1. Presenter: Justine A. Kavle, PhD, MPH
Addressing Challenges to Immediate and Exclusive Breastfeeding in the First Months of Life- Findings From Egypt
Presenter: Justine A. Kavle, PhD, MPH
Sohair Mehanna, Gulsen Saleh, Mervat A. Fouad, Magda Ramzy, Doaa Hamed, Mohamed Hassan, Ghada Khan, Rae Galloway
Removed “Global Maternal and Newborn Health Conference, Mexico City” as there wasn’t a lot of space.
Do you have the photo credit for this? We need to have at least the funding organization to use this photo. Typically, we list photo credits as: “Funding Organization (MCSP or MCHIP etc)/Photographer’s name”
**All of the photos in the slide deck can be credited to Justine

2. Outline
Global progress on exclusive breastfeeding, within the context of SDGs and the World Health Assembly goals
Key barrier to exclusive breastfeeding – insufficient breastmilk
Findings from Egypt
Top 3 strategies to improve exclusive breastfeeding

3. Sustainable Development Goal (SDG) Target: Ending All Forms of Malnutrition by 2030
Malnutrition affects all countries and 1 of 3 people on the planet.
Malnutrition takes many forms: children and adults who are skin and bone, children who do not grow properly, people who suffer from imbalanced diets and those that are overweight and obese.
Malnutrition takes many forms: children and adults who are skin and bone, children who do not grow properly, people who suffer from imbalanced diets and those that are overweight and obese.
Tackling barriers to exclusive breastfeeding is one key in meeting SDG targets
Tackling barriers to exclusive breastfeeding is one key in meeting SDG targets
Global Nutrition Report, 2015

4. Little Progress in Exclusive Breastfeeding Rates Since 1990
UNICEF, 2013
Little Progress in Exclusive Breastfeeding Rates Since 1990
UNICEF, 2013

5. Tracking Countries’ Progress on Exclusive Breastfeeding Global Nutrition Report, 2015
World Health Assembly Global Target by 2025: Increase the rate of exclusive breastfeeding to 50%
Egypt
While 6 are off course and show large reversals in rates (Cuba, Egypt, Kyrgyztan, Mongolia, Nepal and Turkey) – whereas India has shown doubling in exclusive breastfeeding rates in past 8 years.
Average annual percentage point increase – instead of annual rate --- on course – is AAPPPI > than or equal to AAPPI, off course/some programs – % , of course no progress, small change (less than 25% of their targeted annual percentage point increase), decline in EBF rates of over 10 percentage points over any recent time period….. Of concern are the 30 countries that have made no progress…. (Tanzania, Malawi, Senegal, Pakistan).
Global Nutrition Report, 2015

6. Qualitative data: i.e. Zambia, Kenya
Perceptions of Insufficient Breastmilk is a Major Barrier to Exclusive Breastfeeding
Perceived insufficient breastmilk
Baby thirsty
Baby hungry
Lack of knowledge of breastmilk nutrients
Lack of knowledge of lactation physiology
Interpretation of baby’s behavior: fussy, continuous crying
Perceived health problems of baby – stomach ache, colic
Coping with health and nutritional needs of baby
Feeding too early: food, liquid, herbal teas
From Justine - I suggest the following arrows – please take out the lines – where you also see the arrows. As there are two shapes.
2015 Review (11 studies)
Mothers stopped practicing exclusive breastfeeding - perceptions of breastmilk inadequacy or excessive crying
Qualitative data: i.e. Zambia, Kenya
Anecdotal evidence
Insufficient milk syndrome stems from poverty, sexism,
and powerlessness, not from poor maternal nutritional
status [28]. Though mothers may claim that it is their
poor nutritional status, evidence suggests that maternal
nutritional status has little effect on breast milk production
or composition, except in severely malnourished
women, i.e., those under 85% of reference weight-for-height
[28]. Greiner, Esterik, and Latham argue that “it is largely a
cultural phenomenon when it [insufficient milk syndrome]
occurs during exclusive breast-feeding, and largely a
physiological response to reduced nipple stimulation once
supplemental feeding has begun” [24]. Other authors
suggest that perceived breast milk inadequacy is underpinned
by a complex and synergistic interaction among
socio- cultural influences, feeding management such as
positioning of babies and attachment while breastfeeding
[32], the baby’s behavior, lactation physiology, and the
mother’s psychological state [26]. Apart from perceived
hunger or thirst, the observed notions of “the baby needs
water” and “the baby has other needs apart from milk to
grow well and faster”
Balogun, 2015, Kavle, 2014, 2015, Matsujama, 2013, Fjeld, 2008

7. Egypt Study: Objective and Methods
Primary Objective: Understand cultural beliefs, perceptions, behaviors in relation to infant and young feeding practices and stunting in Lower Egypt and Upper Egypt
Methods:
120 in-depth interviews - mothers of children 0-23 months of age, using Trials of Improved Practices (TIPs) methodology
Conducted in Arabic, audio-recorded, transcribed, translated into English
Dominant themes identified and a coding scheme developed
Qualitative analyses carried out using NVIVO 10.0
Kavle, 2014 & 2015

8. Mothers are committed
to breastfeeding and understand its benefits. Yet, only 25% of Egyptian mothers were exclusively breastfeeding in the first 6 months of life.
others held the common belief that colostrum or the ‘first milk’ is ‘valuable’, ‘clean’ and ‘full of nutri- ents’ and eagerly discussed how breastfeeding allows the child ‘to immediately feel the mothers love’ cre- ating ‘a bond between the mother and child’, as well as protects the child against illness.

9. Breastfeeding is Valued, Yet Prelacteal
Feeding is Common
“I had a natural delivery at a private doctor’s clinic. The first breastfeeding session was 2-3 hours after birth. When I went home my mother gave my baby herbal drink using a syringe as prescribed by my doctor. I gave her herbal drink for about two days, once in the morning and once at night until my milk came in and the baby was able to latch on.”
- Mother, Lower Egypt
Kavle, 2014 & 2015

10. Herbal Drinks and Teas Delay Initiation of Breastfeeding
Herbal Drinks and Teas Delay Initiation of Breastfeeding. Continued use makes Exclusive Breastfeeding Difficult in the First 6 Months
Prescribed herbal drinks in first days of life
Believed to stop child from crying -mother initiates
breastfeeding or until milk “comes in”
Separation from infants after birth is common
Continued use of herbal drinks to “help babies sleep at
night”, sooth “cries of hunger”
Breastmilk is “not enough” - supported by grandmothers
Examples of baby
herbal drink
Mothers are often persuaded by health providers and grand- mothers to give prelacteal liquids, such as herbal drinks,1 herbal tea infusions (i.e. caraway, anise) and sugar/rice water, after birth in the initial days of life. Commercial herbal health products are locally pro- duced and marketed as nutritional supplements for babies and young children.
Mothers relayed that health providers prescribe herbal drinks to ‘wash the gut of the baby’, thereby soothing the baby’s colic or crying until mothers are able to initiate breastfeeding, 6–8 h after birth or until a mother’s milk ‘comes in’. Mothers are often sepa- rated from their newborn babies after birth and herbal drinks are used as temporary solution to provide some fluids to babies until mothers and babies are reunited. Continued use of herbal drinks in the first 6 months is believed to act as soothing and calming agents to ‘help babies sleep at night’. Herbal teas (i.e. anise, caraway) are also viewed as solutions for stomach trouble or ‘cries from hunger’ – an indi- cation that the child is not nourished enough from breastfeeding alone.
Kavle, 2014 & 2015

11. - Grandmother, Lower Egypt
“I knew he was ready to eat when he kept crying at four months. I told the mother - your breastfeeding is not nourishing him, and the child is a human like us who needs to eat - what will your milk do for him?”
- Grandmother, Lower Egypt
Q: Do you have the photo credit?
R: Photos belong to Justine
Prelacteal feeding is the entry point for mixed feeding – as encouraged and prescribed prelacteal feeding is the entry point for mixed feeding - which is believed to remedy insufficient breastmilk and other problems of “fussy” children.

12. Breastfeeding is Valued as a Natural Choice Only if Mothers Have Enough, Good Quality Breastmilk – “Thick and Heavy, Not Weak and Light, or Little”
Infants “not nourished enough” by breastmilk alone and are “still hungry” – main reason for introducing food and liquids early
Some combine breastfeeding with infant formula
Feed “light and simple” foods as early as 2 months
Initial screening of foods to assess readiness to eat
Encouraged by some doctors and grandmothers
breastfeeding as a ‘natural choice’, mothers experi- enced challenges to initiating exclusive breastfeeding and qualified their views of breastfeeding based on whether they had ‘enough’ breast milk. Encouraged and prescribed prelacteal feeding is the entry point for mixed feeding – which is believed to remedy insufficient breast milk and other problems of ‘fussy’ children. Continued use of herbal drinks in the first 6 months is believed to act as soothing and calming agents to ‘help babies sleep at night’. Herbal teas (i.e. anise, caraway) are also viewed as solutions for stomach trouble or ‘cries from hunger’ – an indi- cation that the child is not nourished enough from breastfeeding alone.
Kavle, 2014 & 2015

13. Strategies to Improve Immediate and Exclusive Breastfeeding - Learnings from Egypt
Provide guidance to health providers and community health workers
Stop prelacteal feeding
Dispel misperceptions of insufficient breastmilk
Not prescribe herbal drinks for children < 6 months of age
Not separate mother and newborn after childbirth – delays initiation
Provide guidance to health providers and community health workers
Stop prelacteal feeding
Dispel misperceptions of insufficient breastmilk
Not prescribe herbal drinks for children < 6 months of age
Not separate mother and newborn after childbirth – delays initiation
Use community support groups to strengthen knowledge at the community level, involve grandmothers and fathers
Use community support groups to strengthen knowledge at the community level, involve grandmothers and fathers
Engage lactation consultant associations to work with health providers to ensure initiation, duration and exclusivity of breastfeeding for the first 6 months of life
Engage lactation consultant associations to work with health providers to ensure initiation, duration and exclusivity of breastfeeding for the first 6 months of life
Insufficient milk has been a concept – known anecdotally and documented in several reviews and studies – we know what needs to be done to achieve 2025 target of increasing breastfeeding and turning the tide from stagnant exclusive breastfeeding rates.
health professionals,, often
hold similar perceptions and attitudes to the caregivers
themselves with regard to breast-feeding and it is important to dispel any misperceptions, and it is critical to provide guidance to stop giving foods/liquids in the first 3 days of life, not prescribe herbal drinks for children less than 6 months of age and not separate the mother and newborn
Maintaining exclusive breastfeeding is challenging, as mothers, fathers, grandmothers and health providers do not recognize early introduction of herbal drinks and foods as a feeding problem, as long as mothers continue to breastfeed, which is highly valued. Continuing education is needed for health care providers and community health workers to counsel on insufficient breast milk, as well as to encourage health providers to not prescribe herbal
drinks to children less than 6 months of age, including ensuring mothers and babies are not separated following childbirth can go far in remedying this problem.
Messages on breastfeeding and complementary feeding need to be given to mothers and their families who do not have this information to improve quantity, quality and frequency of meals within the context of reducing junk food. These messages should be dis- seminated through local organizations, community health workers and health care providers and reinforced through cooking classes and through maternal and child health clinics.
using messages developed in the TIPs counseling guide – to strengthen exclusive breastfeeding practices,
Focus on quantity, quality and frequency.
Kavle, 2014 & 2015