Screening, prevention, and management of maternal acute malnutrition and anemia in Ethiopia: evidence from a longitudinal eCohort study

Background

Undernutrition during pregnancy, including both micronutrient deficiencies and chronic energy deficiency, is an important public health concern with negative consequences for maternal, neonatal, and child health, development, and economic outcomes through the life course. Despite widespread efforts to address undernutrition during pregnancy, there is little evidence on the quality of management of maternal undernutrition in high-burden settings. Data on follow-up care for undernutrition over the course of pregnancy is particularly scarce. In this study, we used a novel longitudinal dataset to examine the quality of care for pregnant women with acute malnutrition and anemia in Ethiopia.

Methods and findings

We analyzed data from the Maternal and Newborn Health eCohort, a multi-country longitudinal study of the content, quality, and experience of maternity care during the prenatal, delivery, and postnatal periods. Data were collected in East Shewa in the Oromia region of Ethiopia from April 2023 to February 2024. Participants were recruited by research staff in a sample of health facilities at the time of their first antenatal care (ANC) contact and followed through delivery. Following Ethiopia’s national guidelines, acute malnutrition was defined as mid-upper arm circumference (MUAC) under 23 centimeters (cm), and anemia was defined as Haemoglobin (Hb) under 11 grams per deciliter (g/dL). We measured adherence to Ethiopia’s national guidelines for screening, prevention, and management of acute malnutrition, and conducted a longitudinal analysis using generalized estimating equations (GEE) to assess factors associated with adherence to iron and folic acid supplementation.

1000 women were enrolled in the eCohort. After excluding women who were lost to follow-up (n= 113), had miscarriages (n=29), or had missing information on nutritional status at baseline (n = 48), the analytic sample included 810 women. At the time of their first ANC contact, 22% of women in the sample had acute malnutrition and 11% had anemia. During the first ANC contact, only 12% of women were screened for acute malnutrition and 96% were screened for anemia. In follow-up care, weight monitoring according to national guidelines was performed for only 4% of women with acute malnutrition, and only 23% of women with anemia received the recommended number of blood tests. Only 11% of women with acute malnutrition ever received supplemental food during their pregnancy. While 89% of women with anemia were given or prescribed iron and folic acid supplements at some point during their pregnancy, only 32% took them throughout the entire pregnancy. Women with secondary education, women in the highest wealth quintile, women who reported past pregnancy complications, and women who received or were prescribed IFA supplements during the first ANC contact were more likely to adhere to IFA supplementation during pregnancy.

Conclusions

This study sheds light on striking gaps in the quality of care for undernutrition during pregnancy in Ethiopia. It is critical to identify approaches to improve the quality of care for undernutrition during pregnancy, focusing not only on screening and management at the first ANC contact but also on follow-up care through the remainder of pregnancy.