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Dr. K P Kushwaha Principal, Prof & Head, BRD Medical College, Gorakhpur District Administration, Lalitpur B.R.D. Medical College, Gorakhpur

2 MSG- evidence Published data on effect of “Mother Support Groups” on IYCF practices are encouraging but such a large community intervention is lacking Such effects would be feasible and reproducible in the long run especially in resource restricted communities BMJ 2012;344:d8287

3 Project Area Slide 3 “BFCHI” (Baby Friendly Community Health Initiative) implemented in all the 6 blocks of Lalitpur

4 The Lalitpur Project…. Purpose
The key purpose of the BFCHI action plan was to improve exclusive breastfeeding and complementary feeding practices

5 The Lalitpur Project…. Objectives
The primary objectives of the study were to evaluate the effect of the BFHI program on the infant and child feeding practices in the community such as – Initiation of breastfeeding within one hour of birth, Prelacteal feeds Exclusive breastfeeding up to six months and Timely introduction of appropriate complementary feeding after six months of age with continued breastfeeding among infants and young children Responsive feeding Feeding during illness

6 The Lalitpur Project…. Secondary objectives
The secondary objectives of the project were to evaluate the effect of BFHI action plan on– Proportion of mothers needing help for feeding Breastfeeding practice indicators- mothers confidence Feasibility of interventions for scale-up/extension of such projects to other districts in the state of Uttar Pradesh as well as other states in India

7 The Lalitpur Project…. Collaborating centers
Department of Pediatrics, BRD Medical College, Gorakhpur and UNICEF, Office of UP jointly collaborated and developed the Baby Friendly Community Health Initiative (BFCHI) plan of action

8 The Lalitpur Project…Methods
Step 1 Assessment of infant and young child feeding practices initially in 3 of the 6 blocks of the district (pre trial research) Step 2 Develop consensus on the goal, purpose, objectives, expected results of the BFCHI plan of action (Protocol development) Step 3 Coordination with ICDS, Health NGOs, local leaders, primary school teachers- develop Mother Support Groups (capacity building)

9 The Lalitpur Project…Methods..
Step 4 Training of resource persons (middle level trainers) using IBFAN/WHO/BPNI/UNICEF 3-in-1modules Step 5 Training of MSG’s by middle level trainers Step 6 Setting up of village resource centers, 6 block IYCF resource centers (2 IYCF counselors available for 6 hrs/day) and referral center for referred cases from field

10 The Lalitpur Project…Methods..
Step 7 Home visits by MSG members (10 visits in first 6 months, 6 visits in next 6 months and 3 visits in 2nd year)- Step 8 Counseling and helping mothers with feeding difficulties and reinforcing optimal practices Step 9 Re-assessment of outcome variables of interest in the community

11 Infrastructure for IYCF counseling in Lalitpur
Total population ,77,447 Intervention population (Jan.2007 to July2010) -Over children Births (from 1stJan, 07–31st Dec-08) Follow up for 0-24m Follow up for 1yr (from Jan, 07– Dec-07) Analysis of Growth cards (WHO) October IYCF counselors (yr 2007), 24 (yr ), -14 (yr 2010), 12 (yr2011), 10 (yr2012) Block Monitors (yr 2007), 8 (yr2008), 4 (yr ) TOTAL babies under two yrs has been reached through AWWs, ASHA and the mother from the mother support groups in the district so for. During 2 yrs period they have followed and weighed babies for variable period of months to 2 yrs,13162 babies have been followed for one full yr(365 days) to calculate neonatal and infant mortality rates. In 1532 babies between 6m to 24 m they have measured weighed and length to gather in March 2009. Slide 11

12 Infrastructure contd…
Total Trained MSGs (1286 centers) ASHA AWWs Helper (AWWs) Shariya Women Other Trained Mothers Performance of Centers Above Average - 4 meeting/month = 50% Average - 3 meeting/month = 35% Below average - <2 meeting/month = 15% Members from 170(28%) mother support groups (one MSG of three members in each village) have contacted babies in their villages minimum of 4 times in a month. Slide 12

13 MSGs-Village Level IYCF Support
Comprise of 3- 4 members of a group including traditional birth attendants, experienced mothers, and community health/nutrition workers- population 1286 Mother Support Groups formed in district of Lalitpur 3858 local women trained for 3 days for 24 hour counselling/referral support in the villages Slide 13

14 MSGs-Village Level IYCF Support….
MSG –salient features…… Trained in basic skills of communication and infant and young child feeding Under direct supervision of counselors-cum-trainers - designated as “facility level counselors” and “trainers” of mother support groups Facility level trainers – in turn- trained by experts of IYCF counseling from medical and nursing backgrounds The MSG’s - 24 hours a day throughout the year Place or office where breastfeeding mothers may seek help

15 Mother Support Groups (MSGs) for the promotion of Infant and Young Child feeding practices
Around 1286 MSGs working with support of BFCHI project 1124 at AWCs 162(288 members) in Sahariya (96) and Majras (66) Promoting IYCF practices in the community through holding community meetings and Home visits.

16 Village Level activities
Demonstrating a thick consistency complement And feeding skill Helping mother to learn breastfeeding positioning Slide 16

17 Village Level activities
Antenatal education of mothers about advantages of breastmilk and breastfeeding and how to succeed in breastfeeding Early initiation of breastfeeding Helping mothers to learn positioning and attachment for effective breastfeeding Prevention of breastfeeding difficulties and breast conditions Expression of breastmilk and katori feeding Exclusivity of breastfeeding Slide 17

18 Activities contd… Identification of sick babies and their referral KMC
Preparing good complementary food for babies and foods to feed Feeding skills for complementary feeding Variety and amount of foods for growing children Growth monitoring Weekly Health and Nutrition Day (Every Saturday) Village Health and Nutrition Day (In a month) BSP, Immunization and Use of MCP Cards Recording of births & deaths Reports Slide 18

19 Support of BFCHI: Creating and Supporting Mother Support Groups
Of the total 1124 centers in the district at AWCs, 643 MSGs were developed as model centers on set standards and handed over to ICDS. The members of MSGs are playing a vital role in advocating and promoting IYCF practices in the community.

20 Sensitization of administration and health officials

21 Training ICDS and health workers

22 Capacity Building (Year 2007-2012)
Middle Level Trainers Training - 2 batches of (7 day integrated 3 in 1 module of BPNI/IBFAN) (50 persons trained at Dept. of Pediatrics, BRD Medical College, Gorakhpur) Training of Front Line Workers - A total of 3858 ASHAs, AWWs, Dais and mother support groups trained. Fifty Two Medical Officers were oriented (1 Day). Twenty Four ICDS Supervisors were oriented (1 Day). The 152 LHVs, ANMs and staff nurses from health and family welfare department were trained using 3 day module 288 Shariya (tribal) members were also trained Slide 22

23 Supervised Training of MSG’s by middle level trainers

24 Training of MSG’s by middle level trainers

25 Training of MSG’s by middle level trainers

26 Setting up of village resource centres

27 Saturday Meetings : WHND days in the district
On the first Saturday the birthdays of all children falling in that month celebrated as “Janmdiwas” Second Saturday celebrated as “God bharai for pregnant women”

28 Continued….. Third Saturday celebrated as “Annaprashan” day (initaiting CF from 6 months) Fourth Saturday celebrated as “Kishori balika diwas” to make them aware on health and nutrition issues

29 Functional IYCF Counseling Centres
District: 1 Block: 6 Village: 1286 Slide 29

30 Strengthening monitoring mechanism
A strong mechanism established to monitor the quality of services being provided by AWW Joint monitoring is being done by BFCHI team along with DPO/CDPOs/Supervisors by using comprehensive checklists to review the functioning of these MSGs

31 The Lalitpur Project…. Study setting
BFCHI - implemented in the district of Lalitpur with support from Government of UP and the Lalitpur District Administration Study design Quasi experimental- before and after study Assessment of feeding practices, nutritional status Intervention- education, counseling and support Reassessment of pre-specified outcome variables

32 The Lalitpur Project…Methods
Sampling and study period Cluster sampling and multi-stage sampling design Pre-intervention stage- 6 blocks selected for collecting pre-intervention data (November 2006) Mothers who have delivered a child within 0-3 months 3-6, 6-12 & months were selected from the sample villages Post-intervention stage- same blocks (December 2011)

33 The Lalitpur Project…Results
Primary outcomes P- value- <0.001 for all outcomes Pre-intervention-2006 ; Post-intervention-2011

34 The Lalitpur Project…Results
Primary outcomes P- value- <0.001 for both outcomes

35 The Lalitpur Project…Results
Secondary outcomes- Mother’s confidence P- value- <0.001 for all outcomes

36 The Lalitpur Project…Results
Secondary outcomes- Mother’s confidence P- value- <0.001 for all outcomes

37 Mothers perception on health of their Children
Dec-2006 Jan-2009 Healthy 47.1% 80.5% Slide 37

38 Final Evaluation by Unicef, UP (2012)
Status of IYCF Key Indicators Baseline Survey (2006) Evaluation Survey (2008) Survey (2011) Final Evaluation by Unicef, UP (2012) Initiation of breastfeeding within an hour (%) 10.9 71.0 62.0 82 Initiation of breastfeeding within 1-3 hours (%) 22.8 14.0 35.0 Pre-lacteal feeding (%) 67.0 15.0 5.0 Exclusively breastfed for 6 months(%) 7.0 50.0 60.0 94 Introduction of thick Complementary feed between 6- 8 m (%) 53.8 85.0 Introduction of compliments at 6 m (%) 43.6 49.0 96.0 (6-8 months) 83 Introduction of compliments at 8m (%) 10.2 36.0 Slide 38

39 Effect of Peer Counselling by Mother Support Groups on Infant and Young Child Feeding Practices: The Lalitpur Experience Komal P. Kushwaha1*, Jhuma Sankar2 , M. Jeeva Sankar2 , Arun Gupta3, J. P. Dadhich4 , Y. P. Gupta5,Girish C. Bhatt1, Dilshad A. Ansari1, B. Sharma1 1 Department of Pediatrics, BRD Medical College, Gorakhpur, India, 2 Department of Pediatrics, AIIMS, New Delhi, India, 3 IBFAN Asia, BP-33, Pitampura, Delhi, India, 4 BPNI, BP-33, Pitampura, Delhi, India, 5 YG Consultants Pvt. Ltd., New Delhi, India Citation: Kushwaha KP, Sankar J, Sankar MJ, Gupta A, Dadhich JP, et al. (2014) Effect of Peer Counselling by Mother Support Groups on Infant and Young Child Feeding Practices: The Lalitpur Experience. PLoS ONE 9(11): e doi: /journal.pone

40 IYCF Practices in the Community before and after the intervention

41 Effect on any IYCF Practices: Multivariate analysis

42 Secondary outcomes of the study population

43 The Lalitpur Project… Project interventions effectively improved IYCF practices in district Lalitpur, UP Concept of ‘mother support groups’ and subsequent counseling and support of the mothers is feasible and sustainable using local resources at the community level

44 The Lalitpur Project… This project has demonstrated real convergence at village level and heightened motivation of workers to prevent malnutrition and morbidity in infants and young children The project has paved the way for several such districts/areas to follow suit

45 Case-1 Sore nipple, engorgement Helped to succeed Slide 45

46 Case-2 Perceived not enough milk Initiation at 30mts of birth
Baby cried during night & was given animal milk Action: Improving position & attachment, giving information Result: Mother succeeded in breastfeeding Slide 46

47 Case-3 Mother name : Smt Lakshmi Father Name : Khushi lal
Baby Name : Sunder Address : Lakhanpura, Jakhaura, Lalitpur Pain during feeding-not able to feed Observation- ∆ Sore nipple engorgement Skills - ∆ Confidence building ∆ Expression ∆ Katori feeding ∆ Position and Attachment ∆ Succeeded in breastfeeding Slide 47

48 Case-4 Mother name : Smt Teja Father Name : Mauji Sheriya
Baby Name : M Address : Jamundhana, Birdha, Lalitpur Sick mother, not feeding right under-nourished baby Observation- Poor attachment Skills - ∆ Open questions ∆ non verbal comm., empathy ∆ Accepting ∆ Informing ∆ Helping in positioning & attachment ∆ Explaining others what has been done Result - Succeeded Slide 48

49 Case-5 Village visit ∆ Mobilizing peoples support
∆ Listening to mothers and observing breastfeeding ∆ Helping mothers to improve attachment ∆ Measuring weight gain ∆ Mothers confident in breastfeeding ∆ Dietary history ∆ Demonstration of making babies feed and active feeding Slide 49

50 Case-6 Severely undernourished orphaned Tribal child
∆ Carried to PHC and NRT centre Action: Gave Vit-A, drugs and Locally prepared cereal mix with oil Result: Wt. gain Slide 50



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