Getting hold of food and reproductive health services are probably the two most difficult things for women in rural southern Madagascar, so it makes sense for UN agencies to combine food aid with maternal and child healthcare.
Drought is chronic in the south of the huge Indian Ocean Island, where the UN World Food Programme (WFP) has been providing food aid since 1968; this is also where, according to a 2009 national Demographic and Health Survey, eight women die every day as a result of complications during pregnancy or childbirth.
"Southern Madagascar is the most food insecure area of the country," the WFP Health and Nutrition Programme Officer in Madagascar, Flora Bertizzolo, told IRIN. "It is also an area with very poor reproductive health indicators - much worse than national average," she said.
Figures from 2008 indicate that over 80 percent of women give birth at home in high-risk conditions, that the level of anaemia in pregnant women is high and linked to malnutrition, and that the level of contraceptive use is extremely low - a mere 5.23 percent.
"Good nutrition is important, but food is not enough to ensure a healthy status," Bertizzolo commented. Great distances and prohibitive travel costs keep many women away from health centres, so food assistance is "a powerful enabler to increase access to health services for the most vulnerable individuals."
Jocelyne Rasoanirina, head of the UN Population Fund (UNFPA) in southern Madagascar, witnessed the multiple challenges Malagasy in the south face during a joint mission with WFP in 2008, which led to the proposal of a two-pronged approach to break the cycle of malnourished mothers giving birth to malnourished babies who grow up to be malnourished mothers.
A joint project was devised to increase access to quality free reproductive health services, and to improve the resilience of the most vulnerable to malnutrition.
The initiative was launched in 2009 - with financing from Monaco and Andorra - in five municipalities in the south of the island and by January 2010 some 3,300 beneficiaries had been reached.
"The results are very encouraging," Rasoanirina said. The number of women opting to give birth at a health centre jumped from an average of 18 percent to 82 percent, and 98 percent of those targeted chose to use family planning services.
Rasoanirina stressed the need for family planning, because research has shown that large families are an important contributor to household poverty. The average Malagasy family has five children, but the number rises dramatically in rural areas, where it is not uncommon for women to have 10 children by their mid-thirties.
WFP's Bertizzolo noted that "Sometimes women are ashamed to go to health centres," because they did not have money to buy appropriate clothes for themselves or their newborn babies and felt embarrassed in the presence of the health personnel.
"For this reason ... each woman is provided with a "dignity kit" with WASH [hygiene and sanitation] items, and clothes to facilitate her access to the health service," and the service at health centre level has been improved.
The window of opportunity
Figures collected by the project's NGO partners in 11 selected municipalities in the district of Ampanihy, after interventions from October 2009 to January 2010 (the lean season), indicated that malnutrition had declined, based on the body mass index (BMI) of pregnant women.
The percentage of women with a BMI below 18.5 - the World Health Organisation cutoff between normal and underweight - dropped from 20.8 percent at the beginning of the first food distribution in October 2009 to 11.4 percent in late January 2010.
"It's about the provision of the right food at the right time," said Bertizzolo. The project focused on giving "CSB plus" – a corn-soya blend with added oil - to pregnant and lactating women, with a customized version for children aged 6 months to 24 months.
Using the "window of opportunity" was crucial, she said. If children did not get the right food in the first two years of life, the damage was irreversible. "Don't wait until a child is malnourished ... prevention is the only way to end chronic malnutrition."
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