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Infant and young child feeding

  • Guatemala | ProCONE Community Demonstration Collaborative | Collaborative Profile
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  • Tanzania | Iringa Region Infant Feeding Improvement Collaborative | Collaborative Profile
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  • Improving outcomes of Premature and Low Birth Weight Babies through Kangaroo Mother Care | Publications

    As a component of its work to address neonatal mortality, the USAID Health Care Improvement Project (HCI) is working with Ministries of Health to implement national Kangaroo Mother Care (KMC) programs in five Latin American countries: Guatemala, El Salvador, Honduras, Nicaragua and Ecuador. This short report describes the technical assistance that HCI is providing to support the implementation and scale-up of the KMC program throughout all phases.

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  • Aplicación del Método Madre Canguro en Bebés Prematuros y de Bajo Peso en 4 Países de América Latina | Publications

    Volante sobre los avances del proyecto HCI en la aplicación del Método Madre Canguro en cinco países de América Latina.

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  • Evaluation of the Institutionalization of Improving the Quality of Maternal-Neonatal Health Care Services in Guatemala | Publications

    The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. From March 2007 to September 2008, ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was implemented using a collaborative improvement approach in 22 health centers, 1 Centro de Atencion Inmediata Materno-Infantil (CAIMI), and 2 hospitals in the San Pedro District of San Marcos Department, in western Guatemala. After this successful demonstration phase, ProCONE best practices and quality improvement processes (documentation of changes implemented, monitoring of key quality of care indicators, and periodic sharing of QI team learning) were spread to 122 additional health facilities in seven high-priority regions of Guatemala, starting in January 2009. The success of this spread phase led to plans to spread these best practices and QI process to new regions of Guatemala and to lower levels of the health system (health posts) in active regions.

    While the initial effectiveness of the ProCONE process has been evaluated and reported through the preparatory, demonstration and initial spread phases, the maintaining of the QI process as an integral, sustained part of the health system and continuing improvement of maternal and neonatal health care since the completion of each phase has not been assessed. Thus, the ProCONE process provides an opportunity to evaluate its institutionalization across the national, health area, district and health center levels of care. By evaluating the institutionalization of the ProCONE process across levels of health care, this study will also contribute to information to identify and improve deficiencies (including updating norms and practice based on new evidence) and lapses in QI or systems performance as well as particularly successful processes that merit previously unanticipated action.
     
    Primary research questions/objectives:
    1. 1.      Have the ProCONE demonstration and initial spread phases maintained the quality of care (QOC) gains for clients over time (between the end of the active collaborative phase and 6 months after the end of the initial spread phase)?
    2. 2.      To what extent are key QI activities still being implemented at the point of service delivery? What QI activities facilitated, impeded or altered the QOC gains? Is there a culture of quality at the site/facility that supports QI implementation and evolution? What activities after the collaborative phase facilitated, impeded or altered this culture over time?
    Secondary research questions/objectives:
    1. 3.      To what extent are key maternal-neonatal QI activities being implemented at the supportive (district, health area, central) levels of the health system? What is the status of the 8 elements of institutionalization in relation to QI? For example, are policies created that encourage a culture of quality, leadership, basic values, allocation of resources, evaluation and strengthening of infrastructure, communications and information, recognition at the district, health area and central levels of the health system? Are regular support and QI coaching, essential inputs, accountability, recognition for QOC and for monitoring of indicators being provided? What factors do or do not facilitate providing this support? Has the QI process been applied to clinical domains and services (other than maternal-neonatal health care)? How and why, or why not?
     
    Use study results on the levels of institutionalization achieved through the collaborative’s implementation processes to define a future focused institutionalization strategy that the MPHSA can implement.
     
    Methodology:

    Various complementary quantitative and qualitative methodologies will be used to evaluate the research questions using a controlled pre-post (quasi-experimental) design. The sample frame includes all of the ProCONE demonstration and initial spread phase facilities and facilities that were unexposed to the ProCONE interventions with similar socio-demographic characteristics for which health service statistics data are available for the same time period.

     

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  • Evaluation of a Collaborative Approach and of ISO Certification to Improve Quality of Maternal-Neonatal Health Care Services in Guatemala: A Comparative Cost Analysis | Guatemala | Publications

    The USAID Health Care Improvement project (HCI) has supported two initiatives in Guatemala focused on improving the quality of health care. The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. The approach of ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was to engage health center staff in quality improvement (QI) teams to monitor compliance with clinical norms and records and improve care through training and coaching, providing Information Education and Communication (IEC) materials and job aids, proving opportunities for shared learning through Collaborative sessions, introducing health improvement activities, and documentation and review of best practices that proved effective in improving process indicators. The demonstration phase was implemented between March 2007 through September 2008 in the department of San Marcos in western Guatemala. In this study, facilities participating in the ProCONE collaborative are referred to as ProCONE alone facilities.

    The International Organization for Standards (ISO) is a non-governmental organization that develops and continually updates standards for quality management systems called ISO 9000. These standards are used by objective ISO auditors to audit and certify that formalized processes conform with up-to-date standards. With support from HCI, the MOH committed to the ISO certification process to evaluate health care QI at Permanent Attention Center San Pedro Sacatepequez (San Pedro CAP), which also participated in the ProCONE demonstration collaborative. Activities to prepare for ISO certification were introduced in October 2009 and continued through July 2010. The audit was conducted and certification provided in October 2010. The audit identified 5 minor areas requiring improvement. The MOH and URC are taking actions to fully comply with the established standards and the CAP is scheduled for re-audit in October, 2011. In this study, the San Pedro CAP is referred to as the ISO+ProCONE facility.
    This study compares the cost-effectiveness of the ISO and ProCONE strategies on essential maternal and neonatal health care best practices and their mediating factors to determine how the Ministry of Health can best leverage each of these strategies in improving and maintaining quality of care.
     
    Research questions/objectives:
    The primary objective of the study is to elaborate how the ProCONE and ISO approaches affect process (mediating) variables, including purchasing, availability of supplies, equipment maintenance, staff competence and training, record keeping and planning, the coverage of care (numbers of patients), compliance with MNH best practices, patient satisfaction and the incremental cost-effectiveness. This information will help to determine whether and where the integration of these two strategies is beneficial. To meet the study objectives, the study will answer the following specific research questions:
    1. 1. What are the current differences in processes (mediating variables) that theoretically affect outcome (coverage, effectiveness and cost-effectiveness)?
    2. 2. What are the relative differences between ISO+ProCONE and ProCONE alone in MNH patient coverage?
    3. 3. What are the differences between ISO+ProCONE and ProCONE alone in MNH best practices?
    4. 4. What is the incremental cost-effectiveness (ICE) of ISO+ ProCONE compared with ProCONE alone; and
    5. 5. What drivers (mediating variables) affect the success of each method?
    Methodology:

    A quasi-experimental research design will be used because the ISO+ProCONE and ProCONE alone study groups were not randomly allocated. The quasi-experimental design takes advantage of the data equally available from both study groups. Data collected in May 2011 in an all-facilities endline cross sectional survey of process variables, patient satisfaction, and patient-provider observation and associated clinical records review. These will be compared with data previously collected in 2009 and 2007.

     

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  • Supervision of community peer counsellors for infant feeding in South Africa: an exploratory qualitative study | Community Resource

    This paper reports on a qualitative study of the experiences of three CHW supervisors who were responsible for supporting infant feeding peer counselors in three diverse settings in South Africa. This study highlights the need to pay attention to the experiences of supervisors in order to better understand the components and complexities of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer CHW programs.

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  • Reaching maternal and newborn care standards in Santa Rose de Lima Hospital | Publications

    This short report describes a successful intervention to promote exclusive breastfeeding in Santa Rosa de Lima National Hospital in La Union, El Salvador.  The report is available in English and Spanish.

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  • Basis for Addressing the Situation of Chronic Malnutrition in Guatemala | Publications

    This document presents an analysis of chronic malnutrition in Guatemala, especially in the departments or health areas receiving technical and financial assistance from the United States Agency for International Development (USAID). In addition to reviewing published documents on the topic, we conducted a secondary analysis of the databases of censuses of schoolchildren. Departmental information on chronic malnutrition from censuses conducted in 1986, 2001, and 2008 shows that the departments with a prevalence of chronic malnutrition higher than the national average (51.1, 49.7, and 45.6 percent, respectively) are Chimaltenango, Sololá, Totonicapán, Quetzaltenango, San Marcos, Huehuetenango, Quiché, Alta Verapaz, and Jalapa. Only Jalapa falls outside USAID’s area of influence and cooperation. The analyses at the municipal level allow 115 of the 165 municipalities included in these areas (70 percent) to be more closely examined, as the prevalence of chronic malnutrition among their schoolchildren exceeds 50 percent. The data also allow targeting within these municipalities.

    This report reviews current scientific and technical knowledge as well as evidence from programs that have been proven effective. For each level of the causes of malnutrition – structural, underlying, and proximate – actions can be identified that will reduce growth retardation. Activities that address the proximate causes are effective in the short term, while those that address the underlying and structural causes take longer to have an impact. Many of the short-term measures are primarily the responsibility of the health sector: changing behavior; providing supplementary micronutrients to children from 6 months to 5 years old, as well as to pregnant women; optimal breastfeeding; providing complementary foods for children from 6 to 23 months old; hygiene; water and environmental clean-up; and managing the ambulatory and clinical care of severe acute malnutrition.
    Another section of this document analyzes programs currently being implemented in Guatemala. The general conclusions drawn from our analysis emphasize the need for more and better coordination and optimization of the numerous activities already underway. This need applies to activities of the health sector and other sectors as well. Social programs should be coordinated, and in many cases integrated, especially at the primary care level. Joint work and cooperation between the health sector and the environmental, agricultural, educational, and employment sectors, among others, should be emphasized in local, regional, and national nutrition and food security initiatives.
    This report is available in both English and Spanish.
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  • Status and Trends in Chronic Malnutrition in Guatemala | Publications

    Malnutrition in Guatemala is evidenced by linear growth or height retardation in preschool and school children and adults, iron-deficiency anemia in both reproductive-age women and children and overweight and obesity in women of reproductive age, as found in numerous health and nutrition surveys conducted over the past fifty years. There is a minor downward trend in chronic malnutrition while overweight and obesity are on the rise. These trends place the country in a phase of a polarizing nutritional epidemiological transition, in which manifestations of deficiencies in energy and macro and micronutrients coexist with imbalances and feeding and nutritional excesses. 

    National averages, however, hide the contrasts found between the metropolitan region, which exhibits the best indicators and more favorable trends, and departments and municipalities with the highest percentage of the indigenous populations where malnutrition prevalences are higher and improvements have been slight. Moreover, there are municipalities which have consistently experienced a deterioration of their nutritional status over the past twenty years. This considerable heterogeneity between communities and population groups was the basis for a proposal made for designing and implementing differentiated intervention packages specific to community groups and depending on the nature, magnitude and duration of the nutritional problems, made in the companion document “Basis for Addressing the Situation of Chronic Malnutrition in Guatemala.” 
    Both at the departmental and municipal levels, statistically significant associations were found in the expected direction between the prevalence of height retardation in preschool and school children in 2008 and variables related to: access and use of health services (use of family planning methods, attendance to prenatal care, qualified childbirth and postpartum care, and infant mortality rate); households living in poverty and extreme poverty; possession of and access to goods and services in homes and basic sanitation; agricultural work, regardless of land ownership; density of micro farms; level of parental education; indigenous population; and size of the family and dependency ratio.
    The adverse nutritional situation in Guatemala contrasts with the rich nutritional information existing in the country and the valuable contributions made to the nutritional sciences worldwide. Moreover, Guatemala—like the rest of the countries in the Central American region—has, since the 1990s, promoted a Food and Nutrition Security Initiative, which currently has a legal basis and a specific law which established the National System of Food and Nutrition Security in 2005. Only by strengthening the authority of the Secretariat of Food and Nutrition Security, as well the effective provision of human, material, and financial resources during a sustained period of time and in the amount and quality corresponding to the magnitude of the country’s food and nutritional problems will allow improvement in this dire situation.

    This report is available in English and Spanish.

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  • Analysis of Effectiveness and Cost Effectiveness of Adding Quality Improvement Collaborative to a Conditional Cash Transfer Program in Guatemala | Publications
    The "Mi Familia Progresa" conditional cash transfer program (CCTP) in Guatemala promotes demand for public health and education services by providing subsidies to families with children under 16 and to pregnant women as long as families meet certain conditions, such as visiting health care centers or ensuring that their children regularly attend school. While evidence suggests that conditional cash transfer programs in low-income countries are effective in increasing access to and use of health services, if the quality of care provided at health facilities is poor, then CCTP programs may have limited impact on health outcomes.
     
    The USAID Health Care Improvement Project (HCI) supports a quality improvement (QI) initiative in specific low-income regions of Guatemala participating in the "Mi Familia Progresa" program. This study compares service quality at CCTP facilities in that were part of the QI intervention with services in comparable CCTP-supported facilities receiving no such intervention. It examines the intervention’s costs and cost-effectiveness.
     
    Methods This cross-sectional study directly observed prenatal and child health care visits to evaluate service quality in 38 CCTP-supported facilities involved in the QI intervention and 12 CCTP facilities that were not part of the intervention. Costs were collected from the QI intervention implementing partners. Multiple logistic regression determined odds ratios of full compliance with quality standards in the intervention compared to the non-intervention groups, controlling for confounders. Using this data, the study estimates the costs per additional service delivered to quality standards in the intervention sites.
     
    Results Full compliance with quality standards was 18 times more likely for both prenatal and child health services. in facilities participating in the QI intervention. During the study period, there were about 95,000 prenatal and 280,000 child health visits in these facilities. For a $293,385 total ($0.78 per service provided) for the QI intervention, there were 60,102 additional prenatal care consultations and 122,900 additional child health consultations done to full compliance with clinical norms. This is an additional cost per prenatal visit delivered in full compliance of $1.25 and an additional cost of $1.78 per child health visit in full compliance.
     
    Conclusion The intervention was associated with improved quality of care for a low additional cost per service delivered to compliance with norms. With a small additional investment, the Guatemala MOH could implement a QI intervention to increase health service quality in all areas where CCTP is operating to increase the quality of and demand for CCTP-supported services.

     

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  • Counseling Cards | Publications

    Counseling Cards
    The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.

    Risk of Passing HIV from Mother to Baby
    Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.

    Infant Feeding Options
    This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.

    Infant Formula or Modified Cow's Milk as a Safe Option
    This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.

    Risk of HIV passing from mother to baby if mother and baby take Nevirapine
    Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.

    How to Breastfeed
    This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.

    How to Hand Express Breast Milk
    This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.

    Many Ways to Position and Attach Baby
    Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.

    During the first 6 months, baby needs only breast milk
    This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.

    Danger Signs
    Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated.

     

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  • Job Aids on HIV and Infant Feeding | Publications

    Health workers in many countries struggle with how to advise women on acceptable, feasible, affordable, sustainable, and safe (AFASS) options for infant feeding in the context of HIV. Making an informed decision about infant feeding is particularly critical for HIV-positive women to reduce the risk of HIV-transmission to their infants.

    WHO, UNICEF, UNAIDS, and UNFPA recently updated their joint guidelines on infant feeding options for HIV-positive women, but such international reference materials often are not available in a form useable by frontline health workers. Tanzania is one of the first countries to develop—and now apply on a national scale—a comprehensive set of job aids on infant feeding and HIV/AIDS that feature high impact graphics and easy-to-follow instructions, reflecting the international guidelines aimed at reducing the risk of transmission of HIV from mother to child.

    The need for counseling job aids reflecting the updated international guidelines was first identified during the development of the a global compilation of programme evidence by URC/QAP in 2003 and formative research conducted in Tanzania. The materials were adapted from several generic counseling tools designed by WHO, UNICEF, and USAID. Funded by USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR), development took place under QAP-supported operations research conducted in 2004 in close collaboration with the Univerity of Bergen, Norway and the Kilimanjaro Christian Medical Centre (KCMC) in Moshi District, Kilimanjaro. The Ministry of Health and the Tanzania Food and Nutrition Centre (TFNC) were major contributors, as were a number of other organizations and national stakeholders An interactive and systematic process was followed to allow both international experts and national stakeholders to review, critique, provide inputs and guide decisions at strategic points throughout the development phase. Stakeholder consensus was an important consideration in the final design of the job aids.

    Healthcare workers throughout Tanzania are currently being trained to effectively use the tools to counsel prenatal and postpartum women to make informed decisions about their infant feeding options and to help women safely practice their chosen infant feeding method. The materials use compelling graphics and easy-to-follow text to facilitate their use and understanding of key messages. To create the imagery, QAP’s team used a state-of-the-art process that employs digital photography, imagery scanning, and computer design graphics.

    The Ministry of Health of Tanzania is providing substantial direction in the training of nurse counselors and the disseminating of the job aids in multiple regions of the country through government facilities. Reflecting growing interest in the adapatation of these job aids for other settings, QAP has worked with national authorities in Uganda and Zimbabwe to adapt the job aids for use by both their National Programmes for the Prevention of Mother to Child Transmission (PMTCT) and Infant and Young Child Feeding (IYCF).

    Published in English and Swahili, the integrated set of materials include:

    Although the materials were developed for use with women in antenatal care clinics and postpartum clinics, the tools are also being used with women in other settings, as well as with fathers, elders, youth, local leaders and others in the community.

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  • Take-Home Brochures | Publications

    Six take-home brochures provide illustrated and easy-to-follow guidelines to enable prenatal and postpartum women to make informed decisions about which infant feeding option is the most acceptable, feasible, affordable, sustainable, and safe (AFASS) for each individual's situation and to help women safely practice the option selected. The brochures graphically depict the step-by-step procedures for women to use in carrying out each of the four infant feeding options.

    How to Breastfeed Your Baby
    This take-home brochure provides mothers with an illustrated guide and detailed step-by-step instructions on how to start and continue breast feeding. It provides information on how to recognize and prevent problems, lists signs to look out for, and identifies what mothers need to remember and know.

    How to Hand Express Breast Milk
    This illustrated brochure graphically depicts and provides mothers with instructions on how to hand express. It includes points to remember and tells mothers how to safely store and feed the milk to the baby. This method is being promoted for use by HIV-positive mothers during the transition from exclusive breastfeeding to replacement feeding in order to minimize the dangerous period of mixed feeding.

    How to Heat Treat Breast Milk
    An insert to the above brochure shows how to safely heat breast milk.

    How to Feed Your Baby Fresh Cow's Milk
    HIV-positive mothers who opt to feed fresh cow's milk to their babies are given a complete list of steps and ingredients needed for safely modifying and feeding fresh cow’s milk to babies. The brochure outlines how to make fresh cow’s milk more nutritionally appropriate for infants. It visually presents the preparation process, stresses the importance of hygiene, and encourages the use of cup feeding. Additional points to remember are covered.

    How to Feed Your Baby Infant Formula
    HIV-positive mothers who opt to use commercial infant formula to feed their babies are given a complete list of steps needed to safely prepare formula and feed their babies. The brochure visually presents the preparation process, stresses the importance of hygiene and encourages the use of cup feeding. Additional points to remember are covered.

    Nutrition: During Pregnancy and Breastfeeding
    Pregnant and breastfeeding women are reminded of the importance of taking a test to determine HIV-status. By becoming aware of their status, HIV-positive women are then able to consult their healthcare providers to determine an appropriate course of action for antiretroviral therapy and nutrition. The brochure points out that good nutrition is especially important to HIV-positive mothers and their infants and gives illustrated pointers on safely preparing foods and planning balanced meals. General points covering meal frequency, water consumption, and diet supplementation are given, and women are reminded to follow their healthcare providers' instructions.

    Feeding a Baby: After Six Months
    This brochure addresses questions that mothers may have regarding how to feed babies who, after six months, are beginning to eat semi-solid foods. HIV-positive women, the brochure notes, should consult a healthcare provider to determine whether it would be best to give another type of milk in place of breast milk. It points out that after 6 months, babies need to gradually begin eating a variety of foods and gives information on types of foods, as well as correct consistency and amounts, to give to babies aged 6, 7-8, 9-12, and 12-24 months. The brochure gives instructions for safe food preparation and storage and covers a range of other points.

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  • HIV & Infant Feeding Question and Answer Guide | Publications

    The HIV & Infant Feeding Question and Answer Guide is intended as a reference tool to provide health workers with information concerning updated international guidelines related to HIV and infant feeding. Health workers can refer to the Guide to explain the complicated and difficult issues related to HIV and infant feeding, provide information and support to help prevent HIV transmission from women to their children, and increase the safety of all infant feeding options, including exclusive breastfeeding, commercial formulas, modified cows' milk, and expressed and heat-treated breast milk. It gives easy-to-understand answers to some of the most common questions that mothers, their families, and communities ask about HIV and infant feeding. The Q&A Guide is based on a generic UNICEF PMTCT infant feeding counseling tool and on the content of the WHO/UNICEF HIV and Infant Feeding Counseling Tools.

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  • HIV and infant feeding: A compilation of programmatic evidence | Publications

    The United Nations-led process of updating the 1998 international guidelines related to infant feeding and the prevention of maternal-to-child-transmission (pMTCT) of HIV called for a review of recent programmatic experience in addition to a review of the new scientific and medical evidence. This document represents an attempt to compile and synthesise reports on a wide variety of relevant programmes conducted since the 1998 guidelines were issued. The programmes presented here range in scale from small community research projects to national programmes. This document is the product of a one-year collaboration between the United Nations Children's Fund (UNICEF) and the Quality Assurance Project (QAP), managed by University Research Co., LLC (URC). Valuable technical inputs were also received from the World Health Organization (WHO) and many individuals and organisations directly involved in HIV and infant feeding programmes. This review brings together in one document a number of important experiences and provides insights that were useful to those involved in updating international guidelines and those involved in adapting them to local settings. It should also serve as a valuable resource to those involved in developing or scaling-up pMTCT-related programmes in the future. (excerpt)

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