Achieving high coverage of Kangaroo mother care practice is possible: Lessons from implementation research for accelerating scale-up in Tigray Region, Ethiopia.

AIM: To evaluate coverage of effective Kangaroo mother care (KMC) by developing a model that would result in high coverage (≥80%) of KMC for newborn weighing less than 2000 g at birth in Tigray region, Ethiopia. METHODS: The study used formative research and continuous programme learning in iterative cycles of model development and modification conducted in close collaboration with the Tigray Regional Health Bureau. Quantitative methods were used to evaluate the various models. All study facilities were enrolled simultaneously, and hospitals and health centres were considered to become KMC-providers. RESULTS: The final scalable model implemented in two rural districts and one special urban zone of Tigray region attained the desired objective, with coverage of effective KMC of 82.3% at discharge. CONCLUSION: Achieving high coverage of KMC is possible through the design of context-specific implementation strategies. The key factors for success were the commitment and strong leadership from the regional health bureau, strong linkages within the health system and between different departments within health facilities, improved health worker knowledge, skills and attitudes, hospitals and health centres that supported KMC performance, and systematic generation and use of data for continuous quality improvement.

Maternal dietary pattern and its association with birthweight in Northern Ethiopia: A hospital-based cross-sectional study.

Birthweight is a useful public health measure of maternal health, nutrition, healthcare delivery, and child morbidity and mortality. Previous research did not focus on dietary patterns but rather on a single or a few foods or nutrients. This study aimed to assess the maternal dietary pattern and its association with birthweight in northern Ethiopia. A hospital-based cross-sectional study was conducted among 373 pregnant mothers in their third trimester of pregnancy who came to attend their routine antenatal care service. The food frequency questionnaire was collected from the previous week, and the birthweight data were collected from the medical records after delivery. Three maternal dietary patterns were identified; dietary pattern includes eggs, milk, milk products, and certain fruits and roots. Dietary pattern 2 includes certain vegetables, green leafy vegetables, vitamin A-rich vegetables, pulses such as beans, peas, and chickpeas, and drinks like coffee, tea, and soda. Dietary pattern 3 includes meat, nuts, and grains such as teff, corn, wheat, and white flour. Dietary pattern 1 (ß = 52.45, p = .03) and dietary pattern 2 (ß = 66.76, p = .01), residency (ß = 287.08, p < .001), a mid-upper-arm circumference of 21-23 cm (ß = 187.10, p = .02), a mid-upper-arm circumference of >23 cm (ß = 272, p = .01), and gestational age at delivery (ß = 12.58, p = .004) were the factors significantly associated with increased birthweight. The maternal dietary pattern has a significant association with birthweight. The focus should be given to maternal dietary patterns to prevent suboptimal and high birthweight.

Practice of Kangaroo Mother Care Among Low-Birth-Weight Infants Discharged from Health Facilities and Its Outcome in Mekelle City, Tigray, Northern Ethiopia.

Background: Kangaroo mother care is a proven intervention shown to be effective in reducing neonatal mortality among low-birth-weight infants. The paucity of evidence regarding the practice at home can be highlighted. This study aimed to assess the practice and outcome of kangaroo mother care at home among mothers having low-birth-weight infants discharged from two hospitals in Mekelle, Tigray, Ethiopia. Methods: A prospective cohort study was conducted among 101 paired mothers and low-birth-weight neonates discharged from Ayder and Mekelle Hospitals. Non-probability purposive sampling was used to select 101 infants. Data were collected from patient charts in both hospitals using interviewer-administered structured questionnaire, anthropometric measurements and were then analyzed using SPSS version 20. Characteristics were analyzed using descriptive statistics. Bivariate analysis was used, and variables with p-value <0.25 were exported to multivariable logistic regression and statistical significance was set at a p-value <0.05. Results: Kangaroo mother care was continued at home in 99% of the infants. Three of the 101 infants died before the age of 4 months with a possible cause of death from respiratory failure. Exclusive breastfeeding was provided for 67% of the infants, and it was higher in infants who started kangaroo mother care within 24 hours of life (AOR 3.8, 95% CI 1.07-13.25). Malnutrition was higher in those with birth weight <1500 grams (AOR 7.3,95% CI 1.63-32.59); small for gestational age (AOR 4.8,95% CI 1.41-16.31) and those provided kangaroo mother care for <8 hours per day (AOR 4.5,95% CI 1.40-16.31). Conclusion: Early initiation and prolonged duration of kangaroo mother care were associated with increased exclusive breastfeeding practice and decreased incidence of malnutrition. Kangaroo mother care should be promoted at the community level.

Barriers and Enablers of KMC Implementation in Health Facility and Community of Tigray Region, Northern Ethiopia: Formative Research.

Background: Kangaroo mother care (KMC) is an evidence-based approach to reducing morbidity and mortality in low-birth-weight and preterm newborns. Barriers for KMC and its effective practice at a larger scale are highly affected by contextual factors. The purpose of this study is to explore barriers and enablers in the community and health facilities for implementation and continuation of KMC. Methods: This formative study employed a qualitative exploratory approach using focus group discussions and in-depth interviews in five zones of Tigray region, Northern Ethiopia. A total of 16 focus group discussions and 46 in-depth interviews were conducted with health workers and community members. The whole process of data collection took an iterative approach. An inductive thematic analysis was done by going through the transcribed data using ATLAS.ti software. Results: The current study found that problems of infrastructure and equipment for KMC practice, shortage of staff, and absence of trained health workers as the most frequently mentioned barriers by health workers. Low level of awareness, lack of support, mother being responsible for the rest of the family, holding babies in the front being traditionally unacceptable, and preference of incubators for better care of small babies were among the barriers identified in the community. Presence of community health workers and the positive attitude of the community towards them, as well as antenatal and postnatal care were among the favorable conditions for the implementation of KMC at health facilities and continuation of KMC at home. Conclusion: Empowering health workers through training to identify preterm and low-birth-weight babies, to do follow-ups after discharge, and creating awareness in the community to change the perception of kangaroo mother care are necessary.

Barriers to utilize nutrition interventions among lactating women in rural communities of Tigray, northern Ethiopia: An exploratory study.

BACKGROUND: While lactation is a physiological process requiring high energy demand to fulfill the nutrient requirements of the mother and the breastfeeding child, many factors affecting maternal nutrient intake can lead to nutritional deficits. Previous studies in Ethiopia have reported the prevalence of maternal and child undernutrition and related complications. However, qualitative studies exploring potential barriers to utilizing available nutrition interventions are limited. This study, therefore, sought to qualitatively explore barriers hindering the uptake of nutrition services among lactating mothers from rural communities in Tigray, northern Ethiopia. METHODS: We conducted 6 in-depth interviews, 70 key informant interviews, and 13 focus group discussions among purposively selected community groups, experts, and lactating mothers between November- 2017 and January- 2018. Audio records of all interviews and focus group discussions were transcribed verbatim (word-to-word) and translated into English. Then, translated data were analyzed thematically using qualitative data analysis software Atlas ti-version 7.4. RESULTS: The participants in this study perceived that lactating mothers in their study area are not properly utilizing available and recommended nutrition interventions, and as a result, their nutrient intake was reported as inadequate. Participants identified inadequate accessibility and availability of foods, feeding practices, cultural and religious influences, focus on agricultural production and productivity, barriers related to health services and poor access to water, sanitation and hygiene as major barriers hindering the uptake of nutrition interventions by lactating women in Tigray, northern Ethiopia. CONCLUSION: The uptake of nutrition intervention services was low among lactating mothers and was hindered by multiple socio-cultural and health service related factors requiring problem-specific interventions at community, health facility, and administrative levels to improve the nutritional status of lactating mothers in the study area.

Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study.

OBJECTIVES: Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage. DESIGN: This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge. PARTICIPANTS: 3804 infants of birth weight under 2000 g who survived the first 3 days, were available in the study area and whose mother resided in the study area. MAIN OUTCOME MEASURES: The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7 days postdischarge. RESULTS: Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7 days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%). CONCLUSIONS: This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice. TRIAL REGISTRATION NUMBERS: ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Food taboos and related misperceptions during pregnancy in Mekelle city, Tigray, Northern Ethiopia.

INTRODUCTION: Most communities, rural or urban, have taboos regarding foods to avoid during pregnancy, and most have local explanations for why certain foods should be avoided. Such taboos may have health benefits, but they also can have large nutritional and health costs to mothers and fetuses. As such, understanding local pregnancy food taboos is an important public health goal, especially in contexts where food resources are limited. Despite this, information regarding food taboos is limited in Ethiopia. Therefore, this study assessed food taboos, related misconceptions, and associated factors among pregnant women in Northern Ethiopia. METHODS: A cross-sectional study of 332 pregnant women in antenatal care (ANC) follow-up at selected private clinics in Mekelle city, Tigray, Ethiopa, recruited between April and May, 2017. Using a semi-structured questionnaire, we assessed whether respondents' observed food taboos, what types of foods they avoided, their perceived reasons for avoidance, diversity of respondents' diets during pregnancy, and respondents' socio-demographic characteristics. After reporting frequency statistics for categorical variables and central tendencies (mean and standard deviation) of continuous variables, bivariate and multivariable logistic regression analyses were conducted to identify the socio-demographic factors and diet diversity associated with food taboo practices. RESULTS: Around 12% of the pregnant women avoided at least one type of food during their current pregnancy for one or more reasons. These mothers avoided eating items such as yogurt, banana, legumes, honey, and "kollo" (roasted barley and wheat). The most common reasons given for the avoidances were that the foods were (mistakenly) believed to cause: abortion; abdominal cramps in the mother and newborn; prolonged labor; or coating of the fetus's body. Maternal education (diploma and above) (AOR: 4.55, 95% CI: 1.93, 10.31) and marital status (single) were found to be negatively associated (protective factors) with observances of pregnancy food taboos. Approximately 79% of respondents had pregnancy diets that were insufficiently diverse, although we did not find any statistical evidence that this was associated with adhering to food taboos. CONCLUSION: The misconceptions related to pregnancy food taboos should be discouraged insofar as they may restrict women's consumption of nutritious foods which could support maternal health and healthy fetal development. Health providers should counsel pregnant women and their husbands about appropriate pregnancy nutrition during ANC visits.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation.

INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it. METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge. ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination. STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019. TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).