Participatory Women's Groups with Cash Transfers Can Increase Dietary Diversity and Micronutrient Adequacy during Pregnancy, whereas Women's Groups with Food Transfers Can Increase Equity in Intrahousehold Energy Allocation

Abstract

BackgroundThere is scarce evidence on the impacts of food transfers, cash transfers, or women's groups on food sharing, dietary intakes, or nutrition during pregnancy, when nutritional needs are elevated.ObjectiveThis study measured the effects of 3 pregnancy-focused nutrition interventions on intrahousehold food allocation, dietary adequacy, and maternal nutritional status in Nepal.MethodsInterventions tested in a cluster-randomized controlled trial (ISRCTN 75964374) were “Participatory Learning and Action” (PLA) monthly women's groups, PLA with transfers of 10 kg fortified flour (“Super Cereal”), and PLA plus transfers of 750 Nepalese rupees (∼US$7.5) to pregnant women. Control clusters received usual government services. Primary outcomes were Relative Dietary Energy Adequacy Ratios (RDEARs) between pregnant women and male household heads and pregnant women and their mothers-in-law. Diets were measured by repeated 24-h dietary recalls.ResultsRelative to control, RDEARs between pregnant women and their mothers-in-law were 12% higher in the PLA plus food arm (log-RDEAR coefficient = 0.12; 95% CI: 0.02, 0.21; P = 0.014), but 10% lower in the PLA-only arm between pregnant women and male household heads (−0.11; 95% CI: −0.19, −0.02; P = 0.020). In all interventions, pregnant women's energy intakes did not improve, but odds of pregnant women consuming iron-folate supplements were 2.5–4.6 times higher, odds of pregnant women consuming more animal-source foods than the household head were 1.7–2.4 times higher, and midupper arm circumference was higher relative to control. Dietary diversity was 0.4 food groups higher in the PLA plus cash arm than in the control arm.ConclusionsAll interventions improved maternal diets and nutritional status in pregnancy. PLA women's groups with food transfers increased equity in energy allocation, whereas PLA with cash improved dietary diversity. PLA alone improved diets, but effects were mixed. Scale-up of these interventions in marginalized populations is a policy option, but researchers should find ways to increase adherence to interventions. This trial was registered at www.controlled-trials.com as ISRCTN 75964374.

'There is no point giving cash to women who don't spend it the way they are told to spend it' – Exploring women's agency over cash in a combined participatory women's groups and cash transfer programme to improve low birthweight in rural Nepal

“…The observed agreement between our qualitative findings – in which most respondents reported spending their cash on milk and fruit – and the quantitative findings of an independent dietary sub-study (Harris-Fry et al, 2018a) – in which micronutrient adequacy and consumption of dairy improved – suggests limited social desirability bias in our interview data. Our findings mirror pilot data from the trial surveillance system in early 2014, which found that 84 of 86 households reported spending their cash transfer on food for the pregnant women.…”

“…We showed how the context, implementation, and mechanism of a participatory women's group intervention created multiple, interlocking forms of social pressure on beneficiary women and their families to spend cash transfers on foods recommended by our NGO staff. Our observed mechanism may help explain how the combined women's group and cash transfer intervention achieved substantial improvements in dietary diversity, micronutrient adequacy, consumption of dairy foods, and relative intra-household allocation of dairy foods to pregnant women (Harris-Fry et al, 2018a), even if it may not have translated into impact on birthweight (Saville et al, 2018). In a context in which pregnant women are expected to eat least and last (Morrison et al, 2018), are perceived as having less need of nutrition than other household members (Morrison et al, 2018), and are found to have the lowest level of energy intake and micronutrient adequacy among adult household members (Harris-Fry et al, 2018b), improving their ability to spend cash on their own nutrition was a significant achievement.…”

“…A cluster-randomised controlled trial did not find a statistically significant impact of cash transfers and women's groups on birthweight in the first 72 h, but inclusion of a larger sample of weights up to 10 days after birth did demonstrate a statistically significant 69 g increase compared with control (Saville et al, 2018). A dietary sub-study also found substantial improvements in pregnant women's dietary diversity, micronutrient adequacy, and consumption of dairy foods (Harris-Fry et al, 2018a).…”

Show me the money

“…Similar results were found for Ecuador, Mexico and Nicaragua (Fernald et al, 2008, Leroy et al, 2008, Macours et al, 2012, Maluccio and Flores, 2005, Paxson and Schady, 2010. Also in Asia, several programmes improved food security measures, for instance in Bangladesh (Ferré and Sharif, 2014), Bihar, India (OPM, 2017) and Nepal (Harris-Fry et al, 2018) .…”

Equity implications of rice fortification: a modelling study from Nepal

“…The LBWSAT sample included 150 households out of 199 eligible households visited, and we modelled potential effects of rice fortification on 128 households (1230 dietary recalls from 384 individuals) because twenty-two households had missing information on rice purchase. Prior analyses show characteristics of respondents and nonrespondents were similar (38) . AHS III data contain 4360 households with 5443 women aged 15-49 years and 3346 children aged 5-12 years.…”