In the scoping review, there was an abundance of journal articles that addressed maternal supplements but few that focused on how to deliver the supplements. The scoping review of maternal supplement programs in developing contexts (which, in this case, included Bangladesh, Ethiopia, India, Kenya, and Nepal), identified three delivery methods for distributing maternal supplements to women during the prenatal period. The first mode reflected programs which had volunteer maternal nutrition educators deliver supplements to the pregnant women’s homes. The second was pregnant women received maternal supplements from school, health center/local center, or village markets. In the final instance, the pregnant women received a ration card to purchase subsidized food.
Volunteer maternal nutrition educator delivers supplements
In the volunteer maternal nutrition educator delivered approach, maternal supplements and/or food rations were brought to the pregnant women’s home. Workers distributed Iron-Folic Acid (IFA) supplements house-to-house in distant communities . This delivery method allowed the pregnant woman to receive the supplements without the inconvenience of traveling during pregnancy.
Pregnant woman receives supplements
In two studies, from Bangladesh, pregnant women received and consumed food supplements from a local community nutrition center distributed by a volunteer [7, 8]. In both studies, the volunteers were local women trained by the implementing government organization to provide supplement packages with nutrition education . The package contained rice, lentils, molasses, oil, and vegetable protein, and was meant to supplement daily food intake already being consumed . Both Bangladesh programs were sponsored by the government.
Subsidized food or cash transfer
Subsidized food was provided to low-income households, pregnant women received a ration card to purchase subsidized food. In India, the Targeted Public Distribution System subsidized food, mostly rice, pulses, and sugars, to below poverty line households . “According to the Targeted Public Distribution System approximately 64% (12,200,000) of all households possessed a Below Poverty Line ration card as of August 2010” .
In Ethiopia, the Productive Safety Net Program provided cash transfers or food supports to households whose adults participated in labor-intensive public works projects . The program offered financial compensation to exempt pregnant and lactating women from public work for six months after their child’s birth . The program offers an increased calorie intake per household but does not address the food quality . To be eligible for this program pregnant women are required to participate in four antenatal care visits including IFA supplementation to receive a cash transfer or food support .
Barriers for programs
From the reviewed literature, it is apparent that sustainability of programs relies on government policies, human resources, communication networks including transportation, and fragile health system infrastructures . The main issue is the low level of awareness among policymakers regarding the severity and consequences that maternal undernourishment has on the population which may, in turn, contribute to the low prioritization of maternal nutrition program management .
Cost, resources, and social status
Poverty is a major barrier which limits access to essential health services. Maternal nutrition is heavily affected by social phenomena including poverty, caste discrimination, and the low social status of women. Pregnant women are unable to afford to purchase the food recommended by nutritional programs . Insufficient food in the household was a major reason for poor diet as well as the sharing of prenatal supplements and food rations with the rest of the household because their family members were also malnourished [5, 6].
Most maternal nutrition programs struggle with limited resources, resulting in shortages of buildings, personnel, equipment, supplies (vitamins, contraceptives, and food), and professional training/support . Limited support and guidance are given to those who are responsible for delivering nutrition services. Volunteer healthcare workers reported having heavy workloads and poor transportation which prevented them from providing adequate education and services to many pregnant women . High turnover rates among voluntary community health workers lead to poor leadership, lack of experience, and difficulty in forming relationships with program participants .
Barriers for participants
There is a lack of awareness and education among pregnant women who participated in nutrition programs. For example, some pregnant women viewed IFA as anemia treatment rather than prevention. In Ethiopia, a key barrier to the nutritional program was that participants lacked awareness of government guidelines for IFA during pregnancy .
Traditional beliefs and customs also affected supplement consumption among pregnant women. Some pregnant women believed “eating down”, defined as eating small amounts, would reduce the babies’ weight, and if they ate too much there would be less space for the fetus to grow in their stomach . Volunteer healthcare workers suggested eating small amounts frequently, but pregnant women could not eat multiple small meals throughout the day because it is considered taboo to eat alone . Religious fasting and taking laxatives was also believed to reduce the babies’ weight and allow for an easier birth . There was also a strong religious belief that everything is in God’s hands including nutrition and health .
Earlier access to nutrition programs resulted in a higher total nutrient intake for mother and baby . The earlier in pregnancy the food program was implemented resulted in better maternal-infant interactions and improved fetal growth and development . Mothers, who were not offered the maternal supplements, suffered from food insecurity resulting in infant distress, high levels of personal stress, and/or depression, leading to poor maternal-infant interactions .
Access also relied on the timely delivery of food rations. Some nutrition program participants reported that it took 1–2 months for food rations to arrive and distribution sites were 3–30 h from their communities making it extremely difficult to obtain especially later in their pregnancy . Some programs refused women as eligible to receive food supplements because of their lack of attendance for antenatal care education. Non-eligible participants felt food distribution was unfair and families who needed food rations were not always considered eligible .
Pregnant participants were counseled to rest during their pregnancy; however, this was not possible because of the enormous work burdens including household chores, collecting water, and agricultural duties . In Sub-Saharan Africa, 7.6 million people were eligible for the Productive Safety Net Program which provided $4 US or 15 kg of unfortified grain per month and exempted participants from work for 6 months during lactation . However, no data was available on how many women were registered and participated in this incentive program .
Strategies to improve program delivery modes
Noznesky et al., (2012) suggested delivering newlywed packages of IFA supplements/ nutritional supplements to all young women who are at risk for anemia before they become pregnant. There needs to be a system for identifying and delivering supplements to all malnourished pregnant women to ensure full coverage of services. Household mapping that is regularly updated could help with identifying the target population . The system should also include data on who received supplements/food rations and monitor the number of antenatal educational/health care visits . Technology can be used to develop and implement a data management system for nutritional programs .
Incentives for trained professionals could be offered to work in remote and rural areas and build public-private partnerships to coordinate implementing nutritional interventions . Manageable workloads should be constructed for volunteers that offer support and guidance through supervision and telecommunications. Volunteers should emphasize teaching lifelong skills, such as home gardening, cooking, and nutritional education, utilizing the food that is available to the participants . Volunteers should educate and support community members to introduce their own initiatives that are appropriate for local culture, tradition, and religious beliefs .
Success is based on the program’s ability to improve nutritional status and education of pregnant women, build partnerships, and improve coordination [6, 9]. Government partnerships will elevate the priority to develop policies and strengthen program interventions . Offering benefits, such as cash transfers to exempt pregnant and lactating women from public work, would enable the mother to purchase food and develop maternal-infant relationships. Improving the monitoring and evaluation system of maternal nutritional programs is essential to measure the effectiveness of delivery methods.