislation

20

Lessons learned: health service levelLessons learned: health service level

7. An appropriate balance for breastfeeding support at7. An appropriate balance for breastfeeding support at maternity, health facility and community levels.

8. Effective implementation of the “10 Steps for Successful Breastfeeding” in health facilities in countriesSuccessful Breastfeeding in health facilities in countries where a substantial portion of women deliver in health facilities.

9. Training in counselling and problem-solving skills10. Performance-based training methodologies11 Integrated training strategy11. Integrated training strategy

21

Lessons learned: community level & ycommunication

12. Trusted community members are indispensable resources for IYCF promotionresources for IYCF promotion and support

13.Coherent and comprehensive communication strategyneeded

22

Lessons learned: infant feeding in gemergencies

14 Ad14. Advance preparations, training of health workers on infant feeding in emergencies, and ongoing briefings withongoing briefings with the media during emergencies can

d th h freduce the chances of misguided actions and misinformation.

23

Recommendations: national level

1. Develop and implement a comprehensive IYCF strategycomprehensive IYCF strategy for implementation at scale

2. Establish and support a coordination mechanism for IYCFIYCF

3. Foster an enabling genvironment

4. Strengthen the organizational and technical capacity for IYCF 24

Recommendations: health services level

5 Take steps to improve5. Take steps to improve breastfeeding practices in maternities

6. Extend IYCF counselling and support beyond maternitysupport beyond maternity services

25

Recommendations: community level & ycommunication

7. Scale up community-based interventions

8. Implement evidence-based, comprehensivecomprehensive communication strategies

26

Thank you!

27