Understanding the factors that determine maternal nutrition practices in Uttar Pradesh, India

Uttar Pradesh, the most populous state in India, has a high burden of undernutrition. It lags behind national averages in maternal nutrition practices. Despite strong policy and program commitments, many maternal nutrition interventions are not yet reaching majority of women during pregnancy. A recent study by researchers from the International Food Policy Research Institute (IFPRI), Alive & Thrive, and others, published in the Maternal and Child Nutrition journal and also included in a supplement of the Current Developments in Nutrition, examines the role of key influential demand and supply factors associated with maternal nutrition practices in Uttar Pradesh.

A maternal check-up during pregnancy in Uttar Pradesh. Image courtesy: Shivani Kachwaha, IFPRI

The determinants of maternal nutrition practices are complex, and each of the practices may have a differing set of determinants. Few studies have examined the determinants for a diverse set of maternal nutrition practices together, and none have been undertaken in the context of Uttar Pradesh. This study, therefore offers some very useful insights in understanding the role of dominant factors associated with maternal nutrition practices in Uttar Pradesh and deriving some practical lessons for implementing policies around them.

Presently, there is a considerable gap in the utilization of existing maternal nutrition services in Uttar Pradesh. According to National Family Health Survey data (NFHS-4 2016), while 76 percent of pregnant women received the first antenatal care (ANC) check-up, for only 26 percent was it followed up with at least four ANCs. Around 62 percent of women received some iron and folic acid (IFA) tablets, but only 13 percent of women consumed IFA tablets for 100 days or more.

To address the challenges of maternal undernutrition in Uttar Pradesh, A&T aims to test the feasibility of improving the provision and uptake of a package of maternal nutrition interventions through the ANC platform using social behavior change and systems strengthening approaches. These include provision of and counselling on IFA and calcium supplements, adequate weight monitoring during pregnancy and counselling on weight gain, interpersonal counselling on diet during pregnancy and on breastfeeding during postpartum, and community mobilization. IFPRI is collaborating with Alive & Thrive in this study to evaluate the impact of delivery of maternal nutrition interventions in Uttar Pradesh.

This paper used baseline data to provides comprehensive information on the multiple factors related to the adoption of four specific maternal nutrition practices – consumption of diverse diets, IFA and calcium supplementation, and weight monitoring – at multiple levels, including individual, household, community, and health services.

The study found that currently only 18 percent of pregnant women met the recommendation of dietary diversity; they consumed 28 IFA and 8 calcium tablets, and were weighed only 1.3 times during pregnancy. Although the current situation is bleak, many of the key factors associated with maternal dietary diversity, IFA/calcium consumption, and weight gain monitoring are modifiable.

This study shows that each specific maternal nutrition practice is influenced by differing sets of determinants. Among the multiple factors, maternal behavioral characteristics (such as knowledge, beliefs and self-efficacy), followed by support from family members, community factors, and adequate health services access are significantly associated with key maternal nutrition practices. Given that diverse diets, IFA and calcium supplements, and weight monitoring are promoted and delivered through a common package, a nuanced understanding of the drivers for each specific practice can help improve access to the full package. For example, maternal diet diversity is a complex outcome and was found to be associated with maternal knowledge and receipt of counseling. Increased consumption of calcium was found to be associated with maternal knowledge, receiving counselling on calcium supplementation, beliefs and self-efficacy, ANC visits and positive social norms.

Through modelling approaches, the effects of individual and combined factors help identify and highlight improvements that may be achieved by the maternal nutrition programs. In particular, these findings provide new evidence on the determinants of calcium consumption and weight monitoring during pregnancy. Under optimal program implementation that explicitly tackles the specific determinants of each maternal nutrition practice, one could expect half of the women to achieve adequate diet diversity, consume an average of 100 IFA and 90 calcium tablets, and be weighed 4.4 times during their pregnancy.

The study findings, based on modelling, suggest that strengthening program operations to improve the supply of interventions and to create adequate demand through behavior change communication, has the potential to improve maternal nutrition practices. The impact evaluation, which is underway, will shed more light on the extent to which Alive & Thrive’s efforts, working with the government of Uttar Pradesh, achieve these impacts. However, along with these efforts, improvements will also be needed in socio‐economic conditions, such as education, income, and employment generating activities to support and sustain behavior change for attaining the World Health Organization‐recommended levels of maternal nutrition. Improving the maternal nutrition practices in Uttar Pradesh will go a long way in improving the overall nutrition status of India.

Access this article: Nguyen, P., S. Kachwaha, R. Avula, M.F. Young, L. Tran, S. Ghosh, R. Agrawal, J. Escobar-Alegria, S. Patil, and P. Menon. 2019. “Maternal Nutrition Practices in Uttar Pradesh, India: Role of Key Influential Demand and Supply Factors”. Maternal & Child Nutrition. https://doi.org/10.1111/mcn.12839)

This blog has been jointly developed and cross-posted by the International Food Policy Research Institute and Alive & Thrive.