I have recently led a review of a programme in the delta of Myanmar where cash has been given to mothers with babies under 6 months, to enable them to stay at home and breastfeed exclusively, instead of going out to work. The monitoring data returned consistently high reports of EBF among the beneficiaries and we wanted to know if these were real (or not) and how/why the women were enabled (or not) to improve their practices. Therefore we took a small sample of 26 mothers and did 24 hour and 7 day diet recalls on their babies' diets. These were a part of detailed semi structured interviews with mothers and their husbands, which included assessing knowledge and understanding of key practices and access to and uptake of various IYCF promotion and support and other livelihoods interventions. The aim was to examine plausibility of the high EBF rates in the monitoring data by getting assuredly accurate data in a small sample and exploring how the good (or bad) practice has been enabled in that individual case.
We found that mothers had good knowledge and understanding of key IYCF practices and all were staying at home, not working, buying more food and nutritious foods, eating better than before etc.. For the recalls the results were that 12 mothers fed only BM, 3 gave BM and multivitamins, 5 gave BM, multivitamins and traditional colic medicine and 4 gave BM and traditional colic medicine (1 gave BM and water, 1 BM and formula). This equates to a 58% exclusive breastfeeding rate if we take the 12+3/15.
However, there was a question about the necessity to exclude infants receiving the traditional colic medicine because it is approved by the Myanmar equivalent of the Food and Drug administration. Including the other 9 children would take the rate of EBF among this small sample to 92%. We are not looking to fudge results, and in fact I don't think we need to as the 58% result seem very positive in terms of prevailing EBF practices and the pathways the review highlights that are enabling this are highly plausible. However I'd be interested to know if anyone has experienced similar challenges elsewhere in terms of classification of EBF when the factor that is making it strictly not exclusive is perceived to be necessary... it makes me wonder how possible it might be, as a next stage, to get mothers to stop using the medicine...
Thanks for your feedback in advance
Hi Vicky,
On a slight tangent (as I do not want responses to deviate from your original request for information). Remunerating mothers to stay at home to try to enable them to exclusively breastfeed is a nice concept, whereby the smaller cohort you studied in detail illustrated encouraging results. As such, if we were to think about the possibility of promoting such a concept in other countries (with subsequently different contexts), it would be necessary to understand the type of 'work' the mothers you surveyed would have usually undertaken and for what purposes this work is undertaken, i.e. for income generation, for subsistence living, for asset creation/diversification etc - what was the situation in your cohort in Myanmar?
If female work for example usually consists of subsistence agriculture, presumably you identified that there was both market access and availability, to enable families to purchase household food commodities that they would otherwise have been cultivating/rearing? I suppose the potential for positive impact for this sort of initiative across different settings comes down to the male and female livelihoods roles within a household. Who does what to support the family and is it plausible simply to provide money to the female party to effectively remunerate the family against work that would normally be undertaken. Have you discussed this issue with your team and if so what are your thoughts around its viability in different settings?
Hatty
Answered:
13 years agoHi Vicky
What an exciting project!
I would say 2 things. First, the agreed definition of EBF allows for ceremonial teas and other medicines so depending on the amount given and the constituents (nutritive or not?), it might be reasonable to assume that the colic remedy does not terminate EBF. If it were me, I'd just ensure that any reports were transparent on this matter.
Second, I'd be uncomfortable reporting proportions (percentages) derived from a qualitative research design. (In which case, it doesn't matter whether colic remedy terminates EBF, you just report what it is and how it is used and let your readers decide.) Qual research can't actually give you numbers. It's just not designed for that. You could use the data you gathered from this interview to survey all (practicable?) mothers in the program (What have you fed your baby in the last 24 hrs: breastmilk, colic remedy, multivitamins, water, butterfly brand, formula, animal milk. ...) and that would give you proportions.
cheers
n
Nina Chad PhD
Answered:
13 years agoFrom Vicky Sibson:
Hi Nina
Thanks for your email and advice. Don't worry - I am not basing our conclusions on a sample of 26!! We have reviewed the (exhaustive) monitoring data to tell us the 'what' and have undertaken the in depth case studies to tell us the 'why' and 'how', and to confirm the 'what'. If that makes sense..
From what you have said I feel tempted to classify the children taking colic medicine as EBF (clearly stating that they have been given that medicine though).
The in depth case studies and the monitoring data together suggest that there is a high prevalence of EBF (+/- vitamins and minerals and colic medicines) among the beneficiary population. This seems strongly related to improved knowledge and understanding of best practices and the enabling 'force' of the cash which has meant mothers have stayed at home with their babies. Interestingly (because 'hunger' was a barrier to breastfeeding promotion during our emergency response) there is also a strong suggestion that mothers/households have spent more on food and women are eating better, and feel that this helps their breast milk production.
Thanks
Vicky
Tamsin Walters
Forum Moderator
Answered:
13 years agoHi Vicky,
Sounds like you have some great data. It is great to see interventions being adequately monitored. I agree with Nina. So long as you make it clear what your definition of exclusive breastfeeding means in any publication it is reasonable to classify infants given "colic medicine" as exclusively breastfed. You could also provide information on exclusive breastfeeding rates without the medicine. So long as everything is there, there is no fudging. The devil is in the detail with any measurement of exclusive breastfeeding and it is oh so frustrating when proper detail is not provided and oh so useful when it is. Where will this all be published?
Karleen
Karleen Gribble
Answered:
13 years agoFrom Vicky Sibson:
Thanks Karleen. I am not sure what we will do with the findings yet, beyond the internal report - perhaps a summary in Field Exchange though...
Hatty, I got your questions and they are all excellent and important in terms of the relevance of these findings and what might be appropriate recommendations for future programmes
I will keep you both posted
Best wishes
Vicky
Tamsin Walters
Forum Moderator
Answered:
13 years agoHi Vicky
Of course, I should have known you were all over it. Without having seen the data, it sounds like you have a very successful - and groundbreaking - project. I it is rare to find an intervention that improves EBF (decreases infants' exposure to foods and fluids other than human milk) in the first six months of life. Like Karleen I would encourage you to publish your findings in an academic journal - Bulletin of the WHO would likely be interested, or perhaps Disasters.
I think it might be possible to work with mothers to avoid the colic remedy - if you could provide them with alternative settling strategies preferrably at the hands of more experienced (respected) mothers and perhaps an alternative explanation for the behaviour the mothers are trying to 'treat' with the colic remedy. (Oversupply (I saw at least one case of this in a village in Labutta)? normal cluster feeding? baby lonely? wonder week?). That said, depending on the composition of the colic remedy, the first question might be, does it do any harm? You might want to see if there is a School of International Public Health somewhere that would be interested in conducting a cohort study comparing incidence of infection amongst EBF infants given the colic remedy and those who aren't (AUSAID might fund such a project?). That would tell you whether your resources might be better deployed on something else.
It is so nice to hear good news from Myanmar!
Nina Chad PhD
Answered:
13 years agoI agree with Nina...very worth aiming for publication in a peer reviewed journal. Happy to assist if and when you decide to go ahead.
Karleen Gribble
Answered:
13 years agoHello Vicky
This is my very first posting but I have been 'reading' for quite awhile. The initiative to pay mums to stay home is wonderful! I support the questions already raised; Is it cost effective? Could there be the possiblity of working with mothers to reduce the need for 'colic' remedy? What volume of 'colic' remedy is given and how often? Could it be expanded and rolled out elsewhere?
The results of your study are so interesting and should be shared, including the amount paid to the family. Please do publish, not only in WHO and Field Exchange (IFE specific) but also to reach the wider readership in a journal specific to breastfeeding- maybe the Journal of Human Lactation?
Cheers
Sue
Sue Saunders
Answered:
13 years ago