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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., (© 2022 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

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., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition-focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight-gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference-in-differences (DID) estimates. Using village-level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight-gain monitoring. Improvements were significantly greater for nutrition-focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well-implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements-particularly FLW training and performance-were likely important to achieving impact., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Improving infant and young child feeding practices is critical for improving growth and reducing child mortality and morbidity. This paper aims to compare predictors of minimum dietary diversity, an important indicator of adequate complementary feeding practices, in Bangladesh in 2011 and 2014. The 2011 and 2014 Bangladesh Demographic and Health Survey were used to examine predictors of minimum dietary diversity among 6-23 months. An additional analysis was conducted for the 18-23-month group, because a significant increase in meeting minimum dietary diversity recommendations was seen in this age group only. Factors found to be associated with practices were compared across time points. In 2011, minimum dietary diversity was 23.8% and increased to 28.8% in 2014. Among children 18-23 months, in 2011, minimum dietary diversity was 32.5% and increased to 42.8% in 2014. Among all children, wealth, education, exposure to media, and antenatal care were significant predictors of dietary diversity. In the 18-23-month age group, significant predictors in 2011 were wealth and decision making. In 2014, significant predictors were education and exposure to media. Demographic trends indicated a significant increase in education and exposure to media between 2011 and 2014. As these were significant for minimum dietary diversity in 2014 overall and for 18-23 months, they might be important targets of future interventions, specifically utilizing media channels and tailoring special strategies for women with low education and limited exposure to media., (© 2018 John Wiley & Sons Ltd.)

This paper applies an implementation framework, based on a behavior change model, to compare four case studies of complementary feeding programs. It aims to expand our understanding of how to design and implement behavior change interventions aimed at improving complementary feeding practices. Four programs met the selection criteria of scale and documented improvements: Bangladesh, Malawi, Peru, and Zambia. We examined commonalities and differences in the design and implementation of social and behavior change approaches, use of program delivery platforms, challenges encountered, and lessons learned. We conclude that complementary feeding practices, in particular dietary diversity, can be improved rapidly in a variety of settings using available program platforms if interventions focus on specific constraints to food access and use effective strategies to encourage caregivers to prepare and feed appropriate foods. A five-step process is presented that can be applied across a range of complementary feeding programs to strengthen their impacts., (© 2017 John Wiley & Sons Ltd.)

The Alive & Thrive programme scaled up infant and young child feeding interventions in Bangladesh from 2010 to 2014. In all, 8.5 million mothers benefited. Approaches - including improved counselling by frontline health workers during home visits; community mobilization; mass media campaigns reaching mothers, fathers and opinion leaders; and policy advocacy - led to rapid and significant improvements in key practices related to breastfeeding and complementary feeding. (Evaluation results are forthcoming.) Intervention design was based on extensive formative research and behaviour change theory and principles and was tailored to the local context. The programme focused on small, achievable actions for key audience segments identified through rigorous testing. Promotion strategies took into account underlying behavioural determinants and reached a high per cent of the priority groups through repeated contacts. Community volunteers received monetary incentives for mothers in their areas who practised recommended behaviours. Programme monitoring, midterm surveys and additional small studies to answer questions led to ongoing adjustments. Scale-up was achieved through streamlining of tools and strategies, government branding, phased expansion through BRAC - a local non-governmental implementing partner with an extensive community-based platform - and nationwide mainstreaming through multiple non-governmental organization and government programmes. Key messages Well-designed and well-implemented large-scale interventions that combine interpersonal counselling, community mobilization, advocacy, mass communication and strategic use of data have great potential to improve IYCF practices rapidly. Formative research and ongoing studies are essential to tailor strategies to the local context and to the perspectives of mothers, family members, influential community members and policymakers. Continued use of data to adjust programme elements is also central to the process. Scale-up can be facilitated through strategic selection of partners with existing community-based platforms and through mass media, where a high proportion of the target audience can be reached through communication channels such as broadcast media. Sustaining the impacts will involve commitments from government and capacity building. The next step for capacity building would involve understanding barriers and constraints and then coming up with appropriate strategies to address them. One of the limitations we experienced was rapid transition of staff in key positions of implementing agencies, in government leadership, donors and other stakeholders. There was a need for continued advocacy, orientation and teaching related to strategic programme design, behaviour change, effective implementation and use of data., (© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)