CONTEXTUAL ANALYSIS OF THE DELIVERY OF ESSENTIAL NUTRITION ACTIONS IN NIGERIA

Abstract

Maternal and child undernutrition persist in Nigeria. Essential Nutrition Actions (ENAs), including iron supplementation, exclusive breastfeeding (EBF), and vitamin A supplementation (VAS) were adopted nationally to reduce undernutrition, since 2004. However, there is paucity of literature on implementation of ENAs in Nigeria, thus, time-trends in coverage and determinants, and delivery context of ENAs in Nigeria were assessed in this study. Quantitative and qualitative methods were used. Data from 2003, 2008 and 2013 Nigeria Demographic and Health Surveys (NDHS) were analysed to establish time-trends and determinants of ENAs coverage. To account for NDHS cluster sampling method, estimates of time-trends and determinants were adjusted using sampling weights in respective datasets. Twenty-nine primary healthcare centers (PHCs), 21 in Ekiti (South) and 8 in Katsina (North) States, were assessed as case studies for delivery context of ENAs in Nigeria. Data from NDHS and case study PHCs were analysed using descriptive statistics, Chi-square tests and regression models. Among 21 nutrition policy/programme stakeholders from case-study states and federal level, perspectives about ENAs implementation were examined using Q-methodology. Coverage of ENAs was low and time-trends varied across ENAs. Iron supplementation prevalence among pregnant women and EBF rate did not change significantly (23.2%, 17.1%, 21.7% and 17.1%, 12.7%, 17.6% in 2003, 2008, 2013, respectively). VAS prevalence among children 6-59 months increased (33.7% to 40.6%) from 2003 to 2013. Utilisation of health system contact points was low; complete immunisation prevalence increased (6.8%, 17.2%, 21.5% in 2003, 2008, 2013, respectively) but was still low in 2013. Similarly, prevalence of skilled antenatal care, ANC (58.1%, 58.0%, 61.1%), delivery in health facilities (32.9%, 36.1%, 36.2%), and skilled delivery assistance (35.4%, 39.5%, 38.7%), was inadequate in 2003, 2008, 2013, respectively. Use of health system contacts was associated with ENAs. In 2008 and 2013, full immunisation increased adjusted odds of VAS 3 times (CI: 10.2–14.4). ANC increased odds of iron supplementation in pregnancy 11 times (CI: 7.9–15.9) in 2003, 12 times (CI: 10.2–14.4) in 2008, and 16 times (CI: 13.8–19.0) in 2013. In 2013, women who had skilled delivery assistance were 2 times (CI: 1.4–3.6) more likely to practice EBF. The poor were less likely than the rich to receive ENAs. Prevalence of skilled ANC was consistently lowest and decreased over time in the poorest quintiles, while richer quintiles had almost universal and increased coverage (p<0.001). In case study PHCs, ENAs were provided inconsistently and not integrated in routine service delivery. Weaknesses existed across health system building blocks assessed as only 3 (15.0%) and 8 (30.8%) of PHCs reported availability of ENAs routine supplies and nutritionists, respectively. Stakeholders identified weak leadership, governance and nutrition information systems, with inadequate funding, as challenges to ENAs delivery. Essential Nutrition Actions coverage was low in Nigeria and associated with inadequate utilisation of health system contact points. The delivery context in Ekiti and Katsina States had insufficient human, financial and material resources for nutrition service delivery. Systematic integration of nutrition interventions into health system services and system strengthening is required to improve coverage.