Dr. Mom knows best: Empowering mothers to diagnose malnutrition

A simple strip of laminated measuring tape roughly the width of a finger and the length of a forearm is revolutionizing the diagnosis of malnutrition and empowering families to better care for their children around the globe.

Called MUAC, which stands for mid-upper-arm circumference, the tape has been a standard tool for community health workers and doctors around the world. The tape, when properly wrapped around a child’s arm, displays a color in a small window, helping caregivers determine if the child is well-fed (green), has moderate acute malnutrition (yellow), or has severe acute malnutrition (red).

What’s new isn’t the tape itself, but who is using it – mothers.

Health providers across much of West Africa have lamented for decades that severely malnourished children are often brought for medical care too late, dimming their chances for a full and speedy recovery and avoiding complications. In fact, globally, only some 33% of children with severe acute malnutrition are currently accessing treatment.

The challenges to improving access to care are multiple. The West African region and many other areas burdened with malnutrition are beset by conflict, making regular health checks difficult. It doesn’t help that peak malnutrition season in West Africa coincides with the rainy season, when reaching communities is most difficult. The hungry season also coincides with annual planting, when community health workers, the precious link connecting these communities with healthcare, are often least available to make health checks.

“Evidence suggests that the single biggest barrier to accessing treatment for child wasting is lack of information. This includes information about how wasting can be diagnosed at home, and information about where treatment is available,” said Grace Funnell, nutrition lead for UNICEF.

It was while watching CHWs belatedly diagnose severely malnourished children in Niger that staff from the Alliance for International Medical Action (ALIMA) recognized the opportunity to empower mothers to understand and monitor their own children’s nutrition status.

In 2012, ALIMA conducted a pilot of what they’ve dubbed “Family MUAC,” handing out the measuring tapes for families to keep and training mothers how to use it. They compared the mothers’ ability to that of CHWs. The pilot demonstrated that mothers trained to use MUAC – which costs six U.S. cents – bring their children for medical care earlier than CHWs, which was saving lives. The researchers found that “mothers can screen their children frequently allowing early diagnosis and treatment thereby becoming the focal point in scaling-up community management of acute malnutrition.”

A larger scale pilot including 12,893 mothers confirmed the finding. The malnourished children were identified earlier by their mothers and brought for medical care. As a result, the children were much less likely to require inpatient care. While the upfront costs of training mothers were higher, the researchers found, the overall costs for the year were significantly reduced.

Since then, ALIMA has trained more than four million mothers to use MUAC to monitor their children’s nutrition. International organizations including World Vision, Save the Children, International Rescue Committee, Action Against Hunger, and MSF have also adopted this strategy. Niger, Burkina Faso, and Mali began rolling out national adoption plans.

But it wasn’t until a decade after the initial research finding that the potential for the strategy was fully realized. “During COVID, when CHWs and communities were quarantined and health checks became less frequent, we saw rapid international uptake,” said Kevin Phelan, nutrition advisor at ALIMA.

During COVID, UNICEF endorsed this approach, and it became common across roughly 35 LMICs. UNICEF is currently working toward the goal of “making the MUAC bands in high-burden countries in Africa and Asia as ubiquitous as thermometers in high-income countries,” said UNICEF’s Funnell.

“We equip mothers with MUAC because we recognize that things work better in partnership with local people and communities,” said Guillaume Le Duc, one of ALIMA’s founders. “It centers the solution in the family and community.”

Dr. Jean-Hervé Bradol, former president of MSF France and a member of the International Council of MSF, added that the approach is powerful because it “places the mothers of malnourished children at the heart of the care system.”

ALIMA, UNICEF, MSF and other organizations have found that Family MUAC increases demand for malnutrition treatment and allows caregivers, even in low literacy, low numeracy environments “to make informed decisions about when and where to seek appropriate care,” said Funnel.

Researchers are now studying how to ensure mothers continue monitoring their children not just over the short term, but over years. And, Phelan added, they are cognizant that any solution that relies on mothers likely adds to a long list of responsibilities she is already juggling. But, he said, supporting women to monitor the health of their own children is a win for everyone involved.

“It is hugely important that this does not negate the role of the CHW,” he said. “This is about shifting the CHW tasks – moving away from screening to teaching community members how to use MUAC bracelets, hence a task more suited to their leadership role in the community.”

At the same time, Phelan cautioned: “We know we can’t put everything on mothers. Finding that sweet spot is tricky. We- can use [this] as a model of the successful shift, made years ago, to outpatient treatment for malnutrition.”

Severely malnourished children were previously routinely admitted to hospitals. But the innovation of ready-to-eat therapeutic food allowed children without other medical complications to be cared for at home, at a reduced cost both to the health system and to their families.

ALIMA has published guidelines for what has been dubbed “family MUAC.” 

GOAL has published a Nutrition Guidance Note on the use of Family MUAC in the context of COVID-19.

UNICEF and its partners also hosted a webinar on the Family MUAC approach in the context of COVID-19. Find the presentation here and the FAQs here.

Save the Children has developed guidance for program mangers implementing the Family MUAC approach during COVID- 19.