Menu
Menu
Menu
Menu
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.
We conducted a postprogramme quasi‐experimental study from November 2020 to June 2021. This design was used to compare maternal undernutrition between the intervention and control groups. The intervention group was drawn from Kayonza District (a rural area) and Kicukiro District (an urban area), two out of the five districts where nutrition‐specific and nutrition‐sensitive interventions were implemented under the Gikuriro programme. They were selected based on their high proportion of food insecurity as reported by the Comprehensive Food Security and Vulnerability Analysis (World Food Programme, 2018) and settlement pattern (rural vs. urban). In selecting the control districts, three criteria were used. These include food insecurity (World Food Programme, 2018), no existing nutrition‐specific and nutrition‐sensitive intervention package and setting whether rural or urban. After considering all the criteria, Gisagara District (a rural area) and Gasabo District (an urban area) were selected. The selected districts are shown in Figure 1. Map of the study area Participants in this study were pregnant women coming for delivery, and who reside in the selected districts of Rwanda. They were recruited consecutively using the following criteria: (1) being a permanent resident in the study area and aged between 15 and 49 years, (2) having been enroled in the selected nutrition intervention package for at least 1 year before pregnancy (for the intervention group), (3) belonging to wealth categories 1 and 2 and (4) those without any known medical, surgical or obstetric conditions. All public health facilities in the selected districts were included and the distribution of participants was based proportionally on population size in each selected health facility in the respective district. The sample size was calculated using a two proportion sample size formula (Casagrande et al., 1978), which is: where Ζ 1 − α/2 (95% confidence) = 1.96; Ζ 1 − β (90% power) = 1.64; P 1 = proportion of undernutrition among pregnant women in Rwanda to be 19.8% (Nsereko et al., 2020) in the nonintervention group; P 2 = proportion of undernutrition in the intervention group to be 9.8% (assuming that the intervention would lead to a 10% decrease); design effect = 1.2; effect size = 10; and P = average for the two proportions. After considering all the assumptions, the sample size was 520 for one group. Allowing for nonresponse rate = 10%, the sample size was adjusted upwards to 572. Therefore, the sample size in each group was 572 giving a total sample of 1144 (572 intervention group and 572 control group). A flow chart of participants' recruitment for the intervention and control arms is presented in Figure 2. Recruitment flow chart The integrated nutrition intervention package refers to one component of nutrition‐specific intervention, which is nutrition education and counselling and three nutrition‐sensitive components, which are promotion of agricultural productivity, promotion of financial literacy and economic resilience and improved access to WASH services. The interventions took place between September 2016 and July 2020. The intervention was funded by USAID and implemented by CRS in partnership with the Government of Rwanda, Netherlands Development Organization and other Rwandan Civil‐Society Organizations. A detailed description of these interventions is provided in Additional File 1. The main objective of the intervention was to improve the nutritional status of women of reproductive age and children less than 5 years. Nutrition education and counselling were promoted through a variety of behaviour change activities, including Village Nutrition Schools, community health clubs, growth monitoring and promotion by trained Community Health Workers. Regarding agriculture, the main activities of the intervention were enhancing agricultural productivity through Farmer Field Schools established in each village, promoting Bio Intensive Agriculture Techniques and distribution of seeds and livestock. The programme also enhanced the Saving and Internal Lending Communities Groups approach as a way of promoting financial literacy and economic growth to tackle financial problems that prevent women and children from attaining better nutritional outcomes. In addition, the intervention extended to roll‐out WASH activities through the Community‐Based Environmental Health Promotion Programme approach adopted by the Government of Rwanda and fostering the integration of WASH and nutrition to improve sanitation, latrines and handwashing facilities. Data collectors were trained on the objectives, the relevance of the study, confidentiality of information, respondent's rights, informed consent, techniques of the face‐to‐face interviews and anthropometric measurements. The interviews were conducted in a private place to ensure the confidentiality and privacy of the participants. Validation and verification of data were done at the end of each day of data collection. Supervisors checked completed questionnaires or checklists daily and signed off each time they supervised the enumerators. The data were collected using a structured questionnaire adopted from other similar studies (Ghosh et al., 2019). However, it was modified to suit the Rwandan context after pretesting it in a district outside the study area. The main component of the questionnaire included maternal sociodemographic characteristics, socioeconomic characteristics and lifestyle factors, as well as obstetric factors. Maternal nutritional status was measured using two anthropometric measurements: MUAC just before delivery and body mass index (BMI) in the first trimester. A flexible nonelastic tape was used to measure the MUAC. It was measured midway between the tip of the shoulder and the tip of the elbow of the less functional arm hanging freely by the woman's side. In addition, antenatal care records were reviewed to retrieve weight and height during the first trimester to estimate the BMI. The weight and height had been measured according to Rwandan Ministry of Health guidelines using the devices available in the health facilities. A woman who had low MUAC (<23 cm) during delivery or low BMI (<18.5 kg/m2) in the first trimester or both were categorized as having maternal undernutrition. Moreover, haemoglobin (Hb) concentration to assess for anaemia was measured using a portable HEMOCUE B‐Hb photometer using one drop of capillary blood obtained via a finger prick by trained midwives and according to Rwandan Ministry of Health guidelines. Based on WHO classification (1989), Hb reading of ≥11 g/dl was considered normal and <11 g/dl was anaemic. The severity of anaemia was grouped into three levels: mild (Hb readings 9–10.9 g/dl), moderate (Hb readings 7–8.9 g/dl) and severe anaemia (Hb < 7 g/dl). Descriptive analysis, including counts, proportions and averages, was used to assess the distribution of the attributes. To assess the balance of the explanatory variables and nutritional status between the intervention and control groups, the χ 2 test (comparing proportion) and independent t test (comparing means) were performed. A multivariable logistic regression model was fitted to identify the association between the integrated nutrition intervention and maternal undernutrition. All potential confounders with a p value <0.1 during the comparison between intervention and control groups were considered in a multiple logistic regression using a ‘backward conditional' selection procedure. The potential confounders included were the main source of fuel/energy for lighting, having household items, alcohol consumption, smoking, exposure to secondary smoke and HIV status. Model adequacy was checked using the Hosmer–Lemeshow goodness‐of‐fit test (p = 0.127), which indicates that the fitted model was adequate. Results were statistically significant at p value <0.05. The data were analysed with help of Statistical Package for Social Sciences Version 25.0 IBM New York. Approval to conduct the study was sought and obtained from the Institutional Review Board of the University of Rwanda College of Medicine and Health Sciences. Authorization to go to the field was also granted by the Ministry of Health, Rwanda. Written informed consent was sought and obtained from each participant.
