Date of Defense:
April 16, 2016
Rwanda, a tiny poor landlocked country in Eastern Africa, is one of the most densely populated countries in the world and home to approximately 11 million people (Farmer 2013). A majority of the population (81.2%) works in agriculture in steep mountainous rural areas (NISR 2012). According to the most recent demographic health survey of 2010, 44.9% of Rwanda’s population lives below the poverty line (DHS 2010).
Two of the most pertinent health issues facing Rwanda today are childhood malnutrition and stunting (Republic of Rwanda 2014). Currently 44% of Rwanda’s children are chronically malnourished or stunted, largely due to insufficient food intake, illnesses, lack of knowledge of infant and young child feeding practices, inadequate hygiene and sanitation, poor primary health care and household food insecurity (DHS 2010). Stunting, wasting and micronutrient deficiencies are a leading cause of childhood mortality (Bhutta 2013).
Rwandan mothers are at high risk for malnutrition and face many complications during pregnancy, largely because of late detection of complications due to low and late attendance of antenatal care visits (ANC) (NISR 2014). Maternal under nutrition contributes to 800,000 neonatal deaths a year in Rwanda (Bhutta 2013). These deaths are linked to small for gestational age births (Bhutta 2013).
Focusing on providing adequate nutrition for the mother and child during the first 1000 days of a child’s existence is crucial to ensuring full cognitive and physical development of the child. As such, antenatal care (ANC) is a valuable means for providing mothers with adequate health and nutrition education during pregnancy as well as preventative care and identification and management of obstetric complications. ANC visits are a great platform for providing nutrition-related interventions such as the promotion of breastfeeding and micronutrient supplementation, healthy diet during pregnancy and methods for growing a home garden with nutritious foods.
Gardens for Health (GHI) is a non-profit organization in Rwanda, that focuses on working directly with mothers and families to prevent and reduce malnutrition, using agriculture based interventions focused on improving nutrition in the first 1000 days of a mothers’ pregnancy and the child’s first two years. Gardens for Health helps families end the cycle of poverty and poor health and address the root cause of malnutrition through partnering with government health centers to bring agricultural solutions and health education to families in need at the point of care. Gardens for Health for health started in 2007 and has grown to become one of the leading malnutrition experts in Rwanda and currently serves over 2000 families from 18 health centers (GHI 2014).
Gardens for Health uses a two-pronged approach, enrolling the most vulnerable mothers in a fourteen week health and agricultural training program. Field educators, local community members, provide all of Gardens for Health trainings. These field educators are also responsible for working closely with the families enrolled in the program and conduct regular home visits and check ups with the families
GHI would like to fulfill its mission to focus on the entire first 1000 days of a child’s life and integrate its program as a part of antenatal care at health centers with the intention of increasing ANC attendance and improving nutrition outcomes for pregnant mothers. By introducing Gardens for Health model as a part of antenatal care, Gardens for Health will be able to deliver a more integrated and preventative model that reinforces existing public sector efforts and has a strengthened focus on childhood chronic malnutrition.
Prior to implementing the pilot project GHI must ensure that the curriculum and services provided are appropriate for pregnant mothers. As part of my field experience I developed a technical report that allowed GHI to make informed decisions on designing and implementing this pilot project.
The focus of the technical report was program development. We conducted twelve focused group discussions with various stakeholders involved in maternal health, including mothers who recently graduated from the GHI program, health center staff and GHI field educators. Through a qualitative assessment we examined barriers to ANC attendance for mothers in the five chosen health centers for the pilot project. We examined various options for best integrating GHI’s resources into supporting pregnant mothers. We examined how to best collaborate with community health workers and how this intervention will affect the current workload of community health workers who work with the Gardens for Health targeted population of pregnant mothers. This project helped develop a plan for capacity building of community health workers. We examined ways to most effectively and accurately enroll pregnant mothers, with the objective of enrolling mothers as early as possible in their pregnancy.
These focused group interviews allowed us to develop insightful recommendations for GHI’s program development. Several key points included the recommendation to create a six to eight week rolling open enrollment education program for all pregnant mothers in the communities GHI works in. Mothers recommended that a modified curriculum be provided with additional support for primigravidae and teen mothers. Most stakeholders agreed that incentives for attendance by mothers and fathers were necessary. These incentives included small funds, porridge during trainings, baby gift boxes, clothing for mothers and a microfinance organization for fathers. Community Health Workers strongly advised being fully integrated into the program and being provided additional nutrition training and using RapidSMS services to connect. They also suggested a cooperative garden at each health center for education purposes and food supply for mothers and community health workers. Another recommendation for Gardens for Health is to use this opportunity to conduct a full Nutritional Impact Study on the value of agriculture based nutrition education with pregnant mothers.
I learned many lessons during this experience. One major take home lesson is to always listen to the local people as they are true experts of their own needs and the idiosyncrasies of their culture. I learned that conducting interviews in Rwanda is logistically and personally challenging. Professional translators are key in asking open-ended questions. I learned that it’s really important to honor people’s time and facilitate focused groups that are open and inclusive. I also learned that it takes a really long time to accomplish anything in Rwanda and patience is necessary. True impact in global health requires big sacrifices, long-term commitment and assimilation.
It was an honor to spend an entire year focused on learning about and supporting maternal and child nutrition projects in Rwanda.
Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, N., Horton, S., et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost? The Lancet, 382(9890), 452-477.
Farmer, P. E., Nutt, C. T., Wagner, C. M., Sekabaraga, C., Nuthulaganti, T., Weigel, J. L., et al. (2013). Reduced premature mortality in Rwanda: Lessons from success. BMJ (Clinical Research Ed.), 346, f65. doi:10.1136/bmj.f65 [doi]
Gardens for Health. Annual Report (2014)
National Institute of Statistics of Rwanda, Ministry of Finance and Economic Planning, Ministry of Health, MEASURE DHS ICF International. (2012). Rwanda demographic and health survey, 2010. Retrieved April 21, 2015, from http://dhsprogram.com/pubs/pdf/fr259/fr259.pdf
Republic of Rwanda. (2014). Musanze district plan to eliminate malnutrition 2014-2017. Kigali: MINECOFIN.