1. Integrating MIYCN-FP in Yemen: Results from
Research Using Trials of Improved Practices
Rae Galloway, Technical Lead for Nutrition,
MCHIP
CORE Group Meeting Presentation, May 7, 2014

2. Yemen: Population, Family Planning
and Nutrition
 24 million people
 Low contraceptive
prevalence
 Highest rates of
stunting in the world
 Limited access to
health and FP
services by women
who often stay in the
home
2

3. Objectives for the Study
 Determine current maternal, infant and young
child nutrition (MIYCN) and family planning
(FP) practices
 Explore if mothers/couples are willing to try
MIYCN-FP practices they are not using
 Identify barriers to trying or continuing to use
ideal practices
 Develop messages to integrate into a
MIYCN-FP counseling package for health
facility and community workers
3

4. Some Reasons for Integrating MIYCN
and FP
 MIYCN status and birth spacing are linked—
short birth spacing is associated with anemia
and underweight in women and underweight
and stunting in children
 Addressing barriers to EBF ensures women
meet LAM criteria
 Linking transition to complementary foods
and family methods at 6 mos promotes timely
introduction of CF and continued BF and
prevents another pregnancy
4

5. Some reasons for integrating MIYCN
and FP
 Increases number of services women (and
husbands) obtain at each contact with health
services
 e.g., men going to FP services with their
wives receive MIYCN information so they can
support these practices at home
 Increases use of optimal MIYCN or FP
practices by linking MIYCN status with birth
spacing & preventing a pregnancy with
meeting the LAM criteria
5

6. What is Trials of Improved Practices?
 TIPs was developed by the Manoff Group,
based on market research methods, for use
in IYCF, iron supplementation, bed nets and
family planning programs
 TIPs is qualitative research that allows
exploration of using new behaviors & gives
program managers feedback about the
behaviors
 TIPs uses small sample sizes to get in-depth
information about the “why” of behaviors
6

7. TIPs Methodology
 Basic Methodology: Three TIPs Visits
 TIPs Visit#1-in-depth interviews about past
and current practices; 24 hour recalls, food
frequency and observations in the home
 TIPs Visit#2-discuss the results of TIPs
Visit#1, counsel on optimal practices,
identification by the mother (or husband) of a
new practice to try
 TIPs Visit#3- visit 6 days later to see if the
practice was tried, barriers/motivators to use
in the future
7

8. TIPs Methodology in Yemen
Location:
 Dhamar Governorate
(south of Sana’a)
 Two districts ( Magreb
and Wesab)
 Two geographical
zones (highland &
lowland)
8
Driving to the highland village
of Thelah, Magreb

9. TIPs Methodology in Yemen
TIPs Participants:
MIYCN interviews:
 16 mothers with
children<2 years (NS
status of child)
FP interviews:
 16 mothers with
children<2 years
 16 husbands of FP
mothers
9
Mother respondent and
her children in Magreb

10. TIPs Methodology in Yemen
 MIYCN and FP TIPs
mothers were
different mothers but
MIYCN mothers were
asked some FP
questions
 FP TIPs husbands
were asked questions
about MIYCN
10
Husband being interviewed by
field staff

11. TIPs Methodology in Yemen
 The study was approved by the JHU IRB and
the Ministry of Health
 Training took place over 5 days and included
technical and human protection training and
practice sessions in the field
 Full consent was obtained from all
participants
 Full consent was obtained for the pictures
taken of respondents used in this
presentation
11

12. Selected Results: Review of Main
Results MIYCN TIPs Visit#1
 No infant<6 months was
EBF; food was introduced
after a few days or weeks
 The reason food was
introduced was mothers
perceived their breast
milk was “insufficient”
 11/16 mothers felt they
didn’t have sufficient
breast milk
 10 mothers said they
thought this because the
child cried after BF
12
Mother and child in Wesab

13. Selected Results: Review of Main
Results MIYCN TIPs Visit#1
 9/16 mothers reported early breastfeeding
problems (cracked or sore nipples;
engorgement) but self-treated (hot presses,
ointment) or in one case sought treatment
 From interviews and observations
breastfeeding practices were not ideal—
mothers didn’t know how to increase breast
milk production, were feeding for short
periods of time or from only one breast
13

14. Three WHO Indicators for a Minimum
Adequate Diet 6-23 months
 Breastfed; if not breastfed, child should
receive 1-2 c. of milk/dairy per day
 Consume at least 4 out of 7 designated food
groups (grains/potatoes; legumes & nuts;
dairy; meat/flesh/fish; eggs; F/V with vitamin
A; other F/V)—if not BF, the child should
consume 4 FG + 1-2 c. milk
 Consume 2-3 meals/day (6-8 mos); 3-4
meals/day (9-23 mos); if not BF, 1-2 extra
meals
14

15. Selected Results: MIYCN TIPs
Visit#1—Three Practices 6-23 mos
15
Age groups
(n=12)
Breastfed or
milk
products
Minimum
number (4) of
food
groups/day
Minimum
number of
meals/day
Meeting all
three
practices
6-8 mos (4) 4 0 3 0
9-11 mos (4) 4 0 2 0
12-23 mos (4) 3 1 1 1
Total 11 1 6 1

16. Selected Results: MIYCN TIPs
Visit#1—Three Practices 6-23 mos
 All but one child continued to be breastfed;
the frequency varied from 1-4 times per day
 The non-BF child received milk but only 100
ml per day
 Meeting the minimum number of meals (6)
was easier than meeting the minimum food
groups (only 1) but as the child got older
meeting the mimimum number of meals
declined
16

17. Selected Results: MIYCN TIPs
Visit#1—Three Practices 6-23 mos
 Only one child (22 mos) out of 12 was fed by
all three practices
 Many children were fed sugar
cookies/biscuits starting as early as one
month
 One child (15 mos) was given only sugary
biscuits (no other foods) and breast milk
 Biscuits are perceived as an easy food to
give to children of any age
17

18. Selected Results: Review of Main
Results MIYCN TIPs Visit#1
 More nutritious foods and snacks were not
given to children for a variety of reasons—
they were not appropriate for younger
children. Milk/dairy & grains/potatoes were
most appropriate as most children (10/12)
received dairy products and grains/potatoes
(8/12)
 Only 2/12 children received foods from the
meat/fish group
18

19. Selected Results: MIYCN TIPs Visit#1—
Reasons for Practices 6-23 mos
 3/12 received Fruits or vegetables; 3/12
received legumes (older children); no child
received eggs
 In some cases the availability of these foods
limited what mothers could feed their children
 Half of children (6/12) received cake or
biscuits the day before with 5 living in Wesab
 About half of mothers were consuming a
more diverse diet than their children.
19

20. Selected Results: MIYCN TIPs Visit#1—
Observations in the Home
 Most mothers washed their hands before
food prep and feeding their child but not with
soap; about half washed their baby’s hand
before feeding (but not with soap)
 While mothers recognized the child not eating
as a sign of poor health/growth, half of
mothers were not using responsive feeding
practices and most mothers reported that
their child did not eat all the food served
20

21. Selected Results: Review of Main
Results FP TIPs Visit#1
 Family planning use varied by zone with one
zone limited by the availability of methods in
the public sector
 Family planning methods were available in
the private sector but at a cost which many
families couldn’t afford
 Most couples in Yemen decide on FP
together; there were a few cases where men
continue to decide if FP should be used.
21

22. Selected Results: Review of Main
Results FP TIPs Visit#1
 MIYCN-FP mothers didn’t know (7/30) or
thought BF was the best way to or could
prevent another pregnancy (15/30) and were
motivated to continue BF to prevent another
pregnancy
 5 mothers alluded to BF criteria to prevent
pregnancy (continuous, exclusive, before
return of menses)
 About half of all mothers knew someone who
had become pregnant while BF
22

23. Selected Results: Review of Main
Results MIYCN TIPs Visit#1
 The majority said it was healthy to wait 2+
years before becoming pregnant
 Half (8/16) of mothers were using a family
planning method—most in one district
 OC and injections were the most common
methods used; one woman had a permanent
method.
 The reasons for not using FP were side
effect;, cost; didn’t need it, couldn’t become
pregnant
23

24. Selected Results: Review of Main
Results MIYCN TIPs Visit#1
 5/8 women who were not using FP said they
would start using a method after their menses
returns and one women said after two years
 All but one mothers felt comfortable about
talking with their husbands about using FP
and said their husbands were supportive and
also wanted to prevent another pregnancy
24

25. Selected MIYCN-TIPs Results
Practice Offered &
Accepted
Tried Succeeded using
daily
Infants 0-5 mos:
breastfeed only
3 3 3
Infants 6-23 mos:
breastfeed from both
breasts until empty
4 4 4
IYC 6-23: vary the
child’s diet
10 10 9
Give more meals/food 3 3 3
Mothers: Vary mother’s
diet
10 10 10
25

26. Family Planning TIPs Results
Practice Sex Offered &
Accepted
Tried Succeeded
Discuss FP
intentions with
spouse
M 8 8 8
F 6 8 8
Go to health
facility for info on
FP
M 13 13 9
F 11 11 7
Start using
modern method
M 8 7 1
F 8 8 1
Satisfied users
discuss benefits
with others in
community
M 0 1 1
F 4 4 4
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27. Feedback from mothers
 MIYCN: most mothers succeeded in trying
one or several practices and reported being
happy with the new practices because they
felt their babies were getting better nutrition,
sleeping better, healthier
 MIYCN: some limitation in the types of food.
Animal foods (meat) was not available all the
time; one mother said she had too many
children to eat more food herself.
27

28. Feedback from FP couples
 Talking with each other about family planning
was not a problem for most couples
 Couples were willing to go for family planning
advice; in some cases men wanted more
information about side effects from modern
methods.
 There was high unmet need but services and
methods were not always available
28

29. Strengths of the study
 In-depth information about beliefs about
health, nutrition and family planning
 Information about past and current practices
 Willingness of mothers and couples to
consider and try new practices
 Demonstrated couples willingness to talk with
each about FP
 Positive feedback from respondents about
trying new practices
29

30. Limitations of the study
 More information is needed about how to
resolve barriers to optimal practices
 Lack of commodities and food limit success
for TIPs
 For FP method uptake, a longer period of
time might be needed between TIPs 2 and 3
30

31. Next steps:
 Finish the key
informant analysis
 Develop MIYCN-FP
messages and
counseling package
 Prepare the draft
report
 Present findings in
Yemen (June)
31
Mother and her children
in Wesab

32. Thank you to the fantastic study
team!
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