Convening private and public sector partners to support mothers and children in Liberia

Introduction

In Liberia in 2016, almost a third of children suffered from stunting and 59% of children under three were anaemic, which impairs children’s physical and mental development and increases the risk of illness and death. Impactful nutrition interventions since 2007 have successfully decreased these figures (stunting from 39% to 31%) – but malnutrition remains far too high.

The programme focused on five counties, Bomi, Bong, Grand Cape Mount, Lofe and Sinoe, where the need is greatest; there is limited capacity of frontline health workers, inadequate distribution systems, poor nutrition indicators and high levels of mortality and morbidity among both mothers and children. These counties were also worst affected by the Ebola crisis.

Although the programme focused on these counties, it also supported some key interventions nationwide.

Liberia was significantly affected by the Ebola epidemic. As Ebola is transmitted by breastmilk, the virus had a secondary impact of reducing the number of babies breastfed, as the use of breastmilk substitutes rose. The programme therefore also paid special attention to promoting breastfeeding where safe to do so.

Our programme

Working with a wide range of partners (Children’s Investment Fund Foundation, UK Aid, UBS Optimus Foundation, Norwegian Agency for Development Cooperation and Medicor Foundation) and implementers UNICEF, our programme was designed to tackle high rates of malnutrition through scaling-up proven nutrition-specific interventions. This meant working hand-in-hand with the Government of Liberia to ensure nutrition services were provided in healthcare facilities across the country. Interventions focused on counselling on adolescent and maternal nutrition, providing iron and folic acid supplementation for mothers, promoting and providing support for breastfeeding, providing deworming treatment, care for children with severe acute malnutrition, and more. Direct nutrition interventions are now provided in over 80% of all public health facilities, a huge increase from just 30% of facilities before the programme.

The programme provides ready-to-use therapeutic food and anthropometric materials to health facilities for treatment of severely malnourished children. It also works with its non-governmental partner, International Medical Corps, to provide technical services to county health personnel in complying with national treatment standards to prevent the death of children and to reduce defaulters in the programme.

Benjamin's story

A year and a half ago, Benjamin, who lives with his grandmother, could hardly sit up. He was ill, and his grandmother, Ma J, took him to a local herbalist thinking he was “sick due to witchcraft”. According to Ma J, treatment by the herbalist did not seem to work, and Benjamin’s situation worsened. His face became puffy, and he had a distended abdomen and skin lesions on his legs and feet.

In September 2015, a general community health volunteer who is part of Liberia’s frontline health worker system, noticed Benjamin during a routine outreach visit to raise awareness and conduct screening for malnourished children. The health volunteer immediately recognised that Benjamin was malnourished and suffering from generalised bilateral pitting edema. He immediately spoke to Ma J, explaining what Benjamin was suffering from, and referred him to the treatment facility for the management of severe acute malnutrition and related complications.

Benjamin showed signs of malnutrition, including thin hair, loss of appetite, a severely distended abdomen, unresponsiveness to the environment, fever, difficulty with breathing, and sick lesions. He was given sugar water, therapeutic milk and other medications in line with national protocols for treatment and based on the symptoms he displayed.

Just 13 days later, Benjamin’s appetite returned, his edema was healed, and he was discharged from the inpatient clinic and referred to an outpatient treatment site for continued treatment until he recovers fully.

The programme in Liberia made significant progress in improving the coverage of high-impact nutrition interventions, supporting almost one million children and over half a million women to access nutrition services nationwide. The impact of this appears to be significant: analysis shows that between 2013 and 2020, stunting, wasting and underweight levels decreased: stunting decreased from 32% to 30%, wasting from 6% to 3% and underweight from 15% to 11% of children. 332,804 pregnant women were reached with counselling on appropriate infant and young child feeding, and 2.1 million children received vitamin A supplementation.

The programme had a focus on treating severe acute malnutrition: by 2020 67,070 children had been admitted and treated, and 97 new facilities around the country had been supported to establish and run treatment services. 597 healthcare workers were trained in the care of children with severe acute malnutrition, ensuring continued high quality of treatment services.

An assessment conducted in 2019 also showed that the programme increased the profile of nutrition within the Government of Liberia, leading to an increase in government spending on nutrition interventions. The programme also led to the inclusion of stunting reduction as a priority area in the new government investment plans and nutrition information systems were strengthened. This increased government prioritisation of nutrition means that there is a greater chance that the positive changes to stunting and wasting figures are sustainable going forward.

Next steps

Despite these positive statistics, challenges remained upon the programme’s conclusion. 30% of children stunted is still a very high figure, and micronutrient deficiencies remained high in 2020: overall, 45% of women of child-bearing age were anaemic, and among pregnant women this figure was even higher, at 52% - this is particularly concerning as anaemia can affect the baby’s development and cause birth complications.

The Liberia I programme did well at addressing the immediate causes of malnutrition by implementing nutrition-specific interventions, as described above. However, to address the underlying causes of stunting and malnutrition, it is paramount to take a multisectoral approach. Nutrition-sensitive interventions are needed for this: they do not focus only on addressing the immediate causes of malnutrition, and instead address key underlying determinants of nutrition such as poverty, food insecurity and scarcity of access to adequate resources. In this way, they are critical in helping to enhance the effectiveness, coverage and scale of nutrition-specific interventions.

We therefore decided to continue our partnership with UNICEF to design a Phase 2. The second phase aimed to broaden the programme’s scope by targeting adolescents and engaging nutrition-sensitive sectors. Continuing the programme aims to sustain achievements made in Phase 1 (and confront challenges posed by the Covid-19 pandemic) and accelerate the reduction of stunting in the country by integrating nutrition-sensitive and nutrition-specific interventions.

Read about the second phase to our programme in Liberia here.

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Photo credits

Header image and Body image: UNICEF Liberia/2021/M.Omar