Establishing a lasting foundation for health through adequate nutrition
The nutritional status of a woman before and during pregnancy is critical for healthy pregnancy outcomes including the nutritional status of her child. Maternal undernutrition contributes to 800,000 neonatal deaths annually and is a risk factor for fetal growth restriction, which is associated with an increased risk of stunting at 24 months of age. Moreover, evidence shows that babies born to stunted and/or underweight women are more likely to be stunted and/or underweight themselves, a process often beginning with fetal undernutrition in utero. As such, the 1,000 days between pregnancy and age two offer a critical window of opportunity to establish a lasting foundation for health through adequate nutrition.
Given the linkages between maternal and child undernutrition, it is essential that maternal and child health interventions help pregnant women reach a state of optimum nutrition as early as possible during pregnancy. To this end, the antenatal care platform is a critical entry point for integrated and preventative care for pregnant women.
Rwanda's antenatal care platform is a strong vehicle for delivering maternal and child health interventions, with 98% of pregnant women attending at least one ANC visit. However, with only 35% of pregnant women meeting the minimum standard of four or more ANC visits and only 38% attending their first visit prior to their fourth month of pregnancy, gaps in this platform must be strengthened in order to maximize its impact and effectiveness. Likewise, compliance with the World Health Organization's recommendations for prenatal supplementation is exceptionally low, with less than 1% of women taking iron and folic acid supplements for at least 90 days during their last pregnancy.
Suggested program approach [UPDATED: December 18]
Using a two-pronged approach, our idea will blend district-wide capacity building and direct program implementation within a subset of Garden for Health's partner health centers. The capacity building component of this approach will utilize our partnership with the Musanze District and our previous experience training district-level nutritionists and community health worker supervisors, and will provide district-wide coverage and training to government-supported community health workers. The direct program implementation component of this approach will enroll pregnant women and their families into our intensive health and agriculture training and provide a model of preventative care and support.
Component #1: Capacity Building
- Train government-supported community health workers on strengthening nutrition-related knowledge and skills, with particular emphasis on pre and postnatal counseling and care, and essential nutrition and hygiene actions during the first 1,000 days;
- Train nurses, nutritionists, and heads of community health workers to create a supportive enabling environment for health workers and to strengthen the health system overall.
Component #2: Direct Program Implementation
- Enroll cohorts of pregnant women within a subset of our partner health centers;
- Hire and train mentor mothers from communities in the catchment areas of our partner health centers to deliver health and agriculture training and home visits and follow up;
- Deliver customized, in-depth health and agricultural education and training to cohorts during and after pregnancy;
- Provide nutrient-dense crops and small livestock, with an emphasis on iron, protein, and Vitamin A, to pilot cohorts via seasonal home garden package and livestock distribution;
- In collaboration with partner health centers, distribute iron and folic acid tablets and deworming pills to cohorts to ensure compliance with World Health Organization recommendations on prenatal supplementation;
- Provide counseling and follow up on the prevention of mother-to-child transmission (PMTCT) of HIV, as needed;
- Conduct maternal and child health-focused home visits and follow up on prenatal and postnatal care.
Preventative and curative: complementary programming [UPDATED: December 18]
While GHI’s core program works with families of children with a pre-existing clinical diagnosis of malnutrition, our idea differs from our core program approach by offering a complementary and reinforcing model designed specifically to prevent, rather than treat, malnutrition.
In addition to our idea’s focus on maternal nutrition during pregnancy, we will adapt the delivery of our training modules to be timed with critical points during pregnancy and from infancy through 24 months of age. For example, our training module on complementary feeding will be delivered when an enrolled mother’s infant is approaching six months of age, allowing her to practically and immediately apply optimal complementary feeding practices. By working with mothers and families from pregnancy through 24 months, we will also extend the duration of family-centered accompaniment (support, counseling, and home visits) that our families receive.
Our expertise and experience [UPDATED: December 18]
As a registered international NGO operating in Rwanda with the Ministry of Health, we currently work with 18 partner health centers across the Gasabo and Musanze districts of Rwanda. This year, GHI's core program will reach over 2,160 families and provide them with the seeds, livestock and education to assure both improved and lasting health. Our program has met exciting success: on average families enrolled in our program have seen their Household Dietary Diversity Score improve by more than 50%. Three years after enrolling in our program, 64% of children are at a healthy weight-for-age, compared to 43% at enrollment. Further, after just one season in our program, 71% of enrolled families report that they are consuming more self-produced food.
Mothers who have graduated from our program have also gone on to demonstrate impressive leadership within their communities. Some have even been elected as community health workers, providing the vital link between household management and clinical treatment of malnutrition. One recent graduate of our program identified more than 20 families in her community who were also struggling with malnutrition, and encouraged them to seek treatment at the health center and enroll in our program.
The demand for our core program, particularly in Musanze District, is high. While we currently enroll 40 families per health center per season, we saw an average attendance of 260 children at each of our 14 partner health centers during enrollment for our upcoming season. We believe that we are poised to leverage this existing demand and incentivize mothers to seek care and attend ANC visits earlier in pregnancy through the idea we have posed. For example, a formal diagnosis of pregnancy at one of our partner health centers may be a prerequisite for referral and entry to the preventation-focused program.
Beyond our core program, we also partner with the Government of Rwanda on the national campaign to eliminate childhood malnutrition, advocate for policies and programs that include agriculture and nutrition, and provide technical assistance and support to regional partners in East Africa.
Given our demonstrated success, existing partnerships with the Government of Rwanda and other NGOs, and above all, our commitment to the families we serve, we believe we are well-positioned to design and ultimately implement this idea.