Using formative research to promote antenatal care attendance and iron folic acid supplementation in Zinder, Niger

Risk factors associated with congenital central nervous system abnormalities in the National Hospital of Zinder, Niger

INTRODUCTION

Congenital malformations of the central nervous system (CNS) are morphological abnormalities of the brain and spinal cord that occur during fetal development. They constitute the second most common congenital disability, after congenital cardiac defects. Many risk factors have been identified; however, these studies included various types of congenital abnormality. Furthermore, there is a lack of information on risk factors for congenital CNS malformation, and notably in the Zinder region of Niger.

OBJECTIVE

This study aimed to identify the risk factors associated with congenital CNS malformations in the Zinder region.

METHODS

In a case-control design, patients with congenital CNS malformation were enrolled between June 2022 and April 2023 in the Department of Neurosurgery of the National Hospital of Zinder.

RESULTS

Family history of malformation (aOR:3.31, 95% CI:1.25-8.78) and consanguine marriage (aOR:2.28, 95% CI:1.23-4.20) were significantly associated with congenital CNS malformation. In contrast, folic acid supplementation (aOR:0.34, 95% CI:0.13, 0.89), multiparity (aOR:0.34, 95% CI:0.13, 0.89), and grand multiparity (aOR, 0.47; 95% CI:0.23, 0.97) had a protective effect.

CONCLUSION

Risk factors such as family malformation history and consanguine marriage increased the risk of developing congenital malformations of the central nervous system. In contrast, folic acid supplementation in the index period and multiparity had a significant protective effect.

Adherence to Iron and Folic Acid Supplementation Among Pregnant Women From Northern Ghana

Iron and folic Acid (IFA) supplementation is an effective intervention for reducing the incidence of anaemia during pregnancy. The WHO recommends at least 6 months intake of IFA to pregnant women. However, in Ghana some women experience challenges with adhering to IFA supplementation. The main objective of the study was to assess the level of adherence to iron and folic acid supplementation and its associated factors among pregnant women in a peri-urban municipality in Northern Ghana. A cross-sectional study was conducted from March to December 2021 among 400 pregnant women who attended ANC in Sagnarigu municipality in Ghana and were selected through a 3-stage random sampling technique. A structured questionnaire was used to collect data. The data were analysed using descriptive statistics, univariate and binary logistic regression statistical tools. Self-reported level of adherence to iron and folic acid supplementation was 84.5%. Knowledge of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) was associated with adherence. Three other factors: time of first antenatal visit (AOR = 0.32: 0.153, 0.649) having history of anaemia [AOR = 2.67: 1.373, 5.201] having side effects of IFA [AOR = 3.70, CI: (1.756, 7.793)], and having knowledge of management of side effects of iron and folic acid supplementation (AOR = 0.08: 021, 0.343) were found to be significantly associated with adherence. Adherence to iron and folic supplementation among the pregnant women was generally frequent. Strategies to increase iron and folic acid supplementation adherence among pregnant women could focus on encouraging pregnant women to have early ANC visits and educating them on how to manage side effects.

Creating Reproductive Health Behavioral Profiles for Women of Reproductive Age in Niger Using Cross-Sectional Survey Data: A Latent Class Analysis

Objectives: To identify health behavioral profiles for women of reproductive age in Niger. Methods: We interviewed married women of reproductive age in Niger in April 2021 (N = 2,709). Latent class analysis based on sociodemographic and behavioral determinants was used to identify classes of women related to use of antenatal care, facility delivery, and modern family planning (FP) use. Results: We found similar classes between the use of antenatal care and facility-based delivery classes with the first class composed of less educated and poor women with weaker behavioral determinants while the second class was more educated and had stronger behavioral determinants. In the facility-based delivery class was the presence of a third class that was poor and uneducated with low levels of knowledge and social norms, but in contrast had much higher levels of positive attitudes, self-efficacy, and partner communication than the first class. A fourth class of younger, more educated women with strong behavioral determinants emerged related to FP. Conclusion: The application of empirical subgrouping analysis permits an informed approach to targeted interventions and resource allocation for optimizing maternal and reproductive health.

Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review

Background

Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation.

Objectives

To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy.

Search Methods

We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies.

Selection Criteria

We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis.

Data Collection and Analysis

Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach.

Main Results

A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1.

Authors' Conclusions

The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.

Out-of-pocket costs and time spent attending antenatal care services: a case study of pregnant women in selected rural communities in Zinder, Niger

Background

Despite an official policy of exemption from health care costs, pregnant women in Niger still face some out-of-pocket costs (OPC) in addition to time costs when they attend antenatal care (ANC) services. We aimed to: 1) assess the OPC for pregnant woman attending ANC, 2) estimate the time spent to attend ANC and the opportunity cost of that time, and 3) assess how OPC and time spent to attend ANC affected ANC attendance.

Methods

Data were obtained from a quasi-experimental descriptive study carried out in the region of Zinder, Niger, which compared pre- and post-intervention cohorts of pregnant women (n = 1736 women who reported attending ANC during their current pregnancy). An ANC attendance score was developed to describe the timing of ANC attendance in regard to the WHO recommendation of attending 4 ANC sessions. OPC and time spent were evaluated separately for associations with ANC attendance using Spearman correlations.

Results

The mean (±SD) age of pregnant women was 25.0 ± 6.4 yr, 19.0% were ≤ 19 yr and 99.7% were in their second or third trimester of gestation at the time of the interview. Among those who were > 13 weeks and > 27 weeks of gestation, 4.0 and 74.4% had attended ANC during their first and second trimesters, respectively. The median (1st quartile (Q1), 3rd quartile (Q3)) ANC score was 0 (− 1, 0), reflecting that the majority of women failed to follow the WHO recommendation. More than half of the women (72.5%) experienced OPC related to ANC. The majority of women (> 80%) reported spending ~ 3 h for an ANC visit, including travel and waiting time. Time spent to attend ANC was not associated with ANC attendance score. Women who experienced OPC, and those who received iron folic acid (IFA) or long-lasting insecticide-treated bednets during an ANC visit, were more likely to have a higher ANC attendance score compared to those who did not.

Conclusion

OPC and time spent were not identified as barriers to ANC visits, and IFA and long-lasting insecticide-treated bednets distribution could be used to motivate pregnant women to attend ANC.

Trial registration

The NiMaNu project was registered at www.clinicaltrials.gov as NCT01832688. Registered 16 April 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06027-2.

"They Merely Prescribe and I Merely Swallow": Perceptions of Antenatal Pharmaceuticals and Nutritional Supplements Among Pregnant Women in Bamako, Mali

OBJECTIVES

New international guidelines for antenatal care (ANC) will likely result in an increase in nutritional supplements and preventative medications for pregnant women in low and middle-income countries. Our objective was to understand how pregnant women in Mali perceive and experience multi-drug regimens in ANC in order to reveal factors that may influence uptake and adherence.

METHODS

We conducted 29 semi-structured interviews and three focus groups with 21 pregnant women in two urban ANC sites in Bamako, Mali. Interviews focused on perception of purpose of ANC pharmaceuticals (particularly iron supplements, sulfadoxine-pyrimethamine as intermittent prevention of malaria and antiretroviral therapy for HIV), beliefs regarding efficacy and risk, and understanding of dosage and regimen. Transcripts were inductively coded and analyzed using the 'Framework' method.

RESULTS

Participant descriptions of medication purpose, understanding of dosing, and beliefs about risks and efficacy varied widely, revealing that many pregnant women lack complete information about their medications. While some were burdened by side effects or complex regimens, women generally held favorable attitudes toward ANC medications. Responses suggest major barriers to adherence lie in the health system, namely insufficient patient-provider communication and inconsistent prescribing practices.

CONCLUSIONS FOR PRACTICE

National health programs looking to improve maternal and child health with ANC pharmaceuticals need to place greater attention on patient counseling and consistent implementation of administration guidelines. Communication that positions pharmaceuticals as beneficial to mother and child, while presenting understandable information about purpose, dosing and potential side effects can promote uptake of multi-drug regimens and ANC services in general.

Grandmothers as Change Agents: Developing a Culturally Appropriate Program to Improve Maternal and Child Nutrition in Sierra Leone

BACKGROUND

Global recommendations on optimal maternal and child nutrition (MCN) practices are clear; however, there is limited literature 1) exploring how roles of family members influence those practices and on 2) designing programs accordingly. Researchers using a family-systems approach in the Global South find that grandmothers often play a vital role in MCN, yet most nutrition programs narrowly target mothers, thereby potentially limiting effectiveness.

OBJECTIVES

This article reports on the results of qualitative research exploring the roles and influence of family members on MCN in southern Sierra Leone, the local MCN beliefs and practices, and how those findings informed the design of a culturally appropriate program.

METHODS

Focus group discussions (FGDs) were conducted with mothers, fathers, and grandmothers in 9 communities in Bonthe District, Sierra Leone. We used participatory tools to explore family members' roles and local MCN beliefs and practices. Interviews were recorded by notetakers and coded and analyzed using a content analysis approach.

RESULTS

A total of 88 mothers, 125 grandmothers, and 79 fathers participated in the FGDs. All groups indicated that 1) grandmothers are the culturally designated advisors and supervisors of women on MCN issues and 2) mothers are not autonomous decision makers and are greatly influenced by grandmothers. The research identified both beneficial MCN practices and gaps between optimal and existing MCN practices-particularly related to maternal diet during pregnancy and exclusive breastfeeding for 6 mo. Research findings were used to design a grandmother-inclusive program.

CONCLUSIONS

Our research showed that mothers are embedded in a family system of caring and supervision where grandmothers have primary influence on MCN practices, clearly supporting the need for grandmothers to have a central role in community MCN programs. It also points to the need for increased use of a family-systems approach in designing public health nutrition programs.

The mixed effects of a package of multilevel interventions on the health and care of pregnant women in Zinder, Niger

Background

Anaemia is prevalent among pregnant women in rural Niger and antenatal care (ANC) attendance is suboptimal. We designed a programmatic intervention including community-based behaviour change communication, provision of essential drugs (including iron folic acid (IFA) supplements) and quality improvement activities at selected integrated health centres (IHCs).

Objective

To assess the impact of the programmatic intervention on: (1) utilisation of ANC, (2) adherence to daily IFA supplementation and (3) prevalence of adequate gestational weight gain (GWG) and anaemia among pregnant women in Zinder, Niger.

Methods

Using a quasi-experimental study design comparing a cohort of women at baseline to another cohort of women at endline, 18 IHCs and surrounding villages were randomly assigned to time of enrolment over 1 year. A baseline survey was implemented among randomly selected pregnant women in 68 village clusters. Subsequently, the intervention was rolled out and an endline survey was implemented 6 months later in the same villages.

Results

Mean age in the baseline (n=1385) and endline (n=922) surveys was 25.8±6.4 years. The percentage of pregnant women who reported attending any number of ANC and an adequate number of ANC for their gestational age, respectively, was not significantly different between the endline and the baseline surveys. Pregnant women in the endline survey were more likely to have received IFA (60.0% vs 45.8%, OR: 2.7 (1.2, 6.1)); and the proportion of pregnant women who reportedly consumed IFA daily in the previous 7 days was significantly higher in the endline than in the baseline survey (46.4% vs 32.8%, OR: 2.8 (1.2, 6.5)). There was no impact on the prevalence of adequate GWG or anaemia.

Conclusions

The programmatic intervention resulted in a modest increase in the number of pregnant women who reported receiving and consuming IFA supplements as recommended, but did not affect ANC attendance and nutritional status.

Theory-driven formative research to inform the design of a national sanitation campaign in Tanzania

Introduction

There are gaps in global understanding about how to design and implement interventions to improve sanitation. This formative study provided insights for the subsequent redesign of a government-led national sanitation campaign targeting rural populations in Tanzania.

Methods

The Behaviour Centred Design approach was used to investigate the determinants of toilet building, improvement and use. Varied, novel, and interactive research tools were employed in fifty-five households in two regions of rural Tanzania. Results were analysed to articulate a Theory of Change, which then informed intervention design.

Results

Participants valued hard work, enterprise, and improving their lives over many years. They wanted better toilets but felt no urgency to act quickly. A common emotional motivator for improving toilets was to protect children from disease (Nurture) but this was insufficient to drive rapid change. Disgust with traditional toilets meant they were built at a distance from the house: an ‘out of sight, out of mind’ attitude. Other powerful motives included the desire to improve living conditions (Create), and to become a modern Tanzanian (Status), albeit without ‘showing off’. Construction costs and water scarcity were the main stated barriers. Receiving information about realistic costs, support accessing materials, and visiting better latrines elsewhere were commonly reported reasons for improving latrines.

Conclusions

The resulting Theory of Change recommended that the intervention should surprise people with a novel conversation about toilets, promote toilets as a means of conferring status, and introduce a perceived urgency to ‘act now’. It should suggest that modest improvements would lead to a better life. Feelings of disgust and fear with poor quality toilets should be amplified, and barriers lessened through promoting transformational toilet improvements, and improving access to modern toilet products. This research provided considerable insight into sanitation behaviours in rural Tanzania, which informed creative intervention design.

Integrating nutrition into health systems at community level: Impact evaluation of the community-based maternal and neonatal health and nutrition projects in Ethiopia, Kenya, and Senegal

Maternal undernutrition and mortality remain high in several African countries. Key nutrition and health interventions improve maternal and birth outcomes. Evidence is scarce on how to strengthen health systems to ensure pregnant women and newborns are reached with these interventions. We conducted three quasi-experimental nonrandomized Community Based Maternal and Neonatal Health and Nutrition projects in regions of Ethiopia, Senegal, and Kenya to demonstrate how proven nutrition interventions could be integrated into health programs to improve knowledge and practices during pregnancy, birth, and postpartum. We evaluated impact on knowledge and practices related to maternal and neonatal care using logistic regression and repeated-measures models with districts as a fixed variable and adjusted for covariates. Combined country analyses show significant positive effects of the intervention on women receiving first antenatal care visit (ANC) during first trimester (OR = 1.44; p < .001), those consuming any iron and folic acid supplement during their latest pregnancy (OR = 1.60; p = .005), those whose <6 months infants were exclusively breastfed (OR = 2.01; p=.003), those whose delivery was facility based (OR = 1.48; p=.031), and those whose postnatal care was facility based (OR = 2.15; p<.001). There was no significant differences between intervention and control groups regarding one or more and four or more ANC visits, women consuming iron and folic acid for ≥90 days, and early initiation of breastfeeding. We conclude that integrating proven nutrition interventions into health programs at community level improved components of access to and use of ANC, delivery services, and postnatal care by women in three African countries.

Using formative research to promote antenatal care attendance and iron folic acid supplementation in Zinder, Niger

In Niger, use of antenatal care (ANC) and iron folic acid (IFA) supplements is suboptimal. The objectives of this paper are as follows: (a) to conduct formative research to understand barriers and beliefs among pregnant women related to ANC, IFA supplementation, and pregnancy outcomes; (b) assess the quality of currently provided ANC services; (c) use the findings to guide the development of programmatic interventions to improve coverage of ANC services and IFA supplementation of pregnant women. Structured in-home interviews (n = 72) and focus groups (n = 4) were conducted with pregnant women in 4 randomly selected villages in rural Zinder. ANC consultations (n = 33) were observed in 5 randomly selected health centres, and exit interviews were conducted with all pregnant women and seven health agents following these observations. During workshops with stakeholders, results of the formative research were interpreted, and programmatic interventions were developed. In home interviews, 72% of women reported having attended at least one ANC visit. They also reported husbands (71%), mothers (40%), and friends (33%) supporting ANC attendance. Among those having attended ANC, only 65% reported taking IFA the day prior to the interview. Three of five health centres visited had IFA in stock. Health staff did not provide IFA supplements during 18 of 33 observed ANC consultations of which only 7 cases could be explained by the lack of IFA supplements in stock. Findings were used to design a 3-pronged intervention: (a) behaviour change communication activities in communities; (b) quality improvement activities in health centres to strengthen ANC; and (c) provision of key supplies required for ANC.