I think ANC is also one of the contact points for IYCF messages especially during the last few weeks of pregnancy. We can give messages about the early initiation of breast feeding after birth and its benefit to the mother during the last few weeks of pregnancy especially to those mothers who are giving birth at home. This will also be the suitable time to advice mother and give her the confidence regarding the inverted nipples if she have, especially to the prime gravida.

Hello,
That was a good observation in the reporting. When it comes to IYCF we handle a woman from conception through to the first 2 years of life. That is the 1000 days. Having said that, the counseling session should include:
1. Women of child bearing age and possibly their spouse that are in the process or are planning to conceive. Reasons being, if a pregnant woman became pregnant while in poor nutritional status, then we are going to have likelihood of maternal death or children born of these mothers predisposed to chronic malnutrition and birth defects if this is not corrected during ANC.
2. Pregnant women again with reason of ensuring that the women maintain good nutritional status and if malnourished correcting the nutritional status. Additionally you are able to prepare these women and their families psychologically and emotionally on the plan of feeding the baby from birth. Information like importance of skin to skin contact, early initiation of breastfeeding within first half hour, rooming in, importance of colostrum, how to initiate and maintain breastfeeding, importance of the different roles of family members All this and more are tackled when mother is in ANC. Remember EBF requires a lot of family support and the mother has to be ready to breastfeed on demand and all these will need planning in advance.
3. Post natal mothers whom you have already mentioned above.

Hope this helps. All the best

Here is a comprehensive guide for infant feeding http://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs - although it is used in the USA programs Many information is applicable and adaptable.

It is better that IYCF key messages are introduced to pregnant mother. The first key message for IYCF is early initiation of Breastfeeding, this message women should be aware before birth, so she can practice on delivery. Also if she is prepared on breastfeeding the baby before birth and have all myths around IYCF burst before the baby is born, she will be more confident in practising the good practices. Most women we worked with always shared they wish they knew before what were the good practices so they could have started early.

Thanks Shafikullah and Neha. My understanding now is better to give IYCF counselling in the last few weeks of pregnancy(say gestational age 9 months) and postpartum period

Thanks Juliet for your explanation. I can gather for example 30 women pregnant in their first trimester and give them messages on breast feedind and how its importance is.... Do you consider this part of IYCF? .. why not consider them part of C4D sessions??

Hello Team,
In our Community based IYCF project and trained IYCF Counselors, project targeted both pregnant and lactating Mothers. Project Key Message are addressed for 1000 days of window of opportunity that, started from the pregnancy, in that reason, we provide IYCF Counseling for pregnant Mothers. Ante-natal care IYCF Key Messages are in UNICEFF IYCF Counseling package, http://www.unicef.org/nutrition/index_58362.html

best,

Yes Tammam We could place it in C4D. However at first trimester we shall be discussing mainly on maternal nutrition which is also part of MIYCN. A pregnant woman's nutrition most especially in first trimester is very important. IYCF is after all a preventative measure

Thank you very much Juliet for your response.

Normally IYCF was for child before 24 months. But to reduce low birth weight it is very important to begin to follow nutrition of women during the pregnancy. However, in practice its not what actually happens in the health facility.
One thousand days (1000 Days) opportunity has to be strengthened.

Very true Madeleine. The pregnancy status was not normally catered for by health facilities. Thankfully because of continued up scaling of nutrition and advocacy on maternal and child health we are now slowly getting into the practice of catering for the unborn child in our counseling.

Dear Mustafa, could you please tell what was your project exactly targeting?? Pregnancy which gestational age? Lactating... is it upto 2years postpartum???

I think at first we need to clearly know what is counselling. Giving too much information to women is not effective so counselling should be done to specific target group in specific time period. I think IYCF counselling should be provide to 8-9 months pregnant women about breast feeding practices and as well as we can give counselling to 5 months child's mother on complementary feeding.

Dear Tamman,
As a mother who has gone through the process of IYCF fully I believe that IYCF counseling needs to start possibly well before pregnancy and pregnancy period is one of the most critical period . For example exclusive breastfeeding is not as easy to practice as it sounds on the books; it is very demanding and the mother has to accept to bear/ cope with sleep deprivation and fatigue. if she is not convinced during pregnancy it is difficult to do so while she is sleep deprived and tired during the exclusive breastfeeding period. I think that you should include pregnant women and possibly their husbands in your IYCF counseling sessions

Yes you are right. Counseling is a continuous process more so for IYCF it is recommended that 2-3 relevant information be given per session. Counseling on maternal nutrition is from time of conception. Breastfeeding plan from around 6 months of pregnancy. Exclusive breastfeeding and maintainance from 8th month of pregnancy and continued followup on contact during PNC clinics with complementary feeding plan once baby is 5 months of age and it continues till age of 24 months

Dear Anonymous 3285, Actually I support your reply. it seems for me very logic

Very true Mueni. Being an advocate of Nutrition especially on IYCF and having practiced it myself it is very important to prepare mothers. The different places i have worked, that is the strategy that actually seemed to bear fruits. When a mother is prepared, the resolve to practice will be there come what may. IYCF is unfortunately more on behavior change. We are not only dealing with the mother to be but also with external influences from husbands, mothers and grandparents among others. Lack of adequate counseling for the mothers will lead to external influence and thus what the mother chooses may depend on whom convinces them most and in most cases the most convenient method will be probably the most probable option

We must recognise that mothers need more than MESSAGES telling them what to do: they need help. Counselling is not just information and advice: it means listening, building confidence and giving support. There is good evidence that showing a mother antenatally how to breastfeed makes a difference to her success: let her practise positioning and attaching a baby using a doll. After delivery she will have more confidence and is less likely to experience the common problems of sore nipples, insufficient milk, and ineffective suckling which are the commonest causes of failure. A good example is the research done by Duffy [Midwifery 1997; 13:189-96], but many health workers have learned this from experience. Showing her other practices like skin-to-skin contact and expressing milk, are also valuable. Such antenatal preparation should be standard practice.

Thanks Savage. Did you work previously or now at any IYCF project. if Yes what was the protocol?

Dear Tammam,

Thanks for your question.

Bear in mind that if we only start to counsel later on, several practices that we would like to avoid may have already occurred (e.g. discarding colostrum, pre-lacteal feeding), some of which may cause contribute to challenges with breastfeeding later on.

Early initiation of breastfeeding (within 1 hour of birth) is a critical, lifesaving activity and helps get breastfeeding off to a good start. We are more likely to support mothers to do this successfully if we have prepared her and her family well antenatally (through practice, support and providing tailored, relevant information)

The days following childbirth can be overwhelming and are not the right time to overload a new mother with information and new ideas.

Consider including during ANC:

- A discussion on how she intends to feed her baby once born. Provide her with the information needed to inform this intention but remember that she doesn't have to decide until the baby is born. If she intends to artificially feed her infant, she will need to make necessary preparations in terms of feeding equipment etc.

- If this is not her first child, ask her about previous (breast)feeding experiences and any difficulties /challenges she faced so you can support her to overcome these.

- If the mother is living with HIV, a discussion needs to be had around how she will feed her infant.

- Include key decision makers / influencers from her family to ensure she receives the support she needs

- Maternal nutrition, skin contact, responding to baby's needs

Try to ensure that women have the information they need by 34 weeks - during this time, explore her thoughts, perceptions, knowledge and feelings and provide tailored information and support based on what she tells you.

http://www.unicef.org.uk/BabyFriendly/Resources/AudioVideo/Communication-in-pregnancy

This is of course so true Felicity. Answering her questions, listening, exploring practical solutions to any issues she faces, and thinking through together , especialy in groups, can make a huge difference, along with accurate information and sorting myths from truths. And we also focus on skin-to-skin and empowering mothers and fathers to know what they can do following the birth to keep control, including hand expressing and understanding what babies can do etc.

La Leche League was the first mother support group of modern times, founded 60 years ago. A saying I used to hear in some of the meetings was "if you knew that in 9 months you were going to be pushed into a swimming pool, wouldn't you want to learn how to swim?" This is just as true of breastfeeding and mothering as it is of childbirth. Pregnancy is the ideal time to begin the consideration or how the baby will be fed and cared for as well as to learn all of the practical information and skills that Felicity mentions. Breastfeeding is a learned skill. A full term baby is born with a suckling reflex and women will produce milk and let it down under normal conditions, but how to put the two together is learned. Increasingly, in urban areas and even in rural areas, the skilled help that mothers used to have is no longer there -- so Pregnancy and ante natal care are times that should not be ignored to introduce important concepts of IYCF, such as putting the baby to breast immediately after birth, exclusive breastfeeding, what colostrum is (many people think its bad and don't want baby to drink, so they introduce pre-lacteals), how to make sure that the next pregnancy is well-timed, etc. It is also often a time when fathers want to learn and it is possible to engage them in playing a new, supportive role to the new mother and ensure that she has the time, space and support she needs to be able to optimally breastfeed and care for her newborn. But, as Felicity says, all of this needs a different approach from one of just providing IYCF messages. It is far better to start in pregnancy, during ANC, with an interactive approach than it is to wait until the baby is born and the IYCF messages are being crammed into the minds of a mother and father who are stressed and haven't been able to think through or plan for the birth over a period of several months. Probably end of 2nd trimester or beginning of third are good times to start. The parents-to-be are fairly confident that there will be a baby and are ready to invest emotionally and there is time in ANC for at least 2-3 discussions with mother and father about what is going to happen once the baby is born. Step 3 of BFHI is: "Inform all pregnant women about the benefits and management of breastfeeding" Becoming informed about the "Management of breastfeeding" requires more than a five minute speech... so best start with the discussion early enough in pregnancy to assure that families are well prepared.

Very well put Judy Canahuati, Teaching mothers effectively on all aspects of IYCF requires more than a five minute speech . it should spread across the 1000 days and even beyond.

i have a concern regarding IYCF nutrition during pregnancy. As everyone noted education/knowledge is really very important. let alone pregnant mother, currently the new ENA is also promoting nutrition education for all women in the reproductive age group. But knowledge is one thing and practice is another. Knowledge is nothing with out practice. in such situation/during IYCF how many mother could actually remember and apply what she knew previously? mothers/community always want to listen and apply it when it in their immediate need. just see for mother who is in the first trimester is given information about complementary feeding is useless and she is not interested at all.

I said this because of our experience in care group which used modular learning method in which all mother pregnant or lactating 0-6 or more than 6 month will be grouped and are educated in IYCF/maternal nutrition. The first session is about maternal nutrition but mothers who have children 6 month do not relate it to their immediate need and concern. so i am saying that we need to provide and need to gear our education to be timely (to their immediate need) with targeted simple key messages. I am not saying education or information is useless but when it is timely and targeted it has the power to change everything.

Starting breastfeeding counselling during pregnancy is vital for all the reasons mentioned here. Sadly, sometimes mothers need to be forearmed against doctors and midwives who tell them that they are incapable of breastfeeding (don't have enough milk, had a caesarean so can't breastfeed etc). In my recent counselling, I have had to prepare pregnant women to advocate for their ability to breastfeed. They may actually need to reassure or convince their health professionals not to discourage them from breastfeeding.

It seems to me that one of the main challenges of Care groups is that they are driven by messaging rather than exploration of mother's concerns at a particular point during her journey into motherhood. Totally agree that a mom or dad will usually not take-away, "remember" what is not relevant at a particular point in time, but if s/he knows that the group is a place to be comfortable and safe in answering questions and concerns, rather than a prerequisite for getting some kind of transfer or service, the questions and concerns will come. Life cycle segregated meetings are no substitute for that immediate post-partum contact where skills such as positioning and latch on are reinforced along with some real time counseling about what supply and demand is all about, making sure that the mom has the support she needs, etc. The division of the rural community or urban/peri-urban neighborhood into volunteer size responsibilities is one of the benefits of the care group which should help assure that no one "falls through the cracks" but families need a combination of anticipatory guidance along with counseling, support and protection in a timely manner. I'm not sure that care groups, in the current way they are conceived, are the best vehicle for all of those things, they are certainly not the only vehicle. But I would not think that its wise to introduce practical information and practice around baby caring until after birth. That's too late and a huge window of opportunity is missed when families, particularly first time families are open to learning new skills and knowledge.

Dear all,

As many experienced persons in this forum have replied Counselling on Breast feeding is not a 5 minute message which is done once. It requires to be started early, done repeatedly and involving the family including the spouse cos the woman will struggle to breastfeed exclusively and successfully if she does not have the support of the family.

Many women have a sticky discharge on pressing nipples as early as the 2nd trimester - this is information that can be given to women but also to note that women who do not have colostrum like fluid so early still produce breast milk after birth.

Clearly explaining the role of exclusive breast feeding as a contraceptive measure can be done with both the woman and her spouse - this can help the man support his wife to breast feed. Today in most countries Progesterone only pills which do not hinder lactation are available freely in Government centres and this is valuable information that must be given also.

Lactation counselling has evolved with time - it is now much more than just speaking on attachment and positioning though this is still very difficult to achieve correctly and must not be forgotten.

Counselling on breast feeding must be done through all trimesters - tweaking the messages appropriately at different points in time.

However in my opinion Counselling on complementary feeding is best done after successful breast feeding is established - the woman's nutrition is emphasised and then in the 4th- 5th month after birth the topic of complementary feeding can be gradually brought in.

Many of you in this forum will be familiar- Dr Felicity Savage herself has responded - her book titled "Nutrition in Developing Countries" has just had a 3rd edition- it remains a book I return to each time one needs to be sure of any issues in IYCF.

Hope this is useful