Saving a child too thin to be vaccinated

By Bethlehem Kiros

Fatima Yesuf, 25, brings her 8 months old daughter to the Metiya health center for checkup and to receive the Plumpynuts food supplementsAMHARA REGION, Ethiopia, February 2016 – Moyanesh Almerew, a Health Extension Worker in Arara Kidanemeheret Kebele (sub-district) in Amhara Region can testify to how bad the current drought in Ethiopia is for children. She is one of thousands employed as part of the nationwide Health Extension Programme, a community-based programme bringing basic health services to the doorstep of Ethiopia’s large, rural population. According to Moyanesh, they have had seen many more cases of severe acute malnutrition among children this year as compared to previous years and the cases they are receiving are worse. Among them, six-month-old, Fikir, whom Moyanesh saw during a home visit, stands out.

“You would not believe how thin she was when we first found her,” recounts Moyanesh, “She had never been vaccinated so when we tried to give her the vaccines, it was not possible because she was only skin and bones,” explains Moyanesh. When she was first brought to the Arara Kidanemeheret Health Post, the child weighed just 4.5 kg and the measurement of her mid-upper arm circumference – the criteria for identifying severe malnutrition – was 10.5 cm. She was severely acutely malnourished.

Thankfully, after receiving treatment, Fikir has gained 2kg after treatment, which included medicine and therapeutic food for several weeks, and her mid-upper arm circumference grew to 11.8 cm, which puts her in the moderately acutely malnourished range. She continues to receive outpatient treatment at the health post.

Moderately acutely malnourished children are enrolled in the World Food Programme-supported Targeted Supplementary Feeding programme through which they receive fortified blended food and vegetable oil for six months to aid their nutritional recovery. Both this and the UNICEF-supported treatment for severe acute malnutrition are routine responses which are all the more critical in a crisis.

Weynitu Demissie, 34, has a 7 months old daughter who is recovering from acute malnutrition
Weynitu Demissie (far left) walks a long distance to get to Arara Kidanemeheret Health Post where she receives therapeutic food for her seven-month-old malnourished daughter, Mastewal. ©UNICEF Ethiopia/2016/Nahom Tesfaye

Seven-month-old Mastewal is another child who has been treated at the Arara Kidanemeheret Health Post. Her mother, Weynitu, says that the drought has taken quite a toll on her family, especially on Mastewal. The child was extremely emaciated before receiving treatment for severe acute malnutrition. Weynitu walks for more than two hours over steep hilly ground to get to the health post for Mastewal’s treatment but she says it is worth all the hardship since her daughter has shown a lot of progress in the last few of months.

To Moyanesh, it is a relief to see the wonders that therapeutic food treatment does for the children. “I doubt that some of these children would have survived if they didn’t receive this treatment,” she says.

Across the country, 458,000 children are expected to need treatment for severe acute malnutrition in 2016. More broadly, 10.2 million people, 6 million of them children, are in need of emergency food assistance due to the drought. UNICEF, the Nutrition sector lead agency, continues to coordinate the nutrition emergency response. With the support of donors, UNICEF provides supplies for the management of severe acute malnutrition and supports the treatment of malnourished children through the community-based management of acute malnutrition, along with training, quality assurance and monitoring of the nutrition emergency response. UNICEF is also supporting efforts to provide drought-affected communities with access to clean water and health services to address major causes of child illnesses and deaths that have been exacerbated by the drought.

To continue nutrition emergency response activities over the coming months, additional funds of US$5 million are needed, subject to needs-based revisions. A further US$ 42 million is needed over the next four years to strengthen nutrition services and build resilience to future shocks among communities that are worst-affected by the drought.

Priests in Amhara advocate to End Child Marriage

Yazew Tagela and Degu Eneyew are both Priests of the Ethiopian Orthodox Church and members of the UNICEF supported Community Conversation Group against Child Marriage in the Bandani Kebele (neighbourhood) of the Dangla Woreda (district) in Amhara, Ethiopia.

Both are vehemently against child marriage, but come from different perspectives:

Yazew Tagela, 41, has directly experienced financial loss as a result of marrying his daughters as children.

Preist Yazew Tagel, member of the conversation group, regrets marrying his two young daughters at a very early age, having learned of the negative consequences of child marriage after the community advocates group was formed. Dangla Woreda, Badani Kebel
Priest Yazew Tagela, 41, has directly experienced financial loss as a result of marrying his daughters as children. He is a member of Bandani Kebele’s Community Conversation Group against Child Marriage, Amhara, Ethiopia ©UNICEF Ethiopia/2016/Mersha

Yazew Tagela comments: “If I had known before what I know now, I could have helped save so many girls. I married both my daughters at age 12 and 16, and I really regret it. I spent 20,000 ETB (around $1,000) on the marriages of my two girls. I could have bought urban land with that, which would now be worth up to 200,000 ETB ($10,000). The girls lead a rural life like me, and do not enjoy life like their peers who were educated.

“Three years later, neither are yet pregnant, but I really worry about that. With the poor living conditions they have, if they give birth life will get more complicated. If I had not married them, they could have contributed a lot to their country through their being educated.

“My own wife was 15 when we married – I was 25. She showed such childish behaviour but I supported her and she became pregnant straight away.”

“As a priest I am responsible for these marriages as I have to marry a virgin girl, so there is so much pressure on the girls being of younger ages. But I am no longer prepared to bless a marriage if a girl is below the age of 18.

“The government has committed to stop child marriage by 2025, but I know we can stop it way before then. This Kebele is a role model for what can be achieved, a learning site. Everyone here shares ideas and supports each other against child marriage.”

Degu Eneyew, 50, has seen first-hand how girls thrive when they are educated.

Preist Degu Eniyew, 50 lives at Dangla Woreda, Badani Kebele, Awi Zone, Amhara Region. He says he values the education of girls after seeing how they can economically improve their own lifestyle as well as their family's, after finishing school.
Priest Degu Eneyew, 50, has seen first-hand how girls thrive when they are educated. He is a member of Bandani Kebele’s Community Conversation Group against Child Marriage, Amhara, Ethiopia. ©UNICEF Ethiopia/2016/Mersha

Degu Eneyew comments: “At the age of 38 in 2003 I went back to school. It was then that I saw the impact education has on the girl – how well she can do in life. But the community sees education negatively as they associate it with a girl’s exposure to risk. We are teaching the community that if a girl is educated she will support the family. Every Sunday I include in my regular preaching to say “no to child marriage” and send girls to school instead.

“Look at the difference between two families – one which is fast to marry its girls too young, one which does not. You can see life’s consequences from child marriage – giving birth early, scarce resources, limited land. You marry a girl before 18 and it is like killing the very life of the girl. Where families are strong enough to send their girls to school the girls have jobs. Her life will be completely different.

“In the past, a priest would bless the marriage of a child. But today, if the girl is under 18 the priest will not be told. The family will conduct a customary marriage instead with any elder, but witnesses to such marriages are criminally liable.

“Hereafter if a marriage involves parties who are under 18 I will denounce it and report it to the police. If the couple are 18 or above I will bless the marriage. I want everyone to condemn the practise as an evil act.”

Elders advise against child marriage in favour of education in Amhara

Ato Zelalem Belay, 70, influential community leader at Dangla Woreda, Badani Kebele, Amhara region.
Zelalem Belay, 70, Elder, speaks in front of Bandani Kebele’s Community Conversation Group against Child Marriage, Amhara, Ethiopia. ©UNICEF Ethiopia/2015/Mersha

Zelalem Belay, 70, is a respected Community Elder and member of the Community Conversation Group against Child Marriage in the Bandani Kebele (neighbourhood) of the Dangla Woreda (district) in Amhara, Ethiopia.

He stands in front of the gathered crowd and speaks with absolute humility and sincerity as he discusses his personal regrets over marrying his daughters when they were children: “At my age I have to tell the truth. Why hide when I can stand here and tell the truth for the betterment of my community,” Zelalem says.

“At first I opposed the change in culture away from chid marriage. I was resisting what the role of the poor girls could be. What options do poor children have? I thought. But I have since become convinced child marriage is not right. I have changed my mind. By supporting poor girls with economic incentives so they can continue their education, there is a different future for them and for their families”, explains Zelalem.

“I was married at 18, to a ten year old girl, but she kept running back to her family. She wanted no physical attachment to me. So three months later I had a second marriage to a 15 year old – it was easy to arrange quickly as my father was wealthy. My first wife, her parents sent her back to school and she married again a few years later.”

Ato Zelalem Belay, 70, has 2 boys and 5 girls
Zelalem Belay, 70, Elder, a member of Bandani Kebele’s Community Conversation Group against Child Marriage, Amhara, Ethiopia. ©UNICEF Ethiopia/2015/Mersha

Zelalem continues: “So you see, in my former life, I had good assets, with family land and property, but then we did not see education as important. But now, those who are educated, they have a higher position than those with just land. A district judge, a school principle – they educate their children so that they have a position in society, they dress well.

Zelalem’s gaze is firm, his voice unwavering as he explains the impact on one of his children: “One daughter, I married her at 15, she gave birth immediately but she is now divorced. I sent her back to school. But she did not perform well. Her life was disturbed and miserable.

“So I strongly advise against child marriage. It is a bad experience for the boy and the girl. If there is a young girl and older man, she will not be responsible for the house and he will always be out spending his money on other women.”

The day before, a neighbour had come to consult Zelalem over marrying his 11 year old daughter. Zelalem explains: “I told him the law and that the marriage may not work out. That he will have lost property in agreeing to a marriage that does not last – divorce when people marry as children is common. I told him his daughter will probably run away. If she runs away to the city she could end up as a sex worker, trying to support herself. Many end up in cities working in local bars. They have nothing to fall back on.

“My life experience tells me that if you marry with an equal age and love each other – when it is a choice – and you share household responsibilities equally, then the marriage will prosper. They can run a business together, the husband can source raw materials and the wife can use them to make local beer to sell. It is a better life.

“I dream to get back to be like a child, and to live such a life.”

Determined men and women form a community to end child marriage

Community advocates of Amhara region, Awi Zone, Badani Kebele, Dangla Woreda. All working hand in hand to transform child marriage practices in Amhara.
A meeting of the Bandani Kebele Community Conversation Group which advocates against child marriage, Saguma village, Bandani Kebele, Dangla Woreda (District) ©UNICEF Ethiopia/2015/Mersha

“We are not just talking about change, we are stopping children from marrying.” A group of determined men and women from various villages in the Dangla Woreda (District) of Amhara, Ethiopia, sit under a tree among a verdant landscape of hills and pasture. Cattle, donkeys, goats, and the steep banks of a river in view. There is a food surplus in this area, the harvest having been plentiful. The talk is lively and incessant as the group discuss their antipathy towards child marriage and their unified commitment to see the practise eliminated in the Kebele (neighbourhood) of Bandani. Known as the Community Conversation Group (CCG), the 35 men and 35 women come from many of the 550 households in Bandani. All are considered influential community members, be that as elders, health workers, religious leaders or members of the Women’s Development Group.

Atalil Abera, 35, chair of women's development group . She works closely with community conversation groups to prevent child marriage.
Atalele Abera, 35, a member of the local Women’s Development Group and of Bandani Kebele’s Community Conversation Group against Child Marriage, Amhara, Ethiopia. ©UNICEF Ethiopia/2015/Mersha

Atalele Abera, 35, a member of the Women’s Development Group, comments: “Our group influences other women and most women want to engage in discussions on child marriage. There were 130 child marriages in this Kebele last year. School is far away and parents fear violence against their children and defilement if they send them on the long journey to school. Many cannot afford to educate their children. I have three children and limited the size of my family by using contraception, so I could ensure they would all be educated.”
Almost every member of the CCG was themselves married either as a child or to a child. They have also faced the decision whether or not to marry their own pre-pubescent daughters and sons. Those who did, now openly regret it, because of the resulting family poverty and the compromised life particularly their daughters now live.

The CCG has “Eyes” and “Ears” members who are tasked with reporting what they see and hear regarding child marriage, prior to a fortnightly meeting, hosted by the Community Conversation Facilitator, Girma Demlash, 30.

The CCG is part of a comprehensive programme against child marriage involving multiple stakeholders. The programme is run by the local government, the Dangla Women, Children and Youth Affairs Office (WCYAO), supported by UNICEF.

Yitayesh Akalu, Expert at the Dangla WCYAO comments: “We have undertaken several trainings with community members on how to implement the UNICEF social mobilisation project against child marriage. That includes how to establish a change group known as a Community Conversation Group. We have trained 10 male and 10 female Community Conversation Facilitators so far. This is the first time we have conducted a comprehensive programme in Dangela Woreda. It is a multi-sectoral programme involving health, education, justice, the community and livelihoods, in the form of a fund to support parents to educate their girls instead of marry them.”

Girma Demlash, Community Conversation Facilitator, comments: “We are very grateful to UNICEF for helping us facilitate the community conversations. Everyone who takes part is committed to ending chid marriage. We have just prevented two marriages – those of a 10 year old and a 13 year old girl – from going forward as a result of the girls reporting to us that their parents were in the process of arranging their marriages. We are not just talking about change, we are stopping children from marrying.”

A Day in the Life of a Well-fed Child: Ethiopia

By Frehiwot Yilma

AMHARA REGION, 05 June 2014 – Kossoye Ambaras is a small lush green village within Wogrea woreda in northern Gondar where it is relatively cold. Amarech Ashager, a 28 years old mother of two, is used to the weather as she lived her whole life here. At the top of her daily agenda is making sure that her family, especially her youngest son, Metages Birhanu of 9 months, is well fed.

Like many of the residents, Amerech does not rise out of bed before 7 a.m., as it is too cold to leave the house. She begins her day by breastfeeding Metages and cooking breakfast for the rest of the household. Her husband, Birhanu Tagel, is a businessman and her eldest son, Muluken, 10, is a third grader. After saying ‘good day’ to Birihanu and Muluken, Amarech will cook breakfast for Metages. Since he was introduced to solid food only three months ago, Metages eats exclusively porridge. Preparing highly nutritious porridge for a child is a technique that Amarech has recently learnt. The base of the porridge, the flour, contains various grains and legumes. For breakfast the added ingredient besides the flour is an egg and minced cabbage. As well as cooking the food, feeding the child to achieve best results is also a discipline. Amarech has learnt to feed her child while also playing and talking to him to keep him engaged.

It takes a village to raise a child

Health Extension workers in Amhara region provide preventive and curative health service to the community
Health Extension workers in Amhara region provide preventive and curative health service to the community ©UNICEF Ethiopia/2014

Amarech and other mothers in the village get support from Health Extension Workers (HEWs) on how to properly raise their children. Today, HEWs Habtam Dese and Yeshiwork Tesfahun are weighing the children in the village to monitor their health and development. They too receive assistance from Gebeyaw Alamerew, the woreda Nutrition and Child Health Officer. In a typical session with a HEW, a six-month-old child will receive a vitamin A supplement, while those aged above one year will additionally receive deworming tablets. With the support of UNICEF, this has become a routine service in the woreda.

Out of 18 children weighed by the HEWs , 16 are in the average weight range. Amarech is one of the happy mothers to learn that her son, Metages, weighs 8.6 kilograms, well in the range of a healthy baby’s weight. “I am so happy that he has gained a few more grams since last time,” she says, smiling. After weighing babies in the community, Habtam and Yeshiwork demonstrate how to make a child’s diet balanced and about the importance of using iodised salt. As the child-friendly food preparation simmers over a fire, the two mothers, whose children’s weight was under the average limit, get counselling on how to improve their baby’s weight. Gebeyaw believes the woreda has come a long way. “In previous years, there were up to eight children per month in Kossoye suffering from Severe Acute Malnutrition (SAM), but this year there have been no cases,” he says. “This is because we monitor the children’s growth and give counselling and other packages of support to the mothers at the earliest stage possible, as we did with the two mothers today.” When the food has finished cooking, Habtam and Yeshiwork let the mothers feed the warm nutritious preparation to their children.

Bridging the nutrition gap before sunset

Amarech Ashager breast feeds Metages Birhanu, 9 months old
Amarech Ashager breast feeds Metages Birhanu, 9 months old © UNICEF Ethiopia/2014

The afternoons in Kossye Ambaras are usually foggy this time of the season. Amarech has subsequently decided to do her laundry the following day and so turns to preparing dinner as well as other domestic chores. For Metages, she has a new menu in mind: adding mashed potatoes and carrots to the porridge. She says she will also never forget adding iodised salt to the food. “Habtam has told us that iodised salt is key to a child’s mental growth. She also told us that we have to put in the salt after the food is cooked and out of the oven so that the iodine does not evaporate with the heat,” she says.

Habtam is one of 38,000 government salaried HEWs currently providing nutritional and other support to mothers and children across all regions of Ethiopia. Development partners such as UNICEF are committed to support this initiative. “Nations will face critical bottlenecks to economic growth if a large proportion of their working-age people’s IQ and productivity are limited by under-nutrition,” says Dr Peter Salama, UNICEF representative in Ethiopia.

As the day draws to an end, Amarech’s house becomes lively as the family come together and discuss their experiences. While breastfeeding Metages, Amarech tells her husband about the importance of investing in their children’s diet to ensure their healthy future. “I will feed my children a variety of foods so that they will have a bright mind,” she says with confidence. “And I will be happy if Metages becomes a doctor.”

On the recent Micronutrient Global Conference (June 2-6, 2014), researchers, policy-makers, program implementers, and the private sector has been discussing ways of overcoming micronutrient malnutrition. The forum has been held under the theme of “Building Bridges”, thus emphasising scientific advances and multi-sectoral programming on adequate micronutrient intake. Read more

In Ethiopia, DFATD support improves community based child and maternal care

By Frehiwot Yilma

Paul Rochon thanks Misa Wondimagen, 25, Health Extension WorkerDERA DISTRICT: AMHARA REGION, 30 October, 2013 – It is early Thursday morning and Gibtsawit Health Post, found in a rural village of Gibtsawit Mariam located 42 kilometres from Bahirdar, is busy with patients. The small room is crowded with mothers who are there to check their babies’ growth; pregnant women having their antenatal care and men and women of the community who are receiving malaria treatment.  Today is a special day, because the health extension workers of the health post are welcoming Mr Paul Rochon, Deputy Minister of International Development, Foreign Affairs, Trade and Development Canada (DFATD) and Dr Peter Salama, UNICEF Representative to Ethiopia.

Misa Wondimagegn, a 25 year old health extension worker, supports the community in Gibtsawit village of Dera district with curative and preventative health and nutrition services.  Misa and her colleagues Meseret and Hagere are supported by the health development army (a network of one volunteer to five Households) attend the 13,366 population of the kebele.

Misa has been working at Gibtsawit Health Post for seven years. “It was just when I finished tenth grade that I had the opportunity to join the training for health extension workers. It was hard convincing people to allow me to monitor the growth of their baby and take my advice about what to feed their children,” she says.  “We travelled long distances to reach as many households in the village as possible.  In each of our visit we tried to improve the health seeking behaviour of the community and eventually encouraged them to go to the health post.”

Growth Monitoring and Promotion is the cornerstone in the Community Based Nutrition Programme.  It creates a platform for the health extension workers to contact the caregivers and check the nutritional status of children, detect growth faltering at early stage and provide counselling on Infant and Young Child Feeding practices (IYCF).

“Now, the situation has changed a lot: we have mothers who bring their children for check-up and pregnant women who come for antenatal care. The support we get from UNICEF and the Canadian Government has increased the variety of treatments we provide for the community. We have outpatient treatment for children diagnosed with severe acute malnutrition and for pregnant women we give antenatal care and supply iron –folate. We promote good Hygiene and sanitation and we also give treatment for common childhood illnesses like pneumonia malaria and diarrhoea for the community,” Misa explains with smile on her face.

Support in Action

Haimanot Andarge, 20, and her daughter Azeb Abraru, 23 month, relax at home in Dera Woreda in Amhara region of Ethiopia

Since 2007, the Canadian Government has been supporting UNICEF Ethiopia’s interventions in Child Survival with Vitamin A and Zinc Supplementation and Integrated Health System Strengthening as well as routine immunization. Dera is one of the 100 UNICEF supported districts implementing the preventive and curative nutrition interventions. It is implementing Community Based Nutrition (CBN), integrated with other Community Maternal New-born and Child Health Interventions (CMNCH) to prevent child malnutrition, focusing on the first 1000 days: the time between conception and when a child turns two years of age.

In August 2013, 1,247 children attended the monthly Growth Monitoring and Promotion session in Dera enabling Misa and the other 78 health extension workers in the district to identify nutritional status of the children, detect early growth faltering, help the caregivers visualize the status and counsel them on appropriate age specific feeding messages using the Family Health Card as a counselling aid and refer children for further care in a timely manner whenever needed.

Haimanot Andarge, a 20 year old mother of baby girl Azeb, is one of the many mothers in the district who got follow ups from Misa and her colleagues during their pregnancy. “Misa used to come to my house regularly ever since she knew I was pregnant. She gave me vaccines and other supplements which was important for my baby. And when my labour began my husband took me to the health post. Misa encouraged me to deliver at Hamusit Health Centre which referred me to Bahirdar Hospital in time as my delivery was complicated. My baby was delivered safely because the health post was in our village to identify my condition,” Haimanot remembered. Her eyes reflect her fear of what might have happened. “ Azeb, is going to be two this year and  Misa still follows up on her  regularly and gives me advice on what to feed her,” adds Haimanot.

Integrating approaches to combat malnutrition

Holding Plumpy'Nut produced in Ethiopia, Misa Wondimagen, 25, Health Extension WorkerOne of the challenges to the health extension workers was what kind of advice to give to families with low income, regarding additional food for their children. “Health Extension Workers usually explain to families to use variety of cereals, animal protein and vegetables. Those who have money would buy and others barter with what they have produced,” explains Ato Worku Endale, Head of the Dera District Health Office. “Recently we have been integrating the health extension programme with the agriculture extension programme to support farmers on what to produce and how they can support their children and family with variety of food items. In addition, the safety net programme that has been implemented in this particular community allows families with low income to be involved in the income generating activities.”

With the integrated multisectoral approach of the government of Ethiopia and the support of UNICEF and partners such as DFATD, the hard work of health extension workers like Misa and colleagues is paying off.

Revolutionizing treatment of Severe Acute Malnutrition (SAM)

The support from UNICEF and the Canada Government that started the preventive nutrition programme of Community Based Nutrition linked with provision of WASH facilities has helped reduce the number of children who are malnourished.  According to Dr. Peter Salama, the collaborative work of all stake holders, the availability of treating health posts within the community have made saving a child easier than ever before.

At the end of the visit the team eagerly waits to hear from Misa and her colleagues on their response to the fundamental question of how many children were lost to malnutrition recently.  “There were 27 children diagnosed with Severe Acute malnutrition in July 2012- August 2013. They were treated with the Out-patient Therapeutic Programme (OTP) and 20 have been cured and seven are still on follow up with good prognosis but we have not lost a single child,” Misa explained boastfully.
Group Photo: Joint visit of UNICEF and DFTAD

“It was not easy to change the attitude of the community. When we started, there was no one before us working with the community reaching every  household door to door. We started from nothing. But with the support of donors like  UNICEF and the Canadian Government, I cannot even remember the last time a child died in the community for the last four years,” Misa reminisces.

“It makes me realise that it was not for nothing that I worked so hard at the beginning. I have brought change in my community.” Misa concludes.