Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.
BACKGROUND
Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition.


OBJECTIVE
Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure


METHODS
Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted.


RESULTS
Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions.


CONCLUSIONS
Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.
Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil.
Cesar G
CG
Victora
Fernando C
FC
Barros
Maria Cecilia
MC
Assunção
Maria Clara
MC
Restrepo-Méndez
Alicia
A
Matijasevich
Reynaldo
R
Martorell
D003362:Cost-Benefit Analysis; D003906:Developing Countries; D005260:Female; D006284:Health Plan Implementation / Q000191:economics; D006293:Health Promotion / Q000191:economics; D006801:Humans; D044342:Malnutrition / Q000178:diet therapy / Q000191:economics / Q000503:physiopathology / Q000517:prevention & control*; D039382:Maternal Nutritional Physiological Phenomena; D018673:Nutrition Policy / Q000191:economics; D011247:Pregnancy; D011256:Pregnancy Outcome