STRENGTHENING MATERNAL NUTRITION in Health Programs

USAID ADVANCING NUTRITION September 2021

PHOTOS FPO

STRENGTHENINGMATERNAL NUTRITION in Health ProgramsA Guide for Practitioners

About USAID Advancing NutritionUSAID Advancing Nutrition is the Agency’s flagship multi-sectoral nutrition project, led by JSI Research & Train-ing Institute, Inc. (JSI), and a diverse group of experienced partners. Launched in September 2018, USAID Advancing Nutrition implements nutrition interventions across sectors and disciplines for USAID and its partners. The project’s multi-sectoral approach draws together global nutrition experience to design, implement, and evaluate programs that address the root causes of malnutrition. Committed to using a systems approach, USAID Advancing Nutrition strives to sustain positive outcomes by building local capacity, support-ing behavior change, and strengthening the enabling environ-ment to save lives, improve health, build resilience, increase economic productivity, and advance development..

DisclaimerThis report was produced for the U.S. Agency for Internation-al Development. It was prepared under the terms of con-tract 7200AA18C00070 awarded to JSI Research & Training Institute, Inc. (JSI). The contents are the responsibility of JSI, and do not necessarily reflect the views of USAID or the U.S. Government.

Recommended CitationUSAID Advancing Nutrition. 2021. Strengthening Maternal Nutrition in Health Programs: A Guide for Practitioners. Arlington, VA: USAID Advancing Nutrition.

Photo Credit: Allan Gichigi/Maternal and Child Survival Program

USAID Advancing NutritionJSI Research & Training Institute, Inc.2733 Crystal Drive4th FloorArlington, VA 22202

Phone: 703–528–7474Email: [email protected]: advancingnutrition.org

GUIDANCE FOR STRENGTHENING MATERNAL NUTRITION IN HEALTH PROGRAMS SEPTEMBER 2021 | 3

ContentsAcronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Checklist: Step-By-Step Guidance on Adding/Adapting Maternal Nutrition Interventions . . . . . . . . . . . . . . . . . . . . . . 6

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

How Can This Guidance Help You? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

For Whom is This Guidance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

How Should You Use This Guidance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

When Should You Use This Guidance? How Long is the Process? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1. Complete a Situation Analysis by Collecting, Reviewing, and Synthesizing Qualitative and Quantitative Data . . . . 9 Determine What Information and Data are Available on Maternal Nutrition for Your Context . . . . . . . . . . . . . 10 Collect Additional Data Needed for Program or Activity Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Review Existing Programming, Country Guidance, and Government Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Synthesize the Data Collected and Develop a Situation Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2. Identify Maternal Nutrition Health Sector Priorities to Develop an Implementation Plan . . . . . . . . . . . . . . . . . . 15 Identify Potential Collaborators and/or Partners, Including Relevant Technical Working Groups (TWGs) . . . . . 16 Work with a Multi-Stakeholder Team to Identify Maternal Nutrition Implementation Priorities, and Roles

and Responsibilities of Key Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Create a Theory of Change and/or Logical Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Develop or Adapt your Program or Activity’s Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

3. Implement, Monitor, Reflect on and Adjust Maternal Nutrition Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Implement the Program, Monitor Progress, and Regularly Collect and Analyze Data on Indicators . . . . . . . . . . 22 Using Monitoring Data, Reflect on Progress and Adjust Interventions Accordingly . . . . . . . . . . . . . . . . . . . . . . . 22

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Annex 1. Key Maternal Nutrition Indicators and Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Annex 2. Additional Tools and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Annex 3. Collecting and Analyzing Maternal Nutrition Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Annex 4. Key Global Guidance on Maternal Nutrition Across the Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Annex 5. Sample Agenda Items for Multi-Stakeholder Workshop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Annex 6. Using a Theory of Change Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Annex 7. Illustrative Implementation Plan Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37


AcknowledgmentsThis program guidance has been realized through the efforts and contributions of various people and institutions. Special thanks go to the authors of the Maternal Nutrition Operation Guidance: Program Considerations for Low- and Middle-Income Countries, Justine Kavle, Melanie Picolo, and Chloe Dilaway. We would like to acknowledge the contributions of several researchers and program implementers who provided valu-able information for this guidance through a technical con-sultation. We also acknowledge USAID Advancing Nutrition staff, including Kate Litvin, for leading the development of this program guidance, and Kristen Cashin for providing technical oversight. Special thanks go to USAID Advancing Nutrition consultant Tara Kovach for her inputs and support writing this document. Finally, we would like to thank USAID for support-ing the development of this guidance, especially Elaine Gray, Jeniece Alvey, and Lindy Fenlason.


AcronymsANC antenatal care

BMI body mass index

BRAC Building Resources across Communities

CLA collaborating, learning, and adapting

COVID-19 novel coronavirus

DHS Demographic and Health Survey

FAO Food and Agriculture Organization

HMIS health management information systems

IFA iron-folic acid

IVR interactive voice response

LBW low birthweight

MCHN Maternal and Child Health and Nutrition

MICS Multiple Indicator Cluster Survey

MIYCAN maternal, infant, young child and adolescent nutrition

PNC postnatal care

QI quality improvement

TWG technical working group

UNAP Uganda Nutrition Action Plan

USAID U.S. Agency for International Development

WASH water, sanitation, and hygiene

WHO World Health Organization

WRA women of reproductive age


CHECKLIST: STEP-BY-STEP GUIDANCE ON ADDING/ADAPTING MATERNAL NUTRITION INTERVENTIONS

1. Complete a situation analysis by collecting, reviewing,and synthesizing quantitative and qualitative data

a Determine what information and data are available on maternal nutrition for your context

a Collect additional data needed for program or activity design

a Review existing programming, country guidance, and government strategies

a Synthesize the data collected and develop a situation analysis

2. Identify maternal nutrition health sector prioritiesto develop an implementation plan

a Identify potential collaborators and/or partners, including relevant technical working groups

a Work with a multi-stakeholder team to identify maternal nutrition implementation priorities, and roles and responsibilities of key stakeholders

a Create a theory of change and/or logical framework

a Develop or adapt your program or activity’s implementation plan

3. Implement, monitor, reflect on and adjust maternalnutrition programming

a Implement the program, monitor progress, and regularly collect and analyze data on indicators

a Using monitoring data, reflect on progress and adjust interventions accordingly


INTRODUCTION

Optimal maternal nutrition during the first 1,000 days (the period from conception to a child’s second birth-day) is critically important to improve nutritional status and health outcomes for women and their infants and also to reduce the risk of adverse birth outcomes, such as low birthweight (LBW) and preterm birth (Black et al. 2008). Yet many women of reproductive age (WRA) in low- to middle-income countries, especially girls entering adolescence, suffer from micronutrient defi-ciencies and infections that make them thin, stunted, or anemic. Data from 62 studies in low-and middle-in-come countries in Africa, Asia, and Latin America and the Caribbean found inadequate micronutrient intakes and low dietary diversity among pregnant and lactating women (Lee et al. 2013).

Maternal stunting (height <145 centimeters) and underweight (low body mass index [BMI]) during early pregnancy are associated with increased risk of poor fetal growth. Deficiencies in calcium and zinc during pregnancy are associated with preterm birth, while iron deficiency anemia during pregnancy is associated with LBW (Black et al. 2013). The 2007 and 2011 Lancet series found that LBW infants with intrauterine growth restriction are at significant developmental risk—in-cluding lower cognitive scores, poorer problem-solving skills, and behavioral issues (Walker et al. 2007; Walker et al. 2011). Children who are malnourished are more likely to become adolescents and adults who are mal-nourished, contributing to a vicious cycle.

Moreover, many girls begin childbearing before they reach full height and weight (Thurnham 2013). Ad-olescent pregnancy is associated with a 50 percent increased risk of stillbirths and neonatal deaths, and an increased risk of low birth weight, premature birth, asphyxia, and maternal mortality (Bhutta et al. 2013; World Health Organization [WHO] 2007). In addition, the risk of stunting is 36 percent higher among first-born children of girls under 18 years in South Asia and 33 percent higher in sub-Saharan Africa—indicating that early motherhood is a key driver of malnutrition and suboptimal well-being (Fink et al. 2014). A life cycle approach to program planning includes improving nu-trition among pre-pregnant adolescents, and promoting delayed marriage and childbearing until after the ado-lescent years. Box 1 provides more information about what is unique about adolescent nutrition.

While many programs targeting the first 1,000 days fo-cus efforts on infant and child health benefits and out-comes of nutrition interventions, maternal diet during pregnancy and lactation, weight gain during pregnancy,

and iron-folic acid and calcium supplementation have received less attention. The lack of program implemen-tation experience and data regarding maternal nutrition interventions created a gap in understanding how to in-tegrate maternal nutrition interventions in the planning and designing of health programs and projects.

This guidance document focuses primarily on health sector actions, but a multi-sectoral approach involving nutrition-sensitive sectors such as agriculture, edu-cation, and others is essential to achieve sustainable progress in maternal nutrition outcomes.

BACKGROUND

In 2019, the Maternal and Child Survival Program, fund-ed by the U.S. Agency for International Development (USAID), produced the publication, Maternal Nutrition Operational Guidance: Program Considerations for Low- and Middle-Income Countries (Kavle, Picolo, and Dillaway 2019). This document describes how to design, imple-ment, and strengthen the delivery of maternal nutrition interventions in the health system. In 2020, USAID Advancing Nutrition tested the operational guidance and its corresponding checklist in collaboration with the USAID Maternal Child Health and Nutrition Activity in Uganda. Based on this experience, and input and feedback provided during an external consultation, USAID Advancing Nutrition developed this updated guidance. This version incorporates a program planning process, as well as additional information on collecting

BOX 1. UNIQUE NUTRITIONAL NEEDS OF

ADOLESCENTS

Adolescence is a period of developmental change. Adolescents experience significant physiological changes, such as physical growth, puberty, and sexual maturation. This rapid physical growth creates increased demand for nutrients and energy (Das et al. 2017; Christian and Smith 2018). Anemia is a serious concern; 16–54 percent of older adolescent girls and 23–36 percent of older adolescent boys are anemic (Benedict, Schmale, and Namaste 2018). Last, adolescence is a key life stage for determining eating habits in adulthood; adolescent food choices, eating frequency, and exposure to food environments at home, school, and the workplace are predictive of adult eating practices (Winpenny et al. 2018). For these reasons, it is important to understand and address the unique nutritional needs of adolescents. The USAID Advancing Nutrition Adolescent Resource Bank provides a collection of multi-sectoral resources for donors, government agencies, and practitioners on programming for nutritional needs of adolescents.

https://www.advancingnutrition.org/resources/adolescent-resource-bank

https://www.advancingnutrition.org/resources/adolescent-resource-bank


and synthesizing data—and developing or adapting an implementation plan. Throughout this document, ma-ternal nutrition refers to key actions leading to positive maternal nutrition outcomes during pregnancy and lactation.

HOW CAN THIS GUIDANCE HELP YOU?

This updated guidance provides step-by-step recom-mendations to add or strengthen maternal nutrition components in programs or services delivered by the health system, including actions to strengthen the overall health system and the enabling environment. After using this document, you will have developed or adapted your program or activity’s implementation plan based on maternal nutrition priorities identified.

FOR WHOM IS THIS GUIDANCE?

This guidance is for nongovernmental organizations working closely with government counterparts and other practitioners who seek to strengthen maternal nutrition services at the facility or community level, or to improve the enabling environment for maternal nutrition.1 You do not have to be an expert in nutrition to use this guidance, but you should include nutrition experts in the design process.

HOW SHOULD YOU USE THIS GUIDANCE?

We designed this guidance for use by a country-based team, with expertise in the following areas—

• program planning and implementation with healthor nutrition interventions specific to the countryor region of focus

• knowledge of and relationships with multi-sectoralnutrition stakeholders in the government, amongdonors, and among implementing partners in thecountry

• knowledge of and experience with data collectionmethods and synthesis.

Involve stakeholders throughout the process, including reaching agreement on maternal nutrition implementa-tion priorities and roles and responsibilities.

1 The enabling environment in this context refers to evidence-based national policies, financial investment, and nutrition governance.

This guidance uses a three-step process:

1. Complete a situation analysis by collecting, review-ing and synthesizing data.

2. Identify maternal nutrition health sector prioritiesto develop an implementation plan.

3. Implement, monitor, reflect on, and adjust maternalnutrition programming.

The details of these steps reflect common components of USAID-funded programs; however, the processes can be adapted to fit a government planning approach or that of another donor. To complement the steps, the annexes provide global guidance on maternal nutrition, illustrative approaches to improve maternal nutri-tion, key indicators to track, and additional tools and resources. Not all guidance will be applicable to every program, so tailor the steps to your program’s specif-ic needs. After using this guidance intensively during program or activity planning, return to it again several months later to assess progress and adjust implementa-tion as needed.

WHEN SHOULD YOU USE THIS GUIDANCE? HOW LONG IS THE PROCESS?

Ideally, review this guidance three to six months before planning your new program or activity. However, you can also apply relevant recommendations to your existing program design and adaptation processes. For example, conduct the process before the work plan cycle or during annual reviews.

The first two steps may take two to three weeks of effort—longer if substantial data collection is required. Step three requires sustained effort over the course of your project. The amount of time required for each step will depend on the availability of maternal nu-trition data, new data collection needs and formative research efforts, and the availability of other stakehold-ers for joint planning.


1. COMPLETE A SITUATION ANALYSIS BYCOLLECTING, REVIEWING, AND SYNTHESIZINGQUANTITATIVE AND QUALITATIVE DATA

The first step to designing or adapting maternal nutrition components in your program or activ-ity is to understand the prevalence of indicators

of maternal malnutrition in your area, contributing fac-tors, and opportunities to improve nutrition and health outcomes. This lays the foundation for developing a situation analysis describing trends in maternal nutri-tion for your geographic focus, the determinants of maternal nutrition (e.g., intrahousehold food allocation and gender/social norms), and the status and quality of available health and nutrition services. This involves gathering existing data, collecting additional data if information is not available, and synthesizing data. By the end of this step, you will be able to identify which intervention approaches could have the biggest impact

on maternal nutrition. If you need additional informa-tion and should collect new data, it will take more time to complete this step.

Key steps:

• Determine what information and data are availableon maternal nutrition for your context

• Collect additional data needed for program oractivity design

• Review existing programming, country guidance, and government strategies

• Synthesize the data collected and develop a situa-tion analysis

Kate Holt/MCSP


STEP 1

Determine What Information and Data are Available on Maternal Nutrition for Your Context

Before undertaking data collection, start by assessing what information—both quantitative and qualitative—is available on maternal nutrition for the audience in your context. Begin by discussing and coordinating data needs and availability with your program’s government counterparts, and creating a plan for collecting, review-ing and synthesizing the data in partnership with them. It is also important to understand the strength of ex-isting government platforms and services your program will build upon, including existing quality improvement (QI) processes.

A wide variety of factors influence maternal nutrition, including actions that directly affect nutritional status and actions that indirectly affect nutrition outcomes (e.g., when nutrition outcomes are a secondary benefit) (Heidkamp et al. 2021). Examine several areas to understand the state of maternal nutrition in your context and how best to approach improving it (Box 2). Focus on a select number of priority areas given your

program or activity’s scope and objectives and your country context.

The situation for adolescent girls and young mothers may be quite different from older women. For each of the priority areas in Box 2, disaggregate quantita-tive data for adolescents, if possible. Additionally, seek qualitative data on specific knowledge, attitudes, and practices for adolescent girls and mothers.

You will likely need to consult several different sources to find data and literature on the maternal nutrition priority areas. Potential data sources include—

• the most recent Demographic and Health Survey(DHS) and reports

• UNICEF’s Multiple Indicator Cluster Survey (MICS)

• national micronutrient surveys

• Malaria Indicators Surveys

• the Ministry of Health’s National Health Manage-ment Information System

• the District Health Information System

• maternal and community health registers

BOX 2. MATERNAL NUTRITION PRIORITY AREAS FOR DATA COLLECTION

• Anemia prevalence and causes (e.g., micronutrientdeficiency, infection, or genetic abnormalities)

• Antenatal care (ANC) and postnatal care (PNC)service coverage, use, and service quality– Content and quality of facility and community-

based counseling on maternal nutrition– Multiple micronutrient supplementation including

iron-folic acid (IFA)– Measurement of gestational weight gain– Quality assurance and quality improvement

protocols and efforts in place

• Breastfeeding practices (e.g., early initiation ofbreastfeeding, mother-infant skin-to-skin contact)

• Family dynamics and social norms around the use andprovision of services, gender-based violence, householddivision of labor during pregnancy, and shared decision-making about household resources and seeking healthcare treatment

• Maternal diet during pregnancy and lactation– Availability, affordability, and use of fortified,

biofortified, and local nutrient-dense foods– Diet-related cultural or religious practices and/or

food beliefs

• Prevalence of underweight, overweight, and short staturein pregnant women and women of reproductive age

• Prevalence of underlying disease burdens that have animpact on maternal nutrition (e.g., malaria, HIV, andpoor maternal mental health)

• Safe motherhood– proportion of babies delivered at health facilities– proportion of babies delivered by a skilled birth

attendant– proportion of babies delivered via cesarean section– proportion of babies delivered pre-term, proportion

of babies that are small-for-gestational age– proportion of babies that are low birth weight– proportion of mothers with pre-eclampsia

• Supportive enabling environment (e.g., availability ofpolicies, protocols supportive of maternal nutrition, sufficient training and capacity of the health workforce)

• Women’s empowerment (e.g., autonomy, decision-making power and intrahousehold food allocation, time allocation, access to and control over income, leadership)

https://dhsprogram.com/

https://data.unicef.org/resources/resource-type/datasets/

https://dhsprogram.com/methodology/survey-types/mis.cfm


STEP 1

• National Bureau of Statistics household surveys

• national or subnational surveys, or research con-ducted by projects/partners and/or universities.

Potential data sources for dietary data include the Food and Agriculture Organization (FAO)/WHO Glob-al Individual Food Consumption Data Tool, the Global Dietary Database, and the Food Systems Dashboard. Annex 1 contains examples of key indicators for mater-nal nutrition to track and potential data sources.

Although national data are often easier to access than subnational and disaggregated data, determine whether there are data specific to your geographic programming area and whether disaggregated data are available (e.g., by age, race or ethnicity, wealth quintile, rural vs. ur-ban). Disparities often exist in intervention coverage by geography and place of residence. If reliable disaggregat-ed data at the district or sub-district level do not exist, consider conducting new data collection or referring to reliable data sources at the national or provincial level.

Collect Additional Data Needed for Program or Activity Design

Gathering available data and information on maternal nutrition will likely reveal missing quantitative and/or qualitative data useful for designing or adapting mater-nal nutrition components in your program or activity. Given your timeline and resources, consider what data you can feasibly collect in a reliable and valid way. You can build the collection of additional data into the base-line study for a new program, or make it part of routine program monitoring or a special study in an ongoing program. Consider conducting formative research to understand the challenges, and identify feasible actions people are willing and able to take in support of mater-nal nutrition in your context, and the motivations for and barriers to action. Box 3 provides tips and consid-erations for conducting formative research.

It may not be possible to collect data in-person in some countries or regions because of health or safety considerations. However, rates of phone access in many low- and middle-income countries exceed 80 percent, making mobile technology a viable method for collect-ing survey data. Mobile surveys are automated, inexpen-sive, and fast. There are three main modes to consider:

• short message service (SMS) that uses text messaging

• interactive voice response (IVR) or automatedvoice surveys

• computer-assisted telephone interviewing, whichuses a live interviewer.

BOX 3. FORMATIVE RESEARCH FOR MATERNAL

NUTRITION

Conduct formative research to understand the context and behaviors leading to maternal nutrition outcomes, and the factors that prevent or support the behaviors. Formative research enables you to understand such factors as social and gender norms, food preferences and beliefs, influential people on maternal nutrition, trusted sources of information and services, and available support to mothers. What you learn will help tailor your activities and interventions to improve maternal nutrition.

Formative research should include mothers, and family members such as mothers-in-law, as well as other influential community members including health workers, traditional providers, farmers and vendors, and/or local leaders. Choose formative research participants who can give the greatest insight on maternal nutrition practices, and who need to lend their support or influence to change existing practices. Aim to speak with a diverse group of women in terms of age, nutritional status, sociodemographic profiles (education, employment, income level), ethnic, tribal, and religious groups, and urban versus rural residents.

Tailor your formative research methods based on your research questions. In-depth interviews and key informant interviews will allow for the greatest amount of privacy to learn about current practices and perceptions, but these methods are also more time and resource intensive. Group interview methods and focus group discussions are appropriate methods when asking about social norms, general beliefs, or potential solutions, but it is often challenging to have group discussions with participants of differing ages, socioeconomic status, or other factors. Trials of improved practices is a useful formative research approach to identify and test new practices and factors that prevent or support the behaviors with participant groups.

When analyzing the results of your formative research, separate the findings by gender, age, socioeconomic factors (e.g., religious or cultural group), location (urban versus rural), and respondent type. This will allow you to look for differences in the types of considerations respondents discuss, the challenges they describe, and the words they use. Word frequencies or word clouds can help summarize many responses. Use the results to develop strategies targeting family and community members who are influential in maternal nutrition, and mothers themselves. For more resources on formative research and qualitative data collection, consult Annex 3.

http://www.fao.org/gift-individual-food-consumption/data-and-indicator/en/


https://www.globaldietarydatabase.org/


https://foodsystemsdashboard.org/


STEP 1

SMS and IVR are feasible on almost every device world-wide. (Refer to Annex 2. Resources on Programming in the Context of COVID-19 for additional resources on mobile surveys and alternatives to in-person data collection.)

QUALITY OF COUNSELING

You may encounter a lack of data on the quality of counseling, the availability and quality of job aids, or other maternal nutrition priority areas at the health facility level. Conducting a health facility observation or a review of health facility records will help capture activities typically not documented at the facility level, such as counseling and cooking demonstrations. Use a health facility assessment to gather data from patient records to assess the level and quality of counseling, the presence and use of social and behavior change materials and job aids, and the availability of commod-ities. Annex 3 provides links to tools and resources that can be adapted to your context.

DIETARY DIVERSITY

For more information on the quality of women’s diets, collect data on dietary intakes, food frequency, food availability, and/or seasonal variability using established indicators. (See Annex 3 for resources.) If applicable, use the Minimum Dietary Diversity for Women indica-tor as a population-level measure of the micronutrient adequacy of women’s diets (FAO 2021). Collecting data on women’s diets can be a resource-intensive process because it requires interviews or surveys to collect information on the different food groups consumed

during a specific period. However, these data will allow you to understand an important dimension of women’s diet quality (FAO 2021).

OTHER FACTORS INFLUENCING MATERNAL NUTRITION

Consider collecting data on social and gender norms, and beliefs, knowledge, and perceptions about mater-nal diet and weight gain during pregnancy—especially dietary intake and dietary diversity. Knowledge and attitudes do not automatically translate to the uptake of behaviors due to factors such as time, availability and affordability of nutritious food, and social, gender, and religious norms. Understanding factors that prevent or support maternal nutrition behaviors is critical to program design, including providers’ behaviors and norms around service provision. Collect these data us-ing quantitative (e.g., household surveys) or qualitative methods (e.g., focus group discussions, key informant interviews). Examine both supportive and potentially harmful values, norms, and knowledge about maternal nutrition. Annex 3 contains additional resources on collecting qualitative data

GENDER ANALYSIS

Conduct a gender analysis to identify and understand gaps between men, women, boys and girls, and the relevance of gender norms and power relations in your context. The Gender Analysis Toolkit for Health Systems can help you think through gender-related barriers and opportunities for improving maternal nutrition (Jhpiego 2020).

Karen Kasmauski/MCSP

https://gender.jhpiego.org/analysistoolkit/



STEP 1

Review Existing Programming, Country Guidance, and Government Strategies

In addition to collecting missing data, it is important to have a full picture of national and subnational guidance and strategies, and of the existing/previous maternal nutrition programming. Review key government docu-ments, including national health and nutrition policies and action plans (including multi-sectoral nutrition), ANC guidelines, nutrition and HIV guidelines, commu-nity health policies, the latest strategic plans, quality of care or quality improvement strategies or guidance, and national health priorities. Keep in mind key global guidance on maternal nutrition (listed in Annex 4) and look for any gaps.

Consider how maternal nutrition is addressed outside of the health sector, and whether it is addressed in strategies or guidance produced for other sectors, such as agriculture and livestock, water, sanitation, and hygiene (WASH), gender, family, social protec-tion, education, and livelihoods strengthening sectors. Intervening in the health system is only one way to improve maternal nutrition, so it is critical to coor-dinate and design complementary efforts with other sectors. Sectoral actions indirectly targeting nutrition outcomes (e.g., WASH, education, agriculture, and pov-erty) have been associated with national reductions in stunting and maternal anemia (Heidkamp et al., 2021). Box 4 presents an example from the USAID Maternal and Child Health and Nutrition (MCHN) Activity in Uganda, which reviewed several national strategies

BOX 4. CASE STUDY: USAID MCHN ACTIVITY IN UGANDA

As part of the USAID MCHN activity’s baseline data collection and program planning, the team reviewed national guidance and government strategies covering maternal nutrition to understand existing maternal nutrition priorities and to identify gaps and areas for strengthening. The team reviewed documents such as the Government of Uganda’s Maternal, Infant, Young Child, and Adolescent Nutrition Guidelines, National Anemia Policy, Maternal Nutrition Guidelines for Uganda, and the Uganda Nutrition Action Plan II. The team also searched for program reports and peer-reviewed literature on the status of pregnant and lactating women in Uganda, including qualitative reports on knowledge, attitudes, and practices, and previous surveys conducted over the past five years. Although the team did not identify relevant multi-sectoral guidelines, other sectors were included through key informant interviews.

In addition to conducting a desk review, the MCHN Activity conducted key informant interviews with program planners and implementers, staff from the ministries of health, agriculture, and gender, and others. Questions included—

• What are the current maternal nutrition priorities inthe district/department/project?

• Which maternal nutrition interventions/activitiesare you currently implementing in your department, district/division, or program/project?

• What challenges have you encountered inimplementing maternal nutrition priorities in yourdistrict/department/project?

• What kind of support do you need to overcome eachchallenge mentioned?

• Are there costs associated with maternal nutritioninterventions that make it difficult to carry them out?

• How has the situation in maternal nutrition changedover the past five years?

• How has high migration from rural areas affected yourcapacity to deliver maternal nutrition services?

• How is the situation changing in relation to COVID-19?

• What are some adaptations you have made to servicedelivery in response to the COVID-19 pandemic?

• Have you encountered any challenges with capacityand staffing for delivery of maternal nutrition activities/services?

Resources and interviews provided an overall picture of national policies and strategies addressing maternal nutrition, and of existing nutrition activities carried out by the government and other agencies. By the end of this work, the MCHN Activity in Uganda had a clearer sense of the current policy and programming landscape, and could begin to understand how its activity could fill existing gaps and strengthen ongoing efforts. For more details on this MCHN Activity case study, consult USAID Advancing Nutrition’s report, Recommended Maternal

Nutrition Implementation Priorities for Uganda.

https://www.advancingnutrition.org/resources/recommended-maternal-nutrition-priorities-uganda-findings-maternal-nutrition-operational

https://www.advancingnutrition.org/resources/recommended-maternal-nutrition-priorities-uganda-findings-maternal-nutrition-operational


STEP 1

and conducted key informant interviews as part of its baseline data collection and program planning efforts.

Collect information on existing maternal nutrition pro-gramming to ensure your activity or program builds on experiences to date and addresses any programmatic gaps. Consider requesting information from donor and government agencies, reviewing program evaluations, or arranging key informant interviews to understand available programs/services, who is implementing them, access, coverage, quality, demand, and strengths/weak-nesses of existing programs/services (CORE Group Nutrition Working Group, Food and Nutrition Techni-cal Assistance III Project, and Save the Children 2015).

Synthesize the Data Collected and Develop a Situation Analysis

Next, compile the data and information you gathered to see the complete picture of maternal nutrition in your area. Everyone who participated in previous data gathering, new data collection, formative research, and document review—including government coun-terparts—should reconvene to present their findings. Refer back to the list of suggested maternal nutrition priorities in Box 2 and discuss which are of greatest concern in your programming area. Discuss how to interpret the findings as a group. There is no “right answer,” so consider all data sources, especially the qualitative research findings.

Some questions to consider when synthesizing data are—

• Are there disparities in women’s nutritional statusand access or use of services among certaingroups? Are there differences in practices or beliefsamong groups? What changes have occurred overtime in nutritional status, service coverage, etc.?

• Which groups experience the greatest amountof risk for maternal nutrition challenges? Whichgroups are least likely to access services? Will weneed specific strategies to reach them?

• How do other factors, such as seasonal variations, climate-related disasters, disease outbreaks, andconflict, affect maternal nutrition? How can weaddress these factors?

• Which maternal nutrition priority behaviors needto be improved? Among which groups? What arethe barriers and enabling factors that prevent orsupport these priority behaviors? For example, how do community or household gender-relatedfactors (including gender-based violence) andcultural or religious factors prevent or supportwomen from using services?

• Who has influence and decision-making powerin the household and community? Who needs totake action to reduce the barriers to maternalnutrition and increase support? For example, whoneeds to provide more resources or food to preg-nant and lactating woman and when?

Depending on your program or organization’s needs, you may choose to summarize your findings in a brief report. Annex 2 provides additional tools and resourc-es on conducting a situation analysis.

Karen Kasmauski/MCSP


2. IDENTIFY MATERNAL NUTRITION HEALTHSECTOR PRIORITIES TO DEVELOP ANIMPLEMENTATION PLAN

Equipped with a better understanding of maternal nutrition in your geographic programming area, you are ready to begin step two: identifying ma-

ternal nutrition priorities for the health sector based on the information collected and synthesized in the prior step. Understanding if maternal nutrition priori-ties exist at the national or sub-national level for your geographic area of interest will help you develop and align your implementation plan to existing efforts.

This highly participatory step will likely require a few meetings or workshops (in-person or virtual, given current health and safety considerations)—including a full-day workshop with representatives from potential collaborators/partners and government counterparts. A separate meeting with program or activity staff will help to develop or adapt your implementation plan.

During this step, you will create an implementation plan for maternal nutrition with agreed upon roles and responsibilities, indicators, program objectives and a timeline.

Key steps:

• Identify potential collaborators and/or partners, including relevant technical working groups

• Work with a multi-stakeholder team to identifymaternal nutrition implementation priorities, androles and responsibilities of key stakeholders

• Create a theory of change and/or logical framework

• Develop or adapt your program or activity’simplementation plan

Kate Holt/MCSP


Identify Potential Collaborators and/or Partners, Including Relevant Technical Working Groups (TWGs)

Your desk review and situation analysis identified other programs and agencies working on maternal nutrition. List these potential collaborators and partners, includ-ing government representatives and TWGs, and identify which ones to invite to your discussion about mater-nal nutrition implementation priorities. Also include representatives from the health sector implementing family planning and reproductive health activities and programs supporting infant and child health; these are opportunities to make contact with mothers re-garding their own well-being. Consider other rele-vant multi-sectoral stakeholders to engage, including agriculture and livestock; WASH, gender, family, social protection, and education; and livelihoods strengthening programming. In addition, consider potential partners working in humanitarian assistance, development, gov-ernment, the private sector, civil society, and academia.

Work with a Multi-Stakeholder Team to Identify Maternal Nutrition Implementation Priorities, and Roles and Responsibilities of Key Stakeholders

Host a full-day workshop that includes members of your own program or activity staff, and representatives of potential collaborators/partners such as government, donors, district health teams, health facilities, commu-nity health providers, non-governmental organizations, etc. The aim of the workshop will be to identify the

maternal nutrition implementation priorities for your geographic programming area, the specific roles and responsibilities of each stakeholder, and a theory of change to identify the necessary conditions to meet to achieve the implementation priorities. Box 5 includes potential maternal nutrition implementation priori-ties within the health sector, identified by the USAID MCHN Activity in Uganda.

Start by presenting the results of your situation analy-sis, and the gaps and areas for strengthening identified in current strategies, policies, and programming. Devel-op prioritization criteria in advance of the workshop and agree on these criteria with workshop participants. Potential criteria could include—

• whether an activity meets an essential need, de-mand, sustainability, coverage, cost-effectiveness, andresources required/resources available to implement

• whether an intervention relates to or builds onexisting efforts

• the comparative advantage of the agency or partner.

Bring the results of the comparison you did in Step 1 of global guidance and national guidelines/policies, if applicable. Discuss the gaps to fill to align with current best practices. Meeting participants may reach different conclusions about the maternal nutrition implementa-tion priorities for your area, so leave sufficient time for a participatory, consensus-based discussion. Annex 5 provides sample agenda items for your workshop.

STEP 2

Kate Holt/MCSP


STEP 2

BOX 5. POTENTIAL MATERNAL NUTRITION IMPLEMENTATION PRIORITIES

The USAID MCHN Activity aligned their priorities with the Government of Uganda’s existing priorities for maternal nutrition, outlined in two guidelines—the Maternal, Infant, Young Child and Adolescent Nutrition (MIYCAN) Guidelines and the Uganda Nutrition Action Plan (UNAP) II. These priorities included—

UNAP II Maternal Nutrition Priority ActionsObjective 1: Increase access to and utilization of nutrition-specific services by children under 5 years of age, adolescent girls, pregnant and lactating women and older persons

Strategy 1.1: Promote optimal MIYCAN practices Priority Actions— • Promote and support health and nutrition education to

increase the level of awareness of good nutrition

• Promote integration of nutrition services in all routine and outreach health services and programs targeting children and mothers

• Manage nutrition for sick children, pregnant and lactating mothers, and other women of reproductive age

• Integrate the management of severe and moderate acute malnutrition into routine health services

• Promote utilization of antenatal and postnatal care services among all pregnant and lactating mothers to monitor child growth, and the health and nutrition status of both the mother and the child

• Promote and support breastfeeding policies, programs, and initiatives.

Strategy 1.2: Promote micronutrient intake among children and womenPriority Actions— • Avail iron-folic acid supplementation for pregnant women

• Promote storage and consumption of iodized salt

• Promote the consumption iron-(bio)fortified staple foods

• Promote the consumption of home-based fortified foods.

MIYCAN Maternal Nutrition Priority Actions • Educate and counsel women on adoption of

healthy eating behaviors during pregnancy and the breastfeeding period

• Promote physical activity/exercise during pregnancy and the breastfeeding period

• Prevent and control common micronutrient deficiencies

• Prevent and control malaria and hookworm infestations among pregnant women and breastfeeding mothers.

By examining existing priorities and assessing gaps, the USAID MCHN Activity identified the following 12 initial priorities, which were refined and prioritized as follows:

• Increase advocacy for maternal nutrition

• Conduct costing for nutrition activities, including maternal nutrition

• Strengthen the use of nutrition data at facility and community levels

• Strengthen multi-sectoral coordination between government and implementing partners at national and district levels

• Strengthen capacity of health facilities and community health workers to provide maternal nutrition services.

The USAID MCHN Activity team organized a virtual workshop with key program staff to incorporate select priorities in its work plan for the next year. The team first discussed how the priorities corresponded with the Activity’s overall purpose—to strengthen government performance in implementing strategies to improve maternal and child health and nutrition outcomes.

The team agreed that priorities three and four corresponded with the project’s objectives to strengthen leadership and governance, roll out national strategies and programs, and ensure coordination and cooperation among stakeholders. By the end of this step, the MCHN Activity team added activities to its work plan that aligned with the maternal nutrition priorities, including—

• strengthening capacity in the use of data at facility/community levels of the health system

• facilitating coordination between technical working groups in the Ministry of Health

• supporting the Ministry of Health with a position paper to increase the supply of maternal nutrition commodities.

The USAID MCHN Activity and USAID Advancing Nutrition disseminated recommended maternal nutrition implementation priorities for Uganda via a webinar, which included representatives from organizations implementing maternal nutrition interventions across the country. Representation from the Ministry of Health participated in the panel discussion and emphasized that the country’s new MIYCAN Action Plan captures many of the identified priorities. For those recommendations not included in the MIYAN, there is opportunity to incorporate them into annual sub-national implementation plans.


STEP 2

By the end of the meeting, map out each stakeholder’s programming areas (including at the national/enabling environment level), interventions, timelines, and staffing, and discuss how to coordinate and align efforts, roles, and responsibilities. This will facilitate joint planning of interventions, phasing of approaches, and complemen-tary—rather than duplicative—efforts.

Create a Theory of Change and/or Logical Framework

You may choose to use a theory of change methodology to map how you and other stakeholders will achieve the maternal nutrition implementation priorities. For more details on creating a theory of change, see Annex 6.

Develop or Adapt your Program or Activity’s Implementation Plan

Equipped with agreed-upon maternal nutrition imple-mentation priorities, a theory of change pathway for maternal nutrition, and a clear picture of your program or activity’s role, you can develop or align your im-plementation plan to reflect your maternal nutrition priorities.

This includes costing the interventions and activities in your plan. Understanding the costs associated with conducting nutrition activities will enable you to deter-mine which investments are most appropriate given the context and resources available. Allocating sufficient budget throughout your program and aligning your costing with the government cycle and budget can help ensure uptake, buy-in, and sustainable financing after your program is complete.

Another critical component of your implementation plan is your approach for monitoring and evaluation, for which you will need to identify—

• indicators to track progress

• how elements of adaptive management will be incorporated in your monitoring and evaluation design

• how often collaborating, learning, and adapting (CLA) reflections will take place, if applicable.

Refer to Annex 1 for examples of maternal nutrition indicators to track such as anemia prevalence, IFA consumption, prevalence of underweight in WRA, ma-ternal diet, breastfeeding practices, and the underlying disease burden among WRA, among others. Monitoring

costs during the life of your program—including staff salaries, trainings, meetings, consultants, supplies, etc. and linking these to specific outputs and outcomes (e.g., the number of people trained, the proportion that increased dietary diversity, etc.)—will provide you with stronger reporting and evaluation data. This helps you measure cost-efficiency or effectiveness of comparable interventions so the most appropriate intervention can be scaled up—and may foster greater support of your activities and results, and greater government owner-ship, particularly across multi-sectoral programming (R4D 2019).

You may need to convene your program or activity team, including team members with expertise in moni-toring and evaluation, costing, program managers, tech-nical team leads, and your finance and operations team. The aim of this meeting will be to agree on your pro-gram objectives, activities, timeframe, and the resources needed for implementation. (See Annex 7 for more information on what to include in your implementation plan.) Your objectives could range from advocacy for maternal nutrition at the national level, to improve-ment of existing maternal nutrition interventions at health facilities, to the introduction of community-level programming for maternal diet and/or maternal anemia. Box 7 lists illustrative key interventions to strengthen maternal nutrition through the health system. If your program or activity already has an implementation plan, consider revising and updating it based on your mater-nal nutrition implementation priorities.

Once finalized, organize a meeting to present and vet your implementation plan with key stakeholders at national or subnational levels, depending on your program’s geographic reach. Continue to meet with the partners and stakeholders identified previously, and dis-cuss joint progress and opportunities for coordination.

BOX 6: PEOPLE-CENTERED HEALTH SERVICES

Participatory approaches to defining problems and solutions can provide better grounding for the design of interventions and tools and generate more sustainable results. People-centered health services consciously adopt the perspectives of individuals, families, and communities and place them at the center of the design and implementation process (WHO 2015). People-centered care includes engaging individuals and their families with empathy, focusing on the individual and their needs, rather than diseases and illness.


STEP 2

BOX 7. ILLUSTRATIVE APPROACHES TO IMPROVE MATERNAL NUTRITION THROUGH

THE HEALTH SYSTEM

Intervening in the health system is only one way to improve maternal nutrition; some interventions like counseling on diet will only achieve so much without complementary efforts from other sectors. For example, providing access to safe, quality, and nutritious foods requires more than solely intervening at the levels described below, but helps women act on counseling they receive. Coordinate and engage with other sectors (i.e., agriculture and livestock, WASH, gender, family, social protection, education, and livelihoods strengthening programming), to ensure women have access to diverse, affordable foods and that the needs of women in humanitarian and fragile settings are met. For more examples of evidence-based interventions to improve maternal nutrition, consult the USAID Technical Guidance Brief on Maternal Nutrition for Girls and Women (2015).

National/Regional and Enabling Environment Level:

Advocate and work with government counterparts to—• Develop or update guidelines on maternal nutrition

in key policy and strategic documents—includingmulti-sectoral strategies and action plans—to reflectglobal guidance.

• Include sessions on maternal nutrition in pre-serviceand in-service training curricula for health workersand community health volunteers.

• Plan for and finance maternal nutrition-relatedservices and activities, and include maternal nutritionin national multi-year development plans andsectoral plans.

• Strengthen national and subnational capacity tocollect, analyze, interpret, and use maternal nutritiondata for planning and decision-making, especially inhealth management information systems (HMIS).

• Strengthen multi-sectoral coordination by linkingnutrition and maternal health programs, as well aswith the agriculture and livestock sector, WASH, gender, family, social protection, education, andlivelihoods strengthening programming.

• Reinforce supply chains for maternal nutritioncommodities to prevent stock-outs and ensurematernal nutrition commodities are on essentialdrug lists.

• Conduct costing for nutrition activities, includingmaternal nutrition.

• Develop policies that support women, such as familyleave policies, availability of childcare, etc.

Health Facility Level:

Advocate and work with government counterparts to—• Strengthen the capacity of health facilities to provide

maternal nutrition services during ANC, deliverycare, PNC, and other contacts by providing jobaids, necessary commodities, health worker trainingand refresher training, and supportive supervision/mentorship.

• Strengthen the capacity of community health workersto provide maternal nutrition services during ANC, delivery care, PNC, and other contacts.

• Develop culturally tailored, simple counselingmaterials on maternal diet, and monitoring andassessing weight gain for use during routine visits(that emphasize small, doable actions).

• Train health providers, such as nurses, localnutritionists, and midwives, in counseling all familymembers on what foods to consume before andduring pregnancy and lactation and why (based onnecessary energy, protein, micronutrients, and fattyacids, including fortified staple foods and condiments), according to the local cultural context. Includesessions on problem solving with family members, active listening techniques, empathy, and role-playing.

• Train health providers on assessing weight gainduring pregnancy; counseling on the optimal useof IFA, multiple micronutrient supplementation, orcalcium supplements, including the management ofside effects; and counseling pregnant women on earlyinitiation and exclusive breastfeeding.

• Address beliefs health providers may hold regardingmaternal dietary intake and weight gain duringpregnancy through training and onsite mentoringto provide local, culturally appropriate solutionsto improve the quality of counseling and servicedelivery.

• Strengthen the quality of maternal nutrition servicesat health facilities by supporting continuous qualityimprovement.

Community Level:

Advocate and work with community-based counterparts to—• Engage grandmothers, fathers, and other key


STEP 2

influencers (e.g., religious and community and faith-based leaders) to support mothers, for example, by reducing mothers’ workload during pregnancy, ensuring mothers have access to diverse diets, providing adequate opportunity for rest, and accompanying mothers during ANC contacts.

• Use home visits, mother-to-mother support groups, peer groups, and/or community support groups todiscuss and resolve challenges faced by women inachieving optimal maternal nutrition and potentialsolutions.

• Incorporate maternal nutrition and well-being ininfant and young child feeding counseling and othercommunity platforms by emphasizing the importanceof adequate diet and dietary diversity, adequate restand social support, for example, for pregnant andlactating women.

• Incorporate maternal nutrition and well-being incommunity early childhood development programs.

• Use mass, social, or community media (e.g., radio, TV, video) and mobile technologies to address suchfactors as social norms and family support that preventor support priority maternal nutrition behaviors(identified through formative research).

• Encourage adolescent girls to consume diverse andiron-rich diets through school-based platforms andyouth groups.

• Promote the completion of secondary school for girlsand delaying marriage and childbearing until after theage of 19.

• Strengthen links between communities and healthcenters, and engage community members and healthworkers in defining and improving the quality ofmaternal nutrition services.

• Partner with community-level programs including non-nutrition programs and other community stakeholdersto promote maternal nutrition—especially amongwomen and girls and those influencing them at thehousehold and community levels, such as mothers-in-law, men/partners, and other relatives.

Individual Level:

Advocate and work with community-based counterparts to—• Conduct outreach to engage mothers and adolescent

girls (who will be utilizing services) and outreachto engage men/partners, mothers-in-law, and otherinfluencers of women and girls at the household andcommunity levels.

• Provide context-specific counseling to mothers onhealthy eating and keeping physically active duringpregnancy to promote a healthy pregnancy, taking intoaccount local availability and access to diverse andnutritious foods.

• Support women’s agency and improved couples’communication, with the aim of the more equitabledivision of household labor and income and jointdecision-making around health and care seeking.

• Ensure adequate opportunities for rest duringpregnancy and lactation by implementing programsthat promote a more equitable division of labor at thehousehold level.

• Identify social norms and individual attitudes and beliefsthat influence food choices and perceptions aboutappropriate weight gain during pregnancy and dietaryintake before and during pregnancy and lactationthrough formative research assessments.

Kate Holt/MCSP


3. IMPLEMENT, MONITOR, REFLECT ON AND ADJUST MATERNAL NUTRITION PROGRAMMING

This step consists of implementing your program or activity; continually monitoring to assess progress and or unintended consequences;

reflecting on the results of your monitoring, and adapt-ing your implementation approach for continuous QI. Adjust your program or activity’s maternal nutrition interventions on what you learn during implementation. Understand how your activity is progressing by regu-larly collecting and analyzing data and through specific learning activities. Box 8 provides an example from the

Alive & Thrive program in Bangladesh, which incorpo-rated regular data monitoring and adaptation as part of its implementation approach.

Key steps:

• Implement the program, monitor progress, and regularly collect and analyze data on indicators

• Using monitoring data, reflect on progress and adjust interventions accordingly

Kate Holt/MCSP


STEP 3

Implement the Program, Monitor Progress, and Regularly Collect and Analyze Data on Indicators

As you design activities and develop materials for implementation, involve participants (e.g., mothers, ado-lescent girls, and their influencers at the household and community levels) in all phases using a human-centered design approach. Building upon what you learned from formative research, involve audience members in the process from conception through implementation to incorporate locally defined needs, ideas, and resources. This includes concept testing, pretesting, dissemination and use of materials, and monitoring. This involves listening to and learning from mothers, adolescent girls, and their influencers before introducing information. The starting point is the community’s perspective—rather than the expert’s information.

During implementation, regularly monitor for changes in your selected indicators to determine whether you are achieving what you expected. Collecting process data will allow you to identify and prevent harmful unintended consequences, understand the quality of program implementation, and change the course of the intervention mid-implementation. Use existing data systems as much as possible and avoid creating parallel systems. For example, many health systems already have QI systems in place. Understand the strength of current platforms and services and determine how to use existing systems in your data collection efforts.

Consider monitoring key process indicators, such as—

• attendance and coverage of facility and communi-ty-level interventions

• quality of implementation and adherence to protocols

• acceptability of delivery approaches by mothers, adolescent girls, and other participant

• groups (e.g., health workers, family members, com-munity or religious leaders)

• perceived benefits and experiences of people implementing the intervention(s) (e.g., community health workers or health facility staff)

• benefits or negative consequences perceived by mothers targeted for the intervention(s).

Collect process data on a regular basis using staff re-ports and routine program data, or conduct implemen-tation research to assess how intervention is occurring and inform how to change course mid-implementation. Implementation research could include an observation-al study, surveys of health workers and women, focus

groups, or other qualitative methods. Implementation outcome variables can include acceptability, adoption, feasibility, cost, coverage and sustainability to provide insights into how the implementation contributes to improved maternal nutrition.

Using Monitoring Data, Reflect on Progress and Adjust Interventions Accordingly

Monitoring your data can enable adaptive manage-ment—“an intentional approach to making decisions and adjustments in response to new information and changes in context” (USAID 2018). Organize “pause and reflect sessions” for your program or activity’s staff to gather information and discuss progress, challenges, and suc-cesses in implementation, and opportunities to improve. Share analyzed process data or anecdotal findings during your sessions. Support health workers and community members to engage in quality improvement at the ser-vice delivery level, and be part of the process of learning and adapting the program approach (Lovich et al. 2003).

Pause and reflect sessions can provide useful infor-mation to make decisions about implementation, and can be part of a larger CLA framework. Use a CLA framework to apply learning across your entire program cycle, including the organizational culture, processes, and resources (USAID 2016). For example, monitoring may show an increase in IFA consumption in one geographic area and a corresponding decrease in anemia prevalence, while a neighboring area may show no change or a decrease in IFA consumption. Pause and reflect sessions can help you examine and discuss what is working better in the first area versus the second, and adjust implemen-tation accordingly. Many different activities can be con-sidered pause and reflect opportunities—an in-person after action review meeting, a Google Document journal that is open for staff input on a quarterly basis. The im-portant thing is the intention for thinking and learning.

Based on what you learn mid-implementation and during purposeful learning activities, consider opportu-nities to change interventions, update the implementa-tion plan, increase or discontinue certain approaches, or modify staffing plans. Annex 2 lists several resources on adaptive management. You have reached the end of this guidance document, but that does not mean the process of implementation, monitoring, and adaptation is finished! We hope this guidance is useful to strength-en maternal nutrition interventions in your program or activity. Consult the annexes for additional tools and resources, and links to program reports from previous maternal nutrition programs as you continue to reflect on implementing, monitoring and adapting your mater-nal nutrition interventions.


STEP 3

BOX 8. CASE STUDY: ALIVE & THRIVE

BANGLADESH

Alive & Thrive collaborated with Building Resources across Communities (BRAC), a nongovernmental organization in Bangladesh, to integrate a comprehensive package of maternal nutrition interventions in a broader health and nutrition program. A comprehensive situation analysis informed the program design, including a review of national policies and strategies, existing data and research, analysis of nutrition indicators, and new formative research efforts to understand the factors preventing or supporting maternal nutrition behaviors as well as food intake patterns among pregnant women.

Based on the results of the situation analysis, and in collaboration with national parliament members and local union council representatives, Alive & Thrive and BRAC identified the following maternal nutrition priorities—

• improving dietary practices

• increasing intake of IFA and calcium supplements during pregnancy and lactation

• improving breastfeeding practices.

Alive & Thrive’s implementation approach used the socioecological model of behavior change, reaching not only mothers but also fathers/male partners, mothers-in-law, and other community members with three key interventions: home visits, community mobilization, and mass communication.

Throughout implementation, Alive & Thrive and BRAC regularly conducted monitoring for sustainable, quality performance. They conducted routine monitoring through randomly selected household visits and verification of health facility registers, and helped the program understand whether it was achieving its expected results and to document the implementation process for replication and scale-up. Indicators the program monitored included—

• enrollment of eligible women

• service quality (through observation)

• practices of frontline workers interviewed (e.g., home visit made, relevant messages given)

• outcomes (e.g., women’s dietary diversity, dietary intake, IFA and calcium adherence, weight gain during pregnancy, optimal breastfeeding practices).

Collecting this information routinely allowed program staff to make adjustments mid-implementation. Alive & Thrive used monthly performance checklists of frontline workers and registers for home visits to determine the topics for monthly refresher training and supportive supervision visits. Monitoring also helped identify which sub-districts were falling behind with enrolling eligible women and in conducting home visits so that the program could reallocate staff. It also led to a greater emphasis on reaching fathers, religious leaders, doctors, and local opinion leaders with community mobilization efforts. Alive & Thrive’s use of routine monitoring as part of a broad measurement, learning, and evaluation approach ensured the successful scale-up of the maternal nutrition package of interventions. It also led to positive changes in maternal nutrition outcomes in Bangladesh.

Sources: Alive & Thrive 2017; Nguyen et al. 2017

Asafuzzaman Captain for ACDI/VOCA


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R4D. 2019. How Evidence Informs Decision-Making: The Scale-Up of Nutrition Actions Through an Early Childhood Development Platform in Malawi. Accessed August 16, 2021. https://r4d.org/wp-content/uploads/SEEMS-Malawi-case-study-final-combined-version.pdf

Thurnham, David I. 2013. “Nutrition of Adolescent Girls in Low and Middle Income Countries.” Sight and Life. 27(3): 26–37. Accessed May 21, 2021. https://sightandlife.org/wp-content/uploads/2017/04/Sight_and_Life_27_1_2013-1.pdf

USAID LEARN. 2016. “CLA Framework & Key Concepts.” Accessed August 17, 2021. https://usaidlearninglab.org/sites/default/files/resource/files/cla_maturity_matrix_overview_final.pdf.

USAID. 2018. “Discussion Note: Adaptive Management.” Accessed May 21, 2021. https://pdf.usaid.gov/pdf_docs/PBAAJ032.pdf.

USAID. 2020. On the Journey to Self-Reliance: Transitioning Nutrition Financing from USAID to Domestic Resources. Accessed August 16, 2021. https://www.advancingnutrition.org/resources/journey-self-reliance-transitioning-nutrition-financing-usaid-domestic-resources

Walker, S.P., T.D. Wachs, J.M. Gardner, B. Lozoff,, G.A. Wasserman, E. Pollitt, J.A Carter, International Child Development Steering Group. 2007. “Child Development: Risk Factors for Adverse Outcomes in Developing Countries. The Lancet 369(9556):145–57. DOI.org/10.1016/S0140-6736(07)60076-2.

Walker, S.P., T.D. Wachs, S. Grantham-McGregor, M.M. Black, C.A. Nelson, S.L. Huffman, H. Baker-Henningham, S.M. Chang, J.D. Hamadani, B. Lozoff, J.M. Gardner, C.A. Powell, A. Rahman, L. Richter. “Inequality in Early Childhood: Risk and Protective Factors for Early Child Development. The Lancet 378(9799):1325–38. DOI.org/10.1016/S0140-6736(11)60555-2.

World Health Organization. 2007. Adolescent Pregnancy: Unmet Needs and Undone Deeds. Accessed May 21, 2021. https://www.who.int/maternal_child_adolescent/documents/discussion/en/.

World Health Organization. 2015. WHO Global Strategy on People-Centred and Integrated Health Services. Accessed August 17, 2021. https://apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_eng.pdf

Winpenny, Eleanor M., Stephanie Greenslade, Kirsten Corder, and Esther M. F. van Sluijs. 2018. “Diet Quality through Adolescence and Early Adulthood: Cross-Sectional Associations of the Dietary Approaches to Stop Hypertension Diet Index and Component Food Groups with Age.” Nutrients 10 (11): 1585. https://doi.org/10.3390/nu10111585.

https://doi.org/10.3945/jn.117.257303

https://doi.org/10.3945/jn.117.257303

https://r4d.org/wp-content/uploads/SEEMS-Malawi-case-study-final-combined-version.pdf

https://r4d.org/wp-content/uploads/SEEMS-Malawi-case-study-final-combined-version.pdf

https://sightandlife.org/wp-content/uploads/2017/04/Sight_and_Life_27_1_2013-1.pdf

https://sightandlife.org/wp-content/uploads/2017/04/Sight_and_Life_27_1_2013-1.pdf

https://usaidlearninglab.org/sites/default/files/resource/files/cla_maturity_matrix_overview_final.pdf

https://usaidlearninglab.org/sites/default/files/resource/files/cla_maturity_matrix_overview_final.pdf

https://pdf.usaid.gov/pdf_docs/PBAAJ032.pdf

https://pdf.usaid.gov/pdf_docs/PBAAJ032.pdf

https://www.advancingnutrition.org/resources/journey-self-reliance-transitioning-nutrition-financing-usaid-domestic-resources

https://www.advancingnutrition.org/resources/journey-self-reliance-transitioning-nutrition-financing-usaid-domestic-resources

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60076-2/fulltext



https://www.who.int/maternal_child_adolescent/documents/discussion/en/

https://apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_SDS_2015.6_eng.pdf

https://doi.org/10.3390/nu10111585

https://doi.org/10.3390/nu10111585


Annex 1. Key Maternal Nutrition Indicators and Data SourcesThis table provides examples of key maternal nutrition indicators to examine during your data collection efforts and potential data sources. Be sure to consider HMIS data in your country prior to external sources.

INDICATOR POTENTIAL DATA SOURCES

Anemia prevalence and causes and IFA consumption

Prevalence of anemia in women of reproductive age (15–49 years) and severity— • Any: Hemoglobin (Hb) < 11 g/dl for pregnant women; Hb < 12 g/dl for non-pregnant women • Mild: Hb 10.0–10.9 g/dl for pregnant women; 11.0–11.9 g/dl for non-pregnant women • Moderate: Hb 7.0–9.9 g/dl for pregnant women; Hb 8.0–10.9 g/dl for non-pregnant women • Severe: Hb < 7.0 g/dl for pregnant women; Hb < 8.0 g/dl for non-pregnant women

DHS

Micronutrient intake among mothers— • Women with a birth in the past five years who received a vitamin A dose in the first two months

after delivery • Women with a birth in the past five years who took no iron (folic acid) tablets or syrup • Women with a birth in the past five years who took iron tablets or syrup for <60 days • Women with a birth in the past five years who took iron tablets or syrup for 60–89 days • Women with a birth in the past five years who took iron tablets or syrup for 90+ days

DHS

% of women who received a hemoglobin test in their last pregnancy DHS, MICS-6

Supplementation among mothers— • % of women with a birth in the past five years who took multiple micronutrient supplementation

daily during pregnancy • % of women with a birth in the past five years who took small-quantity lipid-based nutrient

supplements daily during pregnancy

Program records (in certain contexts)

Prevalence of underweight and overweight in pregnant women and women of reproductive age

% of women ages 15–49 with height below 145 cm DHS

% of non-pregnant, non-postpartum women ages 15–49 by nutritional status based on specific body mass index levels— • Women who are thin according to BMI (<18.5) • Women with normal BMI (18.5–24.9) • Women who are overweight or obese according to BMI (>=25.0)

DHS

% of women with a low mid-upper arm circumference (<22.5) Health facility records

% of women who gain weight in the last two trimesters of pregnancy within the recommended range for their weight status

Service statistics, ANC cards, or other clinic-based records; samples of home or community-based records reviewed

Maternal diet during pregnancy and lactation

% of mothers who receive counseling on maternal diet during ANC DHS-8*

Minimum dietary diversity for women—% of women 15–49 years achieving dietary diversity (who consumed at least five out of ten defined food groups the previous day or night)

DHS-8*, FAO STAT

% of women 15–49 years consuming sweet beverages DHS-8*

% of women 15–49 years consuming unhealthy foods DHS-8*

Average food consumption (in grams per person per day) FAO STAT

Average percentage contribution of different foods to the total consumption—in daily diet FAO STAT, Global Dietary Database, Food Systems Dashboard

Breastfeeding practices

% of last-born children born in the past 2 years who started breastfeeding within one hour of birth DHS

% distribution of youngest children under 2 years who are living with their mother who are exclusively breastfeeding

DHS


INDICATOR POTENTIAL DATA SOURCES

Prevalence of underlying disease burdens

% of mothers of children 0–59 months of age who took deworming medication during the pregnancy

DHS

% of mothers of children 0–59 months of age who received intermittent preventive treatment for malaria during the pregnancy for their last live birth

DHS

Prevalence of malaria infection measured using microscopy Malaria Indicator Survey

% of women ages 15–49 who gave birth in the 2 years preceding the survey who were counseled and tested for HIV

DHS

ANC/PNC contacts

% of women with a birth in the last 5 years, distributed by highest type of provider of ANC for most recent birth

DHS

% of women with a birth in the last 5 years receiving ANC from a skilled provider for the most recent birth

DHS, MICS-6

% of women with a birth in the last 5 years, distributed by number of ANC visits for the most recent birth

DHS, MICS-6

% of women with a birth in the last 5 years, distributed by number of months pregnant at the time of the first ANC visit for the most recent birth

DHS

% of women screened for malnutrition in ANC Health facility records

% of women receiving 1st ANC contact before 12 weeks gestation Health facility records

Among women giving birth in the 2 years preceding the survey, percent distribution of the mother’s first postnatal check for the most recent live birth by time after delivery

DHS, MICS-6

% of women with a live birth in the 2 years preceding the survey who received a postnatal check 2 days after giving birth

DHS, MICS-6

Safe motherhood

% of live births in the past 5 years delivered in a health facility DHS

% of births in the 5 years preceding the survey that were assisted by a skilled provider DHS

% of live births in the 5 years preceding the survey delivered by caesarean section DHS

% of live births in the 5 years preceding the survey weighed at birth reported as less than 2.5 kg DHS

Other factors that prevent or support maternal nutrition

% of women receiving food or cash assistance during last pregnancy DHS-8*

% of women and men ages 15–49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances— • she goes out without telling him • she neglects the children • she argues with him • she refuses sex with him • she burns the food.

DHS, MICS-6

% of women who make decisions about their own health care independently or jointly with their husband/partner

DHS-8*

*DHS-8 Modules will be released in late 2021 and these data are not expected for several years.

SOURCESCroft, Trevor N., Aileen M. J. Marshall, Courtney K. Allen, et al. 2018. Guide to DHS Statistics. Rockville, Maryland, USA: ICF.

FAO and WHO. 2021. “Global Individual Food Consumption Data Tool.” Accessed May 21, 2021. http://www.fao.org/gift-individual-food-con-sumption/data-and-indicator/en/.

FAO. 2021. “FAOSTAT.” Accessed May 21, 2021. http://www.fao.org/faostat/en/#home

GAIN and Johns Hopkins University. 2021. “Food Systems Dashboard.” Accessed May 21, 2021. https://foodsystemsdashboard.org/

Global Dietary Database. 2021. “Global Dietary Database.” Accessed May 21, 2021. https://www.globaldietarydatabase.org/

MEASURE Evaluation. 2020. “MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database–Women’s Nutrition.” Accessed May 21, 2021. https://www.measureevaluation.org/prh/rh_indicators/womens-health/womens-nutrition.

UNICEF. 2021. “MICS6 Indicators and Definitions.” Accessed August 19, 2021. https://mics.unicef.org/tools



http://www.fao.org/faostat/en/#home

https://foodsystemsdashboard.org/


https://www.measureevaluation.org/prh/rh_indicators/womens-health/womens-nutrition.

https://mics.unicef.org/tools


Annex 2. Additional Tools and ResourcesMATERNAL NUTRITION EVIDENCE AND LITERATURE REVIEWS

Black, Robert E., Cesar G .Victora, Susan P. Walker, Zulfiqar A. Bhutta, Parul Christian, Mercedes de Onis, Majid Ezzati, et al.. 2013. “Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries.” The Lancet 382 (9890):427–451. https://doi.org/10.1016/S0140-6736(13)60937-X.

Black, Robert, Lindsay H. Allen, Zulfiqar A. Bhutta, Laura E. Caulfield, Mercedes de Onis, Majid Ezzati, Colin Mathers, et al. 2008. “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences.” The Lancet 371 (9608): 243–60. https://doi.org/10.1016/S0140-6736(07)61690-0.

Duffy, M., S. Lamstein, C. Lutter, and P. Koniz-Booher. 2015. Review of Programmatic Reponses to Adolescent and Women’s Nutrition Needs in Low and Middle Income Countries. Arlington, VA: Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

Kavle, Justine A. and Megan Landry. 2017. “Addressing Barriers to Maternal Nutrition in Low‐and Middle‐Income Countries: A Review of the Evidence and Programme Implications.” Maternal & Child Nutrition 14(1): e12508. https://doi.org/10.1111/mcn.12508.

Keats, Emily C., Jai K. Das, Rehana A. Salam, Zohra S. Lassi, Aamer Imdad, Robert E. Black, and Zulfiqar A. Bhutta. 2021. “Effective Interventions to Address Maternal and Child Malnutrition: An Update of the Evidence.” The Lancet 5(5), 367–384. https://doi.org/10.1016/S2352-4642(20)30274-1.

Lamstein, S., T. Stillman, P. Koniz-Booher, A. Aakesson, B. Collaiezzi, T. Williams, K. Beall, and M. Anson. 2014. Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Findings from a Systematic Literature Review. Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

Maternal and Child Survival Program. 2017. “MCSP Nutrition Brief: Addressing Barriers to Maternal Nutrition: Evidence and Program Considerations.” Accessed May 21, 2021. https://www.mcsprogram.org/wp-content/uploads/2017/05/MCSPNutritionBriefBarriersToMaternalNutrition-1.pdf.

Nguyen, Phuong, Edward Frongillo, Tina Sanghvi, Gargi Wable Grandner, Zeba Mahmud, Lan Tran, Bachera Aktar, et al. 2018. “Engagement of Husbands in a Maternal Nutrition Program Substantially Contributed to Greater Intake of Micronutrient Supplements and Dietary Diversity during Pregnancy: Results of a Cluster-Randomized Program Evaluation in Bangladesh.” The Journal of Nutrition 148 (Suppl 1):1352–1363. doi.org/10.1093/jn/nxy090.

Nguyen, Phuong H., Tina Sanghvi, Sunny S. Kim, Lan M. Tran, Kaosar Afsana, Zeba Mahmud, Bachera Aktar, et al. 2017. “Factors Influencing Maternal Nutrition Practices in a Large Scale Maternal, Newborn and Child Health Program in Bangladesh.” PLoS ONE 12(7): e0179873. https://doi.org/10.1371/journal.pone.0179873.

U.S. Agency for International Development (USAID). 2015. “Maternal Nutrition for Girls and Women: Technical Guidance Brief.” Washington, DC: USAID

Victora, Cesar G., Parul Christian, Luis Paulo Vidaletti, Giovanna Gatica-Domínguez, Purnima Menon, and Robert E. Black. 2021. “Revisiting Maternal and Child Undernutrition in Low-Income and Middle-Income Countries: Variable Progress Towards an Unfinished Agenda.” The Lancet 397(10282):1388–1399. https://doi.org/10.1016/S0140-6736(21)00394-9.

https://doi.org/10.1016/S0140-6736(13)60937-X

https://doi.org/10.1016/S0140-6736(07)61690-0

https://doi.org/10.1111/mcn.12508

https://doi.org/10.1016/S2352-4642(20)30274-1

https://www.mcsprogram.org/wp-content/uploads/2017/05/MCSPNutritionBriefBarriersToMaternalNutrition-1.pdf

https://www.mcsprogram.org/wp-content/uploads/2017/05/MCSPNutritionBriefBarriersToMaternalNutrition-1.pdf

https://academic.oup.com/jn/article/148/8/1352/5040613

https://academic.oup.com/jn/article/148/8/1352/5040613

https://doi.org/10.1371/journal.pone.0179873

https://doi.org/10.1016/S0140-6736(21)00394-9.

https://doi.org/10.1016/S0140-6736(21)00394-9.


RESOURCES ON SCALING UP MATERNAL NUTRITION PROGRAMS

Alive & Thrive. 2018. How to: A Guide to Maternal Nutrition Programming. Dhaka, Bangladesh: Alive & Thrive. Accessed May 24, 2021. https://www.aliveandthrive.org/en/node/10270

Alive & Thrive. 2017. Implementation Manual: Community-Based Maternal Nutrition Program, Bangladesh. Dhaka, Bangladesh: Alive & Thrive.

SOCIAL AND BEHAVIOR CHANGE TOOLS AND RESOURCES, INCLUDING THE ENABLING ENVI-RONMENT

ACCELERATE Project, The Manoff Group. n.d. “Behavior Profile: Pregnancy Daily Intake.” Accessed August 17, 2021. https://thinkbigonline.org/share/EFFBFD490117465C9D4D4A5873C4A6D6.

ACCELERATE Project. n.d. “Behavior Profile: Pregnancy Diet Diversity.” Accessed August 17, 2021. https://thinkbigonline.org/share/05A8DD0E1377468EBA8877A86FDBB9AD.

Alive & Thrive. 2019. Nutrition for Pregnant and Lactating Women: Key Points to Remember. India: Alive & Thrive.

Alive & Thrive. 2017. Tools for Delivering Maternal Nutrition Programs, Catalogue. Dhaka, Bangladesh: Alive & Thrive.

ENN, GOAL, LSHTM, Save the Children, and collaborators. 2018. “C-MAMI Tool, Version 2.” Accessed May 21, 2021. www.ennonline.net/c-mami.

Institute for Reproductive Health, Georgetown University. 2020. The Social Norms Exploration Tool. Washington, DC: The Passages Project.

Sethuraman, Kavita, Tara Kovach, Lesley Oot, A. Elisabeth Sommerfelt, and Jay Ross. 2018. Manual for Country-Level Nutrition Advocacy Using PROFILES and Nutrition Costing. Washington, DC: FHI 360/Food and Nutrition Technical Assistance III Project (FANTA).

USAID Advancing Nutrition. 2021. Social and Behavior Change Resources for Women’s Healthy Diets: 5 Gaps and Recommendations. Arlington, VA: USAID Advancing Nutrition.

USAID Advancing Nutrition. 2020. Social and Behavior Change Do’s and Don’ts: Getting It Right for Multi-Sectoral Nutrition Programming. Arlington, VA: USAID Advancing Nutrition.

USAID Advancing Nutrition. 2020. Prioritizing Multi-Sectoral Nutrition Behaviors. Arlington, VA: USAID Advancing Nutrition.

USAID Advancing Nutrition. 2020. Program Guidance on Engaging Family Members in Improving Maternal and Child Nutrition. Arlington, VA: USAID Advancing Nutrition.

USAID Advancing Nutrition. 2020. Behaviors to Improve Nutrition. Arlington, VA: USAID Advancing Nutrition.

WHO. 2012. “Global Database on the Implementation of Nutrition Action (GINA).” Geneva, Switzerland: WHO.

https://www.aliveandthrive.org/en/node/10270

https://thinkbigonline.org/share/EFFBFD490117465C9D4D4A5873C4A6D6

https://thinkbigonline.org/share/05A8DD0E1377468EBA8877A86FDBB9AD

https://thinkbigonline.org/share/05A8DD0E1377468EBA8877A86FDBB9AD

https://www.ennonline.net/c-mami


SITUATION ANALYSIS AND PROGRAM PLANNING RESOURCES AND EXAMPLES

Compass. n.d. “How to Conduct a Situation Analysis.” Accessed May 21, 2021. https://www.thecompassforsbc.org/how-to-guides/how-conduct-situation-analysis.

FAO (Food and Agriculture Organization of the United Nations). 2018. “Online Course: How to Conduct a Nutrition Situation Analysis.” Rome: FAO.

UNICEF (United Nations Children’s Fund). 2014. Approach to Nutrition Programming in the East Asia and Pacific Region: Situation Analysis. Bangkok, Thailand: UNICEF.

Wageningen University and Research. 2012. “Multi-stakeholder Partnerships: Make a Visual Theory of Change.” Accessed May 21, 2021. http://www.mspguide.org/tool/make-visual-theory-change.

ADAPTIVE MANAGEMENT RESOURCES

Bond. 2016. “Adaptive Management: What It Means for CSOs.” Accessed May 21, 2021. https://www.bond.org.uk/resources/adaptive-management-what-it-means-for-csos.

Ross, Joey, Ami Karlage, James Etheridge, Mayowa Alade, Jocelyn Fifield, Christian Goodwin, Katherine Semrau, et al. 2021. Adaptive Learning Guide: A Pathway to Stronger Collaboration, Learning, and Adapting. Washington, DC: USAID MOMENTUM.

USAID LEARN. 2016. “CLA Framework & Key Concepts.” Washington, DC: USAID LEARN.

USAID. 2018. “Discussion Note: Adaptive Management.” Washington, DC: USAID Bureau for Policy, Planning and Learning.

RESOURCES ON PROGRAMMING IN THE CONTEXT OF COVID-19

Breakthrough ACTION and USAID Advancing Nutrition. 2020. “Guidance on SBC for Nutrition During COVID-19: Technical Brief.” Accessed May 21. 2021. https://Covid19communicationnetwork.org/Covid19resource/guidance-on-sbc-for-nutrition-during-Covid-19-technical-brief/.

World Food Programme, UNICEF, Global Nutrition Cluster, and GTAM. 2020. “Protecting Maternal Diets and Nutrition Services and Practices in the Context of COVID-19.” Accessed May 21, 2021. https://www.nutritioncluster.net/Protecting_Maternal_Diets_and_Nutrition_Services_and_Practices_Covid-19.

MATERNAL NUTRITION PROGRAM REPORTS AND BRIEFS

Alive & Thrive. 2018. “Integrating Proven Maternal Nutrition Interventions Into Antenatal Care Programs: How We Can Optimize Strengths and Avoid Missed Opportunities in India.” Accessed May 21, 2021. https://www.aliveandthrive.org/en/resource/integrating-proven-maternal-nutrition-interventions-antenatal-care-programs-how-we-can.

Maternal and Child Survival Program. 2019. “MCSP Nutrition Brief: Key Country Experiences in Addressing Maternal Nutrition through Nutrition-Health Integrated Programming.” Accessed August 19, 2021. https://www.mcsprogram.org/resource/nutrition-brief-key-country-experiences-in-addressing-maternal-nutrition-through-nutrition-health-integrated-programming/?_sfm_resource_topic=nutrition.

UNICEF (United Nations Children’s Fund). 2020. Nutrition, for Every Child: UNICEF Nutrition Strategy 2020–2030. New York: UNICEF.

USAID Advancing Nutrition. 2020. Recommended Maternal Nutrition Priorities for Uganda: Findings from the Maternal Nutrition Operational Guidance Field Test. Arlington, VA: USAID Advancing Nutrition.

https://www.thecompassforsbc.org/how-to-guides/how-conduct-situation-analysis

https://www.thecompassforsbc.org/how-to-guides/how-conduct-situation-analysis

http://www.mspguide.org/tool/make-visual-theory-change

https://www.bond.org.uk/resources/adaptive-management-what-it-means-for-csos

https://www.bond.org.uk/resources/adaptive-management-what-it-means-for-csos

https://Covid19communicationnetwork.org/Covid19resource/guidance-on-sbc-for-nutrition-during-Covid-19-technical-brief/

https://Covid19communicationnetwork.org/Covid19resource/guidance-on-sbc-for-nutrition-during-Covid-19-technical-brief/

https://www.nutritioncluster.net/Protecting_Maternal_Diets_and_Nutrition_Services_and_Practices_Covid-19

https://www.nutritioncluster.net/Protecting_Maternal_Diets_and_Nutrition_Services_and_Practices_Covid-19

https://www.aliveandthrive.org/en/resource/integrating-proven-maternal-nutrition-interventions-antenatal-care-programs-how-we-can



https://www.mcsprogram.org/resource/nutrition-brief-key-country-experiences-in-addressing-maternal-nutrition-through-nutrition-health-integrated-programming/?_sfm_resource_topic=nutrition




RESOURCES ON MULTI-SECTORAL APPROACHES TO NUTRITION

Scaling up Nutrition. 2021. “Scaling Up Nutrition (SUN) Toolkit on Multistakeholder Platforms (MSP) for Nutrition.” Accessed May 21, 2021. https://msptoolkit.scalingupnutrition.org/.

Brouwer, H., J.H.A.M Brouwers, Minu Hemmati, F. Gordijn, R.M. Herman Mostert, and J.L. Mulkerrins. 2017. The MSP Tool Guide: Sixty Tools to Facilitate Multi-stakeholder Partnerships. Wageningen, Netherlands: Wageningen University and Research.

ONLINE LEARNING COURSES

Nutrition International. 2021. “Maternal Micronutrient Supplementation: What Does it Take to Improve Adherence?” Accessed August 17, 2021. https://www.nutritionintl.org/learning-resource/maternal-micronutrient-supplementation-what-does-it-take-to-improve-adherence/

https://www.nutritionintl.org/learning-resource/maternal-micronutrient-supplementation-what-does-it-take-to-improve-adherence/

https://www.nutritionintl.org/learning-resource/maternal-micronutrient-supplementation-what-does-it-take-to-improve-adherence/


Annex 3. Collecting and Analyzing Maternal Nutrition DataThe following are examples of tools for collecting and analyzing quantitative and qualitative data on nutrition services in the health system. Adopt or adapt these tools for other country contexts.

HEALTH SERVICE ASSESSMENT TOOLS

TITLE AUTHOR(S) PURPOSE URL

Nutrition Service Delivery Assessment Tools for Hospitals and Centers in Uganda

FANTA III (Food and Nutrition Technical Assistance)

Assess the status and monitor the quality of implementation of nutrition services in health facilities in Uganda

https://www.fantaproject.org/tools/nutrition-service-delivery-assessment-tools-hospitals-and-health-centers-uganda

Program Review of Essential Nutrition Actions: Checklist for District Health Services

Sanghvi, Tina, Serigne Diene, John Murray, Rae Galloway, and Ciro Franco

Support district health teams to strengthen the nutrition components of their primary health care programs

https://pdf.usaid.gov/pdf_docs/Pnacw614.pdf

Service Provision Assessment The DHS Program Collect information on the overall availability of different facility-based health services in a country and its readiness to provide those services. This tool is undergoing a revision in 2021.

https://dhsprogram.com/methodology/Survey-Types/SPA.cfm

Service Availability and Readiness Assessment

Health Statistics and Information Systems, WHO

Assess and monitor the service availability and readiness of the health sector and to generate evidence to support the planning and managing of a health system

https://www.who.int/healthinfo/systems/sara_introduction/en/

QUALITATIVE DATA COLLECTION TOOLS AND GUIDANCE


Conducting Formative Research on Adolescent Nutrition: Key Considerations

USAID Advancing Nutrition

Provides key considerations for conducting formative research on nutrition behaviors with adolescents

Forthcoming

Designing by Dialogue: A Program Planners’ Guide to Consultative Research for Improving Young Child Feeding

The Manoff Group Shares tools to design, carry out, and analyze the results of formative, consultative research and to use them to design effective programs to improve infant and young child feeding

https://www.manoffgroup.com/wp-content/uploads/Designing-by-Dialogue.pdf

Formative Research: A Guide to Support the Collection and Analysis of Qualitative Data for Integrated Maternal and Child Nutrition Program Planning

CARE Provides basic information and tools needed to conduct and analyze qualitative research to improve maternal and infant and young child nutrition

https://www.fsnnetwork.org/resource/formative-research-guide-support-collection-and-analysis-qualitative-data-integrated

Guidance for Formative Research on Maternal Nutrition

USAID’s Infant & Young Child Nutrition Project

Provides specific information to help guide the development and design of a formative research process for a maternal nutrition program or intervention

http://www.iycn.org/resource/guidance-for-formative-research-on-maternal-nutrition/

Program Guidance on Engaging Family Members

USAID Advancing Nutrition

Offers practical recommendations for designing and adapting interventions that effectively engage family members in improving maternal and child nutrition

https://www.advancingnutrition.org/resources/program-guidance-engaging-family-members

Trials of Improved Practices Guide

The Manoff Group Provides an overview of the trials of improved practices technique to identify and test new practices and factors that prevent or support the behaviors with participant groups

https://www.manoffgroup.com/wp-content/uploads/summarytips.pdf

OTHER TOOLS FOR NUTRITION DATA COLLECTION AND ANALYSIS






























Collecting Data with Mobile Surveys in Low- and Middle-Income Countries During COVID-19

Charles Lau, RTI International

Provides recommendations on using mobilizing surveys as an alternative to face-to-face surveys

https://www.rti.org/insights/mobile-survey-data-collection-covid-19

District Assessment Tool for Anemia (DATA)

The SPRING Project, JSI Research & Training Institute, Inc.

Helps districts assess their current anemia situation and strengthen anemia programming at the district level

https://www.spring-nutrition.org/publications/tools/district-assessment-tool-anemia-data

Minimum Dietary Diversity for Women: An Updated Guide for Measurement

Food and Agriculture Organization of the United Nations

Defines and describes a food group diversity indicator for diet quality: micronutrient adequacy

http://www.fao.org/documents/card/en/c/cb3434en

Nutrition Reference Guide Catholic Relief Services, Chemonics, CORE Group

Provides organizations with a reference guide of nutrition-specific tools and approaches, information on how and when to use them, and special considerations for their use

https://coregroup.org/resource-library/nutrition-reference-guide/

Nutrition Program Design Assistant

CORE Group Nutrition Working Group, Food and Nutrition Technical Assistance III Project (FANTA), and Save the Children

Helps organizations design the nutrition component of their community-based maternal and child health, food security, or other development program. Includes quantitative and qualitative data collection tables for adaptation

https://www.fantaproject.org/tools/nutrition-program-design-assistant-npda

Tips for Collecting Primary Data in a COVID-19 Era

Overseas Development Institute

A web-based repository designed to bring together experiences and resources for collecting remote primary data in a COVID-19 era. Materials come from books, journal articles, newspaper articles, blogs, and webpages, and include experiences of conducting participatory, qualitative, and quantitative research, as well as potential ethical issues and how to approach them.

https://odi.org/en/publications/tips-for-collecting-primary-data-in-a-covid-19-era/

Women’s Empowerment in Agriculture Index (WEAI)

International Food Policy Research Institute, Oxford Poverty and Human Development Initiative, and USAID's Feed the Future

Provides a comprehensive and standardized measure to assess women’s empowerment and inclusion directly in the agricultural sector (WEAI). The Project WEAI seeks to measure women’s empowerment in project-specific contexts, and includes optional modules tailored to nutrition and health programs.

https://www.ifpri.org/project/weai




















Annex 4. Key Global Guidance on Maternal Nutrition Across the Life CycleThe following table summarizes key global guidelines on maternal nutrition. For more details on a specific recom-mendation and for context-specific recommendations, consult the original source listed in the third column. These guidelines are up-to-date as of July 2021. Please consult the World Health Organization website for the latest infor-mation on global guidelines.

TIME IN THE LIFE CYCLE

GLOBAL GUIDELINES SOURCE

Pre-pregnancy Daily iron supplementation for menstruating adult women and adolescent girls, living in settings where anemia is highly prevalent (40% or higher in this age group)

WHO 2016a

Eight key actions for improving adolescent nutrition—1. promoting healthy diets2. providing additional micronutrients through fortification of staple foods and targeted supplementation3. managing acute malnutrition4. preventing adolescent pregnancy and poor reproductive outcomes5. promoting preconception and antenatal nutrition 6. providing access to safe environment and hygiene 7. promoting physical activity8. disease prevention and management.

WHO 2018

Pregnancy Provide counseling on healthy eating (e.g., dietary diversity, balanced protein energy intake, and food quantity) and keeping physically active to stay healthy and prevent excessive weight gain

WHO 2016b

• Daily oral IFA supplementation with 30 to 60 mg of elemental iron and 400 μg (0.4 mg) of folic acid • If daily iron is not acceptable due to side effects, and in populations with anemia prevalence < 20%,

intermittent oral IFA supplementation with 120 mg of elemental iron and 2800 μg (2.8 mg) of folic acid once weekly

WHO 2016b

Antenatal multiple micronutrient supplements that include IFA, recommended in rigorous research WHO 2020a

Balanced energy-protein dietary supplementation, recommended in undernourished populations WHO 2016b

Daily calcium supplementation (1.5–2.0 g oral elemental calcium), in populations with low dietary calcium intake, and only in the context of rigorous research

WHO 2016b

Preventive anti-helminthic treatment is recommended for pregnant women after the first trimester as part of worm infection reduction programs, in endemic areas

WHO 2016b

Minimum of eight ANC contacts: one contact in the first trimester, two contacts in the second trimester, and five contacts in the third trimester

WHO 2016b

Monitor for adequate gestational weight gain over the duration of pregnancy. Recommended gestational weight gain varies depending on pre-pregnancy body mass index (BMI) category— • BMI <18.5: 12.7–18.2 kg • BMI 18.5–24.9: 11.4 kg–15.9 kg • BMI 25.0–29.9: 6.8 kg–11.4 kg • BMI ≥30: 5.0kg–9.1 kg

Rasmussen et al., 2009

Birth Delayed cord clamping from 1–3 minutes recommended for all births, while initiating simultaneous essential neonatal care.

WHO 2014

All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery

WHO 2017

Facilitate and encourage early and uninterrupted skin-to-skin contact between mothers and infants as soon as possible after birth.

WHO 2017

Mothers should receive practical support to enable them to initiate and establish breastfeeding and manage common breastfeeding difficulties, with additional support for establishing and maintaining milk supply for mothers of small and sick newborns.

WHO 2017, WHO 2020b

https://www.who.int/


TIME IN THE LIFE CYCLE

GLOBAL GUIDELINES SOURCE

Postnatal • If birth is in a health facility, mothers and newborns should receive PNC in the facility for at least 24 hours after birth

• If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth

WHO 2013

Minimum of three PNC contacts recommended for all mothers and newborns, on day 3 (48–72 hours), between days 7–14 after birth, and six weeks after birth

WHO 2013

Counsel mothers and provide support for exclusive breastfeeding at each postnatal contact. WHO 2013

Mothers should be counseled on nutrition, hygiene (especially handwashing), birth spacing and family planning, malaria prevention (if applicable), and adequate rest/exercise.

WHO 2013

Oral iron supplementation, either alone or in combination with folic acid, may be provided to postpartum women for 6–12 weeks following delivery for reducing the risk of anemia, in settings where gestational anemia is of public health concern

WHO 2016c

Integrate psychosocial interventions to support maternal mental health in early childhood health and development services

WHO 2020c

Quality of Care Quality statement 1.1b: Newborns receive routine care immediately after birth. WHO 2016d

Quality statement 1.1c: Mothers and newborns receive routine postnatal care. WHO 2016d

Quality statement 1.9: No woman or newborn subjected to unnecessary or harmful practices during labor, childbirth, and the early postnatal period.

WHO 2016b

SOURCES

Rasmussen, Kathleen M., Ann L. Yaktine, Institute of Medicine (US), and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines (Eds.). 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academies Press.

WHO (World Health Organization). 2013. WHO Recommendations on Postnatal Care of the Mother and Newborn. Geneva: World Health Organization.

WHO. 2014. Guideline: Delayed Umbilical Cord Clamping for Improved Maternal and Infant Health and Nutrition Outcomes. Geneva: World Health Organization.

WHO. 2016a. Guideline: Daily Iron Supplementation in Adult Women and Adolescent Girls. Geneva: World Health Organization.

WHO. 2016b. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: World Health Organization.

WHO. 2016c. Guideline: Iron Supplementation in Postpartum Women. Geneva: World Health Organization.

WHO. 2016d. Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. Geneva: World Health Organization.

WHO. 2017. Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: World Health Organization.

WHO. 2018. Guideline: Implementing Effective Actions for Improving Adolescent Nutrition. Geneva: World Health Organization.

WHO. 2020a. Nutritional Interventions Update: Multiple Micronutrient Supplements During Pregnancy. Geneva: World Health Organization.

WHO. 2020b. Protecting, Promoting and Supporting Breastfeeding: The Baby-Friendly Hospital Initiative for Small, Sick and Preterm Newborns. Geneva: World Health Organization.

WHO. 2020c. Improving Early Childhood Development: WHO Guideline. Geneva: World Health Organization.


Annex 5. Sample Agenda Items for Multi-Stakeholder Workshop 1. Briefly present findings from your maternal nutrition situation analysis.

2. Present suggested maternal nutrition priority recommendations based on your situation analysis, and discussalignment with existing government priorities and guidance on maternal nutrition.

3. Map out stakeholders’ existing programming areas, interventions, timelines, and staffing—and opportunitiesfor complementary efforts.

4. Develop a theory of change and logical framework to address the implementation priorities (See Annex 3).

5. Discuss roles, responsibilities, and a general timeline for agreed on maternal nutrition implementation priori-ties. Determine which activities to incorporate in your program or activity’s implementation plan.

6. Agree on a schedule for follow-up meetings and discussion.

Annex 6. Using a Theory of Change Methodology Using a theory of change methodology will help you map how you and other stakeholders will achieve the mater-nal nutrition implementation priorities you have identified. After you have identified the desired outcomes, work backwards to identify the “preconditions” or intermediate outcomes to reach. Rationales, or statements of why one outcome appears to be a prerequisite for another, explain the links between outcomes. At the end, you will have an “outcomes pathway” showing each outcome in a logical relationship to all the others, and a chronological flow. An example of a theory of change statement: If health worker capacity and motivation are strengthened, then the quality of ANC counseling will improve, and pregnant women will be more likely to complete the recommended number of ANC contacts.

Review more information and examples in the USAID LEARN article, “What is this thing called ‘Theory of Change?’”

Inputs Outputs Short-term outcome

Medium-term outcome

Long-term outcome

https://usaidlearninglab.org/lab-notes/what-thing-called-theory-change


Annex 7. Illustrative Implementation Plan OutlineI. Background

a. Country/Regional Contextb. Program/Activity Objectivesc. Theory of Change

II. Maternal Nutrition Priorities

III. Implementation Matrix

a. Activities/Interventionsb. Partners/Implementersc. Key Deliverablesd. Timelinee. Staff and Materials Needed

IV. Monitoring and Evaluation Plan

V. Emergency Protocols

USAID ADVANCING NUTRITION USAID Advancing Nutrition is the Agency’s flagship multi-sectoral Implemented by: nutrition project, addressing the root causes of malnutrition to JSI Research & Training Institute, Inc. save lives and enhance long-term health and development.2733 Crystal Drive4th FloorArlington, VA 22202

This document was produced for the U. S. Agency for Interna-tional Development. It was prepared under the terms of contract Phone: 703–528–7474

Email: [email protected] 7200AA18C00070 awarded to JSI Research & Training Institute, Web: advancingnutrition.org Inc. The contents are the responsibility of JSI and do not necessari-

ly reflect the views of USAID or the U.S. Government.September 2021

Kate Holt/MCSP

Documents

STRENGTHENING MATERNAL NUTRITION in Health Programs