Feeding the unborn babies

By Severin Kabakama

Dr Severin Kabakama (MD Dar) is Assistant Project Officer (Early Child Development) in the Western Tanzania Refugee Program, UNICEF Kasulu Field Office. He has worked for twelve years as medical officer in Tanzania (of which 5 year have been spent with the Rwandese, Congolese and Burundian refugee programs in Western Tanzania)

In 1998, UNICEF initiated a supplementary feeding program for pregnant women in the Kigoma/Kagera refugee program of Western Tanzania. The programme which is still ongoing was implemented in order to reduce the prevalence of low birth weight and improve pregnancy outcome. Prevalence of low birth weight in the camps at the start of the intervention was 30% (Low Birth Weight is defined as weighing less than 2500g at birth). The main causes of LBW are malaria, HIV infection, worm infestation and lack of adequate nutrient intake during pregnancy. Women enrolled in the programme are given a dry takehome ration from the second trimester (from 16 weeks gestation age) to delivery. Approximately 30,000 pregnant women in eleven refugee camps are involved in the intervention.

The World Food Program (WFP) provides the supplementary ration while UNICEF through operational partnership with implementing agencies, closely monitors the implementation of the programmes and its outcome.

Ration size and quality

The daily ration comprises 200g of CSB (Corn Soya Blend), 20g of vegetable oil and 20g of sugar per pregnant woman providing a total of 1018 Kcal (38g of protein). This is distributed every two weeks at the nutrition supplementation Unit. In total it is assumed that a pregnant woman receives about 3180 Kcal per person per day if the general ration is included (2100 Kcal¹ per person per day from general distribution).

The weighing, mixing and distribution of the supplement is normally carried out by the pregnant women themselves, who have been recruited onto the programme through their attendance at antenatal clinics where verification of gestation age is necessary.

The distribution process

Names are called out by a nutrition attendant with each beneficiary receiving a "premix" for 14 days - about 3.36Kg. As large numbers are always involved (approximately 400 for a camp of 38,000 refugees), a roster for each block/village in the camp is used to avoid congestion and time wasting. Nutritional education (emphasising the nutritional value of the supplementary ration) and cooking demonstrations are frequently conducted at the distribution site.

Main findings and lessons learnt

The programme has contributed to a reduction in low birth weight in the camps. Prevalence of LBW has decreased from 30% to 8.5 - 10% in different camps. These results are similar to a study in Gambia in 1997 where a 50% reduction in LBW was observed after supplementation with groundnut-based high energy biscuits (providing 1000 kcal per person per day).

The success of the program is mainly due to close cooperation between the pregnant women themselves, the service providers at the antenatal clinic and the personnel at the supplementary feeding units.

Added impacts and benefits of the programme

• the women organise themselves and take a strong leadership role in nutritional aspects of the programme.
• an improved attendance of pregnant women at the antenatal clinics with coverage reaching almost 100%.
• an increased number of pregnant women receiving malaria prophylaxis, de-worming and iron supplementation (at the ante-natal clinic).
• an earlier enrolment in the ante-natal programme resulting in earlier identification of pregnancy risk factors.

Programme Constraints

• It has been difficult to evaluate programme effectiveness as allocation of a dry take home ration has meant that actual consumption by intended beneficiaries is uncertain, i.e. some of the ration may be consumed by other household members.
• The effectiveness of the programme has been compromised due to interruptions in the general ration food pipeline (i.e. to be optimally effective supplementary feeding programmes need to supplement an adequate general ration). For example, as of July 2000, there has been a 40% cut in the general ration. This was the first time the general ration supply had been compromised during the programme. While the supplementary feeding of pregnant women has continued during this period there has been a drop in overall intake from 3180 Kcal to 2522 Kcal per pregnant women per day (a drop of about 20%).

¹Comprising of 360g maize meal/grain (410g), 120g pulses, 40g CSB and 20g vegetable oil per person per day (pppd). An additional 50 g of maize is provided to offset the milling costs and wastage totalling 410g pppd.