The 2021 Lancet series underscores the importance of adequate maternal dietary intake alongside scale up of complementary interventions, such as multiple micronutrient and Ca supplementation, through national health systems(Reference Victora, Christian and Vidaletti1–Reference Keats, Das and Salam3). Supporting pregnancy and postnatal care (PNC) is seminal – as data indicate countries’ progress towards attaining World Health Assembly targets for maternal anaemia and low birth weight is slow(Reference Victora, Christian and Vidaletti1–Reference Osendarp, Akuoku and Black4).
Poor-quality diets, inadequate access and quality of essential nutrition health services and suboptimal diet-related behaviours and practices continue to hold back progress globally(Reference Lee, Talegawkar and Merialdi5–Reference Kavle and Landry7). Worldwide shifts from traditional diets towards greater consumption of unhealthy ‘junk’ foods, alongside sociocultural, economic and political factors, have contributed to a steady rise in the number of overweight (BMI > 25 kg/m2) and obese (BMI > 30 kg/m2) women from 69 to 390 million during 1975–2016(Reference Abarca-Gómez, Abdeen and Hamid8). The recent COVID-19 pandemic and the Ukraine–Russia war has further disrupted food systems and threatens to exacerbate poor-quality diets due to rising food prices, limited availability and access to nutritious foods, and an increasing reliance on cheap staples (i.e. cereals, roots and tubers) and ultra-processed foods in low- and middle-income countries (LMIC) (9–12). The 2022 State of Food Insecurity and Nutrition in the World (SOFI) report reveals that moderate or severe food insecurity disproportionately affects women more so than men, globally and across every region of the world(12). Underweight and anaemia are likely to worsen – which affects 170 and 520 million women, respectively(13).
While maternal nutrition is considered integral to the 1000-d window of opportunity, programming efforts have largely neglected maternal nutrition and focused on prevention and treatment of child undernutrition(Reference Jaacks, Kavle and Perry6,Reference Kavle and Landry7,Reference Fox, Davis and Downs14) . Maternal nutrition counselling during antenatal care (ANC) and PNC is a core WHO recommendation for all women, regardless of nutritional status(15). Yet, often counselling is not tailored to women’s nutritional needs and situations with the quality, intensity and frequency required to achieve meaningful improvements in nutrition outcomes through current programming efforts (i.e. healthy dietary intake and maternal nutritional status)(Reference Kavle and Landry7,Reference Kavle, Picolo and Dillaway16,Reference Shekar, Condo and Pate17) . Further, counselling on appropriate gestational weight gain is not adequately and consistently integrated as part of routine ANC in LMIC(Reference Kavle and Landry7). Recent meta-analyses reveal that excessive pregnancy weight gain is associated with higher risk of obesity, caesarean section and large-for-gestational age infants, while inadequate weight gain increases risk of delivering a small-for-gestational age infant(Reference Goldstein, Abell and Ranasinha18).
The objectives of this paper are to: (1) examine gaps in key elements of quality maternal nutrition counselling, including provider capacity building, frequency, content, and use of delivery platforms in low-, middle- and high-income countries and (2) offer programme considerations to strengthen delivery of maternal nutrition counselling.
Design and methods
A gap analysis was conducted on actual v. recommended elements of maternal nutrition counselling during pregnancy and lactation carried out globally. The analysis was comprised of a review of peer-reviewed and grey literature, followed by programmatic considerations. Elements related to quality maternal nutrition counselling are as follows: provider capacity building (i.e. interventions such as courses/tools for improving provider knowledge and/or counselling skills), frequency, content (i.e. counselling on maternal diet, weight gain during pregnancy and/or physical activity during ANC and/or PNC) and delivery platforms, based on evidence from several seminal papers, WHO recommendations and standards of care for ANC and PNC(15,Reference Torlesse, Benedict and Craig19–21) . These elements are described in a conceptual framework (see Fig. 1) which delineates key components of quality maternal nutrition counselling provided at routine facility and community ANC and PNC services.
Conceptual framework on elements related to quality maternal nutrition counselling delivered through facility and community routine health contacts. Bold-bordered boxes with * denote elements explored in this gap analysis
The search strategy was developed and included the following key words in various combinations of the Medical Subject Headings (MeSH) terms: ‘maternal nutrition’, ‘eating’, ‘maternal diet’, ‘maternal dietary intake’, ‘counseling’ and ‘health care’. Articles on counselling for micronutrient (i.e. iron folic acid supplementation) are excluded from this gap analysis, as this analysis focuses on specific, neglected areas of maternal nutrition counselling, inclusive of counselling on maternal diet, weight gain during pregnancy and physical activity(Reference Kavle and Landry7). PubMed, Cochrane Library, CINAHL Plus and Scopus databases were searched using the above key words, and libguides, opengrey.eu, greylit.org, greynet.org were perused for non-published, grey literature of programme reports published from January 2010 to December 2021. Quantitative, qualitative and mixed methods studies were included in the final gap analysis, based on the quality of evidence presented in the studies.
The initial search resulted in 506 peer-reviewed articles. Titles and abstracts were reviewed and screened to determine initial inclusion. Exclusion criteria included studies/trials with non-human subjects (i.e. animals); articles reporting only study/clinical trial protocols, systematic reviews, data and literature reviews, and articles that reported maternal counselling focused solely on infant and/or young child nutrition, articles that focused on behaviours and/or medical interventions associated with addressing or treating smoking cessation, gestational diabetes, HIV/PMTCT, and articles that examined specific individualised dietary interventions tailored to obese women/excessive weight gain, rather than public health approaches. After this initial exclusion of these articles, thirty-seven articles were confirmed for final inclusion in this gap analysis (see Table 1).
List of studies include in the maternal nutrition counselling gap analysis
The final thirty-seven articles were chosen based on the following criteria and elements defined in the conceptual framework: (a) identified specific elements related to the provision and/or quality of maternal diet counselling during pregnancy and postpartum (i.e. time and frequency); (b) provided data on key elements that affected counselling given on maternal diet during pregnancy and post-partum/lactation, including provider capacity, content, frequency and/or delivery platforms; and (c) provided information on counselling on appropriate weight gain during pregnancy and/or physical activity/maternal rest, within the context of counselling on maternal nutrition (if a and b criteria were met).
Findings
This gap analysis examined key elements of quality maternal nutrition counselling, which is comprised of building provider capacity to counsel, frequency, content (i.e. weight gain and physical activity during pregnancy, healthy eating during antenatal and postnatal periods) and delivery platforms (see Table 1).
Capacity building for health providers on maternal nutrition counselling
Two studies examined capacity building interventions (course/tools) on improvement of provider knowledge and counselling provision during ANC(Reference Jennings, Yebadokpo and Affo22,Reference Malta, Carvalhaes and Takito23) . In Brazil, a 16-h training course and three workshops on healthy eating and physical activity during pregnancy resulted in improved provider knowledge scores, as well a greater proportion of women who reported receipt of guidance on ‘leisure-time walking’ (50·7 % v. 19·1 %) and ‘healthy eating’ at ANC (58·6 % v. 33·3 %)(Reference Malta, Carvalhaes and Takito23). In Benin, pictorial job aids (i.e. capacity building tools) which were used to counsel health providers showed higher receipt of messages on ‘eating more and varied’ during pregnancy (+4·8 ppt) and breast-feeding messages (+32·0 percentage points (ppt) – early initiation, +41·3 ppt – exclusive breast-feeding) in intervention v. control arm(Reference Jennings, Yebadokpo and Affo22).
Frequency of counselling on maternal nutrition
Two studies reported that frequent attendance at ANC, either early in pregnancy or the number of visits, may not result in greater receipt of maternal nutrition counselling on the topics of dietary intake, breast-feeding, weight gain during pregnancy or physical activity(Reference Joseph, Piwoz and Lee24,Reference de Jersey, Nicholson and Callaway25) . In Malawi, while ANC attendance was high, women received, on average, one instance of nutrition counselling and rarely received breast-feeding counselling on early and/or exclusive breast-feeding during ANC (0·06 instance). Counselling on adequate nutrition during pregnancy was observed in less than half (44%) of first visits and one-third (33%) of later ANC visits (4th and onwards)(Reference Joseph, Piwoz and Lee24). In Australia, in a study of pregnant women, at 36 weeks’ gestation, only 21% of women ‘sometimes-always’ received counselling on the amount of food to eat, and half of these women were encouraged to be physically active(Reference de Jersey, Nicholson and Callaway25,Reference Yeneabat, Adugna and Asmamaw26) . In Haiti, only 5% of counselling messages were received during the first ANC visits, and 50 % of counselling messages (five of ten messages) were received at follow-up ANC visits(Reference Mirkovic, Lathrop and Hulland27).
Quality of content on maternal nutrition counselling
Counselling on maternal dietary intake, weight gain and physical exercise during antenatal care and postnatal care
Data from nine studies reveal that health providers gave no to little generalised information on maternal nutrition, based on women’s experiences of ANC and PNC(Reference Yeneabat, Adugna and Asmamaw26–Reference van der Pligt, Olander and Ball33). In Ethiopia, women who did not receive any dietary counselling were 3+ times more likely to have inadequate dietary diversity (aOR = 3·31, 95 % CI (1·49, 7·35))(Reference Yeneabat, Adugna and Asmamaw26). Specific content of the maternal nutrition counselling provided during ANC and PNC was not reported – beyond breast-feeding counselling which was received by three-fourths of women during PNC(Reference Mirkovic, Lathrop and Hulland27). In Laos, a cross-sectional study revealed that while counselling materials were available in half of rural clinics, these materials were used in less than 10 % of counselling sessions on diet during pregnancy (10 %) and after childbirth (3 %)(Reference Phommachanh, Essink and Wright31). Moreover, counselling was received by about one-third of rural women(Reference Phommachanh, Essink and Wright31). In two studies, women described receipt of non-specific, dietary advice, which included ‘eat a variety of food’, ‘don’t restrict food’ and ‘walk’, which was perceived as ‘confusing’ and ‘difficult to interpret’ in relation to their dietary intakes and levels of physical activity(Reference Ferrari, Siega-Riz and Evenson28,Reference Kunath, Günther and Rauh29) . In a singular study in Australia, receipt of advice on nutrition during pregnancy and physical activity was nearly 30 percentage points (ppts) higher than advice provided during the postnatal period(Reference van der Pligt, Olander and Ball33).
In Tanzania, a programme evaluation revealed that health provider knowledge on women’s nutrition was substantially greater (range + 23–70 ppts) than the provision of counselling messages on ‘important types of food to eat’, ‘eat a variety of foods at meals’ and ‘take regular meals’ during PNC(Reference LeFevre, Mpembeni and Kilewo32). In contrast, in India, where pregnant women were ‘encouraged to eat well as an important part of a healthy pregnancy’ (Reference Ramakrishnan, Lowe and Vir34). Foods such as pulses, chapattis, milk, yogurt, green leafy vegetables, fruits and kichidi (i.e. rice and lentils) were advised for consumption primarily by family members and health providers(Reference Ramakrishnan, Lowe and Vir34).
Fifteen studies revealed information gaps in counselling on weight gain during pregnancy from women’s and providers’ experiences(Reference Yeneabat, Adugna and Asmamaw26,Reference Emery, Benno and Salk35–Reference Santo, Forbes and Oken48) . In India, some women stated they had no knowledge of gestational weight gain, while others reported that 4–10 kg (kg) was ‘adequate weight gain’, which differed from facility and community health workers’ knowledge of optimal weight gain during pregnancy (i.e. 10–15 kg)(Reference Kunath, Günther and Rauh29). Evidence reveals that in high-income countries, counselling on weight gain during pregnancy varies widely, with 16–67 % of women receiving guidance(Reference Emery, Benno and Salk35–Reference Ferrari and Siega-Riz39,Reference Stotland, Gilbert and Bogetz43,Reference Whitaker, Wilcox and Liu46,Reference Yamamoto, McCormick and Burris47) . Women lack knowledge on how much weight to gain during pregnancy and often receive incorrect and/or insufficient advice from health providers(Reference Morris, Nikolopoulos and Berry30,Reference Swift, Pearce and Jethwa36–Reference Mercado, Marquez and Abrams40) . In a few high-income countries, pregnant women were more likely to be advised on gestational weight gain, and physical activity if they were affected by overweight/obesity in comparison with women of normal weight(Reference Emery, Benno and Salk35–Reference Nikolopoulos, Mayan and MacIsaac38,Reference Stotland, Gilbert and Bogetz43,Reference Whitaker, Wilcox and Liu46–Reference Santo, Forbes and Oken48) . Providers described not being comfortable discussing ‘delicate topics’ (i.e. women affected by obesity were perceived to ‘gain too much weight’ or women are underweight)(Reference Chang, Llanes and Gold37,Reference Wennberg, Hörnsten and Hamberg41) . Providers held views that they had ‘too little knowledge and/or training’ for conducting dietary counselling, as diet is viewed as ‘hard to change’.(Reference Chang, Llanes and Gold37,Reference Wennberg, Hörnsten and Hamberg41–Reference Stotland, Gilbert and Bogetz43) . From the perspective of pregnant women, information on weight gain during pregnancy is often from experience in prior pregnancy(Reference Swift, Pearce and Jethwa36), culture and habits(Reference Chang, Llanes and Gold37,Reference Stotland, Gilbert and Bogetz43) , and advice from family or friends (i.e. ‘eating for two’)(Reference Kavle and Landry7,Reference Swift, Pearce and Jethwa36) .
Delivery platforms for maternal nutrition counselling
Six studies showed that an integrated package of nutrition counselling interventions delivered through multiple delivery platforms – including group and interpersonal counselling, home visits and food demonstrations – improved maternal diet and/or weight gain during pregnancy(Reference Nguyen, Kim and Sanghvi20,Reference Nair, Tripathy and Sachdev49–Reference Akter, Roy and Thakur53) . Three studies in Bangladesh showed that intensive and frequent counselling by both health facility workers and community volunteers, engagement with key influencers (i.e. fathers), and provision of free-of-charge micronutrient supplements improved maternal, infant and young child nutrition outcomes and reduced household food insecurity in nutrition-intensive v. routine care groups(Reference Nguyen, Kim and Sanghvi20,Reference Nguyen, Frongillo and Sanghvi50,Reference Frongillo, Nguyen and Sanghvi51) . Significantly higher numbers of women visited by health workers early in pregnancy (6·0 v. 3·7 times) and at home by health volunteers in the nutrition-focused MNCH, in comparison with the routine care group (8·1 v. 3·2 times)(Reference Nguyen, Kim and Sanghvi20). In addition, greater than 90 % of women, who recently delivered, received counselling on nutrition during pregnancy and breast-feeding(Reference Nguyen, Kim and Sanghvi20). A significantly greater proportion of mothers in the nutrition-intensive group v. routine care received messages on nutrition during pregnancy, including eat a variety of foods and measure weight, only feed breastmilk after birth, consume iron folic acid (IFA) and Ca supplements, and consume a diversified maternal diet (see Table 2)(Reference Nguyen, Kim and Sanghvi20). Fathers reported significantly increased awareness and knowledge of dietary diversity (i.e. lentils, flesh foods and yellow/orange fruit). Fathers also had increased awareness of maternal diet during pregnancy, micronutrient supplementation, weight gain and rest during pregnancy and supported food, IFA and Ca supplement consumption(Reference Nguyen, Frongillo and Sanghvi50).
Programme considerations for strengthening quality of maternal nutrition counselling delivered via antenatal and postnatal care health contacts, based on gap analysis findings
IFA, iron folic acid.
* According to WHO, task shifting is defined as ‘the redistribution of tasks among health workers’ (WHO 2008).
Moreover, three studies reinforced the potential of multiple delivery platforms to deliver maternal nutrition counselling interventions(Reference Nair, Tripathy and Sachdev49,Reference Nikièma, Huybregts and Martin-Prevel52,Reference Akter, Roy and Thakur53) . In Bangladesh, one study revealed that the provision of a nutritious and easy-to-prepare local food recipe (i.e. khichuri, comprised of two fistfuls of rice, one fistful of dal (lentils), one egg, five teaspoons of soya oil and one fistful of leafy vegetables) combined with group counselling during pregnancy (i.e. adequate weight gain, frequency of food intake from three to five times daily, food hygiene, maternal rest, early initiation of and exclusive breast-feeding for breast-feeding) resulted in significantly increased pregnancy weight gain (+ 1·73 kg) and meal frequency (34 % of women) in the intervention v. the control group(Reference Akter, Roy and Thakur53). In India, a singular home counselling visit in conjunction with frequent participatory women’s group meetings (i.e. two to three meetings per month) during pregnancy resulted in significantly higher minimum dietary diversity in intervention v. comparison areas (adjusted OR 1·40; 95 % CI (1·03, 1·90), P = 0·0311)(Reference Nair, Tripathy and Sachdev49). In Burkina Faso, a facility-based, 1:1 maternal counselling intervention, on portion size, meal frequency, and dietary diversification, resulted in a threefold increase in women’s exposure to nutrition counselling in comparison with the control group(Reference Nikièma, Huybregts and Martin-Prevel52). However, effects of this interventions were limited as only 9·4 % of women improved food intake or dietary diversity due to late ANC attendance (2nd or 3rd trimester)(Reference Nikièma, Huybregts and Martin-Prevel52).
Discussion
This gap analysis examines key elements related to delivery of quality maternal nutrition counselling through country health systems. Our findings corroborate those documented in previous papers which showed that information on the type, quality and coverage of maternal nutrition counselling is limited in selected country contexts, such as Bangladesh, Burkina Faso, India, Nepal and Pakistan(Reference Kavle and Landry7,Reference Sanghvi, Nguyen and Tharaney54) . Our analysis also confirms earlier findings that inadequate health provider training on maternal diet, weight gain during pregnancy, and/or physical activity, lack of counselling skills and time to counsel due to client load and/or insufficient use of existing health resources may contribute to gaps in maternal nutrition counselling content and frequency of delivery (Reference Kavle and Landry7,Reference Goldstein, Abell and Ranasinha18,Reference Yeneabat, Adugna and Asmamaw26–Reference Morris, Nikolopoulos and Berry30) . Findings from this gap analysis further reveal that despite global recommendations on maternal nutrition counselling, counselling on adequate dietary intake, weight gain during pregnancy and physical activity are not delivered with the desired content nor quality. When women do not receive specific dietary counselling with key actions or plans, they are less equipped with information to improve their own dietary intake and diversity(Reference Yeneabat, Adugna and Asmamaw26). This is particularly salient given the glaring absence of maternal nutrition counselling tailored to the nutritional status of pregnant women – particularly those who suffer from overweight and obesity in LMIC – who require continued nutritional guidance through the postnatal period. While recent compiled data reveal that pregnant women across North and sub-Saharan Africa, Asia and the Middle East regions experience lower weight gain in comparison with Europe and Latin America, it is increasingly recognised and established that excessive weight gain is occurring with greater frequency in LMIC(Reference Asefa, Cummins and Dessie55–Reference Goldstein, Abell and Ranasinha57).
Our findings on gestational weight gain counselling also show that while weight is often recorded by health providers, it is often not disclosed or discussed with women, leading to confusion on the amount of weight to gain during pregnancy and ‘why’ this is important, regardless of pre-pregnancy BMI(Reference Emery, Benno and Salk35,Reference Nikolopoulos, Mayan and MacIsaac38) . Inadequate health provider knowledge or familiarity with gestational weight gain recommendations affected whether women were counselled, and specifically on ‘how’ to achieve recommendations, a problem of global significance(Reference Emery, Benno and Salk35,Reference Nikolopoulos, Mayan and MacIsaac38,Reference Power and Schulkin42) . Further, while US-based Institute of Medicine guidelines are recommended as part of WHO ANC standards, there is a need for greater understanding and evidence to inform on the development of global and regional standards on weight gain during pregnancy which reflect the variation in populations(15,Reference Goldstein, Abell and Ranasinha57) .
Moreover, information and counselling on attaining adequate weight gain during pregnancy was a source of confusion for both health providers and women – a neglected, yet critical component of ANC. A recent global review of maternal weight gain policies in fifty-three countries showed that only half of countries were aware of country guidelines on weight gain during pregnancy(Reference Scott, Andersen and Valdez58). Moreover, only 13 % of country policies included guidance on healthy postpartum weight(Reference Scott, Andersen and Valdez58). On a positive note, this analysis found that health providers in high-income countries tended to provide targeted counselling on gestational weight gain for pregnant women affected by overweight and obesity, showing that context-specific and tailored counselling is feasible. However, such counselling was often not given to underweight or normal-weight pregnant women. This sheds insight into the need to equip providers with counselling skills and peer-to-peer mentorship to provide culturally resonant, tailored advice to women. Moreover, taking into account excessive energy intakes among some pregnant and lactating women is needed(Reference Miele, Souza and Calderon59). Obesogenic consumption patterns, defined as eating ultra-processed foods, processed foods and/or food groups rich in carbohydrates, fats and sugars, can comprise up to 37 % of foods consumed during pregnancy(Reference Miele, Souza and Calderon59,Reference Kavle, Mehanna and Khan60) . Yet, such food consumption patterns are often not routinely addressed with women during ANC and PNC, especially among overweight and obese women – a key gap in current health service provision globally(Reference Miele, Souza and Calderon59,Reference Kavle, Mehanna and Khan60) .
Health provider capacity to counsel women during routine ANC and PNC health contacts is often hindered by lack of staff and time at health facilities. This situation is likely to be exacerbated by the predicted shortage of 18 million healthcare professionals in the workforce by 2030(61,Reference Liu, Goryakin and Maeda62) . Task shifting to community-level providers from nurses and physicians has been shown to enhance access, demand and use of health services at facility and community level and mitigate shortages in health personnel and limited time for counselling while building trust within communities(Reference Tulenko, Møgedal and Afzal63,Reference Perry, Zulliger and Rogers64) . A singular study showed lay nurses provided significantly more maternal nutrition counselling than nurse-midwives on the following key messages: ‘eat more and varied foods’ (85·7 % v. 73·3 %), ‘at least 4 prenatal visits’ (85·2 % v. 65·5 %) and ‘take IFA supplements’ (90·1 % v. 75·7 %)(Reference Jennings, Yebadokpo and Affo65).
Other studies have shown that community health workers provided better care in comparison with medical personnel, in terms of child health outcomes (i.e. integrated management of childhood illness, malaria), improved key nutrition practices and support (i.e. breast-feeding promotion and support, micronutrient supplementation, identification and treatment of acute malnutrition) and were more likely to motivate mothers to complete four ANC visits (OR = 1·85, 95 % CI (1·14, 3·00), P = 0·012)(Reference Tulenko, Møgedal and Afzal63,Reference Perry, Zulliger and Rogers64,Reference Stansert Katzen, Tomlinson and Christodoulou66,Reference Horwood, Butler and Barker67) . Moving forward, it is critical that community-based providers (i.e. community health volunteers) have clear roles and expectations with respect to maternal nutrition counselling, including renumeration within communities, health systems and non-governmental organisations(Reference Kavle and Landry7,Reference Tulenko, Møgedal and Afzal63) . In addition, building community-based providers’ skillsets on the provision of communication on maternal nutrition via group counselling and/or home visits, with ongoing supportive supervision and mentoring from facility providers, is an important step in task shifting(Reference Kavle and Landry7,Reference Tulenko, Møgedal and Afzal63) .
Involvement of community and health facility providers to deliver both individual and group nutrition counselling interventions has demonstrated improvements in maternal dietary diversity and pregnancy weight gain, and engagement of key family members, as documented in this analysis. These findings are similar to a recent meta-analysis of clinical trials from high-income countries which found that mixed and multi-pronged interventions (diet, lifestyle, gestational weight gain monitoring and behaviour change component) reduced risk of excessive weight gain for women with lower educational levels (OR 0·735; 95 % CI (0·561, 0·963), P = 0·026) and reduced kilograms gained per week (β –0·053, P < 0·001) among women with high educational levels(Reference O’Brien, Segurado and Geraghty68). Yet, few studies have documented maternal nutrition counselling interventions and approaches within the context of health service delivery and programmes, which remains a key gap in the evidence base.
Considerations to strengthen delivery of maternal nutrition counselling
While there is less available evidence for a few elements (i.e. provider capacity building and frequency) described in this gap analysis, key insights into how to strengthen delivery of quality maternal nutrition counselling can be gleaned from available information and experience, as outlined in Table 2 (Reference Kavle and Landry7,Reference Kavle, Picolo and Dillaway16,69–71) .
Moving forward, concerted efforts are needed to integrate maternal nutrition counselling into pre- and in-service curricula, while documenting effectiveness of standard health provider training, supportive supervision and mentoring via MIYCN programming (i.e. nutrition-specific and nutrition-sensitive interventions). Development of global and/or regional weight gain standards alongside practical tools that can feasibly track weight gain for women and health providers alongside information on nutritional status, dietary intake and physical activity may be considered as part of future programming, as was recently explored in Brazil(Reference Kac, Carilho and Rasmussen72). Understanding how to feasibly estimate pre-pregnancy BMI via maternal recall is also a critical piece, as most women present mid to late in pregnancy for ANC(73).
Countries may also explore incorporating measures of quality maternal nutrition counselling, as a part of Quality of Care standards developed by the maternal and newborn health communities (i.e. WHO Maternal Newborn Health Quality of Care standards) – as lack of standardised ANC and PNC quality improvement measures is a key gap highlighted in this analysis(21). Such quality measures may consider timing, frequency and duration of counselling, and health provider knowledge. In addition, the lack of standard monitoring indicators for maternal, infant, and young child nutrition to guide, monitor and inform on programmatic efforts is a gap in routine data collection. There is a globally recognised need for frequent and consistent collection of maternal nutrition indicators through large surveys (i.e. Women’s Minimum Dietary Diversity – MDD-W) and via routine health systems to monitor programmes and to guide changes in country programming at national and subnational levels(Reference Kavle and Landry7,Reference Gillespie, Menon and Heidkamp74) . Moving forward, the development and use of standardised MIYCN indicators through the first-ever global District Health Information System-2 (DHIS-2) Standard Nutrition Module (i.e. indicators for maternal nutrition counselling and maternal counselling on health and nutrition topics for ANC/PNC) will be crucial to ascertaining country progress(75).
Finally, from a programmatic perspective, attention is sorely needed to improve provider capacity to counsel, and in the attainment of quality health service delivery for maternal nutrition interventions. Efforts that link health systems strengthening to food systems interventions which widen the diversity of local food supplies, as well as the access, availability and affordability of nutritious foods, should be conjoined in the future for maximal impact.
Limitations
This gap analysis has several limitations. Information provided in this analysis has been extracted from studies which reveal information gaps on provider training (i.e. pre- and in-service content), supportive supervision, mentoring and quality improvement for maternal nutrition counselling. Lack of data on the extent, frequency and content on counselling on maternal dietary intake, weight gain during pregnancy and/or physical activity, as well as information on counselling provided during PNC, are limitations to this gap analysis. We also note that there may be unpublished programme or project findings, used for internal project/programme monitoring and use, that are not available on public domains, which may have been omitted from this analysis.
Conclusion
This gap analysis reveals that delivering maternal nutrition counselling via multiple platforms (individual, group, facility and community) has the potential for success and may be considered in the design of future programmes. Evidence in this analysis also shows that women affected by overweight and obesity in high-income countries receive targeted nutrition counselling, whereas tailored, context-specific counselling is often not carried out in LMIC. This gap analysis highlights considerations for improving maternal nutrition counselling by addressing health providers’ time to counsel, cultivating interpersonal communication/counselling skills to contextualise counselling to respond to the changing face of malnutrition, as well as task shifting and engagement with and support from family and community members. Strengthening the enabling environment to support quality of ANC and PNC services can aid with better integration of maternal nutrition counselling (i.e. content, frequency and timing) into primary health services.
This gap analysis did not cover the important pre-conception period, which offers an opportunity to counsel adolescent girls, women and their families on the importance of nutritious diets, physical activity and entering pregnancy at an adequate weight. Identifying and creating opportunities to improve the nutrition of adolescent girls and women before they are pregnant while securing the increased nutritional needs of those who become pregnant and/or decide to breastfeed are crucial for all adolescent girls and women. For example, the development of a country-led and culturally informed approach focused on promoting healthy eating habits (i.e. eat locally available and diverse fruits and vegetables, physical activity, and adequate weight) conjoined with multisectoral, nutrition-sensitive efforts, such as income generation schemes, agriculture (i.e. local gardening), social protection, and youth movements may empower women’s and girl’s agency and create greater sustainability long term(Reference Barker, Dombrowski and Colbourn76). In sum, the integrated delivery of maternal nutrition counselling as part of routine healthcare can be emboldened by country identification of multiple delivery platforms – including linking community structures with social protection systems and food systems – to improve women’s access to nutritious diets and nutrition services.
Acknowledgements
We gratefully acknowledge UNICEF-NY nutrition team colleagues, especially Nita Dalmiya, who provided feedback on early drafts of the manuscript. Financial support: This paper received no specific grant from any funding agency, commercial or not-for-profit sectors and was supported by funding from Kavle Consulting, LLC, a woman and minority-owned small business social impact firm. Authorship: J.A.K. formulated the research question, designed and carried out the gap analysis, compiled and interpreted the data and wrote the article. Ethics of human subject participation: Not applicable.
Conflicts of interest:
Justine A. Kavle worked as a consultant for UNICEF-NY to compile background documentation and a literature review to inform on maternal nutrition programming efforts.
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