Integrating MIYCN with Family Planning_Galloway_5.7.14

Integrating MIYCN-FP in Yemen: Results from Research Using Trials of Improved Practices

Rae Galloway, Technical Lead for Nutrition, MCHIP

CORE Group Meeting Presentation, May 7, 2014

Yemen: Population, Family Planning

and Nutrition

24 million people

Low contraceptive

prevalence

Highest rates of

stunting in the world

Limited access to

health and FP

services by women

who often stay in the

home

2

Objectives for the Study

Determine current maternal, infant and young

child nutrition (MIYCN) and family planning

(FP) practices

Explore if mothers/couples are willing to try

MIYCN-FP practices they are not using

Identify barriers to trying or continuing to use

ideal practices

Develop messages to integrate into a

MIYCN-FP counseling package for health

facility and community workers3

Some Reasons for Integrating MIYCN

and FP

MIYCN status and birth spacing are linked—

short birth spacing is associated with anemia

and underweight in women and underweight

and stunting in children

Addressing barriers to EBF ensures women

meet LAM criteria

Linking transition to complementary foods

and family methods at 6 mos promotes timely

introduction of CF and continued BF and

prevents another pregnancy4

Some reasons for integrating MIYCN

and FP

Increases number of services women (and

husbands) obtain at each contact with health

services

e.g., men going to FP services with their

wives receive MIYCN information so they can

support these practices at home

Increases use of optimal MIYCN or FP

practices by linking MIYCN status with birth

spacing & preventing a pregnancy with

meeting the LAM criteria5

What is Trials of Improved Practices?

TIPs was developed by the Manoff Group,

based on market research methods, for use

in IYCF, iron supplementation, bed nets and

family planning programs

TIPs is qualitative research that allows

exploration of using new behaviors & gives

program managers feedback about the

behaviors

TIPs uses small sample sizes to get in-depth

information about the “why” of behaviors

6

TIPs Methodology

Basic Methodology: Three TIPs Visits

TIPs Visit#1-in-depth interviews about past

and current practices; 24 hour recalls, food

frequency and observations in the home

TIPs Visit#2-discuss the results of TIPs

Visit#1, counsel on optimal practices,

identification by the mother (or husband) of a

new practice to try

TIPs Visit#3- visit 6 days later to see if the

practice was tried, barriers/motivators to use

in the future7

TIPs Methodology in Yemen

Location:

Dhamar Governorate

(south of Sana’a)

Two districts ( Magreb

and Wesab)

Two geographical

zones (highland &

lowland)

8

Driving to the highland village

of Thelah, Magreb


TIPs Participants:

MIYCN interviews:

16 mothers with

children<2 years (NS

status of child)

FP interviews:

16 mothers with

children<2 years

16 husbands of FP

mothers 9

Mother respondent and

her children in Magreb


MIYCN and FP TIPs

mothers were

different mothers but

MIYCN mothers were

asked some FP

questions

FP TIPs husbands

were asked questions

about MIYCN

10

Husband being interviewed by

field staff


The study was approved by the JHU IRB and

the Ministry of Health

Training took place over 5 days and included

technical and human protection training and

practice sessions in the field

Full consent was obtained from all

participants

Full consent was obtained for the pictures

taken of respondents used in this

presentation11

Selected Results: Review of Main

Results MIYCN TIPs Visit#1

No infant<6 months was

EBF; food was introduced

after a few days or weeks

The reason food was

introduced was mothers

perceived their breast

milk was “insufficient”

11/16 mothers felt they

didn’t have sufficient

breast milk

10 mothers said they

thought this because the

child cried after BF12

Mother and child in Wesab



9/16 mothers reported early breastfeeding

problems (cracked or sore nipples;

engorgement) but self-treated (hot presses,

ointment) or in one case sought treatment

From interviews and observations

breastfeeding practices were not ideal—

mothers didn’t know how to increase breast

milk production, were feeding for short

periods of time or from only one breast

13

Three WHO Indicators for a Minimum

Adequate Diet 6-23 months

Breastfed; if not breastfed, child should

receive 1-2 c. of milk/dairy per day

Consume at least 4 out of 7 designated food

groups (grains/potatoes; legumes & nuts;

dairy; meat/flesh/fish; eggs; F/V with vitamin

A; other F/V)—if not BF, the child should

consume 4 FG + 1-2 c. milk

Consume 2-3 meals/day (6-8 mos); 3-4

meals/day (9-23 mos); if not BF, 1-2 extra

meals14

Selected Results: MIYCN TIPs

Visit#1—Three Practices 6-23 mos

15

Age groups

(n=12)

Breastfed or

milk

products

Minimum

number (4) of

food

groups/day

Minimum

number of

meals/day

Meeting all

three

practices

6-8 mos (4) 4 0 3 0

9-11 mos (4) 4 0 2 0

12-23 mos (4) 3 1 1 1

Total 11 1 6 1



All but one child continued to be breastfed;

the frequency varied from 1-4 times per day

The non-BF child received milk but only 100

ml per day

Meeting the minimum number of meals (6)

was easier than meeting the minimum food

groups (only 1) but as the child got older

meeting the mimimum number of meals

declined

16



Only one child (22 mos) out of 12 was fed by

all three practices

Many children were fed sugar

cookies/biscuits starting as early as one

month

One child (15 mos) was given only sugary

biscuits (no other foods) and breast milk

Biscuits are perceived as an easy food to

give to children of any age

17



More nutritious foods and snacks were not

given to children for a variety of reasons—

they were not appropriate for younger

children. Milk/dairy & grains/potatoes were

most appropriate as most children (10/12)

received dairy products and grains/potatoes

(8/12)

Only 2/12 children received foods from the

meat/fish group

18

Selected Results: MIYCN TIPs Visit#1—

Reasons for Practices 6-23 mos

3/12 received Fruits or vegetables; 3/12

received legumes (older children); no child

received eggs

In some cases the availability of these foods

limited what mothers could feed their children

Half of children (6/12) received cake or

biscuits the day before with 5 living in Wesab

About half of mothers were consuming a

more diverse diet than their children.

19

Selected Results: MIYCN TIPs Visit#1—

Observations in the Home

Most mothers washed their hands before

food prep and feeding their child but not with

soap; about half washed their baby’s hand

before feeding (but not with soap)

While mothers recognized the child not eating

as a sign of poor health/growth, half of

mothers were not using responsive feeding

practices and most mothers reported that

their child did not eat all the food served

20


Results FP TIPs Visit#1

Family planning use varied by zone with one

zone limited by the availability of methods in

the public sector

Family planning methods were available in

the private sector but at a cost which many

families couldn’t afford

Most couples in Yemen decide on FP

together; there were a few cases where men

continue to decide if FP should be used.

21


Results FP TIPs Visit#1

MIYCN-FP mothers didn’t know (7/30) or

thought BF was the best way to or could

prevent another pregnancy (15/30) and were

motivated to continue BF to prevent another

pregnancy

5 mothers alluded to BF criteria to prevent

pregnancy (continuous, exclusive, before

return of menses)

About half of all mothers knew someone who

had become pregnant while BF22



The majority said it was healthy to wait 2+

years before becoming pregnant

Half (8/16) of mothers were using a family

planning method—most in one district

OC and injections were the most common

methods used; one woman had a permanent

method.

The reasons for not using FP were side

effect;, cost; didn’t need it, couldn’t become

pregnant23



5/8 women who were not using FP said they

would start using a method after their menses

returns and one women said after two years

All but one mothers felt comfortable about

talking with their husbands about using FP

and said their husbands were supportive and

also wanted to prevent another pregnancy

24

Selected MIYCN-TIPs Results

Practice Offered &

Accepted

Tried Succeeded using

daily

Infants 0-5 mos:

breastfeed only

3 3 3

Infants 6-23 mos:

breastfeed from both

breasts until empty

4 4 4

IYC 6-23: vary the

child’s diet

10 10 9

Give more meals/food 3 3 3

Mothers: Vary mother’s

diet

10 10 10

25

Family Planning TIPs Results

Practice Sex Offered &

Accepted

Tried Succeeded

Discuss FP

intentions with

spouse

M 8 8 8

F 6 8 8

Go to health

facility for info on

FP

M 13 13 9

F 11 11 7

Start using

modern method

M 8 7 1

F 8 8 1

Satisfied users

discuss benefits

with others in

community

M 0 1 1

F 4 4 4

26

Feedback from mothers

MIYCN: most mothers succeeded in trying

one or several practices and reported being

happy with the new practices because they

felt their babies were getting better nutrition,

sleeping better, healthier

MIYCN: some limitation in the types of food.

Animal foods (meat) was not available all the

time; one mother said she had too many

children to eat more food herself.

27

Feedback from FP couples

Talking with each other about family planning

was not a problem for most couples

Couples were willing to go for family planning

advice; in some cases men wanted more

information about side effects from modern

methods.

There was high unmet need but services and

methods were not always available

28

Strengths of the study

In-depth information about beliefs about

health, nutrition and family planning

Information about past and current practices

Willingness of mothers and couples to

consider and try new practices

Demonstrated couples willingness to talk with

each about FP

Positive feedback from respondents about

trying new practices29

Limitations of the study

More information is needed about how to

resolve barriers to optimal practices

Lack of commodities and food limit success

for TIPs

For FP method uptake, a longer period of

time might be needed between TIPs 2 and 3

30

Next steps:

Finish the key

informant analysis

Develop MIYCN-FP

messages and

counseling package

Prepare the draft

report

Present findings in

Yemen (June)

31

Mother and her children

in Wesab

Thank you to the fantastic study

team!

32

Integrating MIYCN with Family Planning_Galloway_5.7.14

Health & Medicine

miycnfp practices

miycn interviews

miycn information

fp services

miycnfp counseling package

current practices

optimal practices

behaviors tips