Hadiya feeds her six-month-old daughter enriched porridge that she learned to make during a cooking demonstration at the Port Bouët II social center.

Since 2007, the IYCN Project has been working to prevent malnutrition of mothers and children younger than two years and to maximize HIV-free survival among children born to HIV-positive mothers. One of the project’s primary approaches to preventing malnutrition is reaching orphans and vulnerable children through government-supported social centers. IYCN works with national-level programs to train social workers in more than 30 centers throughout the country to monitor children’s growth and counsel caregivers on optimal infant and young child feeding practices, particularly within the context of HIV. In addition to counseling materials, the project supplies the centers with anthropometric equipment and cooking materials. At the heart of the community, social workers support community health workers to identify children with the highest risk of mortality—those who are severely acutely malnourished. The community health workers conduct home visits to see how caregivers are preparing enriched porridge for their moderately malnourished children, and encourage households to bring their children for monthly growth monitoring and promotion sessions at the social centers.

Hadiya explains how she likes to come to the social center to receive care that she knows is good for her child.

“I come here every week. This is my first child in ten years, and I want to protect her and keep her healthy,” she said.  

Hadiya attends weekly cooking demonstrations to learn about new ways to prepare enriched porridge using locally available foods that she can afford. She explains that she will continue to breastfeed throughout the night and day and offer porridge in the morning and evening. Several mothers explain that before they started coming to the social center, they gave their children water because they thought they were thirsty. In talking with social workers, they learned that giving only breastmilk frequently was the perfect nourishment for their children until six months of age.

Having scales, height boards, and mid-upper arm circumference tapes has helped the social workers to better monitor children’s growth over time and to identify when a child has faltering growth or is already malnourished.

“[Before receiving equipment], we would look at physical characteristics, like edema and loose skin, to decide if a child was suffering from [severe] malnutrition,” remarked one social worker.

Social workers at the Koumassi social center.

Another social worker explains that now during counseling sessions, she starts by looking at the child’s weight over time on the growth chart to determine if the child is growing well.

“When we see weights going up and down over time, we know there is something wrong. I ask what is going on: is your child sick, how do you feed, what do you feed?” she said.  

She asks the caregiver about feeding practices: whether the child younger than six months is being exclusively breastfed; about breastfeeding positions; and when the child is older than six months, whether the child is given thin porridge made of cereal flour and water.

“I explain that giving this thin porridge will only make them sicker. Depending on the mother’s responses, I advise her,” the social worker explained.   

After being trained on counseling caregivers about optimal feeding practices, the social workers feel more confident in their services.

“The training we received was very practical in that we learned to identify when a child wasn’t growing well and what to do about it. We learned about vitamins and what micronutrient deficiencies children are at risk of. I [now] counsel moms on choosing the salt with iodine in it, to keep oranges in the shade so the sun won’t destroy the vitamin C, and that palm oil is rich in vitamin A. We also learned to make thicker and enriched porridge by adding powdered milk or soy flour,” explained one social worker.

Another shares that “before [the training], we didn’t know we were making thin porridge and advised moms to start [breastfeeding] at four months.”

Now that the neighborhood is safe and the social center is running again, Hadiya says that she will continue to come to the social center to hear the various talks on family planning and nutrition, have her child weighed and immunized, and attend cooking demonstrations now that she has introduced solid food.

Sydney and his provincial health team identified a solution that could prevent illness and save lives: training health workers to support mothers on safer infant feeding practices at health care centers. Yet despite prioritizing the intervention in the province’s action plan, the objective went unmet year after year—mostly because of a lack of local trainers with expertise in infant and young child feeding. Sydney had been waiting for the Ministry of Health’s national trainers to make their way to the province, but they were always occupied working in other parts of the country.

Eastern Province Trainers, including Sydney (back, left), on a supervisory visit to Mwami Hospital in Eastern Province.

Finally, Sydney found an opportunity to move forward with his plan to offer HIV-positive moms the nutrition support they needed. In January 2009, with the help of the US Agency for International Development’s Infant & Young Child Nutrition (IYCN) Project, the Ministry of Health built a provincial team of ten trainers to lead nutrition training activities and follow up with health workers to ensure they are using their new skills. IYCN is providing assistance to update the curricula and materials for six-day trainers’ workshops, coordinating with provincial staff to supervise participants after training, and conducting exit interviews to learn about mothers’ views on the quality of infant feeding counseling provided by trainees.

Since the first training in February 2009, Eastern Province trainers have reached more than 135 nurses and other health care workers to improve critical counseling skills and nutrition expertise. Sydney is pleased with the result; now the province can proceed independently and quickly to meet the need for nutrition training for health providers.

Sydney, who is one of the province’s trainers, has seen dramatic changes in health worker practices first hand. Since a training workshop he conducted at one health facility, workers there have corrected harmful advice for mothers. Before the training, they commonly encouraged mothers to give infants water with sugar shortly after birth, causing a delay in initiation of breastfeeding and making them more vulnerable to infection, including HIV. Now, says Sydney, they offer accurate information, encouraging mothers to initiate exclusive breastfeeding immediately after birth.

According to Joseph Mudenda of the Ministry of Health’s Nutrition Division, creating provincial training teams is a sustainable approach that gives the provinces increased autonomy to carry out activities on their own.

“Now, the provinces are more in control of their resources. When they plan for activities, they will know they have what they need to get health workers trained,” said Joseph.

The Ministry of Health has noted that the approach in Eastern Province has saved costs and made it easier to follow up with health workers after training. As a result, the Ministry has started replicating the model in all of Zambia’s nine provinces.

Sydney continues to reach more health workers to improve their skills. His goal is to reach all eight districts in the province. He says the approach is helping to make a difference for mothers and children.  

Learn more about IYCN activities in Zambia. 

Photos: Aurelio Ayala III, Richard Lord, Nampo

Rose Mireille Exumé, IYCN Haiti Country Coordinator, leads an infant feeding training workshop for baby tent counselors from Project Concern on March 10, 2010.

“I am grateful that I can continue to assist mothers and babies with good nutrition under these difficult circumstances. I have hope that we can prevent malnutrition for many children,” said Rose Mireille.

Together with UNICEF and other partners, Rose Mireille is training emergency health workers to provide vital infant feeding counseling for new mothers as they strive to keep their babies healthy after the earthquake. The trained counselors offer support for mothers in baby tents located in refugee camps across the country, where more than a million people reside in makeshift living spaces made of sheet steel, plastic, or tarps. The baby tents are a safe and welcoming place for mothers to escape the stress of the camps and receive psychosocial support, health care, and infant and young child feeding counselling.

IYCN's Rose Mireille Exumé leads three counselors in a role play activity to discuss good attachment.

By helping to facilitate training workshops for nurses and other health workers from organizations like Save the Children, Action Against Hunger, and Project Concern International, Rose Mireille ensures that counsellors in the baby tents have the knowledge and skills they need to overcome barriers and challenges to good infant feeding after an emergency. Dispelling harmful misconceptions about breastfeeding is one of the greatest challenges for health workers, according to Rose Mireille. Although exclusive breastfeeding during the first six months of life protects against illness and improves survival during emergencies, many mothers believe that their milk is tainted or limited as a result of the stress they have endured, she said.  

During training workshops, Rose Mireille skilfully leads participants, like Solange Pierre and Edwine Charles, in practicing counselling skills, facilitating small group discussions, and demonstrating good breastfeeding techniques to help mothers overcome misconceptions and gain confidence in their ability to feed their children. Solange and Edwine—both nurses who have already received nutrition training—said the training from IYCN has increased their knowledge of infant feeding during emergency situations and improved their counselling skills.  

“With this training, I am better able to counsel mothers,” said Solange.

In this roleplay, a father doesn't want his wife to breastfeed and a community health worker shares the benefits of breastfeeding.

Rose Mireille has already trained more than 200 health workers in Port au Prince, Leogane, and Jacmel to meet the demand for more skilled counselors in baby tents, mobile clinics, and other locations. She is continuing to respond to requests for technical assistance to help a wide range of organizations offer appropriate infant feeding training for their workers.

As she continues to lead IYCN’s efforts to prevent malnutrition in Haiti, Rose Mireille also tends to the safety and well-being of her own family. She is thankful that her entire family, including her seven children, survived the disaster. Although their house has some cracks, they were able to stay in their home—sharing tents in their front yard with friends in need of shelter. While most of her children still wait for schools to re-open, she has encouraged them to volunteer in the camps to help other families who are not as fortunate.

“Focusing on helping others is helping us get through this,” said Rose Mireille.

Learn more about IYCN activities in Haiti. 

Nadine Boucher’s daughter, Jerika, 7 months old, is growing well, thanks to support from Solange Pierre and other counselors at the baby tent located in the Place Boyer Refugee Camp.

“I have less stress when I come to the tent; that’s good for my baby. I come to weigh her once a week. I like to see that she gains weight. It shows me the baby is healthy. That encourages me to keep up,” Nadine said.

Since the January 12 earthquake, life has been difficult. Nadine and her baby Jerika, a 7-month old girl, live with Nadine’s sister in one of the camp’s many makeshift spaces made of tarps. The two women can’t leave their temporary home at the same time because they fear their belongings will be stolen. Finding food has been difficult because tickets for donated food often run out too quickly. Nadine has been losing weight and sometimes fears that Jerika will also lose weight and become malnourished.

Nadine Boucher (center) takes refuge with other mothers in the baby tent at Place Boyer Refugee Camp.

Yet despite the challenges, Jerika has continued to gain weight and thrive, with the help of Solange Pierre and two other counselors at the baby tent. During frequent visits for counseling, Nadine learns about practicing good hygiene to prevent illness and how to make sure Jerika gets the most nutritious meals from what little food is available. After practicing exclusive breastfeeding for six months, Nadine has successfully continued to breastfeed while adding complementary foods once Jerika turned 6 months old in February.

Solange and her colleagues are continuing to give Nadine the encouragement she needs to nourish her baby and keep her healthy. Now, Nadine shares what she learned from the counselors with her family members and other mothers in the camp.

“As long as I live in this camp I will return [to the baby tent]. I stop by every day. I love to come here to talk to the counselors and the other mothers. Coming to the tent makes me feel better,” said Nadine.  

Learn more about IYCN activities in Haiti.

Photos: Aurelio Ayala III, Richard Lord, Nicole Raccine

Mothers review a poster on food groups, provided by the IYCN Project, during a nutrition discussion at a baby tent in the Place Boyer Refugee Camp in Pétion-Ville, Haiti.

At the Place Boyer Refugee Camp in Pétion-Ville, a suburb of Port au Prince, Solange Pierre, 35, welcomes four mothers-to-be into the baby tent. Inside, the safe, calm atmosphere is a welcome relief for Ketly, 21; Cherline, 24; Spina, 16; and Immacula, 18, who live among the 3,000 temporary residents at the camp, where life can be stressful and uncertain. On this hot, March day, Solange leads a discussion about good nutrition during pregnancy. She asks the expecting mothers to share their experiences feeding their babies and shows them a poster of food groups as they sit on the floor.

“The baby tent is a place for mothers to come when life is simply too much to handle. They meet other mothers who have lost important parts of their lives with the earthquake. They sit and talk, they share, and they encourage each other,” said Solange.

At a baby tent in the Place St. Pierre Refugee Camp in Pétion-Ville, Haiti, counselors regularly assist mother Mona to weigh her baby Jonalson, 3 months, to check his growth.

Shortly after the January 12 earthquake, Solange started working as a counselor and baby tent coordinator for Project Concern International. With more than ten years of experience as a nurse, she wanted to make a difference by supporting mothers and children in the camps. In a typical day, she leads discussion groups on different nutrition topics, weighs children to monitor their growth, offers counseling on infant feeding, and walks around the camp encouraging mothers to visit the baby tent.

In late January, she participated in an IYCN training workshop for emergency workers from Project Concern International to improve nutrition knowledge and counseling skills in light of the emergency. The training has helped her offer accurate nutrition information and effective counseling for mothers.

A mother and child at a baby tent in Port St. Marie I Refugee Camp in Port-au-Prince.

After the IYCN training, encouraging mothers to relactate (the practice of starting to breastfeed again after stopping) is a priority for her and other counselors. She has seen many mothers who have stopped breastfeeding after the earthquake in response to a widespread cultural belief that breastmilk goes bad after a mother suffers an emotional shock. She now spreads the word about relactation: it is beneficial for babies and it is possible to begin breastfeeding again even after stopping for a few months.

“There are several things I had not understood well that I now understand [after the IYCN training], she said. “Relactation is one of them. I did not know it could be done, and since the baby tent has started we have had four mothers who are now breastfeeding again.”

A counselor discusses breastfeeding experiences with mothers at the baby tent in Port St. Marie I.

Solange says that overcoming the misconceptions and barriers to good nutrition in the camps can be challenging, but her goal is to prevent malnutrition for all children.

“It can be done,” she asserts.  

Learn more about IYCN activities in Haiti.

A mother in Madagascar who receives nutrition support from the WFP.

But she believes the families she serves need more than food to prevent malnutrition. That is why the WFP team—located in the capital city of Antananarivo and in sub-offices around the country—collaborates with other organizations to make sure that food is part of an integrated effort to prevent malnutrition and improve health.

“Food is not the only solution to nutritional problems. We need to work with a range of partners who offer behavior change interventions, health systems strengthening, and capacity building in order to effectively reduce malnutrition,” she said.

But in a country where diverse aid organizations are working on a variety of nutrition and health activities, it has been difficult for implementers like Flora to identify potential partners working in different areas of the country. That’s where IYCN’s Gap Analysis of Nutrition Coverage in Madagascar came in. In 2008, IYCN conducted a survey of nutrition partners in Madagascar to understand the coverage of interventions, including essential nutrition actions and growth monitoring and promotion. The project used geographic information systems technology to map the results. In January 2009, IYCN published a report showing where different nutrition organizations were working, where interventions overlapped, and where there were gaps.

The results helped WFP and other organizations improve program planning, identify needs for nutrition interventions, and find new partners. After seeing the analysis, Flora and her team realized that their activities were not well linked to other existing nutrition programs. As a result, WFP has identified several new nutrition partners in the south of the country, where thousands of people are vulnerable to malnutrition as a result of a chronic drought. The analysis also helped the team plan more effectively so that their programs did not overlap with other interventions. In 2008, WFP started collaborating with the United Nations Population Fund on maternal and child health and nutrition activities in ten health centers in the drought-prone south.

“Since food is only a part of the effort to prevent malnutrition, IYCN’s analysis is helping WFP to identify health and nutrition partners in the most food-insecure areas,” said Flora.

After working in Madagascar for nearly two years, Flora sees the difference that food is making in the lives of mothers and children. She believes that combining food assistance with other interventions to prevent malnutrition and improve health will have a lasting impact.

View IYCN’s Gap Analysis of Nutrition Coverage in Madagascar.

Learn more about IYCN activities in Madagascar.

Patricia Nawa with two of her five children at the Kanyama Health Centre in Zambia.

When Patricia Nawa was pregnant with her fifth child, she tested positive for HIV. The 37-year-old mother in the urban Zambian township of Kanyama faced a frightening question that so many mothers-to-be in her community must confront every day: How do I protect my baby from the virus?

Patricia didn’t know that the wheels were already in motion to provide her with the information she needed to keep her baby healthy, beginning with a health worker named Victoria Ndhlovu. Nurse Victoria’s knowledge had already helped protect other infants from HIV, and if it reached Patricia soon enough, she too could shield her child from the epidemic.

A harmful choice

As a nurse manager at the bustling Kanyama Health Centre in Lusaka, Victoria has seen how misinformation about HIV prevention can put babies in harm’s way. The virus can be passed from a mother to her child through breastfeeding, yet in many situations, infants who are not fed breast milk suffer infections such as diarrhea and pneumonia and are prone to malnourishment—all life-threatening conditions.

Victoria Ndhlovu, a nurse manager at the Kanyama Health Centre in Lusaka, Zambia, displays her certificate after completing an IYCN training course.

To prevent HIV infection through breastfeeding, health providers in poor countries around the world often incorrectly counsel women like Patricia to stop breastfeeding if their babies test HIV negative at 6 weeks old, the earliest time for detecting HIV infection after delivery. But many families cannot meet the requirements needed to safely choose replacement feeding for their infants. The cost of formula can be prohibitively expensive, and countless families do not have access to the clean water or sanitary conditions they need to prepare formula without making their infants sick. Without realizing it, they may be endangering their babies by feeding them formula to avoid HIV.

Victoria and her health center colleagues had seen numerous babies facing possible irreversible damage caused by severe malnutrition. Their mothers, following inaccurate advice, had switched to replacement feeding, but their children became seriously ill from infections and malnutrition.

“We all felt hopeless and sad,” said Victoria. “We weren’t sure how to keep this from happening to more babies.”

View an interview with Nurse Victoria. She talks about how volunteers are supporting mothers to improve infant and young child feeding in the Kanyama community. [Posted December 2010]

Understanding risks

In November 2008, Victoria found her answer at a six-day workshop led by the Infant & Young Child Nutrition (IYCN) Project. The IYCN Project supports the Ministry of Health in training health care workers and community volunteers in Zambia about infant feeding. These workers and volunteers counsel new mothers about good feeding practices to ensure that HIV-positive women receive the best information to protect their babies’ health.

Victoria Ndholovu supervises volunteers as they assist mothers with good breastfeeding techniques.

Victoria knew that exclusive breastfeeding—breastfeeding without adding any other foods or fluids to a baby’s diet—is best for babies during their first six months of life. But like many other health providers at the workshop, she did not realize that replacement feeding increases an infant’s risk of death from common diseases. She also learned that giving other foods or fluids to breastfed infants younger than 6 months increases the risk of HIV infection compared to babies who are exclusively breastfed. According to World Health Organization guidelines, HIV-positive mothers should avoid breastfeeding only when replacement feeding is acceptable, feasible, affordable, sustainable, and safe.

Spreading the word, improving knowledge

After the training, Victoria was determined to prevent more babies from suffering. Working quickly, she pulled together 70 community volunteers from Kanyama Health Centre for a two-day orientation based on what she had learned at the IYCN workshop. She wanted to be sure the health center was well equipped to support mothers on good infant feeding practices. Health workers often don’t have time to counsel mothers, so volunteers fill that key role.

The participants gained critical knowledge about infant feeding and were able to sort through the mixed advice they had been giving to new mothers. Before the training, some volunteers confessed that they were not confident in how to best counsel HIV-positive mothers about feeding their infants. After the course, they were ready to offer mothers correct, consistent information.

Help for Patricia

Patricia Nawa, with baby Nawa, receives infant feeding support from a community volunteer at the Kanyama Health Centre in Zambia.

Patricia Nawa is one of these mothers. When Patricia tested positive for HIV with her child still in the womb, a trained community volunteer advised her on her best options for feeding her baby and protecting the infant from HIV. Heeding this advice, Patricia began exclusive breastfeeding when she gave birth to a healthy boy. And when the infant tested negative for HIV at 6 weeks old, Patricia continued to breastfeed exclusively.

When her baby, Nawa, reached 6 months of age, replacement feeding was still not acceptable, feasible, affordable, sustainable, and safe, so Patricia continued to breastfeed him as she introduced complementary foods. Now, nine months after baby Nawa’s birth, Patricia is transitioning her son to other milks—and watching him grow into a robust little boy, free, so far, from HIV.

“I am happy that I came for counseling,” she says. “I am confident that my child is growing well.”

It’s the kind of story Nurse Victoria is pleased to see, and one of many that Kanyama health staff can now proudly share. Victoria will continue to train health workers and volunteers to deliver accurate and consistent messages to mothers. Together, they are improving infant feeding support for Patricia and her baby, and for families throughout Kanyama.

Learn more about IYCN activities in Zambia.

Tsepo with his mother at the Litsoeneng Health Centre, April 2009.

But this wasn’t always the case for Tsepo. When he was 8 months old, Mabeata visited his home to monitor his growth and discovered that he wasn’t gaining weight at a normal rate. Immediately, she encouraged his mother, Malehloa, only 16 years old, to take him to the clinic to correct the problem. After participating in a training workshop conducted by the Infant & Young Child Nutrition (IYCN) Project, the community health worker knew that it was critical to send babies with growth problems to the clinic as soon as possible. She even walked with Malehloa and Tsepo from Khopolo to visit the clinic.

“I was very concerned about Tsepo. I wanted to be there to help Malehloa understand the problem and coordinate with the nurses to follow up after the visit,” Mabeata explained.

At the clinic, Adelina—one of a small staff that includes three nurses and two counselors—asked the young mother questions about how she was feeding Tsepo. Malehloa, who stopped going to school once she was pregnant, had practiced exclusive breastfeeding since Tsepo was born. As a result, he had hardly been sick during his first six months and he was growing normally.

The problem with his growth probably started after that. Malehloa didn’t know that Tsepo needed complementary foods (other foods and fluids) in addition to breast milk to keep him well nourished now that he was older than 6 months. 

Adelina, a nurse (right), and Mabeata (left) review Tsepo's growth chart together at the Litsoeneng Health Centre, April 2009.

To improve Tsepo’s nutrition, Adelina and Mabeata helped Malehloa identify foods she already had at home—like enriched porridge and fruits—that would be good for Tsepo. They encouraged her to continue to breastfeed in addition to feeding Tsepo enough nutritious complementary foods at the right frequency. To help him catch up on his growth as quickly as possible, Adelina gave Tsepo a nutritional supplement.

“I learned that breastfeeding alone does not satisfy the baby after six months, so I have to add other foods that are good for Tsepo,” said Malehloa.

Now, Mabeata makes frequent home visits to check Tsepo’s growth and ensure that Malehloa feeds him enriched porridge and other good foods several times a day. She smiles when she talks about how happy and healthy Tsepo is now. She has seen steady improvements in his growth.

“I am very proud. It gives me strength to see how Tsepo is growing,” she said.

Mabeata’s quick actions and persistent follow-up probably prevented Tsepo from becoming severely malnourished. In Lesotho, many babies, even those who have grown well for the first six months of life, do not receive adequate complementary foods—putting them at risk of malnutrition and making them more susceptible to severe childhood illnesses, stunted growth, developmental delays, and death. Volunteers like Mabeata are the critical link between communities and the life-saving prevention and treatment available at health facilities.

To prevent malnutrition, the IYCN Project is working to improve the links between health facilities and communities like Khopolo. IYCN provides infant and young child feeding training workshops for community health workers, emphasizing increased collaboration with health facilities. Since IYCN conducted a training workshop at the Litsoeneng Health Centre for Mabeata and 30 other community health workers—one for each village in the area—the clinic staff have seen an increase in referrals for growth-faltering from community health workers.

Mabeata, a community health worker, with Tsepo and his mother at the Litsoeneng Health Centre, April 2009.

Adelina believes that community health workers are vital to improving the health of mothers and children served by the clinic. She says it’s not always easy to get families to the facility. They often prefer to go to traditional healers in their villages or they do not have time to walk—sometimes more than six miles to the clinic

“We cannot afford to go house to house. If we need to get information to the villages, the community health workers are there on our behalf,” Adelina said.  

Mabeata has all of the qualities necessary to go door to door to teach mothers about good feeding practices. She is well respected, empathetic, and a responsible mother—that’s why everyone at a village council meeting pointed to her when the clinic needed a volunteer to promote good health in the village 19 years ago. Her advice goes a long way toward making sure children have a chance for a healthy life.

“Now I tell other moms about Tsepo’s story and how we helped him. I think it motivates them to improve feeding practices for their babies,” Mabeata said.

Learn more about IYCN activities in Lesotho.