Maternal nutrition interventions in Bangladesh: delivery at scale and mainstreaming into the health system
This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Deborah Ash, Zeba Mahmud, Kristen Kappos, Santhia Ireen and Thomas Forissier.
Deborah Ash is Project Director for the Alive & Thrive initiative in Bangladesh, managed by FHI Solutions.
Zeba Mahmud is Senior Strategic Partnership Advisor for the Alive & Thrive initiative in Bangladesh.
Kristen Kappos is Associate Director of South Asia Programs for the Alive & Thrive initiative.
Santhia Ireen is Deputy Country Director and Senior Technical Advisor for the Alive & Thrive initiative in Bangladesh.
Thomas Forissier is Regional Director of South Asia Programs for the Alive & Thrive initiative.
The Alive & Thrive initiative, managed by FHI Solutions, is currently funded by the Bill & Melinda Gates Foundation, Irish Aid, the Tanoto Foundation, UNICEF and the World Bank.
Background
Despite recent strides towards improved maternal health in Bangladesh, many women of reproductive age are still affected by undernutrition. Poor dietary diversity, anaemia and micronutrient deficiencies, such as calcium deficiency, put future mothers at risk of pregnancy and delivery complications and death. For their infants, growth and development may be compromised, with over a quarter being born with a low birth weight (LBW). This has implications for the weight and stature of infants into childhood and can also increase their risk of developing diseases such as obesity, diabetes and heart disease later in life.
The importance of maternal nutrition has been recognised by the Government of Bangladesh (GoB) and partnerships with non-governmental organisations (NGOs) which resulted in various programmes having been implemented since 1996. However, challenges related to the cost effectiveness of these programmes and their low impact on nutrition targets, such as reducing LBW and stunting, have highlighted the need for a more comprehensive and integrated approach.
Integrating maternal nutrition into Alive & Thrive (A&T)/BRAC Health, Nutrition and Population Programme
Between 2015 and 2016, Alive & Thrive (A&T) explored the feasibility of integrating maternal nutrition into the maternal, newborn and child health (MNCH) programme of BRAC’s large-scale Health, Nutrition and Population Programme (HNPP) in Bangladesh. A&T’s intervention package was delivered alongside BRAC’s standard MNCH programme in 10 ‘intensive’ (intervention) sub-districts, known as upazilas, while 10 ‘non-intensive’ (control) upazilas received only the BRAC programme. The A&T package included home-based counselling of pregnant women and new mothers on dietary intake and diversity with an additional emphasis on coaching and demonstration. BRAC workers also encouraged regular antenatal care (ANC) attendance, use of micronutrient supplements (iron folic acid (IFA) and calcium), routinely monitored weight gain and supported women on early breastfeeding initiation and exclusive breastfeeding. Efforts were also made to mobilise women’s social support networks around improved maternal nutrition behaviours and to target husbands to shift social norms on pregnancy and gender.
Programme effectiveness and lessons learnt
In just one year, the A&T intervention significantly improved the coverage of maternal nutrition services and the use of both IFA and calcium supplements. Dietary diversity was also improved and exclusive breastfeeding rates increased. These results demonstrated that integrating maternal nutrition into large-scale MNCH services was feasible and effective.
Findings from the study and from a sustainability assessment conducted by Harvard University provided important lessons for programmers and policymakers to ensure the effectiveness and sustainability of Social Behaviour Change (SBC) programmes. In particular, programmes should promote small doable actions via multiple platforms using a high intensity of exposure. Both the quantity and quality of SBC messages are important and supportive supervision of health providers is essential to their effective delivery of these messages. In addition, maternal, infant and young child nutrition (MIYCN) must be made a priority for frontline workers (FLWs), despite high turnover and competing responsibilities, with the possible use of incentives (financial or non-financial such as awards or certificates) for motivation. There is also a need to target secondary audiences, such as husbands, mothers-in-law, community elders and health workers, alongside pregnant women and new mothers, to facilitate and encourage maintenance of positive behaviour change. Finally, rigorous data, sustained financing and building advocacy coalitions for maternal nutrition are essential to improving the coverage and quality of interventions as well as supporting and sustaining progress in the long term.
Integration of maternal nutrition into large-scale MNCH services
BRAC has continued to support intensive counselling on maternal nutrition as part of its ongoing Essential Health Care programme. The compelling results of the implementation research have influenced the GoB to work with A&T, and other partners, to accelerate the mainstreaming of maternal nutrition within the health system. As such, SBC approaches and counselling messages have been institutionalised into national nutrition frameworks, guidelines and tools to strengthen service delivery coverage and quality. Several interlinked progressive steps have been taken including:
- Integration of maternal nutrition components (counselling, monitoring weight gain and IFA supplementation) into ANC services delivered at primary healthcare facilities (community clinics) and the inclusion of indicators into the national Health Management Information System (HMIS) to monitor their delivery
- Development of quality assessment guidelines for maternal nutrition by A&T for routine monitoring by the GoB
- Development of national guidelines for maternal nutrition and expanded comprehensive pre-service training for FLWs including SBC approaches and maternal counselling messages
- Delivery of MIYCN messages by Directorate General of Family Planning (DGFP) FLWs
- Prominence of maternal nutrition interventions and programme components in the National Nutrition Services Operational Plan (NNS-OP)
- Integration of maternal nutrition into the terms of reference of the Infant and Young Child Feeding (IYCF) Alliance
Integration of maternal nutrition into social protection programming
Further to nutrition-specific programmes, the results of the implementation research have influenced integration of maternal nutrition in nutrition-sensitive programming. Most notably, A&T was commissioned by the GoB and the World Food Programme (WFP) to develop a nutrition Social Behaviour Change Communication (SBCC) strategy for the government’s Improved Maternity and Lactating Mother Allowance (IMLMA). The IMLMA is a cash transfer plus health service social protection programme under the Ministry of Women and Children Affairs (MoWCA) which aims to improve the nutrition situation of poor and extreme poor women. IMLMA beneficiaries receive support from pregnancy until their child reaches four years of age. A&T’s national SBC strategy outlines priority nutrition practices and SBC materials and approaches as well as target audiences and communication channels for these. It also provides a monitoring and evaluation framework for these efforts. IMLMA is currently being evaluated in eight upazilas from eight divisions of the country by the International Food Policy Research Institute (IFPRI) with the lessons learnt informing a GoB-led scale-up to 64 upazilas by 2021.
Challenges experienced in the integration process
While there has been documented progress in integrating maternal nutrition into nutrition-specific and nutrition-sensitive programmes, experiences highlight certain challenges. Specifically, overburdened health facilities face personnel and logistics shortages which threaten the effective integration of maternal nutrition. Advocacy to fill vacant posts and task shifting may be necessary to ensure coverage and quality of MIYCN services that do not currently fall under existing FLWs’ primary targets. Incentive schemes may be useful in motivating FLWs but require strong policy advocacy for investment given that incentives are not widely used in the GoB public health system. In addition, the high turnover of staff at frontline, management and leadership levels impedes the maintenance of a shared understanding and commitment to improving maternal nutrition. Routine monitoring systems are similarly constrained by workload burdens, capacity issues and technology challenges. This limits the information available to make timely and strategic decisions. These issues will need to be addressed to improve the quality and coverage of maternal nutrition interventions in the long term.
Conclusions
Implementation research conducted by A&T has demonstrated that integrating maternal nutrition into existing large-scale programme platforms can have significant impacts on the coverage of maternal nutrition services, maternal dietary diversity and supplement use as well as exclusive breast-feeding rates in a relatively short time period (one year). Programme effects were likely due to the carefully designed, context-specific package of maternal nutrition interventions and the high quality and coverage of the programme delivery.
A&T, GoB and other partners have since utilised the lessons learnt to accelerate the mainstreaming of maternal nutrition into nutrition-specific and nutrition-sensitive programming. A&T has also accelerated the drive for systemic change in key government priority areas including the use of data for decision-making by district and upazila managers and FLWs, building the skills of FLWs through guidelines and tools and strengthening supportive supervision practices and community engagement platforms to raise awareness of maternal nutrition. This system is intended to achieve sustainable increases in the quality and coverage of maternal nutrition interventions and ultimately improve the health and wellbeing of women and their children in Bangladesh.