Opportunities and challenges in delivering maternal and child nutrition services through public primary health care facilities in urban Bangladesh: a qualitative inquiry

BACKGROUND

Public primary health facilities are an important source of nutrition services for the urban areas in Bangladesh. We aimed to understand the challenges and facilitators of delivering maternal and child nutrition services through public sector from the perspectives of the users and service providers.

METHOD

The study was conducted in selected public primary health care facilities and their catchment area in Dhaka city from April-July 2019. We carried out 15 free listing exercises and 43 semi-structured interviews (SSI) with pregnant women and mothers of 0-24 months old children; 6 key informant interviews (KII) with facility managers and healthcare providers; and observed service delivery in 8 health facilities.

RESULTS

Findings reveal that public primary health facilities address some economic and cultural barriers to access such as cost and provision of female service providers for maternal and child health services but challenges such as distance, waiting time, and cleanliness remained. In terms of service provision, there were gaps in provision of anthropometric measurement and counseling, and healthcare providers had inadequate training and therefore, knowledge of nutrition. The low priority given to nutrition services during program design hampered the delivery of nutrition services provided through urban public sector health facilities.

CONCLUSIONS

There were important gaps in terms of service provision and capacity of healthcare providers, and therefore, the quality of nutrition service provided through public primary health care facilities. To maximize the coverage of quality nutrition services in the urban areas, it is important to think through the design of nutrition service delivery and allocate adequate resources to fill the material and capacity gaps.

Strengthening Nutrition Interventions during Antenatal Care Improved Maternal Dietary Diversity and Child Feeding Practices in Urban Bangladesh: Results of a Quasi-Experimental Evaluation Study

BACKGROUND

Bangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services.

OBJECTIVES

We assessed the effect of integrating maternal, infant, and young child nutrition interventions, delivered at urban Maternal Neonatal and Child Health facilities, on maternal dietary diversity, iron and folic acid (IFA) and calcium consumption, and child feeding practices.

METHODS

We used a quasi-experimental design with a nonrandom assignment of 20 health care facilities in Dhaka to intensive and standard service arms. We conducted facility-based observations and community-based surveys at baseline (2020) and endline (2022) (n = 2455 observations and surveys with 1678 pregnant women [PW] or recently delivered women [RDW] at endline). We derived difference-in-difference (DID) estimates, adjusted for characteristics that differed at baseline or endline, and accounted for clustering.

RESULTS

Exposure to antenatal care (ANC) was similar in both arms: two-thirds of RDW received ANC during the first trimester and three-fourths received ≥4 ANC checkups. Compared to the standard arm, a higher proportion of PW in the intensive arm received counseling on dietary diversity (DID: 45 percentage points [pp]), and a higher proportion of RDW received IFA (25 pp) and calcium supplementation (19 pp), showed adequate weight gain (44 pp), and recorded appropriate child feeding (27 pp). Improvements were greater in the intensive than the standard arm for the number of food groups consumed (DID: 1.1 food groups) and minimum dietary diversity (23 pp); no effect was observed for IFA and calcium consumption during pregnancy. However, effects were observed for early initiation of (20 pp) and exclusive breastfeeding (45 pp), introduction of solid or semisolid foods (28 pp), and egg and/or flesh food consumption (33 pp) among children. Minimum dietary diversity and acceptable diet remained low in both arms.

CONCLUSIONS

Intensifying nutrition in government-aligned health care services delivered by experienced nongovernmental organization-run facilities is a feasible model to address the urban health gap, nutrition services coverage, and improve practices. The trial was registered at clinicaltrials.gov as NCT03882268.

Factors affecting the micronutrient status of adolescent girls living in complex agro-aquatic ecological zones of Bangladesh

Inadequate intake of both macro and micronutrients is the major determinant of micronutrient deficiencies in adolescent girls. This study assessed multiple micronutrient status including vitamin D, iron, vitamin A, and urinary iodine concentration among adolescent girls through two seasonal cross-sectional surveys conducted during dry and wet seasons. Mixed-effects linear and logistic regression analysis were conducted to assess associations between micronutrient status, salinity and seasonality. The mean age of the girls was 14 years. Vitamin (OH)D insufficiency was significantly higher in freshwater areas in wet season compared to dry season (wet season: 58% and dry season: 30%, P < 0.001). In wet season, risk of vitamin (OH)D insufficiency was three times higher compared to dry season (AOR: 3.03, 95% CI 1.71, 5.37, P < 0.001). The odds of vitamin (OH)D insufficiency was 11 times higher in fresh water areas compared to high saline areas (AOR: 11.51, 95% CI 3.40, 38.93, P < 0.001). The girls had higher risk of iron deficiency in wet season. Despite the environment being enriched with micronutrient-contained aquatic food, adolescent girls in coastal areas experience different micronutrient deficiencies. The high prevalence of vitamin (OH)D insufficiency in freshwater locations and seasonal iron deficiency in high saline areas needs attention.

Using scenario‐based assessments to examine the feasibility of integrating preventive nutrition services through the primary health care system in Bangladesh

The National Nutrition Services of Bangladesh aims to deliver nutrition services through the primary health care system. Little is known about the feasibility of reshaping service delivery to close gaps in nutrition intervention coverage and utilization. We used a scenario‐based feasibility testing approach to assess potential implementation improvements to strengthen service delivery. We conducted in‐depth interviews with 31 service providers and 12 policymakers, and 5 focus group discussions with potential beneficiaries. We asked about the feasibility of four hypothetical scenarios for preventive and promotive nutrition service delivery: community‐based events (CBE) for pregnant women, well‐child services integrated into immunization contacts; CBE for well‐children, and well‐child visits at facilities. Opinions on service delivery platforms were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women was perceived as feasible, but workforce shortages emerged as a key barrier. Challenges such as equipment portability, upset children and a fast‐moving service environment suggested low feasibility of integrating nutrition into outreach immunization contacts. In contrast, CBE and facility‐based well‐child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation. In conclusion, integrating preventive and promotive nutrition services require addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services.

This study uses a scenario‐based feasibility testing approach to explore potential interventions to strengthen preventive and promotive nutrition service delivery through the primary health care system.

Our findings highlight three highly feasible potential platforms (community‐based events [CBE] for pregnant women, CBE for well‐children and well‐child visits at facilities) to expand preventive services. Scaling these community‐based services requires addressing current challenges in the health system (including human resource and logistic gaps) and investment in demand creation for these services.

Data Use Aids Adaptation and Continuation of Maternal, Infant and Young Child Nutrition (MIYCN) Services in Urban Health Facilities in Bangladesh During the COVID-19 Pandemic

Objectives

The COVID-19 pandemic disrupted health services worldwide. Alive and Thrive (A&T) is testing MIYCN integration into non-governmental organizations’ (NGOs) health services in eight facilities in Dhaka. We aimed to develop a data-driven urban MIYCN intervention pathway adapted to continue delivering nutrition services during COVID-19.

Methods

A&T used its learnings from previous interventions and formative research to design an urban MIYCN intervention with a social and behavior change strategy set to improve nutrition practices. Mixed monitoring data were used to track the intervention elements capacity building, demand creation, service delivery, and supervision; and COVID-19 situation domains lockdown, restrictions, guidelines, staff turnover, contextual and behavior changes, adaptations, and budget implications. COVID-19 studies as well as external value chain, market, and food security reports were used. Monthly monitoring data were used to identify and validate potential adaptations.

Results

Intervention adaptations and adoption of government requirements for nutrition services allowed MIYCN services to continue during the pandemic; recurrent users reached seven or more counseling sessions. The intervention incorporated virtual capacity building; MIYCN counseling, supervision, and demand creation for services via mobile phones; and community mobilization via satellite clinics and referrers. The use of monitoring data allowed documenting the intervention pathway with some original intervention components pre-pandemic, and other components delivered after adapting to restrictions during lockdown and after lockdown was lifted. Adaptations were based on national and global requirements and on social and individual behaviors during the pandemic (e.g., fearful mothers not coming to facilities).

Conclusions

Data use elucidated how to deliver urban MIYCN services and adapt amidst the ongoing pandemic. NGOs providing government-aligned health services can potentially address the urban gap, and advance nutrition services and improved practices during crisis. Documenting an evidence-based intervention pathway visualizing adaptations will guide the endline study to maximize learnings for the MIYCN community in Bangladesh and globally.

Funding Sources

Bill & Melinda Gates Foundation through Alive & Thrive FHI Solutions.

Violations of International Code of Breast-milk Substitutes (BMS) in commercial settings and media in Bangladesh

The International Code of Marketing of Breast‐milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national ‘Breast‐milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013’ of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross‐sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ² tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among “other milk” for children aged 0 to <36 months compared to formulas and growing‐up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations.

This is the first known study documenting violations in retail outlets, online stores, and media using the standard NetCode protocol in Bangladesh.

BMS Code violations were high in retail stores and were more prevalent in the capital city compared to others.

Violations were significantly higher in the internet compared to radio, television, and newspapers, highlighting the need for strengthening the monitoring of internet‐based promotions.

It is essential to allocate resources to sensitize retail stores to the BMS Code to enhance the implementation of the law.

Provision and utilisation of health and nutrition services during COVID-19 pandemic in urban Bangladesh

The COVID-19 pandemic is expected to have profound effects on healthcare systems, but little evidence exists on service provision, utilisation, or adaptations. This study aimed to (1) examine the changes to health and nutrition service delivery and utilisation in urban Bangladesh during and after enforcement of COVID-19 restrictions and (2) identify adaptations and potential solutions to strengthen delivery and uptake. We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children <2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic. Services delivery for women and children which require proximity were severely affected; weight and height measurements fell by 20-29 percentage points (pp) for pregnant women and 37-57 pp for children, and child immunisations fell by 38 pp. Declines in service utilisation were large, including drops in facility visitations (35 pp among pregnant women and 67 pp among mothers), health and nutrition counselling (up to 73 pp), child weight measurements (50 pp), and immunisations (61 pp). The primary method of adaptation was provision of services over phone (37% for antenatal care services, 44%-49% for counselling). Despite adaptations to service provision, continued availability of routine maternal and child health services did not translate into service utilisation. Further investments are needed to provide timely and accurate information on COVID-19 to the general public, improve COVID-19 training and provide incentives for health care providers and ensure availability of personal protective equipment for providers and beneficiaries.

Provision and Utilization of Health and Nutrition Services During the COVID-19 Pandemic in Urban Bangladesh

Objectives

The COVID-19 pandemic is expected to have extensive effects on healthcare systems. The Government of Bangladesh has concerns about diminished coverage and quality of maternal and child health services, but little published information exists on service provision, utilization, and adaptations. We examined changes to maternal and child health and nutrition service delivery and utilization in urban Bangladesh during and after the enforcement of COVID-19 restrictions and identified adaptations and potential solutions to strengthen service delivery and uptake.

Methods

We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children < 2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic.

Results

Most services for pregnant women remained available during COVID-19 restrictions, with the provision of antenatal care (ANC) services falling by 6.6 percentage points (pp). Services for women and children which require proximity, however, were more severely affected; weight and height measurements fell by 20–29pp for pregnant women and 37–57pp for children, and child immunizations fell by 38pp. Declines in service utilization were large, including drops in facility visitations (35pp among pregnant women and 67pp among mothers), health and nutrition counseling (up to 73pp), child weight measurements (50pp), and immunizations (61pp). The primary method of adaptation was provision of services over phone (37% for ANC services and 44–49% for counselling of pregnant women or mothers with young children).

Conclusions

Despite adaptations to service provisions, continued availability of routine maternal and child health services did not translate into service utilization. Further investments are needed to provide timely and accurate information on COVID-19 to the public, improve COVID-19 training and provide incentives for health care providers, and ensure availability of personal protective equipment for both providers and beneficiaries.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Bill & Melinda Gates Foundation, through Alive & Thrive, managed by FHI Solutions.

Using Novel Scenario-Based Assessments to Examine Feasibility of Integrating Preventive Nutrition Services Through the Primary Healthcare System in Bangladesh

Objectives

Bangladesh's National Nutrition Services aims to deliver nutrition services to pregnant women and children through the primary health care system. Previous research highlighted gaps in coverage of preventive nutrition intervention delivery through this system but little is known about feasibility of reshaping service delivery to close the gaps. Prior to designing new approaches, we used a novel scenario-based feasibility testing approach to assess potential to strengthen service delivery.

Methods

We interviewed 32 service providers and 16 policymakers and conducted 4 focus group discussions with potential beneficiaries, asking respondents about the feasibility of four hypothetical scenarios for preventive service delivery: community-based events (CBE) for pregnant women; well-child services integrated into immunization contacts; CBE for well-children and well-child visits at facilities. Transcribed interviews were systematically coded, synthesized and interpreted using a pre-defined framework.

Results

Opinions on the need for new platforms for preventive services were mixed; some recommended new platforms, but others suggested strengthening existing delivery points. CBE for pregnant women were perceived as feasible, but workforce shortages emerged as a key challenge. Challenges such as equipment portability, upset children, and a fast-moving service environment suggested low feasibility of integrating nutrition into immunization contacts. In contrast, CBE and facility-based well-child visits emerged as feasible options, conditional on having the necessary workforce, structural readiness and budget support. On the demand side, enabling factors include using interpersonal communication and involving community leaders to increase awareness, organizing events at a convenient time and place for both providers and beneficiaries, and incentives for beneficiaries to encourage participation.

Conclusions

A scenario-based approach is an efficient method to assess potential feasibility options for nutrition service delivery. Introducing preventive nutrition services requires addressing current challenges in the health system, including human resource and logistic gaps, and investing in creating demand for preventive services.

Funding Sources

Bill & Melinda Gates Foundation, through A&T, managed by FHI 360.

Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study

BACKGROUND

Severe acute malnutrition (SAM) in children is the most serious form of malnutrition and is associated with very high rates of morbidity and mortality. For sustainable SAM management, United Nations recommends integration of community based management of acute malnutrition (CMAM) into the health system. The objective of the study was to assess the preparedness of the health system to implement CMAM in Bangladesh.

METHODS

The assessment was undertaken during January to May 2014 by conducting document review, key informant interviews, and direct observation. A total of 38 key informant interviews were conducted among government policy makers and program managers (n = 4), nutrition experts (n = 2), health and nutrition implementing partners (n = 2), development partner (n = 1), government health system staff (n = 5), government front line field workers (n = 22), and community members (n = 2). The assessment was based on: workforce, service delivery, financing, governance, information system, medical supplies, and the broad socio-political context.

RESULTS

The government of Bangladesh has developed inpatient and outpatient guidelines for the management of SAM. There are cadres of community health workers of government and non-government actors who can be adequately trained to conduct CMAM. Inpatient management of SAM is available in 288 facilities across the country. However, only 2.7% doctors and 3.3% auxiliary staff are trained on facility based management of SAM. In functional facilities, uninterrupted supply of medicines and therapeutic diet are not available. There is resistance and disagreement among nutrition stakeholders regarding import or local production of ready-to-use therapeutic food (RUTF). Nutrition coordination is fragile and there is no functional supra-ministerial coordination platform for multi-sectoral and multi-stakeholder nutrition.

CONCLUSION

There is an enabling environment for CMAM intervention in Bangladesh although health system strengthening is needed considering the barriers that have been identified. Training of facility based health staff, government community workers, and ensuring uninterrupted supply of medicines and logistics to the functional facilities should be the immediate priorities. Availability of ready-to-use therapeutic food (RUTF) is a critical component of CMAM and government should promote in-country production of RUTF for effective integration of CMAM into the health system in Bangladesh.

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24-59 months old, 1428 children 6-14 years old, and 1412 nonpregnant, nonlactating women. The study's objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of the fortification of key staple foods. The current intakes of several micronutrients-namely, iron, zinc, folate, vitamin A, and vitamin B12-were found to be insufficient to meet the needs of Bangladesh's children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.

An Assessment of the Potential Impact of Fortification of Staples and Condiments on Micronutrient Intake of Young Children and Women of Reproductive Age in Bangladesh

Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24-59 months old; 1428 children 6-14 years old; and 1412 non-pregnant, non-lactating women. The study's objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of fortification of key staple foods. The current intakes of several micronutrients, namely, iron, zinc, folate, vitamin A and vitamin B12, were found to be insufficient to meet the needs of Bangladesh's children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes.

An evolving perspective about the origins of childhood undernutrition and nutritional interventions that includes the gut microbiome

The Sackler Institute for Nutrition Science and the World Health Organization (WHO) have worked together to formulate a research agenda for nutrition science. Undernutrition of children has profound effects on health, development, and achievement of full human capacity. Undernutrition is not simply caused by a lack of food, but results from a complex interplay of intra- and intergenerational factors. Representative preclinical models and comprehensive well-controlled longitudinal clinical studies are needed to further understand the contributions and the interrelationships among these factors and to develop interventions that are effective and durable. This paper summarizes work on mechanisms underlying the varied manifestations of childhood undernutrition and discusses current gaps in knowledge and challenges to our understanding of undernutrition and infection/immunity throughout the human life cycle, focusing on early childhood growth. It proposes a series of basic and clinical studies to address this global health challenge.

Nutrition of children and women in Bangladesh: trends and directions for the future

Although child and maternal malnutrition has been reduced in Bangladesh, the prevalence of underweight (weight-for-age z-score <-2) among children aged less than five years is still high (41%). Nearly one-third of women are undernourished with body mass index of <18.5 kg/m2. The prevalence of anaemia among young infants, adolescent girls, and pregnant women is still at unacceptable levels. Despite the successes in specific programmes, such as the Expanded Programme on Immunization and vitamin A supplementation, programmes for nutrition interventions are yet to be implemented at scale for reaching the entire population. Given the low annual rate of reduction in child undernutrition of 1.27 percentage points per year, it is unlikely that Bangladesh would be able to achieve the United Nations' Millennium Development Goal to address undernutrition. This warrants that the policy-makers and programme managers think urgently about the ways to accelerate the progress. The Government, development partners, non-government organizations, and the academia have to work in concert to improve the coverage of basic and effective nutrition interventions, including exclusive breastfeeding, appropriate complementary feeding, supplementation of micronutrients to children, adolescent girls, pregnant and lactating women, management of severe acute malnutrition and deworming, and hygiene interventions, coupled with those that address more structural causes and indirectly improve nutrition. The entire health system needs to be revitalized to overcome the constraints that exist at the levels of policy, governance, and service-delivery, and also for the creation of demand for the services at the household level. In addition, management of nutrition in the aftermath of natural disasters and stabilization of prices of foods should also be prioritized.