Addressing Chronic Malnutrition in Madagascar

October 3, 2016

Madagascar has one of the highest rates of childhood stunting in the world. Over half of children are chronically malnourished, and more than one-fourth are severely malnourished. Researchers will evaluate the impact and cost-effectiveness of combining different nutrition and child development interventions to help the government of Madagascar optimize the impact of its community-based nutrition program on nutritional and child development outcomes.

Stunting as a result of chronic malnutrition during gestation and early childhood (the first 1000 days) has lifelong implications well beyond physical size. Research has shown that stunting by the age of 2 years predicts poor cognitive, language and behavioral development, higher rates of morbidity and mortality, and worse longer term outcomes including labor market participation. Effective and high impact programs that improve nutrition in the first 1000 days, from conception to age two, are essential to helping children achieve their developmental potential. Given the interplay of so many factors that can have an effect on a child’s healthy development, governments are focusing on better nutrition and improved feeding practices for pregnant women and children -- while also working to improve sanitation, hygiene, and child stimulation. The program being evaluated in Madagascar will improve our understanding of the usefulness of integrating intensive nutrition counseling with nutritional supplements for pregnant mothers and children or with early childhood stimulation.


Research area: Early Childhood Nutrition, Development, and Health
Country: Madagascar
Evaluation Sample: 125 poor communities in Madagascar
Timeline: 2012 - 2017 (Completed, endline report pending)
Intervention: Intensive counseling, child and mother nutritional supplements, early childhood stimulation
Researchers: Emanuela Galasso, Development Research Group, World Bank; Lia Fernald, School of Public Health, University of California at Berkeley; Christine Stewart, University of California at Davis; Ann Weber, Stanford University; Christine Stewart, University of California Davis; Harold Alderman, International Food Policy Research Institute; Mamane Zeilani, Director of operational research at Nutriset; Jumana Qamruddin, World Bank; Voahirana Rajoela, World Bank; Remi Rakotomalala, National Coordinator, Health Program Implementation Unit, Ministry of Health; Valerie Ranaivo, Statistician & Project Manager, Proessecal
Partners:  Madagascar National Nutrition Office; Madagascar Ministry of Health; School of Social Service, Madagascar; University of California at Berkeley; University of California at DavisStanford UniversityNutriset



Madagascar is an extremely poor country, with more than 92 percent of people living on less than $2 a day. More than half of children under the age of five are chronically malnourished. 

Fifteen years ago, Madagascar’s Office of Nutrition initiated a large-scale, community-based nutrition program that is still operating throughout the country. The program includes monthly growth-monitoring sessions for infants and young children up to age 5, and community mobilization and nutrition education for primary caregivers. The government is currently focusing on what else can be done during the first 1,000 days of life to reduce stunting when children are most at risk for developmental delays. This evaluation will help the government improve the national nutrition program by examining several components that can be scaled up for pregnant women and their babies in the first two years after birth.

Yosef Hadar / World Bank

Intervention and Evaluation Details

The evaluation is a multi-arm intervention trial nested within the existing national nutrition program. The national program consists primarily of monthly nutrition education and growth monitoring sessions at which community workers deliver information about good nutrition and hygiene. Women in the treatment groups will receive the augmented intervention with the standard program; those in the control group will receive only the “status quo” monthly growth monitoring and nutrition sessions given through the national program.


Intensive counseling: A community worker visits homes to provide personalized intensive counseling to women. The worker, who receives special training in communication and problem solving, follows a “diagnostic tree” to help plan an affordable, diversified diet tailored to pregnant women and children, as well as to overcome barriers to changing behavior.

Intensive counseling plus nutritional supplements for children: Six to 18-month old children receive lipid-based nutritional supplements in addition to the home visits for mothers. The supplements provide 118 kilocalories per day and nearly 100 percent of the recommended nutrients for young children. The counselors instruct the families to mix the supplements into children’s food twice per day. Mothers receive the packets of supplements at the monthly growth monitoring sessions.

Intensive counseling plus nutritional supplements for young children, pregnant and new mothers: In addition to the counseling and nutritional supplements for children, a third group of mothers will also receive lipid-based supplement during pregnancy and the first six months after their child’s birth during breast-feeding. The supplement will be 40 grams per day, providing about 200 kilocalories and one to two times the recommended micronutrients. The mothers will receive all supplements at the monthly sessions.

Intensive counseling plus early childhood stimulation: Community workers in a fourth intervention arm visit the homes of children 6-18 months to educate primary caregivers on the benefits of early childhood stimulation and responsive. Workers follow a weekly protocol for delivering age-appropriate messages and practice activities for improving childhood cognitive outcomes.


Researchers will conduct a multi-arm randomized-controlled trial to test the effectiveness of the interventions. Drawing from a sample of 125 communities in Madagascar’s current nutrition program, researchers will randomly assign communities into five groups of 25 each. One will be the control group, receiving the national program alone, while the other four will receive the national program plus one of the four interventions described above.

The design will allow researchers to measure the impact of each incremental treatment in terms of improvements in child and mother wellbeing. The researchers will administer detailed surveys at the beginning of the intervention and again after 18 months. The main information tools are questionnaires to a random sample of families of 30 children and 10 pregnant women in each community. The survey will contain sections on demographics, water and sanitation, education, household expenditures, food security, shocks, measurements of child and mother health and development, and prenatal care. The follow-up survey will also include questions about the perceived benefits from the program, child birth details, and breastfeeding history. Researchers will also survey community nutrition workers about socioeconomic characteristics, experience, and organization of the program activities. In addition, researchers will collect village-level information on issues such as infrastructure and climate shocks. Finally, hemoglobin will be measured to assess anemia and key micronutrient indicators will be obtained from blood samples in a subset of children at follow-up.

Policy Impacts

Early child interventions can improve the development of hundreds of millions of children worldwide. This project will be among the first to examine the relative impact and cost-effectiveness of different packages of intensive counseling, lipid-based nutrition, and early child stimulation coupled with an existing large-scale growth promotion program.