Promoting Breastfeeding in Pakistan

The Problem: Breastfeeding is one of the oldest “ancestral technologies” for infant care and health. Yet infant formula marketing and misinformed beliefs (e.g., breastmilk, especially colostrum, can be poisonous to infants) have disrupted this and contributed to low breastfeeding rates and poor infant and child nutrition and health outcomes in Pakistan. A strong network of tens of thousands of community health workers ("Lady Health Workers", LHWs) has been trained by UNICEF and the government on breastfeeding knowledge and promotion, but they need additional support to build acceptance for these ideas in rural communities. Our Solution: We propose to leverage and expand the LHW program in Punjab through remote, app-based coaching with LHWs and build on their community contact to involve elders (especially grandmothers) in breastfeeding promotion through peer outreach. Scalability: Given the reach of community health workers worldwide, our Solution can be scaled beyond Punjab to millions of people.

Justification: Breastfeeding is directly important for both infant and maternal health outcomes. For example, breastfeeding protects infants from lethal infections such as diarrheal disease and pneumonia (UNICEF and WHO 2019), particularly in contexts, such as Pakistan, where water quality is often poor. Worldwide, nearly 14% of deaths ofto children <24 months (over 820,000 deaths) could be averted each year with optimal breastfeeding practices. The WHO recommends early initiation (within one hour of birth), exclusive breastfeeding for the infant’s first 6 months, and continued breastfeeding up to 2 years or beyond.

Pakistan has one of the world's highest neonatal mortality rates, and persistently high infant and child mortality. Only 20% of infants are breastfed within the first hour, and only 35% are exclusively breastfed at 4-5 months (2017-18 DHS). In Punjab, Pakistan’s most populous province, with over 110 million people (2017 National Population and Housing Census), the breastfeeding rates are even lower, only 10% and 42%, respectively (2017-18 MICS). Poor water quality combined with widespread beliefs against feeding babies colostrum (first milk) and that mothers’ milk can be poisonous (Zakar 2018, Qureshi 2017) contribute to the  low early and exclusive breastfeeding rates and poor infant and child nutrition and health.

Our Solution leverages an existing community-based health worker training program in Punjab, Pakistan, to promote early and exclusive breastfeeding through: (1) improving breastfeeding support from grandmothers  through peer outreach; and (2) providing remote coaching of LHWs through an app.

Pakistan’s Lady Health Worker (LHW) program provides regular home visits, basic clinical services (e.g., family planning, vaccinations, growth monitoring) and health education, thereby connecting poor rural households and the formal healthcare system. In 2018, UNICEF and the Government of Punjab rolled out a major initiative to increase breastfeeding rates through perinatal education provided by LHWs. This training emphasizes demonstrative training for mothers and dispelling common breastfeeding myths such as giving prelacteal feeds and  avoiding feeding colostrum .

Our Solution will initiate direct communication between LHWs and members of the paternal family (in particular grandmothers) to more effectively promote breastfeeding. This intervention will harness the influence of family members through peer-to-peer support with grandmothers to complement the current breastfeeding  promotion for  mothers.  We will support this activity with  regular mobile check-ins with LHWs via an app, allowing LHWs to receive guidance about specific questions raised by mothers and elders that they would otherwise be unable to answer.

Our Solution is aimed at community-based health workers (called Lady Health workers) in Punjab, Pakistan, and the communities they serve, particularly pregnant women and newborns in rural areas. 

As described above, Pakistan’s LHWs provide clinical services, health education, and community mobilization, serving as vital links between low income households and health facilities. LHWs are each responsible for a catchment area of approximately 1,000 people/200 households. They visit approximately 27 households per week. Nearly 55% of new mothers reported LHW visits in the prior month in Punjab (2017-18 MICS).

Our team conducted qualitative research in Punjab in December 2019-January 2020. Via interviews in four rural districts with LHWs, as well as interviews with government health officials, UNICEF representatives, and clinicians (Obstetricians/Gynecologists and Pediatricians), we explored issues such as the work of LHWs, particularly implementation of the new infant feeding  curriculum rolled out in 2018, and breastfeeding knowledge and practices, including the role of traditional beliefs and the pervasiveness of infant formula marketing. LHWs described uptake and use of the new curriculum, but found that the beliefs of family members (particularly fathers and  grandmothers) in some cases hindered best breastfeeding practices.

Our Solution leverages an existing community-based health program to promote and support early initiation and exclusive breastfeeding of infants in Punjab, Pakistan. Optimal breastfeeding practices have both direct and indirect effects on infant (as well as maternal) health outcomes, including improved infant nutrition and protection from lethal infections such as diarrheal disease and pneumonia.

This Solution is centrally aligned with Solve’s Maternal and Newborn Health Challenge; it touches on several dimensions of the Challenge, but is most aligned with: Expand access to high-quality, affordable care for women, new mothers, and newborns -- in the form of breastfeeding training and support.