Patterns in Pre-Lacteal Feeding Among Mothers in Urban Cambodia, Nepal, Senegal, and Tanzania

PATTERNS IN PRE-LACTEAL FEEDING AMONG MOTHERS IN URBAN CAMBODIA, NEPAL, SENEGAL, AND TANZANIA

Assessment and Research on Child Feeding (ARCH)

Alissa M. Pries, Khin Mengkheang, Indu Adhikary, Aminata Ndiaye, Margaret Benjamin, Mary Champeny, Bineti Vitta, Alison Feeley, Sandra L. Huffman

Global Maternal Newborn Health Conference STUDY BACKGROUND

• Pre-lacteal feeding and early use of breast-milk substitutes interferes with successful breastfeeding

• Sales and promotion of breast-milk substitutes are increasing in low income countries

• Heath facility-based marketing can have a negative impact on early breastfeeding practices and duration of breastfeeding Promoting breastmilk substitutes within the health system can negatively impact breastfeeding, thereby threatening infant and young child nutrition and health. RESEARCH OBJECTIVES

• Estimate the prevalence of promotional practices occurring within the health system for breast-milk substitutes – Commercial advertising and display of product branding – Recommendations from health professionals – Free samples and branded gifts

• Document breastfeeding support and counseling provided in health facilities

• Document early breastfeeding practices and consumption of breastmilk substitutes among newborns (pre-lacteal feeding) RESEARCH DESIGN

• Structured interviews among mothers discharged after delivery in Phnom Penh, Kathmandu Valley, Dakar Department, and Dar es Salaam

• Cross-sectional, health facility-based survey

• Sample size of 280 mothers in each site to detect 10% promotion prevalence rate MOTHER CHARACTERISTICS

100% Work outside the home 80% 60% 30% 40% 23% 26% 20% 10% 0% Phnom Penh (N=306) Kathmandu Valley Dakar (N=288) Dar es (N=304) Salaam(N=295) 100% Caesarean delivery 80% 60% 40% 28% 24% 18% 20% 14% 0% Phnom Penh (N=306) Kathmandu Valley Dakar (N=288) Dar es (N=304) Salaam(N=295) EDUCATIONAL ATTAINMENT

100% 5% 21% 22% 12% Terary 90% 31% 31% 80% 44% 55% Secondary 70%

60% 58% Primary 50% 29% 40% Non-formal/pre- primary 30% 32% 4% None 20% 12% 26% 10% 4% 1% <1% 0% 2% 7% 4% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) HEALTH SYSTEM PRACTICES BASED ON MOTHERS’ REPORTS

100% Received support with posioning/aachment 90% 80% 70% 64% 58% 60% 50% 40% 30% 30% 20% 14% 10% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) HEALTH SYSTEM PRACTICES BASED ON MOTHERS’ REPORTS

100% Received free sample of breastmilk substute 90% 80% 70% 60% 50% 40% 30% 20% 10% 10% 0% 0% 0% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) HEALTH SYSTEM PRACTICES BASED ON MOTHERS’ REPORTS

100% Observed breastmilk substute adversement in 90% facility 80% 70% 60% 50% 40% 30% 20% 8% 10% 4% 3% 2% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) HEALTH SYSTEM PRACTICES BASED ON MOTHERS’ REPORTS

100% Observed breastmilk substute branding on facility 90% equipment 80% 70% 60% 50% 40% 32% 30% 18% 20% 10% 5% 4% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) HEALTH SYSTEM PRACTICES BASED ON MOTHERS’ REPORTS

100% Recommendaon to use breastmilk substute 90% from health staﬀ 80% 70% 60% 47% 50% 40% 30% 20% 13% 8% 10% 6% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) EARLY BREASTFEEDING PRACTICES AMONG MOTHERS

100% Held newborn immediately 90% 80% 70% 60% 56% 50% 41% 40% 32% 30% 20% 9% 10% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) EARLY BREASTFEEDING PRACTICES AMONG MOTHERS

100% Iniated breaseeding within 1 hour 90% 80% 68% 70% 60% 50% 41% 40% 34% 30% 20% 10% 5% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) EARLY BREASTFEEDING PRACTICES AMONG MOTHERS WHILE IN HEALTH FACILITY

100% Provided a pre-lacteal feed while in health facility 90% 80% 70% 62% 60% 57% 50% 40% 35% 30% 20% 10% 5% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) LIQUIDS PROVIDED AS A PRE-LACTEAL FEED

100% Provided breastmilk substute as a pre-lacteal 90% feed 80% 70% 57% 56% 60% 50% 40% 13% 30% 20% 10% 3% 0% Phnom Penh Kathmandu Valley Dakar (N=288) Dar es (N=306) (N=304) Salaam(N=295) MAIN REASON REPORTED FOR WHY A BREAST-MILK SUBSTITUTE PRE-LACTEAL FEED WAS GIVEN

Need to return to work Pain aer surgery Breastmilk did not come in Not enough breastmilk

100% 90% 78% 80% 70% 61% 60% 54% 49% 50% 40% 30% 27% 30% 20% 20% 13% 14% 8% 11% 11% 10% 0% 0% 0% 0% 0% Phnom Penh (n=174) Kathmandu Valley Dakar (n=36) Dar es Salaam (n=9) (n=170) TIMING OF DISCHARGE OF MOTHERS AFTER DELIVERY

100% 10% 6% 90% 32% 80%

70% 64% 59% 60% 62% 50% ≥48 hours 40% 24-48 hours 65% 30% <24 hours

20% 34% 35% 29% 10% 0% 2% 4% Phnom Penh Kathmandu Dakar (N=288) Dar es (N=306) Valley (N=304) Salaam(N=295) FACTORS ASSOCIATED WITH PRE-LACTEAL FEEDING

In Phnom Penh, Kathmandu and Dakar:

• Education level – In Kathmandu and Phnom Penh, mothers who attended secondary or tertiary levels of education were around twice as likely to provide a pre-lacteal feed • Delivery via C-section – 3x, 12x and 10x as likely to provide a pre-lacteal feed as compared to mothers delivering by normal/vaginal delivery.

• Recommendations from health professionals to use breast-milk substitutes – In Kathmandu, where around half of mothers reported receiving such a recommendation from a health professionals, these mothers were 20 times as likely to provide a breastmilk substitute as a pre-lacteal feed, as compared to mothers that did not receive a recommendation. CONCLUSIONS

• Initiation of breastfeeding within the first hour after delivery was reported by less than half of mothers in Phnom Penh and Kathmandu Valley, and among only 5% of Dakar mothers

• Results indicate high rates of pre-lacteal feeding, commonly with breast-milk substitutes, in Phnom Penh, Kathmandu and Dakar.

• In Phnom Penh, Kathmandu and Dakar receiving a health professional’s recommendation to use breast-milk substitutes was associated with pre-lacteal feeding among mothers DISCUSSION

• Health workers’ advice and counseling plays an influential role in shaping mothers’ infant and young child feeding practices

• Prior studies have also noted the influential role of pre-lacteal feeding recommendations by health workers in increasing rates of pre-lacteal feeding

• Given that pre-lacteal feeding increases risk of infection, can impede colostrum consumption and breast milk production, and reduces duration of exclusive breastfeeding, results from this study carry great weight for neonatal health RECOMMENDATIONS TO REDUCE RATES OF PRE-LACTEAL FEEDING

BUILD HEALTH WORKER SKILLS: Training of health workers on lactation management to reduce use of pre-lacteal feeds, support women with c-sections to breastfeed and limit infant formula use in the health facility.

ELIMINATE PROMOTION: In line with the Code, restriction of formula company promotion in health facilities should be enforced THANK YOU!

- We are grateful to the mothers who gave up time to be interviewed and the health facility staff at each of the facilities where the study was conducted.

- Thank you to the members of the Cambodia, Nepal, Senegal, and Tanzania ARCH Advisory Committees for their advice and review of this research.

- We appreciate the advice provided by: Elhadj Issakha Diop, Dale Davis, Shrid Dhungel, Ndeye Yaga Sy Gueye, Nancy Haselow, Rolf Klemm, Gary Mundy, Akoto Osei, Victoria Quinn, Ame Stormer, Aboubacry Thiam, Zaman Talukder, Elizabeth Zehner, and Yang Zhenyu.

- Thank you to the Bill & Melinda Gates Foundation for its support of this research.