Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition.
Objective
Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure
Methods
Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted.
Results
Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions.
Conclusions
Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.
VictoraCGHabichtJPBryceJ. Evidence-based public health: moving beyond randomized trials. Am J Public Health2004;94:400–5.
2.
VictoraCGHansonKBryceJVaughanJP. Achieving universal coverage with health interventions. Lancet2004;364:1541–8.
3.
HansonKRansonKOliveira-CruzVMillsA. Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up. J Int Dev2003;15:1–14.
4.
ManghamLJHansonK. Scaling up in international health: what are the key issues?Health Policy Plan2010;25:85–96.
5.
MasonJBSandersDMusgrovePSoekirmanGallowayR. Community health and nutrition programs. In: JamisonDTBremanJMeashamARAlleyneGClaesonMEvansDBJhaPMillsAMusgroveP, eds. Disease control priorities. 2 ed.Washington, DC: World Bank and Oxford University Press; 2006:1053–74.
6.
SanghviTDaryOHoustonR. How can vitamin and mineral deficiencies be reduced? Implementing proved interventions at scale. Food Nutr Bull2007;28:S182–96.
7.
BryceJCoitinhoDDarnton-HillIPelletierDPinstrup-AndersenP. Maternal and child undernutrition: effective action at national level. Lancet2008;371:510–26.
8.
Flour Fortification Initiative G, GAIN, Micronutrient Initiative, USAID, World Bank, UNICEF. Investing in the future. A united call to action on vitamin and mineral deficiencies. Global Report 2009. Ottawa: US Centers for Disease Control and Prevention, 2009.
9.
HortonSMannarVWesleyA. Food fortification with iron and iodine. Copenhagen: Copenhagen Consensus Center, 2009.
10.
KlemmRHarveyPWainwrightEFaillaceSWasantwisutE. Scaling-up micronutrient programs: what works and what needs more work? The 2008 Innocenti Process. Washington, DC: Micronutrient Forum, 2009.
11.
LavioletteLMannarV. Scaling up and sustaining nutrition interventions. Lessons learned from success in the Asia-Pacific Region. 2008 White Paper. Seattle: The National Bureau of Asian Research, 2008.
12.
Standing Committee on Nutrition—United Nations System. Landscape analysis on countries' readiness to acelerate action in nutrion. Geneva: ACN, 2009.
13.
World Health Organization. Scaling up nutrition. A framework for action. Geneva: WHO, 2010.
14.
ZimmermannMB. Iodine deficiency in pregnancy and the effects of maternal iodine supplementation on the offspring: A review. Am J Clin Nutr2009;89:668S–72.
15.
UNICEF. State of the world's children 2009. New York: UNICEF, 2009.
16.
DeitchlerMMasonJMathysEWinichagoonPTuazonMA. Lessons from successful micronutrient programs. Part I: Program initiation. Food Nutr Bull2004;25:5–29.
17.
CodlingKvan der HaarFGorsteinJTimmerAIvanovaL. Assessing household use of adequately iodized salt: a methodology that combines use of rapid test kits and quantitative assessment. Sight and Life2007;Suppl 3:40.
18.
UNICEF. Universal salt iodization in Nigeria. Process, successes and lessons. Abuja: Ministry of Health—Nigeria, 2005.
19.
EgbutaJOnyeziliFVanormelingenK. Impact evaluation of efforts to eliminate iodine deficiency disorders in Nigeria. Public Health Nutr2003;6:169–73.
20.
DunnJT. Seven deadly sins in confronting endemic iodine deficiency, and how to avoid them. J Clin Endocrinol Metab1996;81:1332–5.
21.
BlencoweHCousensSModellBLawnJ. Folic acid to reduce neonatal mortality from neural tube disorders. Int J Epidemiol2010;39:i110–21.
22.
FiedlerJLMacdonaldB. A strategic approach to the unfinished fortification agenda: feasibility, costs, and cost-effectiveness analysis of fortification programs in 48 countries. Food Nutr Bull2009;30:283–316.
23.
GwatkinDRRutsteinSJohnsonKSulimanEWagstaffAAmozouA. Socioeconomic differences in health, nutrition, and population. Washington, DC: World Bank, 2007.
24.
Centers for Disease Control and Prevention. Trends in wheat-flour fortification with folic acid and iron—worldwide, 2004 and 2007. Morb Mortal Wkly Rep2008;57:8.
25.
WilliamsLJRasmussenSAFloresAKirbyRSEdmondsLD. Decline in the prevalence of spina bifida and anencephaly by race/ethnicity: 1995–2002. Pediatrics2005;116:580–6.
26.
BowerCEadesSPayneJD'AntoineHStanleyF. Trends in neural tube defects in Western Australia in Indigenous and non-Indigenous populations. Paediatr Perinat Epidemiol2004;18:277–80.
27.
Imhoff-KunschBFloresRDaryOMartorellR. Wheat Flour Fortification is unlikely to benefit the neediest in Guatemala. J Nutr2007;137:1017–22.
28.
HurrellRRanumPde PeeSBiebingerRHulthenLJohnsonQLynchS. Revised recommendations for iron fortification of wheat flour and an evaluation of the expected impact of current national wheat flour fortification programs. Food Nutr Bull2010;31:S7–21.
29.
ChenLTRiveraMA. The Costa Rican experience: Reduction of neural tube defects following food fortification programs. Nutr Rev2004;62:S40–3.
30.
DaryOHarveyPHoustonRRahJ. The evidence of micronutrient programs: a selected review. Washington, DC: The Micronutrient Forum, 2008.
31.
Department of Health South Africa, UNICEF, GAIN. A reflection of the South Africa maize meal and wheat flour fortification programme (2004 to 2007). Pretoria: The Department of Health South Africa and UNICEF South Africa, 2008.
32.
SayedARBourneDPattinsonRNixonJHendersonB. Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa. Birth Defects Res A Clin Mol Teratol2008;82:211–6.
33.
ModjadjiSEPAlbertsMMamaboloRL. Folate and iron status of South African non-pregnant rural women of childbearing age, before and after fortification of foods. S Afr J Clin Nutr2007;20:89–93.
34.
AssuncaoMCSantosISBarrosAJGiganteDPVictoraCG. [Effect of iron fortification of flour on anemia in preschool children in Pelotas, Brazil]. Rev Saude Publica2007;41:539–48.
35.
YipR. Iron supplementation: country level experiences and lessons learned. J Nutr2002;132:859S–61S.
36.
BarrosFCVictoraCGScherpbierRGwatkinD. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Rev Saude Publica2010;44:1–16.
37.
SanghviT. Maternal iron-folic acid supplementation programs: evidence of implementation and impact. Beijing: Micronutrient Forum, 2009.
38.
RoweAKde SavignyDLanataCFVictoraCG. How can we achieve and maintain high-quality performance of health workers in low-resource settings?Lancet2005;366:1026–35.
39.
GallowayRDuschEElderLAchadiEGrajedaRHurtadoEFavinMKananiSMarsabanJMedaNMooreKMMorisonLRainaNRajaratnamJRodriquezJStephenC. Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries. Soc Sci Med2002;55:529–44.
40.
GillespieSKevanyJMasonJ. Controlling iron deficiency. Geneva: United Nations, ACC/SCN; 1991.
41.
JamesCDHansonKMcPakeBBalabanovaDGwatkinDHopwoodIKirungaCKnippenbergRMeessenBMorrisSSPrekerASouteyrandYTiboutiAVilleneuvePXuK. To retain or remove user fees? Reflections on the current debate in low- and middle-income countries. Appl Health Econ Health Policy2006;5:137–53.
42.
MoraJO. Integrated Anemia Control Strategy has significantly reduced anemia in women and children in Nicaragua. Ottawa, Canada: Micronutrient Initiative, 2007.
43.
Ministry of Health and Population, New ERA Nepal, Macro International. Nepal Demographic and Health Survey 2006. Kathmandu: Ministry of Health and Population (MOHP), 2007.
44.
ImdadABhuttaZA. Maternal Nutrition and Birth outcomes: effect of balanced protein energy supplementation. BMC Public Health2011;11:S17.
45.
World Bank. Repositioning nutrition as central to development. A strategy for large-scale action. Washington, DC: World Bank, 2006.
46.
HeaverR. India's Tamil Nadu Nutrition Program: lessons and issues in management and capacity development. Washington, DC: World Bank Health, 2003.
47.
ShekarM. The Tamil Nadu Integrated Nutrition Project: a review of the project with special emphasis on the monitoring and information system. Ithaca, NY, USA: University of Cornell, 1991.
48.
RushD. Maternal nutrition and perinatal survival. J Health Popul Nutr2001;19:S217–64.
49.
World Bank. Implementation completion report (India): Second Tamil Nadu Integrated Nutriton Project (Credit 2158-IN). Washington, DC: World Bank, 1998.
50.
World Bank. Maintaining momentum to 2015? An impact evaluation of interventions to improve maternal and child health and nutrition in Bangladesh. Washington, DC: World Bank, 2005.
51.
PelletierDShekarMDuLKostermansK. The Bangladesh Integrated Nutrition Project. Effectiveness and lessons. Washington, DC: World Bank, 2005.
52.
KarimRDesplatsGSchaetzelTHerforthAAhmedFSalamatullahQShahjahanMAkhtaruzzamanMLevinsonJ. Seeking optimal means to address micronutrient deficiencies in food supplements: a case study from the Bangladesh Integrated Nutrition Project. J Health Popul Nutr2005;23:369–76.
53.
HossainSMDuffieldATaylorA. An evaluation of the impact of a US$60 million nutrition programme in Bangladesh. Health Policy Plan2005;20:35–40.
54.
KarimRLamsteinSAkhtaruzzamanMRahmanKAlamN. The Bangladesh Integrated Nutrition Project: endline evaluation of the community based nutrition component. Dhaka: Institute of Nutrition and Food Science, University of Dhaka, 2003.
55.
LoevinsohnBHardingA. Buying results? Contracting for health service delivery in developing countries. Lancet2005;366:676–81.
56.
NaharSMascie-TaylorCGBegumHA. Impact of targeted food supplementation on pregnancy weight gain and birth weight in rural Bangladesh: an assessment of the Bangladesh Integrated Nutrition Program (BINP). Public Health Nutr2009;12:1205–12.
57.
Save the Children. Thin on the ground: questioning the evidence behind World Bank-funded community nutrition projects in Bangladesh, Ethiopia and Uganda. London: Save the Children UK, 2003.
58.
BegumHAMascie-TaylorCNaharS. The impact of food supplementation on infant weight gain in rural Bangladesh: an assessment of the Bangladesh Integrated Nutritional Program (BINP). Public Health Nutr2007;10:49–54.
59.
ShaheenRde FranciscoAEl ArifeenSEkstromECPerssonLA. Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh. Am J Clin Nutr2006;83:1355–61.
60.
HabichtJPMartorellRVictoraCG. UNU Report to the World Bank: review of the evidence for a moratorium on the activities of the Bangladesh Integrated Nutrition Program. Tokyo: United Nations University, 2003.
61.
LevinsonFJRohdeJE. Responses to: “an evaluation of the impact of a US$60 million nutrition programme in Bangladesh”. Health Policy Plan2005;20:405–6.
62.
GalassoEUmapathiN. Improving nutritional status through behavioral change: lessons from Madagascar. Washington, DC: World Bank, 2007.
63.
GuyonABQuinnVJHainsworthMRavonimanantsoaPRavelojoanaVRambelosonZMartinL. Implementing an integrated nutrition package at large scale in Madagascar: The Essential Nutrition Actions framework. Food Nutr Bull2009;30:233–44.
64.
ShrimptonRThorne-LymanATrippKTomkinsA. Trends in low birthweight among the Bhutanese refugee population in Nepal. Food Nutr Bull2009;30:S197–206.
65.
YipRScanlonKTrowbridgeF. Improving growth status of Asian refugee children in the United States. JAMA1992;267:937–40.
66.
LagardeMHainesAPalmerN. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev2009;(4):CD008137.
67.
RawlingsLBRubioGM. Evaluating the impact of conditional cash transfer programs. World Bank Res Obs2005;20:29–55.
68.
BassettL. Can conditional cash tranfer programs play a greater role in reducing child undernutrition?Washington, DC: World Bank, 2008.
69.
FiszbeinASchadyN. Conditional cash transfers: reducing present and future poverty. Washington, DC: World Bank; 2009.
70.
BarberSLGertlerPJ. The impact of Mexico's conditional cash transfer programme, Oportunidades, on birthweight. Trop Med Int Health2008;13:1405–14.
71.
HoddinottJSkoufiasE. The impact of PROGRESA on food consumption. International Food Policy Research Institute (IFPRI) discussion Paper 150 (May 2003). Food Nutr Bull2003;24:379–80.
72.
LeroyJLRuelMVehrhofstadtE. The impact of conditional cash transfer programs on child nutrition: a review of evidence using a programme theory frameworkJ Dev Effect2009;1:102–29.
73.
BarberSLGertlerPJ. Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme. Health Policy Plan2009;24:18–25.
74.
AttanasioOGomezLCHerediaPVera-HernandezM. The shortterm impact of a conditional cash subsidy on child health and nutrition in Colombia. London: Institute of Fiscal Studies, 2005.
75.
SepulvedaJBustreoFTapiaRRiveraJLozanoROlaizGPartidaVGarcia-GarciaLValdespinoJL. Improvement of child survival in Mexico: the diagonal approach. Lancet2006;368:2017–27.
76.
RiveraJASotres-AlvarezDHabichtJPShamahTVillalpandoS. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA2004;291:2563–70.
77.
RosadoJRiveraJLopezGSolanoL. Development, production, and quality control of nutritional supplements for a national supplementation programme in Mexico. Food Nutr Bull2000;21:30–4.
78.
AdatoMCoadyDRuelM. An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff. Washington, DC: International Food Policy Research Institute, 2000.
79.
SkoufiasEDavisBde la VegaS. Targeting the poor in Mexico: an evaluation of the selection of households into PROGRESA. World Dev2001;29:1769–84.
80.
BarberSLGertlerPJ. Empowering women: how Mexico's conditional cash transfer program raised prenatal care quality and birth weight. J Dev Effect2010;2:51–73.
81.
ZarcoAMoraGPelcastreBFloresMBronfmanM. Aceptabilidad de los suplementos alimenticios del programa Oportunidades. Salud Publica Mex2006;48:325–31.
82.
UNICEF. Child poverty: a role for cash transfers in West and Central Africa?New York: UNICEF/Overseas Development Institute, 2009.
83.
GilliganDOHoddinottJTaffesseAS. An analysis of Ethiopia's Productive Safety Net Program and its linkages. Washington, DC: International Food Policy Research Institute, 2008.
84.
HypherN. Lasting benefits: cash transfers and child survival in Mozambique, Malawi and Ethiopia. London: Save the Children UK, 2010.
85.
LimSSDandonaLHoisingtonJAJamesSLHoganMCGakidouE. India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet2010;375:2009–23.
86.
World Health Organization. The World Health report 2005: make every mother and child count. Policy brief 3: access to care and financial protection for all. Geneva: WHO, 2005.
87.
VictoraCGFennBBryceJKirkwoodBR. Co-coverage of preventive interventions and implications for child-survival strategies: evidence from national surveys. Lancet2005;366:1460–6.
88.
MasonJHuntJParkerDJonssonU. Investing in child nutrition in Asia. Asian Dev Rev1999;17:1–32.
89.
MasonJLotfiMDalmiyaNSethuramanKDeitchlerM. The Microutrient Report: current progress and trends in the control of vitamin A, iodine and iron deficiencies. Ottawa: Micronutrient Initiative, 2001.
90.
GwatkinDRErgoA. Universal health coverage: friend or foe of health equity?Lancet2011;377:2160–1.
91.
VictoraCGVaughanJPBarrosFCSilvaACTomasiE. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet2000;356:1093–98.
92.
Evaluation Gap Working Group. When will we ever learn? Improving lives through impact evaluation. Washington, DC: Center for Global Development, 2006.
93.
ShrimptonRVictoraCGde OnisMLimaRCBlossnerMClugstonG. World wide timing of growth faltering: implications for nutritional interventions. Pediatrics2001;107:E75.
94.
VictoraCGde OnisMHallalPCBlossnerMShrimptonR. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics2010;125:e473–80.
