Micronutrient.org | @micronutrient | facebook.com/micronutrient A health systems strengthening approach to improve nutrition of pregnant women and newborns

micronutrient.org | @micronutrient | facebook.com/micronutrient

A health systems strengthening approach to improve nutrition of pregnant women and newborns in Ethiopia, Kenya and Senegal.

Jacqueline Kung’u1, Banda Ndiaye1, Crispin Ndedda1, Girma Bogale1, Emily Gold1, Lynnette Neufeld, 2 Luz Maria De-Regil1

1Micronutrient Initiative, 2Global Alliance for Improved Nutrition

@micronutrientfacebook.com/micronutrient


micronutrient.org [email protected]/micronutrient

Introduction• Pregnant women and newborns are among the

vulnerable populations in any community• We commissioned demonstration projects to

generate evidence for strengthening the health systems to ensure pregnant and newborns are reached with proven health and nutrition interventions

• Approach used in each country suitable to existing health system context




Community Based Maternal and Newborn Health projects

1. EthiopiaSupporting Ethiopia’s Health Extension Program to increase access to quality maternal, neonatal and nutrition services

2. KenyaImproved care and Nutrition for Women at Risk during Pregnancy through a Novel Community-Facility Linkage program

3. SenegalDevelopment and piloting of comprehensive Maternal and Newborn Community Health (MNCH) policy for Senegal.

Maternal and Neonatal morbidity and mortality reduced




Program Theory - Ethiopia

MNHN training guidelines and booklet

Supply and Medical equipment improved

Knowledge, skills and practice of Guide Team s & CQI Teams at the community to improve demand for MNHN services

Improved MNHN Service uptake

Improved MNHN Service Quality

Maternal and Neonatal morbidity and mortality

reduced

Providers Knowledge, Skill, and Commitment

on MNHN services improved

OutcomesInput Impact

Monitoring and Collaborative Quality Improvement (CQI) at

Health Facilities

Access: Availability of trained Guide team in the community that provides MNHN services




Behavior change Interventionsat the community

CHW training Facilities

TBA orientation

Incentive packageCollective and individual

Retention of CHWs in program

Improved care &

nutrition of pregnant women &

newborns

Teamwork and simulation training (PRONTO)Intervention only

Increased MNH & Nutrition knowledge

Harmonized EmONC Training(MoH)

Intervention & Comparison

TBAs as birth

companions

Improved skills and knowledge

Increased demand for

services

Increased utilization of

services

OutcomesInput Impact

Program Theory - KenyaC

om

mu

nit

y m

ob

iliz

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n a

nd

R

efer

ral

(Dem

and

cre

atio

n)

Hea

lth

fac

ilit

y st

ren

gth

enin

g

Maternal and Neonatal morbidity and mortality

reduced




Formation of and training of facilitators of influencer and

pregnant women peer groups

Health extension workers trained and have ECS

New health huts enlisted and equipped

Outcomes

Decreased Newborn Infection

Input

Supply and distribution issues resolved for misoprostol, IFA, MgSO4

loading dose (at health post only)

Decreased PPH

Impact

Child birth preparation

Quality ANC, including effective

counselling

Early ANC Appropriate use of iron-folic acid supplements

Early and exclusive

breastfeeding

Delivery with trained provider in

community (low risk)

Delayed and quality care

umbilical cord clamping

Mesoprostol use

Comprehensive package of MNH services designed

Decreased anemia prevalence in pregnant women

MgSO4 loading dose use at health

post

Program Theory- Senegal

Matron, Bajenou Gox and Relay trained and have effective

communication strategy (ECS)) Maternal and Neonatal morbidity and mortality

reduced




Quasi experimental study design using mixed methods

Baseline assessment(Qualitative +

Quantitative)2013

Endline assessment(Qualitative +

Quantitative)2015

InterventionEthiopia - Integrated set of activities and essential servicesKenya - Community facility LinkageSenegal – Pilot the defined package of services at community level Measure the

impact of intervention on

various outcome and impact indicators

1. Mothers with children 0-11 mths

2. Pregnant women3. CHW/HEW4. TBA5. HF Staff

No random assignment Intervention + Comparison

Process/Midterm evaluation – Evaluate the process of implementing the intervention




ANC Visits

Indicator Intervention Comparison

Kenya Ethiopia Senegal Kenya Ethiopia Senegal

n/N (%) n/N (%) n/N (%) n/N (%) n/N (%) n/N (%)

% of mothers of children 0-11 m of age who attend ANC at least 4 times during most recent pregnancy.

178/41343%

48/9984.8%

202/108618.6%

99/20448.5%

28/9712.9%

146/35041.7%

% of mothers of children 0-11 m of age who received ANC in the first trimester during most recent pregnancy

79/42718.5%

51/24620.7%

330/109430.2%

19/2049.3%

56/10724.3%

177/39245.2%




IFA utilization



n/N (%) n/N (%) n/N (%) n/N (%) n/N (%) n/N (%)

% of mothers of children 0-11 m of age who report having taken IFA during the latest pregnancy ≥ 90 d

105/28636.7%

6/1773.4%

760/136755.6%

45/10941.3%

13/2126.1%

379/44285.7%

% of mothers of children 0-11 m of age who report having taken any IFA during pregnancy

309/46466.6%

178/99517.8%

1020/144470.6%

131/21860.1%

211/97121.7%

389/48179.6%




The pregnant women and mothers of young children were all positive about ANC especially because of the check-ups, vaccinations and the fact that they receive a mosquito net.

Reasons given by some for not visiting ANC :• ANC is not beneficial - especially in the first trimester• The hospital smell is offensive• Their mothers-in-law do not encourage them to seek ANC and so they do

not attend to please them (this contradicts some of the responses from mothers in-laws, who said, for example, that the women are simply lazy and don’t attend ANC)

• They find the process of being examined very tiresome• Fear of being tested for HIV.

Understanding Barriers to and Opportunities for ANC in Kenya: Pregnant Women




Understanding Barriers to and Opportunities for ANC in Ethiopia: Women• Most participants believed that there is no need to go for ANC services

as the services are meant for pregnant women who are sick. Those who had ANC visit noted that health care providers were doing nothing if the mother and fetus are healthy during the visit.

• A mother of nine children from Golina Botena district remarked “ I didn’t use ANC services because I was healthy. A woman should go for antenatal care services if she gets ill”

• On the other hand, in depth interview participants indicated that women who had a problem during their pregnancy go to health institutions for repeated follow-up




Understanding Barriers to and Opportunities for ANC in Senegal : Lactating women, Husband, Mother in-law• Geographical barriers-- All participants stated that distance was a critical

barrier and inaccessible roads.• Cultural barriers – “…Husbands should get more involved on aspects of

ANC. Their support is only financial…”(Mother in-law).• “…Women are used to hiding their pregnancy and always inform us late

to avoid evil spirit…” (Husband). • Training barriers-- “…The health workers are not patient or lack

training…” (Husband)• BCC barriers – “...Religious and traditionalists ignore the benefits of IFA

and propose healing plants due to lack of sensitization…” (Mother in-law)• Opportunities- Women who had received advices on ANC were more

likely to do it early and completely




Health facility Staff, Mothers in Law and Midwives

According to the health facility staff, women come for ANC:• Late, usually when they are about 6 months or even near term• when they are sick or have a problem • when they cannot afford or pay for services

The following are considered to be greatest worries and most common problems facing pregnant women in the community: • Facilities being too far; Lack of transport - especially at night; Diseases (such as

malaria, HIV); Anemia, poor nutrition; Poverty, polygamy; Unaffordable hospital charges ; Ignorance

According to mothers in-laws and mid-wives ,pregnant women should make ANC visits early enough, preferably at three months gestation period.

Reasons they indicated for women not attending ANC as required included:• Laziness; Ignorance; Fear of harsh facility service providers (although the retired

mid-wives were previously health service providers); Financial constraints; Distance; Fear of injections/drugs




Postnatal Care



n/N (%) n/N (%) n/N (%) n/N (%) n/N (%) n/N (%)

% of lactating women who initiate breastfeeding within one hour after birth.

276/29792.9%

365/96737.7%

743/410153%

117/13586.6%

522/96154.3%

232/43952.8%

% of mothers of children 0-11 m of age who delivered with skilled attendant

81/25831.4%

63/9976.3%

801/143355.9%

66/11955.5%

58/9716%

276/46759.1%

% of women who received post natal care 48 hours after delivery

235/27286.4%

11/1861.1%

964/139759%

144/14798%

21/2680.8%

403/45588.6%




• Financial barriers– “…Certain mothers are obliged to work to have some money and leave baby to mother in- law…”(Matron).

• Cultural barriers resulting from mother -in-law– “…It is the fault of mothers-in-law who ignore the nutritional values of the Breastfeeding…” (Matron)

• Opportunities– Period of breastfeeding initiation and duration of exclusive breastfeeding are well-know by CHWs– “… The breastfeeding should start immediately after the baby born…” (Bajenu Gox)

Understanding Barriers to and Opportunities for Facility Based Post natal Care and breastfeeding in Senegal




• The TBAs are aware of the need for six months of exclusive breastfeeding, but some children start crying after breastfeeding – this is taken as a sign that breast milk is not enough and as such start being fed porridge.

• TBAs said that apart from breast milk, a woman can give porridge made from millet to the child. At four months, the mother can start giving avocados and pawpaws. A mother will know that she is supposed to wean because some children will want to eat what the mother eats at the age of 4 months

Understanding Barriers to and Opportunities for Exclusive Breastfeeding in Kenya - TBAs




Understanding Barriers to and Opportunities for breastfeeding in Ethiopia

In-depth interview participants raised several reasons for not giving first milk (colostrum). • the first milk is contaminated with dirt which gets in through the

nipples. This milk is discarded and the next fresh milk which is assumed to be cleaner is given to the baby.

• discarding the first milk will enable to initiate production of adequate milk subsequently.

• if the first milk, which stayed for long and exposed to the sun is given to the new born, it can cause abdominal pain.




Understanding Barriers to and Opportunities for breastfeeding in Ethiopia

• In some instances herbal medicines are given to the newborn to make the child well as s/he grows.

“ It is our culture that the baby is given a medicine so that he will be a good person when he grows up. The father brings the herb and it will be mixed with milk and will be given to the baby” (a mother from Ewa district).




Conclusions and Next Steps

• Maternal health service utilization was found to be very low and presents an opportunity for CBMNH intervention to make a difference

• ANC in first trimester needs to be promoted more than “any” contact during pregnancy

• Completed ANC needs to be promoted by sensitization and more involvement of community groups

• Emphasis has been put on BCI to address key project components during pregnancy, delivery and PNC– maternal nutrition, breastfeeding practices, cord care




Acknowledgements

• Communities

• All partners – MoH, ManHEP, University of Addis Ababa, AMREF, PRONTO, ChildFund, University of Nairobi, Université Cheikh Anta Diop – ISED.

• DFATD

Documents

Micronutrient.org | @micronutrient | facebook.com/micronutrient A health systems strengthening approach to improve nutrition of pregnant women and newborns