Abstract
Maternal anaemia prevalence in low‐income countries is unacceptably high. Our research explored the individual‐, family‐ and community‐level factors affecting antenatal care uptake, iron folic acid (IFA) intake and consumption of micronutrient‐rich diets among pregnant women in the plains of Nepal. We discuss how these findings informed the development of a home visit and community mobilisation intervention to reduce anaemia in pregnancy. We used a qualitative methodology informed by the socio‐ecological framework, conducting semi‐structured interviews with recently pregnant women and key informants, and focus group discussions with mothers‐in‐law and fathers. We found that harmful gender norms restricted women's access to nutrient‐rich food, restricted their mobility and access to antenatal care. These norms also restricted fathers' role to that of the provider, as opposed to the caregiver. Pregnant women, mothers‐in‐law and fathers lacked awareness about iron‐rich foods and how to manage the side effects of IFA. Fathers lacked trust in government health facilities affecting access to care and trust in the efficacy of IFA. Our research informed interventions by (1) informing the development of intervention tools and training; (2) informing the intervention focus to engaging mothers‐in‐law and men to enable behaviour change; and (3) demonstrating the need to work in synergy across individual, family and community levels to address power and positionality, gender norms, trust in health services and harmful norms. Participatory groups and home visits will enable the development and implementation of feasible and acceptable strategies to address family and contextual issues generating knowledge and an enabling environment for behaviour change.
Highlights
Anaemia in pregnancy affects 38% of women and is one of the main causes of maternal deaths and adverse pregnancy outcomes in lowand middle-income countries (Daru et al, 2018; Rahman et al, 2016)
We report on findings from qualitative research in rural plains Nepal to explore the factors affecting anaemia in pregnancy
We will engage with men in three ways: (1) as family members through encouraging them to play an active role in preventing anaemia in pregnancy during home visits; (2) supporting community groups to discuss how they would like to engage with men; and (3) through inviting them to large community meetings where groups plan community actions
Summary
Anaemia in pregnancy affects 38% of women and is one of the main causes of maternal deaths and adverse pregnancy outcomes in lowand middle-income countries (Daru et al, 2018; Rahman et al, 2016). Based on the literature about drivers of anaemia in this context and the need to look beyond the individual when understanding behaviours, we developed a conceptual framework to enable analysis of the individual-, family- and community-level factors (and the interaction between them), which affect access to antenatal care, IFA adherence and consumption, and consumption of micronutrient-rich foods. Research shows that Nepalese households discriminate against pregnant women in the allocation of food, and they often receive smaller proportions of food compared with other family members (Gittelsohn, 1991; Harris-Fry et al, 2018) This literature on anaemia, antenatal care uptake and gender in Nepal indicates that the drivers of anaemia are complex and interacting and operate at multiple levels. Our research sought to explore the individual-, family- and community-level factors affecting antenatal care uptake, IFA intake and consumption of micronutrient-rich diets among pregnant women in the plains of Nepal. Our findings were used to inform the development of an intervention to reduce anaemia in pregnancy, exemplifying how contextual understanding can be used to inform the design of appropriate interventions
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