Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study

Morrison, Joanna; Giri, Romi; Arjyal, Abriti; Kharel, Chandani; Harris‐Fry, Helen; James, Philip; Baral, Sushil; Saville, Naomi; Hillman, Sara

doi:10.1111/mcn.13170

Cited by 22 publications

(67 citation statements)

References 75 publications

(100 reference statements)

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“…Recent qualitative research in the plains of Nepal found that when some women became pregnant they were prioritised and ate first, however, many women still cooked, served food and then late last, sometimes leading to not eating enough, even while pregnant (Morrison et al, 2021). On the other hand, pregnancy may lead to morning sickness or food aversions, leading women to eat less or not eat certain foods, leading to lower dietary diversity (Christian et al, 2006;Harding et al, 2017).…”

Section: Key Messagesmentioning

confidence: 99%

Do changes in women's household status in Nepal improve access to food and nutrition?

Diamond‐Smith

Puri²,

Neuhaus

et al. 2022

Maternal & Child Nutrition

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Women's nutritional status remains poor in South Asia, impacting maternal and infant health outcomes. Women's household status is also low, as evidenced by eating behaviours. We started with triadic qualitative interviews with newly married women, husbands and mothers‐in‐law to explore the link between women's status and eating patterns, followed by longitudinal data from a cohort of 200 newly married women in rural Nepal to measure associations over time. Quantitative data were collected every 6 months for 18 months (four rounds of data) between 2018 and 2020. Interviews suggested that household relationships, women's status, and how much and what types of food she was given were intricately linked. Using mixed effects logistic regression models, we explore the association between markers of changing women's status (becoming pregnant, giving birth and working outside the home) on two outcomes (eating last always/usually and achieving minimum dietary diversity). We also explore for interaction between women's status and household food insecurity. Pregnancy increases women's dietary diversity, but this is not sustained post‐partum. Women who work outside the home are less likely to eat last in the household. Food insecurity is associated with both the order of household eating and dietary diversity. Interactions between food insecurity and giving birth suggested that women who give birth in food insecure households are more likely to eat last in the household. Changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long‐lasting and depend on food security status.

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Section: Key Messagesmentioning

confidence: 99%

Do changes in women's household status in Nepal improve access to food and nutrition?

Diamond‐Smith

Puri²,

Neuhaus

et al. 2022

Maternal & Child Nutrition

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“…A limitation of many other studies is that gender is examined only in binary terms of male and female roles or knowledge. Morrison et al (2021) emphasise the need to understand 'the intersection of gender with intergenerational hierarchies' to inform intervention design. They conclude that efforts to decrease maternal anaemia should not only target and provide information to pregnant women, and rather should involve other family members, especially powerful mothers-in-law and men.…”

Section: Family Systemsmentioning

confidence: 99%

“…Beyond the informational support provided by the grandmothers, or mamitas, the authors strongly emphasise the importance of the emotional support they provide through their proximity, experience and commitment to the dyad. Critiquing the nuclear family model in MCN programmes, they assert that a family systems framework is more relevant in contexts where the family network and intergenerational family relationships are strong, supported by collectivist cultural values.In rural Nepal,Morrison et al (2021) conducted formative research on maternal anaemia based on a socio-ecological framework, inspired by Bronfenbrenner's seminal construct(1977), to investigate factors at the individual, family and community levels that affect antenatal visits, iron-folic acid supplement intake and pregnant women's diet. The research aimed to understand the roles and influence of family actors, specifically husbands and mothers-in-law, and the gender and intergenerational power dynamics between them and with the pregnant wives.…”

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confidence: 99%

Introduction: A family systems approach to promote maternal, child and adolescent nutrition

Aubel¹,

Cunningham

2021

Maternal & Child Nutrition

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In all cultures, women and children are embedded in family systems that determine roles, relationships, patterns of communication and authority between family members. Especially in non‐western societies, maternal and child nutrition practices are determined not only by the biological parents but also by other influential family members. Most maternal and child nutrition research and interventions do not consider the constellation of family roles and influence on women and children and continue to focus on the mother–child dyad and individual knowledge, attitudes and practices. There is growing agreement on the need to adopt an ecological framework to address public health issues, including those dealing with maternal and child nutrition. This special issue presents examples of research from a variety of settings that employed an ecological, family systems approach either to investigate maternal, child or adolescent nutrition issues or to design interventions that engaged various actors within family settings. These 11 articles contribute to a growing body of evidence supporting the relevance of a wider family systems perspective for nutrition research and interventions. Key themes across studies include the limitations of using a nuclear family model for research and intervention design, the need for formative research that comprehensively explores family systems, increasing recognition of the extensive involvement and support provided by grandmothers, and the importance of engaging men in culturally appropriate ways based on community dialogue and women's perspectives. Future maternal and child nutrition research and interventions can be strengthened by systems thinking that acknowledges that individuals are situated within family and community systems.

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“…As indicated by the NEC review, this includes access to food and supplements. Other studies, including our formative research, suggest this also includes addressing complex factors such as gender norms, power hierarchies, community cohesion and trust in health services [ 61 ].…”

Section: Introductionmentioning

confidence: 99%

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women’s groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal

Saville

Kharel²,

Morrison

et al. 2022

Trials

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Background Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes. Methods This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299–4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13–49 years and able to respond to questions. After 1–2 missed menses and a positive pregnancy test, consenting women < 20 weeks’ gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12–21 and 22–26 weeks’ gestation) with iron folic acid (IFA) supplement dosage tailored to women’s haemoglobin concentration, plus monthly PLA women’s group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks’ gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression. Discussion Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy. Trial registration ISRCTN 12272130.

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Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study

Cited by 22 publications

References 75 publications

Do changes in women's household status in Nepal improve access to food and nutrition?

Do changes in women's household status in Nepal improve access to food and nutrition?

Introduction: A family systems approach to promote maternal, child and adolescent nutrition

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women’s groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal

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