Optimal Infant and Young Child Feeding by All: the Baby Friendly Community Initiative in

1. Optimal Infant and Young Child Feeding by All: the Baby Friendly Community Initiative in The Gambia

2. The National Nutrition Agency of GAMBIA (NaNA) used the Triple A approach to develop its strategic plan to improving IYCF Assessment: • Most deliveries occurred at home • Little contact with formal health system • Feeding practices heavily influenced by traditional • beliefs Analysis: • Integrated, community-based • strategy needed • Make linkages between maternal and infant nutrition and • a clean environment • Using Step 10 of BFHI, decision to include men in the • village support group (VSG), so that nutrition becomes “everyone’s • business”. • Picture: Mary Kroeger, CNM, MPH,Birthing Practices and their Influence on Breastfeeding Success: • Review of the Evidence And Recommendations for Developing and Developed Countries

3. Gambia: Baby Friendly Community Initiative (1995+) THE 10 STEPS TO SUCCESSFUL INFANT FEEDING Every …village… should have an enabling environment for mothers to practice optimal breastfeeding

4. A Village Support Group, trained in infant feeding: • Informs and advises all • pregnant and nursing women, • including their spouses, • on the importance of an • adequate maternal diet • using locally available • foods, including the • benefits to both maternal • and infant health. 2.Informs all pregnant women and their spouses about the benefits of breastmilk, including colostrum.

5. 3. Advises and encourages mothers to initiate breastfeeding within an hour after birth and not give any pre-lacteal feeds, unless advised by medical personnel. 4. Informs both mothers and fathers about the benefits of exclusive breastfeeding and encourages all mothers of healthy newborns to breastfeed exclusively for six months.

6. 5. Informs both mothers and fathers about the hazards and costs of bottle-feeding, the use of infant formula, and the use of pacifiers (comforters). 6.Ensures that orphans receive breastmilk by encouraging the traditional practice of wet nursing for babies who have lost their mothers at birth (in low prevalence HIV settings only)

7. 7. Advises and encourages mothers to introduce locally available weaning foods when the infant is approximately 6 months of age. 8. Advises and encourages all mothers and caregivers on the use of fermented cereal in the preparation of infant weaning foods, including advice on its benefits.

8. 9. Teaches all mothers and caregivers about the benefits of adequate personal hygiene and environmental sanitation to infant health, including the basic principles for the preparation of safe food for infants and young children.

9. 10. Encourages mothers to support each other in optimal breastfeeding practices by forming informal support groups for infant feeding.

10. Respect for the culture, and good community entry are key to mobilization In Sukota, the combination of these groups have implemented a community “law” that gives women 9 months of “maternity leave” from field work Informal Support Group Village Support Group Village Development Council

11. RESULTS

12. Initiation of Breastfeeding An Evaluation took place 10 months after the initiation of the Intervention in 12 pilot communities • 100% initiated • breastfeeding • within 24 • hours of • delivery • 36% of the women initiated BF immediately • 88% within the first hour. • 97% initiated by the second hour. Jallow . I. 2002. THE BABY FRIENDLY COMMUNITY INITIATIVE – AN EXPANDED VISION FOR INTEGRATED EARLY CHILDHOOD DEVELOPMENT IN THE GAMBIA.Banjul

13. Introduction of other foods and liquids at baseline and after two years of intervention 1995 (n=222) 1997(n=299)

14. Growth in Village Support Groups and VSG Members

15. BFCI “rescued” the “Maaka”,a traditional rest house, to encourage mother-baby togetherness when mothers return to fieldwork.Fathers build this. Sukota is beginning to teach other communities about Their maternity leave from fieldwork from third trimester of pregnancy until their baby is six-months old.

16. As part of its commitment to safe, nutritious foods for mothers, infants and young children, the BFCI now includes a dietary diversification plan This includes assisting communities to establish community gardens with micro-nutrient rich foods for local consumption. NaNA provides training and seeds to Agricultural extension workers when communities commit to organic, consumption-based gardens and a community sustainability fund.

17. HOW DID THEY DO IT?

18. PROCESS IN THE COMMUNITY 1st: Get everyone in the community involved! . Meet with the decision-makers and discuss the issues Head of the VDC accepting a symbolic gift of kola nuts “You may need to meet three times for them to understand,but when they do, they will find people.”

19. VSG MEMBERS • VILLAGE HEALTH WORKER • TBA • 5 ELECTED • MEMBERS OBLIGATORY: 2 MEN

20. THE BFCI TRAINING OF TRAINERS Content of Training Program for Community Health Nurses and DHT Staff WHO/UNICEF Breastfeeding Training Manual (1993) and Wellstart International Breastfeeding Basics • BREASTFEEDING CONDITIONS/PROBLEMS AND SOLUTIONS • BREASTFEEDING AND FAMILY PLANNING • THE GAMBIA CODE OF MARKETING OF BREAST MILK SUBSTITUTES • BREASTFEEDING TWINS, LOW BIRTH WEIGHT AND SICK BABIES • HOW TO FEED A BABY WHO CANNOT BREASTFEED • BREASTFEEDING AND THE WORKING MOTHER • COMPLEMENTARY FEEDING • MATERNAL NUTRITION • FACTORS INFLUENCING BREASTFEEDING • INCREASING BREAST MILK, RELACTATION AND EXPRESSION OF BREAST MILK • ENVIRONMENTAL SANITATION/PERSONAL HYGIENE • GROWTH MONITORING • PRACTICAL SESSIONS • BREASTFEEDING AND A SICK MOTHER • NaNA gave a TOT to CHN, who in-turn carried out a TOT for VSG. • The first training was for 42 people (6 groups of 7), with a CHN • responsible for each group. • Resource persons, provided by NaNA, rotated around the groups.

21. LESSONS LEARNED Trained VSG shared the following information: • Caring for children has become everyone’s business, • not just a woman’s business. • When the community first received the information, they all sat down, • even the children, and discussed it. • A “law” was made that stated all women should be relieved of heavy work for six months after giving birth. • Since the program began, • diarrhea and the common cold have • been reduced among newborns.

22. LL:Changes in supportive behavior: • Men had to assist women with what to eat, as soon as they knew they were pregnant (TBA informs the VSG) • Men needed to make sure that • women ate meat and fish or green vegetables and ground nuts if there was not enough money, • Men also needed to ensure their wives went to the ANC when referred by the TBA

23. Table 2. LL:RESPECTING COMMMUNITY CULTURE AT COMMUNITY ENTRY: • Identify an entry point in the community (in this case the • Traditional Birth Attendant and the Village Health Worker) • They present the team formally to the Village Leaders/Elders • Prayers are held then a symbolic gift is donated to the community • through the Elders by the central team (in this case, colanuts) • Following a brief discussion with the elders, villagers are invited to join the meeting by the elders • The team is introduced to the villagers, the gift displayed • and then put aside for later • The agenda is stated and the meeting starts • The meeting ends with prayers

24. LL in the process evaluation: Inclusion of men in support groups: key to father and Grandfather- to-father and mother support   • The inclusion of men in nutrition intervention programmes is crucial not only to ensuring success, but sustainability also. • Empowering both men and women with the same knowledge gave greater dividends in terms of improved and sustained • infant feeding practices than if only the women had been empowered. • Men are interested in the nutritional well-being of their wives and children and should be included in nutrition intervention programmes.

25. LL: process evaluation: • People felt there was unity in the community • as a result of shared involvement in and • commitment to the project. • The communities were able to accomplish common • goals and tasks such as having community health • accessible in the community itself and improving • village sanitation. • Dissemination strategy was effective as others outside • The support groups had received the information. • In 1995, no one believed exclusive breastfeeding was • possible or desirable. Today, when entering a community, • there are no arguments.

26. LL:The type of VSG training • The training should also be motivating and not simply equip participants with theoretical knowledge. • The training equipped support groups with practical skills to solve simple problems such as sore nipples and engorged breasts • Practical knowledge increased their credibility • in the communities. • Participants had the opportunity to question, argue and discuss the issues, and just not passively accept what they were being taught. They had the opportunity to understand bio-medical concepts against their traditional background. • The original VSG members now consider themselves as human resources for training their peers in other communities.

27. LL: The creativity of information dissemination • Feedback to the communities at all stages of an intervention is instrumental to keeping up motivation, as is regular monitoring and supervision • Dissemination of information by members of a community to their peers, including follow-up to encourage compliance, is very effective in influencing community behaviour. Modelling, peer support, practical information and skills, and singing • Information dissemination through home visits and gatherings, such as village meetings and ceremonies. • TBAs present information during a home delivery and encourage and assist new mothers to initiate breastfeeding immediately after delivery. .

28. The creativity of information dissemination… • Singing and dancing is very much part of daily life in traditional rural communities, • The “10 steps” were translated and made into songs to sing at every available opportunity. • Songs included: • Adequate maternal diets; • Appropriate local foods, ie millet and green leafy vegetables; • Benefits of early initiation of breastfeeding to mothers and infants • Benefits of colostrum; • Definition of exclusive breastfeeding • and its protective role; • Adequate environmental sanitation • and personal hygiene. The whole community, including children, can sing these songs and remember the messages.

29. LL:5 Interaction with other Programs: Support Group members successfully advocated for and Incorporated the following into their communities with training: Environmental Sanitation Community Clean-up AIDS Risk reduction information EPI Malaria control And bed-net dipping MCH ANC Supplements during pregnancy Growth monitoring

30. “Susundiri Timaringo” Perfect Breastfeeding