In Chad, the Mother-MUAC approach improves treatment access for malnourished children
This is a summary of a Field Exchange field article that was included in issue 65. The original article was authored by Hyppolite Gnamien, Chantal Autotte Bouchard, Jean-Robert Bwanaissa Shabani, Emily Helary and Marion Blanloeuil
Hyppolite Gnamien is the Medical Coordinator of the Première Urgence Internationale mission in Chad.
Chantal Autotte Bouchard is the health and nutrition referent for Première Urgence Internationale Headquarters.
Jean Robert Bwanaissa Shabani is the Health/Nutrition Technical Manager in Ouaddaï for the Première Urgence Internationale mission in Chad.
Emily Helary is a Program Officer at Première Urgence Internationale Headquarters.
Marion Blanloeuil is Desk Assistant at Première Urgence Internationale Headquarters.
In Chad, the implementation of Mother-MUAC created a more financially sustainable form of community screening as well as providing higher screening coverage and performance.
- Mother-MUAC implementation is relatively straightforward and empowers the mother to look after the health of her own children and children in her village.
- Regular monitoring of the mothers' activity and good supervision is important to ensure accurate mid-upper-arm circumference (MUAC) measurements.
- Context specific barriers to accessing treatment require addressing to ensure that early detection of malnutrition translates into early treatment, thereby reducing the complications and mortality associated with delayed treatment.
Background
In Chad, one in 10 children die before they reach five years of age, with malnutrition being a major contributing factor. In 2016, on request from national authorities, Première Urgence Internationale (PUI) began implementing a severe wasting prevention and treatment programme in Ouaddaï province, located on the border with Sudan. The programme covers 24 health centres (HC) and targets children under five years of age and pregnant and lactating women.
Implementation of the Mother-MUAC
Until May 2018, community health agents called Community Relays (in French, ReCos) conducted community screenings and referrals of wasted children aged 6-59 months. ReCos were assigned to a group of villages to carry out malnutrition screening on a regular basis. They were supervised by a team of around four community health workers (CHW) from each HC. These screenings were expensive as both the ReCos and CHWs were paid.
In May 2018, in response to a reduction in funding, Mother-MUAC screening was introduced. Mother-MUAC involves training mothers to identify wasting by using a colour-coded tape to measure mid-upper-arm circumference (MUAC) or by detecting oedema (swelling caused by fluid retention in the body). Unlike other programmes, where mothers only screen their own children, PUI trained mothers to also screen children from within their village. Mother-MUAC was introduced not only as a more financially sustainable form of community screening to also increase the early detection and referral of children identified as being wasted which reduces the complications and deaths associated with late treatment.
Process for introducing Mother-MUAC
The process of moving from the ReCo screening to Mother-MUAC was implemented over a two-month period (June/July 2018). First, PUI, together with the District Executive Teams, discussed the approach with key health staff in each district so that these people could then sensitise the community on the value of the early detection of children who are wasted and the role of mothers in the prevention of malnutrition. In collaboration with these people and community leaders/ women's groups in villages, 769 out of 960 villages were identified to be a part of the Mother-MUAC programme. In each village, mothers to be part of the programme were identified using the following criteria:
- Women of childbearing age
- Available and active in their community
- Accepted by the community
- Village resident for at least one year
- Agreed to conduct screening activities on a voluntary basis
Identified mothers received a one-day training. Training covered how to use a MUAC tape to screen for wasting, identification of oedema, effective infant and young child feeding practices and how to refer children identified as being wasted. From May 2018 to December 2019, 15,004 mothers were identified and trained.
Following training, mothers received MUAC tapes and red and yellow coupons which replaced referral forms. Trained mothers then gave these red and yellow coupons to mothers with children identified as severely and moderately wasted respectively. Mothers screened all children aged 6-59 months in their village on a monthly basis. When a child was identified as wasted, the caregiver was told by the trained mother to transfer the child to the HC for treatment. If the caregiver refused, the trained mother would try to convince the caregiver to go to the HC. When the caregiver of the identified child went to the HC, she gave the coupon to the health worker who then performed a further assessment to validate the diagnosis based on the admission criteria of the national protocol. Transportation costs for the referral were covered by the families of the referred child.
Monitoring Mother-MUAC
Monitoring was carried out by the CHWs who were already trained and experienced in MUAC screening. Each month, the CHWs summarised the number of children referred via Mother-MUAC at each HC. Each CHW also conducted random MUAC measurements in households covered by the Mother-MUAC programme to ensure the effectiveness of the screening and the reliability of measurements. A monthly review was also conducted with the PUI teams comparing screening by mothers to CHW screening at HCs. When an area showed low performance, individual training with mothers was conducted to ensure consistency.
Programme performance
Screening coverage increased from 79.5% to 85.5% when using the Mother-MUAC approach. In terms of performance, 63.2% of children who were identified as wasted by trained mothers were confirmed and admitted compared to 50.3% in the CHW-ReCo approach. The outpatient cure rate for Mother-MUAC was 95% compared to 91.5% for the CHW-ReCo approach. The inpatient cure rate between the two approaches was not significantly different. In addition, mothers showed strong participation in the approach and HC staff reported that mothers were more cooperative and less likely to default. The approach also reduced programme support costs by 27%.
Discussion and conclusions
Community-based malnutrition screening has shown that more regular and earlier detection of children with wasting could reduce the risk of death and illness. The Mother-MUAC approach has proven effective in Chad in facilitating diagnosis and accelerating the management of children at risk of becoming wasted. The implementation process is straightforward and empowers mothers to be actors in the health of their children. Furthermore, as the mother's motivation is not financial, it creates a more sustainable approach to community screening which can be replicable and scaled up.
In this context, HC attendance was low before the Mother-MUAC approach was implemented. Long distances from HC, the presence of natural barriers in the rainy season, mothers' refusal to be referred, lack of authorisation from their husbands and the heavy workload of mothers were identified as the main barriers to attending HC. The implementation and monitoring of Mother-MUAC helped to strengthen community support and facilitate acceptance of the programme in the area.
Moving forward, additional efforts will be made to improve compliance with referrals, such as intensifying sensitisation (including targeting men) and the strengthening of a community solidarity fund to provide financial aid to families not able to afford the transportation costs.
Looking ahead, PUI aims to continue to support the management of wasting in this area while working towards handing over activities to the government structures.
For more information, please contact Chantal Autotte Bouchard at cautottebouchard@premiere-urgence.org