1. Ensuring Effective Caring Practices within Families and Communities Isatou Jallow Executive Director National Nutrition Agency (NaNA) The Gambia

2. 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. 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 58 th 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. 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. 5 Breastfeeding = Foundation for Care  Breastfeeding the act combined with breastmilk the product cuts across all the categories of care

6. 6 Examples of caring practices in 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. 7 Child Development Multi-dimensional and inter-dependent  Social, emotional, cognitive and motor performance  Patterns of behaviour  Health and nutritional status

8. 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. 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. 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. 11 UNICEF conceptual framework of the determinants of nutritional status (IFPRI/Benson 2004)

12. 12 Women Produce, Reproduce, Nurture, and Care

13. 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. 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. 15

16. 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. 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. 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. 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 Africa15436.935.239.645.1 Western18634.732.910.912.7 Central19342.237.85.66.8 Eastern15444.4 15.819.4 Northern4227.421.75.84.6 Southern15625.424.61.5

20. 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. 21 Foetal Nutritional status – proxy indicator of maternal nutritional status Huffman, et al., 2000

22. 22 The Burden of Malnutrition Haunts you through your whole life - Impacts the next generation

23. 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. 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. 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. 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. 27 Linking Stakeholders and Actions Macro actions – Government level Policies Meso actions – Service delivery Level- provision of Services e.g. Immunisation, Nutrition Information, training Micro actions – Communities, Households e.g. Utilisation of services

28. 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. 29 Care-giving across generations – Grandmothers and Siblings – singing, dancing, feeding, comforting

30. 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. 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. 32 Village Support Group on Infant Feeding

33. 33 Baby Friendly Rest House at the Fields

34. 34 Local communities disseminating messages through songs and dances on maternal/infant nutrition, environmental sanitation/personal hygiene

35. 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. 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. 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. 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. 39 Care-Nutrition-Early Childhood Development-Socio-Economic Development “No Nation can afford to waste its greatest national resource, the intellectual power of its people. But that is precisely what is happening where low birth weight is common, where children fail to achieve their full potential growth, where micro-nutrient deficiencies permanently damage the brain, and where anaemia and short- term hunger limit children’s perform- ance at school.” (Nutrition: Foundation for Development UN SCN, 2000, Geneva)