Maternal and child nutrition: Findings from inception studies in Malawi

What we know: Malawi has a primarily rural population susceptible to climate shocks, which are a key driver of malnutrition. Maziko is a five-year integrated Maternal and Child Grant research project targeting mothers and children under five years in eight traditional authorities in Balaka and Ntcheu districts.

What this adds: This two-part article first highlights the findings from Maziko inception studies, which indicate the current nutritional situation in the selected districts, before exploring beyond these statistics by looking at the context, opportunities, and surprise findings which were observed. High levels of poverty, food insecurity, climate vulnerability, and poor access to health/nutrition services were observed, but maternal mental health was also found to affect maternal and child nutrition.

Maziko¹ is one of Save the Children’s flagship cash ”œplus” for nutrition projects – combining maternal and child cash transfers with a package of government endorsed multi-sectoral (”œplus”) interventions – to address the main drivers of poor nutrition and child development in Balaka and Ntcheu districts of Malawi.

Maziko is unique. First, because the ”œplus” component is multi-sectoral, combining a nutrition focused community outreach and behaviour change intervention with nutrition sensitive livelihood, food security and gender transformative components. Many cash plus for nutrition interventions tend to focus only on nutrition education/communication. Second, Maziko aims to improve not just child nutrition but also child development, by addressing ALL the main drivers of each and facilitate a successful transition between nutrition service delivery platforms and Community Based Child Care Centers. Third, Maziko has a large mixed methods research component which generates evidence on impact and cost effectiveness of the cash plus approach, as well as the drivers of change.

Findings from the first-year inception period of the Maziko have been published² and are summarised here. The inception period included a baseline quantitative survey of 2,686 households across 262 villages, a detailed qualitative (immersion) study of 12 households, a district capacity assessment to identify bottlenecks in service provision for nutrition and early child development, and a cost of the diet study to determine the affordability of a nutritious diet. A detailed breakdown of the methodology and full results is beyond the scope of this summary but can be seen in the original report.

Baseline findings showed that the burden of malnutrition for children under two years was high: Stunting prevalence was 31%, underweight was 8%, and wasting was 1.4%. Exclusive breastfeeding rates were high (77%), although qualitative findings indicate that the early introduction of liquids and food may be more common than reported. Bottle feeding, a common entry point for enteric infections, was uncommon (1%) but poor hygiene practices including limited use of soap for handwashing, unsafe disposal of babies faeces and contamination of domestic areas with animal faeces were widespread.

Dietary diversity is also generally poor, with family meals consisting of maize, with over boiled green leaves. Although 85% of children were reported to continue breastfeeding up to 23 months, in line with World Health Organization recommendations, only 16% of children aged under two years achieved minimum dietary diversity and 49% were fed frequently enough. Only 1 in every 10 children consumed an adequate diet for their age.

Food security is a concern in the project area. Climate shocks are prevalent and there is a general lack of safety nets to rely upon when shocks occur – due to limited funding, poor coordination, high staff turnover, and inadequate use of data. Social assistance, both cash-based and in-kind, are limited. The cost of a nutritious diet, which increased by 25% between April 2021 and May 2022, increases vulnerability in the population – where household food expenditure accounted for 55% of total expenditures.

85% of households had experienced loss of crops due to droughts or floods in the previous 12 months

Due to the diversity and array of challenges present, the inception findings highlight the need for a multi-sector approach. The initial report does highlight Malawi’s success with multi-sectoral policy, as strong policies and strategies do exist. Yet, policy implementation is affected by resource and coordination constraints.

The Maziko project comes at a key time for the government of Malawi, as they develop their nutrition sensitive social protection system. Malawi’s current national social support programme only reaches 2% of mothers and children under two years. We hope that this project will generate the evidence needed to demonstrate the relevance of categorical targeting and support advocacy for the expansion of the national social support programme to target mothers and young children in the first 1,000 days. 

The project inception period and studies summarised above were extremely valuable as they helped us to identify the key drivers of malnutrition and poor child development. They reinforced the need for a multi-sectoral package of interventions – targeting mothers and young children from conception.

Unexpected learnings

Some of the research findings were expected (e.g., high levels of poverty, food insecurity, climate vulnerability, and poor access to health/nutrition services).  However, the findings that surprised us most were around women’s mental health and wellbeing. Specifically, how this affected their own and their children’s health, growth, and wellbeing. The quantitative (baseline survey) found that 26% of women reported depressive symptoms (using a self-reporting questionnaire questionnaire). Symptoms included feeling tired all the time (39%), feeling tense or worried (42%), or having trouble thinking clearly (24%). At the extreme end, 7% of women reported having suicidal thoughts.

Qualitative research proved especially insightful. This was ”œimmersion” research, whereby researchers (Save the Children and government staff, trained by Empatika³) lived in households for four days and four nights, gathering evidence by living women’s lives. The detailed immersion report⁴ presents a sobering read, showing that women are overwhelmed with chores and childcare. They feel stressed, undervalued, and have no time to care for themselves – which affects their milk production and childcare. Fathers were either absent or disengaged and children were often left to their own devices.

The surveys also looked at childcare practices across the nurturing care framework⁵ and found that childcare was primarily seen as the mother’s responsibility. This led to limited and basic care, with very little extra and intentional play and stimulation as mothers are too tired and overstretched. The quantitative survey included family care indicators which found that children have limited or no access to toys or books (21% have homemade toys and only 2% have books). Furthermore, around 40% of women reported playing or singing songs with their children within the previous three days.

Targeting the gaps

These findings highlight gaps within the government of Malawi’s main nutrition outreach system and social and behaviour change curriculum (the Care Group and Scaling Up Nutrition community counselling package⁶). We needed to fill these gaps to ensure the project’s cash ”œplus” package addressed the main drivers of malnutrition and poor child development at community level.

Whilst the Care Group approach and curriculum is very comprehensive, it primarily targets women, and doesn’t focus on maternal mental health and wellbeing. To address this, the Department of Nutrition and HIV/AIDS, with UNICEF, adapted UNICEF’s Caring for the Caregiver⁷ approach to the Malawi context. Save the Children then integrated this into the Maziko ”œplus” package. We also adapted Save the Children’s ‘Male Champions’ approach to engage men to become more supportive and engaged fathers and husbands.

The value of a combined package

One of the main challenges with multi-sectoral programming is that it can be both costly and overwhelming – with too many issues needing to be addressed at the same time.  Whilst the inception studies (summarised above) confirm the need for a multi-sector approach to address a multitude of challenges, they also identify priority drivers that could reduce the potential impact of cash transfers and other ”œplus” interventions. These drivers (women’s poor mental health and wellbeing being the most important one), will hopefully be improved through the combination of interventions: Cash transfers, regular home visits (with frontline volunteers trained in the Caring for the Caregiver approach), and more engaged fathers and husbands. Small, achievable behaviours were also identified through a people driven design exercise (led by Empatika), to prioritise and adapt behaviours to promote through the Care Group system.

We would like to thank our donors (Power of Nutrition; their back donors, the Conrad Hilton Foundation; the United Kingdom Foreign, Commonwealth and Development Office; and Irish Aid) who have provided the flexibility to adapt and improve this intervention package. We would also like to thank our partners, IFPRI (leading the research component); Give Directly (leading on the cash component); Empatika (who designed and trained our staff to conduct the immersion and people driven design work); our district partners, representing every sector leading the implementation of these interventions; and our Save the Children Maziko staff.

These partners, working alongside the Government of Malawi, showcase the value added by comprehensive, multisectoral collaboration – without which these initial findings and the development of the broader project would not have been possible. These efforts should be applauded, as this is not always the norm. We believe that this combined package can be truly transformational, and we look forward to sharing more findings from this project moving forward.

For more information, please contact Natalie Roschnik at n.roschnik@savethechildren.org.uk