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Undernutrition is associated with maternal morbidity and poor pregnancy outcomes. This qualitative study seeks to understand the multilevel factors influencing maternal dietary practices in Niger, including the impact of pregnancy illnesses on diet. Criterion-based, purposive sampling was used to select pregnant women and household members from 24 villages in a rural district of the Maradi Region in south-central Niger. Semistructured interviews (n = 153) and focus group discussions (n = 38) explored 4 primary themes: (a) perceptions of ideal diet during pregnancy, (b) barriers to consuming the ideal diet, (c) coping strategies including dietary responses related to pregnancy illnesses, and (d) changes in perceptions from early to late pregnancy. Longitudinal data collection allowed for repeated interviews of pregnant women to document changes in dietary practices throughout pregnancy. Transcripts were coded using an inductive approach informed by grounded theory methodology. Participants categorized foods into 4 primary dietary taxonomies when discussing ideal maternal diets but cited constraints related to accessibility and availability impeding routine consumption of these foods. Perceptions of “modern,” urban foods as healthy, coupled with key structural barriers such as food costs, were identified. Maternal morbidity influenced food consumption, as women reported reducing food intake early in pregnancy in response to illness episodes. Although awareness of optimal foods for supporting healthy pregnancies was moderately high, some misconceptions were observed and multilevel barriers to food security restricted opportunities for consuming these foods. Nutrition-specific and nutrition-sensitive interventions could improve access and availability of acceptable foods for supporting increased dietary intake during pregnancy.
This qualitative study was nested within a cluster randomized trial assessing the effectiveness of prenatal supplementation on infant immunogenicity to oral rotavirus vaccination (“Efficacy and Safety of a Pentavalent Rotavirus Vaccine Against Severe Rotavirus Gastroenteritis in Niger,” http://clinicaltrials.gov Identifier: {“type”:”clinical-trial”,”attrs”:{“text”:”NCT02145000″,”term_id”:”NCT02145000″}}NCT02145000), conducted in the Madarounfa Health District within Maradi Region of south‐central Niger (Isanaka et al., 2017). In 2012, 17.9% of women of reproductive age in this region were underweight (body mass index < 18.5 kg/m2), with 11.8% of babies born with low birthweight (less than 2,500 g) and an estimated fertility rate of 8.4 (ICF International, INS, 2013). In the parent trial (beginning March 2015), 3,000 pregnant women across 53 villages were randomized to receive one of three nutritional supplements during pregnancy—iron and folic acid (IFA) pills, multiple micronutrient (MMN) capsules, or medium‐quantity lipid‐based nutrient supplement (MQ‐LNS; a 40‐g fortified, ready‐to‐use paste made of peanuts, oil, dried skimmed milk powder, sugar, and 22 micronutrients) sachets. Mothers and children participating in the trial receive health care free of charge, including prenatal supplements. No food assistance is provided to villages in the study catchment area. Women were included in the parent trial if they were less than 30 weeks of gestation at time of enrolment; intended to remain in the study area through delivery and for 2 years thereafter; and did not display or report chronic health conditions, severe illness, pregnancy complications, or peanut allergy. Community leaders provided consent for their villages to participate in the study prior to randomization and recruitment of participants. The qualitative substudy purposively sampled pregnant women participating in the parent trial and household members (husbands and in‐laws) in 24 villages. Pregnant women in selected villages were sampled across age groups, gestational ages, and parent trial supplement arm assignment. As most women initiated prenatal supplementation during the first trimester, gestational age provides a proxy for duration of prenatal supplementation usage at the time of qualitative data collection. Midwives and health assistants affiliated with the parent trial were also sampled, given their influence on pregnant women's health behaviours. Qualitative data were collected in two phases: July–August and November–December 2016. Using semistructured interviews and focus group discussions, we sought to understand local food consumption preferences, dietary intake during pregnancy, experiences with illnesses throughout pregnancy, and other related health‐seeking behaviours. Questions gauged participant perceptions of ideal maternal diets and the extent to which these diets deviated from typical nonpregnancy diets; sources of information for dietary decision‐making in pregnancy; and factors perceived to influence dietary outcomes in pregnancy, such as food availability/access as well as maternal illness. The longitudinal design aimed to capture changes in the experiences, including health and nutrition‐related behaviours and perceptions, of women as they progressed through their pregnancies. In the first phase of data collection, semistructured interviews and focus group discussions were conducted with participating women across all three trimesters, their husbands and mothers‐in‐law, and study health staff. To capture women's changing perceptions and attitudes during their pregnancies, semistructured interviews and focus groups in Phase 2 were conducted with a subset of Phase 1 participants in the later stages of their pregnancies (≥20 weeks of gestation) or who had recently delivered. These women were sampled across parent trial supplement arms based on their gestational age and their willingness to participate in follow‐up data collection activities. Compared with Phase 1 participants, women participating in Phase 2 data collection activities were prompted to discuss any changes to their food consumption patterns and illness experiences in the later stages of their pregnancy using modified interview and focus group discussion guides based on emergent findings from Phase 1. Participant sampling within the parent study arms across study phases (interviews: IFA = 50, MMN = 54, LNS = 49; focus groups: IFA = 9, MMN = 10, LNS = 19) was intended to achieve representation among participants consuming different prenatal supplements, because supplement properties could influence food intake patterns differentially, and to ensure data saturation was reached across groups (Morse, Barrett, Mayan, Olson, & Spiers, 2002). Study staff conducted interviews and led focus group discussions in Hausa. Interview and focus group recordings were transcribed verbatim and translated into English. Transcripts were uploaded into Dedoose (version 7.5.27, Los Angeles, CA) to facilitate data management. In alignment with the inductive approach underpinning data collection, two principal coders drew from key tenets of grounded theory to identify and capture salient themes emerging from the transcripts (Charmaz, 2006). A multistep analytic process was followed. First, topics included in the interview and focus group discussion guides served as the 23 topical codes during the preliminary open coding process and memo taking (Creswell & Miller, 2000). Emergent themes informed the development of a more refined codebook that included 38 response codes and served as the analytic framework for the remainder of the coding process. This final list of codes was applied to the transcripts and included a combination of categories identified a priori and emergent themes identified during the open coding process. Third, themes and subthemes were reassembled through axial coding and memos using narrative matrices and chronological arrays, through which coded textual data were organized into various tabulated presentations, stratified by participant categories and noteworthy topics (Yin, 2016). This method of reconstructing coded data enabled identification of salient themes across participant groups and constant comparison of emerging categories across the study phases (Charmaz, 2006). Phase 1 transcripts were coded in full prior to coding of Phase 2 interview and focus group transcripts, a process that allowed data collection and analysis to be iterative (Morse et al., 2002). The study was approved by the Comité Consultatif National d'Ethique (Niger); the Comité de Protection des Personnes (France); the Commission d'Ethique de la Recherche sur l'Etre Humain, Hôpitaux Universitaires de Genève (Switzerland); Research Ethics Review Committee of the WHO (Switzerland); and the Western Institutional Review Board (United States). Individual written informed consent was obtained from all study participants in the local language (Hausa) prior to data collection activities.
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