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June 2008 Series No 6

**Understanding Child Malnutrition in the Sahel: A Case Study from
Goundam Cercle, Timbuktu Region, Mali**

**Introduction**

Malnutrition is a major health problem affecting approximately 32% of
all children in developing countries (UNICEF, 2004). It is an underlying
factor in over 50% of the deaths (equivalent to between 10 and 11
million) of children under 5 years of age who die each year of
preventable causes (Steve Collins *et al*. September 2006). According to
the 2006 United Nations Consolidated Appeals Process (CAP) for West
Africa, an estimated 52% of children's deaths in the region are caused
by malnutrition.[^1]

The causes of child malnutrition are almost always complex,
multidimensional, and interrelated. They may range from factors as
pervasive in their impacts as political instability and slow economic
growth to those as specific in their manifestations as diarrhea and
respiratory infections. The Food and Agriculture of the United Nations
groups the causes of malnutrition under four broad categories: food,
health, sanitation, and child-care inadequacies.

In West Africa, there are on-going debates about the relative
contributions of each of these factors in the high and persistent levels
of malnutrition that characterize the region. Until recently, there was
a general view that this problem was related primarily to a lack of food
in the region. More recently, a consensus is developing that poor water
quality, a lack of knowledge of good childcare and child feeding
practices, poor health and sanitation service coverage, and childhood
diseases play a major role. Many recent studies indicate that current
interventions aiming to reduce the prevailing above normal rates of
child malnutrition in the West African region have had little impact.
These studies suggest that the causality of these problems has been
misunderstood and inappropriate actions have been implemented.

Within the framework of its food security projects in West Africa,
USAID's Office of Food for Peace (FFP) is financing many food security
programs with child nutrition components. These provide a number of
opportunities to try to answer this question. The regional office of FFP
in Dakar has therefore chosen to use a case study format to assess the
causes of high and persistent malnutrition in the Sahel region and the
appropriateness of an intervention that is addressing this problem.

The Goundam Food Security Initiative (GFSI)[^2] in Mali, carried out by
the international non-governmental organization, Africare, has been
chosen as the case study for this purpose. Anthropometric data gathered
at various points under this effort were thoroughly analyzed, relevant
literature on child nutrition reviewed, and the actions of the
initiative considered within this context in order to identify timely
and appropriate responses.

**Regional and National Context**

The Sahel has some of the highest acute child malnutrition rates in the
world**.** According to the latest available surveys conducted in
Burkina, Chad, Mali, Mauritania and Niger (UNICEF, 2006), 1.4 million of
the under-five children in these countries are suffering from acute
malnutrition. Although this rate varies from country to country, the
regional prevalence of acute malnutrition is often above the 15%[^3]
globally-accepted emergency threshold. Curiously, high incidences of
malnutrition are not limited to the most food-insecure areas in the
Sahel. Extremely high rates are also found in some of the more food
secure areas of the region. According to the results of the 2006
Demographic and Health Surveys, the northern regions of Mali - Timbuktu,
Gao, and Kidal -- where some of the worst food insecurities are found,
had chronic child malnutrition rates of 43.9%, 33.5% and 32.6%
respectively. However, the main cereal and cotton production regions of
the country to the south of these areas had far higher stunting rates of
46 % for the Sikasso region, 39.1% for Koulikoro and 40% for the Segou
region. Recent surveys conducted in cities like Niamey and Ouagadougou
also show that child malnutrition is not only concentrated in rural
areas. In these capital cities, about 16% of the children under-five
suffer from acute malnutrition.

In the Sahel, chronic malnutrition in children is generally widespread
(Table 1). Thirty-seven per cent of under-fives in the region (i.e.,
one-in-three, or a total of 3.6 million children) suffer from chronic
malnutrition. What is more worrying is that approximately 50% of
under-fives are either chronically undernourished, or suffering from
severe chronic malnutrition (West Africa 2006 CAP**)**. In Burkina Faso,
chronic malnutrition increased from 30% to 39% between1993-2003. In
Niger, the level of stunting among children under-three has gone from
27% in 1992 to 41% in 1998 and 45% in 2006. In Mali during the same
period, the rate of stunting increased from 30% to 38%. The underweight
prevalence in the region also shows a similar pattern: 30% of children
under-five were underweight in 1993 compared to 38% in 2003, which is
classified as very high by WHO (West Africa 2006 CAP). Surveys conducted
in Chad (UNICEF, 1996-2005) showed similar high levels of childhood
malnutrition: stunting (41%), underweight (37%) and wasting (14%) for
children under-five. According to UNICEF, about 52% of children's deaths
in the Sahel are attributable to malnutrition.

Table 1: Nutritional Status of Children under five in

the Sahel and Guinea

+--------------------+------------+-------------------+--------------+
| Country            | Stunting   | Underweight       | Wasting      |
+--------------------+------------+-------------------+--------------+
| Burkina Faso^a^    | 38.7%      | 37.7%             | 18.6%        |
|                    |            |                   |              |
| Chad^b^            | 40.9%      | 36.7%             | 13.5%        |
|                    |            |                   |              |
| Mali^c^            | 37.7%      | 26.7%             | 15.2%        |
|                    |            |                   |              |
| Mauritania^d^      | 34.5%      | 31.8%             | 12.8%        |
|                    |            |                   |              |
| Niger^e^           | 39.7%      | 40.1%             | 13.6%        |
|                    |            |                   |              |
| Senegal^f^         | 16.3%      | 17.3%             | 7.6%         |
|                    |            |                   |              |
| Guinea^g^          | 35.0%      | 25.9%             | 9.0%         |
+--------------------+------------+-------------------+--------------+

Sources: (a) DHS 2003, (b) DHS 2004, (c) DHS 2006, (d) AGSVA --
WFP/Mauritania 2005,

\(e\) MICS2 Niger/UNICEF 2001, (f) DHS 2005, (g) DHS 2005

Mali is a developing country in West Africa with a total population of
11,716,829. The majority of its population is comprised of subsistence
farmers. A low literacy rate (46.4% overall) and life expectancy (49
years), scarcity of natural resources, poor infrastructure, periodic
droughts, frequent locust invasions (most recently in 2004), and lack of
highly fertile land are all factors contributing to its rank of 174 out
of 177 countries on the UN Development Index. The data presented in
Table 2 summarize child malnutrition rate trends in Mali from 1998 to
2005. As shown by these data, stunting has been gradually increasing in
Mali since 1988/1989. Starting from a 27% level in 1988/1989, the rate
reached 38% in 2000/2001. Since then, it has stabilized. Wasting and
underweight rates, on the other hand, have been observed to decrease
significantly during the 1988-2001 period, but wasting increased in
2006.

Table 2: Trend of Child malnutrition rates in Mali

+-----------------------+----------+----------+----------+----------+
| Indicators            | 19       | 19       | 20       | 2005-06  |
|                       | 88-89(1) | 95-96(1) | 00-01(2) | (3)      |
+-----------------------+----------+----------+----------+----------+
| Stunting (height/age) | 27%      | 30%      | 38%      | 38%      |
|                       |          |          |          |          |
| W                     | 18%      | 23%      | 11%      | 15%      |
| asting(weight/height) |          |          |          |          |
|                       | 43%      | 40%      | 34%      | 27%      |
| Under                 |          |          |          |          |
| nourished(weight/age) |          |          |          |          |
+-----------------------+----------+----------+----------+----------+

Source: (1) World Bank Operations Evaluation Department; (2) DHS/Mali
2001 (3) DHS/Mali 2006

**Project Area Context**

Three child nutrition indicators have been monitored by the GFSI project
in the Goundam/Dire area during the last ten years.

*Child malnutrition Indicators*

The anthropometric measurements of the children are transformed into
indices of height- for-age, weight-for-age and weight-for-height
z-scores. Thus, by using these z-scores, one can determine the various
levels or forms of child malnutrition according to their deviations from
the median. For example, anthropometric child measurements of -2 or -3
z-scores indicate moderate and severe child malnutrition, respectively.
In other words, children who are less than two SDs to three SDs below
the median of the reference population are classified as moderately or
severely malnourished.

*Wasting or acute malnutrition* is expressed by the ratio:
weight-for-height \< -2 SD, and \<-3 SD. This anthropometric indicator
measures recent weight loss or emaciation which indicates acute
malnutrition. Also, it indicates a recent change in nutritional status
related to a sudden deprivation of food or negative reaction to
nutritive substances that result in fast loss of weight. The strongest
prevalence of wasting is observed during the periods of famine, severe
seasonal food shortages or during serious illnesses (Jean-Pierre
Lachaud). It is the indicator most usually used in Africa for the
evaluation of food crisis situations because of the difficulties
associated with the incertitude in establishing the ages of children. In
emergencies, the prevalence of acute malnutrition is used as an
indicator of the severity of the crisis. The convention is that moderate
plus severe wasting rates of 5% to 10% among children indicate a
precarious food situation, and the rates between 1% to 20% suggest there
is a serious public health problem (Agadez and Tillaberi Food Security
Initiative -ATFSI-, Baseline Study July 2007).

*Stunting (delay of growth) or chronic malnutrition* is expressed by a
height/age ratio. It translates into a state of nutritional deficiency
related to frequent episodes of acute malnutrition or long periods of
food deficiency, often combined with a persistent or periodic poor
health in the first years of life. This form of malnutrition constitutes
a good indicator of the socio-economic development of a community (the
structural situation).

*Underweight* is expressed by a weight/age ratio. It indicates a
pathological status resulting from the relative or absolute deficiency
of one of the most essential nutritive substances and or/calories. The
most extreme symptoms of this form of malnutrition are characterized by
a severe muscular atrophy resulting from a loss of weight or a delay of
growth. This form of malnutrition is relatively sensitive to the
fluctuations in the short term access to health. Low weight/age can
result from either stunting or wasting.

**Method**

*Study area*

Data used in this study were collected during the final evaluation of
the GFSI project implemented by Africare in the Goundam and Diré circles
in Mali. The study area is located in the northern region of Mali about
1,000 km from the capital city - Bamako. The population density is less
than 2 people per km^2^. The area belongs to the Sahelo-Sahara zone with
average rainfall varying between 100 and 300 mm per year. The Goudam
area is a zone of recessional farming system around lakes while in the
Diré zone, wheat and rice production are practiced using irrigation from
the Niger River. Livestock (cattle, sheep and goat) breeding is the
second major activity of the population. An important fraction of this
population is nomad even if they have started to be sedentary. The
Goundam and Diré circles are one of the most food insecure communities
in Mali.

*Participants*

Data used in this study were collected during the final evaluation of
the GFSI project implemented by Africare in the Goundam and Diré circles
in Mali. Participants in the study were selected from a sample of 22
villages that benefited from Africare's project activities.
Anthropometric measurements (height-for-age, weight-for-age, and
weight-height) of 860 under five age children from these villages were
collected. 570 mothers of children (out of 860 children under age five)
of 0-23 month age were interviewed on child feeding practices,
information on knowledge, attitude and practices related to child
health.

*Data analysis*

This study, being a part of a series of child malnutrition studies
initiated by the Regional Food for Peace Office (RFFPO), intends to
analyze the relationship between child malnutrition status and the
socio-economic status of households. Descriptive statistical analysis
and cross-tabulation method were used to analyze this relationship.
Chi-square test was performed for categorical variables to determine
their association with child malnutrition status. For this purpose, most
variables were transformed into nominal variables. The results of these
analyses will be used to perform multivariate analysis.

**Results**

As data presented in Table 3 in 2006, the overall nutritional status of
children under five in the Goundam/Dire area was poor. However, compared
to the 2003 data, the situation has been improving because of the
Africare/Mali GFSI project interventions. For example, 28% of the under
five children in the project area were chronically malnourished in 2006
as compared to 34% in 2003. Similarly, the rate of underweight children
under five decreased from 37% in 2003 to 34% in 2006. However, acute
malnutrition or wasting among children under five increased sharply in
July 2006 reaching 16% as compared to 2003 when the rate was 11%. This
rate (16%) is above the World Health Organization emergency threshold
rate. In 2007, the final evaluation team of the GFSI project noted
"Overall, the nutrition activities have made great strides in a very
short time towards achieving the project's objectives of enhancing the
health and nutrition of mothers and children. The population underwent
important changes of attitude and in practices toward family nutrition
especially that of the child, care of pregnant mothers and sanitation.
Another important achievement lies in the new community structures
delivering essential health services, such as child growth monitoring,
nutrition education and individual nutrition/health counseling, close to
villages. The "Solidarity Cell" is another important local health and
development instrument brought into these villages by the project,
providing security funds and food stocks for child nutrition
rehabilitation or emergency health care for children and mothers."

Usually in West Africa, malnutrition tends to be lower during the first
year of life, when breastfeeding is more common, than in later years
(CBASSE 1993). These findings were confirmed by the Goundam/Diré
anthropometric data (Figure 1). In the study area, stunting rate in
children younger than 6 months was 11% while it reached 41% for 48-59
month old children. A similar trend was found with underweight rate. For
the wasting rate, the problem appears to be more serious in the 12 - 35
months age groups where rates are the highest after which it sharply
drops in the 36-59 months age groups.

Figure 1: Evolution of Malnutrition Rate in Relation to Children's Ages
![](media/image2.wmf){width="5.302083333333333in"
height="2.759027777777778in"}

Source: Africare Mali GFSI final evaluation survey

In addition, the study shows (Annex 1) that there are more stunted and
underweighted boys than girls. However, with regards to wasting rate,
there was no significant difference between boys and girls. The
prevalence of child malnutrition varies according to location or among
social, cultural, and economic groups. The villages from the Goundam
circle are the first generation villages[^4] of the project, and the
Diré villages are the second generation with the program (five years
with the program). The Goundam villages are more food insecure than the
Diré villages. For short term malnutrition (underweight and wasting),
the Goundam circle was more affected than Diré. For example, in 2006 the
underweight rate was 37% in Goundam against 27% in Diré. The rate of
wasted children was 18% in Goundam against 10% in Diré. Overall, first
generation villages with agricultural potential had less malnourished
children than new villages with no agricultural potential (Annex 1).
Economic development potential and good child feeding practiced by
mothers seem to be critical determinants of child malnutrition in the
study areas.

The study collected data (2006) on three major factors (i.e., type of
dwelling, access to potable water and use of latrines by the family)
that appeared to influence the nutritional status in children under
five. Analyses of the data show that short-term child malnutrition
(i.e., underweight and wasting) is linked to poor dwelling environments
(straw as compared mud-walled habitats), and lack of sanitation (i.e.,
no use of latrines). Where the population uses straw-wall houses (e.g.
nomad population) with no latrines, underweight rate in children under
five was 40% with 17%-23% of wasting rates (Annex 1). Both
anthropometric parameters were lower in villages where children were
raised in better constructed houses (e.g., mud or bricks-walled houses)
and the families used latrines. The use of latrines confirms the
numerous health benefits associated with hygiene. Improved living
quarters were also equally beneficial, probably because of protecting
the children from environmental hazards such as dust, heat, cold, etc.
In contrast, the chronic malnutrition rate was less (23%) in children
raise in straw habitat compared to mud-wall house children (29%).

Furthermore, analysis of data on the socio-economic status and mothers'
characteristics and their effects on children's malnutrition status
showed that mothers' age, their education levels, and their child
feeding practices had direct impacts on the nutritional status of the
children (Annex 1). The study showed that 23%, 26% and 13% of the
children who were exclusively breastfed during the first six months of
life were stunted, underweight and wasted, respectively. In contrast,
when children were not exclusively breastfed during the first six months
of life, 31%, 41% and 19% of them were stunted, underweight and wasted,
respectively. These results confirm the importance of mothers' knowledge
about child breastfeeding, particularly, during the first six months of
life. Also, prenatal consultation of mothers with health care providers
and delivery of their infants with the assistance of skilled birth
attendants were positively correlated with children's nutritional
performance. Such health care significantly reduced the rate of child
malnutrition in the study areas.

Child malnutrition may arise from a number of conditions, such as lack
of food, early cessation of breastfeeding, and diseases. These factors
are generally interrelated, making it difficult to determine exactly how
a child becomes malnourished. Relevant statistical methods such as the
bivariate technique were used to evaluate the relationship between these
factors and child malnutrition status. This bivariate technique allows
to select variables (modalities) which are significantly (χ^2^ test
value \> 2 or Prob = 0.000) associated with the malnutrition of children
under five in the study areas. The SPAD computer software was used to
perform this analysis.

**Stunting**: the results of the bivariate analysis showed that the
status of stunted children in the Goundam/Diré circles is associated
with seven major variables: age of child, child's sex, weight/age ratio
of child, mother's child feeding practice (particularly during the first
six months of the child's life), episodes of diarrhea, access to
drinking water and the educational level of the mother. There was a
strong (χ^2^ = 36.7 p= 0.000) relationship between child chronic
malnutrition and underweight. For instance, the overall rate of
underweight children was 34% in the study area. Regarding, the sub
sample of stunted children, 69% of them was underweight. On the other
hand, the relationship between stunting and wasting was weak (p= 0.03).
Child's age seems to be an important determinant of chronic malnutrition
in Goundam and Diré. The most affected age classes were 12-23 months
(χ^2^ = 9.7 p= 0.000), 36-47 months (χ^2^ = 7.7 p= 0.000) and 48 -- 59
months (χ^2^ = 6.3 p= 0.000). In most nutritional studies conducted in
Africa, children under 3 months of age are, on average, heavier than the
standard children. From 6 to 23 months of age, malnutrition becomes more
common as children experience repeated bouts of diarrhea and other
childhood diseases (CBASSE 1993). Also, there is clear evidence that the
major damage caused by child malnutrition takes place within the first
two years of life. Once children have become stunted, they are likely to
remain in that status into adulthood (Martorell et al.
1994![](media/image3.png){width="8.333333333333333e-2in"
height="7.291666666666667e-2in"}). Mother's child feeding practice is
associated with child chronic malnutrition (χ^2^=5.9 p=0) in
Goundam/Diré. Also, the level of association between stunting and child
breastfeeding was strong (χ^2^ = 4.48 p=0.000).

Numerous studies (Salah E.O Mahgoub et al., 2006; Kristen B Simondon,
2001) conducted in many parts of the world have demonstrated the
beneficial effects (e.g., richness of diet, boosting the immune system,
etc) of breast-feeding which is strongest in the first year. Mother's
milk from breast-feeding provides important nutrients needed for growth.
The milk also protects the child against diseases such as diarrhea and
boosts the immune system so the risk of infection is reduced during
weaning as the child starts to consume foods that may be contaminated
with pathogens (Linda S. et al, October 1996). The protective effects of
breastfeeding on children's nutritional status show that breastfeeding
is an important part of child care. However, poor breastfeeding
practices by mother such as prolonged breastfeeding or failure to
introduce adequate complementary foods as recommended places children at
risk for stunting or underweight (Madzingira N. 1995; Fawzi WW et al.
1998).

In this study, diarrhea was strongly (χ^2^ = 3.7 p= 0.000) associated
with child chronic malnutrition. Diarrhea during the first 6 months of
life resulted in long term height deficit that is likely to be
permanent. In contrast, diarrhea after the first 6 months of age showed
temporary effects. Mother's educational level (illiteracy) was also
significantly (χ^2^ = 4.01 p= 0.000) linked to the chronic child
malnutrition in Goundam/Dire areas. The study results showed that the
prevalence of stunting in the Goundam/Dire area was also associated with
the use of polluted water from traditional wells and rivers.

One important variable (low birth weight) associated with child
malnutrition was missing in this survey. The relation between low child
birth weight and stunting is well documented in child malnutrition
literature. The effect of low child birth weight was found strongest in
the first year of the childhood (Linda S. et al. October 1996).

Waterlow (1994) and Uauy (1994) concluded that despite numerous studies,
relatively little is known about the causes and mechanisms of stunting.

**Underweight**: in addition to the variables associated with stunting
as described above, child's low weight for age ratio was strongly linked
to wasting (χ^2^ = 30.4 p= 0.000), child's age (above 6-11 months),
fever episodes (χ^2^ = 9.4 p= 0.000), diarrhea (χ^2^ = 5.6 p= 0.000),
type of habitat used ((χ^2^ = 6.0 p= 0.000), the use of latrine (χ^2^ =
7.5 p= 0.000) and the low educational level of mothers. Globally, 16% of
the total population of children under five in the study was wasted.
However, when the data were analyzed on the sub-sample of underweight
children only, the rate of wasting in children under five jumped to 37%.
Children above 11 months old were the most affected by the underweight
problem. The prevalence of children suffering from episodes of fever and
diarrhea 15 days before the survey was 10% and 30%, respectively. Among
the underweight children, 16% and 36% of mothers declared that their
child had experienced fever and diarrhea episodes during the last 15
days before the study. Furthermore, the result showed that underweight
rate in children was associated with poverty. Twenty per cent of the
underweight children were raised by mothers living in straw houses---
typical living quarters for poor families---as compared to 16% for
children of the general population living in such housing quarters.
Moreover, in underweight children, 23% were living in the second
generation villages of the project with low development potential[^5].
In general, 18% of children under five were assessed in such an
environment. Like stunting, underweight was associated with the age of
the child. The prevalence of underweight becomes significantly higher
between the ages of 12-23 months. This age class is very critical in the
Sahel because it corresponds to the weaning period of children under
five. Other studies in developing countries showed that diarrheal
disease was increased when infants were not breast-fed, when water
quality and excreta disposal were poor, and when weaning foods were
prepared in an unhygienic manner (Cebu Study Team 1991 and
1992, VanDerslice et al.
1994![](media/image3.png){width="8.333333333333333e-2in"
height="7.291666666666667e-2in"}).

**Wasting or acute malnutrition:** the study results showed that this
form of malnutrition is strongly associated with deprivation of food and
poor environment (straw house, fever, diarrheal diseases). In the study
area, wasting is strongly associated with underweight ((χ^2^ = 30.4 p=
0.000). In 2006, the average rate of underweight children was 34% in the
Goundam/Dire area. However, among the wasted children, 75% was
underweight. According to nutrition specialists, the low weight/age
ratio of a child can result either from stunting or wasting. Women
living in a poor environment (i.e., houses built with straw) had the
highest prevalence of wasted children (χ^2^ = 8.4 p= 0.000). The results
showed that 25% of women with wasted children under five were living in
a poor environment characterized by straw houses and inappropriate
excreta disposal. Household food availability and access are also
important determinants of the acute malnutrition of children under five
in the Sahel region in general. In Goundam/Dire, the wasted children
rate was strongly associated (χ^2^ = 6.7 p= 0.000) with those households
that reduced their food ration because of poverty, women who reduced the
frequency of feeding their child because of poverty (χ^2^ = 8.8 p=
0.000), and women who indicated the loss of weight of their children was
associated with poor access to food (χ^2^ = 4.3 p= 0.000). The GFSI
survey results showed that 51% of women affirmed their household reduced
food ration because of lack of food. But, for women with wasted children
under five, this rate was 62%. Also, 29% of surveyed women reduced the
frequency of their children feeding because of lack of food. In the
sub-sample of women with wasted children mothers, this rate was 41%. As
for stunting and underweight, wasting is associated with the age of the
child. The most vulnerable age class is 12-23 months (χ^2^ = 8.3 p=
0.000) and 24 -- 35 months (χ^2^ = 11.2 p= 0.000). Episodes of diarrhea
and fever were common in the Goundam/Dire area and significantly
associated with wasting. Even though, efforts have been made by the
project to reduce the prevalence of these diseases they are still a
public health concern. For instance, the prevalence of diarrhea among
children under five was 47% in 2003; it was reduced to 31% in 2006 by
the project. Its prevalence among wasted children under five was 37%
during the same period. A high prevalence of blood diarrhea (15%) was
found with wasted children against 8% in the children under five in
general in the study area. In the project second generation villages
with limited development resources[^6], the percent of wasted children
living was 8% higher than the average rate (16%).

**Conclusion**

The causes of child malnutrition in developing countries are well known
and workable solutions do exist. However, in the Sahel, the complexity
of this issue and the relationship between its underlying causes make it
difficult and obscure and slow down the progress of efforts to combat
this problem. In the study area, malnutrition rates in children under
five were reduced as a result of FFP-funded Title II projects. Despite
the positive achievements, there are still high levels of wasting (16%)
and underweight (34%) in the study area. Economic development potential,
good maternal child feeding practices and prenatal consultations seem to
be critical determinants of child malnutrition in the Sahel region.

The results of this descriptive analysis confirm the observations and
findings of other studies that show higher rates of stunting associated
with age of the child, underweight, child's sex (boy), mother's child
feeding practices (i.e., breastfeeding, complementary feeding, etc) and
the educational level of mothers, episodes of diarrhea and fever, and
access to drinking water. With regard to wasting, findings show that
this form of malnutrition is strongly associated with food deprivation
and poor living environment (i.e., straw dwellings, fever, and diarrhea
diseases of child). Variables associated with underweight were either
from stunting or wasting. These findings imply that reduction of child
malnutrition in the Sahel is a long term development issue that the
international community should understand and address. It cannot be
solved by sporadic emergency interventions as it is a multidimensional
issue that can be treated only with the allocation of adequate and
reliable development resources.

  --------------- ------------ ------------- ---------------- ------------- --
  Annex 1: Mali-                                                            
  Goundam/Dire                                                              
  Cercles --                                                                
  Child                                                                     
  Malnutrition                                                              
  Descriptive                                                               
  Statistics                                                                

                               Stunting (%)  Under-weight (   Waisting (%)  
                                             %)                             

  **Children                                                                
  age**                                                                     

  \< 6                         11.0          0.8              3.5           

  06- 12                       19.6          19.8             10.0          

  12 -- 23                     35.9          43.9             22.6          

  24 - 35                      25.2          43.9             26.3          

  36 -- 47                     29.5          33.8             12.6          

  48-59                        41.4          44.5             10.6          

  Total                        28.2          34.3             16.1          

  **Children                                                                
  sex**                                                                     

  Boy                          32.1          35.6             16.0          

  Girl                         23.6          32.8             16.3          

  **Cercle**                                                                

  Goundam                      27.9          36.7             18.1          

  Dire                         28.9          26.9             10.1          

  **Village                                                                 
  categories**                                                              

  Old village                  20.0          25.7             14.3          
  with potential                                                            

  Old village                  33.8          31.0             9.9           
  with limited                                                              
  potential                                                                 

  New village                  30.2          35.0             16.2          
  with potential                                                            

  New village                  31.1          44.9             20.9          
  with limited                                                              
  potential                                                                 

  **Type of                                                                 
  habitat**                                                                 

  Mud                          29.0          33.2             15.0          

  Straw                        22.3          39.9             23.2          

  **Potable water                                                           
  source**                                                                  

  Traditional                  33.2          35.3             15.1          
  well                                                                      

  Rivers                       31.8          37.7             14.1          

  Modern well                  28.8          35.9             17.9          

  Borehole                     26.8          33.7             15.5          

  **Hygenic                                                                 
  environment**                                                             

  Latrine                      29.8          27.8             14            

  Nature                       26.7          40.7             17.9          
  --------------- ------------ ------------- ---------------- ------------- --

Source: Africare Mali GFSI Final evaluation Survey --December 2006

  ------------------------- ---------------- --------------- --------------
  Annex 2: Mali-                                             
  Goundam/Dire Cercles --                                    
  Child Malnutrition                                         
  Descriptive Statistics                                     

                            Stunting (%)     Under-weight(   Waisting (%)
                                             %)              

  **Socio-economic                                            
  characteristics of Child                                   
  mother**                                                   

  **Education level**                                        

  Primary school            27.9             19.7            10.8

  Medersa                   7.7              24              8

  Secondary school          9.3              16.1            16.1

  Analphabete               27.7             28.2            13.7

  adult literacy            21.0             49.3            5.6

  Coranic school            28.1             35.3            17.8

  **Age (year)**                                             

  \< 20                     13.1             6.5             3.3

  20 - 24                   23.5             29.3            12.4

  25- 29                    28.5             34.5            18.1

  30-34                     26.6             39.8            16.7

  35-39                     28.3             32.5            23.1

  40 and +                  34.5             38.3            15.1

  **Assisted by a village                                    
  birth attendant**                                          

  No                        27.0             34.4            17.4

  Yes                       24.1             26.7            11.6

  **Prenatal Consultation**                                  

  No                        26.0             35.3            19.3

  Yes                       24.8             28.4            12.2

  **Breastfeeding**                                          

  No                        30.8             41.4            18.7

  Yes                       23.3             26.3            13.6

  **Breastfeeding after                                      
  delivery**                                                 

  Immediately               19.2             25.3            13.8

  8 hours after             28.5             27.7            10.1

  24 hours after            21.9             26.0            18.9

  48 hours after            38.5             31.3            6.99

  **Nothing before                                           
  breastfeeding**                                            

  No                        27.1             36.6            18.7

  Yes                       24.8             25.0            10.5

  **Reduction the number of                                  
  child feeding because of                                   
  poverty**                                                  

  No                        28.9             32.5            13.2

  Yes                       21.5             33.5            22.1
  ------------------------- ---------------- --------------- --------------

Source: Africare Mali GFSI Final evaluation Survey --December 2006

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[^1]: Refer to the FY 2006 USAID Bureau for Democracy, Conflict, and
    Humanitarian Assistance (DCHA) Sahelian West Africa Malnutrition
    Situation Report #1.

[^2]: GFSI is a USAID/Office of Food for Peace Title II, non-emergency,
    Development Assistance Program and, as such, has an overall goal of
    improving household food security.

[^3]: According to nutritionists, when the prevalence of acute
    malnutrition in children over 6-59 months old is \> 10% the
    nutrition situation children needs to be considered as serious ;
    when it is \> 15% the nutrition situation of children needs to be
    considered critical.

[^4]: Defined as villages that have been benefiting from GFSI activities
    for 10 years.

[^5]: Lack of agricultural land

[^6]: The project second phase villages with limited potential for the
    development of irrigation