A recent study in Mqanduli and surrounding areas in the Eastern Cape found that children's healthy growth and development is not only undermined by their inability to access nutritious food but that unhealthy environments and poor access to routine child health services such as Vitamin A supplementation and deworming, also impede healthy child development.
The study was conducted by The Grow Great Campaign, in partnership with Philani Maternal, the Child Health and Nutrition Trust and the Nelson Mandela University. The study findings were compiled in a report launched last month. The Grow Great campaign aims to "galvanise South Africa toward achieving zero stunting by 2030".
The report warns that amid high levels of unemployment and food insecurity due to the COVID-19 pandemic, it is expected that "the nutrition profile of children under five in Mqanduli and surrounding villages will have further deteriorated". Although the report was launched last month, the data was collected between June and August 2019.
Figures provided by the Eastern Cape Department of Health hint that this expectation is not entirely misplaced given the disruption in some routine health services due to the COVID-19 pandemic.
According to the report, preventative measures such as routine deworming and administering Vitamin A at the required intervals are critical in the early development of children since they support the rapid growth of children who are not consuming enough nutrients. "Children who do not have an up-to-date deworming schedule and who had missing records of Vitamin A doses were more likely to be stunted and that robs them of employment prospects in adulthood and traps their families in intergenerational cycles of poverty," the report states.
In terms of access to routine child health services, the findings show that 27% of the children surveyed who were older than six months, "had no record of receiving their most recent Vitamin A dose". For children who were older than one year, only 27% had a deworming schedule that was up to date. The findings also show that 5% of the children surveyed "were reported to have had diarrhoea in the two weeks preceding the survey".
Yet, although the findings highlight that both deworming and Vitamin A coverage was "suboptimal" among the survey participants. "there were no statistically significant associations found between poor deworming or low Vitamin A coverage and increased odds of stunting".
The findings further underscore the importance of the First 1000 Days of life of a child as a period of particular vulnerability to stunting. "Children under two years old were found to be at an increased risk of stunting compared to their 24- to 60-month-old counterparts." Yet the findings show that 13% of the children surveyed had a low birth weight, which "was found to increase the odds of a child being stunted by nearly three times".
The findings also highlight how important maternal nutrition interventions are at the beginning of pregnancy. "At present in South Africa, state social assistance for the purposes of nutrition support for vulnerable and poor children is only provided after the child is born in the form of the Child Support Grant," the report states. "South Africa does not provide this kind of support to vulnerable and poor pregnant women. This is a missed opportunity because, as has been demonstrated in this study, much of the vulnerability to stunting begins in pregnancy."
The findings show the prevalence of stunting among children younger than five for the Mqanduli area was 24% and this was coupled with high levels of low birth weight. Low birth weight at birth, this study found, "increased the odds of a child being stunted by almost three times".
"Among the 1 431 children surveyed whose mothers were 18 years or older, stunting was identified in 336 children (of whom 94 were severely stunted). The prevalence is only one percent lower than the provincial estimate of 25% and also lower than the national estimate of 27%.
The World Health Organization defines stunting as "the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. Children are defined as stunted if their height-for-age is more than two standard deviations below the WHO Child Growth Standards median."
Poor access to basic services
It is not only access to routine health services and routine nutritional interventions that are important, but access to basic services can also play a role in healthy child development.
The report notes that no child surveyed had access to piped water in the home. "The majority of caregivers (55%) collected water from a dam, river, or spring, some 38% depended on communal water, and 7% harvested rainwater. Most of the children surveyed (72%) lived in households whose primary source of sanitation was a ventilated pit latrine, 24% made use of a pit latrine or long drop, 3% had no access to sanitation facilities and 1% used portable toilets, the findings show.
The annual Child Gauge, a report compiled by the Children's Institute at the University of Cape Town, has highlighted similar findings on access to services and how they impact child health over the years. In its 2020 report, the Institute states that "young children are particularly vulnerable to diseases associated with poor water quality" and that "gastro-intestinal infections with associated diarrhoea and dehydration are a significant contributor to the high child mortality rate in South Africa". "There has been little improvement in children's access to water over the past 15 years."
Nutrition and food systems strategist at Grow Great Anna-Marie Müller says child health and nutrition have long-term impacts on cognitive development.
"The proactive measures to prevent stunting begin at the primary healthcare system by identifying and supporting children who may be at risk of malnutrition," she says. "The results show that the dietary diversity score of children aged six months to 23 months is at 43%. This is the age of vulnerability to malnutrition when children transition from breastfeeding to the household diet," she says.
"Everything needs to be done to support their (children's) immune system so that the energy they have is available for growth instead of fighting infections. Mqanduli, near Mthatha, is experiencing a double burden of both under and over-nutrition, with 14% of children under five in this survey found to be overweight and 6% obese."
Müller says children who were found to be obese are at risk of simultaneously being stunted and overweight compared to children of normal weight and puts children at long-term risk of non-communicable diseases such as heart disease and diabetes.
She says these conditions can be diagnosed and treated at the community level by strengthening Community Health Worker (CHW) programmes to ensure that children in the Mqanduli area are routinely growth monitored and benefit from basic preventative primary healthcare services. "Communities also need to be taught that healthy food is not expensive, but all we need is for every household to have a vegetable garden so that children can get the nutrients they need."
Health department: Plans are in place
The Grow Great report states that children in Mqanduli have "poor access to adequate water and sanitation, [which are] known risk factors for diarrhoea and stunting. Given the evidence that a combination of interventions, including improving water and sanitation, access to nutritious food and behaviour change support are necessary to improve child growth outcomes, reducing stunting in this setting requires a multisectoral response."
Referring to the report Mkhululi Ndamase, spokesperson for Eastern Cape Health MEC Nomakhosazana Meth agrees that the findings reinforce the importance of inter-sectoral collaboration to address the social determinants of health that negatively contribute to poor health outcomes, including child malnutrition.
"Currently there is a Mother and Child Development Programme facilitated by the Department of Social Development that involves the Department of Home Affairs, the Department of Education and the Department of Rural Development and Agrarian Reform as well as NGOs to address child malnutrition.
The programme is being implemented in OR Tambo (Ingquza Hill and Port St Johns) and Ntabankulu," says Ndamase. "It has since reaped positive outcomes for children, especially in Ingquza Hill, which was previously a hotspot for children dying from malnutrition."
Ndamase explains that Ingquza Hill was identified as a hotspot in 2017 "when a total of 40 babies out of 201 that were admitted in hospital died". "This is because of poverty that leads to poor nutritional intake, poor growth monitoring, and promotion." Along with interruptions in clinic visits, the use of traditional medicine on babies was also identified as the cause, including poor access to child grants due to unavailability of birth certificates and identity documents of mothers, says Ndamase.
In Mqanduli, the Grow Great report found that "the sex of the child, inadequate access to sanitation, not having a birth certificate by age five, not receiving a Child Support Grant (CSG) by age five, having a low birth weight, being identified with either moderate acute malnutrition or severe acute malnutrition, underweight or obesity were statistically significant risk factors for stunting". 4% of children under five surveyed and 8% of those under one year did not have a birth certificate. 94% of those under five have been registered and received a child support grant.
According to Ndamase, the department focuses on providing clinical care and support in the first 1 000 days of a child's life to prevent child malnutrition (including stunting). "This starts from the period of conception up to the age of two years. This period is critical in the physical and cognitive development of any child. When proper nutrition is missed during that period, a lot of irreversible damage could be caused, including stunting."
Ndamase says all health facilities offer nutrition education to all pregnant women and mothers with young children and nutritional assessments are routinely done to identify malnourished mothers and children. "Nutritional supplements are available for those patients who are eligible, such as those who are underweight or wasted. Ward-based Community Outreach Teams also educate mothers at community-level on complementary feeding of children under five years to prevent malnutrition," he says.
According to Ndamase the department's Growth Monitoring and Promotion Programme is implemented at Primary Health Care and hospital levels to identify children that are underweight, wasted, stunted, and overweight. "Identified malnourished children are given nutritional supplements that have been certified safe and suitable for consumption by the adjudication team at a national level. A fully-fledged nutrition program emphasising community nutrition through food gardens in collaboration with relevant departments is a requirement," he says.
Ndamase, however, conceded that in the 2020/2021 financial year, the department fell short of their 64% target of distributing Vitamin A supplements, saying their actual performance was 61%. He says the reduced numbers were due to fewer people visiting clinics during the stricter levels of lockdown. "Vitamin A supplements are also administered at Early Childhood Development centres, which were closed at alert levels 3, 4, and 5 of the COVID-19 regulations," he says.
In the same financial year, the number of children under five in the province identified as malnourished was 6 016, says Ndamase.
Explaining why the target is at 64% and what informs that, Ndamanse says, "Vitamin A supplementation is given to children in the age range of 12 to 59 months. Vitamin A is administered at intervals of six months in different cohorts. For some children, the follow-up visits for the administration of Vitamin A fall outside the reporting period of the financial year. A higher proportion of children in the age category of 12-59 months are not frequently visiting clinics for the immunisation service because as age progresses, there are fewer immunisations due as per schedule.
"Caregivers usually prioritise clinic visits for immunisations over those for growth monitoring and Vitamin A supplementation due to long distances or taxi fares to be paid," he says. "To address the issue, Ward Based Outreach Teams (WBOTs) assist with administering Vitamin A at the community level." He says ECD centres are also roped in for this purpose and a total of 399 113 children in the province received Vitamin A supplements in the 2020/2021 financial year.
Disaggregated data needed
Speaking at the virtual launch of the report, Executive Director of the Grow Great Campaign, Dr Kopano Matlwa Mabaso said the prevalence of stunting among South Africa's children is worryingly high while little progress has been made in the last two decades. "The prevalence rates are far higher than would be expected for an upper-middle-income country and far higher than many of South Africa's counterparts in the developing world."
Matlwa Mabaso said part of the challenge is that we don't have sufficient detailed and disaggregated data at provincial or even district level on the nutritional status of our children.
"This makes it difficult to target intervention and resources in communities. Detailed data is important to be able to adequately target resources and interventions to make sure that we are supporting children most at risk."