Examining coverage, content, and impact of maternal nutrition interventions: the case for quality-adjusted coverage measurement

• Type of Material: Article
• Authors: Naima Joseph, Emory University; Ellen Piwoz, Bill and Melinda Gates Foundation, Seattle; Dennis Lee, Harvard TH Chan School of Public Health; Address Malata, Malawi University of Science and Technology; Hannah H Leslie, Harvard TH Chan School of Public Health
• Language: English
• Date: 2020-06-01
• Publisher: UNIV EDINBURGH, GLOBAL HEALTH SOC
• Publication Version: Final Published Version
• Copyright Statement: © 2020 by the Journal of Global Health. All rights reserved.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.7189/jogh.10.010501
• Title of Journal or Parent Work: JOURNAL OF GLOBAL HEALTH
• Volume: 10
• Issue: 1
• Start Page: 010501
• End Page: 010501
• Grant/Funding Information: This work was supported by a grant of the Bill & Melinda Gates Foundation to the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health (OPP114893), through US Fund for UNICEF.
• Keywords: LOW-INCOME; SYSTEMATIC ANALYSIS; Science & Technology; INFANT; UNDERNUTRITION; ANTENATAL CARE; DEATHS; MORTALITY; Public, Environmental & Occupational Health; PROGRESS; Life Sciences & Biomedicine
• Research Categories: Health Sciences, Public Health; Health Sciences, Health Care Management

Abstract

Background Reductions in neonatal mortality remain stagnant, despite gains in health care access and utilization. Nutrition interventions during antenatal care (ANC) and in the immediate postpartum period are associated with improved neonatal outcomes. Adjusting coverage estimates for the quality of care provided yields greater insight into health system performance and potential population health benefits of accessing care. In this cross-sectional study, we adjust maternity care coverage measures for quality of nutrition interventions to determine the impact on infant birth weight and breastfeeding. Methods We used household data from the Malawi 2013-2014 Multiple Indicator Cluster Survey to assess use of maternal health services and direct observations of ANC and delivery from the 2013 Service Provision Assessment to measure nutrition interventions provided. We adjusted coverage measures combining self-reported utilization of care with the likelihood of receipt of nutrition interventions. Using adjusted log-linear regression, we estimated the associations of these nutrition quality-adjusted metrics with infant birthweight and immediate breastfeeding. Results Health facility data provided over 2500 directly observed clinical encounters and household data provided 7385 individual reports of health care utilization and outcomes. Utilization of ANC and facility-delivery was high. Women received nutrition-related interventions considerably less often than they sought care: over the course of ANC women received a median of 1.6 interventions on iron, 1 instance of nutrition counseling, and 0.06 instances of breastfeeding counseling. Nutrition quality-adjusted ANC coverage was associated with a reduced risk of low birthweight (adjusted relative risk [ARR] 0.87, 95% confidence interval (CI) = 0.79, 0.96) and increased likelihood of immediate breastfeeding (ARR = 1.04, 95% CI = 1.02, 1.07); nutrition quality-adjusted post-delivery care was also associated with greater uptake of immediate breastfeeding (ARR = 1.08, 95% CI = 1.02, 1.14). Based on these models, delivering nutrition interventions consistently within the existing level of coverage would decrease population prevalence of low birthweight from 13.7% to 10.8% and increase population prevalence of immediate breastfeeding from 75.9% to 86.0%. Conclusions Linking household survey data to health service provision assessments demonstrates that despite high utilization of maternal health services in Malawi, low provision of nutrition interventions is undermining infant health. Substantial gains in newborn health are possible in Malawi if quality of existing services is strengthened.