lessons learned from breastfeeding promotion in armenia

Lessons Learned from Breastfeeding Promotion in

Armenia

Kim Hekimian, PhD

Institute of Human Nutrition,

Columbia – AUA Symposium

May 26, 2014

A quick history of the problems….

• Gained independence

in 1991

• Blockaded by Turkey

and Azerbaijan

• War, Earthquake

• No heat, no electricity

A Story of Humanitarian Assistance Gone Wrong… • Economic collapse,

infrastructure changes, poor

water quality

• Increases in Infant Mortality,

Diarrhea, ARI

• Infant formula as

humanitarian aid post-1988

o 900 metric tons annually

o Growing dependency; impending cessation

o MOH faces dilemma

What were mothers feeding

infants?

The importance of research!

• Very little data

• Mostly anecdotal

• “Women can’t breastfeed

because of stress”

• USAID funds national study

First Phase: Qualitative Research

• Focus groups

o With Mothers

o With Mothers-In-Law

o With Pediatricians, Nurses, Ob-Gyns

• In-depth interviews

• Observations at Maternity Hospitals

• Develop a picture of the problem, generate hypotheses to be tested quantitatively

Use of a Conceptual Model for

Behavior Change

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health •ARI •Diarrhea •Infections

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Feeding Behaviors

Infant Feeding Practices, Baseline

7/26/13

"Improving Infant Feeding Through

Multiple Interventions"," Kim

Hekimian, PhD

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Free Distribution of Formula

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Post Partum Care Practices, baseline

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

What did the Pediatricians say?

7/26/13

"Improving Infant Feeding Through

Multiple Interventions"," Kim

Hekimian, PhD

Armenian Pediatricians’ Knowledge Regarding

Breastfeeding: Percent Answering Correctly

Statements Read 1993 (n = 70)

1997 (n = 92)

A newborn baby must be given water to quench thirst, even if BF [False]

7.2% 84.6%

“Test Weighing” is the best way to determine if breast milk is insufficient and should be supplemented with formula [False]

23.2% 75.0%

Babies should be breastfed on a schedule [False]

31.4% 93.4%

Breast milk with a watery texture should be supplemented with formula [False]

57.1% 82.2%

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Predisposing Factors •Maternal Knowledge •Socio-Demographic

Variables

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

What did the moms say? “անբավարար” (insufficient)

“Կաթ չկա” (There’s no milk)

“երեխան լաց էր լինում”

(The child was crying)

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Predisposing Factors • Mothers’

Knowledge, Education, SES, etc.

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Policy Changes •MOH Directive •Donor Agency -

Formula Distribution

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Predisposing Factors Mothers’ Knowledge, Education, SES, etc.

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Policy Changes •MOH Directive •Donor Agency -

Formula Distribution

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Predisposing Factors • Mothers’

Knowledge, Education, SES, etc.

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Policy Changes •MOH Directive •Donor Agency -

Formula Distribution

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Promotional Activities •Physician Training •IEC Campaign

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Behavioral Outcomes •Infant Feeding

Practices

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework)

Infant Health Outcomes • ARI • Diarrhea • Infant

mortality

Predisposing Factors • Mothers’

Knowledge, Education, SES, etc.

Social Marketing Campaign

Six Main Messages

Health Education Material

Conceptual Framework of Factors Influencing Breastfeeding Behavior

in Armenia (Based on the Precede-Proceed Framework, Green 1991)

Policy Changes •MOH Directive •Donor Agency -

Formula Distribution

Promotional Activities •Physician Training •IEC Campaign

Predisposing Factors •Maternal Knowledge •Socio-Demographic

Variables

Reinforcing Factors •Healthcare Provider

Support in Hospitals

Enabling Factors •Postpartum Care

Practices Regarding Breastfeeding

Environmental Factors •Formula Availability •Water Quality •Medical School

Curriculum

Behavioral Outcomes •Infant Feeding

Practices Infant Health •ARI •Diarrhea •Infections

0

20

40

60

80

100

120

Ever

Breastfeed

Immediate

Initiation

First BF > 24

hrs after

birth

Prelacteal

Feed w/

Formula

Rooming-in

Changes in Post-Partum Practices,

Armenia 1993 - 2010

1993

1997

2010

Empty Nursery

Post-Intervention

Duration of breastfeeding

10.9

4.2

1.8

Ever breastfed Exclusively breastfed Predominantly breastfed

Median of exclusive breastfeeding in:

2000 – 1.0

2005 - 0.8

2010 - 1.8

Median of duration in months

K. Saribekyan, Armenia MoH, based

on DHS 2010

Leadership

Lessons Learned