Assessing the Feasibility of Integrating a Package of Maternal Nutrition Interventions Into Antenatal Care Services in Burkina Faso
Condition: Maternal Dietary Diversity; Iron-Folic Acid Supplementation; Early Initiation of Breastfeeding
Study type: Interventional

Summary: 
      Alive & Thrive (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 Burkina
      Faso, A&T developed an intensive package of maternal nutrition interventions to be integrated
      into existing ANC services delivered through government health facilities that align with the
      latest global evidence. These included intensified counseling and support on dietary
      diversity and quality during pregnancy, iron-folic acid (IFA) supplements consumption,
      importance of ANC and increasing the number of visits, adequate weight-gain monitoring, and
      early initiation of and exclusive breastfeeding. The evaluation used a two-arm
      cluster-randomized, non-masked trial design, consisting of two cross-sectional surveys of
      pregnant and recently delivered women (i.e. with a child under 6 months of age) in 2019 and
      2021.
    

Detailed description: 
      Routine antenatal care (ANC) offers opportunities to receive a broad range of health
      promotion and prevention services including support for adequate nutritional care for
      pregnant women and their newborns, and any required medical treatment. In 2016, World Health
      Organization (WHO) updated its guidelines on ANC with a high priority placed on nutrition
      interventions. These guidelines also recommended increasing the number of ANC from at least
      four to eight contacts to improve women's positive experience of care and to reduce perinatal
      morbidity and mortality. Following these new recommendations, the government of Burkina Faso
      is working with WHO and other partners to revise the national guidelines on ANC and test
      elements of the essential core package of routine ANC needed by women throughout pregnancy.

      A&T Burkina Faso, developed an intensive package of maternal nutrition interventions to be
      integrated into existing ANC services delivered through government health facilities that
      align with the latest global evidence. These included intensified counseling and support on
      dietary diversity and quality during pregnancy, iron-folic acid (IFA) supplements
      consumption, importance of ANC and increasing the number of visits, adequate weight-gain
      monitoring, and early initiation of and exclusive breastfeeding. IFPRI tested the feasibility
      of the behavior-change interventions and examined their impacts on pregnant women's health
      and nutrition practices and breastfeeding practices of recently delivered women, compared
      with standard antenatal care services provided in control areas.

      The study was designed as a two-arm cluster-randomized, non-masked trial, consisting of two
      cross-sectional surveys at baseline and endline. The unit of randomization was the health and
      social promotion center (CSPS, Centre de Santé et de Promotion Social in French) catchment
      area. 40 CSPS in Boucle du Mouhoun and 40 CSPS in Hauts-Bassins were randomly assigned to
      intervention/control. A baseline cluster/facility-level and household survey took place in
      November-December 2019. Soon after the completion of the baseline survey, the interventions
      were implemented at the CSPS and villages within the intervention areas for approximately 10
      months (less than 1 year, caused by brief service interruptions in March-April 2020 due to
      the COVID-19 pandemic). The endline survey took place in January-March 2021.

      The overall study objective is to evaluate the feasibility of integrating locally relevant
      maternal nutrition interventions into ANC services provided by the government health system
      and their impact on diet quality and quantity and utilization of nutrition interventions
      during pregnancy.

      The implementation research study addresses three research questions:

        1. What are the program impacts on maternal nutrition practices: (1) consumption of
           diversified foods and adequate intake of micronutrient, protein and energy compared to
           recommended intakes; (2) consumption of IFA supplements during pregnancy; and (3) early
           breastfeeding practices?

        2. Can the coverage and utilization of key nutrition interventions (maternal nutrition
           counseling, weight gain monitoring, distribution of and counseling on IFA
           supplementation, and breastfeeding counseling) and number of ANC contacts be improved
           through health system strengthening and nutrition-focused social and behavior change
           communication (SBCC; interpersonal communication and community mobilization) approaches?

        3. What factors influenced integration and strengthening of maternal nutrition
           interventions into the government ANC service delivery platform?
    

Intervention name(s): Health Facility Level Interventions; Community Level Interventions; Health System Level Interventions
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Intensified counseling on maternal dietary diversity and quality using job aids
Counseling on purpose of IFA supplementation, managing side effects, and importance of adherence to daily consumption
Distribution/prescription of IFA tablets at each ANC visit
Use of pill card/reminders for pregnant women and their spouses
Monthly IFA tablet stock monitoring to assure sufficient supplies
Measurement of weight gain during each ANC visit and advise on healthy weight gain
Checks for functioning scales and use of monitoring sheets
Intensified counseling on early initiation of breastfeeding and exclusive breastfeeding using job aids
Reminder on importance of early ANC attendance and 4+ visits; Advocacy among community leaders (traditional and religious leaders, local associations, etc.) about ANC
Gatherings among grandmothers, husbands, and other influencers about ANC and their roles
Promotion of ANC service utilisation and the importance of early ANC visit during the first trimester.
Early identification of pregnant women
Support women's group discussions
2-3 home visits per pregnant woman by community health workers (Agent de santé a base communautaire; ASBC) which will include counseling on diet quality, breastfeeding, importance on adherence to daily IFA consumption and side effect management, etc.; Training on nutrition interventions during ANC for all ANC providers and community health workers
Semi-annual supervision by the Regional Health Directorate (Direction Regionale de la Santé; DRS)
Quarterly supportive supervision of health facility staff by the health district management team
Monthly supportive supervision of ASBCs
Monthly review between health facilities and ASBCs
Training and use of data registers
Training and use of mother's cards to record up to 8 ANC visits and nutrition services
Training on data utilization to improve coverage and quality
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: maternal nutrition; antenatal care; Burkina Faso