Addressing barriers to maternal nutrition in low- and middle-income countries: A review of the evidence and programme implications

Feasibility, acceptability and equity of a mobile intervention for Upscaling Participatory Action and Videos for Agriculture and Nutrition (m-UPAVAN) in rural Odisha, India

Addressing undernutrition requires strategies that remove barriers to health for all. We adapted an intervention from the 'UPAVAN' trial to a mobile intervention (m-UPAVAN) during the COVID-19 pandemic in rural Odisha, India. In UPAVAN, women's groups viewed and discussed participatory videos on nutrition-specific and nutrition-sensitive agricultural (NSA) topics. In m-UPAVAN, weekly videos and audios on the same topics were disseminated via WhatsApp and an interactive voice response system. We assessed feasibility, acceptability, and equity of m-UPAVAN using a convergent parallel mixed-methods design. m-UPAVAN ran from Mar-Sept 2021 in 133 UPAVAN villages. In Feb-Mar 2021, we invited 1000 mothers of children aged 0-23 months to participate in a sociodemographic phone survey. Of those, we randomly sampled 200 mothers each month for five months for phone surveys to monitor progress against targets. Feasibility targets were met if >70% received videos/audios and >50% watched/listened at least once. Acceptability targets were met if >75% of those watching/listening liked the videos/audios and <20% opted out of the intervention. We investigated mothers' experiences of the intervention, including preferences for m-UPAVAN versus UPAVAN, using in-person, semi-structured interviews (n = 38). Of the 810 mothers we reached, 666 provided monitoring data at least once. Among these mothers, feasibility and acceptability targets were achieved. m-UPAVAN engaged whole families, which facilitated family-level discussions around promoted practices. Women valued the ability to access m-UPAVAN content on demand. This advantage did not apply to many mothers with limited phone access. Mothers highlighted that the UPAVAN interventions' in-person participatory approaches and longer videos were more conducive to learning and inclusive, and that mobile approaches provide important complementarity. We conclude that mobile NSA interventions are feasible and acceptable, can engage families, and reinforce learning. However, in-person participatory approaches remain essential for improving equity of NSA interventions. Investments are needed in developing and testing hybrid NSA interventions.

Cultural food practices and sources of nutrition information among pregnant and postpartum migrant women from low- and middle-income countries residing in high income countries: A systematic review

Women in low- and middle-income countries (LMICs) may engage in a range of cultural food practices during pregnancy, including restricting or avoiding foods high in protein and iron, and foods rich in vitamins and minerals. While research has explored the cultural food practices of pregnant women in LMICs, there is less understanding of the continued cultural food practices of women who migrate to high-income countries and then become pregnant. This systematic review explores the existing research on cultural food practices and sources of nutrition information among pregnant and postpartum migrant women from LMICs, residing in high-income countries. A systematic search was conducted in April 2024 across Global Health, CINAHL, and MEDLINE, published in English, with no date restrictions. Eligible studies included those focused on pregnant and postpartum women who had migrated from LMICs to high-income countries. Studies were excluded if they comprised of non-immigrant women or did not involve LMIC participants. Screened were studies for eligibility, data were extracted, and study quality was assessed. In total, 17 studies comprising qualitative (n = 10) and quantitative (n = 7) approaches were included. In 14 studies participants adhered to cultural food practices, wherein certain nutritious foods were restricted during pregnancy or the postpartum period; three studies noted limited adherence due to support, acculturation, and access to traditional foods. Most studies (n = 10) reported traditional "hot" and "cold" food beliefs during pregnancy and postpartum, aiming to maintain humoral balance for maternal and child health and to prevent miscarriage. Nutrition advice was sought from family members, friends, relatives, healthcare providers, and media sources, with a preference for advice from family members in their home countries. There is a need for culturally appropriate nutrition education resources to guide pregnant migrants through healthy and harmful cultural food practices and overall nutrition during this crucial period. (PROSPERO Registration: CRD42023409990).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Barriers to adequate nutrition in pregnant adolescent Colombian females

Pregnant adolescent females face nutritional challenges. The nutritional demands of a growing fetus, when added to the requirements for growing adolescent bodies, are risk factors for undernutrition. An adolescent expectant mother's nutritional status therefore affects both the mother's and the child's future growth, development, and potential development of diseases later in life. In Colombia, the rate of female adolescent pregnancies is higher than neighboring countries and the global average. The most recent data suggest that approximately 21 % of all pregnant adolescent females in Colombia are underweight, 27 % suffer from anemia, 20 % suffer from vitamin D deficiency, and 19 % suffer from vitamin B12 deficiency. Contributing factors to these nutritional deficiencies during pregnancy may be the region in which the female lives, the female's ethnicity, and the female's socioeconomic and educational status. In rural parts of Colombia, limitations regarding access to prenatal care and food choices that include animal source proteins may also contribute to nutritional deficiencies. To help remedy this, recommendations include encouraging nutrient dense food sources with higher protein content, eating one additional meal per day, and taking a prenatal vitamin throughout the pregnancy. Making healthy eating choices can be difficult for adolescent females with limited resources and education; therefore, it is recommended that discussions about nutrition begin at the first prenatal visit for optimum benefits. These factors should be considered for the development of future health policies and interventions in Colombia and other low-income and middle-income countries where pregnant adolescent females may be experiencing similar nutritional deficiencies.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Impact of COVID-19 on Micronutrient Adequacy and Dietary Diversity among Women of Reproductive Age from Selected Households in Bangladesh

Women of reproductive age (WRA) are recognized as a nutritionally sensitive demographic that is vulnerable to micronutrient deficiencies. The purpose of this study is to determine the situation and influencing factors of diet diversity and micronutrient adequacy during the pandemic-induced economic lockdown period among women living in a selected area of Bangladesh. Twenty-four-hour dietary recall was used to measure the nutrient intake and also used for constructing the Minimum Dietary Diversity for Women (MDD-W) and nutrient adequacy ratio (NAR). Household food insecurity and coping strategies were also measured. Multivariate logistic regression was carried out to identify the link between potential risk factors and MDD-W. About two-thirds (59.9%) of the study subjects did not meet the MDD-W threshold. The women's total energy and protein consumptions were 1475.1 kcal and 46.3 g, respectively, with the diversified diet group consuming more than the non-diverse diet group. Except for vitamin C, vitamin A, and vitamin D, all micronutrients evaluated in the diversified diet group had significantly higher NAR values than the non-diverse diet group. The mean adequacy ratio (MAR) of the overall reproductive women was 0.468 ± 0.096, and it was significantly associated with MDD-W. Another notable finding is that attainment of minimal diversity was not sufficient to achieve acceptable nutrient adequacy for women, pertaining to their low-quantity intake. In addition to this, household size, women's education, coping strategy, and the MAR were found to be significant determinants of MDD-W in the multivariate logistic regression analysis. The findings of the present study therefore highlight the impending need for interventions that ensure good dietary quality for women even during crisis periods.

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.

Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe District, South Ethiopia: A qualitative study

Evidence about innovative methods to facilitate nutrition education counseling and promote the intended behavior change at scale is limited. We assessed the acceptability and feasibility of a video-based health education intervention aiming to promote community care for pregnant women, mothers, and infants in the Dirashe District, Ethiopia. Using a phenomenological study design, the experiences of study participants in a trial testing the effectiveness of video-based health education on birth outcomes and nutritional status of mothers and their infants six months postpartum were assessed. Focus group discussions (FGDs) and key informant interviews (KIIs) were used to collect the data. The study was conducted in the Dirashe District, South Ethiopia. Five FGDs and 41 KII were conducted among video implementers, mothers, nurses, and health extension workers (HEWs) in eight intervention villages. All data were collected with a tape recorder. The tape-recorded data were transcribed and then translated into English. Data were analyzed using thematic content analysis. The videos delivered messages about nine themes on health, nutrition, and hygiene related to mothers and infants. Overall, the video-based health education interventions was acceptable and feasible. Messages delivered were found to be clear, easily understandable, culturally acceptable, and relevant to the needs of the mothers. Feasibility was affected by the nature of the work, lack of help, and overlapping duties of the HEWs. The video-based health education intervention was acceptable and feasible. It was suggested that determining a common location/venue to show the videos, involving husbands, and involving HEWs could improve the intervention. Trial registration: The effectiveness "parent" study was registered as a clinical trial with the U.S. National Institute of Health (www.ClinicalTrials.gov; NCT04414527). The qualitative study included recipients from the same cohort (participating mothers from the intervention group), in addition to video implementers, health extension workers the Health Development Army, and nurses from the intervention communities.

A modular systematic review of antenatal interventions to address undernutrition during pregnancy in the prevention of low birth weight

BACKGROUND

Poor nutrition during pregnancy can lead to adverse birth outcomes including low birth weight (LBW).

OBJECTIVE

This modular systematic review aimed to provide evidence for the effects of seven antenatal nutritional interventions on the risks of LBW, preterm birth (PTB), small-for-gestational-age (SGA) and stillbirth (SB).

METHODS

We searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and CINAHL Complete between April and June 2020, with a further update in September 2022 (Embase only). We included randomized controlled trials (RCTs) and reviews of RCTs to estimate the effect sizes of the selected interventions on the four birth outcomes.

RESULTS

Evidence suggests that balanced protein and energy (BPE) supplementation for pregnant women with undernutrition can reduce the risk of LBW, SGA and SB. Evidence from low and lower middle-income countries (MIC) suggests that multiple micronutrient (MMN) supplementation can reduce the risk of LBW and SGA in comparison with iron or iron and folic acid supplementation and lipid-based nutrient supplements (LNS) with any quantity of energy can reduce the risk of LBW in comparison with MMN supplementation. Evidence from high and upper MIC suggests that supplementation with omega-3 fatty acids (O3FA) can reduce the risk and supplementation with high-dose calcium might possibly reduce the risk of LBW and PTB. Antenatal dietary education programs might possibly reduce the risk of LBW in comparison with standard-of-care. No RCTs were identified for monitoring weight gain followed by interventions to support weight gain in women who are underweight.

CONCLUSIONS

Provision of BPE, MMN and LNS to pregnant women in populations with undernutrition can reduce the risk of LBW and related outcomes. The benefits of O3FA and calcium supplementation to this population require further investigation. Targeting interventions to pregnant women who are not gaining weight has not been tested with RCTs.

Inadequate dietary diversity practices and associated factors among postpartum mothers in Gambella town, Southwest Ethiopia

The shortage of diversified diets in lactating postpartum mothers is a severe problem in developing countries. The promotion of diverse diets is important to improving micronutrient nourishment and adequate energy intake for lactating mothers. To date, there is limited evidence regarding inadequate dietary diversity practices among lactating postpartum mothers in Gambella region. The study is aimed to determine inadequate dietary diversity practice and associated factors among lactating postpartum mothers in Gambella city, southwest Ethiopia. Mixed methods were employed on 407 randomly selected lactating postpartum mothers and 15 purposively selected key informants from February 28 to March 24, 2021. A pre-tested questionnaire and interview guide were used for data collection. Data were analyzed using Statistical Package for the Social Sciences version 21 software. Binary logistic regression models were used to determine the associated factors of dietary diversity. Qualitative data were analyzed manually through a thematic approach. The prevalence of inadequate dietary diversity practice was 60.2%. Having no education (AOR = 3.74, 95% CI: 1.18, 11.88), employed women(AOR = 0.37, 95% CI: 0.18, 0.75), meal frequency < 3 meals (AOR = 2.92, 95% CI: 1.04, 8.71), time taken to market > 30 min (AOR = 4.20, 95% CI: 2.01, 8.76), not received nutrition education (AOR = 2.0, 95% CI:1.09, 3.68), having home gardening (AOR = 0.32, 95% CI: 0.18, 0.57) and having big animals (AOR = 0.12, 95% CI: 0.05, 0.29) were significant factors of inadequate dietary diversity practice. Diet habits, food taboos, low social status of women in ownership of household assets, low family support, order of feeding, child preference for resource distribution in a polygamous family, and health care provider's advice were the main mentioned reasons for inadequate dietary diversity practices. The prevalence of inadequate dietary diversity practices were high compared to previous studies. Having no education, employed women, meal frequency < 3 meals, time taken to market > 30 min, not receiving nutrition education, having a home garden, and having big animals were significant factors of inadequate dietary diversity practice. Nutrition intervention focused on nutrition education to increase meal frequency should be provided for lactating postpartum mothers to improve inadequate dietary diversity practices.

Improving coverage of antenatal iron and folic acid supplementation and malaria prophylaxis through targeted information and home deliveries in Côte d'Ivoire: a cluster randomised controlled trial

INTRODUCTION

Coverage of antenatal iron and folic acid (IFA) supplementation and malaria chemoprophylaxis remains low in many low-income and middle-income settings. We assessed the effectiveness of personal information (INFO) sessions and personal information session plus home deliveries (INFO+DELIV) to increase coverage of IFA supplementation and intermittent preventive treatment in pregnancy (IPTp), and their effectiveness on postpartum anaemia and malaria infection.

METHODS

We included 118 clusters randomised to a control (39), INFO (39) and INFO+DELIV (40) arm, in a trial conducted between 2020 and 2021 with pregnant women (age ≥15 years) in their first or second trimester of pregnancy in Taabo, Côte d'Ivoire. We used generalised linear regression models to assess intervention impact in postpartum anaemia and malaria parasitaemia, and displayed resulting estimates as prevalence ratios.

RESULTS

Overall, 767 pregnant women were enrolled and 716 (93.3%) were followed up after delivery. Neither intervention had an impact on postpartum anaemia, with estimated adjusted prevalence ratios (aPRs) of 0.97 (95% CI 0.79 to 1.19, p=0.770) for INFO and 0.87 (95% CI 0.70 to 1.09, p=0.235) for INFO+DELIV. While INFO had no effect on malaria parasitaemia (aPR=0.95, 95% CI 0.39 to 2.31, p=0.915), INFO+DELIV reduced malaria parasitaemia by 83% (aPR=0.17, 95% CI 0.04 to 0.75, p=0.019). No improvements in antenatal care (ANC) coverage (aPR=1.05, 95% CI 0.81 to 1.36, p=0.692), IFA (aPR=2.00, 95% CI 0.89 to 4.46, p=0.093) and IPTp (aPR=1.03, 95% CI 0.87 to 1.21, p=0.728) compliance were found for INFO. INFO+DELIV increased ANC attendance (aPR=1.35, 95% CI 1.02 to 1.78, p=0.037) and compliance with IPTp (aPR=1.60, 95% CI 1.41 to 1.80, p<0.001) and IFA recommendations (aPR=7.06, 95% CI 3.68 to 13.51, p<0.001).

CONCLUSIONS

INFO+DELIV can substantially increase compliance with IFA supplementation and improve malaria prevention. However, the increases in IFA supplementation are likely insufficient to address the prevalence of often severe anaemia in this population.

TRIAL REGISTRATION NUMBER

NCT04250428.

Factors associated with nutrition intervention adherence: Evidence from a cluster-randomised controlled trial in Kenya

Nutrition experts point to the importance of a multipronged approach to address high stunting rates in rural areas. This can include nutrition-specific and -sensitive interventions, such as the provision of micronutrient powder, eggs, and chlorine, and nutrition training to improve feeding practices. In 2018, an agricultural nongovernmental organisation initiated a multipronged approach as part of a randomised trial. However, adherence to a programme with so many components can be challenging for participants. The aim of this study is to understand which factors are associated with high adherence in complex multifaceted nutrition-sensitive agricultural programmes. We used a mixed method approach in which we used bivariate and multivariable analyses to estimate the relationship between child and caregiver demographic factors with product adherence. We analyzed data from six focus groups and 120 feedback sessions on barriers to product adherence. We found that the age and sex of the child did not influence product adherence, but caregivers were more likely to adhere to all products if they were not the child's biological mother (most often grandmothers) (0.28 higher adherence score; p < 0.001) and if caregivers were older (0.34 higher adherence score, p < 0.001). A higher monthly training attendance, combining product distribution and interactive training, predicted stronger product adherence. Participants noted that adherence was supported by the early demonstration of positive results, regular reminders, interactive trainings, and the encouragement of family members. These findings underscore the importance of combining product distribution with training and include potentially targeting grandmothers and other caregivers who may demonstrate higher product adherence.

Food taboos and their perceived reasons among pregnant women in Ethiopia: a systematic review, 2022

BACKGROUND

There are foods considered as taboo across different communities in the world and in Ethiopia in particular. Although food taboos exist across all ages or physiologic states, they are predominant among pregnant women and children. Identifying such foods among pregnant women is crucial in providing focused interventions and prevents their negative consequences. Therefore, the aim of this review was to review the available evidence on food taboos and their perceived reasons among pregnant women in Ethiopia to provide comprehensive and precise evidence for decision making.

METHODS

Electronic search of the literature was made from Pub-Med, Google Scholar, Google Scopus, and Medline databases using search terms set based on the PICO/PS (Population, Intervention/exposure, Comparison, and Outcome) and PS (Population and Situation) search table. The search was made from December 05, 2020 - December, 29, 2021, and updated on January, 2022. All quantitative and qualitative studies published in English were included in the review. The systematic review protocol was registered at INPLASY (Registration number: INPLASY202310078). The outcome of interest was food taboo for pregnant women and its perceived reasons. The results of the review was narrated.

RESULTS

After identifying eighty two articles, thirteen were found eligible for the review. Vegetables, fruits, and fatty foods like meat, and dairy products were considered as taboo for pregnant women in different parts of Ethiopia. The reasons stated for the food taboo vary from fear of having a big baby, obstructed labour, and abortion to evil eye and physical and aesthetic deformities in the newborn.

CONCLUSIONS

Though not uniform across the country, there are foods considered as taboo for pregnant women in Ethiopia due to several perceived reasons, misconceptions, and societal influences. This could increase the risk of malnutrition and could have short and long term consequences on both the mother and her growing foetus. Therefore, context specific nutritional counseling with emphasis during ante-natal care and post-natal service is important.

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.

An mHealth Intervention to Reduce Gestational Obesity (mami-educ): Protocol for a Randomized Controlled Trial

BACKGROUND

The World Federation of Obesity warns that the main health problem of the next decade will be childhood obesity. It is known that factors such as gestational obesity produce profound effects on fetal programming and are strong predictors of overweight and obesity in children. Therefore, establishing healthy eating behaviors during pregnancy is the key to the primary prevention of the intergenerational transmission of obesity. Mobile health (mHealth) programs are potentially more effective than face-to-face interventions, especially during a public health emergency such as the COVID-19 outbreak.

OBJECTIVE

This study aims to evaluate the effectiveness of an mHealth intervention to reduce excessive weight gain in pregnant women who attend family health care centers.

METHODS

The design of the intervention corresponds to a classic randomized clinical trial. The participants are pregnant women in the first trimester of pregnancy who live in urban and semiurban areas. Before starting the intervention, a survey will be applied to identify the barriers and facilitators perceived by pregnant women to adopt healthy eating behaviors. The dietary intake will be estimated in the same way. The intervention will last for 12 weeks and consists of sending messages through a multimedia messaging service with food education, addressing the 3 domains of learning (cognitive, affective, and psychomotor). Descriptive statistics will be used to analyze the demographic, socioeconomic, and obstetric characteristics of the respondents. The analysis strategy follows the intention-to-treat principle. Logistic regression analysis will be used to compare the intervention with routine care on maternal pregnancy outcome and perinatal outcome.

RESULTS

The recruitment of study participants began in May 2022 and will end in May 2023. Results include the effectiveness of the intervention in reducing the incidence of excessive gestational weight gain. We also will examine the maternal-fetal outcome as well as the barriers and facilitators that influence the weight gain of pregnant women.

CONCLUSIONS

Data from this effectiveness trial will determine whether mami-educ successfully reduces rates of excessive weight gain during pregnancy. If successful, the findings of this study will generate knowledge to design and implement personalized prevention strategies for gestational obesity that can be included in routine primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05114174; https://clinicaltrials.gov/ct2/show/NCT05114174.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44456.

Predictors of vitamin A rich food consumption among women living in households growing orange-fleshed sweetpotatoes in selected regions in Uganda

Objective

Vitamin A deficiency (VAD) has serious public health consequences including morbidity and mortality for populations in low and middle-income countries (LMICs), especially for children under 5 years and pregnant women. LMICs are at greater risk of VAD, in part due to low levels of consumption of vitamin A-rich foods most of which are plant-based, such as orange-fleshed sweet potatoes (OFSP), with lower bioavailability than animal sources of the vitamin A. Food-based approaches such as biofortification of OFSP, including promoting the consumption of vitamin A-rich biofortified staple crops, has been shown to be potentially effective in improving the status of vitamin A and other micronutrients. This study examined vitamin A-rich food consumption and its predictors among women of reproductive age from OFSP-growing households in two regions of Uganda.

Methods

A cross-sectional survey was conducted among 617 OFSP growing households, focusing on women in the reproductive age group from the northern and eastern regions of Uganda. Households were not receiving any VAD-related intervention at the time of the survey. Quantitative data included vitamin A-rich food consumption, knowledge on vitamin A, and rich food sources dietary intake, using a 7-day food frequency questionnaire. Vitamin A consumption and risk of deficiency were estimated using the Hellen Keller International guide.

Results

The majority of women in this study were either pregnant (80%) or lactating (17%). More than 70% of the study population had a weighted vitamin A rich food consumption mean score of <6 days per week, indicating a high risk of VAD. Knowledge about vitamin A [b (SE) = -0.18 (0.50), p < 0.001] was significantly and inversely associated with vitamin A rich food consumption.

Conclusion

Components of food insecurity such as availability, affordability, utilization, and changing food preferences may contribute to the unexpected inverse relationship between knowledge and consumption of vitamin A rich foods. Scaling up biofortified food initiatives, including OFSP, can improve consumption of vitamin A rich foods with effective strategies to comprehensively address consumption barriers such as lack of nutrition education, cooking skills, and storage facilities, as well as low production levels and perceived contamination of biofortified foods.

Effect and Challenges of an Integrated Nutrition-Intervention Package Utilization among Pregnant Women and Lactating Mothers in Rwanda: An Exploratory Qualitative Study

Background

Malnutrition among pregnant women and lactating mothers remains an issue of public health concern in developing countries. The Gikuriro program, an integrated nutrition-specific and nutrition-sensitive intervention, was implemented in 5 districts of Rwanda for 5 y to address this problem. Postprogram quasi-experiments showed significant effect of the intervention on maternal and child undernutrition. Notwithstanding, there was a need for a qualitative study to explore the views of the beneficiaries and implementers regarding its benefits, challenges, and limitations to inform future interventions.

Objective

This study aimed to explore the effect and challenges of an integrated nutrition-intervention program among pregnant women and lactating mothers.

Methods

This was a qualitative study involving 25 community health officers and 27 nutritionists as key informants and 80 beneficiaries in 10 focus group discussions. All interviews and group discussions were audio-recorded, transcribed verbatim, translated into English, and double coded. A deductive and inductive content analysis approach was used with the help of ATLAS.ti, version 9.15.

Results

The study identified several positive effects, such as improved knowledge and skills on nutrition, a positive mindset toward a balanced diet, perceived improved nutrition, and economic independence among pregnant women and lactating mothers. However, some of the main obstacles of the integrated nutrition intervention were lack of awareness of the program, negative beliefs, poverty, lack of spousal support, and time constraints. Moreover, the study identified a main limitation: the lack of inclusiveness for all social categories.

Conclusions

This study demonstrates that integrated nutrition interventions have perceived positive effect on nutrition; however, such interventions may face some challenges and limitations. These findings suggest that, apart from contributing to the body of evidence for scale up of such interventions in resource-limited settings, economic challenges and misconceptions have to be addressed to maximize the effect of such interventions.

Using FIGO Nutrition Checklist counselling in pregnancy: A review to support healthcare professionals

The period before and during pregnancy is increasingly recognized as an important stage for addressing malnutrition. This can help to reduce the risk of noncommunicable diseases in mothers and passage of risk to their infants. The FIGO Nutrition Checklist is a tool designed to address these issues. The checklist contains questions on specific dietary requirements, body mass index, diet quality, and micronutrients. Through answering these questions, awareness is generated, potential risks are identified, and information is collected that can inform health-promoting conversations between women and their healthcare professionals. The tool can be used across a range of health settings, regions, and life stages. The aim of this review is to summarize nutritional recommendations related to the FIGO Nutrition Checklist to support healthcare providers using it in practice. Included is a selection of global dietary recommendations for each of the components of the checklist and practical insights from countries that have used it. Implementation of the FIGO Nutrition Checklist will help identify potential nutritional deficiencies in women so that they can be addressed by healthcare providers. This has potential longstanding benefits for mothers and their children, across generations.

Determinants of Maternal Diet Quality in Winter in the Kyrgyz Republic

Diet quality influences maternal health and nutrition from preconception through pregnancy and lactation, as well as infant health and nutrition. Women are vulnerable to poor nutrition given their increased nutrient requirements during the prenatal period through the first 2 years postpartum. Minimum diet diversity among women, a good predictor of adequate micronutrient intake, is often used as a proxy for diet quality. The Kyrgyz Republic is experiencing a triple burden of malnutrition-stunting in children, overweight and obesity in women, and micronutrient deficiencies and anemia in both women and children. In this study, we assessed factors associated with the quality of maternal diets in winter when micronutrient-rich foods may be more difficult to access due to scarcity and price. We conducted secondary data analysis from a survey conducted in the winter of 1,359 mothers of children aged younger than 2 years. Women were asked about the types of foods they stored and preserved in the fall and whether any remained in winter. After controlling for maternal characteristics, household size, main source of income, and region (including urban and rural), women with preserved food remaining at the time of the survey, who stored more than 4 different types of food in the fall, and who lived in Jalal-Abad oblast were more likely to have consumed a minimally diverse diet. Where seasonality affects food availability, promoting culturally appropriate home processing of a variety of foods in the fall and increased market access may improve diet diversity in winter.

Dietary diversity and associated factors among women of reproductive age in Jeldu District, West Shoa Zone, Oromia Ethiopia

BACKGROUND

Women of reproductive age are at a higher risk of insufficient micronutrient intake due to their low dietary diversity which has an impact on child growth and development, anemia and low birth weight. However, there are no information from the study area. Hence, the study aimed to assess dietary diversity and associated factors among reproductive-age women in Jeldu District, West Shoa Zone, Oromia Region, Ethiopia, 2018.

METHODS

A community-based cross-sectional study was undertaken among 634 women of reproductive age. The study participants were recruited using a systematic sampling method. The data were collected using a structured questionnaire based on 24-hour dietary recalls. The data were checked, coded, and entered into EpiData version 3.1 before being exported to SPSS Version 21 for analysis. Descriptive statistics like frequency standard deviation, mean and proportions were computed., both binary and multivariable logistic regressions were run at 95 percent confidence intervals. A P-value of <0.05 was used to declare a statistically significant association between dietary diversity and explanatory variables.

RESULTS

The proportions of women who consumed greater than or equal to five food groups were 81.9%. Agro-ecological zone of highland (AOR = 7.71: 95% CI: 3.72, 15.99), women who have a radio (AOR; 1.87: 95% CI; 1.17, 2.99) and women's decision-making power to purchase food for household (AOR; 3.93:95% CI; 2.3, 6.71) and having own mobile phone (AOR: 1.92 (1.74, 3.16)) were statistically associated with food dietary diversity.

CONCLUSION

The proportion of women who met the minimal standard for dietary variety requirements was high. The presence of radios, mobile phones, women's purchasing decision power, as well as possessing large cattle, and the agroecological zone of the participants were all important predictors of dietary variety among reproductive-age women. The local media, agriculture office, health office, and women, youth, and children office all need to pay more attention to the determinants of dietary variety in women.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

Effect of an exercise intervention during pregnancy on metabolic health parameters and delivery outcomes in Indian women

Moderate physical activity is important during pregnancy. However, this concept is new in India. This study reported the effect of an exercise intervention on weight changes and delivery outcomes in pregnant Indian women. 60 pregnant women in two groups underwent a pregnancy intervention between 20 weeks of gestation till delivery. Group 1 attended a supervised prenatal weekly exercise session with diet advise & walking for 30 min/day from 20 weeks of gestation till delivery. Group 2 received regular prenatal care at the hospital with general advice on physical activity during pregnancy. Outcome variables-body weight, body mass index (BMI), waist & hip circumference, gestational weight gain (GWG), post-partum weight retention (PPWR) and 2 delivery outcomes, i.e. mode of delivery and prolonged labour. The readings were taken at baseline, at delivery and at 2 months post-delivery. Intervention group retained less PPWR than the control at 2 months post-delivery. Similar results were found for various obesity parameters, waist (5.60±4.96 and 9.46±4.64, P=0.003) and hip (4.33±4.25 and 7.70±7.46, P=0.036) circumference and BMI at 2 months post-partum (2.41±1.65 and 4.28±3.75, P=0.015). Incidence of caesarean section and prolonged labour was less in intervention group too (P=0.012). The pregnancy lifestyle intervention significantly reduced weight retention, obesity parameters, and reduced pregnancy complications, in Indian women.

Clinical Trial Registry India no. CTRI/2017/04/008322

Association between 1st trimester diet quality & gestational weight gain rate among pregnant women in Dhulikhel, Nepal

BACKGROUND

Despite promising data from high-income countries, the impact of diet quality on gestational weight gain (GWG) has not been investigated in the context of many low-income countries including Nepal.

METHODS

We prospectively examined the association between 1st trimester diet quality and GWG rate among a cohort of singleton pregnant women (n = 101; age 25.9 ± 4.1 years) from a community-based periurban hospital in Dhulikhel, Nepal. Diet quality was assessed from the adapted Nepali version of the 21-item PrimeScreen questionnaire in the 1st trimester. The diet quality score is based on consumption frequency of 21 food group components (score ranging 0-42), categorized as healthy (12 groups) versus unhealthy (9 groups), with higher scores indicative of better overall diet quality. The GWG rate was calculated as the measured weight at early-to-mid 3rd trimester (28-35 wks) minus the weight at 2nd trimester (13-25 wks), divided by the number of weeks in between. Linear regression estimated the association between diet quality and GWG rate, adjusting for a priori covariates (i.e. age, education, ethnicity, pre-pregnancy BMI, and nausea/vomiting.) RESULTS: The mean GWG rate in mid-to-late pregnancy was 0.46 ± 0.2 kg/wk and the mean diet quality score was 23.6 ± 2.5. Based on pre-pregnancy BMI, 49.4% of women had excessive GWG rate, while nearly equal numbers had either adequate GWG or inadequate GWG rate. There was no significant association between diet quality and GWG rate [adjusted β (95% CI) = -0.02 (-0.05, 0.01); p = 0.14]. The mean GWG rate was marginally higher (0.57 vs. 0.44 kg/wk; p = 0.06) among those with high versus low (2 + servings vs. 0-1 serving/wk) intake of red meat; similar findings were seen when comparing red meat intake between women with excessive versus adequate GWG (Cramer's V = 0.2; p = 0.06).

CONCLUSIONS

While 1st trimester diet quality is not related to GWG among Nepali women, a high intake of red meat may be a potential risk factor for excessive GWG in this population.

Integrating Women and Girls' Nutrition Services into Health Systems in Low- and Middle-Income Countries: A Systematic Review

Women's nutrition has been highlighted as a global priority to ensure the health and well-being of both them and future generations. This systematic review summarises the available literature on the integration of nutrition services for girls and women of reproductive age (GWRA) into existing public health systems across low- and middle-income countries, as well as any barriers to integration. We searched PubMed and Cochrane Database of Systematic Reviews for articles published since 2011 according to eligibility criteria. A total of 69 articles were included. Evidence suggested that several services for GWRA are well integrated into public health systems, including antenatal care services, nutrition education and counselling, and micronutrient supplementation programmes. However, there was limited evidence on the integration of family planning, adolescent health, and reproductive health services. Barriers to integration fell into five main themes: lack of training and capacity building, poor multisectoral linkages and coordination, weak advocacy, lack of M&E systems, and inequity. We identified a lack of evidence and services for non-pregnant GWRA and for women postpartum. Addressing barriers to integration and gaps in nutrition services for GWRA would increase service coverage and contribute to improving health outcomes for GWRA and future generations.

Magnitude and effects of food cravings on nutritional status of pregnant women in Southern Ethiopia: A community-based cross sectional study

BACKGROUND

Food cravings is a strong and intense urge to consume a specific food and reported as being associated with overweight and overall caloric intake in pregnant women. However, the nutritional and anthropometric consequences are not well recognized. Therefore, this study aimed to assess magnitude and effects of food cravings on nutritional status of pregnant women in Southern Ethiopia.

METHODS

A community-based cross-sectional study conducted among 586 randomly selected pregnant mothers at Sidama Regional State from June 1-20, 2019. Pre-tested and semistructured face-to-face interview questionnaires used to collect the data. The data were cleaned, coded, and entered into Epi Data version 3.1 and analysed using SPSS IBM version 20. The bi-variable and multivariable logistic regression used to identify the possible factors of food cravings. Principal component analysis used to determine the wealth status of the study participants. Adjusted Odds Ratio (AOR) together with 95% Confidence Intervals (CIs) used to declare statistical significance.

RESULTS

The study found that nearly three in five, 309 (58.3%) [95%, CI: 54.2%-62.8%] of the study participants reported food cravings. Meat (71.5%) and Fruits (41.7%) were the most frequently craved. About one-third, 194 (36.6%) of the study participants were undernourished (MUAC < 23 cm). Age of women (20-34 years), government employed, Antenatal Care (ANC), Pica practice, lowest wealth quintile, and skipping meals were statistically associated with food cravings. Whereas, wealth quintile and ability to consume craved food were factors associated with the nutritional status of pregnant women. Moreover, our study result found that maternal undernutrition and food cravings were statistically associated (p<0.001).

CONCLUSION

The prevalence of food cravings in this study is comparable to the global level. However, the magnitude of undernutrition found to be higher. Thus, health care providers need to take every opportunity to encourage women to adopt healthful dietary practices during pregnancy.

Dietary patterns and childhood stunting in Zimbabwe

Background

Diet is one important predictor of children’s growth, and often dietary interventions can assist with reversing adverse nutrition outcomes. Traditionally research has focused on individual food items or food classes to generate an understanding of disease risk. Dietary patterns provide a holistic approach to understanding the relationship between exposure and outcome.

Method

A matched case-control study was conducted. Caregivers of 450 children (225 cases, 225 controls) aged 6–59 months were asked to describe the diet their children had consumed in the previous 7 days using a Food Frequency Questionnaire. Dietary patterns were developed using factor analysis and regression analysis was conducted to assess which dietary pattern was associated with childhood stunting.

Results

Three dietary patterns were identified: modern (n = 181), low animal-source (n = 158), and traditional (n = 111). Children with the low animal source dietary pattern had increased odds of being stunted (AOR 1.03, p < 0.05). Three demographic factors (Child’s age, father’s age and having a sibling < 24 months apart) were identified as significant predictors of consumption of any of the traditional and low animal source diet (P < 0.001).

Conclusion

Nutrition intervention such as health education, counselling and supplementary feeding should include a holistic approach to dietary education not only focusing on promoting a balanced diet but improvement strengthening the upgrading of child’s dietary pattern taking into cognisant both quantity, and quality of nutrients provided to the child.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00607-7.

Strengthening maternal nutrition counselling during routine health services: a gap analysis to guide country programmes

OBJECTIVE

The WHO recommends counselling on healthy eating, weight gain, and physical activity during antenatal care (ANC) and postnatal care (PNC), yet advice and information are often not tailored to women's nutritional needs and contexts. The purpose of the gap analysis was to identify key elements related to the provision of maternal nutrition counselling during routine health contacts and provide programme considerations to strengthen quality service delivery.

DESIGN

A search of PubMed, Cochrane Library, CINAHL Plus and Scopus databases was conducted to retrieve studies from January 2010 to December 2021. Using inclusion criteria, quantitative, qualitative and mixed methods studies were included in the final gap analysis.

SETTING

Low-, middle- and high-income country contexts.

PARTICIPANTS

Following application of gap analysis criteria, thirty-seven articles from sixteen countries were included in the analysis.

RESULTS

Gaps in delivery of maternal nutrition counselling include provider capacity building, frequency, content and delivery platforms. Globally, counselling on appropriate weight gain during pregnancy is often not delivered with the desired content nor quality, while targeted counselling to overweight and obese women was provided in several high-income country contexts. Delivery of maternal nutrition counselling through multiple delivery platforms demonstrated improvements in maternal diet and/or weight gain during pregnancy.

CONCLUSIONS

Strengthening the integration of maternal nutrition counselling into pre- and in-service curricula, routine health provider training, supportive supervision and provider mentoring is needed. Future efforts may consider generating global and regional weight gain guidelines and incorporating maternal nutrition counselling indicators as part of quality-of-care ANC/PNC standards and routine health systems.

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.

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven ‘Alive & Thrive’ intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.

CHW communication strategies are useful in developing persuasive narratives that capture influential family members’ value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs.

Predictors of Major Dietary Patterns Among Pregnant Women Attending Public Health Facilities in Eastern Ethiopia: A New Epidemiological Approach

Background

Dietary pattern analysis is a robust statistical procedure that efficiently characterize the dietary intakes of individuals. However, there is a lack of robust dietary intake evidence beyond nutrient intake in Ethiopia. This study was to answer, what are the major dietary consumption patterns and its predictors among pregnant women in Ethiopia.

Methods

A facility-based survey among 380 randomly selected pregnant women using a contextualized food frequency questionnaire (FFQ) over 1 month recall was used. The frequency of food consumption was standardized to daily frequency equivalents, and a sequential exploratory factor analysis was used to derive major dietary patterns. A multivariable ordinary logistic regression model was fitted with all its assumptions.

Results

Three major dietary patterns (“fruits and animal-source foods,” “cereals, tubers, and sweet foods,” “legumes and vegetables”), explaining 65% of the total variation were identified. Women snacks (AOR = 1.93; 1.23–2.75), without food aversion (AOR = 1.59; 1.08–2.35), non-fasting (AOR = 0.75; 1.12–2.12), and receiving nutritional counseling (AOR = 1.96; 1.25–3.07) were significantly positively associated with a higher tercile of fruits and animal-source food consumption. Non-working mothers (AOR = 1.8;1.23–2.76), chronic disease (AOR = 1.88; 1.14–3.09), or received nutritional counseling (AOR = 1.33; 0.88–2.01), were fasting (AOR = 1.33;0.88–2.01), and no food cravings (AOR = 4.27;2.67–6.84), and aversion (AOR = 1.60;1.04–2.44) had significantly higher odds of consuming cereals, tubers, and sweet foods. Literacy (AOR = 1.87; 1.14–3.09), urban residence (AOR = 2.10; 1.10–3.93), low socioeconomic class (AOR = 2.68; 1.30–5.23), and skipping meals (AOR = 1.73; 1.15–2.62) were associated with higher odds of legume and vegetable consumption.

Conclusion

Socioeconomic class, literacy, occupation, getting nutritional counseling, habits of food craving, food aversion, and fasting can predict a woman’s dietary pattern.

Trends and Determinants of Underweight among Children under Five Years in Ethiopia: Further Analysis with Ethiopian Demographic and Health Survey 2005-2016-Multivariate Decomposition Analysis

Background

Underweight is one of the paramount major worldwide health problems, and it traces a big number of populations from infancy to old age. This study aimed to analyze the trends and predictors of change in underweight among children under five years in Ethiopia.

Method

The data for this study were accessed from three Ethiopian Demographic and Health Survey data sets 2005, 2011, and 2016. The trend was examined separately for the periods 2005–2011, 2005–2016, and 2011–2016. Multivariate decomposition analysis of change in underweight was employed to answer the major research question of this study. The technique employed the output from the logistic regression model to parcel out the observed difference in underweight into components, and STATA 14 was utilized for data management and analysis.

Result

Perceiving the overall trend, the rate of underweight was decreased from 38% in 2005 to 24% in 2016. The decomposition analysis results revealed that, about 12.60% of declines in underweight have been explained by the difference in population characteristics or endowments (E) over the study period. The size of the child at birth, husband's education, women's education, and household wealth index contributed significantly to the compositional decline in underweight.

Conclusion

The magnitude of underweight among children under five years indicates a remarkable decline over the last ten years in Ethiopia. In this study, two-twelfth of the overall decrease in underweight among children under five years over the decade was due to the difference in characteristics between 2005 and 2016. Continuing to educate the population and boost the population's economy is needed on the government side in Ethiopia.

Effectiveness of interventions to address obesity and health risk behaviours among people with severe mental illness in low- and middle-income countries (LMICs): a systematic review and meta analysis

INTRODUCTION

People with severe mental illness (SMI) are more likely to have obesity and engage in health risk behaviours than the general population. The aims of this study are (1) evaluate the effectiveness of interventions that focus on body weight, smoking cessation, improving sleeping patterns, and alcohol and illicit substance abuse; (2) Compare the number of interventions addressing body weight and health risk behaviours in low- and middle-income countries (LMICs) v. those reported in published systematic reviews focusing on high-income countries (HICs).

METHODS

Intervention studies published up to December 2020 were identified through a structured search in the following database; OVID MEDLINE (1946-December 2020), EMBASE (1974-December 2020), CINAHL (1975-2020), APA PsychoINFO (1806-2020). Two authors independently selected studies, extracted study characteristics and data and assessed the risk of bias. and risk of bias was assessed using the Cochrane risk of bias tool V2. We conducted a narrative synthesis and, in the studies evaluating the effectiveness of interventions to address body weight, we conducted random-effects meta-analysis of mean differences in weight gain. We did a systematic search of systematic reviews looking at cardiometabolic and health risk behaviours in people with SMI. We compared the number of available studies of LMICs with those of HICs.

RESULTS

We assessed 15 657 records, of which 9 met the study inclusion criteria. Six focused on healthy weight management, one on sleeping patterns and two tested a physical activity intervention to improve quality of life. Interventions to reduce weight in people with SMI are effective, with a pooled mean difference of -4.2 kg (95% CI -6.25 to -2.18, 9 studies, 459 participants, I ² = 37.8%). The quality and sample size of the studies was not optimal, most were small studies, with inadequate power to evaluate the primary outcome. Only two were assessed as high quality (i.e. scored 'low' in the overall risk of bias assessment). We found 5 reviews assessing the effectiveness of interventions to reduce weight, perform physical activity and address smoking in people with SMI. From the five systematic reviews, we identified 84 unique studies, of which only 6 were performed in LMICs.

CONCLUSION

Pharmacological and activity-based interventions are effective to maintain and reduce body weight in people with SMI. There was a very limited number of interventions addressing sleep and physical activity and no interventions addressing smoking, alcohol or harmful drug use. There is a need to test the feasibility and cost-effectiveness of context-appropriate interventions to address health risk behaviours that might help reduce the mortality gap in people with SMI in LMICs.

Maternal dietary diversity during lactation and associated factors in Palghar district, Maharashtra, India

Dietary adequacy and diversity during the lactation period are necessary to ensure good health and nutrition among women and children. Behavioral interventions pertaining to health and nutrition counselling during pregnancy and lactation are critical for awareness about dietary diversity. The issue assumes salience for marginalized communities because of the Covid-19 pandemic and associated economic and societal disruptions. This paper assesses the dietary patterns among 400 lactating mothers in the tribal-dominated district of Palghar in Maharashtra, India in 2020. The study is based on primary data regarding consumption of 10 food groups among women across 10 food groups based on 24-hour recall period. The primary outcome variable was binary information regarding Minimum Dietary Diversity defined as consumption from at least 5 food groups. Econometric analysis based on multilevel models and item-response theory is applied to identify food groups that were most difficult to be received by mothers during the early and late lactation period. We find that the daily diet of lactating mothers in Palghar primarily consists of grains, white roots, tubers, and pulses. In contrast, the intake of dairy, eggs, and non-vegetarian food items is much lower. Only Half of the lactating women (56.5 percent; 95% CI: 37.4; 73.8) have a minimum diversified diet (MDD). The prevalence of lactating women with MDD was higher among households with higher income (73.1 percent; 95% CI: 45.2; 89.9) than those in lower income group (50.7 percent; 95% CI: 42.3; 58.9). Lactating Women (in early phase) who received health and nutrition counseling services are more likely (OR: 2.37; 95% CI: 0.90; 6.26) to consume a diversified diet. Food groups such as fruits, meat, poultry, fish, nuts, and seeds were among the rare food items in daily diet. The dietary pattern lacking in fruits, nuts, and heme (iron) sources indicates more significant risks of micronutrient deficiencies. The findings call for improving dietary diversity among lactating mothers, particularly from the marginalized communities, and are driven by low consumption of dairy products or various fruits and vegetables. Among the different food items, the consumption of micronutrient-rich seeds and nuts is most difficult to be accessed by lactating mothers. Also, diet-centric counseling and informing lactating mothers of its benefits are necessary to increase dietary diversity for improving maternal and child nutrition.

Food aversion during pregnancy and its association with nutritional status of pregnant women in Boricha Woreda, Sidama Regional State, Southern Ethiopia, 2019. A community based mixed crossectional study design

Background

Despite high prevalence, food aversions are closely linked to the dietary intake of pregnant women. Thus, understanding this behavior is important in addressing the issue of maternal nutrition. Therefore, the aim of this study is to provide information on the prevalence and associated factors of food aversion and its relationship with the nutritional status of pregnant women in Boricha Woreda, Sidama Regional state, Southern Ethiopia, 2019.

Methods

A community based mixed cross sectional study was conducted among 505 randomly selected pregnant mothers at Boricha Woreda, Southern Ethiopia from June 1–20, 2019. Pre-tested and structured face-to-face interview questionnaire and focus group discussion guide were used to collect quantitative and qualitative data respectively. The quantitative data were cleaned, coded and entered into Epi Info version 7.1.4.0 and then exported to SPSS IBM version 20 for further analysis. The qualitative data were analyzed manually using a content analysis.The bi-variable and multivariable logistic regression was used to identify the possible factors of food aversion. AOR with the respective 95% CIs was used to declare statistical significance.

Results

Nearly, seven-in-ten (69.2%) of the pregnant women were averted of at least one food. Cereal (45.9%) and enset (44.2%) were averted by majority of the participants. The mean (± SD) MUAC measurement was 22.7 (± 2.4) cm. Pregnant women of age group of 24–28 [AOR = 3.04, 95% CI (1.72–5.35)] and 29–33 years [AOR = 2.00, 95% CI (1.02–3.92)], nausea during [AOR = 1.77, 95% CI (1.16–2.70)] and having additional meal [AOR = 1.68, 95% CI (1.02–2.75)] were significantly associated with food aversion. Maternal nutritional status and food aversion was sstatistically significant (p-value < 0.001).

Conclusion

High prevalence of food aversions (69.2%) and under nutrition (34.6%) among pregnant women is found. Therefore, the Woreda Health Office needs to intensify the integration of maternal nutrition into ANC services and training of health providers as well as critical appraisal of health extension workers should also be considered.

Pregnancy is a complex and absolutely important period in women’s life. Thus, in order to sustain a successful pregnancy, a mother experiences a number of physiological and behavioral changes. Notably, food aversions are the number one changes experienced by pregnant women. Food aversions are characterized by the repulsion and avoidance of particular foods and the most common aversions are nonalcoholic caffeinated beverages, meat, fish, poultry and eggs. Therefore, the aim of this study was to determine the magnitude and its association with nutritional status of Pregnant Women in order to provide concrete scientific evidence for the concerned stakeholders.

A community based mixed cross-sectional study was conducted among 505 pregnant mothers selected from five randomly selected kebeles of Boricha Woreda. Pregnant women in the age range of 19 to 49 years and who were apparently healthy were interviewed. Four hundred ninety seven participants were interviewed voluntarily with a response rate of 98.4%. The mean (± SD) age of the women was 22.3 (± 5.5) years. Pregnant women who were averted at least one food were 344(69.2%); where cereal (45.9%) and enset (44.2%) were averted by the majority of the participants. Hence pregnant women who practice food aversion had higher likely to be a malnourished. Pregnant women who were less than thirty three years of age, who had nausea, and ate additional meal were more urged to avert a particular foods. Whereas, women with better nutritional status had less food aversion practice.

In conclusion; despite a pregnant woman requires a healthy diet embedded with adequate intake of energy, protein, vitamins and minerals to meet maternal and fetal needs, the magnitude of food aversion and maternal under nutrition in the study area was high.

Traditional prenatal and postpartum food restrictions among women in northern Lao PDR

Culturally determined food restrictions are common among pregnant and postpartum women in Asia. This study aimed to describe perinatal dietary restrictions, factors associated with food avoidances and attainment of minimum dietary diversity (MDD‐W) among women in Lao PDR. Mother–child (aged 21 days to <18 months) dyads (n = 682) were enrolled into a cohort study in northern Lao PDR and interviewed at one time point postpartum. During pregnancy and postpartum, 1.6% and 97% of women reported following dietary restrictions, respectively. Cluster analysis identified four distinct postpartum dietary patterns: most restrictive (throughout first 2 months postpartum); least restrictive; 2 weeks highly restrictive and 1 month highly restrictive, followed by 19%, 15%, 5% and 62% of women, respectively. Greater maternal age, gravidity and higher household socioeconomic status were associated with allowing more diverse foods, while women from food insecure households followed more restrictive diets for longer. Women belonging to the Hmong ethnic group followed a highly restrictive diet of white rice and chicken for the first month postpartum. MDD‐W was achieved by 10% of women restricting their diet at the time of the interview compared with 17% of women who were consuming their normal diet (p = 0.04). Postpartum dietary restrictions are widespread among women in northern Lao PDR. These highly restrictive diets, low dietary diversity and food insecurity likely contribute to micronutrient deficiencies in women that may have important consequences for their breastfed infants through reduced breastmilk micronutrient content, which requires further exploration. Culturally appropriate strategies to increase micronutrient intakes among women should be considered.

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.

Dietary Changes Among Breastfeeding Mothers

BACKGROUND

Breastfeeding mothers have been avoiding foods in their diet based on ancient beliefs that it can prevent/reduce unsettled infant crying-fussing behavior.

RESEARCH AIMS

This study aimed to explore (1) the prevalence of maternal dietary changes during the postpartum period; (2) the demographic and infant feeding differences between women who made dietary changes and those who did not; (3) the reasons for dietary change; and (4) what specific foods were avoided.

METHODS

A prospective, cross-sectional 2-group comparison using an online survey mixed-methods design was advertised via social media and Australian websites. Anonymous volunteers who were presently breastfeeding or had breastfed for any length of time in the past were eligible.

RESULTS

Of 1,262 participants, 966 (77%) avoided foods/beverages in their diet. The most commonly avoided beverages were alcohol (79%) and coffee (44%), and the most commonly avoided foods were chili (22%), milk-chocolate (22%), cabbage (20%), onion (20%), and garlic (16%). Reasons for dietary avoidance related to baby being unsettled (31%), baby having wind/gas (29%), colic (11%), and crying (10%). Of 245 participants who removed dairy, 80 (33%) did not substitute with calcium-rich alternatives. Food and beverage avoidance commenced as early as 1 week postpartum and continued until mean (SD) infant age of 9 (5) months.

CONCLUSIONS

It is commonplace for breastfeeding mothers to avoid foods and beverages for reasons associated with infantile colic. Of major concern is the duration of food avoidance during a time of increased nutritional requirements. This information may assist in improving the nutritional support given to breastfeeding mothers.

A Narrative Review of Nutritional Malpractices, Motivational Drivers, and Consequences in Pregnant Women: Evidence from Recent Literature and Program Implications in Ethiopia

Maternal nutrition is very important for the wellbeing of pregnant women, childbirth, and lactating women, which are crucial and meant for the wellbeing of a mother and newborn baby. This narrative review discusses nutritional malpractices, motivational drivers, and their consequences typically from Ethiopian pregnant women's context. Different studies (regarding less of study design and type) done among pregnant women (aged 15-49 years) by considering pregnancy-related outcomes and timing of nutritional malpractices were included mostly. Accordingly, taboos of healthy diets, craving for unhealthy foods (sweet, fat, raw, and salty/spicy foods), and nonfood items (soil, coffee residue, stone, and ash) were practiced majorly by the women. The birth difficulty, fetal head plastering, fetus discoloration, fetus burns, abortion, and abdominal cramp are the primary drivers of taboos of healthy diets. Hormonal change and social and nutrient-seeking behavior are the most prevalent drivers to the consumption of unhealthy foods. Additionally, personal interest, flavor, and color of items are important motivators to practice pica. Such pica practice hurts nutrient intake, absorption of iron/zinc, abdominal health, and diarrhea occurrence. Food taboos are high predictors of health disorders, such as intrauterine growth restriction, infection, bleeding, preeclampsia, stillbirth, early birth, low birth weight, retarded development of cognitive, and anemia. Craving and eating unhealthy foods were interconnected with chronic disease development (hypertension, diabetes, heart disease, and cancer), discomforts, preterm labor, preeclampsia, and intrauterine growth restriction in women. Additionally, it is also associated with stillbirth, low birth weight, obesity, birth defect/deficit, hypertension, cancer, diabetes, metabolic syndrome, renal disease, decreased fetal growth, behavioral change, heart failure, and poor cognitive development in the infant. Overall, these nutritional malpractices are significantly associated with many argumentative pregnancies as well as developmental consequences leading to the direction of infant and maternal mortality and morbidity. Therefore, urgent implementation of health and nutrition education programs considering food misconceptions and beliefs regarding pregnancy and use of ground-breaking ways to play down the negative and maximize potential positive dietary effects designed by the government of Ethiopia could also serve as a long-term solution to the problem.

Exploring maternal nutrition counseling provided by health professionals during antenatal care follow-up: a qualitative study in Addis Ababa, Ethiopia-2019

Background

Nutritional awareness and practice of women during pregnancy could be determining their nutritional status, which significantly affects the outcome of pregnancy. Therefore this study aims to explore the maternal nutrition counseling provided by health professionals for pregnant women, Barriers to maternal nutrition, and major interventions.

Methods

A descriptive study design with a qualitative method by using ground theory tradition, based on constructivist research approach and Charmaz’s (2000) study design has been conducted from September-01/2019 _November-16/2019 among pregnant women who got ANC service in Addis Ababa, Ethiopia. A purposive sampling technique was used. Practical observations and in-depth interviews were conducted. The sample size adjustment has been carried out according to the information saturation obtained, and finally, 81 practical observations, In-depth interview with two center managers, nine health professionals and eleven term pregnant women has been conducted. An observational checklist and Semi-structured, open-ended questionnaires were used. Data, the environment, and methodological triangulation were carried out. A conceptual framework has been established based on the data collected about the whole process of maternal nutrition counseling during pregnancy. ATLAS TI software was utilized for information analysis.

The results

Most participants responded that maternal nutrition counseling provided to pregnant mothers is not adequate and neglected by most stakeholders. From 81 practical observations, health professionals counseled to mothers were 10 what to feed, 4 what to limit to consume, and 5 were counseled about what to eat during pregnancy. Close to all the respondents agreed on the importance of providing nutrition counseled by the nutritionists. Most of the study participants emphasized a shortage of time as primary barriers. Institutional Barriers, Professional Barriers, Maternal Barriers, and Community Barriers were major barriers to nutrition counseling.

Conclusions

Generally, maternal nutrition counseling provided to pregnant mothers was not adequate and neglected by most stakeholders. Shortage of time due to client flow, Institutional Barriers, Professional Barriers, Maternal Barriers, and Community Barriers were major categories of maternal nutritional counseling barriers. Information update and timely preparation were recommended to health professionals.

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.

Gestational weight gain in 4 low- and middle-income countries and associations with birth outcomes: a secondary analysis of the Women First Trial

BACKGROUND

Adequate gestational weight gain (GWG) is essential for healthy fetal growth. However, in low- and middle-income countries, where malnutrition is prevalent, little information is available about GWG and how it might be modified by nutritional status and interventions.

OBJECTIVE

We describe GWG and its associations with fetal growth and birth outcomes. We also examined the extent to which prepregnancy BMI, and preconception and early weight gain modify GWG, and its effects on fetal growth.

METHODS

This was a secondary analysis of the Women First Trial, including 2331 women within the Democratic Republic of Congo (DRC), Guatemala, India, and Pakistan, evaluating weight gain from enrollment to ∼12 weeks of gestation and GWG velocity (kg/wk) between ∼12 and 32 weeks of gestation. Adequacy of GWG velocity was compared with 2009 Institute of Medicine recommendations, according to maternal BMI. Early weight gain (EWG), GWG velocity, and adequacy of GWG were related to birth outcomes using linear and Poisson models.

RESULTS

GWG velocity (mean ± SD) varied by site: 0.22 ± 0.15 kg/wk in DRC, 0.30 ± 0.23 in Pakistan, 0.31 ± 0.14 in Guatemala, and 0.39 ± 0.13 in India, (P <0.0001). An increase of 0.1 kg/wk in maternal GWG was associated with a 0.13 cm (95% CI: 0.07, 0.18, P <0.001) increase in birth length and a 0.032 kg (0.022, 0.042, P <0.001) increase in birth weight. Compared to women with inadequate GWG, women who had adequate GWG delivered newborns with a higher mean length and weight: 47.98 ± 2.04 cm compared with 47.40 ± 2.17 cm (P <0.001) and 2.864 ± 0.425 kg compared with 2.764 ± 0.418 kg (P <0.001). Baseline BMI, EWG, and GWG were all associated with birth length and weight.

CONCLUSIONS

These results underscore the importance of adequate maternal nutrition both before and during pregnancy as a potentially modifiable factor to improve fetal growth.

What stops us from eating: a qualitative investigation of dietary barriers during pregnancy in Punjab, Pakistan

OBJECTIVE

Adequate dietary intake during pregnancy is vital for the health and nutritional status of both mother and fetus. The nutritional status of reproductive age women in Pakistan is poor, with 14 % being underweight (BMI < 18·5) and 42 % experiencing Fe deficiency anaemia. This may stem from beliefs, practices and other barriers influencing dietary intake. This qualitative study seeks to determine which factors impact dietary intake during pregnancy in rural Punjab.

DESIGN

In-depth interviews and focus group discussions were conducted and then analysed using thematic analysis.

SETTING

Three purposively selected rural districts (Sahiwal, Okara and Pakpatan) with the highest prevalence of maternal and child malnutrition in the province of Punjab, Pakistan.

PARTICIPANTS

Mothers with children under age two (n 29) and healthcare providers with at least 5 years of experience working in the district (n 12).

RESULTS

We identified a combination of physiological, socio-cultural and structural barriers that inhibited healthful dietary intake during pregnancy. The primary physiological barriers to optimal dietary intake and dietary practices included food aversions and food cravings. Food classification, fear of a difficult childbirth, fear of high blood pressure and household food politics were the principal socio-cultural barriers. Additionally, two structural barriers, inadequate antenatal counseling and a lack of affordable food options, were identified.

CONCLUSIONS

Our study demonstrates that complex barriers prevent pregnant women in the Punjab area from consuming adequate dietary intake and that antenatal health education programmes and structural interventions are needed to support healthful dietary practices during this critical period.

Evidence for factors associated with diet and physical activity in African and Caribbean countries

Objective

To identify and describe summarized evidence on factors associated with diet and physical activity in low- and middle-income countries in Africa and the Caribbean by performing a scoping review of reviews.

Methods

We searched the Medline®, LILACS, Scopus, Global Health and Web of Science databases for reviews of factors associated with diet or physical activity published between 1998 and 2019. At least 25% of studies in reviews had to come from African or Caribbean countries. Factors were categorized using Dahlgren and Whitehead's social model of health. There was no quality appraisal.

Findings

We identified 25 reviews: 13 on diet, four on physical activity and eight on both. Eighteen articles were quantitative systematic reviews. In 12 reviews, 25-50% of studies were from Africa or the Caribbean. Only three included evidence from the Caribbean. Together, the 25 reviews included primary evidence published between 1926 and 2018. Little of the summarized evidence concerned associations between international health or political factors and diet or associations between any factor and physical activity across all categories of the social model of health.

Conclusion

The scoping review found a wide range of factors reported to be associated with diet and physical activity in Africa and the Caribbean, but summarized evidence that could help inform policies encouraging behaviours linked to healthy diets and physical activity in these regions were lacking. Further reviews are needed to inform policy where the evidence exists, and to establish whether additional primary research is needed.

Dietary Patterns and Determinants of Pregnant and Lactating Women From Marginalized Communities in India: A Community-Based Cross-Sectional Study

Objective: Dietary pattern analysis has emerged as a balanced and realistic approach that reflects how the food is consumed in real life. However, previous studies have overlooked the two important phases in women's life, pregnancy, and lactation. We aimed to explore dietary patterns and their determinants among pregnant and lactating women from marginalized families in rural areas and urban slums of India. Methods: It was a community-based cross-sectional study conducted across four districts of India, one from each region (North, West, East, and South). We used a structured questionnaire to collect data on socio-demographic characteristics and access to nutrition services. The dietary data were collected using a qualitative food frequency questionnaire having 204 food items, which were clubbed into 16 major food groups. The principal component analysis method was employed to identify dietary patterns (prefixed at 4). We used multinomial logistic regression to explore associations of socio-demographic and access to nutrition services' variables with identified dietary patterns. Results: The data of 476 pregnant and 446 lactating women were assessed. Four patterns explained for 54% of the variation in their food intake. The patterns identified were low-mixed vegetarian (19%), non-vegetarian (15%), high-mixed vegetarian (11%), and calorie-rich (9%). The low-mixed diet was rich in rice, roots and tubers, green leafy vegetables, and other vegetables. The non-vegetarian diet was characterized by high loadings for nuts or seeds, chicken, meat or fish, eggs, beverages (milk-based), and snacks. The high-mixed vegetarian diet was rich in cereals other than rice and wheat, pulses, and fruits. The calorie-rich diet had high factor loadings for wheat, butter and oil, sweets, and milk and milk products. Hindus and women who lived in rural areas had higher odds of consuming a low-mixed vegetarian diet and lower odds of a high-mixed vegetarian diet. Working women and those who received nutrition advice during pregnancy or lactation had 2-3 times higher odds of consuming a high-mixed vegetarian diet. Conclusions: A high prevalence of a low-mixed vegetarian diet among women can have adverse pregnancy and birth outcomes. Healthy dietary patterns during pregnancy and lactation are required to meet the increased micro- and macronutrient requirements for improved maternal and child health.

The role of cultural beliefs on eating patterns and food practices among pregnant women: a systematic review

CONTEXT

Despite the importance of cultural beliefs in clinical practice, few systematic reviews have investigated how these beliefs influence food practices in pregnant women.

OBJECTIVE

To explore the role of cultural beliefs in eating patterns and food practices among pregnant women, highlighting food recommendations, food taboos and restrictions, and their association with health.

DATA SOURCES

A systematic review was conducted using the following electronic databases: PubMed, Scopus, CINAHL, PsycINFO, and Web of Science from May 2014 to May 2019.

DATA EXTRACTION

Articles were included if the studies included pregnant women, analyzed how cultural beliefs may influence eating patterns, were peer-reviewed articles with original data, published in the last 5 years, and in English or Spanish language. Quality assessment was also performed.

DATA ANALYSIS

A total of 544 articles were identified in the search and 24 were included in the final analysis (17 using qualitative design, 6 using quantitative design, and 1 with a mixed-design). These studies were predominantly from the African continent (n = 15). Our findings showed that culture is a key factor related to "taboos" and food restrictions, which are transmitted by the family or members of community, having a strong religious or spiritual influence. All these restrictions are related to the fear of unfavorable pregnancy outcomes such as the risk of abortion, dystocia, and congenital macrosomia, or are used to avoid child problems such as cutaneous and respiratory disorders.

CONCLUSIONS

Findings from this study indicate cultural beliefs are strongly associated with food patterns and eating habits in pregnant women. Administrators and health professionals should be aware of these beliefs to minimize problems in the perinatal period.

Assessing statistical similarity in dietary intakes of women of reproductive age in Bangladesh

Women of reproductive age (WRA) need adequate nutrient intakes to sustain a healthy pregnancy, support fetal growth, and breastfeed after childbirth. However, data on women's dietary intake in low‐ and middle‐income countries (LMICs) are limited, and assessment of differences between dietary intakes of pregnant or lactating women compared with that of nonpregnant, nonlactating (NPNL) women is untested. Using single, multiple‐pass 24‐h dietary recall data from a sample of WRA residing in rural Bangladesh, we examined women's dietary intakes for energy, protein, calcium, iron, vitamin A, and dietary diversity for three groups: NPNL (n = 2,903), pregnant (n = 197), and lactating women (n = 944). We used equivalence testing to examine similarity in adjusted intakes for pregnant versus NPNL women and lactating versus NPNL women with a predetermined equivalence threshold based on recommendations specific for each reproductive stage. On average, both pregnant and lactating women had insufficient intakes for all dietary measures. Although statistically significant differences were observed between pregnant and NPNL women for energy intake and dietary diversity and between lactating and NPNL women for energy and protein intake, the magnitudes of these differences were too small to reject equivalence. Statistical similarity was also evident in all micronutrients and dietary diversity for both two‐group comparisons. Understanding statistical differences and similarities between dietary measures of women in distinct reproductive stages has important implications for the relevance, appropriateness, and evaluation of maternal diet‐enhancing interventions in LMICs, especially during pregnancy and lactation, when demand for macronutrients and micronutrients is elevated.

Obstetrical care is associated with child's dietary diversity in Indonesia: analysis from Demographic and Health Survey 2017

OBJECTIVE

To explore the influence of obstetrical care factors on dietary diversity and individual food group consumption in Indonesia.

DESIGN

Cross-sectional study to assess the association between pregnancy care factors and dietary diversity score, minimum dietary diversity (MDD) and consumption of seven food groups.

SETTING

Data from the Indonesia Demographic and Health Survey 2017.

PARTICIPANTS

A total of 5113 children aged 6-23 months.

RESULTS

Dietary diversity score was significantly higher for children whose mothers received four or more prenatal care visits, were delivered at a health facility, had a professionally trained delivery assistant and were delivered by C-section. Children born at a health facility and delivered by a health professional had higher odds of meeting MDD (adjusted OR (AOR) 1·45, 95 % CI 1·18, 1·79 and OR 2·10, 95 % CI 1·54, 2·87, respectively). Four or more antenatal visits, delivering at a health facility and having a professional delivery attendant were associated with higher odds of consumption of lentils (AOR 1·66, 95 % CI 1·23, 2·25, AOR 1·30, 95 % CI 1·02, 1·65 and AOR 1·79, 95 % CI 1·19, 2·69). Four or more antenatal visits, delivering at a health facility and having a professional delivery attendant had higher odds of consumption of other fruits and vegetables (AOR 1·70, 95 % CI 1·23, 2·35, OR 1·23, 95 % CI 1·03, 1·61 and OR 1·90, 95 % CI 1·29, 2·79).

CONCLUSIONS

Efforts focusing on providing nutritional education during antenatal care and delivery should be encouraged, especially for mothers seeking care outside of a health facility.

Appréciation des interventions de lutte contre la malnutrition maternelle par la population à Madagascar

INTRODUCTION

Madagascar has adopted strategies to fight against maternal malnutrition, but the evaluation of their implementation is not effective.Purpose of research: The present study aims to describe beneficiary appreciation of interventions to fight maternal malnutrition and to identify their expectations.

METHOD

A qualitative study was conducted in the Amoron&#8217;i Mania region, Madagascar. The study included mothers of children under 5, pregnant women, and other family members and community members (fathers, grandmothers, matrons and community workers). Six focus groups and 16&#160;individual interviews were conducted to collect the data. The thematic analysis was used.

RESULTS

Food supplementation, improved production of agriculture and livestock, and nutrition education, operated by NGOs, are the best-known interventions. The health centers were not mentioned as interveners and their interventions were ignored. The effectiveness of the intervention is generally judged on the benefits perceived by the beneficiaries. Interveners working on a project basis were assessed as unsustainable. Two main problems were mentioned: first, the insufficiency of agricultural production resulting in the inaccessibility of the ingredients required for the nutrition education, and second the low coverage of the interventions. The improvement of agricultural production is the main suggestion mentioned to fight against maternal undernutrition.

CONCLUSIONS

Beneficiaries thought that existing interventions in the region are insufficient to address the problem of malnutrition among mothers.

Nutrient Adequacy Is Low among Both Self-Declared Lacto-Vegetarian and Non-Vegetarian Pregnant Women in Uttar Pradesh

Poor dietary intake during pregnancy remains a significant public health concern, affecting the health of the mother and fetus. This study examines the adequacy of energy, macronutrient, and micronutrient intakes among self-declared lacto-vegetarian and non-vegetarian pregnant women. We analyzed dietary data from 627 pregnant women in Uttar Pradesh, India, using a multiple-pass 24 h diet recall. Compared to non-vegetarians, lacto-vegetarians (~46%) were less likely to report excessive carbohydrate (78% vs. 63%) and inadequate fat intakes (70% vs. 52%). In unadjusted analyses, lacto-vegetarians had a slightly higher mean PA for micronutrients (20% vs. 17%), but these differences were no longer significant after controlling for caste, education, and other demographic characteristics. In both groups, the median intake of 9 out of 11 micronutrients was below the Estimated Average Requirement. In conclusion, the energy and micronutrient intakes were inadequate, and the macronutrient intakes were imbalanced, regardless of stated dietary preferences. Since diets are poor across the board, a range of policies and interventions that address the household food environment, nutrition counseling, behavior change, and supplementation are needed in order to achieve adequate nutrient intake for pregnant women in this population.