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

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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 facility‐based 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.

Abstract

This paper describes the process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during antenatal care. We used multiple information sources to contextualize a package of globally recommended maternal nutrition interventions and developed four country‐specific models to tackle missed opportunities for nutrition within health services. Theory of change ¹ for strengthening maternal nutrition interventions ² in ANC services.

Key messages

Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.
The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.
Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.
Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models.

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Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Haidong Wang, Kaja M Abbas, Mitra Abbasifard … (2021)

Summary Background Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. Interpretation Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Funding Bill & Melinda Gates Foundation.

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Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda

Cesar Victora, Parul Christian, Luís Vidaletti … (2021)

13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.

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Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries.

Parul Christian, Sun Lee, Moira Donahue Angel … (2013)

Low- and middle-income countries continue to experience a large burden of stunting; 148 million children were estimated to be stunted, around 30-40% of all children in 2011. In many of these countries, foetal growth restriction (FGR) is common, as is subsequent growth faltering in the first 2 years. Although there is agreement that stunting involves both prenatal and postnatal growth failure, the extent to which FGR contributes to stunting and other indicators of nutritional status is uncertain. Using extant longitudinal birth cohorts (n=19) with data on birthweight, gestational age and child anthropometry (12-60 months), we estimated study-specific and pooled risk estimates of stunting, wasting and underweight by small-for-gestational age (SGA) and preterm birth. We grouped children according to four combinations of SGA and gestational age: adequate size-for-gestational age (AGA) and preterm; SGA and term; SGA and preterm; and AGA and term (the reference group). Relative to AGA and term, the OR (95% confidence interval) for stunting associated with AGA and preterm, SGA and term, and SGA and preterm was 1.93 (1.71, 2.18), 2.43 (2.22, 2.66) and 4.51 (3.42, 5.93), respectively. A similar magnitude of risk was also observed for wasting and underweight. Low birthweight was associated with 2.5-3.5-fold higher odds of wasting, stunting and underweight. The population attributable risk for overall SGA for outcomes of childhood stunting and wasting was 20% and 30%, respectively. This analysis estimates that childhood undernutrition may have its origins in the foetal period, suggesting a need to intervene early, ideally during pregnancy, with interventions known to reduce FGR and preterm birth.

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Author and article information

Contributors

Phuong Hong Nguyen:

ORCID: http://orcid.org/0000-0003-3418-1674

P.H.Nguyen@cgiar.org

Journal

Journal ID (nlm-ta): Matern Child Nutr

Journal ID (iso-abbrev): Matern Child Nutr

Journal ID (doi): 10.1111/(ISSN)1740-8709

Journal ID (publisher-id): MCN

Title: Maternal & Child Nutrition

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 1740-8695

ISSN (Electronic): 1740-8709

Publication date (Electronic): 14 June 2022

Publication date Collection: October 2022

Volume: 18

Issue: 4 ( doiID: 10.1111/mcn.v18.4 )

Electronic Location Identifier: e13379

Affiliations

[ ¹ ] Alive & Thrive Initiative, FHI Solutions Washington District of Columbia USA

[ ² ] Poverty, Health and Nutrition Division, International Food Policy Research Institute Washington District of Columbia USA

[ ³ ] Alive & Thrive Initiative, FHI Solutions New Delhi India

[ ⁴ ] Alive & Thrive Initiative, FHI Solutions Ouagadougou Burkina Faso

[ ⁵ ] Alive & Thrive Initiative, FHI Solutions Addis Ababa Ethiopia

[ ⁶ ] Alive & Thrive Initiative, FHI Solutions Dhaka Bangladesh

[ ⁷ ] Alive & Thrive Initiative, FHI Solutions Abidjan Cote d'Ivoire

Author notes

[*] [* ] Correspondence Phuong Hong Nguyen, Poverty, Health and Nutrition Division, International Food Policy Research Institute, 2001 I St, NW, Washington, DC 20005, USA.

Email: P.H.Nguyen@ 123456cgiar.org

Author information

Phuong Hong Nguyen http://orcid.org/0000-0003-3418-1674

Sunny S. Kim http://orcid.org/0000-0003-3960-3354

Article

Publisher ID: MCN13379

DOI: 10.1111/mcn.13379

PMC ID: 9480954

PubMed ID: 35698901

SO-VID: e220295e-7129-4b8b-9159-7f2d71b9959f

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date revision received : 17 April 2022

Date received : 01 December 2021

Date accepted : 17 May 2022

Page count

Figures: 3, Tables: 3, Pages: 18, Words: 11796

Funding

Funded by: Bill and Melinda Gates Foundation , doi 10.13039/100000865;

Award ID: OPP1135090

Custom metadata

source-schema-version-number 2.0

cover-date October 2022

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.1.8 mode:remove_FC converted:16.09.2022

Keywords: anc,counselling,integrated health services,maternal nutrition,micronutrient supplements,pregnancy weight gain

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Keywords: anc, counselling, integrated health services, maternal nutrition, micronutrient supplements, pregnancy weight gain

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

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Most cited references 37

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda

Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries.

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