A&T Nigeria: Summary and problem statement
1. Executive Summary
Every year, millions of children die and many more fail to realize their full potential because of undernutrition in the critical 1,000
day period. Nigeria is home to about 7% of the world's sub-optimally breastfed children and ranks second in countries with high
mortality due to sub-optimal feeding. Progress in reducing undernutrition has been hampered by a number of challenges (many
of which are not unique to nutrition, but rather are systemic and are operational issues that affect numerous sectors) but
unprecedented political attention to undernutrition over the last few years has created a critical window of opportunity in
Nigeria. We believe this investment has the potential to lower deaths attributable to sub-optimal breastfeeding through
implementation of Alive & Thrive’s (A&T) proven approach, drawing on experience and lessons learned from the program’s first
phase.
Because of the size and complexity of Nigeria, the program is proposed to focus on two states, Lagos and Kaduna, with national
level advocacy. All four components from A&T’s framework will be applied in the states: (1) advocacy and policy; (2) interpersonal
communication and social mobilization; (3) mass communication; and (4) strategic use of data.
The primary learning question for the evaluation in Nigeria will be: Can implementation of the four component framework in
Nigeria have an impact on infant and young child feeding (IYCF) behaviors similar to what was observed in Phase I A&T countries?
The primary outcomes to be measured will be IYCF practices in the two states where A&T will be implementing all four
components—Lagos and Kaduna. The outcomes are related to the WHO-recommendations for optimal breastfeeding and
complementary feeding practices for children under 24 months of age. These will include, but may not be limited to: increases in
early initiation of breastfeeding (within one hour of birth), increases in exclusive breastfeeding, and increases in minimum diet
diversity and minimum meal frequency among children 6-23 months. These will be the primary outcomes of two of the key A&T
components: interpersonal communication and community mobilization and mass communication. A&T experiences in other
countries have shown that a model that incorporates advocacy for pro-IYCF policies and strategic use of data are effective at
achieving the behavioral outcomes listed above due to their positive impact on supportive social norms. Additional outcomes
expected from these two components include: improved implementation of IYCF-friendly policies and increased use of data to
support IYCF programs and policy.
2. Problem Statement
Infant mortality, stunting/wasting, and IYCF
Nigeria, the most populous country in Africa with 178.5 million people,1 has some of the world’s lowest maternal and child health
indicators. In the last five years, moreover, rates of improvement slowed and the country barely reached the half-way mark
toward its 2015 MDG targets. According to the most recent Nigeria Demographic and Health Survey (NDHS-2013),2 under-5
mortality was 128 deaths per 1,000 live births and infant mortality was 69. The neonatal mortality rate hardly changed in the
preceding five years, dropping from 41 to 37 deaths per 1,000 live births. The maternal mortality ratio also remained high at 560
per 100,000 live births.
Nutrition indicators have shown a similar pattern of stagnation. The exclusive breastfeeding rate for 0-6 month olds—a practice
that can significantly reduce child deaths—has remained unchanged since 1999 at an astounding 17%. Stunting among children
under 5, high at 37% nationwide, dropped 3 percentage points over the previous 5 years. But the rate of wasting actually rose—
from 14% to 18%. Table 1 shows basic nutrition indicators for children 0-23 months in Nigeria nationally and for the two priority
program states of Lagos and Kaduna by richest and poorest socioeconomic status (SES) quintiles. 3 The data highlight the
distribution of population by wealth in the two states (strongly reflecting the urban vs. rural population divides). The data also
highlight the extreme nutritional deficiencies prevalent particularly in Kaduna across wealth quintiles, and the presence of high
wasting even among the urban rich in Lagos.
1
World Bank data. Available at: http://data.worldbank.org/country/nigeria
National Population commission [Nigeria] and ICF Interntaional (2014). Nigeria Demographic and Health Survey 2013. Aguja, Nigeria, and Rockville, MD,
USA: NCP and ICF International. (Henceforth NDHS 2013)
3
USAID has been conducting a review of data quality (especially anthropometry) in the NDHS 2013. At project outset, A&T will consider any
issues/implications related to this review and will conduct its own anthropometric survey to establish baseline measures for the project areas.
2
Table 1: Nutritional status of children < 2 year in the richest and poorest* quintiles, nationally and by region (NDHS 2013)+
Indicator
National
Poorest – richest
Lagos
Poorest – richest
Kaduna-Urban
Poorest – richest
Kaduna-Rural
Poorest – richest
Stunting (% < -2SD)
Severe stunting (% < -3SD)
Wasting (% <-2SD)
Severe Wasting (% < -3SD)
48 – 14
29 – 6
19 – 13
6–3
N/A – 9
N/A – 1
N/A – 17
N/A – 3
N/A – 60
N/A – 39
N/A – 33
N/A – 18
53 – N/A
39 – N/A
44 – N/A
19 – N/A
*Note: Wealth quintiles were calculated based on the national sample. In Lagos, the survey identified no women into the two bottom quintiles. In urban
Kaduna, the survey identified no women in the poorest quintile. In rural Kaduna, the survery identified women in the richest (top) quintile. Some of the
very wide variation in status among these sites may be a function of the way the index was identified and warrants study.
+
The NDHS survey did not focus specifically on children aged 0-2 and the sample for this subgroup is small. See also footnote (3) on possible issues
refarding anthropoetric data quality.
Undernutrition undermines the health and development benefits of country investments. The Foundation 2015-2020 strategy
notes:
Millions of children die and many more fail to realize their full potential because of undernutrition in the critical 1,000 day
period between their mother’s pregnancy and their second birthday. Malnutrition is responsible for nearly half of all underfive child deaths each year. Children who miss out on good nutrition during these 1,000 days never achieve full physical or
mental growth, limiting their ability to learn in school and reducing their productivity as adults.
IYCF interventions focus on preventing undernutrition in the 1,000 day window of opportunity. However, causes of
undernutrition may be multi-sectoral and, similarly, no single strategy is likely to bring about large-scale change. Determinants
may range from basic food security, to wealth and social status, to access to services, to maternal education, to broad-based
social norms and cultural beliefs and family practices. The two priority states for this program—Lagos and Kaduna—offer an
opportunity to investigate determinants and plan program strategies
A banker: “It is just not feasible to exclusively breastfeed
for large populations (10.7 million and 7.3 million respectively) with
for six months. Is it that easy? Well, I’d like to do it, if I
distinct urban and rural differences (Lagos state is mostly urban) and
don’t have to work. Our workplaces are strictly for
other variations (such as predominant ethnic and religious groups)
business, not for nursing mothers. If you still need your
that to some degree reflect the enormous diversity of the country.
job, you’ll not take your baby into a bank.” On pumping
According to WHO guidelines, the level of severe wasting in rural
milk: “The milk easily sours and besides, it is better for
Kaduna may also require a fundamental difference in emphasis on
the baby to suck directly from the source than be fed
supplementation vs. prevention. (See Section 3. Scope and Approach
with a bottle. So, at two months, I had to stop exclusive
for further on the state-level rationale).
breastfeeding – using infant formula along with breast
milk when I’m available.“
Why breastfeeding is becoming unpopular, by mothers
Wole Oyebade, The Guardian (newspaper), August 12,
2013
The current status of IYCF practices to be addressed by A&T
Priority nutrition practices for children under 2 years of age include
timely initiation of breastfeeding (BF), exclusive BF up to age 6
months, introduction of complementary foods (CF) around 6-8
months of age with appropriate frequency of meals and diversity of
food groups, and continued BF up to two years.
Given the close tracking of urban and rural residence with SES status in the two priority states, one would expect poorer practices
in rural areas—but this is not consistently the case. For example, Table 2 shows that in the two states, timely initiation of BF was
lowest in largely urban Lagos (only 19%) compared to Kaduna (U-39%, R-35%). Continued BF for children 12-24 months was also
lowest in Lagos (75%) compared to Kaduna (U-78%, R-92%).
However, generally in 2013, IYCF practices were poor in both of the priority states. Giving pre-lacteals within the first 3 days was
common (Lagos-42%; Kaduna/U-60%, R-66%). The majority of babies received plain water. Further, receiving water was a norm
for infants of all ages. Even during the first month of life, most infants nationwide (54%) were given water in addition to
breastmilk. By 4-5 months, only 10% of infants nationwide received breastmilk with no additional liquids. The belief that infants
require water is the chief reason for the low exclusive BF rate among infants 0-6 months in the priority states (Lagos-37%;
Kaduna/U-19%, R-7%).
2
Table 2: Nutrition-related indicators for Nigeria (national), Lagos, and Kaduna (NDHS 2013)
Indicator
Nigeria
Lagos
Timely initiation of BF (<1 hr)
*Prelacteal given during the first 3 days
Exclusive BF (<6 mo)
Exclusive BF at 4-5 mos
Timely introduction of CF (6-8 mo)
*Early introduction of CF (4-5 mo)
Minimum meal frequency of CF (6-23 mo)
Dietary Diversity (> 4 groups) of CF (6-23 mo)
Minimum acceptable diet (6-23 mo)
Continued BF at 12-15 mos
*Infant formula (0-6 mos)
*Bottle feeding (0< 23 mo)
33
60
17
10
64
38
60
19
10
78
6
16
19
42
37
20
67
24
46
11
3
75
12
27
Urban
Kaduna
39
60
19
18
86
40
93
29
24
78
8
20
Rural
Kaduna
35
66
7
0
80
54
85
10
8
92
7
13
*These four indicators show percent practicing harmful behaviors; other indicators are for positive behaviors.
Bottle feeding is a particularly dangerous practice and the NDHS 2013 notes that the trend is increasing. In Lagos, 27% of all
children under 2 were bottle fed the previous day. Acceptability of the practice is particularly evident when data are
disaggregated by age: in Lagos, 42% of children 6-11 months were bottle fed and in urban Kaduna, 39% of children 0-5 months
were bottle fed. Giving infant formula is less common but still worrisome, especially in Lagos (12%).
Nigerian infants are typically introduced to complementary foods both too early and too late. According to the NDHS 2013,
introduction of solid or semi-solid foods between 4-5 months was especially prevalent in Kaduna (U-40%, R-54%) but also
common in Lagos (24%). At the same time, only 64% of children nationwide were introduced to complementary foods “on time”
(between 6-8 months). Timely introduction was lower in Lagos (67%) vs. Kaduna (U-86%, R-80%).
The quality and frequency of foods given varies greatly. Nationally in 2013 only 10% of children 0-23 months received a minimum
acceptable diet (Lagos-3%, Kaduna U-24%, R-8%). Poor dietary diversity was the biggest factor; only 11% of children in Lagos
received the recommended four or more food groups, compared to Kaduna (U-29%, R-10%). Minimum meal frequency was
particularly problematic in Lagos (only 46% of children) compared to Kaduna (U-93%, R-85%). See infant feeding practices by age
in urban Lagos and rural Kaduna in the figures on the next page.
Figure 1 (a) and (b): Infant feeding practices by age (in months) in urban Lagos and rural Kaduna (NDHS 2013)
(b) Rural Kaduna
(a) Urban Lagos
100%
100%
80%
80%
60%
60%
40%
40%
20%
20%
0%
0%
0-1
2-3
4-5
0-1
3
2-3
4-5
Potential determinants of IYCF practices (social and public health context)
Policies, services, social norms, and various household characteristics may all be important determinants of the key IYCF
practices. Ineffective implementation of the International Code of Marking of Breastmilk Substitutes (BMS) and lack of a policy on
maternal workplace protection (Convention 183) are major issues for Nigeria. An even greater problem has been the lack of
improvement over time in basic maternal and child health services. Table 3 (following page) shows that in 2013, nationwide
coverage of services was two or more times higher in urban areas than in rural areas. Notably, 66% of urban women had skilled
attendance at birth, compared to only 23% of rural women. This is a crucial service not only to ensure survival of both mother and
baby, but to assist with BF initiation. In contrast, prevalence of a postnatal visit within two days of delivery was high everywhere.
This contact is also an important opportunity to help the mother establish exclusive BF. (In rural Kaduna, 46% of visits were by
traditional birth attendants [TBAs] and their skill levels may vary.)
Basic coverage and reach problems are also common for child health services. In 2013, care-seeking for child diarrhea (which can
be a valuable window for changing IYCF practices) was low in Lagos (42%) and even lower in Kaduna (12%).
Table 3: Health service indicators for Nigeria (national), Lagos, and Kaduna (NDHS 2013)
Indicator
Nigeria
(urban/rural)
52
38 (67/23)
94
28 (35/26)
Four or more ANC visits
Skilled attendance at birth
Postnatal visit (<2 days)
Care-seeking for child diarrhea (0-23 mo)
Lagos
97
87
94
42
Urban
Kaduna
60
55
99
Rural
Kaduna
34
20
96
12
Countdown 20154 emphasizes the challenge for Nigeria in achieving SES equity in services. Those in the two richest quintiles
benefit from up to four times better coverage of MNCH services than those in the lowest two quintiles. Moreover, this imbalance
is often greater than the basic urban/rural split. Nationwide, only around 10% of the poorest women have skilled attendance at
birth and only around 20% have 4 ANC visits. Improving practices through face-to-face counseling will be a challenge given the
low use of services by those who are most vulnerable.
Other determinants play less certain roles in IYCF practices and their effects need to be studied. Table 4 provides more
information on different household characteristics that may influence practices. (See also, section “3. Scope and Approach”)
Table 4: Maternal/household characteristics and preferences, Lagos, and Kaduna (NDHS 2013)
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Indicator
Lagos
Urban Kaduna
Rural Kaduna
Religious identification
Christian 57%, Muslim 33%
Ethnic identification
Place of giving birth (public
facility/private/home)
Maternal literacy
Weekly media access by
women
Household ownership of
mobile phone
Yoruba 58%, Igbo 20%
Public = 21%, Private = 57%
Home = 22%
81%
Radio = 60%, TV =73%
Muslim 66%, Christian 21%
(more Muslim in rural areas)
Hausa 54%, Fulani 8%
Public = 47%, Private =7%
Home = 56%
50%
Radio = 39%, TV = 43%
Publ.=19%, Priv.=1%
Home=80%
19%
Radio=26%,TV=16%
97%
91%
63%
Available at: http://www.countdown2015mnch.org/country-profiles/Nigeria
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Given reliance on private providers even by the poorest groups (for maternal delivery but also for advice on common illnesses)
engaging this sector will be an important strategy. Religious institutions may be powerful channels for reaching even the “hard to
reach” in all areas. In Lagos and Kaduna, the potential of mass media is uncertain before considering factors such as wealth and
maternal education. In rural areas, where only 26% of women listen to the radio weekly, use of mass media will be particularly
challenging. Although a high percentage of households reported having a mobile phone, access by women is not well known.
(Nationally, male ownership is predominant).5
A&T’s Theory of Change
To address these challenges and issues described in the Problem Statement, A&T developed a Theory of Change, which underpins
our approach to work in Nigeria and describes the links between the individual barriers and chosen strategies, approaches, and
likely impact.
Figure 2: A&T Theory of Change
If we address these barriers…
 Inadequate
resources and
priority given to IYCF
interventions in
MNCH
 Few health care
service contacts
during child’s first 2
years
 Inadequate
knowledge, skills,
and motivation of
frontline health
workers to support
IYCF
 Poor families face
food insecurity
 Lack of social
support for
recommended IYCF
practices among
family members,
community leaders,
frontline health
workers
 Lack of large-scale
interventions to shift
social norms, beliefs,
and IYCF behaviors
 Cultural
misperceptions and
traditional practices
(e.g., giving water) in
with these strategies……..
then we can achieve…..
 Targeted advocacy &
technical support at
national and State
levels
 Improved contacts
with mothers at 0-24
months for BF/CF
counseling (facility-,
community-, homebased)
 Health care provider
(public, private, NGO)
orientation, training,
and performance
improvement in IPC
 Identification of foods
available even in food
insecure households
 Social mobilization
through Ward Dev.
Committees, religious
associations, NGO
programs
 Mass and traditional
media and mobile
phone communication
to reach multiple
audiences and
address relevant
beliefs and
misperceptions
 Data collection/use to
improve interventions
and policies
 Additional IYCF
resources from
States and other
stakeholders
 Guidelines issued
by State Ministers
of Health to
prioritize IYCF in
all health services
 Mothers
supported during
pregnancy, at
delivery, and up
to 2 years to feed
as recommended
 Health workers
achieve high
coverage &
quality
 Perception
among foodinsecure families
that
recommendations
are feasible
 Communities
enlightened to
support priority
IYCF behaviors
 Widespread
perception that
recommended
IYCF practices
are the norm
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IMPACT
 Increase in IYCF
practices: early
initiation of
breastfeeding,
exclusive
breastfeeding,
minimum dietary
diversity, minimum
meal frequency
 Increase in
newborn and infant
lives saved
 Improved child
health, growth, and
development
Broadcasting Board of Governors, Gallup (2014). Contemporary Media Use in Nigeria. Available at: http://www.bbg.gov/wpcontent/media/2014/05/Nigeria-PPT-FINAL.pdf
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