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Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts. Key messages: Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models. [ABSTRACT FROM AUTHOR]

Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence‐based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self‐efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress. Key points: Delivering nutrition services to all pregnant women is essential for maternal and child health outcomes but remains a challenge.Nutrition gaps in antenatal care (ANC) include lack of specificity in national guidelines and protocols, bottlenecks in micronutrient supplies, low ANC provider knowledge and skills, inadequate supervision to reinforce counseling, and not engaging families to encourage key practices.National protocols for ANC should be more specific for the four nutrition interventions (micronutrient supplements, weight gain monitoring, counseling on diets and counseling on breastfeeding) and assign accountability for coverage and quality.Country models are needed for improving provision and utilisation of nutrition interventions through ANC that are based on comprehensive policy frameworks. [ABSTRACT FROM AUTHOR]

The aim of this study is to investigate the effects of Education, Employment, Economic Status and Empowerment (introduced as the 4Es) and other explanatory socio‐demographic factors on the utilization of maternal health care services in India. This study used data from the National Family Health Survey‐4 (2015–2016). Separate logistic regression models were fitted for four or more antenatal care visits, skilled birth attendance and postnatal care to understand the effects of 4Es on the utilization of maternal health care services in India. The findings indicate positive effects of education on antenatal care, skilled birth attendance and postnatal care, the effects of higher education being even stronger in case of antenatal care. Education leads to employment, economic status and empowerment which in turn are significantly associated with the use of antenatal care and skilled birth attendance. Interestingly, in case of postnatal care, while controlling for economic status and empowerment, the effects of education vanish. Overall, education, employment, greater economic status and empowerment emerged as reliable predictors of the use of all three maternal health care services. The positive association between the 4Es and maternal health care services utilization reiterates the need for rigorous monitoring and evaluation of the existing policies and programs, coupled with efforts to change societal attitudes toward females through political advocacy and commitment which is reflected in parallel investment in girl education, job creation for poverty reduction to facilitate women empowerment. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to understand the complex relationship between maternal complications and women's characteristics in India. Methods: The present study builds structural equation modeling (SEM) using the data from the National Family Health Survey round 4 (2015–16) and includes 190, 898 women who had given their last birth during 5 years preceding the survey. Based on eight questions related to maternal complications, the SEM constructed two latent variables – complications during pregnancy (PREGCOMP) and delivery (DELCOMP). Results: Result shows that prolonged labor was highly prevalent (42%) among women, followed by vaginal bleeding (34%) and swelling in legs, body or face (32%). Women from affluent households (β = −0.02 for each‐middle, richer and richest quantile), with higher education (β = −0.02), timing when they received first ANC (β = −0.003) and women who received full ANC (β = −0.01) had a lower risk of PREGCOMP. However, consanguineous marriage (β = 0.01) was positively related to PREGCOMP. Further, women with PREGCOMP (β = 0.20), rural residents (β = 0.02), having exposure to mass media (β = 0.01), and who had facility delivery (β = 0.04) were at high risk of DELCOMP. Women with pregnancy complications are more likely to have delivery complications. [Correction added on 27 November, after first online publication: The statement "who received full antenatal care (ANC) (β = −0.05)" has been removed.] Conclusion: Socioeconomic and demographic factors significantly affect both the latent variables. This study concludes that the use of intensive healthcare services reduces health complications. The paper recommends early visits and full ANC checkups to reduce pregnancy complications. [ABSTRACT FROM AUTHOR]