It is hard to believe that it has been seven years since I first put my feet on the ground in Liberia to assist UNICEF and the Liberian Ministry of Health (MoH) through the USAID-funded Rebuilding basics health Services (RBHS) project in rolling out nutrition interventions using the Essential Nutrition Actions (ENA) framework.
During my first visit while traveling all throughout the capital city of Monrovia, it was evident that the country still bore deep scars from 14 years of a horrible civil war, with walls pockmarked with bullet holes, abandoned and nonexistent roads, and the lingering fear still present in the eyes of the people. From a health and nutrition perspective, the situation was grim, as well; nutrition was mainly recuperative as the population, and in particular, the children had suffered from the food shortage for many years. Some of the data at that time showed wasting in up to 40% of children under five. By 2009, it was time for the MoH to think about a better future for the population and how to tackle the high rate (47%) of chronic malnutrition (stunting).
In 2010, JSI joined the MOH’s plan for a healthier population by starting work on the Liberian Agricultural Upgrading Nutrition and Child Health (LAUNCH) project to support the roll out on the Essential Nutrition Actions (ENA), using training materials validated by the MOH, UNICEF, and USAID.
Under the LAUNCH project, I made my first visit to the north-central region in Nimba County to the Duo Taiayee health clinic in 2011. At this time there was no promotion or support to improve nutrition practices of pregnant and lactating women and mothers with children under two. This was exemplified by the fact that no pregnant or lactating women received counseling on their diets and almost none received iron/folic acid, de-worming or malaria Intermittent Treatment and prevention (ITP). Furthermore, no support was provided for optimal breastfeeding – all women breastfed by making scissors with their fingers, thereafter stopping the flow of breast milk, and none had knowledge in the correct positioning and attachment.
JSI assisted the County Health Nutrition Coordinator in Nimba, Steven Wongbah to roll out a training program for health providers in seven similar health facilities and to extend the training to the general Community Health Volunteers (gCHV) recognized by the MoH. The training sessions were followed by regular supervision visits, some with formal assessment and refresher training.
When the MOH prohibited trained traditional midwives (TTMs) from conducting deliveries at home, my colleague Ella Jablai and I decided to test how task shifting of the TTM could be used to improve nutrition practices. The ENA training utilized the community guide and reference document, in simple English, and monthly group meetings were led by the health center Officer in Charge, Rachel Khowon.
About four years after this introduction, I was lucky to assist at one of these monthly meetings. Nineteen women, between 40 and 60 years old, were present and explained the nutrition tasks they performed during the past 2-4 years. It was remarkable that all the recommended nutrition (and beyond) practices for pregnant and lactating women were known, and the TTM gave many examples of pregnant and sometimes lactating women who are now coming regularly to be advised on their diet. Mary Gbamai, the TTM leader, said, “I am very confident that my knowledge to assist pregnant and lactating women in eating more nutritious foods is critical for having a stronger and healthier mother and baby”. As part of the government policy, TTM are referring women to antenatal care; while doing so, they recommended they get vaccines and supplementations. The efforts of the TTM have been successful as data from the LAUNCH project shows improvement in Iron/Folic supplementation among pregnant and lactating women.
One TTM explained how she usually clamps and cuts the umbilical cord when she has to do deliveries in the village (for women who did not reach the health facility) or when she helps the nurse-midwife at the health facility. “After the baby is out, I dry it with a cloth. When I have finished the cord does not do “boum-boum” and I can then clamp and cut it.” This practice is recommended to build the infant iron storage up to one year of age.
Breastfeeding, as breastfeeding always does, brought a lot of animation in the TTM group and all wanted to give examples of how their work with mothers on improving the position and latching of newborns. Putting the baby on the breast immediately after birth was a very positive practice for them as “it decreases bleeding, expels the placenta and reduces pains after the delivery”. It is clear that in their eyes, such a simple and unique intervention represents a “breakthrough” in improving delivery outcomes. Colostrum was also mentioned as being essentially in making the newborn strong!
As a result to the work of the TTMs and the support provided by the head of the health center, during the immunization session, where many young babies are present, I did not see any “finger scissors” and all women were adequately putting their young infants on the breast correctly.
Finally, it was very interesting to notice but not surprising at all that their knowledge and even interest in complementary feeding was minimal; only the introduction of foods at six months was mentioned.
In conclusion, I would like to stress the importance of engaging TTMs in promoting and supporting nutrition practices of pregnant and lactating women and of newborns as we move forward in striving to achieve the goal of “ending preventable women and child deaths.” As home deliveries by Traditional Birth Attendants are discouraged, the important question to consider is whether we could use TTMs who are well-recognized community members as allies to improve nutrition practices and therefore women health and birth outcomes. It is evident that all TTMs were very vocal in the needs for family planning and protecting young girls from pregnancies, which is another critical intervention to decrease mortality and improve nutrition outcomes.
Thirty percent of women deaths are related to undernutrition and anemia. Undernourished women give birth to low birth weight babies, a precursor of stunting, and low birth weight babies have higher risk of dying during the neonatal period.
The Lancet Breastfeeding Series, launched last month, reminds us of the cost-effectiveness of breastfeeding and, for the first time, demonstrated the potential in decreasing neonatal death through early and exclusive breastfeeding.
TTM/TBAs represent strong allies at the community level to support relevant nutrition practices for pregnant and lactating women and young babies. We should not ignore them as they are a strong force in the communities and are respected by pregnant women and other community members. In addition, programs in reproductive health and newborn care have the responsibility to foster and enhance these targeted nutrition practices to improve the outcomes of their programs.
 LAUNCH (2010-2016) is a USAID Food for Peace funded project managed by ACDI/VOCA with Project Concern International, Making Cents International, and JSI. This project aims to improve food security of vulnerable people living in the rural Bong and Nimba counties by distributing food rations to pregnant and lactating women and children 6-23 months, enhancing farmers’ agriculture practices, encouraging primary school attendance and rolling-out the MOH adopted ENA framework among health providers, community workers and across communities.