Integration of nutrition supplementation and parenting support into Madagascar’s national nutrition program: the Mahay study

• In Event: 2-154 - Cost-effective and Scalable Early Childhood Interventions in LMICs: Evidence from Chile, Kenya, India, and Madagascar.

Integrative Statement

Over half of the world’s children suffer from poor nutrition, and experience delays in physical and mental health and development. There is limited evidence evaluating the delivery of lipid-based, nutrition supplementation on growth and development during pregnancy and early childhood in the context of a program setting; furthermore, there is limited evidence on effects of scaled-up, home-visiting programs that promote child development. The Mahay Study (‘smart’ in Malagasy) builds on an existing platform of community-based nutrition program sites at scale throughout Madagascar. The objective was to determine whether packages that expand the intensity and the scope of the current program can significantly alter the pattern of severe growth faltering and delays in child development among young children in Madagascar. The study was designed not only to measure the impact of each treatment arm compared to the status quo, but also to estimate differential effects and costs of each incremental layer with an eye to scale-up.

We conducted a cluster-randomized controlled trial to test the effectiveness and cost-effectiveness of combined interventions to address chronic malnutrition and poor child development. We enrolled pregnant women and children <1 y into one of 5 groups: (T0) existing program with monthly growth monitoring and nutritional/hygiene education; (T1) is T0 + home visits for intensive nutrition counseling; (T2) is T1 + lipid-based supplementation (LNS) for children 6-18 months old; (T3) is T2 + LNS supplementation of pregnant/lactating women; and (T4) is T1 + intensive home visiting program to support child development. Primary outcomes were linear growth (height-for-age z-scores) and child development (cognitive, language, motor and social development). Secondary outcomes included anemia, child morbidity, household food security and diet diversity, maternal knowledge of hygiene, feeding and home stimulation practices. Analyses were intention-to-treat.

The study enrolled 3738 mothers and children, who were assessed at 12 and 24 months’ intervals. There were no main effects of any of the interventions on any measure of anthropometry or child development outcomes. In sub-group analyses, there were significant effects of T2 and T3 on growth and anaemia among the youngest children with the greatest exposure to the program and of T4 on child development in better off communities. There were main effects of nutrition counselling on increasing protein food intake in the previous 24 hours, but no effects on dietary diversity score or morbidity.

Our findings suggest that children’s growth can benefit from maternal or child LNS to mitigate the prevalence of stunting but only if supplementation begins by age 6 mo. Limited uptake of key child stimulation behaviors may have hindered potential impact of the integrated nutrition and early stimulation counseling on child development outcomes.

Authors

• Lia Fernald, University of California, Berkeley
  Non-Presenting Author

• Ann Weber, Stanford University
  Non-Presenting Author

• Emanuela Galasso, The World Bank Development Research Group
  Presenting Author

• Christine P Stewart, University of California Davis
  Non-Presenting Author