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

Evidence on Strategies for Integrating Nutrition Interventions with Health and Immunization Systems in Conflict-affected Areas of Low- and Lower-middle-income Settings-A Systematic Review

CONTEXT

Pervasive conflict and war adversely affect a nation's sustainable development. Health and health systems deteriorate, causing long-lasting impacts on diets and nutrition. For the most vulnerable, integrated models of delivery of essential nutrition interventions are critical for the efficiency and sustainability of programs in these settings.

OBJECTIVE

The objective of this systematic review was to provide evidence on coverage, utilization, and impact of integrated programs in conflict-affected, low- and middle-income countries (LMICs).

DATA SOURCES

A database search was conducted in MEDLINE, Embase, CINAHL, and CENTRAL from January 1, 2000 to February 14, 2024. Gray literature was also reviewed.

DATA EXTRACTION

Quantitative and qualitative studies, including observational or intervention designs, and reviews and program evaluations conducted in LMICs, focusing on women (≥19 years) and children (0-19 years) were included. Data extraction and risk-of-bias assessment were conducted independently by 2 investigators using a standardized tool.

DATA ANALYSIS

In total, 93 studies (103 reports) were included from 25 countries, including 32 unique gray literature records. The conflict-affected regions included South-East Asia (n = 27), Eastern-Mediterranean (n = 8), Africa (n = 58), and the Americas (n = 1). The review distinguished programs based on nutrition-specific, nutrition-sensitive, and health components. Although the coverage and utilization of integrated nutrition and health programs has been substantial, the impact of the strategies on health and nutrition has been limited. The meta-analysis found no significant differences in rates of wasting among children under 5 years; however, it showed that children who received an integrated strategy experienced a 28% lower risk of underweight (P = .007) and a 12% reduced risk of stunting (P = .05) compared with those who did not.

CONCLUSION

This review has provided an in-depth insight into integrated nutrition and health strategies in conflict-affected settings, identifying key facilitators and barriers that can inform future policy and program design. Integrating nutrition programs into health systems and enhancing government and community ownership could enhance efficiency and sustainability, given challenging environments.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022373993.

Effect of Nutrition Education During Pregnancy on Iron-Folic Acid Supplementation Compliance and Anemia in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

CONTEXT

Stakeholders implement nutrition education to prevent and control anemia during pregnancy. Nutrition education during pregnancy can increase the consumption of iron-folic acid (IFA) supplements and encourage behavioral changes. However, there is no comprehensive meta-analysis to determine the effectiveness of this intervention.

OBJECTIVE

This review aimed to determine the effect of nutrition education on IFA supplementation (IFAS) compliance, hemoglobin level change, and prevalence of anemia in low- and middle-income countries.

DATA SOURCES

The systematic searches on Ovid Medline, Scopus, Embase (Elsevier), Web of Science, Health and Medical Collection (ProQuest), and Google Scholar were conducted until September 11, 2023. The updated searches were performed on November 16, 2023.

DATA EXTRACTION

In total, 12 436 records were imported to Covidence. Of these, 9109 records were screened by title and abstract. A total of 112 records were evaluated in full, and 53 articles were ultimately included based on eligibility.

RESULTS

Fifty-three peer-reviewed research articles met the inclusion criteria, involving 13 475 pregnant women. Those who received nutrition education during pregnancy were 2.80 times more likely to comply with IFAS (odds ratio = 2.80; 95% CI: 2.04, 3.83; I2 = 66.20%). There was an average increase of 0.88 g/dL (Cohen's d = 0.88; 95% CI: 0.63, 1.13; I2 = 96.17%) in hemoglobin levels among women who received nutrition education. A meta-regression analysis revealed that 61.85% (adjusted R2 = 61.85%) of heterogeneity between standardized mean differences was explained by anemia status, intervention duration, and geographic region. Also, pregnant women in the nutrition education group had a 34% (relative risk = 0.66; 95% CI: 0.54, 0.80, I2 = 86.85%) lower risk of anemia compared with the control group.

CONCLUSION

Nutrition education during pregnancy improves compliance with IFAS, increases hemoglobin levels, and reduces the risk of anemia. Therefore, it is crucial to enhance the existing nutrition education program to prevent and control anemia during pregnancy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023454241.

Application of the integrated gateway model on child nutrition behaviors in Niger: An exploratory analysis

OBJECTIVE

To identify potential gateway factors and behaviors that are associated with infant and young child feeding (IYCF) practices in the Maradi and Zinder regions of Niger through application of the Integrated Gateway Model.

METHODS

We analyzed data from 2,727 married women of reproductive age including details on child feeding practices for their 2,551 children between the ages of 0 to 23 months. We assessed the association of three gateway behaviors (i.e., any antenatal care, facility delivery, and communication on nutrition practices) and gateway factors (i.e., behavioral determinants, exposure to information, decision-making agency, and woman's group participation) on four IYCF practices (i.e., early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency, and minimum dietary diversity) while controlling for age, parity, educational attainment, and household wealth.

RESULTS

We found antenatal care was associated with exclusive breastfeeding of children 0-5 months [adjusted odds ratio (aOR): 1.17 (95% confidence interval (CI): 1.03-1.33)], and minimum meal frequency of children 6-23 months [aOR: 1.10 (95% CI: 1.03-1.17)], and facility delivery was associated with early initiation of breastfeeding among children 0-5 months [aOR: 2.08 (95% CI: 1.39-3.12)]. We found negative associations with exclusive breastfeeding and communication on nutrition practices with husbands, family/friends, and health workers. Exposure to nutrition messages through radio, women's groups participation, and with health workers was positively associated with minimum dietary diversity. Self-efficacy was positively associated with both early initiation of breastfeeding, exclusive breastfeeding among children 0-5 months and minimum dietary diversity among children 6-23 months. Women's agency was positively associated with early initiation of breastfeeding.

CONCLUSION

The association of antenatal care and facility delivery with child nutrition outcomes suggest intervening before a woman becomes pregnant or early in her pregnancy could improve nutrition outcomes. Programs strengthening the continuum of care should identify gateway behaviors to maximize adoption of priority health behaviors.

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.

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.