Intensified Nutrition Interventions in Antenatal Care Services Increased Consumption of Iron and Folic Acid Supplements and Early Breastfeeding Practices in Burkina Faso: Results of a Cluster-Randomized Program Evaluation

"Strengthening maternal nutrition interventions delivered through government ANC [antenatal care] services was feasible and effective in improving maternal nutrition practices."

In Burkina Faso, Alive & Thrive (A&T) and partners worked to strengthen the provision of iron and folic acid (IFA) supplementation and interpersonal counseling on maternal nutrition and breastfeeding through antenatal care (ANC) services and community-based contacts in 2 regions. This study was conducted to evaluate A&T maternal nutrition interventions in 2 western regions - Boucle du Mouhoun and Hauts-Bassins - by assessing the impacts of intensified nutrition interventions during ANC compared with standard ANC services on intervention coverage and maternal nutrition practices.

A cluster-randomised evaluation compared 40 health centre catchment areas in intervention areas with 40 in control areas. Table 1 in the paper offers a description of A&T services and inputs in intervention compared with control areas. For example, in the area of community mobilisation, control areas received standard Les Agents de Santé à Base Communautaire (ASBC) activities through the government health system (not focused on maternal nutrition), whereas intervention areas received: orientation of community leaders (traditional and religious leaders, local associations, etc.) about ANC and maternal nutrition; ASBC-led meetings with husbands and mothers-in-laws about maternal nutrition and how to support pregnant women; promotion of ANC service utilisation and the importance of early ANC visit during the first trimester by community leaders; and early identification and referral of pregnant women. Major focus was placed on training service providers and reinforcing their skills and materials for counseling.

Repeated cross-sectional surveys in 2019 and 2021 (960 pregnant women and 1,920 women with children 0-5 months of age per survey round) provided data on impact indicators, intervention exposure, and other factors. The researchers derived difference-in-difference (DID) effect estimates, adjusted for geographic clustering, for maternal dietary diversity, IFA consumption, and early breastfeeding practices.

More women in intervention areas had 4+ ANC visits (DID: 8.3 percentage points [pp]) and started ANC during the first trimester (DID: 10.5 pp), compared with control areas. There was a larger impact on community-based contacts during pregnancy, specifically home visits (DID: 29 pp) and community meetings (DID: 24 pp). Improvements were achieved in exposure to nutrition counseling on dietary diversity (DID: 44.4 pp), food quantity (DID: 42.9 pp), adequate weight gain (DID: 35.1 pp), and breastfeeding (DID: 25.9 pp). Women in intervention areas consumed more IFA supplements during pregnancy (DID: 21 tablets). Early initiation of and exclusive breastfeeding also improved (DID: 17.0 and 8.3 pp, respectively).

However, dietary diversity (4 out of 10 food groups) and mean probability of adequacy of micronutrient intake (14%) among pregnant women remained low in both areas. It is plausible that the 1-year duration of interventions was relatively short for changing dietary behaviours in this context; also, over one-third of study households were food insecure, which may have been a barrier to increasing dietary diversity.

In conclusion: "Overall, the results showed the feasibility and effectiveness of integrating a package of intensified nutrition interventions into ANC services delivered through the government health services in Burkina Faso, even within a short implementation period of 1 y during the COVID-19 pandemic. Continued efforts to strengthen the delivery and use of maternal nutrition services may be required for greater behavior changes, as well as to address family support, social norms, food environments, and other factors to improve women's diets during pregnancy."