Ensuring Effective Caring Practices within Families and Communities

Isatou JallowExecutive Director

National Nutrition Agency (NaNA)The Gambia

2

Overview of Presentation

Background on care, caring practices, indicators

The situation of women and children

How do we ensure effective caring practices within families and communities?

The way forward

3

How important is Care in the African context?

An African Regional Nutrition Strategy (1993-2003) adopted by the then OAU African Council of Ministers at their 58th session in 1993 cited inadequate care as an important factor in the poor nutritional status of women and children in Africa. This according to the strategy, was due to the disappearance of the traditional African extended system.

4

Defining Care and Caring Practices

“Behaviours and practices of caregivers to provide the food, health care, stimulation and emotional support necessary for children’s healthy growth and development”

3 categories of Care:

Nutritional, Psychosocial and Physical

5

Breastfeeding = Foundation for Care

Breastfeeding the act

combined with breastmilk the product cuts across all the categories of

care

6

Examples of caring practicesin all three categories

Breastfeeding Providing emotional security Reducing the child’s stress Providing shelter and clothing Feeding, bathing supervision of child’s toilet Preventing and attending to illness Nurturing and showing affection Interaction and stimulation Playing and socialising Protecting from exposure to pathogens providing a relatively safe environment for exploration

7

Child Development

Multi-dimensional and inter-dependent Social, emotional, cognitive and motor

performance

Patterns of behaviour

Health and nutritional status

8

Child Development

Early years (first 3) critical foundation for healthy psychosocial development - intelligence, personality and social behaviour

Brain development <1year is rapid and extensive and is vulnerable to environmental influence – nutrition, health, care and stimulation.

9

Child Development

Early stimulation such as talking, singing to the child makes the child more responsive

A child’s capacity for mental and social development depends on biological systems shaped by early experience and attachment

Studies show that children who have secure attachments early in life, function better in society and perform better in school

Stimulating a child is like motivating a worker – the output is greater

10

Nutrition Security and Early Childhood Development

Nutrition Security – Food security coupled with a sanitary environment, adequate health services and knowledgeable care to foster good nutritional status through the life cycle and across generations

Food; Health; Care; Safe Environment

Early Childhood development – an integrated approach that promotes a holistic view of the chid and a coordination of activities in the five priority areas – health, water, hygiene and sanitation, nutrition, early stimulation/education and protection

11

UNICEF conceptual framework of the determinants of nutritional status (IFPRI/Benson 2004)

Household food security

Quality of care

Healthy environment,

health services

Nutritional status

Dietary intake

Health status

Outcome

Immediate determinants

Caregiver resources

knowledge & access to education

health status control of

resources

Resources for health

availability of public health services.

sanitation, access to clean water.

Food security resources

quantity food produced

quality food produced, diet diversity

cash income food transfers

Underlying determinants Poverty constrains the level of these determinants for individual households.

Political & ideological framework

Economic structure

Potential resources Human, agro-ecological, technological

Basic determinants The impact which the resources potentially available to the household have on nutritional status is mediated & constrained by overarching economic, political, and institutional structures.

Institutions

12

Women Produce, Reproduce, Nurture, and Care

13

Care for the Caregiver

“Mothers and babies form an inseparable biological and social unit; the health and nutrition of one group cannot be divorced from the health and nutrition of the other” (Resolution WHA55.25 on Infant and Young Child Nutrition).

14

Caring practices

Family planning services – contraceptive use Ante-natal care Skilled attendance at birth Post-natal care Maternity protection laws Education Reducing workload during pregnancy and

lactation Reducing the mother’s stress Showing care and affection for the mother

15

16

Indicators of Care for Women and Children

Child Mortality Rates Nutritional status –

underweight, stunting, wasting

Exclusive breastfeeding rates

Complementary feeding Immunisation coverage Use of insecticide treated

nets Provision of clean water and

adequate sanitation

Maternal mortality rates Low Birth Weight Family planning services –

use of contraceptives Micro-nutrient deficiencies Proportion of household

utilising Iodised salt Vitamin A supplementation

coverage Skilled attendance at birth Proportion of children

attending early childhood centres

17

The situation of Women and Children

10.8 million children die each year in the developing world

41% of child deaths from Sub-Saharan Africa

Risk factors include unhygienic environment, unsafe and inadequate water, poor sanitation and undernutrition as an underlying factor

Maternal mortality estimated at 940 per 100,000 for sub-Saharan African (UNICEF SOWC 2005).

18

Women and Children

14 out of 18 countries with Neonatal Mortality Rates of >44 per 1000 are from Sub-Saharan Africa

Countries in conflict situations register the highest rates

Maternal Health and health care are important determinants of neonatal survival

19

Child Mortality Rates and Nutrition status in Africa (0 – 5 years)

Region/

Sub-

region

Child Mortality

Rates

Deaths per 1000 births

2002

Prevalence of stunting %

<2SD height for age

1990 2000

Number of stunted children

millions

1990 2000

Africa 154 36.9 35.2 39.6 45.1

Western 186 34.7 32.9 10.9 12.7

Central 193 42.2 37.8 5.6 6.8

Eastern 154 44.4 44.4 15.8 19.4

Northern 42 27.4 21.7 5.8 4.6

Southern 156 25.4 24.6 1.5 1.5

20

Women and Children

Infant feeding practices – exclusive breastfeeding rates infants <6months 28% for SSA, 50% of children between 20-23 months still breastfeeding

Utilisation of preventive health services e.g. immunisation of children less than desired

Female literacy levels low but progress in some countries

21

Foetal Nutritional status – proxy indicator of maternal nutritional status

Percent Low Birth Weight (<2.5 kg) in Africa

12

6

1314

9 9

17

10

13

98

1311

14

11 1112

0

5

10

15

20

25

Per

cen

t

Huffman, et al., 2000

22

The Burden of Malnutrition

Haunts you through your whole life - Impacts the next generation

OLDER PEOPLE

Malnourished

BABY Low

Birthweight

CHILD Stunted

ADOLESCENT Stunted

WOMAN Malnourished

PREGNANCY Low weight gain

Inadequate food, health, &

care

Reduced capacity to care for child

Higher mortality

rate

Impaired mental

development

Increased risk of adult chronic disease

Inadequate catch-up

growth

Untimely / inadequate feeding

Frequent infections

Inadequate food, health, & care

Reduced mental capacity

Inadequate food, health, & care

Inadequate food, health, & care

Higher maternal mortality

Inadequate fetal nutrition

Inadequate infant nutrition

Reduced physical labor capacity,

lower educational attainment,

restricted economic potential,

shortened life expectancy

Reduced physical labor capacity,

lower educational attainment

23

Challenges to effective caring practices

Economic/Political High poverty levels and several countries in

conflict situations, governments unable to provide basic public services

Health Services/Disease burden HIV/AIDS, Malaria, Micronutrient

deficiencies

24

Challenges

Sub-Saharan Africa with highest HIV/AIDs prevalence figures

Africa with highest fertility risks in the world “too frequent + too soon – early marriages

SSA with 30% of world’s Maternal deaths Low access in many countries to clean water

and sanitation – rural/urban disparities Low maternal literacy levels

25

Family & Community 12 Practices for Child Survival, Growth, Development (WHO, 2004)

Immunisation Breastfeeding Complementary feeding Micronutrients Hygiene Treated Bed nets Foods and fluids during illness Home treatment Care seeking Adherence Stimulation Antenatal care

26

Ensuring effective Caring practices within families and communities – Who is responsible?

Stakeholders at different levels of society

Actions at different levels of society

Stakeholders and Actions complement each other

27

Linking Stakeholders and Actions

Macro actions – Government level

Policies

Meso actions –Service delivery

Level- provision ofServices e.g.

Immunisation, NutritionInformation, training

Micro actions –Communities,

Households e.g.Utilisation of

services

28

Macro – Meso - Micro Actions

Government Polices – maternity protection laws; food fortification laws, National Code of marketing of breastmilk substitutes

Service delivery level – immunisation, vitamin A and iron supplementation, nutrition and health education

Community/Household level – visits to service delivery centres for care, brestfeeding, hygienic practices

29

Care-giving across generations – Grandmothers and Siblings – singing, dancing, feeding,

comforting

30

Fathers as caregivers – time to document fathers’ contribution

Can fathers be encouraged to take a more active role in care-giving?

Father’s contribution to care-giving – is it being underestimated?

Fathers smoking away from their families – a caring practice?

31

Ensuring effective caring practices within families and communities – An example

from The Gambia

The Baby Friendly Community Initiative - Promoting Exclusive breastfeeding

Building on Traditional and local knowledge, beliefs and practices

e.g. communities’ local knowledge of young animals being breastfed exclusively for a period of time and surviving

Traditional shelters at the fields to enable lactating mothers take their infants to the fields

Involvement of men in all aspects of the intervention Supporting communities to create an enabling

environment

32

Village Support Group on Infant Feeding

33

Baby Friendly Rest House at the Fields

34

Local communities disseminating messages through songs and dances on maternal/infant nutrition, environmental sanitation/personal

hygiene

35

The Lancet Child Survival Series(caring practices)

Interventions to reduce Child Mortality Rates

Preventive Treatment Breastfeeding 13% Insecticide Treated Nets 7% Complementary Feeding

6% Clean delivery 4% Water/sanitation/hygiene

3% Vitamin A 2% Tetanus Toxoid 2% Newborn temperature

management 2% Measles vaccine 1%

Treatment Intervention Oral rehydration therapy

(ORT) 15% Antibiotics for sepsis 6% Antibiotics for pneumonia

6% Antimalarials 5% Newborn resuscitation 4% Antibiotics for dysentry 3%

36

The Way forward - Questions to ask:

How can we achieve universal coverage with these interventions?

What local skills and knowledge do families have on ECD and care for mothers and their children?

What additional skills and knowledge do they need to improve current caring practices?

How can local knowledge and skills be used positively to enhance caring practices?

How can local practices that ensure psychosocial stimulation of children be documented and promoted?

What is the situation of care for the girl child? Do communities and families recognise the vulnerability of the

adolescent girl? Educating the girl child – is it recognised as a caring practice

by communities and families?

37

Questions to ask:

Care and Support for women during pregnancy and lactation – how can men be supported to take an active role?

What child caring activities can men participate in? What is the role of the traditional media in promoting effective

caring practices? How are international rights instruments understood at the

local level – within families and communities? How can we ensure that governments reporting on the CRC

include indicators pertaining to caring practices and Early Childhood Development?

The Vulnerable among the Vulnerable – women and children living with HIV/AIDS and or living in conflict situations – how do communities and families cope – what resources do they require to ensure adequate care?

38

Millennium Development Goals, Care and ECD

Reduce extreme hunger and poverty Achieve universal primary school

education Promote Gender equality and empower

women Reduce Child mortality Improve maternal health Combat HIV/AIDS, malaria and other

diseases

39

Care-Nutrition-Early Childhood Development-Socio-Economic Development

“No Nation can afford to waste itsgreatest national resource, the intellectual power of its people. Butthat is precisely what is happening where low birth weight is common, where children fail to achieve their full potential growth, where micro-nutrientdeficiencies permanently damage thebrain, and where anaemia and short-term hunger limit children’s perform-

ance at school.” (Nutrition: Foundation for DevelopmentUN SCN, 2000, Geneva)