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Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

ABSTRACT: Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ?3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization-recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.

SUBMITTER: Nguyen PH

PROVIDER: S-EPMC6852235 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

Nguyen Phuong Hong PH Kachwaha Shivani S Avula Rasmi R Young Melissa M Tran Lan Mai LM Ghosh Sebanti S Agrawal Rajeev R Escobar-Alegria Jessica J Patil Sumeet S Menon Purnima P

Maternal & child nutrition 20190618 4

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consu ...[more]

PMID: 31066195

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Project description:BackgroundIn response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers' experiences and challenges in collecting and using data for decision making.ObjectiveThe aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making.MethodsIn-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences.ResultsData were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors.ConclusionsThe use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

Project description:BackgroundPoor patient experiences during delivery leads to delayed presentation at facilities and contributes to poor maternal health outcomes. Person-centered maternity care (PCMC) is a key component of quality. Improving PCMC requires changing the process of care which can be complex and necessitate significant external input, making replication and scale difficult. This study compares the effectiveness two Quality Improvement (QI) intervention phases, one Intensive, one Light-Touch.MethodsWe use a matched case-control design to compare two phases of a QI Intervention targeting PCMC, with three facilities in each. The Intensive phase was introduced into three government facilities where teams were supported to identify, design, and test potential improvements over 12?months. The Light-Touch phase was subsequently introduced in three other government facilities and changes were tracked over six months. We compared the two groups using multivariate linear regression and difference-in-difference models to assess changes in PCMC outcome RESULTS: Both Intensive and Light-Touch arms demonstrated large improvements in PCMC. On a scale from 0 to 100, Intensive facilities increased in PCMC scores from 85.02 to 97.13, while Light-Touch facilities increased from 63.42 to 87.47. For both there was a 'halo' effect, with a similar improvement recorded for the specific improvement activities focused on, as w ell as aspects of PCMC not directly addressed.ConclusionsThis study demonstrates that a short, inexpensive, light-touch and directive intervention can change staff practices and significantly improve the experiences of women during childbirth. It also shows that improvements in a few areas of provider-patient interaction have a 'halo' effect, changing many other aspects of patient-provider interaction at the same time.Trial registrationQI Phase 1 - NCT04208867 . Retrospectively registered. December 19th, 2019. QI Phase 2 - NCT04208841 . Retrospectively registered. December 23, 2019.

Project description:BACKGROUND:Coaching can improve the quality of care in primary-level birth facilities and promote birth attendant adherence to essential birth practices (EBPs) that reduce maternal and perinatal mortality. The intensity of coaching needed to promote and sustain behavior change is unknown. We investigated the relationship between coaching intensity, EBP adherence, and maternal and perinatal health outcomes using data from the BetterBirth Trial, which assessed the impact of a complex, coaching-based implementation of the World Health Organization's Safe Childbirth Checklist in Uttar Pradesh, India. METHODS:For each birth, we defined multiple coaching intensity metrics, including coaching frequency (coaching visits per month), cumulative coaching (total coaching visits accrued during the intervention), and scheduling adherence (coaching delivered as scheduled). We considered coaching delivered at both facility and birth attendant levels. We assessed the association between coaching intensity and birth attendant adherence to 18 EBPs and with maternal and perinatal health outcomes using regression models. RESULTS:Coaching frequency was associated with modestly increased EBP adherence. Delivering 6 coaching visits per month to facilities was associated with adherence to 1.3 additional EBPs (95% confidence interval [CI]=0.6, 1.9). High-frequency coaching delivered with high coverage among birth attendants was associated with greater improvements: providing 70% of birth attendants at a facility with at least 1 visit per month was associated with adherence to 2.0 additional EBPs (95% CI=1.0, 2.9). Neither cumulative coaching nor scheduling adherence was associated with EBP adherence. Coaching was generally not associated with health outcomes, possibly due to the small magnitude of association between coaching and EBP adherence. CONCLUSIONS:Frequent coaching may promote behavior change, especially if delivered with high coverage among birth attendants. However, the effects of coaching were modest and did not persist over time, suggesting that future coaching-based interventions should explore providing frequent coaching for longer periods.

Project description:This paper explores the multilevel factors associated with maternal health utilization in India's most populous state, Uttar Pradesh. 3 key utilization practices: registration of pregnancy, receipt of antenatal care, and delivery at home are examined for district and individual level predictors. The data is based on 5666 household surveys conducted as part of a baseline evaluation of the Uttar Pradesh Technical Support Unit (UPTSU.) program.This intervention aims to assist the Government of Uttar Pradesh in increasing the efficiency, effectiveness, and equity of service delivery across a continuum of reproductive, maternal, new-born, child, and adolescent health (RMNCH+A) outcomes.The paper employs multilevel models that control for individuals being nested within districts in order to understand the predictors of maternal health care utilization.The study identifies several individual-level predictors of health care utilization, including: literacy of the woman, the husband's schooling, age at marriage, and socio-economic factors. Key predictors of pregnancy registration include husband's schooling (OR 1.49, 95% CI 1.26-1.76), having a bank account (OR 1.36, 95% CI 1.11-1.68), and owning a house (OR 2.28, 95% CI 1.85-2.80). Factors affecting antenatal care include the woman's literacy (OR 1.49, 95% CI 1.28-1.73), the respondent having had a job in the last year (OR 1.39, 95% CI 1.10-1.77), and owning a house (OR 2.83, 95% CI 2.27-3.53). Home delivery tends to be associated with woman's literacy (OR 0.62, 95% CI 0.54-0.72) and marriage age of 15 and younger (OR 1.48, 95% CI 1.26-1.73).Interventions having equity considerations need to disrupt existing patterns of the health gradient. Successful implementation of such interventions, necessitate understanding the mechanisms that can disrupt the unequal utilization patterns and target domains of disadvantage. Knowledge of key predictors of utilization can aid in the implementation of such complex interventions.

Project description:BackgroundThe sustainable development goals (SDG) aim at satisfying three-fourths of family planning needs through modern contraceptive methods by 2030. However, the traditional methods (TM) of family planning use are on the rise, along with modern contraception in Uttar Pradesh (UP), the most populous Indian state. This study attempts to explore the dynamics of rising TM use in the state.MethodsWe used a state representative cross-sectional survey conducted among 12,200 Currently Married Women (CMW) aged 15-49 years during December 2020-February 2021 in UP. Using a multistage sampling technique, 508 primary sampling units (PSU) were selected. These PSU were ASHA areas in rural settings and Census Enumeration Blocks in urban settings. About 27 households from each PSU were randomly selected. All the eligible women within the selected households were interviewed. The survey also included the nearest public health facilities to understand the availability of family planning methods. Univariate and bivariate analyses were conducted. Appropriate sampling weights were applied.ResultsOverall, 33.9% of CMW were using any modern methods and 23.7% any TM (Rhythm and withdrawal) at the time of survey. The results show that while the modern method use has increased by 2.2 percentage points, the TM use increased by 9.9 percentage points compared to NFHS-4 (2015-16). The use of TM was almost same across women of different socio-demographic characteristics. Of 2921 current TM users, 80.7% started with TM and 78.3% expressed to continue with the same in future. No side effects (56.9%), easy to use (41.7%) and no cost incurred (38.0%) were the main reasons for the continuation of TM. TM use increased despite a significant increase (66.1 to 81.3%) in the availability of modern reversible methods and consistent availability of limiting methods (84.0%) in the nearest public health facilities.ConclusionInitial contraceptive method was found to have significant implications for current contraceptive method choice and future preferences. Program should reach young and zero-parity women with modern method choices by leveraging front-line workers in rural UP. Community and facility platforms can also be engaged in providing modern method choices to women of other parities to increase modern contraceptive use further to achieve the SDG goals.

Project description:BackgroundA variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention-ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DALY) averted as a result of ReMiND intervention as compared to routine maternal and child health programs without ReMiND.MethodsA decision tree was parameterized on MS-Excel spreadsheet to estimate the change in DALYs and cost as a result of implementing ReMiND intervention compared with routine care, from both health system and societal perspective. A time horizon of 10 years starting from base year of 2011 was considered appropriate to cover all costs and effects comprehensively. All costs, including those during start-up and implementation phase, besides other costs on the health system or households were estimated. Consequences were measured as part of an impact assessment study which used a quasi-experimental design. Proximal outputs in terms of changes in service coverage were modelled to estimate maternal and infant illnesses and deaths averted, and DALYs averted in Uttar Pradesh state of India. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.ResultsCumulatively, from year 2011 to 2020, implementation of ReMiND intervention in UP would result in a reduction of 312 maternal and 149,468 neonatal deaths. This implies that ReMiND program led to a reduction of 0.2% maternal and 5.3% neonatal deaths. Overall, ReMiND is a cost saving intervention from societal perspective. From health system perspective, ReMiND incurs an incremental cost of INR 12,993 (USD 205) per DALY averted and INR 371,577 (USD 5865) per death averted.ConclusionsOverall, findings of our study suggest strongly that the mHealth intervention as part of ReMiND program is cost saving from a societal perspective and should be considered for replication elsewhere in other states.

Dataset Information

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

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Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

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