Critical assessment of the current indicator for antenatal iron-containing supplementation coverage: Insights from a mixed-methods study.

Daily consumption of iron-containing supplements is recommended for all pregnant women but there is no approved global standard indicator for assessing supplementation coverage. Furthermore, the validity of commonly used coverage indicators for iron-containing supplement consumption is questionable. The WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring, and partners, have systematically worked to identify a feasible and valid indicator of iron-containing supplement coverage for reporting by countries. In 2019, we conducted key informant interviews with respondents in eight countries, fielded an online survey (in three languages using SurveyMonkey) to which 142 nutrition professionals from 52 countries responded, and used Demographic and Health Surveys (DHS) data from four countries to assess determinants of the quality of iron-containing supplement coverage data. Less than half (45%) of online survey respondents were satisfied with the current methods for collecting iron-containing supplement coverage data in their context. Recommended changes by study respondents include recall period <5 years, adding questions about counselling, including other beneficiary groups, and assessing supply chain functionality. The DHS analysis suggested an association between time since pregnancy and data quality. Data heaping on multiples of 30 was observed in 40%-75% of data. There is a clear demand for a revised indicator and measurement guidance for coverage of iron-containing supplementation during pregnancy. Future research should continue the development and validation of a global indicator, to more precisely validate the quality of recall data, including the distinction between distribution and consumption using various question formulations.

Applying international guidelines for calcium supplementation to prevent pre-eclampsia: simulation of recommended dosages suggests risk of excess intake in Ethiopia.

OBJECTIVE: To simulate impact of Ca supplementation on estimated total Ca intakes among women in a population with low dietary Ca intakes, using WHO recommendations: 1·5-2·0 g elemental Ca/d during pregnancy to prevent pre-eclampsia. DESIGN: Single cross-sectional 24 h dietary recall data were adjusted using IMAPP software to simulate proportions of women who would meet or exceed the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL) assuming full or partial adherence to WHO guidelines. SETTING: Nationally and regionally representative data, Ethiopia's 'lean' season 2011. SUBJECTS: Women 15-45 years (n 7908, of whom 492 pregnant). RESULTS: National mean usual Ca intake was 501 (sd 244) mg/d. Approximately 89, 91 and 96 % of all women, pregnant women and 15-18 years, respectively, had dietary Ca intakes below the EAR. Simulating 100 % adherence to 1·0, 1·5 and 2·0 g/d estimated nearly all women (>99 %) would meet the EAR, regardless of dosage. Nationally, supplementation with 1·5 and 2·0 g/d would result in intake exceeding the UL in 3·7 and 43·2 % of women, respectively, while at 1·0 g/d those exceeding the UL would be <1 % (0·74 %) except in one region (4·95 %). CONCLUSIONS: Most Ethiopian women consume insufficient Ca, increasing risk of pre-eclampsia. Providing Ca supplements of 1·5-2·0 g/d could result in high proportions of women exceeding the UL, while universal consumption of 1·0 g/d would meet requirements with minimal risk of excess. Appropriately tested screening tools could identify and reduce risk to high Ca consumers. Research on minimum effective Ca supplementation to prevent pre-eclampsia is also needed to determine whether lower doses could be recommended.

Prevalence of and factors associated with antenatal care seeking and adherence to recommended iron-folic acid supplementation among pregnant women in Zinder, Niger.

The World Health Organization recommends iron and folic acid (IFA) supplementation for pregnant women. The high prevalence of anaemia among pregnant women in Niger warrants better understanding of the utilization of antenatal care (ANC) and IFA. We aimed to assess the prevalence of and factors associated with ANC coverage and adherence to IFA recommendation among pregnant women. Pregnant women (n = 923) from 64 randomly selected villages within the catchment area of 12 health centres were interviewed during a baseline household survey in Zinder, Niger. ANC and IFA coverage were 60.1% and 43.6%, respectively. Only 71.7% of women who attended ANC received IFA. Of the 401 women who reportedly received any IFA supplements, 99.3% had attended any ANC during their current pregnancy and 68.6% reported adherence to recommended IFA supplementation (i.e., consumed IFA every day in the previous week). Women with gestational age ≥27 weeks were more likely to have attended ANC than women with gestational age <27 weeks (85.9% vs. 27.5%, odds ratio [OR]: 21.81, 95% confidence interval [CI]: 13.81, 34.45). Women who reportedly received husbands' advice about attending ANC were more likely to attend ANC (OR: 1.48, 95% CI [1.03, 2.11]) and adhere to IFA recommendations (OR: 1.80, 95% CI [1.04, 3.13]) compared to those who did not receive any advice. ANC attendance is crucial to ensure distribution of IFA supplementation among pregnant women in Zinder. Interventions to improve ANC and IFA adherence will require promotion of early ANC, ensure availability of IFA at ANC, and involve husbands in ANC.

Integrating nutrition into health systems at community level: Impact evaluation of the community-based maternal and neonatal health and nutrition projects in Ethiopia, Kenya, and Senegal.

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 <6 months infants were exclusively breastfed (OR = 2.01; 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.

Emerging Evidence and Critical Issues with the Use of Single-Drop Capillary Blood for the Measurement of Hemoglobin Concentration in Population-Level Anemia Surveys.

Accurate and precise measurement of hemoglobin concentration is critical for reliable estimations of anemia prevalence at the population level. When systematic and/or random error are introduced in hemoglobin measurement, estimates of anemia prevalence might be significantly erroneous and, hence, limit their usefulness. For decades, single-drop capillary blood has been the most common blood source used for the measurement of hemoglobin concentration in surveys, especially in low-income and middle-income countries. In this study, we highlight historical and emerging evidence that single-drop capillary blood introduces a high degree of random error (variability) to hemoglobin estimates, leading to less reliable estimates of anemia prevalence at the population level. At present, the best practice is to collect and use venous blood for measurement of hemoglobin with an automated hematology analyzer, following standard operating procedures and quality assurance measures. Where use of an automated analyzer is not possible, the analysis of venous blood in a point-of-care hemoglobinometer by trained phlebotomists or specimen collectors should be considered. A forthcoming systematic review will provide additional evidence on the accuracy and precision of single-drop capillary blood for hemoglobin assessment. In the meantime, we raise caution when using single-drop capillary blood for hemoglobin measurement as it can result in inaccurate hemoglobin estimates and less reliable anemia prevalence estimates.

Effectiveness of nutrition counseling for pregnant women in low- and middle-income countries to improve maternal and infant behavioral, nutritional, and health outcomes: A systematic review.

Background: Nutritional counseling, which includes two-way interactive education, has been hypothesized to improve the health and nutritional status of pregnant women, but little is known about the impact such practice of care might have on maternal and infant health and behavioral outcomes of pregnant women living in low income, low-middle income, and upper-middle-income countries (LMIC)s. Objectives: We conducted a systematic review to appraise the effectiveness and impact on health equity of two-way nutritional counseling practices in LMICs on maternal and infant behavioral, nutritional, and health outcomes. Search Methods: We conducted electronic searches for relevant studies on Medline, Embase, CINAHL, PsychInfo, and the Cochrane CENTRAL for randomized and non-randomized trials on the effectiveness of two-way interactive nutritional counseling among pregnant women from the date of database inception up to June 22, 2021. In addition, we searched references of included studies in systematic reviews, gray literature resources, and unpublished studies or reports that satisfied our eligibility criteria using a focused Google search. Selection Criteria: We included randomized and non-randomized controlled studies (NRS), controlled before and after, and interrupted time series that assessed the effectiveness of two-way interactive nutrition counseling targeting pregnant women in LMICs. Data Collection and Analysis: Data extraction and risk of bias were conducted in duplicate. The risk of bias (ROB) for randomized trials (RCT) was assessed according to the Cochrane Handbook of Systematic Reviews, and ROB for NRS was assessed using the Newcastle-Ottawa scale (NOS). RCT and NRS were meta-analyzed separately. Main Results: Our search identified 6418 records and 52 studies met our inclusion criteria, but only 28 were used in the quantitative analysis. Twenty-eight studies were conducted in Asia, the most in Iran. Eight studies were conducted in Africa. Two-way interactive nutritional counseling during pregnancy may improve dietary caloric intake (mean difference [MD]: 81.65 calories, 95% confidence interval [CI], 15.37-147.93, three RCTs; I 2 = 42%; moderate certainty of evidence using GRADE assessment), may reduce hemorrhage (relative risk [RR]: 0.63; 95% CI, 0.25-1.54, two RCTs; I 2 = 40%; very low certainty of evidence using GRADE assessment), may improve protein (MD: 10.44 g, 95% CI, 1.83-19.05, two RCTs; I 2 = 95%; high certainty of evidence using GRADE assessment), fat intake (MD: 3.42 g, 95% CI, -0.20 to 7.04, two RCTs; I 2 = 0%; high certainty of evidence using GRADE assessment), and may improve gestational weight gain within recommendations (RR: 1.84; 95% CI, 1.10-3.09, three RCTs; I 2 = 69%). Nutrition counseling probably leads to the initiation of breastfeeding immediately after birth (RR: 1.72; 95% CI, 1.42-2.09, one RCT). There was little to no effect on reducing anemia (RR: 0.77; 95% CI, 0.50-1.20, three RCTs; I 2 = 67%; very low certainty of evidence using GRADE assessment) risk of stillbirths (RR: 0.81; 95% CI, 0.52-1.27, three RCTs; I 2 = 0%; moderate certainty of evidence using GRADE assessment) and risk of cesarean section delivery (RR: 0.96; 95% CI, 0.76-1.20, four RCTs; I 2 = 36%; moderate certainty of evidence using GRADE assessment). Authors' Conclusions: Our review highlights improvements in maternal behavioral and health outcomes through interactive nutrition counseling during pregnancy. However, we are uncertain about the effects of nutrition counseling due to the low certainty of evidence and a low number of studies for some key outcomes. Moreover, the effects on health equity remain unknown. More methodologically rigorous trials that focus on a precise selection of outcomes driven by the theory of change of nutrition counseling to improve maternal and infant behavioral and health outcomes and consider equity are required.

Chlorhexidine cord care after a national scale-up as a newborn survival strategy: A survey in four regions of Ethiopia.

INTRODUCTION: Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource constrained settings. The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017. However, there is lack of evidence on the provision of this important intervention in Ethiopia. In this paper, we report on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia. METHODS: A standardized Nutrition International Monitoring System (NIMS) survey was conducted from January 01 to Feb 13, 2020 in four regions of Ethiopia (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region [SNNPR]) on sample of 1020 women 0-11 months postpartum selected through a multistage cluster sampling approach. Data were collected using interviewer-administered questionnaires in the local languages through home-to-home visit. Accounting for the sampling design of the study, we analyzed the data using complex data analysis approach. Complex sample multivariable logistic regression was used to identify the determinants of chlorhexidine cord care practice. RESULTS: Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% (95% confidence interval [CI]: 41.1%- 51.2%) of all newborns. Chlorhexidine cord care started within 24 hours after birth for 34.4% (95% CI: 29.5%- 39.6%) of newborns, though this varied widely across regions: from Oromia (24.4%) to Tigray (60.0%). Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more. Further, neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care, relative to those born without a skilled attendant (adjusted odds ratio [AOR]: 10.36, 95% CI: 3.73-28.75). Besides, neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care relative to newborns born to mothers who did not have knowledge of the benefit of chlorhexidine cord care (AOR: 39.03, 95% CI: 21.45-71.04). CONCLUSION: A low proportion of newborns receive chlorhexidine cord care in Ethiopia. The practice of chlorhexidine cord care varies widely across regions and is limited mostly to births attended by skilled birth attendants. Efforts must continue to ensure women can reach skilled care at delivery, and to ensure adequate care for newborns who do not yet access skilled delivery.

Reconsidering the Tolerable Upper Levels of Zinc Intake among Infants and Young Children: A Systematic Review of the Available Evidence.

Safe upper levels (UL) of zinc intake for children were established based on either (1) limited data from just one study among children or (2) extrapolations from studies in adults. Resulting ULs are less than amounts of zinc consumed by children in many studies that reported benefits of zinc interventions, and usual dietary zinc intakes often exceed the UL, with no apparent adverse effects. Therefore, existing ULs may be too low. We conducted a systematic bibliographic review of studies among preadolescent children, in which (1) additional zinc was provided vs. no additional zinc provided, and (2) the effect of zinc on serum or plasma copper, ceruloplasmin, ferritin, transferrin receptor, lipids, or hemoglobin or erythrocyte super-oxide dismutase were assessed. We extracted data from 44 relevant studies with 141 comparisons. Meta-analyses found no significant overall effect of providing additional zinc, except for a significant negative effect on ferritin (p = 0.001), albeit not consistent in relation to the zinc dose. Interpretation is complicated by the significant heterogeneity of results and uncertainties regarding the physiological and clinical significance of outcomes. Current zinc ULs should be reassessed and potentially revised using data now available for preadolescent children and considering challenges regarding interpretation of results.

Situational analysis of infant and young child nutrition policies and programmatic activities in Chad.

Progress towards reducing mortality and malnutrition among children <5 years of age has been less than needed to achieve related Millennium Development Goals (MDGs). Therefore, several international agencies joined to 'reposition children's right to adequate nutrition in the Sahel', starting with an analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of the situational analysis are to compile, analyse, and interpret available information on infant and child feeding, and the nutrition situation of children <2 years of age in Chad, as one of the six targeted countries. These findings are available to assist in identifying inconsistencies and filling gaps in current programming. Between June and October of 2008, key informants responsible for IYCN-related activities in Chad were interviewed, and 53 documents were examined on the following themes: the promotion of optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, management of acute malnutrition, prevention of mother-to-child transmission of human immunodeficiency virus (HIV), food security, and promotion of good hygienic practices. Chad is not on track to reaching the MDGs of reducing mortality by two-thirds and malnutrition by half among children <5 years of age between 1990 and 2015. Most of the key IYCN topics were addressed in a national policy to combat malnutrition and micronutrient deficiencies. No national nutrition policy was yet ratified in Chad, so the target of many documents reviewed was the malnourished child. Researchers have identified some barriers to optimal feeding practices. However, the majority of these surveys were small scale, so they do not necessarily provide information relevant to the general population. Expanded surveys would be needed for developing evidence-based educational messages targeted to local needs. Reviewed training materials and related programmes being implemented in Chad provide specific guidance for nearly all of the key IYCN topics, except for appropriate feeding choices for the prevention of mother-to-child transmission of HIV. Some of the programmes were intended for national coverage, but we could not confirm whether these programmes were actually implemented nationally. Monitoring and evaluation reports were available for some small-scale programmes, but few of these evaluated whether IYCN-specific programme components were implemented as designed and none evaluated whether participants adopted the promoted feeding practices. Establishment of the policy and programme framework has commenced for improving IYCN practices. Formative research is needed to guide the development of evidence-based training materials and programmes to address the nutritional needs of infants and children. Once more directed programmes are established, there is a further need for rigorous monitoring and evaluation to ensure that training is adequate, programmes are implemented as designed, and effective programmes are identified for expansion nationally. Evaluations are also needed to determine where human and institutional capacity building is needed to carry out these activities as they are implemented. National and international support will be required to complete these enhancements, and thus improve the health and nutritional status of infants and young children in Chad.

Situational analysis of infant and young child nutrition policies and programmatic activities in Mali.

Progress towards reducing mortality and malnutrition among children <5 years of age has been less than needed to achieve related Millennium Development Goals. Therefore, several international agencies joined to 'Reposition children's right to adequate nutrition in the Sahel', starting with a situational analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of the situational analysis are to compile, analyse and interpret available information on infant and young child feeding, and the nutrition situation of children <2 years of age in Mali, as one of the six targeted countries. Between June and September 2008, key informants responsible for conducting IYCN-related activities in Mali were interviewed, and 117 documents were examined on the following themes: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, screening and management of acute malnutrition, prevention of mother-to-child transmission of HIV, food security, and hygienic practices. Most of the key IYCN topics were addressed in national policies, training materials, and programme documents. Information on the national coverage and impact of these programmes is generally not available. Exclusive breastfeeding (<6 months) has increased in Mali, but no studies identified the contributors to this increase. Despite improvements in breastfeeding practices, optimal infant, and young child feeding is still practiced among too few young children in Mali. Several research articles were identified, but few of these were linked to programme development. Some programme monitoring and evaluation reports were available, but few of these were rigorous enough to identify whether IYCN-specific programme components were implemented as designed or were achieving desired outcomes. Therefore, we could not confirm which programmes contributed to reported improvements. Monitoring of programmes managing malnutrition identified gaps in human and institutional capacities to fully carry out intended interventions and the government has recognized the overall lack of adequate numbers of health care providers to carry out necessary programmes in Mali, of which nutrition programmes are a part. The policy and programme framework is well established for support of optimal IYCN practices, but greater resources and capacity building are needed to: (i) conduct necessary research to adapt training materials and programme protocols to programmatic needs; (ii) implement rigorous monitoring and evaluation that identify effective programme components; and (iii) apply these findings in developing, expanding, and improving effective programmes.

Situational analysis of infant and young child nutrition policies and programmatic activities in Burkina Faso.

Progress towards reducing mortality and malnutrition among children < 5 years of age has been less than needed to achieve related Millennium Development Goals. Therefore, several international agencies joined to 'Reposition children's right to adequate nutrition in the Sahel', starting with an analysis of current activities related to infant and young child nutrition (IYCN). The objectives of the present paper are to compare relevant national policies, training materials, programmes, and monitoring and evaluation activities with internationally accepted IYCN recommendations. These findings are available to assist countries in identifying inconsistencies and filling gaps in current programming. Between August and November 2008, key informants responsible for conducting IYCN-related activities in Burkina Faso were interviewed, and 153 documents were examined on the following themes: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, screening and treatment of acute malnutrition, prevention of mother-to-child transmission of HIV, food security and hygienic practices. National policy documents addressed nearly all of the key IYCN topics, specifically or generally. Formative research has identified some local barriers and beliefs related to general breastfeeding and complementary feeding practices, and other formative research addressed about half of the IYCN topics included in this review. However, there was little evidence that this formative research was being utilized in developing training materials and designing programme interventions. Nevertheless, the training materials that were reviewed do provide specific guidance for nearly all of the key IYCN topics. Although many of the IYCN programmes are intended for national coverage, we could only confirm with available reports that programme coverage extended to certain regions. Some programme monitoring and evaluation were conducted, but few of these provided information on whether the specific IYCN programme components were implemented as designed. Most surveys that were identified reported on general nutrition status indicators, but did not provide the detail necessary for programme impact evaluations. The policy framework is well established for optimal IYCN practices, but greater resources and capacity building are needed to: (i) conduct necessary research and adapt training materials and programme protocols to local needs; (ii) improve, carry out, and document monitoring and evaluation that highlight effective and ineffective programme components; and (iii) apply these findings in developing, expanding, and improving effective programmes.

Situational analysis of infant and young child nutrition policies and programmatic activities in Niger.

Due to limited progress towards reducing mortality and malnutrition among children <5 years of age, an alliance of international agencies joined to 'Reposition children's right to adequate nutrition in the Sahel,' starting with a situational analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of this analysis are to compile, analyse, and interpret available information on infant and child feeding and the nutrition situation of children <2 years of age in Niger, as one of the six targeted countries. Between August and November 2008, key informants responsible for conducting IYCN-related activities in Niger were interviewed, and 90 documents were examined on: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, prevention of mother-to-child transmission of HIV, management of acute malnutrition, food security, and hygienic practices. The results reported are limited by the availability of documents for review. Mortality rates are on track to reaching the Millennium Development Goal to reduce mortality among young children by two-thirds by 2015, but there has been no change in undernutrition, and total mortality rates are still high among young children. Nearly all of the key IYCN topics were addressed, specifically or generally, in national policy documents, training materials, and programmes. A national nutrition council meets regularly to coordinate programme activities nationally. Many of the IYCN-related programmes are intended for national coverage, but few reach this coverage. Monitoring and impact evaluations were conducted on some programmes, but few of these reported on whether the specific IYCN components of the programme were implemented as designed or compared outcomes with non-intervention sites. Human resources have been identified as inadequate to fully carry out nutrition programmes in Niger. Due to these limitations, we could not confirm whether the lack of progress in reducing malnutrition was due to ineffective or inadequately implemented programmes, though both of these were likely contributors. The policy framework is well established for the promotion of optimal IYCN practices, but greater resources and capacity building are needed to: (i) increase human capacities to carry out nutrition programmes; (ii) expand and track the implementation of evidence-based programmes nationally; (iii) improve and carry out monitoring and evaluation that identify effective and ineffective programmes; and (iv) apply these findings in developing, expanding, and improving effective programmes.

Situational analysis of infant and young child nutrition policies and programmatic activities in Senegal.

Progress towards reducing mortality and malnutrition among children <5 years of age has been less than needed to achieve related Millennium Development Goals (MDGs). Therefore, several international agencies joined to 'Reposition children's right to adequate nutrition in the Sahel', starting with an analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of the situational analysis are to compile, analyse and interpret available information on infant and child feeding and the nutrition situation of children <2 years of age in Senegal, as one of the six targeted countries. These findings will be used to assist in identifying inconsistencies and filling gaps in current programming. Between August and December 2008, key informants responsible for conducting IYCN-related activities in Senegal were interviewed, and 157 documents were examined on the following themes: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, prevention of mother-to-child transmission of HIV, management of acute malnutrition, food security and hygienic practices. Nearly all of the key IYCN topics were addressed, specifically or generally, in national policy documents. Senegal reported substantial improvements since the 1990s towards reducing infant and young child mortality and underweight, and increasing exclusive breastfeeding among infants <6 months of age (34%). Senegal is one of the few countries in the region that is nearly on track for reaching related MDGs. Notable activities that may have played a role include: (1) vitamin A supplementation was expanded to nearly semi-annual national campaigns starting in 1994; (2) the Ministry of Health partnered with several national and international agencies to scale up child survival activities under the umbrella of the Basic Support for Institutionalizing Child Survival (1994-2006); (3) a national nutrition division was developed to support a national nutrition strengthening programme; (4) the national nutrition counsel was organized to coordinate nutritional activities across various organizations and governmental sectors, involving representatives from health, agriculture and surveillance; and (5) an integrated communications programme was developed to support harmonized behaviour change communication tools for the health and nutrition sectors. Along with these activities, a number of programme evaluations were conducted to ensure that programmes obtain desired results. Although useful, these evaluations were not rigorous enough to identify effective programmes that contributed to the mentioned reductions in the prevalence of underweight and mortality, and increases in exclusive breastfeeding. The policy and programme framework is well established for support of optimal IYCN practices in Senegal. Despite the recent improvements in infant and young child nutritional status indicators, there is still much to do. Greater resources and continued capacity building are needed to: (1) conduct necessary research for adapting training materials and programme protocols to programmatic needs; (2) improve and carry out monitoring and evaluation that identify effective programme components; and (3) apply these findings in developing, expanding and improving effective programmes.

Accelerating improvements in nutritional and health status of young children in the Sahel region of Sub-Saharan Africa: review of international guidelines on infant and young child feeding and nutrition.

The United Nations Convention on the Rights of the Child holds governments responsible to ensure children's right to the highest attainable standard of health by providing breastfeeding support, and access to nutritious foods, appropriate health care, and clean drinking water. International experts have identified key child care practices and programmatic activities that are proven to be effective at reducing infant and young child undernutrition, morbidity, and mortality. Nevertheless, progress towards reducing the prevalence of undernutrition has been sporadic across countries of the Sahel sub-region of Sub-Saharan Africa. In view of this uneven progress, a working group of international agencies was convened to 'Reposition children's right to adequate nutrition in the Sahel.' The first step towards this goal was to organize a situational analysis of the legislative, research, and programmatic activities related to infant and young child nutrition (IYCN) in six countries of the sub-region: Burkina Faso, Chad, Mali, Mauritania, Niger, and Senegal. The purposes of this introductory paper are to review current information concerning the nutritional and health status of infants and young children in the Sahel and to summarize international guidelines on optimal IYCN practices. These guidelines were used in completing the above-mentioned situational analyses and encompass specific recommendations on: (i) breastfeeding (introduction within the first hour after birth, exclusivity to 6 months, continuation to at least 24 months); (ii) complementary feeding (introduction at 6 months, use of nutrient dense foods, adequate frequency and consistency, and responsive feeding); (iii) prevention and/or treatment of micronutrient deficiencies (vitamin A, zinc, iron and anaemia, and iodine); (iv) prevention and/or treatment of acute malnutrition; (v) feeding practices adapted to the maternal situation to reduce mother-to-child transmission of HIV; (vi) activities to ensure food security; and (vii) the promotion of hygienic practices concerning food preparation and storage and environmental sanitation. The following papers in this issue will present results of the situational analyses for the individual countries.

Situational analysis of infant and young child nutrition policies and programmatic activities in the Islamic Republic of Mauritania.

Progress towards reducing mortality and malnutrition among children <5 years of age has been less than needed to achieve related Millennium Development Goals (MDGs), so several international agencies joined to 'reposition children's right to adequate nutrition in the Sahel', starting with an analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of the situational analysis are to compile, analyse, and interpret available information on infant and child feeding, and the nutrition and health situation of children <2 years of age in Mauritania as one of the six target countries (Burkina Faso, Chad, Mali, Mauritania, Niger, Senegal). These findings are available to assist countries in identifying inconsistencies and filling gaps in current programming. Between August and November of 2008, key informants responsible for conducting IYCN-related activities in Mauritania were interviewed, and 46 documents were examined on the following themes: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, prevention of mother-to-child transmission of human immunodeficiency virus (HIV), management of acute malnutrition, food security, and hygienic practices. Mauritania is on track to reaching the MDG of halving undernutrition among children <5 years of age by 2015. National policy documents, training guides, and programmes address nearly all of the key IYCN topics, specifically or generally. Exceptions are the use of zinc supplements in diarrhoea treatment, prevention of zinc deficiency, and dietary guidelines for preventing mother-to-child transmission of HIV. Substantial infrastructure capacity building was also recently implemented in nutritionally high-risk regions, and increases were reported in exclusive breastfeeding rates among children <6 months. The recent National Behaviour Change Communication Strategy is intended to address the needs of adapting programme activities to local needs. Despite these noteworthy accomplishments, the prevalence of acute malnutrition remains high, mortality rates did not decrease as malnutrition rates decreased, the overall prevalence of desirable nutrition-related practices is low, and human resources are reportedly insufficient to carry out all nutrition-related programme activities. Very little nutrition research has been conducted in Mauritania, and key informants identified gaps in adapting international programmes to local needs. Monitoring and evaluation reports have not been rigorous enough to identify which programme activities were implemented as designed or whether programmes were effective at improving nutritional and health status of young children. Therefore, we could not confirm which programmes might have been responsible for the reported improvements, or if other population-wide changes contributed to these changes. The policy framework is supportive of optimal IYCN practices, but greater resources and capacity building are needed to (i) support activities to adapt training materials and programme protocols to fit local needs, (ii) expand and track the implementation of evidence-based programmes nationally, (iii) improve and carry out monitoring and evaluation that identify effective and ineffective programmes, and (iv) apply these findings in developing, disseminating, and improving effective programmes.

PROTOCOL: The effects of empowerment-based nutrition interventions on the nutritional status of women of reproductive age in low- and middle-income countries.

The systematic review will answer the follow research questions: (1) What is the effectiveness of different empowerment approaches employed within nutrition interventions on the nutritional status of women of reproductive age in low- and middle-income countries? (2) What implementation and contextual factors contribute to or detract from the effectiveness of these interventions?

PROTOCOL: Effectiveness of nutrition counselling for pregnant women in low- and middle-income countries to improve maternal, infant and child behavioural, nutritional and health outcomes: A systematic review.

The objective of this systematic review is to identify, appraise and synthesise the best available evidence on the effectiveness of nutritional counselling and education interventions on maternal, infant and child health outcomes, and assess the differences in effects across participants' PROGRESS+ characteristics. To achieve these objectives, we will aim to answer the following research questions: What is the effectiveness of nutrition counselling interventions for pregnant women in low- or middle-income countries on maternal, infant and child health outcomes? What are the impacts of nutrition counselling interventions on maternal, infant and child health outcomes across participants' PROGRESS+ characteristics?

Estimating nutrient fortification levels in condiments and seasonings for public health programs: considerations and adaptations.

Condiments and seasonings have been considered as potential vehicles for fortification in place of, or in addition to, fortifiable staple foods. Methodologies for establishing fortification programs focus primarily on use of staple foods, which are consumed in larger portions than condiments and seasonings. Some fortification models assume self-limiting consumption relative to the maximum energy consumed by target populations. However, this assumption may prove incorrect for estimating fortification concentrations of condiments and seasonings because they may only provide negligible energy. Although flavor or color may limit consumption, these limits would vary across each condiment or seasoning vehicle. In addition, the small volume of condiments and seasonings consumed relative to staple foods can lead to proportionally larger potential errors than with staple foods when measuring usual dietary intakes for establishing safe and effective fortification concentrations. This paper reviews available methods for setting fortification levels, whether or how available methods or conceptual frameworks could be adapted to condiments and seasonings, and gaps in knowledge for appropriately using condiments and seasonings as vehicles for fortification in public health.