Integrating maternal nutrition in antenatal care (ANC) platforms is feasible – and improves nutrition practices, according to the results of Alive & Thrive’s implementation research in Burkina Faso, Ethiopia, and India. Alive & Thrive presented the results of the research during a webinar in July with support from IFPRI, which conducted the studies in each country.
“Alive & Thrive’s work in Bangladesh, which was completed in 2015, demonstrated that it was feasible to integrate streamlined interventions within ANC services,” said Tina Sangvhi, Alive & Thrive senior technical advisor. “But that was only one context, and a particularly unique one at that. We knew we needed to study what this would look like in other settings.”
Related manuscript: "Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India", June 2022, Maternal and Child Nutrition
The positive results in Bangladesh in 2015, followed by the publication of WHO’s ANC guidelines in 2016, made it possible for Alive & Thrive to engage governments in three countries where overall ANC services were being reviewed in light of new WHO guidance. Consequently, the evidence and tools from Bangladesh served as the starting point for adaptations and implementation in the other countries – Burkina Faso, Ethiopia, and India.
Alive & Thrive provided technical assistance to governments in each country to develop and implement a streamlined package of evidence-based interventions. The interventions covered four components, with slight variations between the countries: counseling on dietary diversity and quality; IFA and calcium supplementation and counseling; weight gain monitoring and counseling; and counseling on breastfeeding.
Technical assistance varied by country, but generally involved working closely with government health officials, involving them in every step of integrating the packages – from designing the intervention to reviewing initial results to developing ideas for scale up. Alive & Thrive’s senior country-level experts discussed their distinctive efforts in a panel moderated by Alive & Thrive Director Sandra Remancus during the webinar.
“The design of the interventions in Burkina Faso was evidence-based with co-design workshops,” explained Maurice Zamifanjaka, country director of Alive & Thrive. “This was very important to increase ownership of the health system stakeholders.”
It also led Alive & Thrive to recognize the importance of leadership and governance to the integrating of maternal nutrition into the ANC platform, he said. As a result, Alive & Thrive is now implementing a study on the role leadership and governance plays in the health system.
Meanwhile, national scale up of the maternal nutrition intervention has quickly proceeded, he added.
“Six health regions requested technical assistance to expand the maternal nutrition interventions, which would reach 220 health facilities,” he said. “For a rapid and coordinated scaling up, the Ministry of Health is developing a national plan … to allow them to progressively offer the package nationwide and mobilize adequate resources.”
In India, building awareness and buy-in followed a similar path: Alive & Thrive used its membership in a national technical working group on maternal nutrition, led by the Ministry of Health, to build commitment to the intervention, said Dr. Sebanti Ghosh, Alive & Thrive’s senior technical advisor in India. Alive & Thrive engaged multiple approaches and leveraged partnerships, too, to support the program’s implementation, she said.
“We had worked on the national level training package job aids and toolkits, and, at the same time, we developed a pool of national level master trainers,” she said. “Then we worked with the state, which started integrating and prioritizing maternal nutrition protocols in their ANC platform, to develop a state-level pool of master trainers. We even involved the state-level institutes – the medical colleges – to be part of this training resource pool. Then the training was cascaded at the sub-state, district and sub-district level.
“Partnerships have been very important in this entire process of scaling up and provided handholding support to the state government for quality assurance of the trainings. We also worked simultaneously to develop e-learning modules with the National Institute of Nutrition to enhance access to the training materials.”
In Ethiopia, close collaboration with stakeholders was also critical, said Dr. Abdulaziz Ali Oumer, Alive & Thrive’s country director.
“From the very beginning, we heavily engaged the government in all phases – design, implementation, review,” Dr. Oumer said. “We shared results at national and regional levels and used these meetings as opportunities to advocate for scaling up. Government is now revising maternal nutrition guidelines based on the implementation research.”
In India, the package was implemented in Uttar Pradesh state; in Burkina Faso, it was implemented in the Boucle du Mohoun and Hauts Bassins regions; and, in Ethiopia, it was implemented in two markedly different regions – SNNPR, which is primarily agricultural, and Somali, which is primarily pastoralist.
Taken together, the experiences in the countries led to deeper understanding of health systems generally, Sanghvi said.
“With these experiences, we further clarified the common barriers across countries that needed to be addressed and the strategies that could be used to address them,” she explained. “Most low and middle income countries will likely need to address these barriers, using a combination of these health systems strengthening and community-based strategies.”
To evaluate the impacts, IFPRI conducted both baseline and endline studies on the implementation of the interventions in each country; in India, the baseline was completed in 2017 and the endline completed in 2019; in Burkina Faso and Ethiopia, the baselines were completed in 2019 and the endlines completed in 2021.
The interventions were carried out primarily at facilities or primarily through community platforms: Most existing ANC services were being delivered at facilities in Burkina Faso, but in Ethiopia and India, community-level services for pregnant were extensive, and complemented facility-based services in important ways.
In each country, study results show that integrating the interventions into the ANC platforms was feasible – and that doing so led to positive impacts on maternal nutrition outcomes.
IFPRI Senior Research Fellow Phuong Hong Nguyen and Research Fellow Sunny Kim presented key results from across the countries.
“Our studies demonstrated the feasibility of strengthening maternal nutrition intervention through ANC delivered through government health systems,” Nguyen said. “And our studies provide evidence of improvements in training, in the use of job aids and materials, and in supervision, along with improvements in service provider knowledge and in the beneficiaries’ exposure or use of services. And the studies show improvements the nutrition practices.”