A continuum of care analysis on adherence towards maternal and child nutrition programs and its association to child stunting in Indonesia

Wiradnyani LAW1,2, Khusun H1, Achadi EL3, Ocviyanti D4, Atmarita5, Roshita A6, Hardinsyah7, and Shankar AH8

Luh Ade Ari Wiradnyani 1Southeast Asia Minister of Education Organization-Regional Center for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia 2Department of Nutrition, Faculty of Medicine, Universitas Indonesia Helda Khusun 1Southeast Asia Minister of Education Organization-Regional Center for Food and Nutrition (SEAMEO RECFON) Universitas Indonesia Endang L. Achadi 3Department of Nutrition, Faculty of Public Health, Universitas Indonesia Dwiana Ocviyanti 4Department of Obstetric and Ginecology, Faculty of Medicine, Universitas Indonesia Atmarita 5Indonesian Nutritionist Association Airin Roshita 6UNICEF Indonesia Hardinsyah 7Department of Community Nutrition, Faculty of Human Ecology, Bogor Institute of Agriculture Anuraj H. Shankar 8Department of Nutrition, Harvard T.H.Chan School of Public Health, Boston Massachusette US

BACKGROUND Stunting_definition and concern  Stunting is chronic undernutrition indicated by height for aged below -2SD from the median of the WHO Child Growth Standards  MAIN CONCERNS: Its long-term and irreversible effect

In Indonesia: 36.4% (2007), 35.7% (2010), 37.2% (2013) (Basic Health Research/Riskesdas data)

BACKGROUND Stunting_The first 1000 days

The first 1000 days of child’s life as WINDOW of OPPORTUNITY to prevent and ‘cure’ stunting (Victora et al, 2010) Intervention to address stunting within this period can make the largest impact (Unicef, WFP, WHO, 2010)

Risk of stunting exist in every stage of child’s life within the First 1000 DaysContinuum of Care in Nutrition during the period is crucial

• Although the causes of stunting are multiple and linked to poverty, effective programmatic intervention are available (Morris et al, 2008) • Those interventions (with high coverage) is estimated to results in a significant reduction of stunting (Bhutta et al, 2008)

During PREGNANCY Iron-Folic Acid Tablets Supplementa tion

AFTER BIRTH 6-23.9 months AFTER BIRTH 0-5.9 months Promotion of Exclusive Breastfeeding

Promotion of Good Complementary Feeding Practices Promotion of Continued Breastfeeding Vitamin A Capsule Supplementation

MCN programs implemented at large scale in Indonesia

Study Objectives and Hypothesis • To assess mother’s adherence towards MCN programs and its association to child stunting from the perspective of continuum of care • To explore factors associated with the adherence

Objective

Hypothesis • Better adherence to series of MCN programs recommendation is associated with lower risk of stunting in 6-59 months old children

Method

Subjects: Mothers with children aged 6-23.9 months

Secondary data analysis (Basic Health Survey 2010)

Secondary data analysis (3 series of Indonesian DHS: 2002, 2007, 2012)

Primary data (qualitative approach)

Method Secondary data Analysis • Dependent variable: Children nutritional status based on height for age z-score • Independent variable: Adherence towards 5 MCN programs • Confounders: Residence, child sex and age, number of U5 child, maternal education, wealth status, maternal height, birth weight, health seeking behavior

• Dependent variable: Adherence towards 5 MCN programs • Independent variable: Mom’s knowledge and Family Support • Confounders: Residence, child age, number of U5, birth order, maternal education, wealth status, health seeking behavior, exposure to mass media

MCN adherence and risk of stunting

Factors associated with the adherence

Operational Definition of the Adherence towards MCN program No

1

2

3

4

5

Operational definition and the category Adherence to series of MCN adherence  Adhere majority= adhered to ≥3 MCN programs  Not adhere majority= adhered to <3 programs Maternal IFAS  Adhere= consumed ≥90 tablets during the recalled pregnancy  Not adhere = consumed <90 tablets during the recalled pregnancy Exclusive breastfeeding for 6 months  Adhere: children received first CF when they were ≥6 months old  Not adhere: children received first CF when they were <6 months old Continued breastfeeding practices  Adhere = mother were still breastfeeding at the time of interview  Not adhere = mother has weaned the children Complementary feeding practices  Adhere =the child received meal consisted of ≥4 food groups and have adequate energy intake  Not adhere =the child received meal consisted of <4 food groups or have inadequate energy intake VAS  Adhere =the child received VAC for the past 6 mos  Not adhere =the child did not receive VAC for the past 6 mos

Reference

Indonesian MoH

Unicef/WHO (2007)

Unicef/WHO (2007); WHO/Unicef,(2008) Dewey and Brown (2002) Indonesian MoH (2005)

Method Primary Data Collection Informants

• Mother of 6-23.9 months old • Family: Husband, Mother/mother-in-law • Health provider: midwives, Community Health Worker

Informants Recruitment

• During Growth Monitoring day • Snow ball method • By chance

Variation of Informant’s characteristic

• MCN adherence • Socio-demographic • Health service utilization

RESULTS

MCN Adherence and Risk of Stunting Subject’s characteristics (N=5733) • • • •

50.5% living in urban Children: 50.1% boys, 67.3% aged ≥12 months Mom’s age: 25-34 years old (52.4%), <25 years old (32.3%) Mom’s educ: primary education graduates (51.6%), secondary education graduates or higher (37.3%) • Child birth weight: born <3000 gram (30.1%) • Mom’s height<150 cm: 33.7% • Not adequate health service utilization: 53.4% Prevalence of stunting: 37.9% (21.4% severe and 16.5% moderate stunting)

Proportion of Mothers Adhered to MCN programs By the Programs (Left), By total number of programs (Right)

%

%

MCN adherence across years 3 series of IDHS

Adherence to series of MCN program recommendation Riskesdas 2010 N=3508

• Total number of subjects with complete data

n=973

• Consumed IFA tablet ≥90 tablets during pragnancy

n=346

• PLUS Practiced EBF for 6 months

n=258

• PLUS currently Breastfed

n=184

• PLUS got VAC

n=32

• Plus good CF

Adherence towards series of MCN programs and risk of stunting Mothers with better adherence (adhered to 3-5 programs) had no significant different risk of stunting of their child than mother with poorer adherence (adhered to 0-2 programs) o (p=0.96, aOR 1.01, 95%CI 0.82,1.24) of severe stunting o (p=0.15, aOR 0.86, 95% CI 0.68, 1.16) of moderate stunting

Does timing of MCN programs intervention matters?

Polynomial multivariate logistics regression predicting the risk of stunting Variables

child age

child's birth weight maternal height IFAS adherence EBF Current BF status CF practices VAS adherence

6-8 mos 9-11 mos ≥12 mos birth weight ≥3000g birth weight <3000g mom is >=150 cm mom is <150 cm adhered not adhered adhered not adhered still breastfed no longer breastfed appropriate not appropriate adhered not adhered

severe 95%CI lower

Upper

0.94 1.03

1.91 1.91

1.53

2.30

1.02

1.54

aOR 1 0.95 2.15 1 1.36 1 1.55

1.28

1.02

1.55

0.86

0.70

1.02

aOR 1 1.34 1.43 1 1.82 1 1.25

moderate 95%CI lower Upper 0.61 1.44

1.48 2.93

1.08

1.71

1.25

1.93

0.96

0.74

1.27

1.16

0.92

0.73

1.15

0.82

1.26

0.81

0.63

1.01

1.05

0.76

1.42

0.98

0.71

1.35

1.05

0.83

1.33

1.03

0.79

1.33

adjusted by residence, child sex, wealth, mom job, mom educ, number of U5, health seeking behavior, completeness of immunization; R square= 9.8%

Maternal height, birthweight, IFAS, and stunting o Maternal height and stunting (Ozaltin et al, 2010; Hambidge et al, 2012) Women with short stature experienced undernutrition in childhood even in the utero (when the reproductive system was mainly developed). When they get pregnant,  The fetus/infant adjust his/her metabolisminfluence the growth and development (Varella-Silva et al, 2009)  Limited space of the fetus to grow (Martorell and Zongrone, 2012)

o LBW and stunting (Abuya et al, 2012; Adekanmbi et al, 2013; Ozaltin et al,

2010; Varella-Silva et al, 2009)  Most LBW infants in developing countries were born at termmainly due to inadequate maternal nutritional factors (Ramakrishnan 2004  Birthweight is indicator of general health of mom and the baby (Faruque et al, 2008)

IFAS, maternal height, birthweight, and stunting IFAS and stunting (Cogswell et al, 2003, Passerini et al, 2012)  Through its impact on birthweight (Balarajan et al, 2013; Christian et al, 2003)

 Through its impact on iron stores of the baby (Pee et al, 2002; School 2011)

Continued Breastfeeding, Wealth, and Risk of Stunting

Stratified by WEALTH

‘LOWER RISK of stunting of nonbreastfed children from low wealth household (aOR=0.74, 95%CI 0.55, 0.98, p=0.04), and NOT among children from middle-high households (aOR=1.05, 95%CI 0.84, 1.31, p=0.66)

Dietary Diversity of currently BF and Non-BF Children

%

Continued Breastfeeding, CF and Risk of Undernutrition  Inline with previous studies in Senegal, Burkina Faso, 14 countries (Ntab et al, 2005; Sawadogo et al, 2006; Marriot et al, 2012)

 Inverse causality (Marquis et al, 1997; Simondon and Simondon, 1996; Gonzales-Consio et al, 2006)

 Breastfeeding was prolonged because the child is already undernourished, and NOT vice versa  Decision to continue breastfeed is based on mom’s perception on child’s health and nutritional status

Continued BF, CF and Mom Perception Findings of the present study o Reason to continue BF was ‘the child often refuse meal’ He does not eat a lot. If he is still breastfed, there is something to replace the foods. I mean, when we still give breastmilk, he will feel full (rural mom, low SES, poor CF practices) o Mom’s perception to rely on breastmilk was reinforced by family, cadre, and midwife (midwife said) It is okay (the child refuse to eat). Usually it is because she (the child) is about to achieve certain milestone. If she receives breastmilk than it is no problem. So, I feel less worried afterwards. The most important is the breastmilk (urban mother of 11 months old girl, low SES, 9y of schooling, poor CF practices)

Factors associated with MCN adherences Secondary Data Analysis (3 IDHS series)

Variable

IFA

Continued BF

CF

VAS

Majority (≥3 programs)

-

v

v

-

v

NR

v

vv

vv

v

Residence

Living in urban

Child’s age

Older age group

Wealth

Wealthier

v

v

vv

-

v

Mom’s education

Higher

-

v

v

-

-

Health seeking practices

Good

vv

-

v

v

vv

Mass media Exposures

More frequent

-

-

v

v

v

Mom’s knowledge

Good

vv

-

v

v

v

Family support

Got better support

vv

-

vv

v

vv

Factors associated with MCN adherences Pattern observed from qualitative approach_IFAS THEME

Mom with GOOD adherence

Mom with POOR adherence

Health seeking practices and role of health service providers

 Adequate ANC visit and received enough tablets  Trust the health staff  Reported side effect, and received appropriate feedback

 Adequate ANC visit but  received insufficient tablets  received INappropriate feedback when reported side effect  Never reported side effect (friend’s bad experience, midwife never asked)

Mom’s knowledge and perception

 Felt the need (pushed themselves to consume)  Knew risk of lack of blood during delivery  IFA tablets is for prevention, and minimize the risk

 Knew risk of lack of blood during delivery, YET  perceived had NO RISK  Had other way to minimize risk  Couldn’t bear the IFA tablets  IFA tablets may cause high blood pressure and it is dangerous  Bleeding during delivery is normal

Family support

 Husband involved in pregnancy and delivery care  Husband were less involved BUT received support from other family/self motivation

 Husband left the issues to mom (up to the mothers)  Mom less expected husband to involve  Husband involved, YET mom stayed with her decision

Public Health Nutrition; Volume 19, Issue 15 October 2016, pp. 2818-2828

Factors associated with MCN adherences Pattern observed from qualitative approach_CF THEME

Mom with GOOD adherence

Mom with POOR adherence

Role of health service providers

 Did not discuss CF with health staff, yet obtained information from other sources

 Did not discuss CF with health staff,  Received INappropriate suggestion from health staff (breastmilk is enough, rely on appetite-booster

Exposure to info

 Intentionally looked for info  Had multiple sources of info  Received appropriate info (responsive feeding, give variety of food)

 Didn’t intentionally looked for info  Had limited source of info (parents, friends), inappropriate info  Received info but reluctant to follow it (the child is picky eater)

Mom’s knowledge and perception

 Had good knowledge on food variety and meal frequency  Put child feeding as priority despite the challenges (child is picky eater, workload)

 Had poor knowledge  Had good knowledge, BUT perceived o child will refused the food o certain foods are not good for young child o less worried with the current practice

Family support

 Husband involved in child care  Husband less involved, yet  Family is nearby  Mom is easy with workload

 Husband less involed, no support from other family  Husband wanted to involve but mom less preferred  Husband/family give inappropriate input

Conclusion and Recommendation (1) Conclusion Pre-pregnancy (maternal height), prenatal factors (intake of IFA tablets during pregnancy, other prenatal conditions reflected by baby’s birth weight) are associated with lower risk of stunting Currently non-breastfed children from poor family had borderline significant higher risk of stunting than currently breastfed children, which may be associated with their poorer CF practices

Recommendation Good nutrition of women before and during pregnancy should be prioritized Promotion of CBF should be done along with promotion of good CF practices.

Conclusion and Recommendation (2) Conclusion • Mother good adherence to all 4 MCN programs were characterized by their intention to look for information, possesion of good support from husband/family • Inappropriate information from health provider/cadre/family/ friends reinforced the missperception of mothers with poor adherence

Recommendation • Provide correct, easy to access and practical information to mothers • Improve capability of health provider and Posyandu cadre as educaton • Involve family in promoting good pregnancy and child care

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