Inequality in Iron Folic Acid Consumption and Dietary Diversity in Pregnant Women Following Exposure to Maternal Nutrition Interventions in Three Low- and Middle-Income Countries

"Large-scale programs usually focus on improving coverage or usage but do not usually have the objective of reducing inequality....Since inequality is a major hurdle in achieving SDGs [Sustainable Development Goals], the program insight gained from this article will be helpful to programmers..."

The literature on poverty and health equality shows that, although large-scale interventions such as nutrition education and counseling may lead to aggregate improvements in maternal and child health and nutrition coverage and practices, disparities among groups often persist and may even widen. The study described in this paper examines the findings of large-scale maternal nutrition programmes (Alive & Thrive - A&T) through an equality lens. It assessed whether disparities in coverage existed after A&T intervention exposure (2015-2022) and if the disparities were different among three countries: Bangladesh, Burkina Faso, and Ethiopia.

The A&T intervention package (see Related Summaries, below) included iron and folic acid supplementation (IFA) and counseling to improve maternal IFA intake and dietary diversity. These components were delivered through existing antenatal care (ANC) programmes and involved strengthening systems, building community demand, improving the performance of ANC providers and community health workers through training and supervision, and monitoring. Training involved building counseling skills, engaging family members and advocating for re-allocation of household budgets, promoting locally available affordable foods, and mobililising communities. Messages for pregnant women (PW) and their husbands differed: Babies' and mothers' health were the focus for PW, and current and future economic costs and benefits and feasible strategies were the focus for their husbands. No food or cash subsidies were provided. 

The researchers conducted a secondary analysis of data from cross-sectional surveys conducted at baseline and endline by the International Food Policy Research Institute (IFPRI) in Bangladesh, Burkina Faso, and Ethiopia. A three-stage sampling was used in the study regions and districts, and clusters were randomly allocation to intervention and non-intervention areas. The same clusters were sampled at endline.

The researchers calculated changes in inequality in the following four indicators:
 

1. Adequate IFA consumption, which indicates whether recently delivered women (RDW) had consumed IFA for at least 90 days during their most recent pregnancy.
2. The IFA counselling indicator, which measures the total number of messages received on IFA - this number differed across study countries.
3. Dietary diversity, which indicates whether a woman had consumed at least five out of ten defined food groups on the previous day.
4. The binary indicator for counselling on dietary diversity, which indicates whether the PW received information on consuming five varieties of food from a health worker during ANC and/or home visits (also during community meetings in Burkina Faso).

Though wealth and education are often correlated, the researchers opted to analyse both wealth and education inequalities in this study to gain insight into the different country contexts.

The study found that statistically significant reductions in education inequality were observed for adequate IFA consumption, counselling on IFA, and dietary diversity in intervention areas of Bangladesh, and for adequate IFA consumption in intervention areas of Burkina Faso.

While wealth inequality in adequate IFA consumption decreased over time in the intervention areas in all three countries, it increased for counselling on IFA in Bangladesh and Burkina Faso. This finding indicates the need for more targeted studies on barriers to counselling services among the less advantaged PW.

Wealth equality declined significantly at endline in the non-intervention group for counselling on IFA in Ethiopia and dietary diversity in Burkina Faso, but not in the intervention group. This finding may be considered a protective effect of the interventions, as the period between baseline and endline was marked by COVID-19 disruptions in Burkina Faso and Ethiopia.

Though the same package of globally recommended A&T interventions was implemented in all three countries, adapting it to existing health systems and local contexts resulted in variations. This, along with external factors such as disruptions due to COVID-19 and content of some indicators, were likely explanatory factors for the differing results across countries. For example, "pro-poor" characteristics of a longstanding community-based maternal, newborn, and child health MNCH) programme in Bangladesh were transferred to the newly integrated A&T nutrition components; the type of remuneration, competence, experience, and commitment of community workers enabled them to more effectively reach the economically poorest and to motivate behaviour change among PW in Bangladesh.

Also in Bangladesh, additional special forums were organised for husbands of PW through outreach sessions at convenient sites and at times convenient for them. Husbands played a pivotal role in each country in facilitating PW attendance at ANC sessions and in the uptake of PWs' IFA consumption and dietary diversity. Similar forums were not successful in Burkina Faso because the staff found it difficult to identify the right venues to reach husbands of PW consistently with high coverage. In Ethiopia, no special gatherings for husbands were used; instead, home visits were made and other family members present in the household were engaged.

Overall, the study shows that there was no generalised shift towards greater equality in A&T intervention areas, even though the overall prevalence of indicators was higher in intervention areas. Yet, although improving equality was not an explicit objective of the programmes, some maternal nutrition indicators were trending towards lower inequality after exposure to nutrition interventions.

The main takeaways for nutrition programmes are:
 

• Assess equality issues through formative studies during the design phase.
• Monitor inequality indicators during implementation.
• Diligently address inequality through targeted interventions, setting aside resources and motivating frontline workers to reduce disparities.
• Make equality analysis a routine part of impact evaluations.