Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential Nutrition Actions Framework

Abstract

Background Madagascar has some of the highest rates of child stunting, maternal malnutrition, and infant mortality in sub-Saharan Africa. Objective To improve infant and young child feeding practices, increase uptake of micronutrient supplements, and improve women's dietary practices through implementation of a nutrition project based on the Essential Nutrition Actions (ENA) framework. Methods Interventions included training, interpersonal communication, community mobilization, and mass media. Changes in practices were assessed through a comparison of data for children under 2 years of age from representative cross-sectional household surveys collected at baseline in 2000 ( n = 1,200) and at the end of program implementation in 2005 ( n = 1,760). The surveys were conducted in six districts with a population of 1.4 million. Results The rate of initiation of breastfeeding within 1 hour of birth increased from 32% to 68%, the rate of exclusive breastfeeding of infants under 6 months of age increased from 42% to 70%, the rate of continuation of breastfeeding at 20 to 23 months increased from 43% to 73%, the rate of feeding children the minimum recommended number of meals per day at 6 to 23 months increased from 87% to 93%, the rate of iron–folic acid supplementation during pregnancy increased from 32% to 76%, and the rate of postpartum vitamin A supplementation increased from 17% to 54% ( p <.001 for all changes). Modest improvement was achieved in maternal dietary practices during lactation and feeding of the sick child after illness. The results were inconclusive regarding food diversity for complementary feeding. No improvements were reported in increasing food intake during child illness or pregnancy. Conclusions The ENA framework allows broad-scale improvement of nutritional practices to be achieved through the maximization of contacts using multiple program opportunities within existing health systems and community structures and through mass media.