Postnatal Care

The study was undertaken within the framework of the assessment of the community effectiveness of Intermittent Preventative Treatment in Infants (IPTi), part of the IPTi Consortium (www.ipti-malaria.org, clinical trial number NCT00152204). We received ethical approval from local and national institutional review boards (Ifakara Health Institute and the National Tanzania Medical Research Co-coordinating Committee) through the Tanzania Commission for Science and Technology. Ethical and research clearance was also obtained from the London School of Hygiene and Tropical Medicine, UK, and the Ethics Commission of the Cantons of Basel-Stadt and Basel-Land, Switzerland. During field work, information sheets in Swahili about the study were given out, explaining why it was being done, by whom, and what it would involve. Consent to participate was obtained in writing from household heads and orally from women answering questions about their pregnancies. Confidentiality of all study participants was assured.
The study was conducted in the districts of Nachingwea, Lindi Rural, Ruangwa, Tandahimba and Newala Districts in Southern Tanzania, which had a total population of over 800,000 people in 2007. The study setting and field methods from a similar survey have been described in detail elsewhere [15] , [16] (link) so the key aspects are summarised here. The area has a wide mix of ethnic groups, including the Makonde, Mwera, Yao. Although most people speak the language of their own ethnic group, Swahili is also widely spoken. The most common occupations are subsistence farming, fishing and small scale trading. Cashew nuts, sesame and groundnuts are the major cash crops while food crops are cassava, maize, sorghum and rice. Most people live in mud-walled and thatched-roof houses; a few houses have corrugated iron roofs. Common water supplies are hand-dug wells which rely on seasonal rain, communal boreholes, natural springs and river water. Most rural roads are unpaved: some are not passable during rainy seasons while others are too steep for vehicles to pass. In 2000–2001 39% of households lived below the poverty line in Lindi and Mtwara regions [27] . The HIV prevalence rates (categorized) for adults age 15–49 years in Lindi and Mtwara regions were estimated to be 4–6% and 7–10% respectively in 2003/4 [27] .
The public health system comprises a network of dispensaries, health centres and hospitals offering a varying quality of care [15] . Nearly all (99%) pregnant women attend antenatal care at least once, and around half of women deliver with a skilled attendant [14] .
Between June and October 2007, a survey team of over 200 field staff visited all 243,612 households in the five study districts. Household heads were asked to give their written consent to participate. In a few households (15,823, 7%), nobody could be found on the day of the survey despite repeat visits by interviewers within the day. Over 99% (225,980) agreed to take part. Female participants age 13–49 who had had a live birth in the year before the survey were then separately asked for written consent to participate and were asked questions relating to use of antenatal care, intrapartum care (such as place of childbirth and birth attendant) and postpartum care including essential newborn care indicators, for the most recent birth. Some questions were only asked to women who had had a non-facility delivery.
The questionnaire was administered in Swahili using handheld computers (personal digital assistants or PDA) to capture responses [28] (link). Standard range, consistency and completeness checks were carried out in the field. Analysis was conducted in Stata version 10 [29] .

The outcome variable of this study was vitamin A supplementation among children aged 6–35 in the last 6 months (yes/no). The independent variables were individual-level variables such as the age of the child, age of the mother, sex of the child, sex of household head, religion, marital status, mother's education, husband's education, wealth status, working status, birth order, parity, possession of radio, possession of a television, number of under-five children in the household, place of delivery of the child, mothers having ANC, and mothers having postnatal care. The community-level variables were residence and region. A region in this study was classified into five Oromia, Amhara, Southern Nation Nationalities and Peoples Region (SNNPR), Tigray, and others. The ‘others' region contains Addis Ababa, Somalia, Afar, Dire Dawa, Benishangul, and Gambella due to their low number of eligible participants for this study. The questionnaire of the survey was pretested and 2 days of training were given to the data collectors and supervisors before the onset of actual data collection.

IVON-IS will be conducted in Lagos State, South West, Nigeria. Specifically, implementation outcomes will be tested in a cluster of six health facilities that have not yet been exposed to training or implementation related to the ongoing IVON trials. The facilities span public (government-owned) and private (individual/organisation-owed) sectors in the state. The cluster will include one tertiary hospital, two secondary hospitals, one comprehensive primary health centre (PHC) in the public sector, and two private hospitals with varied patient bases. The selected facilities will be in proximity and linked to the state’s existing referral process. The cluster will represent a sub-unit of the health system and reflect the points of antenatal and postnatal care for pregnant women. Indeed, in Lagos, public health facilities manage 27% of deliveries in the state, while private health facilities take up about 48% [27 ]. Using projected data from our ongoing IVON clinical trials, we estimate that we will screen about 4000 pregnant and postpartum women per annum and have approximately 400 women eligible for treatment for anaemia.