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Seeds, Knowledge, and Support: Preventing Maternal and Child Malnutrition During the First 1,000 Days [UPDATED: December 18]

Malnutrition is an underlying cause of death for 2.3 million children each year and contributes to poor health and poverty for millions more. In Rwanda, the situation is critical; 44% of children under the age of five suffer from chronic malnutrition. Gardens for Health International will adapt our innovative model - providing families with the seeds, knowledge, and support to fight and prevent malnutrition in their homes - to an earlier point in the continuum of care: during pregnancy. By expanding our program to this critical entry point, we will deliver an integrated and preventative model that reinforces public sector efforts and strengthens the focus on one of Rwanda’s most pressing health challenges: chronic malnutrition.

Photo of Jessie Cronan
23 20

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Gardens for Health International will provide peer-to-peer agricultural support, health education, and accompaniment to vulnerable pregnant mothers. By using these methods to address maternal and child undernutrition during the 1000 day window of opportunity, we will strengthen the quality of antenatal care (ANC) interventions and provide a preventative and supportive framework for mothers and children to thrive.

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.

Who will benefit from this idea and where are they located?

Gardens for Health works with smallholder farm families for whom agriculture has the potential to be a key driver of better health, but who – for a variety of reasons – are struggling with malnutrition and its effects.

This idea will be implemented in Musanze District, where chronic malnutrition rates are among the highest in the country (63.3%), and where 91% of the population is engaged in agriculture. It will target pregnant women in Ubudehe 1 and 2, the country’s most vulnerable socio-economic categories, who reside within the catchment areas of a subset of our partner health centers.

How could you test this idea in a quick and low-cost way right now?

There are a variety of methods in which we could test our idea immediately and in a low-cost way. We would organize focus groups and one-on-one interviews with currently enrolled or graduated mothers. This discussion and reflection will allow us to identify the barriers and facilitators to achieving optimum nutrition during pregnancy in partnership with mothers. We would also interview staff at our current partner health centers, with an emphasis on speaking with the maternal and child health community health workers, on the barriers and facilitators they face to helping women and children achieve lasting health and nutrition outcomes. Both of these methods would help us to better understand how to best adapt and expand our proven program approach to meet the needs of pregnant women at this earlier entry point in the continuum of care. Finally, we would also conduct a review of the existing evidence on programs and interventions in order to further inform and refine our program design and implementation.

What kind of help would you need to make your idea real?

Expertise and experience with the following: models of accompaniment / mentor mothers; health and agriculture programs targeting pregnant women in developing countries; effective programmatic approaches to strengthening antenatal care platforms, particularly with achieving four or more antenatal care visits and reaching compliance with WHO’s recommendations prenatal supplementation.

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.

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Photo of Chioma Ume
Team

Hello Jessie! We've been having early childhood experts take a look at the ideas in Refinement and I'd like to share some of their feedback with you: Consider the most effective ways to train community health workers to engage and motivate them as well as supervise them on an ongoing basis. Also consider their existing job functions and how best to integrate the new training and activities so that it is feasible. It looks like you are considering a model that begins with attention to ante-natal care but contributes to a continuum of care through the early years. Would this include paying attention to the social and emotional well being of mothers and assisting them to provide responsive stimulating caregiving? The planned home visits could provide a means of delivering this more holistic package.

Photo of Jessie Cronan
Team

Hi Chioma:

Thanks so much for sharing this feedback. We really appreciate the expert input!

To answer the question that has been posed, the training modules that we deliver to our families include topics that impact indirectly impact health and nutrition outcomes -- such as gender based violence, mental health, listening and communication, and early childhood development. We feel that these topics are critical to delivering an integrated, holistic program that fully addresses the cycle of poverty and malnutrition that our families face.

In this context, the home visits that have been posed in this idea would support and enhance this full package - for both mother and child - from pregnancy through the child's first 24 months.

Thank you for giving us the space to highlight and articulate these components of our idea more clearly!

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