,NuJ:1Ul1~~~~~~ - DOH Central Library - Department of Health

3.5.3 Sampling design.... 28
3.5.4 Mode of data analysis 29
3.6 Semi-annual validation of level of intervention
implementation 36
3.7 Project management and administration 37
3.8 Data processing :........................................................ 39
3.9 Implementation schedule 40
4. THE PROJECTAREA 45
4.1. Socio-economic-demographic profile of La Union 45
4.2. Health indices 46
4.3. Rural Health Unit (RHU) profile 47
4.4 PHC implementation profile 48
5. RESULTS OF THE PROJECT OPERATrONS COMPONENT 50
5.1 Training of project implementors .. 50
5.2 Delivery & monitoring system implementation 51
5.2.1 Coverage of the IFSD project 51
5.2.2 Compliance with protocol....... 52
5.2.2.1 Identification and referral of
Pregnant Women (PW) 52
5.2.2.2 Delivery of interventions 54
5.2.2.3 Monitoring of PW supplementation 59
5.2.2.4 Monitoring of pregnancy outcome 61
5.3. PHC support system 62
5.3.1 Barangay Health Worker (BHW) involvement 62
5.3.2. Primary health care committee involvement 63
5.4. Problems in project implementation 64
5.4.1. Accomplishment of project monitoring forms 64
5.4.2. Declining participation of BHW and
PHC Committee in the project 64
5.4.3. Leakage of project supplement 65
5.4.4. Low compliance with protocol....................... 65
5.4.5. General project with administration 65
5.5. Early response schemes 65
5.5.1. Dialogues and reinforcement training of
project implementors 65
5.5.2. Revisions on project operations 66
5.5.3. Seminar-Workshop among RHU and
PHC Committee officers 66
5.5.4. Workshop with provincial and district task forces 66
ii

9.3 Selected variables & nutritional status of infants
28 days after birth 106
9.4 Parameters for targetting pregnant women 107
10. CONCLUSIONS AND RECOMMENDAnONS .
10.1 Extent of anemia problem among PW .
10.2 Effectiveness of food, iron and Nutrition Information
and Education (NIE ) interventions ..
10.2.1 Reduction of anemia among PW .
10.2.2 Reduction of the incidence of low birthweight .
10.3 Cost effectiveness analysis .
10.4 Issues and policies on anemia and low birthweight
prevention and control program ..
10.4.1 Need for iron and food supplementation ..
10.4.2 Targetting of PW for food supplementation ..
10.4.3 Strengthening of the NIE program .
10.4.4 Other components .
10.5 Delivery system within the PHC framework ..
11. REFERENCES .
12. APPENDICES 119
A. Implementor's guide for midwives 119
B. Course design for IFSD training of RHM, PHN and Supervisors 144
C. Course design for IFSD training of BHWs and
Barangay Primary Health Care Committee (BPHCC)
Chairmen............................................................................................... 154
D. Listof variables :............................................ 157
E. Memo ofagreement 177
F. Duties and responsibilities of project implementors 180
G. IPSD problems, recommendations and
actions taken as of May 31, 1985 185
H Findings on IFSD project implementation, Jan-Aug 1985 188
I. Plan of action for the integration of the IFSD project in PHC 198
J. Summary of plan of action for integration of IFSD in PHC 202
K. Frequency tables on dietary intake 205
iv
108
109
109
109
109
110
110
110
111
111
112
112
115
•

.
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table 18
LIST OF IFSO TABLES
Page
Prevalence of nutritional anemia among pregnant
women in 1976, 1978, 1982, 1987 5
Studies on the effect of maternal malnutrition on
the offspring 6
Studies on the effect of anemia among pregnant women............. 7
Studies on the effect of Iron supplementation 10
Three months nutrina cycle menu 19
Treatment group assignments based on geographic features
and selected health statistics 22
IFSD Monitoring system 27
List of varia bles used in multiple regression analysis
on anemia among pregnant women (PW) 30
List of variables used in multiple regression analysis
on low birthweight among infants 31
List of independent variables used in logistic regression
analysis for the different research objectives 33
IFSD Database 40
IFSD Implementation schedule :......... 42
Provincial averageand range of values (per municipality)
of selected population and health indices, La Union, 1985
Public Health Nurse/Rural Health Midwife training
accomplishments..................................................................................... 50
BHW Training accomplishments , 50
Coverage of IFSD project December 1984-December 1986 51
Percent distribution of pregnant women by place
of prenatal check-up first to third validation studies 52
Percent distribution of pregnant women by place of prenatal
check-up and treatment group 53
v
47

Table 19
Table 20
Table 21
Table 22
Table 23
Table 24
Table 25
Table 26
Table 27
Table 28
Table 29
Table 30
Table 31
Percent distribution of pregnant women by
Age of Gestation (AOG) in month during enrollment
in IFSD project and treatment group 54
Percent distribution of pregnant women by protocol used
in receipt of Ferrin and treatment group, first to
third validation studies 55
Percent distribution of pregnant women by protocol used
for receipt of Nutrina and treatment group, first
to third validation studies 55
Percent distribution of pregnant women by AOG
(in months) on first intake of Nutrina supplement
and treatment group, post sur:vey 56
Percent distribution of pregnant women by AOG
(in months) on first intake of Ferrin supplements
by treatment group, post survey 56
Percent distribution of pregnant women by number
of Nutrina packs received per month and treatment group,
first to third validation studies 57
Percent distribution of pregnant women by frequency
of receipt of nutrina and treatment group, first to
third validation studies 57
Percent of pregnant women who received NIB materials
by type and treatment group, first to third validation studies ...' 58
Percent distribution of pregnant women by action/advise
received during receipt of NIE materials and treatment group,
first to third validation studies 58
Percent of pregnant women visited for monitoring of
supplement intake by type of personnel and treatment
group, first to third validation studies 59
Percent distribution of pregnant women by frequency of .
visit conducted by staff and treatment group, first to
third validation studies 60
Percent distribution of pregnant women by ferrin daily
dosage and treatment group, first to third validation studies ...... 60
Percent of pregnant women whose infants were weighed
at birth and 28 days after by treatment group, first to
third validation studies 61
vi

Table 32
Table 33
Table 34
Table 35
Table 36
Table 37
Table 38
Table 39
Table 40
Table 41
Table 42
Table 43
Table 44
Table 45
Table 46
·Percent of barangay health workers involved in IFSD
activities by treatment group, first to third validation studies .... 62
Percent of RHM who obtained assistance from BPHCC
by type of assistance given, first to third validation studies 63
Distribution of pregnant women by age of gestation and
treatment group, pre.-and post-survey 70
Mean values (x), standard deviations (s.d.) and corresponding
sample sizes (n) for selected socio-demographic variables
by treatment group and for the total sample, pre-survey 71
Distribution of pregnant women by educational
attainment and treatment group, pre-survey................................ 72
Distribution of pregnant women by past pregnancy
outcome and treatment group, pre-survey.................................... 73
Number and percent of pregnant women with clinical
signs and symptoms by type and treatment :group, pre-survey.. 74
Prevalence of parasites by type and treatment
group, pre-survey 75
Distribution of pregnant women by nutritional status and
treatment group, pre-survey 75
Number and percentage of pregnant women with adequate
% RDA for various nutrients by treatment group, pre-survey.. 76
Number and percentage of pregnant women who smoke
and drink alcohol by treatment group, pre-survey....................... 77
Percent relative change of pregnant women who
obtained correct answer by k-item from pre- to post-survey
by treatment group 78
Percentage of pregnant women who had pre-natal check-up
prior to conduct of survey by treatment group,
pre-and post-survey 79
Percent distribution of pregnant women by start of pre-natal
check-up and treatment group, pre-and post-survey.................... 79
Percentage distribution of PW by place of pre-natal
check-up and treatment group, pre-and post-survey..................... 80
vii

Table 47
Table 48
Table 49
Table 50
Table 51
Table 52
Table 53
Table 54
Table 55
Table 56
Table 57
Table 58
Table 59
Table 60
Table 61
Percent distribution of pregnant women by reasons for
no-prenatal check-up and treatment group,
pre-and post-survey 81
Mean intake by type of nutrient and treatment group,
pre-and post-survey 82
Statistically significant differences in nutrient intakes from
pre- to post-survey by treatment group 83
Percent of PW with adequate fat and carbohydrate intake
by treatment group, pre-and post-survey.......................................... 84
Ranges of percentage of PW whose intake levels were
less than 50% of RDA for selected micronutrients in the
four treatment groups"pre- and post-survey..................................... 85
Prevalence of anemia before and after supplementation
by treatment group 88
Anemia status by treatment group and age of gestation
at the time of pricking 89
Prevalence of anemia at baseline and adjusted
prevalence after intervention by treatment group 90
Incidence of low birthweight before and after
supplementation by treatment group 91
Cost of BHW involvement in identification and
referral activity by treatment 96
Total cost of intervention by expenditures item and
trea tmen t 97
Breakdown of total cost by item, capital &
recurrent and source ,........ 98
Cost per capita by expense category and
treatment group 98
Comparison of adjusted relative change in anemia status
and cost per capita of 2 interventions 100
Comparison of relative change in low birthweight and
cost per capita of 3 interventions 101
viii

Table 62
Table 63
Table 64
Table 65
Table 66
Table 67
Comparison of cost per capita and cost per capita
per unit of effectiveness for the different type of
cost components 103
Results of the logistic regression analysis on the
interrelationship between anemia status and
socio-economic, demographic and
intervention variables 104
Results of the logistic regression analysis on the
interrelationship between birthweight and
socio-economic, demographic and
intervention variables : 105
Results of the multiple regression analysis on the
interrelationship between birthweight and the
socio-conomic, demographic and
intervention variables , , 106
Results of the logistic regression analysis on the
interrelationship between nutritional status of the child
at 28 days after birth and socio-economic, demographic
and intervention variables 106
Results of the logistic regression analysis to identify
predictors of low birthweight among pregnant
women without intervention , 107
ix

LIST OF FIGURES
Page
Figure 1 IFSD Conceptual framework in the context of primary
health care 17
Figure 2 Treatment allocation, La Union Province 21
Figure 3 IFSD Delivery and monitoring system 25
Figure 4 IFSD Project organizational structure 38
Figure 5 Significant landmarks in the IFSD Study, 1982-1989 , 43
Figure 6 Factors affecting effectiveness of Iron Supplementation
Delivery 69
Figure 7 Percentage distribution of DOH contribution to the
project costs according to type of personnel paid 99
Figure 8 Percentage distribution of capital and recurrent costs according
to source and funds. 99
x
.. '

.
month of pregnancy until birth, and (c) Nutrition Information and Education (NIE)
using four brochures on iron supplementation, food supplementation, food
prescription and anemia control and prevention reinforced with face to face
counselling during consultations and pre-natal visits.
The study was conducted in the province of La Union in Northern Philippines. All
the 20 rural health units of the province were allocated to the four treatment groups
namely: (l) Food Group; .(2) Iron Group; (3) Food and Iron Group and (4) NIE Group
using the following criteria for their assignment: a) expected number of 7-9 months
PW at any given time, b) variability in the geographical features, c) homogeneity in
the overall birth rate, death rate, and infant mortality rate across treatment groups.
The delivery of interventions for the pregnant women was effected through the
health care delivery system of the Department of Health, primarily through the
Rural Health Midwives (RHMs) supported.by the Barangay Health Workers (BHWs)
within the PHC framework. Before the start of the delivery, these implementors
were trained together with their supervisors, the Public Health Nurses (PHNs), the
Municipal Health Officers (MHOs), the Area Nurse Supervisors (ANS) and the
District Nutritionists (DNs) and provincial technical staff.
The project delivery system was integrated into the activities and functions of the
RHMs and BHWs at the barangay level within the existing maternal and child health
program. Materials for the interventions were delivered directly to the Rural Health
Units (RHUs) to minimize delays and thus ensure the availability of supply at the
barangay level when needed by the targets.
Extent of iron deficiency anemia problem
The study indicates a poor nutritional status among the pregnant women in the
study ·population. The data showed that only 12.4% of the population at baseline had
adequate iron intake based on the 24-hour food recall method, and the prevalence of
nutritional anemia using the WHO cut-off point of 11 gil hemoglobin concentration
by the cyanmethemoglobin method ':Vas 40.4%.
Moreover, in the treatment groups where there was no iron supplementation, the
prevalence of anemia increased. The Food group showed an increase of 20.8% and
the NIE group, 12.1%, after the 1 1/2 years implementation of the project 0984­
1986). A similar nationwide trend was apparent. The FNRI nationwide survey in
1987 showed an 32.9% increase from 1982 in the prevalence of anemia among PW.
Effectiveness of food and iron supplementation on Nutrition Information and
Education (NIE) intervention
Reduction of anemia among pregnant women
Iron supplementation using the present health delivery system within the
framework of PHC was effective in reducing the prevalence of nutritional anemia
among pregnant women in the community. Statistics showed that it was possible to
reduce the prevalence of anemia in a community b/4.0% after 1 1/2 years of iron
xii

On the other hand the cost effectiveness analysis of the reduction of low birthweight
showed the NIE Group to be the most .cost effective intervention followed by the
Food and Iron Group, the Iron Group and the Food Group in that order.
In an already existing health delivery system however, the Iron Group was more cost
effective than the combined Food and Iron Group in the reduction of anemia.
Correspondingly, the Iron Group was more cost effective than the Food and Iron
Group in the reduction of low birthweight.
Cost of preventing anemia and low birthweight
The cost of preventing one case of anemia or-low birthweight in the community was
also computed for policy guidance purposes. For an on-going food and/or iron
supplementation program the total cost of preventing one case of anemia in the
community was I24,438 ($317) for the combined Food and Iron Group and 12521 ($37)
for the Iron Group. The costs of preventing one case of low birthweight in the
community by treatment group were: NIE Group, 12167 ($12); Food and Iron Group,
PS,547($610); Iron Group 122216 ($158); and Food Group, P12,860 ($919).
Recommendations based on the effectiveness of iron and food supplementation
A significant finding of the study is that the iron group was shown to be effective in
the reduction of both the anemia of PW and low birthweight (LBW) of the infant.
The NIB intervention was not enough to reduce the prevalence of anemia among
PW as shown in the increased prevalence of anemia among PW in the treatment
groups without iron intervention. The iron treatment is considered to be cost
effective in the reduction of both anemia and LBW. With these findings it is thus
recommended that iron supplementation be implemented nationwide to improve
the nutritional status of pregnant women and their offspring.
The combined food and iron intervention was also shown to more than treble the
reduction in the prevalence of anemia compared with iron intervention alone while
the reduction in the incidence of low birthweight, was doubled food alone. The
same treatment group was found to be cost effective more than iron alone or food
alone. It is thus highly recommended that food supplements be given to pregnant
women starting on the 7th month of gestation to birth. However it appears that
food intervention is costly (P333.91 for a zero based program or P205.76 involving
supplies and training cost only) per pregnant woman. Multiply these figures by the
number of pregnant women in a community, and the sum becomes enormous.
One alternative for the government is to adjust the existing food supplementation
program to include the pregnant women. If the supply of food commodities would
still be insufficient, the high risk mothers could then be given priority.
The NIB Group performance in the study shows the possibilities of a strengthened
NIE program capable of increasing the dietary knowledge and practices among
pregnant women. This package can be promoted to cover all pregnant women. The
pregnant women should be trained to determine the amount of food they require,
particularly how to increase their calorie intake through additional servings of rice,
addition of oil and high calorie foods (like bucayo or boiled root crops) for snacks, and
xiv

The RHM and the BHW must observe closely the problems of the PW
during supplementation so as to give proper advice especially in
dissociating the real side effects of iron from other symptoms and educating
the PW on the need and benefits of iron supplementation.
b) BHWs should undergo rigid recruitment procedures and" be given
adequate training on the significance, benefits and operating procedures of
anemia control and prevention. Supervision/motivation of BHWs must
also be improved. Furthermore, a study should be conducted to determine
the specific achievable roles that should be given to the BHWs given their
educational and economic background. There is also a need to involve
other volunteer groups in the community in social marketing especially on
the importance of iron and pre-natal care. The teachers can also participate
in relaying these messages to the parents through their pupils. Alternative
delivery systems may be set-up like the use of supply/points service stations
where the PW can get their supplements in case of failure of deliveries.
c) A study should. be made to determine the validity of midwives' claims of
overload and their needs for motivation and training to improve their
altitude, efficiency and effectiveness.
d) Primary Health Care should be strengthened by the government
considering its high potential for developing community participation in
the delivery of health services to achieve the goal of health for all by the
year 2000. There should be a re-evaluation of the PHC strategies and its reidentification
in the health delivery system. Thus, BPHCC should be
reactivated, this time more vigorously to instill in the members a deeper
knowledge and appreciation of its concepts, strategies and goal-to improve
the quality of life of Filipinos.
xvi

ACKNOWLEDGMENTS
We gratefully acknowledge the support given by the following to the project: (a) the UNITED
STATES AGENCY FOR INTERNATIONAL DEVELOPMENT

TIlE INTER-AGENCY RESEARCH COMMITTE AND STAFF FOR TIlE IFSD PROJECT
(1982-August 1989)
Name
Dr. Florentino S. Solon
Mrs. Mercedes A. Solon
Dr. Rodolfo F. Florentino
Dr. Antonio Acosta
Dr. Carrnencita Reodica
Dr. Aurora S. Villarosa
Dr. Virginia Basaca-Sevilla
Dr. James Schiesselman
Dr. Ophelia O. Mendoza
Dr. Rudy Tan
Dr. Stella V. Gonzales
Mrs. Adelisa Ramos
Dr. Fernando Sison
Dr. Manuela Unite
Dr. Conrado Galsim
Dr. Juvencio Ordoiia
Dr. Ceferino Gonzales
Mrs. Romualda M. Guirriec
Mr. Miguel D. Lopez
Positionls Held
Project Director and Steering
Committee Member, Executive Director,
1983-1990(NCP)
Project Co-Director and Management
Committee Member, 1983-1990(NCP)
Project Co-Director - Proposal
Development, 1983-1990 (NCP)
Steering Committee Member, 1983-1986 (OOH)
Steering Committee Member, 1983-1986 (OOH)
Steering Committee Member, 1983-1986 (OOH)
Steering Committee Member, 1983-1986 (OOH)
Project Consultant, 1984-1988 (USAID-Washington)
Project Consultant, 1983-1990 (UP-CPH)
Project Consultant- Proposal
Development, 1983 (UP Stat. Center)
Project Consultant- Research,
National Task Force Member, 1983-1990 (OOH)
Project Consultant - Delivery and
Monitoring Component, National
Task Force Member, 1984-1990(DOH)
Project Consultant, 1989-1990 (UP-CPH)
Management Committee Member
Phase I, II, 1983-1986(RHO-DOH)
Management Committee Member, 1986-1989
Phase II (RHO - DOH)
Provincial Project Leader, 1986-1989
(IPHO-DOH)
Provincial Project Leader, Documentation
(IPHO-DOH)
Project Leader - Phase I, 1982 - 1983 (NCP)
Project Leader - Phase II, 1983-1986 (NCP)
xviii

Amelia Picardal
Marcelina Tadina
Elaine Zarate
Prisca G. Juloya
Aida Estigoy
Shirley Gapuz
Nancy Coloma
Edna Bilagot
Corazon Valdez
DISTRICT NUTRITIONISTS
Caba
San Fernando
Rosario
Aringay
Bauang
Bauang
Balaoan
Santol
Sudipen
Rosalina P. Estillore - Noguilian District
Manchu R. Pascual - Agoo District
Marlene Micua - Balaoan District
AREA NURSE SUPERVISOR
Agripina Blanco
Sonia F. Sarmiento
Lucia Estocapio
Perla Viduya
Ester V. Asprer
RURAL HEALTH MIDWIVES
San luan Rural Health Unit
Imelda Galvez
Leonila Palaroan
Estrelita Quejado
Tubao Rural Health Unit
Yolanda Milanes
Myrna Balderas
Julita de Vera
San Gabriel Rural Health Unit
Erlinda Rosqueta
Amelita Ariado
MarjorieBuquing
rugo Rural Health Unit
[ulita Domede
Beatriz Ortaleza
Bacnotan Rural Health Unit
Anita Abril
Fe Fernandez
- Balaoan District
- Bacnotan District
- Naguilian District
- Rosario District
- DGMH District
Susan Amita
Teresita Lictaoa
Norma Viola
Gloria Nelly Laroya
Tita Halog
Clairta Clarita
',r
Clarita Abad
Lourdes Magpayo
Nancy Camilo
Marissa Pinon
Florida de Guzman
[osefina Oreiro
Felipa Ricanor
xx
Merle Peralta
Nora Guerrero
Maxima Lopez
Perla Viduya
Remy Collado
Evangeline D. Llavore ­
Ofelia Laconsay
Evangeline Cabanban-
Marciana Bugasan
Angelita Quejado
Elvira Agtarap
Grace Mabalot
Susana Estoque
Elda Daoara
Jovita Castro
Jovita Baniqued
Norma Carta
Corazon Cardinez
Adoracion Padilla
Sto, Tomas
San Gabriel
Bacnotan
Puga
Bacnotan
Tubao
Sanjuan
Sanjuan

San Fernando Rural Health Unit
Agripina Tilan Nelia Ordofia Agnes Luz Florendo
josephine Rivero Lolita Molanida Gloria Gurtiza
Pacita Naro Purita Flores Swarnaba Marilyn Gaona
Rosa Baleita Limayo Corazon Cacayan Erlinda Ramos
Milagros Flores Ducusin Consuelo Ballesteros Rosa Quilates Balcita
Trinidad Lubrica Emelita Corpuz Emily Bautista
Caba Rural Health Unit
Santinela Fermin Marilyn Camacho Herminia de Vera
Francisca Valdez Lydia Dicolon Letecia Maglaya
Bangar Rural Health Unit
Luciana Maracha Natividad Balanon Consolacion Maracha
Aurelia Ramos Delfina Monis Constancia Cariano
Felicita Millares Nilda Ramos Linda Lacuadra
Teresa Bermudez
Luna Rural Health Unit
Aurea Otero Consuelo Bautista Purificacion Flores
Cleta Navarete Florita Corpus Ester Sibayan
julita Ciron Ester Castro Marieta Bautista
Anabelle Sibayan
Rosario Rural Health Unit
Lolita Apilado Luzviminda Zarate Sanchez Elizabeth Labonete
Gloria Boadilla Erlinda Posadas Elena Perez
Eloisa Guieb Elizabeth Ramos
Elaine Diaz Zarate Aurelia Albina Cariaso Blicilda Halog
Lourdes Passcua Marilyn Celis
Aringay Rural Health Unit
Marciana Dulay jemina Pascua Remedios Rullan
Serafina Barba Remedios Yaranon Teodora Arizala
jennifer Balangue Lilia Padilla josephine Maranes
Bauang Rural Health Unit
Norma Quedit Myrna Sabado Emma Cacdac
julita Subido Lydia dela Cruz Violeta Noriega
Corazon Argonza Zozima Gutierrez Elimeli Tingcay
Leonora Manantan CorazonDumaguing Aurea Hidalgo
Teresita Subido Manzano
xxii

IFSD Project Staff - Nutrition Center of the Philippines (NCP)
Mrs. Paulita Latoja-Duazo
Miss Rosemarie Gerolaga
Miss Carolina Pascual
Miss Rosario Ocampo
Miss Myrtle Corpus
Miss Myrthle Famorca
Miss Marichu Rosal
Dr. Jane Teliaken-Dominguez
Dr. Michael Fabay
Dr. Lester Lora
Dr. Rizalina Umel
Mr. Wilson Estillore
Mrs. Merlyn Lorenzo
Mr. Edmundo Savella
Miss Marcita Uy
Miss Imelda Borja
Miss Zenaida Casasola
Miss Jessica Delim
Mrs. Liliosa Delena
Miss Prodema Quezada
Mrs. Lourdes A1barillo
Miss Maritess Lagarto
Mrs. Diana Decena
Mrs. Cecilia Delgado
Statistician, 1988-1989
Statistician, 1987
Writer, 1984
Writer, 1984
Nutritionist Supervisor, 1987-1989 Field
Operations Officer, 1985-1986
Nutritionist Supervisor, 1987-1989
Data Processing Supervisor, 1984-1986
Nutritionist, Field Operations Officer, 1984-1985
Project Physician - Pre-Survey,
Project Physician - Post-Survey
Project Physician - Pre-Survey
Project Physician - Post-Survey
Medical Technologist - Pre-Survey
Medical Technologist - Pre-& Post­
Survey
Medical Technologist - Post-Survey
Medical Technologist - Pre-Survey
Nutritionist-Interviewer - Post-Survey
Nutritionist-Interviewer - Post-Survey
Nutritionist-Interviewer - Post-Survey
Nutritionist-Interviewer - Post-Survey
Nutritionist-Interviewer - Pre-Survey
Sociologist - Proposal Development, 1983
Researcher-Nutritionist - Proposal
Development, 1983
Member, National Task Force, 1983-1984
Member, National Task Force, 1983-1984
xxiii

Miss Myrna B. Bumatay
Miss Isabel B. Burnatay
Mr. Eddie Molina
Mrs. Arlene Abueg
Mr. Ferdinand Bernardo
Mr. Hector Gutierrez
Mr. Anthony Rconisto
Mrs. Milagros Almeda
Mr. Frank Montevirgen
Miss lsabelita M. de Leon
Mrs. Lorna Rabulan
Miss Agnes Alma Alejo
Miss Ana Caranay
Mr. Peter Mendoza
Mrs. Kezia Paras
Mr. Amado Rosalinas
Mr. Rolando Capinpin
Mr. Rodolfo Somera
Mr. Dionisio Tuvera
Mr. Raymundo Halvin
Mr. Benjamin Hernandez
Mr. Joaquin Almeda
•
Interviewer, Junior Researcher, 1986
Interviewer, Coder, 1986
Coder, Encoder, 1986-1989
Senior Programmer, 1985-1986
Programmer, 1985-1987
Programmer, 1987-1990
Programmer, 1986
Finance Officer, 1982-1989
Editor, 1988-1990
Secretary-Typist, 1982-1989
Secretary-Typist, 1987-1990
Secretary-Typist, 1990
Typist, 1984
Artist, 1984
Accountant, 1982-1990
Driver, 1984-1986
Driver, 1984-1986
Driver, 1984-1986
Driver, 1984-1986
Delivery Aide, 1884-1986
Administrative Officer, 1982-1990
Property Officer, 1982-1989
xxiv

1. INTRODUCTION
Background and Rationale
In the Philippines, nutritional anemia affects approximately 34% of pregnant women
and is more prevalent in rural (34.8%) than in urban (32.5%) areas (1). This problem
among pregnant women is of high importance because of its effects on the offspring.
Previous studies show that pre-natal and neo-natal physical growth retardation is
associated with high risk of infant malnutrition, morbidity and mortality (3-10,12-22).
Nutritional improvement of the mother therefore through available health care
services will reduce the risks and complications associated with pregnancy and
childbirth, and thus improve pregnancy outcome, survival. and physical and mental
development of the offspring. It will maintain her capacity to perform other kinds
of work and thus contribute to the economic survival of the family. Consequently,
any investment made to decrease the incidence of maternal malnutrition will
benefit not only mothers and their offspring but also the community as a whole.
In seeking to reduce the problem of ma ternal malnutrition and its effects, the
Nutrition Center of the Philippines (NCP) and the Department of Health (DOH) thru
its Nutrition Service have embarked on the project, IRON AND FOOD
SUPPLEMENTATION FOR PREGNANT WOMEN WITHIN THE FRAMEWORK
OF PRIMARY HEALTH CARE (PHC). The project is an innovative scheme to
implement iron and food supplementation for pregnant women using

The Health Care Delivery System Within The Framework of Primary Health Care
Through the years, the Philippine government has taken measures to meet the
growing demand for health services made difficult by factors such as scarce resources,
a rapidly growing population and spiralling inflation. It has expanded and
constructed its health care delivery system to serve a bigger percentage of the
population. In 1954, in order to meet the increasing medical and health needs of the
people, the Rural Health Law was passed creating a rural health unit in every town
of the Philippines, with a health manpower compliment of a doctor, a nurse, a
midwife and a rural sanitary inspector.. An amendment of the Law in 1957 provided
for more additional personnel depending on population sizes. In 1974, the Ministry
of Health strengthened the rural health unit services by restructuring the health care
delivery system in its attempt to expand health and medical services particularly to
the rural areas. Midwives were recruited, trained and deployed to serve a population
of more or less 5,000 people (23).
In 1978, during the Alma Ata Conference in the USSR, the Philippines adopted the
Primary Health Care approach as a means of making its health care strategy more
effective in meeting the health needs of the Filipinos. Formally launched in October
1979 through Letter of Instruction 949, the PHC approach aims to provide essential
health services that are community-based, accessible, acceptable and sustainable at a
cost which the community and government can afford. In the context of PHC, the
community recognizes and accepts the responsibilities for its own health care and is
prepared to take concerted action and use its own resources for the purpose. The
government health system in turn, renders the basic health services and provides
guidance and even leadership when indicated on areas concerned with the
community's health (24).
In 1980, PHC was piloted in 12 provinces, one in each region (25). It included the
following four fundamental elements: 1) active community participation and
involvement; 2) inter-sectoral cooperation; 3) development and use of appropriate
technology to meet local health needs and 4) development of support mechanisms to
sustain PHC implementation. Under the PHC Organization and Management, the
DOH is the lead agency for implementation with other ministries as cooperating
agencies. PHC committees were set up at the regional, provincial, municipal and
barangay levels. Composed of the health officer, who served as the PHC coordinator
and representatives from cooperating government and private agencies, each
committee was responsible for coordinating, monitoring and reviewing project
activities. The focal point of PHC was the barangay where PHC activities were
actually implemented.
As of May 31, 1984, 38,100 out of the total of 38,369 or 99% of all barangays in the
country had been initiated to PHC and had PHC committees in varying degrees of
implementation. A total of 214,696 Barangay Health Workers (BHWs) or 1 per 31
population have been selected and trained to help mobilize the community to
support PHC and to assist in the delivery of health services to the people. Ultimately
these workers are envisioned to effect the transfer of skills on health-related matters
to the members of the community (25).
2

Within this framework of Primary Health Care, the health delivery system has now
become a 4-tier system. The staffing complement in the RHU servicing each
municipality in the country (which consists of one Municipal Health Officer (MHO),
one Public Health Nurse (PHN), one Sanitary Inspector (Sl), and resident midwives
equivalent in number to one per 5,000 population) has now been reinforced with a
barangay health worker (BHW). The BHWs make the first point of contact handling
arrangements for referrals, and rendering essential health care to the local
community. The resident midwife at the Barangay Health Stations who provides
the second level service is responsible for the supervision and training of the BHWs
in her area. Her supervision includes regular meetings at the BHS. At the next
level, the PHN visits the BHS and the barangays in her jurisdiction. These
supervisory visits cover the management aspects of the station, general nursing
matters including elements of medical care, medical referrals and the organization
and management of health education approaches to individual groups and to the
local population. The MHO, the fourth level, exercises general supervision over the
RHU staff. This is done through individual conferences and staff meetings.
Objectives and Significance of the Project
This project addresses the general issue of finding ways to meet the problem of
maternal malnutrition at the community level, specifically within the context of the
existing rural health care delivery system. While the literature abounds with studies
establishing the effects of iron and food supplementation in increasing the
hemoglobin levels of pregnant women and the birthweights of their infants
respectively, there is a dearth of studies dealing with the delivery system for such
intervention schemes. For public health workers in particular, the main question of
interest still lies in developing a system within the existing structure for health
service delivery which will ensure the proper identification and adequate coverage of
target groups, the efficient delivery of the intervention and the periodic monitoring
of clients to check on compliance and related problems. Unless these different
components of service delivery will be sufficiently covered, the optimum effects of
different forms of community intervention will not be attained.'
The current thrust on Primary HealthSare makes projects of this nature timely and
relevant. Since the structure for PHC-has properly been established in most
Philippine communities, the next step is to study the mechanics of the system. indepth,
as it applies to a particular health service, and in the process, identify its
strengths and weaknesses in order to make improvements. This project aims to
contribute to this end by making use of the existing health care delivery system as the'
setting in identifying the best form of community intervention to meet the specific
problems of anemia among pregnant women and low birthweight of their babies.
Specifically, the objectives of the project are as follows:
1. Using the present health care delivery system as the channel for delivery of
intervention:
a. measure the effect of iron supplementation on the prevalence of nutritional
anemia among pregnant women'
3

. measure the effect of food supplementation on the incidence of low
birthweight among infants
c. determine the cost-effectiveness of iron and food supplementation under the
different schemes to be undertaken in this study.
2. determine the relationship between selected socio-economic, dietary and
anthropometric characteristics of pregnant women, the different forms of
intervention given and anemia and/or low birthweight.
3. determine the effect of iron and food supplementation on the nutritional status
of the offsprings of target pregnant women 28 days after birth.
4. determine maternal and/or household parameters for targetting pregnant
women for food supplementation. J
4

Specific studies on the effect of anemia in the PW on the other hand. show strong
association between anemia and increased risk of premature delivery and maternal
and fetal morbidity and mortality (see Table 3) (4-10). Moreover, scientific literature
has cited decreased work performance among PW even with mild to moderate
anemia (3).
.Table 2. Studies on the Effects of Maternal Malnutrition on the Offspring
Sample Test of Signi-
Author Size ficance Effects
Federick,1973 16,994 chi-square olow birthweight .
Niswander,1974 11,767 multiple reg- olow birthweigh
ression & prenatal death
analysis
Lechtig,1976 olow birthweight
D'Souza, 1981 452 mothers student's t-test osmallerhead
circumference
& length
Love,1985 68,241 live- total and partial oprematurity
births coefficients of
correia tion
Husaini,1986 1332 correlations, -Iow birthweight
simple &
multiple
regression
Mitchell,1987 1080 single- path analysis olow birthweight
ton preg- & linear regnancies
ression 'analysis
6

Table 3. Studies on the Effects of Anemia Among Pregnant Women
AUTHOR SAMPLE TEST OF SIGNI- EFFECTS
SIZE FICANCE
Lowenstein,1966 305anemic Correlation • megaloblastic bone
.PW narrow changes
Roszkowski,1966 486PW • Low birthweight, short
1966 babies, still births,
neonatal deaths, fetal
heart rate disturbance,
congenital
malformations
Harriwn,1973 185 anemic • fetal growth retardation
mothers • low birthweight
Garn,1981 59,391 • fetal perinatal death,
consecutive gestational prematurity,
pregnancies low birthweight, low
Apgar Score
Johnson,1981 Correlation analysis • high mortality rate
• intrauterine hypoxia
patients
KIein,1982 68,241 Correlation • prematurity
Fleming,1987 • breathlessnes, reduced
capacity for work
In 1984 , the incidence of low birthweight in the Philippines was 18% (2) signifying a
high rate. of maternal undernutrition. Low birthweight has been shown to affect
physical, mental and psychologic growth (22,27-30).
A project conducted in Albay, Philippines showed that the probability of a child with
low birthweight to become malnourished six months later was about 3 times greater
than those born with normal weights (31). Early protein-energy malnutrition is the
most extensive and serious public health problem affecting children in developing
countries. Maternal nutrition as a predisposing factor therefore needs to be assessed
and attended to by health/nutrition programs.
Nutritional improvement of pregnant women combined with the use of available
health care services, is associated with improved chances of survival, physical
growth and mental development of the offspring. In the long run, this is less costly
than providing intensive medical care for the mass of underweight and premature
babies born to undernourished pregnant women. It can also be inferred that
7

investments aimed at decreasing the incidence of maternal malnutrition will benefit
not only mothers and their offsprings but the country as a whole.
Interventions for Anemia and Low Birth Weight
The high prevalence of iron deficiency anemia among PW underlines the need for
iron supplementation during pregancy. The high incidence of low birthweight also
indicates the need for intervention to improve the nutritional status of the mother.
Three of the interventions which have been tested through the years are food
supplementation, iron supplementation, and nutrition information and education.
Food Supplementation
Depletion of maternal stores, even if due to famine, during the first two trimesters of
pregnancy may be compensated by adequate intervention during the third trimester
(32,33).
Several food supplementation programs have. been shown to improve pregnancy
outcomes. The Massachusettes WIC supplementation program has decreased the
low birthweight incidence, neonatal mortality and increased gestational age (34). A
daily 431 Kal supplementation of African women resulted in increased birthweight
and head circumference among babies, over a control group (35). However, the effect
on birthweight is affected by season whereby positive effects were shown on wet
season but not on dry season. A food supplementation study on Thai pregnant
women showed similar results on birthweight (36). The study also showed a
significant decrease in the prevalence of anemia in the supplemented groups and an
increased prevalence in the control group.
In the Philippines, supplementation of pregnant women was also a priority of the
government but for the at-risk group only. The Implementing Guidelines of the
Philippine Food and Nutrition Program (PFNP) in 1981 (37) states that it shall be the
objective of the PFNP to reach approximately 25% of pregnantmo,thers of identified
severely and moderately underweight infants and preschoolers through
interventions which will last for not more than 6 months. This wohld be integrated
in preschool feeding programs with a daily provision of supplemental food
equivalent to 200 Kcal and with NIE activities emphasizing proper child care and
feeding practices. The lack however, of defi'ned targets covered in 'the
accomplishment reports of the PFNP since 1981 to 1984 implies there was no definite
intervention on Food Supplementation for PW (38-41). This may be due to lack of
government resources to give full implementation to the program.
Itwas in 1986 that a PW food supplementation program was implemented in the
form of the DOH-CARE Targetted Food and Assistance Program(TFAP) (42). The
objective of this collaboration, among others is to rehabilitate malnourished
pregnant mothers to reduce the incidence of LBW newborns from 18% in 1986 and
17% in 1987 to 12% in 1992. Targets are mothers who are in their 4th to 9th month of
pregnancy and anemic mothers (based on clinical signs or a hemoglobin level below
10 gm/100 ml) in areas which have more than 20% of the identified severely and
moderately undernourished preschoolers and are not covered by feeding programs
8
J,
1
J
j,
J

unsupervised iron delivery system, the required dosage was 120 mg. elemental iron
per day. Close monitoring and supervision of intake by the mother is necessary to
assure compliance. Side effects can also be minimized through constant feedback
between targets and health team.
To understand the etiology and prevention and control of nutritional anemias, an
important factor to note is the physiology and chemistry in the absorption of iron.
Narasinga Rao presented a summary of extensive studies conducted on the subject
(60). The author summarized that the body capacity' to excrete iron was very
limited and hence iron balance was regulated primarily by its absorption from the
gut. Factors that played important roles are the enhancers a) gastric juice, lactic acid,
chelating agent intake, ascorbic acid, sugar, amino acid, dicarboxilic acid, hydroxy
acids. The inhibitors are phosphates, phytates, phosphorous compounds in egg and
milk, and tannin which are predominantly present in vegetable foods. Iron
absorption is strongly influenced by the combination of foods eaten in a given meal
(3). The absorption of iron from a given meal of rice, vegetable and spices may be
doubled with the addition of fish, mea t, poultry and other sea foods. Conversely
the drinking of tea during or shortly after meal has a marked inhibitory effect on
iron absorption.
Nutrition Information and Education
Nutrition education is a highly cost-effective solution to malnutrition and its
consequences. It expands knowledge, creates awareness, modifies attitudes, changes
behavior and improves the nutritional status of the individual.
Table 4. Studies on the Effects of Iron Supplementation
AUTHOR TYPE & DOSAGE RESULTS
TESTED
Shalom,1968 100 mgironfromferrous gluco- • Iron supplementation gave rise
nate wi 5 mg folic acid & to Hb concentration
100I!gvit.B12daily
Iyengar, 1970 daily dosageof 30mg of • daily supplement of 30mg given
elemental iron as ferrous iron during the last 100 days of
fumaratewi or wlo VitB12 pregnancywasadequate to
& folic acid for 100days maintain satisfactory
on the 24th week hematological status during
pregnancy
Basu,1973 75,150 mg elementaliron • womenreceiving ironshow a
ferrous gluconate with or wi0 significant rise in HB.
Vit B12 and folic acid on the • Vit B12 & folic acid did not
26th week of gestation for enhance the effectof iron
28days supplementation
Sood,1974 Vit B12, folic 30-240 mg • groupswi ironshowincreases in
. elemental iron as ferrous HB
fumerate from 26th to the • highest increasein groups
,
10

TYPE & DOSAGE
AUTHOR 1ESTED RESULTS
36th or 38th week of preg- receiving 120& 240 mg of iron
nancy together with Vito B12 & folate
• however even in the
supplemental groups, still a
high prevalence of anemia &
iron deficiency was evident.
• iron alone did not produce as
good results as iron plus Vit B12
& folate.
Aung Than - Batu,197 daily dose of 120 & 180 mg • the supplemented groups showed
ferrous sulfate from 22 nd - a 0.4 & 0.7g/de in Hb for iron
25th to 38th -40th week alone and iron plus folic add
respectively
Charoenlarp,1981 daily dose of 240 mg • statistically significant
ferrous sulfate w/ or w/ 0 increase in Hb concentration in
all supp. grps.
Thane Toe,1982 daily dose 60, 120, 240 • only significant increases in
mg of ferrous sulfate for ferritin levels were seen among
12 weeks under strict PW given 120& 240mh ferrous
personal supervision sulfate with or without folic
acid.
• However, there were no
differences in final Hb levels
among the supplemented groups.
Jackson ,1982 60,180mg elemental iron • Hb rose significantly (p

TYPE & DOSAGE
AUTHOR TESTED RESULTS
Valyasevi,1983 6O,120,240mg ironwi orwlo • the increase in Hb concentration
folic acid with daily was statistically significant
supervisionor motivation where thedose ofiron was 120 or
from 18-22 weeks to6 wks 240wi or wlo folic add
after delivery • the Hb responsein the .
motivation group was the same
as in thesupervisedgroup
• the subjects with low initial Hb
(8-9.9) showed highly
significant increasing Hb level
after ten weeks suppl.
Solon,1984 60,120 mg fast & slow release • only120 mg elementaliron was
iron preparation, supervised adequate to significantly
& unsupervised adrninistra- improve the anemia status of PW
tionfor 100 days in field iron supplementation
Several studies have shown the effectiveness of nutrition education. Gomez (61)
documented the effectiveness of mothercraft nutrition classes in reducing the
incidence of malnutrition. Devadas and Sarojini showed how the school could
improve the knowledge, beliefs and food practices among the primary school
students. Bowering et al, (62) presented the greater effectiveness of paraprofessional
assistance in addition to clinic counselling as compared to counselling alone, in
changing dietary practices. Cerquiera (63) demonstrated the effectiveness of mass
media techniques in increasing learning and improving food habits. These effects
would be similar to what could result from the direct method of education through
person-to-person contact.
The Primary Health Care approach as the delivery channel for
health and nutrition services
The Philippine government health delivery systems have corne a long way. Until
enactment in 1954 of the Rural Health Act (RA 1080), the local health services were
organized as sanitary divisions, each covering one to four municipalities depending
on the population size (23). With the enactment of the Rural Health Law, the
sanitary divisions were replaced by Rural Health Units which cover one municipality
each with a staffing complement of a Municipal Health Officer (MHO), a Public
Health Nurse (PHN), a Rural Health Midwife (RHM) and a Sanitary Inspector (51).
In a subsequent amendment of the Law (RA No. 1891) in 1957 additional personnel
from medical officers to sanitary inspectors were provided in relation to population
sizes.
Then to meet the increasing population demand for health care, the restructured
health care delivery system expanded the RHU set-up in the establishment of
12

Then to meet the increasing population demand for health. care, the restructured
health care delivery system expanded the RHU set-up in the establishment of
barangay health stations manned by resident -midwives at a ratio of one for every
5000 population,
Although the staffing pattern had been enlarged, it was not sufficient to meet the
demands of a rapidly increasing population. There were always limited budgets and
other logistical problems especially on medical supplies. In addition, in the
developing countries, hundreds of millions of people were suffering and dying from
malnutrition and diseases that could be prevented.
As early as in 1973, the World Health Organization (WHO) and United Nations
Children's Fund (UNICEF) observed some of the successful or potentially successful
programs in a number of countries. The final report of this study "Alternative
approaches to meeting basic health services in developing countries" was presented
to the twentieth session of the UNICEF/WHO Joint Committee on Health Policy in
February 1975. In May 1975, the Twenty-Eight World Health Assembly considered
the study to be the basis for a major worldwide program for primary health care. The
first regional working group on Basic Health Services met in Manila from 21 to 29
September 1976 to a) exchange views and information on the concepts, trends and
status of basic health services in the region with particular reference to primary
health care b) consider theapplication of the results of operational research studies
on basic health services, c) prepare guidelines for the future development of basic
health services with emphasis on PHC and d) consider the role of international
agencies in the promotion and development of basic health services (64).
Then the Ministers of Health or their representatives from 134 countries met in
Alma Alta in 1977 under auspices of the World Health Organization, and discussed
the failure of health programs to meet the needs of their populations. The meeting
set the goal of 'achieving "Health for All" through the primary health care approach
by the year 2000(65).
In accordance with the Alma Ata Conference in 1977, the then Ministry of Health in
the Philippines printed and distributed in 1980 the national strategy and plan of
action for achieving health for all Filipinos by the year 2000. The strategy calls for an
active and continuing partnership among the communities, private and
government agencies, in health development It is a strategy which focuses
responsibility for health on the individual, his family and the community so that
people cease to be mere recipients of services and become partners in health
development (24).
During the same year, PHC was piloted in 12 provinces, one in each region (25). It
included the following four fundamental elements: 1) active community
participation and involvement; 2) inter-sectoral cooperation; 3) development and
use of appropriate technology to meet local health needs and 4) development of
support mechanisms to sustain PHC implementation. Under the PHC Organization
and. Management, the DOH is the lead agency for implementation with other
ministries as cooperating agencies. PHC committees were set up at the regional,
provincial, municipal and barangay levels. Composed of the health officer, who
13
. ,

served as the PHC coordinator and representatives from cooperating government
and private agencies, each committee was responsible for coordinating, monitoring
and reviewing project activities. The focal point of PHC was the barangay where PHC
activities were actually implemented.
As .of May 31, 1984, 38,100 out of the total of 38,369 or 99% of all barangays in the
country had been initiated to PHC and had PHC committees in varying degrees of
implementation. A total of 214,696 Barangay Health Workers (BHWs) or 1 per 31
population have been selected and trained to help mobilize the community to
support PHC and to assist in the delivery of health services to the people. Ultimately
these workers are envisioned to effect the transfer of skills on health related matters
to the members of the community(25).
In La Union, as of December 31, 1984, all 575 barangays in the province had PHC
Commitees in varying degrees of implementation. A total of 4,929 BHWs had been
trained. Ninety percent of this number were active establishing a ratio of one to
every 17 households (66).
Several studies have been conducted on PHC. In the Philippines,as early as in the
1970s, primary health care projects and related activities were already existing. The
World Health Organization presented in 1978 the results of an observation study
made over a period of two months on some 20 primary health care projects in
different areas of the country. The report documented among others the need for
a) policy document on PHC, b) program development for PHC to include the
following activities: lEC, organizing for action, provision of essential health care
services, integration in community development, and research and development; c)
forum for PHC; d) legislation and regulation and e) international collaboration (23).
Flahault documented also the factors contributing to the success of the PHC projects
in some countries including one case study in the Philippines. These include: a)
social preparation of the community to generate a collective commitment to be
active participants in the project, b) greater coordination efforts between the
proponents and the community leaders, c) strong commitment of health officers, d)
endorsement and selection of the BHWs by the community itself, and e) the
community as not only the recipient but the manager-owner of the program. If these
are the strong points of the PHC program, their lack can also lead to an ineffective
program. In addition management particularly supervisory skills have to be
developed among PHC leaders (67).
Schrimshaw also summarized problems in several countries: a) lack of proper
training and motivation of health personnel, b) lack 'of interest among recipients in
preventive programs and negative attitudes of their patients and c) lack of
understanding of the financial and time constraints of recipients (68). Shah added a)
negative feelings about the projects among PHC staff, 'i.e., that their services were for
projects/programs under operational research and not true PHC services, b) other
heavy assignments of the PHC staff leaving little time for the project programs, c)
high drop out rate of volunteer workers, d) inadequate training, and e) difficult and
poor communications (69).
14

These studies were not sufficient however .to design a nationwide detkiled strategy
for an integrated PHC approach in. health projects particularly in the prevention and
control of anemia among PW. The present study's objective is to develop and test
strategies to reduce the prevalence of anemia among PW and low birthweight among
their infants using the PHC approach. Lessons from this study can generate
recommendations for the PHC approach in terms of strategy for the health programs.
lS

3. PROJECf DESIGN
Conceptual Framework
The IFSD project aimed to reduce the prevalence of nutritional anemia among pregnant women
and incidence of low birthweightamong their infants within the framework of the Primary Health
Care Approach. Determination of the direct effect of the intervention inputs; i.e., iron & food
supplementsand NIE materials, on the nutritional status ofPWand theirinfants take into account
a number of variables.
The conceptual framework of this project is shown in Fig. 1. Represented in the Schema are the
key variables in the project design namely the environmental, program and outcome factors. The
specific variables comprising each factor as well as the inter-relationship among them are also
defined.
Environmental Factors
These are divided into factors external or internal to the local community. These include the source
of the initiative whether local or external: professionals or community laymen, the nature and
degreeofinvolvementofthe sponsoringagency (USAID) in programdevelopment,the requirements
of the sources of the funding, and the quantity and quality of technical assistance received.
The characteristics of the community and its relationship to the project include socio-economic
status, demographic factors, medical resources in the area, levels of community understanding
and expectations, degree of community involvement, etc.
A stock of current resources for health care is important in addressing the specific needs of the
program. These include facilities, equipment, manpower, pharmaceuticals and other supplies.
The physical requirements of the programs can then be established in terms of facilities,
equipment, manpower, training requirements, pharmaceuticals, other supplies, schedule of
programs, and utilities.
Program Factors. These variables are further classified into four groups:
1. Scope of services
2. Provider
3. Delivery system
4. Program
refers to the interventions addressed to the target population.
refers to the characteristics of the professional implementors and
auxiliary personnel.
refers to the involvement of distinct categories of
personnel!committees.
refers more specifically to development of administration,
materials, implementation and training of monitoring personnel,
delivery and monitoring of supplements, of compliance and
impact.
16

Outcome Effects
The outcome effects of the project can be regarded as having two components namely impact and
stability.
Impact is measured in terms of the KAP score/index on health and nutrition of the pregnant
women. It can also be expressed in terms of measures of health outcome, the % change in
hemoglobin level or anemia status and the % change in low birthweight.
In thecase of stability, two aspectsare worthstudying,the ability of the programto maintaina full
complement of providers over time and the ability of the program to generate adequate demand
and to control costs in orderto move toward self-sufficiencyand reduce dependence on subsidies.
In the analysis of the outcome effects, the effect of intervening variables must be controlled -or
explained. A more detailed discussion of this will beshown in the presentation of project results
by specific objectives in chapter VII.
To attain its objectives, the project was conducted incorporating both operations and research
components. The operations component ensured the delivery of the food and iron supplements
to the pregnant women using the designed delivery systems while the research component
measured the program effect. A detailed discussion of these two components is presented in
sections 3.4 and 3.5 of this chapter.
Intervention Inputs
The project involves three (3)forms of intervention directed at the reduction of nutritional anemia
among pregnant women and low birthweight among their infants:
(a) food supplements called "NUTRINA" which come in 18 different varieties of sweets,
biscuits, chips, noodles and drinks. One pack of Nutrina gives an additional 400calories
per day from the 7th month of pregnancy until child delivery.
The criteria used in the selection of Nutrina varieties were that the food supplement should
be:
• high in caloric content (not less than 400calories per 100 grams)
• made of mdigenous, locally produced or available food material
• highly acceptable among the target group
• having a shelf-life of 3 months or more
• in a form that will discourage sharing with other members of the
family
• relatively low cost
• easy to distribute
• requiring only simple or available technology for its production
Table 5 is a list of the Nutrina varieties used in the IFSD Project. The 18 varieties werean offshoot
of an original 5 varieties and were intended for a 3-month Nutrina menu cycle. This was done
to avoid monotony as well as to encourage continuous compliance with supplementation for the
whole supplementation period. Each pregnant woman was given 30 food packets per month
consisting of the different varieties scheduled for the month.
18

Table 5. Three month Nutrina cycle menu
Month1 Month2 Month3
1. Panocha with peanut 1. Peanutbrittle 1. Gro (butter)
2. Gro ( Choco) 2. Pilipit(type of biscuit) 2. Skimmilk (coffee)
3. Biscocho 3. Skimmilk (cocoa) 3. Sotanghon with skim milk/
4. SkimMilk(mocha) 4. Kamatsili ( type of biscuit) galletas( biscuit)
5. SweetBeans/Matamisna bao 5. Banana chips with sugar/ 4. Monggo with brown sugar/
6. Banana chips with sugar/ ampao pinipig(rice biscuit> biscocho (toastedbread)
galletas 6. Gabi with salr/ugoy-ugoy 5. Gabichips with sugar/panutsa
. 7. Bucayo (coconut candy) (biscuit) with peanuts
7. Nutri-noodle 6. Ugoy-ugoy (biscuit)
7. Bucayo
(b) Iron supplements called "FERRIN" - which come in the form of uncoated tablets of ferrous
sulfatecontaining 60mg elemental iron and 250mg folate pertablet. The prescribed dosage
was 2 tablets daily starting on the fifth month of pregnancy until child delivery. The iron
tablets werepurchased through the UNICEFand repacked according to specifications for use
of the project. Each pregnant woman was given one bottle containing 60 tablets monthly.
(c) NlE materials -Two brochures namely the Anemiabrochure and FoodPrescriptionSlip were
given to all the pregnant women to increase their level of awareness of proper health and
nutrition during pregnancy especially on what food to eat .and how much to breastfeed. For
the Iron And Food & Iron Groups additional two brochures namely Ferrin Brochure and
Nutrina Brochure were given to motivate them to take food and iron supplements. These
NlE materials supported the "face-to-face" counselling conducted by midwives among
pregnant women during consultation and pre-natal visits.
All pregnant women under the care of the rural health midwives were given the supplements
appropriate to the treatment condition and/or NlE materials.
Treatment Allocation
Given the 3 forms of intervention, four treatment groups were designated to test the effect of food
and/or iron supplements singly and in combination, namely: (t) Food Group, (2)Iron Group, (3)
Food & Iron Group, and (4) NlE Group. .
All 20 rural health units or municipalities of the province were included in the project. The RHUs
were allocated to the 4 treatment groups purposively rather than at random using the following
criteria:
• expected number of 7-9 months PW at any given time
• variability in the geographical features; and
• homogeneity in the overall birth rate, death rate and infant mortality rate across treatment
groups.
Because of the budgetary constraints of the project, the number of pregnant women to be given
food supplementation was limited to 200 per month per treatment group wherefood was part of
the intervention. Since only women 7-9 months pregnant would be given food supplementation,
19

their expected numberwas used as one ofthe important criteria in groupingtogethermunicipalities
for the assignment of treatment. For the whole province, the estimated number of women 7-9
months pregnant at any time by 1984 was 2454. There was no limit set for the Iron and NIEGroups.
Limits, however, were established for the Food and Food & Iron Groups.
Amongso many possible combinations ofmunicipalities which would give the above breakdown
of women 7-9 months pregnant, the one which gavea good mixture of municipalities according
to geographic features was chosen. This was done to ensure that each treatment group would have
both coastal and mountainous municipalities, thereby controlling the effect of this factor lest it
affect the efficiency of midwives and other primary health care workers in delivering the
intervention assigned to their respective places. In addition, it was ascertained' that the overall
birth rate, death rate and infant mortality rate were more or less homogeneous across treatment
groups. Since these indices are indirect measures of the socio-economic status of a community,
requiring their homogeneity across treatment groups is a step towards attaining comparability
with respect to these variables at baseline. Table 6 shows the treatment group assignment
following homogeneity in the pre-set variables while Figure 2 shows the location of each
municipality under each treatment group.
Project Operations Component
The conceptual framework in P: 17 discusses that the project was implemented with both
operations and research components. This section discusses in detail the activities conducted in
the operations component particularly preparatory training, delivery and monitoring system.
Preparation for Project Implementation
Tohave more solid bases for the development and finalization of the various interventionschemes
andstrategies to be adopted in the IFSDProject, a RHU BaselineStudy and PHCC BaselineStudy
in La Union were conducted. The RHU Baseline Study was aimed specifically at establishing a
baseline profile of the RHU in terms ofits actual and operatingprocedures for service delivery and
monitoring systems especially for the control of anemia, and at assessing the training needs of the
RHM as the key person in the proposed delivery system.
Data were collected at the municipal and barangay level. The Municipal Health Officers (MHO)
of the 20 municipalities were the main respondents at the municipal level, the Rural Health
Midwives (RHM)at the barangay level. The study focused on the following aspects of the RHU
health delivery system: a) MOH-RHU organizational and functional set-up, b) funding sources/
standard procedures in the procurement of medical supplies, c) standard procedures followed in
the delivery for RHU Personnel.d) training program/activities for RHU Personnel, e) status of
anemia control in the area.f) RHU link with other PFNPline agencies in the locality, g) mid-wives'
basic knowledge & practices on similar control programs, h) MOH-RHU evaluation and
monitoring system.
ThePHCC BaselineStudysought todeterminethe readiness of the PHC organization toimplement
the project with the RHM. It would identify gaps in the PHC implementation for selection and
development of project inputs. The minimum requirement of the project was for the PHC
Committee to have been at least organized in the barangays and the members identified to
undertake specific functions.
20

Table 6. Treatment Group Assignments Based on Geographic Features and Selected Health Statistics.
Crude Crude Infant
Expected.# of Birth Death Mort.
Treatment Geographic Women 5-7 Rate/ Rate/ Rate/
Group Municipality Features mos.Pregnant 1000 1000 1000
Food 211 27.4 5.8 45.1
Tubao M
51an Juan CM
Food 204 23.3 5.2 41.3
and Bacnotan ,CM
Iron San Gabriel M
Pugo M
Iron 808 29.5 6.6 45.6
Burgos M
Sudipen CM
Sto.Tomas CM
Agoo CM
Balaoan eM
Santol M
Naguilian M
,
NIE 1230 25.4 6.8 50.6
Aringay CM
Bagulin M
Bauang C
Caba C
Luna M
San Femando CM
Bangar CM
Legend:
C - Coastal
M - Mountainous
CM Coastal/Mountainous
Training system
Orientation of Supervisors
The implementation of the IFSD Project in La Union started with the orientation of the project
supervisors at the 'provincial, district and municipal levels. The provincial health officer, his
assistant and Provincial Task Force members, the district chief of hospitals and the municipal
health officers were given an orientation on the project rationale, objectives, methodology and
project design and on their roles and responsibilities in the project by the National Task Force. A
22

separate and detailed training of the key implementors was conducted.
Training of Project Implementors
A training package for the different RHU health personnel was developed. Trainees were divided
into two groups. The first group consisted of the direct implementors namely the public health
nurses (PHNs) and the rural health midwives (RHMs)including their supervisors - the area nurse
supervisor (ANS)and the district nutritionist (DN). The second group consisted of the auxiliary
workers, i.e., the barangay health workers (BHWs). The objective of the training was to develop
the knowledge, attitudes and skills of these key implementors of IFSDin their respective areas.
There were 13Implementors' Manuals developed, i.e.,1 per type of implementor (PHN, RHM and
BHW)for each treatment group and a common manual for the ANS/DN for all treatment groups.
1) Training of PHN, RHM, ANS and DN
The training package for these implementors was designed to develop their capabilities for the
following project activities: enrollment of PW, requisitioning and delivery of supplies,
monitoring of supplementation and pregnancy outcome and reporting. ..
These implementors were trained by the National Task Force composed of OOH and NCP staffs
with the assistance of theRegional and Provincial Task Force members. Since the intervention
and some project protocols were specific to treatment groups, the training of midwives, nurses
and their area supervisors was correspondingly done by treatment group. The training of
implementors in a specific treatment group was scheduled one month before the start of project
operations i.e., the delivery of intervention in that treatment group.
Avariety oftraining methods were employed. These included lecture-discussions, demonstrations
and role-playing on project tasks. Workshops and group work exercises were also conducted
using actual data of the implementors to ensure a thorough understanding of their tasks in the
project. The two-day training covered the following topics:
1. An Update on Maternal Nutrition
2. Project Rationale and Objectives
3. The IFSD in the context of Maternal and Child Health (MCH) services through the PHC
Approach, and
4. IFSDProject Operations
The training tools used were NIE materials (Ferrin, Nutrina and Anemia Brochures and Food
Prescription Slip) for module 1, Implementors' Manuals and delivery and monitoring forms for
modules 2, 3 and 4. Other training aids were the Course Design and Syllabus, Instruction Sheets
and a Training Syllabus for BHWs. A sample Implementor's Manual for RHM and the Course
Design is shown in Appendix A and B.
2) Training of BHWs
The barangay health workers played a vital role in the implementation of the IFSDproject because
they were assigned the task of recruiting and referring target pregnant women to the midwives.
They were also tasked to assist the midwives in the delivery of the interventions and the
monitoring ofsupplementation. Assuch, the training package for BHWs was designed to develop
their capabilities in the delivery of these services.
23

The barangay health workers were trained by the midwives and nurses assisted by the Provincial
Task Force members one week after the latter's training on the project. The BHWs were grouped
by barangay or groups of adjacent barangays in a midwife's catchment area.
The training technique also consisted.of lecture-discussions, demonstrations and exercises
particularly on the accomplishment of forms. The half-day training covered the following topics:
1. Update on Maternal Nutrition
2. Project Rationale and Objectives, and
3. Project Operations
Training tools also consisted of NIE materials, implementors' manuals, monitoring forms and the
Course Design (Appendix A-C)..
The Delivery System
The delivery of interventions (i.e., iron and/or food supplements and NIE materials) for the
pregnant women was done through the health caredeliverysystem ofthe DOH, primarilythrough
the midwives within the framework of the PHC approach. Various strategies along the
preparation ofthe area, the provision ofiron and food supplements, training and nutritionsupport
for the nurses, midwives and barangay health workers were developed in consideration of the
existing delivery system. These schemes were integrated into the activities and functions of the
midwives and BHWsat the barangay level within the existing maternal and child health program.
Usually, the intervention should pass through regional, provincial and district levels before finally
going to the municipal level. This was, however, considered a long channel which might entail
delays and problems, e.g., transport. Also because of the variability of interventions at the place
and time they were needed for the project, the interventions were delivered directly to the RHU.
The PHN acted as the receiving and disbursing officer. To give maximum logistical support, the
delivery of supplements in the Food and Food & Iron Groups was madedirectly to the BHSwhile
in the Iron and NIE Groups, delivery was made to the RHU only. Thus, the RHMs in the latter two
treatment groups obtained the supply for their catchment area from the nurse at the RHU.
The BHWin tum received her supply for the PW in hercatchment of 20households from the RHM
in the BHS. One month'ssupply of iron supplements was given regularly to the PW whereas the
delivery of food supplements was done weekly or bi-weekly depending on the terrain of the
catchment area. The NIE materials were delivered directly to the PW by the RHM, accompanied
by face to face counselling on proper dietary habits and practices. The above delivery flow is
shown in Figure 3.
Project Monitoring System
A monitoring system which kept a close watch over the two categories of indicators, the process
and the outcomeindicators, was designed. The process indicators refer to the procedures by which
the planned interventions were delivered to the intended targets and the problems which were
encountered in the course of implementation. The outcome indicators refer to the amount of
intervention delivery vis-a-vis its effects/results/impact on the targets. This data gathering
considered the existing forms in the DOH monitoring framework. The monitoring for the project
was conducted covering the regional, provincial, district, municipal, and barangay levels through
24

DELIVERY SYSTEM MONITORING SYSTEM
PUBLIC HEALTH
NURSE
BARANGAY
HEALTH WORKER
•
RURAL HEALTH
MIDWIFE
HOUSEHOLDS
• Number ofTarl!et
PW In the Munfclpallty
• Compliance with
Protocol
• Number ofTarget PW
In the Barangay
• PregnancyStatus and
Outcome
• Compliance with
Protocol and Supplementation
• Number ofPW In the
Purok
• Compliance wit;h
Supplementation
FIG. 3. IFSD DELIVERY AND MONITORING SYSTEM
25

the existing system of the RHU. The specific indicators for each type are the following:
• process indicators compliance with protocol by project implementors, stock inventory
levelat the RHU/BHS; problemsencountered in makinginterventions
available.
• outcome indicators - pregnancy identified, profile ofpregnantwomen, pregnancyoutcome,
birthweight, complaints and compliance with interventions by PW.
At the municipal level, before the PHN received her supply for the RHU she prepared a Stock
Receipt and Distribution Form which recorded the requirements of supplements for the RHU for
the month. This form was updated during receipt of supplements from the Delivery Staff and
distribution to the RHM. In the same manner, the RHM also kept almost the same forms for the
recording of receipt and distribution of supplements from the PHN up to the BHWs. The BHW
also kept a record of her deliveries to the PW at the back of her manual. After delivery of the
supplements the BHW visited the PW weekly to follow up complaints and compliance with
supplementation. These were recorded in the Pregnancy Monitoring/Supplementation Card.
Each PW recipient no matter what treatment group she was in, was given a copy of the card. On
the 28th day after the birth of the infant, the forms were forwarded to the RHM who submitted
them to the PHN for relay to the Operations Staff. .
A Master List of Pregnant Women was maintained at the BHS by the RHM. This recorded all
pregnant women in the BHS by barangay and the schedule of receipt of supplements.
One NIE Supply Form was also kept by the RHM for the 18 months of operation to record the
number of copies of NIE materials received at the BHS. Problems during delivery and
implementation were fed back through the Stock Receipt and Distribution Form. All these forms
were submitted to the PHN for submission to the Operations Staff.
The Operations Staff reviewed the problems in the Stock Receipt Distribution along with the
RHM's observations and problems encountered in the delivery of the intervention, and fed these
back to the Central Office. The Central Office in consultation with the National and Provincial
Task Forces, then intervened to lessen the operational difficulties encountered. The monitoring
flow presented above is also shown in Figure 3. Table 7 on the other hand,shows the flow of data
collection using the different monitoring forms.
The Research Component
The research component was conducted separately from the implementing RHU system and was
done by the Nutrition Center of the Philippines in consultation with the Steering and Management
Committees and supervision by the DOH-NCP National Task Force. Since the main objective of
the research component of the project was to measure the program effect, the major activity was
the conduct of baseline and follow-up surveys. The baseline survey was conducted before the
training of project implementors and before the start of the delivery and monitoring operations;
the follow-up survey was done at exactly 18 months after the start of the delivery of the
intervention. Both surveys were cross-sectional rather than longitudinal in nature hence most if
not all of the subjects differed between the two surveys. This approach was taken for the following
reasons: 1) the main unit of analysis relative to the assessment of program effect is the community
rather than the pregnant woman hence it was not necessary to follow up on the same subjects; 2)
26

supposed to have a catchment area with a population of 5,000. Actual data from the field however
showed that the midwives in La Union have catchmentareas which are highly variablein size, with
populations ranging from 596to 10,964. Since variations in the size of the population beingserved
were deemed to affect the efficiency of the health worker in delivering the assigned form of
intervention, this factor was used as stratification variable in the study. In particular, the expected
number of women 5 to 9 months pregnant to be served by each midwife was projected considering
the actual size of her catchment area. The midwives assigned to each treatment group were then
stratified into three groups as follows: those serving less than 15 pregnant women at any given
time, those serving 15 to 29 pregnant women, and those serving 30 and over. The percentage
distribution of the expected total number of women 5 to 9 months pregnant by stratum was
computed, and the sample size of 200per treatment group was allocated to each of the 3 strata by
proportional allocation. The corresponding number of midwives expected to serve the resulting
number of sample women per stratum was determined and selected at random from the list of
midwives in each stratum. All pregnant women in the catchment area of each midwife drawn as
sample were included in the research component of the project. .
Mode of Data Analysis
The analysis of the data derived from the research component of the project used different units'
of analysis and different groups of subjects, depending upon the particular research objective that
was addressed. The specific statistical techniques that were used to meet each objective are
described in the following sections.
Effect of Food and Iron Supplementation
The primary consideration in the analysis of the data to assess the effect of food and iron
supplementation is the fact that the main thrust of the project is not to determine the effect of the
different forms of interventions per se, but to determine their effects given the health care delivery
system actually being implemented, The patient then, in the context of the project, is not the
individual pregnant woman but the community. Given this, the unit of analysis used to assess the
effect of food and iron supplementation on anemia and birthweight is the RHU, rather than the
mother or the infant.
The response variable used in determining the effect of the different forms ofintervention on
anemia was the prevalence of anemia by RHO, Two levels of analysis were done. At the crude
level, the % relative change in the prevalence of anemia between the.baseline and post-surveys was
determined and comparisons were made among the treatment groups. This was computed for all
women taken altogether as well as by age of gestation at the time of pricking. The second level of
analysis was intended to come up with a more refined estimate of the prevalence of anemia per
RHU and per treatment group after the implementation of the different forms of intervention,
adjusting for the effect of other variables. This was done by multiple regression analysis using the
arcsine transformation for the dependent variable, since it is in the form of proportions. The
specific variables included in the model are outlined in Table 8.
29

Table 8. List of Variables Used in Multiple Regression Analysis on Anemia Among Pregnant Women
MODEL COMPONENT VARIABLE USED AS INDICATOR
Dependent Variable:
Effectof intervention on anemia prevalence % Anemic at post-survey per RHU
Independent Variables:
Intervention 3 dummy variables representing
food, iron and food and iron groups,
with the NIE group as reference
BaselinePrevalence % anemic at baseline
Level of implementation of the % of eligible pregnant women who
intervention received the supplementation
Other forms of intervention received % of eligible pregnant women
,. taking elemental iron from sources
other than the project
Food and dietary patterns of % with'adequate iron intake
pregnant Women % with adequate ViI. C intake
% With adequate calorie intake
Health status of pregnant women % with hookworm
% with trichuris
% of pregnant women with normal
nutritional status
% Bleeder
Socio-economic status of community Median per capita income of RHU
% with at least high school education
,
The same approach was used in detennining the effect of the different forms of intervention on
birthweight, with the incidence oflowbirthweight perRHU as the response variable. At the crude
level of analysis, the % relative change between the incidence of low birthweight at baseline and
post-surveys was also computed for all women taken altogether, as well as by age of the woman.
Two categories were used for this, those at risk «20 or >35 years of age) and those not at risk
(between 20 to 35 years old). At the second level of analysis, multiple regression analysis using the
arc sine transformation was also applied to comeup with a refined estimate of the incidence oflow
birthweight at post-survey. The specific variables included in the model are outlined in Table 9.
30

Table 9. List of Variables Used in Multiple Regression Analysis on Low Birthweight Among Infants
MODELCOMPONENT VARIABLE USED AS INDICATOR
Dependent Variable:
Effectof intervention on incidence % with low birthweight babies per RHU
of low birth weight
Independent Variables:
Intervention 3 dummy variables representing the
food, iron, food and iron groups, with
the NIE as reference
Baseline incidence 1984 incidence of low birthweight
per RHU, based on the records of the
Provincial Health Office
Level of implementation of the % of eligible pregnant women who
intervention received the supplementation
Other forms of intervention received % of eligible pregnant women who
received other forms of supplementation
(c.g, elemental iron, multivitamin)
from sources other than the
project
Food and dietary patterns of % with adequate calorie intake
pregnant women
Prevalence of risk factors % of women 35 years old
% with gravida ,,5
% of women with birth interval between
last and present birth :5730 days
% smokers
% premature births
SES of Community Median per capita income
% with at least high school education
The third response variable considered in assessing the effect of food and iron supplementation
was the nutritional status of the infant 28 days after birth, To meet this objective, the infant was
used as the unit of analysis.Logistic regression analysis was applied, with the nutritional status of
the child, categorized as moderately/severely underweight or otherwise, as the dependent
variable. The list of independent variables are shown in Table 10.
Relationship Between Socio-Economic. Dietary. Anthropometric Factors and Study Outcomes
To determine the nature of the relationship between the different socio-economic, dietary and
anthropometric variables and the response variable in the study (i.e., anemia and birthweight), it
was deemed more meaningful to use the mother or the infant as the unit of analysis instead of the
31

RHU. To refine the analysis further, mothers who had not received any supplementation at the
time of pricking, or infants whose mothers did not get any supplementation for the duration of the
pregnancy were excluded from the analysis. Logistic regression analysis was used to meet this
objective, with anemia status (anemic or not) and birthweight status (low or normal) as the
dependent variables. The list of independent variables are enumerated in Table 10.
Parameters for Targetting Pregnant Mothers
To identify the different parameters that can be used for targetting pregnant women for food
supplementation, the responsevariableofinterest islow birthweight. This isunderthe assumption
that food supplementationis meant to affect the birthweight ofthebaby. Since this objective is akin
to identifying the significant predictors of low birthweight in the absence of any intervention, only
mothers in the control or NIB group were included in the analysis. Logistic regression analysis was
used to meet this objective, with the birthweight status of the infant (low or normal) as the
dependent variable. The independent variables considered were those which were either
routinely collected or could be easily gathered. The list of independent variables is shownin Table
10.
32

Table 10. List of independent variables used in logistic regression analysis for the different research
objectives
Effectsof supplemen- Relationship between Relationship between Parameters for
Type of tation on the NS of selected variables . selected variables targetting PW for
variables infants after 28 days and anemia and birthweight food supplementation
Dependent Dummy variables Dummy variables Dummy variable Dummy variables
variable representing the NS representing the representing the representing the birthof
infant 28th days anemia status of PW birthweight status weight status of infant
after birth with with normal as of infants with in the NIE group with
normal or over- reference normal weight as normal weight as
weight as reference reference reference
Independent
variables
Intervention 3 dummy variables 3 dummy variables 3 dummy variables
representing Food, representing Food, representing Food,
Iron, Food & Iron Iron, Food & Iron Iron, Food & Iron
Groups with the NIE Groups with the NIE Groups with the NIE
Group as reference Group as reference Group as reference
Level of Age of gestation at
intervention the time of pricking
Other forms Dummy Variable
of representing receipt
intervention of elemental iron
with receipt as
reference
Health Dummy variable
status representing the
of the presence or absence
family of other 2nd
and 3rd degree I
malnourished in the
family with none
as reference
Dummy variable
representing the
birthweight status
of the infant with
normal as reference
,
33

Table 10. Continuation
Effects of supplemen- Reiationship between Relationshi p between Parameters for
Type of tation on the NS of selected variables selected variables targetting PW for
variables infants after 28 days and anemia and birthweight food supplementation
Obstetrical Dummy variables Number of livebirths Number of livebirths Number of livebirths
history representing
- history of previous Dummy variable Dummy variable
pregnancy loss with representing representing
none as reference - history of previous - history of previous
- the length of pregnancy loss w / pregnancy loss w /
gestation categorized none as reference none as reference
as premature and
fullterm with premature
as reference
Health Dummy variables Amount of sticks of Dummy variables
status -hookworrn cigarettes smoked representing
ofPW infestation byPW - the NS of PW based
categorized as on standard weight
none, light & Dummy variables for height w /more
very light & representing than or equal to 95%
moderate & hca vy - the NS of PW based of standard weight
with none as on standard weight as reference
reference for height w/ more - positive for hyper-
-the presence or thanor equal to 95% tension categorized
absence of scurvy of standard weight as greater than or
with absence as as reference equal to 140/90 and
reference - the presence or less than; with less
-the presence or absence of thyroid than as the reference
absence of bleeding disorder with - the presence or
with absence as the absence absence of thyroid
reference as reference disorder with
- the hemoglobin absence as reference
status of PW with - the presence or
below 10giml as absence of murmurs
reference with absence dS
reference
- the presence or
absence if kidney
disease with absence
as reference
- the presence or
- absence of edema
with absence
as reference
- the presence or
absence of lassitude
with absence as
reference
.34

Table 10. Continuation
,
Effects of supplemcn- Relationship between Relationship between Parameters for
Typcof tation on the NS of selected variables selected variables targetting PW for
variables infants after 28 days and anemia and birthweight food supplementation
Food and Dummy variables Dummy variables
dietary representing representing
pallemsof - the adequacy of - the adequacy of
pregnant iron intake with calorie intake with
women bclowRDA as inadequate intake
reference as reference
- the adequacy of - the adequacy of
ViI. C intake with protein intake with
bclowRDAas inadequate intake
reference as reference
Knowledge KAPScores KAPScores KAPScores
health and
nutrition
" .
3S
- the hemoglobin
status of PW with
below 10 g/ml as
reference
- Arm Circumference
- history of TB with
none as reference
- smokers or nonsmokers-with
smokers as reference
- height of PW

"
Table 10. Continuation
Effects of supplemen- Relationship between Relationship between Parameters for
Type of tation on the NS of selected variables selected variables targetting PW for
variables infants after 28 days and anemia and birthweight food supplementation
Socio- Annual per capita Annual per capita Annual per capita AgeofPW
economic income income income Household size
status AgeofPW AgeofPW number of pre- number of preschoolers
scholers
Number ofpre- Number of pre- in the family in the family
schoolers in the schoolers in the Dummy variables
family family representing Dummy variables
Dummy variables Dummy variables - age of PW with representing
representing educa- representing Educa- 20 - 35 as reference - education of PW
tion of PW tion of PW - classifying PW as categorized as no
categorized as no categorized as no with or without schooling, elemenschooling,
elemen- . schooling, elernen- occupation with tary, high school &
tary, high school & tary, high school & no occupation as vocational & college
vocational, and vocational and reference with no schooling as
college with no college with no - education of PW reference
schooling as schooling as categorized as no - classifying PW as
reference reference schooling. elemen- with or without
tary, high school & occupation with no
vocational & colleg occupation as
with no schooling a reference
reference
Semi-Annual Validation of Level of Ii'lterventjon Implementation
A vital component of both the monitoring system and research aspect of the IFSD Project was the
conductofvalidationstudies. Essentially the validationstudiessought to reviewtheimplementation
of the project activities to gauge the efficiency and effectiveness of the delivery and monitoring
systems. Specifically, the validation studies would determine:
I. the extent of compliance of project implementors with a set of protocols in the delivery and
. monitoring system.
2. the extent of compliance with supplementation of PW
3. the PHC support system obtained in the implementation of the IFSD Project,
and
4. the factors that affected the level of performance in the delivery of services of RHU personnel
in the IFSD Project.
Validation provides the basis for the assessment of the feasibility of using the PHC approach in the
delivery of supplements.
36,

To achieve thefirst objective, themidwives, nurses and barangay health workers who weredirectly
involved in project implementation were interviewed. The interviews focused on how they
actually implemented their specific tasks in the following activities: (1) identification and referral
ofPW; (2)requisitioning ofsupplies; (3)delivery of intervention; (4)monitoring ofsupplementation
andG) reporting.
To validate the responses of project implementors, the pregnant women who were the recipients
of the services were likewise interviewed. '
For the second objective, the pregnant women who received the intervention were interviewed on
their receipt of the NIE materials and/or supplements. The amount of supplement intake for a
period of one month was also determined including effects felt or complaints against the
intervention.
Forthe third objective, the midwives and nurses were interviewed on thesupport obtained from
supervisors and organizations/agencies in their localities, The interview placed emphasis on
validation of the involvement of the Barangay and Municipal Primary Health Care Committees
as elicited from the midwives, nurses and municipal health officers. To have a more concrete
assessment, however, of. the PHC Committee's involvement, the municipal and barangay PHC
Committee chairmen were interviewed.
The validation studies involved only a sample of pregnant women who were then receiving
intervention at the time of the studies. The studies included, however, a complete listing of the
municipal health officersand publichealth nurses, area nursesupervisorsand district nutritionists
because of thesmall numberof these types of implernentors. Itwas in thecoverageof themidwives
that the three studies differed. The first and second studies covered only 80 sample midwives or
53% of the total midwives in La Union. The third study, however, covered all 152 midwives to
fulfill the fourth objective, i.e., determining the factors that affected performance in projects such
as the IFSD.
Project Management and Administration
The Iron and 'Food Supplementation Delivery project was a joint undertaking of the Nutrition
Centerof the Philippines (NCP) and the Departmentof Health (DOH). As such, the administration
of the project was shared between the two agencies.
This involvement was formally forged through a memorandum of agreement signed by the two'
agencies. A copy of this Memorandum of Agreement is in Appendix E.
In its organizationalstructure Figure 4, the project was headed by a SteeringCommitteesupported
by a Management Committee. The Steering Committee's primary responsibility was to provide
policy directions for the planning, implementation, dissemination and utilization of research
findings. The Management Committee, on the other hand, was primarily tasked to provide
directions in the form of technical guidance in the conduct of specific project activities at the area
and central office levels.
A project leader at both area and central levels was designated to coordinate and oversee the
implementation of activities. At the central level, the project leader, supported by a National Task
37

Force planned project activities in these general categories:
a) Research
b) Training
c) Delivery and Monitoring
Project plans and schedules were discussed with and/or relayed to the area project leader and a
Provincial Task Force, who in tumcoordinated and monitored the implementation of activities in
the different RHUs in the province.
The organizational structure, moreover, depicts the linkages between the OOH, particularly the
Rural Health Units (RHU),and the Primary Health Care Committeesin the implementation of the
project. In this set-up,not only were the health personnel in the OOH structuregiven specific tasks;
PHC committees at various administration levels were also enjoined to assist in project
implementation.
Generally, the PHC Committees were asked to coordinate with the RHU/BHS personnel in
activity implementation. Specifically, the PHCC
• provided administrative support to the RHU/BHS staff in project
implementation
• tapped continuous BHW involvement
• provided logistical support particularly in the delivery of supplements
• monitored project status, problems encountered with RHU/BHS officers and recommended
solutions
• provided feedback on status to higher level committees.
The specific tasks of various project implementors and PHC Committees are listed in Appendix
F.
Data Processing
\ .
The IFSQ.Project has a comprehensive data base consisting of several files. The various files fall
into the two major components of the project i.e.,Research andOperations. The table belowshows
the specific files and subfiles under each major category.
Initial data processing was conducted at the field level. After each data collection day, initial
processing was conducted as follows:
1. Field Edit of Interview Schedule (IS)
2. Corrections and Final Editing of IS
3. Pre-coding of Pre-Determined Responses; and
4. Listing of Responses for Open-Ended Questions
Processing activities at the NCP, on the other hand, were as follows:
1. Categorization of responses for open-ended questions
2.. Coding of data
39

3. Data encoding
4. Machine editing
5. Production and review of marginal runs; and
6. Production and review of analysis runs
The processing of data was done using an IBM-PC-XTand 1 PC compatible which were donated
by USAID. The NCP bought another PC Compatible because of the bulk of data to be processed.
The softwares used for data analysis are 1984 SPSS (Statistical Package for the Social Sciences) for
the IBM-PC-XTand the 1981 BMDP softwares, also donated b}' USAID.
Table 11. IFSD data base
ResearchFiles
1. Pre-and post-survey
1.1. Biochemical.
1.2. Clinical
1.2.1 Nutritional status of pregnant
women
1.2.2 Nutritional status of pre school
.children
1.3. Socio-econornic status
1.4. Dietarydata
1S. Knowledge,attitude and practices
(KAPlof pregnant women
1.6. Compliance with NlE materials
1.7. Receiptof NIE materials
2. Validation studies
2.1. Implementors' compliance with protocol
2.2. Compliance with supplementation of pregnant women
2.3. PHC support system
2.4. Factorsthat affectlevelof intervention implementation
Implementation Schedule
Operations Files
1. Deliveryof intervention and monitoring
1.1. Target per BHS, RHU
1.2. No. enrolled
1.3. No. receivingsupplements
1.4. Problems
2. Operations data supplementation and
pregnancy outcome of lFSD Project
2.1. Socio-eco-derno profile
2.2. Pregnancy profile
2.3. Supplementation record
2.4. Pregnancy outcome
2.5. 28days post -natal outcome
The IFSD Project underwent two phases of implementation namely: Phase I - Preparation for
Project Implementation; and Phase II - Project Implementation Proper.
Phase I started in March 1982 lasting up to September 1984.
Phase I started with the conception and development of the IFSD project proposal in March 1982.
In May of the same year, the proposal was submitted to USAID for funding. In September 1982,
after some revisions on the proposal, approval for funding of the project was obtained. From
September1982 to June 1983,a series of meetings among USAID, DOH and NCP officers and staff
were conducted to finalize project design, schedule of activities and the budget.
40

4. THE PROJECf AREA
The Iron and Food Supplementation Delivery Project was conducted in the province of LaUnion.
This province was chosen as the study area for the following reasons:
. ,
a, Its geographic area and population are both moderate in size, A small province may not
present the typical problems of delivery systems related to size; a large province on the other
hand will pose logistic and budgetary problems since the project design is for a province wide
supplementation of all pregnant women,
b. It has both coastal and mountainous areas, This enables the identification ofproblems in the
delivery of supplementation for different types of terrain.
c. Its proximityto Manila facilitates project monitoring and control.
d. It has moderate birth and infant mortality rates, the typical setting for the type o{intervention
being tested in this project.
e. The Primary, Health Care approach to service delivery is functioning in theprovince, This is
a fundamental requirement in the choice of the studyarea since this is the delivery system that
is being tested. .
f. The prevailing peace and order situation is good.
A detailed description of the socio-economic, demographic and health profile of La Union is
presented in the following section:
Socio-Economic-Demographic Profile of La Union
La Union lies in the northwestern coast of Northern Philippines. It is a 275 kilometer drive from
Manila, The western portion of the province is plain while the eastern portion gradually rises in
elevation making the province one of the most mountainous in the region, Though the terrain is
predominantly hilly, only 25%of its cultivated lands lies in the valley while 75%lies in the coastal
plain. With farming, fishing and cottage industries as the most common source of income, 43% of
the families have a monthly income ofP500,00 andbelowwhile 70 %belong to the P1,000and below
income bracket (56),
The total land area of the province is 149,309 hectares, It is made up of20 municipalities and a total
of 575barangays, In 1984, it had a total population of 488,990, with a population growth of 1,80%,
Preschoolers (0-83 months) comprised 20.8% of the total population while schoolers (7-14 years
old) made up 19,8%,
LaUnion has 20 Rural Health Units serving populations which varied in size from 4,535in Burgos
to 73,453 in capital town of San Fernando. Likewise, the towns varied much in population density,
with a minimum of ,68 persons per square kilometer for the RHU of Santol to 27,24 persons for
Aringay. The average family size for half of the RHUs was 5;three others had an average of 4 while
2 had an average of 7,
45

Health Indices
In 1984, La Union had 14,552 livebirths resulting in a crude birth rate (CBR) of 21.65 perl000
population (57). This was slightly lower than the national figure of 27.8 per 1000population. At
the level of the Rural Health Unit, twelve (60.0%) of the RHUs were serving municipalities which
had1984crude birth rates ranging from 25to 34per100population. Three 05.0%) RHUs had CBR's
below 20/1000 population with the minimum at 16.3per 1000 population for Caba. Agoo had the
maximum CBR with a rate of 43.6 per 1000 population. The same RHUs have minimum and
maximum levels, if the indication for natality is expressed in terms of the general fertility rate
(GFR). The GFR for Caba was 72.5births per 1000women aged 15 to 44 corresponding figure for
Agoo was 194.5births per 1000 women in the reproductive age groups.
Seven of the municipalities with RHUs had crude death rates lower than 5.0 per 1000population.
Only 3 RHUs had CDRs of at least 1000population, with Agoo having the highest rate at 12.31
1000. The crude death rate for the whole province was only 7.4 per 1000 population, which was
far lower than that ofthe national figure. Such low levels howevermay not necessarily reflect better
health conditions. Rather, they could be an effect of underreporting and underregistration of
deaths. The leading causes of mortality were pneumonia, diseases of the heart and cardiorespiratory
arrest.
Very widevariations occured amongthe RHUs with respect to the infantmortaltiy rate. The lowest
rate for 1984 was that of Sudipen with an IMR of 8.8 infant deaths per 100 livebirths. Four other
RHUs had IMRs below 20.011000. On the other hand, 5RHUs had IMR's of at least 50.0/1000 with
the highest rate being 72.5infant deaths per 1000livebirths for Caba. The three leading causes of
infant deaths in the RHUs were pneumonia, prematurityand congenital debility.
There were 119 reported fetal deaths for the whole province in 1984. Of these 21 were from Agoo
and 29 from San Fernando. In terms of rates, Agoo and Sto. Tomas had the highest figures with
fetal death rates of 12.9and 17.43per 1000livebirths, respectively. Four RHUs namely in San Juan,
Santol, Bagulin and Aringay did not report any fetal death.
Data on abortions and stillbirths were also available, although theircompleteness and accuracy are
questionable. In the case of abortions for example, only 33 cases were reported for the whole
province in 1984, with data coming from only 3RHUs: 16from San Juan, 15from Bauang and 2 from
Bagulin. The total number of stillbirths reported for the same year was 43 with data coming from
only 9 RHUs. The incidence of maternal mortality was likewise rare, with only 9 maternal deaths
for the whole province, occuring in 6 RHUs. Overall, the 20 RHUs varied much in terms of the
different health status indicators.
In 1984,estimated total of pregnancies computed from Iivebirths, stillbirth and abortion statistics
in the province was 14,628 . The general fertility rate was 96.57 as against the national general
fertility rate of 121.9. Total reported abortions and stillbirths were 33 and 43, respectively. The
range of abortion cases per RHU was from 0-16cases for that year while stillbirths ranged from
oto 10 cases. There were a total of 9 maternal deaths in the province with most municipalities
having no reported case while the highest reported was 2 maternal deaths. Maternal death rate
for the whole of La Union was 1.13 as against the national figure which was 9.
In 1984, there were a total of 3,162deaths which is equivalent to a death rate of 6.47 (per 1,000
population); the national figure was 5:9. The 3 leading causes of mortality were pneumonia,
46'

diseases of the heart and cardio- respiratory arrest. The 3 leading causes of morbidity, on the
other hand, were bronchitis, diarrhea and upper respiratory tract infection.
The average and range values for the above population and health indices are shown in Table 13.
Table 13. Provincial average and range of values (per municipality) of selected population and health
indices San Fernando, La Union, 1985
Health Indices Provincial Range
,
1. Population 488,990.00 4,535 - 73,543
2. Population density 362.00 0.68 - 27.24
3. Familysize 50.00 4-7
4. Crude birth rate (per 1,000 population) 21.65 16.3 - 43.6
.
5. Generalfertilityrate (per 1,000 women) 96.57 72.5 - 194.5
6. Crude death rate (per 1,000 population) 7.40 0-12.30
7. Infant mortality rate (per 1,000 livebirths) 47.70 8.8-72.5
8. Feotal death rate (per 1,000 population) 119.00 12.9 -17.43
.
9. No. of abortions 33.00 0-16
10.No.of stil1births 43.00 0-10
11. Maternaldeath rate 1.13 -
.Source: Vital Statistics Report, IPHO, La Union
The RHU Profile
As shown by the RHU Baseline survey results of this study (70), the DOH structure in La Union
.is headed by the Integrated Provincial Health Officer supported by an assistant Provincial Health
Officer. The IPHO implements and monitors the different projects of the DOH at the provincial
level. The province is divided into 5 districts; thus, under the IPHO are 5 District Health Offices
(DHO) each manned by the head of the District and Chief of Clinic from the district hospital. The
DHO has a Special Field Services Task Force composed of supervisors of personnel counterparts
at the municipal level or district coordinators of programs under the department. Under the
District Health Office areRural HealthUnits (RHU). Each RHU is composed of a Municipal Health
Officer, a Public Health Nurse, a Rural SanitaryInspector anda number of Rural Health Midwives
(RHM) depending on the total population of the municipality. If the Rural Health Unit is not
attached to the district hospital, the RHtJ has a Public Health Dentist and a Dental Aide. Under
each RHUs are several Barangay Health Stations each manned by a Rural Health Midwife. There
area total of 152RHMs who are each deployed to servean average of 4 barangays per person. The
highest number of barangays covered is equivalent to 8, and the average population size per
catchment is 3,123. The services rendered by the RHM cover a wide range: immunization,
47

maternal and child health services, environmental sanitation, family planning, Operation Timbang,
mothercraft, Targetted Food Assistance, NIB, anemia control, under six clinic, diarrhea
control, leprosy control, malaria control and TBcontrol.
Among the rural health midwives interviewed, only 48% answered that iron supplements were
availableat the RHU. Moreover, only 35%mentioned the pregnant womenas the recipients of this
supplement. The problems encountered in the delivery of supplements were: a) lack of supplies,
b) complaints of sideeffects and c) recipients' dislike for the taste of iron. In this study, it was seen
that about 72% of PW visited the BHSmonthly for pre-natal check-tip. There were 15 monitoring
forms accomplished regularly by the RHM (l form weekly, 8 monthly, 2 quarterly, 2 semiannually
and 2 percase seen in the BHS). Eighty three percent of the RHMs encountered problems
in the RHU monitoring system. These were lack offorms (48%) andtoo muchandtimeconsuming
paperwork (26%). Fifty eight percent of the RHMs reported problems directly to the PHN, 49%to
the MHO, and 5.3% to the PHO and DHO.
The data also showed that the midwives claimed their knowledge on nutritional anemia was
inadequate,(50% to 74%)hence the need for a refresher course or update on the currenttrends and
management of anemia, its detection, prevention and control.
PHC Implementation Profile
The level ofPHC implementation before the start ofthe project in 1984was as follows: 100%of the
"barangays
were beyond level 1(SocialPreparation/Awareness Level).Five Percent (5%) were then
at level 2 (Organization Level) and 67% were already at level 3 (Implementation Level), and 28%
of the barangays were at level 4 (Project Maintenance Level) (71).
Results of the BPHCC survey before the start of the project showed that 8% of the barangay
committees were inactive (71). Annual programs/work plans were not prepared and were not
considered as important documents. Instead, activities were arranged orally or could only be
gleaned from the minutes of past PHCC meetings. Membership in the BPHCC was limited toa
specific segment of the community or a select few rather than including the whole community.
Most of the members and officersof the BPHCCas well as the BHWs were not clear on the concept
of the PHC and of the working relationship between the BPHCC and Municipal Primary Health
Care Committee (MPHCC). Thus, linkageandcoordinationbetween the BPHCCandMPHCC was
lacking. The rural health midwives were the moving spirit of the BPHCC. The BPHCC was very
much dependent on the RHMs even if they were functioning at level 4.
Within the PHC approach, the Barangay Health Workers (BHWs)are the peripheral-level health
workers in the community. The following are the target specific services rendered by the BHWs
in La Union:
48

5. RESULTS OF THE PROJECf OPERATIONS COMPONENT
This chapter discusses the results of the implementation of the project's operations component
specifically the training, delivery and monitoring systems.
Training of Project Implementors
Table 14 presents the number of RHMs and PHNs trained by treatment group during the actual
training schedule. The implementors were trained by the Inter-agency National Task Force and
DOH Regional and Provincial Task Forces. The data show that among the PHNs the Food groups
had 100% training coverage. In contrast, only 62% in the Iron Group were trained, The reasons for
non-attendance were nurses' leaves or resignations. Ninety three percent (93%) among the RHMs
attended the training. All those who were not able to attend the scheduled training were followed
up by the Project Supply Officer and public health nurse, and trained.
Table 14. PHNIRHM Training Accomplishment
PHN RHM
Treatment Target Trained Target Trained
Group No No % No. No. %
Food 3 3 100 13 13 100
Iron 8 5 62 47 45 96
Food & Iron 4 4 100 21 21 100
NIE 12 11 92 71 62 87
TOTAL 27 23 85 152 141 93
Table 15 presents the number of reported active BHWs lrained by municipality and treatment
group before intervention implementation. Data show almost equal percentage of BHWs trained
(82-85%), .
Table 15. BHW Training Accomplishment
Trained
Treatment Group Target No. No. %
Food 353 299 85
Iron 1766 1501 85
Food & Iron 440 364 83
NIE 2310 1900 82
Total 4869 4064 83
,
so

Coverage of the IFSD Project
Delivery and Monitoring System Implementation
Enrollment of pregnant women in the IPSD project started in December 1984 and lasted up to
December 1986. Through these months of operation, a total of 14,609 PW were enrolled in the
project.
One way to assess the efficiency of the delivery system used was through a study of percentage
coverage. The percentagecoverage was computed by comparing the total numberofPW enrolled
with the total numberof pregnanciesduring the months of operation in each treatmentgroup.The
number of pregnancies, on the other hand, was computed based on the numberof Iivebirths and
foetal deaths in the project area reported by each RHU. Percentage coverage by RHU and
treatment group is shown in Table 16.
Table 16. Coverage of the IFSD Project, December 1984- December 1986.
No. of Pregnancies'? No. of Percentage
Treatment/RHU (Livebirths & Foetal Enrollees" Coverage
Deaths)
I. FOODGROUP
Sanjuan 980 842 86
Tubao 749 991 132
TOTAL 1729 1833 106
II. Food & Iron Group
San Gabriel 484 533 110
Pugo 516 463 90
Bacnotan 1106 1095 99
TOTAL 2106 2091 Q9
Ill. Iron Group
Naguilan 1660 1150 - 69
Santol 398 , 400 101
Balaoan 1366 913 67 . ,
Burgos 180 189 105
Agoo 3159 1443 46
StoTomas 884 511 58
Sudipen 514 485 94
TOTAL 8161 50Q1 62
IV. NIEGroup
Bagulin 366 430 117
San Fernando 5065 2019 40
Caba 460 467 102
Bangar 1163 1079 93
Luna 1027 1059 '. 103
Rosario. 1366 1212 89
Aringay 1690 1228 73
Bauang 1997 1394 70
TOTAL 13134 8888 68
Overall Total 25130 . 17903 71
Sourcel/RHU Data
"IFSDMonitoringSystemData
......
, ."
51

Overall results show that 72% of the total pregnant mothers in La Union were enrolled in IFSD.
The coverage in the treatment groups with food supplement was significantly higher than that of
the without food treatment groups. The attractiveness of the supplement in the Food Group and
in the Food & Iron Group contributed largely to the high coverage. In fact, an excess of coverage
in the food groups was noted. The only reason for this other than the increased coverage in the
treatment was the temporary migration ofothermothers to these areas where the food supplement
was available. Noted too was the excessive coverage insomemunicipalities in the Iron Group. The
combined active/close supervision of MHOs and PHNsand the dedication of wokers contributed
to this result. The lower coverage in the Iron and NIE Groups, on the other hand, may have been
due to the interplayof the following factors: a) the Iron supplement or NIE materials alone may not
have been sufficient to attract or encourage PW to enroll; and b) low involvement of BHWs in the
identification and referral of PW for enrollment in the IFSDproject. Reason for the latter factors
will be discussed in details in the section on Problems in Project Implementation (p, 64).
Compliance with Protocol
This' section shows the degree of compliance of project implementors with protocols in the
performance ofactivities at different periods of project implementation. Results are discussed per
major project activity using results of the 3 validation studies and data from the operations file.
Identification and Referral of PW
1) Place of Pre-Natal Check-up
The identification and referral activity called for the BHW to identify and refer all pregnant women
in her 'sector to the midwife for enrollment in the project. The validation studies reaffirm the high
percentage use of the rural health facilities for pre-natal check-up. The results show that 93%
in the first validation, 90% in the second and 88% in the third went to the barangay health station
and/or main health center for their pre-natal check-up. (Refer to Table 17).
Table 17. Percent distribution of pregnant women by place of pre-natal check-up,first to
third validation studies
Placeof Validation studv
pre-natalcheck-up First Second Third
BHS 75.0 85.0 83.3
MHC 18.0 5.0 7.9
Others 7.0 7.1 9.1
PW did not yet
have any check-up 0.0 2.9 2.8
A study of the masterlist of almost all pregnant women enrolled in the project, as retrieved from
the nurses and midwives, supports the findings from the validation studies which included only
a sample of PW. Results show that 95.7 % of all PW enrolled availed of the services of the main
health center and BHS for pre-natal examinations. (Refer to Table 18).
52

Table 18. Percent distribution of pregnant women by placeof pre-natal check-up and treatment
group
Treatment Group' DH/IPH RHU BHS OTHERS
I. FOODGROUP 1.4 30.5 64.3 3.9
Sanjuan 2.1 31.9 61.2 4.8
Tubao 0.7 29.0 67.4 2.9
II. o
FOOD& IRONGROUP 0.3 15.7 82.7 1.4
San Gabriel 9.5 21.2 73.6 5.3
Pugo 1.5 26.2 73.9 0.0
Bacnotan . 0.6 27.6 91.8 0.0
III. IRON GROUP 1.1 23.3 71.6 4.0
Naguilian 1.3 42.2 54.0 2.5
Santol 0.0 14.8 67.8 17.5
Balaoan 0.4 12.1 84.1 3.4
Burgos 0.0 73.5 23.0 3.6
Agoo 3.1 1.9 94.9 0.1
Sto. Tomas 0.0 43.7 56.3 0.0
Sudipen 0.0 27.7 65.3 6.9
IV. NIE GROUP 0.9 11.1 84.6 3.4
Bagulin 0.9 14.2 73.0 11.8
San Fernando 2.3 13.7 82.5 1.6
Caba 0.0 3.3 96.3 0.3
Bangar 0.0 10.1 89.1 0.8
Luna 0.4 13.8 82.1 3.7
Rosario 0.5 7.3 87.8 4.5
Aringay 0.3 0.0 99.7 0.0
Bauang 0.0 25.2 64.9 9.9
LA UNION 1.0 17.9 77.9 3.3
.
2) Age of Gestation (AOG) on First Pre-Natal Check-up
The project suggested that pregnant women should go for pre-natal check-up with the midwife
and enroll in IFSD on or before the fifth month of pregnancy. Enlistment in the project before the
fifth month of pregnancy was recommended because of the importance of early pre-natal checkups
and also in order to attain the full benefits of supplementation. Data from the operations file
show that compliance with enrollment in the project on or before the fifth month of pregnancy was
highest in the Food & IronGroup (68.58%)., (Refer to Table 19.) Thesignificantly higher percentage
of PW who enrolled on orbefore their fifth month in these treatment groups may be attributed to
the protocol that a mother is already entitled to receive iron supplements on the fifth month of her
pregnancy. This protocol may have therefore enticed more PW from the Iron and Food & Iron
Groups to enlist inthe project earlier than in the Food Group. Table 18 also shows that enrollment
on the 6th-7th months of pregnancy was greatest in the Food Group. This may be partlyattributed
to the project protocol which entitled PW to receive food supplements from the 7th through the
53

Table 22. Percent distribution of pregnant women by AOG (in months) on first intake of Nutrina
supplements and treatment group, post survey
Age of gestation Treatment \'TOUO
(months) Food Food & Iron Overall
5th 0.9 3.1 2.2
6th 30.4 50.9 42.5
7th 57.1 42.9 48.9
8th 8.9 2.5 5.1
9th 2.7 0.6 1.5
n 112 163 275
Table 23. Percent distribution of pregnant women by AOG (in months) on first intake of Ferrin
supplements and treatment group, post survey
Age of gestation Treatment \'TOUO
(months) Iron Food & Iron Overall
4th 22.1 28.2 26.5
5th 44.1 51.2 49.2
6th 26.5 13.5 17.2
7th 7.4 4.7 5.5
8th 0.0 1.8 1.3
9th 0.0 0.6 0.4
n 68 170 238
3) Quantity of Nutrina Received
A PW in the Food and Food & Iron Groups should receive 30 packets of the food supplement
monthly. Results, however, show that this protocol was not always met. The three studies
revealed that only 84%, 54% and 81% of the mothers interviewed received from 26-31 packs per
month (Refer to Table 24). The irregularinvolvement of the BHW in the delivery of supplies to the
PW or the delayed visit of the PW to the health center to get hersupplies could have largely caused
the insufficient number of Nutrina received monthly. The other reasons cited by the midwives for
56

the insufficient number of Nutrina packets received or the leakage in delivery were as follows:
either the Nutrina was used as incentive to the BHW, or as a token or fare for the transport of the
supplies to the midwives' catchment areas particularly in the far-flung barangays.
Table 24. Percent distribution of pregnant women bynumber of Nutrina packs received per month and
treatment group, first to third validation studies
Ranges of Nutrina Food Food & Iron Overall Total
packs /month 1 2 3 1 2 3 1 2 3
15 packs 33.3 14.3 0.0 0.0 21.4 26.3 14.8 17.9 16.1
16-25 packs 8.3 35.7 0.0 0.0 21.4 5.3 3.7 28.6 3.2
26-31 packs 58.3 50.0 100.0 100.0 57.1 68.4 81.5 53.6 80.6
4) Frequency of Delivery of Nutrina
While the delivery of Nutrina was designed to be done weekly for control and monitoring
purposes, only 41% of the PW in the first validation, 57% in the second and 22% in the third,
received their supplies on a weekly basis. (Refer to Table 25). For practical reasons, midwives,
barangay workers or the PW found it more convenient to deliver or get the supplies bi-monthly
or monthly.
Table 25. Percent distribution of pregnant women by frequency of receipt of Nutrina and treatment
group,lirst to third validation studies
Fnnn 'nn.-! &,. ,nn I T,,tol
Frequency 1 2 3 1 2 3 1 2 3
Weekly 33.0 78.6 25.0 46.7 35.7 20.0 40.7 57.1 21.9
2x per Month 25.0 7.1 8.3 26.7 28.6 40.0 25.9 17.9 28.1
Monthly 25.0 14.3 66.7 6.6 28.6 40.0 14.8 21.4 50.0
Others 17.0 0.0 0.0 20.0 7.1 0.0 18.5 3.6 0.0
5) Receipt of NIB Materials
A pregnant woman, irrespective of the treatment group she was in, should receive an Anemia
brochure and Food PrescriptionSlipuponenrollmentin the project. Inaddition to these brochures,
PW in the Food Group were given a Nutrina brochure, in the Iron Group, a Ferrin brochure, and
in the Food & Iron Group, both Nutrina and Ferrin brochures. Results of the validation studies,
however, show that a substantial numberof the PW did not receive the required brochures.

to Table 26). As far as the delivery of Anemia and Food Prescription Pad is concerned, a higher
percentage of PW in the NIE Group recei ved their copies of the NIE materials from FirstValidation
to Third Validation than in the other treatment groups.
Table 26. Percent of pregnant women who received NIE materials by type and treatment group, first to
thirdvalidation studies
Type of brochure
Treatment Anemia ' Nutrina Ferrin Food Rxpad
group 1 2 3 1 2 3 1 2 3 1 2 3
Food 50.0 35.7 83.3 33.0 42.9 83.3 - - - 33.0 42.9 66.7
Iron 65.0 605 50.0 - - - 71.0 80.0 67.9 43.0 60.9 40.0
Food & Iron 50.0 75.0 65.0 75.0 60.0 60.0 70.0 80.0 75.0 55.0 70.0 47.4
NlE 73.0 90.0 83.3 - - - - - - 55.0 75.0 82.0
Overall 57.0 73.0 72.4 59.0 52.9 85.8 71.0 80.0 69.3 50.0 66.4 64.8
Moreover, project protocol required the midwife to explain to the PW the contents of the brochures
as part of the pre-natal counselling on health nutrition. Table 27 shows the non-eompliance with
this protocol. Instead,a range of90 - 97% of the PW were given only instructions to read and follow
the contents of the brochures upon receipt of the materials. Midwives claimed that explaining the
contents of the brochures to the pregnant women required a lot of time and that they had other
tasks and patients to attend to.
Table 27. Percent distribution of pregnant women by action lad vice received during receipt of NIE
materials and treatment group, first to third validation studies
Action / Advice Given
Treatment group Brochure given with instruction Explanation about the
10 read/follow message brochure given
1 2 3 1 2 3
Food 100:0 83.4 90.0 0.0 16.7 10.0
Iron 82.8 97.4 965 17.0 2.6 3.6
Food & Iron 93.0 875 100.0 7.0 125 0.0
NIE 94.0 90.8 975 6.0 9.3 25
Overall 90.0 92.2 97.1 10.0 7.8 2.9
58

Table 29. Percent of pregnantwomen by frequency ofvisit conducted by staff and treatment group, first
to third validation studies
Frequencyof visit
Treatment Weekly 2x/ Month Monthly Others
group 1 2 3 1 2- 3 1 2 3 1 2 3
Food 63.0 66.0 0.0 0.0 16.7 12.5 0.0 0.0 0.0 36.9 16.7 87.5
Iron 58.0 73.6 8.0 0.0 18.4 2.0 0.0 7.9 4.0 42.0 0.0 86.0
Food & Iron 41.0 70.6 26.7 0.0 17.6 0.0 0.0 11.8 13.3 59.0 0.0 60.0
NIE 50.0 53.9 12.3 0.0 28.8 0.0 0.0 11.5 1.5 50.0 5.8 86.2
Overall 53.0 63.8 11.5 0.0 _22.7 1.5 0.0 9.2 3.6 47.0 4.2 83.3
2) Daily Intake of Ferrin
The project prescribed a daily dosage of 2 tablets of the iron supplement. There was a high
compliance rate as seen from the high percentage of PW found to be taking 2 tablets daily: 92.8%
in the first, 88.7% in the second and only 78.6% in the third validation. This was gathered from
interview of the mothers. Anotherinformation on the overall complianceof the mothers using the
counting method showed a low compliance with iron supplementation. (See Table 30).
Table 30. Percent distribution of pregnant women by Ferrin daily dosage and treatment group, first to
third validation studies
Dailyintake Iron Food & Iron Overall Total
of Ferrin 1 2 3 1 2 3 1 2 3
1 tablet per day 6.0 7.1 18.1 0.0 5.0 10.0 4.3 6.5 16.5
2 tablets per Day 92.0 90.5 75.9 95.0 85.0 90.0 92.8 88.7 78.6
3 tablets per day 2.0 0.0 1.2 5.0 10.0 0.0 2.9 3.2 1.0
PW stopped intake
of Ferrin 0.0 2.4 4.8 0.0 0.0 0.0 0.0 1.6 3.9
3) Immediate Effects of Ferrin Supplementation
The pregnantwomenwho tookthe iron tabletsexperienced variedeffects of Ferrinsupplementation.
In the first validation, 54 % of the PW claimed to have experienced positive effects, also 54% in the
60

PHC Support System
The IFSDproject was launched to help strengthen andbroaden the coverage of maternal andchild
health care services in the barangays through the Primary Health Care Approach. The support of
the Barangay Health Workers and the PHC Committee at the barangay level in project
implementation was therefore expected.
BHW Involvement
The IFSD Project required BHW involvement in three major activities: (a) identification and
referral ofpregnantwomen, (b) deliveryofsupplementsand(c)follow-up ofPW'ssupplementation.
The over-all picture showed that BHW involvement was highest in the first activity followed by
monitoring of supplementation and least in delivery of supplements. Results of the first and
second validation studies (Table32)showed that half (i.e.,54%,2nd validation) of the volunteer
workers were involved in identification and referral activity, only one-fourth (i.e., 17% - 1st
validation, 26% - 2nd validation) in delivery of supplements and only one-third (i.e., 30% - 1st
validation, 42% - 2nd validation) in monitoring of PW's supplementation. Although a small
percentage of the BHWs were involved, a general increase in their involvement in the activities
can be noted from the first to the second validation studies. The increase is attributed to the
motivational dialogues conducted with these worker by the midwives, which stressed the
importance of their tasks for the success of the project.
Table32. Percentof Barangay Health Workers involvedin IFSD activities by treatmentgroup, first and
.second validation studies.
Roles of BHW Focd Iron Food&Iron NIE Overall total
I
1 2 1 2 1 2 1 2 1 2
,
IDand referral 30 75 49 48 42 39 65 60 54
Delivery 50 35 15 35 42 61 6 8 17 26
Follow-up 30 42 36 35 32 61 25 42 30 42
A study of the results by treatment group shows that the NIE Group had the highest percentage
of BHWs involved in the identification activity, followed by the Food Group, the Iron Group and
then the Food & Iron Group. While the Food & Iron Group fared the lowest in the first activity,
it had the highest average number (from the 2 validation studies) of BHWs involved in both
delivery and monitoring of supplementation activities. Furthermore, among the threegroups with
supplementation, BHW involvement during delivery was significantly higher in the Food and
Food & Iron Groups than in the Iron Group. This result is consistent with an earlier conclusion
that the delivery of medicine was still entrusted to the midwife rather than to the BHW;
Conversely, the delivery of food intervention was already entrusted by the PW to the auxiliary
workers. The NIE Group showed only

Overall resultsshowed thatthe Food & Iron Groupobtained the most BHW support than the other
treatment groups.
Primary Health Care Committee Involvement
To determine the involvement or non-involvement of the Municipal and Barangay.PHC
Committees (MPHCC/BPHCC) in the IFSDProject, committeechairmen were interviewed. In the
first validation study, only 51% of the barangay chairmen were aware and involved in the
implementation of the project in their areas. Concerned about this low participation, the project
task force convened the municipal and barangaycommittee chairmen together with the RHU staff
to fully orient them on the project and clarify their roles in implementation. The meetings also
served as venue for the RHU and PHC activities. In the second validation, percentage awareness
and involvement of barangay and municipal PHC committees improved: BPHCC - 73%'and
MPHCC - 86%. The midwife who played a vital role in project implementation was also
interviewed on the PHC Committee involvement. Results of the interview support the findings
obtained from the PHCC chairmen ofan increased involvement of the committees: 78% of the
midwives in the first validation and 89% in the second obtained assistance from Barangay PHC
Committees.
The results of the third validation, however, show that this high level of involvement was not
sustained: only 27% of the midwives obtained assistance from the barangay committees in the
implementation of IFSD activities in their barangays. The decrease was an effect of. a political
upheaval in the country which resulted in the undefined status of many local organizations even
up to the time of the third validation study.
It was gathered from the interviews of midwives that it was in the identification and referral of PW
where involvement was greatest, followed by the task of information dissemination. The other
forms of assistance obtained by the midwives were in the (1) distribution of supplementsand NIE
materials; (2) visitation of PW; (3) supervision/motivation of BHW and (4) coordination of
implementation of IFSDactivities in the barangay. Table 33 shows the percentages of midwives
who obtained assistance from the barangay committee per type of involvement in the three
validation studies.
Table 33. Percentof RHMwho obtained assistancefrom BPHCC by type ofassistancegiven,first to third
validation studies
Type of Assistance 1st validation 2nd validation 3rd validation
1. Identification and referral of PW 44·0 49.0 34.2
2. Distribution of N/F/NIE materials 7.0 6.0 7.9
3. Infodisseminationabout IFSD, 22.0· 20.0 23.7
H & N counselling of PW/ bgy
. 4. Visitation of PW 11.0 6.0 13.2
5. Supervision/Motivation of BHW 19.0 16.0 5.3
6. Coordinationof implementation of 14.0 16.0 21.0
IFSD projectin the barangay and
conducts meeting
63

From the interviews of the municipal chairmen, it was learned that the involvement of the
municipal PHC committee was limited to logistical and administrative functions. Logistical
support took the form of providing for transportation in the delivery of supplements to the
barangays, for the training of BHWsand for monitoring. Administrative support was in the form
of meetings with committee members and barangay captains to elicit theircooperation. The PHC
Committee also encouraged its members to disseminate information about IPSDin the course of
implementing agency projects in the barangays.
Interviews with barangaychairmen on their specific involvement in the IPSDprojectconfiimed the
forms of assistance mentioned by the midwives. Moreover, the logistical and-administrative
supportgiven by the municipal committee was reportedly extended by the barangay counterpart.
Aside from the Primary Health Care Committee, the midwives also noted the organizations or
persons in the barangay who in one way or another helped in project implementation. The most
commonly mentioned organizations were the Balikatan sa Kaunlaran, the Barangay Council,
Catholic Relief Services (CRS), Kabataang Barangay, tbe workers of the Population Commission, .
DepartmentsofAgriculture and LocalGovernment and the teachers. Assistance rendered by these
organizations was in the following areas: -
1) identification and referral of PW
2) distribution of supplements and NIE materials
3) information dissemination about the project in Purok meetings or mothers' classes as well
as in their own organization meetings, and
4) logistical support e.g. provision of transport or fare for delivery of supplies, incentives to
BHWs.
Problems in Project Implementation
In this project which aimed to assimilate the activities within the regular workload and functions
of the RHU staff and PHC Committee, problems were expected. The problems encountered were
as follows:
On the Accomplishment of Project Monitoring Forms
The operations component of the project relied on secondary daia collection. In the submitted
Supplementation Cards some inaccuracies and incompleteness of information were observed.
Only 53%of the Supplementation Cards, were retrieved from the total enrolled pregnant women.
Midwives claimed the other cards were lost by the PW. Moreover, the forms needed for
requisitioning and delivery of supplies by the midwives and nurses were sometimes
unaccomplished.
The common complaint from midwives and nurses was the bulk of paperwork required by the
project. Though the importance of the monitoring forms was explained, their accomplishment was
considered an additional task to what the personnel claimed was already a heavy workload.
On Declining Participation of BHW and PHC Committees In Project Implementation
The participation of BHWs is very vital for expanding the reach of health delivery sevices. The
project had shown that it would be possible to solicit the support of the outreach workers. The non-
64

participation of some BHWs in project activities may have been due to lack of proper orientation
and motivation on the importance of the activities. Although BHWs were trained on their tasks,
for onereason or anothersomewere unable or unavailable to perform their-tasks. This was partly
due to the absence of incentive. Midwives and health workers had expressed their need for
incentives because IFSO project activities were seen as an additional workload.
The non-involvement of some PHC Committees in the project is believed to have been due to lack
of proper communication and weak linkages at various implementing levels. .
On Leakage of Project Supplement
A certain amount of leakage in the delivery of Nutrina was experienced since Nutrina was used
as incentive to the BHWs or as token or fare for their transport.
A consequence of theleakage was the incompletedelivery of Nutrina to thePW, as shownin Figure
8. The discrepancy may also have been due to the irregularity of the BHW/midwife's delivery
or the irregularity of the PW's visit to the health center to obtain her supply.
On Low Compliance with Protocol
Validation results show the need for improvement in the compliance with a numberof protocols.
A major reason which contributed to this is that, the midwives already consider their workload
heavy and their tasks in the IPSO make it heavier. A second reason is the inability of the project
implementors to fully internalize or consider their tasksin the project as part of their task in the
delivery of maternal and child health services, Consideration of the IPSO as a separate and
additional work thereby led to low compliance with project protocols.
On General Project Administration
Because of the natureof the project, an outsideentity suchas the Nutrition Centerof thePhilippines
was called upon to do much coordination, monitoring and implementation. This was disadvantageous
to a certain extent because the area tended to look upon the project as a separate activity,
and total reliance on the NCr staff became a protocol which deviated from the general objective
of PHC as a community participation-based approach.
Early Response Schemes
Cognizant of these problems, the IFSONational Task Force and projectstaff implementedvarious
activities to minimize problems and improve project implementation.
Dialogues and Reinforcement Training of Project ImpIementors
In response to the problems that surfaced in the early months of operation, dialogues with the
project implementors were conducted by the National Task Force and Project Staff. Thedialogue
served as a venue not only for discussing problems but also for eliciting recommendations to
minimize these problems. . '
Continuing dialogues with implementors were conducted by the Project Operations Staff during
the monthly delivery of supplements. Two such major dialogues where problemswere brought
up with the implementors (RHMs, PHNs, MHOs and their supervisors at the district, provincial
65

and regional levels) were conducted on April 18 & 19, 1985 (4 months after start of delivery) and
in August 1985 (8 months after start of delivery). Outputs of these dialogues are shown in
Appendix G and H.
Revisions on Project Operations
Based on the recommendations obtained from the dialogues with the implementors, some major
changes in project operations were made:
• simplification and reduction of monitoring forms
• elimination of infant weighing on the 7th day after birth
• introduction of the 3-monthcycle Nutrina menuconsisting of 18 varieties to keep the PW from
being satiated with only 5 varieties
• distribution of barscales to improve compliance with the weighing task
Seminar-Workshop among RHU and PHC Committee Officers
The results of the first validation study were fed back to the project implementors through a
workshop. One of the major findings of the first validation study was the non-involvement of
many PHC Committees in implementation because of poor linkage between the RHU and the
municipal andbarangay committees.
Non-involvement was also due to the present inactive status of many PHC Committees. The
seminar-workshop was then conducted primarily to help the RHUand PHCCommittees plan on:
1. how to strengthen RHU - PHCC linkages
2. how to reactivate the PHC Committees
3. how to integrate the IFSD as an activity of PHC
The output of the workshop was a Plan of Action is shown in Appendix I.
Workshop with Provincial and District TaskForces
To remove the notion that IFSD was a separate activity or to make the implementors realize that
the IFSDwasa project ofthe localhealthdepartment,the planningofactivities,projectadministration,
implementationand monitoringweresharedwith the Provincial and District TaskForce members.
The National Task Force conducted meetings with local task forces on the:
• design and implementation of the Provincial Form
• planning and assignment of the monitoring task to the local staff
• consultation on protocols/content of project activities as well as on the conduct of these
activities, e.g., 2nd, 3rd validation studies, RHU visits
• plan of action and delegation of responsibilities for monitoring the implementation of the
Municipal Plan of Action designed during the seminar-workshop
RHU Visits
The Nationaland ProvincialTask Force membersconductedRHU visits to assist themunicipalities
in implementingthe Plan of Action designed during the workshop. The RHU visits wereattended
by members/officers of both municipal and barangay PHC Committees and RHU staff. Through
66

these visits, the reactivation of the PHC Committees and their consequent involvement in the IPSD
were expected to be achieved.
Summary of the Operations Component
The trainingactivities underthe operations component showed that all nursesand midwives were
given training/follow-up and reinforcement training to effectively carry out their functions in the
project. Eighty three percent (83%) of the BHWs were also given a half day formal training to
effectively assist in the delivery system.
From December 1984through December 1986, The IPSDproject covered a total of 17,903 PWs or
77%of the targetted number. Findings show that Food supplements were an incentive for higher
pre-natal coverage while the iron supplementation resulted in an earlier start of pre-natal checkup
because of the early start of supplementation. On the average PW started to go for pre-natal .
check-up when they were 5 months pregnant. However,almost one halfof the mothers werefirst
identified on dates beyond the prescribed start of iron supplementation. /
AdecreasingBHWinvolvementin the project was noted. This is howevertrue not only for the IPSD
project but for the entire health delivery services in the country. The RHM reported only 60% of
BHWs who were active at the end of the project as against 90% at the start. Reasons for low
unsustained participation are: a) preoccupation with household or farm work, b) absence of
incentive and c) lack of appreciation of the importance of their role. Where the intervention was
iron, the PW would rather get the supply from the RHU because they were afraid to get medicines
from BHWs.
Results show that orily 54%to 84%of PW received the correct number of food supplements. The
reasons for this are the irregular BHW involvement and delayed visits of PW to BHS to get their
supply. Food supplements were also used by BHWs as fare for transportation.
The RHM, BHWand the PW found it more convenient to deliver or get the nutrina on a monthly
or bi-monthly basis rather than weekly.
Most frequently only 40-83% of PW received their NIE materials and a very low 2-16% received
an explanation of the brochure upon receipt from the RHM. The RHMs found it time consuming
to explain the 'brochures considering their hectic schedule.
There was also a decreasing involvement of BHWs in monitoring. The RHMs ruled the gap as
shown in the increasing percentage of mothers who claimed they were visited by the RHM. Only
46-83 % of the PW were visited at least once: However a high percentage were visited weekly
during the first and second validation. The frequency became irregular at the third validation
period.
The PW on the average took only 52% of the total tablets required during the entire supplementation
period.
The low compliance was attributed to the supplementation side effects, the PWs forgetting to take
the tablet and lack of continuity of supply because of low BHW involvement and delayed visits
to BHS.

The results show that BHW involvement is crucial to the delivery system. The low BHW
involvement has been cited most frequently as the reason for the low level of accomplishment.
Another vital force which could have improved the level of project accomplishments is the
BPHCCinvolvement. Where the BPHCCwas involved, logistical, administrativeandcoordinative
support was provided. The BPHCC also assisted in information dissemination regarding the
project and conducted BHW activities like identification and referral of PW, delivery and
monitoring of supplies. The decreasing BPHCC involvement in the project was due.to:a) the
lack of communication/feedback system from the RHU to BPHCC,b) weak linkages, and c)
inactive committees/officers.
Other problems encountered during delivery were the following.ajoveralllow compliance with
protocol because of heavy workload, andinability to internalize IFSDtasks as partof thedelivery
of MHC services, b) low retrieval of pregnancy monitoring and supplementation cards, c)
incompleteor inaccurate information in some monitoringdata,andd) complaints ofimplementors
of heavy paperwork, heavy workload and IFSD tasks as additional load.
Asignificant finding relates to the decreasing involvement of the BHWs. The PW were persuaded
to go to the BHSor RHM to get their own supplies, in accordance with the principle of the primary
health care approach to involve the targets themselves. An alternative strategy also involving the
PW themselves in the delivery is to bring the supply depot closer, for instance, from the BHS to
the house of a trusted and very active BHW.
On the whole, since the project aimed to determine the effectiveness of a delivery system at the
local level, certain inputs were provided and strategies modified to ensure the av.ailability of the
supplements at the time when the targets needed them. Thus supplements were delivered
directly to the RHU. In food intervention, additional transport direct to the BHS was provided.
Also when the RHU-PHCC linkages was found to be inadequate or not functioning at all, 'the
project facilitated andcoordinated the RHU visits which served asa fora for PHCC reorganization.
Close feedback monitoring system was functioning between NCP and the provincial office such
that requirements were immediately attended to. Monthly reinforcement training also during the
first monthsof operations was conducted to familiarize project implementors on project protocols.
That problems occurred inspite of these additional support systems shows that in future
implementation, there is a need to apply the above mentioned inputs/ marketing strategies to
ensure project impact. A deeper analysis of the delivery system to identify in greater detail the
operational problems was also called for. Figure 6 presents the factors that may affect the
effectiveness of an iron supplementation delivery project based on the lessons from the study. A
detailed analysis of the factors affecting service delivery is also documented in a related study
using the project's data (72).
68

6. DESCRIPTIVE PROFILE OF SAMPLE PREGNANT WOMEN
Chapters 6 to 9 of this report discuss the findings of the research component in relation to the
objectives of the project namely: a) the effectiveness of the project in terms of reducing the
prevalence of iron deficiency anemia and low birthweight in the community (Chapter 7), b) cost
effectiveness of iron and food supplementation (Chapter8), and c) socio-economic, demographic
and intervention variables on mothers and children (Chapter 9). Chapter 6 presents the socioeconomic,demographic,
healthand nutrition profiles of thesamplemothers included in thestudy.
Age of Gestation At Pre-and Post-Surveys
The research component included data from a cross sectional sample of 807 pregnant women at
baseline and 867 pregnant women at post-survey. Although the food supplementation covered
only women who were at least in the 7th month of gestation, both the baseline and post-surveys
included pregnant women in their 5th to 9th month of gestation in all treatment groups. This was
done since one of the major objectives of the project was to determine the effect of the different
forms of intervention on the over-all prevalence of anemia among high-risk groups .in the
community (i.e, those who are at least 5 months pregnant), rather than among the specific targets
ofthe intervention. Table34 shows the distribution of the samplesaccording to theage of gestation
and treatment group, for both surveys.
Table 34. Distribution of pregnantwomen by age of gestation and treatmentgroup, pre-and post-survey
Treatment group
Age of gestation Total Food Iron Food & Iron NIE
No. % No. % No. % No. % No. %
Pre survey
5 months 184 22.8 51 25.6 47 23.7 47 23.7 39 18.4
6 months 189 23.4 51 25.6 45 22.7 39 19.7 54 25.5
7 months 190 23.5 43 21.6 42 21.2 55 27.8 50 ·23.6
8 months 186 23.0 42 21.1 46 23.2 47 23.7 51 24.0
9 months 58 7.2 12 6.0 18 9.1 10 5.1 18 8.5
TOTAL 807 100.0 199 100 198 100 198 100 212 99.94 ,
Post survey
5 months 159 18.3 38 18.8 35 17.6 48 20.0 38 16.8
6 months 207 23.9 55 27.2 43 21.6 57 23.8 52 23.0
7 months 242 27.9 63 31.2 64 32.2 67 27.9 48 21.2
8 months 202 23.3 35 17.3 50 25.1 52 21.7 65 28.8
9 months 57 6.6 11 5.4 7 3.5 16 6.7 23 10.2
TOTAL 867 100 202 100 199 100' 240 100 226 100
Socia Demographic Characteristics
The pregnant women included in the sample were in the prime of their child bearing ages with a
mean age of27.2 years. Their husbands were in general, 2 to 3 years older with a mean age of 30.4
years. The mean household size was 5 - 6 members, which is larger than the mean family size of
70

Table 36. Distribution of pregnant women by educational attainment and treatment group, pre-survey
Treatment group
Educational Total Food Iron Food & Iron NIE
attainment No. % No. % No. % No. % No. %
No schooling 5 0.6 1 05 2 1.0 0 0.0 2 0.9
Elementary 362 44.9 101 SO.8 85 42.9 87 43.9 89 42.0
High schoolI 288 35.7 57 28.6 80 40.4 69 34.8 82. 38.7
Vocational
College 152 18.8 40 20.1 31 15.7 42 21.2 39 18.4
TOTAL 807 100 199 100 198 100 198 100 212 100
Past Pregnancy Outcome
Health Profile
The mean number of pregnancies for all women taken altogether was 3.5. In terms of the number
of livebirths, the reported.value ranged from 0 to 12, with a mean of 2.3. About two-thirds of the
women (64.3%) had at most only 2livebirths while only one-tenth (9.8%) had 6 - 12 livebirths.
The incidence of abortion among the women in the sample was 16%, with 7 of them having 3 to 4
abortions in the past. The incidence of stillbirths was much lowerat 4.1%. Perinatal and neonatal
deaths wereevenless common with corresponding proportionsof 3.2%and 1.2%, respectively. In
general, no significant difference existed between the four treatment groups with respect to the
past pregnancy outcomes of the women if the ANOVA test is used. This is shown in Table 37.
72

Very few pregnant women had a history of heart disease and malaria. Influenza and/or
pneumonia was the most common, with a prevalence of 27.3 % for all women taken altogether.
Moreover, the Z test reveals that the NIE Group had the highest percent With weak/irregular
heartbeats compared to FoodGroupand Food & Iron Group; the Food and Iron Group the lowest
percentwith murmurscomparedwith Food and NIE Groups; Food was highest with percentrales
compared with Food & Iron and Iron Groups and NIE higher than Iron Group; the Food and Iron
Group was highest with pretivial edema compared to the Food and NIE Groups.
Among the differentcomplaints in relation to pregnancy, dizziness was the mostcommon (69.2%),
followed by vomiting (46.8%) and lassitude (43.4%). Bleeding was experienced by only 33 (4.1 %)
outof the807pregnantwomen in thesample. Again theZ test showed the NIE with highest percent
of PW experiencing vomitting and dizziness, the Food & Iron Group higher than Iron Group .and
the Food Group higher than Iron Group in percent of PW experiencing'vomitting.' However the
treatment groupsare homogenousas far as sleeplessness, anorexia, lassitude, edemaand bleeding
are concerned.
Table 38. Number & percentage of pregnant women with clinical signs and symptoms by type and
treatment group, pre survey
Treatment £l"OUO
Signs & Total Food Iron Food Iron NIE
Svrnotoms No. % No. % No. % No. % No. %
Pallor
Conjunctiva 551 68.3 117 58.8 147 74.2 146 73.7 141 66.5
Mucosa 248 30.7 59 29.6 74 37.4 64 32.3 51 24.1
Nailbeds palm 154 19.1 49 24.6 49 24.7 32 16.2 24 11.3
Scurvy 105 13.0 13 6.5 12 6.1 41 20.7 39 18.4
Cheilosis 47 5.8 4 2.0 9 4.5 12 6.1 22 10.4
Enlarged thyroid 85 10.5 15 7.5 17 8.6 36 18.2 17 8.0
Weak,irregular
heartbeats 28 3.5 5 2.5 6 3.0 3 1.5 14 6.6
Murmurs 37 4.6 14 7.0 6 3.0 4 2.0 13 6.1
Rales 36 4.5 14 7.0 4 2.0 5 2.5 13 6.1
Abdominalscar 40 5.0 14 7.0 13 6.6 6 3.0 7 3.3
Pretevialedema 107 13.3 18 9.0 27 13.6 41 20.7 21 9.9
Other Med.&
Related History
TB 30 3.7 6 3.0 5 2.5 7 3.5 12 5.7
Influenza/Bronco 222 27.5 56 28.1 49 24.7 41 20.7 76 35.8
pneumonia
Kidneydisease 41 5.1 17 8.5 4 2.0 7 3.5 13 6.1
Heart disease 9 1.1 5 2.5 3 1.5 0 0.0 1 0.5
Malaria 6 0.7 2 1.0 1 0.5 2 1.0 1 0.5
Complaints related
to pregnancy
Vomitting 380 47.1 85 42.7 64 32.3 92 46.5 139 65.6
Dizziness 560 69.4 128 64.3 122 61.6 140 70.7 170 80.2
Sleeplessness 210 26.0 53 26.6 58 29,.3 45 22.7 54 25.5
Anorexia 257 31.8 60 30.1 65 32:8 68 34.3 64 30.2
Lassitude 351 43.5 85 42.7 77 38.9 88 44.4 101 47.6
Edema 91 11.2 23 11.6 24 12.1 21 10.6 23 10.8
Bleeding 33 4.1 8 4.0 6 3.0 7 3.5 12 5.7
74

Parasitism
Since parasitism is an established risk factor in anemia, a stool examination was also undertaken.
However, only 686 (85.0%) of the 801 pregnant women submitted stool samples. The results are
shown in Table 39.
Table 39. Prevalence of parasites by type and treatment group,.pre-survey
Treatment group
Type of Total Food Iron Food & iron NIE
parasites No. % No. % No. % No. % No. %
n WI n WI n WI n WI n WI
Hookworm 686 22 3.2 173 2 1.2 177 12 6.8 187 7 3.7 149 1 0.7
Ascaris 686 176 25.7 173 40 23.1 177 60 33.9 187 40 21.4 149 36 24.2
Trichuris 686 343 50.0 173 83 48.0 177 110 62.1 187 73 39.0 149 77 51.7
Table 39 shows that of the 3 types of parasites, trichuris was the most common, with half (50.0%)
of the women being positive for it. Hookworm had the lowest prevalence at 3.2%. Statistical
differences exist among the four treatment groups with respect to the prevalence of the different
types of parasites, with those in the iron group having the highest prevalence for hookworm,
. ascaris and trichuris. The NIE on the other hand, showed higher prevalences of trichuris than the
Food and Iron Group, while inversely for hookworm, the Food and Iron Group had higher
prevalence than the NIE Group.
Nutritional Status
About seven out of every ten pregnant women(72%) in the sample were at-risk of delivering low
birthweight babies based on their weight for age standards. The four/treatment groups were
comparable with respect to the nutritional status of the pregnant women,which is shown in Table
40.
Table 40. Distribution of pregnant women by nutritional status and treatment group, pre-survey
Treatment l'l'OUD
Nutritional Total Food Iron Food & Iron' NIE
status No. % No. % No. % No. % No. %
Normal 226 28.0 53 26.6 58 29.3 58 29.3 57 26.9
Nutritionally 581 72.0 146 73.4 140 70.7 140 70.7 155 73.1
at-risk
75

,
Group (3.27% average). Table 43 shows the relative, and average change in the percentage of
PW with correct answers per K-item.
Table 43. Percent relative change of pregnant women who obtained correct answers by K item from
pre-to post-survey by treatment group
Treatmentgroup
K item Over-all Food Iron Food & Iron NIE
What is anemia 1.1 2.0 1.2 -1.5 2.9
Causes of anemia 2.9 2.4 2.5 5.0 1.6
Effects of anemia on 6.1 11.0 1.7 5.3 6.4
pregnant mother
Effects of anemia on 10.8 8.0 7.2 4.0 12.0
the fetus
Iron rich food 2.4 3.4 5.1 3.5 -2.0
Energyrich food -0.1 -{j.9 0.7 6.4 -0.9
Protein rich food 2.3 -0.1 -0.1 7.1 2.2
Bodyregulating 4.7 -0.5 1.7 11.8 53
rich food
Difference in the 17.6 7.3 12.0 28.6 20.8
diet of a PWand
anon-PW
Reasonfor taking 2.4 6.1 1.0 2.1 0.4
supplements
The questions were also analyzed by major topics namely: (1) on anemia, (2) on sources of
nutrients and (3) on diet during pregnancy.
There was an increase of knowledge of the PW on all the 4 anemia-related topics. The question
on the correct cause of anemia obtained the highest relative change from pre- to post periods.
However, a noticeably low percentage of PW knew the correct cause of anemia in both surveys
(i.e., only 2.1% at pre and 5.0% at post).
On the sources of nutrients, more than 60%knew the right sources of iron-rich and energy-giving
foods while less than 40% knew the right sources of protein-rich and body-regulating foods.
At baseline, only 7.4% of the respondents knew the correct difference in the diet of a pregnant and
non-pregnant woman. At post, this increased to 25%, registering the highest relative change of
2.4%among the K-iterns. Inbothsurveys, more than 90%of the PW knew the importance of taking
supplements during pregnancy.
78

Pre-Natal Check-up
Nutrition counselling during mother's classes and health center visits always stressed the
importance of regular and early pre-natal check-up. This was also given emphasisin the IFSD NIE
materials distributed to the PW. During the surveys, the PW were asked if they already had prenatal
check-up during present pregnancy. Overall results showed an increased percentage ofPW
who already had pre-natal check-up from pre-to post-survey (7.4 to 82.5%). Across treatment
groups, results showed a significant lowest percentage of PW who went for pre-natal check-up in
the Food Group while the Iron Group is significantly higher compared to Food and Iron Group
and the NIE Groupat baseline. At post, again the Food Group is significantly lower than the Iron
Group and the Food and Iron Group; and the Food and Iron significantly higher than NIE
(Table 44).
Table 44. Percentage of PW who had pre-natal check-up prior to conduct of survey by treatment
group, pre-and post-survey
Treatment'group
Period Total Food Iron Food & Iron NIE
Pre survey 70.4 57.3 81.8 71.2 71.2
Post survey 82.5 73.3 84.4 92.5 78.3
% Relative 17.2 27.9 3.2 29.9 10.0
Change
The importance of early pre-natal check-up was among the messages stressed in PW counselling
and in the NIE materials distributed. Results showed an increase of PW who had their first prenatal
check-up within the 1st - 5th month of their pregnancy from pre-to post- period in the Iron
and Food & Iron Groups while there was a decrease in the Food and NIE (control) Groups (refer
to Table 45). For the Food and NIE Groups, however, there was an increase of mothers who went
for their first check-up within the 6th-7th month while the reverse was true for the Iron and Food
& Iron Groups. All the treatment groups showed a decrease in start of check-up only during the
8th - 9th month of pregnancy.
Table 45. Percentage distribution of PW by start of pre-natal check-up and treatment group, pre-and
post-survey
Treatmentgroup
AOG at start of Total Food Iron Food & Iron NIE
check-up(months) Pre Post Pre Post Pre Post Pre Post Pre Post
Ist- 5th 68.3 70.1 68.4 58.8 67.9 73.2 68.8 77.5 68.2 67.2
6th - 7th 27.1 27.8 27.2 39.2 27.2 25.0 27.7 20.7 26.5 29.9
8th - 9th 4.6 2.1 4.4 2.0 4.9 1.8 3.5 1.8 5.3 2.8
79

These findings show that the protocol for start of receipt of the IFSD Supplement somehow
influenced the start of check-up of the mothers. More PW in the Food Group in the post-survey
thanat pre-surveyhad the tendency to start their enrollment in IFSDonly on their 6th or7th month
because the project protocol calls for the PW to receive Nutrina only from the 7th month of
pregnancy. Similarly, more PW in the Iron and Food & Iron Groups at post-survey had their first
check-up on or before the 5th month when they were already qualified to receive Ferrin tablets.
Results (pre-and post1also show an increased percentage of PW who preferred the RHU and BHS
and a decreased percentage of those who availed of the government hospitals and the TBA
(Table 46).
Table 46. Percentagedistribution of PWby placeof pre-natal check-upand treatment group, pre-andpostsurvey
Treatmentgroup
Placeof Pre- Natal Tota! Food Iron Food & Iron NIE
Check-up Pre Post Pre Post Pre Post Pre Post Pre Post
1. RHU/BHS 80.1 87.1 70.2 83.8 88.3 89.3 85.8 91.9 73.5 81.9
2. Government 11.4 6.6 16.7 10.8 8.6 8.0 7.1 3.2 14.6 7.9
hospital
3. Private clinic/
Hospital 5.4 5.7 7.7 4.7 3.1 4.8 5.7 5.0 5.3 8.5
4. Hilot 3.0 0.6 4.4 0.7 0.0 0.0 1.4 0.0 5.6 1.7
Majority (i.e., 54% at pre, 57% at post) of the PW claimed that they were preoccupied with
household or farm work, and thus did not have time for pre-natal check-up. One fifth (i.e., 20%
at pre, 17% at post) of the PW believed that they were in good health and felt no need to go to the
health center. A few did not realize the importanceof earlypre-natalcheck-upbutopted for checkup
only during the latter months of pregnancy. Others found the distance to the health station so
exacting that they preferred going to the nearby hilot. Some other PW cited lack of moneyas the
cause for not having a pre-natal check-up. Some of the PW even admitted laziness as their
reason.The distribution of pregnant women according to their reasons for not having any checkup
is presented in Table 47.
80

Table 47. Percent distribution of PW by reason for no pre-natal check-up and.treatment group, preand
post-survey
Treatment group
Reason for no Total Food Iron Food &:Iron NIE
pre- natal Pre Post Pre Post Pre Post . Pre Post Pre Post
check-up
1. Preoccupied with
household work 54.0 . 57.9 43.5 50.0 55.6 61.3 63.2 72.2 59.0 59.2
(attitudinal)
2. PW in good health 20.9 17.1 22.4 20.4 13.9 12.9 21.1 11.1 23.0 18.4
3. Distance/Hilot 3.8 5.2 2.4 7.5 5.6 3.2 3.5 0.0 4.9 6.1
4. No infonnation/
Deferred check-up 10.4 14.5 13.0 14.9 19.4 19.4 3.5 16.7 6.6 102
5. Lack of money 7.9 3.3 12.9 3.7 0.0 .0.0 . 8.8 0.0 4.9 5.1
6. Others/Don't know 3.4 2.0 5.9 3.7 5.6 3.2 0.0 0.0 1.6 0.0
Dietary Intake
The counselling ofPW by midwivesand the IEC materialsincluded messagesonthe food sources
of the different nutrients and on properdiet during pregnancy. To measure the effectiveness of
the counselling.and IEC materials, the dietary intake of the PW wasdetermined using the 24-hour
dietary recall method. Table 48 shows the mean intake of the sample mothers by nutrient and
treatment groupat pre- and post-survey. Table 48 on the otherhand, shows the treatment groups
with significantly increasing/decreasing (-) values from pre-and post-survey.
,
81

Table 48. Mean intake of pregnant women by nutrient and treatment group, pre-and post-survey
Treatment group
Tolal Food Iron Food & Iron NIE
Nutrients Pre Post Pre Post Pre Post Pre Post Pre Post
Calories (Kcal) 1738.6 2037.7 1676.1 2039.0 1785.6 1907.6 1798.7 2082.5 1697.2 2103.7
Carbohydrates (gm) 319.3 364.4 312.6 362.0 320.5 338.1 332.9 378.3 312.0 374.8
Protein (gm) 50.3 55.9 47.8 56.2 52.4 52.2 51.3 57.3 49.9 57.5
Fats (gm) 26.4 36.7 24.1 37.8 30.0 35.8 26.3 34.7 25.2 38.5
Iron (mg) 11.7 12.5 11.1 12.0 12.8 11.4 11.4 12.8 11.5 13.5
Retinol (meg) 329.6 364.3 239.2 276.5 507.0 315.3 256.8 286.1 316.9 569.0
Betacarotene (i.u.) 2425.0 2775.6 2186.3" 2073.5 2370.4 1766.3 2713.6 3015.2 2430.7 4037.3
Thiamine (mg) 0.7 0.8 0.7 0.8 0.8 0.7 0.7 0.9 0.7 0.8
Riboflavin (rng) 0.5 0.6 0.5 0.6 0.6 0.6 0.5 0.7 0.5 0.7
Niacine (rng) 16.4 18.5 15.9 18.8 17.5 17.7 16.3 18.7 16.0 18.7
Ascorbic acid (mg) 99.9 66.3 153.5 52.4 109.6 54.3 71.9 69.8 66.8 85.5
Caloric Intake
The amount of caloric intake of the PW increased apparently from baseline to follow-up in the four
treatment groups as shown in Table 48. Table 49 shows statistically significant increases in
nutrient intake in all treatment groups except the Iron Group.
An analysis of the mean intake from baseline to post shows that the mean intake increased in all
treatment groups. However, intake deficiency was noticeable with 39% to 48% of the PW at
baselineand 53% to 65% at post-survey going above 74% ofRDA (refer to Table 1 of Appendix K).
No significant difference among treatment groups was seen at baseline.
82
•

Table 49. Statistically significant differences innutrient intake from pre-to post-surveyby treatment
group
Nutrient Food Iron Food & Iron NIE
Calories •• ... •••
Protein • ••• •••
Fat •• •• .............
Carbohydrates .......... ,........
Iron ••• ••
Retinol
Protein Intake
Beta carotene "''''....
Thiamine ••• ••
Riboflavin .......... •
Niacine •• ....... .........
VitaminC (-)".... '" (-).. ••
LEGEND:
• Lessthan 0.10
•• Lessthan 0.05
••• Lessthan 0.01
•••• Lessthan 0.0001
Table 48 shows statistically significant increases in intake of foods rich in protein by the subjects
from pre-to post-period except for the Iron Group where mean intake remained the same. The
general increase in intake of the nutrient may have reduced the number ofPW who were getting
below 50% of the protein RDA (refer to Table 2 of Appendix K). However, protein deficiency
was still a problem with only 34% to 46% of PW at pre-survey and 46% to 60% of mothers at postsurvey
getting above 74% of RDA. Again, no significant differences among treatment groups
were seen during baseline.
Fat Intake '
Table 48 shows a higher fat intake of the PW at follow-up than at baseline in all treatment groups
except the Iron Group. At baseline level, the iron group had the highest mean intake of 30 grams
while the food group had the lowest with only 24 grams daily. However these differences are not
statistically significant. At follow-up, the NIE group had the highest mean intake of 39 grams and
the food & iron group the lowest meanof35 grams. In terms of increase in grams from pre-to post-
83

survey, however, the NIE Group showed highly statistically significant results together with the
Food and Iron arid the Food Groups.
While there is no stipulated fat requirement in the diet in the Philippines, it is suggested that at
least 20 %of caloric ROA be supplied by dietary fat. Table 50 shows that from pre-to post-survey,
therewasanincreaseof pregnant womenin all thetreatment groupswhosefat intakewasadequate
in meeting thesuggested fat intake requirement. Overall, PW withadequate fat intake increased
by 75% with the NIE group attaining the highest relative change of 119.0%.
Although there was an increase of pregnant women with adequate fat intake from pre-to postperiod,
fat intake deficiency was stilI a problem with 60-71 % and 46-48% of PW getting less than
50% of fat ROA (refer to Table 3 of Appendix k),
Table SO. Percent of PW with adequate intake of fat and carbohydrate by treatment group, pre-and postsurvey
Fat Carbohydrates
Treatment Group Pre Post % Relative Pre Post % Relative
Change Change
Food 13.1 25.2 92.4 46.7 63.9 36.8
Iron 16.2 22.1 36.4 505 60.3 19.4
Food & Iron 13.1 21.3 62.6 55.6 70.8 27.3
NIE 12.1 26.5 119.0 48.6 67.7 39.3
Carbohydrates Intake
TOTAL 13.6 23.6 73.5 SO.3 66.0 31.2
As indicated in Table 48, carbohydrates intake was higher at post-survey than at baseline period.
The food & iron group consistently had the highest mean intake in both pre-and post-survey, i.e.,
332 grams and 378 grams, respectively. At baseline, the food and NIE groups had the lowest mean
intake of 312 grams while at post, the iron group was lowest with 333 grams. In terms of gram
increasein meanintakefrom pretopost-period, the NIE group had thehighest increase of 63 grams,
followed by the food group - 49 grams, the food & iron group -45 grams and; the iron group - 18
grams. However, only the Food and Iron Group and the NIE Group were statistically significant.
It is suggested that a level of 50 - 60% of total caloric requirements should be supplied by
carbohydrates. Table 50shows also an increase ofPWfrom pre-topost-surveywhosecarbohydrate
intake was adequate (Le., at least 50 % of caloric ROA) in all treatment groups. There was a relative
change (increase) oI-31.2% PW with adequate intake again, with the NIE Group attaining the
highest relative change of 39.3%.
84

Iron Intake
At baseline, the Iron Groupshowed significantly higher iron intake compared to the three other
treatment groups. From pre-to-post period (Table48),intake of iron increased in all the' treatment
groups except in the iron group which experienced a slight decrease in mean intake at postsurvey.
Further, only the NIE and the Food & iron Groups showed statistically significant
increases. Iron intake deficiency as shown in Table 5 of Appendix K was worse than that of
protein and calorie with only 23-35% and 27-40% ofthe subjects getting above 74% of the RDA
at pre- and post- period, respectively.
Vitamin C
For the micro-nutrient vitamin C, the mean intakesignificantly decreased from baseline to follow­
.up in the four treatment groups. Moreover, vitamin C deficiency was a problem even worse than
iron deficiency with 45 -65% of the mothers at baseline and 54 - 72% at follow-up getting less
than 50%of the RDA in the four treatment groups. The iron groups for both surveys registered
the highest percentage of PW on this level of intake (i.e.,

In summary, while an over-all increase in mean intake was observed for the different nutrients
from baseline to follow-up, with the exception of vitamin C, deficiency of intake vis-a-vis RDA
was a common problem in all treatment groups. Moreover, deficiency of intake was more
alarming' for the micro nutrients (except niacin) than for the macro nutrients with a higher
percentage of PW getting less than 50% of the RDA in the former than in the latter.
Thehigh percentageofPWwho wereunableto comply with RDA for various nutrients indicated
economic difficulties. These results justify food supplementation as a priority intervention of
health and nutrition programs along with NIE materials,
Moreover, the high and increased percentage ofPW whocould not comply with Vitamin C RDA
may justify the inclusion of Vitamin C tablets as an added supplement in health programs using
iron as an intervention. The benefits from iron supplementation can best be attained if the vehicle
for its enhanced absorption is assured.
Common Misconceptions on Anemia and Related Topics
A review of the answers to KAP questions showed many misconceptions on anemia and related
topics. These are:
On What is Anemia
• low blood pressure
On Causes of Anemia
• lack of sleep
• taking a bath at night
• eating sour food
• over-fatigue
• impeded menstruation
• irregular eating habits
Effects of Anemia on Pregnant Women
• vomiting
• loss of appetite
• weight loss
• miscarriage
• sleeplessness
• beri-beri
Effects of Anemia on the Fetus
• child will be anemic/pale
• child will have
edema
beri-beri
convulsion
abnormalities
Differences in the Diet of a Pregnant Woman and a Non-Pregnant Woman
• controlled intake of all food
• food fallacies:
eggplant and patola(sponge gourd) cause edema/beri-beri
86

patola, katuray (sesban flower), carnote leaves (sweet potato tops) and prickly
leafy vegetables cause anemia
Reasons Why A Pregnant Woman Need Not Take Supplements
• the pregnant woman doesn't feel any illness
• the supplement might cause excessive growth of the fetus
• food intake is sufficient
These misconceptions along with the results of the knowledge items provide the bases for
detennining which topics should be emphasized during counselling, e.g., mother's classes or
during pre-natal check-up. The results also provide information on which topics should be highly
stressed in future NIE materials to be distributed to project clientele.
It is worthwhile to note that results of validation of compliance with project protocols show
that only about 10% of the mothers were given explanations by the midwives on the contents of
the brochures. It can therefore be inferred that the increase in knowledge was largely due
to the PW's own interpretation of the brochures, not to discount their stock knowledge. If the
brochures were explained by the midwives, the increase in level of knowledge could have
been greater. These results imply that effective training or counselling strategies should be
considered for greater impact of messages on the health and nutrition of the clientele.
87

7. EFFECfS OF FOOD AND IRON INTERVENTION
ON THECOl\1MUNITY
Themainobjective of this project was to determine the effect of food andiron supplementation as
community interventions, using the existing health care delivery system. Since the primary
interest was to assess the effect of the interventions on the community rather than on individual
pregnantwomenandtheirinfants, theunitofanalysisusedwastheRuralHealthUnit (RHU). The
indicatorsused weresummary measuresat the communitylevel namely the prevalenceof anemia
among pregnant women and the incidence of low birthweight among their infants. The results of
the analysis are described in the following sections.
Supplementation and Prevalence of Anemia
The prevalenceof anemiaamong women5 to 9 months pregnantbefore theimplementationof the
project was 40.4 %. For the different treatment groups, it varied from 33,2 % among those in the
food group to 46.2% in the NIE group.
After the implementation of the project, the overall prevalence remained the same. Changes
however occurred among the different treatment groups with decreases in prevalence occuring
among those in the Iron, as well as in the Food & Iron Groups. Thelargest decrease wasin the food
& iron group, whose post-intervention prevalence went down by 15.4 % from that at baseline
surveylevel. In the case of the Food and NIE groups, theprevalenceofanemia was higherat postsurvey
thanat baseline levels. This increasing prevalence is consistent with trends shown by the
nationwide FNRI surveys from 1982 to 1987. The FNRl nationwidestudyshoweda 33% increase
in the prevalence of anemia from 34 in 1982 to 45.2% in 1987. The detailed results are shown in
Table 52.
Table 52. Prevalence of anemia before and after supplementation by treatment group
Pre-Survey Post-Survey %Absolute %Relative
Treatment Group No. % No. % Charige(2) Change(1)
n Anemic Anemic n Anemic Anemic
Food 199 66 33.2 202 81 40.1 6.9 20.9
Iron 198 85 42.9 199 81 40.7 -2.2 -5.2
Food & Iron 198 77 38.9 240 79 32.9 -6.0 -15.4
NlE 212 98 46.2 226 110 48.7 2.4 53
TOTAL 807 326 40.4 867 351 40.5 0.1 0.2
(1)%RelativeChange = (% post-%Pre)/% Pre} • 100
(2)%Absolute change = %post -%Baseline
88

.The effect of iron supplementation on the other hand was shown at the sixth month of gestation:
the prevalence of anemia started to decrease among the groups given iron, with the largest
decreaseoccurringin the food & irongroup. This group consistentlyshowed thelargest %relative
decrease in prevalence among the different treatment groups for succeeding ages of gestation,
except for the 9th month when the trend suddenly reverted. However, thesamplesizesat this age
of gestation were too small for the rates to be stable.
Thefood groupstarted to showdecreases in the prevalence of anemiaat the 8thmonthof gestation,
or a month after the start of food supplementation. The NIB group on the other hand showed
erratic trendsfrom oneage of gestation to another. One majorfactor which may haveaffected the
absorption of dietary iron at these AOG is the high calorie intake of mothers. Data also show a
relatively higher dietary intake of iron for the Food Group at this AOG.
Since it is recognized that the above analysis is crudetn that it fails to adjust for the effect of some
pertinent variables in which the different RHUs and the different treatment groups may not be
comparable (e.g, % coverage of supplementation and health status of the pregnant women), a
second level of analysis wasdone. A more refined estimate of the prevalence of anemia per RHU
and 'per treatment group after the implementation of the different forms of intervention was
computed, adjusting for the effect of possible confounding variables using multiple regression
analysis. Independentvariablesconsideredarelisted in thesection on mode of dataanalysis. The
resulting prevalence figures at post-survey derived from the regression equation and the corresponding
percent relative change are shown in Table 54.
The results in Table54indicate that evenafteradjustment for the effects of otherfactors, thegroups
given iron still showed decreases in the prevalence after implementation of the project, with the
food & iron groupshowingthelargest decrease. The increase in the prevalenceamong those in the
NIE group was magnified by the adjustment, the % relative change having increased from 5.1%
to 12.1%.
Table 54. Prevalence of anemia before and adjusted prevalence after intervention by treatment group
Pre Adjusted Post- % Absolute % Relative
Treatment Group, Prevalence Survey Prevalence Change Change
.
Food 33.2 40.1 6.9 20.8
Iron 42.9 41.2 -1.7 -4.0
Food & Iron 38.9 33.7 -5.2 -13.4
NIE 46.2 51.8 5.6 12.1
TOTAL 40.4 41.6 1.2 3.0
Although the main interest in the regression analysis was in the refinement of the-estimated
prevalence after the intervention rather than in the identification of factors significantly affecting
it, it may be worthwhile to note that among the independent variables considered, the following
turned out to be significantly related to the prevalence of anemia at post-survey in the community:
90

1. Dummy variables for type of intervention
2. % of pregnant women with supplementation
3. % of pregnant women with hookworm
4. % of pregnant women with trichuris
5. % bleeder
6. % with high school education
These results indicate that the effects of the different treatments were significantly different from
that of the control group. In addition, the coverage of the project, the health statusof the pregnant
women especially their being infected with parasitism and their educational attainment are
important factors influencing the impact of the different forms of intervention on anemia, as
measured in the post- survey.
Supplementation and Incidence of Low Birthweight
In 1984when the project was started in LaUnion, the incidence of low birthweight for the province
based on the data from the Integrated Provincial Health Office (IPHO) was 4.5 %. Among the
treatmentgroups,differences existed in the prevailingrates, with values rangingfrom 2.5%among
RHUs belonging to the iron group, to 6.6%among those in the NIB group.
After the implementation of the project, the incidence of low birthweight decreased to 3.2% for
all treatment groups altogether, resulting in a % relative decrease of 28.9% below that of the
baseline figure. This figures were based on the birhtweights recorded by the midwives, based on
project protocol. Similar decreases were observed among the different treatment groups, except
for the Irongroup. The Food & Iron group likewise showed the largest %relativedecreaseat 52.4%.
This is showin in Table 55.
Table 55. Incidence of low birthweight before and after supplementation by treatment group
Post- Survey Incidence
1984 A -h"l A"" _.....
Treatment Incidence No. % % % %LBW % %
Group (n %) n LBW LBW Absolute Relative Post Absolute Relative
Change Change Survey Change Change
Food 4.8 187 7 3.7 -1.1 -22.0 3.2 -1.6 -33.3
Iron 25 143 4 2.8 0.3 11.9 2.1 -M -16.0
,
Food & Iron 4.2 204 4 2.0 -2.2 -53.3 15 -2.7 -{,4.3
N1E 6.6 187 8 4.3 -2.3 -35.2 3.7 -2.9 -43.9
TOTAL 4.5 721 23 3.2 -1.3 -29.1 2.6 -1.9 -42.2
Since it is recognized that maternal age affects the incidence of low birthweight, it was also
attempted to detemine the effect of the different types of intervention on low birthweight,
controlling. for age of the mother. This analysis was however later disregarded since the sample
sizes per treatment group for the age groups at risk (i.e., 35) were too small to come up
with stable estimates.
91

As in the prevalence of anemia, a second level of analysis was also done, in orderto comeup with
a more refined estimate of the incidence of low birthweight after project implementation. The
effects of otherfactors wereadjusted through regressionanalysis. The setof Independentvariables.
included in the analysis were earlier presented in the section on mode of data analysis. The
resulting estimates after adjustment are shown in Table 55.
The results indicate thatafteradjustingfor theeffects of otherfactors; all treatmentgroupsbrought
about a decrease in the incidence of low birthweight, with the Food & Iron group still having the
largestdecrease. Itis interestingto note that evenafterthe adjustment,thedecreasein theincidence
of low birthweight in the NIE group is still larger than that of the Iron and the Food groups.
Among the variables included in the model, the following turned out to be significantly related to
the incidence of low birthweight at post-survey:
1. dummy variables for the different types of intervention
2•.% of PW with other types of supplementation
3. % with adequate calorie intake
4. % PW with gravida >= 5
5. % PW with birth interval < 730 days
6. % of PW < 20 or >35 years of age
7. % premature
8. median per capita income
9. %PW with high school education
These results indicate that the effects of the different treatment groups are significantly different
from that of the controlgroup. The othervariables whichturnedoutto be significantareconsistent
with those of other studies.
92

8.: Cost Effectiveness
One of the objectives of this study is to develop a method to facilitate the estimation of costs and
health effects of intervention aimedat reducing the prevalence ofanemiaamong pregnant women
and incidence of low birthweight among infants of these pregnant women.
Cost effectiveness analysis (CEA) is a formal analytical technique which involves the identification,
measurement and comparison of all the significant costs and desirable consequences of
alternative means of addressinga given problem. One of its principal objectives is to structureand
analyze information in a way that will inform and assist policy makers on how to make the most
effective use of limited resources. Itcan be used as a planning tool by way of predicting costs and
effectiveness of alternative future programs. As an evaluative tool, CEA involves an assessment
of the realized costs and effectiveness of existing or past programs. Frequently, a retrospective
evaluation assumesa prospectiveintentby addressing the following questions: should a program
be continued? H so, how should it be modified? CEA facilitates the decision-making process by
allowing the comparison of cost perunit of effectiveness among competing alternatives designed
to achieve the same objective.
CEA applied to this study measured the desirable program consequences in non-monetary units
such as the reduction in prevalence of anemia among pregnant women and the reduction in the
incidence of low birthweight.among infants of these pregnant women. Specifically, the following
indicators were used as measures of effectiveness: (a) absolute and relative change in anemia
status from baseline levels and (b) absolute and relative change in low birthweight from baseline
levels.
Important cost components relevant to the actual implementation of the different intervention
schemes being tested were identified and estimated. The cost per unit of effectiveness of each
alternative was then analyzed andcomputed. Results of the CEA became the basis in selecting the
type of supplementation to be recommended for implementation.
Determination of Program Costs
The total cost of the program was derived by identifying and calculating the costs involved in the
different processes undertaken. The project covered four main activities namely materials
development, training of personnel, delivery oi supplements and monitoring compliance and
impact. The amountof resources consumedundereach of theseactivities varied according to type
of intervention given.
In order to have a beller look into the nature of costs incurred by the project, the different cost
categories were further classified and compared according to expense categories, type (capital vs
recurrent) andsectoraldivision (DOH vs USAID). Per capita costs were also computedto facilitate
comparisons between the different types of intervention. The details of.the computations and
corresponding results are presented in the following sections.
,
Cost Components
Four types of expense categories were considered in the project namely personnel services,
maintenance and operating expenses, supplies and materials,and equipment outlay.
The cost of personnel services covered costs for NCP-based personnel, Department of Health
93

National Task Force (seven consultants), Department of Health Local Task Force (provincial
Health Officer, Asst. Provincial Health Officer, Senior Supervising Public Health Nurse, Senior
Health Educator, Provincial Nutritionist), and Project Implernentors (MHO, ANS, ON, PHN,
BHW). The honoraria, training allowances, transportation allowances of these people were also
incorporated in this expense item.
Animportantfactorconsidered in the computation of personnel cost is thefact that the RHU staff
undertake several other activities in addition to those required by the project. Corresponding
project costs therefore had to be pro-rated according to the amount of time spent by each type of
personnel on the project. Specifically, this was derived in the following manner:
1. The averagenumberof hoursspentpermonthby each type of implementor for eachproject
activity was determined. This was derived by interviewing a random sample of each
category of implementors on the time spent by them for the project.
2. The results of the validation studies and data from Project Operations were incorporated
to determine the actual level of Involvement of a specific category of implementors in each
activity per intervention;
3. Thehourlysalary rates of the RHM, PHN, ANS, ON and MHO weredetermined from their
monthly salary; those of the BHW were based on the minimum daily wage rate for
agricultural workers;
4. The total cost of involvement per type of implementor per intervention was computed
using the relevant factors and hourly wage rates.
In the case of BHWs, the correspondingcost of services rendered could not bedetermineddirectly
since theyare volunteerworkersand hencedo not receive salaries. For purposesof cost estimation,
their project-related activities were quantified by determining the opportunity cost of employing
them in the service delivery of the different programs. A detailed description of the estimation
method used is presented in a separate section. -
The computation of maintenance and operating expenses (MOE) included rental of equipment
and vehicles, repairand maintenance, travelling expenses, representation expenses (for meetings/
seminars/workshops), gasoline, utilities and communication. The cost estimating procedures
used for MOE was based on rental fees charged for computer services and vehicles.
Supplies and materials covered office supplies, Nutrina - related, Ferrin-related as well as IEC
related items. Equipment costs on the other hand included the cost of bar scales. Although other
equipment like a computerwas purchased, its cost was excluded since it was utilized more for the
research rather than the operations component of the project.
All costs incurred in 1985and 1986werediscounted to their values in 1984which was the first year
of project implementation. This was done to have a common reference date and hence facilitate
comparison of cost figures. The discount factors applied were based on inflation rates as reported
by the National Economic and Development Authority (NEDA).
94

Computation of opportunity COSts
As mentioned earlier, one of the problems met in cost estimation is the assigmentof cost to services
renderedby barangayhealthworkers (BHW) who were employed on a volunteerbasis. Since they
do not have monthly salaries on which to base the cost of services, an alternateapproach taken was
to compute for opportunity cost. Thisinvolved the determination of how much the BHWs would
have earned had they been doing a paid job. Another decision needed was determining the type
of job they were most likely to get had they not opted to become volunteer BHWs.
A review of the population composition according to occupational groups shows that a higher
percentage of the population are engaged as farmers or farm helpers compared with any other
occupational groups. This implies that the BHWs would have most likely been agricultural
workers had they opted to take a paid job. The 1984hourly wage rate of agricultural workers was
therefore used as basis for the computation of opportunity cost.
Asin the case of the other health workers, the first step in the costing process is to determine the
amount of time spent by BHWs in the different activities assigned to them. According to project
protocol, they have four main activities namely:
1) Identification and referral of pregnant women
2) Delivery of supplies
3) Monitoring of PW supplementation
4) Delivery of regular maternal and child health (MCH) services
From the interviews of BHWs in the Food group, it was found that an average of 4.68hours were
spent by a BHW in identifying and referring (accompanying) a pregnant woman for enrollment
with the midwife at the barangay health station. To determine the actual level of involvement of
the BHWs in the identification and referral activity, relevant results of the validation studies and
data from Project Operations were considered. These were (l) the number (or percentage) of
trained BHWs in the treatment group who were actually involved in the activity and (2) the
average number of pregnant women enrolled in the treatment group per month. With data on
these variables, the average number of pregnant women identified per month by a BHW was
determined. In the case of the Food group for example, the computed mean number of pregnant
women identified per BHW per month was 0.5, or 1 PW per BHW for every 2 months.
On the basis of the daily minimum wage of P26.00 ($1.86) perday for non-plantation agricultural
workers outside Metro Manila, an hourly wage rate of P3.25 ($0.23) was arrived at. Thus,
considering the factors in determining actual involvement of BHW in identification and referral,
the hourly wage rate and the number of months of project operations in an intervention, the total
cost of involvement was computed. The total cost was first divided into capitaland recurrent costs.
The recurrent costs of involvement from November to December of 1985 and from January to
December of 1986were discounted to their 1984values. The discount factors of .870and .756for
a I-year and 2-year adjustment, respectively were used, with a fixed economic internal rate of
return or hurdle rate of 15%.
The relevant factors and the computation of opportunity cost of BHW involvement in identification
and referral activity per treatment group are shown in Table 56. The same process was used
in costing BHW involvement in other project activities and that of the nurses, midwives and
doctors.
95

Table 57. Total and Per Capita by Treatment Group
Number
Treatment Group Total rod ofPW Per Capita
Amount % Covered Cost
IronSuplementation 1'612,062.00 205 1833 1'333.91
$ 43,718.71 $ 23.85
Food & Iron 1'711,884.00 23.8 2091 1'340.45
$50,848.86 $ 24.32
Iron 1'731,633.00 245 5091 1'143.71
$ 52,25950 $10.27
NIEC 1'932,530.00 31.2 8888 1'104.92
$ 66,609.29 $ 7.49
. TOfAL 1'2,988,109.00 100.0 17903 ··1'166.90
$ 213,436.36 $ 1'1.92
Cost by Expense Category
A comparison of the nature of expenses incurred for the different treatment groups can be done by
looking at the breakdown of the total cost according to expense category. This is shown in
Table 58. The data show that for both the iron and NIB groups, the major cost component was
personnel services, with about three-fourths of the total cost going to this expense category. In
contrast, the correspondingfigure for the intervention groups involving food isat most only 31.8%.
The four treatment groups also differed largely according to the proportion of total cost allocated
for supplies and materials. Whereas this category accounted for about two-thirds of the expenditures
of the intervention groups involving food, the corresponding proportions for the iron and
NIE groups are only 8.9%and 7.6%, respectively.
The above findings result from the large difference between the price of food (Nutrina) and iron
(Ferrin) supplements. Whereas a pack of Nutrina costs t>3 on the average, one Ferrin tablet costs
only 3 centavos.
Thecost of the project percapita was also determined for each type of expensecategoryandfor each
treatment group. This is shown in Table 59. The results show that the iron group has the largest
per capita cost for personnel services while the food and iron group has the highest per capita cost
for supplies and materials. The four treatment groups do not differ in terms of per capita cost for
maintenance and operating expenses and for equipment outlay.
97

Table 58. Breakdown of Total Cost by Item, Capital 8t Recurrent and Source
OOH USAID
Capital Cost
Personnel Services P 467,106.11 P 117,245.54
Maintainance & Operating P 171,576.33
Expenses
Supplies and Materials P 524,529.99
Equipment Outlay P40,921.09
Reccurent Cost
Personnel Services P 960,666.59 P92,926.82
Maintainance & Operating P 130,865.75
Expenses
Supplies and Materials P 428,778.29
Equipment Outlay
Table 59 Cost per capita by Expense Category and Treatment Group
Cost Per Capita by Treatment Group
ExpensesCategory Food Iron Food & Iron NIEC
Personnel Services P 106.24 P87.57 P 111.75 P 77.77
Maintainance & P 16.99 P 16.92 P 16.87 P 16.88
Operating Expenses
Supplies & Materials P 208.38 P 233.67 P 12.81 P 7.99
Equipment Outlay P 2.30 P2.29 P 2.28 P 2.28
TOTAL COST PER P 333.91 P 340.45 P 143.71 P 104.92
CAPITA $23.9 $24.3 $10.3 $ 7.5
Sectoral Division Cost
The total cost of the project was borne by both the Philippine Department of Health (OOH) and
the United States Agency for International Development (USAID). The OOH counterpart
amounted to P604,417.00 ($43,172.64) covering 46.5% of the total project cost. This amount was
solely for personnel services, of which 56.5% represented the opportunity cost of the 3352BHWs
involved in the project. The rest of the OOH contribution covered the honoraria given to the 152
RHMs, 20 MHOs and 25PHNs!ANSs!DNs in thestudyareas for the duration of the project. This
98

is shown in Figur;:...e:....7:..... --,
RHM
24.9%
PHNIANSIDN
6.5%
BHW
56.5%
Fig. 7 Percentage Distribution of DOH Contribution to the Project Cost According to Type of
Personnel Paid.
USArD fundson the other hand amounted to 1"1,598,511.00 ($114,179.36) covering 53.5% of the
totalbudget, It was applied to all the four (4) types of expense categories.
The sectoral division costs can be further broken down into capital and recurrent costs. Capital
costs refer to the valuation of resources which are essential to start or launch the program.
Recurrent costs on the other hand involve the valuation of resources which are necessary to keep
the program gomg.
Of the capital costs of the project, two-thirds (66.2%) was borne by USAID funds. The pattern
however reversed in the case of recurrent costs, with the DOH counterpart being higher than of
USAID. This is shown in Fig. 8.
100
90
80
70
60
50
40
30
20
10
66.2
43.4
o -I--.L.-----""---+-.l...---_-L--t
Becarrent
Legend:
2J R8QJrrent
o Captal
Fig. 8 Percentage Distribution of Capital and Recurrent Costs According to Source and Funds.
99

Cost Effectiveness Analysis .
The cost effectiveness of the different forms of intervention considered in this project wasassessed
using the cost percapita perunit of effectiveness as the main parameter. This wasdoneseparately
for anemia and low birthweight. The cost effectiveness of the different interventions was also
determined using different cost components. These are presented in the following sections.
Prevalence of Anemia
The results of this study showed that the two treatment groups involving iron brought about a
significant reduction in the percentage of mothers with anemia before and after the intervention.
Table 60showsa comparisonof the cost percapitaand the percentage relative changefor thesetwo
interventions. It also shows the resulting values for the cost per capita per unit of effectiveness.
A closerlookat Table 75 shows that while the cost percapita for the food and iron supplementation
is 2.4 times higher than that of iron supplementation, it is also 3.3 times moreeffective. As a result,
food and iron supplementation is more cost effective than iron supplementation alone, as
evidenced by its lower cost per capita per unit of effectiveness.
Table 60. Comparison of Adjusted Relative Change in Anemia Status And Cost Per Capita of 2
Interventions
Relative Change (%) Cost Per Unit of
Treatment Group in Anemia Cost Per Capita Effectiveness
Iron Group -4.0 J> 143.71 J> 35.93
Food & Iron Group -13.4 J> 340.45 J> 25.41
A more practical parameter for assessing the cost effectiveness of a program is the cost of
preventing onecase of anemia. This entails dividing the total cost for each type of intervention by
the expected number of anemia cases prevented out of the total number of pregnant women
covered, using the absolute percentage change. The values which resulted were J> 8,453.59 and
J> 6,547.14for the iron group and the food and iron groups respectively. The extremely high costs
for preventing an individual case results from the following factors:
1. The total cost includes all the four expense categories. This would be relevant only if the
project to be implemented starts from zero and would have to pay for all the personnel
involved. In the DOH setting however, the delivery system is already in existence and
the only additional costs to be incurred as a result of the project are the costs of
supplementation and training of personnel.
2. The cost represents the cost for mass rather than t".rgetted intervention, since the project
included all pregnant women irrespective of whether they are at-risk or not.
As a result of the first factor indicated above, a recomputation of different parameters for cost
effectiveness was done, using different cost components. This is presented in Section 8.3.
100

Incidence of Low Birthweight
In the case of low birthweight, all the four treatment groups were found to. bring about a decrease
in its incidence before and after the program. A comparison of the %relative change, the cost per
capita and the cost per capita perunit of effectiveness among the different intervention groupsare
shown in Table 61.
Table 61. Comparisonof Adjusted Relativechange(%) in low Birthweigltt Status and costper capitafor
Different Treatment Groups
Relative Change(%) Cost Per Capita Unit
TreatmentGroup in LowBirthweight CostPer Capita of Effectiveness
FoodSupplementation -33.3 1'333.91 1'10.03
Food & Iron Supplementation -64.3 1'340.45 1'5.29
NIEC -43.9 1'104.91 1'2.39
Iron- -16.0 1'143.71 1'8.98
The table shows that of the four treatment groups, intervention in the form of NIE is the most cost
effective. Although the food and iron supplementation is more expensive than food alone, it is
twice more effective and has ended up to be more cost effective.
In terms of the cost of preventing one case of low birthweight the resulting values ranged from
1'3,617.93 ($258.42) for the NIEC group to 1'35,927.76 ($2566.27) for the iron group. The contributing
factors behind the excessively high cost which were earlier enumerated also apply to the above
figures.
Sensitivity Analysis
The cost effectivenessanalysis presented earlierincludedall forms ofexpenses bornebythe project
including the salary of DOH personnel and the opportunitycosts of volunteer workers. Itaccounts
for the total cost that would have been incurred if the project were to start from zero and hire its
own personnel for its implementation. It represents what it costs for an agency other than DOH
to implement a project of the same nature and extent of coverage.
In the context of DOH however, such a setting is not realistic, since the personnel who can be
utilized for project implementation are already in existence. Their salaries are already paid
irrespective of the existence of the project. All that is needed is to train them on the various
aspects of project delivery. In the case of BHWs, their utilization as volunteer workers is part of
the community involvement aspect of the PHC approach hence their opportunity cost need not
be accounted for.
-'-
101

In view of this observation, a separate analysis of cost effectiveness was done using different cost
components representing different assumptions andsettings. Such an approach is called sensitivity
analysis and aims to determine whether changes in the assumptions made as basis for the'
computations result in changes in the corresponding conclusions.
Three forms of cost components were considered as follows:
Cost 1
Cost 2
Cost 3
Includes cost of supplementation and training of personnel, MOE for delivery of
suppliesand staff supervision, salary of personnel and opportunitycost of volunteer
workers.
Includes cost of supplementation and training of personnel, MOE for delivery of
supplies and staff supervision
Includes cost of supplementation and training of personnel
Cost 1 is the same as the total cost used in the analysis and discussions presented in the earlier
sections. Cost 2 considers the fact that the delivery system is already in existence in the DOH
networkand hence no additionalcosts are needed for the services of DOH personnel. Cost 3 further
assumes that the delivery of supplements and supervision of staff are part of the DOH responsibilities
and hence the corresponding costs are already borne by the agency irrespective of the
program's existence.
Table 62 shows a comparison of the project cost per capita and cost per capita per unit of
effectiveness for the 3 types of cost components. The results showthat indeed, the results change
with changes in the cost components. If either Cost 2 or Cost 3 is used, iron supplementation
becomes more cost -effective than food and iron combined as intervention fo'rthe prevalence of
anemia. In the case of the incidence of low birthweight, NIEis the most cost-effective intervention
followed by iron 'supplementation.
102

Table 62. ComparisonofCost per Capita and CostperCapitaper Unit i1fEffectivenessfor Three Different
Types of Cost Components
Cost per Capita per
Parameter/Treatment Cost per Capita Unit of Effectiveness
Group Cost 1 Cost 2 Cost 3 Cost 1 Cost 2 Cost 3
Anemia Status
Food and Iron 1'340.45 1'252.88 1'230.78 1'25.41 1'18.87 1'17.22
$ 24.32 $18.06 $16.48 $1.82 $1.35 $1.23
,
Iron 143.71 31.96 8.86 35.93 7.99 2.22
$10.27 $228 $0.63 $ 2.57 $0.57 $0.16
Low Birthweight
Food and Iron 1'340.45 1'252.88 1'230.78 1'5.29 1'3.93 1'3.59
$ 24.32 $18.06 $16.48 $ 0.38 $0.28 $0.26
Food 333.91 227.68 205.76 10.03 6.84 6.18
$ 23.85 $16.26 $14.70 $0.72 $0.49 $0.44
Iron 143.71 31.96 8.86 8.98 2.00 0.55
$10.27 $2.28 $0.63 $0.64 $0.14 $0.04
NIEC 104.91 27.15 4.86 2.39 0.62 0.11
$ 7.49 $1.94 $ 0.35 $0.17 $0.04 $0.01
As in the earlieranalysis, the cost of preventing one case of anemia and low birthweight was also
determined using the different cost components. The resulting values arestill extremely high. In
the case of anemia for example, the cost of preventing one case using Cost 3 is 1'521.35 for iron
supplementation and 1'4,438.08 for food and iron combined. These resulting high values of
prevention even after retaining only the most basis cost components leads to question the
practicality of the mass intervention approach which was used in this project. In the same vein, it
emphasizes the need for studies for the development of easily collectible and sensitive indicators
of anemiaandlow birthweightwhichcan be used by field workers for targetting pregnant women
for supplementation.
103
•

9. EFFECTS OF SOCIO-ECONOMIC, DEMOGRAPHIC AND
INTERVENTION VARIABLES ON MOTHERS AND CHILDREN
Although the main objective of the project was to determine the effect of the different forms of
intervention at the community level, the data that were generated also enabled the determination
of the effects of food and iron supplementation using the mothers and their infants as units of
analysis. The specific response variables considered were the anemia status of each pregnant
woman (normal or anemic), the birhtweight of each infant (normal or low) and the nutritional
statusof each child28days afterbirth (normal or malnourished). In addition to the differentforms
of intervention, the effects of selected socio-economic and demographic factors on each of these
response variables were also-assessed.
Inaddition to thedetermination of the effects of selected variables on anemiaand lowbirthweight,
this study also intended to identify matenal and/or household parameters which can be used for
targettingpregnantwomenfor food supplementation. Althoughin thisstudyall pregnantwomen
in the community were given supplementation irrespective of whether or not they belonged to
high-risk groups, this cannot always be done, especially for expensive forms of intervention like
food. This leads to theproblem of identifying variables whichcanbe used to identify target groups
for such forms of supplementation.
Selected Variables and Anemia Status of Pregnant Women
To determine the nature of the relationships among the different socio-economic, demographic
and intervention variables and anemia status, logistic regression analysis was applied, using the
pregnant woman as the unit of analysis. Only those who had received any form of supplementation
at the time of pricking were considered in the analysis. This included 434 pregnant women,
of whom 166 were anemic and 268 had normal hemoglobin levels. The independent variables
included in themodel werepresented in Table 12of Chapter3 of this report. The results areshown
below.
Table 63. Results of the LogisticRegression Analysis on the interrelationships between anemia status
and socio-economic, demographic and intervention variables
Significant Regression
Variables Coefficient (Bi ) Standard Error (Bi ) EXP. (Bi)
Food & Iron Group -0.2.015 0.1042 0.1370
Moderate to above 0.37011 0.2103 5.810
hookworm inrestation
.
No. of Livebirths 0.11241 0.0561 1.1200
The results once again indicate that of the four treatment groups, the combined food and iron
supplementation was the one which showed significant effects on anemia status, even if the
pregnantwomanis used as the unitof analysis. Hookworminfection hada very significant effect,
with the odds of becoming anemic being 5.8 times as much for a pregnant woman with at least
moderate infestation compared to one with only light infestation or none at all. The number of
livebirths in the past is another risk factor of anemia. The effects of all the other variables
considered in the model were not statistically significant.
104

Selected Variables and Low Birthweight
In terms of the relationship between socio-economic, demographicand intervention variables and
birthweight, not one of the four treatment groups turned out to be statistically significant. This
result could however be due to small sample sizes with only 14 out of the 499 infants included in
the analysis having low birthweight. Of the other independent variables considered, only the
length of gestationand educational attainment turned out to be significant. Results show that the
oddsof a prematurechild to have lowbirthweight were 1.93 times higher than those of a full term
child. The results with respect to educationalattainment is contrary to expectations in that a Child
with a college-educated mothershowed greater odds of having low birthweight than one whose
mother had not been to school at all. These are shown in Table 64.
Table 64. Results of the Logistic Regression Analysis on the intenelationships betweenbirth_ight
and socio-economic, demographic and intervention variables
Significant Regression
Variables Coefficient (Bi ) Standard Error (Bi ) EXP. (Bi)
Food & Iron Group -0.2.715 0.1042 0.137
Length of Gestation 0.6557 0.3428 1.9300
College Education 0.5226 0.5226 1.6900
In view of the sample problem in the application of logistic regression analysis to the data, an
alternate method of analysis was done to determine the relationship between the different socioeconomic,
demographicand intervention variables, and birthweight. Multiple regression analysis
was applied using the actual birthweight of the child as independent variable, instead of the
birthweight status (low vs. normal) which was used earlier. This approach makes full use of the
data on birthweight but differs from logistic regression analysis in the interpretation of the
regression coefficients.
Tenvariables were identified to be significant predictors of birthweightusingmultipleregression
analysis. 'Theseare showninTable 65,withthe correspondingregressioncoefficientsandstandard
errors. Among the four treatment groups, the effects of food and 'iron combined, as well as iron
alone turned out to be significantly different from that of the control group. The-regression
coefficients of 19.41 and 23.34 grams respectively represent the difference between the mean
birthweightof children whose mothers belonged to these treatment groups and thecontrol group.
Of the different diseases considered, hypertension was the only significant predictor of birthweight.
Theregressioncoefficient of-24.76grams means that on theaverage, themean birthweight
of infants with hypertensivemothers is lower than those with normal mothers by 24.76 grams. As
in logistic regression analysis, educational attainment is a significant predictorof birthweight,
with the mean birthweight of children whose mothers never went to school at all being significantly
lower than those whose mothers have either an elementary ora high school education. The
level of nutrition knowledge, attitudes and practices, as measured by the'KAP score, was also
directly related to birthweight. All the 10 significant predictors accounted for 14.4% of the total
variability in the birthweight of the child.
105

The above results indicate that of the four treatment groups it was again the Food & Iron group
which had a significant effect on the nutritional status of the infant. The odds that a child could be
malnourishedifthe mother was given Food & Iron supplementation during pregnancy wasonly
29.5% of thecorresponding odds of a mother who was in the NIB group during pregnancy..The
weight at birth is another important risk factor in that the odds of being malnourished is 23 times
higher for a child with lowbirthweightas comparedto anotherchild with normal birthweight. Per
capita income and history of previous pregnancy loss are other variables with significant effects
on the nutritional status of the infant.
Parameters for Targetting Pregnant Women
To identify the parameters for targetting women for food supplementation, only women who had
not received any form of supplementation(i.e., those in the NIB group) were included in the
analysis. Since this objective is akin to identifying the predictons of low birthweight for possible
intervention, the response variable used was the birthweight status of the child, categorized as
normal or low. Of only 187 mothers included in this part of the analysis, 8 had infants with low
birthweight. The results are shown in Table 67.
Table 67. Res\llts of the Logtstic Regression Analysis to identify predictors of low birthweight among
pregnant women without intervention .
Significant Regression
Variables Coefficient (Bi ) Standard Error (Bi ) EXP. (Bi)
Height of PW -0.01180 0.0096 0.9800
Presenceor Absence of 1.47014 '0.6768 4.3800
murmurs
Arm Circumference -0.0387 0.0224 0.9600
Age of PW(20 or >35) 0.8774 0.4935 2.4000
College Education 0.7538 . 0.4337 2.1200
The results in Table 68 show that of the independent variables considered, the significant
predictors which can be used as parameters for targetting women for food intervention are those
whichare related to health (presence of murmurs) and nutrition (height, armcircumference). Age
is another risk factor associated with the very young and older mothers (35). These age
groups have a greater chance (2.4 times ) of having low birthweight babies compared to those in
the 20-35 age group. Once again, the result on educational attainment is contrary to expectations,
with college-educated women being more likely to have low birthweightbabies than to thosewho
have no education at all.
107

10. SUMMARY OF CONCLUSIONS AND.RECOMMENDATIONS
The Iron and Food Supplementation Delivery for Pregnant Women was conducted
to test strategies and evaluate the effectiveness of food and iron supplementation on
the prevalence of anemia among pregnant women and incidence of low birthweight
among their infants within the framework of the PHC approach. The findings of the
study are summarized in the following conclusions and recommendations.
Extent of the anemia problem among pregnant women
High prevalence of nutritional anemia among pregnant women
Statistics show that nutritional anemia among pregnant women remains highly
prevalent worldwide especially in developing countries (43). Nutritional anemia is
already an established cause of maternal and infant morbidity and mortality, low
birthweight babies and poor infant development (4-10).
Royston reported that nutritional anemia affected over half the pregnant women in
Asian countries. The prevalence rate was found to be as high as 80% in some areas
(43). The Philippine National Survey in 1987 has shown that 45.2% of Filipino
pregnant women were suffering from anemia (11).
These statistics are similar to the data gathered in this study, i.e. 40.4% of the PW are
anemic. Comparable, too with the prevalence data is the finding on low intake of
iron wherein 38% of the sample PW had less than 50% intake based on RDA and
34% had only 50-74% intake.
Increasing prevalence of nutritional anemia
Not withstanding significant advances in knowledge and technology on the
prevention and control of nutritionalanemia, the problem has worsened as shown
. in the Philippine nationwide .survey results (1,11,26). In this study, the prevalence of
anemia in the Food Group where there was completely no iron intervention
increased by 21 %. Like other nutrition problems, anemia is closely related with the
economic and financial stability of the population. Thus with inflation and
worsening economic conditions in the country, there is need to give priority to a
comprehensive prevention and control program for nutritional disorders especially
anemia among pregnant women.
108

Effectiveness of Food and iron supplementation and NIE Intervention
Reduction of anemia among pregnant women
The study showed that iron supplementation using the present health delivery
system within the framework of PHC was effective in reducing the prevalence of
anemia among pregnant women. The reduction of prevalence by 4% in this study
was trebled (13.4%) when iron was combined with food supplementation. The low
percentage reduction, however, may be due to the low compliance (only 52%) among
pregnant women with the prescribed dosage and the high prevalence of parasitic
infection particularly hookworm and trichuris.
On the other hand, the NIE intervention was not enough to reduce anemia in the
community as shown in the increased prevalence in the treatment groups without
iron, i.e., the prevalence of anemia increased by 20.8% in the Food Group and 12.1 %
in the NIE group. The lower increase in the NIE group may be due to the fact that
some of the mothers received iron supplements distributed by the DOH.
Reduction of the incidence of low birthweight
On the other hand all the treatment groups brought about a reduction in the
incidence of low birthweight. The Food and Iron Group registered 64.3% reduction
followed by the NIE Group (43.9%), the Food Group (33.3%) and the Iron Group
(16.0%).
The problem of low birthweight is more complex. Literature has traced the causes of
the problem to the birthweight of the mother, the mother's .height which is a
measure of her nutritional status since birth, her immediate weight gain during
pregnancy, maternal age and education, and other health practices like smoking and
alcohol drinking 03-21).
In this study alone, the following factors were found related to the birthweight of the
infants: height, household size, mother's education, KAP Score, food and iron, and
iron supplementation, presence of other supplementation.adequacy of calorie intake
and presence of hypertension. The prevalence of anemia in the study' was estimated
controlling for the effect of these confounding variables. That the NIE group also
showed a higher percent reduction in incidence of LBW can be explained by the
possible presence of other major confounding factors which might not have been
controlled for.
Another possible reason was the poor compliance. with the distribution of the food
supplements i.e., so many of the targets (at least 30%) were not able to receive their
required allotment of supplements particularly because of the' irregular involvement
of the BHWs and late enrollment. Compliance with iron supplementation was also
low, i.e., mothers on the average complied only with 52% of prescribed dosage.
A further possible explanation for the NIE performance was that the NIE group
showed a highest mean intake in calorie, iron, protein, carbohydrates, beta carotene
and Vitamin C during the post-survey. The same group also showed the highest
109

increases in mean intake from pre-to post-surveys for calories, irori, Vitamin C, fats
and carbohydrates. One contributing factor to this better dietary performance is the
higher percentage of PW who received their NIB brochures. This assumption is
supported by the result of the one way ANOVA test on the receipt of anemia
brochures and knowledge scores and dietary intake. Test results showed 'that PW
who received their anemia brochures, showed significantly higher knowledge scores
and iron intake than those who did not receive the material. Similarly, the PWs
who received their Food Prescription Slip had significantly higher knowledge scores
and protein intake than those who did not. These mothers also showed a higher
calorie intake but the result was not significant.
Cost of intervention
Cost effectiveness analysis of iron and food supplementation
The costs of a food and iron supplementation program which would depend on its
own resources and provide compensation for manpower including volunteer
workers (opportunity cost), would amount to 11333.91 ($23.9) to provide food
supplements to a pregnant woman, P340.45 ($24.3) for a combined food and iron
supplementation, P143.71 ($10.3) for iron supplementation and P104.91 ($7.5) for NIB
intervention (based on 1984 peso values).
With support, however, from the ongoing program of the Philippine government,
and the concept of PHC promoting self reliance through the volunteer health
workers, the amount is only P205.76 ($14.7) for food, P230.78 ($16.5) for combined
food and iron, P8.86 ($0.6) for iron and P4.86 ($0.4) for NIB, per pregnant woman.
Cost effectiveness analysis
Although higher in cost, the combined food and iron group was more cost effective
than the Iron Group in the reduction of anemia.
In the reduction of low birthweight, however, the NIE Group was the most cost
effective intervention. The Food and Iron Group, the Iron Group and the Food
Group followed in that order.
With an already existing health delivery system, the Iron Group was more cost
effective than the combined Food and Iron Group in the reduction of anemia.
Likewise, the Iron Group was more cost effective than the Food and Iron Group in
the reduction of low birthweight.
Issues and policies on anemia and iow birthweight prevention and control program
Need for Iron and Food Supplementation
The iron intervention was effective in the reduction of both the anemia of PW and
LBW of the infant, while the NIB intervention was not able to reduce the prevalence
of anemia among PW. The iron treatment was cost effective in the reduction of both
110

I
l
Other components of intervention packages for the reduction of anemia and low
birthweight
At the community level, other significant factors related to the prevalence of anemia
are the prevalence of parasitic infection (e.g. hookworm and trichuris), incidence of
bleeding, coverage of the project and education. These factors influence the impact
of the different interventions on anemia.
Significant factors in the incidence of low birth weight are: presence of other types of
supplement mostly multi-vitamins, the number or percentage of PW with adequate
calorie intake, with gravida greater or equal to 5, with birth interval of less than 730
days, of less than 20 or more than 35 years of age, median per capita income, with
high school education and percentage of premature babies.
These nutrition problems interface with other health problems and the socioeconomic
and demographic situation in the community. Therefore there is a need of
integrating control programs for these problems in other national or local
development programs. Agriculture, population,economic and health policies have
to be developed in relation to one another. With the number of agencies
implementing their respective programs, intersectoral coordination is a crucial
issue and should be well defined.
Close supervision and monitoring
A major factor of effectiveness is the lew compliance with iron supplementation
\, because of its side effects among pregnant women, as well as low compliance with
iron and food supplementation delivery because of decreasing BHW involvement.
Compliance can be improved through close supervision and monitoring. This
should start with a proper orientation of DOH staff on the significance of the work to
develop their sense of ownership of the project. The supervisors should motivate
the workers on their roles and closely supervise them to help them identify and.
solve their problems. A Pilot Iron Supplementation Study for the control of anemia
among pregnant women by Solon et. al. showed the advantages of close supervision
in increasing program effectiveness. The study concluded that the 60 mg iron given
without supervision for 100 days seemed inadequate to bring about substantial
improvement in the hemoglobin picture, but that with supervision or an assurance
of regular intake of the full dosage, the 60 mg dose produced significant effect. The
mean compliance rate among the supervised group was significantly higher at 93%
than that of the unsupervised (77%) (59).
Results of the delivery system
Delivery System within the PHC Framework
The study showed an increase in the number of pregnant women going for pre-natal
check-up and an increase in PW getting their NIE materials from the RHU/BHS and
BHW. The following problems, however were also encountered: a) difficulty to
convince mothers to participate in iron supplementation, b) lack of awareness of
LMP/late enrollment of PW, c) the problem of sharing to family members especially
112

Revision of projeel tools
Some project inputs have to be revised. The monitoring system must be made
simpler and motivation of workers in its implementation must be prioritized in the
development of the training system.
114

22. Wiener G et al. Correlatesof low birthweight: Psychological slatusat six to seven years of age.
Pediatrics 1965; 35:434-444.
23. Angara A A. Observations on the Rural Health Care Delivery Systems in the Philippines.
1978. WHO Regional Office for the Western Pacific, Manila. 1978.
24. MOH. A national strategy and plan of action for achieving health for all Filipinos by the Year
2000. MOH,Philippines, 1980.
25. DOH. Primary Health Care status. Department of Health, Philippines, 1983.
26. FNRI. First National Nutrition Survey Philippines, 1978. Food & Nutrition Research Institute,
Department of Science and Technology, Manila, 1979.
27. Churchill JA, Neff JW, Caldwell OF. Birthwcight and intelligence. Obstetric andGynecology
1966; 23:425-429.
28. Singer JE,Westphal M, Niswander K. Relationship of weight gain during pregnancy to birthweight
and infact growth & development in the first year of life. Obstetric & Gynecology 1968;
31(3): 417-423.
29 Antonov AN. Children born during the siege of Leningrad in 1942. Journal of Pediatrics 1947;
30:250.
30. Nutrition FoundationofIndia. Maternal nutrition, laclationand infantgrowthin urbanslums.
Scientific Report #9, New Delhi, 1988.
31. Solon FSet. al. The NutritionSurveillance Project Report. Nu trition Centerof the Philippines,
Metro Manila Philippines, 1980.
32. Lechtig A et al. Effectof food supplementation during pregnancy on birthweight, Pediatrics
1975; 56(4): 508 -519
33. Mora JO et al. Nutritional supplementation and the outcome of pregnancy. The American
Journal ofClinical Nutrition 1979; 32:455 -462.
34. Kotelchuck M et al. WIC participation & pregnancyoutcomes: I. Birthweight, Massachusetts
Statewide Evaluation Project. American Journal of Public Health 1984; 74(10): 1086-1092.
35. Prentice A et al. Prenatal dietary supplemenlation of African women & birthweight, LAncet
1983; 489-491.
36. Tontisirin K et al. Formulation and evaluation of supplementary foods for Thai pregnant
women. American Journal ofClinical Nutrition 1986; 43: 931 -939.
37. NNe. Implementing guidelines of the Philippine Food & Nutrition Program. National
Nutrition Council, Makati, 1981.
38. NNe. 1981 Philippine Nutrition Program Annual Report. National Nutrition Council,
Makati,1981.
39. NNe. 1982 Philippine Nutrition Program Annual Report. National Nutrition Council,
Makati,1982.
40. NNe. 1983 Philippine Nutrition Program Annual Report. National Nutrition Council,
Makati,1983.
41. NNe. 1984 Philippine Nutrition Program Annual Report. National Nutrition Council,
Makati,1984.
42. DOH. DOH-CARE Targetted Food Assistance Program Implementing Guidelines. Department
of Health, Philippines, 1987.
43. Royston E. The prevalence of nutritional anemia in women in devclopingcountries. Acritical
review of available information. World Health Statistics Quarterly 1982; 35(2):52-66.
44. WHO. Nutritional Anemias. WHO, Geneva, 1968.
116

45. WHO. Control of nutritional anemia with special references to Iron deficiency. Report of an
IAEA/USAID/WHO Joint meeting. WHO, Geneva, 1975.
46. INACG. Guidelines for the eradicationof iron deficiency anemia. The NutritionFoundation,
New York, 1977.
47. Bothwell TH. Iron Deficiency in Women. INACG, The Nutrition Foundation, Washington
D.e., 1981.
48. Levy S et al. A therapeutic trial in anemia of pregnancy. Israel Journal Medical Science 1968;
4(1):218-222.
49. Iyengar L. Effect of dietary supplements on birth weight of infants, First Asian Congress on
Nutrition, Hyderbad India. 20 Kamal Printers. 1971.
50. Basu RN et al. Etiopathogenesis of nutritional anemia in pregnancy: A therapeutic approach.
TheAmerican Journal ofClinical Nutrition1973; 26:591-594.
51. Sood Sket al. WHO SponsoredCollaborativeStudieson nutritional anemiain India. Quarterly
Journal ofMedicine, New Series 1975; XLI.\': 241-258.
52. Aung - Than- Batu, Thane -Toe, Khin-Kgi-Nyunt. A prophylactic trial of iron and folic acid
supplements in pregnant Burmese women. Israel Journal Medit.,1 Science 1976; 12(12):1410­
1417.
53. Charocnlarp, Iron Supplementation Studies in Bangkok Thailand, Progress in Clinical and
Biological Research 1981; 77:355-361.
54. Thane-Toe, Thein-Than. The effectsoforal iron supplementationon ferritin levels in pregnant
Burmese women. American Journal ofClinical Nutrition 1982; 35:95-99.
55. Jackson RY, Latham Me. Anemia of pregnancy in Liberia, West Africa: A therapeutic trial.
American Journal ofClinical Nutrition1982; 35: 710-714.
56. Vijayalakshoni P, Shobana R. Impact of iron and folic acid supplementation on expectant
mothers and their offspring. The Indian Journal ofNutritionand Dietetics 1982; 19:363.
57. SrisupanditSet al. Aprophylactic supplementationofiron and folate in pregnancy. Southeast
AsianJournal ofTropical Medicine 1983; 14(3): 317-322.
58. Valyasevi et. al. The studyof iron supplementation ofPWin Ubol Province Thailand. Institute
of Nutrition, Medical Faculty University, Bangkok, Thailand. 1985.
59. Solon FS et al. Iron Supplementation for the control of ntritional anemia among pregnant
women. Food and nutrition research division. Nutrition Center of the Philippines, Metro
Manila, Philippines, 1984(unpublished terminal report).
60. Narasinga Rao BS. Physiology of iron absorption on supplementation. British Medical Bulletin
1981; 37(1):25 -30.
61. Gomez T. The educational value of supplemental feeding. Philippine Journal of Nutrition
Education 1979; 32(4):189-192.
62. BoweringJ et al. Roleof EFNEPaides in improvingdiets of pregnant women. Journal Nutrition
Education 1976; 8(3).
63. Cerqueira T et al. A comparison of mass media technique and a direct method for nutrition
education in rural Mexico. Journal Nutrition Education 1979; 11(2).
64. WHO.Final Report of the First Regional Working Group on BasicHealth Services, Manila 21­
29 Sept. 1976, Manila 1976.
65. WHO. International Conference on Primary Health Care, Alma Ata (1978, USSR) PHe. WHO,
Geneva, 1978.
66. DOH La Union Primary Health Care Annual Reports 1984-88. Department, of Health,
Philippines, 1984-1988 (Unpublished).
117

67. Flahault 0, Raemer Ml. Leadership for primary health care: Levels, functions and requirements
based on twelve case studies. WHO, Geneva, 1986.
68. ScrimshawNS. Integratingnutrition into programmesofPHC. Food andNutrition Bulletin/988;
10(4):19-28.
69. Shah PM, Shah KP. Provision of health and nutrition services at the grassroots level in the
Palghar and Kasa projects and the possibility of their replication. Food and Nutrition Bulletin
/976; 3(1):1-7.
70. NCP IFSO Operations manual. Nutrition Center of the Philippines, Metro Manila Philippines,
1984.
71. Solon FSCommunication to the !PHO, La Union Province. 1984.
72. Solon FS et, al. Factors affecting service delivery, IFSO Project. Nutrition Center of the
Philippines, Metro Manila Philippines, 1989.
73. Hallberg L,Ryttinger L,SolvellL. Side effectsoforal iron therapy. ActaMedica Scandinauia /966;
Suppl 459:3-10.
74. DOH. Family Profile. OHO, IPHO, La Union, 1985.
118

Appendix A
IMPLEMENTORS' GUIDE FOR MIDWIVES
IRON AND FOOD SUPPLEMENTATION FOR PREGNANT WOMEN
IN
PRIMARY HEALTH CARE
•
NUTRITION CENTER OF THE PHILIPPINES
AND
MINISTRY OF HEALTH
January, 1985
119

PREFACE
The pregnant womaninyourcommunityand the child she carriesin herwombneedyou! Asonepriority
group of our country's health and nutrition program, they need proper attention from you to ensure that they:
• get prompt and adequate pre-natal care;
• receive and understand nutritional advice for health foetal growth and normal childbirth;·and
• learn and follow the specific steps to maintain good health during this delicate period.
Our iron and Food Supplementation Project for Pregnant Women was launched specifically to answer
these needs. This Guide was developed to help you serve them properly and effectively as an implementor of
the Project.
To do this, every effort must be taken:
,
• to pass on to the mother timely INFORMAnON upon which she can make decisions;
• to shape the right ATITIUDES by correcting harmful practices and motivating and promoting
acceptable ones; and
• to follow-up her PRACTICES withhome visits and pre-natal counselling, reinforcing everypositive
behavior and gently guiding her until she makes a HABITof the health and nutrition practices that
she has learned.
This is then your opportunity to demonstrate your dedication to the services you have committed
yourself to do for your community. It is an opportunity that caIlson you to help make pregnancy a happy and
fulfilling experience for both the mother and her child.
GOOD LUCK AND MAYGOOD BLESS YOU IN YOURWORK!
, .
121

These NIB materials consist of the following:
• ANEMIA Brochure
• Food Prescription slip
• FERRIN Brochure
• NUTRINA Brochure (How Much to Eat and Why>
The Anemia Brochure provides information on what anemia is, its causes, signs, symptoms, treatment
and prevention
The Food Prescription Slip gives information on the three basic food groups to guide mothers on what
and how much food to eat.
The FERRIN Brochure gives information on what, why and when they need iron supplementation. Its
purpose is to motivate the mothers to take the iron tablets being given to them.
The FERRIN iron tablets are distributed directly to you at the Barangay Health Station. You will issue
these in turn to the Barangay Health Workers for distribution to pregnant women on their scheduled dates of
receipt of supplements. But in cases where the BHW's are-unable to do the distribution, you may issue iron
supplies to mothers who go to you directly.
YOUR ROLE IN PROJECT IMPLEMENTATION
You will.be primarychannel for the delivery of iron and food intervention to our target pregnant women
in your catchment area. Also in our efftort to have'the local community responsive and involved in this health
improvement program, their chosen representatives, the Barangay Health Workers will be collaborating with
you. You will therefore need to work very closely with the BHWs in your catchment area in this undertaiking..
The following are the different operations to be conducted at your level to implement and monitor the
project.
A. Oganizational and Training of BHWs
B. Pre-natal activities
1. Identifying and Enrolling Pregnant Women
2. Requisitioning and Receiving Supplies
3. Distributing Supplies
4. Monitoring Compliance to
4.1 Supplementation
4.2 Protocol
C. Natal activities
Monitoring Pregnancy Outcomes of
1. Deliveries You or the Hilots Have Attended
2. Deliveries Attended by Hospital Attendants
D. Post-natal activitie
Conducting Post-Natal Follow-up of:
1. Mother
2. Infant
124

B1. Pre-natal activities
1. Identifying and enrolling pregnant women
No.
1
You and your Barangay Health Workers are continuously identifying pregnant women in
your catchment area for iron and food supplementation. Pregnant women are referred to you for
pre-natal check-up and enrollment in our FERRINand NUTRlNA Supplementation Project.
When to be Conducted
Tools to Use
Your Responsiblities
1.1 Verify the pregnancy status of women
you have identified or were referred to
you by the Barangay Health Workers
in your catchment area
1.2 Enroll all the pregnant women living
in one barangay in a Barangay Master
List of Pregnant Women
Your Responsibilities
Date of
Name of Pregnant Woman Address
Registry
(3) (4)
(2) .
1 11-9-84 Bumatay, Asuncion S.
12 Gomez
St. Bo. Abo
2 11-10-84 Padilla, Rosa R. Bo. San Luis
3 11·15-84 Balagat, Teresita D. Bo. San Luis
Name of BHW
(5) DH
Place of Pre-Natal
Care (6)
0-
PH RHU BHS
THERS
LMP
(7)
PACITACRUZ v 10-15-84
GLORIA PEREZ .> 8-28-84
127
•
•
•
As soon as pregnant women are identifted by
you or are referred to you in the Barangay
Health Station by BHWs.
Barangay Master List of Pregnant women (to
be accomplished with a duplicate copy)
Maternal Health Record
(to be accomplished with a duplicate copy)
Anemia Brochure
Food Prescription Slip
FERRINand NUTRINA Brochures
How to Accomplish Each
Do a pre-natal check-up on all pregnant
women that you and your BHWs have
identified in your catchment area
Fillup items (1) to (43)of the Maternal Health
Record (See the Explanatory Notes on MHR).
Fillup items (l) to (10)of the BarangayMaster
List of Pregnant Women.
How to Accomplish Each
NUMBER. Number each pregnant woman that
you enroll in the Master List.
DATE OF REGISTRY. Record the date of the
pregnant woman's initial visit with you .
NAME OF PREGNANT WOMAN. Write the
pregnant woman's family name, given name, and
her middle initial.
ADDRESS. Write the house number (if any) and
the name of the street or purok.
NAME OF BHW. Identify the name of the
Barangay Health Worker assigned to her area of
residence.
PLACE OF PRE-NATAL CARE. Indicate with
a check mark the place where she usually goes or
intends to go for her pre-natal consultation.

"Maternal Health Record (tobe filled up
in duplicate copy) for each newly identified
pregnant woman.
"FERRIN brochures and Supplementation
Cards to be given together withthe
inititial supply of FERRINiron tablets.
"NUTRINA brochures (to be given
together with the inititial supply of
NUTRINA)
"Other delivery/monitoring forms
B2.1.2 Fill up the NIE Material Supply Form
in requisitioning supplies from the
PHN at the RHU during the first week
of the succeeding month.
Materials Dec Jan Feb
1. No. of New Enrollees for
the current month - 7
2. No. received per material
3. 2.1 NIE Materials
2.1.1 Anemia Brochures 4Ll 8
2.1.2 FERRIN Brochures ,0 '0
2.1.3 NUTRINA Brochure .!lr q
2.1.4 Prescription Slip s» B
B2.2 Get your monthly supply of NIE materials
during the first week of the succeeding
month.
3. Distributing supplies
"The number of Maternal Health Records to be requested
is equal to the total new enrollees of the
current monthplus 10%allowance multiplied by 2
"Count all the number of pregnant women who will
start their iron supplementation on the succeeding
monthi.e.,those at the 5thmonthofpregnancy. The
number of FERRIN brochures and Supplementation
Cards is equivalent to this number.
"Countall the numberof pregnantwomenwho will
start their food supplementation on the succeeding
monthi.e.,those at the 7th monthof pregnancy. The
number of NUTRINA brochures to be requested is
equivalent to this number.
"The following quantities of delivery and monitoring
forms will be required for the duration of the
project (18 months):
1) BarangayMasterList - fourforms perbarangay
2) Stock Card - one card for each barangay and
another one for your whole catchment area per
supplement
3) NIE Material Supply Form - one form for your
catchment area.
Fill up item (1) of NIE Material Supply Form with
the number of new enrollees during the current
month.
Fill up item (2) with the number of materials to be
received. Update the number with the actual
number received from the PHN.
2.2 Delivery/Mon itoring Forme
2.2.1 Form I B
2.2.2 Form rc -5 -
2.2.3 Form 101/102 f
2.2.4 Form IEIIIB q
2.2.5 Form IIA
2.2.6 Maternal Health
1 -
Record
"Getyoursupply from the PHNattheRHU. Present
your accomplished NIE Material Supply Form with
the attached Barangay Master Lists of Pregnant
Women.
"Record other NIE materials you have received for
distribution to pregnantwomenon the NIE Material
Supply Form. Record in the Remarks portion any
problemyou haveencountered in the requisitioning
and delivery of NIE materials.
Care in the distribution of supplies to Barangay Health Workers is important to ensure that these
reach yourtarget mothers. This needs propercoordinationandproperrecordingof receiptof suppliesduring
distribution.
132
I'"

When to be conducted Two to three days before scheduled dates of iron andlor
food supplementation by pregnant women for the distribution
of NliTRINA and FERRIN'supplements and brochures.
First pre-natal consultation of the pregnant woman with
you for the distribution of the Anemia brochure and the
Food Prescription Slip.
Tools to Use Supplementation Card
Barangay Master List of Pregnant Women
Anemia Brochure
Food Prescription Slip
FERRIN and NUTRINA Brochures
3J Coordinate with your BHWson specific
dates when they can get Food
Prescription Slip, their supplies of
FERRINandNUTRINAsupplements
FERRIN and NUTRINA brochures
and Supplementation Cards for distribution
to pregnant women.
In cases when the mothers get their
FERRIN/NUTRINA stocks directly
from you, coordinate the scheduIe
with them so that it coincides with
their predetermined dates of receipt
found in column(9)of yourBarangay
Master Lists.
Inform the BHW of their receipt of
supplies so she can conduct monitoring
and follow-up activities.
LA UNION INTEGRATED PROVINCIAL HEALTH OFFICE
DISTRICT: _
RURAL HEALTH UNIT: _
BARAN GAY HEALTH STATION: _
BARANGAY: _
1. NAME OF MOTHER _
Family Given Middle
2. ADDRESS _
# Street/Purok
133
How to Accomplish Each
'Determine number of women who are about to
start FERRININUTRINAsupplementationin the
current month, as reflected in column (9) of the
Barangay Master List. Allot a Supplementation
Card and a FERRIN/NUTRINA brochure for
each of them.
Fillup the identification page(items I t06) ofeach
Supplementation Card.
(1) NAME OF MOTHER - Write the family name,
given name and middle initial of the pregnant
woman.
(2) ADDRESS - Write the house number (if any),
the street and the purok,
(3) LMP - Indicate the date of her last menstrual
period.
(4) EDCB - Indicate her Expected Date of Childbirth.
(5) NAME OF BHW - Write the name of the BHW
assigned to her area of residence.
(6) NAME OF MIDWIFE· - Write your name.

3.2 Distribute the FERRIN/NU1RINA supplies,
FERRIN/NU1RINA brochures and supplementation.
Cards to the BHWs on predetermined
dates. Ideally, these dates should not be
longer than two to three days before the pregnant
women are scheduled to received their
supplements (start, of the 5th, 6th, 7th, 8th and
9th months of pregnancy for·FERRIN and start
of the 7th, 8th, and 9th months for NUTRINA).
3.3 Update the Barangay Master List of Pregnant
Women during the distribution of supplies to
BHWs.
3.4 Distribute the Anemia brochure and Food Prescription
Slip to pregnant women during their
first consultation with you and conduct nutrition
information and education. .
3.5 Remind the pregnant women to keep their
Supplementation Cards in a safe place during
their pre-natal consultation with you.
Ask them to bring their Cards to the BHSeach
time they come to see you.
During pre-natal visits, check whether the
pregnant women have read the four NIE brochures
that were given to them by asking them
some questions on the messages contained in
the materials.
4. Monitoring compliance
( 1111. DATE SUPPlEMENTC
•
RECEIVED
"Refer to column (9) of your Barangay
Master Listof PregnantWomen. Upon distribution
of FERRIN/NUTRINA supplies
to the BHWs,encircle the dates marked for
receiving the supplements in column (9)of
the Barangay Master List.
"Upon validation/verification of the pregnancy
status of the mothers, i.e., on their
first pre-natal check-up with you, give
them one Anemia brochure and one Food
Prescription Slip.
The conduct of spot check to find out if pregnant women take FERRIN /NUTRINA regularly and
correctly is necessaryto ensurecompliance. Monitoring results willhelp you assess the progress of the project
and find out problems in the field and provide solutions for them as early as possible. Through careful
inquiries from the motheryou willbeable toassess the BHWin terms ofcompliance to protocol and effectivity
in the performance of their tasks. The following monitoring guide will help you undertake this task
efficiently.
Your Responsibilities
A. Compliance to FERRIN/NUTRlNA
Supplementation
When to be conducted
Tools to Use
134
How to Accomplish Each
Spot checks during the 5th, 7th and 9th
month pre-natal check-ups
Supplementaton Cards
Maternal Health Records

Your Responsibilities
A4.1 Review the Supplementation Cards
broughtby the pregnantwomen to the
BHS during pre-natal check-ups to
monitor:
A4.1.1 Actual distribution of supplies
A4.1.2 Compliance of mothers to
supplementation
A4.1.3 Problems affecting regular com
pliance and actions taken on
problems
A4..2 Motivate mothers to continue taking
FERRIN/NUTRINA until her
delivery
A4.3 Review the utilization ofNIE materials
by mothers.
Check whether mother is
practising proper nutrition
during pregnancyby checking
her diet during her prenatal
check-ups.
A4.4 Accomplish items (33) to (43) of the
Maternal Health Record for the results
of each of your pre-natal visits.
B. Compliance to protocol
When to be conducted
Tools to Use
•
135
How to Accomplis Each
"Check whether the BHW properly distributed the
amounts alloted for each pregnant woman (NO. OF
SUPPLEMENTS GIVEN) on the prescribed dates of
distribution (DATE SUPPLEMENTS GIVEN). Compare
the dates of distribution in the Supplementation
Cards with the dates indicated under your Barangay
Master Lists to verify the distribution of FERRIN and/
orNUTRINA.
Likewise,ask the motherwhenshe received her supply
of FERRIN and/or NUTRINA and compare this with
her scheduled date of receipt as shown in her Supplementation
Card.
"Check whether the BHW monitored amounts of
FERRIN/NUTRINA consumed by mother each week
(COMPLIANCE) and the amounts left over after a
month of supplementation (NO. OF SUPPLEMENTS
LEFD.
"Reviewthe problems recorded and the actions recommended
by the BHW. Checksufficiencyofactions. Ask
mother if she has other problems and recommend
actions.
"Reinforce the importance of FERRIN/NUTRINA.
Correct any misconceptions and wrong nutritional
practices during the conduct of NIE activities.
"Ask the mother what her usual diet has been since the
last time she has seen you and record these in item (30)
of the Maternal Health Record (MHR).
Determine sufficiencyof food and nutrient intake as to
quality and quantity based on the Food Prescription
Slip. .
Record the food prescription given in item (31)of the
MHR.
During your regular health clinic in the different
barangays of your catchment area.
Training Handout No.4
Supplementation Cards

Your Responsibilities
Spot check the BHW on the
following:
B4.t Identification and referral of pregnant
women
B4.2 Delivery of supplements to intended
targets
B4.3 Monitoring of pregnant women's
compliance to supplementation
B4.4 Reminding pregnant women
about their pre-natal check-up
schedule
B4.5 Assisting you in the MCH Program
B4.6 Reporting of her accomplishments
to you.
Problems You May Encounter
A. Identifying and enrolling pregnant women
At BHW does not assist in the identification
and enrollment of pregnant women.
AU Attitudinal BHW does not believe
in the project.
A1.2 Time constraints BHW has other
jobs/preoccupations.
136
How to Accomplish Each
"Refer to Training Handout No.4 for actions to take in
cases of non-compliance,
"Ask the BarangayPHCC Chairmanwho the pregnant
women are in the area during yourbarangay visits for
other health services.
•Ask pregnant women when they see you at the BHS
about other pregnant women they know of in their
purok. Find out during their initial visit who referred
them to you.
"Spot check Supplementation Card
(Supplementation Records portion) for the date of
receipt of supplements and the quantity received.
"Check the Supplementation Records portion of the
Supplementation Card for the weekly follow-up of the
BHW (NO. OF SUPPLEMENTSTAKEN/REASONfor
SUPPLEMENTATION) and the actions she recommended
(ACTION TAKEN).
"Ask mothers during their pre-natal visits who
instructed them to come to you. Also check presence
of BHWs duringthesepre-natalcheck-upsof the mothers.
Action to be Taken
• Determine reasons for disinterest or lack of
cooperation.
• Reorient the BHW on proper nutritionduring
pregnancy. Explain food supplementation
and the use of nutrition information and education(NIE)
materials, Presenttheactivitynot
as an additional task but ratheras an opportunity
to gain knowledge. Give importance to
her role as project implementor in the field.
• Adjust to the BHW's availability. Otherwise,
inform the Barangay PHCC for a substitute
BHW or for other remedial actions.

Problem You May Encounter
r. Monitoring compliance to supplementation and
protocol
C1. The pregnant woman complains about the
taste of FERRIN/NUTRINA.
C2. The Pregnant woman forgets to take her supplements
regularly. -
C3. The pregnant woman complains about the
side effects of iron supplements.
C3.1 Diarrhea
C3.2 Constipation
C3.3 BlackStool
b. Conducting post-natal follow-up of the mother
and the infant
01. The pregnant woman does not want to go
for pre-natal check-up.
02. The pregnancy of the woman.
03. Record of delivery outcome is difficult to
collect.
04. Delivery record was not filled up.
138
Action to be Taken
• Advise her to eat something e.g.,:banana, or tc
drink water to wash down any aftertaste of thc
FERRINiron tablets or NUTRINA food supple
ments. Advise her to alternate the food supple
ments she takes each day to vary her merienda.
• Advise the BHW to assign a member of thc
pregnant woman's family who will remind he
about her daily intake of NUTRINA and FER
RIN supplements.
• Tell the mother to stop taking supplements fo
three days. If diarrhea still persists, refer her tc
the Municipal Health Officer (MHO) for treat
ment. If it stops, tell her to resume her supple
mentation but to lower the dosage to one table
per day for one week. If after this period diar
rhea has completely stopped, return the dosag
to two tablets per day.
• Stop supplementationfor threedays. Adviseth
pregnantwoman to drink plentyof waterand t
eat fruits. Ifconstipation persists, refer her to th
MHO. Ifit stops, lower the dosage for one wee
after which you can return to the prescribec
dosage if there are no side effects.
• Before the mother starts iron supplementatior
tell her to expect a change in the color of he
stool.
• Ask the BHWtocall the attention of the pregnan
woman to the improtanceofpre-natal care. Visi
the pregnant woman at home at least once te
motivate her to see you at the BHSfor pre-nata
check-up.
• Refer her to the PHN/MHO for the assessmen
of her enrollment in the project and for clos
follow-up of her pregnancy
• Follow-up/remind the motherabout theaccom
plishment of the Supplementation Card.
• List the births/pregnancy-outcomes that wer
not recorded by the hospital attendants anr
submit these to the PHN.

Your.Responsibilities
2. Deliveries Attended by Hospital
Attendants
Follow up the pregnancy
outcome of births delivery in the
How to Accomplish Each
'Follow up accomplishment of the Supplementation
Card by hospital birth attendant during your home
visits to facilitate post-natal follow-up.
Accomplish Maternal Health Record using the data in
the Supplementation Card.
In case the Supplementation Card was not accomplished
by the delivery attendant, submit the Card to
the Public Health Nurseso that she can forward it to the
Area Nurse Supervisor for data collection and accomplishmentof
the needed information. Make the necessary
notations if this is so (i.e., the Supplementation
Card was filled up using hospital reeords.) ,
D. Post-Natal Activities
The mother has now delivered her baby. This is one of the most critical periods of our project and
you need to monitor the progress of both the mother and the newborn to see if they have been spared of the
risks of pregnancy and childbirth.
When to be Conducted At least two times coinciding with the cord dressing
for post-natal follow-up of the mother.
7th and 28th day after birth for post-natal follow-up of
the infant. Only one dayis allowed in case data collection
is not really possible during these scheduled
dates.
For each infant follow-up, indicate if child is:
ALIVE (indicate weight in kilograms)
DEAD (specify cause)
140
•

REMEMBER .
The pregnant woman in your community and the child she carries in her womb have placed their
confidence in you and the way, you discharge your work.
As an implementor of the IRON AND FOOD SUPPLEMENTATlON PROJECT,assess everyeffort you
have given and ask yourself?
• What could have done Better?
• What More should I have done?
• What services could I have done More Often?
Bylooking into ourselves moreclosely and truthfully, we learn to make out tasks more challenging for us
and fulfulling for those whom we serve.
Our pregnant women and children need you.
Let us not fail them.
143

AppendixB
COURSE DESIGN
A. COURSE DESCRIPTION
COURSE TITLE: IRON AND FOOD SUPPLEMENTATION DELIVERY PROJECT TRAINING
FOR RURAL HEALTH MIDWIVES, PUBLIC HEALTH NURSES, &< SUPERVISORS
RATIONALE:
In support to the Iron and Food Supplementation Delivery Project (lFSD),
a system for training was developed to facilitate field operations effectively. Since the
project will be implemented within the approach of the primary health care (PHC),
targets for training are the RHU field health personnel. First group to be trained are
the implementors and supervisors, Le. Area Nurse Supervisor (ANS), Public Health
Nurse (PHNl, Municipal Primary Health Care Chairman, District Nutritionist, and Rural
Health Midwives (RHM). The second group to be trained are the barangay health
health workers (BHW). The trained midwives will conduct.the training of the BHW.
Since the role of the midwives and other implementors is important in the
implementation of the project, this training protocol Wasdeveloped for them. Itis
expected that the results of this training will develop their capabilities in the implementation
of the IFSD project.
OBJECTIVES:
General:
Specific:
CONTENTS:
To improve the knowledge, attitude and skills of implementors, i.e. Dietary
Nutritionist, Public Health Nurses and Rural Health Midwives, in the implementation
of Iron and Food Supplementation Delivery Project in the province of La Union.
At the end of the training, participants will be able to:
1. explain the rationale, objectives, structure and methodology of the project,
2. discuss the relationship of proper nutrition during pregnancy to the
health of both mother and the newborn,
3. carry out their respective roles and functions in the operation of the project,
4. do specific tasks pertinent to their role and function, and
5. integrate IFSDactivities to the nutrition program of La Union
through the Primary Health Care Approach.
I. Update on Maternal Nutrition
1. Nutrition and Health in Pregnancy
2. Causes and Effects of Maternal Undernutrition
3., Signs of Malnutrition Among Pregnant Women
4. Review of Nutritional Anemia (definition, causes and symptoms).
5. Effects of Nutritional Anemia
6. Magnitude of Anemia Problem in the Philippines
7. Prevention, Treatment and Control of Iron Deficiency Anemia.
144

II. Overview of the Project
1. Rationale and Objectives of the Project
2. Methodology and Organizational Structure of the Project.
3. Roles, Duties and Responsibilities of the Participants.
III. IFSD in the Context of MCH Services through the PHC Approach
1. The PHC System (A Review)
2. The MCH Services at Barangay Level
3. IFSD Delivery and Monitoring System Through the PHC Approach
4. Organization and Training of the BHW
IV. Project Operations in the MCH Services Within the PHC Approach
A. Prenatal Activities
1. Identification and Enrollment of Pregnant Women.
2. Requisitioning for Food and Iron Supplements (Nutrina & FERRIN)
3. Distribution of Nutrina and Ferrin, and Using NlE Materials
4. Monitoring Compliance with Supplementation and with Protocols
B. Deliveries
1. Attending to Deliveries
2. Monitoring of Deliveries Attended by Gov. Hospitals/Hilots
e. Post Partum Follow Up Activities
1. Monitoring Nutritional Status of Child
EXPECTED TRAINEES: Participants are the Public Health Nurse, District Nutritionists,
Area Nurse Supervisors, Rural Health Midwives, and Primary Health Care
Committee Chairmen
VENUE: REGIONAL HEALTH OFFICE, REGION 1, SAN FERNANDO, LA UNION
DAY/TlME: December 8 and 9,1984, 8:00 - 5:00
TRAINING STRATEGIES:
Training Method: A variety of teaching methods will be used such as
lecture-discussion, workshop, group workexercises, demonstration
and return demonstration, role playing.
Training Aids: Training handouts on Course Design, Instruction Sheets,
delivery and monitoringforms,brochure on anemia, Ferrin and
Nutrina, Food Prescription Pad, and Training Syllabus for BHW,
and Implementor's Manual.
145

B. COURSE SYLLABUS
IFSD TRAINING FOR RURAL HEALTHMIDWIVES, PUBLIC HEALTH
NURSES, AND DIETARY NUTRITIONISTS
Learning Content Training
Day Time Objective. Outline Methodology Material. Lecturer
12/8/84 At the end of this
8:00
session, each parti-
cipant should be
able to:
-8:30 • Register Registration Registration M. Enero/
8:30 • Participate in A. Opening Cere-
-8:45 Opening ceremony mony
9:00-
I
Phil. Nat. Anthem
Forms D.David
Invocation N. Dalinguez
Inspirational Talk Dr. Unite
Introduction of
Trainors Mrs. Felix
9:30 React to Course B. Course Object- Presentation Hand out #1 E. Felix
Objectives,expect- ives, Expected Out-
9:30-
ations, & syllabus puts, Content,
Mechanics &
Schedule
10:15 At end of this MODULE 1. UP· Lecture/ Flip chart, Dr. E.
session, the partici- DATE ON MATER· Discussion Discussion Gonzalez
pants should be NAL NUTRITION Guide in
able to: the module
• discuss the im- • Nutrition and content
portance of proper Health in
nutrition during Pregnancy
pregnancy
e identify the causes • Causes & Effects
& effect. of mater- of Maternal Under-
nal undernutrition nutrition
-recognize the signs • Signs of Malof
malnutrition nutrition Among
among pregnant Prcgnant Women
women
146

Learning Content Training
Day Time Objectives Outline Methodology Materials Lecturer
10:15-
• identify/ enume- • Review of N utrirate
causes and tional Anemia
symptoms of nutri- (definition, causes
tional anemia & symptoms)
• review the mag- • Anemia Problem
nitude of anemia in the Philippines
problem in the
Phils.
• enumerate the • Effects of Nutrieffects
of nutri- tional Anemia
tional anemia
.·enumerate prac- • Prevention, Treat-
tical approaches ment and Control
toward preven tion, of Iron Deficiency
treatment and Anemia
control of nutri-
tional anemia
among pregnant
women
10:30 B R E A K
At the end of the MODULE II. Lecture/ Flip Chart M. Lopez
10:30- session, each parti- PROJECT ORIENT- Discussion
11:00 cipant should be AllON
able to:
• describe the • Rationale &
rationale & object- Objectives of the
ives of the project Project
• describe the • Methodology &
methodology and Organiza tional
organizational Structure of the
structure of the Project
project
• define their res- • Roles, Duties & Elicit chalk, board
peetive roles & Responsibilities participants'
functions in the of the Participants reaction
implementation of
specific activities
ofthe project
147

Learning Content Training
Day Time Objectives Outline Methodology . Materials Lecturer
11:00- At the end of this MODULE Ill. IFSD Dr. J. Draculan
12:00 session, each parti- IN THE CONTEXT
cipant should be OF MCH SERVICES
able to: THROUGH THE
12:00-
PHC APPROACH
- review what is • PHC Overview Lecture/ hand-out
Primary Health discussion
Care (PHC)
- review the mater- • MCH Overview
nal and child health
care services
«relate her role in • IFSD Delivery & Implemen- Flipchart M. Crisostomo
the IFSD in the Monitoring System tor's Manual
context of the MCH for Midwives
services thru the
PHC Approach
1:00 L U N C H B R E A K
1:00-
2:30 • plan for the orga- Organization & Workshop Flicharts A. Ramos
nization & training Training of BHW Discussion worksheets
of BHW by: exercises,
1. assessing the demonstra-
BHW in her catch- tion
ment area,
2. developing a
program of work to
ensure presence of
BHW in all her
catchment areas,
3. describing the Training M.Enero
training design for Design
BHW on the IFSD,
and
4. scheduling the
BHW training
prior to deli very of
food supplements
148

Learning Content Training
Day Time Objectives Oulline Methodolog> Materials Lecturer
2:30- • Describe the Lecture/Dis- Sample food M. David
5:30 characteristics of cussion supplements
the Food and Iron demonstra- brochure on
Supplements tion Nutrina
• Demonstrate her A. Pre-Natal Discussion, Flipcharts M. Crisostomo
specific roles along Activities Systems role playing, worksheets
the following: and Procedures dernonstra-
1. 10 and enroll- • Identification & ses
ment of PW, Enrollment of PW
2. requisitioning • Requisitioning &
& Distribution of Distribution of
supplies, and Supplies
3. monitoring of • Monitoring of
compliance to pro- Compliance
tocols & to supple-
mentation
tion, exerci-
• Preparation & B. Delivery Role playing worksheet M. Crisostomo
submission of Attendance demonstra- forms
reports tion, exerci-
C. Post Partum
Follow-up Activi-
ties Systems &
Procedures
9-Nov At the end of this Workshop on the Exercise on Monitoring & E. Felix
(2nd session each parti- Following Project actual filling IEC Materials M. Crisostomo
day) dpant should be able Systems & Proce- up of forms M. Enero
able to: dures based on j. Lacson
ses
targets & Dr. Gonzales
role play data Dr.Draculan
• Implement the A. Pre-natal A. Ramos
prescribed systems Activities Participants
and procedures & will be
demonstrate her grouped tor
specific role on: this activity
8:00- 1. 10 & enrollment 1. ID/Enrollment
8:30 ofPW ofPW
•
149

C. TRAINING HANDOUTS FOR TRAINORS
BHW TRAINING
MODULE I. UPDATE ON MATERNAL NUTRITION
Leaming Teaching Materials!
Objectives Content Techniques Aids
At the end of
the sessions
each participant
should be able A. NUTRITION AND HEALTH
to: DURING PREGNANCY
• Explain the What happens to the mother when she Ask BHW their
importance of is pregnant? knowledge on the
proper nutrition importance of
during preg- When the mother is pregnant, a new proper nutrition
nancy person is being formed inside her body.
Growth and development of the fetus
during pregnancy
takes place. The unborn child is com- 1. What happens
pletely dependent on the health and to the mother
well being of the mother and all when she is
nutrients are needed to develop a pregnant
healthy baby. 2. What are the BHWlmplesigns
and symp- mentor's
toms of pregnancy Guide page 7
Why is proper nutrition important
during pregnancy?
Proper nutrition is important during
pregnancy:
• to meet the nutritional needs of
the baby
• to meet the nutritional needs of
the fetus
• to build nutrient reserve in preparation
for delivery and lactation
• Identify the Causes of Maternal Undernutrition
causes of mater- • inadequate food intake
nal under- • poor absorption
nutrition • infection
• wrong beliefs and practices
150
.

Learning Teaching Maerialsl
Objectives Content Technique Aids
• Identify the Effects of Maternal Undernutrition: Ask BHW their BHW Impleeffects
of mater- • low birthweight babies experiences with mentor's
nal under- • stillbirth and prematurity undernourished Guide Page 1
nutrition • complications during pregnancy pregnant women.
What are the
effects on the
mother? on the
baby
• Recognize the Signs of Malnutrition in Pregnant
signs of mal- Women
nutrition
among preg- The appearance of a pregnant woman car AskBHWhow
nant women suggest whether or not she is malnouri- they recognize
shed. Observe the following: maternal under-
• thinness or emaciation nutrition
. • failure to gain weight Diet Prescrip-
• sickly condition tion Leaflet
• Identify An adequate diet is the most important 1) discuss and remeans
of pre- for the pregnant mother view the three
venting and • she should eat more food and a food groups
treating under- variety of foods 2) Ask BHWto
nutrition among • she should eat 25% more food than enumerate foods
pregnant she was eating before she became included in each
women pregnant food group
B. NUTRITIONAL ANEMIA
• Define Nutri- What is Nutritional Anemia?
tionaI
Anemia Nutritional anemia is a condition AskBHWto Anemia
brought about by a deficiency of nutrient enumeratesigns Brochure
needed for blood formation. These and symptoms of
nutrients are iron, folate, Vitamin B12 anemia
and other nutrients
• Explain why Why should anemia be controlled
anemia should among pregnant women?
be controlled
among pregnan t Anemia should be prevented among Ask BHW to Anemia
women pregnant women because: enumerate effects Brochure
1. the anemic pregnant women may of anemia among
become susceptible to diseases and in- pregnant women
. fections; weak and inactive; sickly
151

Leaming Teaching Maerialsl
Objectives Content Technique Aids
2. the anemic pregnant women may have
low birthweight infants
• Identify Treatment and Prevention:
means of pre- 1. diet which is rich in iron Ask BHW to Anemia
venting and Iron rich foods include: malunggay, enumerate foods Brochure
treating anemia liver, kulitis, saluyot, alugbati, rich in iron
amongpreg- munggong pula, ampalaya leaves
nantwomen 2. Iron Tablets - easily increase the intake
of iron
MODULE 11. PROJECT OVERVIEW
Leaming Teaching Maerialsl
Objectives Content Technique Aids
At the end of
the session
participant
should be able
to:
• Explain what What is the Food Supplementation
is the IFSD Delivery Project within the
project Primary Health Care Approach
The activity is piloted in La Union • Give an overprovince
to strengthen and broaden the view of the MCHS
coverage of the Maternal and Child activities conducted ,
Health Services (MCHS) at the Bgy. Health
Station
• Recognize the The activity aims to:
importance of • improve the nutritional status of the • Ask the BHW BHW Imple-
the project mother activities of, MCHS mentor's
Food supplementation will help meet where she has Guide Page 3
the increased food needs of the mother been involved
as a results risk and complication in the past
associated w/ pregnancy and child birth
is prevented
• reduce the incidence of low birth- • lecture/
weights among their newborn, thereby discussion
producing more health Filipinos
152

Leaming Teaching MaerialsJ
Objectives Content Technique Aids
Iron supplementation will help meet
the increased HB requirement of the
mother during pregnancy
• reduce the prevalence of anemia and
its effects
You the BHW will be greatly involved
in its implementation and the project
success lies greately in your hands
• Identify what What are the interventions to be lecture/discussion
are the inter- given to all the pregnant women
vention to be in the barangay?
given
,
To meet these objectives there are
three interventions to be given:
1) NUTRINA food supplementation
2) Ferrin iron supplementation
3) Nutrition Information and
Education (NIE) materials
NUTRINA Food Supplemenets Show samples of
(Discuss the following in detail using the theNUTRINA
BHW Implementor's Guide page 3 and food supplement
NUTRINA Brochure)
• What food supplements to be given
- type/varieties
- # of calories given per day per mother
• Who will be given
• When to take
Ferrin Iron Sipplements
• What iron supplements will be given:
- mg elemental iron tablet
- dosage per day
• Who will be given
• When to take
• Side effects & intervention to
minimize
NIE Materials Read the content NUTRINA
ofthe3 NIE Brochure
Discuss the following in detail using materials Anemia
BHW Implementor's Guide page 4 Brochure Pre-
• What are the three brochures to be scription
given Leaflet
• when will it be given to each mother
153

Appendix C
COURSE DESIGN FOR TRAINING OF FOOD, FOOD & IRON & IRON GROUPS
A. COURSE DESCRIPTION
COURSE TITLE: IRON AND FOOD SUPPLEMENTATION DELIVERY PROJECT TRAINING
FOR BARANGAY HEALTH WORKERS AND BARANGAY PHCC CHAIRMAN
RATIONALE:
The Barangay Health Workers (BHW) playa vital role in the implementation of the IFSD
Project because they are assigned the task of recruiting and referring target pregnant mothers
to the Rural Health Midwives (RHM). They will also assist the midwives in the delivery of
supplements and other interventions.
This training will therefore, be conducted to improve the knowledge attitude and skills (KAS)
of the BHW in the delivery of these services for the IFSD project.
COURSE OBJECTIVES:
General: To improve the knowledge, attitude and skills of the BHW in the delivery of
IFSD services within the concept of Primary Health Care (PHC)
Specific: At the end of the training the participants will be able to:
1. explain the rationale and objectives of the IFSD Project to the pregnant woman,
2. explain nutritional anemia and how to control anemia in a pregnant woman,
3. identify pregnant women in her assigned purok for referral to
Public Health Midwives,
4. deliver iron and food supplements, NIE material to target pregnant
mother in her purok, and
5. Inonitor the food supplement intake among the target pregnant mothers
CONTENTS:
1. Update on Nutritional Anemia
1. Maternal Nutrition
2. What is Nutritional Anemia
3. Why Should Anemia be Controlled
4. How Can We control Anemia
II. Project Overview
1. What is the IFSD Project
2. Why is IFSD Important to the Mother, BHW and the Community
3. Whose Project is the IFSD Project
4. What are the Roles and Functions of BHW in the Project
III. Project Operations
1. The BHWs Role in the control of Nutritional Anemia
1.1 Identification and Referral of Pregnant Mothers
1.2 Distribution of Iron and Food Supplements to Target Pregnant Women
1.3 Monitoring Compliance to Supplementation of Target Pregnant
Mothers in her Purok
2. Tools to Enable the BHW to do her Task Effectively
2.1 Implementor's Guide for BHWs
2.2 NIE Materials - Brochures on a) Anemia, b) FERRIN, c) NUTRINA and
d) Food Prescription Slip
DATE: Dec. 1984
VENUE: La Union
DURATION: 1/2 day
METHODOLOGY: Lecture. discussion and demonstration
154

B. COURSE SYLLABUS
Fadli-
Dayt Teaching Training tatorsl
Title Learning Objectives Content Outline Technique Materials Lecturers
DEC.
1984 MODULE 1.
LA At the end of this module, UPDATE ON Lecture/ implementor's
UNIOl'i each participant should MATERNAL Discussion Manual for
112 be able to: NUTRITION BHW
DAY NIE materials:
AskBHW:
1) Describe proper nutri- - Maternal nutrition 1. Whathappens • anemia
tion during pregnancy to mother when brochures
and lactation she is pregnant e.prescription
2. Importance of leaflet
proper nutrition • nutrina
during pregnancy brochures
• Ferrin
2) Describe nutritional - What is anemia: 3. Signs & Symp- brochures
anemia • signs/symptoms/ toms found
• causes/effects/ among anemic
• prevention/control cases
3) Know why anemia, - Why should anemia 4. Effectsof
among pregnant women be controlled anemia among
be controlled PW
4) Know and identify the - What are the iron- S. Iron rich foods
iron-rich foods rich foods
5) Familiarize wi th the - Project's NIE 6. Read the broproject's
supplies/ materials and sup- chures & enumematerials
for the preg- plements for the rate important
nantwomen target pregnant messages
mothers
, ...' .
ISS

Facili-
Dayl Teaching Training tatorsl
Title Learning Objectives Content Outline Technique Materials Lecturers
At the end of this module, MODULE II. Lecture/Discus- Implementor's
each participant should be PROJECT sion Manual for
able to: ORIENTATION AskBHW: BHW
1. MCH Services
she is involved
1) Describe the rationale & - What is IFSD Proj. with
objectives of the project The PHC Approach
- Why is it important
2) Describe his role and - Whose project is it
functions in the irnple- - Who are encourage
mentation of specific to participate in
activities the project
3) Clarify and assume the - Roles and function Demonstration
specific tasks pertinent to ofBHW
his'role and functions
At the end of this module, MODULE III. Lecture Implementor's
each participant should PROJECT Manual for
be able to: OPERATION BHW
1) Enumerate his specific - How can BHW Demonstration of
role in the prevention assist in the pre- the BHW particiand
control of anemia vention/control of pation from In &
among pregnant women anemia at the Referral to Monibarangay
level toring
.
2) Follow specific project
instructions on how to
use the project tools
properly
- filling-up of forms - instructions in demonstra- Forms
filling-up forms tion on the
forBHW filling-up
of forms
- utilization of imple- - how to use the
mentor's manual implementor's
manual
156

Appendix D
UST OF VARIABLES
IRON AND FOOD SUPPLEMENTATION DELIVERY FOR PREGNANT WOMEN WITInN lHE
pRIMARy HEALlH CARE PROGRAM
I. OPERATIONS DATA
1. Profile of PW and Husband
1.1 Age
1.2 Educational attainment
1.3 Occupation
2. Obstetrical History
2.1 Number of pregnancies
2.2 Number of children born alive
2.3 Number of living children
2.4 Number of abortions
2.5 Number of stillbirths
2.6 Number of perinatal death
.3. Data on present pregnancy
3.1 IMP
3.2 EDCB
3.3 3 fundic height measurements at different AOG
4. Data on Supplementation
4.1 Typeof supplements taken in
4.2 Compliance to supplementation
as per dosage given
number of tablets for the whole duration of pregnancy
frequency of taking supplements
reason for irregular/stopped supplementation
other problems/complaints
5. Pregnancy Outcome
5.1 Delivery date
completion of pregnancy term (premature, full term, post term)
5.2 Condition of infant
Iivebirth
stillbirth
spontaneous abortion
5.3 Birthweight
5.4 Pregnancy complications
normal
hemorrhage
toxemia
placenta previa/abruptia sepsia
nature of delivery
abnormality
attendant
5.5 Weight of infant at 28th 'day after delivery
II. BASruNE AND POST-SuRVEYS
1. Profile
1.1 Age
1.2 LMP
1.3 EDCB
1.4 AOG
157

2. Clinical Assessment
2.1 BP, pulse rate
2.2 Head and neck - presence/absence of
eyes, conjunction pallor
scurvey
cheilosis
neck - enlarged thyroid
2.3 Heart - presence/absence of
heart beats, strong, regular
murmurs
others, specify
2.4 Lungs- presence/absence of
breaths sounds, not impaired
rales
2.5 Abdomen - presence/absence of abdominal scar
2.6 Fundic height in centimeters
2.7 Upper extremities - presence/absence of palm pallor
2.8 Lower extremities - presence/absence of pretevial edema
2.9 Other medical and related history - presence/absence of
heart disease
malaria
TB
influenza/pneumonia
kidney disease
2.10 Complaints in relation to present pregnancy:
vomiting
dizziness
sleeplessness
anorexia
lassitude
.edema
bleeding
others
3. Anthropometric and BiochemicalAssessment of PW and PS
3.1 Weight of PW in kg.
3.2 Height of PW in em.
3.3 Arm circumferencein em.
3.4 Time of blood collection
3.5 Hemoglobin values - Ist, 2nd samples
3.6 Number of preschoolers in the Family
3.7 Nutritional status of preschoolers weight for height
3.8 Nutritional status of preschoolers weight for age
3.9 Stoolexam - egg counts .
4. Socio-economicand Demographic Profile of PW
4.1 Household size
4.2 Family size
4.3 Type of family of respondent
4.4 Distribution of family member by age and sex
4.5 Educational attainment of household members
4.6 Occupation of household members: Primary and Secondary
158

On Smoking Habits
6.24 Type smoked
6.25 Frequencyof smoking
6.26 No. of sticks per month
6.27 Reason for smoking
6.28 Type of alcohol consumed
6.29 Frequency of drinking
6.30 Amount consumedpermonth
On Mother's Activity
6.31 Daily activities
6.32 Ranking of activities from most to least extrenuous
6.33 Source of health and nutrition information during pregnancy
6.34 24-hour Dietary Recall of PW
amount of nutrient eaten
% adequacy of intake (occupation w/ RDA)
.Food practices
6.35 Compliance to supplementation and protocol (only during post-survey)
supplements taken during presentpregnancy
manner by which PW receives Nutrina/Ferrin other supplements
AOG at the start of supplementation
Frequencyof receipt/buying of supplements
, number of supplements received/bought in one month
compliance to supplementation - actual vs. prescribed dosage
compliance to supplementation - no. of tablets/mg. of elemental iron
6.36 Receipt for IEC materials
receipt of specific materials
personnel who issued IECmaterials
when materials was received
explanation given to PW upon receipt of materials
Assessment of IEC materials
160

Objectjye yariableslData
3. To determine
accuracy of informationsubmitted
through
the monitoring forms
3.1 SES/pregnancy
profile 3.1.1
3.2Pregnancy
Outrome
3.3 Compliance
to supplementation
Review of
FonnID1
Pregnant Women (PW)
- date of birth/age
- educ, attainment
- occupation
- LMP
- EDCB
3.1.2 Husband of PW
- date of birth/age
- educ. attainment
- occupation
3.1.3 Household Size
3.1.4 OB History
- no. of pregnancies
- no. of children born alive
- no. of abortions
- no of stiJIbirths
- no. of deaths one
month after delivery
3.2.1 Date of birth
3.2.2 Place of birth
3.2.3 Condition at birth
3.2.4 Pregnancy complication
3.2.5 Nature of Delivery
3.2.6 Attendant at Birth
3.2.7 Weighing conducted at:
- birth
- one month after birth
3.2.8 Instrument used
3.3.1 Food & Iron Supplements
received/bought
3.3.2 AOG when initital supply
was received/bought
3.3.3 Frequencyof receipt/buying
3.3.4 Total supplements taken
since start
3.3.5 Dosage required--?
3.3.6 No. given in the last delivery
3.3.7 Date of last delivery/buying
3.3.8 No.ronsumed
162
Source Interview of:
RUM BHW S'yjsors pw MOther
x
x
x
x
x x
x x
x x
x x
x x
x x
x x
x x
x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x

Objes:tiye yariableslData
3.4 Compliance
to" Protocol
IV. RHU STUDY VARtABLES
Revinvof
fomtIDl
3.3.9 Frequency of taking supplements
3.3.10 Time of taking supplements
3.3.11 Changes/side effects observed
3.3.12 Extent/degree the changes/side
effects was felt before supplementation
3.3.13 Extent/degree the changes/side
effects was felt during supplementation
3.3.14 Action taken'
3.3.15 Person consulted
3.3.16 Recommendation given
3.4.1 Person consulted for pre-natal
check-up
3.4.2 Frequency of pre-natal
3.4.3 No. of BHW visits
3.4.4 Purpose of BHW visits
Source Interview of:
RUM BHW S'yjSOJll pW MOther
A.l Knowledge
Project implementors/recipients knowledge on anemia related topics:
VARIABLES Respondent
MHO PHN ANS/DN RHM BHW PW pp
1. What is (nutritional)
anemia? ..J ..J ..J ..J ..J ..J
2. Age group most vulnerable
to anemia ..J ..J ..J ..J
3. Effects of anemia on an
individual ..J ..J ..J ..J
4. Effects of anemia on
pregnant women ..J ..J ..J ..J ..J ..J
5. Effects of anemia on fetus ..J ..J ..J ..J ..J ..J
6. Causes of anemia ..J ..J ..J ..J ..J ..J
7. Signs and symptoms of
anemia ..J ..J ..J ..J ..J
8. Methods of assessing iron
status ..J ..J ..J ..J
9. Recommended hemoglobin
cut-off level ..J ..J ..J ..J
10. Recommended form of
iron for treatment of iron
deficiency anemia ..J ..J ..J ..J
11. Iron content of Ferrin .
tablet ..J ..J ..J ..J ..J
, 163
x
x
x
x
x
x
x
x
x
x
x
x

VARIABLES Respondent
MHOPHN ANSIDN RHM BHW PW ipp
12. Iron content of 133mg
ferrous sulfate V V V V
13. Measures to undertake if
patient vomits and experience
gastro-intestinal
disturbances from iron
supplementation V V V V v
14. Normal effects of iron
supplementation v v v v v v
15. Measures to undertake to
minimize iron requirements
V V V v
16. Period in which iron in-
take is mandatory among
v v
pregnant women V V
17. Which food enhances iron
absorption
18. Iron-rich foods
19. Body-building foods
20. Energy-rich foods
21. Source of body-regulating food
22. Calorie content of Nutrina
23. Normal birthweight
24. Breastfeeding practices
25. Start of weaning period
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
V
v
V
V
V
v
V
v
V
v
V
v
V
v
V
v
v
v
26. Practices to observe to
·Iessen incidence of anemia
amonz infants V V V V V
A.2 Project Implemenors/recipients' KAP on project protocol
VARIABLES RESPONDENTS
MHO PHN ANS/DN RHM
1. Start of enrollment in IFSD (AOG) V V V V
2. Activities to undertake during
enrollment of PW v v
3. Identification of at-risk PW V V
4. Action on at-risk PW prior to enrollment v v
5. Schedule of requisitions of supplies v v v v
6. Procedure for detemining number
of PW for IEC/Supplementation v
7. Validation procedure of PHN/RHM's
requisitions V V V
8. Schedule of submission of requisitions
V V
164
.'
•

VARIABLES RESPONDENTS
MHO PHN ANS/DN RHM
9. Activities undertaken to determine·
Ferrin requisitions for the whole
municipality
10. Activities undertaken to determine
IEC requisitions for the whole
municipality
11. Start of nutrina supplementation oJ oJ oJ
12. Start of ferrin supplementation oJ oJ oJ
13. AOG when NIE materials should
have been received oJ oJ oJ oJ
14. Activities undertaken during deli-
very of supplements/IEC materials
to the BHS
oJ
15. Protocol for handling of stock onhand
oJ oJ
16. Activities undertaken to conduct an
Inventory Control of Stocks oJ oJ oJ oJ
17. Number of Stockcards to maintain oJ oJ
18. Who should keep the Supplementation
Card oJ oJ oJ oJ
19. Schedules for spotchecking of PW's
compliance to supplementation/NIE oJ oJ
20. Activities undertaken to spotcheck
PW's compliance to supplementa-
tion
21. Activities undertaken/forms to
spotcheck in monitoring com-
pliance to protocols
22. Activities undertaken to spotcheck
compliance to delivery of supplies
and compliance to monitoring of
oJ
oJ
oJ oJ oJ
oJ oJ
supplementation by BHW
oJ oJ
23. Schedule for monitoring of submission
of forms by RHM oJ
24. Actions undertaken in complaints
from Iron Supplementation oJ oJ
25. Frequency of PW's prenatal checkup
26. Activities undertaken during
attendance of birth deliveries
27. Retrievalfsubmission schedule of
Supplementation Cards oJ oJ.
28. Protocol for handling missing data
in pregnancy outcome oJ oJ
29. Schedule for follow-up weight
taking of infants oJ oJ
30. Information to gather during post
natal check-up oJ
,.
, .
165
oJ
·oJ
,

VARIABLES RESPONDENTS
MHO PHN ANS/DN RHM
31. From whom should status of project
be monitored V
32. To whom should project status be
fedback V
33. What monitoring forms are regularly
submitted to project operations
staff V V
34. Activities undertaken by NIE
counselling v v
Bt. Attitude: Attitudinal questions determined the degree of agreement/disagreement of the
staff on the followin statements.
VARIABLES RESPONDENTS
MHO PHN ANS/DN RHM BHW
t. The IFSD improves NS of PW v v v v
2. IFSD reduces the incidence of LBM among
infants V V V v
3. IFSD is beneficial to the PW and to the com. V V V v
4. That all PW in my catchment area should
be enrolled in IFSD V V v v
5. PW should be given pre-natal checkup
at least once a month V V V v
6. IFSD NIE ma terials are useful for
pre-natal counselling V V
7. The explanation of the content of the
brochures to PW during pre-natal
check-up is time consuming V
8. IFSD brochure for requisitioning and
receipt of supplies is necessary V V V v
9. The BHW is the appropriate person
to deliver Nutrina to PW V V V V v
10. The BHW is the appropriate person
to deliver Ferrin to PW V V V V v
11. Nutrina is useful to the PW and her baby V V v v v
12. Ferrin is useful to the PW and her baby v v v v v
13. Nutrina supplementation should
start earlier than 7th month of pregnancy V V V v
14. Ferrin supplementation should start
earlier than 5th month of pregnancy v v v v
15. NIE materials are useful guides to
proper health and nutrition prac-
V
V v
tices during pregnancy v v v
16. Monitoring of PW's supplementation
is necessary V V V V v
17. Monitoring of PW's supplementation
maybe done on a monthly basis V V v v v
18. Monitoring of PW's supplementation
is also the task of the RHM/BHW v v v v v
------------------------------------- ------
166

B2. Attitude of Pregnant Women on BHSServices
Information on the following variables were asked from the pregnant mothers to
determine their attitude towards the delivery of health center services.
1. The BHS/RHU have adequate personnel to attend to patients need. Why?
Scales used were as follows:
- very adequate inadequate
- adequate very inadequate
- uncertain
2. Do you find it difficult to ask help from the health center workers? Why?
Scales used were as follows:
- very difficult easy
- difficult very easy
- uncertain
3. Do you think the health center workers show sufficient concern for the health of the
patients? Why?
Scales used were as follows:
- very much concern little concern
- muchconcern very little concern
- uncertain
4. Do the health center personnel always treat patients equally? Why?
Scales used were as follows:
- always sometimes
often never
uncertain
5. Do health workers loose their temper over the patients? Why?
Scales used were as follows: .•
never often
sometimes always
- uncertain
C. Practice Questions in the Practice Interview Schedule intended to determine the
actual practice of specific activities assigned to the project implementors.
Their actual practice mayor may not be according to the protocol designed
for project implementaiton.
1. Municipal Health Officer
1. Frequency of MHO meeting with RHM
2. Frequency by which IFSD is part of the agenda
3. Frequencyof RHM feedback to MHO about lFSD
4. Frequency of PHN feedback to MHO about IFSD
5. Validation of protocol for Nurses' feedback to MHO about RIM services
6. Activities undertaken in monitoring compliance to protocol
7. Frequencyof monitoring
8. Problems feedback regarding IFSD
9. Action undertaken by MHO
to. Recommendations for IFSDimplementation
168
.,

B. On monitoring of PW's compliance to supplementation function
8. Activities undertaken to monitor PW's compliance to supplementation
9. Frequency of interview
10. Information asked
c. On Other Fucntions
1. Handling of missing data in pregnancy outcome
2. From whom is project status monitored
3. Frequency of monitoring project status
4. To whom is project status feedback
5. Frequency of feedback
6. Activities undertaken with regards to nutrition information
7. Forms monitored for regular submission to operations staff
4. Rural Health Midwife
A. Identification, referral and enrollment of PW
1. Date or AOG for PW enrollment
2. Activities undertaken during enrollment
3. Action taken on at-risk PW cases
B. Requisitioning and receiving of supplies
4. Schedule of preparation of requisitions
'5. Protocol followed in determining number of stocks to be requisitioned
6. Schedule of submission of requisitions
7. handling of stock-on-hand
8. What stock cards to maintain
C. Delivery of Supplements and NIE Materials
9. What NIE materials to give to PW
10. Activity undertaken/instructions given when issuing NIE materials
11. Start of Nutrina supplementation
12. Start of Ferrin supplementation
13. Date or AOG of receipt of each NIE material
14. Activities undertaken to monitor compliance to delivery of supplies
D. Monitoring of PW's Supplementation
15. Who keeps the supplementation card?
16. Schedule of spotchecks of PW's compliance to supplementation
17. Activities undertaken during spotchecks of supplementation
18. Action taken on complaints from iron supplementation
E. Monitoring of Pregnancy Status and Outcome
19. Frequency of PW's pre-natal check-up
20. Activities undertaken during attendance of birth deliveries
21. Activities undertaken during post natal check-up
22. Schedule of follow-up weight taking of infants
23. Schedule of RHM's submission of supplementation card to PHN
170

5. Barangay Health Workers
v. Pregnant Women
A. Identification, referral and enrollment of PW
1. Date or AOG of PW identification/enrollment
2. Activities undertaken to assist the RHM in the enrollment of all PW in
the catchment area
3. Activities undertaken after identification of a PW
4. Forms used in enlisting PW
5. Information obtained upon PW's enrollment
B. Delivery of Supplies
6. IEC materials delivered by BHW
7. IEC materials delivered by BHW
8. Schedule of delivery of IEC materials
9. Activity undertaken/instruction given when issuing IEC materials
10. AOG start of Nutrina supplementation
11. AOG start of Ferrin supplementation
12. Protocol followed in determining the!.'W in the sector for supplementation
13. Schedule of requisition of supplies from RHM
14. Schedule of distribution of supplies to PW
15. Frequency of delivery of Nutrina to each PW
16. Information asked during delivery of supplies
17. Frequency of delivery of Ferrin to each PW
18. Number of Nutrina packs received by PW
19. Number of Ferrin received by each PW
C. Monitoring of Pregnancy Outcome
20. Frequency of monitoring of PW supplementation
21. Information asked during monitoring
22. Forms used during monitoring
23. Who keeps supplementation card
D. Monitoring of Pregnancy Outcome
24. Assistance given to RHM in monitoring of pregnancy and pregnancy outcomes
1. Validation of Accuracy of Information Recorded in the Monitoring Forms - this is determined
by matching the answers of the PW during the interview with the information 'recorded in the
monitoring forms on the following variables:
1.1 Birthdate of PW
1.2 Educational attainment of PW
1.3 Occupation of PW
1.4 LMP
1.5 EDCB
1.6 Birthdate of husband
1.7 Occupation of husband
1.8 Educational attainment of husband
1.9 Household size
1.10 Gravida
1.11 Number of children born alive
,.-'{ .
171

1.12 Number of living children
1.13 Number of abortion
1.14 Number of stillbirths
1.15 Number of neonatal deaths
2. Validation of Protocol - pregnant women were interviewed for 2 purposes: (1) to validate
compliance with various protocols by both RHM and BHW and (2) to validate compliance of
the PW with supplementation. Information on the following variables were obtained.
2.1 Identification and enrollment of PW
AOG or date of enrollment of PW
length of stay of PW in barangay
AOG of PW during interview
2.2 Delivery of supplements/IEC materials
manner by which PW receives Nutrina/Ferrin
AOG start of receipt of Nutrina/Ferrin
frequency of receipt of Nutrina/Ferrin
prescribed daily consumption of Nutrina/Dosage of Ferrin
number of supplements received per month
validation of PW's receipt of IEC materials
personnel who issued IEC materials
date/AOG of receipt of IEC materials
explanation given to PW during receipt of materials
rating of IEC materials
2.3 Monitoring of pregnancy and compliance to supplementation
place of pre-natal check-up
number of times PW went for pre-natal check-up
personnel who conducts pre-natal check-up
personnel who conducts follow-up visit of PW's supplementation
frequency of visit of personnel
activities conducted during follow-up visit
actual daily consumption of Nutrina/Ferrin
changes felt from Nutrina/Ferrin supplementation
positive effects felt from Nutrina/Ferrin supplementation
start of positive effects felt
duration of positive effects felt
negative effects felt from Nutrina/Ferrin supplementation
validation whether "Negative Effect" felt even before supplementation
AOG negative effects felt before supplementation
duration "Negative Effects" felt before supplementation
start of "Negative Effects" felt during supplementation
duration of negative effect felt during supplementation
action taken on Negative Effect/s
other iron supplements taken by mother during present pregnancy
AOG start of supplementation
change felt from supplementation of other supplements
positive effect/s felt from supplementation
start positive effect/s felt
Negative Effect/s felt from supplementation
validtaion whether Negative Effect was felt even before start of supplementation
AOG "Negative Effect" felt before supplementation
start "Negative Effect" felt during supplementation
action taken in Negative Effect/s felt
172

2. Profile of the Midwife's Catchment Area
2.1 Socio-economic and demographic data
2.2 BHW Involvement
3. Assessment of IFSDInputs
3.1 Adequacy of IFSDSupplies Delivered
3.2 Adequacy of Implementor's Manual
Specifically, information on the following variables were obtained:
A. Profile of the staff
a) Socio-eeonomic and demographic data"
1. source of staffs salary
2. place of residence of staff
3. place of residence of family
4. frequency of going home to family
5. duration of stay with family
6. travel time to family residence
7. profile of household
household size
family size
type of family respondent
no. of schoolers in the family
distribution of family residnce by age and sex
household/family employment status: number unemployed
health personnel status: age, sex, eudcational attainment, other
occupation, total annual income
health personnel's spouse status: same variables as household/family
status
total household/family income
educational attainment of household members
"Personnel Profile of MHO and PHN was limited to Socio-Economic and
Demographic Variables
b) Activities/Functions of the Midwife
8. regular activities undertaken
9. ranking of activities from most to least prioritized
10. number of hours spent per week per regular activity
11. number of hours spent per week per IFSDmajor activity
12. other daily activities undertaken by health personnel
13. number of hours spent per day per activity
c) Employment History
14. number of years in service as midwife
15. number of years in service in the municipality
16. number of years in service in the present catchment area
17. validation of any change of catchment area from October 1984 - October 1986
18. Date/s of change
19 Reason for change/s
d) Profile of the Midwife's Catchment Area
20. name of BHSof current assignment
174

21. number of barangays in catchment area
22. total population of the catchment area (1985)
23. total number of infants (1 yr. old) in the CA. (1985)
24. total preschoolers (0-6 yrs. old) in the A. (1985)
25. total pregnant women in the CA. (1985)
26. total number of households in the C A. (1985)
27. total number of families in the CA. (1985)
28. weighted average family income of CA. (1985)
29. weighted average household income of CA. (1985)
30. nutritional status of catchment area - number normal, first degree, second
degree, third degree, overweight PS
.31. total births per year in catchment area - 1983, 1984, 1985, 1986
32, topographic description per barangay
33. Barangay road description
34. mode of transportation to barangay hea.th station
35. amount of fare from RHM residence to BHS
36. travel time
37. distance in kilometers
VIII: Availabilitv and adequacv of inputs
\
\
VARIABLES
A. IFSD Training
1. Attendance of IFSD Training
2. rating of adequacy of training
given:
MHO
x
PHN
x
RESPONDENTS
ANS/DNRHM
x x
BHW PW PP
duration- x x x x
content x x x x
method used
effectiveness of resource
x x x x
speakers x x x x
\
\
3.
venue
if non-attendance of training
reason for non-attendance
personnel who later gave
x x x x
(
i, \ ,
t
\
! ,
I
}
B.
orientation in the project x
Supervision
1. Who supervises the staff x
2. How is Supervision undertaken x
3. Frequency of supervisor's visit to
monitor activities x
4. Adequacy of visit x
5. Frequency of meeting/consultation
with supervisor to discuss
status and problems in BHS
services x
6. Frequency of meeting consultation
with suprvisor to discuss status and
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
problems in IFSD x x x x
7. Rating given on conduct of
supervision x x x x
8. Reason for rating x x x x
\
l
1
\
175

RESPONDENTS
VARIABLES MHO PHN ANS/DN RHM ,BHW PW PP
C. Level of motivation from supervisor
1. Rating given to supervisor on
the following:
1.1 Is he encouraging x x x x
1.2 Is he supportive of your tasks x x x x
1.3 Is he considerate x x x x
1.4 Does he give criticism
constructively?
Does he give recommendations
on? x x x x
1.5 How to improve your work? x x x x
1.6 Does he motivate your in
the performance of your tasks? x x x x
2. Motivational activities conducted
by supervisors x x x x
D. Support system Obtained by staff
1. persons/agencies who give
support in implementation of
IPSO project x x x x
2. Kind of support given x x x x
3. Problems encountered re coordination
with agencies in IPSO
implementation x x x x
4. Actions undertaken
E. Monitoring
1. Frequency of attendance of RHU
meetings x x x x
2. Frequency by which IPSOstatus/
problems are discussed in RHU
meetings x x x x
3. Frequency of attendnace of
District meetings x x x x
4. Frequency by which IPSO status
problems are discussed in
district meetings x x x x
5. Comments on: •
5.1. RHU meetings x x x x
5.2 District meetings x x x x
176

KNOW ALL MEN BY THESE PRESENTS:
AppendixE
MEMORANDUMOF AGREEMENT
This Agreement made and entered into and executed by and between:
The NUTRITION CENTER OF THE PHILIPPINES, a private foundation, with office
address at NCP Bldg. , South Superhighway, Makati, Metro Manila, represented by its Deputy
Executive Director, .Mcrcedes A. Solon, hereinafter referred to as the party of the first part,
-a n d-
The MINISTRY OF HEALTH, with office address at San Lazaro Compound, Rizal
Avenue, Sta. Cruz, Manila, represented by the Minister of Health, Jesus c. Azurin, hereinafter
referred to as the party of the second part.
WHEREAS, one of the major thrusts of the Nutrition Center of the Philippines and the
Ministry of Health is the reduction of the prevalence of nutritional anemia and calorie
deficiencyainong pregnant women;
WHEREAS, the Ministry of Health has a well established network of personnel
engaged in Primary Health Care;
WHEREAS, the Nutrition Center of the Philippines is the lead agency in mobilizing
the private sector for participation in the Philippine Nutrition Program;
WHEREAS, the Nutrition Center of the Philippines and the Minsitry of Health are
actively engaged in operaions research;
WHEREAS, the existing situation empahsizes the need for an intensive and
collaborative effort to promote IRON AND FOOD SUPPLEMENTATION FOR PREGNANT
WOMEN WITHIN THE FRAMEWORK OF PRIMARY HEALTH CARE;
NOW, THEREFORE, for and in consideration of the foregoing premises and the mutual
convenants, agreements and stipulations herein made, the parties agree to undertake a project
"Iron and Food Supplementation for Pregnant Women Within the Framework of Primary
Health Care" and to carry out the following functions and responsibilities hereinafter set
forth:
1. OBJECTIVES OF THE PROJECT
To develop and test strategies to reduce the prevalence of nutritional
anemia among pregnant women and of low birth weight among their infants,
under the present health care delivery system.
II. FUNCTIONS AND RESPONSIBILITIES
177

AREAOF RESPONSIBILITIES
Phase I
I) That the party of the first part shall
a ) Prepare a workable protocol for the study
b) Prepare pre-test questionnaires and other tools necessaary for the
project
c) Identify and pre-test a food supplement; negotiate with potential
manufacturers for subsequent food supplementation
d) Conduct a baseline profile on the RHU system of the chosen study
area
e) Develop training and NIEC materials for use in thestudy
2. That the party of the second part shall:
a) Review the project protocol
b) Provide technical advice on project planning and implementation
c) Endorse the project to the Regional and Provincial Health
Offices
d) Provide awareness and monitoring of the project at the national
level
Phase 1\
I) That the party of the first part shall:
a) Recruit and train personnel for the conduct of the study (see
attached)
b) Provide funds for:
I) Logistical requirements
2) Honoraria for consultants and project participants from the
Ministry of Health
3) Equipment and supplies
4) Travel expenses and per diems of. Nutrition Center of the
Philippines personnel and Ministry of Health project
participants
c) Implement study as per approved protocol
d) Produce IECmaterials and food supplement
e) Submit progress reports and terminal report
2) That the party of the second part shall:
a) Provide required personnel complement for the study
(Attachment)
b) Permit health personnel to travel in connection with the
implementation of the project
c) Participate in the preparation of reports
III. WORKING RELATIONSHIP BETWEEN THE MINISTRY OF HEALTH AND
NUTRITION CENTER OF THE PHILIPPINES
Designated personnel from each agency are to work closely in the
implementation of all activities connected with the project. Task forces
consisting of personnel from both agencies will be formed as a strategy to
maintain the close working relationship. Moreover, dissemination and
adoption of the research outputs in whatever form will be a shared
responsibility of the two parties under defined operational guidelines and
expected outputs. Project participants shall be entitled to credits for
authorship and/or co-authorship of research paper(s) commensurate to their
178

participation in the conduct of the study and/or preparation of technical
reports.
IV. GENERAL PROVISIONS
The Project Protocol shall form an integral part of this Memorandum of
Agreement. It shall contain the detailed description of the project including
objectives. Methodologies and schedule which shall serve as implementing
guidelines for the conduct of the study.
V. EFFECTIVITY
This Agreement shall be for a period of three (3) years from the date
signing.
This Agreement shall be valid and binding by and between the parties,
their successors-in-interest and assignees.
IN WITHESS WHEREOF, the parties have affixed their signatures
this second day of December. 1983. Makati, Metro Manila.
MERCEDES A, SOLON
Deputy Executive Dirtector
Nutrition Center of the Philippines
WITNESSES:
Rornuaida M Guirriee
Nutrition Center of the Philippines
179
JESUSC. AZURIN, M.D.
Minister
Ministry of Health
Aurora S. Villarosa
Ministry of Health
•

•
Appendix F. Duties &: Responsibilities of Project Implementcra
Projedof Duties & Responsibilities Per Implementors
Operation BHW-PHCC Health Officers/
Members RHM PHN PSO DN PHCC Chairman
Level of Implementation
Barangay Municipal Provincial District MunIReg'l
• Pre-imple- • train BHWs & -acts as resource • prepares initial • Act as resource ein charge of
mentation Bgy PHCC chair- person'in the request of supply person on the Nut. supervision,
activities men on the ratio- training of BHW based in estimates &0 lEC delivery monitoring k
nale &: mechanics of target PW for in the training of control of pro].
of the project the province BHW implementation
at their own
level &c: areas of
concern
A. Continuous Continuously Health Officers:
identification identifies preg- • on the delivery
&: enrollment nant women (PW) ImmRHUto
ofPW in their catch- BHW
ment areas -on medical
management of
fills-in notebook PW
usingformat of - on monitoring of
FORM lA-I health services
record
Refers PW to
RHM
validates status
of PW in the bgy
Accomplishes
FORM IBI
B. Monthly Re- Consolidates on Consolidates on a Consolidates on PHCC Chairmen
quisitioning of a monthly basis monthly basis a monthly basis - on the delivery
Supplies pregnant mothers target PW for targets for supple- of supplies from
who are in their implementation mentation for BHWto PW
5th-9th month in the municipa- each municipality - on supplementaage
of gestation Iity based on past and assess suffi- tion follow-up
(AOG) from the month's FORM ciency of supply ofPW
FORM lB 1 &. ICIlIA submitted - on continous
prepares FORM by all midwives Prepares RSO for strengthening
ICIlIA in the municipa- needed supplies of organization
Iity and send to NCP building for the
Submits FORM for delivery of needs of the
IC/II A at PHN Records this tar- supplies project and
wI attached get on the FORM similar under-
FORM lBI !for the IC/11A accompli- Acknowledge re- taking for the
previous months shed FORMiC/ ceipt of supplies good of the
form IC/IIA for IIA w / attach- upon delivery community
the bgy &: awaits ments for validaapraval
&: re- tion of request &:
leases of request release of supply
Acknowledged acknowledges
1.80

Project Duties 8< Resoonsibtlitiee Per Imnlementers
Operation BHW-PHCC Health Officersl
Members RHM PHN PSO ON PHCC Chairman
Level of Implementation
Baran.av Municipal Provincial District MunIR..'1
2. Update FORM 2. Update FORM 2. Submits past 2. Process data
IA1 (in notebook) IB1 after each months FORM for entry to the
after each sup- supplementation lC/llA to PSO micro-computer
plementation &:: &:: medical for monitoring
medical follow- follow-ups analysis
ups 2.1 edit consistencyand
accuracy
3. Let mother 3. Accomplish 3. Collectsthe
acknowledge re- FORM IC/llA accomplished
ceipt of supple- for request of monitoring forms
ments in the supplies from from RHMs of
FORM IC/llA the RHM level all barangays in
Form prepared and distribution the municipality
by RHM for the to PW (the latter & submits to PSO
barangay upon w /the assistance
issuance of sup- of BHW for sup·
plements plements).
4. Accompllshes 4. Accompllshes
Supplementation FORM M: after
Records portion each regular
of FORM 101 consultation
during issuance withPW
of supplements
5. Accomplishes
FORM ID1 for
the pregnancy
outcome and infant
follow-up
portions
183
2.2 enter data for
each PW i n the
master Table of
PWData
2.3 Pack andsends
to NCP the ff.
- accomplished
I
monitoring forms
- completely
filled-up Master
Table ofPW
Data
- empty bottles
for cleaning
,
e

•
Project Duties &: Responsibilities Per Implementors
Opention BHW-PHCC Health Officersl
Members RHM. PHN PSO DN PHCC Chainnan
Level of Implementation
Barangev Municipal Provincial District MunlRe.'\
6. AceoIDl'lishes
FORM C. for
each 3 - 6 months
follow-up after
birth
7. Submits all
completely
accomplished
forms to PHN
- FORM IBI
- FORM IC/IlA
-FORMIDl
-FORM"M"
-FORM "c-
F. Organiza- • Continuous in- • Assist PHCC • Act as resource • Act as resource
tional building volvement in the duringprogram- person during person during
for theproject implementation ming and plan- programming nutritionprogofthe
project ningofPHCC and planning ramming and
ofPHCC planning of
PHCC
,
184
.

Re: FERRIN
83. Problem - Side effects of FERRIN which include the following:
a) chest pain
b) edema
c) severe nape pain
d) dizziness
e) vomi tting
f) gastro intestinal pain
g) L8M
Action Taken - A validation team will be investigating this sometime in June.
Samples of FERRIN and other iron preparation in the area were presented to FDA for
analysis of potency and contamination.
84. Problem - Fishy taste of iron causing nausea and vomitting among PW.
Recommendation - Can the project consider coating the iron tablets with sugar?
85. Problem - Refusal of mother to take FERRIN
Recommendation - investigate the reasons and further motivation
B6. Problem - midwife complaints on the retrieval of iron bottles.
Recommendation - this should be done to lessen additional cost of supplementation.
Re: NIE and Forms
B7. Problem - delayed distribution of Supervisor's Manual for PHN
B8. Problem - need additional forms in the RHU in case the RHM goes on leave with her
locker locked.
Action Taken - Extra forms to be kept at RHU has been distributed this May, 1985
delivery.
C. Re: Monitoring
Cl. Problem - Filling in of the Maternal Record is time consuming and too many forms to
accomplish.
Action Taken - variables and forms were restudied. Form 101 and 102 have been
revised to include the most significant variables from the MHR. MHR will be dropped
unless desired by municipality/province. Form 1C will be accomplished per BHS
instead of per barangay.
C2. Problem - Submitted forms by the RHM were not properly completely and accurately
filled in.
Recommendation - Proper filling-in of forms should be discussed during monthly staff
meetings.
C3. Problem - Delays in consolidation because of delayed submission by RHM
186

O. Re: Overall Project Implementation
01. Problem - failure of some BHWand PW to get their supply on time
Recommendation - mobilization of the barangay PHCC is needed, MHO should
coordinate with the municipality PHCC for the administration of this project
02. Problem - non-cooperation of some RHMs
03. Problem - Non-cooperating of some BHWsbecause of
a) too many forms
b) overloaded wi work
c) need incentives
Recommendation - Ayerage no. of PW per BHW is less than one. ·This means that a
BHW has the average one visit to make every week to her PW neighbor and which
will also take her one or two minutes of recording the PW's compliance to
supplementation.
Problem - What help can be given to AP's aside from NIE materials (This was from
the Control Group).
Recommendation - The project is a research of whose objective is to compare
effectiveness of the 4 treatments. As such modifications like giving of FERRIN in
control should not be made. However, existing interventions to APs before the project
maybe given which may include distribution of available ferrous sulfate tablets to
anemic mothers.
187

Project Activity
1. ID and Enrollment of PW
2. Requisitioning/Receipt of
Supplies
3. Delivery of .Supplies
AppendixH
Findings on IFSD Project Implementation
(August 1985)
IECGroup
1.1 Coverage - only 74% of PW were enrolled for IFSD
intervention compared with the 75% target (PW)
coverage of the project
1.2 BHW Involvement - 78% of the BHW interviewed
were involved in the ID and enrollment of PW
1.3 Place of Pre-Natal - 91% of the PW interviewed go to
the MHC/BHS for their pre-natal check-up
2.1 Schedule of Requisitioning - 68% of RHM submit
their requisitions to the PHN before delivery
schedule; as a result, stocks unloaded for some BHS
were based on estimates.
2.2 On Accomplishment of Project Forms - Some midwives
do not fill up the required forms for requisition and
receipt of supplies
2.3 On validation of Requests - PHN sometimes fails to
double check requistions of midwives which may
result to under or over supply of supplements and
forms.
3.1 Percentage of PW who Received IEC materials:
Anemia Brochure 73%; Food Prescription Slip - 55%.
The project expects that all PW enrolled should
receive these IEC materials .
3.2 Importance of IEC materials - IEC materials are
given to assist the BHW/RHM to motivate the PW
on compliance to supplementation practices.
However, the BHW/RHM do not always give
explanations on the contents and imprortance of the
lEC materials upon issuance to the PW. Hence, the
objectives of these brochures are not fully achieved
3.3 Other Problems
- Difficulty of RHM in getting lEC materials
from the MHC due to distance
accessibility problems
- Frequent request for incentives for
BHW/RHM
188

4. Monitoring Compliance to
Supplementation and
Protocol
5. Monitoring of Pregnancy
Outcome
4.1 Follow-up Visits: Follow-up visits of PW to monitor
and record compliance to supplementation on RHU ­
given medicines is found out to be difficult for
RHM/BHW. Reasons for this difficulty are as
follows:
a) distance/accessibility to PW's house
b) BHW has no time because of her work and. no
incentives
c) laziness of BHW
d) workload of RHM
4.2 Accomplishment of supplementation Card
This card records among other the PW profile which
will provide da ta on compliance and pregnancy
outcome. Among the PW who were given/prescribed
to take-in supplements (medicines), only 64% of the
cards seen during validation were filled up.
Moreover, some FW do not have a supplementation
card.
5.1 Monitoring of Weight Data
Compliance to weighing of infants by RHM at birth
was 84%; and weighing infants 28 days after birth
was only 59%. Reasons cited by the midwives for
their failure to weigh are as follows:
a) MW was not informed immediately by hilot
about delivery
b) PW delivered in hospital
c) Distance/inaccessibility to PW's house
d) Tight schedule of MW particularly for the 28th
day follow-up weighing
5.2 Submission of Monitoring Reports:
difficulty/delays in retrieval of
monitoring forms
incomplete/inconsistent information in ID2and
MHR
189

Project Activity
1. 1D and Enrollment of PW
2. Requisitioning/Receipt of
supplies
3. Delivery of Supplies
Findings on IFSD Project Implementation (August, 1985)
Food Gll!I!P
1.1 Coverage - Only 52% of PW were enrolled for IFSD
intervention compared with 75% target (PW)
coverage of the project
1.2 BHW Involvement - 36% of the BHW interviewed
were involved in the 1Dand enrollment of PW
1.3 Place of Pre-natal - 91% of the PW inierviewed go to
the MMC/BHS for their pre-natal check-up
2.1 Schedule of Requisitioning: 71% of RHM prepare
their requisitions before delivery schedule
2:2 On accomplishment of project forms: Some midwives
do not fill-up the required forms for requisitioning
and receipt of supplies
2.3 On validation of requests: PHN sometimes fails to
double check requisitions of midwives which may
result to under or oversupply of supplements and lEC
materials
3.1 Source of Supply: 92% of the PW receive their
supplements from the BHW 8% of the PW receive
their supplements from the RHM
3.2 No. of Nutrina Received Per Month: 42% of PW
received S 25 packs per month; 58% of PW received
26- 30 packs per month (Required packs to be received
= 30 packs/mo.) Linkage happen anywhere within
the delivery channel (RHM>BHW>PW). Possible
reasons for linkages are as follows: Nutrina used as
incentive to the BHW; Nutrina used as "payment" for
transport of supply; irregular involvement of BHW in
delivery; failure of RHM to check regularity of
delivery of supply to PW.
3.3 Percentage of PW who received IEC materials:
Anemia Brochure - 50%; Nutrina Borchure - 33%.
Food Prescription Slip - 33%; The project expects that
all PW enrolled should receive these IEC materials
3.4 Importance of IEC materials: IEC materials are given
to assist the BHW/RHM to motivate the PW on
compliance to supplementation and improve
knowledge on maternal health and nutrition
practices. However, the BHW/RHM do not always
give explanations on the contents and importance of
the IEC materials upon issuance to the PW. Hence,
the objectives of these brochures are not fully
achieved.
190

4. Monitoring Compliance to
Supplementation and
Protocol
3.5 ' Other Problems:
- Difficulty of RHM in the transport of Nutrina
to BHS not reached by delivery vehicle
Frequent request for incentives for BHW/RHM
Non-involvement/irregular involvement of BHW
in delivery due to work and attitude
4.1 Intake of Nutrina -
50%of PW consume 1 pack per day
33% of PW consume 2 packs perday
17% of PW consume 3 packs perday
Intake of more than one pack/day may suggest that
Nutrina is used not just as a supplement for the PW
but for the other household member especially the
children as some mothers were honest enough to
admit
4.2 Effects of Supplementation - No reported negative
effects of Nutrina. However, there are
apprehensions among some PW that-too much intake
of sweets might result to having a big baby, hence the
difficulty in deliver
, 4.3 Follow-up Visits: Weekly follow-up visits of PW to
monitor and record compliance was found out to be
difficult for the RHM/BHW. Reasons for this
diffuculty are as follows:
a) distance/accessibility to PW's house
b) BHWhas no time because of her work and no
incentives
c) laziness of BHW
d) workload of RHM
4.4 Accomplishment of Supplementation Card:
This card records among others the pregnant women's
profile which will provide data on compliance and
pregnancy outcome. However, among the
supplementation cards seen during validation, only
42% were filled-up. Moreover, some PW do not have
a supplementation card.
191

5. Monitoring of Pregnancy
Outcome
5.1 Monitoring of Weight Data. Compliance to weighing
of infants by RHM at birth was 83%; weighing of
infants 28 days after birth was also 83%. Reasons
cited by the midwives for their failure to weigh are
as follows:
a) MW was not informed immediately by hilot
about delivery
b) PW delivered in hospital
c) Distance/Inaccessibility to PW's house
d) Tight schedule of MW particularly for the
28th day follow-up weigh
5.2 Submission of monitoring reports:
difficulty / delays in retrieval of
monitoring forms
incomplete/inconsistent information in IDI and
MHR
192

Project Activity
1. ID and Enrollment of PW
2. Requisition/Receipt of
Supplies
3. Delivery of Supplies
Findings onIFSD Project Implementation (August, 1985)
IronGroyp
1.1 Coverage - Only 43% of PW were enrolled for IFSD
intervention compared with 75% target (PW)
coverage of the project
1.2 BHW Involvement - 49% of the BHW interviewed
were involved in the ID and enrollment of PW
1.3 Place of Pre-natal - 95% of the PW interviewed go to
the MHC/BHS for their pre-natal check-up
2.1 Schedule of Requisitioning: 72% of RHM submits
their requests to the PHN before delivery schedule;
as a result stocks unloaded for some BHS were based
on estimates
2.2 On accomplishment of project forms: Some midwives
do not fill-up the required forms for requisitioning
and receipt of supplies
2.3 On validation of requests: PHN sometimes fails to
double check requisitions of midwives which may
result to undersupply or oversupply of supplements
and IEC materials
3.1 Source of Suply: 11% of the PW receive their
supplements from the BHW; 62% of the PW receive
their supplements from the RHM; 27% of the PW go
to the BHS/MHC to get their supplements
3.2 Receipt of IEC materials - Percentage of PW who
receive IEC materials Anemia Brochure 65%, Ferrin
Brochure, 71%; and the Food Prescription Pad 43%.
The project expects that all PW enrolled should
receive these IEC materials.
3.3. Importance of IEC materials - IEC materials are
given to assist the BHW/RHM to motivate the PW
on compliance to supplementation and improve
knowledge on maternal health and nutrition
practices. However, the BHW/RHM do not always
give explanation on the content and importance of the
IEC Materials upon issuance to the PW. Hence, the
objective of these brochures are not fully achieved.
3.4 Other Problems in delivery:
Difficulty of RHM in the transport of Ferrin
from MHC due to distance and inaccessibility
problems
Frequent request for incentives for BHW/RH¥
Non-involvementlirregular involvement of BHW
in delivery due to work and atittude
193

4. Monitoring Compliance to
Supplementation and
Protocol
5. Monitoring of Pregnancy
Outcome
4.1 . Intake of Ferrin -
92% of PW take 2 tablets/day
6% of PW take 1 tablet per day
2% of PW take 3 tablets per day
4.2 Effects of Supplementation - 64.5% have experienced
the positive effects while only 12.5% of the PW
interviewed experienced negative effects, 23%
experienced no change at all
4.3 Follow-up Visits: Weekly follow-up visits of PW to
monitor and record compliance was found out to be
difficult for the RHM/BHW. Reasons for this
diffuculty are as follows:
a) distance/inaccessibility to PW's house
b) BHW has no time because of her work and no
incentives
c) laziness of BHW
d) workload of RHM
4.4 Accomplishment of Supplementation Card:
This card records among others the pregnant women's
profile which will provide data on compliance and
pregnancy outcome. However, among the
supplementation cards seen during validation, only
37% were filled-up. Moreover, some PW do not have
supplementation,card.
5.1 Monitoring of Weight Data. Compliance to weighing
of infants by RHM at birth was 69% and weighing of
infants on the 28th day after birth was only 54%.
Reasons cited by the midwives for their failure to
weigh are as follows:
a) MW was not informed immediately by hilot
about delivery
b) PW delivered in hospital
c) Distance/Inaccessibility to PW's house
d) Tight schedule of MW particularly for the
28th day follow-up weighing
5.2 Submission of monitoring reports:
difficulty/ delays in retrieval of
monitoring forms
incomplete/inconsistent information in form
ID1 and MHR
194
;.

Project Activity
1. ID and Enrollment of PW
2. Requisition/Receipt of
Supplies
3. Delivery of Supplies
Findings on IFSD Project Implementation

4. Monitoring Compliance to
Supplementation and
Protocol
3.5 Other Problems in delivery:
- Difficulty of RHM in the transport of
Nutrina/Ferrin from MCH due to distance
and inaccessibility problems.
Frequent request of incentives for
BHW/RHM
Non-involvement/irregular involvement of
BHW in delivery due to work and atittude
4.1 Intake of Nutrina/Ferrin -
93% of PW consume take 1 pack/day
7% of PW take 3 packs per day
Intake of more than 1 pack/day may suggest that
Nutrina is used not just as a supplement for the PW
but for the other household members especially the
children as some mothers were honest enough to
admit. 95% of PW take 2 tablets per day; 5% take 3
tablets per day
42 Effects of Supplementation - 64.5% have experienced
the positive effects while only 12.5% of the PW
interviewed experienced negative effects, 23%
experienced no change at all for Ferrin.
No reported side effects of Nutrina. However, there
are apprehensions among some PW that too much
intake of sweets might result to having a big baby,
hence, the difficulty in delivery.
4.3 Follow-up Visits - Weekly follow-up visits of PW to
monitor and record compliance was found out to be
difficult for the RHM/BHW. Reasons for this
diff iculty are as follows:
a) distance/inaccessibility to PW's house
b) BHWhas no time because of her work and no
incentives
c) laziness of BHW
d) workload of RHM
4.4 Accomplishment of Supplementation Card
This card records among others the pregnant women's
profile which will provide data on compliance and
pregnancy outcome. However, among the
supplementation cards seen during validation, only
75% were filled-up. Moreover, some PW do not have
supplementation card.
196

5. Monitoring of Pregnancy
Outcome .
5.1 Monitoring of Weight-Data Compliance to weighing
of infants by RHM at birth was 100%; weighing of
infants 28 days after birth was only 80%. Reasons
cited by the midwives for their failure to weigh are
as follows:
a) MW was not informed immediately by hilot
about delivery
b) PW delivered in hospital
c) Distance/lnaccessibiliIy to PW's house
d) Tight schedule of MW particularly for the
28th day follow-up weighing
5.2 Submissionof monitoring reports
difficulIy/delays in retrieval of
monitoring forms
incomplete/inconsistent
information in form 101 and MHR
197

.
Appendix I. Plan of Action for the Integration of the IFSD PRoject in PRe
Food GroUI>
Person in October November December
Problems
1. Problems
Constraints
• resignation of some
Solutions
• reorganize-
Activities
• dialogue w/
charee
MHO
1
x
2 3 4 1 2 3 4 1 2 3 4
Affecting members of the MPHCC tion existing mem-
PHC bers of the
. Structure
2. None
3. None
MPHCC regarding
vacancy
• filling up of
the vacancy
4.110& • Late enrollment of the ·IEC by the re-motivation RHU x
enrollment PW due to unawareness RHM and PHN and recruit- staff
ofPW of the on-going project in chaircatch- ment of new
eNon-involvement e.g. ment areas volunteer
attending school, work- «motivation & workers
ing, no incentives recruitment of
new volunteer
workers .
4.2 Requisi- •.non-accomplishment • motivation • re-orienta- PHO,DN x
tion and of the required project on the part of tion of RHM on
receipt of forms - added work theRHM the importance
supplies
ofthediff.
forms
43 Delivery
of Supplies • PW does not receive th • frequent dial- dialogue bel. x
right amount of Nutrina ogue of the theRHM&
because of the under- RHM,BPHCC BHW
delivery of required and RHM
(packs) supply by the
PW
4.4 Monitor- • Difficulty to conduct • motivation on follow-up x
ofCompli- follow-up visi Is of PW BHW on imporance
to sup· by BHW/RHM - due to tance of follow
plementation distance, workload up of supple-
- to protocol mentation date
4.5 Monitor- • insufficient weighing • BHWshould barangay
ing of for BHW and hilots make arrange- officials
Pregnancy • non-follow-up of mcnt in the
Outcome hilot deliveries due to rotation of
distance and terrain weighing
scales
198

Iron GroUD
Problems Constraints Solutions
• coordinate WI
the local gov't
(MLG) wi regards
to the
construction of
better roads
1. Problems
Affecting
PHC
Structure
2. Problems
on Specific
Roles of
MPHCCI
MHO
1) No regular meetings
conducted
2) No RCG organized
due to lack of orientation
and it is not a felt
need
1) there shld.
be a regular
meeting to be
conducted on a
fixed date to be
decided upon
by the committee
members
Person ir Odober November December
Adivities charge 1 '2 3 4 1 2 3 4 1 2 3 4
1) special mlngs MPHCCI
to set date of MHO
regular mtngs,
2) and possible MPHCC
restructuringof
the MPHCC
1) Lack of proper orient- 1) there shld. 1) re-briefing
ation and coordination be a formal 2) periodic
of IFsD both with the briefing & coor- dialogue bet.
MPHCC and MHO dination in the NCP represen-
2) Lack of supervision implementa- tatives, MHO,
and control on the part tion of IFSD MPHCC on
of the MHO brought 2) involvement the progress
aboui by the non - in- of MHO from of the program
volvement since the the startof and problems
start of the program the program encountered
3) there shld.
be a periodic
appraisal of
the program
together wi
the problems
encountered.
3. Problemson 1) no regular meetings
PHC Linkage conducted
4.1 In the
IFSD Activities
- ID
and Enrollmentof
PW
1) Distance, terrainand
accessibility
2) inadequate information
on the concept of
the orozrarn
- periodic
meetings shld.
be conducted b)
MPHCCand
I)HW
1) maximize
utilization of
BHW
2) Intensification
of IEC
1) re-training
ofBHW
199
15
program not later than Oct. 30,1985
coordina
tor at the
prov'!.
level
RHU personnel
NCP personnel

FOOD AND IRON GROUP
Person ir October November December
Problems
4.2..........none
Constraints Solutions Activities charge 1 2 3 4 1 2 3 4 1 2 3 4
4.3......... none
4.4.........none
4.5 ....... none
1. Problems I) irregular meeting I) Dialogue I) Atleast PHO/ x
Affecting w / the chair- quarterly chairman
PHC man of the meeting MPHCC
Structure MPHCC chairman
2. Problems Orientation on lFSD -to call a meeting/ Chairman x
on Specific between BPHCC and meeting/dia- dialogue MPHCC
Roles of MPHCC members logue between
MPHCC/ members
MHO
3. Problems Written reports to duplicate all duplicate of Nurse x x x
onPHC Mayors regarding reports so as reports
Linkages project therefore to have a copy
additional forms be for the mayro
given per RHU
4.1 !Dand - BHW involvement in . Intensive dialogue Nurse x x x
Enrollment of identification of PW motivation
PW is only 53%
4.2 Requisi- - requisition forms not - closer super- supervisor Nurse x x x
tion and re- filled up on time vision bynurse
ceipt of - failure of nurse to onPW
supplies check requisitions of
4.3 Delivery 1) low participation of I) motivation meeting bel. x x x
Supplies BHW in the distribu- to midwife and
tion of Ferrin (Adv, of proj.) BHWw/in
2) transport of supplies carchment
,
area
-confer w.
BPHCCand
ask help
4.4 Monitoring- weekly follow-up of - follow-up
of Comolianc4PW comoliance bv PW at risk
200
-.
,
,.'

FOOD AND IRON GROUP
Person ir October November December
Problems Constraints Solutions Activities cheree 1 2 3 4 1 2 3 4 1 2 3 4
-to suppleme RHM and BHW os low only, for
ation normalPW-
- to protocol monthly
4.5 Monitorin - Monitoring of weight - closer superof
Pregnancy on the 28th day after vision of PW
Outcome birth (80%) only byNurse/MlK
- delegate
weighing to
BHW
1. Problems 1) no representative/ 1) convince
Affecting action officers PHC/rep]ace
PHC 2) lack of regular members who
Structures meetings dropped
3) lack of manpower/ 2) agreementorganization
MPHCC quarterly semichairman
very busy quarterly, etc.
4) difficultyin conven- 3) one group reing
the group sponsible for
training course
2. Problems 0 1) role of chairman 1) further cla- meeting/ Chairman
Specific Roles not clear rification of dialogue MPHCC
ofMPHCC/ the role of the
MHO MPHCCby
provincial
primary action
group
3. Problems 0 1) lack of coordination 1) coordination
PHC Linkage between linkages with other
agencies
4.1 .....none
4.2 ..... none
4.3 ......none
4.4 ...... none
45 Monitorin 1) Difficulty in moni- 1) follow-up 1) follow-up
of Pregnancy toring pregnancy out- visit to PW visit to PW
Outcome come by the hilots delivered by
and the hospital the hilots and
hospitals
201

Level:
Appendix J. Summaryof Plan of Action for the Integration of IFSD Project in PHC(t)
District
Planned Activities Plan of Work to Implement
(As ID in the Seminar-WorksholJ Role Identified Role Schedule Staff Assi2ned
L PHC Structure
1. Reorganization/Reactiva- - takechargeof reactiva- - ID and prioritizemunition
of PHC Com ting MPHC Com by cipalities which need ANS,DNand
frequent dialogue reorganization Before End of Special Field
- schedulereorganization of 1985 Services Task
of MPHC Force
IT. Reorganization of Roles on - provide assistance to the . simultaneous w / reorgani-
- PHCC municipalitieson orient- zation
- IFSD ation of roles
2.1 Reorientation on Roles - coordinatorof orienta- - ANS/DN to give feed- Before End of ANS,DNand
of MPHCCom/BPHCCc tion back on progress of IFSD 1985 Special Field
on IFSDand on PHC and on restructuring to - Monthly Services Task
district chief Force
2.2 Dialogue between Projec - ANS/DN to get regular
Coordinators and Imple feedbacks from PHN /
mentors on IFSD status RHN
and problems
IlL PHCLinkages
3.1 Periodic Dialogue - Coordinators . simultaneous or immediate- ANS,DNand
between Mun.

\
Level: IPHO
Integration of IFSD Project In PHC
Planned Activities Plan of Work to Implement Staff
(Asm in the Semtnar-worksbce Role Identified' Role Schedule Assllllted
I. PHC Structure
1. Reorganization/Reactiva- - provide technicalassist- - frequent / informal dialogue during routin Dr.Ordofla
tion of PHC Com ance to districton re- with district staff during routine PHOCstaff
organization and reorient- visitations visits PRM
ation of roles, whenever - dialogue w / district chief whenever
necessaryor requested. neccessary
monthly
II. Reorganizationof Roles on meeting
- PHCC
- IFSD
2.1 Reorientation on" Roles
of MPHCCom/BPHCCom
on IFSDand on PHC
2.2 Dialogue between Projec -coordinate w/proj.
Coordinators and Imple coordinators on project
mentors on IFSD status status
and problems
m. PHC Linkages
IV. Project Activities
4.1 Retraining/Recruitment
ofBHW
4.2 Dialogues/motivation - provide technical - informal dialogue during
ofBHW support to staff visits
4.3 Follow-up of RHMs re - Municipality
accomplislunent of Forms
4.4 Frequent dialogues - Monitoring . Monitoringcompliance of
between RHM & BHW reports Monthly
on delivery of supplies Routine
4.5 Dialogue between RHM - provide feedback to RHO
& BPHCCom on project thru a Prov'l consolidated.
status/problems Report
4.6 Admin & Technical
Support to MHO & PHN
4.7 Follow-up of RHM by
PHN on submission of
101/102
203

Table 3: Distribution of pregnant women by fat intake adequacy.level and treatment group, pre-and posl-sun'ey
Fat Pre-Survey Post-Survev
Intake
I'" OFRDA)
Food
No.
Imn
No.
FoodIt Ieo
No.
NIE
No.
Total
No. No.
ood Imn-' .
No,
Food 6: 11'0
,No. .'"
NIE
No.
Total
No.
'"
'"
'"
'"
'"

(
Table 5: Distribution of pregnant women by iron intake adequacy level and treatment group, pne-uul po.Hurvey
Iron Pre-Survey Post-Survev
Intake
(" OFRDA)
Food Iron Food &:1m NIE Total
No. No.
" "
Food Iron food 6: 1m NIE Total
No.
" No.
" No.
"
No. No. No. " " " No. " No.
"
0-24 10 5.0 12 6.1 9 4.5 9 42 40 5.0 4 20 6 3.0 1 0.4 7.0 3.1 18 21
25-49 67 33.7 65 328 57 28.8 77 363 266 33.0 63 31.2 83 41.7 56 233 45 19.9 247 28.5
50-74 63 31.7 51 25.8 85 4.29 77 363 276 34.2 75 37.1 57 28.6 86 35.8 83 36.7 301 34.7
75-99 40 20.1 32 16.2 28 14.1 25 11.8 125 15.5 33 163 32 16.1 66 27.5 52 23.0 183 21.1
'100 19 9.5 38 19.2 19 9.6 24 113 100 12.4 27 13.4 21 10.6 31 12.9 39 17.3 118 13.6
TOTAL 199 100 198 100 198 100 212 100 8117 100 202 100 199 100 240 100 226 100 867 100
Table 6: Distribution of pregnant women by Vit C intake adequacy level and treatment gmup, pre-andpost-survey
Vit.C Pre-Survev Post-Survev
Intake Food Iron Food &:Ire NIE Total Food Iron Food &:11'0 NIE Total
(.. OFRDA) No. .. No• .. No. No.
" .. No. No. .. No. .. No• .. No. .. No.
"
..
0-24 52 26.1 81 40.9 67 33.8 63 29.7 263 32.6 91 45.0 96 48.2 72 30.0 SO 35.4 339 39.1
25-49 37 18.6 49 24.7 50 25.3 69 32.5 205 25.4 54 26.7 48 24.1 78 32.5 42 18.6 222 25.6
50-74 24 12.1 22 11.1 31 15.7 35 16.5 112 13.9 28 13.9 24 12.1 38 15.8 32 14.2 122 14.1
75-99 19 9.5 7 3.5 19 9.6 10 4.7 55 6.8 8 4.0 9 4.5 17· 7.1 22 9.7 56 6.5
'100 67 33.7 39 19.7 31 15.7 35 16.5 172 213 21 10.4 22 11.1 35 14.6 50 221 128 14.8
TOTAL 199 100 198 100 198 100 212 100 807 100 202 100 199 100 240 100 226 100 867 100
207

Table': Distribution of prrgnanl women byretinol intake adequacy level and tru.tm.mt group, preoand poskurvey
Retinol Pre-Survev Post-Survev
1nbk. Food Iron Food&:11'0 NlE ToW Food Iron Food &: 1m NIE Total
('" OFRDA) No. ... No. ... No. ... No. ... No. ... No. ... No • ... No • ... No. ... No. ...
0-24 65 32.7 49 24.7 56 28.3 63 29.7 233 28.9 64 31.7 70 35.2 7S 31.3 53 235 262 30.2
25-49 80 40.2 83 41.9 83 41.9 80 37.7 326 40.4 86 42.6 64 32.2 89 37.1 89 39.4 328 37.8
50-74 36 18.1 36 18.2 40 20.2 29 13.7 141 175 28 13.9 35 17.6 51 21.3 49 21.7 163 18.8
75-99 11 55 14 7.1 10 5.1 23 10.8 58 7.2 13 6.4 17 85 12 5.0 16 7.1 58 6.7
> 100 7 35 16 8.1 9 4.5 17 8.0 49 6.1 11 5.4 13 65 13 5.4 19 8.4 56 65
TOTAL 199 100 198 100 198 100 212 100 807 100 202 100 199 100 240 100 226 100 867 100
Table 8: Distribution level of pregnant women by thiamine intake adequacy level and treatment group, pre-and posHurvey
Thiamine Pre-suwev Post-Surv_
Inlne Food Iron Food &:tre NlE Total Food Iron Food II; 1m NIE Total
(","OFRDA) No. ... No. ... No. .... No. ... No. ... No. ... No . ... No. ... No. ... No. ...
0-24 27 13.6 29 14.6 18 9.1 25 11.8 99 12.3 16 7.9 24 12.1 9 3.8 19 8.4 68 7.8
25-49 97 48.7 84 42.4 84 424 94 44.3 359 445 88 43.6 88 44.2 86 35.8 82 36.3 344 39.7
50-74 42 21.1 37 18.7 64 32.3 63 29.7 206 255 56 'Zl.7 62 31.2 83 34.6 76 33.6 277 31.9
75-99 14 7.0 30 15.2 22 11.1 21 9.9 87 10.8 21 10.4 16 8.0 32 13.3 23 10.2 92 10.6
>100 19 95 18 9.1 10 5.1 9 4.2 56 6.9 21 10.4 9 45 30 125 26 115 86 9.9
TOTAL 199 100 198 100 198 100 212 100 807 .100 202 100 199 100 240 100 226 100 867 100
208
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;

,
Table9: DUtrlbution of pregnant women by riboflavinintakeadequacylevel and treatment poup, pre-&nd. post-sarvey
RIB Pre-SurveY Post-SurveY
Intake Food Iron Food 6: Ire NIE 'ToUl Food Iron Food 6: 110 NIE ToUl
('" OPRDA) No. No. No. No. No. No. No. No. No. No.
'"
'"
'"
'"
0-24 48 24.1 46 232 G 21.7 48 22.6 185 22.9 32 15.8 36 18.1 21 8.8 31 13.7 120 13.8
25-49 106 53.3 97 49.0 106 53.5 111 52.4 420 52.0 109 54.0 114 57.3 124 51.7 109 48.2 456 52.6
50-74 33 16.6 34 172 36 18.2 41 19.3 144 17.8 46 22.8 39 19.6 68 28.3 61 27.0 214 24.7
75-99 7 35 16 8.1 9 45 7 3.3 39 4.8 9 45 7 35 18 75 17 75 51 5.9
2100 5 2.5 5 2.5 4 2.0 5 2.4 19 2.4 6 3.0 3 15 9 3.8 8 3.5 26 3.0
TOTAL 199 100 198 100 198 100. 212 100 807 100 202 100 199 100 240 100 226 100 861 100
Table 10: Distribution of prepnt women by Niacin intake adequacy level and treatment group, pre-andposkurvey
Niacin Pre-survev Post-Survev
!nUke Food Iron Food AtIro NIE ToUl Food Iron Food" Iro NIE Total
('" OPRDA) No. No. No. No. .. No. No. No. No. No. No.
'"
'"
'"
0-24 2 1.0 I 05 0 0.0 2 0.9 5 0.6 2 1.0 0 0.0 0 0.0 I 0.4 3 0.3
25-49 18 9.0 13 6.6 9 4.5 14 6.6 54 6.7 4 2.0 9 45 12 5.0 9 4.0 34 3.9
50-74 41 20.6 37 18.7 51 25.8 59 27.8 188 23.3 30 14.9 39 19.6 26 10.8 27 11.9 122 14.1
75-99 56 28.1 42 212 47 237 52 245 197 24.4 50 24.8 G 21.6 50 20.8 56 24.8 199 23.0
.,00 82 412 105 53.0 91 46.0 85 40.1 363 45.0 116 57.4 108 54.3 152 63.3 133 58.8 509 58.7
TOTAL 199 100 198 100 198 100 212 100 807 100 202 100 199 100 240 100 226 100 861 100
..
o
209
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Table 11 : Distribution of pregnant women by B carotene intake adequacy level and treatment group, pre-and post-survey
B carotene Pre-survev Post-Survev
Intake
(,. OFRDA)
Food Imn Food ok lro NlE Total
No.
"
Food Imn Food ok lro NIE Total
No.
" No.
" No.
" No.
"
No.
" No.
" No.
" No.
" No.
0-24 71 38.7 83 41.9 75 37.9 .. 39.6 319 395
.' , "
82 40.6 90 45.2 69 28.8 72 31.9 313 36.1
25-49 50 25.1 38 19.2 37 18.7 48 22.6 173 21.4 50 24.8 52 26.1 50 20.8 21 9.3 173 20.0
50-74 29 14.6 32 16.2 23 11.6 28 13.2 112 13.9 28 13.9 22 11.1 41 17.1 33 14.6 124 14.3
75-99 13 65 13 6.6 18 9.1 15 7.1 59 7.3 11 5.4 13 65 20 8.3 17 7.5 61 7.0
>tOO 30 15.1 32 16.2 45 22.7 37 175 144 17.8 31 15.3 22 11.1 60 25.0 83 36.7 196 22.6
TOTAL 199 100 198 100 198 100 212 100 807 100 202 100 199 100 2.0 100 226 100 867 100
210