A Situation Analysis of Effective Interventions, Barriers and Opportunities for Improving Maternal Nutrition in Bihar, India Public

Abstract

Introduction: Maternal underweight and anemia are serious problems in Bihar and are
important factors in the persistence of high levels of child undernutrition. Although
numerous programs and platforms exist for delivering effective interventions for
improving maternal nutrition, the coverage and quality of these interventions is low and
they are not achieving the desired results.

Objective: This study aimed to assess the status of effective interventions for improving
maternal nutrition in Bihar and to identify barriers and opportunities for expanding
coverage and quality.

Methods: Forty-eight key informant interviews were conducted with policy makers,
program managers and service providers in Bihar at state, district, block and facility
levels. Secondary data was collected from survey reports and program documents. All
data was analyzed thematically.

Results: Numerous barriers impede the delivery of effective interventions for improving
maternal nutrition in Bihar. Implementation level barriers include the shortage of human
resources; an inadequate supply of basic equipment and supplies; and low recognition of
the magnitude and consequences of maternal undernutrition. Policy level barriers include
low prioritization of maternal nutrition and the lack of emphasis on delaying and spacing
births. Societal barriers include poverty, gender inequality and caste-based
discrimination. Innovations for improving program delivery include household mapping
and microplanning; cash incentives for meeting targets; and electronic fund transfer
systems. Potential platforms for delivering interventions include Panvjayati Raj
Institutions, women's Self-Help Groups, and programs to educate and empower
adolescent girls.

Discussion: Significant progress has been made in recent years by the new Government
of Bihar to expand the coverage and quality of public health services throughout the state.
However, due to years of neglect under previous governments, much remains to be done.
Recommendations for strengthening the delivery of interventions to improve maternal
and birth outcomes include setting targets in program implementation plans, increasing
outreach to adolescent girls and women outside of pregnancy, strengthening field
supervision, empowering women and increasing the involvement of community-based
organizations. Recommendations will be shared with the Government of Bihar and its
partners to assist them in their efforts to improve maternal and child health.

Table of Contents

Table of Contents

1. Introduction. 1

1.1. Rationale. 1

1.2. Problem statement 4

1.3. Purpose statement 7

1.4. Study objectives. 7

1.5. Research questions. 7

1.6. Significance Statement 8

2. Lit Review.. 10

2.1. Maternal undernutrition. 10

2.2. Low birth weight 12

2.3. Effective interventions for maternal and birth outcomes. 14

2.3.1. Iron folic acid supplementation. 14

2.3.2. Multiple micronutrient supplementation. 15

2.3.3. Protein and energy supplementation. 16

2.3.4. Food Fortification. 18

2.3.5. Community nutrition interventions. 19

2.3.6. Deworming. 19

2.3.7. Treatment and prevention of malaria. 19

2.3.8. Family planning interventions. 20

2.3.9. Development interventions. 21

3. Methods. 22

3.1. Introduction. 22

3.2. Setting and study population. 23

3.2.1. Selection of sites for field visits. 23

3.2.2. Selection of key informants. 25

3.3. Research design. 26

3.3.1. Research instruments. 26

3.3.2. Research procedures. 28

3.3.3. Data Analysis. 29

4. Results. 30

4.1. Overview of Bihar 30

4.2. Maternal undernutrition. 31

4.3. Existing interventions for improving maternal nutrition. 34

4.3.1. Iron Folic Acid supplementation. 35

4.3.2. Deworming. 36

4.3.3. Protein energy supplementation. 37

4.3.4. Nutrition education. 37

4.3.5. Family planning. 38

4.3.6. Social Safety Nets. 39

4.4. Platforms and mechanisms for delivering interventions. 40

4.4.1. Primary Health Care System.. 40

4.4.2. National Rural Health Mission. 43

4.4.3. Integrated Child Development Services (ICDS) 45

4.4.4. School Anemia Control Program.. 47

4.4.5. Targeted Public Distribution System (TPDS) 47

4.5. Barriers to the effective delivery of interventions. 48

4.6. Promising innovations. 49

4.7. Other potential delivery platforms. 50

5. Discussion. 51

5.1. Barriers. 52

5.1.1 Implementation level 52

5.1.2 Policy level 55

5.1.3 Societal level 57

5.2. Innovations. 60

5.3. Other potential delivery platforms. 63

5.4. Strengths and limitations. 66

6. Conclusions and Recommendations. 67

7. References. 71

8. Appendices. 82

8.1. List of key informants by position and organization. 82

8.2. Key Informant Interview Guide. 85

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Mot-clé	Nutritional interventions Maternal anemia Bihar Maternal undernutrition
Committee Chair / Thesis Advisor	Martorell, Reynaldo, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs Non-US governmental agency (e.g., Minister of Health in Haiti) Does not apply (no collaborating organization)

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