Effect and Challenges of an Integrated Nutrition-Intervention Package Utilization among Pregnant Women and Lactating Mothers in Rwanda: An Exploratory Qualitative Study.

Background: Malnutrition among pregnant women and lactating mothers remains an issue of public health concern in developing countries. The Gikuriro program, an integrated nutrition-specific and nutrition-sensitive intervention, was implemented in 5 districts of Rwanda for 5 y to address this problem. Postprogram quasi-experiments showed significant effect of the intervention on maternal and child undernutrition. Notwithstanding, there was a need for a qualitative study to explore the views of the beneficiaries and implementers regarding its benefits, challenges, and limitations to inform future interventions. Objective: This study aimed to explore the effect and challenges of an integrated nutrition-intervention program among pregnant women and lactating mothers. Methods: This was a qualitative study involving 25 community health officers and 27 nutritionists as key informants and 80 beneficiaries in 10 focus group discussions. All interviews and group discussions were audio-recorded, transcribed verbatim, translated into English, and double coded. A deductive and inductive content analysis approach was used with the help of ATLAS.ti, version 9.15. Results: The study identified several positive effects, such as improved knowledge and skills on nutrition, a positive mindset toward a balanced diet, perceived improved nutrition, and economic independence among pregnant women and lactating mothers. However, some of the main obstacles of the integrated nutrition intervention were lack of awareness of the program, negative beliefs, poverty, lack of spousal support, and time constraints. Moreover, the study identified a main limitation: the lack of inclusiveness for all social categories. Conclusions: This study demonstrates that integrated nutrition interventions have perceived positive effect on nutrition; however, such interventions may face some challenges and limitations. These findings suggest that, apart from contributing to the body of evidence for scale up of such interventions in resource-limited settings, economic challenges and misconceptions have to be addressed to maximize the effect of such interventions.

Effectiveness of Integrated Maternal Nutrition Intervention Package on Birth Weight in Rwanda.

Inadequate maternal nutrition before and during pregnancy is a principal risk factor for poor fetal development, resulting in low birth weight (LBW) and subsequently, poor child growth. Most studies focus on the impact of nutritional interventions after birth while only a few interventions consider integrated nutrition service packages. Therefore, there is limited evidence on whether integrated maternal nutrition interventions have a positive effect on birthweight. Thus, a post-program quasi-experimental study was carried out to determine the effectiveness of the integrated maternal nutrition intervention package on low birth weight in Rwanda. A total of 551 mother-baby pairs from the intervention and 545 controls were included in the analysis. Data regarding socio-demographic, maternal anthropometric parameters, and dietary diversity were collected using a structured questionnaire. Birth weight was assessed right after delivery, within 24 h. Logistic regression, linear regression, and path analysis were fitted to determine the effectiveness of the intervention on birth weight. The study found that the intervention reduced LBW by 66.99% (p < 0.001) and increased average birth weight by 219 g (p < 0.001). Logistic regression identified reduced risk of LBW among the intervention group (AOR = 0.23; 95%CI = 0.12-0.43; p < 0.001). It was also observed that the direct effect of the intervention on birth weight was 0.17 (ß = 0.17; p < 0.001) and the main indirect mediator was maternal MUAC (ß = 0.05; p < 0.001). Moreover, maternal passive smoking exposure and MUAC < 23 cm were found as risk factors for LBW. This study has demonstrated that an integrated maternal nutritional intervention package can significantly reduce LBW in low-income settings and should, therefore, be considered to improve birth weight.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda.

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition-specific and nutrition-sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi-experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty-two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid-upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m2 ) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15-0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale-up of these interventions nationally in Rwanda.

Consistency and timeliness of intrapartum care interventions as predictors of intrapartum stillbirth in public health facilities of Addis Ababa, Ethiopia: a case-control study.

INTRODUCTION: approximately one-third of the global stillbirth burden occurs during intrapartum period. Intrapartum stillbirths occurring in the health facilities imply that a foetus was alive on admission to labour and had greater chances of survival with optimum obstetric care. Active monitoring and follow-up by skilled birth attendants becomes critical to determine the progress of labour and to decide any emergency obstetrical care actions. Timely monitoring of labour progress indicators including fetal heart rate (FHR), uterine contraction maternal vital signs, vaginal examination (VE) are vital in reducing intrapartum stillbirth. METHODS: a case-control study was conducted using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and 3 public hospitals of Addis Ababa between July 1st, 2010 to June 30th, 2015. Data were collected from charts of all cases of intrapartum stillbirths meeting the inclusion criteria and randomly selected charts of controls from each public health facility in 2: 1 control to case ratio. RESULTS: over 90% of both cases and controls received FHR monitoring care albeit the timing was substandard. More women in the live birth group than intrapartum stillbirth group received timely care related to uterine contraction (OR 2.42, 95% CI 1.77 - 3.30) and blood pressure monitoring (aOR 1.41, 95% CI 1.09 - 1.81). 1.2% and 0.3% of women in the intrapartum stillbirth and livebirth groups developed eclampsia respectively. CONCLUSION: substandard timing and application of labour monitoring interventions including FHR, uterine contraction can predict intrapartum stillbirth in public health facilities.

Labour admission assessment results of index pregnancy as predictors of intrapartum stillbirth in public health facilities of Addis Ababa: A case-control study.

BACKGROUND: Approximately one-third of the global stillbirth burden occurs during intrapartum period. The ability to assess obstetric parameters including effacement, dilatation, uterine contraction, decent, rupture of the uterus, and moulding of the foetal head are among the essential competencies required by obstetric service providers admitting women for labour in health facilities. Misdiagnosis of these conditions could result in unnecessary obstetric interventions and unfavourable obstetric outcomes including intrapartum stillbirth. This study aimed to assess associations between missed diagnosis plus complication of labour on admission and intrapartum stillbirth. METHODS: A case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 20 public health centres and three public hospitals of Addis Ababa between 01 July 2010 and 30 June 2015 was conducted. Data were collected from charts of all cases meeting the inclusion criteria. Medical records of women with livebirths were randomly selected and reviewed from each public health facilities in two to one (2:1) control to case ratio. Accordingly, 728 cases of stillbirth out of 1,056 charts met the inclusion criteria whereas 1,551 controls out of 1,705 were also considered in the study. RESULTS: Proportionally, more women in the stillbirth group (39.4%) than in the livebirth group (30.2%) experienced ruptured membrane on admission, with the difference being statistically significant (OR 1.7, 95% CI 1.37-2.03). Significantly higher proportion of women in the intrapartum stillbirth group experienced FRH lower than 110/min, a result suggestive of foetal distress on admission. Proportionally, more women in the intrapartum stillbirth group (14.5%) than in the livebirth group (4.5%) had breech foetal presentation on admission for labour, the difference being statistically significant (aOR 3.26 95% CI 1.93-5.50). Intrapartum stillbirth was slightly higher among women with cervical dilatation 4cm or more on admission (OR 1.2, 95% CI 1.00-1.45). This could be owing to delay in seeking obstetric care or misdiagnosis of the condition, a situation that seeks more rigorous study to determine the underlying causal links. Diagnosis of foetal member was missed among more cases than controls where the difference was statistically significant (aOR 1.51, CI 1.03-2.19). CONCLUSION: Low FHR, non-vertex foetal presentations and ruptured cervical membrane were predictors of intrapartum stillbirth. Health facilities could avert unnecessary foetal loss by undertaking timely actions to manage obstetric emergencies on admission to labour.

Maternal and foetal medical conditions during pregnancy as determinants of intrapartum stillbirth in public health facilities of Addis Ababa: a case-control study.

INTRODUCTION: globally, intrapartum stillbirth accounts for 1 million deaths of babies annually, representing approximately one-third of global stillbirth toll. Intrapartum stillbirth occurs due to causes ranging from maternal medical and obstetric conditions; access to quality obstetric care services during pregnancy; and types, timing and quality of intrapartum care. Different medical conditions including hypertensive & metabolic disorders, infections and nutritional deficiencies during pregnancy are among risk factors of stillbirth. Ethiopia remains one of the 10 high-burden stillbirth countries with estimated rate of more than 25 per 1000 births. METHODS: a case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 23 public health facilities of Addis Ababa during the period July 1, 2010 - June 30, 2015 was conducted. Data was collected from charts of all cases of intrapartum stillbirth meeting the inclusion criteria and randomly selected charts of controls in two to one (2:1) control to case ratio. RESULTS: chronic medical conditions including diabetes, cardiac and renal diseases were less prevalent (1%) among the study population whereas only 6% of women experienced hypertensive disorder during the pregnancy in review. Moreover, 6.5% of the study population had HIV infection where being HIV negative was protective against intrapartum stillbirth (aOR 0.37, 95% CI 0.18-0.78). Women with non-cephalic foetal presentation during last ANC visit were three times more at risk of experiencing intrapartum stillbirth whereas singleton pregnancy had strong protective association against intrapartum stillbirth (p<0.05). CONCLUSION: untreated chronic medical conditions, infection, poor monitoring of foetal conditions and multiple pregnancy are among important risk factors for intrapartum stillbirth.