Introduction

Evidence of the child survival, immune function and cognitive development benefits of breastfeeding are well documented. The World Health Organization (WHO) has designated improved breastfeeding as a Sustainable Development (SDG) Goal. According to Victora et. al., “the scaling up of breastfeeding to a near universal level could prevent 823,000 annual deaths in children younger than 5 years and 20,000 annual deaths from breast cancer.”

In this post, I present findings from a study that compares inequalities in coverage and practices related to breastfeeding in areas where programs were implemented with areas where they were not. It is one of a series of five inequality studies we have recently completed on adolescent, maternal, infant and young child nutrition. We selected Bangladesh, Burkina Faso and Vietnam where breastfeeding programs had been implemented for several years. The study and the programs were implemented by the Alive & Thrive initiative, FHI 360 with funding from the Bill and Melinda Gates Foundation.

From 2009-2017, Alive & Thrive implemented breastfeeding programs at national scale in Bangladesh, Burkina Faso and Vietnam while also documenting the strategies and conducting rigorous evaluations. Our exploration of whether the programs benefited the disadvantaged mothers and infants was triggered by concerns about providing coverage to those who need it most and the global literature showing the risk of inequalities in program coverage as health programs expand rapidly. We invited two experienced statistical experts in the field of inequality and nutrition to join our team – Dr. Deepali Godha and Professor Edward Frongillo – and selected countries with different socioeconomic contexts and programs.

Methods

The data needed to assess inequalities already existed in cross‐sectional household surveys conducted as part of evaluation studies. Our team re-analyzed publicly available data from endline surveys done in 2014 in Bangladesh and Vietnam after 4‐years and in 2017 in Burkina Faso after 2‐years of program implementation. The data was collected through interviews with mothers of infants under 6 months of age, “with a final sample size of 998 mother/baby pairs in Bangladesh, 1162 in Burkina Faso and 1002 in Vietnam,” (Page 3) Mothers were asked about their current breastfeeding practices and their recall of exposure to program interventions including counseling by a trained health worker and their recall of public education messages including through mass media such as TV or radio. The survey also collected information on the mother’s household wealth and the number of completed years of her schooling.

We aimed to understand if the program interventions were reaching both the better-off and disadvantaged groups equally and if the breastfeeding practices recommended by the WHO were different in better-off groups as compared with disadvantaged groups of mothers. The practices included exclusive breastfeeding (EBF), early initiation of breastfeeding (EIBF), and feeding of colostrum (early breastmilk that is rich in nutrients and immune factors).

• The study explored three questions:
• Do program interventions reach mothers equally across the better-off and disadvantaged mothers, and if not, are there differences by types of interventions?
• Is there inequality in breastfeeding practices and if so, does it favor the better-off or disadvantaged?
• If there is inequality, what is the magnitude of this inequality in program and non-program areas?

To answer these questions, the team selected the Erreyger’s Index (EI), an econometric measure of inequality that is used to compare different populations (e.g., countries) or groups (e.g., program and non-program areas). The EI considers each mother’s rank on a spectrum of wealth or education as well as the outcome of interest, which in our case is breastfeeding practices and program coverage.

Findings

As noted in our article, “Our results on wealth inequality in programme [sic] coverage showed that IPC contacts for BF counselling slightly favoured [sic] the poorer mothers or had almost no bias in the countries in both intervention and nonintervention areas,” (Page 11). The programs did show an impact but the magnitude of bias favoring the less well-off was lower in intervention areas, indicating that more advantaged mothers may have benefited from the program.

In examining the coverage of public education/mass media, we found that in all program and non-program areas in the three countries, more advantaged mothers benefited from this intervention. The pro-rich bias was less in program as compared with non-program areas only in Bangladesh but in Burkina Faso and Vietnam, the pro-rich bias was higher in program areas. We should clarify that the public education/media channels were selected to also reach influential persons and they are better-off and more advantaged members of society including employers of women, doctors, producers and distributors of breastmilk substitutes. However, mothers also needed the information.

Additionally, “our results on wealth inequality in breastfeeding practices show that EBF in the three countries and EIBF in two out of three countries were pro‐poor in program areas at endline, indicating an advantage for less well‐off mothers,” (Page 10). In each country, specific program design factors may have protected breastfeeding practices among the less well‐off mothers. For example, breastfeeding services were delivered in Bangladesh through home visits by incentivized volunteers and providers; while in Vietnam a campaign was implemented to encourage mothers to seek breastfeeding counselling services at rural health centers, (Page 10).

In Burkina Faso, we found evidence of “bias in favor of better off mothers in three critical breastfeeding practices, namely, EIBF, colostrum feeding and giving pre‐lacteal foods that are not recommended,” (Page 10). Although we do not have sufficient data to understand the causes behind this finding, one explanation is that due to a rapid rise in institutional deliveries in Burkina Faso, health facilities may not have adopted antenatal, delivery and postpartum services that would have supported breastfeeding practices among disadvantaged mothers. Alternatively, traditional practices surrounding newborns in Burkinabe communities may have prevailed over breastfeeding recommendations (Page 10).

Our analysis also found that “more educated mothers had an advantage over less educated mothers in practicing EBF in program areas in Bangladesh and Vietnam, where we had data,” (Page 11).

Conclusion and Implications 

The findings suggest the need to take steps for intentionally reducing social, economic or logistical barriers for less well‐off mothers to obtain breastfeeding counselling. In future, to reinforce interpersonal counseling with additional communication channels, the programs need to support both interpersonal communication and public education/mass media plus additional methods that directly reach disadvantaged mothers.

Our study shows that health services where mothers are counseled and communication channels that provide important reminders and motivation to improve breastfeeding practices should be designed specifically to reach disadvantaged mothers as part of comprehensive large-scale breastfeeding strategies. Equality will not happen spontaneously. We looked at programs that “combined population‐wide interventions with interpersonal interventions, but reductions in inequalities in the three country programs did not substantially contribute to a pro-poor advantage,” (Page 11). Our study indicates that this is a serious gap as the negative health and development consequences of poor infant feeding are greater among the disadvantaged families and communities and less well‐off mothers should receive priority, as noted by Vilar-Compte, et. al.

Scaling up interventions that improve breastfeeding practices without ensuring benefits for the less socioeconomically advantaged mothers is not enough for obtaining the best health and nutrition outcomes. Accelerating the implementation of multi-channel breastfeeding promotion programs can increase coverage and produce impacts on breastfeeding indicators on a large scale, but it is not enough to reduce gaps among different socioeconomic groups.

The lack of explicit goals and strategies for reducing inequalities were among the biggest impediments to maximizing outcomes. Resources need to be allocated from the start when designing programs based on an understanding of the barriers to services and essential communications on critical topics such as feeding young infants. Additionally, tracking inequalities and flexibility to shift resources and re-train program implementers are key to meeting the needs of the disadvantaged. Ongoing engagement with local authorities and community leaders would protect against unexpected lapses in the flow of program benefits to those who need them the most. To start with, we need to determine why the disadvantaged are being left behind in current programs and what we should do jointly through participatory planning in different contexts to get every mother and child safely through the early window of opportunity, not only alive but also to thrive.

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