Alive & Thrive

This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary. We plan to consider undertaking additional work on this program in the future.

Summary

Published: September 2018

We spoke with Dr. Karin Lapping and Sujata Bose about updates on Alive & Thrive on February 27, 2019.

What is the problem?

The World Health Organization (WHO) and UNICEF have issued infant feeding guidelines centered on promoting breastfeeding, but current breastfeeding practices in many countries fail to follow these recommendations. They believe that increasing breastfeeding rates is critical to improving health, nutrition, and mortality outcomes.1

WHO and UNICEF recommend that ideal feeding for infants should include:

• Early initiation of breastfeeding within 1 hour of birth
• Exclusive breastfeeding (EBF) from birth until 6 months of age2
• Partial breastfeeding with complementary solid foods from 6 months until 24 months of age or older3

WHO estimates that as of 2017, global breastfeeding rates did not reflect these goals, with early initiation reaching 44% of infants, exclusive breastfeeding reaching 40%, and 24 months of breastfeeding reaching 45%.4

While these recommendations apply to all infants worldwide, the risks of inadequate breastfeeding behaviors are likely to be higher in low-resource environments with poor sanitation and worse substitute foods.5

What is the program?

Breastfeeding support programs may solve barriers to breastfeeding and allow mothers to breastfeed longer and more intensively, in accordance with the WHO/UNICEF recommendations. This report focuses on an intensive package of infant and young child feeding interventions, with a major focus on breastfeeding promotion and support, which was designed and delivered by Alive & Thrive in cooperation with local health systems in an effort to create a supportive environment for breastfeeding. Alive & Thrive’s program consisted of four components, which differed somewhat by context:6

• Intensified interpersonal counseling. In Bangladesh, pregnant women and mothers of children up to 2 years old received monthly home visits from health workers and volunteers with education and coaching about breastfeeding and complementary feeding.7 In Vietnam, counseling occurred in health facilities. Mothers were supposed to receive 9-15 individual and/or group counseling sessions, 8 of which focused on breastfeeding.8
• Community mobilization. Sensitization of community leaders and theater shows about infant and young child feeding.9
• Mass media communications. In Bangladesh, this component included national TV advertising spots during popular programs, with supplemental community screenings of the ads in treatment areas with limited TV access.10 Efforts in Vietnam also included mobile device, internet, and billboard advertisements.11
• Policy advocacy. Activities to promote national awareness of infant and young child feeding issues in Bangladesh,12 and strides to extend paid maternity to six months and strengthen the national code of marketing of breast milk substitutes in Vietnam.13

Less intensive types of breastfeeding support programs are discussed in more detail in our interim review of breastfeeding promotion programs.

What is the program’s evidence of effectiveness?

Increases in breastfeeding rates

A set of two related cluster-randomized trials tested Alive & Thrive’s breastfeeding program operating in Vietnam and Bangladesh. Over six years, randomly-selected areas of each country received treatment at scale with the intensive four-pronged approach to breastfeeding promotion described above. Control areas received standard, non-intensified breastfeeding counseling and promotion, so the results reflect the impact of intensive programs over standard, less intensive ones.14 The RCT results are reasonably strong: the program demonstrated a large impact on exclusive breastfeeding in both countries, over and above a control group already receiving some treatment with breastfeeding support, and it significantly increased rates of early initiation of breastfeeding in Bangladesh.

Specifically, in Bangladesh, there were large and statistically significant increases in both early initiation of breastfeeding within one hour of birth (increase of 16.7 percentage points over the control group to 94.2%; 95% CI 2.8–30.6, p = 0.021) and exclusive breastfeeding rates in children one to six months old (increase of 36.2 percentage points from 48.5% to 87.6%; 95% confidence interval 21.0–51.5).15 In Vietnam, there was a statistically significant increase in exclusive breastfeeding in children one to six months old (increase of 27.9 percentage points over the control group from 18.9% to 57.8%; 95% confidence interval 17.7-38.1) but not in early initiation, which decreased in both groups but by less in the intensive treatment group.16

In addition, Alive & Thrive claims that its policy advocacy activities in Vietnam led to legislation that strengthened the national maternity leave policy and regulations on the marketing of breast milk substitutes.17 We have not examined the case for Alive & Thrive’s role in passing this legislation. To the extent that its actions were influential, this is a plausible additional impact of Alive & Thrive’s program that could persist over a long period of time. The headline RCT results may also understate Alive & Thrive’s impact on breastfeeding behavior change in Vietnam, since policy changes apply to the whole country, benefitting both control and treatment communities.

In contrast to the programs covered in our interim review of breastfeeding promotion programs, the Alive & Thrive trials study a generally more intensive breastfeeding promotion intervention. Based on our previous research, it appears that less intensive promotion programs may also be effective, but Alive & Thrive’s intensive program may be able to generate additional gains in breastfeeding rates. In addition, the trials of Alive & Thrive’s intervention attempted to treat entire communities over several years and demonstrated impact at scale, in contrast to other evidence that comes from small trials in more controlled environments.18

Health benefits of the program

Breastfeeding may protect against morbidity and mortality from diarrhea as well as several additional health benefits for women and children. Please see our interim review of breastfeeding promotion programs for more information.

Is the program cost-effective?

A preliminary cost-effectiveness model for this intervention is available here. Alive & Thrive’s intensive breastfeeding promotion programs may be in the same range of cost-effectiveness as our other priority programs for some ranges of program costs, but this estimate depends on several very uncertain assumptions. In particular, we lack key information about program costs.

Note that our cost-effectiveness analyses are simplified models that do not take into account a number of factors. There are limitations to this kind of cost-effectiveness analysis, and we believe that cost-effectiveness estimates such as these should not be taken literally due to the significant uncertainty around them. We provide these estimates (a) for comparative purposes and (b) because working on them helps us ensure that we are thinking through as many of the relevant issues as possible.

In addition to our questions about modeling the cost-effectiveness of breastfeeding listed here, major uncertainties specific to our current cost-effectiveness model of Alive & Thrive’s program include:

• Program costs. We do not have data on program costs. Are average costs for this intensive program substantially higher than for less-intensive interventions that may also be effective? Are those costs justified by stronger results?
• Policy impact. Is there evidence that Alive & Thrive was instrumental in passing policy reforms in Vietnam that may have sustained results over time? Should this impact factor into the cost-effectiveness model?
• Program location. Where would Alive & Thrive use new funding for its programs? The current model assumes that it would work in an area with high diarrhea disease burdens, and cost-effectiveness could fall if that were not the case.

Key questions for further investigation

Questions we would ask as part of further investigation include:

• How similar is Alive & Thrive’s current work to the programs trialed in its RCTs?
• What is the cost of the program? How much additional cost is associated with the intensive program compared to a less intensive one?
• How long would the intensive program continue to have an impact? How would Alive & Thrive transition to a maintenance program?
• Is there room for more funding? Where and how would Alive & Thrive use additional funds?
• What is the story behind breastfeeding-related legislation in Vietnam, and how likely is it that this legislation would have been passed without Alive & Thrive’s assistance?

Sources

Document	Source
WHO & UNICEF, Revised Baby-Friendly Hospital Initiative 2018	Source (archive)
WHO et al. 2008	Source (archive)
Menon et al. 2016	Source (archive)
Horta & Victora 2013	Source (archive)

• 1

  ”Breastfeeding is critical for achieving global goals on nutrition, health and survival, economic growth and environmental sustainability….

  Inadequate breastfeeding practices significantly impair the health, development and survival of infants, children and mothers. Improving these practices could save over 820 000 lives a year.” WHO & UNICEF, Revised Baby-Friendly Hospital Initiative 2018, p. 8.
  

• 2

  Exclusive breastfeeding is defined as requiring the infant to receive breastmilk and only allowing her to receive “ORS [oral rehydration solution], drops, syrups (vitamins, minerals, medicines)” in addition. WHO et al. 2008, p. 4.

• 3

  “WHO and the United Nations Children’s Fund (UNICEF) recommend that breastfeeding be initiated within the first hour after birth, continued exclusively for the first 6 months of life and continued, with safe and adequate complementary foods, up to 2 years or beyond.” WHO & UNICEF, Revised Baby-Friendly Hospital Initiative 2018, p. 8.

• 4

  “Globally, a minority of infants and children meet these recommendations: only 44% of infants initiate breastfeeding within the first hour after birth and 40% of all infants under 6 months of age are exclusively breastfed. At 2 years of age, 45% of children are still breastfeeding.” WHO & UNICEF, Revised Baby-Friendly Hospital Initiative 2018, p. 8.

• 5

  “Several mechanisms for a possible protective effect of breastfeeding against gastrointestinal infections have been proposed, including the presence in breastmilk of substances with antimicrobial or immunological properties, avoidance of contamination (as in non-human milk or baby bottles), and the general nutritional status of breastfed infants. . . . [N]on-breastfed infants are more exposed to pathogens that may cause diarrhea than breastfed subjects. Many studies attest to the presence of pathogens in foods offered to infants. For example, in The Gambia, Rowland et al observed that weaning foods traditionally given to children were contaminated with microorganisms that could cause gastrointestinal infections. Another study from Chile showed that most feeding bottles harbored large numbers of pathogens that could cause gastrointestinal infection.

  Last, it has been proposed that in low-income settings optimal breastfeeding practices can prevent undernutrition associated with repeated infections and with the use of over-diluted breastmilk substitutes. Good nutrition is essential for non-specific immunity that contributes to fighting infections in general.” Horta & Victora 2013, p. 12.

• 6

  Alive & Thrive has operated and studied its initiative in both Bangladesh and Vietnam.

• 7

  “In intensive areas, IPC [intensified interpersonal counseling] was based on multiple age-targeted IYCF-focused visits to households with pregnant women and mothers of children up to 2 y of age by the FLW and volunteer, as well as home visits by a nutrition-focused FLW, called Pushti Kormi, who was an additional human resource to provide more skilled support for breastfeeding and complementary feeding. In these areas, Shasthya Kormi and Pushti Kormi conducted monthly home visits and introduced age-appropriate IYCF [Infant & Young Child Feeding] practices, coached mothers as they tried out the practices, and engaged other family members to support the behaviors. . . . These workers were supervised using observation checklists, and their workload was monitored. Cash incentives (US$6–US$8/mo) were given to the volunteers in the intensive areas for intervention delivery performance, which included ensuring high coverage, carrying out age-appropriate counseling at home visits, and collecting maternal reports of practicing the recommended behaviors. Households were unaware of this performance incentive.” Menon et al. 2016, p. 7.

• 8

  “Save the Children worked with the government of Viet Nam to establish a total of 781 government health facilities at the province, district, and commune levels that used a social franchising model, called Mat Troi Be Tho (MTBT), to deliver facility-based individual and group counseling. All facilities were required to meet minimum criteria including a standardized counseling room, trained staff, and availability of job aids and client materials. The program aimed to deliver 9 to 15 counseling contacts to each mother-child pair from the last trimester of pregnancy through the child’s first 2 y of life, including eight breastfeeding-focused contacts in the first 6 mo of life. Referrals, CM, promotional print materials, and TV advertising were used to generate demand for preventive IYCF [Infant & Young Child Feeding] counseling services, a concept new to most families. Training and supervision, incentives to the health facilities, and tools to collect data were applied to improve the quality of services.” Menon et al. 2016, p. 7.

• 9

  “CM [community mobilization] included sensitization of community leaders to IYCF [Infant & Young Child Feeding], and community theater shows focused on IYCF.” Menon et al. 2016, p. 7.

• 10

  “The MM [mass media] component consisted of the national broadcast of seven TV spots that targeted mothers, family members, health workers, and local doctors with messages on various aspects of IYCF [Infant & Young Child Feeding]; two of the spots focused on breastfeeding. Buys of media airtime were designed for multiple airings during the country’s most watched programs. In intensive areas that had limited electricity and TV access, supplemental activities were conducted to air the TV spots, and other IYCF films produced by the project, through local video screenings.” Menon et al. 2016, p. 7.

• 11

  “The MM [mass media] component consisted of a nationally broadcast campaign using TV and the digital space (internet and mobile phone applications); three of four TV spots focused on breastfeeding. In intensive areas, the MM campaign also included additional out-of-home advertising through billboards and LCD screens.” Menon et al. 2016, p. 7.

• 12

  "PA [policy advocacy] included workshops to share data, engagement of journalists to broaden reporting on IYCF [Infant & Young Child Feeding] in the media, creation of an IYCF alliance and other such activities, which aimed at creating additional countrywide awareness of policies and programs to support breastfeeding." Menon et al. 2016, p. 7.

• 13

  "PA [policy advocacy] at the national and provincial levels targeted the extension of paid maternity leave to 6 mo, strengthening of the code of marketing of breast milk substitutes, and improving provincial planning for IYCF [Infant & Young Child Feeding] and nutrition actions." Menon et al. 2016, p. 7.

• 14

  “Alive & Thrive was implemented over a period of 6 y (2009–2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.” Menon et al. 2016, p. 1.

• 15
  • "In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0–51.5, p ＜ 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8–30.6, p = 0.021; 63.7% to 94.2%)." Menon et al. 2016, p. 2.
  • "EBF in children under 1 mo of age did not differentially improve by intervention group in
    either country. Impacts in both countries were due to the differential improvements in EBF in favor of the intensive group among children 1–5.9 mo." Menon et al. 2016, p. 17.

• 16
  • “In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7–38.1, p ＜ 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI −1.3 to 21.4, p = 0.072).” Menon et al. 2016, p. 2.
  • Menon et al. 2016 finds that self-reports of EBF in Vietnam may be affected by social desirability bias that leads to overestimated results, but these results remained strong and statistically significant after adjusting for this bias. This issue did not appear to affect the Bangladesh results or other outcomes. “We measured social desirability in both countries to assess, and account for, potential biases in our main impact estimates for reported breastfeeding practices. We found evidence of a social desirability bias for EBF in Viet Nam, but not in Bangladesh. There was no evidence of this bias for other breastfeeding outcomes. In Viet Nam, as social desirability scores for EBF increased, reported EBF increased in both groups, but more so in the intensive group. After adjusting for this differential increase, the impact estimate for EBF in Viet Nam remained strong and statistically significant (DDE 15.2 pp, p = 0.008).” P. 19.

• 17

  Alive & Thrive’s policy advocacy activities in Vietnam included: “Technical and financial support to National Nutrition Strategy and IYCF [Infant and Young Child Feeding] Action Plan; integration of IYCF into provincial nutrition plans; strengthening of the national Code on Marketing of Breast Milk Substitutes (Decree 21); strengthening of the national maternity leave policy, health insurance, insurance law, and workplace support programs. Media outreach.” Menon et al. 2016, p. 6.

• 18

  “At-scale interventions combining intensive IPC [intensified interpersonal counseling] with MM [mass media], CM [community mobilization], and PA [policy advocacy] had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs.” Menon et al. 2016, p. 2.