Topic: Systems-based Practice M aternal and neonatal mortality rates remain high in many low-income and middle-income countries. To attain the Millennium Development Goals 4 and 5, different approaches to improve birth outcomes have been tried, including community-based interventions. Effects on survival have been heterogeneous and uncertain. This systematic review and meta-analysis of randomized controlled trials (RCTs) was done to assess the effects of women's groups practicing participatory learning and action on birth outcomes in low-resource settings.Seven databases and citations from reference lists were searched for RCTs carried out in Bangladesh, India, Malawi, and Nepal. Inclusion criteria for studies in the systematic review included: RCT, the intervention contained the stages of a participatory learning and action cycle, most participants were aged 15-49 years, and outcomes reported included maternal mortality, neonatal mortality, and stillbirths. The participatory learning and action cycle had 4 phases: (1) identify and prioritize problems during pregnancy, delivery, and postpartum; (2) plan;(3) implement locally feasible strategies to address the priority problems; and (4) assess the activities. Subgroup analyses were carried out to identify population-level predictors of effect. Incremental cost-effectiveness ratios were used for trials in which significant effects on the neonatal mortality rate were reported. Cost-effectiveness was expressed as the incremental cost per neonatal death averted and life-year saved.Seven RCTs performed between 1999 and 2011 that included a total of 119,428 births met the inclusion criteria. Group facilitators in the participatory programs were local women who were not health workers; they coordinated 9-13 group meetings per month after receiving 7-11 days of training in maternal and newborn health and participatory facilitation techniques. Exposure to women's groups was associated with 37% and 23% reductions in maternal and neonatal mortality, respectively. No association was found between participatory learning programs and a reduction in stillbirths. The proportion of pregnant women participating in the groups was linearly associated with reductions in both maternal and neonatal mortality, but no evidence of associations was found between the effects of the intervention and background mortality or institutional delivery rates. In studies in which Z30% of pregnant women participated in women's groups, a 55% reduction in maternal mortality and a 33% reduction in neonatal morality was observed. The women's participatory learning and action groups had strong effects on clean delivery practices for home deliveries and noticeable effects on breastfeeding. Women's groups were a highly cost-effective intervention as determined by World Health Organization standards. The intervention could save an estimated 283,000 newborns and 41,100 mothers per year if implemented in rural areas of 74 countdown countries (those countries targeted for attaining Millennium Goals by 2015).Wome...
Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal’s Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n=18), health service providers (n=4), district (n=1) and national stakeholders (n=4), as well as policymakers (n=3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n=2) and health facility operation and management committee members (n=2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers’ limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.
Background and objectives Women’s nutritional status is important for their health and reproductive fitness. In a population where early marriage is common, we investigated how women’s nutritional status is associated with their age at marriage (marking a geographical transfer between households), and at first pregnancy. Methodology We used data from a cluster randomised control trial from lowland Nepal (n = 4,071). Outcomes including body mass index (BMI) were measured in early pregnancy and trial endpoint, after delivery. We fitted mixed-effects linear and logistic regression models to estimate associations of age at marriage and age at pregnancy with outcomes, and with odds of chronic energy deficiency (CED, BMI <18.5 kg/m2), at both timepoints. Results BMI in early pregnancy averaged 20.9 kg/m2, with CED prevalence 12.5%. In 750 women measured twice, BMI declined 1.2 (95%CI 1.1, 1.3) kg/m2 between early pregnancy and endpoint, when CED prevalence was 35.5%. Early pregnancy was associated in dose-response manner with poorer nutritional status. Early marriage was independently associated with poorer nutritional status among those pregnant ≤15 years, but with better nutritional status among those pregnant ≥19 years. Conclusions and implications The primary determinant of nutritional status was age at pregnancy, but this association also varied by marriage age. Our results suggest that natal households may marry their daughters earlier if food insecure, but that their nutritional status can improve in the marital household if pregnancy is delayed. Marriage age therefore determines which household funds adolescent weight gain, with implications for Darwinian fitness of the members of both households. Lay Summary In lowland Nepal, the primary determinant of women’s nutritional status was age at pregnancy. However, among those pregnant early, those married earlier had poorer nutritional status, suggesting they were married to ameliorate food insecurity. Marriage age determines which household funds adolescent weight gain, with fitness implications for members of both households.
Objectives: Maternal factors shape the risk of infant undernutrition, however the contributions of age at marriage versus age at pregnancy are rarely disentangled. We explore these issues in a population from lowland rural Nepal, where median ages at marriage and first pregnancy are 15 and 17 years respectively and marriage almost always precedes pregnancy. Methods:We analyzed data on first-time mothers (n = 3002) from a clusterrandomized trial (2012)(2013)(2014)(2015). Exposures were ages at marriage and pregnancy, categorized into groups. Outcomes were z-scores for weight (WAZ), length (LAZ), head circumference (HCAZ), and weight-for-length (WLZ), and prevalence of wasting and stunting, for neonates (<8 days) and infants (6-12 months). Mixed linear and logistic regression models tested associations of marriage and pregnancy ages with outcomes, adjusting for parental education, household assets, caste, landholding, seasonality, child sex, intervention arm, randomization strata and cluster.Results: For neonates, pregnancy <18 years predicted lower LAZ, and <19 years predicted lower WAZ and HCAZ. Results were largely null for marriage age, however early pregnancy and marriage at 10-13 years independently predicted neonatal stunting. For infants, earlier pregnancy was associated with lower LAZ and HCAZ, with a trend to lower WAZ for marriage 10-13 years. Early pregnancy, but not early marriage, predicted infant stunting.Conclusions: Early marriage and pregnancy were associated with poorer growth, mainly in terms of LAZ and HCAZ. Associations were stronger for neonatal than infant outcomes, suggesting pregnancy is more susceptible to these stresses. Early marriage and pregnancy may index different social and biological factors predicting child undernutrition.
Background Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices. Methods We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators. Results The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children’s books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices. Conclusions Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal.
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