Project Background
Nias island is the largest island off North Sumatra province’s west coast in Indonesia. It has a significant level of poverty and is ranked well below the Indonesian national standards. The Nias government requested SurfAid to expand its Mother and Child Health (MCH) program to the Gido subdistrict, where health outcomes have consistently been some of the worst in Nias. At the start of the programme, services were poor at the local mother and child Posyandu (Community Health Post), and health staff capacity was very low, leading to low attendance at the Posyandu.
SurfAid worked successfully with the local government and communities to improve this. We supported village midwives to increase their capacity to deliver antenatal care services, supported the health volunteers (Kader) to run the Posyandu, and delivered training and supported communities on key health behaviours that are crucial for MCH.
However, the uptake of key health behaviour – immediate and exclusive breastfeeding – continues to be low, putting infants at risk. Exclusive breastfeeding (meaning no food or drink other than breast milk) prevents pathogen ingestion through food and water, and in light of Gido’s compromised water quality, is a vital safeguard against infections.
Weighing process is an important part
of the development of children. Posyandu gave a notebook for every child so
their parents and Kader can monitor the development of their children. (Photo
by: Adzwari Ridzki)
Key Project Activities
Conversations with members of the local community shed light on deeply rooted cultural practices and beliefs that hinder the adoption of exclusive breastfeeding. There was a prevailing lack of awareness regarding the multiple advantages of breast milk. The pivotal challenge, however, was the lack of support from husbands, as women on Nias are often engaged in farming duties far from home.
Traditionally, women are expected to resume fieldwork three months after childbirth to support their spouses. They leave their infants with slightly older siblings or grandparents for prolonged periods, since community members strongly believe that infants should not accompany mothers to the fields. As mothers are more likely to breastfeed their babies directly (as there are often no absence of bottles, pumps, or ways to store breastmilk), infants do not receive exclusive breastfeeding as recommended.
To address these issues, SurfAid:
- Developed culturally appropriate informational materials to increase community engagement and understanding about the importance of breastfeeding, including practical guidelines for breast milk storage. This included bespoke video instructions, posters and brochures in the local language.
- Distributed the materials to the District Health Office, Regional Hospital, village midwives, and Kader Posyandu, and trained these stakeholder groups to use the materials, so that they can continue the interventions beyond this programme.
- Provided “classes for fathers” to improve their understanding of key women’s health issues, and especially to support exclusive breastfeeding practices. In Nias, men and in-laws still hold significant household-level decision-making power, so any solution must include them.
Key Project Outcomes
This project contributed directly to SurfAid's ongoing Mother and Child Health EHOWU2 program. EHOWU2’s central focus is to respond to key challenges the communities of Gido faced, including lack of access to quality basic health services, low access to basic health knowledge, and a lack of clean water and sanitation facilities.
This project contributed specifically to key behaviour change on immediate and exclusive breastfeeding, which in turn contributed to the overall EHOWU2 program results of lower infant and maternal deaths.
Specifically, the percentage of mothers and caregivers who:
- have knowledge of the 5 priority MCH behaviours. (antenatal care, exclusive, immediate breastfeeding, colostrum, birth spacing) went from 29% to 60%
- practise the 5 priority MCH behaviours went from 41% to 53%.
Further, some men, specifically fathers, included in the project changed their thinking about their contribution and responsibilities on childcare and support for breastfeeding. This is significant and the impacts of such changes in parenting practice cannot be underestimated.
Posyandu in Hiliduho served not only
children but pregnant women. Posyandu Kader gave vitamins to the pregnant
woman. The Kader asked pregnant women to come regularly to check up on their
pregnancy. (Photo by: Adzwari Ridzki)
Community involvement
SurfAid’s programmes seek to increase enthusiasm and demand for behaviour change activities, rather than providing short-term incentives for people to get involved, which often prove to be ineffective for longer-term sustainability. Levels of demand for programme activities directly correlates to positive uptake and outcomes. SurfAid worked to create an environment where community members wanted to participate, contribute or even become health volunteers (Kader), by demonstrating the benefits to families and communities, creating a supportive environment, and removing barriers to becoming Kader.
The Kaders served as peer educators and worked with SurfAid staff to create the relevant materials. Almost 100% of the health volunteers are women. Through an empowering methodology, SurfAid fosters local leadership, cultivating the potential of village residents to drive community progress. In a sign of progress, Kaders were able to voice their aspirations for village strategy in the village decision-making forum. Having women included in decision-making processes and feeling confident and able to use their voice to pursue the changes they wish to see is one of this project’s and EHOWU2’s greatest achievement.
What's next?
A year after the project ended, an impact study was done. It concluded in general the results of the EHOWU2 program were still good. The number of toddlers visiting the Posyandu was still high, as was the skill level of Kader. Prenatal care and childbirth with the assistance of health workers continued to be good. The skilled Kaders kept delivering quality information and support to the key behaviours.
These results are sustained by policy support from the central government to villages related to MCH and support from the local government for Posyandu, as indicated by the existence of a special line in the village budget (APBDes). In some villages the budget had even increased.
Project background
SurfAid works in remote islands in Indonesia, where access to basic services is very low. This contributes to high maternal and child mortality rates, and low mother-and-child health status. Indonesia is one of ten countries with the highest number of deaths under the age of five due to lack of basic health care, access to clean water and sanitation, and food insecurity. Nearly 28 million Indonesians lack safe water, and 71 million lack access to improved sanitation facilities.
Breast milk is one of the most important components of infant care. It provides complete nutrition and helps to prevent and fight infections. Malnutrition can make a person more susceptible to infection, and infection contributes to further malnutrition - causing a vicious cycle.
Exclusive breastfeeding (meaning no food or drink other than breast milk) helps break this cycle as it prevents the intake of pathogens in food or water. Given the poor water quality in Indonesia, exclusive breastfeeding can help protect infants, minimising the damage caused by the malnutrition-infection cycle.
Project overview
The World Health Organization (WHO) and UNICEF recommend early initiation of breastfeeding, exclusive breastfeeding to 6 months and partial breastfeeding (meaning a diet of breast milk along with some other food and drink) to age 24 months to improve infant and maternal health. In Nias, a remote island in Indonesia, uptake of exclusive breastfeeding is very low.
Our interviews with community members show that traditional practices and beliefs negatively impact the uptake of the practice and there is limited knowledge about the advantages of breast milk. The main barrier however, is the lack of support for husbands. All Nias women have farming tasks in the field, often hours away from their home. Usually, women are expected to go back to work in the field to support her husband three months after delivering their child.
They leave their babies at home for hours in the care of slightly older siblings or grandparents because community members strongly believe that babies should not go with their mother to the field. As mothers are more likely to breastfeed their babies directly (as there are often no bottles, pumps, or ways to store breast milk), these babies do not receive exclusive breastfeeding as recommended.
This project will focus on increasing the uptake of exclusive breastfeeding by gaining the support of husbands, fathers and male family members.
Activities will include:
- Developing information, education and communication materials to increase community engagement and knowledge about the importance of breastfeeding, and practicalities how to store breast milk.
- Delivering information and behavior change sessions to husbands, fathers and male family members on exclusive breastfeeding.
What's covered in project cost
$22,500 of the total $25,000 raised by the Footprints Network will go towards:
- Development of a community-led educational video and games on how fathers can support exclusive breastfeeding, tailored to local cultural context. This includes: workshop with health promotion staff, community volunteers for script development, practising, renting equipment, producing the video and games.
- Development of information materials, including posters and brochures, on key messages on exclusive breastfeeding, for men and women, tailored to local cultural context.
- Workshops with fathers and mothers and community health volunteers in two sub-districts in Nias (Hiliduho and Gido) using the developed materials.
The remaining $2,500 will go towards accountability and quality assurance costs.
Partners and community involvement
This project will work directly with communities in Hiliduho and Gido, training community health volunteers as peer educators to increase community engagement and education on key messages. SurfAid works with communities to develop their own solutions that are culturally and geographically appropriate to the unique environment of remote islands. Using a ‘hand up, not a hand out’ approach, SurfAid develops leaders from within villages and builds their capacity to support the development of the community.
In conjunction with the villages themselves, SurfAid also works in partnership with the Indonesian government to achieve national priorities and increase the sustainability of achieved outcomes.
Part of a larger strategy
SurfAid is implementing an overarching five-year Mother and Child Health program in Nias that focuses not only on improving nutrition, but access to clean water and health education services too.
This project is one of many smaller projects which contribute to the desired outcome of improved nutrition and mother and child health. Uptake of breastfeeding provides one of the three requisite components to achieve this outcome: improved health status and food utilisation. Other projects within the program address food availability and access to food (additional household income).