A mixed method study exploring adherence to and acceptability of small quantity lipid-based nutrient supplements (SQ-LNS) among pregnant and lactating women in Ghana and Malawi.

Moses K Klevor,Nozgechi Phiri,Seth Adu-Afarwuah,Mamane Zeilani,Per Ashorn,Kenneth Maleta,Ulla Ashorn,Anna Lartey,Kathryn G Dewey,Mary Arimond,Juha Pyykkö

doi:10.1186/s12884-016-1039-0

Abstract

BackgroundSupplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods.MethodsThe objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation. We enrolled women before 20 gestation weeks into randomized trials in Ghana (n = 1320) and Malawi (n = 869). In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation. In the control groups participants received multiple micronutrients (MMN) during pregnancy and lactation or iron and folic acid (IFA) during pregnancy and calcium during lactation. We used questionnaires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability.ResultsThe mean self-reported adherence during the supplementation period was lower in Ghana (79.9 %) than in Malawi (91.7 %) for all supplements (difference 11.8 %, P < 0.001). Over time, adherence increased in Malawi but decreased in Ghana. In both countries, adherence in the SQ-LNS group was non-inferior to that in the control groups. Participants typically reported consuming SQ-LNS as instructed but when interviewers queried about experiences, most of the women described incidents of non-adherence. A usual reason for not consuming SQ-LNS was nausea and vomiting during pregnancy. Especially in Malawi, women reported sharing SQ-LNS with families and friends. Sustained use of SQ-LNS was attributed to expected health benefits and favorable sensory attributes. Often women compared their pregnancy to previous ones, and were of the view that SQ-LNS made a positive difference.ConclusionSelf-reported sustained adherence to consume SQ-LNS daily was high in both sites but lower in Ghana than in Malawi. In Ghana, adherence decreased over time whereas in Malawi adherence increased. Acceptability and adherence appeared interlinked, complex and context-related. Sustained consumption of SQ-LNS may require tailoring interventions by context.Trial registrationThe Ghana trial was registered at clinicaltrials.gov as NCT00970866, and the Malawi trial as NCT01239693.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1039-0) contains supplementary material, which is available to authorized users.

Highlights

Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings
Self-reported sustained adherence to consume SQ-LNS daily was high in both sites but lower in Ghana than in Malawi
The main aim was to test a hypothesis that provision of 20 g sachet SQ-LNS to mothers during pregnancy and during the first 6 months of lactation and to their infants from 6 to 18 months of age would result in favorable birth outcomes and improved child growth compared to children of mothers in the two control groups: one receiving either multiple micronutrient tablets (MMN) during pregnancy and lactation or iron and folic acid tablets during pregnancy (IFA) and placebo tablets during lactation

Summary

Introduction

Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods. Linear growth failure in childhood, stunting, is the most common growth deficit globally. Stunting begins in utero and continues especially during the vulnerable period of complementary feeding [25, 27]. Inadequate maternal diet during pregnancy and lactation, combined with increased nutrient requirements, play a crucial role in the etiology of stunting [1]. As more global attention is directed towards length gain in infancy and childhood, there is a need to better understand the potential of interventions towards reaching the global goal

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