Integrating Nutrition Interventions into an Existing Maternal, Neonatal, and Child Health Program Increased Maternal Dietary Diversity, Micronutrient Intake, and Exclusive Breastfeeding Practices in Bangladesh: Results of a Cluster-Randomized Program Eval

"Addressing nutrition during pregnancy by delivering interpersonal counseling and community mobilization, providing free supplements, and ensuring weight-gain monitoring through an existing MNCH [maternal, neonatal, and child health] program improved maternal dietary diversity, micronutrient supplement consumption, and EBF practices."

Limited evidence exists on delivering multiple interventions for maternal nutrition simultaneously. Alive & Thrive (A&T) addressed this gap by integrating an intensified, nutrition-focused package of interventions into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh. This article reports findings from a cluster-randomised impact evaluation comparing nutrition-focused MNCH with a standard MNCH programme on coverage of nutrition interventions, maternal dietary diversity, micronutrient supplement intake, and early breastfeeding practices.

BRAC, a large national non-governmental organisation (NGO) in Bangladesh, has been providing community-based MNCH services, including standard nutrition interventions, since 2010. In 2015, A&T designed a package of interventions to include in the existing MNCH programme with the goal of improving maternal diet quality, micronutrient intakes, and breastfeeding practices. Although some nutrition interventions were provided in the standard MNCH programme (see Table 1 in the paper), the nutrition-focused MNCH included greater specificity of interpersonal counseling, engaged fathers more explicitly, conducted community mobilisation activities, provided free supplements, and monitored weight gain during pregnancy. The maternal nutrition interventions were implemented from August 2015 to December 2016.

For example, community mobilisation in the nutrition-focused MNCH model involved husbands' forums and video shows. Husbands of pregnant women were reached twice during pregnancy (in the second and third trimesters) through forums to discuss several topics related to ensuring adequate supplies of foods and micronutrient supplements and supporting their wives to practice optimal nutrition behaviours. Video shows and interactive communication were carried out in the community for women, their husbands and family members, local leaders, village doctors, and government health workers. There was no community mobilisation in the standard MNCH programme.

The researchers used a cluster-randomised design with cross-sectional surveys at baseline (2015) and endline (2016) (n = 300 and 1,000 pregnant or recently delivered women, respectively, per survey round). They derived difference-in-difference (DID) effect estimates, adjusted for geographic clustering and infant age and sex.

Coverage of interpersonal counseling was high; >90% of women in the nutrition-focused MNCH group were visited at home by health workers for maternal nutrition and breastfeeding counseling. The coverage of community mobilisation activities was approximately 50%. Mothers in the nutrition-focused MNCH group reported a significantly higher exposure to messages on nutrition during pregnancy (effect: 66.5 percentage points (pp) for eating a variety of foods and 38.5 pp for measuring weight) and on breastfeeding practices (effect: 16 pp for not feeding the child anything other than breast milk after birth and 8.6 pp for feeding expressed breast milk).

Improvements were significantly greater in the nutrition-focused MNCH group than in the standard MNCH group for consumption of iron and folic acid, or IFA [effect: 9.8 pp; 46 tablets] and calcium supplements (effect: 12.8 pp; 50 tablets). Significant impacts were observed for the number of food groups consumed (effect: 1.6 food groups), percentage of women who consumed ≥5 food groups/day (effect: 30.0 pp), and daily intakes of several micronutrients. The nutrition-focused MNCH programme had a large, significant effect on the proportion of mothers who reported exclusively breastfeeding their infants 0-6 months of age (effect: 31 pp), reaching 87% at endline. Early initiation of breastfeeding slightly increased in nutrition-focused MNCH areas, but no significant differential effect was observed. "Tailored messages and additional support around delivery, either at home or in health facilities, are needed to improve early initiation of breastfeeding in these contexts."

The researchers assert that, given the short (1-year) period of intervention, "the effects were substantial". They attribute the impact to "a well-designed and locally relevant package of maternal nutrition interventions, high quality of service delivery, and high service coverage of the base MNCH program. The strategic use of data from different sources (program conceptual framework, formative research, and evidence from other existing studies) to carefully design the context-specific package of proven nutrition interventions...resulted in a program that could be effectively delivered under real-life conditions as part of the MNCH program....Interventions were also designed to engage husbands, mothers-in-law, and the broader community to support mothers in obtaining foods and other supplies needed to achieve the recommended practices."

Per the researchers: "Lessons learned from this intervention, together with training manuals, job aids, and other materials, are being shared with the Bangladesh government and elsewhere in the efforts to integrate and reinforce nutrition interventions delivered through routine health care services. Future studies should include objective measures, such as biomarkers for iron and calcium, and examine whether successful integration of nutrition interventions into an existing high-quality MNCH large-scale program leads to nutrition effects beyond improved maternal diets and micronutrient intakes and improved longer-term newborn, infant, and child health outcomes."

In conclusion: "This effective model could be adapted into other health systems in similar contexts, particularly for program models that rely on incentivized frontline workers for conducting home-based interpersonal counseling and community mobilization....To ensure successful implementation and impact, special consideration is also needed with regard to strengthening existing health services and a functional network of skilled frontline workers."