Integrated Early Childhood Development at UNICEF: How does breastfeeding fit in?

UNICEFProgramme Division

Nutrition Section

UNICEF

Objectives -- The participant will:

Understand the general principles of I/ECD Explore how to introduce breastfeeding in discussion

of I/ECD Explore how to introduce breastfeeding in

discussions addressing the other 4 Strategic priorities

Understand the 3 sectors enhanced by LAM Discuss the development of new “hooks” to increase

interest in breastfeeding

UNICEF

Brainstorm Group 1: Breastfeeding in Other MTSP Strategies

Girl’s Education Cognitive and psycho-social

achievement highly

associated with breastfeeding

Educate girls for important

role as future mothers: “An

educated girl educates her

family and society about

breastfeeding”

UNICEF

Brainstorm Group 2: Breastfeeding in Other MTSP Strategies

Immunisation Plus

Breastfeeding provides first immune protection, and Vitamin A, among others, helps fight disease

Colostrum is the first immunisation Immediate contact reduces illness by

regulating temperature Provides first doses of Vitamin A Disease-free = sanitary, and prevents spread

of bacteria Visit is an opportunity to counsel on

breastfeeding

UNICEF

Brainstorm Group 3: Breastfeeding in Other MTSP Strategies

HIV/AIDSStrong nutrition link; EBF decreases

transmission Counselling is an opportunity to talk

with mothers about breastfeeding Use PMTCT sites to strengthen BFHI

and to monitor Code Lactation management to prevent and

treat breast health problems reduces transmission

UNICEF

Brainstorm Group 4: Breastfeeding in Other MTSP Strategies

Child Protection

Nurtured and breastfed children less likely to be deserted and abused

Refugee situations must know about the dangers of BMS

Violence in the home: mother-baby togetherness and support of relationship can protect baby

Calming effect of breastfeeding for frustrated mother Food security: feeding mother is less expensive than

artificial infant feeding , reducing financial stress, and

Birth spacing leads to better family health

UNICEF

1. Have your menses returned?

2. Are you supplementing regularly or allowing long

periods without breastfeeding, either day or night?

3. Is your baby more than six months old?

4. The mother’s chance of pregnancy is increased. For continued protection, and to achieve a healthy three (3) years of child spacing, advise the mother to begin using a complementary family planning method and to continue breastfeeding for the child’s health, adding complementary feeding at about 6 months.. When the answer to one of these

questions becomes YES....

NO

NO

NO

There is only a one to two percent chance of pregnancy

at this time.

Ask the mother, or advise her to ask herself these three questions:

YES

YES

YES

The Lactational Amenorrhea Method (LAM):

Supports Breastfeeding, Birth Spacing and Timely Complementary Feeding

UNICEF

Try to develop a new “hook”!!

Select another sector (e.g., environment, food security, micronutrient programme, malaria, or other intervention area) that does not currently emphasize optimal breastfeeding

Consider what intervention or concept could be “socially marketed” that would “hook” those from this other discipline that are not currently supporting optimal breastfeeding into being supporters of breastfeeding.

UNICEF

Individual Work:Creative New Hooks(1)

Malaria– Bednet to keep baby safe and breastfed: “safe inside and

out” Environment

– Breastfeeding has no waste products, no fuel, no commercial waste

– Breastfeeding takes less water during shortages Education

– Psychosocial interaction that starts with breastfeeding leads to time spent with the child, story-telling and reading

UNICEF

Individual Work:Creative New Hooks(2)

Micro-enterprise– Breastfeeding women are reliable and willing to work from

home Credit Banks

– Women who breastfeed have a track record of involvement and responsibility, and likely to pay back loan

Peacekeeping– Children who are breastfed are more compassionate to others

Others– Pharmaceuticals: With the increase in resistant pathogens,

breastfeeding is important -- now more than ever.

UNICEF

Expand your Ideas through Teamwork!

When Faced with a Complex New “Vehicle”

Hakuna matata...I/ECD?

UNICEF

UNICEF

Nutrition related MTSP target indicators

Reduction in anemia prevalence among women of reproductive age by 15%

> 60% of children receive appropriate home care for prevention and treatment of malnutrition

> 60% of pregnant women use adequate antenatal services

UNICEF

Focus of I/ECD

Integrated ECD is based on child’s rights principles and the life-cycle approach, developed to co-ordinate actions at different levels, aiming to improve:– Quality of family care

– Family access to good basic services and adequate livelihoods

– Community & policy environment needed to support the previous points.

General Goals: Child Survival, Growth and Development

UNICEF

What is Integrated Early Childhood Development?

The Importance of the Mother-Child Dyad “A good start on life”

“Children under 3 y.o.”

“Support women’s health, nutrition, and well-being”

“Links to maternal health and survival”

Maternal nutrition for birth weight and maternal survival, early initiation of exclusive breastfeeding (EBF)

EBF, appropriate CF which includes responsive feeding, VitA, Birth spacing

Mother-child vs Child orientation, empowering caretaker to act and interact

If mom survives, the child is 3- 5 times more likely to survive

UNICEF

Breastfeeding is the Heartbeat of Primary Health

Logo, Breastfeeding Division, IRH

Oral Rehydration

Growthand Development

ImmunizationMaternal Health and Survival

Nutrition

Birth Spacing and Fertility

Reduced Cancer and Chronic Disease

Breastfeeding supports:

UNICEF

What is Optimal Breastfeeding?

Six months exclusive breastfeeding Continued breastfeeding with appropriate

complementary foods and feeding for 2 years and beyond

Related maternal nutrition and care (Birth Interval of 3 years or more)

UNICEF

Breastfeeding -> Early Childhood Development

Decreased child desertion in hospitals Best growth in first 6 months Improved elements of neuro-psycho-motor development

at age 1-2, and up to 12 Improved vision from a few months to years Increased independence and parental trust Increased intelligence quotient (IQ) assessed at ages 8

and 9 years; at age 18 years Decreased infectious and chronic illness, and decreased

impact of several metabolic conditions, supporting continued thriving

Increases in breastfeeding are associated with:

UNICEF

Breastfeeding -> Early Childhood Development Increased adolescent perceptions of maternal caring Higher reading comprehension, mathematical ability,

and scholastic ability assessed during the period from 10 to 13 years;

Higher teacher ratings of reading and mathematics assessed at 8 and 12 years;

Higher levels of attainment in school leaving examinations

Contribution to birth intervals, allowing more attention to care and feeding, and maternal nutritional recovery:

Result: children are alive and thrive!

UNICEF

Current and Planned Interventions: The Same Target Audience for All

ANTENATAL CARE

SAFE DELIVERYADEQUATE BIRTH WEIGHT

OPTIMAL AND RESPONSIVEINFANT AND

YOUNG CHILD FEEDING

AT LEAST THREE YEARSBIRTH SPACING VIA

FAMILY PLANNING USE

ANTENATAL CARE

MPSMNI

Malaria Presumptive Tx/Nets

Expanded MPS/SMBFHI

“Expanded Step Ten”CODEMNICF

IMCI/CIMCIIMM

FP(UNFPA)ECDLAM

BF/CF

CARE SEEKING

UNICEF

Current and Planned Interventions: The Same Target Audience for All

ANTENATAL CARE

SAFE DELIVERYADEQUATE BIRTH WEIGHT

OPTIMAL AND RESPONSIVEINFANT AND

YOUNG CHILD FEEDING

AT LEAST THREE YEARSBIRTH SPACING VIA

FAMILY PLANNING USE

ANTENATAL CARE

MPSMNI

Malaria Presumptive Tx/Nets

Expanded MPS/SMBFHI

“Expanded Step Ten”CODEMNICF

IMCI/CIMCIIMM

FP(UNFPA)ECDLAM

BF/CF

CARE SEEKING

UNICEF

0

0.5

1

1.5

2

2.5

3

3.5

4

<17 18-23

24-29

30-35

36-41

42-47

48-53

54-59

60+

Relative Risk, 0<5 yoMortality 1-4 yo

1mo-12mo

<1mo

Birth Spacing Saves Children’s Lives: Relative risk of mortality with various birth intervals compared to a 3 year birth interval

Months Birth Interval

UNICEF

Approximate Annual Pregnancy Rate If:

Non-lactating = 60%Lactating = 40%Lactating and amenorrheic = 15%Fully lactating and amenorrheic = 5%Fully lactating, amenorrheic, <6 months

postpartum = 2%LAM users = <2%

UNICEF

Why does LAM have improved efficacy?

Slightly, but significantly, shorter intervals Slightly, but significantly, more feeding

episodes per day Greater attention to night feeds Dedication to breastfeeding patterns for

fertility impact

Conclusion: Women who choose LAM will practice closer to optimal breastfeeding behaviors

UNICEF

Bellagio II

CONFIRMED efficacy of LAM SUGGESTED further study might enable

“relaxing” the fully breastfeeding and 6 month requirements

DEFINED menses return as 2 consecutive days of bleeding or a vaginal bleed that the woman perceives of as a menses (after 8 weeks pp)

ENCOURAGED worldwide implementation fo LAM for all of its positive impacts

UNICEF

Breastfeeding vs LAM:Influencing other Sectors

LAM BF

BF Patterns

Birth SpacingFertility MTCT

Increased Child Healthand Survival

LAMuse

FP Uptake

UNICEF

Objectives of this Session

Understand the general principles of I/ECD Explore how to introduce breastfeeding in discussion

of I/ECD Explore how to introduce breastfeeding in

discussions addressing the other 4 Strategic priorities

Understand the 3 sectors enhanced by LAM Discuss the development of new “hooks” to increase

interest in breastfeeding

UNICEF

Thank you

Asante-sana

Salamat po

Merci

Gracias

Danke

Spasibo

Abrigato

Barakallaofik

Infant and Young Child Nutrition and Related Maternal Issues:

Targeting the Mother-Child Dyad -The Mother-Baby-Friendly Plan of Action

UNICEFProgramme Division

Nutrition Section

37

57

45

46

49

45

38

33

17

0 10 20 30 40 50 60 70 80 90 100

World

Developing Countries

Least developed countries

CEE/CIS

Sub-Saharan Africa

Latin America/Caribbean

Middle East/North Africa

South Asia

East Asia/ Pacific

Source: UNICEF, 2001

EXCLUSIVE BREASTFEEDING RATE (< 4 months), 1995-2000

UNICEF

4843

79

525249

81

55

0

10

20

30

40

50

60

70

80

90

100

ExclusiveBreastfeeding (0-3

mos.)

ComplementaryFeeding (6-9 mos.)

ContinuedBreastfeeding (12-15

mos.)

ContinuedBreastfeeding (20-23

mos.)

Pe

rce

nt

TRENDS IN BREASTFEEDING 1990-2000

+8% +15% +3% +5%

Percentchange 1990-2000

Includes only countries with trend data

UNICEF

(BFHI) Ten steps to successful breastfeeding

1.Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4.Help mothers initiate breastfeeding within one half-hour of birth.

5. Show mothers how to breastfeed and maintain lactation,even if

they should be separated from their infants.

UNICEF

(BFHI) Ten steps to successful breastfeeding

6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.

7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.

8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or

soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups

and refer mothers to them on discharge from the hospital or clinic

UNICEF

The Baby-Friendly Hospital Initiative:

Vital...

• A maternity facility can be designated when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented The 10 Steps.

• Process controlled by national breastfeeding authorities, using Global Criteria. Implementation guides for the BFHI developed by UNICEF and WHO.

• BFHI Part II provides the Global Criteria and outlines how to transform hospital practices.

• Part IV and Part VI help to verify the ending of free and low-cost supplies of breastmilk substitutes. Additional BFHI Parts, including questionnaires used by external teams to assess facilities before Baby-Friendly designation, are available.

http://www.unicef.org/programme/breastfeeding/

UNICEF

...but is it sufficient? Baby Friendly and Beyond

Is it time to expand beyond BFHI? If so, in what direction? How can we support the World Fit for Children goals, the new

UNICEF priorities, the war on HIV, while maintaining support and interest in best start for children: the caring of an empowered mother?

What specific components would extend the effort towards increased empowerment of women while maintaining the focus on the importance of optimal breastfeeding?

Is the idea of an "Expanded Step Ten," per se, attractive to you? “Mother-Child Dyad Initiative”? MBFAP?

Other ideas?

UNICEF

Timing of subsequent pregnancy by month postpartum and by

breastfeeding status

0

10

20

30

40

50

60

70

80

90

0 3 6 9 12 15 18 21 24 27 30 33 36 Months since last birth

% p

reg

nan

t

Non-lactating,non-contracepting -IndiaNon-lactating,non-contracepting -AlaskaLactating, non-contracepting -India

Lactating, non-contracepting -Alaska

IRH

UNICEF

Schema for Breastfeeding Definition

Full Partial Token

ExclusiveAlmost

Exclusive HighMedium

Low

MinimalFull or Nearly Full Breastfeeding

Significant Fertility ImpactLow Partial/Token Breastfeeding

Minimal Fertility ImpactLabbok M and Krasovec K, 1989

UNICEF

Focus of Nutrition Interventions:

Main focus areas: Ante-natal period is associated with infant

growth, morbidity & mortality which makes maternal health and nutritional status essential

After birth, growth faltering needs to be prevented, and this should happen from early childhood onwards.

UNICEF

Complementary Feeding:Basic Principles

Maintaining Optimal Breastfeeding Timing of initiation of CF and transition Deciding on amount to give Ensure viscosity Preparing foods for ready digestion Understanding Energy, Protein, and Micronutrient

needs, and food choices Learning and practicing interactive and supportive

feeding behaviours

UNICEF

Legislation Policy Health Sector Community/SocialStage 1 Identify related goals in the country or sub-region

Advocate for BCM/EMCN, using available spokespersons Assemble and analyse available baseline information toidentify potential catalyzers and obstacles

Identify/develop a national authority for eachStage 2

Stage 3 Dev.toolStage 4 Imple&M

Assess, Analyse, and Modify Activities

PMTCT, Code , BFHI and I/ECD EMBFI Planning:

Four Stages in Implementing “Expanded Step Ten”: Expanded Mother/Baby Friendly

Interventions

UNICEF

Legislation Policy/Standards

Health Sector Community/Social Advocacy

Stage 1 Identify related goals in the country or sub-region Advocate for Breastfeeding/Complementary Feeding/Maternal health and nutrition using available spokespersons

Assemble and analyse available baseline information to identify potential catalyzers and obstaclesIdentify/develop a national authority for eachStage 2

Include legislators Include policymakers

Include accreditation authority Include major NGOs andother social/religiousorganisations.

Include charismaticleaders from alllevels

Stage 3 Together assesscurrent legislationrelated to creation ofa supportiveenvironment, (e.g.,commercialinfluences, maternityprotection andrelated social reform

Togetherassesscurrentpolicies andstandardsrelated tocreation of asupportiveenvironment

Together assess hospitalconformity with “Ten Steps”and medical and nursingcurricula related to BCM

Together carry out systems-based checklist

assessment of

specific obstetric/gynaecological, paediatric, andother health practices thatimpact on BCM

Together assesscommunity needs andsocialmobilisation/marketingpossibilities forbehaviour change

Assess capacity andgaps

Identify issues thatmay be causingconfusion, such asHIV/AIDS, and clarifyapproaches withupdated information

Togetheridentify majormedia and keyleaders insocial, religious,sports, etc.sectors

Develop mediacampaign

Developresourceattraction plan

Stage 4 Develop/passlegislation

Implement andenforce

Use nationalcommunicationnetworks to ensurepublic awareness

Useexpertrespectedandtechnicallyup-to-datecommittee todevelop newstandardswithpractitioners

Continue BFHI activities Use systems-based

assessment to develop keyadditional activities

Train key trainers Co-ordinate appraisal and

reform of hospital practices Co-ordinate updating of all

medical, nursing and adjunctpersonnel undergraduatecurricula

Develop culturallyappropriate job-aidsfor addressing gaps

Train key trainers Implement behaviour

change support in allongoing communityand social activities

Supportcommunicationscampaigns to raiseawareness

Implementmedia andleadrshipadvocacy efforts

Continueupdating messagesand resourcesidentificationapproaches

Assess, Analyse, and Modify Activities

A simple checklist of practices is under development

UNICEF

Integrated Early Childhood Development at UNICEF: Targeting the Mother-Child Dyad -

Vital to MTSP Success

UNICEFProgramme Division

Nutrition Section

UNICEF

Bellagio I -- 1988

“Women who are not using family planning, but who are fully or nearly fully breastfeeding and amenorrheic, are likely to experience a risk of pregnancy of less than 2% in the first 6 months after delivery”

Developed into LAM algorithm by group of FP and MCH program leaders at Georgetown, IRH

Studied in other formats by FHI and others

UNICEF

Return of Menses among Exclusively Breastfeeding Women: Cumulative Percent by Six-Month Life Table

0

10

20

30

40

50

60

1 2 3 4 5 6

Control Group

LAM Group

UNICEF

Average Number of Feeds per Day by Month Postpartum

6.5

7

7.5

8

8.5

9

1 2 3 4 5 6 months

LAM group

Control group

*

* * *

*p<0.05

UNICEF

Results of Studies on LAM Efficacy by 6 (or 9) Month Life Table

99.6 98.8 99 99.4 100 98.5 100 99.5 96.5

80

85

90

95

100

Chile

1

Ecua

dor

Phili

ppin

es

Paki

stan

New

Zeal

and

Multi

cent

er

Post

-Ma

rket

ing

9-Mo

nth

Wor

king

%

UNICEF

Median duration of breastfeeding and lactational amenorrhea

in selected countries

0

5

10

15

20

25

30

35

Bangladesh Sri Lanka Senegal Peru

Breastfeeding AmenorrheaDHS, 1980s

UNICEF

Return of Ovulation During Lactation, by Feeding Pattern

and Recurrence of a Menses-like Bleed

0102030405060708090

Full Partial None Full Partial None

Nu

mb

er o

f W

om

en

No Ovulation prior to Bleed Ovulation prior to Bleed

<60 days pp > 60 days pp

Derived from Perez et al, 1979

UNICEF

Conclusions (1 of 2) Interactive Breastfeeding and Responsive feeding are major

elements in the life of the 0-3 year old

Early, Exclusive and Sustained Breastfeeding are shown responsive to intervention programs

ECD benefits inescapably from the presence of a living, health, and well-informed mother who is supported by her community - breastfeeding is empowering

If optimal infant and young child feeding is programmed, nearly all aspects of ECD are addressed and supported.

UNICEF

Conclusions (2 of 2) We have initiatives in place that support ECD

– BFHI and Expanded BFHI– Enforcement of the Code of Marketing– New: Complementary Feeding in BF context– Nutrition Package of IMCI and Community IMCI– Making Pregnancy Safe/Safe Motherhood– Micronutrients programs - Vit A, Iodised salt, iron/folate, multi-vitamins– Others

Integrating their strengths by consistent messages at every contact will be the challenge

Targeting the maternal-child dyad may be a key to cross-sectoral integration