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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]

In Nepal, India, Bangladesh and Pakistan, policy focused on improving access to maternity services has led to measures to reduce cost barriers impeding women's access to care. Specifically, these include cash transfer or voucher schemes designed to stimulate demand for services, including antenatal, delivery and post-partum care. In spite of their popularity, however, little is known about the impact or effectiveness of these schemes. This paper provides an overview of five major interventions: the Aama (Mothers') Programme (cash transfer element) in Nepal; the Janani Suraksha Yojana (Safe Motherhood Scheme) in India; the Chiranjeevi Yojana (Scheme for Long Life) in India; the Maternal Health Voucher Scheme in Bangladesh and the Sehat (Health) Voucher Scheme in Pakistan. It reviews the aims, rationale, implementation challenges, known outcomes, potential and limitations of each scheme based on current available data. Increased use of maternal health services has been reported since the schemes began, though evidence of improvements in maternal health outcomes has not been established due to a lack of controlled studies. Areas for improvement in these schemes, identified in this review, include the need for more efficient operational management, clear guidelines, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity. Au Népal, en Inde, au Bangladesh et au Pakistan, la politique centrée sur l'élargissement de l'accès aux services de maternité a débouché sur des mesures de réduction des obstacles financiers qui empêchent les femmes d'avoir accès aux soins, plus précisément des transferts de fonds ou des chèques conçus pour stimuler la demande, notamment de soins prénatals, obstétricaux et du post-partum. Pourtant, en dépit de leur popularité, on sait peu de choses de l'impact de ces programmes. L'article décrit cinq interventions majeures : le programme Aama (des mères) (élément de transfert de fonds) au Népal, le Janani Suraksha Yojana (plan de maternité sans risque) en Inde, le Chiranjeevi Yojana (plan pour une longue vie) en Inde, le projet de chèques de santé maternelle au Bangladesh et le système de chèques Sehat (santé) au Pakistan. Il examine les objectifs, les justificatifs, les obstacles à l'application, les résultats connus, le potentiel et les limites de chaque projet, avec les données disponibles. Un recours accru aux services de santé maternelle a été enregistré depuis le début des projets, mais sans qu'il soit possible de déterminer les améliorations de la santé maternelle, faute d'études contrôlées. L'étude recense les domaines d'amélioration des projets qui ont besoin d'une gestion opérationnelle plus efficace, de directives claires, de transparence financière, de plans de viabilité, de preuves d'équité et, surtout, de confirmer leur impact sur la qualité des soins, et la mortalité et morbidité maternelles. En Nepal, India, Bangladesh y Pakistán, debido a políticas centradas en mejorar el acceso a los servicios de maternidad, se ha intentado reducir las barreras de costo que impiden el acceso de las mujeres a los servicios: específicamente, transferencias de dinero o programas de cupones diseñados para estimular la demanda de los servicios, incluida la atención antes, durante y después del parto. Pese a su popularidad, no se sabe mucho acerca de su impacto o eficacia. En este artículo se resumen cinco intervenciones importantes: el Programa de Madres (transferencias de dinero) en Nepal; el Plan por una Maternidad sin Riesgos y el Plan por una Vida Larga, ambos en India; el Programa de Cupones para Servicios de Salud Materna en Bangladesh; y el Programa de Cupones para servicios de salud, en Pakistán. Se analizan los objetivos, la justificación y los retos de la implementación, los resultados, el potencial y las limitaciones de cada plan según los datos. Desde el inicio de estos planes, ha aumentado el uso de los servicios de salud materna, aunque por falta de estudios controlados no hay evidencia de mejoras en los resultados. Entre las áreas a mejorar figuran: la eficiencia de la administración operativa, directrices claras, transparencia financiera, planes de sostenibilidad, evidencia de equidad y, sobre todo, un impacto comprobado en la calidad de la atención y en las tasas de mortalidad y morbilidad maternas. [ABSTRACT FROM AUTHOR]

Background: While community capabilities are recognized as important factors in developing resilient health systems and communities, appropriate metrics for these have not yet been developed. Furthermore, the role of community capabilities on access to maternal health services has been underexplored. In this paper, we summarize the development of a community capability score based on the Future Health System (FHS) project's experience in Bangladesh, India, and Uganda, and, examine the role of community capabilities as determinants of institutional delivery in these three contexts.Methods: We developed a community capability score using a pooled dataset containing cross-sectional household survey data from Bangladesh, India, and Uganda. Our main outcome of interest was whether the woman delivered in an institution. Our predictor variables included the community capability score, as well as a series of previously identified determinants of maternal health. We calculate both population-averaged effects (using GEE logistic regression), as well as sub-national level effects (using a mixed effects model).Results: Our final sample for analysis included 2775 women, of which 1238 were from Bangladesh, 1199 from India, and 338 from Uganda. We found that individual-level determinants of institutional deliveries, such as maternal education, parity, and ante-natal care access were significant in our analysis and had a strong impact on a woman's odds of delivering in an institution. We also found that, in addition to individual-level determinants, greater community capability was significantly associated with higher odds of institutional delivery. For every additional capability, the odds of institutional delivery would increase by up to almost 6 %.Conclusion: Individual-level characteristics are strong determinants of whether a woman delivered in an institution. However, we found that community capability also plays an important role, and should be taken into account when designing programs and interventions to support institutional deliveries. Consideration of individual factors and the capabilities of the communities in which people live would contribute to the vision of supporting people-centered approaches to health. [ABSTRACT FROM AUTHOR]