Breastfeeding in Haiti: Beliefs, attitudes and behaviors Mohamed Ag Ayoya UNICEF and UPenn – Social Norms and Social Changes Course July 12, 2012

Background  One of poorest countries in LAC region - independence in  10 million inhabitants  Under 5 mortality high (80 per 1000 live births)  35% of under 5 deaths attributable to malnutrition  Major cause of child malnutrition: inappropriate infant and young child feeding (IYCF) practices.

Recommended IYCF practices (UNICEF and WHO) Empirical evidence shows that appropriate IYCF practices prevent 19% of all deaths of under 5s in the developing world (Lancet 2008).  Early initiation of breastfeeding (breast milk within the 1st hour of life).  In Haiti, only 44% of mothers initiate breastfeeding within 1 hr  Exclusive breastfeeding for 6 months (no liquid or solid foods given to the child except medicines).  In Haiti, only 41% of children < 6 months are exclusively breastfed  Introduction of energy and nutrient dense age appropriate complementary foods at 6 months and continued breastfeeding up to 24 months and beyond.

Factual beliefs hindering optimal IYCF practices First milk is dirty and should be discarded. Sweet tisanes or a mixture of oils and different leave extracts (locally called “lok”) given after birth open up child’s intestine and help eliminate the meconium. The child cannot survive without water, especially during hot seasons. Mother’s milk alone is not enough for the child in the first 6 months of life. Bad news and strong emotions spoil mother’s milk. If mother spends time under the sun, she can’t breastfeed; her milk becomes hot and can cause diarrhea to the child. Child should not eat eggs; he will become a thief. Mothers-in-law and grandmothers have power and know best how to feed a child; thus must be obeyed to.

There is a network of beliefs, which support the custom, and norms (obedience to elders) that all contribute to the inadequate IYCF practices in Haiti.

Previous solutions (What has been done till now? )  Baby Friendly Hospital Initiative.  7 hospitals certified in  increase in exclusive BF but not sustained  Networks (youths, religious leaders, scouts, women’s groups etc...) to promote breastfeeding.  BCC campaigns (mass media, community-based, inter-personal through positive deviants and medical professionals).  High level advocacy to influence policies.  Baby tents after the earthquake (January 2010)  Exclusive BF increased from 24.6% in 2010 to 56.9% in 2012 in one of the areas where evaluation was conducted.

Reasons for successes and failures  Better understanding of breastfeeding’s health and economic benefits.  Linking breastfeeding with beautiful and healthy babies.  Agressive promotion of breastmilk substitutes by industry through health networks and mass media.  Persistent beliefs (core) and attitudes.  Lack of family support (husbands, mothers-in law etc.)  Ignorance of bottle feeding dangers.  Ineffective communication strategy (proposed solutions often far from people and social norms).

Strategies to introduce changes  Diagnostic study and a detailed analysis of the community dynamics and the networks.  Understand better the factual beliefs, attitudes and practices that hinder appropriate breastfeeding practices  More importantly what is supporting them o Why is first milk considered dirty? o Why is water necessary for a child under 6 months? o Why breastmilk alone is not enough for such child? o Where did you learn these information? o What a mother thinks is good for her baby and why? o What a mother thinks other mothers think is good for their babies and why? o How strong does a mother feel about following or not following what her mother-in-law says she should or should not do? o How does a mother-in-law perceive her daughter in law who doesn’t obey to her? And what are the sanctions?

Strategies to introduce changes  Diagnostic study and a detailed analysis of the community dynamics and the networks. o What are the most important people for the mothers and why? o What are the attitudes of these important people? o Who talks to whom in a typical community?  Broader discussion and an open dialogue with communities based on the results of the study o Trigger argumentation and engagement o make them feel that they are co-responsible and part of the solution of the problem.

Strategies to introduce changes  Comprehensive long term communication IYCF strategy o Culturally acceptable o Fits into the context (urban, rural, poor, rich etc..) o Creative (showing clearly that breastmilk contains water) o Addresses rationale of existing wrong factual beliefs o Includes all reference group members (Networking) o Messages delivered by trustworthy sources and trained facilitators o Offers alternative to wrong factual beliefs o Highly visible and publicized  Incentives (Collectives not individuals) o Moral and image (Awards, certificates) o Financial (through conditional cash transfers)  Advocate or ambassador (preeminent figure) o First Lady of Haiti

Existing strategies to strengthen  Baby Friendly Hospital Initiative o Train health professionals on the 10 steps for a hospital to become baby friendly o Monitor the implementation of the 10 steps o Work with Ministry of Health to provide certification to hospitals implementing effectively the 10 steps  Law on breast milk substitutes o Provide technical and financial support to the Ministry of Commerce and Industry and the Ministry of Health to enforce the law  Women’s groups and community-based organizations o Support existing groups and creation of new ones o Build more upon the positive deviants  Mass media campaigns o Support widely use of radios and TVs to support community- based communication for development (C4D) activities.

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