IYCF in Zimbabwe

By Fistum Assefa

Fitsum Assefa is currently working as UNICEF Nutrition Manger, in Zimbabwe.

Zimbabwe has a high prevalence of stunting (32%) and low prevalence of wasting/acute malnutrition (3%) (DHS 2011). The trend in stunting suggests deterioration as compared to the early 90s, while the prevalence of acute malnutrition remained the same or slightly improved. Of note, the national average masks the prevailing disparities across geographic regions and wealth status, for example, there are districts with stunting prevalence of over 40% and both stunting and acute malnutrition are much higher among the poorest segment of the population as compared to the wealthiest.

CMAM services in Zimbabwe were initiated as of 2006, with rapid expansion from 2009 (see Figure 1). Due to the low acute malnutrition context and existing health care infrastructure¹ it has been possible to integrate the management of severe acute malnutrition (SAM) in Zimbabwe with the existing curative and preventive health care delivery system. Currently over 70% of the 1600 health facilities provide inpatient and outpatient SAM treatment on a routine basis.

To help fill an existing gap, training materials to support integration of infant and young child feeding (IYCF) in CMAM were developed at international level in 2009² and piloted in Zimbabwe (2010), However, this approach has failed to show any impact on prevailing IYCF practices. This is partly related to the fact that it is unrealistic to expect a rare situation (<0.5% SAM) to be an entry point to a universal problem (>90% of infants and young children with poor IYCF practices). Also, CMAM offers no contact with newborns and generally speaking, with infants in the first six months of life. On the contrary, we find our cIYCF initiative as a key opportunity to ensure access and compliance to other health and nutrition services, including treatment of SAM.

The cIYCF assessment and counselling service initiated in Zimbabwe is one of the many solutions we are pursuing simultaneously to ensure optimal IYCF is practiced. These include improving policy, guidelines and tools for use at different levels of management and service delivery, addressing the socio-culturaleconomic barriers that take account of the role and influence of others/gatekeepers within the family/community (grandmothers, elders, fathers), addressing the health workers’ and managers’ knowledge and skill gaps, and advocating for longer term commitment, integration and resources for IYCF programming.

The missing elements in previous IYCF promotion efforts (e.g. through world breastfeeding week (WBW) communications, and the WHO 40 hours training to master trainers, facilitators and health workers) is lack of vision and accountability mechanisms that link the training to provision of counselling service and changes in IYCF practices. A typical ‘cascade’ approach in IYCF training takes 8 – 10 people at a time as ‘master trainers’ (who are not always trained through a competency based approach), who in turn train ‘facilitators’ (training usually undertaken in a hotel or a training facility, mainly theoretical, with little skills based training), who then are expected to further train the frontline facility staff and VHWs. Often when country training action plans are drafted, after regional or national TOT, the cost and time implications are unrealistically huge that discourage national decision makers and donors.

Because of resource and logistical challenges, training of frontline workers typically lacks quality and coverage. Such an approach results in a few ‘trained’ health workers spread thinly throughout the country. This means that those who are not trained or are trained using earlier guidelines outweigh those trained using more recent guidelines. The few newly trained staff often cannot exhort significant influence and their skills, knowledge and passion slowly dies off.

Zimbabwe has attempted to address this by finding a means for efficient and rapid expansion of knowledge, skills and tools covering a whole district at a time (within a week) and attaching trained people to real cases that they follow, starting with pregnancy/early infancy to about two years of life. In our approach, quality of training is emphasized and the trainer/trainee ratio is 1:4/5, as per evidence of the ideal ratio that can facilitate skills based training. Valuable tools are included in the training package for pre-post assessment that determine improvement in knowledge and skills. An example of the impact of training in one location is shown in Figure 2.

To date, 14 districts have been covered by this initiative, resulting in over 2,000 CCs and over 20,000 mothers/infants accessing counselling services on an on-going basis (1CC:10 mother/infant pairs). In addition, these 20,000 women take part in supporting other mothers and access peer support themselves, as every trained health worker facilitates the establishment of at least one mother-to-mother support group in their village.

During the trainings and supportive supervision visits, it is emphasised that assessment and counselling on IYCF is one of the key interventions towards addressing undernutrition in Zimbabwe and that the role of VHWs is pivotal to the current momentum in the country to address stunting as a matter of urgency (e.g. SUN movement, National Food and Nutrition Security Policy, etc.). We encourage a sense of accountability by each VHW towards ensuring optimal IYCF practices and to contribute to further understanding of barriers and facilitation of IYCF practices in their catchment community. Accountability is increased through location training reports that record who has trained who, the contact details of trained VHWs (including cell phone numbers where available) and who is following up which infant/mother pair. This will allow determination of any pattern of training and service provision outcome that can be explained by quality of training and support.

So far, the VHWs appear motivated and inspired to identify pregnant mothers from the early days of pregnancy (which is also required by other initiatives such as Maternal Mortality Reduction, PMTCT³, etc.) and provide IYCF counselling. They are also motivated to keep a record of how feeding practices are evolving with each infant/child over time. This can easily be linked to nutritional outcomes, given the demand for a growth monitoring and promotion service in Zimbabwe. Such a system of ongoing identification, assessment and counselling of mothers will serve as an opportunity to promote use and compliance of other health and nutrition services and serve as a backbone to build on additional interventions in IYCF, such as home fortification of food. This in turn can improve the demand and effectiveness of community level IYCF counselling services.

Zimbabwe hopes to share experiences in relation to results of this initiative on IYCF practices and nutritional outcomes in future issues of Field Exchange.

For more information, contact: Fitsum Assefa, email:fassefa@unicef.org

¹Though weakened by the recent crisis, it is in the process of recovery/being rebuilt stronger.

²Integration of IYCF support into CMAM, Oct 2009. ENN, IFE Core Group, Nutrition Policy Practice. Funded by the Global Nutrition Cluster (IASC).

³Prevention of Mother to Child Transmission of HIV