1. Mothers screening for malnutrition by MUAC
Ali Ouattara, Deputy Director of Operations
ALIMA – the Alliance for International Medical Action
MSF Scientific Day / Johannesburg June 2016

2. MUAC I & II: Why ALIMA began this research…
-In 2011 ALIMA began studying the feasibility of training
mothers to use mid-upper arm circumference (MUAC)
The strategy of empowering mothers to play a more
central role in screening for malnutrition responded to
two recurring operational/medical issues:
Late presentation (resulting in more complications)
Low program coverage (often <50%)

3. MUAC I: Pilot Study, proof of concept September 2011 – April 2012
Arch Public Health. 2015 May 18;73(1):26. doi: /s z. eCollection 2015.
Mothers Understand And Can do it (MUAC): a comparison of mothers and community health workers determining mid-upper arm circumference in 103 children aged from 6 months to 5 years.
Blackwell N, Myatt M, Allafort-Duverger T, Balogoun A, Ibrahim A, Briend A.

4. MUAC I: Mothers can reliably measure MUAC
Results
(n = 103 mother-child pairs)
Excellent agreement
Errors only at boundaries
No difference left/right arm measures
Sensitivity and specificity of mothers’ measures:
- SAM: 77%, 91%
- GAM: 96%, 82%
Source: Blackwell et al. Archives of Public Health 2015 73:26   doi: /s z

5. MUAC II: Large-scale trial May 2013 – April 2014
Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger
Franck G.B. Alé, Kevin P.Q. Phelan, Hassan Issa, Isabelle Defourny, Guillaume Le Duc, Geza Harczi, Kader Issaley, Sani Sayadi, Nassirou Ousmane, Issoufou Yahaya, Mark Myatt, André Briend, Thierry Allafort-Duverger, Susan Shepherd, Nikki Blackwell

6. MUAC II: Health Zones comparison
CHWs Zone
Takieta
(control)
8 867
42%
4.7%
902
10.2%
28.4%
Mothers Zone
Dogo
(intervention)
9 908
39%
4.4%
1 047
10.6%
29.4%
Population < 5 y (n)
% Pop. >15 km from health center
SAM prevalence May/June 2013
SAM admissions Apr-Dec 2012
SAM Admissions per pop. <5 y
Point coverage May/June 2013

7. MUAC II: Training strategy
Dogo: Mothers Zone
May 2013: mass training campaign
Group sessions and 1-on-1 demonstrations
Supplemental trainings during coverage surveys and at consultations
12,893 mothers/caretakers trained in year
1.6 /1: Ratio mothers-trained/child <5
Takieta: CHWs Zone
May 2013: CHWs trained with standard curriculum (6 h theory, 2 h practical)
Supplementary training when poor MUAC agreement w health center agents
36 CHWs trained and supervised in year
1 / 250: Ratio CHW/child <5

8. MUAC II: Key messages for mothers
What is acute malnutrition?
Project to identify malnutrition early, before complications arise
How to perform MUAC: everyone can do it.
How to ‘read’ the colors
SEVERE: Go to health center within 2 days
MODERATE: Refer to MAM program?
NORMAL: Continue to feed your child well

9. MUAC II: Results (Admissions, June 2013-May 2014)
Mothers
1 371 (%)
564 (41.1)
572 (41.7)
221 (16.1)
5 (0.3)
9 (0.7)
CHWs
988 (%)
407 (41.2)
410 (41.5)
161 (16.3)
6 (0.6)
4 (0.4)
Total admissions
MUAC <115 mm, height ≥65/67 cm
WHZ <-3, MUAC ≥115 mm, height ≥ 65/67 cm
WHZ <-3, height <65/67 cm (no MUAC taken)
Edema, MUAC <115 mm, height ≥ 65/67 cm
Edema

10. MUAC II: Results (Distribution of MUAC at admission)
Median MUAC in Mothers vs. CHWs zone was 1.6 mm greater (95% CI = 0.65; 1.87) (p = 0.007)
for children admitted by MUAC 

11. MUAC II: Results (Hospitalization, Agreement, Coverage)
Hospitalizations for all admissions:
At admission
During course of treatment
for admissions by MUAC <115 mm:
Agreement with MUAC at health center
Point coverage, April 2014
Mothers
2.33%
7.22%
0.70%
7.73%
75.4%
35.14%
CHWs
9.01%
11.84%
7.75%
13.32%
40.1%
32.35%
Risk Ratio
[95%CI]
0.26 [0.17;0.38]
0.61[0.47;0.79]
0.09 [0.03;0.25]
0.58 [0.40;0.85]
1.88 [1.69; 2.10]
Difference [95%CI]
2.78% [-16.34%; 21.90%]
p-value
<0.0001
0.0021
0.9484

12. MUAC II: Results (Hospitalization, Agreement, Coverage)
Hospitalizations for all admissions:
At admission
During course of treatment
for admissions by MUAC <115 mm:
Agreement with MUAC at health center
Point coverage, April 2014
Mothers
2.33%
7.22%
0.70%
7.73%
75.4%
35.14%
CHWs
9.01%
11.84%
7.75%
13.32%
40.1%
32.35%
Risk Ratio
[95%CI]
0.26 [0.17;0.38]
0.61[0.47;0.79]
0.09 [0.03;0.25]
0.58 [0.40;0.85]
1.88 [1.69; 2.10]
Difference [95%CI]
2.78% [-16.34%; 21.90%]
p-value
<0.0001
0.0021
0.9484

13. MUAC II: Results (Hospitalization, Agreement, Coverage)
Hospitalizations for all admissions:
At admission
During course of treatment
for admissions by MUAC <115 mm:
Agreement with MUAC at health center
Point coverage, April 2014
Mothers
2.33%
7.22%
0.70%
7.73%
75.4%
35.14%
CHWs
9.01%
11.84%
7.75%
13.32%
40.1%
32.35%
Risk Ratio
[95%CI]
0.26 [0.17;0.38]
0.61[0.47;0.79]
0.09 [0.03;0.25]
0.58 [0.40;0.85]
1.88 [1.69; 2.10]
Difference [95%CI]
2.78% [-16.34%; 21.90%]
p-value
<0.0001
0.0021
0.9484

14. MUAC II: Results (Cost comparisons, in USD)
Mothers
4 883
1 958
1 759
8 600
1.04
CHWs
826
1 958
611
18 585
21 980
3.00
Trainings
Supervision costs and fees
Materials
Cash incentives
Total costs
Cost per child <5 years old

15. MUAC II: Strengths and Limitations
Higher median MUAC and fewer hospitalizations in Mothers Zone
Coverage similar in both zones and mothers had better agreement with MUAC by agents at health center
Screening by mothers cost much less
Limitations
Study lasted 11 months; it takes time to see full benefits of approach
Uneven MAM services; how to message when no MAM program?
65/67 cm height limit for MUAC excludes short low-MUAC kids

16. MUAC II: Conclusions
Mothers are non-inferior to CHWs in screening by MUAC at much lower cost
Making mothers the focal point of MUAC screening strategies is feasible at scale and should be included in regular CMAM programming
Family MUAC screening strategies will be most efficient in MUAC-based programs integrating SAM/MAM (e.g. better coverage, Maust et al in Sierra Leone)

17. Acknowledgements and thanks
The Ministry of Public Health in Niger
UNICEF, ECHO, and OFDA
The ALIMA and BEFEN teams
All the mothers and children in Dogo and Takieta