A scientific report published in April calls for a shift in interventions to tackle malnutrition in children in Rwanda under the age of two.

Among recommendations, authors urge renewed focus to “fast-track” pre-pregnancy nutrition. Adolescent nutrition before pregnancy, they say, has a bigger impact on stunting in children than previously thought.

The ‘Nutrition, Markets and Gender: An integrated approach towards alleviating malnutrition among vulnerable populations in Rwanda’ survey, was supported by United Nations agencies including the World Health Organization, UNICEF, World Food Program and the Food and Agriculture Organization. It makes a series of recommendations to drive down stunting and malnutrition in the country.

“For the first time, we can clearly see that waiting until a woman is pregnant before intervening in her/their diet is often too late for tackling stunting,” said co-author Mercy Lung’aho, a nutritionist at the International Center for Tropical Agriculture (CIAT).

“Focusing on the established 1000-day nutrition target – from the start of a woman’s pregnancy until her child’s second birthday – is not enough.

“We need to target undernourished adolescent girls – fast-tracking nutrition well before a women becomes pregnant – with more nutritious food.”

The study also points to other drivers of stunting and malnutrition, which in turn pinpoint sociological, financial and agricultural factors fueling the problem.

The malnutrition challenge

Stunting increases the risk of illness and premature death in children. It is also associated with abnormal physical growth, delayed mental development, poorer school performance, and later, reduced productivity in the work force. The effects of stunted growth can be permanent and even passed on to the next generation.

While Rwanda has made significant gains in reducing hunger and undernutrition, a third of children are stunted, the report showed. Accelerated progress is needed to cut child stunting to 18 percent by 2018 and end hunger and under-nutrition by 2050, as outlined in Rwanda’s goals.

Dr. Louis Butare, co-author and Director General of the Rwanda Agriculture Board, said that in 2012, Rwanda’s Gross Domestic Product would have been 11.5 percent higher had stunted growth in children been tackled. “A multi-faceted response needs to be launched on all fronts to tackle this problem in line with findings of this study,” he said.

1,000-day window not enough

Examining the causes of malnutrition, authors established that nutritional status is determined by three broad factors: access to sufficient, safe and nutritious food; access to quality water, health services and sanitation; and care practices of women and children.

The study, which gathered from more than 2,700 households across Rwanda, calls for focus on boosting nutrition in women pre-pregnancy and adolescent girls, ensuring women enter pregnancy at optimal nutrition status.

Next, focus should be on pregnant mothers during the antenatal period, and last but not least, on children under 24-months. But the report also points to other, complimentary pathways to reducing malnutrition in Rwanda, recommending that no one solution alone is enough.

Poor health, sanitation and diet diversity

Credit: Stefanie Neno / CIAT

Credit: Stefanie Neno / CIAT

Sanitation was clearly linked to stunting: Households that sourced drinking water from public or communal sources were three times more likely to be stunted than those with access to treated water. In addition, children with good diet diversity were around 60 percent less likely to be stunted.

The report also found that families earning less cash income from livelihood activities including farming, had a higher number of stunted children compared with families with other income-generating opportunities.

Boosted farm productivity also has an impact on stunting: families producing more than 500 kilograms of crops are 50 percent less likely to have stunted children. This is because families typically spend extra income from extra crops on food – so those with low income suffer twice: they can neither produce enough food for subsistence, nor buy extra food.

Investing in farming as a business

The study also highlights that farmers who invest in better quality seed and improved varieties or fertilizers for example, recorded less stunting in children. On the other hand, stunting significantly increased when households relied on seeds provided as free handouts, and families that didn’t use fertilizer were around 15 percent more likely to have stunted children.

Yet only three percent of households surveyed put farming inputs – fertilizer or improved seeds – top of the list for investment, indicating that although boosted agricultural production can lead to improved nutrition, investing in agricultural inputs is not a household priority.

Gender mainstreaming and empowerment

Using the Women Empowerment in Agriculture Index, authors found that stunting is around half as likely – 46.6 percent – in families where women don’t control valuable “productive assets” – like mobile phones for information about and access to seeds, farm inputs like fertilizer, or credit.

When women can make decisions about selling agricultural land and have access to the credit, their children are around 20 percent less likely to be stunted. Empowerment of both women and men is therefore crucial to reduce stunting.

Investing in labor-saving technology also allows mothers to spend more time providing nutrition through breastfeeding, or improving sanitation, health and emotional care, resulting in lower stunting of their children.

Mainstreaming gender empowerment into land intensification programs and health education strategies is therefore crucial to address malnutrition, say authors.

Sowing the seeds: towards improved nutrition

Data suggests that efforts to tackle malnutrition should also include other micronutrient deficiencies such as anemia. For example, in Gisenyi sector in north-western Rwanda, stunting levels are at their lowest at 16 percent. Yet the number of overweight women, and levels of anemia in both women and children are “alarming,” among the highest in the sectors sampled.

Yet what this also shows is that generalizing data at provincial or district level to smaller areas at sector level may skew the bigger picture, blinding public health planners and policy makers to otherwise obvious success stories, authors point out. For example, Rubavu district, with a high burden of childhood stunting, can learn from Gisenyi sector, where stunting numbers are at their lowest.

The findings of the report suggest that no single sector is able to address malnutrition alone – in part because no single drivers can be attributed to its cause. Improved coordination among health and agricultural sectors as an approach, the study suggests, offers the best opportunity towards linking agriculture to nutrition, achieving Rwanda’s Compact2025 commitments, and driving down stunting.

This study was led by the Rwandan Agriculture Board in partnership with CIAT, under The Pan-Africa Bean Research Alliance (PABRA). The work was supported by the Rwandan Ministry of Health, and UN partners the World Health Organization, UNICEF, the World Food Program, the Food and Agriculture Organization, as well as the Canadian International Development Agency and Swiss Agency for Development and Cooperation. The Women Empowerment in Agriculture Index was developed by the International Food Policy Research Institute.  

Download the report synthesis and the 4-page summary

Get involved:

  • This study methodology can be expanded to other geographic areas, to determine drivers of malnutrition in other countries.
  • A comparative study in countries where improved coordination among health and agricultural sectors has already worked could compliment this research to establish specific progressive interventions.
  • Interventions could improve the impact of community health workers in social behavioral change communication and maternal and child health extension services.
  • Adolescent health and nutrition could be enhanced by improving the quality of school meals.