Frontline experiences of Community Infant and Young Child Feeding in Zimbabwe

By Wisdom G. Dube, Thokozile Ncube and Paul Musarurwa

Wisdom G. Dube is the Gokwe North district nutritionist, Ministry of Health and Child Welfare (MOHCW), Zimbabwe.

Thokozile Ncube is the UNICEF Nutrition Officer and one of the Master Trainers for community infant and young child feeding (cIYCF) trainings in Zimbabwe.

Paul Musarurwa, is a district nutritionist for MOHCW in Goromonzi district. He took part in the cIYCF training in Gokwe North district as a facilitator and was a Team Leader in one of the training sites.

The authors acknowledge the leadership of the Ministry of Health and Child Welfare, Department of Nutrition, for championing expansion of IYCF services in Zimbabwe. We would like to specifically acknowledge the work and support of Mrs. Ancikaria Chigumira (Deputy Director of Nutrition), Zephania Gomora, Provincial Nutritionist for Manicaland and Miriam Banda, Nutrition Intervention Manager. The authors also gratefully acknowledge the work of Mary Lung’aho and Maryanne Stone Jimenez (master trainers) and the facilitators in the Gokwe North training (see table of names at the end of the article). Finally, many thanks goes to all the trained community IYCF counsellors for their taking part in the training and the Gokwe North district health executive team for their support during the training.

This article shares the perspective of three individuals in Zimbabwe, directly involved in rollout of community based support to infant and young child feeding (cIYCF). The content was captured in an exchange between the authors during training between 10-14th of October, 2011 in Gokwe North, one of the districts in Zimbabwe. A postscript by Fitsum Assefa (UNICEF Zimbabwe) provides some context to the cIYCF approach in Zimbabwe.

Background to IYCF in Zimbabwe

Volunteer Health Workers and facilitators at Svisivi, Gokwe South

Undernutrition is widespread in Zimbabwe, with 1 in every 3 children being stunted. Despite subscribing to the Global Infant and Young Child Strategy¹ since 1991, being a ‘breastfeeding nation’ with 77% of infants breastfed at least until their first birthday (mean duration of breastfeeding 18 months), and years of effort to expand infant and young child feeding (IYCF) interventions (e.g. BFHI², training of health workers on IYCF, integration of IYCF in CMAM etc.), key IYCF practices in Zimbabwe remain very poor and unchanged.

Only six per cent of Zimbabwean infants under the age of 6 months are exclusively breastfed. Nearly one in three children (27 per cent) receive soft, semi-solid, or solid foods before the age of 3 months, and more than half (52 per cent) receive soft, semi-solid, or solid foods before the age of 6 months³. Less than one in ten children (8 per cent) receive a minimum acceptable diet, and very few regularly receive eggs, meat, legumes, or fruits and vegetables, owing to economic constraints but also strong food taboos. Seventy-five per cent of Zimbabwean infants are reported to initiate breastfeeding within one hour after birth, however, qualitative studies reveal widespread use of pre-lacteal feeds and discarding of colostrum (the first breastmilk produced after birth). Considering the evidence that support for optimal IYCF practices remains the highest impact intervention towards ensuring survival, growth and development of children, improving the IYCF practices of mothers, infants and young children remains one of the key priorities for Zimbabwe.

Motivation behind community infant and young child feeding (cIYCF) innovation in Zimbabwe

In Zimbabwe, the need to build the capacity of Village Health Workers (VHWs) to support mothers and caregivers on optimal infant feeding practices and to refer issues they cannot handle to the health institutions was apparent. Hundreds of health workers at different institutions in the country have been trained in IYCF counselling using the WHO 40 hour training manual since 1991. However, the impact of the training has not been felt, as evidenced by the low rates of exclusive breastfeeding in the country (32%) that has not changed over the past two decades (DHS 2011⁴). When the UNICEF community IYCF counselling package was introduced in 2011 (see Box 1) , Zimbabwe had already identified the need and was ready to strengthen and scale up effective IYCF counselling in the community.

We believe that the provision of skilled IYCF counselling services at community level, where trained VHWs have direct contact with mothers, their infants/children and broader families at large, can contribute significantly to improving IYCF practices and the reduction of chronic undernutrition. For many years, IYCF initiatives in Zimbabwe have concentrated on training health workers. This assumes IYCF counselling is mainly provided at health institutions. However in reality, health workers are very busy and do not have enough time to give adequate attention and time (especially considering the recent economic and social crisis that has resulted in severe understaffing of the health system). At a health facility, IYCF ‘talks’, given as part of health talks, are mostly limited to informing mothers of the benefits of breastfeeding rather than listening and counselling based on an individual mother’s condition. Such an approach only reaches those who are accessing health services because of scheduled services (e.g. antenatal care (ANC) and immunisation) or due to illness and does not reach those who are not able/have no need to access these services. In addition, such talks miss critical contact times to assess, counsel and influence IYCF practices in a proactive and sustained manner. It is also worth noting that while the social and cultural determinants of IYCF are significant, the approach of health education at a facility focuses on the mother, who does not have the sole responsibility or control over deciding IYCF practices.

While the role of VHWs in Zimbabwe includes communicating on all aspects of health, including nutrition, to date there has been very limited IYCF included in their training and job aids. Thus VHWs have not been enabled to provide an effective IYCF assessment and counselling service.

cIYCF strategy

The cIYCF strategy is to ensure that all mothers and caregivers of babies aged 0 to 24 months of age in Zimbabwe have access to skilled IYCF assessment and counselling within the communities they live in. An individual VHW covers about 100 households and knows the population in his/her catchment and their various needs very well.

While we appreciated the approach and materials of the UNICEF community IYCF package, we were concerned by the typical cascade approach of training⁶ that needs a lot of time and money to reach every health worker. Scale and speed of expanding this training and demonstrating results at scale were at the centre of discussions from the outset of starting the cIYCF initiative in Zimbabwe.

Considering various factors and opportunities, including funding, the national IYCF Technical Working Group (IYCF TWG) endorsed that at least 150 community counsellors (CC) were trained in each district (70 - 100% of VHW in a district), within the shortest period possible - one week. The TWG developed a plan on how to achieve this. The 150 CCs were divided into six groups of 25. Each group of 25 CCs was allocated four facilitators/ master trainers from the national pool along with two overall organizers/managers. In order to allow ‘hands on’ practice/skills with cases, the trainings were conducted at a health centre/close to the community. This approach differs from previous practice that involved conducting such trainings in hotels or conference centres, an approach that was ineffective and costly. As well as ensuring coverage, this standardised training of at least 150 CCs per district in a week forms a critical mass of health workers with updated knowledge and skills and a movement towards changing IYCF practices. Furthermore, the trained CCs are required to identify and attach to 5 - 10 pregnant women or infant-mother pairs to continue practicing/perfecting their assessment and counselling skills, as well as start/continue providing a counselling service.

Cascade of cIYCF capacity development

The IYCF TWG was formed in February 2011 to review and initiate the process of adapting the UNICEF community IYCF package to Zimbabwe. An official from the Ministry of Health and Child Welfare and one from UNICEF participated in the Regional Master Training of Trainers (TOT) on cIYCF held in Nairobi, Kenya in March 2011. An action plan for Zimbabwe was developed at the regional training and the plan was endorsed by the IYCF TWG in April 2011. Since then, two national training of trainers (TOTs) have been held, generating 57 facilitators to scale up the community level trainings.

Zimbabwe was fortunate to host the second regional/ESARO TOT and managed to train a further 12 national facilitators. The regional training was followed immediately by modeling the training of CCs towards provision of skilled community IYCF counselling services in one district of Zimbabwe (Gokwe South) in July 2011. The district training was observed and supported by two international IYCF experts who had played a key role in the development and dissemination of the UNICEF community IYCF package and who had led the regional TOT. A total of 84 CCs resulted from the initial community level training, who were each attached to ten pregnant women and/or infantmother pairs. The one week training of 84 CCs therefore resulted in 840 women accessing skilled counselling services. This model is now being used to roll out the provision of skilled community counselling to every district in the country.

Rollout of cIYCF in Zimbabwe

A total of 12 districts were trained between August and December 2011. From the 12 districts, close to 2,000 VHWs were trained to support an initial 20,000 women from pregnancy to 24 months of lactation. Each of the trained VHWs also initiates and facilitates at least one mother support group in the community, to allow women to share experiences and support each other with optimal IYCF practices. To ensure adequate support supervision for the trained CCs, in every district where training is done, VHW trainers and one nurse from every health institution is also trained and equipped with a check list for support supervision. CCs refer mothers with complications they cannot handle to the local health centre and the health centre staff likewise refer mothers who need community support to the community counsellors. The programme is showing some promising results and there are requests to roll it out in the remaining 50 districts in 2012, funds permitting.

Follow up of cIYCF

A supportive supervision and monitoring system is currently being developed. A simple register/notebook, prepared with and for use by trained CCs, lists all pregnant mothers and infants/children aged 0 - 24 months. It documents not only IYCF practices and challenges but also other key interventions such as maternal iron/folate supplementation and compliance. VHWs have monthly meetings with health centre staff and are expected to submit monthly reports on the programme and discuss any difficult issues at the monthly meetings. Already, through these interactions, health centre staff, such as nurses, are recognising that the VHWs have greater knowledge and skills on optimal IYCF counselling than they do. As a result, they are requesting relevant training and support to enable them to effectively support and supervise the VHWs.

Experiences so far

The facilitators, who are a mixture of nutritionists, nurse midwives and tutors, are very committed and hard working. In all districts that have undergone training, enthusiastic VHWs are keen to learn new skills and greatly appreciate the training package. They enjoy using the counselling cards and feel they have been lacking this kind of material to do their work effectively. The trained CCs are challenged to ‘adopt’ at least 10 pregnant women during/right after their training, register them and follow them up for about 2 years. With more experience and newer pregnancies, this number per VHW will grow.

The idea is to have a simple mechanism that will allow documentation of infant feeding practices of children from birth until 24 months old, while providing timely support and counselling.

VHWs are expected to follow up various health services including maternal, newborn, expanded programme on immunisation (EPI), HIV, and conduct frequent visits to households in their catchment areas. Follow up visits will also include nutrition screening (mid upper arm circumference). The provision of good IYCF assessment and counselling skills will improve the efficiency and credibility of the VHWs as they address critical issues of various households. In addition, the peer support groups that each VHW is expected to facilitate will further contribute to addressing the challenges of mothers and families in ensuring optimal IYCF practices.

"Even as a male VHW I am now able to support mothers with positioning and attachment using t he pictorial counseling cards. The pictures and the messages that go with them are so clear that supporting mothers has been made much clearer." The VHW also commented that he had problems counseling on giving a diversified diet, but now with the pictorial food groups, he is able to discuss and help mothers identify what foods to mix together to come up with a "4 star diet."
Noel Nkomo, VHW, Gokwe North

cIYCF target

This cIYCF counselling initiative aims to improve IYCF practices, particularly the exclusive breastfeeding rate and the quality and timeliness of complementary food introduction. By doing so, it aims for a reduction in the levels of stunting that is unacceptably high in Zimbabwe. The programme will also ensure that children with acute malnutrition are quickly identified and referred to health facilities for management. This initiative will explore this by investigating nutritional outcome indicators by IYCF services received and actual practice. We look forward to sharing future experiences and outcomes of cIYCF with the Field Exchange readership.

For further information, contact: Thoko Ncube, email: tncube@unicef.org and Wisdom G. Dube, email: 23760478@nwu.ac.za (currently with the Centre of Excellence for Nutrition, Potchefstroom)

¹A national commitment/cabinet decision for improving food and nutrition security in Zimbabwe and a response to the call by the Convention of the Right of the Child 1990, of which Zimbabwe is signatory

²Baby Friendly Hospital Initiative

³Available from http://www.measuredhs.com

⁴However, giving oil for infants is widely practiced in Zimbabwe, and survey conducted in 2010 that probed on giving oil has shown only 5.8% EBF, majorly explained by the addition of oil in the analysis.

⁵Available at http://www.unicef.org/nutrition/index_58362.html

⁶For an example of cascade training in practice, see: Fitsum Assefa, Sri Sukotjo (Ninik), Anna Winoto and David Hipgrave (2008). Increased diarrhoea following infant formula distribution in 2006 earthquake response in Indonesia: evidence and actions. Field Exchange, Issue No 34, October 2008. p30. Available from http://fex.ennonline.net/34/special.aspx