"Infant and Young Child Feeding (IYCF) Practices in the Community"
Alive & Thrive Initiative: Community Component

Kaosar Afsana , Director Health, BRAC Health Programme

Over the last few decades, Bangladesh has attend tremendous achievement in health, particularly in child mortality. But child nutrition is still a huge problem. Bangladesh government has taken a major step giving utmost priority to IYCF, but still at a slower pace. NGOs and academic institutions are also doing good. Beyond IYCF we should also look at the nutrition status of mothers. Breast feeding is another important issue. Mothers are continuously complaining that they do not have enough milk. There are very simple interventions to solve this problem, but, unfortunately, we are not reaching them to teach how to improve breastfeeding and milk flow. Behaviour and practices along with the complementary feed is another problem in Bangladesh. I will also emphasis on partnership because we need to learn from each other.

Dr. Mohammad Raisul Haque , PhD, Senior Programme Manager , BRAC Health Programme

Countries that have shown strong commitment and invested heavily in IYCF show significant progress in the field of exclusive breast feeding. Since around 1996 we have found that exclusive breast feeding has gone up by more than 20% on average in more than 20 countries. And Bangladesh is one of these countries. Majority have been receiving some other food or fluid in the early months, and still we have some poor breast feeding and complementary feeding practices. These foods are often introduced too early or too late, and are nutritionally inadequate and unsafe.

Directly, malnutrition has caused one third of the estimated 9.5 million deaths that occurred in 2006 in children less than 5 years. Global burden of diseases has been increasing due to malnutrition. Malnutrition is also linked to long term impairment of growth. Malnutrition during the first 2 years of life causes stunting, impaired intellectual performance, reduction in capacity for physical work and implications on national development.

In 2002, WHO with the help of UNICEF, introduced Global Strategy for Infant and Young Child Feeding Practices, and based on that Bangladesh government has developed National Strategy for Infant and Young Child Feeding in 2007. They developed Infant and Young Child Feeding (IYCF) National Action Plan in 2009. Finally in October 2010, National Communication Framework and Plan for Infant and Young Child Feeding in Bangladesh has been framed to improve the nutritional situation in the community as well as in the country.

We have found some very important recommendations in these strategic papers relatively early initiation of breast feeding, exclusive breast feeding for 6 months and nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond. From studies we have found that IYCF has been impacting very positively optimally Breastfeeding prevents 13% of deaths in children less than 5 years globally; appropriate complementary feeding practices would result in 6% reduction in under 5 mortality, and increase in work capacity, intellectual performance, reproductive outcomes and overall health.

Proper IYCF practices will provide adequate nutrition during infancy and early childhood which is essential for growth, health and development of children to their potential. At the same time training of health workers is very much important to provide those services to the community. Counseling mothers or care givers on age specific feeding practices is also very important.

So what can we do to improve our IYCF situation? We have to emphasise on public private partnership to enhance and strengthen our IYCF practices. Even knowledge sharing and promotion of large scale implementation of comprehensive programs for replication of IYCF have tremendous opportunity to scale up the programme all over the country. If we can get that support and promote IYCF with strong government leadership and commitment and partnerships with major stakeholders we would be able to eradicate malnutrition.

Dr. Zeba Mahmud, Country Director, MI

It is very easy to tell mothers that do not give water or pre-lacteal but there is peer pressure from extended family member to give the baby honey, water, sweet like foods. Parents wash babies tongue from a religious perspective and give bath to the baby every day, and thus hamper exclusive breast feeding. We have to ensure that nothing means nothing, only exclusive breast feeding. Babies should be provided only mother's milk, no complementary milk up to 2 years of age.

Dr. Tahmeed Ahmed, Director, ICDDR, B and Professor, BRAC University

64% exclusive breast feeding rate in Bangladesh is tremendous. But I want it to be double checked.

Why do we need IYCF? The primary objective is to maintain the normal growth and mental development of a child. The second objective is to control rampant level of malnutrition. Bangladesh has one of the highest levels of stunting in the world. Bangladesh is even worse off than many Sub-Saharan countries. Our stunting prevalence is 41 where Sudan is at 40%.

Food security is a very important issue. 30 % of our population does not have access to food that will enable them to lead a healthy life. If you consider 41% stunting level then you will see food insecurity is sky high in these families. In IYCF there are three common rules- a number of minimum meals to a child, minimum number of food groups that means increase of diversity in the diet and animal source food. You know how expensive these foods are now. It is a matter of serious consideration.

Dr. Sultana Khanum , SUN & IMTF Global Task Force Member

In May,2012 World Health Assembly endorsed 6 goals for all the WHO member countries- stunting, wasting, low birth weight, overweight, micro nutrient status particularly anemia and nutrition behaviour changes and that is breast feeding . Bangladesh has signed this resolution. All these should be achieved by 2025. We have to get the WHO on board to fulfill their commitment to IYCF.

In the SUN movement we have said 1000 days of opportunity that means from pregnancy to two years of age. Now how much effort is made during the anti-natal period to influence behavioral changes of the pregnant women for exclusive breast feeding? It should be taken seriously because there is mother.

Dr. Ferdousi Begum, Country Manager, FANTA, FH360

In our country early marriage is still very prevalent. Most of our mothers are adolescents. So when we plan a programme for nutrition we should focus on adolescent.

Preparation of the providers is a very critical area where we are lagging behind in terms of skills, supplies, information and supervision. Preparation of mothers, care givers and families is also very important which is not taken care of at the national level.

A working woman gives 30-35 years to an employer but she does not get 12 months for exclusive breast feeding.

Dr. Md. Mohsin Ali, Nutrition Specialist, Unicef

As far as I know, the rate of exclusive breast feeding till the age of 6 months is 35%. That means two third are still beyond exclusive breast feeding. So we have to critically think of our level of achievement.

Complementary feeding has been falling in the cracks as we start the discussion of IYCF with breast feeding and end with breast feeding. We come to know from recent data that the rate of complementary feeding is declining. If we want to address the stunting issue, which is very concerning, we have to ensure proper complementary feeding.

In the case of food security, awareness is more important than access. Because three-fourth of our population can access nutritional foods but they do not have the awareness to provide their children with nutritional foods. We have to carefully consider these issues in our programmes.

Dr. Rukhsana Haider , Chairperson, TAHN Foundation & Chair , CSA for Sun, Bangladesh

100 per cent exclusive breast feeding is not possible. We have data that in urban areas 70% mothers could exclusively breast feed for five months only despite individual counseling support. There is also question of working women. Most of the women work in informal sectors and there are no facilities for them to exclusively breast feed their child.

Dr. Salima Rahman, Executive Director, RDRS Bangladesh

In rural areas women, also, are engaged in income generating activities. So they cannot take care of their babies and the chance of complementary feeding by the peer members of the family remains high.

Food adulteration is also a serious issue which should be considered along with food security.

Dr. Selina Amin, Plan Bangladesh

We usually target mother and child. But we have to target the husband also. They should be made aware of exclusive breast feeding and complementary feeding.

In our labour laws we have provision for leave for having children but usually it is divided into pre and after of birth. So mothers cannot continue exclusive breast feeding up to six months. I think the order should be very specific, and it should be leave for six months after delivery.

Tina Sanghvi, Senior Country Director, Alive & Thrive

We have been conducting monitoring of the access as well as comprehension of the television messages for the last two years. And the last round of monitoring has shown that more than 70% women of reproductive age all over Bangladesh have actually seen or heard the television message . And 50% mothers of children under 2 are able to correctly repeat back at least two messages per television spot that is absolutely accurate, either the message itself or the dialogue or story related with the message. So when we calculate how many children there are in Bangladesh and we take 50% of them then Bangladesh is one of the success stories of the world in terms of how quickly we have been able to reach mothers and clarify most of the urgent messages for them.

Dr. Shahed Rahman , National Nutrition Coordinator, CARE, Bangladesh

I want to emphasize on documenting our experiences and sharing our experiences with each other and with the government. Multi-sector engagement from the root level is of utmost necessity.

Government should allocate more funds for nutrition because this is an investment in the future generation.

There is also issue of women empowerment because in most of the cases the father goes to market and he decides the menu.

Dr. Iqbal Kabir, BBF, Vice Chairperson, Nutrition Consultant, MSPT

In Asia, including Bangladesh, we have good health infrastructure but we are still way behind African nations in terms of stunting though the latter do not have such well structured infrastructure. I think higher level of empowerment of women in Africa makes the difference. In Africa they have some sort of control over land; they have some sort of decision making power.

Education is another important issue. In various researches on infant breast feeding we find that maternal education can really help to change.

Dr. Tahmeed Ahmed
Does availability of rice means food security? No. We have shortage of pulse production, vegetable and fruits production. Not to speak of poultry and other small fishes. Egg price has increased 150%. How can a lower middle class family avail it daily, not to speak of the poor people?

Government has taken an initiative to mainstream nutrition programme through community clinics under the National Nutritional Service (NNS). The NNS has been in operation for only six months. I want to actually see how and when the nutritional plan is implemented thoroughly, and that is our goal. We should have at least one community health worker dedicated to nutritional care in every community clinic.

We need some direct nutrition-specific interventions like IYCF, Vitamin A supplementation, Iron Folic Acid supplementation, micro nutrient powder, iodized salt and treatment of severe acute malnutrition. At the crux of all these interventions lies effective counseling that we call behaviour change communication. Through these interventions we will be able to reduce 30-305% stunting, not 100%.

So, further, we need nutrition sensitive interventions that are indirect interventions like women empowerment and improvement in female literacy and livelihood.

Dr. Ferdousi Begum
I will suggest creating some simple messages by using The Daily Star because this is a multilateral issue and policy makers should be sensitized so that nutrition can get an important place in our Annual Development Plan, and only then will we be able to link up the nutrition issue to our MDG.

A joint action plain under the leadership of the NNS is very important for us. We have to coordinate all the nutrition interventions by different stake holders.

Dr. Md. Mohsin Ali
IYCF indicators are directly linked with stunting rate. Khulna does the best in all the IYCF indicators and so its stunting rate is the lowest in Bangladesh.

Keeping the counseling at the top level should be our number one IYCF intervention, but we are most reluctant to do it. We have no dedicated nutrition worker in Bangladesh. We have to train our health workers on counseling especially on complementary breast feeding. No counseling is documented anywhere. We have to make them accountable like EPI programme.

Dr. Sultana Khanum
Civil society organizations are working very closely with the government in this sector. In 2011 we formed Civil Society Alliance for SUN which has been working for scaling up the nutrition programmes. We have drafted the country strategy paper for the government. We are very much active in the NNS programmes. Through this alliance we are coordinating multi-sectoral interventions in this sector.

Kaosar Afsana
We have not touched upon the mental health issue. It is associated with breast feeding. This is a neglected area, perhaps, in all developing countries. Poverty and violence have impact on mother's milk flow.

Brig Gen ( Retd) Shahedul Anam Khan, Editor, Op- Ed & Strategic Issues, The Daily Star
I just want to flag some issues. This is not just breast feeding, complementary feeding is equally important. I want to quote Churchill, “There can be no finer investment for a community than to put milk into babies.”

Food security is another important issue. There is both lack of awareness and lack of access.

Monitoring performance of health workers at the grass root level, and some health workers may be dedicated to IYCF programmes. Dovetailing the whole nutrition thing with national programmes is also necessary. It should fall within the national development programme.

We should not be restricted to the roundtable alone. Please let us know specifically what part the media can play.