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The State of Current Knowledge
The Mexican "Minimum Package"
The Evaluation of Success or Failure
The Wider Influence of Maternal and Child Nutrition Programmes
General Conclusion
References
7.1. It is frequently claimed that we know enough to bring about a significant improvement in nutritional health; the impediment is our political unwillingness to implement the necessary economic reforms. This report is an unsuitable forum for a detailed discussion of the latter issue, and this section will therefore concentrate on what we do or do not know, and present a general discussion of the problems involved in the practical implementation oh health programmes at a community level.
The State of Current Knowledge
7.2. It is clear that the dietary intake of many pregnant and lactating mothers in the Third World is well below current recommendations both for energy and many nutrients; there are a number of reasons for this, depending on socio-economic circumstances. It must be recognized, however, that our estimates for physiological needs may be somewhat excessive and thus the current recommendations may not be a realistic target for health planners.
7.3. Nevertheless, it is a fact that the weight and body-composition changes that take place during the pregnancies of average women in developing countries fall short of that considered desirable in the Western world, and the results are low average birth-weights and a greater incidence of light-for-age babies. It is generally accepted that low birth-weight is a considerable handicap for the child's subsequent growth and development, especially under circumstances prevailing in the developing world.
7.4. There is strong evidence that the Third World lactating mother's health and well-being is affected by her customary diet, and although she may produce remarkably large amounts of milk for long periods of time, this is only achieved by intensive child suckling.
7.5. Unless the food intake of lactating mothers is exceptionally low, milk output seems to peak at about 750 ml/d. Dietary supplementation of the mother does not boost volumes above this level, although there is strong circumstantial evidence that, as during pregnancy, the mother's own health and physiological function can be substantially improved, leading to a greater capacity for work and feeling of general well-being.
7.6. Between four to six months children will begin to need some supplementary feeding, depending on the mother's milk output and the individual physiological needs of the particular child. Some children are able to grow and function for longer than six months on breast-milk alone, but equally, other children may need supplementation before four months.
7.7. The precise time is bound to vary from child to child, but there is no reason why this should lead the mother to stop breast-feeding; breast-milk is likely to be far better, nutritionally, than any other food the child will receive, particularly in the developing world.
7.8. The nutritional importance of breast-feeding needs to be stressed in all public health programmes, but so does the rational introduction of other forms of feeding.
7.9. In the developing countries there can be no doubt that both mothers and their young children constitute the group most clinically vulnerable to malnutrition: both need to be given equal consideration in the development of community nutrition programmes. Such programmes, whether primarily educational or involving the actual provision of supplementary food, must be integrated with other aspects of public health, such as those concerned with the prevention of disease, immunization, and the early treatment of common infections. Because of the link between an improved nutritional status and the return of fertility during lactation and the proven beneficial effects of good birth spacing, both for mother and child, family-planning programmes are of special relevance.
7.10. A plan for a "minimum package" for nutritional health was introduced to the workshop by Dr. Chavez of the National Institute for Nutrition in Mexico City. It will be applied in 3,300 primary health centres covering the whole country. These are situated such that there is approximately one doctor for each 20,000 inhabitants. These doctors will be supported by health "promotors" beated in each community within the area served by each centre. A system of indicators will be used to detect problems before they become too serious. The action package has been kept simple in order to make it easy to apply and to be maintained longitudinally. It has three components, one for pregnancy, one for infancy, and the third to deal with problems in children over one year old.
7.11. For pregnancy, a main consideration is dietary education regarding different mixtures of regional foods advisable for the pregnant mother. Teaching sessions will be supported by posters and pamphlets. Depending on precise area needs, this dietary education will be supported by therapeutic iron and vitamin supplements. Special attention will also be given to teaching hygiene to prepare the woman for her eventual motherhood. Towards the end of pregnancy the importance of immediately breast-feeding the newborn will be stressed, plus the introduction of more adequate hygienic measures surrounding child-birth.
7.12. When the baby is two months old the mother will be taught to prepare supplementary foods. Again, depending on the region, vitamin status will be safeguarded by administering to the baby A, C or D, as appropriate. Between four and six months the provision of supplementary foods will be recommended, particularly to those who are low in weight. Teaching will also be provided on how to integrate the child into the family diet. Depending on the area and socio-economic level, complete weaning occurs between six and fourteen months of age. Around six months, therapeutic iron will also be provided as needed.
7.13. When the child reaches one year of age, he will be tested and treated for parasite infestation. Additional dietary education will be provided, paying special attention to regionally available food.
7.14. This nutritional package for the mother and child will be backed by national educational measures via radio and television, and by a system for the distribution and sale of low-cost foods. Supportive education will also be carried out in schools and other governmental organizations.
The Evaluation of Success or Failure
7.15. When developing countries have limited resources and there are competing demands for them, it is inevitable that there will be pressures to set priorities, with demonstrable success scoring highly. Some countries have assessed the viability of programmes by examining the effectiveness with which they have reached target groups(1). In the Sri Lanka Country-Wide Programme, for example, 75 per cent of mothers at risk were reached, but the success rate with children with second- and third-degree protein-energy malnutrition was only 50 per cent. It could be concluded, therefore, that mothers were a better proposition. Decisions should, however, not be made merely on the number of beneficiaries; coverage cannot be the sole estimate of a programme's effectiveness, even if it does look good in the statistics book.
7.16. A nutrition intervention programme should be evaluated in terms of improvement in nutritional status (see chapter 9), but unfortunately success is difficult to identify using such criteria. In Sri Lanka (2), after a decade of maternal supplementation, estimates of the incidence of low birth-weight remain unchanged. Likewise, current surveys of pre-school-child malnutrition do not show a change from a survey carried out in 1975/76. This lack of success is a common finding; Beaton and Ghassemi have recently reviewed a number of international programmes, and it was impossible to demonstrate a significant improvement in any of them (1).
7.17. Why this is so is not easy to determine, but at least some of the blame must rest on logistic failures. It is considered in Sri Lanka, for example, that community involvement is crucial to the success of a government-sponsored programme, as this helps to minimize such problems at the local level.
7.18. General education has also been shown to be an important factor. Soysa 12) has related the level of education of Sri Lankan women to their utilization of health services and has found a positive correlation. She has claimed that literacy is one of the main factors responsible for the reduction in birth-rates in Sri Lanka. She has postulated that one of the reasons why nutrition messages are not getting through to the rural areas is because of inadequate attempts to improve conventional methods of education.
7.19. One common "leakage" of food aid identified in Sri Lanka was intra-familial, and perhaps the only practical approach is towards whole family units. This would increase the cost of a food-aid programme, but no woman in any culture will restrict food to her own use; she will always share it with her family. Thus, it might produce a better success rate if the whole family were aided, not just those clinically at risk.
The Wider Influence of Maternal and Child Nutrition Programmes
7.20. With all the complex social, economic, and political factors working against health improvements, it is not surprising that there is such a high apparent failure rate. There can, however, be positive achievements that are rarely taken into account. The introduction of a specific nutritional programme directed at the mother and her child succeeds in focusing the attention of governments on a specific health issue in a way that more indirect ways, such as wage increases, never can. This is an all-important factor politically and socially in shaping national policy. Clear research evidence must come from many countries before supplementary feeding is condemned outright as being totally ineffective and hence of low priority. This highlights the need for collaborative research of an applied nature between different developing countries.
7.21. In conclusion, it can be said that primary health centres must care for the nutritional health of both the mother and her children. Doctors and nurses, as well as auxiliaries, must be trained in maternal and child care and not just in obstetrics or paediatrics. Because an improvement in the nutrition and health status of a lactating woman can probably lead to an enhancement of her fertility, community-relevant family-planning procedures need to be identified and introduced as part of a complete health package.