Abla Al Alfy

This description of Abla Al Alfy's work was prepared when Abla Al Alfy was elected to the Ashoka Fellowship in 2013 .

Introduction

Abla Al Alfy is creating a cadre of skilled child nutrition professionals to support mothers during the first two years of their child’s life, a critical age for cognitive and physical development. These Child Nutritional Counselors provide valuable information and skills to mothers through nutrition centers in hospitals and homes across Egypt.

The New Idea

After realizing that doctors and nurses may not have the time, capacity, or sometimes knowledge to advise new mothers, Abla introduced licensed Child Nutritional Counselors to the Egyptian health system. Primarily from outside of the medical profession, they are changing the landscape of the healthcare system, dedicating themselves to serving new mothers in hospitals, primary care clinics, community centers, and in their homes. Child Nutritional Counselors focus on educating and changing the behavior of new mothers so that they adhere to proper and safe nutrition practices for their children in the first critical years of life.

Although Abla works with traditional doctors and nurses to ensure that they have the right information to pass on to mothers, the key to her work is engaging those closest to new infants and mothers—such as other mothers, midwives, family members, and community actors who are trusted and influential in decision-making.

Through seemingly simple provisions, the impact of systemizing and institutionalizing support services and resources for new Egyptian mothers cannot be underestimated. After completing training to attain certification, Nutritional Counselors provide real-time health and nutritional support to mothers during their child’s first two years of life. Abla is strategically targeting their work on the most at-risk population, which ensure maximum gains in nutrition rates in Egypt.

The Egyptian Ministry of Health and Population has recently agreed to adopt and integrate this new certification process into the public healthcare system. In addition, the government has pledged to support Abla’s plan to create Child Nutrition Centers within public hospitals, primary health care (PHC) centers, and community centers.

The Problem

The first two years of a child’s life are crucial to cognitive and physical development, affecting both the child’s early and adult years. Improper nutrition during the first two years, part of which includes a lack of breast-feeding and early introduction of formula, may result in a number of short- and long-term negative effects, such as psychological and physical diseases as well as neurodevelopment delay. In 2010, the Millennium Development Goals confirmed that malnutrition is one of the main causes of death among children under five. Additional causes are low breast-feeding rates and infection due to poor prenatal care. While there have been successful efforts by governments, the United Nations, and citizen organizations (COs) to reduce child mortality rates for those under five, malnutrition before two remains a devastating scourge.

The under-five mortality rate has improved in Egypt over the past few years. Children under two, however, are not meeting growth indicators such as height, weight, hearing ability, motor development and other benchmarks mainly due to malnutrition. In fact, more than 50 percent of Egyptian children have stunted physical and cognitive development, making optimal early child nutrition a national priority. The problem stems from mothers lacking adequate information regarding child health and nutrition from doctors, practitioners, and health workers—and from a deficit of nutrition training for health professionals in the first place. As a result of poor nutrition, children under two continue to suffer from a variety of ailments beyond mental and physical stunting including iron deficiency, low immunity (breast-feeding increases immunity), and increased mortality. Malnutrition also correlates to higher incidence of childhood allergies, obesity, diabetes, and infections (mainly pneumonia and gastroenteritis). Not only does poor child nutrition affect early life, it also has terrible long-term effects such as an increased hypertension, obesity, and coronary heart disease—all of which carry the added burden of high medical expenses for families and communities.

Though the widespread, long-term health benefits of breastfeeding are well-documented only 28 percent of Egyptian babies are exclusively breast fed during the first six months and 58 percent of Egyptian mothers stopped breastfeeding due to misconceptions about insufficient milk, lack of information on the benefits of breastfeeding, and lack of assistance from nurses on lactation management. In addition, 81 percent of mothers reported that they did not get enough help with breastfeeding after the birth of their child, and 71 percent of mothers who went for a follow up visit reported a need for more education on child nutrition. There are currently only 250 lactation consultants in all of Egypt and little to no resources regarding what and how to feed children during their first two years, especially after the mother stops breastfeeding.

In addition to other problems with this system, 90 percent of medical school graduates do not have the opportunity for hands-on training since further university medical schooling is granted only to those who are in the top of the class. Since adequate post-medical school training is inaccessible to them, most newly graduated pediatric doctors, even those eager to pursue continued education and specialized training in subspecialties like neonatal care, do not have a way to do so. They should, but do not have specific training with children between zero to six months as well as training in aftercare and specific child nutrition practices that are needed until the age of two to ensure the baby’s survival and wellbeing.

The Strategy

Abla founded the Egyptian Members Association of the Royal College of Pediatrics and Child Health (EMA-RCPCH), using a three-tiered approach to target community actors (citizen sector workers, mothers, and family members), health workers (nurses and midwives), and doctors. While working as a pediatrician and neonatologist, Abla realized that doctors and nurses are an important resource for new mothers but they often do not have the time or knowledge to provide them with adequate training on breastfeeding and child nutrition.

To address this problem, Abla has introduced Certified Nutritional Counselors in Egypt. These counselors work in hospitals, community centers, and in the homes of new mothers to give child nutrition counseling—specifically from the time of birth until the child is two years old. Abla has designed a training curriculum that is focused on nutrition during the child’s first six months; six months to one year; and one to two years. Each of these stages is critical to a child’s development. In addition to being properly trained on breastfeeding techniques, nutritional counselors learn what types of foods should be introduced to the baby’s diet during these three stages. They learn how to measure a child’s nutritional health, how to recognize and solve nutritional problems; and they receive training on proper immunization practices so that they can also provide this knowledge to mothers. Counselors also learn communication and active listening skills to maximize their effectiveness. Integral to Abla’s approach is for counselors to urge mothers to bring someone—their husband, mother, sister, or neighbor—when they meet with a counselor or visit a nutrition center. This is to ensure that accurate information is reinforced within their closest circles. As a result, the mother will not receive contradictory advice and the community will become educated about child nutrition practices. Outside of the major cities in Egypt, close knit communities and a strong emphasis on family makes extended family and community members especially influential with regard to child nutrition practices. Knowing the importance of word of mouth in Egyptian society, Abla encourages mothers, nurses, and those who participate in the training workshops to talk among their friends and family.

A key element to the certification program is that anyone can complete the training and take the two tests (practical and written) upon completion. The first audience Abla targets for certification is local community workers—COs, mothers, and family members who do not necessarily have a background in the health sector. Abla recognizes that mothers who have breastfed in the past are going to have more influence than a male doctor in teaching and advising new mothers about how to breastfeed and what foods to feed their infant. Understanding the importance of breastfeeding and how little it is practiced in Egypt, many mothers have registered for the certification only because they want to help new mothers do what is best for their children. Abla also recognizes that it is important to certify other health workers, including midwives, nurses, and doctors. Doing so will provide a larger network of support for new mothers as they learn not only how to breastfeed but also safe nutritional practices for their babies. Abla has succeeded in initial negotiations with the Ministry of Health and Population, who have shown eagerness and interest to implement certification nationally.

To ensure the sustainability of the certification program and the quality of the counselors, Abla requires all nutritional counselors to become recertified every two years. The process is an opportunity to collect data, monitor quality, and track impact. The nutritional counselors share extensive information regarding the number of cases they worked on, the individuals they helped, and the type of support they provided. Abla also monitors newly certified counselors and practitioners by assessing child nutrition indicators among the children of mothers who received counseling, compared with national surveys where the program is not yet implemented.

Abla is also creating nutritional counseling centers within hospitals to offer mothers’ specialized guidance. She has founded two nutrition counseling centers in Benha Children Hospital and Mansoura Medical Center in Egypt. Abla promotes the centers with the Ministry of Health, private hospitals, government hospitals, primary health centers, and other community centers. Additionally, she has created family support groups in Qalyobia and Dakahlia governorates (states of Egypt) and promotes thisidea with local health COs working in different governorates. Abla is securing such partnerships so that hospitals will direct mothers to the nutritional centers if they need support or advice after they leave the hospital. These centers also provide immunizations and birth certificates for children. Abla plans to significantly expand the reach and number of the nutritional counseling centers in the coming years.

Abla has also created a curriculum with training manuals for doctors, nurses, midwives, and other health professionals. The curriculum is focused on practical training through a community-centered approach to pediatrics with close attention to child nutrition under the age of two as well as child development indicators. To make it accessible and appealing, Abla uses visuals and compresses information into a shorter amount of time so that more people can attend. She transformed a training for practitioners on child nutrition (breastfeeding) developed by UNICEF and the World Health Organization into a two-day interactive training. Abla also created an at-home module of the information to make it easier for people to study at their convenience.

To scale and expand her work, Abla has created many key partnerships. In 2005 she became certified as an international lactation consultant and has since been elected to serve as the Secretary General for the Egyptian Lactation Consultants Association. Abla uses the current 250 lactation specialists from this organization to help with her program’s training and monitoring. She and her team of consultants conduct bimonthly follow-up visits to monitor the implementation of the child nutrition standards taught during training with the health workers in the hospitals. A key partnership with Save the Children has enabled Abla to extend the reach of her program to practitioners in public hospitals and clinics in Qalyobia (Qanater, Khairia and Kafr Shokr), Zakazik, Qena, Bany Suif, Sohag, and Assyuit.

Abla also convinced the Royal College of Pediatric and Child Health to hold membership exams in Egypt. This gives doctors the opportunity to continue their education with an emphasis on community-based neonatal pediatrics. Moreover, Abla made Egypt the first country in the region to gain approval from the Royal College in the UK to award the International Diploma of Child Health. Abla redesigned and adapted the course to fit the Egyptian context with an online module and assessment system. The diploma offers practical “bedside” training and will be a six-month program. In 2013, the Royal College approved the international accreditation of the Egyptian Pediatric Fellowship, which Abla and her team have been working to improve and update.

The Person

Abla was included in family decision-making early on. During adolescence, she was closely involved in her community, supporting families who had experienced loss during a recent war by collecting money and distributing clothes.

Amidst her community involvement, Abla knew that her passion was working with children. She went to medical school to study pediatrics to work with infants. At each hospital, she asked herself how she could help her colleagues become better doctors and serve her patients more effectively. In addition to being a practicing pediatrician, Abla has been an educator, an innovator, a child health development professional, and a reformer wherever she has worked.

After marriage, Abla and her husband moved to Kuwait for their careers. While there, Abla implemented new initiatives in the hospitals where she worked, and focused on working with new mothers and teaching them how to breastfeed. In one hospital, Abla was able to raise the breastfeeding rate from 10 percent to 90 percent in just one year. After working in Kuwait for 18 years, she moved back to Egypt so that her son could attend medical school. Upon her return, Abla was shocked at the meager standard of pediatric care and the lack of community pediatric services in Egypt. Additionally, she was surprised at the large number of young medical graduates that wanted more on-the-job training but were not able to find work. Abla began to train young graduates and, though her efforts were admired by many, she faced opposition from hospital officials more concerned with saving costs than improving the quality of healthcare for infants and their mothers. This experience motivated her to start her own organization to improve pediatric child nutrition and child care in Egypt.