Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia

Objectives

This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka).

Design

A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data.

Findings

There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries.

Recommended actions include

(1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Strengthening Nutrition Interventions during Antenatal Care Improved Maternal Dietary Diversity and Child Feeding Practices in Urban Bangladesh: Results of a Quasi-Experimental Evaluation Study

BACKGROUND

Bangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services.

OBJECTIVES

We assessed the effect of integrating maternal, infant, and young child nutrition interventions, delivered at urban Maternal Neonatal and Child Health facilities, on maternal dietary diversity, iron and folic acid (IFA) and calcium consumption, and child feeding practices.

METHODS

We used a quasi-experimental design with a nonrandom assignment of 20 health care facilities in Dhaka to intensive and standard service arms. We conducted facility-based observations and community-based surveys at baseline (2020) and endline (2022) (n = 2455 observations and surveys with 1678 pregnant women [PW] or recently delivered women [RDW] at endline). We derived difference-in-difference (DID) estimates, adjusted for characteristics that differed at baseline or endline, and accounted for clustering.

RESULTS

Exposure to antenatal care (ANC) was similar in both arms: two-thirds of RDW received ANC during the first trimester and three-fourths received ≥4 ANC checkups. Compared to the standard arm, a higher proportion of PW in the intensive arm received counseling on dietary diversity (DID: 45 percentage points [pp]), and a higher proportion of RDW received IFA (25 pp) and calcium supplementation (19 pp), showed adequate weight gain (44 pp), and recorded appropriate child feeding (27 pp). Improvements were greater in the intensive than the standard arm for the number of food groups consumed (DID: 1.1 food groups) and minimum dietary diversity (23 pp); no effect was observed for IFA and calcium consumption during pregnancy. However, effects were observed for early initiation of (20 pp) and exclusive breastfeeding (45 pp), introduction of solid or semisolid foods (28 pp), and egg and/or flesh food consumption (33 pp) among children. Minimum dietary diversity and acceptable diet remained low in both arms.

CONCLUSIONS

Intensifying nutrition in government-aligned health care services delivered by experienced nongovernmental organization-run facilities is a feasible model to address the urban health gap, nutrition services coverage, and improve practices. The trial was registered at clinicaltrials.gov as NCT03882268.

Right message, right medium, right time: powering counseling to improve maternal, infant, and young child nutrition in South Asia

Introduction

Quality counseling can positively impact maternal, infant and young child nutrition (MIYCN) behaviors linked to poor nutrition outcomes. Global guidance includes 93 recommendations on MIYCN counseling.

Methods

A desk review and key informant interviews sought to assess compliance to the recommendations, reach and quality, systemic gaps and opportunities for MIYCN counseling in seven South Asian countries. Ninety-three (93) policies and guidelines, 180 counseling materials and over 50 documents were reviewed; 115 key informant interviews were conducted. Information synthesis captured eight domains. Data from national surveys were analyzed to determine MIYCN counseling reach, quality and association with nutrition behaviors.

Results

Results showed that national guidelines were inconsistent with global recommendations for seven thematic areas. Coverage of contacts points like antenatal and postnatal care (ANC, PNC) with potential to deliver MIYCN counseling was highly variable. Having at least four ANC contacts was significantly associated with consumption of 100+ iron folic acid tablets in all countries. Rates of early initiation of breastfeeding (18% Pakistan to 90% Sri Lanka) were lower than institutional delivery rates, except for Bangladesh and Sri Lanka. PNC contact within 48 h of birth was positively correlated with exclusive breastfeeding in India, Pakistan and Sri Lanka (OR 1.4, 3.1, 3.2). Health worker contacts and wealth status equally influenced child's dietary diversity in India. MIYCN services were add-on roles for community-based workers, except in India. Supervision mechanisms exist but were not focused on quality of MIYCN services. Counseling resources were predominantly paper based (>70%), had rural-focused messaging on diets and mainly targeted women. Platforms to engage men were largely missing. Health management information systems included indicators on maternal contact points in all countries but not for children. Assessing funding for MIYCN counseling was challenging as costs were subsumed across several budget line-items.

Discussion

The research findings can be used to (1) align country guidance with global recommendations, (2) review workforce responsibilities and capacity building with supervision, (3) assess the need for new counseling materials based on coverage of content, service providers and audience, (4) integrate MIYCN counseling indicators in information systems and (5) include MIYCN counseling services with activities and budget in country plans.

Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

BACKGROUND

The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists.

OBJECTIVES

This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences.

METHODS

We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring.

RESULTS

Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence.

CONCLUSION

A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.

The Financial Costs of Mass Media Interventions Used for Improving Breastfeeding Practices in Bangladesh, Burkina Faso, Nigeria, and Vietnam

Breastfeeding is essential for child survival but globally less than fifty percent of infants receive adequate breastfeeding. Gaps in breastfeeding knowledge and misinformation are widespread. Mass media aims to motivate mothers and families, encourage care-seeking, improve social norms, and counteract misleading advertising. However, the costs and coverage of mass media are not well documented. Our study provides a cost-accounting of four large-scale mass media interventions and coverage obtained through mass media. We retrospectively calculated annual costs and costs per beneficiary of mass media interventions based on expenditure records in four countries. The interventions were a part of multi-component breastfeeding strategies in Bangladesh, Burkina Faso, Nigeria, and Vietnam. Annual costs ranged from 566,366 USD in Nigeria to 1,210,286 USD in Vietnam. The number of mothers of children under two years and pregnant women ranged from 685,257 to 5,566,882, and all designated recipients reached during the life of programs ranged from 1,439,040 to 11,690,453 in Burkina Faso and Bangladesh, respectively. The cost per mother varied from USD 0.13 USD in Bangladesh to 0.85 USD in Burkina Faso. Evaluations showed that mass media interventions reached high coverage and frequent exposure. This analysis documents the financial costs and budgetary needs for implementing mass media components of large-scale breastfeeding programs. It provides annual costs, cost structures, and coverage achieved through mass media interventions in four low- and middle-income countries.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

BACKGROUND

Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

METHODS

We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2.

RESULTS

In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges.

CONCLUSIONS

Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Improving quality of antenatal care services in a high case load tertiary care teaching hospital (Ganesh Shankar Vidyarthi Memorial (GSVM) Medical College) in Kanpur, Uttar Pradesh, India

In India, half of all pregnant women between the ages of 15 and 49 years are anaemic. In Uttar Pradesh (UP), this figure is slightly higher at 51%. Unfortunately, only 5.4% pregnant women received full antenatal care (ANC) (National Family Health Survey 4, 2015-2016). A formative research conducted in UP in 2016 found that only 9% of pregnant women in UP consume the five recommended food groups, as per global recommendations.Ganesh Shankar Vidyarthi Memorial Medical College Hospital is one of the four high case load tertiary care facilities in Kanpur, UP, with an obstetrics and gynaecology (OBGY) outpatient department (OPD) of 2500-3000 consultations with delivery load of 250-300 deliveries per month and paediatric OPD of approximately 5400-6000 consultations per month. It was identified that pregnant women visiting the OPD for ANC were not receiving maternal nutrition-related services, and anthropometric measurements to assess nutritional status and gestational weight gain were also not done.The department of OBGY decided to apply the four-step Point of Care Quality Improvement (POCQI) approach using Plan-Do-Study-Act cycle for implementation of the maternal nutrition protocol during ANC.In April 2019, with the support of A&T, the hospital team applied the POCQI methodology to improve ANC service provision. By the end of 2019, the measurement and recording of anthropometric parameters increased to 84% and 74% for height and weight, respectively, from the baseline of zero. Hb testing increased from 58% to 84% and blood pressure (BP) monitoring from zero to 84%. Maternal nutrition counselling was delivered to 76% of the pregnant women visiting the OPD, which was a significant achievement for a new practice introduced into the system.The improved practices identified and implemented by the department are being sustained through active engagement of the staff and supportive leadership of the department of OBGY.

Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

BACKGROUND

To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring.

OBJECTIVES

This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package.

METHODS

We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling.

RESULTS

Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%).

CONCLUSIONS

Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.

India's 2.42 Million Frontline Health Workers Enable Restoration of Health and Nutrition Service Delivery After Early COVID-19 Lockdowns

Objectives

Modeling studies have estimated impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes, but little is known about actual delivery status. We studied disruptions and restorations of health and nutrition services by frontline workers (FLWs) in India during COVID-19.

Methods

We conducted phone surveys with 5500 FLWs in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in the August-October period (T2) and

analyzed changes between T1 and T2. We also analyzed publicly available administrative data (AD) from 704 districts including the pre-pandemic period (T0) to examine disruptions and restoration of services.

Results

Phone surveys suggest, in T1, opening of village centers, fixed day events, growth monitoring, and immunization services was <50% in several states. In T2, restorations of center-based services were seen, with increases of >33% in >= 3 states. Food supplementation was least disrupted both in T1 and T2. AD highlights geographic variability both in disruptions in T1 compared to T0 and restorations in T2. FLWs’ adaptations to ensure service provision included home delivery (60 to 96%), ensuring physical distancing (33 to 86%), coordinating with other FLWs (7 to 49%), and using phone (∼2 to 65%). Challenges included personal fears, walking long distances, and beneficiaries’ non-cooperation.

Conclusions

Services to mothers and children were disrupted during lockdown and restored thereafter. Rapid policy guidance and local adaptations by a strong cadre of FLWs likely enabled service resumption. However, gaps remain, and more research is needed on use of services by clients.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.

Understanding Implementation and Improving Nutrition Interventions: Barriers and Facilitators of Using Data Strategically to Inform the Implementation of Maternal Nutrition in Uttar Pradesh, India

BACKGROUND

In response to the high levels of maternal nutrition in Uttar Pradesh, Alive & Thrive (A&T) aimed to strengthen the delivery of nutrition interventions through the government antenatal care platform, including leveraging ongoing data collection to improve program delivery and reach (registered at clinicaltrials.gov as NCT03378141). However, we have a limited understanding of providers' experiences and challenges in collecting and using data for decision making.

OBJECTIVE

The aim was to identify barriers and facilitators to the 1) collection of data and 2) use of data for decision making.

METHODS

In-depth interviews (n = 35) were conducted among block-level government staff, frontline worker (FLW) supervisors, and A&T staff in 2 districts in Uttar Pradesh. Systematic coding of verbatim transcripts and detailed summaries were undertaken to elucidate themes related to data collection and use. FLW supervisors (n = 103) were surveyed to assess data use experiences.

RESULTS

Data were used to understand the reach of maternal nutrition services, estimate the demand for supplements, and guide identification of areas of low FLW performance. About half of supervisors reported using data to identify areas of improvement; however, only 23% reported using data to inform decision making. Facilitators of data collection and use included collaboration between health department officials, perceived importance of block ranking, and monthly review meetings with staff and supervisors to review and discuss data. Barriers to data collection and use included human resource gaps, inadequate technology infrastructure, FLW educational level, political structure, and lack of cooperation between FLWs and supervisors.

CONCLUSIONS

The use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Despite intensive data-collection efforts, the use of data to inform decision making remains limited. Collaboration facilitated data collection and use, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

Strengthening Nutrition Interventions in Antenatal Care Services Affects Dietary Intake, Micronutrient Intake, Gestational Weight Gain, and Breastfeeding in Uttar Pradesh, India: Results of a Cluster-Randomized Program Evaluation

BACKGROUND

Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services.

OBJECTIVES

We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices.

METHODS

We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018-2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices.

RESULTS

Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7-14 percentage points (pp)] and counseling on core nutrition messages (DID: 10-23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron-folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A-rich foods (10 pp, 11 g/d), other vegetables and fruits (22-29 g/d), and gestational weight gain (0.4 kg).

CONCLUSIONS

Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.

Improving Antenatal Care (ANC) Focusing on Maternal Nutrition (MN) Services and Counseling Through Quality Improvement (QI) Approach in a Medical College Hospital in India

Objectives

To demonstrate feasibility of applying Quality Improvement (QI) approach to improve maternal nutrition (MN) services and counseling during ANC provision at a state-run medical college hospital.

Methods

Doctors and staff from the departments of Obstetrics & Gynaecology (OBGY), Pediatrics and Community Medicine in GSVM Medical College, Kanpur, Uttar Pradesh (a high case load facility) were trained on Point of Care Quality Improvement (POCQI) methodology developed by WHO, URC and All India Institute of Medical Sciences (AIIMS) by a team of QI experts engaged by Alive & Thrive (A&T). Thereafter, the OBGY department formed a QI team with the aim of improving MN component within the ANC services for pregnant women (PW). Specifically, QI aims to be achieved between May– Aug 2019 were set as: At least 80% of PW complete height, weight gain, blood pressure (BP) and hemoglobin (Hb) measurement and receive nutrition counselling, of which 70% can recall the MN nutrition messages imparted during the counselling session. Since no system for recording ANC data existed except Hb (50%), the baseline was set as zero for all other parameters. Post a system process review and problem analysis, 4 areas for improvement were identified: i) Streamlining patient flow; ii) ensuring timely availability of diagnostic reports to facilitate early detection of anemia; iii) recording and tracking of anthropometric data and, iv) provision of nutrition counselling to all PW. Simple and doable changes such as deployment of Red Cross volunteers for crowd management and patient flow, use of government-issued mother and child protection (MCP) cards for recording anthropometric data, engagement of HIV counselor for nutrition counselling etc. were applied with assistance and mentoring from QI experts.

Results

84% of the PW completed weight gain, Hb and BP measurement. MN counselling was delivered to 76% of the women. Exit interviews of PW to assess the comprehensiveness of the counselling provided show a steady improvement (∼12–15%) in retention of messages related to weight gain, importance of Ca and IFA, frequency of meals and diet diversity.

Conclusions

It is feasible to improve MN services including counseling at ANC OPD in medical college hospital using QI approach, without additional resource investment.

Funding Sources

The Bill & Melinda Gates Foundation.

Understanding How the Strategic Use of Data Can Improve the Implementation of Maternal Nutrition Interventions in Uttar Pradesh (UP), India

Objectives

Maternal undernutrition remains high in India and is associated with maternal mortality and adverse birth outcomes. To address this challenge, Alive & Thrive (A&T) aimed to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in UP. The nutrition-intensified ANC (I-ANC) intervention facilitated regular use of data to enable corrective actions. We aimed to understand how maternal health data was used for improving the delivery of maternal nutrition services and to identify factors associated with data use.

Methods

In-depth interviews (N = 35) were conducted among sub-district government staff, frontline worker (FLW) supervisors and A&T staff in two districts in UP. Systematic coding of verbatim transcripts and detailed summaries was undertaken to elucidate themes and patterns related to data use and facilitators and barriers.

Results

Sub-district government staff reported using government data (i.e., HMIS) to estimate demand for prenatal supplements. Sub-district government staff, FLW supervisors and A&T staff used government and intervention monitoring data to understand the impact and reach of services delivered to women. Key indicators on the attendance of pregnant women at community health events and number of women receiving adequate supplements was discussed with FLWs in monthly review meetings. Data review guided identification of areas of low FLW performance (i.e., monitoring weight gain) and prompted refresher trainings. Facilitators of data use included collaboration between sub-district health department officials on data analysis and monthly review meetings to provide feedback on improving performance (including counseling topics and stock of supplements). Barriers to data use included staff vacancies, education level of FLWs and conflicts between FLWs and supervisors.

Conclusions

Use of data for decision making is critical for supporting intervention planning and providing targeted supervision and support for FLWs. Collaboration facilitated the use of data, but structural barriers such as staff vacancies need to be addressed to improve the implementation of maternal nutrition interventions.

Funding Sources

Bill & Melinda Gates Foundation (through Alive & Thrive, managed by FHI 360) and Emory University.

Strengthening Nutrition Interventions in Antenatal Care Services Had Modest Impacts on Diet Diversity, Micronutrient Intake, and Breastfeeding in Uttar Pradesh, India

Objectives

Interventions to improve maternal nutrition are poorly integrated into antenatal care (ANC) services in India. Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization implemented through government ANC services. We evaluated the impact of nutrition-intensified ANC (I-ANC) compared to standard ANC (S-ANC) on diet diversity, consumption of iron-folic acid (IFA) and calcium supplements, and early breastfeeding practices.

Methods

We used a cluster-randomized design with cross-sectional surveys at baseline (2017) and endline (2019) (n ∼660 pregnant women and 1800 recently delivered women per survey) and a process evaluation. We derived difference-in-difference effect estimates, adjusted for geographic clustering, gestational age, infant age, and sex.

Results

Coverage of interventions was high at endline; 70–90% women were contacted by frontline workers at home or nutrition centers. Women in the I-ANC arm were significantly more likely to have received counseling on core nutrition messages (10–18 percentage points [pp]) than those in the S-ANC arm. Dietary diversity improved modestly among pregnant women in the I-ANC arm compared to the S-ANC arm (effect: 8.3 pp). The number of food groups consumed increased slightly over time but remained low in both arms. The percentage of women who consumed 100 + IFA improved equally in both arms (from 8 to 25%). Small significant impacts were observed for any consumption of IFA and calcium supplements (effects 10.3 and 12.4 pp, respectively). Significant impacts were also observed for non-prelacteal feeding (effect: −6.3 pp) and exclusive breastfeeding (effect: 7.4 pp) but not for early initiation of breastfeeding. The process evaluation found that system-level and supply-chain challenges, household context, and local diet preferences affected implementation and uptake.

Conclusions

Intensifying nutrition in existing government ANC services resulted in modest improvements in maternal nutrition practices. Dietary diversity and consumption of supplements remained sub-optimal. Additional efforts are needed for further improvement of maternal nutrition services.

Funding Sources

Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI 360.

Priority-Setting for Novel Drug Regimens to Treat Tuberculosis: An Epidemiologic Model

BACKGROUND

Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen's ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective.

METHODS AND FINDINGS

We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113-187) and 16 (95% UR: 9-23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4-10) and 0.6 (95% UR: 0.3-1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%-20%) and 11% (95% UR: 6%-20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%-46%) and RR TB mortality by 30% (95% UR: 18%-44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99% reduced TB mortality by 6% (95% UR: 1%-13%, half the impact of a fully optimized regimen), and increasing the efficacy against RR TB from 76% to 94% lowered RR TB mortality by 13% (95% UR: 6%-23%). Reducing treatment duration or improving ease of adherence had smaller but still substantial impact: shortening RS TB treatment duration from 6 to 2 mo lowered TB mortality by 3% (95% UR: 1%-6%), and shortening RR TB treatment from 20 to 6 mo reduced RR TB mortality by 8% (95% UR: 4%-13%), while reducing nonadherence to the corresponding regimens by 50% reduced TB and RR TB mortality by 2% (95% UR: 1%-4%) and 6% (95% UR: 3%-10%), respectively. Limitations include sparse data on key model parameters and necessary simplifications to model structure and outcomes.

CONCLUSIONS

In designing clinical trials of novel TB regimens, investigators should consider that even small changes in treatment efficacy may have considerable impact on TB-related incidence and mortality. Other regimen improvements may still have important benefits for resource allocation and outcomes such as patient quality of life.