An adequacy evaluation of a maternal health intervention in rural Honduras: the impact of engagement of men and empowerment of women / Evaluación de la suficiencia de una intervención de salud materna en un entorno rural de Honduras: repercusión de la participación de los hombres y el empoderamiento de las mujeres

Objective. To determine the impact that a 6-year maternal and child health project in rural Honduras had on maternal health services and outcomes, and to test the effect of level of father involvement on maternal health. Methods. This was a program evaluation conducted through representative household surveys administered at baseline in 2007 and endline in 2011 using 30 cluster samples randomly-selected from the 229 participating communities. Within each cluster, 10 households having at least one mother-child pair were randomly selected to complete a questionnaire, for a total of about 300 respondents answering close to 100 questions each. Changes in key outcome variables from baseline to endline were tested using logistic regression, controlling for mother's education and father's involvement. Results. There were improvements in most maternal health indicators, including an increase in women attending prenatal checkups (84% to 92%, P = 0.05) and institutional births (44% to 63%, P = 0.002). However, the involvement of the fathers decreased as reflected by the percentage of fathers accompanying mothers to prenatal checkups (48% to 41%, P = 0.01); the fathers' reported interest in prenatal care (74% to 52%, P = 0.0001); and fathers attending the birth (66% to 54%, P = 0.05). There was an interaction between the fathers' scores and the maternal outcomes, with a larger increase in institutional births among mothers with the least-involved fathers. Conclusions. Rather than the father's involvement being key, changes in the mothers may have led to increased institutional births. The project may have empowered women through early identification of pregnancy and stronger social connections encouraged by home visits and pregnancy clubs. This would have enabled even the women with unsupportive fathers to make healthier choices and achieve higher rates of institutional births.

Objetivo. Determinar la repercusión de un proyecto de salud maternoinfantil de 6 años de duración, en un entorno rural en Honduras, sobre los servicios de salud materna y los resultados asistenciales, y estudiar el efecto del grado de participación del padre en la salud materna. Métodos. El programa se evaluó mediante una serie de encuestas a los hogares representativos administradas al inicio de la intervención, en el 2007, y al concluir en el 2011, con 30 muestras de agrupaciones de familias elegidas al azar entre las 229 comunidades participantes. Dentro de cada agrupación, se seleccionaron aleatoriamente 10 familias compuestas al menos por una madre y un hijo para que contestasen un cuestionario, con lo cual se reunieron en total cerca de 300 personas encuestadas que respondieron casi 100 preguntas cada una. Se analizaron las variaciones en los criterios principales de valoración, entre el inicio y el final de la intervención, mediante técnicas de regresión logística, controlando el nivel educativo de la madre y la participación del padre. Resultados. Se observaron mejoras en la mayoría de los indicadores de salud materna, incluido un aumento de la cantidad de mujeres que acudieron a los controles prenatales (variación de 84% a 92%, P = 0,05) y de los partos atendidos en centros sanitarios (variación de 44% a 63%, P = 0,002). Sin embargo, se redujo la participación del padre, tal como refleja el porcentaje de padres que acompañan a la madre a los controles prenatales (variación de 48% a 41%, P = 0,01), el interés comunicado por el padre en la asistencia prenatal (variación de 74% a 52%, P = 0,0001) y el porcentaje de padres que estuvieron presentes en el parto (variación de 66% a 54%, P = 0,05). Se constató una interacción entre las puntuaciones paternas y los resultados asistenciales maternos, así como un aumento mayor de los partos en centros sanitarios en los casos en que el padre se involucraba menos. Conclusiones. Más que la participación del padre como factor clave, el aumento de los partos asistidos en centros sanitarios puede haberse debido a los cambios en las madres. Es posible que el proyecto empoderase a las mujeres y les permitiese percatarse antes de su embarazo y reforzar sus conexiones sociales con visitas domiciliarias y grupos de embarazadas. Esto habría facilitado, aun en los casos en los que el padre no se involucraba, que las mujeres tomasen decisiones más saludables, y que aumentasen las tasas de partos atendidos en centros sanitarios.

Community Level Fortification: Lessons from Projects in Malawi, Senegal and Tanzania.

Objectives: Rural smallholder farming communities are inadequately reached by national food fortification initiatives. World Vision projects in Malawi, Senegal and Tanzania explored the implementation and sustainability potential for community level fortification to increase households' access to micronutrients. Methods: Fortification projects were initiated within an integrated nutrition and health program. Micronutrient premix was added to staple grains during milling at medium scale mills (Malawi), village hammermills (Malawi, Tanzania) or at home after milling (Senegal, Tanzania). In Senegal two community bakeries for fortified bread were established. Partial cost-recovery systems were implemented in all projects but sustainability plans in Malawi and Senegal relied on a transition to independent business models to fund ongoing premix and quality control costs, with community oversight. Results: The projects introduced a novel method of increasing micronutrient intake which was widely accepted by local communities. More than 20,000 households accessed fortified grains. Common challenges included accessibility of premix supply and quality control services, and costrecovery. Operating in rural areas increased premix supply costs and limited quality control monitoring by national standards agencies. Sustainability of activities without external funding was limited. Transition to cost-recovery was overcome in Malawi through extensive community sensitization but resulted in a shift to food-to-food fortification in Tanzania. In Senegal, community committees sustained premix procurement through fortified bread sales. Conclusions: Community level fortification was well accepted and has potential to improve micronutrient intake of rural households unreached by commercially fortified products. Further formative work is needed to identify contextually feasible systems for premix supply, quality control and cost recovery.