READ: MAMI (by ENN and GOAL)
ENN – Introduction to MAMI and lessons learned
MAMI stands for the management of at-risk mothers and infants under six months. It is an integrated approach to link both prevention and treatment for this vulnerable group, focusing on identifying and acting early to prevent growth decline and reduce risks.
Within MAMI, SAM and MAM are not differentiated. Instead of referring to malnutrition, it refers to the continuum condition of at-risk infants and growth failure.
The MAMI vision: Every infant under six months, at every community or health service contact, is nutritionally assessed and appropriately supported to survive AND thrive.
The MAMI approach is located within a wider ecosystem of growth and health during pregnancy that involves not only infant and maternal factors but wider family and societal factors too. Some we can influence, many we cannot at least in the short term. But we need at the very least to be mindful of wider factors that affect a mother’s and infants well being and the capacity of her capacity to care for her baby and to do all we can to empower her to do so.
Within the MAMI approach, evidence around the weight-for-age (WFA) and MUAC measurements are used and built upon to identify at-risk infants, such as infants with low birth weight (LBW) or infants who are both wasted and stunted. The approach stresses that anthropometry is not the same as diagnosis: it tells you nothing about the underlying causes that need to be addressed. These problems may be complex, and are not always related to nutrition. Breastfeeding support in infants under six months is absolutely necessary, but it is not sufficient to manage risk.
The MAMI approach is about building the right relationships at an individual level, between mother and infant, within families, communities, at a service level, and at a policy level.
To help prioritise research needs, ENN undertook a Child Health and Nutrition Research Initiative prioritisation to help create order to a long list of gaps. The following priorities have guided their work and the wider collective ever since:
- How should infant SAM be defined?
- How to integrate case management into other healthcare programmes?
- What are the priority components of a package of care for outpatient treatment of infant SAM?
The C-MAMI tool was developed as a first step to catalyse case management in infants, providing programmers with a first step to help manage their cases. It caters for at risk infants who are not sick enough for inpatient care, but are at risk. It provides strengthened community based support. The details of the C-MAMI Tool allow for identification and management of many problems with specific and practical solutions, that can be delivered at community level.
Promising progress in MAMI has already been made over the last 10 years. Malnourished infants under six months old are no longer a blind spot in efforts to tackle malnutrition. There has been a shift in policy: the WHO SAM guidance update in 2013 included community based management, with for the first time an explicit section on infants under six months. Programming that is informed by the C-MAMI tool is being implemented in a number of different contexts.
But this is not yet reflected in national guidance uptake, so we’re not there yet. In a review of 48 national guidelines on SAM undertaken by ENN, none included community-based management for infants. All still rely on inpatient care. Countries are demanding more robust evidence.
Thus, two important strategies going forward are to integrate identification and management into existing health systems and services, and to simplify MAMI management. The international nutrition community are currently caught up in trying to simplify protocols for CMAM in older children. We can learn from these lessons and consider simplification and scale from the beginning.
GOAL – MAMI programme experiences
During the session on MAMI, GOAL has shared their experiences of MAMI programme implementation and programme outcomes. In Ethiopia they have been implementing programmes focusing on the South Sudanese refugee response since 2016. There are four nutrition sites with MAMI services, and IYCF counsellors also offer a MAMI programme. Mothers and infants are screened monthly with the CMAM screenings, and community-level screening is due to start soon. There have been 57 enrolments from June to August 2019.
In Bangladesh, the first phase of the Rohingya response by GOAL started in November 2017. There are seven nutrition sites offering MAMI services, including specific MAMI counsellors and supervisors. Cross-sector community mobilisers conducted community screening. Between November 2017 and June 2018, 1964 infants were referred for MAMI assessment, and 847 mother-infants were undergoing full MAMI assessment.
There have been a number of programme challenges with regards to MAMI implementation. These challenges have to do with team capacity, programme set-up and linkages, anthropometric measurements, and programme outcomes and monitoring, evaluation and learning. However, all these challenges can be overcome through targeted proposed solutions. These include for example working with other agencies to establish referral mechanisms, and intensifying the sensitisation of communities on the risks of infants under six months and the benefits of MAMI, among many others.