Tina Sanghvi, PhD: No relevant financial relationship(s) with ineligible companies to disclose.
Objectives: To document socioeconomic inequalities in breastfeeding program coverage and practices after program implementation and compare the pattern of wealth- and education-related inequalities between intervention and non-intervention areas.
Methods: We used endline surveys from RCT evaluations that had shown significant overall improvements in early initiation (EIBF) and exclusive breastfeeding (EBF) in randomly allocated intervention areas. Program coverage of mothers with infants below six months of age was assessed for interpersonal communication or counselling and public education and media. We analyzed the distribution of coverage and practices by the mothers' socioeconomic status using Erreygers index to identify the direction and magnitude of inequalities at endline in the two treatment areas.
Results: The countries varied in maternal characteristics, breastfeeding practices, and types of program platforms for delivering counseling and public education. None of the programs had explicit equality objectives. At endline, exclusive breastfeeding was pro-poor in intervention areas in all countries (range -0.001 to -0.037). Early initiation was pro-poor in Bangladesh (-0.038) and Vietnam (-0.162) and more pro-poor in intervention areas. Intervention coverage was not consistently pro-poor. Counseling coverage often favored the poor (range -0.001 to -0.036), but public education and media consistently favored better-off women (range 0.151 to 0.199). Public education and media also favored the more educated women slightly. However, the pro-educated bias was less pronounced in intervention areas.
Conclusions: Widely used interventions for promoting breastfeeding such as counseling and public education and media do not favor the less advantaged sufficiently to reduce inequalities substantially. To achieve the greatest payoff from programs, future intervention design methods need to explore barriers to program participation and alternatives for reaching the poorer and less educated women. Countries need to set targets and track inequalities and not only overall coverage in breastfeeding promotion programs.
Funding Sources: The Bill & Melinda Gates Foundation funded the study under grant number INV-042392, awarded to Alive &Thrive, FHI 360.
