Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Abstract

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country-specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community-level activities were essential for complementing facilitybased services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts.

Integrating and coordinating programs for the management of anemia across the life course

“…The program for WRA in Viet Nam integrated community‐based WIFAS distribution with facility‐based deworming, with 85% deworming coverage and 72% of participants reporting taking at least 75% of WIFAS after 72 months of implementation 63 . Integrating facility‐ and community‐based delivery platforms has been shown to be successful for improving coverage and adherence of IFA for pregnant women, as well as increasing ANC attendance 74,75 . For example, Nepal initiated an Iron Intensification Program to improve IFA coverage through community‐based delivery complementing ANC services 76 .…”

“…Prevention and prompt treatment of infections should also be promoted. The process used by the Alive & Thrive program to strengthen the integrated delivery of maternal nutrition interventions (including IFA) through ANC services in four countries provides a model that could be applied to anemia interventions 75 . Contextualized solutions were developed through a rigorous process of assessment, analysis, stakeholder engagement, capacity building, and system strengthening appropriate to the local health delivery platforms and key barriers to integrated programming in the four countries 75 .…”

“…27,42,43,87 Lack of knowledge regarding malaria as well as barriers to seeking ANC services also compromise IPTp coverage. 88 Community-based platforms integrated with facility-based ANC are a recommended strategy to address some of these barriers [74][75][76] and could also be used to deliver WIFAS and deworming to nonpregnant WRA. 63 Evaluations of MNP programs have similarly found demand-side factors to influence reach and uptake, particularly related to caregivers remembering to use the MNPs as directed and managing perceived changes in the taste or appearance of food with MNPs added.…”

“…Integrating community-based platforms with facility-based ANC services has been shown to effectively improve coverage of both ANC and 90+ IFA, and should be considered for inclusion in national strategies, with a sufficient and sustained allocation of resources for training and support of both facility-based and community-level personnel. 42,[74][75][76] Workplaces are another potential delivery platform for reaching WRA with integrated anemia control interventions in settings with high rates of female employment. 73 As anemia compromises productivity, investment in effective workplace programs to address it should be attractive to employers.…”

Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

“…14 Large operational gaps in IFA interventions have been reported, including inconsistent supplies of IFA, inadequate health provider skills and tools to provide high quality counseling, insufficient emphasis on community and family engagement, and poor recognition of anemia and its serious risks. 11 The counseling provided during ANC visits does not address individual factors in PW that contribute to nonadherence. 12,15 The existing literature on IFA adherence provides insights on barriers and factors associated with adherence, 12,[16][17][18][19] but there are only a few studies with empirical evidence on the effectiveness of adherence interventions in the context of large-scale ANC services.…”