WBW2019: Empower Parents, Enable Breastfeeding

By Karin Lapping

First celebrated in 1992 by World Alliance for Breastfeeding Action, World Breastfeeding Week is now observed in over 120 countries by UNICEF, WHO and partners too numerous to list including individuals, organizations, and governments. Alive & Thrive is proud to be a part of this important week of action.

As this year’s theme makes plain, we need to empower parents to enable breastfeeding. The Cost of Not Breastfeeding tool makes clear why that is so important. We supported the research underlying the tool and then developed an interactive online version that makes it easy for anyone to see just what’s at stake: 700,000 preventable deaths and $1 billion dollars a day. Those statistics powerfully illustrate why we need to do more to support breastfeeding. This great video brings the data to life:

As World Breastfeeding Week kicks off today, I’m happy to announce that we have added French translations of the online tool for francophone countries in West Africa, further increasing access to the information. In coming weeks, we are also adding advocacy briefs for many countries, providing summaries of the data and concrete advocacy actions to increase the rate of exclusive breastfeeding.

Much needs to be done to ensure mothers and infants – and their families and communities, indeed all of us – gain from the benefits of breastfeeding. Training of health workers remains an important means to achieve the global goal of 50% exclusive breastfeeding by 2025 – and 70% by 2040 .

Alive & Thrive Photo Credit : Shafiqul Alam Kiron

In June we launched an e-learning course, Investing in Child Nutrition, in French and English specifically targeting health workers. Already more than a dozen people have completed the course and more than 500 people worldwide have registered to take it. You can too – it’s free and easy to use on just about any device connected to the Internet!

Across the Alive & Thrive world, we are supporting activities and events to celebrate World Breastfeeding Week:

  • In Nigeria, we are collaborating with many partners – the Government of Nigeria, Save the Children, Nutrition International, USAID, and Civil Society-Scaling Up Nutrition and others – on a major national campaign, “Start Strong/Zero Water,” which will launch Aug. 6. We are also launching a major report on maternity entitlements, an assessment of the implementation of parental leave entitlements and workplace breastfeeding support policies and the variety of maternity entitlements offered by the public and private sectors. We are going to broadcast on Facebook Live from the launch event on Aug. 6 at noon in Abuja (WAT; 7 a.m. EST) – go to our Facebook page at that time to tune in!
  • In Bangladesh, we are supporting a national-level symposium on the economic cost of not breastfeeding and to raise awareness of the country’s Breast-milk Substitute act’s key provisions. With WHO and Plan International, we are also supporting “breastfeeding camps” to raise awareness of the importance of breastfeeding and provide breastfeeding education and support to mothers who attend the camps.
  • In India, A&T is organizing “Breastfeeding in India: Commitment to collective actions under the Infant Milk Substitute Act to protect, promote and support breastfeeding,” in New Delhi on Aug. 5, collaboratively supporting activities with UNICEF and the National Health Mission in Uttar Pradesh, and supporting a plenary session during a national level conference, “Lactacon,” which is being organised by the state chapter of Federation of Obstetric and Gynaecological Societies of India – more than 400 practitioners and experts from the field of obstetrics and gynaecology are expected to attend from across the country.

We are promoting these and many other events with posts on our Twitter, Facebook, Instagram and YouTube accounts. Follow us on these pages to find out more about the activities and gain access to various resources we will be promoting throughout the week.

World Breastfeeding Week allows us to emphasize the importance of breastfeeding. We can – and must – do more to address the costs, 700,000 lives and $1 billion a day. Join the global effort to support breastfeeding and convince policy makers to act to do so as well.

Karin Lapping is the Director of Alive & Thrive.

Understanding the factors that determine maternal nutrition practices in Uttar Pradesh, India

Uttar Pradesh, the most populous state in India, has a high burden of undernutrition. It lags behind national averages in maternal nutrition practices. Despite strong policy and program commitments, many maternal nutrition interventions are not yet reaching majority of women during pregnancy. A recent study by researchers from the International Food Policy Research Institute (IFPRI), Alive & Thrive, and others, published in the Maternal and Child Nutrition journal and also included in a supplement of the Current Developments in Nutrition, examines the role of key influential demand and supply factors associated with maternal nutrition practices in Uttar Pradesh.

A maternal check-up during pregnancy in Uttar Pradesh. Image courtesy: Shivani Kachwaha, IFPRI

The determinants of maternal nutrition practices are complex, and each of the practices may have a differing set of determinants. Few studies have examined the determinants for a diverse set of maternal nutrition practices together, and none have been undertaken in the context of Uttar Pradesh. This study, therefore offers some very useful insights in understanding the role of dominant factors associated with maternal nutrition practices in Uttar Pradesh and deriving some practical lessons for implementing policies around them.

Presently, there is a considerable gap in the utilization of existing maternal nutrition services in Uttar Pradesh. According to National Family Health Survey data (NFHS-4 2016), while 76 percent of pregnant women received the first antenatal care (ANC) check-up, for only 26 percent was it followed up with at least four ANCs. Around 62 percent of women received some iron and folic acid (IFA) tablets, but only 13 percent of women consumed IFA tablets for 100 days or more.

To address the challenges of maternal undernutrition in Uttar Pradesh, A&T aims to test the feasibility of improving the provision and uptake of a package of maternal nutrition interventions through the ANC platform using social behavior change and systems strengthening approaches. These include provision of and counselling on IFA and calcium supplements, adequate weight monitoring during pregnancy and counselling on weight gain, interpersonal counselling on diet during pregnancy and on breastfeeding during postpartum, and community mobilization. IFPRI is collaborating with Alive & Thrive in this study to evaluate the impact of delivery of maternal nutrition interventions in Uttar Pradesh.

This paper used baseline data to provides comprehensive information on the multiple factors related to the adoption of four specific maternal nutrition practices – consumption of diverse diets, IFA and calcium supplementation, and weight monitoring – at multiple levels, including individual, household, community, and health services.

The study found that currently only 18 percent of pregnant women met the recommendation of dietary diversity; they consumed 28 IFA and 8 calcium tablets, and were weighed only 1.3 times during pregnancy. Although the current situation is bleak, many of the key factors associated with maternal dietary diversity, IFA/calcium consumption, and weight gain monitoring are modifiable.

This study shows that each specific maternal nutrition practice is influenced by differing sets of determinants. Among the multiple factors, maternal behavioral characteristics (such as knowledge, beliefs and self-efficacy), followed by support from family members, community factors, and adequate health services access are significantly associated with key maternal nutrition practices. Given that diverse diets, IFA and calcium supplements, and weight monitoring are promoted and delivered through a common package, a nuanced understanding of the drivers for each specific practice can help improve access to the full package. For example, maternal diet diversity is a complex outcome and was found to be associated with maternal knowledge and receipt of counseling. Increased consumption of calcium was found to be associated with maternal knowledge, receiving counselling on calcium supplementation, beliefs and self-efficacy, ANC visits and positive social norms.

Through modelling approaches, the effects of individual and combined factors help identify and highlight improvements that may be achieved by the maternal nutrition programs. In particular, these findings provide new evidence on the determinants of calcium consumption and weight monitoring during pregnancy. Under optimal program implementation that explicitly tackles the specific determinants of each maternal nutrition practice, one could expect half of the women to achieve adequate diet diversity, consume an average of 100 IFA and 90 calcium tablets, and be weighed 4.4 times during their pregnancy.

The study findings, based on modelling, suggest that strengthening program operations to improve the supply of interventions and to create adequate demand through behavior change communication, has the potential to improve maternal nutrition practices. The impact evaluation, which is underway, will shed more light on the extent to which Alive & Thrive’s efforts, working with the government of Uttar Pradesh, achieve these impacts. However, along with these efforts, improvements will also be needed in socio‐economic conditions, such as education, income, and employment generating activities to support and sustain behavior change for attaining the World Health Organization‐recommended levels of maternal nutrition. Improving the maternal nutrition practices in Uttar Pradesh will go a long way in improving the overall nutrition status of India.

Access this article: Nguyen, P., S. Kachwaha, R. Avula, M.F. Young, L. Tran, S. Ghosh, R. Agrawal, J. Escobar-Alegria, S. Patil, and P. Menon. 2019. “Maternal Nutrition Practices in Uttar Pradesh, India: Role of Key Influential Demand and Supply Factors”. Maternal & Child Nutrition. https://doi.org/10.1111/mcn.12839)

This blog has been jointly developed and cross-posted by the International Food Policy Research Institute and Alive & Thrive.

New cost of not breastfeeding tool launched

A new research study and online tool illustrates the dramatic costs – in human lives and to the global economy – due to inadequate breastfeeding: almost 700,000 lives annually and a billion dollars a day.

Listen to Dr. Dylan Walters, lead author of the Cost of Not Breastfeeding, in this interview with Voice of America:

The cost of not breastfeeding tool allows users to explore data on breastfeeding in 34 countries. Click on image to go to the tool.

The tool was developed by health economist Dr. Dylan Walters with support from Alive & Thrive, an international maternal and child nutrition initiative funded by the Bill & Melinda Gates Foundation.

“Each year not breastfeeding newborns and young children according to recommendations costs global society nearly 700,000 lives and US$341 billion dollars, or 0.7% Gross National Income, in health system costs and lost productivity due to premature mortality, and cognitive losses,” Dr. Walters said. “The world must act to mobilize financial resources necessary and political commitment to achieve the World Health Assembly Global Nutrition Target of exclusive breastfeeding prevalence of 50% by 2025 because it is a human right, it saves lives, and improves the prosperity of economies.”

The online tool, available on Alive & Thrive’s website, provides background on the impacts of not breastfeeding in 34 countries. The tool is based on Dr. Walters’ research published by Health Policy and Planning Journal on June 24 (https://doi.org/10.1093/heapol/czz050), which provides data on estimates for the human and economic costs of not breastfeeding for over 100 countries.

“We need to be sensitive to the constraints and hardships faced by mothers and families in a world that lacks basic support systems for their physical, psycho-social, and economic well-being,” Dr. Walters said. “Even more, mothers and families are up against a constant barrage of corporate marketing of alternatives and misinformation spread that undermines what should be boringly second nature and not stigmatized by society.”

Expanding paid family leave to the minimum 18 weeks as recommended by the International Labor Organization would enhance the ability for mothers to exclusively breastfeed. It would further benefit mothers to align this duration with the recommended 6 months of exclusive breastfeeding.

Launched just three weeks before World Breastfeeding Week (Aug. 1-7), the tool is a valuable resource for advocates, said Roger Mathisen, program director of Alive & Thrive’s office in Southeast Asia and a co-author of the paper.

“The data are sending us a compelling message: we must do more to support breastfeeding,” Mathisen said. “With this tool, we hope advocates around the world will be emboldened further in their efforts to obtain greater support from governments.”

Dr. Linh TH Phan, Regional Program Coordinator in Southeast Asia for Alive & Thrive, said the tool was valuable for efforts to increase support for breastfeeding worldwide.

“Low- and middle-income countries, particularly in sub-Saharan Africa and South Asia, and their people, have the most to gain from adopting universal breastfeeding within the first hour of life, exclusively for the first 6 months, and continued for more than two years,” Dr. Phan said. “But wealthier countries also have room for cognitive gains and probably reductions in the burden of childhood obesity and maternal cancers and Type 2 diabetes.”

People can do many things to improve support for breastfeeding mothers. Demanding government adopt policies that promote breastfeeding, compelling employers to provide breastfeeding support at work sites, and ensuring health workers are adequately trained to support mothers to breastfeed are just a few positive actions that can help the world reach the goal of 50% exclusive breastfeeding prevalence by 2025. Additionally, governments should enforce the International Code of Marketing of Breast-milk Substitutes.

For seven actions implementers and donors from governments, philanthropies, international organizations and civil society can take to create a more enabling environment for breastfeeding, visit the Global Breastfeeding Collective: https://www.k4health.org/toolkits/breastfeeding-advocacy-toolkit/tools-collectives-7-policy-actions.


Hospitals to become Centers of Excellence for Breastfeeding in Viet Nam

The Viet Nam Ministry of Health and A&T co-organized an Implementation Workshop to formalize “Centers of Excellence for Breastfeeding” (CoE) with the participation of directors and staff from 29 hospitals, leaders from Departments of Health (DOH), Centers for Disease Control (CDC), and Reproductive Health Centers (RHC) in nine provinces.

The ministry introduced the designation criteria and accreditation roadmap while A&T and the Learning & Research Center for Newborn Care and Human Milk shared assessment results of the first 21 evaluated hospitals, consolidated from surveys of mothers, self-assessments and external evaluators. The innovative CoE approach provides new insight, renewed commitment and a clear path forward for hospitals in promoting early and exclusive breastfeeding and newborn care.

By the end of the workshop, each hospital and provincial DOH/CDC/RHC presented their committed action plans. As the next step, A&T will work with the hospitals to finalize and execute their improvement plans with the aim of 10 CoEs being accredited during this year’s World Breastfeeding Week, Aug. 1-7.

The following resources on the Centers of Excellence for Breastfeeding are available on A&T’s website:

Philippines institutes its “First 1,000 Days” law

The Philippines Secretary of Health Francisco Duque III addresses government colleagues, development partners, and civil society representatives in the ceremonial launch of the “First 1,000 Days” law and its Implementing Rules and Regulations on 2 May 2019. Photo credit: Paul Zambrano/Alive & Thrive

The Philippines promulgated Republic Act 11148 – the “Kalusugan at Nutrisyon ng Mag-Nanay Act” – better known as the “First 1,000 Days” law. The law seeks to institutionalize the convergence and scale-up of programs from different sectors around the critical first 1,000 days of life, spanning from conception to the first two years. The law also focuses on strengthening the implementation and enforcement of the existing nutrition-related laws and policies, such as the Philippines Milk Code regulating the marketing of breastmilk substitutes (BMS).

One salient feature of the “First 1,000 Days” law is that it updates the current definition of BMS to include follow-on formula and growing-up milks, aligning the law with the latest WHO global recommendations and further strengthening what is already one of the strongest legal measures against BMS marketing in the ASEAN region. A&T was part of the technical working group that developed the law’s Implementing Rules and Regulations.

Kaduna State adopts six months maternity leave policy for female public servants

Kaduna Governor Nasiru El-Rufai announced a new state policy of six months’ maternity leave for female public servants.

The Kaduna Governor Nasiru El-Rufai announced a new state policy of six months’ maternity leave for female public servants. The policy aims to facilitate breastfeeding of infants by women working within the civil service. With the announcement, Kaduna State becomes the second state after Lagos State to commit to extending maternity leave to six months.

Working with partners at CS-SUNN and Save the Children, A&T supported a variety of efforts that led to the new policy, including advocacy meetings and events with government institutions and soliciting the support of the Head of the Civil Service as well as the commissioners for Health, Budget and Planning, and Women Affairs. A&T will support a series of advocacy events during and after World Breastfeeding Week (Aug. 1-7) to promote similar policies in 11 other states and nationally.

New e-learning course designed to scale up IYCF knowledge and skills for health workers now available

A new free e-learning course is now available for health workers involved in infant and young child feeding (IYCF) practices, Alive & Thrive announced today.

Leading experts in infant and young child feeding practices guided the development of the Invest in Child Nutrition e-learning course.

Investing in Child Nutrition is a free, publicly available online course designed to provide guidance, skills, and practical information to health workers to promote, protect, and support breastfeeding and complementary feeding. The course is available in French and English at www.iycfhub.org.

“We know from experience that while face-to-face learning for health workers is valuable, there is an enormous gap in the proportion who actually receive face-to-face learning,” said Roger Mathisen, Regional Director of Alive & Thrive’s Southeast Asia program. “By using online communication channels, this course can reach more health professionals in a consistent and user-friendly way that gives them the tools to save lives and contribute to improving child nutrition.”

Working with UNICEF and a global network of experts in IYCF, Alive & Thrive developed the course based on the World Health Organization (WHO) Combined Course on Growth Assessment and IYCF counselling (2012) and supplemental content from WHO, the United Nations Children’s Fund (UNICEF), the Global Health Media Project, and the Raising Children Network (Australia).

The course was developed with the support of UNICEF and includes advice from experts on infant and young child nutrition from all over the world. The steering committee members include:

  • France Begin, Senior Advisor, Early Childhood Nutrition, UNICEF
  • Dr Aashima Garg, Nutrition Specialist, UNICEF
  • Dr Michele Griswold, PhD, MPH, RN, International Board-Certified Lactation Consultant (IBCLC), Past President of the International Lactation Consultant Association (ILCA)
  • Dr Rukhsana Haider, MBBS, MSc, International Board-Certified Lactation Consultant (IBCLC), PhD, Founder and Chair, Training & Assistance for Health & Nutrition Foundation (TAHN) (Chair)
  • Dr Phuong Huynh, Phuong Huynh, MD, MSc, PhD, Deputy Head, Food and Nutrition Training Center, National Institute of Nutrition Viet Nam
  • Terrie Wefwafwa HSC, Nutritionist and CEO, Karibuni-Kenya and past Head, Division of Nutrition Ministry of Health, Kenya
Photo courtesy ©Norwegian Directorate of Health.

Each of the nine modules starts with an introductory video featuring insights from experts and highlighting learning goals. The interactive content includes photos, graphics, videos, and animations, as well as audio clips to engage the user. Activities and knowledge checks aid learning and promote user interactivity with the course content, while links to additional resources and references promote further learning.

The modules are:

  • Course overview
  • Counseling skills
  • Breastfeeding – basic
  • Breastfeeding – advanced
  • Complementary feeding
  • Growth assessment
  • HIV and infant feeding
  • Policies and programmes
  • Supportive supervision
  • Additional information

The course’s development was driven by the significant positive impacts that occur when infant and young children feeding recommendations are practiced: Over 820,000 children’s lives could be saved each year if all children were breastfed according to international recommendations. UNICEF estimates that six per cent – or 600,000 – under-five deaths can be prevented by ensuring optimal complementary feeding.

For women to be successful in adapting and sustaining breastfeeding and other recommended infant and young child feeding practices, and for countries to meet the Sustainable Development Goals, support for IYCF is needed in homes, workplaces, health care settings, and communities. The new e-learning course brings access to training in IYCF counseling to more health workers.

The course was funded by Alive & Thrive, with technical assistance from UNICEF, and created by Manta Ray Media. The Alive & Thrive initiative, managed by FHI 360, is funded by the Bill & Melinda Gates Foundation, Irish Aid, the Tanoto Foundation, and UNICEF.

Acknowledgement and special thanks are given to the Bill & Melinda Gates Foundation, WHO, Global Health Media Project, Raising Children Network (Australia), and other global IYCF experts for their support in providing content, multimedia, and expert input to this course. Usability testing was conducted with the support of the Department of Health and Kalusugan ng Mag-Ina, Inc. (KMI) in the Philippines, and the National Institute of Nutrition, Viet Nam.

Integrating MIYCN into medical college curriculums to address knowledge and practices gaps in India

At nine colleges in two states in India, faculty in medical colleges are learning how to better integrate maternal, infant and young child nutrition (MIYCN) practices into the undergraduate curriculum with Alive & Thrive support. The program is aimed at better equipping students to help pregnant mothers and young children in the future.
Faculty, doctors, senior residents, junior residents, interns and staff nurses at a two-day training at Government Medical College, Kannauj, Uttar Pradesh.

Emphasizing the importance of proper nutrition practices is a key learning initiative for faculty at the colleges, said Dr. Sebanti Ghosh, Country Program Director for Alive & Thrive India who has over 20 years of experience in the health, nutrition and development sector across India and South Asia.

“It was hands-on, sitting together with the faculty and some national experts, and we worked out this integrated curriculum using the existing approved format and a facilitated guide so the faculty can teach this integrated curriculum in a standardized manner,” Ghosh said. “This then got endorsed through the State Medical Education Directorate and the Health Department and we are now orienting all of the faculty in the colleges on this curriculum.”

The program is now reaching 500 faculty at the nine medical colleges located in Bihar and Uttar Pradesh states. Ultimately, they in turn will reach 1,100 students who are admitted to the colleges annually.

The program started with a 2017 baseline assessment of knowledge and practices around MIYCN. The assessment sought to evaluate: the degree to which MIYCN is addressed in the pre-service curricula of medical colleges; the degree to which MIYCN interventions are included in the routine delivery of services offered by the departments of Obstetrics and Gynecology, Pediatrics and Preventive and Social Medicine; and, medical colleges’ contributions to research, planning, implementation and monitoring of MIYCN programs.

Early Initiation of Breastfeeding being practiced in C-Section delivery in Sri Krishna Medical College & Hospital, Muzaffarpur, Bihar. Photo Credit: SKMCH, Muzaffarpur.

The assessment had several findings:  first, among students – including undergraduate, post-graduate and nursing students – knowledge was lacking, especially knowledge on dosage of iron folic acid (IFA) and calcium tablets and diet diversity of pregnant women. However, most students were aware of early and exclusive breastfeeding, and there was a high rate of knowledge of breastfeeding during illness for 0 to 6-months-old infants.

Among department heads and teaching faculty, the survey found that 49% believed infant and young child feeding (IYCF) was adequately covered, while only 40% thought that maternal nutrition was adequately covered.

Knowledge among nursing staff from the OBGY department on maternal nutrition interventions was low overall and awareness about iron folic acid and calcium supplementation was below 20%. Knowledge of recommended weight gain and minimum diet diversity during pregnancy was below 40% among the nursing staff.

Further, the assessment found that research on MIYCN remains a neglected area: Only 23% of surveyed teaching faculty had published any paper on MIYCN topics in the last two years and only 25% of the post-graduate students presented their research at conferences or published it in journals.

Ghosh said maternal infant and young child nutrition was not well prioritized in the curriculum.

“There were missing components and the teaching was often not very standardized,” Ghosh said.

Creating a strategy  to work with faculty and national experts, the program seeks to prioritize the topics that have not been adequately covered, Ghosh said.

She said there were clear learning gaps among the students, which the program seeks to remedy through hands-on and coordinated, integrated learning across Pediatrics, Gynecology & Obstetrics and Community Medicine.

A&T will advocate  to scale-up the program across all medical colleges in Bihar and Uttar Pradesh as well as other states with government and partner support.

The nine colleges taking part in Bihar and Uttar Pradesh states include: GSVM Medical College, Kanpur; BRD Medical College Gorakhpur; MLN Medical College, Allahabad; and Government Medical College, Kannauj in Uttar Pradesh. In Bihar, the colleges are: Patna Medical College, Patna; Sri Krishna Medical College, Muzaffarpur; Darbhanga Medical College, Darbhanga; Anugrah Narayan Medical College, Gaya; and AIIMS, Patna.

Nutrition data profiles guide efforts to scale up MIYCN in three regions of Burkina Faso

Participants at regional MIYCN workshops in three of Burkina Faso’s 13 regions—the Centre Nord, Nord, and Sud Ouest—used nutrition profile data to help health district management teams develop workplans for scaling up MIYCN through RMNCAH platforms. Measures of chronic malnutrition – nationally and by region – were among the data shared at the workshops.

Participants also reflected on the percentage of mothers reporting early initiation of breastfeeding, the giving of colostrum, exclusive breastfeeding for the first six months, the introduction of complementary foods, and dietary diversity, among other data. The workshops included 68 representatives of each health district within the regions (50 men and 18 women).

At the end of the workshop, each health district committed to action plans to strengthen MIYCN interventions. These included actions focused on using evidence for routine nutrition service planning and setting clear and realistic service delivery targets. Two regional workshops planned in coming weeks will focus on completing draft workplans for all the country’s regions. Read more about A&T’s work in Burkina Faso.