Factors influencing quality nutrition service provision at antenatal care contacts: Findings from a public health facility-based observational study in 21 districts of Bangladesh.

Sk Masum Billah,Nazia Binte Ali,Shams El Arifeen,Abdullah Nurus Salam Khan,Michael John Dibley,Phuong Hong Nguyen,Sufia Askari,Camille Raynes-Greenow,Md Shahjahan Siraj,Patrick John Kelly,Purnima Menon,Sharon Mary Brownie

doi:10.1371/journal.pone.0262867

Abstract

Malnutrition during pregnancy is associated with increased maternal morbidity and mortality and has a long-term negative impact on child growth and development. Antenatal care (ANC) is the formal point of contact for pregnant women to receive preventive health and nutrition services. We assessed the quality of nutrition service delivery during ANC and examined its influencing factors related to the health facility, health care provider (HCP) and client characteristics. We conducted a cross-sectional assessment in 179 facilities, including 1,242 ANC observations and exit interviews of pregnant women from 21 districts in Bangladesh. We considered four essential nutrition services at each ANC contact including maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplement provision. We defined a composite 'quality nutrition service' outcome by counting the number of services (out of four) provided at each ANC from observation data. We explored both the supply-side and the client-level factors of quality nutrition service using multilevel Poisson regression. Overall, only 15% of clients received all four nutrition services. Performance of weight measurement (79%) was higher than IFA provision (56%), anaemia assessment (52%) and nutrition counselling (52%). The multivariable analysis showed that quality nutrition service delivery is positively associated with good logistical readiness of the facilities (aIRR: 1.23, 95% CI: 1.08-1.39), consultation by paramedics (aIRR 1.23, 95% CI: 1.06-1.42) and community health care providers (aIRR 1.32, 95% CI: 1.12-1.57), HCPs' knowledge on maternal nutrition (aIRR 1.04; 95% CI: 1.01-1.08), better HCP-client communication (aIRR 1.14; 95% CI: 1.04-1.26) and use visual aids or ANC card (aIRR 1.18; 95% CI: 1.11-1.27). We found limited associations between HCP training and external supervision with the quality of nutrition services. In conclusion, the quality of nutrition service provision during ANC is suboptimal. Public health nutrition programmers should ensure the facilities' logistical readiness, and revisit and reinforce the content and modality of training and supportive supervision of the HCPs. They should also emphasize positive HCP-client communication and the use of job aids to improve the quality of nutrition service provision during ANC.

Highlights

Maternal nutrition is a major global public health concern
A comprehensive analysis of data from 69 low and middle-income countries (LMIC) suggested that receiving antenatal care (ANC) from appropriate sources and with recommended frequency was associated with positive birth outcomes and childhood nutrition [7]
This paper aims to assess the quality of nutrition service provision during ANC and examine its influencing factors related to facility readiness, health care providers, the process of care, and client characteristics

Summary

Introduction

Undernutrition and micronutrient deficiencies during pregnancy are associated with increased maternal morbidity and mortality and have a long-term negative impact on child growth and development [1, 2]. The principal drivers for maternal malnutrition are poor-quality diets, low intake of micronutrient supplements and lack of access to quality healthcare during pregnancy [5, 6]. Evidence suggests receiving three or more ANC visits is likely to reduce maternal malnutrition by three-fold [8]. All these findings highlight the need for improving coverage and quality of nutrition services during pregnancy

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