Socioeconomic determinants of malnutrition among mothers in the Amoron'i Mania region of Madagascar: a cross-sectional study

A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar

BACKGROUND

Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy.

METHODS

This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches.

RESULTS

In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso.

CONCLUSIONS

The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Dietary diversity, undernutrition and associated factors among pregnant women in Gindeberet district, Oromia, Ethiopia: a cross-sectional study

BACKGROUND

Appropriate levels of dietary diversity are essential for proper physiology of human being and it is crucial to consume healthy foods at every phase of life, especially during pregnancy. Inadequate dietary diversity and malnutrition are risk factors for low birth weight, intrauterine growth reduction and small for gestational age. This study was aimed to assess dietary diversity, undernutrition and associated factors among pregnant women in Gindeberet district, Oromia, Ethiopia, 2020.

METHOD

A community based cross-sectional study was conducted among 627 pregnant women in Gindeberet district selected by systematic random sampling from October 10/2020- November 10/2020. Data were collected through interviewer administered questionnaires. The collected data were coded and entered to Epi-info version 7.2.2.6 and analyzed by SPSS version 23. Logistic regression analysis was carried out to identify factor associated with undernutrition and dietary diversity. Level of statistical significance was declared at p-value < 0.05.

RESULTS

overall prevalence of inadequate dietary diversity and undernutrition were 276 (44.4%) and 110 (17.7%) respectively. Pregnant women who did not receive antenatal care (AOR = 2.32, [95% CI: 1.38, 3.90]), family size ≥ 5 (AOR: 2.93; [95%CI: 1.10, 7.79]), unprotected sources of water (AOR: 4.14; [95% CI: 1.63, 10.52]) were significantly associated with undernutrition. Rural residence (AOR = 2.59, [95% CI: 1.66-4.04]), pregnant women who did not received ANC (AOR = 2.52, [95% CI: 1.58-4.03]) and nutrition information (AOR = 1.43; [95% CI: 1.10, 2.10]) were significantly associated with dietary diversity among pregnant women.

CONCLUSION

undernutrition and inadequate dietary diversity among pregnant women were high in study area. Source of drinking water, ANC visit and family size were significantly associated with pregnant women undernutrition. Place of residence, ANC visit and nutrition information were significantly associated with inadequate dietary diversity. Therefore, pregnant women, government, non-governmental organization and stakeholders should focus on importance of ANC visit, clean source of drinking water and adequate dietary diversity to improve nutritional status of pregnant women.

Determinants of Malnutrition and its associated factors among pregnant and lactating women under armed conflict areas in North Gondar Zone, Northwest Ethiopia: a community-based study

INTRODUCTION

Maternal malnutrition remains a major public health problem, particularly in low and middle-income countries and war-affected areas like Ethiopia. Malnourished pregnant and lactating women with low nutrient stores have babies with poor mental and physical development, increasing the risk of poor birth outcomes. Despite the fact that the majority of Ethiopian mothers are malnourished, there is little evidence in war-affected areas. Therefore, the objective of this study was to assess the prevalence of undernutrition and associated factors among pregnant and lactating mothers in the war affected area of North Gondar Zone, northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted from April 10 to May 25, 2022. A multistage random sampling technique was used to select 1560 pregnant and lactating mothers. MUAC was to ascertain the outcome variable. Data was entered and analyzed by using EPI INFO version 3.5.3 and SPSS version 24, respectively. A multivariable logistic regression analysis was employed to identify the factors associated with acute malnutrition. An adjusted odds ratio (AOR) with a 95% confidence interval was used to show the strength of the association, while a P-value of 0.05 was used to declare the significance of the association.

RESULTS

The prevalence of acute malnutrition among pregnant and lactating women was 34.3% at the 95% CI (31.9-36.8). The age of the mothers (AOR = 0.73; 95% CI: 0.54, 0.99), family size 6-8 (AOR = 1.21; 95% CI: 1.03, 1.82), and greater than or equal to 9 family sizes (AOR = 0.44; 95% CI: 0.19, 0.97), were significantly associated with acute malnutrition.

CONCLUSIONS

In the current study, the prevalence of acute malnutrition among pregnant and lactating mothers is high in the study area. Mother's age and family size were factors associated with acute malnutrition in war-affected areas. As a result, mothers with large families will require special assistance to reduce the impact of malnutrition.

Does Raising Livestock Improve Household Food Security and Child Dietary Diversity in a Rural Region of Madagascar?

Madagascar is one of the poorest countries and has an alarming prevalence of food insecurity and child undernutrition. Most of the Malagasy population live from agricultural activities making livestock a livelihood asset and a source of animal-source foods, especially for smallholder farmers. This study aimed to examine the association between livestock ownership, household food security, and children's dietary diversity in a rural region of Madagascar. Data from a cross-sectional survey of 344 respondents were used to assess the association between household tropical livestock units (TLU) per capita, Household Food Insecurity Access Scale (HFIAS) scores, and dietary diversity scores (DDSs) among children aged 6-23 months. The estimation results from the ordered probit model showed that household TLU per capita is negatively associated with HFIAS scores and positively associated with DDSs among children. Additionally, households with mothers who received information on childcare and nutrition from health facilities and community nutrition agents were more likely to be food secure and have better dietary diversity. Therefore, promoting livestock ownership and strengthening nutrition-sensitive messages focusing on the benefits of raising livestock to mothers from rural Madagascar will likely be effective in improving household food security and nutrition for children.

Drivers and distribution of the household-level double burden of malnutrition in Bangladesh: analysis of mother-child dyads from a national household survey

OBJECTIVE

The double burden of malnutrition (DBM) has become an emerging public health issue in many low- and middle-income countries. This study aims to provide important evidence for the prevalence of different types of DBM at the national and subnational levels in Bangladesh.

DESIGN

The study utilised data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017-2018. Multivariable logistic regression was performed to identify the sociodemographic factors associated with DBM.

SETTING

Nationally representative cross-sectional survey.

PARTICIPANTS

8697 mothers aged 15 to 49 years with <5 children.

RESULTS

The overall prevalence of the DBM was approximately 21 %, where the prevalence of overweight mother (OWM) & stunted child/wasted child/underweight child (SC/WC/UWC) and underweight mother (UWM) & overweight child (OWC) was 13·35 % and 7·69 %, respectively, with a higher prevalence among urban households (OWM & SC/WC/UWC = 14·22 %; UWM & OWC = 10·58 %) in Bangladesh. High inequality was observed among UWM & OWC dyads, concentration index (CI) = -0·2998, while low level of inequality of DBM were observed for OWM & SC (CI = 0·0153), OWM & WC (CI = 0·1165) and OWM & UWC (CI = 0·0135) dyads. We observed that the age and educational status of the mother, number of children, fathers' occupation, size and wealth index of the household, and administrative division were significantly associated with all types of DBM.

CONCLUSIONS

Health policymakers, concerned authorities and various stakeholders should stress the prevalence of DBM issues and take necessary actions aimed at identifying and addressing the DBM in Bangladesh.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition-specific and nutrition-sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi-experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty-two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid-upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m2 ) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15-0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale-up of these interventions nationally in Rwanda.

Spatial distribution and determinants of undernutrition among reproductive age women of Ethiopia: A multilevel analysis

INTRODUCTION

Malnutrition is one of the most devastating problems in Ethiopia and is inextricably linked with poverty. Women in the reproductive age group and children are most vulnerable to malnutrition due to low dietary intakes, inequitable distribution of food within the household, improper food storage and preparation, dietary taboos, infectious diseases, and care. Therefore, this study aimed to assess the spatial distribution and determinants of undernutrition among reproductive age of Ethiopia.

METHODS

The study was based on the 2016 Ethiopian Demographic and Health Survey. The study included a total sampled weight of 15,139 women aged 15-49 years. The ArcGIS version 10.7 and SaTScan version 9.6 statistical software were used for exploring the spatial distribution of undernutrition. A multilevel logistic regression model was fitted to determine the individual and community level factors associated with women undernutrition. Finally, the factors which were significant at 95% confidence interval were reported.

RESULT

The spatial analysis revealed that women undernutrition was significantly varied across the country. The SaTScan analysis identified a total of 144 significant hotspot areas of maternal undernutrition with three significant spatial windows. Of these, 134 clusters were primary. The primary spatial window was identified in the southeast Tigray, northwest Afar, central and north Amhara regions (LLR = 57.48, P<0.01, RR = 1.51). Age at first marriage (AOR = 1.57: CI 1.33, 1.99), middle wealth index (AOR = 3.15: CI 1.4, 6.97), rural residence (AOR = 2.82: CI 1.22, 6.52), being in Afar region, Tigray region and Harari region (AOR = 4.88: CI 1.71, 13.91), (AOR = 4.17: CI 1.57, 11.06) and (AOR = 3.01: CI 1.05, 8.68) respectively were significantly associated with women undernutrition.

CONCLUSION

In Ethiopia, undernutrition had significant spatial variations across the country. Residence, age at first marriage, wealth index and region were significantly associated with undernutrition. Therefore, public health interventions that reduce reproductive age women undernutrition and enhance women awareness towards undernutrition in hotspot areas of undernutrition is crucial.

Prevalence and associated factors of undernutrition among pregnant Sudanese women

BACKGROUND

Maternal undernutrition is a global health challenge, and it is associated with significant maternal and perinatal morbidity and mortality. This study aimed to assess the prevalence and the factors associated with undernutrition among pregnant women in Sudan.

METHODS

A cross-sectional study was carried out in Saad Abuelela Hospital in Khartoum, Sudan, from June to December 2019. Sociodemographic and obstetric characteristics were collected through a questionnaire. Mid-upper arm circumference was measured. Undernutrition was defined as a mid-upper arm circumference of <23 cm. Multiple logistic regression was used to assess the factors associated with maternal undernutrition.

RESULTS

Of 1801 pregnant women, 226 (12.5%) were undernourished. Multivariable analysis revealed that ≤2 antenatal care clinic visits (adjusted OR [AOR]=3.06, 95% CI 1.68 to 5.58) was associated with undernutrition. Age (AOR=0.90, 95% CI 0.87 to 0.94) and haemoglobin levels (AOR=0.81, 95% CI 0.67 to 0.97) were negatively associated with undernutrition. There was no association between parity, education, interpregnancy interval, occupation and maternal undernutrition.

CONCLUSIONS

Our findings indicated that 12.5% of the pregnant women in Khartoum were undernourished. More effort and action are need to improve the counselling and future inclusion of a supplemental food supply for undernourished pregnant women.

Prevalence of undernutrition and its associated factors among pregnant women in Konso district, southern Ethiopia: a community-based cross-sectional study

Background

Undernutrition during pregnancy is an important public health problem. It is highly prevalent in Ethiopia but not sufficiently addressed yet. Hence, this study aimed to assess the prevalence of undernutrition and its associated factors among pregnant mothers in Konso district, Ethiopia.

Methods

Community-based cross-sectional study was conducted with a qualitative inquiry from December 2018 to January 2019. A multistage stratified sampling technique was used to select 527 subjects and quantitative data were collected from these subjects using a structured interviewer-administered questionnaire and additionally qualitative data were generated through two focus group discussions among purposely selected discussants. Mid upper arm circumference (MUAC) was measured by standard non-stretchable MUAC tape. Data were entered into Epi-data version3.1 and analyzed by SPSS version 21. In multivariable binary logistic regression, a statistically significant association was declared at p-value < 0.05 while thematic framework analysis was employed for the qualitative data.

Results

Among 501 participants, the overall prevalence of undernutrition (MUAC < 23 cm) was 43.1% (95% CI 38.7–47.5%). Household food security (AOR = 3.1; 95% CI: 2.1–4.6), low dietary diversity score (AOR = 4.9; 95% CI: 2.6–9.2), medium dietary diversity score (AOR = 2.3; 95% CI: 1.2–4.7), absence of latrine (AOR = 1.8; 95% CI: 1.2–2.6) and having family resource decision making by husband only (AOR = 1.7; 95% CI: 1.1–2.6) were significantly associated factors. Traditional believes to restrict food such as egg, milk, and milk products, avocado for women, weak nutrition education and malnutrition screening program, daily consumption of locally prepared alcoholic drink called “Cheka”, drought-prone nature of this setting, traditional way of farming practices and low socio-economic status were found to be barriers for women’s undernutrition.

Conclusions

The prevalence of undernutrition was found to be higher than previously reported findings. Household food security, dietary diversity, latrine availability, family resource decision making, food restrictions, weak maternal nutrition education, and malnutrition screening program, the practice of depending on a local alcoholic drink called “Cheka”, drought, traditional way of farming and low socio-economic status were identified factors. Hence, interventions targeting maternal nutrition education, hygiene, and sanitation promotion, household food insecurity improvement strategies should be implemented to improve the nutritional status of pregnant women.

Influence of Socioeconomic Determinants on Undernourishment in South Asia: A Panel Cointegration Analysis

Background: Undernourishment is a major public health challenge worldwide, with severe economic consequences. If occurs in the first years of life, it may cause long-lasting effect, particularly regarding personal development and economic growth of the country. Objectives: The current study aimed to investigate the influence of socioeconomic factors, particularly education and national income, on undernourishment in selected countries of South Asia. Methods: The annual panel data for 2001 to 2018 were analyzed using the vector error correction model (VECM) technique and the Toda-Yamamoto Granger causality test (TYGCT). Results: According to the results of the VECM, adult literacy has mixed effects on undernourishment in the short run, while in the long term, it is associated with significant improvements in undernourishment. There is a negative association between economic growth and undernourishment in the short term; while, it disappears in the long term. The TYGCT is designed to validate the findings of the VECM as well as to investigate their robustness. According to the findings of the TYGCT, adult literacy alone can both improve undernourishment and enhance economic growth. Conclusions: This study demonstrated a negative association between undernourishment and adult literacy rate in the long term; that is, higher literacy is associated with lower rates of undernourishment, which in turn results in improved community health. Adult literacy causes declined undernourishment and enhanced economic growth. Therefore, South Asian countries should incorporate appropriate interventions based on health and nutritional evidence in the curricula of schools to, firstly, gear up the nutritional awareness and, secondly, to strive redistribution of income among the relatively poor, which may reduce the undernourishment to a significant extent.

Anemia, chronic energy deficiency and their relationship in preconception women

OBJECTIVE

This study aims to assess the prevalence of anemia and chronic energy deficiency (CED), and their relationship in preconceptions women in Takalar District, South Sulawesi, Indonesia.

METHODS

This study was a cross-sectional study of 300 preconceptions women. Data were collected by questionnaires, anthropometric measurements, and 24-h recall. Hemoglobin was assessed using Hemocue. Data were analyzed using chi-square and logistic regression tests.

RESULTS

Most mothers aged 20-30 years (65.3%) and the length of education was 10-12 years (41%) and the average income was 1-2 million (46.7%). The prevalence of anemia was 23% and chronic energy deficiency (CED) was 18%. There was some factor related to chronic energy deficiency, among others age (P=0.000), education (P=0.020), occupation (P=0.034), parity (P=0.000), and also between anemia with CED (P=0.018). After controlling for other variables there was an influence of anemia 2 times more likely to suffer from chronic energy deficiency.

CONCLUSION

We found that the prevalence of anemia and chronic energy deficiency (CED) is still high in preconception women and there is a significant borderline between anemia and CED.

Inequalities in maternal malnutrition in Ethiopia: evidence from a nationally representative data

BACKGROUND

Despite promising progress made in several maternal health indicators, maternal malnutrition (especially undernutrition) remained one of the greatest development challenges for Ethiopia. The main purpose of this study was to examine the disparities in maternal malnutrition and estimate the population level impacts of key risk factors in Ethiopia.

METHODS

The analysis was made based on the Ethiopian Demographic and Health Survey (EDHS 2016) data, containing 9949 non-pregnant women. Multiple logistic regression was used to examine the effects of selected explanatory variables on the two nutrition morbidity outcomes (undernutrition and obesity). Two population weighed regression-based measures (the Slope Index of Inequality/SII and Relative Index of Inequality/RII) and Population Attributable Fractions (PAFs) were employed to examine the inequalities in maternal malnutrition.

RESULTS

The prevalence of maternal undernutrition and overweight or obesity were 21% and 6%, respectively. In the multiple logistic regression, four variables appeared to have significant association with both undernutrition and overweight/ obesity, namely age of the women, residence, maternal education, and non-monetary wealth (p < 0.05). Both the absolute and relative measures of inequalities showed remarkable differences in maternal undernutrition, significantly favoring the higher socioeconomic groups (p < 0.05). Further analysis of inequalities, using the Population Attributable Fractions (PAFs), revealed that the combined population level impacts of all the significant risk factors amount 80.38%, from which 25% is attributed to the three socioeconomic variables (non-monetary wealth, maternal education and paternal education).

CONCLUSION AND POLICY IMPLICATION

Given the high disparity in both under nutrition and overweight and/or obesity, the study emphasized the need for policy and program efforts to promote parental education in Ethiopia. Strengthening nutrition sensitive mass literacy programs is recommended along with improving women's employment and rural households' income for increased access to better diet.

Prevalence and associated factors of undernutrition among pregnant women visiting ANC clinics in Silte zone, Southern Ethiopia

BACKGROUND

Maternal undernutrition is highly prevalent in underdeveloped countries. Hence, this study was intended to determine the prevalence and associated factors of undernutrition among pregnant women visiting ANC clinics in Silte Zone.

METHOD

Facility-based cross-sectional study was conducted from July to January 2019. Systematic random sampling technique was used to select 422 study participants from 11 randomly selected health facilities. Data was collected by using a structured-interviewer administered questionnaire. Mid upper arm circumference (MUAC) was measured by standard non stretchable MUAC tape. Data was entered into a computer using Epi data 3.1 and edited, cleaned, and analyzed using SPSS version 20. Both bivariate and multiple logistic regression analyses were employed to identify factors associated with maternal undernutrition.

RESULT

In this study, the overall prevalence of undernutrition among study subjects was 21.8%. Age greater than 31 years of women (AOR = 0.15; 95% CI: 0.03, 0.93), Birth intervals > 2 years (AOR = 0.18; 95% CI: 0.04, 0.76), good nutritional knowledge (AOR = 0.34; 95% CI: 0.17, 0.67), and having no dietary change as a result of current pregnancy AOR = 6.02; 95% CI: 2.99, 12.14) were significantly associated with undernutrition.

CONCLUSIONS

The prevalence of undernutrition among pregnant women was 21.8%. Current estimate is lower than previously reported in the study area but higher than reported in developed country. Age of women, Birth intervals, and Dietary change as a result of current pregnancy and Nutrition knowledge were important risk factors/ predictors of undernutrition (MUAC < 23 cm). Interventions targeting maternal nutrition education and child spacing with giving special emphasis to adolescent pregnant women are recommended.

Social identity as a driver of adult chronic energy deficiency: analysis of rural Indian households

This study investigates the effect of social identity (caste, religion, gender, and asset) on adult chronic energy deficiency (CED) using the Indian Human Development Survey (IHDS) data from 2005 and 2011. From 2005 to 2011, out of 63,323 adult individuals, four-fifths (85.7%) of men and two-fifths (44.7%) of women improved their health status from CED to non-CED. The lowest improvement was observed among Dalit (Scheduled Casts, Scheduled Tribes) women: 41.9% moved from CED to non-CED status. We also find significant differences in prevalence of CED between Dalit and non-Dalit individuals and households. To achieve a significant improvement in CED, programs targeting malnourishment must be prioritized the Dalit households.

Food consumption and undernutrition variations among mothers during the post-harvest and lean seasons in Amoron'i Mania Region, Madagascar

BACKGROUND

Seasonal variation affects nutrition particularly in contexts where people's food consumption depends on their production of food. Assessing the effect of the season on nutrition status can help us to identify strategies to address undernutrition. This study aims to measure the variations in food consumption and the incidence of undernutrition according to season, and to identify the factors associated with the incidence of undernutrition.

METHODS

A cohort study was conducted among 608 mothers aged between 18 and 45 years living in the Amoron'i Mania Region of Madagascar. Inclusion in the study occurred during the post-harvest season, and mothers were followed until the end of the next lean period (7 months). A dichotomous variable of the frequency of consumption of various foods was used to establish variation in food consumption. Body Mass Index < 18.5 kg/m2 and Middle Upper Arm Circumference < 220 mm were used to measure incidence of undernutrition. A generalized linear model was used to identify factors associated with the incidence of undernutrition and to derive relative risks.

RESULTS

During the lean season, the frequency of consumption of leafy green vegetables, peanuts, fish, and eggs decreased significantly. In contrast, the frequency of fruit, legumes, and non-leafy green vegetables consumption increased significantly. The prevalence of undernutrition (based on the BMI and/or MUAC) among mothers increased from 19.6% in the post-harvest period to 27.1% in the lean period (p < 0.001). The incidence of undernutrition (based on the BMI and/or MUAC) during the follow-up was 12.2%. The factors related to undernutrition were low and medium score of movable property possession (Adjusted RR = 3.26 [1.33-7.94] and Adjusted RR = 2.48 [1.01-6.10]), no toilet (Adjusted RR = 1.76 [1.07-2.91]), and pregnancy (Adjusted RR = 2.92 [1.42-6.04]) (based on the MUAC only for pregnancy).

CONCLUSION

This study highlights the variation in the frequency and type of food consumption and subsequent deterioration in mothers' nutritional status during the lean season. Economic, hygiene, and reproductive factors were associated with undernutrition. Analyzing the existing interventions to fight maternal undernutrition is necessary to determine whether or not seasonality is considered and addressed.

Educational Approaches to Encourage Pro-Environmental Behaviors in Madagascar

Madagascar is a biodiversity hotspot under threat, with about 80% of the population living below the poverty line and dependent on the use of diminishing local resources. Environmental education (EE) can act as an important tool for biodiversity conservation, however, its implementation is challenging in low-income countries. Here, we provide a review of 248 EE interventions throughout Madagascar. We highlight how EE can promote pro-environmental behaviors and show the major obstacles it faces, using Madagascar’s Lake Alaotra as a case study area. All EE activities are implemented by non-governmental organizations (NGOs) and international institutions. EE and community engagement have been shown by practitioners and scientific research alike to be valuable tools but are severely restricted in their impact when their outreach is limited by insecure and insufficient funding, and often funding periods that are too short. Another major hindrance to EE producing positive changes in people’s real-life decisions in low-income countries like Madagascar, arises when lessons are taught to a population that is at once understanding and severely constrained in its choices due to poverty, and corresponding malnutrition, that forces people to make unsustainable decisions on a daily basis. Our conclusions should help to improve the practice of EE in Madagascar and other low-income countries.

Burden and determinants of undernutrition among young pregnant women in Ethiopia

Undernutrition is a major public health concern due to its association with the mortality and disease burden of women and children. This study aimed at identifying the extent and determinants of undernutrition among young pregnant women in Ethiopia. A multivariable regression analysis was fitted to identify determinants of undernutrition and anaemia in a sample of 1,393 pregnant women. Risk ratios (RRs) with 95% confidence interval (CI) were estimated. All the analyses were performed using STATA version 14 and adjusted for clustering. The study revealed that 38% of the women were undernourished and 22% were anaemic. Improved maternal education, RR = 0.94, 95% CI [0.89, 0.98]; higher wealth status, RR = 0.72, 95% CI [0.47, 0.95]; higher minimum dietary diversity for women, RR = 0.87, 95% CI [0.77, 0.98]; increased maternal height, RR = 0.96, 95% CI [0.94, 0.98]; and protected water source, RR = 0.93, 95% CI [0.86, 0.96], have decreased the risk of undernutrition while using unimproved toilet, RR = 1.31, 95% CI [1.06, 1.63], and depression, RR = 1.33, 95% CI [1.14, 1.55], increased the risk of anaemia. Animal source food consumption decreased both the risk of undernutrition, RR = 0.85, 95% CI [0.77, 0.94], and anaemia, RR = 0.91, 95% CI [0.85, 0.95]. The burden of undernutrition is still high. Although improved socio-economic status and dietary practices decreased the risk of undernutrition, poor health and environmental conditions were still significant risk factors. These findings suggest the need to target this set of important determinants to significantly decrease the burden of undernutrition among young pregnant women.