Infant Mortality In sub-Saharan Africa Research Articles

Locusts Fly, Babies Die: Desert Locusts and Infant Mortality in Sub-Saharan Africa

Locusts Fly, Babies Die: Desert Locusts and Infant Mortality in Sub-Saharan Africa

The potential of provitamin A maize ( Zea mays L.) biofortification in sub-Saharan Africa: Current status, opportunities, challenges and perspectives: A review

Abstract Maize is a potential crop for improving food and nutritional security for over 300 million people in sub-Saharan Africa (SSA). It is the most preferred cereal crop in SSA because of its diversified uses, taste and higher grain yield potential compared to other cereals. However, overdependence on maize-based diets without vitamin A supplementation is associated with the highest rates of vitamin A deficiency (VAD) in SSA. Vitamin A deficiency mostly affects children under the age of 5 years, pregnant and lactating women, accounting for the worst disease burden, and infant mortality in SSA. To date provitamin A maize breeding programmes of HarvestPlus partnered with CIMMYT and IITA, private seed companies and national plant breeding programmes developed at least 70 elite varieties to curb VAD in SSA. This review summarizes the potential of provitamin A maize in SSA focusing on (1) reasons why maize is a good choice for provitamin A biofortification, (2) the prevalence of vitamin A deficiency in SSA, (3) the Global Hunger Index (GHI) and extent of hidden hunger, (4) possible interventions to curb vitamin A deficiency in SSA and their applicability, (5) status of the provitamin A maize varieties released, (6) level of adoption and consumer perception of provitamin A maize-based food, (7) the impact of climate change in maize productivity in SSA and (8) the breeding methods for developing provitamin A maize-resilient genotypes to mitigate the effects of climate change in SSA.

Cost-effectiveness of community-based distribution of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria, and the Democratic Republic of Congo

IntroductionMalaria in pregnancy is a major driver of maternal and infant mortality in sub-Saharan Africa. The WHO recommends the administration of intermittent preventive treatment with sulfadoxine pyrimethamine (IPTp-SP) at antenatal...

Mobile phone coverage and infant mortality in sub-Saharan Africa

Infant mortality is still high in Sub-Saharan Africa. Mobile phone technology has the potential to reduce mortality by facilitating the exchange of information. To test for effects, we combine georeferenced information on mobile phone signal coverage with infant mortality data on 1,268,041 children born in 30 Sub-Saharan African countries between 1999–2016. Our results reveal that infant mortality risk drops substantially as mobile phone coverage expands. Infants are 0.9 percentage points less likely to die within the first year after birth compared to their sibling(s) when mobile phone signal is available. In line with this result, we also find that fertility rates decline with the rollout of mobile coverage. Suggestive evidence indicates that improved health knowledge is relevant in explaining our findings. Mobile-phone related changes in access to in-person healthcare services or improvements in income opportunities, on the other hand, are unlikely to play an important role.

Impact of an Online Program of Bubble Continuous Positive Airway Pressure Education in a Resource-Constrained Setting.

Respiratory distress is a leading cause of preterm infant mortality in sub-Saharan Africa. Bubble continuous positive airway pressure (CPAP) is emerging as a potentially safe, cost-effective way of delivering noninvasive respiratory support in low-income and middle-income countries. However, without healthcare providers who are knowledgeable and skilled in the use of this technology, suboptimal neonatal care and related health disparities are likely to persist. We hypothesized that an Internet-based, blended curriculum on bubble CPAP for bedside providers in low-resource mother-baby units (MBUs) could be developed and implemented and lead to improvements in clinical knowledge, reasoning, and learner confidence in bubble CPAP. Clinical educators from Israel, Ghana, and the United States used the analysis, design, development, implementation, and evaluation (ADDIE) design framework to create an online curriculum for two MBUs in Kumasi, in the Ashanti Region of Ghana. Participants completed pre and post curriculum knowledge tests and completed surveys on their perspectives. Fifty-four interdisciplinary health professionals from the MBUs participated in the curriculum. Median knowledge test scores improved from 64% (interquartile range [IQR] = 50-72%) to 81% (IQR = 71-89%) after participation in the curriculum (P < 0.001). Learners reported high levels of confidence with bubble CPAP after participating in the curriculum and evaluated the curricular components highly. An online curriculum was successfully implemented and led to changes in healthcare worker knowledge in bubble CPAP. This may be an effective way to deliver education to healthcare professionals in resource-constrained countries and warrants further study.

Commentary: on the effects of health expenditure on infant mortality in sub-Saharan Africa: evidence from panel data analysis

BackgroundThis commentary assesses critically the published article in the Health Economics Review. 2020; 10 (1), 1–9. It explains the effects of health expenditure on infant mortality in sub-Saharan Africa using a panel data analysis (i.e. random effects) over the year 2000–2015 extracted from the World Bank Development Indicators. The paper is well written and deserve careful attention.Main textThe main reasons for inaccurate estimates observed in this paper are due to endogeneity issue with random effects panel estimators. It occurs when two or more variables simultaneously affect/cause each other. In this paper, the presence of endogeneity bias (i.e. education, health, health care expenditures and real GDP per capita variables) and its omitted variable bias leads to inaccurate estimates and conclusion. Random effects model require strict exogeneity of regressors. Moreover, frequentist/classic estimation (i.e. random effects) relies on sampling size and likelihood of the data in a specified model without considering other kinds of uncertainty.ConclusionThis comment argues future studies on health expenditures versus health outcomes (i.e. infant, under-five and neonates mortality) to use either dynamic panel (i.e. system Generalized Method of Moments, GMM) to control endogeneity issues among health (infant or neonates mortality), GDP per capita, education and health expenditures variables or adopting Bayesian framework to adjust uncertainty (i.e. confounding, measurement errors and endogeneity of variables) within a range of probability distribution.

Evaluation of a turbidimetric C-reactive protein assay to monitor early-onset neonatal sepsis in South Kivu (Democratic Republic of the Congo)

Neonatal sepsis, a condition defined as bacteremia within the first month of life accompanied by signs of systemic infection, is the most preventable cause of infant mortality in sub-Saharan Africa. Despite the development of new infection markers, C-reactive protein (CRP) is the most extensively studied acute phase reactant so far and the preferred index in many neonatal intensive care units (NICUs). The aim of the present study was to evaluate an affordable, non-commercial turbidimetric CRP assay for monitoring early-onset neonatal sepsis (EOS). A total of 148 neonates admitted at the NICU of the Hôpital Provincial Général de Référence de Bukavu to diagnose and to monitor EOS were enrolled in the study. CRP was assayed using a functional turbidimetric assay based on the interaction of CRP with phosphocholine containing particles (Intralipid®). In total, 62/148 (41.9%) cases were identified as blood culture-proven EOS. Different serum CRP slopes were observed among the different birth weight categories. Moreover, the serum (CRP 48 h-CRP 12 h) difference and the birth weight predicted the outcome of these septic newborns. Our turbidimetric CRP assay is a potential novel tool that can be used in the management of EOS in sub-Saharan Africa. The simplicity of the assay and the extremely low price make the CRP method very well suited for developing countries.

The effects of health expenditure on infant mortality in sub-Saharan Africa: evidence from panel data analysis

IntroductionAlthough health expenditure in sub-Saharan African countries is the lowest compared with other regions in the world, most African countries have improved their budget allocations to health care over the past 15 years. The majority of health care sources in sub-Saharan Africa are private and largely involve out-of-pocket expenditure, which may prevent healthcare access. Access to healthcare is a known predictor of infant mortality. Therefore the objective of this study is to determine the impact of health care expenditure on infant mortality in sub-Saharan Africa.MethodsThe study used panel data from World Bank Development Indictors (WDI) from 2000 to 2015 covering 46 countries in sub-Saharan Africa. The random effects model was selected over the fixed effects model based on the Hausman test to assess the effect of health care expenditure on infant and neonatal mortality.ResultsBoth public and external health care spending showed a significant negative association with infant and neonatal mortality. However, private health expenditure was not significantly associated with either infant or neonatal mortality. In this study, private expenditure includes funds from households, corporations and non-profit organizations. Public expenditure include domestic revenue as internal transfers and grants, transfers, subsidies to voluntary health insurance beneficiaries, non-profit institutions serving households or enterprise financing schemes as well as compulsory prepayment and social health insurance contributions. External health expenditure is composed of direct foreign transfers and foreign transfers distributed by government encompassing all financial inflows into the national health system from outside the country.ConclusionHealth care expenditure remains a crucial component of reducing infant and neonatal mortality in sub-Saharan African countries. In the region, where health infrastructure is largely underdeveloped, increasing health expenditure will contribute to progress towards reducing infant and neonatal mortality during the Sustainable Development Goals (SDGs) era. Therefore, governments in the region need to increase amounts allocated to health care service delivery in order to reduce infant mortality.

Comparison of three classes of Marginal Risk Set Model\xa0in predicting infant mortality among newborn babies at Kigali\xa0University\xa0Teaching Hospital, Rwanda, 2016

BackgroundThe Infant Mortality Rate (IMR) in Sub-Saharan Africa (SSA) remains the highest relatively to the rest of the world. In the past decade, the policy on reducing infant mortality in SSA was reinforced and both infant mortality and parental death decreased critically for some countries of SSA. The analysis of risk to death or attracting chronic disease may be done for helping medical practitioners and decision makers and for better preventing the infant mortality.MethodsThis study uses popular statistical methods of re-sampling and one selected model of multiple events analysis for measuring the survival outcomes for the infants born in 2016 at Kigali University Teaching Hospital (KUTH) in Rwanda, a country of SSA, amidst maternal and child’s socio-economic and clinical covariates. Dataset comprises the newborns with correct information on the covariates of interest. The Bootstrap Marginal Risk Set Model (BMRSM) and Jackknife Marginal Risk Set Model (JMRSM) for the available maternal and child’s socio-economic and clinical covariates were conducted and then compared to the outcome with Marginal Risk Set Model (MRSM). That was for measuring stability of the MRSM.ResultsThe 2117 newborns had the correct information on all the covariates, 82 babies died along the study time, 69 stillborn babies were observed while 1966 were censored. Both BMRSM JMRSM and MRSM displayed the close results for significant covariates. The BMRSM displayed in some instance, relatively higher standard errors for non-significant covariates and this emphasized their insignificance in MRSM. The models revealed that female babies survive better than male babies. The risk is higher for babies whose parents are under 20 years old parents as compared to other parents’ age groups, the risk decreases as the APGAR increases, is lower for underweight babies than babies with normal weight and overweight and is lower for babies with normal circumference of head as compared to those with relatively small head.ConclusionThe results of JMRSM were closer to MRSM than that of BMRSM. Newborns of mothers aged less than 20 years were at relatively higher risk of dying than those who their mothers were aged 20 years and above. Being abnormal in weight and head increased the risk of infant mortality. Avoidance of teenage pregnancy and provision of clinical care including an adequate dietary intake during pregnancy would reduce the IMR in Kigali.

MiRNA-146a polymorphism increases the odds of malaria in pregnancy

BackgroundPlasmodium falciparum infection during pregnancy is a major cause of poor maternal health, adverse foetal outcome and infant mortality in sub-Saharan Africa. Genetic disposition is involved in susceptibility to malaria in pregnancy and its manifestation. MicroRNAs (miRNAs) influence gene regulation including that of innate immune responses. A miRNA-146a rs2910164 G > C single nucleotide polymorphism (SNP) has been associated with increased risks of several diseases, but no data as to malaria are available.MethodsThe association between miRNA-146a rs2910164 and P. falciparum infection among 509 Ghanaian women attending antenatal care (ANC) and 296 delivering Ghanaian primiparae was investigated. Malaria parasites were diagnosed by microscopy and PCR. Leukocyte-associated hemozoin in placental samples was recorded as well. Proportions were compared between groups by Fisher’s exact test, and logistic regression models were used to adjust for possible confounders.ResultsBy PCR, P. falciparum infection was detected in 63% and 67% of ANC attendees and delivering primiparae, respectively. In both groups, two in three women were either heterozygous or homozygous for miRNA-146a rs2910164. Among ANC attendees, homozygosity conferred increased odds of infection (adjusted odds ratio (aOR), 2.3; 95% CI, 1.3–4.0), which was pronounced among primigravidae (aOR, 5.8; 95% CI, 1.6–26) but only marginal in multigravidae. Likewise, homozygosity for miRNA-146a rs2910164 in primiparae increased the odds of past or present placental P. falciparum infection almost six-fold (aOR, 5.9; 95% CI, 2.1–18).ConclusionsThese results indicate that SNP rs2910164 G > C is associated with increased odds for P. falciparum infection in first-time pregnant women who are considered to lack sufficient acquired immune responses against pregnancy-specific strains of P. falciparum. These findings suggest that miRNA-146a is involved in protective malarial immunity, and specifically in the innate component.

Malaria Control and Infant Mortality in Africa

Has massive distribution of insecticide-treated-nets contributed to the reduction in infant mortality in Sub-Saharan Africa over the past 15 years? Using large household surveys collected in 16 countries and exploiting the spatial correlation in distribution campaigns, we estimate the relationship between the diffusion of bednets and the progress in child survival. We find no evidence of a causal link in cities, and no impact either in rural areas with low malaria prevalence. By contrast, in highly malarious rural areas where bednet coverage reached high levels, above 75% of households, infant mortality has been reduced by at least 3 percentage points, which amounts to 25% of the initial mortality. The identified impact is even higher for the children of mothers with no education. It lies at the upper bound found with RCTs, most likely because those were implemented in contexts with lower mortality and/or malaria prevalence.

Health care expenditure and infant mortality in sub-Saharan Africa

The paper examines the impact of public health expenditure on under-five and infant mortality rates in 10 selected sub-Saharan African countries for the period 2000–2008. The results show that government health expenditure has a positive effect on under-five and infant mortality. However, the results show GDP per capita, health aid, hiv prevalence and immunization have significant negative effects on under-five and infant mortality. The results clearly suggest that health care expenditures have not been translated to improvement in under-five mortality in sub-Saharan Africa. The results possibly reflect the high level of corruption and fungibility of public health expenditure in sub-Saharan Africa countries.

Socio-economic and Demographic Covariates of Infant Mortality in Sub-Saharan Africa: Application of Analysis of Variance (ANOVA) and Multiple Regression Models

The main thrust of the study is investigate the main socio-economic and demographic antecedents and proximate factors influencing Infant Mortality Levels and Patterns in Sub-Saharan African&#x0D; The source of data of the study is largely from the 2001-2005 UNDP Human Development Reports, National Census Results, DHS data and Demographic survey results of Sub-Saharan African Countries.&#x0D; The analytical techniques include analysis of univariate and bivaraite frequency distributions, ANOVA, correlation matrix and Multivariate regression models. Each country is taken as the unit of observation and a total of 42 countries are covered. The dependent variable is the level of Infant Mortality whereas 14 independent variables as the predictors influencing the Infant Mortality conditions are considered. &#x0D; The model outputs suggested that all the fourteen independent covariates appeared to influence the levels of infant mortality positively or negatively, but in varying values of statistical significance, due to multicollinearity among the independent variables as manifested in the correlation matrix which appear to hinder clear understanding of the impact of each independent variable on infant mortality. However, the stepwise regression output identified the critical covariates of the infant mortality levels.&#x0D; In conclusion, the study indicated that persistent high infant mortality level in the African -Continent has yet to continue for some decades before coming down to acceptable levels. The main reasons which largely appeared to maintain high Infant Mortality Levels among the Sub-Saharan Countries were noted to be the widespread poverty conditions and low level of health services and education in rural Sub-Saharan Africa. Consequently, the high infant mortality in rural Africa has been observed to be influenced by high fertility level, family planning programmes, education and employment, among other background and proximate variables.

The Differential Mortality of Undesired Infants in Sub-Saharan Africa.

With high rates of infant mortality in sub-Saharan Africa, investments in infant health are subject to tough prioritizations within the household, in which maternal preferences may play a part. How these preferences will affect infant mortality as African women have ever-lower fertility is still uncertain, as increased female empowerment and increased difficulty in achieving a desired gender composition within a smaller family pull in potentially different directions. I study how being born at a parity or of a gender undesired by the mother relates to infant mortality in sub-Saharan Africa and how such differential mortality varies between women at different stages of the demographic transition. Using data from 79 Demographic and Health Surveys, I find that a child being undesired according to the mother is associated with a differential mortality that is not due to constant maternal factors, family composition, or factors that are correlated with maternal preferences and vary continuously across siblings. As a share of overall infant mortality, the excess mortality of undesired children amounts to 3.3 % of male and 4 % of female infant mortality. Undesiredness can explain a larger share of infant mortality among mothers with lower fertility desires and a larger share of female than male infant mortality for children of women who desire 1-3 children. Undesired gender composition is more important for infant mortality than undesired childbearing and may also lead couples to increase family size beyond the maternal desire, in which case infants of the surplus gender are particularly vulnerable.

Impact of High Patient Volume on Midwifery Education in Kampala, Uganda

PurposeThe purpose of this study was to understand the barriers to midwifery education within a high‐volume hospital in Kampala, Uganda. Our aim was to determine students’ and midwives’ perceptions of the educational process in the context of a setting with high patient volume.Research QuestionWe hypothesized that when compared with students, practicing midwives view high patient volume as a greater barrier to education.SignificanceDespite advances in maternal care, maternal and infant mortality in sub‐Saharan Africa have continued to lag behind the rest of the world. With an ongoing rise in pregnancies in this region, urgent attention is needed to better train, educate, and retain student midwives.MethodsWe conducted a cross‐sectional survey‐based study to identify challenges to midwifery education among students and midwives based at Mulago National Referral Hospital in Kampala. We surveyed 60 midwives and 51 midwifery students. Likert‐scale responses were dichotomized and chi‐square tests were used to examine differences in perceptions between students and midwives.ResultsWe identified notable and significant differences in perceptions between midwives and midwifery students when examining the impact of patient volume on education and practice. These differences persisted across multiple questions relating to the educational process. When compared with students, a larger proportion of midwives felt that high patient volume impaired education relating to midwifery knowledge (33% vs 12%, P &lt; .01) and clinical skills (43% vs 4%, P &lt; .01), and contributed to high stress levels (75% vs 35%, P &lt; .01).DiscussionWhile there is ample research on educating midwives within a broader global context, limited research has explored how midwifery training is impacted by high patient volume. Student midwives may view high patient volume as an educational opportunity, while practicing midwives consider high patient volume a barrier to teaching. This difference may relate to a greater perceived responsibility for patient care by midwives. Our findings suggest that excessive patient volume may be impairing midwives’ ability to effectively teach their students the midwifery model of care while balancing their high patient workload. Additional research is urgently needed to identify how to support midwifery practice in health care environments with high patient demand.

Association of type of birth attendant and place of delivery on infant mortality in sub-Saharan Africa.

To examine the association between type of birth attendant and place of delivery, and infant mortality (IM). This cross-sectional study used self-reported data from the Demographic Health Surveys for women in Ghana, Kenya, and Sierra Leone. Logistic regression estimated odds ratios (ORs) and95% confidence intervals. In Ghana and Sierra Leone, odds of IM were higher for women who delivered at a health facility versus women who delivered at a household residence (OR=3.18, 95% confidence interval, CI: 1.29-7.83, p=0.01 and OR=1.62, 95% CI: 1.15-2.28, p=0.01, respectively). Compared to the use of health professionals, the use of birth attendants for assistance with delivery was not significantly associated with IM for women in Ghana or Sierra Leone (OR=2.17, 95% CI: 0.83-5.69, p=0.12 and OR=1.25, 95% CI: 0.92-1.70, p=0.15, respectively). In Kenya, odds of IM, though nonsignificant, were lower for women who used birth attendants than those who used health professionals to assist with delivery (OR=0.85, 95% CI: 0.51-1.41, p=0.46), and higher with delivery at a health facility versus a household residence (OR=1.29, 95% CI: 0.81-2.03, p=0.28). Women in Ghana and Sierra Leone who delivered at a health facility had statistically significant increased odds of IM. Birth attendant type-IM associations were not statistically significant.Future research should consider culturally-sensitive interventions to improve maternal health and help reduce IM.

Polygynous contexts, family structure, and infant mortality in sub-saharan Africa.

Contextual characteristics influence infant mortality above and beyond family-level factors. The widespread practice of polygyny is one feature of many sub-Saharan African contexts that may be relevant to understanding patterns of infant mortality. Building on evidence that the prevalence of polygyny reflects broader economic, social, and cultural features and that it has implications for how families engage in the practice, we investigate whether and how the prevalence of polygyny (1) spills over to elevate infant mortality for all families, and (2) conditions the survival disadvantage for children living in polygynous families (i.e., compared with monogamous families). We use data from Demographic and Health Surveys to estimate multilevel hazard models that identify associations between infant mortality and region-level prevalence of polygyny for 236,336 children in 260 subnational regions across 29 sub-Saharan African countries. We find little evidence that the prevalence of polygyny influences mortality for infants in nonpolygynous households net of region-level socioeconomic factors and gender inequality. However, the prevalence of polygyny significantly amplifies the survival disadvantage for infants in polygynous families. Our findings demonstrate that considering the broader marital context reveals important insights into the relationship between family structure and child well-being.

Factors associated to infant mortality in Sub-Saharan Africa.

Half of the 10 million children who die annually in the world are from Sub-Saharan Africa (SSA). The reasons are known, but lack of will and resources avoid the development of sustainable policies. Associated factors to the high infant mortality rate (IMR) in SSA have been investigated in this research. An ecological multi-group study was designed comparing rates within SSA. The dependent variable is the IMR and health services, economic and development indicators are the independent variables. Information and data sources were WHO, World Bank, UNICEF and UNDP (1997–2007). IMR mean value is 92.2 (per 1000 live births) and a relationship with several of the factors could be observed. In the bi-variate analysis direct relationship was observed with maternal mortality rate and an inverse relationship was observed with prenatal care coverage, births assisted by skilled health personnel, gross national income per capita, per capita government expenditure on health, social security expenditure, adult literacy rate, net primary school enrolment rate, population with access to safe drinking water (in urban and rural areas) and with population with access to basic sanitation in rural areas. In the multi-variate analysis IMR had an inverse relationship with children under 5 years with diarrhoea who receive oral re-hydration, with social security expenditure as percentage of general government expenditure on health and with per capita government expenditure on health. The situation in SSA would change if their inhabitants received education and information to demand more equitable polices and better investments from their governments.

Contraceptive practice in a tertiary hospital in south-south Nigeria

Background: The high maternal and infant mortality in sub-Saharan Africa has been associated with unplanned pregnancy, high parity and short birth intervals. Use of effective contraceptive methodssignificantly reduce maternal and infant mortality and improved quality of life. This study determines the contraceptive practice among clients in a tertiary hospital. Method: The record cards of all clients that accepted contraceptive methods in the family planning clinic at the University of Uyo Teaching Hospital, Uyo over a 7-year period were reviewed. Results: There were 1094 new contraceptive acceptors during the study period. The modal age group of the clients was 25 – 34 years (59.3%); majority of the clients were multiparous (59.8%), christians (99.6%) and 71.0% had at least secondary school education. The most commonly accepted contraceptive methods were the intrauterine contraceptive device (45.0%) and oral contraceptive pills (28.1%), while clinic personnel (63.1%), and friends and relatives (20.1%) were the most common sources of information on contraception. Conclusion: Intrauterine contraceptive device and oral contraceptive pills were the most frequently accepted methods of contraception. We advocate increase in the contraceptive options including implants. The print and electronic media should be more involved in the awareness programs on contraception.

Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential Nutrition Actions Framework

Madagascar has some of the highest rates of child stunting, maternal malnutrition, and infant mortality in sub-Saharan Africa. To improve infant and young child feeding practices, increase uptake of micronutrient supplements, and improve women's dietary practices through implementation of a nutrition project based on the Essential Nutrition Actions (ENA) framework. Interventions included training, interpersonal communication, community mobilization, and mass media. Changes in practices were assessed through a comparison of data for children under 2 years of age from representative cross-sectional household surveys collected at baseline in 2000 (n = 1,200) and at the end of program implementation in 2005 (n = 1,760). The surveys were conducted in six districts with a population of 1.4 million. The rate of initiation of breastfeeding within 1 hour of birth increased from 32% to 68%, the rate of exclusive breastfeeding of infants under 6 months of age increased from 42% to 70%, the rate of continuation of breastfeeding at 20 to 23 months increased from 43% to 73%, the rate of feeding children the minimum recommended number of meals per day at 6 to 23 months increased from 87% to 93%, the rate of iron-folic acid supplementation during pregnancy increased from 32% to 76%, and the rate of postpartum vitamin A supplementation increased from 17% to 54% (p < .001 for all changes). Modest improvement was achieved in maternal dietary practices during lactation and feeding of the sick child after illness. The results were inconclusive regarding food diversity for complementary feeding. No improvements were reported in increasing food intake during child illness or pregnancy. The ENA framework allows broad-scale improvement of nutritional practices to be achieved through the maximization of contacts using multiple program opportunities within existing health systems and community structures and through mass media.