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The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen

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The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen AUTHORS: Ali Mohamed Assabri, Chelsea Cooper, Khaled Ali Al-Gendari, Anne Pfitzer, and Rae Galloway This report was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-00 and Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of The Maternal and Child Health Integrated Program (MCHIP) and The Maternal and Child Survival Program (MCSP), and do not necessarily reflect the views of USAID or the United States Government. Table of Contents Abbreviations ............................................................................................................................................. ii Acknowledgments .................................................................................................................................... iii Executive Summary .................................................................................................................................. iii Introduction and Background on Yemen .................................................................................................. 1 Methodology .............................................................................................................................................. 4 Results .................................................................................................................................................... 10 Number of Respondents ....................................................................................................................... 10 Participant Characteristics ................................................................................................................... 10 TIPs Visit 1 and Key Informant Interviews: Key Findings .................................................................... 12 Family Planning Perceptions and Use .............................................................................................. 14 Reproductive Intentions and Decision-Making ................................................................................ 19 Return to Fecundity and LAM ........................................................................................................... 20 Infant and Young Child Feeding Practices ....................................................................................... 21 Handwashing and Cleanliness in the Home (Observations in the Home) ..................................... 31 Child Health, Growth, and Nutritional Status .................................................................................. 32 Food Supply, Access, and Decision-Making .................................................................................... 35 Mothers and fathers revealed that in all but one family someone chewed khat. In .................... 37 Place of Delivery and Newborn Care ................................................................................................ 37 TIPs VISITS 2 and 3: Results and key findings .................................................................................... 37 FP-TIPs Visits 2 and 3 Results .......................................................................................................... 38 MIYCN-TIPs Visits 2 and 3 Results ................................................................................................... 42 Discussion and Recommendations ....................................................................................................... 48 Conclusions ............................................................................................................................................ 54 Appendix A: Yemeni Foods and Dishes ................................................................................................. 56 Appendix B: Nutritional Status of Children, by Age Group and District ................................................ 57 Appendix C: MIYCN-FP Counseling Guide—Revised Based on Study Findings ..................................... 58 The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen i Abbreviations ANC antenatal care EBF exclusive breastfeeding or exclusively breastfed FP family planning IDI in-depth interview IFA iron-folic acid (supplements) IUD intrauterine device IRB institutional review board KI key informant LAM lactational amenorrhea method MCHIP Maternal and Child Health Integrated Program MIYCN maternal, infant, and young child nutrition MOPHP Ministry of Public Health and Population R-Y Rial TFR total fertility rate TIPs Trials of Improved Practices USAID United States Agency for International Development WHO World Health Organization ii The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen Acknowledgments This study was conducted with funding from the United States Agency for International Development (USAID) to the Maternal and Child Health Integrated Program (MCHIP). The principal investigators (Anne Pfitzer and Dr. Ali Mohamed Assabri) and co-investigators (Chelsea Cooper, Dr. Khaled Ali Al-Gendari, and Rae Galloway) would like to acknowledge and sincerely thank the following people, who made this study possible: At the National Level Dr. Nagiba A. Alshawafi, Deputy Minister, Population and Reproductive Health Ms. Lenna A. Al-Aryani, Head of the Nutrition Division In Dhamar Governorate Dr. Muhmmed Yahya Al-Jumah, General Manager, Ministry of Public Health and Population In Maghreb Ans and Wesab Assafel Districts Mothers, fathers, and key informants participating in the study Field Researchers Ms. Ashwaq Qaied Thelah Ms. Nadhirah Mohammed Moqbel Ms. Karimah Abdullah Yahia Qosailah Ms. Nagah Mahmood Al Ahasab Mr. Amin Mohammed Saeed Alrubaie Mr. Lutf Yahia Zaid USAID-Yemen Ms. Lynn Krueger Adrian, Senior FSO Health Advisor, Yemen Dr. Alia Al Mohandes, Senior Health Development Officer Dr. Muneer M. Ghailan, Health and Population Specialist Dr. Ashraf Ali Zabara, Health and Population Specialist USAID-Washington, D.C. Dr. Nahed Matta, Senior Maternal and Newborn Health Advisor and Agreement Officer’s Technical Representative, MCHIP Ms. Patricia MacDonald, Senior Technical Advisor, USAID/Global Health/Population and Reproductive Health MCHIP in Yemen Dr. George Sanad, Chief of Party Dr. Nagwa Winget, Technical Advisor Dr. Hashem Darwish, Nutrition Officer Mr. Jerry Farrell, Chief of Party, Save the Children (MCHIP partner) MCHIP in Washington, D.C. Ms. Holly Blanchard, Senior Reproductive Health/Family Planning Advisor Ms. Barbara Deller, Senior Maternal and Newborn Health Technical Advisor Dr. Justine Kavle, Senior Technical Officer, Nutrition Team Ms. Kate Brickson, Senior Program Officer, Maternal Health Team Ms. Victoria Rossi, Senior Program Officer, Yemen Ms. Margot Paulson, Program Assistant, Yemen Ms. Rebecca Levine, Senior Program Officer, Yemen Executive Summary The Power of Counseling: Changing Maternal, Infant, and Young Child Nutrition and Family Planning Practices in Dhamar, Yemen iii BACKGROUND The United States Agency for International Development (USAID)-funded Maternal and Child Health Integrated Program (MCHIP) provides technical assistance and support to the Ministry of Public Health and Population (MOPHP) in Yemen. An important area of focus for MCHIP’s work in Yemen is to strengthen maternal, infant, and young child nutrition (MIYCN) and family planning (FP) counseling and service linkages, facilitate the use of both services, and increase the adoption of optimal MIYCN and FP practices. Combining efforts to improve nutrition and family planning is important because both malnutrition and closely spaced pregnancies increase maternal and child morbidity and mortality. This study was conducted in two districts of Dhamar, Yemen, to inform the development of evidence-based programming to address high rates of malnutrition, short inter-pregnancy intervals, and low contraceptive prevalence in the country. The study assessed mothers’ and couples’ ability to adopt recommended nutrition and FP practices, identifying barriers and facilitating factors for optimal practices. Dhamar governorate is located south of Sana’a city, and the two focal districts for the study, Wesab Assafel and Maghreb Ans, represent two of the main agro-ecological zones in the governorate (plains and valleys or lowlands and terraces and low mountains or highlands). Although there has been deterioration in the economy in the last several decades and political instability recently, Yemen has experienced improvements in some FP, health, and nutrition indicators. The Yemen Demographic and Health Survey1 found that the total fertility rate (TFR) declined from 6.5 in 1997 to 4.4 in 2013. Even with this positive change, the TFR remains high and only 29% of married women ages 15–49 were using a modern contraceptive method at the time of the survey. The survey also found that stunting in children younger than age 5 declined from 52% in 1997 to 41% in 2013.2 Infant and young child feeding practices remain extremely poor, with only 13% of babies exclusively breastfed in the first 6 months after birth and only 15% of children ages 6–23 months receiving a minimum acceptable diet, as defined by
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