Mercy Freeman sits on a small hospital cot in one of Liberia’s emergency hospitals, looking down at her frail son, whose dark eye sockets have sunk into his bony face.

“He just started getting thin and thin[ner]. I do not know what is happening, that is why I brought him to the hospital,” the 18-year-old single mother says, worried and confused.

She has been feeding her 18-month-old son, Mark, bowl after bowl of plain rice without realising that he had become severely malnourished despite being regularly fed. After two weeks in hospital, Mark is still too weak to sit up, his skin dropping in large folds off his scrawny legs. He weighs only half of what he should be for his age and height.

“Most of these mothers are too young [when they start bearing children],” says Dr. Taban Dada, medical director at Redemption Hospital in Liberia’s capital Monrovia, one of the country’s largest public hospitals. “Many of them are having a lot of children before they are adequately prepared. At the end of the day, they’re not able to take care of these children properly.”

Adequate preparation, argues Dada, includes a high school education, maturity, financial resources to support a child and a basic understanding of nutrition and childcare, such hygiene and proper feeding.

Teenage mothers

A third of Liberian mothers give birth to their first child before the age of 19, according to 2007 national Ministry of Health statistics, making Liberia one of the countries with the highest rates of teenage pregnancy in the world.

Dada claims it is these young mothers who are to blame for the country’s alarming malnourishment rates, saying they are based on women’s ignorance about what makes up a healthy diet, not lack of food. Almost 40 percent of children under the age of five suffer chronic malnutrition, according to the country’s 2008 national nutrition policy report.

The authors of the report also found that the major developmental disruption caused by malnutrition takes place in the womb, mostly due to iron, iodine and vitamin A deficiency in the mother, as well as in the first two years of a child’s life. This often leads to stunting and irreversible brain damage.

“The children’s IQ will be reduced. They will not cope well in school,” worries Dada.

He says the Ministry of Health needs to follow through on its policy recommendations to introduce nutrition education into the school curriculum and train pregnant mothers about balanced diets during hospital visits.

Lack of parenting skills

In north central Liberia, amidst small rice fields and cassava crops, Ruth Zansi, the manager of a feeding programme for 900 children at the Hope for the Nations Children Recovery Centre in Ganta, agrees that lack of parenting skills and education are often to blame for malnutrition. But that’s not necessarily the mothers’ fault.

“During war time, people were scattered, people could not go to health centres or get an education,” explains Zansi, referring to 14 years of civil crisis that left an estimated 250,000 people dead, hundreds of thousands displaced and communities destroyed.

A 2008 government report reveals that 44 percent of teenage girls have never gone to school, and 62 percent of women are illiterate, mainly as a result of the civil war.

“Mothers do not understand that [their children] are malnourished. They think someone has [be]witched the child. They only come [to the feeding programme] because they are pushed, but they would rather go to a witch doctor,” explains Zansi who herself is a mother of eight.

Zansi’s staff patiently teach teenage mothers about the benefits of breastfeeding and how to supplement meals with affordable proteins, such as beans and nuts.

Food insecurity

While she cuddles a small boy with a swollen belly, she argues that poverty and food insecurity are also critical factors causing malnutrition. Liberia remains one of the poorest countries in the world, according to the 2008 United Nations Development Programme Human Development Index, and rampant unemployment means many families are too poor to diversify their diets with vegetables, meats and other high-nutrient foods.

Since the civil war ended in 2003, Liberia has imported more than half of its food and struggled to introduce large-scale farming of rice, cassava and corn.

Teenage mothers do not intentionally harm their children, agrees Save the Children child protection programme manager Geoffrey Oyat: “They do love their babies. They try to do their best. But within the context they’re operating in, they do not have the resources to look after their child.”

Oyat says with poverty and high unemployment comes a high rate of teenage and unplanned pregnancies: “[The girls] are providing for themselves, exposing themselves, trying to sell in the streets and getting boyfriends.”

Poverty

Back at the paediatric ward at Redemption Hospital, malnourished children with swollen bellies are fed rice mixed with green vegetables and a protein-rich milk blend. Like Mark, most of the toddlers are stunted and severely underweight. Because of their weak immune systems, they are also more vulnerable to diarrheal diseases, malaria and pneumonia than other children.

Freeman, who dropped out of school in Grade 8, struggles to understand the doctor’s explanations, but Dada is confident that she will be able to nourish Mark back to health with some support from the hospital. He has given Mercy a schedule to access dry rations of enriched porridge at a nearby clinic to provide her son with the nutrients he needs to grow.