Stunting Reduction Strategies in Rwanda

Stunting Reduction Strategies in Rwanda Deanna OLNEY and Joanne ARSENAULT PROGRAM BRIEF AUGUST 2020 Introduction The prevalence of stunting in Rwandan children under 5 years of age remains very high at 38% (NISR, 2015), despite a decrease over the previous decade from 51% (NISR, 2006). In Rwanda, the prevalence of stunting changes with age with the lowest prevalence found among children less than 6 months of age and a peak of nearly 50% among children 18-23 months of age (Figure 1). In addition to varying by age, stunting in Rwanda also varies by sex (Figure 1) and wealth quintile (Figure 2). Boys are more likely to be stunted than girls and stunting prevalence decreases as wealth increases. The prevalence of stunting also varies across regions in Rwanda and between rural and urban areas with those in rural areas more likely to be stunted than those in urban areas. Figure 1: Prevalence of stunting by age and sex 1 70% 60% 50% 40% 30% 20% 10% 0% 0-5 mo 6-11 mo 12-17 mo 18-23 mo 24-59 mo All All Boys Girls 1 Derived from the 2015 DHS Data for Rwanda Tackling stunting is a priority of the Government of Rwanda, which has tasked the National Early Childhood Development Program (NECDP) with the goal of reducing stunting through Early Child Development programs to 19% in line with the Sustainable Development Goals and the Rwanda National Health Sector Plan 2018-2024 (NECDP, Rwanda Biomedical Center). 1

The World Bank has identified seven-evidenced based interventions that could reduce stunting (Shekar et al., 2017) from a set of interventions reviewed in the 2013 Lancet Series on Maternal and Child Nutrition (Bhutta et al., 2013) that are believed could reduce child deaths if implemented widely (Box 1). Three of the interventions target pregnant women, one targets mothers and three target young children. This brief describes these interventions in the context of Rwanda. Box 1: Interventions to reduce stunting (Shekar et al., 2017) In pregnancy 1. Micronutrient supplementation 2. Balanced protein energy supplements 3. Intermittent presumptive treatment for malaria in pregnancy in malaria-endemic areas For mothers 4. Counselling on infant and young child nutrition and hygiene practices For children 5. Vitamin A supplementation 6. Prophylactic zinc supplementation 7. Public provision of complementary foods Interventions for pregnant women and mothers Child stunting typically increases during the first two years of life, but it can start during the antenatal period due to maternal factors such as a woman s nutritional status, dietary practices or infections during pregnancy. Evidence suggests that children who are born small for gestational age (SGA) have 2.8 times greater odds of being stunted at 2 years of age (Christian, 2014). In Rwanda, children < 5 y who were born small or very small (with respect to weight for age) have higher rates of stunting (50% and 61%, respectively) than children who were average or larger size at birth (35%) (NISR, 2015). In addition, babies born to thin (BMI<18.5 kg/m 2 ) compared to normal weight mothers are also more likely to be stunted (49% and 40%, respectively). These two comparisons suggest that poor maternal nutrition is likely a contributing factor for child stunting in Rwanda. Antenatal micronutrient supplementation Antenatal micronutrient supplementation includes iron and folic acid (IFA), and one or more additional micronutrients, for approximately 180 days per pregnancy. Supplements are delivered as part of antenatal care. Antenatal micronutrient supplements have been shown to reduce low birth weight and SGA births (Keats et al., 2019). A recent study in Guatemala suggests that the provision of multiple micronutrient powders designed to reduce stunting and given to pregnant women from pregnancy through 6 months postpartum and then to the child from 6-24 mo of age in the context of a multisectoral nutrition program can reduce stunting (Olney et al., 2018). In Rwanda, pregnant women receive IFA supplements at antenatal visits. Recent data from the government indicates IFA was distributed to 55% of pregnant women through the health system, but information on actual use is unknown (personal communication, NECDP). 2

Based on self-reported data, 80% of women received an iron supplement during pregnancy, but only 3% took IFA for 90 or more days (as recommended), and 68% took IFA for less than 60 days (NISR, 2015). While IFA supplements are effective for reducing anemia in pregnancy, there is no evidence that IFA can reduce stunting. To reduce stunting, the Government of Rwanda may want to consider testing the efficacy of providing a multiple micronutrient powder to pregnant women and their children 6-24 mo of age that has been shown to be effective in reducing child stunting in Guatemala (Olney et al., 2018) and Bangladesh (Shafique et al., 2016) in place of the current IFA. Balanced energy-protein supplementation for pregnant women Balanced energy-protein supplementation involves the provision of food supplementation during pregnancy to at-risk women, with the supplement providing no more than 25% of energy from protein. Balanced energy-protein supplementation has been found to increase birthweight and reduce the risk of SGA (Ota et al., 2015). In Rwanda, the Government distributes free fortified blended food supplements to pregnant women in Ubudehe category 1 (the poorest of 4 categories) and some in category 2. The Shisha Kibondo supplement is a maize-corn blend with vitamin/mineral premix produced locally by Africa Improved Foods. Approximately 23,000 women have been reached by the program since 2017 (personal communication, NECDP). The impact of the program on child stunting has not yet been evaluated, although an economic analysis predicted a 532 million USD cost-savings attributed to benefits of increased labor productivity due to reduced stunting rate from 38% in 2016 to 20% in 2013 partly as a result of children's consumption of the FBF (Zinnes et al., 2018). Intermittent presumptive treatment of malaria in pregnancy in malaria endemic regions Presumptive treatment of malaria includes providing at least two doses of sulfadoxinepyrimethamine during pregnancy. Treatment is delivered as part of antenatal care and is recommended by WHO (WHO, 2004). Rwanda adopted this policy in 2004 but suspended it in 2008 due to decreased malaria transmission and increased resistance to sulfadoxinepyrimethamine (President s Malaria Initiative, Rwanda, Malaria Operational Plan FY 2018, USAID 2015). The current policy focuses on early detection and treatment along with distribution and promotion of use of long-lasting insecticide treated bednets. In 2015, it was estimated that about 73% of pregnant women slept under an ITN (MOP FY 2018). A feasibility study has also recently been conducted to test a new approach to that consists of intermittent screening and testing for malaria in pregnant women in high transmission areas. Reducing morbidity in women during pregnancy can reduce stunted growth in infants. Counseling for mothers and caregivers on good infant and young child nutrition and hygiene practices Counseling on infant nutrition comprises of either individual or group-based sessions to promote exclusive breastfeeding delivered in the community and/or health facility. Breastfeeding promotion resulting in increased rate of exclusive breastfeeding impacts stunting by reducing diarrhea incidence (Lamberti et al., 2011). 3

In Rwanda, education for behavior change relating to infant and young child feeding (IYCF) is part of the National Community Based Nutrition Protocol (MoH, 2010). Community health workers conduct mother s group education on breastfeeding, complementary feeding, hygiene and sanitation, and awareness of infectious diseases. Meal planning and culinary demonstrations are also provided. Counseling cards are used at health centers and by community health workers for individual counseling of pregnant women. The counseling cards are part of The National Community Maternal, Infant and Young Child Nutrition (MIYCN) Counseling Package developed by the Ministry of Health Rwanda and several key partners based on the UNICEF Community Infant and Young Child Feeding (IYCF) Counselling Package (UNICEF, 2011). Documentation of counseling or exposure to breastfeeding promotion is not available, but according to the 2014-15 DHS, 44% of women who had a live birth in the previous 5 years had the recommended 4 or more antenatal care visits and 52% had 2-3 visits (DHS, 2015). Based on these data, it is likely that most pregnant women have been exposed to promotion of exclusive breastfeeding. Rwanda has the highest rate of exclusive breastfeeding at 87% (UNICEF, 2019). Breastfeeding promotion remains a top priority to ensure continued high rates and is supported universally by numerous nutrition organizations working in Rwanda. Although the exclusive breastfeeding rate is very high, indicators related to complementary feeding are sub-optimal. The available data suggests that both meal frequency and dietary diversity are substantial issues in Rwanda (DHS, 2015). This suggests that as children transition to complementary foods at 6 months of age, that they are at-risk for not receiving adequate diets which can increase their risk of becoming stunted (or staying stunted). 4

Table 1: Interventions that can reduce stunting being implemented in Rwanda Current intervention or program Coverage Compliance Comments Pregnant women Antenatal micronutrient supplementation Iron-folic acid during pregnancy 55-80% <32% For this type of intervention to potentially reduce stunting IFA would need to be replaced with a multiple micronutrient supplement designed to reduce children born SGA and to reduce stunting. Balanced energy-protein supplementation for pregnant women Pregnant women in Ubudehe 1 and some in Ubudehe 2 23,000 women Unknown Effectiveness of the program for stunting reduction is unknown. However, children at all wealth levels are at risk of stunting. Thus, if the program is effective it would likely need to be expanded to women and children in other Ubudehe categories. Intermittent presumptive treatment of malaria in pregnancy in malaria endemic regions Mothers Counseling on good infant and young child nutrition and hygiene practices Children Vitamin A supplementation Prophylactic zinc supplementation Discontinued in 2008 N/A N/A Currently routine distribution of insecticide treated bed nets at antenatal visit. Provision of iron and low dose folate. Case management. Community-based and individual counselling provided at various contact points Not available Not available Exclusive breastfeeding rate indicates that counselling on at least some practices is widespread. Other practices related to complementary feeding are suboptimal, but it is not clear if this is due to a lack of knowledge or other resource-based constraints. 6-11 mo of age: 2 doses (100,000 IU/y) and 12-59 mo: 1 dose (200,000 IU) >90% >90% Not provided N/A N/A While zinc supplementation is not provided on its own, it is provided as part of a multiple micronutrient powder Ongera. The dose is 4.1 mg versus the recommended 10 mg. Public provision of complementary food for children Children in Ubudehe 1 and some in Ubudehe 2 Unknown Unknown Effectiveness of the program for stunting reduction is unknown. However, children at all wealth levels are at risk of stunting. Thus, if the program is effective it would likely need to be expanded to women and children in other Ubudehe categories. 5

Infants and young children Vitamin A supplementation for children Vitamin A supplementation programs distribute two doses per year (100,000 IU) for children age 6 11 months and 200,000 IU for children age 12 59 months), either through mass campaigns or in health facilities. Vitamin A indirectly influences stunting by reducing diarrheal incidence (Imdad et al., 2017). In Rwanda, the Government with support by UNICEF provides the high dose capsules twice per year during Maternal and Child Health (MCH) week in April and October, along with deworming. At the last MCH week in October 2019, 92% of infants 6-12 months old and 94% of children 12-59 months old received vitamin A capsules (personal communication, NECDP). Prophylactic zinc supplementation Prophylactic zinc supplementation provides zinc at a dose of 10 mg/day (120 packets per child per year). A review of zinc supplement studies reported an impact on linear growth in children < 5 years (Imdad & Bhutta, 2011). This program is not in effect in Rwanda. However, there is national distribution of multiple micronutrient powders which includes 4.1 mg of zinc. A small study in northern Rwanda with 5-30 month old children reported a significant positive association between dietary zinc intake assessed by 24-hour recall and height-for-age Z score after controlling for some other factors (Uwiringiyimana et al., 2019). The impact of the distributed MNPs on child stunting is unknown. However, these MNPs were not designed to reduce stunting. Alternative formulations have been shown in two recent studies to effectively reduce stunting (Shafique et al., 2016, Olney et al., 2018). Testing these alternative formulations in this context may be prudent. Public provision of complementary food for children Complementary food programs provide supplements for children consisting of 100 1,500 kcal per day which are typically are fortified with micronutrients. A review of studies found that providing complementary food to children reduced stunting by 67% in food-insecure populations (Lassi et al., 2013). In Rwanda, the Government distributes free fortified blended food (FBF) supplements to children < 2 years of age in Ubudehe category 1 (and some in category 2). The Shisha Kibondo supplement is a maize-corn blend with vitamin/mineral premix produced locally by Africa Improved Foods. Approximately 88,000 children have been reached by the program (personal communication, NECDP). As noted previously, the impact of the program on child stunting has not yet been thoroughly evaluated. A cross-sectional survey conducted by WFP in 2018 reported that children 12-23 months of age consuming FBF were significantly less stunted, particularly among children aged 18-23 months (20% compared to 40% of children not consuming FBF); however it was noted that a rigorous evaluation with a control group is necessary to confirm an impact of the program on stunting (WFP, 2018). To achieve the goal of reducing stunting to 19% children it is likely that children in at least the first three Ubudehe categories need to be reached as stunting is 30% or more across all wealth quintiles among children 12-23 mo of age and for the first four wealth quintiles among children 24-59 mo of age (Figure 2). 6

Figure 2: Prevalence of stunting by age and wealth quintile 1 70% 60% 50% 40% 30% 20% 10% 0% 0-5 mo 6-11 mo 12-17 mo 18-23 mo 24-59 mo All First Second Third Fourth Fifth 1 Derived from the 2015 DHS Data for Rwanda Conclusions In Rwanda, two of the interventions for women and two for young children are currently being implemented. For women, coverage data is unclear for breastfeeding promotion, although the rate of exclusive breastfeeding in Rwanda is higher than any other country. For children, coverage of vitamin A supplementation is very high, although its impact on stunting indirectly through reduced diarrheal disease is unclear in the country. The provision of supplemental food to women and young children during the first 1000 days from pregnancy through 23 months of age has the potential for impact on stunting, but the government program has not yet been appropriately evaluated. It is likely that the program would need to be expanded to cover more mothers and children as stunting prevalence is very high (>30%) across the first four wealth quintiles and high (>20%) even within the highest wealth quintile (Figure 2). Although these seven interventions can reduce stunting, it is well understood that reducing stunting often requires multiple interventions that address issues related to food, health and care as well as improving the enabling environment to support such actions. Thus, continued commitment to designing and implementing context-specific nutrition-sensitive multisectoral programs is needed to reduce child stunting, along with other programs to control infectious disease and combat poverty. 7

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