Gaps in the implementation and uptake of maternal nutrition interventions in antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India

Abstract

Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence-based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self-efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress.

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

“…for adapting maternal and newborn health services, where the steps involved incorporating global recommendations into programme protocols, building system readiness to implement services through well-defined tasks and staff skills development, provision of training tools and improving equipment/ supply chain specifications and record-keeping protocols. Similar findings have been reported on the importance of clear and comprehensive guidelines and protocols, a skilled workforce, availability of equipment and supplies and adequate resources to meet needs(De Brouwere et al, 2010).Before programme design, pre-existing gaps and challenges in service provision protocols, micronutrient supply chains, monitoring and supervision, interpersonal communication and weak community linkage were identified(Sanghvi et al, 2022). Despite different contexts, there were some common actions to strengthen MNIs within ANC across the countries, including (a) specific health systems strengthening actions are required for integrating nutrition interventions (e.g., improving access to ANC through community outreachactivities and task-shifting to trained and supervised community workers); (b) reducing underlying barriers to improving provider and community worker skills and motivations and uptake of interventions by PW are critical; and (c) data from diverse sources should be used strategically and continuously before and during implementation to inform prioritization and decision-making.…”

“…The adherence of PW to recommended nutrition practices was low (Kim, Ouédraogo, et al, 2020; Kim, Sununtnasuk et al, 2020; Nguyen et al, 2015, 2018). Inadequate understanding of MNIs and poor skills in counselling among providers were common (Sanghvi et al, 2022). We developed tools for strengthening counselling quality with specific content for each MNI based on global recommendations.…”

“…The four MNIs existed in principle at the national policy level in all the countries with a few gaps (e.g., calcium supplementation was not included in ANC in Burkina Faso and Ethiopia). However, ANC in all countries had missing elements in MNI protocols and did not adequately specify nutrition‐related tasks for facility‐based and community‐level service delivery, supervision and monitoring (Sanghvi et al, 2022 ). Although IFA supplementation was better addressed than the other nutrition interventions, knowledge gaps related to all MNIs were observed among ANC providers and PW.…”

“…Before programme design, pre‐existing gaps and challenges in service provision protocols, micronutrient supply chains, monitoring and supervision, interpersonal communication and weak community linkage were identified (Sanghvi et al, 2022 ). Despite different contexts, there were some common actions to strengthen MNIs within ANC across the countries, including (a) specific health systems strengthening actions are required for integrating nutrition interventions (e.g., improving access to ANC through community outreach activities and task‐shifting to trained and supervised community workers); (b) reducing underlying barriers to improving provider and community worker skills and motivations and uptake of interventions by PW are critical; and (c) data from diverse sources should be used strategically and continuously before and during implementation to inform prioritization and decision‐making.…”

“…The adherence of PW to recommended nutrition practices was low (Kim, Ouédraogo, et al, 2020;Nguyen et al, 2015Nguyen et al, , 2018. Inadequate understanding of MNIs and poor skills in counselling among providers were common (Sanghvi et al, 2022).…”