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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
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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.

15 comments

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Spam
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.

Spam
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!

Spam
Photo of Lwala Community Alliance
Team

Gardens for Health- it is wonderful to see you in the refinement round. We admire your work in Rwanda and have been grateful for the training our Kenyan staff have received from you in the past.

You outlined the challenge of getting women to attend antenatal care early in their pregnancy. We see very similar trends in Kenya where women tend to wait until mid/late pregnancy to begin antenatal care, which is often the main reason that women do not achieve 4 visits (there just isn't enough time before delivery). This seems like a real challenge for prenatal nutrition in particular. How would you address this issue in the malnutrition intervention you describe? Can you talk more about that?

I am sure you are already working with women of reproductive age as a general target - regardless of whether they are currently pregnant. Could any insight be gleaned from these women?

In Lwala we have utilized Traditional Birth Attendants to conduct health outreach to pregnant women and encourage entry into antenatal care. Because Traditional Birth Attendants already have strong trust relationships with their clients, they may have access to earlier information on pregnancies. We also incentivize our outreach workers with incentive pay if their clients reach the 4 visits. Would that work in your context?

Spam
Photo of Jessie Cronan
Team

Hi Lwala:

Thank you for your input! We’re excited to see you in the refinement round as well. You’ve asked us excellent, thought-provoking questions that we’ve addressed below. We’ve also revised our idea description, and we would love additional comments and feedback from your team.

1.)Given the demonstrated demand for our program, one idea we have been discussing internally is to capitalize on this demand and use a formal diagnosis of pregnancy at one of our partner health centers (or attendance at a first ANC visit within the first trimester of pregnancy) as a prerequisite for women to be referred to and enrolled in our program.

2. )Yes, absolutely! We already have anecdotal information from the mothers that we have worked with stating that they would have liked to receive our training during more relevant points in the continuum of care (ie. learning about nutrition during pregnancy while pregnant, learning about complementary feeding as their child approaches six months, and so on). We hope to address this in our idea by tailoring our training modules for more timely and relevant delivery. We do plan to speak with women who have been in our program for their critical input and feedback during the refinement phase.

3. ) While we are unable to pay government-supported community health workers (although we can certainly explore what is and is not possible with the GoR's current performance-based financing programs), we hope that the capacity building component of our idea will build the effectiveness of CHWs. As you well know, CHWs play a key role at the community level, both in terms of identifying vulnerable families and building close and trusting relationships. We would love to hear if you have any suggestions or experience with non-financial incentives.

Spam
Photo of Lwala Community Alliance
Team

Thanks for taking the time to reflect and revise Jessie. It great that your current client base has expressed interest in learning about nutrition during pregnancy while pregnant, learning about complementary feeding as their child approaches six months, and so on.

We have heard about the use of WASH related items as a great incentive for prenatal care. So for instance a pregnant woman is supposed to come for 4 visits. On visit 1 she receives a Jerry Can for water. On visit 2 she receives chlorination tabs. On visit 3 she receives hand soap, etc. In this way you are using health tools to incentivize prenatal completion and at the same time strengthening her WASH behavior. Would their be a similar incentive scheme using nutrition or gardening items?

Spam
Photo of Jessie Cronan
Team

Hi Lwala:

Many thanks for the fantastic suggestions on non financial incentives! We really love the idea of using health tools to reinforce and incentivize antenatal care while simultaneously encouraging other optimal health-related practices and behaviors. We could develop a similar scheme based on our current home garden package by providing additional seeds and/or livestock as certain benchmarks (e.g. number of ANC visits, etc.) are met. Great idea!

Spam
Photo of Sanjali Jain
Team

A proper nutrition program is very necessary. Especially for people with low income. Mostly they can't afford quality food.
Great you also found an institution (Gardens for Health) who will provide equipment accordingly.

Spam
Photo of Jessie Cronan
Team

Many thanks for your comment, Sanjali! We are happy that you like our idea. In addition to addressing issues of access and affordability, we believe that education and empowerment are also critical to achieving optimal health and nutrition outcomes.

Spam
Photo of Dedo N. Baranshamaje
Team

This is quite impressive how GHI address most of health related issues from a nutritional stand point and specifically at early stage of life. Communities should only go through curative methods when prevention methods have failed.

Spam
Photo of Jessie Cronan
Team

Thank you for your support, Dedo!

Spam
Photo of Japhet Aloyce Kalegeya
Team

Hi. Jessie This is a great idea that has direct impact on the problem of the challenge faced parents in low income communities. I impresed with this idea, let me add some of my thoughts,

POOR NUTRITION is a challenge faced by the community because….
There is a poor agriculture production, so parents cannot get enough food for feeding their children.
There is a lack of income, so parents can not be able to purchase nutritious food for feeding their children.

The idea created by Jessie is targeted to tackle the problem of nutritional status of under five children, pregnant and lactating women in Tanzania, the issue being addressed by studying and scrutinizing the inside of the problems associated with parents in low-income communities ensure children thrive in their first five years.


During the inspiration phase we found that about 175 children under five years die from January to June 2014 from causes related to malnutrition, and that is a single greatest cause of child death in our country, we learned that people are getting one meal per day, this situation found to Maria Maganga a mother of three children, the first born with 2 years, second born with 1 year and 6 months, and third child with 6 months and eat one meal per day. Also we found learned that 99 villages are faced with the food insecurity with the 20,467 tons in 2013/2014, there is a poor agriculture production, and smallholders farmer are not access the better products and inputs, such as micro-drip irrigation system, drought-restart hybrid seed and asset-backed micro-loans, also we found that there is an absence of the stakeholders groups that are

Since the idea is under the process of being implementation, the design team have done a pilot assessment, capture feedback learning from the community, and found that; the idea impressed most people and were able to voice their desires for the program and activities planned. Most said that “The idea will help parents to afford a nutritious diet”. Other said “This program will help parents to raise income and solve the problem faced them in caring their children of under five years” other were showed their inspirations and claiming that “We will cried and lost our trust if we will miss this program of promote income generating activities in agriculture and livestock” So this idea will make children to be safe from the deaths.
Once we understand how crucial the idea was and able to integrate into the program, learning continued to emerge thanks to feedback from the community and experts ( Agriculture and nutrition officer.

Spam
Photo of Diini Omar
Team

This appeal really excellent idea, when a mother wants to feed her child its great knowledge to know what is the best health seed to feed her child most of the time mother feels pressure and hustle to find food for her child and doesn’t think the consequence. Expanding your program to this critical entry point, will totally deliver a fixed this problem in Rwanda. Good luck! Diini

Spam
Photo of Jessie Cronan
Team

Thank you for your support, Diini!

Spam
Photo of OpenIDEO
Team

Congratulations on making the Zero to Five Challenge Refinement list, Jessie! We like that you are thinking about an integrated approach to maternal and child nutrition and impressed by the success you’ve had working in Rwanda. We are interested to know more specifics as to how the idea that you are proposing is different from the programming that GIH is already running. You mention training community health workers to play a key role in this initiative – do you have existing partnerships that would allow you to do that? If not, how do you plan to get the support required for their participation? Your idea suggests many different ways that you could get feedback about this idea and we’d encourage you share the outcome of these conversations with our community. We’d also like you to consider ways that you can test an aspect of your idea by creating a prototype. Finally, lots of the ideas in this challenge set out to tackle similar issues – make sure to reach out to potential collaborators and update your post with the ways that members of OpenIDEO can help you! Check out tips for Refinement http://ideo.pn/0to5-tips-refine for some tools to help you get started.

Spam
Photo of Jessie Cronan
Team

Thank you for your great comments and suggestions! We’ve updated our idea description to clarify the questions that you’ve posed. Please take a look and let us know what you think. We welcome additional comments and feedback.