Asmamaw Eshete REGIONAL WORKSHOP SPIR II Learning Event Co-organized by IFPRI, USAID, CARE, ORDA, and World Vision MAY 16, 2023 - 9:00AM TO MAY 17, 2023 - 5:00PM EAT

1. SPIR II RFSA | 2023 Learning Event
Determinants of Maternal Nutrition in
PSNP Woredas, Ethiopia
Asmamaw Eshete, Nutritionist
IHS Global Consultancy, small grant project

2. Outline
Major Covered areas in the study presentation
Background
Study scope, PLW nutrition, research
questions, gaps to feel.
Methods
Qualitative and Quantitative methods
applied.
In-depth interview findings
Five thematic areas and key findings
The IMNS Model
The PLW nutrition interventions model
developed from the study.
Objective
The four objectives of the research.
Desk review findings
Key desk review findings and framework
developed.
Recommendations
Key recommendations provided under each
thematic areas.
The IMNS Framework
The vicious cycle of causes of maternal
nutrition and intervention approach
01.
03.
05.
07.
02.
04.
06.
08.

3. Research
questions
PLW
Nutrition
Background
• Improving women’s diets, access to nutrition services, and care practices
before and during pregnancy and while breastfeeding is critical to prevent
malnutrition-particularly in the first 1000 days
• In Ethiopia, maternal dietary practices are influenced by economic, social, and
cultural barriers.
• What specific factors determine PLW nutrition?
• How are those factors sourced, transmitted, and retained?
• What makes PLW deviant from those factors living in food-secured and non-
secured HHs?
• The current research findings have not robustly shown how barriers from the
demand, supply, and community sides are inter-related
• How barriers/information is being sourced, disseminated, and retained to determine
maternal dietary practices is not well understood
• Deviant maternal nutrition practices not yet identified
Gaps to fill

4. Objectives
OBJECTIVE 01
Exploring potential barriers to pregnant and lactating
women's nutrition in SPIR II/PSNP5 intervention areas.
OBJECTIVE 02
Exploring the sources, mechanisms, and approaches to transfer and
retain community-level knowledge, information, and habits related to
maternal nutrition.
OBJECTIE 03
Exploring deviant maternal practices in food insecure and
secure PLW households for further policy recommendation
and study
OBJECTIVE 04
Understanding the gender-related barriers to PLW’s nutrition

5. Methods
• SLOT
• Existing barrier
• Conceptual framework
developed
Document and
literature
review
• 7 FGD (RLs, CL, GM/M-in-L)
• 40 KII (PLW, HSPs, PM)
• 32 HH Observations (PLW’s HH)
Qualitative data
collected
• Major barriers and causes
identified in 5-themes
• MN conceptual model generated
Analysis and
reporting
Coordination
• Consultancy team
• SPIR II, HEWs, WrHO
Operational definitions
• PD-PLW = FI-HH + MUAC >23cm
• ND-PLW = FS-HH + MUAC <23cm
Analysis
• Altas ti. qualitative software
• SPSS
• Coding, categorization,
thematic analysis.

6. SLOT Analysis
Results
Strength Limitation
• Maternal nutrition is well considered in
policies, strategies and guidelines;
• Strategies to address gender issues;
• Generated lessons from last PSNP4;
• PSNP5 prioritize PLWs and caretakers with
malnourished children as Temporary Direct
Support (TDS) clients.
• Exemption of PLW from fasting by Ethiopian
Orthodox Tewahedo Church
• Nutrition governance system;
• Budget gap on Food and Nutrition Strategy
(FNS)
• E-DHS missed to do PLW nutritional status;
• Exclusion of chronic food insecure
households in PSNP5;
• Community-based health insurance (CBHI)
not adequately responsive to services at
health facilities
Opportunities Threats
• Availability of economic and financial access
initiatives;
• Coverage of media & telecom
• Gov’t priorities to food security and large-
scale agricultural investment
• Climate change
• Insecurity and displacement
• Drought and pandemics
• High food price

7. Results cont’d

8. THEME 1
Barriers to PLW's dietary practices vary across their
socioeconomic, religious, and cultural backgrounds
Poor PLW nutrition counseling at HFs
Analysis and
reporting
Fasting
Common food taboos.
“Expectant mothers are supposed to refrain
from good foods that make the fetus grow
bigger in her womb including bananas,
mango, sugarcanes, and orange” Lactating
mother, P6
Seasonal pattern, availability and economic
accessibility.
“Lentils and chickpeas are said to cause
stomachache for children as they get their
food from their mother through
breastmilk.” ND-L Mother, Amhara region

9. THEME 2
Transgenerational sources and transfer of community-level
information and habits that affect maternal feeding practices
Food taboos are initiated from mothers’ experiences and are perceived as
preventive measures for the mother and the baby.
Analysis and
reporting
WHO sourced
How conveyed
How retained
Family members, social gatherings, meetings,
and discussing with PLWs during clinic visits, etc.
Traditional healers, community women/elders (e.g.,
grandmothers and mothers-in-law)
Developing scenarios from bad birth outcomes.

10. THEME 3
Peculiar nutrition behaviors help positive deviant PLWs in food-
insecure households
Analysis and
reporting
 Have multiple sources of information
 Have a supportive household culture and feeding habits
 Consume more locally available, and cheaper nutritious food items
 Tend to be less influenced by food taboos
 Understand the nutritional effects of fasting and have a flexible attitude toward fasting
practices (time)
 Better practice and use of preventative medical services (ANC, PNC, EPI)
 Aspire to participate in diversified small business/IGA

11. THEME 4
Inter-related factors that contribute to negatively deviated PLW in
food-secure households
Analysis and
reporting
 A negative experience with the health services received from the health facilities
 Negative deviant mothers have poor feeding routines, not flexible in fasting practices
(fasting duration)
 Limited understanding of types of food and frequencies of feeding for PLW
 Less visited by agriculture and HEWs at the household level

12. THEME 5
Gender norms are both supporting and discouraging PLW’s nutrition
Analysis and
reporting
 Less focus on and attention given to the period of pregnancy than lactation
 Husband’s role is mostly supportive
 Household decision-making power rests with husbands
 Women empowerment initiatives not strong enough to mitigate gender-related
issues relevant to maternal nutrition

13. Observation findings
Health service and ITN use: ANC follow-up card and ITN (bed net) were missing in all
observed households
Human and animal living rooms: Most PLWs reside in separated room from animals
(69 %). Only 59% had animal-rearing practices
Backyard gardening: Most households have no backyard (75%), and only 13% have fruit
trees
Sanitation: only 59% has latrines in their compound, and 47% had soap in the HH
Water source: Only 34% of households has a water source in their compound
Access to market: Most PLWs (91%) had close market access;
Analysis and
reporting

14. The interconnectedness of barriers to m aternal nutrition
Taboo
Incom e
Gender &
cultural
norm s
Fasting
Nutrition
Know how
Service use
Food taboosare generated by elders,
transfer through the generation, and are
the common barrier to maternal
nutrition.
Food Taboos
Poor health service readiness,
provision, and missed opportunitiesfor
maternal nutrition service at health
facilities.
Quality of health service and
utilization
Inadequate maternal
nutrition knowledge and
capability to prepare and
use a balanced diet.
Gender and cultural Norm s
Maternal feeding ishighly affected by
fasting due to lessflexibility of
religiousleadersand the devotion of
the followers
Fasting
Gender and cultural norms
negatively favor maternal
nutrition practices
Lack of awareness &
nutrition know- how
Low income, accessto
nutrition and support
system
Socio- econom ic problem s
Analysis and
reporting
FRAMEWORK SYNTHESIS

15. Analysis and
reporting
FRAMEWORK SYNTHESIS…
Integrated Maternal Nutrition Service m odel
Maternal nutrition promotion needsto
focuson lifestyle approaches, a balanced
diet, adequate rest, and exercise.
Maternal lifestyle prom otion
Major causesof locally important food taboos, fasting,
and cultural and gender normsneed to be addressed.
Missed opportunitiesfor maternal nutrition counseling,
and malnutrition preventative measuresat health
facilitiesneed to be strengthened
Malnutrition prevention and treatm ent
Women’s nutrition education, improved
household income, and gender norms
significantly contribute to the maternal
nutrition
Maternal em powerm ent
Food taboos, fasting, gender
and cultural barrier, health
service quality, and use
Malnutrition
prevention &
treatm ent
Nutrition education,
income, gender
Maternal
em powerm ent
A balanced diet,
adequate rest,
exercise
Maternal Lifestyle
prom otion
Integrated
Maternal nutrition
Service

16. Conclusion
• Barriers: structural and policy, socio-economic, social, and cultural norms and maternal feeding
practices still pose challenges to maternal nutrition
• Mechanisms to source, transmit, and retain barriers: related to previous experiences of
elders, traditional scenario development cultures for birth outcomes and adoption of barriers by
traditional healers
• Deviant PLW: entertaining equal opportunity and risks of the setups for existing barriers and
food taboos are not at the same level in nutritional behavior and status
• Implementation challenges: though policies, strategies, programs, and guidelines are
endorsed to give due attention to maternal nutrition, its implementation gaps are limited to
addressing maternal nutrition on the supply side

17. Recommendations
• Use of strategic documents: Support to disseminate the newly launched Ethiopia Food Based
Dietary Guideline (FBDG) to reach mothers especially those following strict religious practices
• Use of the deviant mothers: Support positive deviant mothers to be influential champions in
their communities
• Improve access: Decentralize the nutrition-specific and sensitive interventions to the nearest point
of community contact
• Break misinformation: Shift traditional scenario development trend on birth outcomes to
scientific and tailored to the community information source, dissemination and retention mechanism
• Participatory research: Design and conduct further participatory research on Positive Deviant
practices

18. Limitations
• Facility level barrier: Institutional readiness to maternal nutrition not assessed in all relevant
sectors
• Men community leaders: Men community leaders not targeted for FGD
• Scope of the study: Deviant behavior of PLW made in PSNP5 Woredas only
• Exclusion error: Inclusion and exclusion errors cannot be avoided while determining HHs

19. Contact
Contact as at HIS GLOBAL CONSULTANCY
Address
IHS Global Consultancy
Netsanet Fetene (MD,MPH, Ph.D.).
CEO, IHS Global Consultancy
E-Mail: netsanetfetene@gmail.com
Phone:+251910137506