Task Shifting in Growth Monitoring: Mother/ Caregivers roles at the Health Facilities

The study was carried out in Ido and Akinyele local government among mothers of Under –five children.

Ten focus group sessions, one group comprises of 6-8 participants were conducted among mothers. Focus Group Discussion (FGD) guide (Appendix 2) was used as a tool to gain better insight to growth monitoring among mothers of infants. Discussion questions focused on definition of growth monitoring, knowledge of mothers on growth monitoring, common illnesses among infants, how the growth monitoring is conducted by health workers and ability of mothers to conduct the growth monitoring, the guide was translated to local language (Appendix 3). Each discussion session lasted for 30-35 minutes with each session involving mothers of infants. The discussion sessions were moderated by the researcher.

The total of 20 Key Informants Interviews was conducted in the two local government areas Ido and Akinyele (2 health workers each from the health facilities). The interviews were conducted among nurses, matron, CHEW, CHO, Health Assistant, and JCHEW. The KII explored information on the respondents’ understanding about growth monitoring, challenges faced during these activities, the health workers’ opinion on training the mothers on how the growth monitoring can be done, recommendation and suggestions on what could be done to improve the service (Appendix 2). Written and oral consent (Appendix 1) was obtained, the interviews were conducted by the researcher, and the other trained Research Assistants were taking notes and watching non-verbal cues from the interviewee.

The use of voice recorder assisted in capturing all vital information provided during the discussions. Participants’ names were not requested; rather, numbers were assigned to them for easy identification. Numbers were not linked with the identifier but were only used for discussion purpose. The researcher conducted the interviews, transcribed, translated, and back-translated the results. The audio-recorded interviews were listened to and compared to the transcriptions to identify inaccuracies/inconsistencies in the transcript data. The codebook was developed by the researcher; this was done to ensure a reliable theme arrangement. Thematic analysis was also used to code the documents and transcripts, pointed by the major research questions on growth monitoring.

In response to the question on what the mothers knew about growth monitoring, different understandings emerged. Some of the explanations relate to giving Infant good food, putting baby on the weight to understand the growth patterns and coming to the health centres on every immunization day. Some mothers narrated their understanding on the growth chart. Some opined that growth monitoring of a child had to do with how heavy or light a baby is when he or she is being carried in the hands of an individual.

However, none was able to provide detailed and specific information that could be adjudged as depth of knowledge on this phenomenon. In addition, only a few could state the importance of growth monitoring but none had ever had the opportunity to practice the procedure. Besides, none of them had the growth monitoring apparatus at home. Overall, the idea about growth monitoring for most mothers is that it is just weight measurement as the measurement of head circumference. Length and mid-upper arm circumference measurements were only done for the Infant at birth alone. Their various understandings of GM are captured in the following quotes:

“Going for immunization and completion of the immunization process.” (Mother B at Ajibode)

“Knowing the food Infant can eat at every stage” (Mother A at Apete)

“It is good to check your baby’s weight so as to know how the baby is growing. If the baby is depreciating in weight, the mother will know how to take care of the baby.” (Mother A at Ologuneru)

 “The way I understand it is that it allows us to know whether the food our Infant is ^sic eating is working on their body and maybe it is what is being needed by their body is what they are getting from breastfeeding, that is the level to which I understand” (Mother B at Omi Adio)

Two of the mothers however explained that whenever the health workers weighed her child, she/he always informed her about what the child was weighing and she recorded it on the card, and that the health workers usually identify the well breast-fed baby through weighing which are done on immunization days.

‘’When my baby was weighed I was encouraged, when I saw the weight because even the nurses said he is ^sic well feed ^sic. So we know that that through the weight, you know that your baby is growing well when you breast feed the baby well’’ (Mother C at Apete)

 “They give us appointment on our card. So you come on your appointment day, but they do it every Wednesday. So this Wednesday is our appointment day another set will come next week Wednesday” (Mother A at Moniya)

One other mother narrated her experience with the health workers during the weighing activities. According to her, when health workers noticed her baby was not growing well, the baby was well taken care of, though she believed that growth retardation is caused by what is called oka. Explaining further on the treatment administered, below are the quotes to corroborate this statement above:

 When I gave birth to my baby, she was initially big but latter reduced in size and when I came here she was taken care of and became okay. She was given injection and I was asked to buy some drugs and was told to breast feed her properly (Mother A at Ido)

Another mother narrated her experience as captured below:

If a baby is under weight and the baby is still breast feeding, the mother should ensure that she eats properly so as to breastfeed properly and bring the baby regularly for weighing to check if the baby is improving and the drugs we can use (Mother D at Apete)

Some of the mothers that were interviewed reported that aside health workers monitoring their Infant’s development, they also engaged in observing the child’s growth by clothing, the quantity and hours of breast sucking, the quantity of food consumed during weaning, and use of beads and sleeping bed. The quotes below capture the respondents’ message:

“Like me now, I normally use my baby ^sic cloth and socks to see if they are really developing because the cloth they sell in the market, they have sizes that one month, two months till other age can wear”. (Mother C at Apete)

“Of course, I can use other means to notice if my baby is growing, like her small shoes even the beads round her hand can also help me”. (Mother A at Moniya)

Most mothers were unaware of how health workers conduct growth monitoring activities in Infant. When probed for some of the measurement, all mothers affirmed that the health workers do not measure some of the parameters like head circumference, height, and middle upper arm circumference for Infant that are up to six months. Two of the mothers responded as follows:

“It’s only the weight they check, they don’t check the height.” (Mother B at Sasa)

“They do not do it, I mean the height.” (Mother A at Elebu)

Another mother has this to say about the height:

When I gave birth to my child, I saw that they used tape rule to measure my child but I wanted to ask them the reason why they were measuring my child with tape rule but they were somehow harsh there. I could not ask them but I was looking at them and it was funny to me that they used tape rule to measure that child. It was funny to me that time (laughing). (Mother E at Elebu)

On the involvement of other entity in growth monitoring either by conventional or unconventional methods, majority of the mothers mentioned health workers as the first person to monitor the babies’ growth while some said it is the responsibility of the parents. Another mother expressed her thought that it’s the duty of the parents and also the teacher at Infant’s school.

When asked about whether they had weighing scales at home, most of the mothers said they did not have. One mother however narrated how she used adult weighing scale to measure her infant as illustrated in the quote below:

“I myself do use the weighing scale. I will stand on it, carry my child and then ask them to subtract my weight from it in order for me to know my child’s weight.” (Mother E at Apete)

Asked further whether they could actually perform what the growth monitoring entails, including measuring of other parameters, some mothers said they could not, since they were not health workers. They were of the opinion that it is the health workers’ responsibility not theirs to perform other GM parameters. However, a few said they could, with one mother interjecting that if they were trained, they would carry out the procedure effectively. Another mother buttressed this by saying she normally observed the procedures at the mission home but did not pay enough attention to the details. These varied opinions are captured below:

“We cannot do it. If we are trained, we can do it.”(Mother C at Elebu)

“I believe there is no mother that cannot do it if trained. We were trained on how to take care of a male child that was circumcised. So when taught, we can do it” (Mother B at Apete)

”We can’t do it, because not all of us are educated. As many as we are, it is hard to get people that can read what is written in our card. Is it one that cannot read that will weigh a child? And if it is all of us, there will be mistakes because it’s not our field. For example I learnt petty trading and I’m asked to administer injection on a child, how do I go about it?” (Mother A at Moniya)

“Okay, since it is not our duty we cannot read the scale.” (Mother D at Elebu)

“I use ^sic to look at it, it is one to something, our mission house mummy used to use it and I look at it at times, just that I do not pay much attention to it.” (Mother E at Ido)

Another mother also compared weighing to the scale used by the frozen food sellers. Her words:

“Me I said you will look at the scale the way you look at it for turkey (all laughed).” (Mother F at Elebu)

Majority of the mothers, after observing the chart at the back of the card, said they did not understand what it represented. Once the health workers write what is needed, mothers hardly check the chart. A mother commented:

“There are some lines, there are zigzag ^sic that we do not understand... I know what the child weighs while weighing the child and they said he weighs 7kg but once they write it, it is somehow; so it is not easy. If it is not your duty to understand it unless they explain to us (laughing) ... I do not check, it is also those that check it that will know” (Mother C at Apete)

In one of the health facilities, a mother confessed that he did not ask what her baby weighed because most of the health workers might shun her; she rather preferred to check from the card herself than asking them. In her words:

“I don’t want them to shun me or say I’m too forward. That was why I did not ask. At birth, I asked and they said her weight was 1.5. When we came back, she was 4.5. I do not know today’s own. Even if it is injection that was given, I ask the type of injection it is. I checked the last one that was done ^sic me and it was 4.5.” (Mother D at Apete)

Asked whether any amount is paid for weighing visits, almost all the mothers affirmed that they normally paid but the amount paid varied from a facility to another. A mother said:

“They just collect 50 naira from us, but we do not know what it’s used for.”

“I paid 20 naira today.” (Mother D at Sasa)

During the discussions, some mothers confused the advantage of immunization to mean that of growth monitoring. One of the major advantages emphasized by all mothers is that GM helps them to know if the baby is growing as expected. The following are some of their responses:

“One will know how the baby is growing for the child development.” (Mother A at Elebu)

‘”If a child is being weighed, one will be able to know maybe, God forbid, nothing happen ^sic to the child that it will allow one to know whether the child has lost weight, that it is good that if a child is being weighed continuously, one will be able to know if the child is not supposed to weigh one particular weight and he/she is supposed to weigh one particular weight, so this is what I know. Mother A at Ologuneru

What I know as its benefit is that it allows us to know how healthy the child is. If the child is growing, when we come around, the health workers showed us the previous weight and the one being done on the day of appointment and if we see that the weight has increased that will make us know that the child is ok. (Mother C at Apete)

The mothers also expressed some of the difficulties/challenges experienced. Lack of equipment at the various facilities and attitude of health workers were reported as major challenges. The quotes below corroborate this:

As individuals arrive, they should be attended to, so that they can go. I came from work and I’m supposed to have gone back, and whenever I come I should be asked what I came for and attended to. I receive my immunization and I go instead of them pilling our cards till everybody is around.” (Mother B at Apete)

”The instruments they use are not enough. If they have more, the work will be faster.” (Mother A at Omi Adio)

“The only thing that is there is that if one did not come in time and once it is 9 O’clock, they will say they have carried the scale inside and one does not have the grace to weigh the child again, finish.” (Mother B at Moniya)

“shortage of staff do ^sic not allow them to have enough time to weigh those Infant self. They will say they need to manage the time that they are short of staff. The person weighing also has ^sic some other things to do to make it fast.” (Mother C at Moniya)

One mother said most times, the health workers wasted their time by delaying them for weighing. It was suggested that if the services can be carried out immediately they arrived at the clinic, it will be better. Two mothers said:

“As we arrive, the immunization is administered, baby’s cloth is removed, baby is weighed and we go. It should be on first come first served.” (Mother D at Moniya)

“I feel like if ten of us arrive, we should be attended to because it’s not all vaccines that can be exposed. If it is exposed and only two people came, the rest becomes a waste. But if it’s ten people and the vaccine on ground can go round, we should be attended to.” (Mother B at Moniya)

However a few participants held a contrary view on health workers delaying mothers, maintaining that some of the mothers arrived at the clinic late, not that the health workers delayed them unnecessarily.

We Yoruba’s do not have (itara) ^zeal to be time conscious, but we will have some people who will use that as excuse and will not come to the clinic because they could not meet up with the time and those diseases that we want to eradicate will not go. I feel as everybody arrives, they should be attended to, and they go. Some people will arrive at 12 noon, despite the fact that they know the right time. Some of us are going back to work and some are not doing anything and don’t really care about the baby’s health. So if they use time consciousness, many people will not come. I feel as we come they should be attended to and they should continue like that. (Mother C at Ido)

There were varied views from respondents with regards to how growth monitoring is done. Some participants stated that the babies’ weight is normally checked during immunization but especially when the child is being delivered at the health facility. The child will be issued immunization card to track the schedule and their weights will be recorded as part of child delivery services. It was also added by a nurse from one of the facilities that growth monitoring cannot be done in details due to insufficient staffs and equipment:

It is mainly done during immunisations. Before the mother is discharged after given birth we have something we tell them about that child, we advise them to feed the child mainly on breastmilk, should not allow water to be given and we do educate them on hygiene… (Female Nurse at Ologuneru PHC)

Many other participants also stated that mostly, the eligible age for the growth monitoring services is usually 0-1 year because the vaccine associated with this programme is given within this period. However, a few opined that since the weighing normally stops at nine months because some of the Infant cannot be measured on the recumbent position because an adult weighing scale is not available.

“We use to weigh them at 9, but at 1, if we ask them to put their baby on the weigh scale, the baby will not comply. That is why we don’t normally weigh. It’s not that we don’t weigh them” (Female Nurse at Sasa PHC)

Some of the health workers interviewed gave their opinion on measuring the height of the child from new-born to document how the child is thriving as per growth. During the interview, however, it was noted that the respondents did not measure the child’s length though one of the health workers responded neither Yes nor No. They gave reasons for not carrying out these activities, below are the quotes to support their claim:

We are doing it here but I can’t lie, we don’t have plenty of staff here. So, we don’t have enough… as today now, we have plenty. About 60 Infant are to be attended to today. Even their parents are sometimes impatient about the procedure and all that. We don’t have enough staff. Sometimes, if we are not busy, we normally measure height… like today, but we are hmmm… plenty today we normally do ^sic it.” (CHEW at Ajibode PHC)

“Majorly we need weigh scale. Then at times we do height. … not all the time we measure height, just once in a while” (Female CHEW at Moniya PHC)

For height measurement, we don’t have but we ^sic are supposed to have. We have but it has got spoilt. (Female Nurse at Sasa PHC)

One of the health workers in the health facility confirmed that measurement of head circumference is supposed to be a vital growth monitoring service activity that should be carried out.

We ought to be doing that hair ^sic circumference, you know? You know we have babies that may develop this hydrocephalous as they are growing up”. (Chief Matron at Ojoo PHC)

At times, initially they said we should be doing their head circumference too but there is no time for that. We are not many. As for now, we are shortage of staff. (Chief Matron at Ojoo)

“ When it is not rush hour, most times because of our staff members are always stressful, we don’t have plenty but when they come early we do head and length measurement for them” (Female CHEW at Moniya PHC)

On measuring the mid-upper arm circumference, much was not said about the MUAC measurement. A nurse said the service does not cover newborn, it’s only for babies from six months upwards. A nurse had this to say:

Ehh... the MUAC measurement is from six month to five years. (Female Nurse at Moniya PHC)

Another respondent expressed her opinion below:

We do that one too. If the baby is having diarrhea or any other disease, we normally get it. (Female CHO at Sasa PHC)

On determining the types of equipment used in weighing, and measuring height and head circumference, staff members in some facilities stated that child weighing is their limit at the clinic. However many of the staff members in other facilities described how they measured the length and the head circumference of infants, saying they used tape rule provided they were not busy and the mothers also came early. Some nurses said that they made infant-weighing very compulsory for mothers though, the mothers themselves sometimes considered the period as a waste of time.

On the equipment items available at the health centre, only the weighing scale and MUAC were mentioned. In addition, they claimed to only use weighing scale for weighing Infant. They were also aware that other measuring equipment items such as tape measure and infantometer should be used at every growth monitoring visit but they were not available for the services. A few CHEW said:

Weighing scale and ehhh… We have this MUAC guide that we use for…we ^sicsupposed to be using everything but we use once in a while (Female CHEW at Moniya PHC)

When a child is identified as not growing well, the health workers always notified the mother on the outcome of such weighing exercise and referred to the nearest health facility if required. A quote to corroborate this is cited below:

When they come for immunization, we ask the mother to bring their immunization card and check the birth-weight. Then we will weigh the child. If the child is not growing well, we use ^sic to carry them along. About three weeks ago, my colleagues discovered one. We noticed that a child of six months was not weighing, growing up to 5kg. So we had to call the attention of the patron. So I don’t know what happened after then. I think the patron referred them” (Female Assistant Nurse at Ajibode PHC )

Apart from notifying mothers, health workers also notified higher-level health facilities through phone calls. Some of the mothers did not go to such referral clinics; they would rather go home to patronize herbs sellers. If referral facilities affirmed that the mothers sent to their facilities with their Infant did not visit the facilities, repeated calls had to be made to such mothers to ensure they actually visited the referral as illustrated in the quote below:

‘ ’You see, some of them are stubborn. Some of them will not go. Yes, some of them believe in herbs. If they freely go to where we asked them to go, some of them will pick and call us, and they give us update of how they are being treated over there. I can say that we have 90% follow up to be sincere’’ (Female Assistant Nurse at Ajibode PHC)

When asked about whether mothers can be trained on how to weigh a child, measure hand circumference and length of the child (whether they can weigh the child on the scale, measure head circumference and length of the child) majority of the health workers said not all mothers will be able to perform these activities. To buttress their point, the respondents cited an example, despite mothers’ immunization education on the part of the body the Infant should receive different vaccines, and some of the mothers cannot explain this. However, few opined that only the educated mothers can be taught how to carry out the growth monitoring services because they can quickly understand. One of the health workers also expressed her readiness to train the mothers if they were interested and ready to learn as shown in the quote below:

I think the good ones and intelligent ones there, so we will take it up while others may not have an interest because we have seen cases; before they start immunization, we used to ^sic educate and teach them on the types of injection to give to their Infant. Some of them will be dragging their legs on the floor and saying “we want to go, we want to go.” If we ask them the name of immunization that their ^sic want to get, if you don’t let us, we have a penalty for it. So, some of the mare ^sicready to learn, while some are not. (Feamle CHEW at Ajibode PHC)

It would have been better if most of them are interested... We will be happy if they are ready to learn. It’s not hard to teach them but most of them are not ready” (Male CHEW at Elebu PHC)

“I don’t think it is possible. So, because it is our work, we ^sic supposed to do it. If we train mothers, mothers can do it, but it is not their work. If we train them, they may do but I think it is not their work”. (Female CHEW at Ajibode PHC)

With respect to the training programme on growth monitoring attended, most health workers affirmed they had not attended any for the past years but one said she attended one at the local government around July 2018 for the preparation of an upcoming de-worming activity.

I attended a training on July 2018 because whenever we do this Vitamin A outreach, we do de-worming and growth monitoring with it too to check weight and everything- (Female CHO at Sasa PHC)

Being probed further whether the mothers were requested to pay for the GM services and the amount normally paid, most of the health workers said mothers do not pay for either cards or weighing services. However, few admitted that they asked mothers to pay for cards (100 naira) and the weighing (50 naira) every visit and buy newspaper or nylon to cover the weighing scale.

We do ask them for tokens. It is not compulsory; we normally use the money collected to buy consumables” (Female CHO at Apete PHC)

On what could be done to improve the GM service, most of the respondents suggested strong government involvement in all the facilities. They based their strong recommendations on the observation that some of the facilities did not have the required (up-to-date/modern) equipment items to deliver the service effectively coupled with manpower shortage.

”Number one, if the government can employ more staff” (Female CHEW at Ajibode PHC)

Another crucial way of the service improvement was also suggested:

“If the MOH can always come to their center to monitor them just to know their weaknesses and strength then everything will go well” (Female Asst. Nurse at Ajibode PHC)

On the contrary, one of the health workers mentioned that the users (mothers of Under-fives) should be educated on GM and its advantages as any of them did not attach any importance to the service.

Well, number one will be ehhh... What I will say is the mothers themselves, if they can get more exposure they can be more exposed. Maybe get more background on the programme, maybe they will be interested. It is just the recipients that might cause some issues.” (Female Asst. Nurse at Ajibode PHC)

On probing further from one of the respondents on the issue of having separate days for the growth monitoring activities, she mentioned Infant Welfare Clinics for mothers to have adequate time to carry out the service as specified by WHO. She personally agreed to the Infant Welfare Clinics because it would help mothers and even health workers to achieve the purpose of growth monitoring.

“To me, I can say if the immunization day can be split, if we actually do the growth monitoring in details, in a situation where we have a large number, it will get to a point that we will be weak, overtired. Let me say, what we can do 0-50% will be more effective to what we do between 51–100%. So it should be splitted ^sic. So, let some come this day, then let another set come the following day. It will be effectively carried out” (Chief Matron at Ojoo)

Also mentioning major barriers, one of the health workers indicated language as a major barrier that may hamper the growth monitoring. Below is the quote:

The majority of them are Hausas, so language barrier, so no Yoruba, no English except Hausa’’ (Female CHO at Sasa PHC)

On the logistic issues faced during the growth monitoring implementation services, one of the facility health workers said they did not face any manpower challenge. On the contrary, one of the nurses mentioned that adequate space, equipment, and staff posed major challenges.