Integrating Nutrition Interventions into an Existing Maternal, Neonatal, and Child Health Program Increased Maternal Dietary Diversity, Micronutrient Intake, and Exclusive Breastfeeding Practices in Bangladesh: Results of a Cluster-Randomized Program Evaluation

Abstract

Background: Maternal undernutrition is a major concern globally, contributing to poor birth outcomes. Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive addressed this gap by integrating nutrition-focused interpersonal counseling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring through an existing Maternal, Neonatal, and Child Health (MNCH) program in Bangladesh.Objectives: We evaluated the effect of providing nutrition-focused MNCH compared with standard MNCH (antenatal care with standard nutrition counseling) on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices.Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n ∼ 300 and 1000 pregnant or recently delivered women, respectively, per survey round). We derived difference-in-difference effect estimates, adjusted for geographic clustering and infant age and sex.Results: Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilization activities was ∼50%. Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid [effect: 9.8 percentage points (pp); 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/d (effect: 30.0 pp), and daily intakes of several micronutrients. A significant impact was also observed for exclusive breastfeeding (EBF; effect: 31 pp) but not for early initiation of breastfeeding.Conclusions: Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices. This trial was registered at clinicaltrials.gov as NCT02745249.

Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia

“…The remaining nine studies met the inclusion criteria and included two studies conducted in Bangladesh (Nguyen et al, ; Nguyen et al, ), five in India (Balakrishnan et al, ; Ghanekar, Kanani, & Patel, ; Prinja et al, ; Shivalli, Srivastava, & Singh, ; Wendt et al, ), one in Nepal (Sharma et al, ), and one in Pakistan (Nisar, Dibley, & Mir, ). These eligible studies included one cluster RCT (Nguyen, Kim, et al, ), four quasi‐experimental studies (Balakrishnan et al, ; Prinja et al, ; Sharma et al, ; Shivalli et al, ), three cross‐sectional studies (Nguyen, Sanghvi, et al, ; Nisar et al, ; Wendt et al, ), and one qualitative study (Ghanekar et al, ). All the nine studies examined the receipt and/or consumption of IFA supplements during pregnancy, two studies examined the receipt and/or consumption of calcium supplements (Nguyen, Kim, et al, ; Nguyen, Sanghvi, et al, ), and one study examined the receipt of information on maternal diet (Nguyen, Kim, et al, ).…”

“…These eligible studies included one cluster RCT (Nguyen, Kim, et al, ), four quasi‐experimental studies (Balakrishnan et al, ; Prinja et al, ; Sharma et al, ; Shivalli et al, ), three cross‐sectional studies (Nguyen, Sanghvi, et al, ; Nisar et al, ; Wendt et al, ), and one qualitative study (Ghanekar et al, ). All the nine studies examined the receipt and/or consumption of IFA supplements during pregnancy, two studies examined the receipt and/or consumption of calcium supplements (Nguyen, Kim, et al, ; Nguyen, Sanghvi, et al, ), and one study examined the receipt of information on maternal diet (Nguyen, Kim, et al, ). There were no studies that reported the coverage of other maternal nutrition interventions.…”

“…Individual factors include women's education level, women's knowledge, demand for services, compliance‐related behaviours, self‐efficacy to follow recommended practices, social norms, and cultural beliefs (Ghanekar et al, ; Nisar et al, ; Shivalli et al, ; Wendt et al, ; Balakrishnan et al, ; Sharma et al, ; Nguyen, Kim, et al, ; Nguyen, Sanghvi, et al, ; Prinja et al, ).…”

“…The proportion of pregnant women receiving free IFA or calcium supplements more than doubled between baseline and end line in the intervention group but decreased by more than 7 percentage points (pp) in the comparison group (difference‐in‐difference effect size (DDE) 62.6 pp for IFA and 73.3 pp for calcium, p < 0.001). Nguyen, Kim, et al () highlighted that the study was carried out in the context of a well‐functioning and robust MNCH programme and that effects may be less in the absence of these conditions.…”

“…The nutrition‐focused MNCH programme in Bangladesh (Nguyen, Kim, et al, ) included a number of initiatives to increase the consumption of supplements by pregnant women in the intervention areas. Women were counselled during home visits on the benefits of IFA and calcium supplements, consequences of IFA or calcium deficiency, doses and duration of IFA and calcium supplementation that should be followed, side effects of supplements and ways to minimize them, and foods that may inhibit their absorption.…”