Into the mouths of babes - The Breastfeeding, Weaning and Growth Monitoring Project in the Philippines
Case Study
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| Teacher's Notes | Student Activities |
| Introduction |
The Breastfeeding, Weaning and Growth Monitoring and Promotion Project (or Child Growth Project for short) was undertaken in the Philippines between 1994 and 1998. It was implemented by the United Nations International Children's Education Fund (UNICEF) with financial support from the Australian Government's overseas aid program. The project was implemented in nine Philippine provinces: Isabela, Quezon, Albay, Masbate, Capiz, Negros Occidental, Eastern Samar, Leyte and North Cotabato.
The project addressed the major factors that contribute to high infant malnutrition in the Philippines, and that lead to increased susceptibility to infection, disease and even death among babies. These are:
- the continuing decline of breastfeeding practices,
- improper complementary feeding practices, and
- the failure to detect and intervene early enough when growth faltering occurs, which often happens after six months of life.
Encouraging mothers to breastfeed their babies can play an important role in reducing infant malnutrition and mortality, and improving infant health. This is because breast milk is an important source of nutrition for infants and it also contains antibodies that protect infants against infection. Cognizant of the many desirable effects of breastfeeding, and the high rate of malnutrition among infants, the Philippine Government began actively promoting breastfeeding. The Child Growth Project, supported by the Philippine Government and funded by Australia, was one of the ways this was done. It encouraged breastfeeding by supporting "rooming-in" (allowing babies to sleep in the same room as their mothers while in hospital), educating mothers about the health benefits of breastfeeding, and other means.
In addition to promotion of breastfeeding, the Child Growth Promotion (CGP) project also educated mothers about complementary feeding habits. Studies undertaken in the Philippines had shown that improper feeding of solid foods to babies was resulting in malnourishment and low age-to-weight ratios for many infants. To address this problem, the CGP focused on strengthening the knowledge and skills of mothers in relation to weaning babies from a pure breast milk diet to one that included semi-solid foods.
The CGP also focused on monitoring and promoting the growth of infants. These activities were seen as important to monitor the size and weight of babies, and to intervene when babies were growing too slowly. Activities related to growth monitoring and promotion (GMP) included development of weighing stations for babies, training health providers and mothers about the nutritional needs of babies, and providing information on how to improve the growth of babies through improved feeding practices.
| Project strategies |
The CGP's long-term objective was to reduce child malnutrition through early onset and prolonged duration of breastfeeding, proper or improved complementary feeding practices, and regular growth monitoring. In order to achieve this, project strategies were put in place at three different levels: national, local and family level. This allowed the project to work with national Philippine Government agencies such as the Department of Health, local hospitals where infants are born, and with individual mothers and their babies.
On the national level, project implementation was coordinated by the Department of Health.
1. National level
To ensure the success of the project, an important first step was to develop an adequate number of trainers. Throughout the project new volunteers and midwives were trained. This allowed the project to extend beyond its initial target areas.
Other developments were:
1.1 Development of educational support materials
A Basic Learning Package (BLP) was developed with frontline health workers. The material was pre-tested to ensure it was user friendly and communicated the message accurately. It was produced in the target provinces' four major dialects.
| Child Growth Reference Guide - information on breast feeding, growth monitoring, food safety and sanitation and dietary management of common illnesses at home. |
| Child Growth Training Activity - a series of activities covering health and nutrition information. |
| Child Growth Counseling Cards - a set of visual aids on breast feeding, complementary feeding, growth monitoring and promotion. |
| Child Growth Comics - a series of five comic magazines containing nutritional information translated into four major dialects. They have proven to be very popular, being easily understood and enjoyable to read. |
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| A series of health messages is conveyed through this training package. |
1.2 Mother and Baby Friendly Hospital Initiative
1.2 Mother and Baby Friendly Hospital Initiative
| Have a written breast feeding policy that is routinely communicated to all staff. |
| Train all health care staff in skills necessary to implement this policy. |
| Inform all pregnant women about the benefits and management of breast feeding. |
| Help mothers initiate breast feeding within half an hour after birth. |
| Show mothers how to breast feed, and how to maintain lactation even if they should be separated from their infants. |
| Give newborn infants no food or drink, other than breast milk, unless medically indicated. |
| Practice rooming in to allow mothers and infants to be together 24 hours a day. |
| Encourage breast feeding on demand. |
| Give no artificial teats or pacifiers (also called dummies or soothers) to breast feeding infants. |
| Foster the establishment of breast feeding support groups and refer mothers to them on discharge from hospital or clinic. |
The most difficult step is sustaining a functional breast feeding support group. The support group's aim is to motivate mothers to practice exclusive breast feeding for about six months and to continue breast feeding for two years or as long as the mother produces milk.
1.3 Implementation of the milk code
Government authorities are working closely with non-government authorities in monitoring the implementation of the Philippine Code on Marketing of Breast Milk Substitutes. In the Philippines, health workers are trained in breast feeding counselling which includes awareness of the milk code. Under the milk code, milk companies must apply for a permit to conduct seminars and workshops for promoting breast milk substitutes.
2. Local (provincial, municipal, village) level
2.1 Promotion of the Child Growth Project (CGP)
On the local level, the CGP was promoted mostly through face-to-face contact. A number of strategies were employed including:
- discussion of the CGP on the agenda at the local council meetings. This ensures that the council is committed to follow-up obligations;
- involving people perceived as influential in the local community. For example the involvement and promotion by the Vice Mayors' ladies group in Capiz encouraged 100 percent attendance of children and mothers during monthly weighing sessions and caregivers' classes;
- regular visits to the villages to meet with officials and leaders to discuss the importance of the project. This approach proved very beneficial in gaining resources and political support which is vital for speeding up project implementation and ensuring its sustainability in the future; and
- exchange visits between barangays that have established weighing posts and trained staff, with provinces about to implement the project.
The basic principle behind the promotion of the CGP is to start with small attainable activities and build on these. For example in North Cotabato they began by constructing a simple shed, using local materials as the weighing post for conducting the monthly weighing of children. The success of establishing the weighing post installed confidence in the community to move on and conduct caregivers' classes on child growth monitoring and promotion, and female literacy.
3. Family level
3.1 Establishment of weighing posts
One of the major features of the CGP is the establishment and operation of weighing posts. A weighing post is generally set up every two or three clusters (a cluster is made up of 20-25 families). The purpose of the weighing station is to weigh children and measure growth, but it is also a strategic venue for providing health nutrition and related services to the community. The weighing post can be purpose built or run from an established structure in the community such as the barangay library, or hall.
Each weighing post is standardized to include basic equipment, educational materials, supplies and record forms (see table below).
| Scales to weigh both the mother and child, and safe toys to promote early psycho-social stimulation. |
| Educational materials including growth monitoring cards and charts to record a child's weight gain. This record is then compared to a growth pattern for a group of children, to detect possible growth faltering. |
| Nutrition education materials include booklets such as "Vitamin A and You" containing information on the importance of vitamin A including signs and causes of vitamin A deficiency. Food prescription slips are pads which contain information sheets with reference to complementary food for young children, what foods, how much and how to prepare them. |
| Supplies include Vitamin A capsules for susceptible children and post-partum women. |
Since weighing posts have been operational, mothers' knowledge, attitudes and practices on monitoring their children's growth and information related to maternal and child health has improved.
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| Weighing scales used to weigh children and measure growth. |
3.2 Conduct of health and nutrition education activities
One of the major activities of the CGP is a series of ten classes for caregivers. They use visually presented child growth counselling cards, covering topics such as health and nutrition during pregnancy and lactation, care of infants and toddlers, and food safety.
The following are comments from some of the mothers who were randomly interviewed to determine possible behavior modification:
"I used to express my first milk secretion (colostrum) before feeding my newborn because I thought that the yellowish fluid was dirty. According to the midwife, this is colostrum and contains important substances needed by my baby to be strong and healthy."
"After attending mothers' classes, I began feeding my eight-month old baby with leafy green vegetables and soft fruits to provide my child with more vitamins. I did not do these with my other children because I was told these were too hard to digest and may cause stomach aches."
"Whenever I brought my child for immunization at the weighing post, I was also taught how to take my child's weight and plot this on the card. The midwife taught us how to interpret the shape of the line (curve) on the card and to report if the child's weight is not improving or has gone down".
3.3 Home and community food production
Household or communal food production is actively promoted through the introduction of demonstration gardens at weighing stations and through the "Vitamin A and You" booklet. Resources needed to implement this activity include availability of seeds and seedlings, tools, farm implements, water and available land space. From observations, nearly all households have some type of food production even if not all foods grown were rich in Vitamin A, such as eggplants and spring onions.
| Conclusion |
The CGP's community-based approach to monitoring and promotion of proper growth and development of young children has proved to be successful in making parents and caregivers take a more active role in this responsibility. The project has also provided valuable lessons on how to draw support from local officials and the community when implementing activities aimed at improving the health and nutritional well being of local people.
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