Jacqueline K. Kung'U

Many countries rely on national household surveys to monitor coverage of nutrition interventions. Following a multi‐year consultative effort, 14 new and revised nutrition coverage indicators were included in the Round 8 Demographic and Health Survey (DHS‐8) core questionnaire. These indicators were better aligned with international recommendations and generate actionable data for policy and programmatic decision making at national, subnational, and global levels. This analysis highlights their potential applications. We included six sub‐Saharan African countries who collected and released DHS‐8 datasets between January 2021 and June 2024 (Burkina Faso, Côte d'Ivoire, Ghana, Kenya, Mozambique, and Tanzania). We present weighted averages for all nutrition coverage indicators from pregnancy through young childhood by country and estimate inequities in coverage. Coverage of nutrition interventions provided during pregnancy, birth, and postnatal care was higher than during infancy and young childhood, with wide variation between and within countries. For the new indicators on prenatal counseling about breastfeeding and maternal diet, Ghana had the highest coverage (88% and 92%, respectively) and Mozambique the lowest (48% and 51%). Postnatal counseling about infant and young child feeding practices was universally lower, ranging from 12% in Mozambique to 50% in Ghana. Subnational region, wealth quartile, and maternal education were consistent drivers of inequity. The greatest differences in coverage were by subnational region, as high as 71 percentage points for coverage of height and weight measurement of young children in Kenya. The expanded DHS‐8 nutrition indicators fill critical information gaps about coverage and inequalities in care.

Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community‐Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi‐country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions.

Delivery with skilled birth attendants is important for reducing maternal mortality in developing countries. However, traditional birth attendants (TBAs) are abundant in such settings, managing deliveries without the skills and resources necessary to prevent mortality in this situations. Interventions that have been proposed to mitigate the situation include redefining the role of TBAs to nutrition advocates and birth companions for pregnant women to health facilities. We thus explored community perceptions on these new roles of TBAs, as birth companions and nutrition advocates, and their influence on health facility deliveries in Kakamega County, Kenya. Qualitative data was collected through key informant interviews with health workers and focus group discussions with lactating mothers, pregnant women, husbands, community leaders, community health volunteers, and TBA. Content analysis was conducted; data was organized into subthemes and conclusions made from each subtheme using Atlas.ti software. TBAs adopted their birth companion role as the majority offered companionship to mothers delivering at health facilities. Mothers were happy with this role as TBAs continued providing companionship even after delivery. The community members were happy with the new role of TBAs and reported increased deliveries at the health facilities. In contrast, TBAs did not adopt the nutrition advocacy role sufficiently. We found that redefining the role of the TBAs into birth companions to support facility‐based delivery is thus feasible and acceptable. Nutrition advocacy by the TBAs should be strengthened to maximize on the opportunity provided by the close association between TBAs and mothers and the community.

Antenatal care (ANC) offers remarkable opportunities to reach a large number of women with effective nutrition and health interventions, including iron (Fe) supplementation. However, all women do not equally seek nor benefit from ANC. We aimed to identify characteristics associated with ANC and Fe use among women in hard‐to‐reach areas in Afar, Ethiopia; Sedhiou and Kolda, Senegal; and Kakamega, Kenya. Women who gave birth within 1 year preceding the survey (n = 4,575) from 15 different sub‐regions were randomly selected and surveyed. Multivariable logistic regression was used to identify associations of socio‐demographic characteristics with ANC and Fe use. Factors that showed positive associations with ANC uptake included education, income, possession of a mobile phone, and the occupation of the mother or another household member. Beginning ANC in the first trimester associated positively with achievement of 4 or more ANC visits, and having any ANC visits related positively with Fe intake. Distance to the nearest health facility was negatively associated, and type of nearest facility and counselling and health education were positively associated with some outcomes. The results from these surveys demonstrate the need to ensure access of services across all population groups and can help identify ANC programming needs.

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 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.

In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012–2013. Qualitative data from focus‐group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility‐based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community‐based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow‐up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community‐based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact.

Objectives: Treatment of diarrhea with zinc and ORS has both life-saving potential and diarrhea prevention benefits, yet here we explore the barriers as to why coverage and adherence remain low. Methods: A synthesis of formative research results from nine countries (Afghanistan, Bangladesh, Ethiopia, India, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand child diarrhea treatment practices and identify the barriers and enablers associated with ORS and zinc use. Results: In all countries, caregivers felt that diarrhea can be adequately cared for at home with local foods and drinks, traditional remedies and herbal medicine, tailored to the type of diarrhea. Perceived causes of diarrhea and advice from senior family members directly influenced treatment seeking. ORS was widely known for preventing dehydration in children with diarrhea, but was perceived as ineffective in stopping diarrhea. Caregivers and some health workers preferred antibiotics and anti-diarrheal medicines to “stop” diarrhea promptly. Outreach activities and free treatment for child diarrhea motivated caregivers to seek facility-based treatment. Barriers to ORS and zinc use include low awareness of zinc at multiple levels, frequent supply stock-outs and poor prescribing practices of health workers. Barriers to adherence to the full course of zinc include the common practice of stopping treatment when diarrhea stops and a lack of caregiver awareness of the benefits of zinc for prevention of diarrhea. Conclusions: Addressing context-specific beliefs about diarrhea causes and the effectiveness of home-remedies is essential to improve care-seeking behaviours. Maintaining adequate supplies and promoting the benefits of zinc will help to improve coverage and adherence.

Introduction of complementary foods in resource poor settings has been associated with diets that are microbiologically unsafe. Bacteria were therefore quantified in samples of drinking water and in two porridges prepared for infant feeding [fortified instant soy rice porridge (SRP) and cooked porridge ( Lishe bora , LB)] in 54 households. Bacterial numbers were measured again after the porridges had been held at room temperature for 4 h (T4). Bacterial numbers in these porridges were benchmarked against those in traditional complementary foods sampled from 120 households. Total bacteria, coliform, and enterobacteriaceae were enumerated using Petrifilm™. Geometric mean log bacterial numbers were lowest for LB at T0 (2.24±0.84 CFU/g aerobic counts) and highest for SRP at T4 (4.63±0.56 CFU/g aerobic counts). Total bacteria were higher at T4 than T0 for both LB (p<0.001) and SRP (p=1.000). Although total bacteria in drinking‐water were significantly lower than in SRP4 (p=0.002) or in traditional complementary foods (p=0.001), they were not significantly different from SRP0 (p=0.543). We therefore recommend addressing food safety concerns in improving complementary foods.