Degree of exposure to interventions influences maternal and child dietary practices: Evidence from a large-scale multisectoral nutrition program.

The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal's 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII's 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores (b = 0.09; p = 0.05), child (aged 2-5 years) DD scores (b = 0.11; p = 0.03), and mothers meeting minimum dietary diversity (OR = 1.16; p = 0.05). There were significant, positive associations between both IPC and CM events and meeting minimum DD (IPC: OR = 1.31, p = 0.05; CM: OR = 1.37; p<0.001) and also between CM events and DD scores (b = 0.14; p = 0.03) among mothers. We found significant, positive associations between mass media and meeting minimum DD (OR: 1.38; p = 0.04) among children aged 6-24 months and between mass media and DD scores (b = 0.15; p = 0.01) among children aged 2-5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores (b = 0.45; p = 0.01), child (aged 2-5 years) DD scores (b = 0.41; p<0.001) and mothers meeting MDD (OR = 2.33; p<0.001). These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets

Reaching mothers and babies with early postnatal home visits: the implementation realities of achieving high coverage in large-scale programs.

BACKGROUND: Nearly half of births in low-income countries occur without a skilled attendant, and even fewer mothers and babies have postnatal contact with providers who can deliver preventive or curative services that save lives. Community-based maternal and newborn care programs with postnatal home visits have been tested in Bangladesh, Malawi, and Nepal. This paper examines coverage and content of home visits in pilot areas and factors associated with receipt of postnatal visits. METHODS: Using data from cross-sectional surveys of women with live births (Bangladesh 398, Malawi: 900, Nepal: 615), generalized linear models were used to assess the strength of association between three factors - receipt of home visits during pregnancy, birth place, birth notification - and receipt of home visits within three days after birth. Meta-analytic techniques were used to generate pooled relative risks for each factor adjusting for other independent variables, maternal age, and education. FINDINGS: The proportion of mothers and newborns receiving home visits within three days after birth was 57% in Bangladesh, 11% in Malawi, and 50% in Nepal. Mothers and newborns were more likely to receive a postnatal home visit within three days if the mother received at least one home visit during pregnancy (OR2.18, CI1.46-3.25), the birth occurred outside a facility (OR1.48, CI1.28-1.73), and the mother reported a CHW was notified of the birth (OR2.66, CI1.40-5.08). Checking the cord was the most frequently reported action; most mothers reported at least one action for newborns. CONCLUSIONS: Reaching mothers and babies with home visits during pregnancy and within three days after birth is achievable using existing community health systems if workers are available; linked to communities; and receive training, supplies, and supervision. In all settings, programs must evaluate what community delivery systems can handle and how to best utilize them to improve postnatal care access

Relative risk for receiving a postnatal home visit within 3 days after birth.

<p>Relative risk for receiving a postnatal home visit within 3 days after birth.</p

Distribution of independent variables¹.

1<p>Missing values were <3% for all variables.</p

Proportion of mothers¹ and newborns receiving CHW home visits in the first week after birth.

<p>This figure shows the percent of mothers and newborns that received a home visit from a community health worker within 0–3 days after birth and 4–7 days after birth in each of the 3 countries included in the analysis – Bangladesh, Malawi, and Nepal. ¹In Nepal, separate questions were asked about postnatal care for the mother and newborn. The woman was asked about only the first two post-discharge checks on her health, but was asked about the first three post-discharge checks for her newborn. Thus the percentage of women visited at home within three days after the birth appears lower than the percentage of newborns visited (41.3% versus 49.6%). Therefore, questions on post-discharge care for the baby were used to calculate the dependent variable in Nepal.</p

Community worker characteristics and home visit schedule, content, and incentives.

1<p>Catchment area population size varies in Nepal depending on terrain; 400 population is based on Terai region such as Bardiya.</p

Newborn care content of postnatal home visits within 3 days after delivery.

1<p>In Malawi, women were asked what was done by an HSA during any home visit; it was assumed that all reported actions applied to visits that occurred within 3 days of delivery for newborns that received multiple visits.</p>2<p>Counseling on breastfeeding included observation, demonstration, or assessment of breastfeeding.</p>3<p>Check the cord, counsel on breastfeeding, check temperature, and weigh baby were collected in both countries. Counseling on danger signs is excluded since it was only collected in Malawi.</p

Country context.

<p><b>Note:</b> Data for proportion of health facility births in Malawi is from 2010; all other data under the columns marked 2011 is from 2011.</p