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Factors Influencing Maternal Nutrition in Rural Nepal: An Exploratory Research Project a

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Jean E. Schumer , Stephanie L. Bernell , Viktor E. Bovbjerg & Marie L. Long

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Health Management and Policy Program, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA b

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Global Nutrition Empowerment, Corvallis, Oregon, USA Accepted author version posted online: 14 Nov 2013.Published online: 17 Jan 2014.

To cite this article: Jean E. Schumer, Stephanie L. Bernell, Viktor E. Bovbjerg & Marie L. Long (2014) Factors Influencing Maternal Nutrition in Rural Nepal: An Exploratory Research Project, Health Care for Women International, 35:10, 1201-1215, DOI: 10.1080/07399332.2013.862792 To link to this article: http://dx.doi.org/10.1080/07399332.2013.862792

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Health Care for Women International, 35:1201–1215, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.862792

Factors Influencing Maternal Nutrition in Rural Nepal: An Exploratory Research Project

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JEAN E. SCHUMER, STEPHANIE L. BERNELL, and VIKTOR E. BOVBJERG Health Management and Policy Program, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA

MARIE L. LONG Global Nutrition Empowerment, Corvallis, Oregon, USA

In this pilot project we examined factors contributing to maternal nutrition among women of child-bearing age in the Western Region of Nepal. We found that rural women are interested in learning about nutrition regardless of educational attainment and that level of education is strongly associated with interest in learning about nutrition (p < .001). Although the majority of women with no education expressed interest in learning about nutrition (71%), a substantial percentage (22%) were not interested. Education and the teaching of basic health messages may hold important benefits for improving maternal and child health. The focus of this study is the examination of factors contributing to maternal nutrition among women of child-bearing age in the Western Region of Nepal. The study is unique in that it is the first of its kind in this region of Nepal, and therefore it may offer some insights regarding rural health in Nepal. Furthermore, conclusions drawn may inform policymakers from other countries that have similar infrastructure, geography, and maternal–child health issues. Dietary deficiency during early life is known to have adverse effects on physiology, biochemistry, and brain anatomy, and may even result in permanent brain damage (De Souza, Fernandes, & do Carmo, 2011). Received 15 February 2012; accepted 2 November 2013. Address correspondence to Jean E. Schumer, Health Management and Policy Program, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Waldo Hall, Corvallis, OR 97331, USA. E-mail: [email protected] 1201

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Malnutrition and undernutrition in mothers and children in developing countries persist to this day, contributing to approximately 800,000 neonatal deaths annually (Bhutta et al., 2013). Approximately 3.1 million child deaths annually result from micronutrient deficiencies, stunting, and wasting (Bhutta et al., 2013). Thus, nutrition intervention remains a major focus of intervention for affected countries as well as for international aid organizations. Worldwide, nine out of ten children are born in low-income and middleincome countries where maternal undernutrition is common (Victora et al., 2008). For women, undernutrition can result in neural tube defects (NTDs) in their offspring. NTDs are preventable when mothers consume supplements of folic acid prior to conception (U.S. Centers for Disease Central [CDC], 1991). NTDs are formed by the third week of gestation (U.S. CDC, 1991, 2004) and are not impacted by women receiving folate later in their pregnancy. In many low- and middle-income countries, NTDs cause a significant economic burden. The cost of diagnosis, inpatient care, treatment, and comorbidities that extend through adulthood are typically borne by the family (Yi, Lindeman, Colligs, & Snowball, 2011). For rural families that are living on a subsistence wage, a diagnosis of an NTD can be emotionally and financially devastating. The country of particular interest to us is Nepal. This research project developed from collaboration between Nepali neurosurgeons at Tribhuvan University Hospital, a teaching hospital in Kathmandu, Nepal, and an American neurosurgeon (Dr. Long). The Nepali surgeons estimated that they operate on and repair approximately 30 to 40 cases per month of NTDs and complications resulting from NTDs (i.e., hydrocephalus, myelomeningocoele, encephalocoele). Given this seemingly high number of cases, we went on to investigate women’s interest in learning about the role of nutrition in preventing NTDs. The objectives of this study are the following: (a) assess the extent to which rural Nepali women are interested in learning about nutrition; (b) assess whether the level of education plays a role in their interest in nutrition; and (c) evaluate the feasibility of fortifying staple foods with micronutrients as a viable option in the regions where the project was conducted. This study piggybacked on work done by Global Nutrition Empowerment (GNE). GNE is a registered U.S. nonprofit organization dedicated to improving nutrition in poor, uneducated rural women, specifically in Nepal. This study served as a pilot project for future GNE work that will focus on the prevention of NTDs and micronutrient supplementation in rural Nepal.

BACKGROUND Nepal is one of 36 countries that account for 90% of the world’s undernourished children (The Lancet, 2010). The vast majority of the population

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lives rurally (85%; Ministry of Health and Population [MOHP], New ERA, and Macro International Inc., 2007). The lifestyle may be described as agricultural subsistence, where most food is grown for local consumption by families or communally by villages that are often comprised of extended family networks. The prevalence rate of stunting for children under 5 is 49%, a figure similar to other countries in the region (Afghanistan, Bhutan, India, Laos; MOPH et al., 2007; UNICEF, 2005). Given that health insurance—private or public—does not exist in Nepal, families bear the financial costs of children born with NTDs. Iron and folate supplements are distributed to all pregnant women in Nepal at the end of their first trimester of pregnancy to treat anemia (MOHP et al., 2007), but this is too late to avert NTDs (U.S. CDC, 1991). Protein energy malnutrition, iodine deficiency disorders, vitamin A deficiency, and iron deficiency anemia are the most common forms of malnutrition in Nepal (Food and Agriculture Organization of the United Nations, 2004). To address micronutrient deficiencies and improve maternal and child health, the government distributes supplemental vitamin A, iron, folic acid, and deworming medications to pregnant women, and it offers educational programs on complementary feeding to mothers of young children (MOHP et al., 2007). Christianson and colleagues (2006) suggest that there is a misconception among ministries of health regarding the cost for preventing birth defects. Most interventions to avert such disorders are carried out in primary or secondary care settings and include optimizing women’s diets, family planning, and managing and avoiding maternal infection. Improving nutrition of vulnerable populations, either commercially via fortification of staple foods or individually with drops, tablets, or sprinkles, has been used in developed and developing countries (Horton, 2006; U.S. CDC, 2004). The fortification methods using zinc, iron, vitamin A, iodine, and folic acid alone or in combination have been shown to be costeffective in Bangladesh, India, Indonesia, and the United States in averting disability and mortality in infants and children (Horton, 2006; Micronutrient Initiative, 2010; U.S. CDC, 1991, 2004).

MICRONUTRIENT SUPPLEMENTATION AND USE OF MATERNAL HEALTH CARE Despite government efforts, the proportion of pregnant women receiving the iron/folic acid supplement during pregnancy was 59% in 2006 (up from 23% in 2001; MOHP et al., 2007). Further, only 7% of women reported taking the tablets for the recommended 180 days (Kulkarni, Christian, LeClerq, & Khatry, 2009; MOHP et al., 2007). These rates vary by location of residence,

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with access and compliance higher in urban areas compared with rural areas (MOHP et al., 2007). There are similar regional differences in the use of maternal health care (MOHP et al., 2007). Government data indicate that 85% of women in urban areas compared with 38% of women in rural areas (who gave birth in the 5 years prior to the MOHP survey) receive prenatal care from a skilled birth attendant at least once for their most recent live birth (MOHP et al., 2007). The use of skilled birth attendants (a doctor, nurse, or midwife) for prenatal care appears to be strongly related to education. Women with secondary education or higher are three times more likely (90%) to use skilled birth attendants for prenatal care compared with rural women (MOHP et al., 2007). Women in the highest wealth quintile were five times more likely (84%) to receive such care compared with women in the lowest wealth quintile (18%; MOHP et al., 2007). Among pregnant women, 59% took iron tablets and 20% took medication for treatment of intestinal parasites, and there are significant variations in use by background characteristics (MOHP et al., 2007). Women who were younger than 20 year of age, pregnant with their first child, urban dwellers, with secondary education or higher, and in the highest wealth quintile were much more likely than their counterparts to have taken iron supplements during their pregnancy (MOHP et al., 2007).

Education Level Women’s level of education varies significantly by location of residence. Fifty-two percent of rural adult women have no education, compared with 32% of urban adult women (Table 1; MOHP et al., 2007). In urban areas, 9.7% of women have higher than secondary education compared with fewer than 2% of rural women (MOHP et al., 2007). According to Gakidou, Cowling, Lozano, and Murray (2010), women with more education are able to make better choices in a range of areas concerning health practices including personal hygiene, nutrition, and parenting practices. Health literacy, defined as the ability to read, understand, and act on health care information, may offer valuable contributions to improving health status of the population under investigation in the present study (Center for Health Care Strategies Inc., 2000, as cited in Kickbusch, 2001).

LITERATURE REVIEW A previous study conducted in the southern region of Nepal that explored factors related to women’s compliance with taking micronutrient supplements (Kulkarni et al., 2009). Kulkarni and colleagues (2009) examined determinants of compliance and women’s perceptions of prenatal

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2Completed

2.3 23.2

Lowest

24.1 25.9

Some primary

5.5 22.6

Second

5.5 5.4

Completed primary1

5.1 22.7

Middle

21.4 13.7

Some secondary

15.6 20.8

Fourth

7.2 1.9

Completed secondary2

71.5 10.8

Highest

9.7 1.5

More than secondary

100 100

Total

100 100

Total

% receiving antenatal care from any level skilled birth attendant (MD, nurse, midwife, volunteer health worker) 84.6 37.5 Body Mass Index (BMI)

Factors influencing maternal nutrition in rural Nepal: an exploratory research project.

In this pilot project we examined factors contributing to maternal nutrition among women of child-bearing age in the Western Region of Nepal. We found...
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