#1Linking microcredit, technology, and breastfeeding promotion in Bauchi State, Nigeria Valerie L. Flax, Alawiyatu Usman Ibrahim, Margaret E. Bentley September 15, 2013 UNC CAROLINA POPULATION CENTER#2● . Infant feeding behaviors in Nigeria 7% of Nigerian infants 4-5 months are exclusively breastfed (EBF) Water is commonly given during the first days of life and throughout breastfeeding Complementary foods are introduced early - 20% at 0-1 months of age Rates of EBF & early breastfeeding initiation are lowest in NE Reference: Nigeria Demographic and Health Survey 2008 2#3Microcredit program as a platform 5-6 women join together and guarantee each others' loans • 4-6 of these small groups. meet with their credit officer monthly to: - - repay their loans learn business development techniques 3#4Project site Bauchi State NIGERIA Bauchi State - Bauchi, Ganjuwa, and Dass local government areas (LGAs) Implemented by Partners for Development with 4 local microcredit organizations - Rahama, Gerewa, Wurno Kowanaka, and WODASS#5Intervention components 7 monthly BF learning. sessions during microcredit meetings • 2x/week cell phone voice and text messages to reinforce key BF messages 1x/month presentation of song or drama related to cell phone messages 5#6Overview of study design Cluster-randomized controlled intervention trial Baseline survey - during pregnancy • Final survey - when infants >6 months ● · Data on implementation process Quality of intervention survey Qualitative data about cell phone use and changes in social norms 9#7Study objective and hypothesis Objective: • To test the effect of an integrated microcredit and breastfeeding promotion intervention on exclusive breastfeeding to 6 months Hypothesis: Increase the proportion of women who EBF to 6 months by 15% in the intervention compared to the control group 7#8Study outcomes Main outcome: • Exclusive breastfeeding to 6 months Selected secondary outcomes: • Breastfeeding initiation within one hour of • delivery Use of non-breastmilk fluids in first three days of life (pre-lacteal feeds) 8#9Study participants Eligibility criteria: Microcredit clients of 4 local partners Pregnant 15-45 years All eligible women invited to participate 6#10Participant Flow 172 monthly meeting groups (2158 clients) 79 meeting groups (484 potentially eligible clients after preliminary screening) 79 meeting groups (461 eligible clients) 93 meeting groups contained no potentially eligible clients 0 meeting groups were excluded. (Reasons for individual ineligibility: 3 were <15 years 19 not pregnant 1 refusal) 1 meeting group lost (Reasons for individual losses: 18 miscarriages 10 stillbirths 5 infant deaths) 40 meeting groups in intervention at baseline (229 clients) 39 meeting groups in intervention at follow-up (196 clients) 39 meeting groups in control at baseline (232 clients) 38 meeting groups in control at follow-up (194 clients) 1 meeting group lost (Reasons for individual losses: 20 miscarriages 5 stillbirths 11 infant deaths 1 maternal death 1 moved away) 10#11Background characteristics (n=390) Characteristic Intervention Control Mean age (years) 25.4 ± 5.7 25.8 ± 5.7 Mean years of education 6.3 ± 4.8 6.2 ± 4.6 Mean parity 4.1 ± 2.4 4.5 ± 2.4 Mean # children < 5 years 1.8 ± 0.6 1.9 ± 0.6 % married 97 100 % with co-wives 56 51 Mean # household items 7.8 ± 2.9 7.4 ± 3.0 Mean # rooms in household 4.9 ± 2.7 4.7 ± 2.7 11#12Percent who intend to do the behavior 80% 70% 60% Feeding intentions at baseline Intervention Control OR 0.8 (0.4, 1.5) OR 1.0 (0.6, 1.8) 50% OR 1.1 (0.6, 1.8) 40% 30% 56% 51% 20% 42% 40% 42% 42% 10% 0% Exclusive BF to 6 mo Initiation of BF within 1 hr Give fluids in first 3 days 12#13Feeding behaviors measured post-intervention Proportion who reported the behavior 80% OR 2.6 (1.6, 4.1) 70% OR 2.4 (1.4, 4.0) 60% 50% 40% 70% OR 0.4 (0.2, 0.8) 30% 64% 48% 20% 43% 10% 29% 14% 0% Exclusive BF to 6 mo Initiated BF within 1 hr Gave non-breastmilk of delivery fluids in first 3 days Intervention ■Control 13#14Client participation 69% of intervention clients attended all 7 BF learning sessions 96% of cell phones received all text and voice messages 85% of small groups presented a song or drama at least once per month 14#15Cell phone use 6% of women surveyed were responsible for group phone 61% of women live <10 min from person with phone 64% said that sharing a phone worked well or very well 15#16Challenges and Limitations Challenges: Many clients had no cell phone Security issues Limitations: • Assessment schedule allowed us to capture exclusive breastfeeding only at 6 months • Research design did not allow analysis of independent effect of intervention components 16#17Conclusions and implications • An integrated microcredit and BF promotion. intervention was successful at changing BF practices Using a group cell phone was feasible Cell phones prompted participants to meet, discuss the messages, and develop songs/dramas • The scaling up of this type of intervention should be tested in existing microcredit programs in Nigeria 17#18Acknowledgements ● · Mekebeb Negerie and Danjuma Yakubu at PFD/Nigeria Credit officers at Gerewa, Rahama, Wodass, and Wurno Kowanaka Eric Daza at UNC Freedom from Hunger Bill & Melinda Gates Foundation to FHI 360, through the Alive & Thrive. Small Grants Program managed by UC Davis 18