Impact of Large-Scale Infant Feeding Promotion on Child Survival and Health in Madagascar

“If a new vaccine became available that could prevent one million or more child deaths a year, and that was moreover cheap, safe, administered orally, and required no cold chain, it would become an immediate public health imperative. Breastfeeding can do all this and more”………Lancet 1994

Photo: Carolyn Kruger

General Context (1) General Context (1)

• Early 1990s hospital-based efforts were successful but weakly linked to community

• Operational research/meta-analyses demonstrate that Breastfeeding promotion is an evidence-based interventions to prevent malnutrition and to improve children under five years old nutrition status (Lancet series)

• There are few impact assessment of large-scale Breastfeeding promotion

• The challenge is to develop and apply standard impact assessment methodology of programmatic behavior change strategy regarding optimal infant feeding behaviors

General Context (2)General Context (2)

• Early initiation of breastfeeding (within an hour of birth)

• Exclusive breastfeeding for first 6 months

• Timely introduction and frequent feeding of nutrient rich complementary foods

• Continued breastfeeding through the second year of life

Optimal Infant Feeding Behaviors

LINKAGES: USAID- Funded ProgramLINKAGES: USAID- Funded Program

• Sustain/advance USAID’s role as a global technical leader

• Extend coverage by working with partners

• Demonstrate exclusive breastfeeding as an achievable goal

• Improve breastfeeding behaviors at scale in 3-5 countries

• Demonstrate what works at the community level

Goal: Improve the health and nutritional status of Children and women

Key Program CharacteristicsKey Program Characteristics

Program Focus Program strategy based on Integrated Management of Childhood Illness (IMCI) approach.

Key Nutrition Behaviors Targeted - Breastfeeding- Complementary feeding- Feeding of sick children- Women’s Nutrition- Vitamin A supplementation- Iron supplementation- Iodized salt

Focus period for presentation January 2000 – September 2001

Geographical Coverage during the focus period

2 Regions10 Districts

Population Covered during focus period 1.33 million

LINKAGES: M&E FrameworkLINKAGES: M&E Framework

INPUTS

- Human Resources

- Financial Resources

- Equipment

PROCESS

- Training

- BCC/IEC

- Mass Media

-Advocacy

OUTPUTS

- Number of Key informants trained

- Number of Mothers counseled

- Number of materials developed

OUTCOMES

- Increased Knowledge

- Improved-Changed Behavior

IMPACTS

- Cost Effective

- Reduced malnutrition

Rapid Assessment (Annual)

&

Performance Monitoring

(Every six months)

Monitoring

(Annual)

Evaluation

(Baseline/Midterm/Endline)

Impact Assessment SystemImpact Assessment System

AnalysisPerformance Monitoring

Impact Assessment

Advocacy

Behavior Change

Performance Monitoring Performance Monitoring

Objective: Assess Knowledge and Counseling skills of the Key Informants (Public and Private Health Workers, Volunteers)

Methodology:

Pre and Post Test during training

Lot Quality Sampling Survey for Public Health Workers and Volunteers in both rural and urban areas (every six months)

Self Assessment for Private Workers and Hospitals in the urban area (every six months)

Behaviors Indicators

1- Timely initiation of breastfeeding (TIBF) within the first hour of birth

2- Exclusive breastfeeding (EBF) among women with infants 0-5 months of age

Rapid Assessment ProceduresRapid Assessment Procedures

# of infants 0-<6 months exclusively bf X 100

total # of infants 0-<6 months

WHO 1991,DHS and Multiple Indicator Cluster Survey (MICS)• 24-hour food feeding recall question

Objectives: Assess Behavior change indicators of the Beneficiary

Methodology:

Rapid Assessment Procedures based on UNICEF and WHO methodology at province/region level (annual)

Include both Quantitative and Qualitative surveys

Cross-sectional survey methodology

Target group: Woman with child 0-5 months

Sample size: 1800

Geographical area: 2 Regions

Rapid Assessment ProceduresRapid Assessment Procedures

Timely Initiation of BreastfeedingTimely Initiation of Breastfeeding(within 1 hour of delivery)(within 1 hour of delivery)

43

64

23

77

34

69

0

20

40

60

80

100

Jan 2000 Sept 2001 Oct 1999 Sept 2000 Apr 2000 Apr 2001

Antananarivo* Fianarantsoa* Total*

Per

cen

t

*p< 0.001

Exclusive breastfeedingExclusive breastfeeding(infants 0–<6 months)(infants 0–<6 months)

44

82

50

86

46

83

0

20

40

60

80

100

Jan 2000 Sept 2001 Oct 1999 Sept 2000 Apr 2000 Apr 2001

Antananarivo* Fianarantsoa* Total*

Per

cen

t

*p<0.001

Cost Effectiveness Analysis

1- Cost effectiveness ratio: e.g. cost per New Acceptor of promoting EBF

[cost of activities to promote EBF]

[target population] * ([EBF rate at end of period] – [EBF rate at baseline])

2- Cost per Beneficiary (per capita)

3- Cost per DALY for Breastfeeding promotion activities

Indicators

4- Mortality averted rate

Cost Effectiveness Analysis: MethodologyMethodology

1- Data Selection:

Type of costs included:- Full costs of program activities (including overhead)

that support the promotion of targeted behaviors in country for both central and district level - Direct cost of HQ costs associated with nutrition promotion activities - Direct costs of program partners

2- Data Collection: All financial data were collected retrospectively

Costs: Entire Program and Promotion Costs: Entire Program and Promotion of EBF and TIBFof EBF and TIBF

478,864

63,19032,347 35,334

136,115

27,065

745,074

299,305

59,412

0

200,000

400,000

600,000

800,000

Totalprogram cost

Cost topromote

EBF

Cost topromote

TIBF

Totalprogram cost

Cost topromote

EBF

Cost topromote

TIBF

Totalprogram cost

Cost topromote

EBF

Cost topromote

TIBF

Antananarivo Fianarantsoa Total

$ U

S

Cost per Beneficiary Cost per Beneficiary

$0.49

$0.05

$0.24

$0.69

$0.07

$0.40

$0.56

$0.12

$0.29

$0

$1

$1

$2

To

tal

Pro

gra

mC

ost

pe

rB

en

efic

iary

TIB

F C

ost

pe

rB

en

efic

iary

EB

F C

ost

pe

rB

en

efic

iary

To

tal

Pro

gra

mC

ost

pe

rB

en

efic

iary

TIB

F C

ost

pe

rB

en

efic

iary

EB

F C

ost

pe

rB

en

efic

iary

To

tal

Pro

gra

mC

ost

pe

rB

en

efic

iary

TIB

F C

ost

pe

rB

en

efic

iary

EB

F C

ost

pe

rB

en

efic

iary

Antananarivo Fianarantsoa Total

$ U

S

Cost per New Acceptor Cost per New Acceptor

$2.91

$8.12

$1.88

$14.22

$2.33

$10.09

$0

$5

$10

$15

TIBF EBF TIBF EBF TIBF EBF

Antananarivo Fianarantsoa Total

$ U

S Pop

26,594

Pop

52,859 Pop

79,453

31

132

34

18.5

9.5

9

0 20 40 60 80 100 120 140

Breastfeeding Promotion(LINKAGES/Madagascar)

ORT

Iodine fortificationprograms

Childhood Vaccinations

Growth monitoring andcounseling

Vitamin A distribution

Cost/DALY ($)Source: Disease Control Priorities in Developing Countries, 2006

Cost-effectiveness of Child Survival Cost-effectiveness of Child Survival InterventionsInterventions

Costs of Breastfeeding Promotion: Costs of Breastfeeding Promotion: Madagascar, 2001Madagascar, 2001

Estimated reduction in infant deaths due to an increase in exclusive

breastfeeding:

Increase in EBF rate: 50% to 86%

Cost per new breastfeeding acceptor: $10

Infants deaths averted: 5%

At a cost of $31/DALY

ConclusionsConclusions1- Comparability with international data

2- Comparability with different child and health survival interventions

3- Availability of crucial information on “How to improve cost effectiveness of programmatic breastfeeding promotion?”

4- Feasibility to assess the evidence-base of behavior change interventions on health and child survival

5- Need to determine how long it takes for these types of behaviors to become cultural norms

T H A N K Y O U