A health systems strengthening approach to
improve nutrition of pregnant women and newborns
in Ethiopia, Kenya and Senegal.
Jacqueline Kung’u1, Banda Ndiaye1, Crispin Ndedda1, Girma Bogale1, Emily Gold1, Lynnette
Neufeld, 2 Luz Maria De-Regil1
1Micronutrient
Initiative, 2Global Alliance for Improved Nutrition
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Introduction
• Pregnant women and newborns are among the
vulnerable populations in any community
• We commissioned demonstration projects to
generate evidence for strengthening the health
systems to ensure pregnant and newborns are
reached with proven health and nutrition
interventions
• Approach used in each country suitable to existing
health system context
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Community Based Maternal and Newborn Health projects
1. Ethiopia
Supporting Ethiopia’s
Health Extension
Program to increase
access to quality
maternal, neonatal
and nutrition services
2. Kenya
Improved care and
Nutrition for Women at
Risk during Pregnancy
through a Novel
Community-Facility
Linkage program
3. Senegal
Development and
piloting of
comprehensive
Maternal and
Newborn Community
Health (MNCH) policy
for Senegal.
Maternal and Neonatal morbidity and mortality reduced
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Program Theory - Ethiopia
Input
MNHN training
guidelines and booklet
Monitoring and
Collaborative Quality
Improvement (CQI) at
Health Facilities
Impact
Outcomes
Providers Knowledge,
Skill, and Commitment
on MNHN services
improved
Improved MNHN Service
Quality
Maternal and Neonatal
morbidity and mortality
reduced
Supply and Medical
equipment improved
Improved MNHN
Service uptake
Knowledge, skills and practice
of Guide Team s & CQI Teams
at the community to improve
demand for MNHN services
Access: Availability of
trained Guide team in the
community that provides
MNHN services
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Program Theory - Kenya
Health facility
strengthening
Community mobilization
and Referral
(Demand creation)
Input
Outcomes
Impact
Behavior change Interventions
at the community
CHW training
Facilities
TBA orientation
Increased MNH
& Nutrition
knowledge
TBAs as
birth
companions
Incentive package
Collective and individual
Teamwork and simulation
training (PRONTO)
Intervention only
Harmonized EmONC Training
(MoH)
Intervention & Comparison
Increased
demand for
services
Increased
utilization
of services
Improved
care &
nutrition of
pregnant
women &
newborns
Maternal and Neonatal
morbidity and mortality
reduced
Retention of
CHWs in
program
Improved skills and knowledge
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Program Theory- Senegal
Outcomes
Input
Formation of and training of
facilitators of influencer and
pregnant women peer groups
Matron, Bajenou Gox and Relay
trained and have effective
communication strategy (ECS))
Delayed and
quality care
umbilical cord
clamping
Delivery with
trained provider in
community (low
risk)
Health extension workers
trained and have ECS
Comprehensive package of
MNH services designed
New health huts enlisted and
equipped
Supply and distribution issues
resolved for misoprostol, IFA, MgSO4
loading dose (at health post only)
Impact
Decreased
PPH
Maternal and Neonatal
morbidity and mortality
reduced
Mesoprostol
use
MgSO4 loading
dose use at health
post
Early ANC
Quality ANC,
including
effective
counselling
Appropriate use of
iron-folic acid
supplements
Child birth
preparation
Early and
exclusive
breastfeeding
Decreased anemia
prevalence in
pregnant women
Decreased
Newborn
Infection
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Quasi experimental study design using mixed methods
Baseline
assessment
(Qualitative +
Quantitative)
2013
1. Mothers with
children 0-11 mths
2. Pregnant women
3. CHW/HEW
4. TBA
5. HF Staff
No random assignment
Intervention + Comparison
Intervention
Ethiopia - Integrated set of activities and
essential services
Kenya - Community facility Linkage
Senegal – Pilot the defined package of
services at community level
Process/Midterm evaluation –
Evaluate the process of
implementing the intervention
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Endline
assessment
(Qualitative +
Quantitative)
2015
Measure the
impact of
intervention on
various outcome
and impact
indicators
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ANC Visits
Indicator
Intervention
Comparison
Kenya
Ethiopia
Senegal
Kenya
Ethiopia
Senegal
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
% of mothers of children 011 m of age who attend
ANC at least 4 times during
most recent pregnancy.
178/413
43%
48/998
4.8%
202/1086
18.6%
99/204
48.5%
28/971
2.9%
146/350
41.7%
% of mothers of children 011 m of age who received
ANC in the first trimester
during most recent
pregnancy
79/427
18.5%
51/246
20.7%
330/1094
30.2%
19/204
9.3%
56/107
24.3%
177/392
45.2%
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IFA utilization
Indicator
Intervention
Comparison
Kenya
Ethiopia
Senegal
Kenya
Ethiopia
Senegal
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
% of mothers of children 011 m of age who report
having taken IFA during the
latest pregnancy ≥ 90 d
105/286
36.7%
6/177
3.4%
760/1367
55.6%
45/109
41.3%
13/212
6.1%
379/442
85.7%
% of mothers of children 011 m of age who report
having taken any IFA
during pregnancy
309/464
66.6%
178/995
17.8%
1020/1444
70.6%
131/218
60.1%
211/971
21.7%
389/481
79.6%
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Understanding Barriers to and Opportunities for ANC in
Kenya: Pregnant Women
The pregnant women and mothers of young children were all positive
about ANC especially because of the check-ups, vaccinations and the
fact that they receive a mosquito net.
Reasons given by some for not visiting ANC :
• ANC is not beneficial - especially in the first trimester
• The hospital smell is offensive
• Their mothers-in-law do not encourage them to seek ANC and so they do
not attend to please them (this contradicts some of the responses from
mothers in-laws, who said, for example, that the women are simply lazy
and don’t attend ANC)
• They find the process of being examined very tiresome
• Fear of being tested for HIV.
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Understanding Barriers to and Opportunities for ANC in
Ethiopia: Women
•
•
•
Most participants believed that there is no need to go for ANC services
as the services are meant for pregnant women who are sick. Those
who had ANC visit noted that health care providers were doing nothing
if the mother and fetus are healthy during the visit.
A mother of nine children from Golina Botena district remarked “ I
didn’t use ANC services because I was healthy. A woman should go
for antenatal care services if she gets ill”
On the other hand, in depth interview participants indicated that
women who had a problem during their pregnancy go to health
institutions for repeated follow-up
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Understanding Barriers to and Opportunities for ANC in
Senegal : Lactating women, Husband, Mother in-law
• Geographical barriers-- All participants stated that distance was a critical
barrier and inaccessible roads.
• Cultural barriers – “…Husbands should get more involved on aspects of
ANC. Their support is only financial…”(Mother in-law).
• “…Women are used to hiding their pregnancy and always inform us late
to avoid evil spirit…” (Husband).
• Training barriers-- “…The health workers are not patient or lack
training…” (Husband)
• BCC barriers – “...Religious and traditionalists ignore the benefits of IFA
and propose healing plants due to lack of sensitization…” (Mother in-law)
• Opportunities- Women who had received advices on ANC were more
likely to do it early and completely
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Health facility Staff, Mothers in Law and Midwives
According to the health facility staff, women come for ANC:
• Late, usually when they are about 6 months or even near term
• when they are sick or have a problem
• when they cannot afford or pay for services
The following are considered to be greatest worries and most common problems
facing pregnant women in the community:
• Facilities being too far; Lack of transport - especially at night; Diseases (such as
malaria, HIV); Anemia, poor nutrition; Poverty, polygamy; Unaffordable hospital
charges ; Ignorance
According to mothers in-laws and mid-wives ,pregnant women should make ANC
visits early enough, preferably at three months gestation period.
Reasons they indicated for women not attending ANC as required included:
• Laziness; Ignorance; Fear of harsh facility service providers (although the retired
mid-wives were previously health service providers); Financial constraints;
Distance; Fear of injections/drugs
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Postnatal Care
Indicator
Intervention
Kenya
Ethiopia
Comparison
Senegal
Kenya
Ethiopia
Senegal
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
% of lactating women who
initiate breastfeeding within
one hour after birth.
276/297
92.9%
365/967
37.7%
743/4101
53%
117/135
86.6%
522/961
54.3%
232/439
52.8%
% of mothers of children 011 m of age who delivered
with skilled attendant
81/258
31.4%
63/997
6.3%
801/1433
55.9%
66/119
55.5%
58/971
6%
276/467
59.1%
% of women who received
post natal care 48 hours
after delivery
235/272
86.4%
11/18
61.1%
964/1397
59%
144/147
98%
21/26
80.8%
403/455
88.6%
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Understanding Barriers to and Opportunities for Facility
Based Post natal Care and breastfeeding in Senegal
•
Financial barriers– “…Certain mothers are obliged to work to have some
money and leave baby to mother in- law…”(Matron).
•
Cultural barriers resulting from mother -in-law– “…It is the fault of mothers-inlaw who ignore the nutritional values of the Breastfeeding…” (Matron)
•
Opportunities– Period of breastfeeding initiation and duration of exclusive
breastfeeding are well-know by CHWs– “… The breastfeeding should start
immediately after the baby born…” (Bajenu Gox)
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Understanding Barriers to and Opportunities for
Exclusive Breastfeeding in Kenya - TBAs
•
The TBAs are aware of the need for six months of exclusive breastfeeding,
but some children start crying after breastfeeding – this is taken as a sign
that breast milk is not enough and as such start being fed porridge.
•
TBAs said that apart from breast milk, a woman can give porridge made
from millet to the child. At four months, the mother can start giving avocados
and pawpaws. A mother will know that she is supposed to wean because
some children will want to eat what the mother eats at the age of 4 months
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Understanding Barriers to and Opportunities for
breastfeeding in Ethiopia
In-depth interview participants raised several reasons for not giving
first milk (colostrum).
• the first milk is contaminated with dirt which gets in through the
nipples. This milk is discarded and the next fresh milk which is
assumed to be cleaner is given to the baby.
• discarding the first milk will enable to initiate production of
adequate milk subsequently.
• if the first milk, which stayed for long and exposed to the sun is
given to the new born, it can cause abdominal pain.
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Understanding Barriers to and Opportunities for
breastfeeding in Ethiopia
• In some instances herbal medicines are given to the
newborn to make the child well as s/he grows.
“ It is our culture that the baby is given a medicine so that he
will be a good person when he grows up. The father brings the
herb and it will be mixed with milk and will be given to the baby”
(a mother from Ewa district).
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Conclusions and Next Steps
• Maternal health service utilization was found to be very low and
presents an opportunity for CBMNH intervention to make a
difference
• ANC in first trimester needs to be promoted more than “any”
contact during pregnancy
• Completed ANC needs to be promoted by sensitization and
more involvement of community groups
• Emphasis has been put on BCI to address key project
components during pregnancy, delivery and PNC– maternal
nutrition, breastfeeding practices, cord care
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Acknowledgements
• Communities
• All partners – MoH, ManHEP,
University of Addis Ababa, AMREF,
PRONTO, ChildFund, University of
Nairobi, Université Cheikh Anta
Diop – ISED.
• DFATD
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