Factors influencing maternal nutrition practices in a large scale maternal, newborn and child health program in Bangladesh

Diet Quality Among Mothers and Children in India: Roles of Social and Behavior Change Communication and Nutrition-Sensitive Social Protection Programs

BACKGROUND

Limited evidence exists on determinants of maternal and child diet quality.

OBJECTIVES

This study examined the role of social and behavior change communication (SBCC) and nutrition-sensitive social protection (NSSP) programs on maternal and child diet quality.

METHODS

Data were from cross-sectional phone survey on 6627 Indian mothers that took place in late 2021. The Diet Quality Questionnaire (DQQ) was used to measure maternal and child diet quality, including minimum dietary diversity (MDD), dietary diversity scores (DDSs), noncommunicable disease (NCD)-protect and NCD-risk scores, adherence to dietary guidelines (All-5 and India-All-6), and unhealthy child feeding. Multivariate regression models were used to explore the association between diet indicators and coverage of SBCC and NSSP programs.

RESULTS

Maternal and child diet quality was suboptimal, with more mothers (57%) achieving MDD than children (23%). SBCC was positively associated with healthy food consumption in children (odds ratio [OR]: 2.14 for MDD; β: 0.60 for DDS and 0.54 for NCD-protect) and mothers (β: 0.38 for DDS and 0.43 for NCD-protect). Cash transfers were associated with healthier diets in mothers (OR: 1.45 for MDD, 1.86 for All-5, and 2.14 for India-All-6; β: 0.43 for DDS and 0.26 for NCD-protect), but less associations noted for children (β: 0.14 for NCD-protect). Receiving food was associated not only with healthier diets in mothers (OR: 1.47 for MDD; β: 0.27 for DDS and 0.33 for NCD-protect) and children (β: 0.19 for DDS and 0.15 for NCD-protect) but also with unhealthy food in children (OR: 1.34). Exposure to multiple programs showed stronger associations with diet quality.

CONCLUSIONS

SBCC has greater positive impact on child feeding than food and cash transfers, while cash has a stronger association with improved maternal diets. Food and cash are also associated with unhealthy food consumption. Our study underscores the importance of interventions that combine education, resource provision, and targeted support to promote maternal and child diet quality.

How Do Social and Behavioral Change Interventions Respond to Social Norms to Improve Women's Diets in Low- and Middle-Income Countries? A Scoping Review

Healthy dietary practices are highly influenced by social norms, the widely-held expectations about the behaviors that are appropriate or typical within a given group. However, many nutrition programs designed to reduce women's undernutrition in low- and middle-income countries do not address the influence of social and gender norms in their interventions, and therefore, there is limited information about how norms-responsive interventions have been designed and implemented. The objective of this scoping review was to identify and describe social and behavioral change interventions designed to improve women's dietary practices and nutritional intake that integrate the influence of social and gender norms. We systematically searched 4 databases (Scopus, Web of Science, PubMed, and CINAHL) for peer-reviewed articles describing design, implementation, and/or assessment of nutrition interventions in low- or middle-income countries. Results are reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review identified 27 articles from 25 projects or research studies that addressed social or gender norms related to women's dietary practices. The majority focused on the pregnancy and lactation periods, and a few aimed to reach all women of reproductive age. Interventions most often endeavored to shift norms through multiple activities, channels, and platforms, aiming to reach not only the primary participants but also influencers and reference groups. Intervention approaches ranged from home visits and support groups to engage influential family members to community-level outreach with opinion leaders such as religious leaders, health care workers, and peer change agents. Most interventions were delivered through the health sector or were community-based, with some nutrition-sensitive agriculture interventions. There is increasing, although still limited, integration of social and gender norms perspectives in the design, implementation, and assessment of interventions to improve women's diets. This comprehensive review summarizes influential norms and intervention approaches, an important step toward enhancing the effectiveness of social and behavioral change interventions by addressing nutrition-relevant norms. This study was registered at Open Science Framework as JSBF7.

Undernutrition and associated factors among pregnant women in Ethiopia. A systematic review and meta-analysis

Background

Maternal undernutrition is a major public health concern due to its association with mortality and overall disease burden for mothers and their children. Maternal nutrition determines pregnancy outcomes since reduced intake of nutrients influences gestational age length, placental function, and fetal growth during pregnancy. The complexity of the intergenerational aspects of maternal nutrition may also confound the design of interventions. Therefore, this research aimed to assess the prevalence of undernutrition and associated factors among pregnant women in Ethiopia.

Methods

We identified the literature from PubMed, EMBASE, Scopus, and CINAHL databases. Data were entered into Microsoft Excel and then exported to Stata version 17 statistical software for analysis. The I2 and Q-statistic values detect the level of heterogeneity, and meta regression was performed to investigate between-study heterogeneity using more than one moderator. JBI quality assessment tools were used to include relevant articles. Evidence of publication bias was indicated using the funnel plot and Egger's linear regression test. The effect size was expressed in the form of point estimates and an odds ratio of 95% CI in the fixed-effect model.

Result

In total, 19 studies fulfill the inclusion criteria. The pooled prevalence of undernutrition among pregnant women was 32% (95% CI 31.3-33.2 I2 = 97.5%, P < 0.0). Illiteracy (AOR = 3.6 95% CI; 2.3-5.6), rural residence (AOR = 2.6 95% CI; 1.2-3.5), a lack of prenatal dietary advice (AOR = 2.6 95% CI; 1.8-3.7), household food insecurity (AOR = 2.5 95% CI; 1.9-3.2), and low dietary diversity score (AOR = 3.7 95% CI; 2.2-5.9) appear to be significantly associated with undernutrition among pregnant women.

Conclusion

The review showed that the prevalence of undernutrition is still high among pregnant women. Illiteracy, rural residence, a lack of prenatal dietary advice, household food insecurity, and low dietary diversity score were significantly associated with undernutrition during pregnancy. Interventions should focus on educating the public and helping families access food or supplements they need through local markets, health systems, and community-based support, as undernutrition is caused by numerous interconnected causes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier: CRD42023417028.

Determinants of iron-rich food deficiency among children under 5 years in sub-Saharan Africa: a comprehensive analysis of Demographic and Health Surveys

BACKGROUND

Iron deficiency is a major public health problem that affects the physical and cognitive development of children under 5 years of age (under-5 children) in sub-Saharan Africa (SSA). However, the factors associated with the limited consumption of iron-rich foods in the region are poorly understood.

OBJECTIVE

This study examined the prevalence and determinants of iron-rich food deficiency among under-5 children in 26 SSA countries.

DESIGN

This nationally representative quantitative study employed pooled data from Demographic and Health Surveys conducted between 2010 and 2019.

METHODS

Representative samples comprising 296 850 under-5 children from the various countries were used. Bivariate and multivariate logistic regression models were used to determine the associations between the lack of iron-rich food uptake and various sociodemographic factors.

RESULT

The overall prevalence of iron-rich food deficiency among the children in the entire sample was 56.75%. The prevalence of iron-rich food deficiency varied widely across the 26 countries, ranging from 42.76% in Congo Democratic Republic to 77.50% in Guinea. Maternal education, particularly primary education (OR 0.62, 95% CI 0.57 to 0.68) and higher education (OR 0.58, 95% CI 0.52 to 0.64), demonstrated a reduced likelihood of iron-rich food deficiency in the sample. Likewise, paternal education, with both primary education (OR 0.69, 95% CI 0.63 to 0.75) and higher education (OR 0.66, 95% CI 0.60 to 0.73) showed decreased odds of iron-rich food deficiency. Postnatal visits contributed significantly to reducing the odds of iron-rich food deficiency (OR 0.90, 95% CI 0.83 to 0.95), along with antenatal visits, which also had a positive impact (OR 0.84, 95% CI 0.74 to 0.95). Finally, residents in rural areas showed slightly higher odds of iron-rich food deficiency (OR 1.12, 95% CI 1.10 to 1.28).

CONCLUSION

Based on the findings, interventions targeting iron-food deficiency in the SSA region should take into strong consideration the key determinants highlighted in this study.

Do timing and frequency of antenatal care make a difference in maternal micronutrient intake and breastfeeding practices? Insights from a multi-country study in South Asia

Despite the established benefits of vitamins and minerals for maternal and neonatal health, global micronutrient deficiency remains a significant concern. As such, the World Health Organization advocates timely antenatal care (ANC) initiation and micronutrient supplementation for expectant mothers. This study investigates the association between ANC timing and frequency and maternal health behaviours, specifically iron-folic acid (IFA) intake, early breastfeeding initiation, and exclusive breastfeeding among married women in South Asia. By utilizing recent Demographic and Health Survey data, this study focuses on married women aged 15-49 in Bangladesh (N = 966), India (N = 89,472), and Pakistan (N = 1,005), specifically primiparous women with children aged 0-23 months living with the motherMultivariable analysis revealed that women receiving ≥4 ANC visits were more likely to consume IFA ≥90 days compared to those with fewer visits in Bangladesh (AOR: 1.85, 95% CI [1.30, 2.63]), India (AOR: 1.87, 95% CI [1.81, 1.94]), and Pakistan (AOR: 1.92, 95% CI [1.24, 2.97]). Women receiving first ANC in the second or third trimester were less likely to consume IFC for ≥90 days compared to those with first-trimester ANC. While the ANC timing did not significantly influence early breastfeeding initiation, ANC frequency was inversely associated with delayed initiation in all countries. Breastfeeding advice during ANC visits was significantly associated with reduced odds of delayed breastfeeding initiation. Neither ANC timing nor frequency significantly predicted exclusive breastfeeding, except for breastfeeding advice in India. This study highlights the importance of ANC in maternal and child health outcomes. ANC timing and frequency, along with breastfeeding advice during ANC, notably influence maternal IFA consumption and early breastfeeding initiation. These findings underscore the need for targeted interventions during ANC visits to enhance maternal and child health practices in low- and middle-income countries.

Prevalence and factors associated with undernutrition and overnutrition among ever-married adolescent girls in Bangladesh: an analysis of national surveys from 2004 to 2017

Nutritional impairment during adolescence may result in adverse physical and reproductive health outcomes. We investigated the prevalence and determined the factors associated with underweight and overweight/obesity among ever-married adolescent girls in Bangladesh. We used Bangladesh Demographic and Health Surveys data conducted in 2004, 2007, 2011, 2014, and 2017. A total of 7040 ever-married adolescent girls aged 15-19 years were included in this analysis. Prevalence of underweight (body mass index [BMI]<18.5 kg/m2) significantly decreased from 39.53% (95% CI = 36.71, 42.43) to 23.62% (95% CI = 21.35, 26.05) during 2004-2017 (p < 0.001). However, prevalence of overweight/obesity (BMI ≥ 23 kg/m2) significantly increased from 5.9% (95% CI = 4.67, 7.43) to 22.71% (95% CI = 20.39, 25.20) during the same period (p < 0.001). The girls with higher age (OR = 0.94, 95% CI = 0.90, 0.99, p = 0.023), higher level of education (OR = 0.60, 95% CI = 0.43, 0.83, p = 0.002), and richest wealth quintile (OR = 0.78, 95% CI = 0.62, 0.98, p = 0.035) had significantly lower risk of being underweight. Adolescent girls having more than one child (OR = 1.41, 95% CI = 1.15, 1.73, p = 0.001) were more likely to be underweight. Elderly adolescents with better economic status were more at risk of being overweight/obese (OR = 2.57, 95% CI = 1.86, 3.55, p < 0.001). Girls married to skilled/unskilled workers (OR = 0.58, 95% CI = 0.44, 0.77, p < 0.001) and persons involved in small businesses (OR = 0.66, 95% CI = 0.49, 0.89, p = 0.007) had lower risk of having a high BMI. Using contraceptive (OR = 0.8, 95% CI = 0.69, 0.94, p = 0.006) was negatively associated with overweight/obese. Although prevalence of undernutrition among ever-married adolescent girls is declining, the proportion of being overweight/obese is increasing in Bangladesh warranting effective strategies to improve adolescent nutrition.

Dietary diversity and associated factors among pregnant women in the Southern Province of Rwanda: A facility-based cross-sectional study

The inadequate dietary diversity of pregnant women in low- and middle-income countries, including Rwanda, is rising and leading to macro and micronutrient deficiencies. The extent of dietary diversity and the factors contributing to it are unknown in Rwanda. This cross-sectional study, with 612 women who attended antenatal care services in Rwanda's Southern Province, identified determinants of dietary diversity among pregnant women. A multistage sampling scheme was used in which four districts were sampled, thereafter one urban and one rural health centre was sampled in each district and finally, a systematic sample of pregnant women was selected in each sampled health centre. Dietary diversity was measured using Minimum Dietary Diversity for Women (MDD-W), and multiple logistic regression models were fitted to identify factors associated with dietary diversity. Only 44.1% (95% confidence interval (CI) of [40.1%, 48.0%]) of participants had adequate dietary diversity. Approximately 95.4% of participants consumed grains, white roots, and tubers. The food groups that were the least consumed consisted of eggs (n = 99, 16.4%), as well as those consisting of milk and milk products (n = 112, 18.5%). The factors which were positively associated with dietary diversity were owning a radio (adjusted odds ratio [aOR] = 1.90 [95% CI 1.27, 2.85]), maternal education (aOR = 1.85 [95% CI 1.28, 2.65]), having a kitchen garden (aOR = 1.69 [95% CI 1.11, 2.57]) and nutrition knowledge score (aOR = 1.45 [95% CI 1.21, 1.74]) for a five-point increase in nutrition knowledge score. The factors negatively associated with dietary diversity include food insecurity, which reduced the odds of dietary diversity (aOR = 0.19 [0.07, 0.50]) per five-unit increase in food insecurity. Furthermore, the odds of adequate dietary diversity were lower among urban residents than rural residents (aOR = 0.69 [0.47, 1.03]). The household size was associated with dietary diversity with the odds of dietary diversity decreasing by 12% for a five-unit increase in household size (aOR = 0.88 [0.79; 0.99]). 23% had poor nutritional status, indicated by their mid-upper arm circumference (MUAC; < 23 cm). Enhanced nutritional education is needed to improve the nutritional knowledge of this population with particular emphasis on the consumption of animal-source foods. Sensitisation activities promoting ownership of kitchen gardens and radios could improve dietary diversity among Rwanda's pregnant women.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review

OBJECTIVES

Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia.

DESIGN

Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach.

DATA SOURCES

MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022.

ELIGIBILITY CRITERIA

We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators.

RESULTS

Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium.

CONCLUSION

Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions.

PROSPERO REGISTRATION NUMBER

CRD42021239143.

Effects of nutrition education and home gardening interventions on feto-maternal outcomes among pregnant women in Jimma Zone, Southwest Ethiopia: A cluster randomized controlled trial

BACKGROUND

Although pro-dietary practices and associated malnutrition are modifiable risk factors, they have a significant effect on maternal and neonatal health outcomes. Therefore, this study aimed to assess the effect of nutritional education and home gardening promotion on feto-maternal outcomes among pregnant women.

METHODS

A three parallel arms community-based cluster randomized controlled trial was carried out in Jimma Zone, Southwest Ethiopia from August 2020 to January 2021. Eighteen selected clusters were randomly assigned into three arms: husband (pregnant woman with her husband), peers (pregnant woman with her peers), and the controls. A total of 348 pregnant women were recruited in a 1:1:1 allocation ratio to the study arms at the baseline and 336 attended the end-line survey. Three nutrition education sessions and four varieties of vegetable seeds were provided for women in the intervention arms (husband and peers) and only routine nutrition education for the controls. Data were collected using a pretested interviewer-administered structured questionnaire. Generalized estimating equation analysis (GEE) and one-way analysis of variance (ANOVA) and Kruskal Wallis test were used to evaluate the effect of the interventions. The intervention effect estimates were obtained through a difference-in-differences approach.

RESULT

In the final model, neonates born to women in the husband group were 232 g heavier than those in the control groups (β = 232, 95%CI: 228.00, 236.27. Similarly, women in the husband group had a 0.45 g/dl greater hemoglobin level than the control groups (β = 0.45, 95% CI: 36.48, 54.40). Likewise, a minimum diet diversity score was higher in the husband group as compared to the controls (β = 0.87 95% CI: (0.56, 1.18).

CONCLUSIONS

Therefore, nutrition education and home gardening interventions resulted in a significant positive effect on the mean birth weight and maternal hemoglobin level among the intervention groups. The findings imply the need for enhancing such interventions to improve feto-maternal outcomes. The trial was registered at Pan African Clinical Trial Registry as PACTR202008624731801.

Calcium supplementation in pregnancy: An analysis of potential determinants in an under-resourced setting

INTRODUCTION

Despite the evidence that calcium supplementation in pregnancy improves maternofoetal outcomes, many women still do not take calcium supplements during pregnancy in Cameroon. This study identifies factors that influence calcium supplementation during pregnancy in a low resource setting.

METHODS

We conducted a cross-sectional hospital-based study (from November 2020 to September 2021) targeting 1074 healthy women in late pregnancy at the maternities of four major health facilities in the Nkongsamba Health District, Cameroon. Data were collected using an interview-administered semi-structured questionnaire and analysed using Epi Info version 7.2.4.0, and the statistical threshold for significance set at p-value = 0.05.

RESULTS

The mean age of the participants was 28.20±6.08 years, with a range of 15-47 years. The proportion of women who reported taking any calcium supplements in pregnancy was 72.62 [69.85-75.22]%. Only 12% of calcium-supplemented women took calcium supplements throughout pregnancy, while a majority (50%) took calcium supplements just for 4-5 months. Women believe that taking calcium supplements is more for foetal growth and development (37.12%) and prevention of cramps (38.86%), than for the prevention of hypertensive diseases in pregnancy (2.84%). About all pregnant women (97.65%) took iron and folic acid supplements during pregnancy, and 99.24% took these supplements at least once every two days. Upon control for multiple confounders, the onset of antenatal care before 4 months of pregnancy (AOR = 2.64 [1.84-3.78], p-value = 0.000), having had more than 3 antenatal care visits (AOR = 6.01 [3.84-9.34], p-value = 0.000) and support/reminder from a partner on the necessity to take supplements in pregnancy (AOR = 2.00 [1.34-2.99], p-value = 0.001) were significantly associated with higher odds of taking any calcium supplements in pregnancy.

CONCLUSION

Calcium supplementation practices in pregnancy remain poor in this population and far from WHO recommendations. Early initiation of antenatal care, a high number of antenatal visits and reminders or support from the partner on supplement intake significantly increase the odds of taking any calcium supplements in pregnancy. In line with WHO recommendations, women of childbearing age should be sensitised to initiate antenatal care earlier and attain as many visits as possible. Male involvement in prenatal care might also boost the likelihood of these women taking calcium supplements.

Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

BACKGROUND

The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists.

OBJECTIVES

This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences.

METHODS

We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring.

RESULTS

Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence.

CONCLUSION

A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India

Background

Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.

Objective

This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.

Methods

We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.

Results

For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.

Conclusion

Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

Comparing delivery channels to promote nutrition-sensitive agriculture: A cluster-randomized controlled trial in Bangladesh

We use a randomized controlled trial in rural Bangladesh to compare two models of delivering nutrition content jointly to husbands and wives: deploying female nutrition workers versus mostly male agriculture extension workers. Both approaches increased nutrition knowledge of men and women, household and individual diet quality, and women's empowerment. Intervention effects on agriculture and nutrition knowledge, agricultural production diversity, dietary diversity, women's empowerment, and gender parity do not significantly differ between models where nutrition workers versus agriculture extension workers provide the training. The exception is in an attitudes score, where results indicate same-sex agents may affect scores differently than opposite-sex agents. Our results suggest opposite-sex agents may not necessarily be less effective in providing training. In South Asia, where agricultural extension systems and the pipeline to those systems are male-dominated, training men to deliver nutrition messages may offer a temporary solution to the shortage of female extension workers and offer opportunities to scale and promote nutrition-sensitive agriculture. However, in both models, we find evidence that the presence of mothers-in-law within households modifies the programs' effectiveness on some nutrition, empowerment, and attitude measures, suggesting that accounting for other influential household members is a potential area for future programming.

Determinants of acute undernutrition among pregnant women attending primary healthcare unit in Chinaksen District, Eastern Ethiopia: a case-control study

Background

Women's undernutrition during pregnancy increases the risks and burdens of maternal and neonatal morbidity, death, and disability through its vicious cycles of irreversible intergenerational negative effects. Despite the high burden of maternal undernutrition during pregnancy in semi-pastoral communities of eastern Ethiopia, there is a paucity of information on its major risk factors. This study revealed determinants of acute undernutrition among pregnant women attending primary healthcare units in Chinaksen district in rural eastern Ethiopia.

Method

A facility-based case-control study was conducted among 113 cases and 113 controls in Chinaksen district from February 01 to March 30, 2017. Data were entered using EpiData version 3.1 and analyzed using SPSS version 24. Multivariable logistic regression analyses conducted to identify significant determinants of acute undernutrition. Adjusted odds ratio (AOR) with a 95% confidence interval was used to report the strength of association and statistical significance declared at p value < 0.05.

Results

Sixty (53.1%) of cases and 56 (49.6%) of controls were in the age group of 25-34 years and their mean ± SD age of cases and controls were 26.6 ± 5.7 and 28 ± 5.5 years, respectively. In this study, larger family size (AOR = 6.98, 95 CI [2.82-17.27]), lack of prenatal dietary advice (AOR = 3.68, 95% CI [1.67-8.00]), did not participate in a cooking demonstration (AOR = 5.41, 95% CI [2.39-12.24]), used substances (AOR = 3.65, 95% CI [1.30-10.23]), absence of basic latrine (AOR = 2.91, 95% CI [1.28-6.58]), low minimum dietary diversity of women (AOR = 2.48, 95% CI [1.20-5.12]), and household food insecurity (AOR = 3.06, 95% CI [1.44-6.51]) were significantly increased the odds of acute undernutrition among pregnant women.

Conclusions

The study revealed that living in crowded families, lack prenatal dietary advice, did not participate in cooking demonstrations, substances use; lack of toilet, low minimum dietary diversity, and household food insecurity were significant risk factors for acute undernutrition among pregnant women. Strengthening multi-sectoral approaches through improving dietary diversity/quality and food access/quantity would be essential to prevent, and reduce the risks, burdens, and impacts of maternal undernutrition during pregnancy.

A conceptual framework for nutritional evaluation, screening, and monitoring of pregnant women: Evidence from a Brazilian cohort of nulliparous women

The present review comes from five previous studies of a multicenter cohort of nulliparous pregnant women from different regions of Brazil. The first study showed a wide difference in consumption of industrialized foods among women from the south and southeast regions compared with northeastern women who chose to eat a healthier diet with fresh natural food. The second investigation intended to understand maternal eating habits, where five dietary patterns were identified: two considered healthy and three with excess protein, ultra-processed foods, fats, and sweets. Considering some barriers to classifying nutrition status during prenatal care, when data on pre-pregnancy weight is unknown, the third study developed a tool to identify three levels of risk for each gestational age range, assessed by measuring arm circumference. Applying those new tools, the associations between maternal nutrition and pregnancy outcomes were investigated: prematurity, pre-eclampsia, gestational diabetes mellitus, and small-for-gestational-age infants. From these analyses, a predictive model was developed indicating that obesity, non-white color, and dietary pattern with excess protein consumption were associated with a greater probability of adverse pregnancy outcomes. Moreover, the potential of the intergenerational influence of head circumference as a proxy for maternal nutrition was analyzed. Using a Path Analysis method, the model was evidenced by different socioeconomic variables. Finally, understanding the complexity of the nutritional assessment, the present conceptual framework was proposed for nutritional assessment, and tracking and monitoring of pregnant women.

What Makes Bangladeshi Pregnant Women More Compliant to Iron-Folic Acid Supplementation: A Nationally Representative Cross-Sectional Survey Result

BACKGROUND

Iron-Folic Acid Supplementation (IFAS) is an effective strategy to prevent iron deficiency anemia during pregnancy. We aimed to explore the key factors associated with compliance to IFA tablets in Bangladesh.

METHODS

This study analyzed the 2017-2018 Bangladesh Demographic and Health Survey data of 3828 pregnant women aged 15-49 years. We categorized compliance into two categories; at least 90 days and full 180 days of consumption. We performed multivariable logistic regression to identify the association between key factors and IFAS compliance.

RESULTS

The prevalence of consumption of IFA tablets for at least 90 days was 60.64%, and only 21.72% of women consumed the IFA for the full 180 days. About three-quarters of the women (73.36%) having at least four antenatal care visits (ANC) consumed IFA for at least 90 days, whereas only three in ten women (30.37%) consumed IFA for a minimum of 180 days. For compliance with IFA for at least 90 days, respondent's age of 20-34 years (aOR 1.26, 95% CI 1.03-1.54), respondent's educational qualification of secondary (aOR 1.77, 95% CI 1.16-2.70) or higher (aOR 2.73, 95% CI 1.65-4.53), husband's educational qualification of secondary (aOR 1.33, 95% CI 1.00-1.77) or higher (aOR 1.75, 95% CI 1.22-2.52), and having received at least four antenatal care (ANC) visits from medically skilled providers (aOR 2.53, 95% CI 2.14-3.00) were significantly associated with higher odds of compliance. For compliance with IFA for at least 180 days, respondent's educational qualification of higher (aOR 2.45, 95% CI 1.34-4.48), and having received at least four ANC visits from medically skilled providers (aOR 2.43, 95% CI 1.97-3.00) were significantly associated with higher odds of compliance. Intimate partner violence was negatively associated with compliance with IFA for at least 180 days (aOR 0.62, 95% CI 0.48-0.81).

CONCLUSIONS

The full compliance to IFAS is still sub-optimal in Bangladesh. Further precise context-specific intervention strategies must be developed and implemented with fidelity.

Knowledge, Attitudes and Practices of Pregnant Women and Healthcare Providers in Bangladesh regarding Multivitamin Supplements during Pregnancy

Micronutrient deficiencies are widespread among pregnant women in low- and middle-income countries (LMIC) and lead to potentially adverse effects for mother and baby. In Bangladesh, maternal malnutrition remains a severe problem, with high rates of anemia (49.6% of pregnant women and 47.8% of lactating women are anemic) and other nutritional deficiencies. A Knowledge, Attitudes, and Practices (KAP) study was conducted to assess Bangladeshi pregnant women's perceptions and related behaviors, as well as awareness and knowledge among pharmacists and healthcare professionals concerning prenatal multivitamin supplements. This was done in both rural and urban areas across Bangladesh. A total of 732 quantitative interviews were conducted (330 with providers and 402 with pregnant women, with an equal split between urban and rural areas for both sets of audiences; 200 women were users of prenatal multivitamin supplements, while 202 women were aware non-users). The study identified a few findings that can guide further research or market-based interventions to reduce micronutrient deficiencies. These include most pregnant women not knowing the right time to start multivitamin supplements (56.0%, [n = 225], stating that a woman should start taking supplements 'after the first trimester'), not knowing their benefits, and how they help both the mother and baby-only 29.5% [n = 59] stated that they believed the supplements helped their baby to grow well). Further, barriers to taking the supplements include women believing a nutritious diet is a substitute (88.7% [n = 293]), and a perceived lack of support from other family members (21.8%, [n = 72]). This suggests that there is a need for further awareness-raising among all pregnant women, their family members, and providers.

Dietary intake and socio-economic predictors of inadequate energy and nutrient intake among women of childbearing age in Karamoja sub-region of Uganda

BACKGROUND

Karamoja sub-region is the most food insecure part of Eastern Africa. The poor status of food security in the sub-region is reflected in the high rate of undernutrition among women of childbearing age (WCBA) and children under 5 years (CUFY). The sub-region is unique in Uganda in terms of cultural diversity, agro-ecology and rainfall pattern and agricultural practices. However, the influence of these unique characteristics on dietary intake of WCBA in the sub-region is less understood. Therefore, this study examined dietary intake and socio-economic predictors of inadequate energy and nutrient intake among WCBA in Karamoja sub-region.

METHODS

A longitudinal study design was used involving 755 WCBA in the harvesting season where 635 were followed-up in the planting season. Data were collected using 24-h recall, dietary diversity and socio-economic and demographic questionnaires.

RESULTS

Intake of energy and nutrients were generally significantly higher (p < 0.05) during the planting season than in the harvesting season. Irrespective of the district, physiological status and season, household consumption of plant-based foods was far higher than intake of animal-based foods dominated by starchy stables (76-100%), dark green leafy vegetables (70-100%) and legumes, nuts and seeds (22-97%) depending on the district. Majority of the respondents had two meals (breakfast: 65-100%; supper: 90-100%) with up to 45% of WCBA who consumed alcohol across meal times. .Overall on average, 57.7, 66.6, 78.5, 60.3, 67.7 and 93.7% of WCBA did not meet the recommended daily allowance (RDA) for energy, protein, calcium, iron, zinc and folic acid, respectively. Binary logistic regression revealed that inadequate intake of energy and nutrients significantly increased (p < 0.05) with the status of being lactating/breastfeeding and was influenced by age of WCBA, number of women married, education level and occupation of the household head depending on season.

CONCLUSIONS

This study demonstrated that dietary intake of WCBA in Karamoja sub-region was inadequate. Age of WCBA, number of women married, education level and occupation of the household head and spouse and being a lactating/breastfeeding mother were the key socio-economic and demographic factors that influenced inadequate intake of energy and nutrients among WCBA.

Qualitative assessment of programmatic constraints in delivery of effective interventions for improving maternal nutrition in Bangladesh

INTRODUCTION

Maternal undernutrition is highly prevalent in most of the developing countries. Prevalence of both extremes of maternal malnutrition (undernutrition and overweight/obesity) are common in those countries. For Bangladesh, the scenario is not different. The Government of Bangladesh recognises maternal nutrition as a public health priority and addresses the issue in its policies and programmes. We identified and analysed the existing maternal nutrition programmes and determined the bottlenecks in implementing the programmes in Bangladesh using qualitative approach.

METHODS

We followed a qualitative research approach and conducted 25 key informant interviews with the programme managers and policymakers, 10 in-depth interviews with the service providers and six focus group discussions with the pregnant women to identify the constraints of programme implementation. We analysed data using thematic and inductive approaches of qualitative research methods.

RESULTS

We have found that successful implementation of maternal nutrition intervention was being hampered by both the demand and supply side issues. On the demand side, major constraints were financial inability of the families to avail maternal nutrition-related services, ignorance of the family members and cultural barriers of using maternal nutrition-related services. Lack of priority and heavy workload of the service providers, lack of human resources, poor monitoring system, lack of medicine to supply and incoordination have been identified as major supply-side constraints in providing maternal nutrition-related interventions in Bangladesh.

CONCLUSION

Both supply side and demand side issues are responsible for the existing bottlenecks in implementing maternal nutrition-related programmes in Bangladesh. Findings of this study will help the policymakers to learn about the programmatic constraints regarding maternal nutrition services in Bangladesh.

Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis

BACKGROUND

Failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby. This study aimed to examine a regional analysis of factors associated with receiving no ANC and inadequate receipt of components of ANC services among Indian women.

METHOD

Information from 173,970 women of reproductive age 15-49 years from the 2019-21 India National Family Health Survey (NFSH-5) was analysed. Logistic regression analyses that adjusted for cluster and survey weights were conducted to assess the socio-demographic and other factors associated with receiving non-use of ANC and inadequate receipt of components of ANC, respectively, in the six regions and 28 states, and 8 union territories in India.

RESULTS

Across regions in India, 7% of women reported no ANC, and the prevalence of inadequate and adequate receipt of components of ANC in all six regions ranged from 67 to 89% and 8% to 24%, respectively. Of all the 36 federated entities, the prevalence of inadequate receipt of ANC components was less than two-thirds in Tamil Nadu, Puducherry, Andaman and the Nicobar Islands, Odisha, and Gujarat. Our analyses revealed that associated factors vary by region, state, and union territories. Women from poor households reported increased odds of receiving no ANC in North, East and North-eastern regions. Women who reported no schooling in South, East and Central regions were associated with increased odds of receiving no ANC. Women from poor households in Himachal Pradesh, Bihar, Uttar Pradesh, Nagaland, Manipur, Uttar Pradesh, and Madhya Pradesh states reported significantly higher odds of inadequate components ANC than women from rich households. The receipt of inadequate components of ANC was significantly higher among women who never read magazines in Delhi, Ladakh, Karnataka, Telangana, Jharkhand, Maharashtra, Uttar Pradesh, Chhattisgarh, Arunachal Pradesh, Manipur, and Mizoram states in India.

CONCLUSION

A better understanding of the factors associated with and incorporating them into the short- and long-term intervention strategies, including free financial support from the Indian government to encourage pregnant women from lower socioeconomic groups to use health services across all regions, states and union territories.

Correlates of maternal, newborn and child health services uptake, including male partner involvement: Baseline survey results from Bangladesh

South Asia bears a substantial proportion of the global maternal mortality burden, with adolescents disproportionately affected. Bangladesh has one of the highest adolescent pregnancy rates in the world, with low utilisation of maternal newborn and child health (MNCH) services. This hampers the country's efforts to achieve optimal health outcomes as envisioned by the Sustainable Development Goals. Male partner involvement is a recognised approach to optimise access to services and decision-making. In South Asia data on male involvement in MNCH service uptake is limited. Plan International's Strengthening Health Outcomes for Women and Children was implemented across four districts in Bangladesh between 2016 and 2020 and aimed to address these issues. Study results (N = 1,724) found higher maternal education levels were associated with use of MNCH services. After controlling for maternal education, service uptake was associated with male partner support level and perceived joint decision-making. The positive association between male support level and MNCH scale was robust to stratification by maternal education level, and by age group (i.e. adolescent vs. adult mothers). These findings suggest that one path for achieving optimal MNCH outcomes might be through structural-level interventions centred on women, combined with components targeting male partners or male heads of households.

Level and Predictors of Minimum Dietary Diversity Among Pregnant Women in Eastern Ethiopia: Evidence From Facility-Based Cross-sectional Survey

Low dietary diversity is one of the most serious public health issues in developing countries, resulting in poor nutritional status, particularly vitamin and mineral deficiencies in pregnant women. However, there is insufficient information on the current status of pregnant women's minimum dietary diversity in Eastern Ethiopia. The main aim of this study is to assess the level and predictors of minimum dietary diversity among pregnant women in Harar Town, Eastern Ethiopia. The study was conducted on 471 women using a health institution-based cross-sectional study design from January to March 2018. A systematic random sampling method was used to select the study participants. A pretested and structured questionnaire was used to collect data on the minimum dietary diversity. A logistic regression model was used to assess the relationship between the outcome variable and the independent variables. A P-value of .05 was used to indicate statistical significance. The proportion of pregnant women who had adequate minimum dietary diversity was 52.7% (95% CI: (47.9%, 57.6)). Urban residence [(AOR = 0.08, 95% CI: (0.02, 0.33)], smaller family size [(AOR = 7.28, 95% CI: (3.25, 16.28)], husband occupation [(AOR = 2.55, 95% CI: (1.39, 4.6)], husband support [(AOR = 3.85; 95% CI: (1.23, 12.02)], having more than 1 dwelling room [(AOR = 5.7, 95% CI: (2.32, 13.8) and medium wealth quantile [AOR = 1.93, 95% CI: (1.13.39)] were associated with adequate minimum dietary diversity. The level of minimum dietary diversity was low in the study area. It was linked to urban residency, smaller family sizes, husband employment, husband support, having more than 1 bedroom, and medium wealth quantile. Efforts should be made to improve husband support, wealth index, husband occupation, and food security status in order to boost mothers' minimal dietary diversity.

Multiple modifiable maternal, household and health service factors are associated with maternal nutrition and early breastfeeding practices in Burkina Faso

Low coverage of effective nutrition interventions in many high-burden countries, due to service provision and demand factors, result in poor uptake of recommended practices and nutrition outcomes. We examined the factors that influence maternal nutrition and early breastfeeding practices and determined the extent that the key factors could improve these practices in two regions in Burkina Faso. We used household survey data among pregnant (n = 920) and recently delivered women (n = 1840). Multivariable regression analyses were conducted to identify the determinants of a diverse diet and iron-folic acid (IFA) supplement consumption, weight monitoring during pregnancy and early initiation of breastfeeding (EIBF). Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal conditions of interventions that address the modifiable determinants. During pregnancy, 21% of women achieved minimum diet diversity (MDD-W), 70% consumed 90+ IFA tablets and 65% were weighed 4+ times; EIBF was 40%. Nutrition knowledge was associated with MDD-W (odds ratio [OR]: 3.2), 90+ IFA (OR: 1.5) and EIBF (OR: 1.9). Positive social norms and family support were associated with 90+ IFA (OR: 1.5). Early and 4+ ANC visits were associated with 90+ IFA (OR: 1.5 and 10) and 4+ weight monitoring (OR: 6.2). Nutrition counselling was associated with 90+ IFA (OR: 2.5) and EIBF (OR: 1.5). Under optimal programme conditions, 41% of women would achieve MDD-W, 93% would consume 90+ IFA, 93% would be weighed 4+ times and 57% would practice EIBF. Strengthening the delivery and uptake of interventions targeted at these modifiable factors has the potential to improve maternal nutrition practices.

Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts.

Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.

The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.

Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.

Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models.

Monitor to innovate with feedback loops: process evaluation protocol for an anemia prevention intervention

Background: Digital process monitoring and evaluation tools designed to capture near-to-real-time intervention data paired with feedback loops have the potential to innovate intervention delivery.

Objective: To describe how a multilevel social norms field trial (RANI) is using feedback loops to enhance intervention delivery.

Methods: We use a mixed-methods process evaluation design to monitor the Reduction of Anemia through Normative Innovations (RANI) project; a three-year randomized control trial which aims to lower rates of anemia among women in Odisha, India. Surveys and structured observation monitor fidelity to implementation and acceptability of implementation activities among study participants. Quantitative data evaluates implementation dose, coverage, exposure, and reach of intervention activities, and qualitative data will delve more deeply into reasons for high or low functioning. Iron folic acid supplement supply and demand are also monitored for stock-outs. Data collected from 130 intervention villages is processed, visualized, and triangulated in near to real-time via Real-time Monitoring for Knowledge Generation (RPM4K), a locally developed software application. Data visualization products facilitate the examination of monitoring data to mitigate bottlenecks and identify and implement tweaks to our intervention delivery strategy on an ongoing basis.

Discussion: Feedback loops facilitate timely course corrections. Feedback loops can also engender a shared understanding of ground realities for a geographically dispersed and culturally diverse team. Leveraging feedback loops, we identify opportunities to provide on-going supportive supervision for our community facilitators promoting joint problem-solving, and communication. Monthly media and hemoglobin level demonstration strategies are informed by participant engagement and acceptability. Stock-outs of iron folic acid tablets activate contingency plans to mobilize local stakeholders and advocate for timely resolutions. Unintended effects are monitored based on ongoing feedback from community facilitators.

Conclusions: Documenting our processes can inform the future implementation or scale up of similar projects embracing feedback loops to iterate and innovate their intervention delivery.

Identifying risk factors in explaining women's anaemia in limited resource areas: evidence from West Bengal of India and Bangladesh

Background

Anaemia among women is a public health problem with associated adverse outcomes for mother and child. This study investigates the determinants of women’s anaemia in two Bengals; West Bengal (a province of India) and Bangladesh. These two spaces are inhabitated by Bengali speaking population since historic past. The study argues that open defecation, contraceptive method use and food consumption patterns are playing crucial role in explaining anaemia.

Methods

Using non-pregnant women belonging to different religious groups, we analyzed a total of 21,032 women aged 15–49 from the nationally representative cross-sectional surveys, i.e., Bangladesh Demographic Health Survey (BDHS-VI, 2011) and National Family Health Survey (NFHS round 4, 2015–16). We performed spatial, bivariate and logistic regression analyses to unfold the important risk factors of anaemia in two Bengals.

Results

The prevalence of anaemia was 64% in West Bengal and 41% in Bangladesh. The significant risk factors explaining anaemia were use of sterilization, vegetarian diet and open defecation. Further, women who used groundwater (tube well or well) for drinking suffered more from anaemia. Also, younger women, poor, less educated and having more children were highly likely to be anaemic. The study also indicates that those who frequently consumed non-vegetarian items and fruits in West Bengal and experienced household food security in Bangladesh were less prone to be anaemic. Hindus of West Bengal, followed by Muslims of that state and then Hindus of Bangladesh were at the higher risk of anaemia compared to Muslims of Bangladesh, indicating the stronger role of space over religion in addressing anaemia. Unlike West Bengal, Bangladesh observed distinct regional differences in women's anaemia.

Conclusions

Propagating the choices of contraception mainly Pill/ injection/IUDs and making the availability of iron rich food along with a favourable community environment in terms of safe drinking water and improved sanitation besides better education and economic condition can help to tackle anaemia in limited-resource areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13806-5.

Iron and Folic Acid Supplementation in Pregnancy: Findings from the Baseline Assessment of a Maternal Nutrition Service Programme in Bangladesh

Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women’s education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

Socio-economic and socio-demographic determinants of diet diversity among rural pregnant women from Pune, India

Background

Diet diversity signifies the nutrient adequacy of an individual and thus has gained widespread significance in recent times. In developing countries achieving maximum diet diversity, especially among pregnant women from rural areas is challenging although of great importance. However, to do so understanding the primary factors associated with diet diversity is important. This paper, therefore, assessed the socio-demographic and socio-economic determinants of diet diversity among rural pregnant women in India.

Methods

The study consisted of a community-based prospective cohort of n = 204 pregnant women attending primary healthcare centers (PHC) across 14 villages in Mulshi Taluka, Pune, Maharashtra, India. The data was collected using a structured questionnaire through a one-to-one interview method.

Results

The prevalence of low, medium and high diet diversity was 56.4%, 33.3%, and 10.3% respectively. Minimum diversity in the diet was achieved among 73.5% of pregnant women. The mean diet diversity score (DDS) was 3.6 ± 1.3 with starchy staples being (100%) of commonly consumed foods. Young (< 20 years) women (OR = 5.2; CI:1.9- 13.8), housewives (OR = 3; CI:1.4–6.7), husbands working as skilled laborers (OR = 2.5; CI:1.2–5.5) were at significant risk of having low diet diversity scores. Whereas, those living in a joint family (OR = 0.3; CI:0.1–0.6), not owning a house (OR = 0.5; CI:0.2–0.9), and having a poor income (OR = 1.9; CI: 0.9- 3.7) were less likely to have low diet diversity.

Conclusion

Socio-economic and demographic factors (maternal age, mother's occupation, and husband's occupation) influenced the diet diversity among pregnant women. Monotonous diets are commonly seen in developing countries, especially in rural areas which can be a risk factor for poor nutrient adequacy and health of pregnant women. Policies and programs about these determinants of diet diversity should be enacted to replace the poor quality diets to ensure improved diet diversity and nutrient adequacy.

The Increase of Knowledge, Attitude, and Practice of Husbands toward the Prenatal Care of their Wives Using the Illustrations Having the Local Cultural Nuance

BACKGROUND: The role of husbands in maternal health during pregnancy is crucial and is related to the high maternal mortality rate in Indonesia. In spite of that, the effort to involve husbands in the maternal health program is still low. AIM: This paper aims to explain the results of the effort to produce learning assisting tools in a form of an illustration having local cultural nuance that can be used to do intervention of health education to increase the participation of husbands in maternal health. METHODS: The research was conducted in Silaen Village, Silaen District in Toba Regency, North Sumatera Province. To make the teaching materials, interviews and focus group discussions were conducted for the village community figures, the village midwives, the pregnant women, and their husbands. After illustrations were made, the trial was conducted to 10 pairs of husbands and pregnant wives. RESULTS: The illustrations made accommodating the role of husbands in maternal health can increase the knowledge, attitude, and practice (KAP) of husbands, including the KAP of their wives. The biggest increase happening in the attitude component (p < 0.05). CONCLUSION: The educational method using an illustration adopting local culture is important to become one of the education teaching alternatives in the effort to improve husband’s KAP.

Gaps in the implementation and uptake of maternal nutrition interventions in antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence‐based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self‐efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress.

Delivering nutrition services to all pregnant women is essential for maternal and child health outcomes but remains a challenge.

Nutrition gaps in antenatal care (ANC) include lack of specificity in national guidelines and protocols, bottlenecks in micronutrient supplies, low ANC provider knowledge and skills, inadequate supervision to reinforce counseling, and not engaging families to encourage key practices.

National protocols for ANC should be more specific for the four nutrition interventions (micronutrient supplements, weight gain monitoring, counseling on diets and counseling on breastfeeding) and assign accountability for coverage and quality.

Country models are needed for improving provision and utilisation of nutrition interventions through ANC that are based on comprehensive policy frameworks.

Critical assessment of the current indicator for antenatal iron‐containing supplementation coverage: Insights from a mixed‐methods study

Daily consumption of iron‐containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron‐containing supplement consumption is questionable. The WHO–UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron‐containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron‐containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron‐containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%–75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron‐containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Health and nutrition professionals have described concerns with current methods for reporting coverage of daily iron‐containing supplementation in pregnant women.

The long recall period (5 years) of commonly used iron‐containing supplement consumption indicators calls into question the validity of these indicators.

Our study indicates that there is demand for a revised indicator and guidance for data collection.

Dietary Supplement Use during Pregnancy: Perceptions versus Reality

This study aimed to examine the prevalence, associated factors and perceptions of dietary supplement use among pregnant Chinese women. A cross-sectional study was conducted to collect data about prevalence, purchase channels, perceptions, and related factors of dietary supplement use from 572 pregnant women, through a face-to-face survey, using a self-designed questionnaire. Of the respondents, 94.8% used at least one dietary supplement, whereas 29.8% used more than four supplements in the previous month. The majority of the pregnant women were highly educated (81.2% had a bachelor’s degree or above) and had the perception that dietary supplements could prevent and improve (89.2%), or treat, nutrition-related diseases (78.7%). Multivariate analysis showed that pregnant women who had used multiple (more than four) supplements were more likely to have a larger gestational age, received fertility treatment, more prenatal visits, and hypothyroidism during pregnancy. Furthermore, pregnant women not only purchased dietary supplements through hospitals (72.6%) and pharmacies (45.1%), but overseas Daigou or online purchases (31.8%) were also a major channel of purchase. A high prevalence of dietary supplement use during pregnancy was observed, with extensive and repeated consumption of nutrients. Pregnant women’s craze for dietary supplements calls for more comprehensive guidelines in China.

Monitor to innovate with feedback loops: process evaluation protocol for an anemia prevention intervention

Background: With the proliferation of the digital age, information and communication technologies paired with feedback loops have the potential to innovate process evaluations. Objective: To describe how a multilevel social norms field trial (RANI) is using feedback loops to enhance intervention delivery. Methods: We use a mixed-methods process evaluation design to monitor the Reduction of Anemia through Normative Innovations (RANI) project; a three-year randomized control trial which aims to lower rates of anemia among women in Odisha, India. Surveys and structured observation monitor fidelity to implementation and receptivity to implementation activities among study participants. Quantitative data evaluates implementation dose, coverage, exposure, and reach of intervention activities, and qualitative data will delve more deeply into reasons for high or low functioning. Iron folic acid supplement supply and demand are also monitored for stock-outs. Data collected from 130 intervention villages is processed, visualized, and triangulated in near to real-time via Real-time Monitoring for Knowledge Generation (RPM4K), a locally developed software application. Data visualization products facilitate the examination of monitoring data to mitigate bottlenecks and identify and implement tweaks to our intervention delivery strategy on an ongoing basis. Discussion: Feedback loops facilitate timely course corrections. Feedback loops can also engender a shared understanding of ground realities for a geographically dispersed and culturally diverse team. Leveraging feedback loops, we identify opportunities to provide on-going supportive supervision for our community facilitators promoting joint problem-solving, and communication. Monthly media and hemoglobin level demonstration strategies are informed by participant engagement and receptivity. Stock-outs of iron folic acid tablets activate contingency plans to mobilize local stakeholders and advocate for timely resolutions. Unintended effects are monitored based on ongoing feedback from community facilitators. Conclusions: Documenting our processes can inform the future implementation or scale up of similar projects embracing feedback loops to iterate and innovate their intervention delivery.

Scoping Review of Intervention Strategies for Improving Coverage and Uptake of Maternal Nutrition Services in Southeast Asia

Maternal undernutrition can lead to protein-energy malnutrition, micronutrient deficiencies, or anemia during pregnancy or after birth. It remains a major problem, despite evidence-based maternal-nutrition interventions happening on ground. We conducted a scoping review to understand different strategies and delivery mechanisms to improve maternal nutrition, as well as how interventions have improved coverage and uptake of services. An electronic search was conducted in PubMed and Google Scholar for published studies reporting on the effectiveness of maternal-nutrition interventions in terms of access or coverage, health outcomes, compliance, and barriers to intervention utilization. The search was limited to studies published within ten years before the initial search date, 8 November 2019; later, it was updated to 17 February 2021. Of 31 studies identified following screening and data extraction, 22 studies were included for narrative synthesis. Twelve studies were reported from India and eleven from Bangladesh, three from Nepal, two from both Pakistan and Thailand (Myanmar), and one from Indonesia. Nutrition education and counselling, home visits, directly observed supplement intake, community mobilization, food, and conditional cash transfer by community health workers were found to be effective. There is a need to incorporate diverse strategies, including various health education approaches, supplementation, as well as strengthening of community participation and the response of the health system in order to achieve impactful maternal nutrition programs.

Dietary Intake Quality Is Affected by Knowledge and Dietary Intake Frequency among Pregnant Women in Muntinlupa, Philippines: A Cross-Sectional Study

Improving the nutrition of pregnant women is essential in reducing maternal and child mortality, which is one of the global nutritional goals of 2025. This study evaluated the factors related to the quality of dietary intake among pregnant women in Muntinlupa, Philippines. We conducted a cross-sectional study of 280 pregnant women at a hospital in Muntinlupa from March 2019 to August 2019 using questionnaires. After the primary aggregation, multivariate logistic regression analysis was used to identify factors associated with the quality of dietary intake in pregnant women. Approximately half of the women (46.4%, n = 130) had a low dietary diversity during pregnancy. Less than 30% of the respondents consumed beans, soybean products, and nuts. In the logistic regression analysis, poor maternal knowledge of nutritional sources to prevent anemia (odds ratio (OR) 4.25, 95% confidence interval (CI) 1.47-12.32, p = 0.01) and less frequent meal consumption (OR 2.15, 95% CI 1.08-4.29, p = 0.03) were significantly associated with poor dietary diversity. Our findings are crucial because they suggest that increasing the knowledge of pregnant women about good nutrition and ensuring that dietary intake is frequent and adequate through antenatal care can improve the nutrition of pregnant women.

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.

Health facility-based counselling and community outreach are associated with maternal dietary practices in a cross-sectional study from Tanzania

Background

Anemia and underweight among women are major public health challenges. Access to health services can improve dietary behaviors and women’s nutritional status. We examined whether exposure to health services is associated with women’s dietary practices in Tanzania.

Methods

Data come from a cross-sectional baseline survey among 5000 female primary caregivers who were randomly selected via two-stage sampling, prior to implementing a maternal and child nutrition program. We ran frequencies on women’s exposure to existing health facility-based counselling, community health worker visits, and attendance at women’s support groups. We examined associations between exposure to these interventions and maternal diets and adjusted for sociodemographic covariates using ordinary least squares regression and ordered logistic regression.

Results

A third of the sample (34.1%) had received any antenatal care (ANC) during their most recent pregnancy or had been advised by anyone about nutrition (37.0%). 68.0% had never had a community health worker (CHW) speak to them about their children’s health and 9.4% had participated in a women’s group. Only 8.0% of mothers ate more than usual during pregnancy and 7.1% ate more types of foods. After adjusting for mother’s age, education and household assets, women who received nutrition advice were 1.3 times (95% CI: 1.1, 1.7) more likely than mothers who did not to eat more during pregnancy. Receiving antenatal care (ANC) and advice on nutrition before, during, and after pregnancy and delivery were highly associated with the mother eating more types of foods. Hearing from a CHW about children’s health but not support group attendance was often associated with various dietary practices. Almost all measures of access to health services were significantly associated with mothers’ frequency of eating in the previous 24 h. Receiving advice on nutrition during pregnancy and after giving birth and CHW contact were associated with mothers’ dietary diversity in the previous 24 h.

Conclusions

Several program exposure variables—especially being counselled about nutrition—were associated with improved dietary practices. Improving service delivery at scale may contribute to improved dietary behaviors in larger populations, given the associations we describe, along with findings from the existing literature.

Mother’s Perception of Anemia and Compliance of Iron Tablet Consumption during Pregnancy

Backgound: Anemia cases are still the main problem found in pregnant women in East Nusa Tenggara Province, Indonesia, especially East Sumba Regency. Anemia is very common in pregnant women and iron deficiency is the main cause. Indonesia has a policy to provide iron supplements to pregnant women. Non-compliance of iron (Fe) tablets is one of the important challenge factors in fighting anemia. Objective: The research objective was to determine the relationship between perceptions and compliance of pregnant women on consuming iron tablets. Methods: This study involved 102 women, namely 34 pregnant women, 34 postpartum mothers and 34 breastfeeding mothers. After obtaining approval from the research ethics commission, data were collected by personal interview. Data were analyzed using the Spearman correlation statistical test. Results: A good perception of 77.5%, moderate 18.6% and less, 5.9%. It was found that the compliance of taking iron tablets was in the good category of 2.9%, sufficient 27.5% and less 69.6%. The results of the Spearman correlation test show a correlation coefficient of 0.164 and a significant 0.100 which means that there is a weak correlation and there is no relationship between perception and compliance of taking iron tablets. Conclusion: The perception of pregnant women about iron is mostly good and the compliance of pregnant women's in taking iron tablets is mostly sufficient. There was no relationship between perception and compliance of taking iron tablets in pregnant women.

Intimate partner violence is associated with poorer maternal mental health and breastfeeding practices in Bangladesh

Exposure to intimate partner violence (IPV) can have profound adverse consequences on maternal and child health. This study aimed to: (1) identify factors associated with IPV during pregnancy and postpartum in Bangladesh; and (2) assess the associations between IPV and maternal mental health and breastfeeding practices. We used data from a cross-sectional survey of 2000 mothers with children <6 months in four districts in Bangladesh. We applied multivariable logistic regression models to examine factors associated with IPV and structural equation modelling to assess the inter-relationships between IPV, maternal common mental disorders (CMD, measured by Self-reporting Questionnaire ≥7) and breastfeeding practices. Overall, 49.7% of mothers experienced violence during the last 12 months and 28% of mothers had high levels of CMD. Only 54% of women reported early initiation of breastfeeding and 64% reported exclusive breastfeeding. Women were more likely to experience IPV if living in food-insecure households, being of low socio-economic status, having low autonomy or experiencing inequality in education compared with husbands (OR ranged from 1.6 to 2.8). Women exposed to IPV were 2–2.3 times more likely to suffer from high levels of CMD and 28–34% less likely to breastfeed their babies exclusively. The indirect path (the indirect effects of IPV on breastfeeding through CMD) through maternal CMD accounted for 14% of the relationship between IPV on breastfeeding practice. In conclusion, IPV is pervasive in Bangladesh and is linked to increased risks of CMD and poor breastfeeding practices. Integrating effective interventions to mitigate IPV, along with routine maternal and child health services and involving men in counselling services, could help both to reduce exposure to IPV among women and to contribute to better health outcomes for women and children.

Barriers to utilize nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia: An exploratory study

BACKGROUND

While lactation is a physiological process requiring high energy demand to fulfill the nutrient requirements of the mother and the breastfeeding child, many factors affecting maternal nutrient intake can lead to nutritional deficits. Previous studies in Ethiopia have reported the prevalence of maternal and child undernutrition and related complications. However, qualitative studies exploring potential barriers to utilizing available nutrition interventions are limited. This study, therefore, sought to qualitatively explore barriers hindering the uptake of nutrition services among lactating mothers from rural communities in Tigray, northern Ethiopia.

METHODS

We conducted 6 in-depth interviews, 70 key informant interviews, and 13 focus group discussions among purposively selected community groups, experts, and lactating mothers between November- 2017 and January- 2018. Audio records of all interviews and focus group discussions were transcribed verbatim (word-to-word) and translated into English. Then, translated data were analyzed thematically using qualitative data analysis software Atlas ti-version 7.4.

RESULTS

The participants in this study perceived that lactating mothers in their study area are not properly utilizing available and recommended nutrition interventions, and as a result, their nutrient intake was reported as inadequate. Participants identified inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services and poor access to water, sanitation and hygiene as major barriers hindering the uptake of nutrition interventions by lactating women in Tigray, northern Ethiopia.

CONCLUSION

The uptake of nutrition intervention services was low among lactating mothers and was hindered by multiple socio-cultural and health service related factors requiring problem-specific interventions at community, health facility, and administrative levels to improve the nutritional status of lactating mothers in the study area.

Holistic-comprehensive approaches to improve nutritional status of children under five years

Background: Malnutrition has been identified as the leading cause of illness and death in almost half of children under 5 years. Hence, to prevent the impact of malnutrition on physical and psychological development, family physicians need to explore new approaches in the health care delivery models that go beyond the scope of practice. A holistic-comprehensive approach will help the physicians develop a more thorough assessment of nutritional status. This study aims to determine factors associated with the nutritional status of children under five years using holistic-comprehensive approaches.

Design and Methods: A case–control design was implemented, with emphasis on the identification of cases and control groups; 48 children confirmed malnutrition cases and 48 control without malnutrition were recruited from a Community Integrated Health Center in East Java, Indonesia. The characteristics of agent, host and environment between groups were compared and analyzed using correlation coefficients, odds ratio, logistic regression analysis, and Structural Equation Modeling-Partial Least Square (SEM-PLS).

Results: The SEM-PLS results showed that environmental factors have a greater influence on nutritional status (t-value >1.96), compared to the host factors. Furthermore, environmental factors having significant associations with nutritional status were poor socioeconomic status, low maternal educational level and not having exclusive breastfeeding. Also, the results of correlation coefficients and OR showed that birth weight (p=0.000, OR=33) and socioeconomic status (p=0.000, OR=22.3) had strong correlations with nutritional status.

Conclusions: Holistic-comprehensive approaches can be used as new ways to determine factors that may be associated with nutritional status of children under 5 years of age.

Factors associated with dietary diversity among pregnant women in the western hill region of Nepal: A community based cross-sectional study

BACKGROUND

Dietary diversity can play an important role in providing essential nutrients for both mother and fetus during pregnancy. This study aimed to assess the factors associated with dietary diversity during pregnancy in the western hill region of Nepal.

METHODS

A cross-sectional study of 327 pregnant women was conducted in an urban municipality of Baglung district in the western hill region of Nepal. A semi-structured questionnaire was used to collect information on household demographic and socioeconomic status, food taboos, household food security status, nutrition-related knowledge in pregnancy, and women's empowerment. Women consuming ≥5 of 10 food groups in the past 24 hours were defined as consuming a diverse diet using the Minimum Dietary Diversity Score for Women (MDD-W) tool. Bivariate and multivariate logistic regression was used to estimate crude odds ratio (cOR) and adjusted odds ratios (aOR) and 95% confidence intervals (CIs) to understand factors associated with dietary diversity.

RESULTS

Almost 45% (95% CI: 39.6-50.4) of the participants did not consume a diverse diet and the mean dietary diversity score was 4.76 ± 1.23. Multivariable analysis revealed that women with greater empowerment (aOR = 4.3, 95% CI: 1.9-9.9), from wealthier households (aOR = 5.1, 95% CI: 2.7-9.3), joint families (aOR = 2.7, 95% CI: 1.4-5.1), employment (aOR = 2.2, 95% CI: 1.2-4.1), and had adequate nutrition knowledge (aOR: 1.9, 95% CI 1.1-3.4) had higher odds of dietary diversity.

CONCLUSION

Along with socioeconomic status, women's empowerment and nutrition knowledge were modifiable risk factors that should be considered as targets for programs to improve women's health during pregnancy.

Training healthcare workers increases IFA use and adherence: Evidence and cost-effectiveness analysis from Bangladesh

Iron and folic acid (IFA) supplementation programmes are important for preventing and controlling anaemia among pregnant women in low- and middle-income countries. However, frontline health care workers often have limited capacity and knowledge, which can compromise such programmes' effectiveness. Between 2012 and 2014, Nutrition International and the Government of Bangladesh implemented a programme intended to increase IFA supplement consumption during pregnancy. The programme provided frontline health care workers with training on the benefits of IFA supplementation, the use of interpersonal communication and health promotion materials during antenatal care visits and health management information systems to track reported adherence to IFA supplementation. Using a quasi-experimental design, this study investigates the programme's effectiveness and cost-effectiveness at increasing IFA supplement consumption and adherence among pregnant women. The difference-in-differences regression analysis comparing outcomes in an intervention and comparison group concluded that the programme increased IFA consumption by an average of 45.05 supplements (P value = 0.018) and increased the share of women that reported adherence to a regime of at least 90 supplements by 40.35 percentage points (P value = 0.020). Knowledge of IFA supplement dosage and benefits also increased among frontline health care workers and pregnant women. The programme cost $47.11 USD (2018) per disability-adjusted life year averted, which is considered highly cost-effective when evaluated against several cost-effectiveness thresholds. This study suggests that the capacity building of frontline health care workers is an effective and cost-effective method of preventing and controlling anaemia among pregnant women in resource-constrained areas.

A review of the maternal iron and folic acid supplementation programme in Nepal: Achievements and challenges

In the late 1990s, an estimated 75% of pregnant women in Nepal were anaemic. Although iron and folic acid (IFA) supplements were available free of charge, coverage among pregnant women was very low. In response, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the coverage of IFA supplementation and anthelminthic treatment during pregnancy, as well as promote the utilization of antenatal care. This review examined how the IIP programme contributed to Nepal's success in increasing the consumption of IFA supplements during pregnancy. Nepal's cadre of Female Community Health Volunteers were engaged in the IIP to support the community‐based distribution of IFA supplements to pregnant women and complement IFA distribution through health facilities and outreach services. As a result, the country achieved a fourfold increase in the proportion of women who took IFA supplements during pregnancy between 2001 and 2016 (from 23% to 91%) and a 12‐fold increase in the proportion who took IFA supplements for at least 90 days during pregnancy (from 6% to 71%). The increase in coverage of IFA supplements accompanied an increase in the coverage of antenatal care during the same period. By 2016, the prevalence of anaemia in pregnant women decreased to 46%, highlighting the need to tackle other causes of anaemia and improve haemoglobin concentration before pregnancy, while maintaining the successful efforts to reach pregnant women with IFA supplements at the community level.

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.

Adherence to Iron and Folic Acid Supplements and Associated Factors Among Pregnant Mothers Attending ANC at Gulele Sub-City Government Health Centers in Addis Ababa, Ethiopia

BACKGROUND

Even though antenatal care (ANC) visits seems to be the key strategy to increase adherence to iron and folic acid supplements during pregnancy, the problem still remains unresolved. Therefore, this study planned to assess adherence to iron and folic acid supplements and associated factors among pregnant mothers attending ANC at Gulele sub-city Government Health Centers in Addis Ababa, Ethiopia, 2019.

METHODS

An institution-based cross-sectional study design was conducted on 403 pregnant women attending ANC at governmental health centers in Gulele sub city of Addis Ababa from May to June, 2019. The study participants were selected by systematic random sampling techniques, and an interviewer administered questionnaire was used to collect data. Descriptive statistics and logistic regression models were used to analyze the data. The results were considered statistically significant at p-value <0.05.

RESULTS

The proportion of mother's adherent to iron and folic acid supplements was 62.3% with a 95% CI of 57.5-67.0. Women who had no formal education (AOR=2.37; 95% CI=1.25-4.51), poor knowledge about anemia (AOR=1.97; 95% CI=1.24-3.13), developing any other health problem during current pregnancy (AOR=2.59; 95% CI=1.55-4.32), attending health information about iron/folic acid supplement (AOR=2.06; 95% CI=1.08-3.921 and forgetful (AOR=2.23; 95% CI=1.40-3.56) mothers were more likely to be non-adherent to the supplement compared with their counterparts.

CONCLUSION AND RECOMMENDATION

The status of maternal adherence was medium compared with other studies, and maternal educational status, knowledge about anemia, exposure to information, experiencing of health problems, and forgetfulness were associated with adherence behavior. This indicates that improving dissemination of information about the supplements and designing a reminder mechanism was needed to improve the adherence status of mothers to the supplement.