Perceptions towards management of acute malnutrition by community health volunteers in northern Kenya.

Child undernutrition is a persistent challenge in arid and semi-arid areas due to low and erratic rainfall, recurrent droughts and food insecurity. In these settings, caregivers face several challenges in accessing health services for sick and/or malnourished children, including long distances to health facilities, harsh terrain, and lack of money to pay for transportation costs to the health facilities, leading to low service coverage and sub-optimal treatment outcomes. To address these challenges and optimize treatment outcomes, the World Health Organization recommends utilizing community health volunteers (CHVs) to manage acute malnutrition in the community. This study explored the perceptions of community members regarding acute malnutrition treatment by CHVs in Turkana and Isiolo counties in Kenya. The study utilized a cross-sectional study design and included a purposive sample of caregivers of children, CHVs, officers who trained and supervised CHVs and community leaders in the intervention area. Focus group discussions and key informant interviews were used to explore perceptions towards the management of acute malnutrition by CHVs. Generally, caregivers and CHVs perceived the intervention to be beneficial as it readily addressed acute malnutrition treatment needs in the community. The intervention was perceived to be acceptable, effective, and easily accessible. The community health structure provided a platform for commodity supply and management and CHV support supervision. This was a major enabler in implementing the intervention. The intervention faced operational and systemic challenges that should be considered before scale-up.

Potential effectiveness of integrating human milk banking and lactation support on neonatal outcomes at Pumwani Maternity Hospital, Kenya.

We assessed the potential effectiveness of human milk banking and lactation support on provision of human milk to neonates admitted in the newborn unit (NBU) at Pumwani Maternity Hospital, Kenya. This pre-post intervention study collected data from mothers/caregivers and their vulnerable neonates or term babies who lacked sufficient mother's milk for several reasons admitted in the NBU. The intervention included establishing a human milk bank and strengthening lactation support. Preintervention data were collected between 5 October 2018 and 11 November 2018, whereas postintervention data were collected between 4 September 2019 and 6 October 2019. Propensity score-matched analysis was performed to assess the effect of the intervention on exclusive use of human milk, use of human milk as the first feed, feeding intolerance and duration of NBU stay. The surveys included 123 and 116 newborns at preintervention and postintervention, respectively, with 160 newborns (80 in each group) being included in propensity score matched analysis. The proportion of neonates who exclusively used human milk during NBU stay increased from 41.3% preintervention to 63.8% postintervention (adjusted odds ratio [OR]: 2.68; 95% confidence interval [CI]: 1.31, 5.53) and those whose first feed was human milk increased from 55.0% preintervention to 83.3% postintervention (adjusted OR: 5.09; 95% CI: 2.18, 11.88). The mean duration of NBU stay was 27% (95% CI: 5.8%, 44.0%) lower in the postintervention group than in the preintervention group. The intervention did not affect feeding intolerance. Integrating human milk banking and lactation support may improve exclusive use of human milk among vulnerable neonates in a resource limited setting.

Challenges and experience of the Ethiopian rural health extension program: implications for reform and revitalization.

BACKGROUND: Despite remarkable gains over the past decade, mounting evidence suggests that Ethiopia's rural health extension program (HEP) is facing serious implementation challenges. We investigated the current and potential future program design and implementation challenges of Ethiopia's rural HEP based on the lived experiences of health extension workers (HEW) implementing the program at the grassroots level. METHODS: We employed a longitudinal qualitative exploration linked to a larger cluster-randomized trial (RCT) which was implemented in 282 villages randomly selected from 18 Kebeles of the Gedeo zone, southern Ethiopia. Data were collected using in-depth interviews with key informants, focus group discussion, and passive observation of program implementation. The data were analyzed manually using a thematic framework analysis approach. Themes and sub-themes were generated by condensing, summarizing, and synthesizing data collected in the field in the form of extended notes and field observation checklists. FINDINGS: Despite considerable gains in availing basic health services to the rural population, HEP seems to suffer serious design and implementation flaws that demand thoughtful and immediate adjustment. The design constraints span from the number and type of intervention packages to the means of dissemination (vehicle) as well as the target population emphasized. As such, some low-cost high-impact interventions that were strongly desired by the community were overlooked, while others were inappropriately packed. The means of distribution - female health extension workers trained with basic prevention skills, were lacking essential skills. They also had high burnout rates and with little engagement with men, were repeatedly mentioned flaws of the program demanding revitalization. Furthermore, the sheer structure of HEP precluded adult and adolescent men, non-reproductive women, and the elderly. CONCLUSION: Despite significant gains over the last couple of months, Ethiopia's rural HEP appears to have reached a tipping point that requires a comprehensive revamp of the program package, means of distribution, and target beneficiaries rather than the "usual" tweaks to reap maximum benefits.

Ownership of small livestock species, but not aggregate livestock, is associated with an increased risk of anemia among children in Ethiopia: A propensity score matching analysis.

Consumption of animal source foods, through livestock production, improves children's growth and micronutrient status. However, research on the relationship between livestock ownership and childhood anemia has produced conflicting results. The current study used robust analytical approaches to examine the effect of household livestock ownership on children's anemia using the most recent secondary data from the national demographic and health survey. We followed a 1:1 closest neighborhood propensity score matching analysis. A propensity score was generated using the binary logistic regression model to compute the probability of owning livestock. From a total of 18,008 households enrolled in the latest Ethiopian Demographic and Health Survey (EDHS 2016), data of 721 index children aged 6-59 months from households owning livestock were matched with a comparable number (721) of children from households without livestock. The paired and independent t-test, matched relative risk (RR), and standardized mean differences were used to compare the distributions of hemoglobin concentration and anemia risks between treatment and control groups. Anemia was found in more than half (54.1% and 58.8%) of children aged 6-59 months from livestock-owning and nonowning families, respectively (p > .05). Aggregate ownership of livestock was not associated with hemoglobin concentration or anemia status (RR = 0.95, 95% confidence interval [95% CI] [0.87-1.04]). Species-wise, poultry was associated with a lower (RR = 0.88, 95% CI [0.84-0.95]) anemia risk, while ownership of goat/sheep was associated with higher (RR = 1.10, 95% CI [1.03-1.17]) risk. In conclusion, ownership of small livestock species (sheep/goats and poultry), but not aggregate livestock ownership, was associated with the risk of anemia among children in Ethiopia. Therefore, agriculture-sensitive nutrition, with a One Health lens approach, is recommended to mitigate the high burden of anemia among children in Ethiopia. In the future, a well-controlled interventional study with more extended periods may be required to fully understand the effects of livestock production and highlight the differences seen across livestock species.

Associations between livestock keeping, morbidity and nutritional status of children and women in low- and middle-income countries: a systematic review.

Livestock keeping can positively influence the nutritional status of populations and households through increased consumption of animal-source foods (ASF) and other indirect pathways, but can also adversely affect health by increasing the risk of diseases. We conducted a systematic review synthesising the current state of knowledge on the associations among livestock keeping, infectious disease and the nutritional status of children under 5 years and women of reproductive age in low- and lower-middle-income countries (LMICs). A comprehensive search of 12 electronic databases and grey literature sources published from 1991 to the end of December 2020 was conducted. Investigations exploring relationships between livestock keeping and risk of infectious disease transmission and nutritional status were selected using pre-defined inclusion criteria. After screening and filtering of 34,402 unique references, 176 references were included in the final synthesis. Most (160/176, 90.1%) of the references included in the final synthesis were from sub-Saharan Africa (SSA) and Asia. About two out of every five (42%) studies reviewed showed that livestock production is associated with improved height-for-age Z scores (HAZ) and weight-for-length/height Z scores (WHZ), while close to a third (30.7%) with improved weight-for-age Z scores (WAZ). Similarly, livestock production showed a positive or neutral relationship with women's nutritional status in almost all the references that reported on the topic. Conversely, four-fifths (66/81, 79.5%) of the references reporting on infection and morbidity outcomes indicated that livestock keeping is linked to a wide range of infectious disease outcomes, which are spread primarily through water, food and insects. In conclusion, in many LMIC settings, livestock production is associated with better nutritional outcomes but also a higher risk of disease transmission or morbidity among women and children.This review was prospectively registered on PROSPERO 2020 [CRD42020193622].

Inhaled Corticosteroids and the Risk of Lung Cancer in Chronic Obstructive Pulmonary Disease Patients: A Systematic Review and Meta-Analysis.

Background: The global prevalence of chronic obstructive pulmonary disease (COPD) is increasing, and the risk of lung cancer in these patients is high. The use of inhaled corticosteroids (ICSs) in COPD patients could help to decrease potential lung cancer risk. We planned to conduct this systematic review and meta-analysis to determine the role of ICS in the risk of lung cancer among COPD patients. Methods: A comprehensive search of PubMed, Science Direct, Google Scholar, and Cochrane library and a manual search of the list of references were conducted. Studies with cohort, case-control, and randomized clinical trial designs for any ICS use reporting the incidence/hazard ratio (HR) of lung cancer were included. The random-effects model was used to pool hazard ratios. Subgroup analysis and metaregression analysis were employed. Funnel plot and Egger regression test were used to assess publication bias. Results: Combining the results of 14 observations, the pooled HR for cancer risk reduction was 0.69 (95% CI 0.59-0.79), p value ≤ 0.001. The use of ICS in COPD patients showed a 31% reduction in the risk of lung cancer. Subgroup meta-analysis showed a significant reduction in the risk of lung cancer as well. Conclusion: The use of ICS in COPD patients reduces the risk of lung cancer. The risk reduction was independent of smoking status and latency period. Future studies should focus on the optimum dose and controlling confounders like asthma.

Maternal vitamin D and growth of under-five children: a systematic review and meta-analysis of observational and interventional studies.

BACKGROUND: Even though previous systematic reviews have reported on the role of prenatal vitamin D on birth outcomes, its effect on child growth is poorly understood. OBJECTIVE: To synthesize a systematic summary of the literature on the effect of maternal vitamin D supplementation on the linear growth of under-five children. METHOD: This study includes studies (both observational and interventional with a control group) that evaluated the effects of prenatal vitamin D status on child linear growth. The mean child length/length for age with 95% confidence interval (CI) was pooled as the weighted mean difference using a random-effects model. A funnel plot was used to assess potential publication bias. RESULTS: A total of 45 studies and 66 reports covering a total population of 44,992 (19,683 intervention or high vitamin D group, and 25,309 control or low vitamin D group) were analyzed. Studies spanned from 1977 to 2022. The pooled weighted mean difference was 0.4 cm (95% CI: 0.15-0.65). A subgroup analysis, based on vitamin D supplementation frequency, showed that mothers who supplemented monthly or less frequently had a 0.7 cm (95% CI: 0.2-1.16 cm) longer child. Supplementation with a dose of >2000 international units increased child length at birth. The weighted mean difference was 0.35 cm (95% CI: 0.11-0.58). CONCLUSION: The evidence from this review shows that maternal supplementation of vitamin D is associated with increased birth length. This is apparent at higher doses, low frequency (monthly or less frequent), and during the second/third trimester. It appears that vitamin D supplementation during pregnancy is protective of future growth in under-five children. Clinical trials are needed to establish evidence of effectiveness for the frequency and dose of supplementation.

Magnitude, Trends, and Determinants of Iodized Salt Availability among Households in Ethiopia: Analysis of Ethiopian Demographic and Health Surveys (2000-2016).

BACKGROUND: Iodine deficiency causes various health problems such as mental defects, goiter, reproductive damage, hypo and hyperthyroidism, stillbirth, abortion, congenital abnormalities, cretinism, mental retardation, muscle anomalies, and reduced work output. Although the adverse effects on health and socio-economic development are well known, they persisted as a public health problem worldwide. Salt iodization is recommended as a simple cost-effective method to prevent iodine deficiency disorders. This study aimed to determine the magnitude, trends, and determinants of iodized salt availability in the household in Ethiopia. METHODS: The current study used the Ethiopian Demographic and Health Surveys conducted from 2000 to 2016 with a total of 57 939 households. Descriptive statistics were performed on selected background characteristics to provide an overall picture of the sample after considering sample weights. To ensure the representativeness of the sample we applied a complex sample design considering household weights, primary sampling units, and the strata associated with it. The Cochran-Armitage test was performed to assess the trend of iodized salt availability in the household. Multivariate logistic regression was used to determine the association between the dependent variable and independent variables. A significance level of .05 was chosen for all analyses. RESULTS: The magnitude of iodized salt availability in the household was 28.45% in 2000, 54.34% in 2005, 15.42% in 2011, and 89.28% in 2016. Iodized salt availability increased from 28.45% [95% CI: 27.69-29.21] in 2000 to 89.28% [95% CI: 88.79-89.75] in 2016. Despite the decline from 2005 to 2011 in the percentage of households with iodized salt, overall, there was a significant increment from 2000 to 2016 in Ethiopia (P-value <.001). There were differences in the status of salt iodization in the administrative region, wealth, family size, and ownership of radio or television. CONCLUSION: Remarkable progress has been made in Ethiopia regarding iodized salt availability in recent years. Besides the current efforts to achieve universal salt iodization, future interventions should prioritize specific groups like those with lower socioeconomic status and geographic areas with lower availability of iodized salt in the household.

Communities and employers show a high level of preparedness in supporting working mothers to combine breastfeeding with work in rural Kenya.

Community Readiness Model (CRM) through pragmatic mixed methods design, combining quantitative CRM survey with qualitative data, was used to assess the level of preparedness and readiness among local leaders, employers and community members in supporting working mothers to combine breastfeeding with work. The study was conducted in one of the tea state farms in Kericho County of Kenya. A total of 17 purposively selected men (fathers), lactating mothers, peer educators, health professionals (doctors, nurses and nutritionists), tea plantation managers and grandmothers were interviewed. The CRM that has six different dimensions was applied to determine the stage of readiness to support working mothers to combine breastfeeding with work. Community Readiness Score (CRS) was calculated descriptively as mean ± standard deviation (SD). Thematic analysis using NVIVO software was used to analyse qualitative data. We found that the mean (±SD) CRS was 7.3 (1.9), which corresponded to the third highest level of the nine stages or the 'stabilization' stage of community readiness. Dimensionally, the mean CRS was the highest (8.3 ± 1.9) for leadership followed by community efforts (7.5 ± 2.1), whereas the lowest CRS was observed for knowledge of efforts (6.6 ± 2.3) and availability of resources (6.6 ± 1.9). In conclusion, high level of readiness to support working women to combine work with breastfeeding with suboptimal knowledge of efforts and availability of resources was observed in the area. Future interventions should focus on enabling the community to feel more comfortable and creating detailed and refined knowledge on combining breastfeeding with work.

Household, dietary and healthcare factors predicting childhood stunting in Ethiopia.

Stunting, decidedly prevalent in Ethiopia, is a reduction of linear growth associated with a series of adverse consequences. However, little is known about its determinants and factors associated in Ethiopia and elsewhere. Therefore, this study aimed to determine major undelying factors associated with risk of stunting among under-five children in Ethiopia. We used the 2016 Ethiopian Demographic and Heath Survey (EDHS) data and analysed a total of 11,023 children aged 0-59 months' data. Bivariate and multivariate logistic regression were fitted to identify key predictors and factors associated with stunting. Results show that, household and demographic factors such as maternal education (AOR: 0.67, 95% CI: 0.51, 0.89), wealth index (AOR: 0.65 (0.54, 0.78), sex of child (AOR: 0.78 (0.72, 0.85), possession of refrigerator (AOR: 0.57 (0.36, 0.89), possession of television and others like twin birth, house main floor material, types of cooking fuel were significantly association with stunting. Among dietary factors, early initiation of breast feeding; feeding powdered or fresh milk (AOR: 0.63 (0.52, 0.76); formula feeding (AOR: 0.41 (0.21, 0.81); consumption of organ meat(s) (AOR: 0.52 (0.32, 0.85) and beta-carotene rich fruits and vegetables were significantly associated lower odds of stunting. Antenatal care (ANC) follow-up, deworming during pregnancy (AOR : 0.11 (0.02, 0.74), institutional delivery (AOR : 0.64 (0.58, 0.71) and birth size (AOR: 5.1 (1.64, 15.88) were among the health care factors associated with stunting of under-five children. In conclusion, stunting is modulated by several household, dietary and healthcare factors, both at household and community-level. Likewise; improving household income, women empowerment, dietary diversity among mothers and children and improving maternal health care system are critical to mitigate under-five stunting more rapidly.

Prenatal vitamin D supplementation and child respiratory health: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Systematic review and meta-analyses of observational studies on maternal vitamin D status and risk of respiratory allergic conditions indicated that mothers who had supplementation during pregnancy could decrease the risk of recurrent wheeze or asthma in their offspring. OBJECTIVES: We conducted this meta-analysis of Randomized Controlled Trials with the primary intention of detecting the effect of prenatal vitamin D supplementation on the offspring's asthma. Secondary outcomes under respiratory health include eczema, lower respiratory tract infections, Immunoglobulin E positive test, upper respiratory tract infections, and allergic rhinitis. METHODS: A comprehensive search of PubMed, ScienceDirect, Google Scholar, and Cochrane Library databases was performed to retrieve randomized controlled trials. Risk Ratio with 95% confidence intervals was computed from dichotomous data using a random-effects model, with I2 >50% representing notable heterogeneity. RESULTS: Six clinical trials met the inclusion criteria, involving a total of 2898 subjects (1461 experimental group and 1437 control group). There was non-significant inverse relationship between vitamin D intake during pregnancy and the occurrence of asthma in offspring (pooled RR = 0.89, 95% CI = 0.69-1.15, I 2  = 46% and Z-static = 0.90, P-value = 0.37). There is no significant difference in the risk of assessed childhood respiratory problems due to maternal supplementation of vitamin D during pregnancy. CONCLUSION AND IMPLICATIONS: Currently, there is no fertile evidence to promote vitamin D supplementation in pregnancy for childhood respiratory health. Future clinical trials should emphasize early initiation of vitamin D supplementation, consider 6 weeks to 6 months postnatal critical window for vitamin D deficiency for offspring, lower risk dose of vitamin D, and identify different phenotypes of asthma and response to vitamin D supplementation.

Dietary diversity cutoff values predicting anemia varied between mid and term of pregnancy: a prospective cohort study.

BACKGROUND: Correcting anemia during pregnancy often requires integrating food and non-food-based approaches. Nonetheless, little is known about specific dietary diversity (DD) cutoff values predicting risk of anemia during the different trimesters of pregnancy. OBJECTIVE: We aimed to determine the lowest possible DD cutoff values associated with risk of maternal anemia at mid and term of pregnancy in a rural resource limited setting of Ethiopia. DESIGN: A multi-center prospective cohort study was conducted enrolling 432 eligible pregnant women from eight rural health centers selected from four districts in Arsi zone, Central Ethiopia. Women were classified into exposed (n = 216) and unexposed (n = 216) groups, based on Women's Individual Dietary Diversity (WIDD) score, and were followed from mid to term of pregnancy. The cutoff values for WIDD corresponding to the lowest risk of anemia were defined by receiver operating characteristic (ROC) curve analysis. Logistic regressions were also fitted to identify food groups associated with low anemia risk during pregnancy. RESULTS: The overall prevalence of anemia increased from 28.6 to 32.4% between mid and term of pregnancy. Calculatedly, using the ROC curve analysis, the minimum WIDD score associated with lower risk of anemia was three and four respectively at these periods. Not consuming animal source foods [adjusted odds ratio (AOR), 2.36; 95% confidence interval (CI), 1.35-4.14], pre-existing anemia (AOR 28.56; 95% CI, 14.33, 56.79), and low DD during pregnancy (AOR, 2.22; 95% CI, 1.09-4.52) were associated with risk of anemia at term. CONCLUSION: The cutoff for WIDD score predicting risk of anemia varied significantly, increasing from three to four, between mid and term of pregnancy. Additional population-based observational and experimental studies validating the metrics are needed before policy level recommendations. TRIAL REGISTRATION: This trial was registered at clinicaltrials.gov as NCT02620943.

Pregnant women have inadequate fiber intake while consuming fiber-rich diets in low-income rural setting: Evidences from Analysis of common "ready-to-eat" stable foods.

The intake of fiber-rich foods during pregnancy has several health benefits to the pregnant woman including lowering the risks of diabetes, preeclampsia, and constipation. However, little is known about the content, daily intake levels, and adequacy of fiber among pregnant women in many low-income settings. We aimed to identify common food items and determine adequacy of dietary fiber intake levels among pregnant women in rural Ethiopia. Dietary data were collected from a subsample (n = 55) of pregnant women enrolled to a larger prospective cohort study (n = 414). Dietary intake level was measured using repeated 24-hr dietary recall method and weighing the total amount of daily food. Fiber content was determined using the Weende method supplemented by other sources.The mean [±SD] dietary fiber intake level was 25.89 [±5.09 mg/g] per day, which declined across pregnancy trimester from 26.01 [±9.18 mg/g] to 22.67 [±9.01 mg/g] and 24.56 [±9.98 mg/g] during the first, to second and third pregnancy trimesters, respectively. Boiled cereals and coffee contributed to nearly two-thirds (63.2%) of the daily fiber intake, while the major bulk of daily food, enjera, contributed to less than a quarter (24.3%) of the fiber intake. Though dietary patterns favor diversified intake for fiber, the mean intake levels below the recommended levels and proportion of women getting adequate to the physiologic stages of pregnancy were inadequate compared to the standard. Mothers, in such community, could benefit from increasing overall intake of existing food to satisfy their fiber needs during pregnancy.

Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol.

BACKGROUND: In many low income countries, the majority of acutely malnourished children are either brought to the health facility late or never at all due to reasons related to distance and associated costs. Integrated community case management (iCCM) is an integrated approach addressing disease and malnutrition through use of community health volunteers (CHVs) in children under-5 years. Evidence on the potential impact and practical experiences on integrating community-based management of acute malnutrition as part of an iCCM package is not well documented. In this study, we aim to investigate the effectiveness and cost effectiveness of integrating management of acute malnutrition into iCCM. METHODS: This is a two arm parallel groups, non-inferiority cluster randomized community trial (CRT) employing mixed methods approach (both qualitative and quantitative approaches). Baseline and end line data will be collected from eligible (malnourished) mother/caregiver-child dyads. Ten community units (CUs) with a cluster size of 24 study subjects will be randomized to either an intervention (5 CUs) and a control arm (5 CUs). CHV in the control arm, will only screening and refer MAM/SAM cases to the nearby health facility for treatment by healthcare professionals. In the intervention arm, however; CHVs will be trained both to screen/diagnose and also treat moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) without complication. A paired-matching design where each control group will be matched with intervention group with similar characteristics will be matched to ensure balance between the two groups with respect to baseline characteristics. Qualitative data will be collected using key informant and in-depth interviews (KIIs) and focused group discussions (FGDs) to capture the views and experiences of stakeholders. DISCUSSION: Our proposed intervention is based on an innovative approach of integrating and simplifying SAM and MAM management through CHWs bring the services closer to the community. The trial has received ethical approval from the Ethics Committee of AMREF Health Africa - Ethical and Scientific Review Committee (AMREF- ESRC), Nairobi, Kenya. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, and presented to local and international conferences. TRIAL REGISTRATION: PACTR201811870943127 ; Pre-results. 26 November 2018.

Perceptions on donated human milk and human milk banking in Nairobi, Kenya.

Donor human milk (DHM) is recomended as the best alternative when use of mothers' own milk is not a feasible option. Kenya has not yet established human milk banks (HMBs) for provision of safe DHM, which is free from any physical, chemical, microbiological contaminants or pathogens. This study aimed to establish the perceptions on donating and using DHM, and establishing HMBs in Kenya. Qualitative data were collected through 17 focus group discussions, 29 key informant interviews, and 25 in-depth interviews, with women of childbearing age, community members, health workers, and policy makers. Quantitative interviews were conducted with 868 mothers of children younger than 3 years. Descriptive analysis of quantitative data was performed in STATA software, whereas qualitative interviews were coded using NVIVO and analysed thematically. Majority of them had a positive attitude towards donating breast milk to a HMB (80%) and feeding children on DHM (87%). At a personal level, participants were more willing to donate their milk to HMBs (78%) than using DHM for their own children (59%). The main concerns on donation and use of DHM were personal dislikes, fear of transmission of diseases including HIV, and hygiene concerns. Ensuring safety of DHM was considered important in enhancing acceptability of DHM and successful establishment of the HMBs. When establishing HMBs, Kenya must take into consideration communication strategies to address the main concerns raised regarding the quality and safety of the DHM. The findings will contribute to the development of HMB guidelines in Kenya and other African contexts.

Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? A cluster randomized-controlled community trial.

BACKGROUND: Low coverage of Skilled Birth Attendance (SBA) is one of the major drivers of maternal mortality in many low- and middle-income countries (LMICs) including Ethiopia. We conducted a cluster-randomized controlled community trial to assess the effect of deploying trained community based nurses to rural communities on the uptake levels of SBA in Ethiopia. METHODS: A three-arm, parallel groups, cluster-randomized community trial was conducted to assess the effect of deploying trained community based reproductive health nurses (CORN) on the uptake of SBA services. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where these new service providers were deployed, a health post (HP) or health center (HC). Baseline and end line surveys were conducted to document and measure the effects of the intervention. Program impacts on SBA coverage were calculated using difference-in-difference (DID) analysis. RESULTS: After nine months of intervention, the coverage of SBA services increased significantly by 81.1% (from 24.61 to 44.59) in the HP based intervention arm, and by 122.9% (from 16.41 to 36.59) in the HC arm, respectively (p <0.01). Conversely, a small and non-significant (2%) decline in SBA coverage were observed in the control arm (P >0.05). The DID estimate indicated a net increase in SBA coverage of 21.32 and 20.52 percentage points (PP) across the HP and HC based intervention arms, respectively (p < 0.001). CONCLUSIONS: Deployment of trained reproductive health nurses to rural communities in Ethiopia significantly improved utilization of SBA services. Therefore; in similar low income settings where coverage of SBA services is very low, deployment of trained community based nurses to grassroots level could potentiate rapid service uptake. Additional cost-effectiveness and validation studies at various setups are required, before scale-up of the innovation, however. TRIAL REGISTRATION: clinicaltrails.gov NCT02501252.

Consumption of dairy, fruits and dark green leafy vegetables is associated with lower risk of adverse pregnancy outcomes (APO): a prospective cohort study in rural Ethiopia.

BACKGROUND: Poor maternal nutrition during pregnancy is a leading modifiable risk factor associated with risks of adverse pregnancy outcomes (APO). Nevertheless, there is paucity of evidence if consumption of some food groups is associated with lower risk of APO, particularly in low-income settings. We aimed to determine whether consumption of some food groups is associated with lower risk of APOs such as: preterm birth (PTB), low-birth weight (LBW), and stillbirth in rural Central Ethiopia. METHODS: A multi-center (8 health centers) prospective cohort study, enrolling 432 pregnant women during their initial antenatal care visit, was employed. All mothers were then followed monthly (for a total of four visits) from enrollment to delivery. Midwives in respective health centers assessed dietary diversity using the Women's individual dietary diversity score and evaluated birth outcomes following standard procedures. Logistic regression models were run to predict association of food groups with the APO. FINDINGS: Out of the 374 pregnant women who completed the study, one in five [74 (19.8%)] experienced at least one of the APO: 34 (9.1%) gave birth to LBW babies, 51(13.6%) had PTB and 17 (4.5%) experienced stillbirth. Poor or inconsistent consumption (<¾ assessments) of dark green leafy vegetables (adjusted odds ratio (AOR) = 2.01; 95% confidence interval (CI): 1.04-3.87), dairy products (AOR = 2.64; 95% CI: 1.11-6.30), and fruits and vegetables (AOR = 2.92; 95% CI: 1.49-5.67) were independently associated with higher APO risks. Whereas, being nonanemic at term (AOR = 0.24; 95% CI: 0.12-0.48) was independently associated with lower APO risks. CONCLUSIONS: Poor or inconsistent consumption of dairy, dark green leafy vegetables and fruits were associated with higher risk of APOs. While community-based trials and mechanistic studies are needed to substantiate these findings, efforts to promote dietary diversity through increased consumption of fruits, vegetables and dairy may be beneficial in this and similar settings.

Effect of Deploying Trained Community Based Reproductive Health Nurses (CORN) on Long-Acting Reversible Contraception (LARC) Use in Rural Ethiopia: A Cluster Randomized Community Trial.

To investigate the effect of innovative means to distribute LARC on contraceptive use, we implemented a three arm, parallel groups, cluster randomized community trial design. The intervention consisted of placing trained community-based reproductive health nurses (CORN) within health centers or health posts. The nurses provided counseling to encourage women to use LARC and distributed all contraceptive methods. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where the new service providers were deployed, health post or health center. We calculated difference-in-difference (DID) estimates to assess program impacts on LARC use. After nine months of intervention, the use of LARC methods increased significantly by 72.3 percent, while the use of short acting methods declined by 19.6 percent. The proportion of women using LARC methods increased by 45.9 percent and 45.7 percent in the health post and health center based intervention arms, respectively. Compared to the control group, the DID estimates indicate that the use of LARC methods increased by 11.3 and 12.3 percentage points in the health post and health center based intervention arms. Given the low use of LARC methods in similar settings, deployment of contextually trained nurses at the grassroots level could substantially increase utilization of these methods.

Pregnant mothers have limited knowledge and poor dietary diversity practices, but favorable attitude towards nutritional recommendations in rural Ethiopia: evidence from community-based study.

BACKGROUND: Mothers' nutrition is crucial for good pregnancy outcomes and in improving children's nutritional status. The present study aimed to examine the level of knowledge and attitude towards maternal nutrition and dietary diversity practices among pregnant mothers in rural central Ethiopia. METHODS: In-depth analysis of data from a prospective study involving a total of 389 eligible pregnant women, enrolled during their second antenatal care (ANC) visit was conducted between August 2014 and March 2015. Study participants were selected by employing systematic sampling techniques. Dietary diversity practices were assessed by asking each individual pregnant woman to provide a single 24-h dietary recall. Simple frequencies and graphs were used to present the analyzed data and interpretations. RESULTS: Vegetables were listed top as major sources of vitamin A (45.5%) and iron (23.8%). Nearly half (47%) of the mothers lacked awareness on balanced and diversified diets. Conversely, nearly three fourths (73.8%) and two thirds (66.8%) of them had favorable attitudes towards dietary diversity and early initiation of antenatal care follow up. With a median dietary diversity score of four, starchy staples (100%), legumes and nuts (89.2%) were major food groups consumed by almost all of the mothers included in the study. CONCLUSION: Though pregnant mothers had limited knowledge and poor dietary diversity practices, they exhibited a relatively favorable attitude towards major nutritional recommendations. Use of antenatal care and its follow up as a point of entry for educating pregnant women and increasing nutrition knowledge and attitude is recommended.