A Feasibility Study of Integrating Maternal Nutrition Interventions Into Antenatal Care Services in Ethiopia: A Cluster-Randomized Evaluation
Phase: NA
Conditions: Maternal Dietary Diversity, Iron-Folic Acid Supplementation, Early Initiation of Breastfeeding
Sponsor: International Food Policy Research Institute

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A Feasibility Study of Integrating Maternal Nutrition 
Interventions into Antenatal Care Services in Ethiopia: 
A Cluster-Randomized Evaluation 
 
 
 
Study Protocol 
 
 
 
International Food Policy Research Institute 
 
June 2, 2021 
VERSION: 2 
 
Clinicaltrials.gov: NCT04125368

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Funding: We acknowledge funding support from the Bill & Melinda Gates Foundation (grant no. 
OPP1171874), through Alive & Thrive, managed by FHI Solutions LLC. Additional financial support was 
provided by CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the 
International Food Policy Research Institute.  
Roles and responsibilities: 
Co-Investigators: 
Dr. Sunny S. Kim 
Research Fellow 
Poverty, Health and Nutrition Division 
International Food Policy Research Institute  
1201 I St. NW 
Washington, DC 20005-3915 
USA 
Phone: +1 202-862-4611 
Email: sunny.kim@cgiar.org  
 
 
 
 
Dr. Purnima Menon 
Senior Research Fellow 
Poverty, Health and Nutrition Division 
International Food Policy Research Institute  
9th Floor, Aggarwal Corporate Tower 
Govind Lal Sikka Marg, Rajendra Place 
New Delhi 110008 
India 
Phone: +91 11-66219-276 
Email: p.menon@cgiar.org  
 
Dr. Amare Worku Tadesse  
Associate Professor of Nutrition and Public Health  
Head, Department of Public Health Sciences 
Addis Continental Institute of Public Health (ACIPH)  
Yeka Sub City, Woreda 13, House No. B227  
P.O. Box: 26751/1000 
Addis Ababa  
Ethiopia  
Phone: +251 116-390018  
Email: amarewaciph@gmail.com  
 
Protocol contributors:  Sunny Kim (Principal Investigator), Celeste Sununtnasuk (Project Manager), 
Amare Worku (Co-Principal Investigator), Yemane Berhane (ACIPH Director, 
Technical Advisor), Hanna Y. Berhane (ACIPH Deputy Director for Research and 
Community Services, Technical Advisor), Phuong Nguyen (Research Fellow), 
Purnima Menon (Co-Principal Investigator) 
 

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Sponsor: 
 
International Food Policy Research Institute (IFPRI)  
1201 I St. NW 
Washington, DC 20005-3915 
USA 
Phone: +1 202-862-3915 
 

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Contents 
I. 
Introduction .......................................................................................................................................... 6 
1.1 Background and rationale ............................................................................................................... 6 
1.2 Objectives ........................................................................................................................................ 6 
1.3 Trial design ...................................................................................................................................... 7 
II. 
Methods: Participants, Interventions and Outcomes ........................................................................... 7 
2.1 Study setting .................................................................................................................................... 7 
2.2 Eligibility criteria ............................................................................................................................ 10 
2.3 Interventions ................................................................................................................................. 10 
2.4 Outcomes ...................................................................................................................................... 11 
2.5 Participant timeline ....................................................................................................................... 12 
2.6 Sample Size .................................................................................................................................... 12 
2.7 Recruitment................................................................................................................................... 13 
III. 
Methods: Assignment of Interventions ............................................................................................... 14 
3.1 Allocation ...................................................................................................................................... 14 
3.2 Blinding (masking) ......................................................................................................................... 14 
IV. Methods: Data Collection, Management and Analysis........................................................................ 15 
4.1 Data collection methods ............................................................................................................... 15 
4.1.1 Health facility observation checklist ................................................................................... 16 
4.1.2 ANC observation checklist and exit interview with pregnant women ................................ 17 
4.1.3 Nurse-midwife questionnaire ............................................................................................. 17 
4.1.4 Health Extension Worker (HEW) questionnaire .................................................................. 18 
4.1.5 Pregnant women questionnaire ......................................................................................... 19 
4.1.6 Recently delivered women and husband questionnaire ..................................................... 20 
4.2 COVID-19 precautionary measures ............................................................................................... 22 
4.3 Data management ......................................................................................................................... 22 
4.4 Statistical methods ........................................................................................................................ 23 
V. 
Methods: Monitoring .......................................................................................................................... 23 
5.1 Data monitoring ............................................................................................................................ 23 
5.2 Harms ............................................................................................................................................ 23 
5.3 Auditing ......................................................................................................................................... 23 
VI. Ethics and Dissemination .................................................................................................................... 24 
6.1 Research ethics approval ............................................................................................................... 24 

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6.2 Protocol amendments ................................................................................................................... 24 
6.3 Consent or assent .......................................................................................................................... 24 
6.4 Confidentiality ............................................................................................................................... 24 
6.5 Declaration of interests ................................................................................................................. 24 
6.6 Access to data ............................................................................................................................... 25 
6.7 Ancillary and post-trial care ........................................................................................................... 25 
6.8 Dissemination policy ..................................................................................................................... 25 
VII. Timeline............................................................................................................................................... 26 
7.1 Study timeline ............................................................................................................................... 26 
References ................................................................................................................................................... 28 
 
List of Tables 
Table 1. Study woredas and total number of available health centers and health posts .............................. 9 
Table 2. Overview of interventions in intensive and non-intensive intervention areas .............................. 10 
Table 3. Sample sizes ................................................................................................................................... 13 
Table 4. Data collection methods and samples ........................................................................................... 16 
Table 5. Description of topics to be included in the health facility observation checklist ........................... 16 
Table 6: Description of modules in the ANC observation checklist and exit interview ................................ 17 
Table 7. Description of modules in the nurse-midwife questionnaire ......................................................... 17 
Table 8. Description of modules in the HEW questionnaire ........................................................................ 18 
Table 9. Description of modules in the pregnant women’s questionnaire .................................................. 19 
Table 10. Description of modules in the recently delivered women’s questionnaire ................................. 20 
 
List of Figures 
 
Figure 1. Study regions .................................................................................................................................. 8 
Figure 2. ANC and breastfeeding indicators among Ethiopian women of reproductive age ......................... 9 
Figure 3. Trial flow ....................................................................................................................................... 15 
 
 

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I. 
Introduction 
1.1 Background and rationale 
Poor maternal nutrition is a major public health concern and has adverse consequences on fetal and 
early childhood growth, infant morbidity and mortality, and health and productivity in adulthood (Black 
et al. 2013). Despite the availability of promising and affordable interventions for improving maternal 
nutrition in developing countries, many women do not receive proven maternal nutrition services during 
pregnancy. In Ethiopia, 62 percent of women receive antenatal care (ANC) from a skilled provider and 
just two-thirds of women who attend ANC receive nutrition counseling; nearly 60 percent of women do 
not consume any IFA tablets during pregnancy (CSA & ICF, 2016).  
 
There is wide recognition of the importance of integrating maternal nutrition interventions in ANC to 
improve maternal and child health (Bhutta et al. 2013). In 2016, World Health Organization (WHO) ANC 
guidelines were updated to place a high priority on nutrition interventions during pregnancy to improve 
perinatal outcomes and women’s experience of care. In Ethiopia, the government has adopted a 
package of maternal nutrition interventions into national guidelines (see Ethiopia’s Federal Ministry of 
Health (FMOH) National Guideline on Adolescent, Maternal, Infant and Young Child Nutrition). Despite 
these efforts, the coverage and quality of maternal nutrition interventions remains low. Alive & Thrive 
(A&T) is interested in improving nutrition coverage among users of government ANC services. 
 
A&T is an initiative that supports the scaling up of nutrition interventions to save lives, prevent illnesses, 
and contribute to healthy growth and development through improved maternal nutrition, breastfeeding 
and complementary feeding practices in several countries. In October 2017, A&T was awarded by the 
Bill & Melinda Gates Foundation’s Ethiopia Office a new five-year agreement to Accelerate 
Improvements in Maternal, Infant and Young Child Nutrition in Ethiopia. The A&T Ethiopia 3.0 
investment (2018–2022) will support the government of Ethiopia to achieve targets set out in the 
national nutrition program (NNP II) and the National Nutrition Sensitive Agriculture Strategy (NNSAS). 
A&T will focus its role on strengthening systems at the national and regional levels for achieving large 
scale and sustainability, and strengthening the evidence base for programs and policies. 
In Ethiopia, A&T will develop and test the integration of an intensive package of maternal nutrition 
interventions into existing ANC services delivered through government health facilities that will align 
with the latest global evidence (WHO, 2016) and the NNP II. These include interpersonal counseling on 
diet quality during pregnancy, counseling on iron-folic acid (IFA) supplementation, adequate weight-gain 
monitoring, counseling on early breastfeeding practices, and systems strengthening through training 
and supportive supervision. The impacts of these intensive interventions in users of government ANC 
services will be compared with standard ANC services.  
1.2 Objectives 
A cluster randomized evaluation trial will be conducted to determine the feasibility and impact of 
integrating locally relevant maternal nutrition interventions into existing ANC services on diet quality 
and utilization of nutrition interventions during pregnancy.  
Research questions for the evaluation include: 

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1) Is it feasible to integrate locally relevant maternal nutrition interventions based on the WHO 
ANC Guidelines into existing ANC services delivered through government health facilities? 
2) Can the coverage and utilization of key nutrition interventions (nutrition counseling, weight 
gain monitoring, IFA supplement consumption, and breastfeeding counseling) be improved by 
integrating nutrition-focused behavior change interventions and health systems strengthening 
approaches into existing ANC services? 
3) Can the quality of diets (dietary diversity and meal frequency) among pregnant women be 
improved by integrating nutrition-focused behavior change interventions and health systems 
strengthening approaches into existing ANC services? 
1.3 Trial design 
The evaluation will use a two-arm cluster-randomized, non-masked trial design, consisting of two cross-
sectional surveys at baseline and endline. The unit of randomization is the health center and associated 
health posts in the catchment area. The baseline survey will take place in October-November 2019, and 
the endline survey will take place in July-September 2021. Program implementation was interrupted 
between April and July 2020 due to the COVID-19 pandemic. The endline survey was postponed to July-
September 2021 to maximize implementation duration. The repeated cross-sectional study design will 
allow us to assess the impact of the maternal nutrition interventions delivered at health facilities on 
currently pregnant and recently delivered women who attend government ANC services.  
 
II. 
Methods: Participants, Interventions and Outcomes 
2.1 Study setting 
Implementation of the maternal nutrition study will take place in two regions: Southern Nations 
Nationalities and People’s Region (SNNPR), a primarily agrarian region, and Somali, a region with a high 
population of pastoralists (see Figure 1). The Somali region is among the poorest of Ethiopia’s nine 
administrative regions, predominantly rural, and relatively ethnically homogeneous. According to the 
most recent Ethiopian census in 2007, 38 percent of the population in Somali is pastoral compared with 
less than one percent in SNNPR (CSA 2007). SNNPR is one of the most populous regions in Ethiopia as 
well as the most diverse; more than 80 ethnic groups reside in the region. 
Study regions were selected by the Government of Ethiopia, so that maternal nutrition intervention 
packages be tested in both agrarian and pastoral settings. Pastoralists—agriculturalists who rely 
primarily on their livestock for their food and income—and the regions they live have had few 
opportunities to be studied in the past, as their migratory nature makes it particularly difficult to track 
them through surveys. Policymakers are requesting programmatic experience across regions so that 
results and interventions can be used for the scale-up of nationally accepted guidelines and targets. 
Current guidelines for ANC services are standardized nationwide, providing further incentive to include 
diverse areas for study implementation. 
 

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Figure 1. Study regions 
 
While there has been an increasing trend in coverage of services during pregnancy and early infancy, 
major gaps in coverage persist nationwide and in study regions (see Figure 2). Current ANC service 
utilization is low in the study regions and nationwide: only 11.8 percent of women in Somali and 38.2 
percent of women in SNNPR achieved the WHO-recommended four or more ANC visits during 
pregnancy (compared to 31.8 percent nationally) (CSA & ICF, 2016). Among women who had at least 
one ANC visit, 48 percent in Somali and 62.3 percent in SNNPR received nutrition counseling. More than 
half (56 percent) of women in Somali and nearly a third (30.4 percent) of women in SNNPR did not 
attend ANC during their pregnancy.  
IFA consumption during pregnancy is also low in Ethiopia. Current WHO guidelines recommend daily IFA 
supplementation for women throughout pregnancy, beginning as early as possible. Ideally, women 
should receive IFA tablets no later than the first trimester, corresponding to 6 months (180 days) of 
supplementation. Very few women (4.2 percent in SNNPR and 2.3 percent in Somali) achieve at least 90 
days of IFA supplementation before delivery (CSA & ICF, 2016). Seventy-two percent of women in Somali 
and 59 percent of women in SNNPR did not consume any IFA tablets during their most recent 
pregnancy.  
Notwithstanding the critical nutritional needs of pregnant women, who must meet the additional 
energy and micronutrient requirements for fetal development and to protect their health through 
pregnancy and delivery, evidence on the dietary intake of pregnant women in Ethiopia is scarce. One 
study conducted in rural SNNPR found that while nearly all pregnant women reported the need for 
dietary improvements during pregnancy, only a quarter of women reported increased food intake and 
no significant differences were found between the dietary intakes of pregnant and non-pregnant 
women (Asayehu et al. 2017). Moreover, even among those pregnant women who claimed improved 
food intake, energy and most micronutrient intakes were inadequate. 
Misconceptions about weight gain during pregnancy and food taboos also persist in some areas of 
Ethiopia. Many rural women in the Oromia region were found to oppose gaining weight during 
pregnancy, out of fear of delivery complications associated with the birth of a large baby (Zerfu et al. 
2016). Limited weight gain, before and during pregnancy, can result in inadequate birthweight and fetal 
growth (Frederick et al. 2008; Siega-Riz et al. 2009).  
SNNPR 
Somali 

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Regarding early breastfeeding practices, nearly all women in Ethiopia have ever breastfed their children, 
with nearly 80 percent of women in SNNPR and Somali reporting early initiation of breastfeeding (within 
one hour of birth) (CSA & ICF, 2016). Exclusive breastfeeding among children during the first 6 months is 
less prevalent; only 40 percent of infants in Somali and roughly 60 percent of infants in SNNPR are 
exclusively breastfed. 
Figure 2. ANC and breastfeeding indicators among Ethiopian women of reproductive age 
 
 
Source: 2016 Ethiopia Demographic and Health Survey 
 
Across SNNPR and Somali regions, A&T selected seven woredas (districts) as potential intervention areas 
on the basis of having adequate health facility access and infrastructure. Four woredas were selected in 
SNNPR and three woredas in Somali region. Fewer woredas were selected in Somali as the communities 
are more homogenous, and those with less security issues were identified. The list of study woredas and 
their corresponding numbers of health centers and posts are presented in Table 1.  
Table 1. Study woredas and total number of available health centers and health posts 
No. Region 
Zone 
Woreda 
Population Kebeles 
Health 
Centers 
Health 
Posts 
1 
Somali 
Fafan 
Gursum 
37,425 
15 
3 
18 
2 
Fafan 
Harawa 
32,034 
16 
2 
15 
3 
Fafan 
Keberi Beyah 
165,518 
29 
5 
34 
4 
SNNPR 
Gurage 
Sodo 
175,400 
54 
7 
39 
5 
Gurage 
Muhor Na Aklil 
119,137 
29 
5 
30 
6 
Silti 
Dalocha 
89,807 
18 
4 
18 
7 
Kembata Tembaro 
Doyo Gena 
78,634 
18 
4 
19 
0
10
20
30
40
50
60
70
80
90
100
Pregnancy
Recently delivered
National 
Somali 
SNNPR 

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2.2 Eligibility criteria 
Women of reproductive age (15 to 49 years old) are eligible for inclusion in the baseline and endline 
surveys if: 1) they are registered at the government health center as currently pregnant and have 
attended at least 1 ANC visit at the government health center/post, or have a child under 6 months of 
age (recently delivered) at the time of the survey and attended at least 1 ANC visit at the selected health 
center/post, 2) reside within sample kebeles in the health center catchment area, and 3) have given 
informed consent. Recently delivered women must have had a live birth within 6 months preceding 
either of the two surveys and the infant must still be alive and living with them. 
At the health center level, the nurse-midwife responsible for providing ANC, available at the time of the 
survey, and has given informed consent will be interviewed. At the health post level, the health 
extension worker (HEW) available at the time of the survey and has given informed consent will be 
interviewed. If more than one health worker/extension worker are eligible, the person primarily 
responsible for ANC or with the most experience in providing ANC (determined as the individual who 
has worked the most years in the current position) at the study health facility will be invited to 
participate.  
2.3 Interventions 
The package of maternal nutrition interventions will include interpersonal counseling on diet quality 
during pregnancy, counseling on IFA supplements, adequate weight-gain monitoring, counseling on 
early breastfeeding practices, and systems strengthening through improving the IFA supply chain, 
training and supportive supervision. Intervention components are presented in Table 2. 
Table 2. Overview of interventions in intensive and non-intensive intervention areas 
CORE INTERVENTIONS 
INTERVENTION  
CONTROL  
At health facilities: 
• Counselling on diet quality 
during pregnancy 
Intensified counselling on dietary diversity and 
increased meal frequency during pregnancy 
Standard counseling at 
health facilities 
• Strengthening distribution 
and promotion of IFA 
supplementation  
Strengthened government distribution of 
supply of IFA with counseling about its 
importance, managing side effects, and 
reminder about subsequent supplies  
Current practice of supply 
and distribution of IFA 
tablets at health facilities 
• Weight-gain monitoring 
Weight-gain monitoring with messaging to 
mothers about healthy diet and adequate rest; 
excess weight gain as a danger sign   
Current practice of weight-
gain monitoring at health 
facilities 
• Counseling on early 
breastfeeding practices  
Intensified counseling on importance, benefits, 
and how-tos of early initiation of breastfeeding 
and exclusive breastfeeding  
Standard breastfeeding 
messages at health 
facilities 
Home visits by HEWs 
Home visits to pregnant women by HEWs to 
discuss maternal nutrition (dietary diversity, 
adequate food intake, IFA supplementation, 
and weight gain), early breastfeeding 
practices, provide ANC and Pregnant Women 
Conference referrals, and engage husbands 
Home visits for routine 
health services 
Pregnant Women Conferences/ 
Mother Support Groups 
HEWs use A&T intervention tools (e.g. posters 
and maternal nutrition follow-up card) to 
reinforce maternal nutrition messages, 
Standard meetings 

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2.4 Outcomes 
The primary outcomes of the study are focused on diet quality measures and IFA supplementation. 
These include: 
1) Maternal dietary diversity and quality of diets among pregnant women 
i. Mean number of food groups consumed by pregnant women 
ii. Proportion of pregnant women who achieve minimum dietary diversity 
2) Use of iron-folic acid (IFA) supplements 
i. Mean number of IFA tablets consumed during pregnancy 
ii. Proportion of women who received 90+ IFA supplements during pregnancy  
The secondary outcomes relate to exposure to and utilization of key maternal nutrition and early 
breastfeeding interventions, as well as capacities at the points of service delivery. These include: 
3) Early initiation of breastfeeding  
4) Use of ANC services (total number of ANC visits and timing of the first ANC visit) 
5) Exposure to nutrition interventions during ANC, including weight gain monitoring (proportion of 
women who are weighed and counselled about adequate weight gain, total number of times 
women are weighed during pregnancy)  
6) Exposure to nutrition information from ANC and other sources  
7) Women’s knowledge and perceptions about maternal nutrition and breastfeeding  
8) Health worker knowledge on benefits and service provision for IFA supplementation, dietary 
diversity counselling, weight gain monitoring, and breastfeeding counselling 
9) Availability of service supports (IFA supplies, records/registers and regular review of nutrition 
intervention coverage and IFA supply data, weight measurement equipment, counseling 
materials, and training and supervision for health workers) 
encourage ANC attendance, distribute IFA 
tablets, measure and track weight gain, 
promote early breastfeeding practices, and 
encourage husband participation 
Kebele and community 
meetings 
HEWs and community volunteers (Women’s 
Development Army (WDA), imams, etc.) 
deliver maternal nutrition messages and 
encourage ANC visits 
Standard meetings  
Training for health staff and 
other actors 
Trainings on the maternal nutrition 
interventions above for health center heads, 
nurse-midwives, HEWs, community volunteers 
(WDA, imams, etc.), woreda health officers, 
and other key actors 
Standard health training 
Supportive supervision for 
health staff and other actors 
Supportive supervision of maternal nutrition 
activities conducted by woreda nutrition 
officers, woreda health officers, TDA or A&T 
Standard health facility 
supervision 

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2.5 Participant timeline 
Enrollment of pregnant and recently delivered women will begin in October 2019, at the time of 
baseline survey. Interventions were planned to be implemented for up to one year, following the 
baseline survey. Then, pregnant and recently delivered women would be assessed at endline, exactly 
one year after baseline. 
In March 2020, the World Health Organization declared COVID-19 a pandemic. Disruptions to work and 
field conditions in Ethiopia resulted in program implementation being halted in April 2020 when the 
Government of Ethiopia declared a state of emergency. A&T began providing supportive supervision in 
July 2020 and refresher trainings for nurse-midwives and HEWs were held in November 2020. 
Interventions will be implemented through July 2021.Pregnant and recently delivered women will be 
assessed at endline in July-September 2021. 
2.6 Sample Size 
The two main survey samples for the primary outcomes will be: 1) pregnant women who attended at 
least 1 ANC at the sampled health center or associated health post, as this sample allows the 
assessment of diet quality during pregnancy; and 2) recently delivered women who attended at least 1 
ANC at the sampled health center or associated health post and who have children <6 months of age, as 
this sample provides the best opportunity to assess the primary outcome related to intervention 
exposure throughout pregnancy (i.e., IFA consumption). Sample sizes were estimated based on current 
known prevalence of the primary outcomes among women who attended ANC, the expected change 
after intervention, power to detect those differences (80%), and level of significance (α=0.05) As the 
intervention was randomized at the cluster level (30 clusters) rather than the individual level, cluster 
effects were considered for sample size calculations.  
For the sample size for pregnant women, we used the number of food groups from the A&T Phase 1 
endline survey for SNNPR (mean: 3.04, SD: 1.39, categorized as 9 food groups; Arimond et al., 2010), 
assuming an intra-cluster correlation (ICC) of 0.21. We calculated that a sample of 270 pregnant women 
per group will be able to detect a minimum of 0.75 food group consumption increase. Using baseline 
data, we observed a mean food group consumption of 3.50 (SD: 1.49) out of 10 food groups. Assuming 
an ICC of 0.096, we estimated that this sample size will detect a minimum difference of 0.61 food 
groups. 
For the sample size for recently delivered women, we used the number of IFA tablets consumed from 
the DHS 2016 data for SNNPR (mean: 33.19, SD: 30.36), assuming an ICC of 0.15. We calculated that a 
sample of 945 recently delivered women per group will be able to detect a difference of 13 tablets 
consumed. For the proportion of women who consumed 90+ IFA tablets, we calculated that a sample of 
450 recently delivered women will be able to detect a minimum of 15% increase in women consuming 
90+ IFA tablets. At baseline, an error in the final Computer-Assisted Personal Interviews (CAPI) form for 
recently delivered women led to missing data values for the outcome variable on total IFA tablets 
consumed. We instead used the percentage of recently delivered women at baseline who ever 
consumed IFA tablets (84.3 %) and assumed an ICC of 0.150. We estimate that the sample size will 
detect a 12.3% increase in women who ever consumed IFA tablets. If husbands of recently delivered 
women are present at the time of the endline survey, they will also be interviewed briefly about their 
exposure to interventions, health and nutrition knowledge and any support provided during pregnancy. 

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Nurse-midwives and HEWs providing ANC in the study areas will also be included in both baseline and 
endline surveys. Three kebeles/health posts (where HEWs fall under the supervision of corresponding 
health centers) will be sampled per health center catchment area. Government guidelines advise that 
pregnant women should receive their first and last ANC visits at the health center, and other ANC visits 
may be provided at health posts. Direct observations of ANC visits (two per health center and one per 
health post) to assess service quality, followed by exit interviews to assess client satisfaction, will be 
conducted at endline among a subgroup of pregnant women attending ANC at the time of the survey. 
At baseline, a light data collection at all facility levels (health centers and health posts) and subsamples 
of pregnant and recently delivered women will be conducted to assess comparability between study 
arms. At endline, the full samples of pregnant and recently delivered women will be surveyed.  
Thus, the overall study samples sizes are presented in Table 3. 
Table 3. Sample sizes  
 
Baseline 2019 
Endline 2020 
 
Intervention 
Control 
Intervention 
Control 
Pregnant women 
90 
90 
270 
270 
Recently delivered women/Husbands  
180 
180 
945 
945 
Nurse-midwives (1 per health center) 
15 
15 
15 
15 
HEW (1 per health post) 
45 
45 
45 
45 
Facility assessments (1 per health center/post) 
60 
60 
60 
60 
ANC observation and exit interview (2 per 
health center, 1 per health post) 
0 
0 
75 
75 
Total (excluding facility assessment)  
330 
330 
1,350 
1,350 
 
2.7 Recruitment 
Health center and health post registries will be reviewed to identify eligible pregnant and recently 
delivered women from the selected study areas for the interview. We will select 3 kebeles per cluster 
(health center catchment area) to recruit 2 pregnant women per kebele at baseline (6 at endline) and 4 
recently delivered women from each kebele at baseline (21 at endline) (to balance achieving a 
geographical spread across the cluster with logistical feasibility). Program monitoring data indicate that 
achieving the sufficient endline sample sizes of pregnant and recently delivered women from 3 kebeles 
per cluster may be difficult. If the required sample sizes cannot be reached from the 3 kebeles alone, 10 
recently delivered women will be sampled from each kebele and 33 will be sampled from each health 
center catchment area and any additional pregnant women needed to reach the sample size can be 
taken from the health center catchment area. Pregnant women will be asked whether they currently 
attend ANC at the selected government health center and/or health post. Recently delivered women 
will be asked whether they attended any ANC at the selected government health center and/or health 
post during pregnancy. From the two separate lists (for pregnant women and for recently delivered 
women), women will be randomly selected by simple random sampling until the required sample sizes 
are reached.  

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III. 
Methods: Assignment of Interventions 
3.1 Allocation  
A cluster is defined as the health center catchment area. Four woredas in SNNPR (with 18 health centers 
and 2 hospitals) and two woredas in Somali region (with 10 health centers) were selected as 
intervention areas (see Figure 3). The samples across the two regions will be pooled to estimate effects 
at program level. We will use stratified randomization to try to balance potential co-interventions and 
confounders. Where there are odd numbers of health centers within woredas, the remaining health 
centers will be randomized within the same region. Then, 15 clusters will be allocated to the 
intervention arm and 15 clusters will be allocated to the control arm by use of computer generated 
pseudo-random numbers.  
3.2 Blinding (masking)   
This evaluation study will be unblinded. Women in the intervention areas will not be informed about the 
results of the randomization. However, there will be no blinding of the interventions at the level of 
service delivery.  
 
 

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Figure 3. Trial flow 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: HC: health center. The baseline and endline surveys will include cross-sectional interviews of pregnant and recently 
delivered women, as well as providers of ANC services at government health facilities.  
 
IV. 
Methods: Data Collection, Management and Analysis 
4.1 Data collection methods 
Data will be collected at the health facility and household levels, using pretested questionnaires. The 
following set of tools will be translated from English to Amharic and used during the baseline and 
endline surveys: 
i. 
Health facility observation checklist 
ii. 
ANC observation checklist and exit interview 
iii. 
Nurse-midwife questionnaire 
iv. 
Health Extension Worker (HEW) questionnaire 
2019 Baseline: Household and health facility-level surveys 
15 HC catchment areas 
A&T intervention areas 
Intensified maternal nutrition 
interventions integrated in ANC 
15 HC catchment areas 
Comparison areas 
Standard services provided 
through ANC  
2021 Endline: Household and health facility-level surveys 
Comparison between program groups 
Randomization 
20 HC catchment areas in SNNPR 
10 HC catchment areas in Somali 

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v. 
Pregnant women questionnaire 
vi. 
Recently delivered women/Husband questionnaire 
Topics included in each of the data collection methods and sample sizes are presented in Table 4. 
Table 4. Data collection methods and samples 
Data collection method 
Topics included 
Health facility observation 
checklist 
Condition of the facility infrastructure, service readiness, services 
provided by the facility, human resources, and ANC monitoring 
system 
ANC observation checklist 
and exit interview 
Direct observation checklist of ANC session to document services 
provided, perceptions of counseling received, and patient satisfaction 
Nurse-midwife questionnaire 
Nurse-midwife’s responsibilities, time commitments and workload, 
capacity, knowledge, motivation, supervision, and ANC service 
provision at the health center 
Health extension worker 
(HEW) questionnaire 
HEW’s responsibilities, time commitments and workload, capacity, 
knowledge, motivation, supervision, and ANC service provision at the 
health post 
Pregnant women 
questionnaire 
Household composition, household socioeconomic status, obstetric 
history, use of ANC, exposure to ANC, maternal nutrition and 
breastfeeding knowledge, household food security, social desirability, 
decision-making power, and mental health  
Recently delivered 
women/Husband 
questionnaire 
Household composition, household socioeconomic status, obstetric 
history, use of ANC, exposure to ANC, maternal nutrition and 
breastfeeding knowledge and practices, pregnancy and postnatal 
care, household food security, social desirability, decision-making 
power, mental health, anthropometry, husband’s health and 
nutrition knowledge, and husband’s perceptions of maternal 
nutrition and roles of husbands and other family members during 
pregnancy 
 
4.1.1 Health facility observation checklist 
A facility observation checklist will be included to obtain information on the presence and condition of 
infrastructure, facility and staff characteristics, ANC equipment and services, patient caseload and 
monitoring of ANC patients. Checklists will be the same for health centers and health posts. 
Table 5. Description of topics to be included in the health facility observation checklist 
Module 
Topic 
Description 
Respondent 
1 
Facility identification 
Location, type of facility 
Enumerator (direct 
observation) 
2 
Infrastructure 
Building amenities and condition 
Enumerator (direct 
observation) 
3 
Facility and staff 
characteristics 
Hours of operation, type and number 
of staff 
Enumerator (direct 
observation) 
4 
ANC equipment and 
materials 
Availability of functioning ANC 
equipment and counseling materials 
Enumerator (direct 
observation) 

17 
5 
ANC services provided 
Services provided in-facility, IFA stocks 
and records 
Enumerator 
(registers, inquire 
with health worker) 
6 
Patient caseload 
Health facility catchment population, 
caseload for ANC, referrals, and 
counselling 
Enumerator 
(registers, inquire 
with health worker) 
7 
Monitoring system 
Monitoring and tracking of ANC 
clients, and records of ANC services, 
community activities, training, and 
supervision 
Enumerator 
(registers, inquire 
with health worker) 
 
4.1.2 ANC observation checklist and exit interview with pregnant women 
Direct observation of ANC sessions will be conducted by the enumerators to document the ANC process. 
In addition, post-observation exit interviews with pregnant women will be conducted immediately after 
observation to assess their satisfaction regarding the services received. 
Table 6: Description of modules in the ANC observation checklist and exit interview  
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, type of facility, and type of 
service provider 
Enumerator (direct 
observation) 
2 
Identification 
Pregnant woman’s name, birthdate, 
age, and antenatal care visit number 
Enumerator (direct 
observation or 
pregnant woman) 
3 
Observation of 
antenatal care session 
Provision and coverage of services 
such as medical history, danger signs 
of current pregnancy, physical 
examination, routine tests, IFA and 
other prophylaxis, and 
counseling/advice about nutrition 
Enumerator (direct 
observation) 
4 
Exit interview 
Services and messages received from 
the provider, and satisfaction with 
services received 
Pregnant woman 
 
4.1.3 Nurse-midwife questionnaire  
Interviews with nurse-midwives who provide ANC services at health centers will be conducted at 
baseline and endline and will gather information on workload and time commitments, ANC service 
provision, knowledge of maternal nutrition and optimal breastfeeding practices, exposure to nutrition 
training, and supervision. 
Table 7. Description of modules in the nurse-midwife questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, health center 
Enumerator 
2 
Demographic 
characteristics 
Age, education, years of experience 
and other characteristics of the nurse-
midwife 
Nurse-midwife 

18 
3 
Time commitments 
and workload 
Workload of the nurse-midwife, 
including responsibilities, time 
commitments, number of 
consultations and patients, monitoring 
and tracking of ANC clients, and 
records of ANC services provided 
Nurse-midwife 
4 
Nutrition counseling 
information 
Topics/messages provided as part of 
nutrition counseling during ANC 
Nurse-midwife 
5 
Maternal health and 
nutrition knowledge 
General knowledge on health and 
nutrition, nutrition during pregnancy, 
anemia, and IFA supplementation 
Nurse-midwife 
6 
Breastfeeding and 
child feeding 
knowledge 
Knowledge of the importance of early 
initiation of breastfeeding and 
exclusive breastfeeding 
Nurse-midwife 
7 
Training exposure 
Exposure to and training received on 
maternal nutrition 
Nurse-midwife 
8 
Supervision and 
contact with other 
health workers 
Frequency and content of supervision 
received from superiors, and contact 
with other health workers 
Nurse-midwife 
 
4.1.4 Health Extension Worker (HEW) questionnaire 
Interviews with HEWs who provide ANC services at health posts will be conducted at baseline and 
endline and will gather information on workload and time commitments, ANC service provision, 
knowledge of maternal nutrition and optimal breastfeeding practices, exposure to nutrition training, 
and supervision. 
Table 8. Description of modules in the HEW questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, health post 
Enumerator 
2 
Demographic 
characteristics 
Age, education, years of experience 
and other characteristics of the HEW 
HEW 
3 
Time commitments 
and workload 
Workload of the HEW, including 
responsibilities, time commitments, 
number of consultations and patients, 
and records of ANC services and 
community activities provided 
HEW 
4 
Nutrition counseling 
information  
Topics/messages provided as part of 
nutrition counseling during ANC 
HEW 
5 
Health and nutrition 
knowledge 
General knowledge on health and 
nutrition, WASH, nutrition during 
pregnancy, anemia, and IFA 
supplementation 
HEW 
6 
Breastfeeding and 
child feeding 
knowledge 
Knowledge of the importance of early 
initiation of breastfeeding and 
exclusive breastfeeding 
HEW 

19 
7 
Training exposure 
Exposure to and training received on 
maternal nutrition 
HEW 
8 
 
 
Supervision and 
contact with other 
actors 
Frequency and content of supervision 
received from superiors, and contact 
with other actors (e.g. kebele leaders) 
HEW 
Note: At baseline, the HEW interview for the Maternal Nutrition study will be conducted at the same time as the 
HEW interview for the Alive & Thrive Ethiopia 3.0 Adolescent Nutrition study. There is one questionnaire for both 
studies, therefore only the modules relevant to the Maternal Nutrition study are included above. 
 
4.1.5 Pregnant women questionnaire 
Detailed interviews with pregnant women will be conducted in their homes at baseline and endline. 
Information on household composition, household socioeconomic status, household food security, 
dietary diversity, obstetric history, maternal nutrition and breastfeeding knowledge, use of ANC, IFA 
consumption, social desirability, women’s decision-making power, and mental health will be collected. 
Table 9. Description of modules in the pregnant women’s questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, household 
Enumerator 
2 
Household roster 
Information on the composition of the 
household, including designation of 
the head of household, a list of all 
household members, their ages and 
sex, and their relationship to the 
pregnant woman, and the highest 
educational level attained and 
activity/employment in the past 
month of all household members at 
least 15 years of age 
Pregnant woman 
3 
Obstetric history 
Marriage, pregnancy, and childbirth 
history 
Pregnant woman 
4 
Use of antenatal care 
(facility-based) 
Frequency, location, provider, and 
timing of ANC use; services/messages 
received during ANC 
Pregnant woman 
5 
Exposure to maternal 
nutrition information 
interventions in the 
community 
Frequency and exposure to maternal 
nutrition information during home 
visits, pregnant women’s 
conferences/meetings, and other 
community meetings or gatherings 
Pregnant woman 
6 
Consumption of IFA 
supplements 
Current consumption of IFA tablets, 
receipt/purchase of IFA tablets, 
tracking of IFA consumption, 
observation of tablets/strips/bottles of 
IFA 
Pregnant woman 
7 
Dietary diversity  
Dietary diversity of the pregnant 
woman and household in the past 24 
hours 
Pregnant woman 

20 
8 
Maternal health and 
nutrition knowledge 
and perceptions 
General knowledge on health and 
nutrition, WASH, nutrition during 
pregnancy, anemia, and IFA 
supplementation, early initiation and 
exclusive breastfeeding 
Pregnant woman 
9 
Food security 
Prevalence of household hunger using 
the FANTA household food insecurity 
access scale (HFIAS) 
Pregnant woman 
10 
Dwelling 
House construction (materials used for 
floor, walls, and roof), availability of 
water and electricity, sources of 
fuel/energy for cooking, WASH 
facilities 
Pregnant woman 
11 
Assets 
Ownership of durable household 
goods (in working condition), including 
tools for agricultural production 
Pregnant woman 
12 
Social desirability  
Desire for social approval 
Pregnant woman 
13 
Women’s role and 
decision-making 
power 
Perceptions on women’s role in the 
household, ownership of productive 
assets and decision-making power   
Pregnant woman 
14 
Mental health 
Mental health status over the past 
month 
Pregnant woman 
 
4.1.6 Recently delivered women and husband questionnaire 
Detailed interviews with recently delivered women will be conducted in their homes at baseline and 
endline. Information on household composition, household socioeconomic status, household food 
security, dietary diversity, obstetric history, maternal nutrition and breastfeeding knowledge, use of ANC 
and postnatal services, IFA consumption during pregnancy, breastfeeding and child feeding practices, 
social desirability, women’s decision-making power, mental health, postnatal functional disability and 
anthropometry will be collected. If husbands of recently delivered women are present at the time of the 
endline survey, they will also be interviewed briefly about their health and nutrition knowledge and any 
support provided during pregnancy. 
Table 10. Description of modules in the recently delivered women’s questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, household 
Enumerator 
2 
Household roster 
Information on the composition of the 
household, including designation of 
the head of household, a list of all 
household members, their ages and 
sex, and their relationship to the 
pregnant woman, and the highest 
educational level attained and 
activity/employment in the past 12 
months of all household members at 
least 15 years of age 
Recently delivered 
woman 

21 
3 
Obstetric history 
Marriage, pregnancy, and childbirth 
history 
Recently delivered 
woman 
4 
Use of ANC and 
postnatal care (PNC) 
services 
Frequency, location, provider and 
timing of ANC/PNC use, 
services/messages received during 
ANC/PNC 
Recently delivered 
woman 
5 
Exposure to maternal 
nutrition interventions 
in the community 
Frequency and exposure to maternal 
nutrition information during home 
visits, pregnant women’s 
conferences/meetings, and other 
community meetings or gatherings 
Recently delivered 
woman 
6 
Consumption of IFA 
supplements 
Consumption of IFA tablets during 
pregnancy, receipt/purchase of IFA 
tablets, tracking of IFA consumption  
Recently delivered 
woman 
7 
Dietary diversity  
Dietary diversity of the pregnant 
woman and household in the past 24 
hours 
Recently delivered 
woman 
8 
Breastfeeding and 
child feeding practices 
Early initiation and exclusive 
breastfeeding practices 
Recently delivered 
woman 
9 
Maternal health and 
nutrition knowledge 
and perceptions 
General knowledge and perceptions 
on health and nutrition, WASH, 
nutrition during pregnancy, anemia, 
and IFA supplementation 
Recently delivered 
woman 
10 
Breastfeeding and 
child feeding 
knowledge 
Knowledge, beliefs and attitudes 
toward early initiation of 
breastfeeding, exclusive breastfeeding, 
and continued breastfeeding 
Recently delivered 
woman 
11 
Food security 
Prevalence of household hunger using 
the FANTA household food insecurity 
access scale (HFIAS) 
Recently delivered 
woman 
12 
Dwelling 
House construction (materials used for 
floor, walls, and roof), availability of 
water and electricity, sources of 
fuel/energy for cooking, WASH 
facilities 
Recently delivered 
woman 
13 
Assets 
Ownership of durable household 
goods (in working condition), including 
tools for agricultural production 
Recently delivered 
woman 
14 
Social desirability  
Desire for social approval 
Recently delivered 
woman 
15 
Women’s role and 
decision-making 
power 
Perceptions on women’s role in the 
household, ownership of productive 
assets and decision-making power  
Recently delivered 
woman 
16 
Mental health 
Mental health status over the past 
month 
Recently delivered 
woman 
17 
Postnatal functional 
disability 
Ability to perform physical tasks and 
activities following birth 
Recently delivered 
woman 

22 
18 
Anthropometry 
Weight and height measurements of 
recently delivered woman and index 
child <6 months of age 
Recently delivered 
woman 
19 
Husband’s support 
during pregnancy  
Support provided during pregnancy 
Husband 
20 
Husband’s exposure 
to maternal nutrition 
information 
Exposure to maternal nutrition 
messages and method of receipt 
Husband 
21 
Husband’s knowledge 
about maternal 
nutrition  
General knowledge on health and 
nutrition, WASH, nutrition during 
pregnancy, anemia, and IFA 
supplementation 
Husband 
22 
Husband’s 
perceptions about 
maternal nutrition 
Husband’s perceptions on maternal 
nutrition and roles of husbands and 
other family members 
Husband  
 
4.2 COVID-19 precautionary measures 
Since early 2020, close-range contacts between enumerators and study participants during data 
collection activities present a particular risk for spreading COVID-19 in communities with vulnerable 
populations. The collaborating survey firm, Addis Continental Institute of Public Health (ACIPH), has 
developed formal fieldwork guidelines based on directives for the prevention and control of the COVID-
19 pandemic by the Ministry of Health (MOH) and Ethiopian Public Health Institute, and UNICEF 
recommendations for surveilling and monitoring nutrition in the context of COVID-19. As part of the 
guidelines, all enumerators and study participants will wear masks (provided to them) and wash or 
sanitize their hands before and after each interview. Interviews will be conducted outside or in a well-
ventilated space and enumerators will maintain two meters of distance from the interviewee and other 
household members. Measuring boards and scales will be sanitized after every anthropometric 
measurement. Any study staff with COVID-19-related symptoms (fever, dry cough, extreme fatigue, 
respiratory problems, or any unusual illness) will be immediately excluded from fieldwork and remain 
isolated as per MOH guidelines. Any study participants with COVID-19-related symptoms will be 
excluded from the study and advised to remain isolated and seek appropriate services according to 
MOH and any local guidelines.  
Before enumerator training begins, all study staff will be tested for COVID-19. Any individual who tests 
positive will be advised to isolate and seek appropriate health services as described above. Study staff 
will also be assessed for COVID-19-related symptoms before each day of enumerator training begins. 
While in the field, field supervisors will assess enumerators each day before starting data collection 
using a COVID-19 symptom monitoring chart. In addition, Co- and Principal Investigators of the project 
will be in daily contact with ACIPH and in-country partners during data collection to assess the changing 
risks and government measures. 
4.3 Data management 
A secure data file structure will be established in an IFPRI-server-based Dropbox Professional folder for 
use by the IFPRI research team and potential collaborators. Original, sensitive (non-anonymized) data 
files and documents will be stored in a folder with access restricted to senior IFPRI researchers. A do file 

23 
will be written to anonymize survey data files and export the anonymized data to a shared Dropbox 
folder for data cleaning and analysis by research support staff and other project team members. 
All changes to the raw data output files from the CAPI software will be recorded. Formatting, reshaping, 
and labeling of data will be documented using detailed and well-annotated do files. 
4.4 Statistical methods 
Data analysis will use econometric analysis to control for (any) differences at baseline and between 
intervention and comparison groups for all relevant variables of interest. Statistical testing for 
differences between the two groups will be done using a random effects regression, accounting for the 
clustering of errors within and across health center catchment areas. 
The randomized study design allows for the identification of causal effects of the maternal nutrition 
intervention through comparisons of mean outcomes between the treatment and control groups. Key 
indicators will include dietary diversity (among pregnant women), IFA consumption, weight gain 
monitoring, and breastfeeding practices (early initiation and exclusive breastfeeding). Impacts will be 
assessed using “difference-in-difference” (DID) estimation and/or analysis of covariance (ANCOVA) 
controlling for covariates. Data management, data cleaning and statistical analyses will be conducted 
using Stata version 16 (Statacorp, USA). The statistical significance for tests will be set at 5% for main 
effects or 10% in case of interactions. All statistical tests will be one-sided. 
V. 
Methods: Monitoring 
5.1 Data monitoring 
Data collection (including observational, women, and health worker data collection) will be undertaken 
using electronic tablets. Checks will be built into the CAPI software and applied at the time of data entry. 
These will include logic checks, valid values, skip patterns, and range checks among others to ensure 
efficiency and high data quality. In addition, enumerator monitoring will be incorporated into the CAPI 
software including recording the duration of interviews and GPS location of enumerators during data 
collection. 
Field supervisors, project manager, and principal and co-principal investigators of the survey firm and 
IFPRI will closely monitor enumerators and the quality of data collected to ensure the integrity of the 
data during data collection. 
5.2 Harms 
Given that the nutrition interventions during ANC are provided according to government guidelines for 
standard health service, we do not anticipate any harms from the study. Any adverse events or 
unintended effects during provision of ANC will be handled according to standard care practices.  
5.3 Auditing 
Not applicable.  

24 
VI. 
Ethics and Dissemination 
6.1 Research ethics approval 
This protocol, informed consent forms, and study questionnaires will be submitted for ethical clearance 
from the Institutional Review Boards (IRB) of FHI 360 and the International Food Policy Research 
Institute in Washington, DC. In Ethiopia, ethical clearance will be sought from the ACIPH IRB. 
A COVID-19 country risk assessment system was developed by IFPRI to help researchers and IFPRI’s IRB 
assess COVID-19 risk in countries where fieldwork is planned. In function of the level of COVID-19 risk 
identified in country, data collection methods will be adapted to minimize the transmission risk of 
COVID-19. Justification for resuming fieldwork with in-person contacts will be provided and accepted by 
the IRB.  
6.2 Protocol amendments 
All amendments to the protocol will be reported (by IFPRI Co-Principal Investigators and ACIPH Co-
Investigator) to and agreed upon with Alive & Thrive. Substantive changes to the protocol that may 
impact the safety of participants or the scientific validity, scope, or ethical rigor of the study will be 
reviewed by the IFPRI IRB.  
Version control using protocol version identifiers and dates will be used to track the history of 
amendments and identify the most recent protocol version. 
6.3 Consent or assent 
After explaining the study’s objectives and procedures, enumerators will seek and obtain written 
informed consent from eligible study participants. Participation in the study is completely voluntary. 
Participants are free to withdraw at any time by informing survey or program staff. 
All COVID-19 transmission risks to study participants (including close contact required for taking 
anthropometric measurements) and the precautionary measures that will be followed during data 
collection to limit the risk of transmission will be included in the informed consent. 
6.4 Confidentiality 
Immediately after data collection, all data will be uploaded and stored securely in an IFPRI-server-based 
Dropbox Professional folder. To protect respondent confidentiality, only senior IFPRI researchers will 
have access to data and documents containing personally identifiable information. Research support 
staff and other project team members will have access to depersonalized data—located in a separate 
IFPRI-server-based Dropbox Professional folder—where direct identifiers have been replaced by 
randomly generated numeric IDs. 
Data that is made publicly available will be carefully screened to remove any indirect and geographic 
identifiers which may breach the confidentiality of respondents. 
6.5 Declaration of interests 
The authors declare that they have no competing interests. 

25 
6.6 Access to data 
All Co- and Principal Investigators of the project (based in the US and in Ethiopia) will have full access to 
the cleaned data. Other project team members will have access to data that has had all personally 
identifiable information removed. 
In compliance with donor (Bill & Melinda Gates Foundation) open access policy requirements, fully 
anonymized datasets will be made publicly available one year after the end of the project. Metadata and 
other documentation of data collection procedures (such as the codebook, data collection instruments 
and interviewer guides/protocols) will also be made publicly available. 
6.7 Ancillary and post-trial care 
Not applicable. 
6.8 Dissemination policy 
Close engagement with the government of Ethiopia is of primary importance to the project. The A&T 
Ethiopia team will be working in close partnership with government entities on strengthening maternal 
health systems at the national and regional levels throughout the duration of the project. Findings will 
be disseminated through in-country events, presentations, and conferences.  
Within the research community, we aim to have the research peer-reviewed and published in high 
quality journals. Preliminary research findings may be presented at international conferences and 
internal IFPRI seminars. 

26 
VII. Timeline 
7.1 Study timeline 
Deliverables/Activities 
2019 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec  
1. Study protocol  
 
 
 
 
 
 
 
 
 
 
 
 
Discuss study design with A&T 
x 
x 
x 
 
 
 
 
 
 
 
 
 
Prepare study protocol 
 
 
x 
x 
x 
x 
 
 
 
 
 
 
2. Baseline data collection tools 
 
 
 
 
 
 
 
 
 
 
 
 
Develop questionnaires/data collection tools 
 
 
 
x 
x 
x 
 
 
 
 
 
 
Select and contract survey firm 
 
 
 
 
x 
x 
 
 
 
 
 
 
Translate questionnaire 
 
 
 
 
 
 
x 
 
 
 
 
 
Program CAPI questionnaire 
 
 
 
 
 
 
x 
x 
 
 
 
 
3. Local and US-based IRB approvals 
 
 
 
 
 
 
 
 
 
 
 
 
IRB application at IFPRI 
 
 
 
 
 
 
 
x 
 
 
 
 
IRB application in Ethiopia 
 
 
 
 
 
 
x 
 
 
 
 
 
4. Baseline survey implementation 
 
 
 
 
 
 
 
 
 
 
 
 
Pretest, revise and finalize questionnaire 
 
 
 
 
 
 
 
x 
 
 
 
 
Enumerator training 
 
 
 
 
 
 
 
 
x 
 
 
 
Data collection 
 
 
 
 
 
 
 
 
 
x 
x 
 
5. Data cleaning and analyses 
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
 
 
 
 
x 
x 
Data analyses 
 
 
 
 
 
 
 
 
 
 
 
x 
 
Deliverables/Activities 
2020 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec  
Data analyses 
x 
x 
 
 
 
 
 
 
 
 
 
 
6. Baseline results tables and datasets 
 
 
 
 
 
 
 
 
 
 
 
 
Draft and finalize baseline results 
 
 
x 
x 
x 
x 
 
 
 
 
 
 
Prepare clean datasets 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 

27 
Deliverables/Activities 
2021 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec  
7. Endline data collection tools 
 
 
 
 
 
 
 
 
 
 
 
 
Develop questionnaires/data collection tools 
 
 
 
x 
x 
 
 
 
 
 
 
 
Translate questionnaire 
 
 
 
 
 
x 
 
 
 
 
 
 
Program CAPI questionnaire 
 
 
 
 
 
x 
x 
 
 
 
 
 
8. Local and US-based IRB approvals 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain IFPRI IRB approvals to conduct fieldwork 
 
 
 
 
 
 
x 
 
 
 
 
 
Obtain local IRB approvals to conduct fieldwork 
 
 
 
 
 
 
x 
 
 
 
 
 
8. Endline survey implementation  
 
 
 
 
 
 
 
 
 
 
 
 
Pretest, revise and finalize questionnaire 
 
 
 
 
 
 
x 
 
 
 
 
 
Enumerator training 
 
 
 
 
 
 
x 
 
 
 
 
 
Data collection 
 
 
 
 
 
 
x 
x 
x 
 
 
 
9. Data cleaning and analysis 
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
 
 
x 
x 
 
 
Data analyses 
 
 
 
 
 
 
 
 
 
x 
x 
x 
10. Endline results tables and datasets 
 
 
 
 
 
 
 
 
 
 
 
 
Draft endline results 
 
 
 
 
 
 
 
 
 
 
x 
x 
Finalize endline report and findings 
 
 
 
 
 
 
 
 
 
 
 
 
Prepare clean datasets  
 
 
 
 
 
 
 
 
 
 
 
 
 
Deliverables/Activities 
2022 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec  
9. Data cleaning and analysis 
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
 
 
 
 
 
 
Data analyses 
x 
x 
 
 
 
 
 
 
 
 
 
 
10. Endline results tables and datasets 
 
 
 
 
 
 
 
 
 
 
 
 
Draft endline results 
 
 
 
 
 
 
 
 
 
 
 
 
Finalize endline report and findings 
x 
x 
x 
 
 
 
 
 
 
 
 
 
Prepare clean datasets  
 
 
 
x 
 
 
 
 
 
 
 
 

28 
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