AID EVALUATION SUMMARY PART I(BEFORE FILLING OUT THIS FORM READ THE ATTACHED INSTRUCTIONS) A REPORTING AID UNIT B WAS EVALUATION SCHEDULED IN C EVALUATION TIMING USAIDBelize CURRENT FY ANNUAL EVALUATION PLAN(Mission or AJDW Office) yes[3 Slipped El ad hoc ] Interim [] final 0 Ox Post [3 other 0

(ES ) Eva] Plan Submission Date FY 0D ACTIVITY OR ACTIVITIES EVALUATED (Ust the following Informaion for project(s) or program(amp) evaluated

If not applicable lIst title and date of the ervuuation report)Projiect 0 ProiectProgram Tte First PROAG Most Planned knount(r ievatereportf

evaluation report) or equivaient recent LOP Obligated(FY) PACO Cost to Datei 505-0029 Breast is Best League (moyr) COOo) (000)

1287 62 0 w Evaluation Report

EACTION DECISIONS APPROVED BY MISSION OR AJDW OFFICE DIRECTORA ct o n( ) Name of officerR q uire spo nsib le fo r Date Actionction(s) Required to be1 Revise budget line items to allow for Action CompletedSJG Brechin-production of additional promotional

31 July 87

materials -hiring a full-time secretary-increased transportation expenses-purchase of additional equipment-replacing present program assistant withmore qualified program assistant2 Develop plan and timetable for District E Middleton 15 Sept 87follow-up of counsellors3 Coordinate with Project HOPE and others for E Middletono technical assistance to develop data col-

30 Oct 87 F lt

lection tool for evaluation of training4 Extend PACD to 588 to coincide with start- SJG Brechin 31 July 87shyup of new child survival project

(Attach extra sheet ifnecessary)F DATE OF MISSION OR AIDW OFFICE REVIEW OF EVALUATION 6 dav 1 yr8 7mo G APPROVALS OF EVALUATION SUMMARY AND ACTION DECISIONS

ProjectProgram L-resewtaive oof icereEvaluationoOfficer rectetaivooeJ~teOfcr-rc salon or Aina 1 CL Signature

Typed Name rec toLauva Middlen A ekEvaeva Brahich D t a

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PAGE 2H KLYA LUA TIO IJ (do n otA OSTRA CT thec d aIPMmProv dideThis project aims through the activities of an indigenous pvoLeague (BIB) the Breast is Bestto improve the nutritional status of infants in Belize by increasingthe number of women who fully breastfeed their infants for four months BIBoperates on a nationwide basis through mass media promotional activities and a network of trained breastfeeding counsellors under the guidance of an ExecutiveDirector (ED) based in Belize City A one-week evaluation was conducted by anindependent consultant familiar with Belize to determine BIBs effectiveness and torecommend actions for the projects final year to improve public education and tomove towards insti utionalization

The major achievements findings and recommendations are Successful promotion of breastfeeding in Belize with a rate ofsolely breastfeeding for the first four months after delivery

over 45 of women

Recommendation More promotional materials in Spanish should be available Model program established for the Crriobean where there are no with ED used as a resource person fOL conferences and seminars

similar programsSuccessful collaboration with MOH and other PVOs including MOH national-levelbreastfeeding coordinator appointed as a liaison to BIB

Recommendation Permanent office space should be sought from MOH to increaseliaison

The ED is over-extended and unable to be itthe Districts as much as is neededBIB also lacks specific plans for following up BFCs Recommendation Hire a full-time secretary and develop timetable for districtfollow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future

Lessons Learned

-Despite lack ofcounsellors do continue to work regularly and submit records of their actvities to the ED

a follow-up plan to support BFCs in the Districts the

BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

I EVALUATION COSTS

Name Pffiliaon Confta Number QR Contract Cost CR Sou e cfT Y Person DaysPamela Putney MSN Independent 505-0029-087-125TDY Cost (USsj) Funcs$1400 Health Consultant

P MiissionOffice Professional Staff Person-Oays (estimate) 2 3 BorrowerGrantee Professional

Staff PersonDays (esnmate)

0

4

--

--

--

--

AID EVALUATION SUMMARY PART II J SUM4ARY OF EVALUATION FINDINGS CONCLUSIONS AND RECOMMENDATIONS (Try not to eGzAddress the following hemp

e 3 page provided)

urpose of acivity(es) evaluated P Princial recommendationsurpose of evaluation and Methodology used

Lessons learnedSFindings and canclusions (relate to ouestions) Mission or Office USAIDBelize

Date this summary preoarea 10 July 1987Title and Date of Full Eiuation Reo Evaluation Report - Breast is Best League Belize 11 June 1987Tnis project aims through the activities of an indigenous PVO the Breast is BestLeague (BIB) to improve the nutritional status of infants in Belize by increasingthe number of women who fully breastfeed their infants for four months Theproject began in January 1985 and ends in December 1987

BIB operates on a nationwide basis through massnetwork of media promotional activities and atrained breastfeeding counsellors under the guidance of an3[rector (ED) and Program Assistant based in Belize City Executive

Liaison is maintained_9-h the MOH to promote breastfeeding in the hospirals especially in Belize Cityere many of Belizes deliveries take placeBelize District Because breastfeeding statistics forare the worst in the country emphasis on breastfeeding promotionfor Belize City has been a priority A one-week interim evaluation was conducted by an independent consultant familiarwith Belize to

assess BIBs effectiveness in increasing public awareness of breastfeedingevaluate BIBs efforts in fund-raising program management and consolidation ofBIBs role as

-- a PVOto recommend actions for the projects final year to to

improve public education andmove towards institutionalization

Methodology The consultant reviewed project documentsand training materials) and (including 1987 Work Planinterviewed MOH personnel atlevel Dreastfeeding counsellors national and district(BFCs) in 4 of Belizes 6 districts staff from

other PVOs coordinating with BIB members of the Board of directors clientsspouses a private physician and otners

The major achievements findings and recommendations are -- Successful oromotion of breastfeeding in Belize with a rate of over 45 of womensolely breastfeeding for the first four months after deliveryRecommendation More promotional materials in Spanish should be available toincrease access to Spanish-speakers

Model program established for the Caribbean where there are nowith ED used as similar programsa resource person for conferences and seminarsSuccessful collaboration with MOH and other Dreastfeeding coordinator appointed as

PVOs including MOH national-level a liaison to BIB

--

--

--

--

Recommendation Permanent office space should be sought from MOH to increaseliaison and work at tne Nursing School and Belize City Hospital should continue toremain a priority

-- The ED is over-extended and unable to be in the Districts as much as is neededBIB also lacks specific plans for following up BFCs

Recommendation Hire a full-time secretary and develop timetable for district follow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future -- Data collection is weak and this weakness needs to be addressed

Other recommendations

I Defer training in Stann Creek District for several months to develop andimplement data collection tool to evaluate impact of training

2 BIB should work with MOH to

--designate Breastfeeding Week in fall 1987

work with MOHMCH Director to develop a physicians education plan

--increase activities at the Nursing School and Belize City Hospital since thelowest rate of Dreastfeeding continues to be in Belize City

3 More thought should be given to a variety of promotional materials such asanother breasfeeding promotonal calendar continuing production of BIB bags andT-shirts and providing sturdy notebooks to BFCs to protect existing promotional materials

4 Increase number ot breast puips as well as rental fees for pumps

5 Purchase a bicycle to increase staff mobility for home visits to womendischarged from the Maternity Ward and to those having difficulties with breastfeeding

Lessons Learned

Despite lack of a follow-up plan to support BFCs in the Districts thecounsellors do continue to work regularly and submit records of their activities to the ED BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

K ATTACHMENTS (Ustattachments submed wt thl Evluaon Summary01we ttah copy of full PAGE 6

evaluation report even Ifone was submitted earlier)

1 Scope of Work

2 Evaluation Rep6rt

L COMMENTS BY MISSION AIDW OFFICE AND BORROWERGRANTEE The evaluation emphasized that institutionalization for BIB is notimmediate future in theOne lesson learned was particularly strikingthe fact the BIB has had Despite

no formal follow-up plan for district workbreastfeeding counsellors were theout in the Districts working recording theirwork and sending these forms into the BIB Executive Director in Belize CityThis has meant that district work has assumed and means

not lost as much impetus as was beingmore time for exploring a working strategy for districtsupport that will not tax the few resources available in the national office The evaluation has documented the successful breastfeeding promotion done byBIB documented the need to extend the project and will be helpful inassessing project direction for the upcoming Umbrella project Itsdocumentation of the EDs being over-extended has given the Board the impetusto agree to hire a full-time secretary to take care of much of the officework freeing the ED for liaison and counselling activities

An independent consultant who had just worked in Belize for 15 monthsfor the evaluation was usedIn this case it was extremely advantageous because sheknew everyone in the MOH and knew Belize and so was able to get a lot ofinformation especially from those in MOH Belizeans in the MOH told her thatthey would not have talked so freely to an outsider

0V Z a

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

--

--

--

--

--

--

PAGE 2H KLYA LUA TIO IJ (do n otA OSTRA CT thec d aIPMmProv dideThis project aims through the activities of an indigenous pvoLeague (BIB) the Breast is Bestto improve the nutritional status of infants in Belize by increasingthe number of women who fully breastfeed their infants for four months BIBoperates on a nationwide basis through mass media promotional activities and a network of trained breastfeeding counsellors under the guidance of an ExecutiveDirector (ED) based in Belize City A one-week evaluation was conducted by anindependent consultant familiar with Belize to determine BIBs effectiveness and torecommend actions for the projects final year to improve public education and tomove towards insti utionalization

The major achievements findings and recommendations are Successful promotion of breastfeeding in Belize with a rate ofsolely breastfeeding for the first four months after delivery

over 45 of women

Recommendation More promotional materials in Spanish should be available Model program established for the Crriobean where there are no with ED used as a resource person fOL conferences and seminars

similar programsSuccessful collaboration with MOH and other PVOs including MOH national-levelbreastfeeding coordinator appointed as a liaison to BIB

Recommendation Permanent office space should be sought from MOH to increaseliaison

The ED is over-extended and unable to be itthe Districts as much as is neededBIB also lacks specific plans for following up BFCs Recommendation Hire a full-time secretary and develop timetable for districtfollow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future

Lessons Learned

-Despite lack ofcounsellors do continue to work regularly and submit records of their actvities to the ED

a follow-up plan to support BFCs in the Districts the

BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

I EVALUATION COSTS

Name Pffiliaon Confta Number QR Contract Cost CR Sou e cfT Y Person DaysPamela Putney MSN Independent 505-0029-087-125TDY Cost (USsj) Funcs$1400 Health Consultant

P MiissionOffice Professional Staff Person-Oays (estimate) 2 3 BorrowerGrantee Professional

Staff PersonDays (esnmate)

0

4

--

--

--

--

AID EVALUATION SUMMARY PART II J SUM4ARY OF EVALUATION FINDINGS CONCLUSIONS AND RECOMMENDATIONS (Try not to eGzAddress the following hemp

e 3 page provided)

urpose of acivity(es) evaluated P Princial recommendationsurpose of evaluation and Methodology used

Lessons learnedSFindings and canclusions (relate to ouestions) Mission or Office USAIDBelize

Date this summary preoarea 10 July 1987Title and Date of Full Eiuation Reo Evaluation Report - Breast is Best League Belize 11 June 1987Tnis project aims through the activities of an indigenous PVO the Breast is BestLeague (BIB) to improve the nutritional status of infants in Belize by increasingthe number of women who fully breastfeed their infants for four months Theproject began in January 1985 and ends in December 1987

BIB operates on a nationwide basis through massnetwork of media promotional activities and atrained breastfeeding counsellors under the guidance of an3[rector (ED) and Program Assistant based in Belize City Executive

Liaison is maintained_9-h the MOH to promote breastfeeding in the hospirals especially in Belize Cityere many of Belizes deliveries take placeBelize District Because breastfeeding statistics forare the worst in the country emphasis on breastfeeding promotionfor Belize City has been a priority A one-week interim evaluation was conducted by an independent consultant familiarwith Belize to

assess BIBs effectiveness in increasing public awareness of breastfeedingevaluate BIBs efforts in fund-raising program management and consolidation ofBIBs role as

-- a PVOto recommend actions for the projects final year to to

improve public education andmove towards institutionalization

Methodology The consultant reviewed project documentsand training materials) and (including 1987 Work Planinterviewed MOH personnel atlevel Dreastfeeding counsellors national and district(BFCs) in 4 of Belizes 6 districts staff from

other PVOs coordinating with BIB members of the Board of directors clientsspouses a private physician and otners

The major achievements findings and recommendations are -- Successful oromotion of breastfeeding in Belize with a rate of over 45 of womensolely breastfeeding for the first four months after deliveryRecommendation More promotional materials in Spanish should be available toincrease access to Spanish-speakers

Model program established for the Caribbean where there are nowith ED used as similar programsa resource person for conferences and seminarsSuccessful collaboration with MOH and other Dreastfeeding coordinator appointed as

PVOs including MOH national-level a liaison to BIB

--

--

--

--

Recommendation Permanent office space should be sought from MOH to increaseliaison and work at tne Nursing School and Belize City Hospital should continue toremain a priority

-- The ED is over-extended and unable to be in the Districts as much as is neededBIB also lacks specific plans for following up BFCs

Recommendation Hire a full-time secretary and develop timetable for district follow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future -- Data collection is weak and this weakness needs to be addressed

Other recommendations

I Defer training in Stann Creek District for several months to develop andimplement data collection tool to evaluate impact of training

2 BIB should work with MOH to

--designate Breastfeeding Week in fall 1987

work with MOHMCH Director to develop a physicians education plan

--increase activities at the Nursing School and Belize City Hospital since thelowest rate of Dreastfeeding continues to be in Belize City

3 More thought should be given to a variety of promotional materials such asanother breasfeeding promotonal calendar continuing production of BIB bags andT-shirts and providing sturdy notebooks to BFCs to protect existing promotional materials

4 Increase number ot breast puips as well as rental fees for pumps

5 Purchase a bicycle to increase staff mobility for home visits to womendischarged from the Maternity Ward and to those having difficulties with breastfeeding

Lessons Learned

Despite lack of a follow-up plan to support BFCs in the Districts thecounsellors do continue to work regularly and submit records of their activities to the ED BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

K ATTACHMENTS (Ustattachments submed wt thl Evluaon Summary01we ttah copy of full PAGE 6

evaluation report even Ifone was submitted earlier)

1 Scope of Work

2 Evaluation Rep6rt

L COMMENTS BY MISSION AIDW OFFICE AND BORROWERGRANTEE The evaluation emphasized that institutionalization for BIB is notimmediate future in theOne lesson learned was particularly strikingthe fact the BIB has had Despite

no formal follow-up plan for district workbreastfeeding counsellors were theout in the Districts working recording theirwork and sending these forms into the BIB Executive Director in Belize CityThis has meant that district work has assumed and means

not lost as much impetus as was beingmore time for exploring a working strategy for districtsupport that will not tax the few resources available in the national office The evaluation has documented the successful breastfeeding promotion done byBIB documented the need to extend the project and will be helpful inassessing project direction for the upcoming Umbrella project Itsdocumentation of the EDs being over-extended has given the Board the impetusto agree to hire a full-time secretary to take care of much of the officework freeing the ED for liaison and counselling activities

An independent consultant who had just worked in Belize for 15 monthsfor the evaluation was usedIn this case it was extremely advantageous because sheknew everyone in the MOH and knew Belize and so was able to get a lot ofinformation especially from those in MOH Belizeans in the MOH told her thatthey would not have talked so freely to an outsider

0V Z a

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

--

--

--

--

AID EVALUATION SUMMARY PART II J SUM4ARY OF EVALUATION FINDINGS CONCLUSIONS AND RECOMMENDATIONS (Try not to eGzAddress the following hemp

e 3 page provided)

urpose of acivity(es) evaluated P Princial recommendationsurpose of evaluation and Methodology used

Lessons learnedSFindings and canclusions (relate to ouestions) Mission or Office USAIDBelize

Date this summary preoarea 10 July 1987Title and Date of Full Eiuation Reo Evaluation Report - Breast is Best League Belize 11 June 1987Tnis project aims through the activities of an indigenous PVO the Breast is BestLeague (BIB) to improve the nutritional status of infants in Belize by increasingthe number of women who fully breastfeed their infants for four months Theproject began in January 1985 and ends in December 1987

BIB operates on a nationwide basis through massnetwork of media promotional activities and atrained breastfeeding counsellors under the guidance of an3[rector (ED) and Program Assistant based in Belize City Executive

Liaison is maintained_9-h the MOH to promote breastfeeding in the hospirals especially in Belize Cityere many of Belizes deliveries take placeBelize District Because breastfeeding statistics forare the worst in the country emphasis on breastfeeding promotionfor Belize City has been a priority A one-week interim evaluation was conducted by an independent consultant familiarwith Belize to

assess BIBs effectiveness in increasing public awareness of breastfeedingevaluate BIBs efforts in fund-raising program management and consolidation ofBIBs role as

-- a PVOto recommend actions for the projects final year to to

improve public education andmove towards institutionalization

Methodology The consultant reviewed project documentsand training materials) and (including 1987 Work Planinterviewed MOH personnel atlevel Dreastfeeding counsellors national and district(BFCs) in 4 of Belizes 6 districts staff from

other PVOs coordinating with BIB members of the Board of directors clientsspouses a private physician and otners

The major achievements findings and recommendations are -- Successful oromotion of breastfeeding in Belize with a rate of over 45 of womensolely breastfeeding for the first four months after deliveryRecommendation More promotional materials in Spanish should be available toincrease access to Spanish-speakers

Model program established for the Caribbean where there are nowith ED used as similar programsa resource person for conferences and seminarsSuccessful collaboration with MOH and other Dreastfeeding coordinator appointed as

PVOs including MOH national-level a liaison to BIB

--

--

--

--

Recommendation Permanent office space should be sought from MOH to increaseliaison and work at tne Nursing School and Belize City Hospital should continue toremain a priority

-- The ED is over-extended and unable to be in the Districts as much as is neededBIB also lacks specific plans for following up BFCs

Recommendation Hire a full-time secretary and develop timetable for district follow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future -- Data collection is weak and this weakness needs to be addressed

Other recommendations

I Defer training in Stann Creek District for several months to develop andimplement data collection tool to evaluate impact of training

2 BIB should work with MOH to

--designate Breastfeeding Week in fall 1987

work with MOHMCH Director to develop a physicians education plan

--increase activities at the Nursing School and Belize City Hospital since thelowest rate of Dreastfeeding continues to be in Belize City

3 More thought should be given to a variety of promotional materials such asanother breasfeeding promotonal calendar continuing production of BIB bags andT-shirts and providing sturdy notebooks to BFCs to protect existing promotional materials

4 Increase number ot breast puips as well as rental fees for pumps

5 Purchase a bicycle to increase staff mobility for home visits to womendischarged from the Maternity Ward and to those having difficulties with breastfeeding

Lessons Learned

Despite lack of a follow-up plan to support BFCs in the Districts thecounsellors do continue to work regularly and submit records of their activities to the ED BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

K ATTACHMENTS (Ustattachments submed wt thl Evluaon Summary01we ttah copy of full PAGE 6

evaluation report even Ifone was submitted earlier)

1 Scope of Work

2 Evaluation Rep6rt

L COMMENTS BY MISSION AIDW OFFICE AND BORROWERGRANTEE The evaluation emphasized that institutionalization for BIB is notimmediate future in theOne lesson learned was particularly strikingthe fact the BIB has had Despite

no formal follow-up plan for district workbreastfeeding counsellors were theout in the Districts working recording theirwork and sending these forms into the BIB Executive Director in Belize CityThis has meant that district work has assumed and means

not lost as much impetus as was beingmore time for exploring a working strategy for districtsupport that will not tax the few resources available in the national office The evaluation has documented the successful breastfeeding promotion done byBIB documented the need to extend the project and will be helpful inassessing project direction for the upcoming Umbrella project Itsdocumentation of the EDs being over-extended has given the Board the impetusto agree to hire a full-time secretary to take care of much of the officework freeing the ED for liaison and counselling activities

An independent consultant who had just worked in Belize for 15 monthsfor the evaluation was usedIn this case it was extremely advantageous because sheknew everyone in the MOH and knew Belize and so was able to get a lot ofinformation especially from those in MOH Belizeans in the MOH told her thatthey would not have talked so freely to an outsider

0V Z a

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

--

--

--

--

Recommendation Permanent office space should be sought from MOH to increaseliaison and work at tne Nursing School and Belize City Hospital should continue toremain a priority

-- The ED is over-extended and unable to be in the Districts as much as is neededBIB also lacks specific plans for following up BFCs

Recommendation Hire a full-time secretary and develop timetable for district follow-up

BIB has been very successful but cannot expect to function at its present levelof activity without continued USAID support for the near future -- Data collection is weak and this weakness needs to be addressed

Other recommendations

I Defer training in Stann Creek District for several months to develop andimplement data collection tool to evaluate impact of training

2 BIB should work with MOH to

--designate Breastfeeding Week in fall 1987

work with MOHMCH Director to develop a physicians education plan

--increase activities at the Nursing School and Belize City Hospital since thelowest rate of Dreastfeeding continues to be in Belize City

3 More thought should be given to a variety of promotional materials such asanother breasfeeding promotonal calendar continuing production of BIB bags andT-shirts and providing sturdy notebooks to BFCs to protect existing promotional materials

4 Increase number ot breast puips as well as rental fees for pumps

5 Purchase a bicycle to increase staff mobility for home visits to womendischarged from the Maternity Ward and to those having difficulties with breastfeeding

Lessons Learned

Despite lack of a follow-up plan to support BFCs in the Districts thecounsellors do continue to work regularly and submit records of their activities to the ED BIBs Board of Directors successfully works together despite the variouspolitical factions represented an unusual situation in Belize

K ATTACHMENTS (Ustattachments submed wt thl Evluaon Summary01we ttah copy of full PAGE 6

evaluation report even Ifone was submitted earlier)

1 Scope of Work

2 Evaluation Rep6rt

L COMMENTS BY MISSION AIDW OFFICE AND BORROWERGRANTEE The evaluation emphasized that institutionalization for BIB is notimmediate future in theOne lesson learned was particularly strikingthe fact the BIB has had Despite

no formal follow-up plan for district workbreastfeeding counsellors were theout in the Districts working recording theirwork and sending these forms into the BIB Executive Director in Belize CityThis has meant that district work has assumed and means

not lost as much impetus as was beingmore time for exploring a working strategy for districtsupport that will not tax the few resources available in the national office The evaluation has documented the successful breastfeeding promotion done byBIB documented the need to extend the project and will be helpful inassessing project direction for the upcoming Umbrella project Itsdocumentation of the EDs being over-extended has given the Board the impetusto agree to hire a full-time secretary to take care of much of the officework freeing the ED for liaison and counselling activities

An independent consultant who had just worked in Belize for 15 monthsfor the evaluation was usedIn this case it was extremely advantageous because sheknew everyone in the MOH and knew Belize and so was able to get a lot ofinformation especially from those in MOH Belizeans in the MOH told her thatthey would not have talked so freely to an outsider

0V Z a

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

K ATTACHMENTS (Ustattachments submed wt thl Evluaon Summary01we ttah copy of full PAGE 6

evaluation report even Ifone was submitted earlier)

1 Scope of Work

2 Evaluation Rep6rt

L COMMENTS BY MISSION AIDW OFFICE AND BORROWERGRANTEE The evaluation emphasized that institutionalization for BIB is notimmediate future in theOne lesson learned was particularly strikingthe fact the BIB has had Despite

no formal follow-up plan for district workbreastfeeding counsellors were theout in the Districts working recording theirwork and sending these forms into the BIB Executive Director in Belize CityThis has meant that district work has assumed and means

not lost as much impetus as was beingmore time for exploring a working strategy for districtsupport that will not tax the few resources available in the national office The evaluation has documented the successful breastfeeding promotion done byBIB documented the need to extend the project and will be helpful inassessing project direction for the upcoming Umbrella project Itsdocumentation of the EDs being over-extended has given the Board the impetusto agree to hire a full-time secretary to take care of much of the officework freeing the ED for liaison and counselling activities

An independent consultant who had just worked in Belize for 15 monthsfor the evaluation was usedIn this case it was extremely advantageous because sheknew everyone in the MOH and knew Belize and so was able to get a lot ofinformation especially from those in MOH Belizeans in the MOH told her thatthey would not have talked so freely to an outsider

0V Z a

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

Project 505-0029 - Breast is Best League ) Project Evaluation

May 18 - 22 1987

Objective The objective of the evaluation is to determine theeffectiveness of this project in (a) developing the Breast is BestLeague into an organization capable of responding to the challengesin Belize of extending and consolidating the practice of breastfeeding 0and (b) attaining the objectives established for trainingand public education

Scope of Work

The consultant will a) As~ess the success of the project in increasing pub lic

awareness of breast feeding issues and benefitsb) Assess the impact the project has had in increasing the

number of sufficiently trained and functioning breast feeding counsellors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO and

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

For each of these Factors findings conclusions and recommendations should be detailed

Methodology and Time Frame

This evaluation will be conducted in Belize over a five day periodMay 18 - 22 1987 The evaluator is expected to meet and interviewpersonnel at the BIB League USAID the Ministry of Health trainedbreastfeeding counsellors and other individuals who have hadcontact with the project in its implementation The consultant willreview program plan training curricula and plans for developmentand institutionalization of the League

Report bull

A draft report is u0 be discussed at the en ojf ic evaiuarion iththe Directors of B- League and USAID Five Opes of the Einalreport must be sub Ltted witihhn fouf- centeL of 1C complet ion of The eva Iuta ion

Qualifications

The consultant must be an experienced professional with at-least 6years involvement in planning implementing and evaluatingbreastfeeding promotion projects An MD or MPH degree would beadvantageousto the consultants credibility in Belliz

Evaluation Report

BREAST IS BEST LEAGUE

BELIZE

Pamela J Putney i June 1987

TABLE OF CONTENTS

Abbreviations Page

I Executive Summary 1 A Project Strengths 1B Project Weaknesses 1C Major Recommendations 1

II Background 3 A BIB League 3

1 Overview 32 USAID Involvement with BIB 3

B Belize 4 1 Social Economic and Political Overview 4 2 Health Care Structure 5 3 MCH Statistics 6 4 National Policies for MCH 7

III Project Objectives and Achievements 9 A ManagementFundraising 9

1 Direction and Execution of Goals 9 a Advisory Board 9 b Collaboration with Project Hope 10 c Leadership Skills of Executive Director 10

2 Finances 11B Training 11

a Curriculum 11 b Recruitment 12 c Implementation 12 d Follow-up 12

C Educational Programs 13 a Inservice for Public 13 b Inservice for Mothers 13 c Inservice for Nurses 13 d Collaboration with Local Organizations 14 e Information PacketsResource Materials 14 f Counseling HoursLending Library 15

D Promotion 13 a CalendarsPosters 15 b RadioTVNewspaper Articles 15 c Awards 16 d T-ShirtsBags 16

IV Analysis 17 A Impact on Public Awareness 17B Training 17C Management 17D Institutionalization 17E Data Collection 18

V Recommendations 19

APPENDICES

Page About the Evaluation 21 List of Contacts 22-23 Statistics on Breastfeeding 24 List of Counselors 25-29

Number

Breast is Best Information Packet

Samples of Counselor Consultations 1

Copies of Letters from Counselors 2 Outline from a Continuing Education Workshop 3 School of Nursing Curriculum 4 Curiiculum for Breast Feeding Counselors 5 Training Pretest 6 By Laws of BIB League 7 BIB League Philosophy 8 List of Accomplishments 1985-86 19 Map of Belize 10

ABBREVIATIONS

BIB Breast is Best

BFC Breast Feeding Counselor

MOH Ministry of Health

PVO Private Voluntary Organization

ORT Oral Rehydration Therapy

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

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II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

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B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

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Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

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In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

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The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

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2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

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III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

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the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

Evaluation Report

BREAST IS BEST LEAGUE

BELIZE

Pamela J Putney i June 1987

TABLE OF CONTENTS

Abbreviations Page

I Executive Summary 1 A Project Strengths 1B Project Weaknesses 1C Major Recommendations 1

II Background 3 A BIB League 3

1 Overview 32 USAID Involvement with BIB 3

B Belize 4 1 Social Economic and Political Overview 4 2 Health Care Structure 5 3 MCH Statistics 6 4 National Policies for MCH 7

III Project Objectives and Achievements 9 A ManagementFundraising 9

1 Direction and Execution of Goals 9 a Advisory Board 9 b Collaboration with Project Hope 10 c Leadership Skills of Executive Director 10

2 Finances 11B Training 11

a Curriculum 11 b Recruitment 12 c Implementation 12 d Follow-up 12

C Educational Programs 13 a Inservice for Public 13 b Inservice for Mothers 13 c Inservice for Nurses 13 d Collaboration with Local Organizations 14 e Information PacketsResource Materials 14 f Counseling HoursLending Library 15

D Promotion 13 a CalendarsPosters 15 b RadioTVNewspaper Articles 15 c Awards 16 d T-ShirtsBags 16

IV Analysis 17 A Impact on Public Awareness 17B Training 17C Management 17D Institutionalization 17E Data Collection 18

V Recommendations 19

APPENDICES

Page About the Evaluation 21 List of Contacts 22-23 Statistics on Breastfeeding 24 List of Counselors 25-29

Number

Breast is Best Information Packet

Samples of Counselor Consultations 1

Copies of Letters from Counselors 2 Outline from a Continuing Education Workshop 3 School of Nursing Curriculum 4 Curiiculum for Breast Feeding Counselors 5 Training Pretest 6 By Laws of BIB League 7 BIB League Philosophy 8 List of Accomplishments 1985-86 19 Map of Belize 10

ABBREVIATIONS

BIB Breast is Best

BFC Breast Feeding Counselor

MOH Ministry of Health

PVO Private Voluntary Organization

ORT Oral Rehydration Therapy

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

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Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

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In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

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The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

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2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

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III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

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the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

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b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

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the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

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f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

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In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

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IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

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1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

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V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

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13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

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APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

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LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

TABLE OF CONTENTS

Abbreviations Page

I Executive Summary 1 A Project Strengths 1B Project Weaknesses 1C Major Recommendations 1

II Background 3 A BIB League 3

1 Overview 32 USAID Involvement with BIB 3

B Belize 4 1 Social Economic and Political Overview 4 2 Health Care Structure 5 3 MCH Statistics 6 4 National Policies for MCH 7

III Project Objectives and Achievements 9 A ManagementFundraising 9

1 Direction and Execution of Goals 9 a Advisory Board 9 b Collaboration with Project Hope 10 c Leadership Skills of Executive Director 10

2 Finances 11B Training 11

a Curriculum 11 b Recruitment 12 c Implementation 12 d Follow-up 12

C Educational Programs 13 a Inservice for Public 13 b Inservice for Mothers 13 c Inservice for Nurses 13 d Collaboration with Local Organizations 14 e Information PacketsResource Materials 14 f Counseling HoursLending Library 15

D Promotion 13 a CalendarsPosters 15 b RadioTVNewspaper Articles 15 c Awards 16 d T-ShirtsBags 16

IV Analysis 17 A Impact on Public Awareness 17B Training 17C Management 17D Institutionalization 17E Data Collection 18

V Recommendations 19

APPENDICES

Page About the Evaluation 21 List of Contacts 22-23 Statistics on Breastfeeding 24 List of Counselors 25-29

Number

Breast is Best Information Packet

Samples of Counselor Consultations 1

Copies of Letters from Counselors 2 Outline from a Continuing Education Workshop 3 School of Nursing Curriculum 4 Curiiculum for Breast Feeding Counselors 5 Training Pretest 6 By Laws of BIB League 7 BIB League Philosophy 8 List of Accomplishments 1985-86 19 Map of Belize 10

ABBREVIATIONS

BIB Breast is Best

BFC Breast Feeding Counselor

MOH Ministry of Health

PVO Private Voluntary Organization

ORT Oral Rehydration Therapy

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

(5)

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

(10)

2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

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CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

APPENDICES

Page About the Evaluation 21 List of Contacts 22-23 Statistics on Breastfeeding 24 List of Counselors 25-29

Number

Breast is Best Information Packet

Samples of Counselor Consultations 1

Copies of Letters from Counselors 2 Outline from a Continuing Education Workshop 3 School of Nursing Curriculum 4 Curiiculum for Breast Feeding Counselors 5 Training Pretest 6 By Laws of BIB League 7 BIB League Philosophy 8 List of Accomplishments 1985-86 19 Map of Belize 10

ABBREVIATIONS

BIB Breast is Best

BFC Breast Feeding Counselor

MOH Ministry of Health

PVO Private Voluntary Organization

ORT Oral Rehydration Therapy

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

(5)

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

(10)

2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

ABBREVIATIONS

BIB Breast is Best

BFC Breast Feeding Counselor

MOH Ministry of Health

PVO Private Voluntary Organization

ORT Oral Rehydration Therapy

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

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B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

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Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

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In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

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The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

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2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

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III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

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the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

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b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

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the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

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f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

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In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

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IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

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1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

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V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

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13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

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APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

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BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

I EXECUTIVE SUMMARY

Breast is Best was founded in 1981 by a group of Belizean women concerned about breastfeeding Since 1985 USAID has funded the Leaguein its efforts to increase public awareness about the benefits ofbreastfeeding versus bottlefeeding and in the promotion of breastfeedingcountrywide With the support of USAID as well as other organizationsBIB has been extremely successful in attaining all the goals of theproject While some problems do exist they are minor and are beingaddressed by the League with assistance from USAID

A Project Strengths

- The League has been very successful in increasing public awareness about breastfeeding through its promotional efforts

- The Executive Director and the Advisory Board have providedstrong leadership in their efforts to carryout the goals of the project

- The League has successfully developed relationships within the Ministry of Health at all levels

- A well functioning training program has been implemented for Breast Feeding Counselors nationwide

- The League has successfully collaborated with other local organizations to promote its goals

- The League has been successful in providing reliable and readily available counseling services to women who wish to breastfeed in Belize

- BIB is a model program There are no other programs like it in the Caribbean

B Project Weaknesses

- The Executive Director is over extended

- The League lacks specific plans for follow-up of their counselors in the Districts

- The League lacks permenant office space

- Data Collection

C Major Recommendations

- A plan for follow-up in the Districts should be developed and implemented

- A full-time secretary should be hired to assist the Executive Director

(1) A

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

(5)

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

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f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

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1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

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13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

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1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

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ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

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CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

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1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

- Serious consideration should be given to deferring the Stann CreekTraining in order to do data collection and analysis

- BIBs work with the MOH at the Nursing School and the Belize CityHospital should remain a priority

- Permenant office space should be sought from the MOH

Further recommendations are detailed in the section on Recommendations in the evaluation

(2)

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

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In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

II BACKGROUND

A Breast is Best League

1 BIB League Overview

BIB League was organized in 1981 by a small group of women who were actively involired in community work in various capacities Allof the women had become convinced of the importance of breastfeeding inrelationship to infant health through both their work and personalexperiences The purpose of the organization was to give helpencouragement and information primarily through personal instructionand contact to women who wanted to breastfeed their babies Mrs JaneUsher then Deputy Minister of Health provided support for the League through the Womens Bureau of the Ministry of Social Services Thefirst neighborhood counselors group was established in the St Martinde Porres area of Belize where several of the League members lived in1982 By 1983 a second group had been established in the Kings Park area of Belize City and Jerri SevutoRN became BIB Leagues firstfull-time director on a voluntary basis In the same year theCanadian High Commission awarded a small grant to the League and thefirst group of officially trained counselors began working in theprenatal clinics In 1984 an office with a lending library andtelephone hotline was established in space provided by the Womens Bureau in Belize City

2 USAID Involvement with Breast is Best League

As a part of an on-going program to strengthen Maternal and ChildHealth Services in Belize in January of 1985 USAIDBelize awarded a grant of $50000 to BIB League in order to strengthen the Leaguesservices and expand its outreach capabilities nationwide The grantenabled BIB to employ a full-time Executive Director Eva Middleton who replaced Jerri Sevuto

In July of 1986 BIB League began sharing office space andreceiving technical assistance from the USAID Funded Project Hope ChildSurvival Project and a full-time field worker Concha Valasquez was hired to assist Eva Middleton

The League currently has an Advisory Board which meets quarterlyThe members of the Board are

Sandra Wade - PresidentProfessional Beautician Michelle Perdomo - Vice PresidentEducatorWife of Cabinet SecretaryLucia Engleton - SecretaryEducatorAbigail McKay - TreasurerProject Hope Management SpecialistEva Middleton - Executive DirectorEducatorPat Benguche - MOH Liason to BIBInspector of Midwives Kathy Esquivel - EducatorWife of Prime Minister Gilda Dennison - MOH Nutritionist Maria Novelo - Educator

Two new members about to be appointed

Zee Edgell - Director of the Womens Bureau Winifred Swift - Acting Principal Tutor School of Nursing

(3) L

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

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In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

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The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

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2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

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III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

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the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

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2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

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b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

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the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

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f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

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In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

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IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

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1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

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V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

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13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

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APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

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LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

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June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

B Belize

1 Social Economic and Political Overview of Belize

Belize is a small country (8866 square miles) located in CentralAmerica It is bound by the Caribbean Sea to the east Guatemala tothe west and south and Mexico to the north Geographically the landis flat and swampy along the coastal areas with the terrain graduallyrising to the west of the country up to 27000 feet above sea levelThe climate is subtropical and is divided by a wet anL a dry seasonHurricanes are a problem historically the most recent having occured in 1978

Demographically Belize is the least densely populated country inCentral America with approximately fourteen people per square mile1984 the estimated population was 162000 In

Belize City is the largesturban center with 27 of the population residing there 24 of tilepopulation resides in the remaining 7 urban centers and 25 lives incommunities of less than 200 inhabitants

Belize has a multi-ethnic population Forty to fity percent ofthe population is of African descent residing primarily in BelizeCity and the district of Belize The next largest ethnic group isHispanic (many being refugees from El Salvador and Guatemala) Otier groups include Mayan indian Mennonite (German) East Indian Chinese and Arab

English is the official language although Creole is used forday-to-day affairs Spanish is spoken by over 42 of the populationand the Mayans speak either Maya Mopan or Kektchi dialects of the Mayan language

The first European settlements in Belize were established bythe English in the seventeenth century and the country was a CrownColony from 1862 until independence in 1981 Belize retains strongties with the British Commonwealth and the English speaking countriesof the Caribbean rather than identifying with the other countriesof Central America The Constitution is modeled on the BritishParliamentary system and the government is currently headed by PrimeMinister Manuel Esquivel of the United Democratic Party There aretwelve other ministers in the cabinet including a Minister of HealthThe Prime Minister and his cabinet establish and direct governmentpolicies in Belize National elections are held every five yearswith twenty-eight representatives chosen for the main house of thelegislature There is an appointed Senate with eight members whichreviews legislation The most recent election was in 1984 when theUnited Democratic Party defeated the Peoples United Party whichhad held government power for twenty years The Peoples United Partyis now the official opposition party

The Belizean economy is based on the export of agriculturalcommodities principally sugar citrus bananas seafood and woodRice beans corn poultry beef and dairy products are produced inBelize for domestic consumption Most international trade takesplace with the United States and the United Kingdom Annual percapita income is 1000 US dollars unemployment is estimated at14 percent The country relies heavily on international assistance for development

(4)

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

(5)

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

(10)

2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

4

t V

-

_

0

good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

5

_PO

_2)

If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

Belize maintains a small defense force with ground naval andair components At the request of the Belize government the BritishArmy has a strong presence in the country (1800 men) Since thenineteenth century Guatemala has claimed Belize Although it hasnever taken military action to enforce that claim the Britishmilitary presence continues to prevent any such attemptEducation is mandatory for chidren between six and fourteenand Belize has a literacy rate (defined as the ability to read andwrite) of about ninety-three percent The majority of schools arerun by the government with a large amount of assistance from variousreligious organizations The Belize College of Arts Science andTechnology (BELCAST) provided training for X-ray technology labshyoratory and other technical fields from 1982 to 1986 when theschool was disbanded The new University College of Belize whichis affiliated with Ferris State College of Michigan has replacedBELCAST but the future of advanced medical technology trainingremains in question Nurses training in some form has been offeredin Belize since 1887 In 1963 a national school of nursing wasformally opened and continues to be the primary source of nursingstaff for the entire country

Physicians and other professionals must receive their trainingoutside the country Most physicians in Belize have been trainedin other Central American countries Mexico India or the Universityof the West Indies

2 The Health Care Structure of Belize

In 1981 at the time of its independence from Britain Belizeshealth care system consisted of six small district hospitals onesmall psychiatric hospital one major hospital in Belize City (600hospital beds in total) and twenty-eight district health centers(staffed by nurses) Forty-five physicians two hundred thirtynurses (one hundred-seven with additional training in midwifery)one pharmacist one radiologist and seven X-ray technicians wereemplwyed by the government Services sponsored by the governmentprovide nearly all the medical care in the country essentiallyfree of charge All physicians must be employed by the qovernmentin order to practice although they may accept private patients afterworking hours There are currently no private hospitals in thecountry although a few private clinics (sponsored by religiousgroups) are in operation in the districts

The twenty-eight-rural health centers provide routine pre-natalcare well-child care immunizations follow-up and treatment ofmalaria TB and other communicable diseases and basic first-aidThe centers are staffed by Rural Health Nurses who have a yearstraining in practical nursing plus one years training in midwiferyand community health Overall responsibility for the managementof the Rural HealthCenters lies with each districts Public HealthNurse Each center serves a population of two to four thousand people

(5)

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

(10)

2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

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f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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4

In an attempt to provide health services to the populationliving in the most remote regions of the country (primarily theToledo district in the far south) not accessible to the Rural HealthCenters a number of Rural Health Posts have been established These are staffed by community health workers on a voluntary basis andprovide basic first-aid some drugs (including treatment for malaria)oral rehydration therapy and health education information Occasionshyally prenatal care is provided The Rural Health Nurse located atthe closest Rural Health Center to the Rural Health Post is responsiblefor overseeing the activities of the community health worker

The district hospitals have approximately thirty beds each and are staffed by one or two physicians four to six nurses (usuallywith midwifery training) and other auxiliary personnel BelmopanPunta Gorda and Orange Walk hospitals have laboratory facilitiesAll the district hospitals have small pharmacies Generally hospitaladmissions in the districts are limited to routine problems that do not require surgery or intensive care (including normal obstetricalcases) Except for Belmopan hospital which is visited regularly bysurgeons from either the British military or various religious organshyizations all cases requiring surgery are referred to Belize HospitalBecause they do not have the equipment or staff to provide acute carethe district hospitals are grossly underutilized The district hosshypitals also provide extensive out-patient services including prenataland mobile health clinics

Belize City Hospital is the tertiary care center for the countryThe facility is in an extreme state of disrepair is over-crowded and is ill-equipped to manage patients with any major complicationApproximately seventy-five percent of all admissions to Belize CityHospital are of an obstetrical gynecological or pediatric nature

3 Maternal and Child Health Statistics

The birth rate (368 per thousand) and the dependency ratio(55 of the population is under 15 years or over 60 years of age) inBelize are relatively high The infant mortality rate has declined steadily from 60 per thousand live births in 1971 to 27 per 1000 livebirths in 1981 However the maternal mortality rate remained fairlyconstant during that period averaging about 50 per thousand livebirths Reliable statistics on the causes of perinatal mortality are not available The most frequent causes of maternal mortalityare toxemia and hemmorage Approximately one out of every twentyshynine children born will die before age five Acute respiratoryinfections account for 12 of infant and 18 of child mortalityDiarrheal diseases account for 9 of infant and child deaths Measlesneonatal tetanus whooping cough and polio are no longer significantcauses of death in infants and children due to expanded immunization coverage between 1979 and 1982 supported largely by UNICEF and PAHO

(6)

The incidence of malnutrition in infants under one year is roughlyeight percent and in children between the ages of one and four itis approximately nineteen percent Malnutrition is most commonlyfound in children living in the Toledo District The percentage ofmothers who breastfeed without supplements for the first four monthsof life varies significantly from district to district with thelowest percentage being in Belize district (29) Nationally theaverage is approximately 40 At least twelve percent of alldeliveries in the country are attended by traditional birth attenshydents The Mayan population does not use trained attendants inchildbirth and it is usually the father who delivers the baby Oversixty percent of deliveries take place in the hospital or rural health centers

4 National Health Policies for Maternal Child Health

The government of Belize has as its official policy that healthis a basic human right and it attempts to provide all Belizeanswith access to total health care This responsibility falls primarilyon the Ministry of Health The government agrees to the principlesof the World Health Organizations goal of Health For All By theYear 2000 The National Health Policy states that health servicesshould be democratic comprehensive educational participatoryand accessible

In 1982 a National Five Year Health Plan was developed andidentified the following as the overall strategy for the provisionof health care in Belize

1 Adoption of the Primary Health Care Approach 2 Promotion of the Health Team Concept 3 Emphasis on Appropriate Manpower Training 4 Utilization of Effective Management Systems 5 Building of Appropriate Infrastructure Development 6 Alternative Sources of Financing

The priority groups identified for special attention weremothers and children the elderly low-income groups the populationliving in underserved areas and the disabled

On-going Maternal Child Health activities in Belize began inin 1974 and in 1976 an agreement between the Government UNICEF andPAHO was signed to fund implement and support the expansion ofservices for mothers and children The 1982 National Five Year Plan identified the following as itsobjectives for the Maternal Child Health Program in Belize

1 The Reduction of Maternal and Child Mortality and Morbidity

(7)

2 The Improvement in the Coverage and Efficiency of Maternal Child Health Services

3 The Provision of Regular Comprehensive Care for ChildrenUnder Five Years of Age with an Emphasis on Supervision oftheir Physical Mental and Nutritional Development

4 The Promotion of Family Life Education for the Adolescent and Adult Population

The specific programs that the Ministry of Health mandated to be carried out included

1 The Promotion of Oral Rehydration Therapy to Combat Mortality and Morbidity from Diarrheal Disease

2 The Provision of Family Life Education 3 The Provision of Prenatal Care 4 Normal Obstetrical Cases to be Delivered by Trained Nurse-Midwives with the Back-up of Physicians in the Event of

Complications

5 The Promotion of Breastfeeding

6 The Provision of Postnatal Care 7 The Provision of Well-Child Care with an Emphasis on Growth

Monitoring 8 Immunization Services for Women and Children Against Tetnus

Polio Measles Whooping Cough TB and Dyptheria

The main burden of carrying out the provision of Maternal ChildHealth Services has fallen to the nursing community in Belize parshyticularly the Public and Rural Health Nurses who staff the healthcenters out-patient an mobile health clinics

(8)

III PROJECT OBJECTIVES AND ACHIEVEMENTS

The overall goal of the BIB League is to improve the nutritionalstatus of babies and infants in Belize by increasing the number of women who fully breastfeed for four months The project specificallyaddresses four major areas in order to achieve that goal These are

A ManagementFundraising

B Training

C Educational Programs

D Promotion

A ManagementFundraising

Objectives

1 To provide direction and to execute the goal of the BIB League 2 To provide longterm finances for continuation of the program

1 To Provide Direction and to Execute the Goal of the BIB League

Outputs

a Advisory Board b Collaboration with Project Hopes Child Survival Project c Leadership QualitiesSkills of Executive Director

a Advisory Board

The BIB League has a strong and active Advisory Baord whichincludes representatives from key professional groups(nursing education)and prominent community members(the Prime Ministers wife) There havebeen some changes in the Board membership over the years however themajority of the members have been involved with the League since itsinception The Board faces many of the usual problems confrontingsimilar organizations These include organization difficulty incoordinating the time commitments of individual members and followthrough on Board decisions However after meeting with the Boardand reviewing its activities over the past several years and its plansfor the future I feel that the Board has done an excellent job inproviding leadership direction and in promoting the goals of the BIBorganization in Belize- through its many activities All members areactive Breast Feeding Counselors which means a considerable timecommitment and the willingness to be available at all hours KathyEsquivel the Prime Ministers wife is a vocal supporter and oftenmentions BIB during her public appearances throughout the countryMichelle Perdomo who is an educator plans to spend her summer vacationwriting a publication for BIB on Belizean Womens Experiences withBreastfeeding All of the educators on the Board have includedclasses on breastfeeding in their curriculum Pat Benguche the Inspectorof Midwives emphasizes breastfeeding in her TBA Training Program andregularly counsels mothers and promotes breastfeeding to the nurses on

(9)

the Maternity Ward at Belize City Hospital and in the Districts Giventhb small population base in Belize the limited resources availableand the professional time commitments of its members I feel thatit is unrealistic to expect more imput from the Board than it isalready giving The Board should be commended for the fine work thatit has done for BIB LeaguePlans are being made by the Executive Director Eva Middleton tohold a Board development workshop in the fall of 1987 in collaborationwith the Project Hope Child Survival Staff and the Belize Family LifeAssociation The Board recognizes the need to enhance its owncohesiveness motivation and personal commitment and plans to continueto work together to address-these issues

b Collaboration with the Project Hope Child Survival ProjectSince July of 1986 the BIB League has shared an office with theUSAID funded Project Hope Child Survival Project The office ismore centrally located physically attractive and spacious than theprevious one This enhances the Leagues visibility and effectivenessClaudia Ford and Abigail McKay both Project Hope Management Specialistshave provided extensive technical assistance to BIB over the past yearspecifically in the development of a new program plan financialmanagement a training curriculum for counselors and actual trainingimplementation in the Districts Dan Bevier the Project HopeInformation Specialist has been assisting with the development of adata collection tool Mary Kroeger the Director states that day today informal management training and problem solving has been providedthrough the sharing of office space Eva Middleton was an activeparticipant in the Project Hope Management Seminar which ran fromSeptember 1986-May 1987 She believes that the course enabled her toaquire valuable organizational skills which she has been able toincorporate effectively into her management of the League and its

programs

c Leadership QualitiesSkills of the Executive Director In evaluating the achievements of the BIB League in Belize overthe past several years the importance of the quality of leadershipthat has been provided by the Executive Director Eva Middletonshould not be underated An educator with 10 years experience Evahad a long history of community activism previous to her involvementwith Breast is Best In her dedication and commitment to the Leagueshe has taken on responsibilities well beyond her job requirementsIn addition to maintaining full-time officecounseling hours sheoften conducts trainings in the Districts on Saturdays Many eveningsduiing the week she gives talks and attends community meetings enhancingthe effectiveness and visibility of the Leaguereached out She has activelyto all of Belizes various ethnic groups and has beencareful to cultivate all segments of the political spectrum in thecountry resulting in broad and strong public support for BIBsactivities nationwide This is an impressive accomplishment in Belizewhere community activism often runs afoul of partisan politics

(10)

2 To Provide Longterm Finances for Continuation of the Program From its inception in 1981 BIB League has been active in fundraising

in order to support the promotion of its goals The Advisory Board as recently formed a separate fundraising committee In addition tothe grant from USAID BIB has received financial contributions from UNICEF CFNI PAHO and the Womens Bureau of Social Services TheLeague periodically initiates membership drives and the Executive Director actively solicits donations from private MDs local businessesand prominent citizens BIB handbags and T-Shirts are sold by the Leaguebut due to the expense involved in producing them this has proven tobe more of a promotional device than a profit making venture Breast pumps are rented to the public which brings in a small fee for theorganization The Advisory Board has held garagecake sales and givenbarbecuesdinners and plans to continue similar activities in the future A fair is planned for the fall of 1987 to promote breastfeeding and raise funds for the League

The goals of institutionalization and financial independence arerecognized by the Executive Director and the Board The League has worked hard to achieve those goals and the budget does not reflect excesses in its allocation of funds for the organizations activities (ie Eva takes buses when travelling to the Districts etc) Giventhe existing level of available resources in Belize however it is unrealistic to propose that BIB League would be able to sustain its current level of expansion and visibility countrywide without financial support from USAID

B Training

Objective

To educate resouce persons who will disseminate breastfeeding information to the public

Outputs

a Training curriculum

b Recruitment of Trainers

c Training Implementation

d Ongoing Follow-up and Support Post Training

a Training Curriculum

A new training curriculum for BIB Leagues BFC Training Programcountrywide was developed in collaboration with Claudia Ford ProjectHope Management Specialist The curriculum is designed to be taughtin 5 weekly sessions for a total of 20 hours A pre and post testevaluation tool was designed to evaluate the success of the trainingThe book The Womanly Art of Breastfeeding is used as a guide (both inEnglish and Spanish) Handouts slides models charts and othertraining materials are used throughout the sessions The new curriculum incorporates Child Survival Strategies such as ORT the importance ofimmunizations and Child Spacing The curriculum appears well designedto meet the training needs of the BFCs (copy in appendices)

(11) NV

b Recruitment of Trainers BFCs are recruited by the Public and Rural Health Nurses(and otherhealth workers) in 6ach District The counselors must be women whohave successfully breastfed at least one infant and be interested inpromoting breastfeeding in Belize by doing volunteer work in the clinicsand their communities as needed They must agree to follow the BIBLeague Philosophy(copy in appendices) The couselors must complete theentire 5 sessions of the course in order to be certified as a BFCThe recruitment process appears to be adequate and it is unusual forthe counselors to drop out once they have begun the training

c Training Implementation

The training is done by Eva Middleton with assistance from theRuralPublic Health Nurses along with other health workers in eachDistrict Assistance has also been provided by the full-time BIBfield worker Project Hope Staff members and Board membersVirtually all the nurses and counselors that I interviewed(seelist of contacts in appendices) stated that they found the training tobe thorough interesting useful and extremely practical NurseMelendez from the San Narcisso Health Center in the Corozol Districtstated that the training was unusually clear and geared to the levelof the counselors Others stated that the training not only increasedtheir knowledge but it also motivated them and gave them the confidenceto counsel mothers who were having problems with breastfeeding Allpersons interviewed stated that they enjoyed the training and that thetraining materials and handouts were excellent Counselors have been trained in every District with the exceptionof Stann Creek Training in the Stann Creek area is scheduled tobegin this summer (see list of trained counselors in each District

in appendices)

d Ongoing Follow-up and Support All the Rural and Public Health Nurses in the Cayo Orangewalkand Corozol Districts stated that the counselors trained were functioningin their communities Many of the counselors are attending the clinicsessions(at the health centers hospitals and mobile) to assistmothers who are having problems with nursing and to promote breastfeedingThe nurses stated that they were supervising the counselors but thatthey would like more frequent visits from the League Counselors are meeting regularly at the San Narcisso Health Center in Corozol toprovide support for eachother and to problem solve The meeting Iattended was lively and the counselors talked enthusiastically abouttheir work The RHN(Nurse Melendez) and a TBACouselor appeared to beproviding strong leadership within the groupA feedback mechanism has been designed to keep the BIB ExecutiveDirector informed on how well the counselors are functioning Duringthe training the counselors are instructed to fillout an outreach formafter each contact with a client(copies in appendices) The purposeof the forms is explained and instruction on how to fill them out isprovided The forms are collected periodically by the Rural and PublicHealth Nurses who send them to Eva Middleton Eva sends a personalthank you note along with comments to all counselors who send in the

filled out forms Currently follow-up and support for the counselors is erraticIt is difficult for the Executive Director to provide ongoing follow-up

till

on a personal basis due to the lack of transportation (she must takelocal buses) and the overall demands of BIB League on the timeA one day continuing education workshop for all trained counselorsis planned for the fall of 1987 and will take place in Belize City

C Educational Programs

Objective To create and distribute resource materials and provide educationalsettings for informing the general public with emphasis on pregnant

and lactating mothers

Outputs a Inservice Education for the General Public b Inservice Education for PregnantNursing Mothers c Inservice Education for Nurses in Hospitals Clinics and at

the School of Nursing d Collaboration with Other Local Organizations e Breastfeeding Information PacketsResources MaterialsNewsletter f Counseling HoursLending LibraryLending of Breast Pumps and

Nipple Shields

a Inservice Education for the General Public BIB League has given numerous workshopslectures at schoolsthroughout the country in its efforts to educate the public aboutbreastfeeding To mention only a few breastfeeding promotion

workshops were given at

-4 nighschools in Belize City -2 district highschools -3 upper division primary schools in the Toledo district Belize rural and Belize City-Preschools in Belize City Dangriga Corozol and Orangewalk

b Inservice Education for Pregnant and Nursing Mothers Trained Bib Counselors the full-time field worker and theExecutive Director have been a constant presence in the prenatalchildhealth clinics in Belize City and the Maternity Ward at Belize CityHospital Mothers are educated about breastfeeding on a one to onebasis and in group discussions Slides are often shown and BIBinformation packets are distributed

c Inservice Education for NUrses in the Hospitals Clinics and Schoolof Nursing Many of the nurses throughout the country have taken BIB LeaguesBFC Training Program(largely the RHampPH nurses) The in-hospitalmaternity nurses have generally resisted the efforts of the BIB Leaguehowever With the recent appointment of Matron Julia Castillo as

(131

the Director of Inservice Education for Belize there is new and greatersupport for the Leagues educational programs with the nurses Aseries of inservice education workshops for the maternity nursesnationwide are being planned in collaboration with Matron CastilloBIB has had an ongoing(but unofficial)relationship with the Schoolof Nursing since 1983 A i-eastfeeding curriculum for the practicalprofessional nursing and midwifery students was developed(copy inappendices) and the Executive Director has given regular lectures onbreastfeeding on an informal basis Twenty-two of the nursing studentsattended a BFC Training and were certified as counselors Therelationship with the School of Nursing is important and will probablybe strengthened further because the Acting Director of the School ofNursing Winifred Swift is about to be appointed to the BIB AdvisoryBoard

d Collaboration with Local Organizations BIB League hag successfully collaborated with local organizationsto educate the public about breastfeeding The League is an activemember of the Belize Nutrition Communication Network The two groupsare about to distribute a jointly written pamphlet on weaning foodwith recipies using local Felizea1 foods They also have had jointdisplays at the Agricultural Show Womens Fairs and other publicgatherings Other groups with which the League is actively involved

are

- The National Health Education Committee - Child Survival Task Force -Council for Volunteer Social Services - Belize Development Corporation - Maternal Child Health Committee (BIB was formaly a memberand now has a Liason relationship through Pat Benguche theInspector of Midwives)

BIB successfully collaborated with Health Talents Internationaland Enfant Refugies du Monde to provide 1 day inservice educationworkshops on breastfeeding to Community Health Workers in the StannCreek and Cayo Districts in March and April of 1987

e Breastfeedinq Information PacketsEducational Resource MaterialsNewsletter The League consistently distributes breastfeeding informationpackets to the public mainly through the clinics and hospitals (copyenclosed) In addition all the 30 Rural Health Centers regularly

receive the packetsA newslether is published several times a year and is distributedby mail to the membershipNew information packets and a series of 10 special informationsheets for distribution to the Maternity Wards have been designed incollaboration with UNICEF HECOPAP Project Hope the MOH and CVSSThe Director of UNICEFBelize Thierry Delrue who is a media expertis collaborating with the League on the completion of a series ofinformation slides about specific areasproblems in breastfeedingThe slides will be used for inservice educational purposes

(14)

f Counseling HoursLending LibraryThe Lending of Breastpumps and Nipple Shields BIB provides regularly scheduled counseling on a drop-in orappointment basis at their office and runs a hotline Monday-Friday9am - 4pm for womenfamilies who need help with or information onbreastfeeding In addition the counselors are available by phone 24hours a day if needed for urgent problems The phone line and officeare usually busy with people seeking advice

has In addition the Leaguean extensive lending library and provides breastpumps and nipple

shields for lactating mothers for a small feeThe successhigh visibility of the Leagues efforts were evidencedto me when I witnessed two fathers dropping by the BIB office toseek counseling so they could better support their wives who werebreastfeeding In a macho culture like Belize it was a surprising scene

D Promotion

Outputs

a CalendarsPosters

b RadioTV SpotsNewspaper Articles c Awards to Mothers Who Breastfeed SuccessfullyOutstanding

Persons in the Promotion of Breastfeeding d Promotional T-ShirtsBags

a CalendarsPosters

In 1986 BIB League produced and distributed over 2000 calendarscountrywide The poster sized calendars depicted Belizean mothersfrom different areas of the country happily nursing their babies were displayed in shops clinics homes and other places throughoutThey

Belize and brought increased attention to the League No calendars were produced for 1987 due to logistical problems There are plansto collaborate with UNICEF on a promotional calendar for 1988

Recently 200 posters promoting breastfeeding were donated to BIBby UNICEF The posters are printed in Spanish and will be of particularuse in the Districts Plans are being made to have the same posterprinted in EnglishCreole

b RadioTV SpotsNewspaper Articles The League sponsors daily radio spots promoting lactation andLeague members often give radio talks on the subject of breastfeedingIn the past 6 months a series of 3 TV spots promoting breastfeedingwere produced for BIB by the Director of UNICEFBelize The spotshave been shown throughout the country(each District has at least oneTV station) and have generated a lot of public attention towardsbreastfeeding The Board members stated that they have frequentlybeen stopped in the streets by people who wish to make positivecomments about the spots Phone calls to the League increase dramatically

after the TV ads are aired

(15)

In the Districts television stitions run the spots withoutcharge as a public service In Belize City however one of thestations Channel 7 charges its regular advertising fee The spotsshould continue to be aired as often as possible and appear to bewell worth the expense PublicGovernment pressure should be placedon the station to air the spots as a public serviceBIB League has had 11 newspaper articles on breastfeeding printedin the local press

c Awards to Mothers Who Breastfeed SuccessfullyOutstanding Personsin the Promotion of Breastfeeding The League distributes certificates of achievement to the clinicsthroughout Belize for presentation by the nurses to mothers who fullybreastfeed their infants for 4 months Periodically specialcertificates of achievement are also awarded to personscounselors fortheir outstanding promotion of breastfeeding in their commuiiities

d Promotional T-ShirtsBags Over 300 promotional T-Shirts and bags have been produced aridsold by BIB in an effort to promote awareness about breastfeeding andto raise funds These itcms have been a popularpromotional toolThe counselors often wear the T-Shirts when they are working andwherever the Executive Director and I travelled people asked for them

(16) 4

IV ANALYSIS

A Project Impact on Public Awareness About Breastfeeding

BIB League has been highly successful in increasing publicawareness about breastfeeding issues and benefits Through the highvisibility and example of the Advisory Board members and the exceptionalleadership provided by the Executive Director the Belizean public has become increasingly aware of the benefits of breastfeeding verses bottlefeeding

No baseline data collection on breastfeeding~in Belize was carried out prior to the USAID funding of the BIB League projectmaking hard eata on attitude and practice changes in breastfeedingunavailable However virtually every person interviewed (contacts inappendices) during the evaluation process felt strongly that the League has had a significant impact on the promotion of breastfeedingin Belize BIB has worked effectively with the media and other organizations to generate publicity for breastfeeding and to promotethe goals of the League

B Training

The training of Breastfeeding Counselors has been well organizedand implemented throughout the project Although problems with follow-up and support of the counselors post training do exist to some extent the counselors appear to be functioning effectively in their role of supporting and promoting breastfeeding The Public and Rural health Nurses expressed an interest nad willingness to offer leadershipand support to the counselors within the limits of their own resourcesprovided that they in turn receive some help form BIB in doing this

C Management

The League has been effectively managed under the direction of the Executive Director Eva Middleton with support from the AdvisoryBoard The Executive Director has consistently sought technical assistance from USAID and other organizations with problem solvingissues when necessary There is a genuine awareness of the issuesfacing the League and plans exist in an effort to address these problems

The Executive Director is over extended however and recommendations to attempt to solve this problem are outlined later in the evaluation

D Institutionalization

BIB League has made significant progress in working with the MOHinspite of often delicate political situations Both Dr NanetteReneau the Director of Maternal and Child Health and Pat Benguche theInspector of Midwives felt strongly that during the past few yearsthe attitude of MOH personnel towards BIB had greatly improved Theappointment of Pat Benguche as the official liason between the MOH andBIB should further improve the situation Support from the new Directorof Inservice Education for Belize and the Acting Principal Tutor at theSchool of Nursings appointment to the Advisory Board should also have

(17)

1q

a positive impact on the Leagues acceptance within the system AllMOH personnel interviewed expressed a desire for BIB to continue towork in close collaboration with the Ministry and Nursing staff

While the League has been active in fundraising it is unrealisticto expect the organization to function at its present level of activitywithout support from USAID

E Data Collection

The lack of data collection is a problem in evaluating the projectsachievements Given the fact that the data collectionanalysisresources in Belize are extremely limited this problem may be difficult to address

(18) e

V RECOMMENDATIONS

1 A timetableschedule for periodic follow-up in the districts should be developed and implemented This would help maintain the level of morale among the counselors and nurses

2 Consideration should be given to hiring a part-time counselor with leadership skills to supervise the counselors in each District

3 Serious consideration should be given to deferring the Stann Creek District Training until next fallwinter in order to developand implement a data collection tool before training takes placeThis would enable the project to better evaluate the specific impact of the training

4 A full-time secretary should be hired at the BIB office to assist the Executive Director in carrying out the goals of the project

5 BIBs work with the MOH at the Nursing School and at Belize CityHospital should remain a priority Belize District continues to to have the lowest rate of breastfeeding countrywide and 40 of all births in Belize take place at Belize City Hospital

6 The League should work closely with the Director of Maternal and Child Health to develop a plan to educate physicians in Belize about breastfeeding

7 Permenant office space should be sought from the MOH This would be a further step towards institutionalization of the League

8 Support should be sought from the Government to designate a Breastfeeding Week in Belize this fall This would help the League with its fundraising activities and increase the organizations visibility

9 More breast pumps should be purchased and the deposit for renting them should be increased

10 More copies of breastfeeding books printed in Spanish need to be purchased

11 Sturdy notebooks should be purchased for the counselors to orgenizeand protect the educational materials which they use in their work

12 A breastfeeding promotional calendar for 1988 should be produced and distributed by the League

(19)

13 BIB League promotional bags and T-Shirts should continue to bemanufactured and sold for promotional purposes

14 A bicycle should be purchased for BIB office staff use

(20)

APPENDICES

About the Evaluation

The evaluation was conducted for the USAIDBelize Mission betweenJune 4-11th 1987 The evaluator was Pamela J PutneyRNMSCNM anurse midwife educator who had previously worked in Belize for 16months with Project Hopes Matching Grant in Maternal and Child HealthShe was assisted by Eva Middleton the Executive Director of BIB LeagueSue BrechinRNMPH HealthPopulationNutrition PVO Project ManagerUSAIDBelize and Sam Dowding Health Project Manager USAIDBelizeInterviews were conducted throughout the seven day period with keyMOH personnel Breast Feeding Counselors clients Rural and PublicHealth Nurses in the Cayo Belize Corozol and Orangewalk Districtsrepresentatives from PVOs involved with BIB League in Belize the BIBLeague Board of Directors and a private MD among others (please seelist of contacts in appendices)

The purpose of the evaluation was to determine the effectiveness of the project in

1 Developing the BIB League into an organization capable ofresponding to the challenges in Belize of extending and consolidating the practice of breastfeeding

2 Attaining the objectives established for training and public education

Specifically the evaluation was designed to

a) Assess the success of the project in increasing public awareness of breast feeding issues and benefits

b) Assess the impact the project has had in increasing thenumber of sufficiently trained and functioning breast feedingcounselors nationwide

c) Evaluate the Leagues efforts in fundraising management ofthe program and consolidation of its role as a local PVO

d) Make recommendations on the course the project should takein its final year in order to improve the impact on publiceducation and the Leagues institutionalization

(21) OP

LIST OF CONTACTS

June 4 1987

Meeting with USAIDBelize Met with

Ed Gales - Acting General Development Officer Sue Brechin - HealthPopulationNutrition PVO Project Manager

Meeting with BIB League Staff Met with

Eva Middleton - Executive Director Concha Gonzoles - Full-time field worker

Meeting with Dr Hoy Obstetrician MOH and private practice

Meeting with Dr Nanette Reneau Director of Maternal and Child Health

MOH

Met briefly with Sam Dowding Health Project Manager USAIDBelize

June 5 1987

Meeting with Project Hope Child Survival Staff Met with

Mary Kroeger - Director Claudia Ford - Management Specialist (terminated 53187)

Meeting with Pat Benguche Inspector of Midwives MOH longterm BIBLeague Board Member and newly appointed official MOH Liason to the BIB League

Meeting with Thierry Delrue Director of UNICEF Belize

Meeting with BIB League Board of Directors

(22)

June 8 1987

Meeting at San Narcisso Health Center in the Corozol District Met with

Marta Melendez -Rural Health Nurse Nicolasa Chan - Traditional Birth Attendent and BIB Counselor Maila Castaneda -BIB Counselor Victoria Gonzalez - BIB Counselor Filiberta Dominanz - BIB Counselor

Meeting at Corozol Town Health Center Met with

Nurse Aragon - Rural Health Nurse Nurse Roland - Public Health Nurse Dr Oscar Rodas - District Medical Officer

Meeting at CARE Office in Corozol Met with

Nancy Minnette - Nurse Health Educator CAREs Child Survival ProjectAngela Gillette - BIB Counselor and CARE Community Health Organizer

Met briefly with Nurse Osorio Public Health Nurse Orange Walk District

Meeting with Mrs Jane Usher former Deputy Minister of Health forBelize Strong supporter of BIB League from its inception in 1981

June 9 1987

Met briefly with Dan Bevier Project Hope Information Specialist

Met briefly with two fathers who stopped into the BIB Office forcounseling regarding the problems that their wives were having with breastfeeding

Meeting at the San Ignacio Health Center in the Cayo District Met with

Nurse Hale - Clinic Nurse Elita Bardalez - Health WorkerBIB Counselor

Met briefly with Jill Kauffman Public Health Nurse Belmopan Hospital

(23)

1984

1985

Rough Statistics Compiled by the MOH on the Number of Infants FullyBreastfed in Belize Until Four Months of Age

Belize 29

Corozol 41

Orangewalk 45

Cayo 79

Stann Creek 48

Toledo 81

Average total 48

Belize 23

Corozol 55

Orangewalk 30

Cayo 60

Stann Creek 44

Toledo 66

No figure were kept in 1986 due to the Immunization Campaign

(24)

ORANGE WALK DISTRICT COUNSELORS

Jennifer Hoare

Eugenia Marin

Soila Banner

Carmen Zetina

Maria G Quintana

Felicita Cantun

Veronica Quetzal

Anita Ack

Teresa Catzim

Angelita B Sanchez

Eulalia Moguel

Susana Osorio

Petrona Vargas

Clarita Perez

Aguida Cantun

Angela Eustaquia Novelo Gillett

Angelia Esther Garcia

Carlos Peralta

Dora Alcia Flores

Eliza Zetina

Dona Costanza

Emiliana Osorio

Santa Martha

San Luis Village

San Felipe

San Felipe

August Pine Ridge

Yo Creek

Guinea Grass Village

Yo Creek

Progresso

Nuevo San Juan

San Lazaro

Nuevo San Juan

OrangeWalk Town

Guinea Grass Village

Santa Martha

Yo Creek

Yo Creek

San Felipe

San Felipe

Orange Walk Town

Orange Walk Town

Orange Walk Town

(25)

1986 TOLEDO DISTRICT COUNSELORS PUNTA GORDA TOWN APRIL 26

Phyllis Alvarez

Carmela Bonell

Violet Budna

Elia Castro

Perlene Chan

Mary Lewis

Joyce Lopez

Ruth Martinez

Adel Nery

Josephine Palacio

Virginia Roches

Teressa Smith

Rose Tingling

(26)

COROZAL DISTRICT COUNSELORS APRIL 11 1987

Sandra Reyes

Irma Aragon

Angelita Mora

Lorna Perez

Cynthia Cruz

Nicholasa Chan

Feliberta Dominguez

Martha Melendez

Faustina Teck

Mireja Teck

Narcelina Coye

Paula Morima

Severriana Correa

Daphne Garcia

Lisbeth Roland

Maila Castanada

Victoria Gonzalez

Nancy Minette

Sartaneja

RHN Corozal HC

Sartaneja

Sartaneja

Sartaneja

San Narciso

San Narciso

RHN San Narciso

San Victor

San Victor

San Victor

Libertad

Xiabe

Libertad

RHN Corozal HC

Louisville

Louisville

CARE Corozal

(27)

CAYO DISTRICT COUNSELORS

Elita Bardalez

Angelita Eck

Maria Sierra

Rita Teck

Elicia Peck

Martha Madrid

Josephine Rerinos

Beatrice Waight

Inez Cubb

Yolanda Berjes

Elodia Leal

Rosita Aurora Iglesia Armandita Simmons

Carol Segurra

Maria Chan

Brumilda Chan

Justina Teck

Maria Luisa Chan

San Ignacio

Santa Elena

Bullet Tree Falls

Crito Rey

Cristo Rey

Santa Elena

Santa Familia

Santa Familia

San Ignacio

Bullet Tree Falls

San Ignacio

San Ignacio Helth Center

Buena Vista

Buena Vista

Cristo Rey

Cristo Rey

Cristo Rey

(28)

1986 BELIZE DISTRICT COUNSELORS GRADUATED MARCH 15

Nursing Students

1 Laila Acosta

2 Martha Escheverria

3 Carolyn Gladden

4 Isidora Paquil

5 Therese Roches

6 Martha Teck

7 Melina Vanegas

Volunteers

8 Gloria Baptist

9 AnnMarie Flowers

10 Geraldine Joseph

11 Alva Miller

12 Sarita Moody

13 Rosine Myvette

14 Valda Oshon

15 Janet Perez

16 Cherrimae Rhaburn

17 Gertrude Velasquez

18 Concha Velasquez

19 Dorla Buckley

20 Emma Cadle

21 Magdalena Cassanova

22 Grace Usher

Flowers Bank

Doublehead Cabbage

Bermudian Landing

Ladyville

Scotland Half-moon

Doublehead Cabbage

Hattieville

Ladyville

Flowers Bank

Burrel Boom

Ladyville

Hattieville

Biscayne

Belize City

Belize City

L221

eA

BELIZE CA

ints to Prevent Diarrohea 6 Keep home and Breast feed baby surroundings as clean

as possible with garbageprcperly covered

and LV 8 Vomiting

((Gastroenteritis)7 Make sure drinking water is boiled or treated

water coveredWash hands properly _I

efore and after handling baby

Wahn t S9 Keep babys hands as clean as possible

they always put hands in their mouths s da feranging diapers 10 Dont use pacifiers (soothers) They always at to dofall on the ground then take the germs into Vshy

babys mouth _ 11 Visit your doctor or nurse at the Child Health

4Y4 - Clinic the Oral Rehydration Unit or the Rural HealthCentre or the Village Health Worker in your area They are always happy to give advice on how to

Wash hands after using the toilet keep your baby healthy

Minhltry of Heailth 9eliI e 1 a

Keep all feeding utensils (cups spoons plates) ean and covered

m flies

N117r

What to do aboutGastro-Ententis or Diarrhoea and Vomiting

A If your baby is vomiting and has loose stools (or diarrhoea)he has gastroenteritis

1

Babies who are not n -

- breastfeed usually get this sickness 7

3 Baby is restless and irritable WeyclcyrRpctoetuIf your child has three or more watery loose abaWhenyou collect your ORS packet to treat your

stools in one day this is called diarrhoea babT please follow these instructions Diarrhoea should be treated properly and earlyotherwise the baby will become dried up or Instructions

othewisudehydrated or1th bab wil bcomedrid4 Baby passes small amount of urine that Mix one (1) packet of ORS in one (1) litre1 m one (1 ) of wat eelooks darker than usual 2 -

(1 i rum quart bottle) of water5 Babys eyes look weak and sunken and dry Give the baby only the amodint that isinstructed on the packet

very little tears when crying 3 Use a cup and spoon feed slowly be patient4 If baby vomits keep giving slowly with a spoon some will stay down 5 This drink will not stop diarrhoea but it prevents the baby from becoming dried up or d ehyd rated 6 Do not starve baby shy offer him the breast orj if he wants his food give it to him (avoid greasy

Dehydration means that the body has lost much or very rich foods)water and salt through diarrhoea and if this 6 Babys mole drop is sunken If baby does not show early improvement takewater and salt is not replaced the baby can witherand shrivel up like a plant that needs to be watered him immediately to the Health Worker Nurse orDo not wait until your baby starts showing these Doctor at the H-lospital Clinic or Health Centre

signs Have your baby treated quickly as soon as If you have not got a packet or Oral Rehydrationyou see signs of diarrhoea Salts make up the homemade solution of You should therefore know how to treat your Clean water (one (1) quart)baby when heshe gets diarrhoea in order PInch of salt (one (1) teaspoon)to avoid dehydration Handful of sugar (one (1) tablespoon)

Signs of Dehydration Treatment for Diarrhoea ( ii alaysUse1 Bby s tirstBaby is thirsty always oral rehydration salts (ORS) to treat yourlicking his lips which baby when heshe gets diarrhoea I

may look dry or cracked ORS packets are available free of cost at all hospitals clinics health centrescommunity and from village health workers

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After Four Months Common Questions Breastfeeding Start giving soft foods such as potatoes yams about Breastfeedingand rice mashed with a fork and feed with

a Sucking produces milk Nurse your baby as otten as he Your baby also needs many different foods wishessuch as bananas beans meat and other o Dnnk plenty of liquids -at least 8 glassfulls every dayvegetables available in the market Ifyou worry about not having enough milk you -ay nothave enough Relax and enjoy your babyYour babys stomach is small and he needs a What if my baby refuses the breastlarge amount of food to grow so you must give A hungry baby will eat unless he is sickmany small feedings each day Feed him four o Do iot offer your baby anything else except the breastor five times each day A bottle may be easier to suck but causes gas colic and

bloating Other foods cause baby to lose his apetite The amount your baby eats will change from for breast milkmeal to meal The best way to know if your baby If baby still has trouble visit your child Health Clinicis getting enough is to visit your health centre WsvdreguarlyandhavehimweigedWill breast milk give my baby diarrhoearegularly and have him weighedstools The food you give your baby should be washed e No The stool of a breastfed baby is soft and yellowishcooked in a clean pot and fed with a clean dish It comes more often than the stools of bottle fed baby

because breast milk is better digesteda A breastfed baby will not have colic or constipation Remember to wash your hands when fixing or allergiesfoods or feeding your baby Any baby may have loose siools If your baby has loosestools continue breastfeedirig and give oral rehydrationContinue breastfeeding your baby until he is at solution by spoonleast one year old

Will breastfeeding make my breasts sago When you are pregnant your breasts are biggerPregnancy stretches them like the skin of your tummystretches

o When your breasts fill with milk they get even biggerwhether or not you breastfeed

oAny woman who has been pregnant will have someC E stretching of her breasts and this may cause slightMsagging after the pregnancy

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good supporting brassiere during pregnancy andnursing wili cause less stretchingThe shape of your breasts is mostly inherited and youcant change that even ifyou wanted to

41

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If you need helpwith anybreastfeedingproblems contact

your HealthCentre

In Belize City visit 1) The Breastfeeding Clinic

Matron Roberts Health CentreWednesdays 8 am 11 a

1 pm- 3 pm The Breast Is Best League

Box 1203 2

is bestyo ur yo u rj

y o u

Belize City Telephone 45528 or 44797

Getting Ready Eat well during pregnancy Drink milk for strong bones and teeth

Eat green vegetables and red meat for strongblood bloodneeds

Eat enough of everything You need extra food now

Do not smoke nor drink alcoholic beveragesThey can be harmful your baby

Do not take any me ihies without seeing a doctor Medicines that are safe to you may be harmful to your baby

Daily Nipple Care Wash breast Oil nipple

F f

Pull and massage nipple Squeeze out early milk

Nipple care is important I

The First Days Offer the breast to the baby as soon as possible

after delivery and offer it on demand every two hours

Support the breast to the babys mouth with one thumb and forefingerhand pressing it back from the nipple with your

Change the baby over to the other breast after ten minutes

9 Your baby gets colostrum from your breast This is

the first milk which is a yellowish and watery fluid very rich in natural vaccines which will protect your baby

e As the colostrum disappears It may look thin and watery this is natural

The more you breastfeed the first three (3) dayi the sooner your milk will come down Avoid bottlerfeeds completely

Up to Four Months During his first months of life your baby only

needs breast milk

Breast milk provides all the food that your baby

e Breast milk is better than cows milk or any infant formula

Totally breastfeeding your baby during the first four months will save you about $500

Breast milk keeps your baby healthy

Mothers milk protects your baby against

- constipation - diarrhoea (loose stools)-allergies

- overweight - vomiting

- bronchitis - other diseases

] Until he is four months old your baby does not require any other liquids not even water

Breastfeeding helps to build the important bond of love between mother and baby

o As a nursing mother you should eat foods that are good for you and in sufficient amounts

Being a working mother is no excuse to stop breastfeeding Your milk can be squeezed outplaced in a clean container and stored in a cold place to be given to your baby while you are

at work

0 When your baby is between 4-6 months old he will begin to need more than breast milk

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ten should I nurse my Baby S What can I do to relieve nipple soreness 9 What about Supplemental Bottles of formulafly breastfeed babiesfeeds ever 2-3 hours (a) Put baby to breast more often and breastfeedfirst weeks with a little-longer stretch Baby only needs breast milk Bottles of faonly 10 minutes per breaste s dur i ng a 24 hour period ( h ope f ully atd decrease mothers milk supply and replacee r a e m tDemand feeding is most important When r s mi k up y an r p a e(b) Put baby to the least sore breast first fect food with less nutritious non-protecDemaWhn d fe is-substitutedins breasts are full of milk and uncomfort- (c) ost impo tan

feed him Be sure baby has dark area around nipple (areo- subsoute la) in mouth as well asrth brest(Mhenth bab the nipple 10 When should I add other foods to my babyr The more the baby sucksat the breast (d) should solid foods be introduced)Expose nipple to sunlight and air

re milk you will have Start other foods between 4-6 months and1 I know if mty baby is getting enough (e) cc

1 1 owgtops Apply small anount of vaseline or pure lanolin breastfeeding Thick porridge fruit juiceis offered both breasts every 2-3 hours or dressesM) Wear loose fitting tally mashed fruit can be added at 4 months ThenI be getting enough If you baby has 6-8 add foods high iriron(g) Do not (like peas beause soap for 4ashing breasts as it will apers and is geining 4-7 ozs fish liver cheese rice yam potatoe caa weeker It takes some babies dry and crack nipple more1-3 weeks to re- spinach and pumpkin)

p their birth weight (h) Nurse in different positions Sore nipples willget better soon 11When should I wean my babyng will it take for my milk supply to

Do not stop giving new baby thevery best If you need more help call the BIB It is recommended that you wean gradually aestablished Hotline 7398 low the child to decide when Breast milk i re you breastfeed in the first 24 hours theyour mature milk will 6 What can I do about leaking most important food in your babys diet upcome in months There is noDO NOT GIVE set time for weaning B

bottle of water or formula in the hospital Leaking at the other breast while breatfeeding oc- may chooseore your milk comes in Your colostrupt to wean at 9 12 18 or 24 monthcurs for about six weeks If you begin leaking joy your little one and the opportunity tomilk) is all baby needs Breastfeed for while out apply pressure against breast to stoputes on and nourish himeach side feed on demand drink dripping Fold your armsacross chest and apply 1ZCan I Greastfeed and work outside the housef liquid eat a well balanced diet and pressure wich the heels of your hand against yourme rest Yor milk supply will be establish- breast or rest chin on your hands and press you can breastfeed7-10 days with frequent breastfeeding and Yes many mothers successfully do bothat Ifagainst your breasts with your forearms breaks and mealwork close to home timesTLES and well regulated in 3-4 weeks or can take your baby to an I do to relieve engorgement (when my

7 How many and what types of stools are normal in you arethe breastfed baby away at feed times you can manuall press milk (or use a pump) and leave the br

irst comes in and my breasts become hard The breastfed stool is usually loose and unformedre) milk for the baby For further details contIt may be yellow to yellowish green to brownish in BIB

ement is the swelling of the breasts when color A lone breastfed baby may stool after everylk first comes in Breastfeed _more fre- 13Who can I call for help if I have any probi after breastfeeding splash warm water on

feed or only once a week either is normal The Breast Is Best League 6 Church Street8 Does my baby need waterreasts or put a hot damp clot h o n breastB Box 1203 Belize City 0 7398 wants to helpminutes 3-4 times a day before feeds

o 2 Be i e it 7 8 wa s to h por Fully breastfed babies do not need any waterwarm shower and following that use successfully breastfeed We have breastfeedthe Breast mild contains all the water they needyour hand to gently stroke counselors trained to help you They willthe breast vBreastfeed on demand drink lots of liquids andd toward the nipple If your baby re- you in your homes send you materials or tIeven on hottest day baby only needs breastmilk to you by telephone the nipple hand express enough milk so ple is soft and baby can take hold Let gin breastfeeding on fuller breast first let a baby miss a feeding DO NOT GIVE by formula or water --- lone breast

RIGHT AFTER BABY IS BORN begin breastfeeding-the sooner the better The early milk will give baby extra protection against sickness And babys nursing will get you back into shape quicker

TRY TO HAVE at least six to eight weeks at home to rest and give baby a good start before you go back to your job Some mothers have to go back sooner but theyask for the shortest hours possible

WHILE YOURE AT HOME you can be with your baby loving and nursing him to your hearts content Many little babies want to nurse every couple of hours This frequentnursing brings in the milk Its so easy and you enjoy baby so much and feel so close to him youll hardly notice how many times you are feeding him

NIGHT FEEDINGS ARE EASIER when youre breastfeeding When baby wakes at night just take him in bed with you to nurse The nighttime nursing helps keep up yourmilk supply ind baby and you both enjoythe nursing and cuddling and drifting off to sleep together

AS SOON AS POSSIBLE after baby is bornlearn how to express milk from your breasts A nurse in the hospital or clinic or another nursing mother may be able to show youhow this is done Theres also a section about expressing and storing mothers milk in the manual THE WOMANLY ART OFBREASTFEED1NG

IQ 1976 La Leche Leagu international Inc

AFTER YOU ARE BACK ON THE JOB you can express milk on your coffee break and lunch hour to take care of the fullness in your breasts The next day you can leave this milk in a bottle to be given to baby

THE MILK YOU EXPRESS will have to be kept cold of course If theres a cafeteria in the office or factory where you work you can ask the manager for a little space on a refrigerator shelf Or you can bring a large thermos jug filled with ice from home to keep your container of milk in while you are at work and while carrying it home to put in your refrigerator Whatever plar you work out it will mean that baby can still have your good milk even when you arent there And youll be moic comfortable too

BEFORE YOU LEAVE FOR-WORK and when you get home you and baby can relax and enjoy a nursing time together Its a nice way to say good-bye for now and Im home again baby During weekends and on daysoff baby can really feast at your breast Andof course you keep right on with those nightshytime nursings

NO AMOUNT OF MONEY CAN BUY the many good things that come with breastfeedingNo formula can compare with mothers milk A baby on breast milk has fewer stomach upsetsand diarrhea But the main thing is babyshppiness YoujhppnsYujust wont believe what thisextra-special aothering will mean to him

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