A Feasibility Study of Integrating Maternal Nutrition Interventions Into Antenatal Care Services in Ethiopia
Condition: Maternal Dietary Diversity; Iron-Folic Acid Supplementation; Early Initiation of Breastfeeding
Study type: Interventional

Summary: 
      Alive & Thrive (A&T) is an initiative that supports the scaling up of nutrition interventions
      to save lives, prevent illnesses, and contribute to healthy growth and development through
      improved maternal nutrition, breastfeeding and complementary feeding practices. In Ethiopia,
      A&T integrated a package of maternal nutrition interventions into existing antenatal care
      (ANC) services delivered through government health facilities (counselling on diet quality
      during pregnancy, distribution and promotion of iron-folic acid (IFA) supplementation, weight
      gain monitoring, counselling on early breastfeeding practices, and systems strengthening
      through training and supportive supervision) and community platforms (home visits, Pregnant
      Women Conferences/Mother Support groups, and community gatherings). The evaluation used a
      two-arm cluster-randomized, non-masked trial design, consisting of two cross-sectional
      surveys in 2019 and 2021.
    

Detailed description: 
      There is wide recognition of the importance of integrating maternal nutrition interventions
      in ANC to improve maternal and child health. In 2016, World Health Organization ANC
      guidelines were updated to place a high priority on nutrition interventions during pregnancy
      to improve perinatal outcomes and women's experience of care.

      In Ethiopia, the government has adopted a package of maternal nutrition interventions into
      national guidelines (see Ethiopia's Federal Ministry of Health National Guideline on
      Adolescent, Maternal, Infant and Young Child Nutrition). Despite these efforts, the coverage
      and quality of maternal nutrition interventions remains low.

      A&T Ethiopia integrated a package of maternal nutrition interventions into existing ANC
      services delivered through government health facilities (counselling on diet quality during
      pregnancy, distribution and promotion of IFA supplementation, weight gain monitoring,
      counselling on early breastfeeding practices, and systems strengthening through training and
      supportive supervision) and community platforms (home visits, Pregnant Women
      Conferences/Mother Support groups, and community gatherings) that align with the latest
      global evidence. IFPRI tested the feasibility of the behavior-change interventions and
      examined their impacts on pregnant women's health and nutrition practices and breastfeeding
      practices of recently delivered women, compared with standard antenatal care services
      provided in control areas.

      The evaluation used a two-arm cluster-randomized, non-masked trial design, consisting of two
      cross-sectional surveys of pregnant and recently delivered women who attended government ANC
      services. The unit of randomization is the health center and associated health posts in the
      catchment area. 18 health centers and 2 hospitals in SNNPR and 10 health centers in Somali
      were randomly assigned to intervention/control. The baseline survey was conducted in
      October-November 2019, and the endline survey took place in July-September 2021. In 2020,
      program activities were interrupted between April and July 2020 due to the COVID-19 pandemic.
      The endline survey was postponed to July-September 2021 to maximize implementation duration.

      The overall study objective was to determine the feasibility and impact of integrating
      locally relevant maternal nutrition interventions into existing ANC services on diet quality
      and utilization of nutrition interventions during pregnancy.

      Research questions include:

        1. What are the program impacts on maternal practices: (1) consumption of diversified foods
           during pregnancy; (2) consumption of IFA supplements during pregnancy; and (3) early
           breastfeeding practices?

        2. Can the coverage and utilization of key maternal nutrition interventions during ANC be
           improved through system strengthening approaches?

        3. What factors influenced the integration and strengthening of maternal nutrition
           interventions into the government ANC service delivery platform?
    

Intervention name(s): Health Facility Interventions; Community Interventions; Health System Interventions
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Intensified counselling on dietary diversity and increased meal frequency during pregnancy.
Strengthened government distribution of IFA supplies with counseling about its importance, managing side effects, and reminder about subsequent supplies.
Weight-gain monitoring with messaging to mothers about healthy diet and adequate rest; excess weight gain as a danger sign.
Intensified counseling on importance, benefits, and how-tos of early initiation of breastfeeding and exclusive breastfeeding.; Home visits to pregnant women by HEWs to discuss maternal nutrition (dietary diversity, adequate food intake, IFA supplementation, and weight gain), early breastfeeding practices, provide ANC and Pregnant Women Conference referrals, and engage husbands.
HEWs use A&T intervention tools (e.g. posters and maternal nutrition follow-up card) at Pregnant Women Conferences/ Mother Support Groups to reinforce maternal nutrition messages, encourage ANC attendance, distribute IFA tablets, measure and track weight gain, promote early breastfeeding practices, and encourage husband participation.
HEWs and community volunteers (Women's Development Army (WDA), imams, etc.) deliver maternal nutrition messages and encourage ANC visits at kebele and community meetings.; Trainings on the maternal nutrition interventions for health center heads, nurse-midwives, HEWs, community volunteers (WDA, imams, etc.), woreda health officers, and other key actors.
Supportive supervision of maternal nutrition activities conducted by woreda nutrition officers, woreda health officers, TDA or A&T.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Maternal Nutrition; Antenatal Care; Ethiopia