Transcript Ministry of Health Royal Government of Bhutan Strategy

Infant and Young Child Feeding Policy and
Strategy
September 2009
Ministry of Health Royal
Government of Bhutan
Dr Arun Gupta MD FIAP(India)
Overview
•
•
•
•
Scientific evidence in brief
Status of IYCF in Bhutan
Problems and underlying factors
Seven strategies and action
recommendations
• Way Forward
Impact of breastfeeding on Long-term health and
Intelligence
• Subjects who were breastfed
experienced lower mean
blood pressure and total
cholesterol.
• Prevalence of
overweight/obesity was 22%
higher in formula fed.
• Type-2 diabetes was higher
among non-breastfed subjects.
• Breastfed babies had higher
performance in intelligence
tests.
This 2007 WHO meta-analysis
showed that magnitude of
effect was similar to public
health interventions given later.
Relative risk of suboptimum breastfeeding during first six
months
15.13
16
14.4
14
12
10.53
10
8
6
4
4.62
2.28
2.49
1.75
3.043.65
1.26
Diarrhoea
mortality
Pneumonia
mortality
Diarrhoea
incidence
2
2.48
1.79 2.07
Pneumonia
incidence
2.85
1.48
0
Predominant breastfeeding
Not breastfeeding
Partial breastfeeding
All cause
mortality
Effect of nutrition-related interventions on infant
mortality and DALYs (in 36 countries)
0.2
0
99 % coverage with hygiene interventions
10.8
99 % coverage with zinc s upplementation
1.3
6.9
6.9
99 % coverage with vitamin A (including neonatal in As ia)
99 % coverage with feeding interventions (promotion of
comple menta ry fee ding and othe r supportive strategies)
2.1
0
8.6
99 % coverage with breas tfeeding promotion and support
11.6
1.5
2
99 % coverage with multiple mic ronutrient supplem entation in
pregnanc y
1.9
2.4
99 % coverage with inte rm ittent preve ntive treatm ent
2.8
99 % coverage with balance d energy protein supplem entation
3.6
0
2
4
Proportional reduction in deaths before 12 months (%)
6
8
10
12
DALYs averted at 36 months (%)
Source: Zulfiqar A Bhutta et al. Maternal and Child Undernutrition Series - 3: What works? Interventions for
maternal and child undernutrition and survival. January 17, 2008. www.lancet.com
14
Impact of Non Exclusive Breastfeeding
During First Six months
77%
(1.06
million)
Due to Non- EBF
1.4 million deaths due to suboptimum breastfeeding
85% (37
million)
Due to Non- EBF
43.5 million DALYs due to suboptimum breastfeeding
Effect of nutrition-related interventions on
stunting (in 36 countries)
1.9
99% coverage with hygiene interventions
9.1
99% coverage with zinc supplementation
99% coverage with feeding interventions (promotion of
complementary feeding and other supportive
strategies)
19.8
99% coverage with multiple micronutrient
supplementation in pregnancy
0.9
1.4
99% coverage with intermittent preventive treatment
99% coverage with balanced energy protein
supplementation
1.9
0
2
4
6
8
10
12
14
16
18
20
Relative reduction in prevalence of stunting at 12 months
22
Child Survival and Nutrition
Status
•
•
•
•
•
•
•
NMR: Not available
IMR: 40 per thousand (2007 )
U5MR: 62 per thousand (2007)
Stunting U5 37%
Underweight 11.1%
Wasting 4.6%
LBW (2500gm or low) 9.3%
State of IYCF in Bhutan
Policy and Programmes: 2008 Assessment
revealed Gaps in policy and programmes (
Health system, outreach, Maternity entitlements,
Code implementation and M&E etc.
Practices
• Good early breastfeeding within an hour : 80%
• Very low exclusive breastfeeding 37% at 4
months and 10% at six months
• Complementary feeding 23%
Problem Areas in IYCF
• Pre- lacteal feeding.
• Exclusive breastfeeding for the first six months is
very rare in all, whether rural or urban communities.
• Not enough milk perception is almost universal : lack
of comprehensive approach.
• Inadequate skills with health workers.
• Breast problems like sore or cracked nipples,
common but poorly managed
Problem Areas in IYCF
– Use of infant formula is very high in 0-6 months being
14%.
– Use of complementary food below six months is very
common, rice and ‘Cerelac’ being very common.
– People believe ‘Cerelac’ is a good food and want to use
this even below six months in spite of the health advice.
– Concept of complementary feeding after six months is
not fully clear.
– Policy on exclusive breastfeeding is not uniformly known
– Maternity benefits are not adequate
– Support level to ALL women is very low.
Underlying Factors
– Cultural beliefs
– Commercial promotion of baby foods
– Almost all mothers perceive that their milk is not enough
for the baby.
– Lack of awareness about physiology of process of
breastfeeding
– Health workers don’t fully understand the complex
hormonal control of breastfeeding.
– Maternity benefits : leave of only 3 months for government
workers is inadequate.
– Women in un- organized sector like laborers have to return
to work because of economic compulsions and not
compensated for wage loss , no provision of maternity
benefits for them.
3 Critical Areas
• Strengthening IYCF in the Health Systems
as part of standards of care
• Protecting Mothers and Children below 2
years from aggressive commercial
promotion of baby foods
• Supporting ALL women to combine
breastfeeding with work
Seven Strategic Actions
1.
2.
3.
4.
5.
6.
7.
PROTECTION
PROMOTION
SUPPORT
INFORMATION(DATA BASE)
EDUCATION and TRAINING
RESEARCH
COORDINATION
Recommendations for Action
Seven Strategies
Protection
• Constitute a drafting committee/group to move
towards legislation to protect breastfeeding from
commercial influence.
• Provide information about commercial sector
influence to health workers on a regular basis.
• Develop and implement communication campaign
on complementary feeding after six months with
use of local home made foods and discourage use
of commercial products.
Promotion
• Launch the campaigns on exclusive breastfeeding for six
months.
• Target teenage persons as a strategy
• High level advocacy to raise the consciousness of national
leaders, including the Royal Family
• Expand the celebration of World Breastfeeding Week
(WBW), to BHUs
• Develop a plan to eliminate erroneous or incomplete
information (Like e.g. belief that Cerelac or rice should be
given during first six months of life).
• Develop IEC materials
• Campaign for economic benefits of breastfeeding
Support
• Provide maternity benefits for all women, in the formal employment
or unorganized sector.
• Formal Sector: Increase Maternity leave, Crèches, flexi hours, work
at home, expression of breastmilk facilities etc.
• Create a Maternity benefit Fund for poor women in the informal
sector in the rural area who have to go out to work for livelihoods.
• DoR should provide paid maternity leave of six months to its women
workers
• Establish IYCF Counselling Centers/lactation clinics
• Link exclusive breastfeeding to growth monitoring.
• Revive BFHI and develop a Baby Friendly Community Imitative
(BFCI) to reach to families through BHUs and ORCs.
Research
• Establish a task force to conduct Infant and Young Child Feeding
research.
• Conduct an assessment of policy and programmes of IYCF every
three years to see the trends. WBTi could be used as a tool.
• In depth qualitative research on exclusive breastfeeding , use of
Cerelac, rice or and other infant formula and foods very early in life,
and complementary feeding.
• Study impact of current HIV and infant feeding policy
• Study the impact of maternity benefits on exclusive breastfeeding in
one district.
• Areas of research should include:
– operational research on what works;
– impact of breastfeeding on contraception, emotional
development, obesity,
– Role of skilled health counseling on exclusive breastfeeding
Information management: data
base
• Include early breastfeeding within one hour,
exclusive breastfeeding from 0-6 months or at 6
months , and complementary feeding during 7th
month in the HMIS.
• Monitor exclusive breastfeeding 0-6 months at
high level, at the Ministerial level, among the
indicators of stunting, underweight, wasting, infant
mortality and under- five mortality.
• Monitor exclusive breastfeeding along with growth
monitoring
Education & Training
• Include concepts of optimal IYCF for health and
development in curricula of primary and secondary
schools, universities and community educational centers.
• Strengthen IYCF in Nurses and health workers
curriculum
• Identify National /Regional Center/District focal points for
training, education and resources and build their
capacity to take this strategy forward
• Develop a plan for training of all nursing staff in maternity
services , the MCH staff, HAs, BHWs, to universalize
reach to all people
Coordination
• Establish a national IYCF committee with
all sectors and having 50% women
representation.
• Strengthen the nutrition department at
national level
• Establish nutrition coordination at the
regional and district centers.
• Establish a budget line for IYCF in the
overall health and development plans
Policy Recommendations
1. Exclusive breastfeeding
• Update the existing policy to make it exclusive breastfeeding for the
first six months.
• Declare that infant feeding counseling is a recognized “service”in
health care system.
• Include exclusive breastfeeding as integral part of the HMIS.
• Add a budget line for IYCF under the child nutrition and health.
• Review and update policy on HIV and Breastfeeding in light of new
WHO guidelines
Policy Recommendations
2. Take legislative action on protection of
breastfeeding to create a long term
sustainable protection
Policy Recommendations
3. Create a support system for women to
combine work with breastfeeding
• Extend maternity leave to 6 months, Crèches,
flexi hours, making it a Legislative Action.
• Create a ‘maternity benefit fund’ for helping
the the poor unorganized sector women who
have to resort to work for livelihoods.
Way forward
• MoH should endorse and communicate widely,
the policy decisions.
• Create a Core group to develop an operational
plan (5 years) within six months.
– Plan should have clear objectives, activities, results
and indicators of measurement and budgetary
resources
– Evaluate the plan after 3-5 years.
• Plan for High level advocacy to achieve policy
and programme inputs.
• Begin action on capacity building within health
systems.
Raise their Voice !
Thanks !