1. NIC-C2 Child Health and Nutrition: Cost-Effective Approaches for Scaling-Up Life-Saving Interventions Infant and young child feeding— approaches to getting impact at scale Tina G. Sanghvi, PhD Senior Country Director for Bangladesh Academy for Educational Development (AED) For USAID, March 2010 Reconvening Bangkok

2. Outline Defining the problem Following the evidence Narrowing the focus Finding large-scale platforms Mainstreaming Lessons learned Shahjahanpur Upazila, Bogra District, Dec ‘09

3. Problem: When, why, where, how Shrimpton et al. 2001 EBF CF  ANC, Delivery, PNC, EPI   Nutrition & infection Asia worse off than Africa

4. Interventions Shahjahanpur Upazila, Bogra District, Dec ‘09

5. ‘Exclusive BF’ – what does this mean for programs? 14.4 ///// Lancet 2008 Relative risks of specific BF practices:

6. Evidence on BF Interventions Cochrane review, 34 trials with29,385 mother–infant pairs from 14 countries: All forms of extra support increased the duration of breastfeeding. Individual, group counselling by medical, paramedical or CHWs is effective. Teaching mothers simple skills to maximize breastmilk intake Lancet, 2008

7. Evidence on BF Interventions Mass media campaigns also shown to be effective “Community-based strategies for breastfeeding promotion should be integrated with additional health-system support” – Breastfeeding support in maternities – Health contacts (timed & targeted) Lancet, 2008

8. Focusing down using formative research Initiation < 1 h No pre-/post lacteals EBF to 6 m (BF)+ solids/ss from 6-24 m Frequency CF Quantity CF Quality of foods Hygienic prep, handwashing ‘Responsive feeding’ Feeding during/after illness Shahjahanpur Upazila, Bogra District, Dec ‘09

9. Focusing down - barriers and facilitators Ideal PracticeBarriersFacilitators Early initiation and colostrum + no pre- post- lacteals Birth attendants, families not aware, relatives, doctors, C-section Trained & motivated doctors, CHWs Exclusive BF for 6 months Mothers/families not aware of dangers, milk ‘insufficient’, doctors Perception that baby gets enough milk, ‘I can do it’ Quantity of semi- solids after 6 m as recommended Mothers not aware of what and how, doctors, relatives No special foods needed, easy, child likes and able to eat, fathers, neighbors, CHWs Animal foods/diversity Mothers/family not aware of what and how, cost Easy (family eats the same), child likes, healthy, can increase no. days/week if not daily Encourage & support child to eat Mothers/families not aware of what and how, time Mother understands importance, family helps to feed child/ shares housework Alive & Thrive, 2009

10. Potential to Improve Practices UrbanRural % Mothers who said HW talked about BF, CF: - During ANC visits - During immunization visits - During sick child visits 9 8 39 7 8 30 Topic covered by health worker % - Only breastmilk before 6 months - Have to feed breastmilk - Continue BF even if baby is sick NOTE: Nothing on CF or BF initiation 18 13 8 29 10 13 Most reliable source of information % - Grandmothers - ’Doctor’ - Husband - Friends/neighbor/other -Health worker 20 24 13 12 38 24 10 6 7

11. Platforms: Scale opportunities BDHS, 2007 BRAC’s 70,000 community-based volunteers

12. Mainstreaming: How to operationalize ? Char in Sibalay Upazila, Manikganj, Dec ‘09 It’s a marketing & advocacy job… wiifm

13. Mainstreaming What? Approach Reach all PW to 2 y children (lists) Counsel mothers in homes, community (BRAC) Link trained health workers with community- based volunteers & workers (BRAC, Govt.) Mobilize family members, opinion leaders (BRAC, Govt.) Monitor quality of counseling Campaign through mass media (Ad company)

14. Mainstreaming What? Implementation Community Worker/Volunteer Training and Support ($$) – Home visits (incentives) – Community forums (existing) – Social mobilization (local advocacy) Health services contacts (advocacy) Mass media ($$, collaborations) Education sector (advocacy) Evaluation: Randomized, control, cross-sectional ($$)

15. Lessons Learned Problem-solving approach (not only messages) Focus on few practices, build confidence of mothers Timing of counseling is key: last trimester of pregnancy, <3 d, 2-4 m, 6-7 m, 9-11 m Ongoing CHW training on large scale

16. Lessons Learned CHWs want mentoring & encouragement, incentives Short training modules can be inserted in ongoing trainings/ meetings In scale up, districts are variable, some need more support Some use MIS for monitoring, others also ‘rapid surveys’ : – Coverage of pregnant women to 2 y – Observed quality of counseling (checklist) – BF & CF practices improvement (std. questionnaire)

17. Conclusion Define the problem v. well Follow the evidence Narrow the focus, local context Find large-scale platforms Mainstream: partnerships, advocacy at all levels, select investments Document lessons, feedback Shahjahanpur Upazila, Bogra District, Dec ‘09