Addressing Barriers to Maternal Nutrition in Low- and Middle-Income Countries: A Review of The Evidence and Programme Implications.

Adequate maternal nutrition during the “first 1,000 days” window is critical from conception through the first 6 months of life to improve nutritional status and reduce the risk of poor birth outcomes, such as low birthweight and preterm birth. Unfortunately, many programmes have targeted implementation and monitoring of nutrition interventions to infants and young children, rather than to women during pregnancy or post-partum. A literature review was conducted to identify barriers to food choice and consumption during pregnancy and lactation and to examine how low- and middle-income countries have addressed maternal nutrition in programmes. A literature review of peer-reviewed and grey literature was conducted, and titles and abstracts reviewed by authors. Twenty-three studies were included in this review. Barriers to adequate nutrition during pregnancy included cultural beliefs related to knowledge of quantity of food to eat during pregnancy, amount of weight to gain during pregnancy, and “eating down” during pregnancy for fear of delivering a large baby. Foods considered inappropriate for consumption during pregnancy or lactation contributed to food restriction. Drivers of food choice were influenced by food aversions, economic constraints, and household food availability. Counselling on maternal diet and weight gain during pregnancy was seldom carried out. Programming to support healthy maternal diet and gestational weight gain during pregnancy is scant. Tailored, culturally resonant nutrition education and counselling on diet during pregnancy and lactation and weight gain during pregnancy, as well as monitoring of progress in maternal nutrition, are areas of needed attention

Community-based Distribution of Iron-Folic Acid Supplementation in Low- and Middle-income Countries: A Review of Evidence and Programme Implications.

The present literature review aimed to review the evidence for community-based distribution (CBD) of iron–folic acid (IFA) supplementation as a feasible approach to improve anaemia rates in low- and middle-income countries. The literature review included peer-reviewed studies and grey literature from PubMed, Cochrane Library, LILAC and Scopus databases. Low- and middle-income countries. Non-pregnant women, pregnant women, and girls. CBD programmes had moderate success with midwives and community health workers (CHW) who counselled on health benefits and compliance with IFA supplementation. CHW were more likely to identify and reach a greater number of women earlier in pregnancy, as women tended to present late to antenatal care. CBD channels had greater consistency in terms of adequate supplies of IFA in comparison to clinics and vendors, who faced stock outages. Targeting women of reproductive age through school and community settings showed high compliance and demonstrated reductions in anaemia. CBD of IFA supplementation can be a valuable platform for improving knowledge about anaemia, addressing compliance and temporary side-effects of IFA supplements, and increasing access and coverage of IFA supplementation. Programmatic efforts focusing on community-based platforms should complement services and information provided at the health facility level. Provision of training and supportive supervision for CHW on how to counsel women on benefits, side-effects, and when, why, and how to take IFA supplements, as part of behaviour change communication, can be strengthened, alongside logistics and supply systems to ensure consistent supplies of IFA tablets at both the facility and community levels

The rise in stunting in relation to avian influenza and food consumption patterns in Lower Egypt in comparison to Upper Egypt: results from 2005 and 2008 Demographic and Health Surveys

Background A 2006 avian influenza (AI) outbreak resulted in mass removal of chickens in Lower Egypt, which decreased the household supply of poultry. Poultry, a key animal-source food, contains nutrients critical for child growth. This paper examines determinants of stunting between 2006 and 2008 in children 6 to 59 months of age within the context of the AI outbreak. Methods The 2005 and 2008 nationally representative Egypt Demographic and Health Surveys (EDHS) were used to analyse anthropometric data from 7,794 children in 2005 and 6,091 children in 2008. Children, 6–59 months of age, with length for age Z-score \u3c −2 S.D. were categorized as stunted. Predictors of stunting were examined by bivariate and multivariable analyses, focusing on Lower Egypt, where a rise in stunting occurred, and Upper Egypt, where stunting declined. Results Between 2005 and 2008, Upper Egypt experienced a significant decline in stunting (28.8 to 21.8%, P \u3c 0.001). Lower Egypt experienced a significant rise in stunting (16.6 to 31.5%, P \u3c 0.001), coinciding with the 2006 AI outbreak. In Lower Egypt (2008), households owning poultry were 41.7% less likely to have a stunted child [aOR 0.58; 95% CI (0.42, 0.81) P = 0.002], and 12–47 month old children were 2.12-2.34 times [95% CI (1.39 – 3.63) P ≤ 0.001] more likely to be stunted than 6–11 month old children. Older children were likely affected by AI, as these children were either in-utero or toddlers in 2006. In Upper Egypt, stunting peaked at 12–23 months [aOR 2.62, 95% CI (1.73-3.96), P \u3c 0.001], with lowered risk (22-32%) of stunting in 24–47 month old children [aOR1.65, 95% 1.07-2.53, P = 0.022, 24–35 month old] and [aOR 1.57, 95% CI 1.01-2.43, P = 0.043 36–47 months old]. A two-fold increase in child consumption of sugary foods between 2005 and 2008 was found in Lower Egypt (24.5% versus 52.7%; P \u3c .001). Conclusions Decreased dietary diversity, reduced poultry consumption, substitution of nutritious foods with sugary foods paralleled a reduction in household raising of birds, following the AI outbreak in Lower Egypt and not Upper Egypt. Increased feeding of sugary foods due to fear of illness or greater penetration of these foods may be related to stunting. Advice on infant and young child feeding is needed to improve dietary intake and reduce sugary food consumption

Association between Anaemia during Pregnancy and Blood Loss at and after Delivery among Women with Vaginal Births in Pemba Island, Zanzibar, Tanzania

The study sought to identify determinants of blood loss at childbirth and 24 hours postpartum. The study was nested in a community-based randomized trial of treatments for anaemia during pregnancy in Wete Town, Pemba Island, Zanzibar, United Republic of Tanzania. Status of anaemia during pregnancy, nutritional information, obstetric history, and socioeconomic status were assessed at enrollment during routine antenatal care. Pregnant women presented for spontaneous vaginal delivery, and nurse-midwives collected information on labour and delivery via partograph. Blood-stained sanitary napkins and pads from childbirth and 24 hours postpartum were quantified using the alkaline hematin method. Moderate-to-severe anaemia (Hb <90 g/L) at enrollment was strongly associated with blood loss at delivery and the immediate postpartum period, after adjusting for maternal covariates and variables of biological relevance to blood loss. Greater blood loss was associated (p<0.10) with duration of the first stage of labour, placental weight, receipt of oxytocin, preterm birth, and grand multiparity. The findings provide unique evidence of a previously-suspected link between maternal anaemia and greater blood loss at childbirth and postpartum. Further research is needed to confirm these findings on a larger sample of women to determine whether women with moderate-to-severe anaemia are more likely to experience postpartum haemorrhage and whether appropriate antenatal or peripartum care can affect the relationships described here

Factors associated with early growth in Egyptian infants: implications for addressing the dual burden of malnutrition

Optimal nutrition is critical to the attainment of healthy growth, human capital and sustainable development. In Egypt, infants and young children face overlapping forms of malnutrition, including micronutrient deficiencies, stunting and overweight. Yet, in this setting, little is known about the factors associated with growth during the first year of life. A rise in stunting in Lower Egypt from 2005 to 2008 prompted this implementation research study, which followed a longitudinal cohort of infants from birth to 1 year of age within the context of a USAID-funded maternal and child health integrated programme. We sought to determine if growth patterns and factors related to early growth differed in Lower and Upper Egypt, and examined the relationship between weight loss and subsequent stunting at 12 months of age. Growth patterns revealed that length-for-age z-score (LAZ) decreased and weight-for-length z-score (WLZ) increased from 6 to 12 months of age in both regions. One-quarter of infants were stunted and nearly one-third were overweight by 12 months of age in lower Egypt. Minimum dietary diversity was significantly associated with WLZ in Lower Egypt (β = 0.22, P < 0.05), but not in Upper Egypt. Diarrhoea, fever and programme exposure were not associated with any growth outcome. Weight loss during any period was associated with a twofold likelihood of stunting at 12 months in Lower Egypt, but not Upper Egypt. In countries, like Egypt, facing the nutrition transition, infant and young child nutrition programmes need to address both stunting and overweight through improving dietary quality and reducing reliance on energy-dense foods

Factors associated with early growth in Egyptian infants: implications for addressing the dual burden of malnutrition.

Optimal nutrition is critical to the attainment of healthy growth, human capital and sustainable development. In Egypt, infants and young children face overlapping forms of malnutrition, including micronutrient deficiencies, stunting and overweight. Yet, in this setting, little is known about the factors associated with growth during the first year of life. A rise in stunting in Lower Egypt from 2005 to 2008 prompted this implementation research study, which followed a longitudinal cohort of infants from birth to 1 year of age within the context of a USAID-funded maternal and child health integrated programme. We sought to determine if growth patterns and factors related to early growth differed in Lower and Upper Egypt, and examined the relationship between weight loss and subsequent stunting at 12 months of age. Growth patterns revealed that length-for-age z-score (LAZ) decreased and weight-for-length z-score (WLZ) increased from 6 to 12 months of age in both regions. One-quarter of infants were stunted and nearly one-third were overweight by 12 months of age in lower Egypt. Minimum dietary diversity was significantly associated with WLZ in Lower Egypt (β = 0.22, P \u3c 0.05), but not in Upper Egypt. Diarrhoea, fever and programme exposure were not associated with any growth outcome. Weight loss during any period was associated with a twofold likelihood of stunting at 12 months in Lower Egypt, but not Upper Egypt. In countries, like Egypt, facing the nutrition transition, infant and young child nutrition programmes need to address both stunting and overweight through improving dietary quality and reducing reliance on energy-dense foods

Implementing a Novel Facility-Community Intervention for Strengthening Integration of Infant Nutrition and Family Planning in Mara and Kagera, Tanzania

Tanzania has high fertility, low contraceptive prevalence and low exclusive breastfeeding (EBF). The Lake Zone, including Mara and Kagera regions, leads the country in total fertility; use of the lactational amenorrhea method (LAM) is negligible. This pre-/post-study explored the effects of a multi-level facility and community intervention (service delivery support, community engagement, media and LAM tracking) to integrate maternal and infant nutrition and postpartum family planning (FP) within existing health contacts. Mixed methods were used, including service statistics, exit interviews, patient-tracking tools for community health workers, client self-tracking tools, supervision data, focus group discussions and in-depth interviews. Results are presented using the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) implementation science framework. The intervention reached primarily the second and fourth wealth quintiles, increased FP and EBF at six weeks postpartum. LAM was very acceptable, provided an entry point for FP conversations and for addressing misconceptions, and reinforced EBF practices. Partners felt encouraged to support spousal nutrition, breastfeeding and FP. Higher adoption in Kagera may be influenced by performance-based financing. The intervention was implemented with generally high fidelity. Maintenance data reflected stakeholder interest in continuing the intervention. A multi-level facility and community intervention was feasible to implement and likely contributed to improved EBF practices and FP uptake, including LAM use

Association between Anaemia during Pregnancy and Blood Loss at and after Delivery among Women with Vaginal Births in Pemba Island, Zanzibar, Tanzania

The study sought to identify determinants of blood loss at childbirth and 24 hours postpartum. The study was nested in a community-based randomized trial of treatments for anaemia during pregnancy in Wete Town, Pemba Island, Zanzibar, United Republic of Tanzania. Status of anaemia during pregnancy, nutritional information, obstetric history, and socioeconomic status were assessed at enrollment during routine antenatal care. Pregnant women presented for spontaneous vaginal delivery, and nurse-midwives collected information on labour and delivery via partograph. Blood-stained sanitary napkins and pads from childbirth and 24 hours postpartum were quantified using the alkaline hematin method. Moderateto-severe anaemia (Hb &lt;90 g/L) at enrollment was strongly associated with blood loss at delivery and the immediate postpartum period, after adjusting for maternal covariates and variables of biological relevance to blood loss. Greater blood loss was associated (p&lt;0.10) with duration of the first stage of labour, placental weight, receipt of oxytocin, preterm birth, and grand multiparity. The findings provide unique evidence of a previously-suspected link between maternal anaemia and greater blood loss at childbirth and postpartum. Further research is needed to confirm these findings on a larger sample of women to determine whether women with moderate-to-severe anaemia are more likely to experience postpartum haemorrhage and whether appropriate antenatal or peripartum care can affect the relationships described here

Program considerations for integration of nutrition and family planning: Beliefs around maternal diet and breastfeeding within the context of the nutrition transition in Egypt

In Egypt, rising maternal overweight and obesity is consistent with the transition to westernized diets and a growing reliance on energy-dense, low nutrient foods. Although the first 1,000 days of life are the focus of many programmes designed to prevent many forms of malnutrition, little attention has been paid to maternal dietary practices and weight gain during pregnancy. This study used in-depth interviews with pregnant women (N = 40), lactating women (N = 40), and nonlactating women (N = 40) to gain an understanding of behaviours, perceptions, and cultural beliefs in relation to maternal dietary intake during pregnancy, lactation, and nonlactation; weight gain during pregnancy; birth spacing; and family planning. Study findings reveal that food choice was driven by affordability, favoured foods, or foods considered appropriate for a specific life stage (pregnant, lactating, and nonlactating). Knowledge of weight gain during pregnancy is limited, especially with regards to excessive weight gain during pregnancy. Diet is often modified during lactation to support breast milk production, and a normal diet resumed when breastfeeding ceases. Within the context of breastfeeding, the lactational amenorrhea method provides an opportunity to improve exclusive breastfeeding practices, maternal diet during lactation, and the transition to other family planning methods by 6 months postpartum. Health care providers should discuss limiting maternal consumption of low nutrient foods such as junk foods, soda, and teas during pregnancy and postpartum. Dietary counselling should accompany information on appropriate weight gain during pregnancy and exercise to prevent excessive weight gain, in the context of the nutrition transition