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Madagascar: Helping partners address nutrition gaps

September 2009

For Flora Bertizzolo, 30, a health and nutrition program officer at the United Nations World Food Program (WFP), getting food to children in need in Madagascar is her first priority. She and her colleagues at the WFP office in Madagascar run a program that gets food assistance to more than 65,000 mothers and children in the most food-insecure areas of the country during the lean season.

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.

Zambia: Improving infant feeding to protect babies from HIV

August 2009

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.”

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.

Lesotho: Connecting communities with health care facilities
to prevent malnutrition

July 2009

At the Litsoeneng Health Centre, a small clinic in a remote area of Lesotho, Adelina, 40, a nurse, and Mabeata, 62, a community health worker in the nearby village of Khopolo, proudly tell the story of Tsepo. He’s a healthy 17-month-old boy who is learning how to walk and loves playing with other children. Mabeata and Adelina meet monthly to monitor his growth and make sure he stays healthy.  

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.  

To improve Tsepo’s nutrition, Adelina and Mabeata helped Malehloa identify foods

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

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. 

Lesotho: Helping babies grow healthy and strong

January 2009

In a small, rural village in Lesotho, Mamorena Namane, 30, proudly shows off her big baby boy outside her modest three-room house. With his chubby legs and broad cheeks, the baby—her second child—is a picture of health. And Mamorena knows why: she has faithfully breastfed the child since he was born.

Mamorena and her son in April 2009.

But health didn’t come easily to her first child. At the urging of her husband’s parents, Mamorena fed the baby only water for the first week of his life until his umbilical cord fell off, a common cultural practice. Eventually she added breastmilk and soft porridge to his diet, which made the infant ill and susceptible to life-threatening infections.

It’s a common tale throughout Lesotho, where mothers frequently delay breastfeeding and nearly half of infants receive liquid and solid foods prematurely. A diet of food other than breastmilk can put babies at risk of illness, stunted growth, and death. A mother’s milk provides infants with the critical nutrients, antibodies, and fluids they need to stay healthy; international recommendations advise beginning breastfeeding in the first hour after a baby’s birth.

Through the Infant and Young Child Nutrition Project, our partners are boosting awareness among families and communities in Lesotho about healthy and safe feeding practices for young children. Because malnutrition contributes to more than a third of child deaths in poor countries, we focus on improving nutrition during the critical period from a mother’s pregnancy until her child is two years old. We train community health workers to support mothers in optimal and safe feeding practices, and mothers learn how to keep their young children healthy and well nourished.

Exclusive breastfeeding helped Mamorena's baby grow healthy and strong.

Mamorena learned about breastfeeding’s value when, inspired by her mother, she trained as a community health worker while pregnant with her second child. The project's training showed her how to support mothers in her community on good breastfeeding practices. She shared the information with her family, and when Mamorena and her husband welcomed their second son, her in-laws encouraged her to start breastfeeding immediately.

Now, Mamorena describes how strong and healthy her younger boy is and how her entire family has supported optimal feeding practices for her baby. She shares what she learned with people throughout her village to help other new mothers overcome cultural barriers to early and exclusive breastfeeding—and to be sure every baby has a chance to grow up healthy and strong.

Learn more about IYCN activities in Lesotho. 

Photos: Aurelio Ayala III, Richard Lord, World Food Program, Josephine Nyambe, Agnes Bwalya, Christine Demmelmaier, , Makatleho Masoabi, Ashely Hughes