1. IUNS 20 th 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

2. IUNS 20 th 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

3. Background

4. IUNS 20 th International Congress of Nutrition, Granada Years Source: Bangladesh DHS, 2011 Percentage of women reporting EBF Trend in EBF in Bangladesh

5. IUNS 20 th International Congress of Nutrition, Granada BF Counseling 1984 Ordinance XXXIII on Regulation of Breastmilk Substitutes (Code ) amended 1990 Years Source: UNICEF Bangladesh Case Study by Luann Martin; DHS Reports Evolution of national BF policies & programs 2004 93-94 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 support nationally through Nutrition /IYCF & Maternal Newborn, Child Health (MNCH) programs 96-97 99-00 2007 Media

6. IUNS 20 th International Congress of Nutrition, Granada Number of HW trained 2010-2011 Number of HW Cumulative Source: A&T Monitoring data for the National Alliance, 2013 HW: Health workers, including incentivized volunteers and doctors Training: 5-day course; 2.5 days for MNCH

7. IUNS 20 th International Congress of Nutrition, Granada Number of times Breastfeeding TVCs aired Cumulative Sources: Asiatic, Unitrend Media buy records Number of airings

8. IUNS 20 th International Congress of Nutrition, Granada Recall of breastfeeding TVC messages n=535 n=454 n=251 n=85 Percent

9. Methods

10. IUNS 20 th International Congress of Nutrition, Granada 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 <6months Objectives: To identify patterns & factors associated with EBF in 2007 and 2011 To determine factors that contributed to improvements in EBF levels in 2011

11. IUNS 20 th International Congress of Nutrition, Granada Conceptual framework Mass media Infant factors Household factors Community factors Maternal factors Facility-based programs Community- level programs Policies & laws Mothers’ knowledge, beliefs, skills & environ- ment Exclusive BF

12. IUNS 20 th International Congress of Nutrition, Granada Variables tested Maternal factorsAge, education, employment status, age at marriage, height, place of delivery, contact with CHW, contact with HW, C-section, TV viewing, birth interval Infant factorsAge, sex, birth order Household factorsWealth quintile, oral contraceptive use Community factorsRural/urban, region Feeding practicesInitiation < 1 h, pre-lacteal feeding Program exposure Not available

13. IUNS 20 th International Congress of Nutrition, Granada 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)

14. Results

15. IUNS 20 th International Congress of Nutrition, Granada EBF across regions of Bangladesh Median duration of EBF increased from 1.8 in 2007 to 3.5 months in 2011 Percentage of women reporting EBF

16. IUNS 20 th International Congress of Nutrition, Granada EBF across sub-groups Residence Wealth index Mother’s education Sex of child Percentage of women reporting EBF

17. IUNS 20 th International Congress of Nutrition, Granada Infant feeding by age (months) Percentage of women reporting feeding -EBF improved in the 4 to 5 month age group also -Did reduced milk use account for the rise in EBF?

18. IUNS 20 th International Congress of Nutrition, Granada Examples of differences between 2007 & 2011 Variable2007 ( n=505) 2011 (n=786) Change %n%n Age of infant (mean months)2.95052.5786-0.4 Delivery in a facility19.010634.129115.2 C-section delivery10.45420.31679.9 Early initiation <1 hr41.820447.63735.8 Prelacteal feeding <3 d54.326535.8258-18.5 Secondary education47.724754.84437.1 Working for pay15.6755.343-10.3

19. IUNS 20 th International Congress of Nutrition, Granada Adjusted odds of EBF by sample characteristics found to be significant VariableCategoryOdds Ratio95% CIp-value Age of infant Month0.550.49, 0.60<0.001 Region, rural BarisalRef grp Chittagong3.251.67, 6.27<0.001 Rajshahi (& Rangpur)2.501.36, 4.610.003 Sylhet2.941.49, 5.800.002 Location of delivery, rural Facility locationRef grp Home0.620.38, 0.990.045 Prelacteal feeding, <3 d NoRef grp Yes0.550.38, 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)

20. IUNS 20 th International Congress of Nutrition, Granada 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

21. IUNS 20 th International Congress of Nutrition, Granada 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

22. IUNS 20 th International Congress of Nutrition, Granada 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

23. IUNS 20 th International Congress of Nutrition, Granada 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

24. Thank you!

25. IUNS 20 th International Congress of Nutrition, Granada 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?

26. IUNS 20 th International Congress of Nutrition, Granada 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