University of Westminster Faculty of Life Sciences MSc Global Public Health Nutrition FACTORS THAT HAVE LED TO IMPROVED MATERNAL NUTRITION OUTCOMES IN LOW AND MIDDLE-INCOME COUNTRIES Jean Jepchirchir Chelimo w1662117 A dissertation submitted in partial fulfilment of the requirements of the University of Westminster for the degree of MSc in Global Public Health Nutrition

University of Westminster
Faculty of Life Sciences
MSc Global Public Health Nutrition

FACTORS THAT HAVE LED TO IMPROVED MATERNAL NUTRITION OUTCOMES IN LOW AND MIDDLE-INCOME COUNTRIES

Jean Jepchirchir Chelimo
w1662117

A dissertation submitted in partial fulfilment of the requirements of the University of Westminster
for the degree of MSc in Global Public Health Nutrition.
August 2018

Module 7HMNT018W.2
Module Leader: Alizon K. Draper
Supervisor: Regina Keith

DECLERATION
I hereby declare that this dissertation is as a result of an independent study and it has not been submitted to this institution or any other academic qualification.

NAME: JEAN JEPCHIRCHIR CHELIMO

SIGNATURE: ______J.J.C_____________

SUPERVISOR: REGINA KEITH

SIGNATURE:

ACKNOWLEDGEMENT
This project was complete due to support and guidance from many people. To my supervisor REGINA KEITH who dedicated herself to see me succeed in it with sincere heart, she guided me through it.
I would like to thank my family for their financial and emotional support.
I extend my sincere thanks to the Almighty Father for the gift of life, good health and wisdom.

TABLE OF CONTENTS
Table of Contents
DECLERATION i
ACKNOWLEDGEMENT ii
TABLE OF CONTENTS iii
LIST OF ABBREVIATIONS v
ABSTRACT vi
1.0 INTRODUCTION 1
1.1 BACKGROUND INFORMATION 1
1.2 LITERATURE REVIEW 2
1.2.1 HEALTH SYSTEMS 2
1.2.2 NUTRITION PROGRAMMES 2
1.3 AIM OF THE STUDY 3
1.4 OBJECTIVES OF THE STUDY 3
1.5 JUSTIFICTAION OF STUDY 3
2.0 METHODOLOGY 4
2.1 RESEARCH DESIGN 4
2.2 METHODS OF DATA COLLECTION 4
2.2.1 LITERATURE BASED RESEARCH 4
2.2.2 QUALITATIVE RESEARCH INCLUDING KEY INFORMANTS 5
2.3 SAMPLING TECHNIQUE 6
2.4 DATA COLLECTION TOOLS 6
2.5 ETHICAL CONSIDERATIONS 7
2.6 DATA ANALYSIS 7
2.6.1 SUPPLEMENTATION 7
2.6.2 HEALTH SERVICE DELIVERY 8
2.6.3 FOOD SECURITY 9
2.6.4 WOMEN EMPOWERMENT 10
2.6.5 POLITICAL WILL 10
2.6.7 OTHER THEMES 10
3.0 FINDINGS 12
3.1 COUNTRIES IDENTIFIED 12
3.2 KEY INDICATORS 12
3.3 HEALTH SYSTEMS STRENGTHENING APPROACH 13
3.3.1 GOVERNANCE AND LEADERSHIP 13
3.3.2 HEALTH WORKFORCE 13
3.3.3 EFFECTIVE HEALTH INFORMATION SYSTEMS 14
3.3.4 EFFECTIVE UNIVERSAL SERVICE DELIVERY 14
3.3.5 HEALTH FINANCING 15
3.3.6 PRO-POOR HEALTH FINANCING SUPPORTED BY SOCIAL SAFETY NETS 16
4.0 ANALYSIS 17
5.0 CONCLUSION AND RECOMMENDATIONS 20
REFERENCES 21
ANNEX 1: PRISMA FLOW CHART DIAGRAM 25
Identification 25
Included 25
Eligibility 25
Screening 25
ANNEX 2: SUMMARY TABLE 26
ANNEX 3: CONSENT FORM 43
ANNEX 4: PARTICIPANT INFORMATION SHEET 44
ANNEX 5: RESEARCH QUESTIONS 45

LIST OF ABBREVIATIONS

BCC- Behaviour Change Communication
CI- Confidence Interval
IFA- Iron and Folic Acid
IFPRI- International Food Policy Research Institute
OR- Odds Ratio
SDG- Sustainable Development Goals
WHO- World Health Organization

ABSTRACT
A diet rich in nutrients before and during pregnancy is linked to improved rates of survival for the mother and the baby. The world has now come to the realization that maternal nutrition is important for both the mother and baby hence the introduction of the first 1,000 days campaign.
This study sought to explore the factors that have led to improved maternal nutrition outcomes in low and middle-income countries. A mixed method approach was used to carry out the research. A literature-based review on peer-reviewed articles and grey literature was carried out as a first phase and a latter phase involved qualitative research including key informant. Analysis was done in 2 stages where literature-based findings were presents in a summary table and the qualitative research from key informants using a thematic context analysis. An important factor in learning the factors that have led to improved maternal nutrition was health systems. Nutrition sensitive interventions were also identified as influencers of maternal nutrition outcomes.
This study recommends that low and middle-income countries should strengthen the building blocks of health systems to improve maternal nutrition outcomes. Data gaps need to be filled by use of standardised indicators to monitor maternal progress.

1.0 INTRODUCTION

1.1 BACKGROUND INFORMATION
“Good nutrition is an essential driver for sustainable development and tackling malnutrition is key to achieving Sustainable Development Goals” (Global Nutrition Report, 2015).
A healthy diet entails eating a range of foods that provides nutrients required for energy and protect one from all forms of malnutrition (WHO, 2015). This is essential for all pregnant and lactating women for good nutrition. Maternal nutrition focuses on the nutrition status of women who are pregnant, lactating or in the reproductive age between 15-45 years and how it affects their children. Women play a vital role in the society, community and at a household level, hence protecting their health and nutrition through public health measures is essential before and during pregnancy (WHO, 2016). Malnutrition which comprises of overweight and obesity, undernutrition and micronutrient deficiencies increases the risk morbidity and mortality (Lancet, 2013). Each year around 285,000 mothers die through pregnancy related causes with more than half of these deaths occurring in Sub Saharan Africa and almost a third in South Asia. Key factor leading to these deaths include the lack of skilled birth attendants, especially in the rural areas, the distance one has to cover to reach the nearest health facility and high rates of poverty (WHO, 2016). Adolescent girls, especially those below 12 years of age, are at the highest risk of maternal mortality due to pregnancy and birth complications (WHO, 2016).
The countdown to 2030 report states that reducing these deaths requires a 90% coverage of the maternal, reproductive, newborn, child health and nutrition interventions and countries must strengthen their analytical capacity to collect and use maternal nutrition data. There are major data gaps at a global and national level. The data gaps are prevalent on what causes death in women, children and adolescents, the quality of care, nutrition programmes, health of adolescents and inputs on health and financial systems (Countdown report, 2017). This lack of data hinders the prioritization, monitoring and evaluation of essential interventions. Lack of data also leads to gaps in nutrition surveillance which include; absence of nutrition indicators, late submission of sub national data and little evidence of the use of data which is available to influence any change. Accountability is also an issue as it is difficult to determine who was responsible for carrying out the interventions, what their duties were and whether or not they fulfilled their duties (Global Nutrition Report, 2014).
1.2 LITERATURE REVIEW
The section below will look into the factors for improved maternal nutrition:
1.2.1 HEALTH SYSTEMS
According to the WHO, they define health systems as “all organizations, people and actions whose primary intent is to promote, restore or maintain health” (Child Health Now report, 2009). Efforts between governments and specific donors needs to be considered to strengthen the systems. The building blocks of the health systems include;
Health service delivery- It is a significant block for the population alongside social factors of health e. g hospitals or clinics. It can be provided by the public and/or private sectors. The characteristics include access, quality, coverage and safety.
Health workforce- It refers to capacity to meet a country’s health goals depending on skills, knowledge, motivation and deployment of the individuals who deliver health services.
Health information systems- It provides a base for making decisions and the key functions include: generation of data, collection, analysis and synthesis and communication of the results and using it.
Access to essential medicines and technology- This is what a well-functioning requires to ensure that the resources they receive are scientifically sound, quality, efficient and cost-effective.
Health system financing- it refers to “functions of a health system concerned with the mobilization, accumulation and allocation of money to cover the health needs of the people, individuals and collectively health systems” (World Health Organization, 2005).
Leadership and governance- It involves establishing policy frameworks that exist, effective overlooking and alliance building, appropriate incentives, consider systems designs and accountability.
1.2.2 NUTRITION PROGRAMMES
These are interventions that are formed on evidence to aid in the improvement of maternal nutrition. There are two types of programmes and they include:
Nutrition specific interventions and programmes- It involves interventions that deal with the direct determinants of malnutrition such as disease and inadequate dietary intake. Some of the interventions include adolescent health and maternal nutrition, maternal dietary supplementation and micronutrient supplementation and fortification (Lancet, 2013)
Nutrition sensitive programmes and approaches- This are the programmes that serve as a delivery platform for the specific interventions. They include agriculture, women empowerment, social safety nets and education (Lancet, 2013).
1.3 AIM OF THE STUDY
The purpose of the study is to explore the factors that have led to improved maternal nutrition in low and middle-income countries.
1.4 OBJECTIVES OF THE STUDY
1. Identify the low and middle-income countries who have succeeded in improving maternal and child nutrition outcomes, supported with good maternal nutrition data.
2. Determine the obstacles that prevent the collection of essential maternal nutrition data.
3. Develop a simple maternal nutrition index to support countries to prioritise evidenced based approaches to improving maternal nutrition outcomes.
1.5 JUSTIFICTAION OF STUDY
This project provides an important opportunity to advance the understanding of the challenges and the way some of the countries have acted on the challenges to feed into future policy formulation and nutrition planning towards achieving sustainable development goal 3. The SDG states; “Ensuring healthy lives and promotion of well-being for all at all times” (United Nations, 2015).
Coming up with factors that support the improvement of maternal and child nutrition in low and middle-income countries will link the research to the world.

2.0 METHODOLOGY
In this section, I will discuss the research design, data collection methods, data collection tools, sampling, data analysis and ethical considerations. The researcher used the CASP checklist to improve the quality of the research design (Critical Appraisal Skills programme, (2017) Qualitative Research Checklist (Online)).

2.1 RESEARCH DESIGN
The researcher carried out a mixed method approach to analyse the information already available while using the richer in-depth qualitative information from key informants on perceptions and experiences to explore the factors affecting success of maternal nutrition programmes. This approach used by the researcher will identify the low and middle-income countries who are have improved their maternal nutrition status and what are the factors that have led to their success. Using the data analysis along with the experience of the key informants the researcher will construct a list of factors that need to be addressed to improve maternal nutrition.
2.2 METHODS OF DATA COLLECTION
The research was conducted in two phases: phase one involved using a mixed method if quantitative literature review, analysing of published work with support from small qualitative research while the latter phase identified key informants to add their perceptions and experiences in relation to the research aims and objectives to develop a more robust understanding of the essential factors needed to improve maternal nutrition outcomes in low and middle-income countries.
2.2.1 LITERATURE BASED RESEARCH
Literature research is easy to access, has little or no cost to acquire the information and may be used to answer research questions but the quality of the research is self-governed, and it is controlled by the marketer thus information needs to be scrutinized for validity and reliability.
A critical analysis of the published work through the results and implications of earlier research studies, reviews of literature or theoretical articles was carried out. This was the first phase of data collection where a systematic review was carried out. The literature was obtained from published peer reviewed journals and also included grey material and peer reviews, due to the lack of evidence in general on this issue. “Grey literature stands for manifold document types produced on all levels of government, academics, business and industry in print and electronic formats that are protected by intellectual property rights, of sufficient quality to be collected and preserved by libraries and institutional repositories, but not controlled by commercial publishers; i.e. where publishing is not the primary activity of the producing body” (Twelfth international Conference on Grey Literature, 2010). The search terms used for the research were: (“maternal nutritional physiological phenomena”MeSH Terms OR (“maternal”All Fields AND “nutritional”All Fields AND “physiological”All Fields AND “phenomena”All Fields) OR “maternal nutritional physiological phenomena”All Fields OR (“maternal”All Fields AND “nutrition”All Fields) OR “maternal nutrition”All Fields) AND interventions All Fields.
The inclusion criteria were reports that had data on maternal nutrition interventions with a timeframe of between 2009 to date. Exclusion criteria included any material written before 2009 and all material focusing on high income countries.
For this phase of the research to promote quality assurance the use of the CASP check list and the development of a Prisma flow chart was carried out see below annex 1.
In all 20 peer articles were included in the review and the summary table of these papers can be found in annex 2.

To support the findings from the literature review key Global Reports were also included such as the annual State of the World’s Mother’s reports from 2009, compiled by Save the Children, the 2009 Child Health Now report developed by World Vision International; the 2014, 2015,2016 and 2017 Global Nutrition Reports compiled by IFPRI and the series of Countdown to 2015 and 2030 reports from 2009 to 2017. The review results supported by the grey material were used to answer objective two in identifying the countries with improved maternal nutrition. This material was also used to identify key factors which led to improvements in maternal nutrition while tracking key indicators used for assessing progress in maternal nutrition. All information obtained was used to support the formation of a simple maternal nutrition index, based on evidence to support countries still struggling to improve maternal nutrition.
2.2.2 QUALITATIVE RESEARCH INCLUDING KEY INFORMANTS
This is the second phase of data collection. Key nutrition specialists in the area of material nutrition were identified and asked a series of open ended questions to support the overall analysis and answer the aims and objectives of the study more effectively.
2.3 SAMPLING TECHNIQUE
Purposive and snowball sampling techniques were used to obtain samples for the research. Purposive sampling refers to the use of judgement expert in selecting cases or cases with a specific purpose (Elmasi, 2017). The participants were chosen for their expertise on maternal nutrition and health, to successfully answer the research aim and objectives. It is a less costly sampling technique, it is readily available and convenient. As it only selects the respondents who are required it is not truly representative of the actual population. Snowball sampling also known as chain referral is a sociometric form of sampling technique. It involves contacting respondents that you know then they refer you potential respondents that have an expertise on the research question (Elmasi, 2017). It is a cheap and simple method that requires very little planning and fewer workforce, but one has little control over the sampling process, representativeness of the sample is not guaranteed and there may be sample bias as the initial respondent may nominate people they know better. In all 10 participants were approached to take part and 5 completed the survey

2.4 DATA COLLECTION TOOLS

• Qualitative survey using open ended questions were used to collect data

OPEN ENDED QUESTIONNAIRES
This is one of the most common form of data collection. The respondents receive a set of questions and they write down the replies to the questions. This was the second phase of data collection. The interviews were completed by gatekeepers such as nutritionists and health workers. The variable used for data collection was maternal nutrition interventions so as to assess the outcomes of the interventions. The information obtained from the questionnaires gave a deeper and broader understanding of the maternal nutrition interventions and the barriers that were faced in collection of the data.
Open-ended questionnaires have low cost, are free from bias and one can have adequate time to think and reply to the questions but in most cases the return rate is usually low, and it is one of the slowest method of data collection.
Critical Appraisal Skills Programme (CASP) checklist was used for quality assurance.
2.5 ETHICAL CONSIDERATIONS
The research was approved by University of Westminster, Faculty of Science and Technology by the Virtual Research Environment. The ethical approval number is ETH1718-1183. Information sheets were given to participants prior to them signing the consent form. All participants had the right to opt out at any time and confidentiality was maintained throughout, with all data stored using the University of Westminster’s data protection guidelines. Ensuring all material was kept in a locked unit or in a password protected file. All participants will be sent a one-page summary of the findings.
2.6 DATA ANALYSIS
Data analysis was done in two stages:
The first stage was the analysis of the literature-based research where key findings along with the strengths and weaknesses of the research is represented in a summary table and in the findings section.
The second stage was the analysis of the questionnaires using a thematic context analysis. The information obtained was analysed, summarized, classified and then tabulated. The main themes and sub themes that emerged were:
2.6.1 SUPPLEMENTATION
Micronutrient supplementation plays an important role in improving the maternal nutrition status. The majority of the key informants who responded felt that it has been proven to work especially iron and folic acid supplementation.
“The quality and accessibility of maternal nutrition services including micronutrient supplementation is a good influencer of maternal nutrition”.
One of the respondents also mentioned that micronutrient supplementation has proven to work in specific contexts.
“In some cases of an emergency situation, there might arise a need for a particular micronutrient and thus seem to work”.
One of the issues that hinders the progress of maternal nutrition is that there is no data to assess the progress made by the interventions. Some of the respondents mentioned that the data on maternal nutrition is limited but not on anaemia for women of reproductive age.
“There is data on anaemia as a biomarker as proxy for multiple micronutrient deficiencies”.
Other than the iron and folic acid, half of the respondents also mentioned another micronutrient supplement as having an impact in maternal nutrition in low income countries.
“Calcium supplementation has been proven to reduce/prevent maternal nutrition to the mothers at risk in low income countries “.
Macronutrient supplementation has also been mentioned by half of the respondents as a maternal nutrition intervention that has proven to work. One of the respondents mentioned:
“Distribution of lipid-based nutrient and macronutrients supplementation has worked in emergency setting”.
2.6.2 HEALTH SERVICE DELIVERY
This is an essential theme as it covers a wide range of factors that brings about improved maternal nutrition.
Access to health care is one major factor that has shown to improve the maternal nutrition status in terms of antenatal and postnatal care.
“Access to antenatal and delivery care has hugely improved the nutritional outcomes”.
“Acting mainly on the first 1000 days of life has had a clear impact on increasing the rates maternal nutrition in low-income countries” indicated one respondent.
Another respondent commented, “The intergenerational impact of nutrition has an impact on maternal nutrition i. e nutrition at early stages of life/ the reproductive age determines maternal nutrition status”.
One respondent stated, “Management of acute malnutrition for pregnant and lactating women has proven to improve maternal nutrition outcomes”.
“There is a difference when it comes to service delivery in an emergency situation especially for the pregnant and lactating women who require lifesaving interventions “said one of the respondents.
Women need to access to family planning services to help in child spacing to help in replenishing nutrients lost from previous pregnancy.
“Access to family planning for women of child bearing age to have control women over reproduction i. e women can choose to birth space as well as manage the number of children”.
Nutrition education can also be an influence good maternal nutrition.
“Education of women on how to prevent maternal nutrition is one of the factors that influence maternal nutrition”.
2.6.3 FOOD SECURITY
This is when “all people at all time have physical, social and economic access to safe and nutritious food to meet their dietary needs and food preferences for a healthy and active life” (World Food Summit, 1996).
One of the pillars of food security that was mentioned by all the respondents include food availability. Majority of the participants mentioned that it was a key maternal nutrition intervention.
One respondent mentioned, “Dietary diversification can be improved through own production and consumption of nutritious food to improve maternal nutrition outcomes”.
Another respondent comment,” Kitchen gardens as well as the growth of biofortified foods such as Vitamin A fortified sweet potatoes is a targeted agricultural intervention will help improve maternal nutrition outcomes”
Food accessibility is another pillar that was mentioned to influence maternal nutrition outcomes.
“Increased access and consumption to food through market access as well as partly use of income to access food to enhance maternal nutrition outcomes”.
One respondent expressed the belief that “Access to adequate and appropriate food through food distribution is a lifesaving intervention for pregnant and lactating women in an emergency situation”.
From the statements above, we can tell that the participants perceive that food security is an important factor that better maternal nutrition outcomes but if there is food insecurity then it can be a barrier to good maternal nutrition.
“Food insecurity is a barrier to good maternal nutrition”
“Lack of accessibility and availability of nutritious food for the pregnant and lactating women can hinder good maternal nutrition” mentioned one respondent.
2.6.4 WOMEN EMPOWERMENT
If women uptake various roles in the society, community and even the household then they will help in enhancing maternal nutrition.
“Women empowerment is an important influence of maternal nutrition”.
When it comes to social safety net interventions if the women are given cash then they will be able to make more informed choices in the food to be consumed.
One of the respondents commented “If women are given a control of purchasing food and choices it will then improve the quality of maternal nutrition outcomes”.
Lack of women in decision making as well as gender gaps in the society then this will hinder the success of maternal nutrition interventions.
“If women are not involved in decision making then the gender gaps are widened and thus cause a barrier to attaining good maternal nutrition outcomes” stated one respondent.
2.6.5 POLITICAL WILL
The government needs to be involved in creation of policies that will aid in the improving maternal nutrition outcomes.
“Committed governments should come up with policies that improve maternal nutrition outcomes” one respondent stated. And another commented, “Extended paid maternity leave laws for mothers working will have a greater impact on maternal nutrition”.
2.6.7 OTHER THEMES
Two of the respondents mentioned that behaviour change communication can improve maternal nutrition.
“Social behaviour communication change designed to address specific barriers to maternal nutrition that not only targets the women but also men, mothers-in-law and community leaders”.
“Behaviour change communication in some communities might contribute to dietary diversification”.
Other findings from the questionnaires revealed other factors that may be barriers to maternal nutrition which include: climate change, water, hygiene and sanitation (WASH), migration and funding.
Lack of data was a factor that was identified when the researcher carried out the literature review and included it in the questions that were asked to the key informants.
One of the respondents stated, “Nutrition data compared to health data is expensive and difficult to obtain”.
Half of the respondents suggested that nutrition outcomes are influenced by other factors such as infectious diseases and the interactions they have. Human resource capacity and the appropriate equipment is also a factor that hinders data collection.

3.0 FINDINGS
Firstly, the findings of the research from both the literature review and key informant interviews identified the low and middle-income counties that have made the progress in maternal nutrition over the years.

3.1 COUNTRIES IDENTIFIED
The top five countries who have improved maternal nutrition outcomes are:
• Brazil
• Bangladesh
• Mozambique
• Malawi
• Cambodia

3.2 KEY INDICATORS
The key indicators used were the coverage figures for the 8 maternal interventions required to improve maternal and child nutrition outcomes as states in Lancet 2013: which include; nutrition specific interventions such as adolescent health and preconception nutrition, maternal dietary supplementation and micronutrient supplementation and fortification and nutrition sensitive interventions such as agriculture, social safety nets, women empowerment and health and family planning services. However maternal mortality rates, maternal anaemia rates, numbers of low birth weight babies, and still birth numbers were also analysed.
See tables below with the key indicators tracked from 2009 for identified countries.
Table 1: Key indicators for countries with improved maternal nutrition.
KEY INDICTAORS
1. Maternal health
2. Skilled birth attendant
3. Political factors
4. Economic status
5. Education state
6. Nutrition in an emergency setting

3.3 HEALTH SYSTEMS STRENGTHENING APPROACH
As mentioned in the literature review, one the factors that influence maternal nutrition is the health system. A health systems framework was used, and it comprised of:
3.3.1 GOVERNANCE AND LEADERSHIP
The national governments, donor countries, international agencies, private sector and the civil society share the responsibility in ensuring that mothers and newborns live healthy lives.
In an emergency setting, the governance of a country can be distorted and thus disrupt the health systems.
3.3.1.1 Political commitment
In Malawi, there was an increase in political commitment and agreed to receive help from international organizations to improve maternal health (State of the Worlds Mothers, 2013).
In the cases of an emergency setting, the governments need to build long term resilience to reduce the effects of damage on health in a crisis. They should also design social protective policies and programmes that cater for the needs of the vulnerable as well as Disaster Risk Reduction (DRR) policies and programmes that build on conflict sensitivity for areas that are susceptible to natural disaster and/or conflicts (State of the World’s Mothers, 2014).
3.3.1.2 Intersectoral approach
World vision links the local community with the district and national government due to its programmes which help to strengthen the bond to improve advocacy for improving maternal, newborn and child health (Child Health Now, 2016).
In Sweden, the government introduced policies that reduced mortality among vulnerable groups. The policies were to improve the living conditions as well as provide water and sanitation to all the residents (State of the Worlds Mothers, 2015).
3.3.2 HEALTH WORKFORCE
The health workers play an essential role in health system strengthening.
3.3.2.1Ensuring skilled supported supervised health workers (4.5 per 1000 pop)
The health workers usually lack morale due to lack of supportive supervision, irregular and low pay, training and promotions in their careers thus they end up migrating to private sector or different countries like in the case of Nigeria where 74% of their doctors’ work in the private sector. (Child Health Now, 2009).
Nigeria like other African countries has large numbers of health workers as human resource but they still have low numbers to deliver services at 1.95 per 1000 population (Global Health Workforce Alliance, 2018).
The number of skilled workers need to be increased and need to be in a safe space to ensure that there is high quality health care in an emergency (State of the Worlds Mothers, 2014).
3.3.2.2 Reaching the hard to reach
Geographical access to health facilities for the pregnant and lactating women is a barrier to access the healthcare needed. Despite these some of the countries such as Bangladesh, Brazil and Malawi have trained their health workers to reach the poorest who struggle to get to health facilities. They also ensured that the health workers taught the women on family planning and also increased their quality in service delivery (State of the Worlds Mothers, 2013).
3.3.3 EFFECTIVE HEALTH INFORMATION SYSTEMS
3.3.3.1 Effective maternal nutrition data collection
The Global Nutrition Report states that data needs to be disaggregated which refers to the separate on of data into different components so as to ensure that everyone is included irrespective of their age, gender and ethnicity. It also states that the data needs to be coordinated and interpreted well in order to track progress of maternal nutrition (Global Nutrition Report, 2017).
One of the respondents suggested that “The UN body needs to standardise the indicators, data collection and repositories and make them available online”. Another respondent stated, “More advocacy needs to be put in place as focus is mostly directed towards child nutrition and birth outcomes”.
3.3.4 EFFECTIVE UNIVERSAL SERVICE DELIVERY
An evaluation of the healthcare inputs, service delivery, impact and outcomes of quality of care and it was found out to be poor. Studies from low and middle-income countries showed that the coverage of ante-natal visits dropping to 30-45% when considering appropriate equipment needed for efficient service delivery. It further dropped to 50% when the process that are carried out in the ante-natal clinics were considered (Countdown Report, 2017). This illustrates that with low quality then there will be no health improvements. Once the women are able to attend antenatal clinics then they will be able to receive supplementation which will preserve their lives.
The Countdown Report goes on to suggest that countries need to improve the quality of services at the point contact to ensure high levels of coverage are reached. It also suggests mid-term coverage goals need to be set for indicators to ensure that universal Sustainable Development Goals are monitored (Countdown Report, 2017).
In 2011, Brazil found out that there was an increase in maternal and child health once an analysis by Child Health Now was carried out, but adolescent girls were not included. As a result, they started a campaign to ensure equal access to health services for all pregnant and lactating women as well as teenage mothers to improve child development and survival as well as prevent unwanted pregnancies (Child Health Now, 2016).
In an emergency situation, pregnant and lactating women need to have access to high quality care through having enough medicine and supplies during the crisis (State of the World’s Mothers, 2014).
3.3.5 HEALTH FINANCING
Developing countries should invest more on the health systems particularly on maternal, newborn and child health to improve maternal outcomes. They also need to come up with cost effective intervention and integrate them into the health systems (State of the World’s Mothers, 2013).
In Brazil, they launched a unified health system to ensure universal access to comprehensive health care without a fee (State of the Worlds Mothers, 2013).
Primary and secondary healthcare should be provided when the pregnant and lactating women need and can afford thus any financial barriers should be removed in the cases of an emergency (State of the World’s Mothers, 2014).
In Nigeria, the federal government spent 1.7% of its budget on health care in 1999 and increased to 6.4% in the 2002. It then dropped to 4% in- 2006 and further dropped in 2014 to 2014. This leads to the community to go through the out-of-pocket system in order to access essential health care which will in turn affect access to health especially those struggling in the community (WHO, 2015).
The local government needs to understand health expenditure and external expenditure not forgetting the out-of-pocket expenditure of its people. This will enable it to compare the financial burden of households for healthcare and how it allocates it resources according to what it needs and financial aid from received from donors (Countdown Report, 2017).

3.3.6 PRO-POOR HEALTH FINANCING SUPPORTED BY SOCIAL SAFETY NETS
Safety nets are programmes that aid in the distribution of either cash (conditional or unconditional) or food to the low-income families. This improves their food security as well as nutrition status. In most cases the women are often part of the cash transfer programme. This is to empower the women as they make better food choices for the household compared to men.
Conditional cash transfer is one of the most common forms of social safety nets and has largely been implemented in Latin America. Most successful stories have been seen in Brazil, Mexico and Nicaragua. the programme had a positive effect on reduction of poverty, increased food consumption and dietary diversification. The programme has also had a positive impact on women’s control over resources, boosted their self-esteem, improved the health and nutrition status and strengthened women’s opportunity in their social networks (Lancet Series, 2013).
In emergency situations, food rations or cash are given to the pregnant and lactating women. When sudden onsets of earthquakes or hurricanes occur, the markets are often destroyed and, in such cases, then cash is preferred (Lancet series, 2013).

4.0 ANALYSIS
In this section, a critical analysis of the findings from both literature review and key informant questionnaires will be done using the health systems building blocks.
The main aim of the study was to explore the perceived factors that have led to improved maternal nutrition outcomes in low and middle-income countries.
A tabulated output of the data obtained from the literature review and key informant interviews showed that health service delivery, one of the health systems building blocks, plays an important role in improving maternal nutrition outcomes. Fist and fore most the health services should be comprehensive. It should prevent, cure, rehabilitate, provide palliative care as well as promote health. The quality of the health services should be safe, effective and should meet the needs of all the women of child bearing age. The women should be able to attend the ante-natal clinics and have safe delivery with no barriers of geographical location and cost. Family planning services are essential for women of child bearing age as it aids in child spacing and prevent the occurrence of unwanted pregnancies. Proper coordination between local community members with other sectors such as non-governmental organization in cases of an emergency through disaster risk reduction will ensure that the quality of health care is maintained. When the above factors are taken into consideration when carrying out health services then it will improve maternal nutrition outcomes.
Health workforce determines the quality and coverage of service delivery. In many countries, there is a shortage of skilled personnel due to poor wages and migration. The health workers prefer working in the cities leaving the rural areas with few or no workers at all. This will compromise in the quality of health care for the women. This can be improved by ensuring more of the people are enrolled to health professional courses so as to improve the numbers. In some communities, the women will not accept health services from men thus should be equal distribution of the health workers in terms of sex, gender and occupation. As observed in the findings section, countries such as Bangladesh and Malawi trained their health workers to meet the needs of the hard to reach and as a result, there was an improvement in maternal nutrition. Lack of morale is an issue when it comes to health workers. The government can come up with strategies that will look into their salaries and working conditions. Monitoring the performance of the health workers is essential to note the gaps which will be available and provide quality training where it is required to ensure improvement of maternal nutrition outcomes.
Majority of the households in low-income countries end up relying on out-of-pocket payments to access health services. This determines the number of women who attend clinics for routine check-ups such as the antenatal clinics where they will not only receive nutrition counselling and education, but they will also receive supplementation. Total expenditure on health which refers to the overall availability of funds required for health. The government expenditure on health the amount of funds raised for healthcare and also how much a government is dedicated to health. Some low-income countries such as Nigeria under budget for their health which ends affect the quality of the health service delivery. Increasing investment on low cost interventions as well as health especially maternal, newborn and child health will influence the improvement of maternal nutrition. International dialogue with donors’ aids in increasing the funds for health and thus develop sustainability of domestic funds as well as provide resources that will contribute to costed plans that are fully funded.
From the results it is evident that leadership and governance is essential to improve maternal nutrition. The national government, donor countries, international agencies, private sector and the civil society require to share the responsibilities to help the pregnant women to live healthy lives. Development of health policies and frameworks by the local government that promote programmes that meet the need of women in the reproductive. This will help empower women and reduce gender inequality thus improve maternal nutrition. In Malawi, they government had high levels of commitment and collaborated with international organizations to provide training and surveillance for their health workers which lead to the country having a strong health system for the mothers and babies. This is a good example of how working with external partners builds harmony thus improving health and maternal outcomes.
Health Information systems provides the base of what decisions are to be made regarding the health system. Its functions include data production, compiling, analysis and synthesis and disseminate and use it (WHO, 2010). This building block from literature review analysis is most lacking. There is very little data on maternal nutrition interventions which make it hard to determine any progress made by the interventions. As suggested by the key informants, indicators need to be standardised and human resource to carry out the data need to be well trained. Other than that, the governments and donors need to be transparent and accountable when they are collecting data on the indicators. The data also needs to be up to date so as to identify where the gaps are and work on them.
Other than the building blocks of health systems, nutrition sensitive programmes show a great impact on improving maternal nutrition outcomes. If the women get educated then it will improve the economic, social and physical capacity thus making more informed choices for their households as well as reduce poverty. It will also prevent early marriages thus prevention of early pregnancies. Women empowerment through social safety nets especially conditional cash transfers, they will increase food security and improve access to health care which will in turn improve maternal nutrition. This will also promote gender equality especially for economic empowerment.
Agricultural interventions were suggested by key informants to have an impact on maternal nutrition. If women get involved in agricultural production where they manufacture their own food which is fortified, consume it or sell it in markets to obtain money for other kinds of food then food security will be enhanced. Bangladesh is a perfect example country that has seen progress through women empowerment.

5.0 CONCLUSION AND RECOMMENDATIONS
This study set out to explore the factors that have led to improved maternal nutrition outcomes in low and middle-income countries. The findings of the research indicate that health systems are the major factor that has led to improved maternal nutrition outcomes. The other factor is nutrition sensitive interventions also play a vital role in maternal nutrition.

Based on the research findings here are several recommendations to be considered:
• Low and middle-income countries should strengthen the building blocks of the health systems which will improve maternal nutrition outcomes.
• Indicators for data collection need to be standardized so as to monitor the progress of maternal nutrition.

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ANNEX 1: PRISMA FLOW CHART DIAGRAM

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit http://prisma-statement.org/PRISMAStatement/FlowDiagram.aspx

ANNEX 2: SUMMARY TABLE
AUTHOR/ YEAR AIM OF THE STUDY/PAPER TYPE OF STUDY DATA COLLECTION APPROACH FINDINGS STRENGTHS WEAKNESS
The Lancet Nutrition Review group et al.,

2013. Identify interventions for improved maternal and child health and how much it will cost. Systematic review PubMed, Cochrane libraries, WHO database and electronic library. Investing in nutrition -specific interventions through involvement of the community and well-planned delivery strategies will reach a greater population.
Linkage between nutrition-specific and sensitive interventions will have a great impact on a country’s burden on maternal undernutrition and mortality. Identification of effective and cost effective interventions. Evidence of the interventions is obtained from efficacy trials other than effectiveness trials.
Ruel M, Alderman H and Maternal and child nutrition study group.

2013. Nutrition sensitive interventions and programmes. Systematic review Demographic health surveys, WHO Social safety nets have shown potential of benefiting both maternal and child health but its needs to be well developed.
Agriculture and safety nets have a large role in poverty reduction, women empowerment and high coverage of nutrition at household and individual level. Nutrition sensitive programmes have a great capacity to boost and benefit nutrition specific actions. Investment needs to be done on the nutrition sensitive interventions.
Mbuagbaw L, Medley N, Darzi A, Richardson M, Garga K and Ongolo-Zogo P.

2015. Determining the impact of health systems and community level interventions to improve antenatal coverage. Intervention review Cochrane pregnancy and childbirth’s trials register. A trial of one intervention versus no intervention led to: Improvement in the number of women who attended antenatal clinics (ANC) for four or more times (average OR 1.11, 95% CI 1.01 to 1.22).
Improvement in the number of deliveries done at a health facility (average OR 1.08, 95% CI 1.02 to 1.15). Improvement of antenatal coverage may be from a single intervention. Relation to whether the interventions were at a community level or health system level was not specified.
Prevention of malaria treatment was not reported.
Sheila C Vir,

2016. Improving women nutrition in South Asia through the integration of nutrition specific and sensitive interventions. Systematic review Peer review and grey literature.
There is an emphasis in reaching women of reproductive age and pregnant women during pregnancy and preconception to ensure that the women have the correct weight and height and free from anaemia.
Combination of nutrition specific and sensitive interventions to empower the woman is essential prior to and during pregnancy. Improved maternal nutrition foe the women through the combination of interventions. Implication of double burden of overweight and anaemia of women in poor economic environments need to be explored more.
Victoria C, Aquino E, Leal M, Monteiro C, Barros F, Szwarcwald C.

2011.
Progress and challenges in maternal and child health in Brazil. Systematic review Vital statistics, population census, demographic and health surveys and published reports. Increase in delivery by skilled birth attendants between the poor and rich women from 71.6% and 98.1% in 1996 to 96.8% and 99.5% respectively.
Antenatal coverage is high. Reduction in socioeconomic inequalities. Quality of maternal health is low despite the increase in service delivery.
Nguyen P, et al.

2017 Assessing the maternal, household and health services factors that influence maternal nutrition practices in Bangladesh. Baseline household surveys. Face-to-face interviews with a structured questionnaire. Nutrition knowledge was a major factor associated with the intake of IFA and calcium tablets with dietary diversity.
Self-efficacy of women was associated with diet diversity to achieve recommended practices and perceptions of social norms.
At a household level, the women who received support from their husbands had an increased intake of the IFA and calcium tablets and had a diverse diet.
Early and frequent antenatal visits and receiving of free supplements were associated with higher intakes of IFA and calcium. Improved maternal nutrition practices. The respondents may have suffered recall and social desirability bias.
Kim S, et al.

2017 Integration of nutrition interventions into existing Maternal, Neonatal and Child Health (MNCH) Programmes in Bangladesh. Cluster randomized designs with baseline and end line cross-sectional surveys. Face-to-face interviews. There was a 90% coverage of interpersonal counselling of the women in MNCH nutrition focus group who carried out home visits.
Community mobilization was at 50%.
Increase in the consumption of IFA and calcium tablets and dietary diversity in the women involved in the MNCH nutrition focus groups. Improved maternal nutrition through supplementation and dietary diversity. Social desirable bias from respondents.
Haider B and Bhutta Z.

2107. Benefits of multiple micronutrient (MMN) supplementation in pregnancy. Systematic review of trials. Cochrane pregnancy and childbirth’s trials register. There was no significant outcome on anemia in pregnancy when micronutrient supplementation was compared against iron, with or without folic acid (average RR at 1.03; 95% CI 0.85-1.24).
MMN supplementation against a placebo group identified reduced risk of anaemia in the third trimester (average RR O.46;95% CI 0.29-0.73). Reduced risk of anaemia in the third trimester. Data was missing in some studies.
Suchdev P, Pena-Rosas J and De-Regil L.

2015. Effects of prenatal home (point-of-use) fortification of food in pregnant women. Randomised control trials and quasi randomised control trials. Cochrane pregnancy and childbirth group trial’s register and international clinical trials registry platform. There was a similar outcome on haemoglobin levels of the mothers at term or near for those who used micronutrient powder fortification and micronutrient supplementation. Assessment of bias. Evidence obtained was limited and of low quality.
Pena-Rosas J, De-Regil L, Gracia-Casal M and Dowswell T.

2015. Determine the impact of oral iron supplementation either by itself or with other vitamins and minerals in pregnant women. Randomised and quasi-randomised trials Cochrane pregnancy and childbirth group trial’s register and international clinical trials registry platform. Iron supplementation reduced the risk of maternal anaemia by 70% (RR 0.30;95%CI 0.19-0.46) and iron deficiency anaemia during pregnancy by 57% (RR 0.43;95%CI 0.27-0.66). Reduced risk of anaemia in pregnancy. No evidence on the effects of iron supplementation on maternal mortality.
Victoria G, et al.

2012 Scaling up maternal nutrition programmes. Systematic review PubMed, Cochrane library, WHO Reproductive Health library and Food and Nutrition Library. Fortification programmes of IFA were less successful compared to salt iodization.
Micronutrient supplementation coverage was good in Nicaragua and Nepal.
Cash transfer program in Mexico was good platform for the delivery of maternal nutrition services.
Improved coverage and behavior on integrated nutrition programs through supplementation and BCC in Bangladesh, Madagascar and India. Programmes can be combined to achieve optimum results. Much of the focus is not on pregnant women and their health in general.
Saldanha L, et al.

2012. Improvement of maternal nutrition through policy and program implementation experience in Ethiopia. Situational analysis and investigation focus. Focus group discussions and in-depth interviews. Low awareness and demand for nutrition services apart from supplementary food.
Barriers to maternal nutrition include prioritization of health and nutrition services and lack of technical capabilities to carry out maternal nutrition interventions. Micronutrient supplementation and social and BCC interventions are promising to improve maternal nutrition. Missing data thus monitoring becomes an issue.
Noznesky E, Ramakrishnan U and Martorell R.

2012. Public health inteventions, barriers and opportunities in improving maternal nutrition in India. Interviews and secondary data collection. Key informants’ interviews.
PubMed, populations-based survey report, journal articles, program planning documents. Barriers to service delivery and interventions include sterilization bias, prioritization issues, poverty, gender inequality, poor management systems and lack of essential inputs.
Local and private partnership with the government led to introduction of structural reforms in the public health system, innovation of approaches and coming up of programs for the unjust group are the solutions that were put in place to improve maternal health by overcoming the barriers and improve service delivery Political will is essential for maternal nutrition interventions. Study was done in districts that had high public health systems
Interviews were not conducted at a community level.
The Health Foundation

2013. Improving maternal nutrition and newborn health in Malawi. Randomized control trials Vital statistics, demographic health surveys. Community mobilization led to a decrease in maternal mortality by 16%.
The government encouraging women to seek delivery in hospitals despite their weak health systems. Development of strategies that will aid in improving maternal nutrition such as advocacy strategy, community and facility mobilization and government commitment. Lack of resources, staff and motivation.
Shrimpton R.

2012. Global policy and programme guidance on maternal nutrition. Interviews Key informant interviews Few countries have maternal nutrition interventions for maternal anaemia and most of it are not effective and lack of funding.
Much attention is not given to maternal nutrition thus it is usually downplayed. Increase in investments for programmes aimed at improving maternal nutrition. Lack of funding and importance given to maternal nutrition programmes.
Rehena S, et al.

2015 How Eastern and Southern Africa is fairing on maternal nutrition. Meta-analysis Google scholar, Cochrane library, Ministry of Health Websites, WHO, WFP, UNICEF and World Bank. Maternal nutrition programmes have been implemented by variety of key players such as the government ministries and non-governmental organizations.
Most of the clusters are clustered in countries with few having initiatives. Overall improvement in maternal health and nutrition indicators in the region. Health systems are weak, poor governance, constrained supplies, low prioritization and limited resource and finance.
Mason J, et al.

2014 The first 500 days: Policies to support maternal nutrition in Northern Nigeria Ethiopia and India. Case studies Key informant interviews, focus group discussions and literature review. Interventions such as the maternal supplementation, salt iodization, family planning programmes, and conditional cash transfers are used for resource provision and public health education. Focus is on maternal nutrition especially anaemia. Implementation issues may be hard to meet the poorest countries.
World Health Organization (WHO),
Department of Equity, Poverty and Social Determinants of Health

2007 Inequalities of maternal and child health in Mozambique. Systematic review WHO website, demographic and Health Surveys. Increase in the number of skilled birth attendants at national level from 44.2% in 1997 to 49.1% in 2003.
Maternal mortality had reduced from 1600 per 100,000 livebirths in 1990 to 408 per 100,000 livebirths in 2003.
Gap between the rich and poor women can be a concern of maternal nutrition. Improvement on maternal health. Inequalities in skilled birth attendance which include socioeconomic aspects, condition of the mother weather health or physical and quality of antenatal care.
Ramakrishnan U, et al.

2012. Public health interventions, barriers and opportunities for improved maternal nutrition in India. Interviews Key informant interviews and focus group discusions. India has a large and strong platform in addressing maternal nutrition thus improve maternal, newborn and child outcomes such as IFA supplementation, micronutrient fortified food and food supplementation alongside maternal counselling and education. Reduction in rates of maternal mortality. It does not consider views from private sectors.
Cetin I and Laoreti A.

2015. Importance of maternal nutrition for health. Systematic review and investigation focus. Focus group discussions, Danish National Birth Cohort and Norwegian Mother and Child Cohort study. Preconception counselling should be of maternal nutrition before and during pregnancy.
Supplementation and/or fortification can make a difference to meet nutritional requirements.
Industrialized countries focus on high-fat and low-quality diet thus does not meet vitamin and mineral requirements. Maternal nutrition affects one’s health before and during pregnancy. Evidence does not support micronutrient supplementation.

ANNEX 3: CONSENT FORM

PARTICIPANT CONSENT FORM

Title of study: Explore the factors that have led to improved maternal nutrition interventions outcomes in low income countries

Researcher: Jean Chelimo

I have been given a Participants Information Sheet, or I have had it explained to me Yes ? No ?
I was given the opportunity to ask questions and I’m satisfied with the answers given Yes ? No ?
I understand that taking part in this study is voluntary and that I may withdraw from the study at any time. Yes ? No ?
I consent to having the interviews/ group discussions recorded Yes ? No ?
I wish to receive feedback from the study Yes ? No ?
I understand that my participation in this study is confidential and that no material, which could identify me personally, will be used in any reports on this study. Yes ? No ?
I wish to receive a copy of this consent form Yes ? No ?
I am willing to participate in the above research study Yes ? No ?

Participant’s name:
Signature: Date:

The consent form will be stored on a password protected laptop and stored according to the University of Westminster’s data storage protocols.

I confirm I provided the participant with the Participant Information Sheet. I have given the participant an opportunity to ask questions and I have answered to the best of my ability.
Researcher’s name:
Signature: Date:
ANNEX 4: PARTICIPANT INFORMATION SHEET

PARTICIPANT INFORMATION SHEET
Title of study: EXPLORE THE FACTORS THAT HAVE LED TO IMPROVED MATERNAL NUTRITION OUTCOMES IN LOW-INCOME COUNTRIES

This study will be carried out by Jean Chelimo, an MSc Student at the University of Westminster. This research is a key requirement for the completion of my MSc in Global Public Health Nutrition. Ethical clearance has been obtained from the University of Westminster: ETH1718-1183 and my supervisor Regina Keith ([email protected]) will be supporting me throughout my research. Please contact her or myself on 020 7911 5000 ext. 64618 or [email protected] with any questions about the research. According to the World Nutrition reports 2014 and 2015, there is not enough data to track progress in all the agreed global nutrition targets to be achieved by 2025 (Global Nutrition Report, 2014/2015). The research will explore one specific data gap, the progress and impact of interventions aimed at improving maternal nutrition. The overall aim of the study is to determine the factors linked to improved maternal nutrition in low income countries in order to develop a maternal nutrition index. The study objectives include understanding the factors that affect maternal nutrition outcomes in low income countries and determining what evidence exists on what is working to improve maternal nutrition and what is not. This study will consider countries that have good maternal nutrition to gain a deeper understanding of what they do and how they have achieved progress. To achieve this outcome the researcher will review secondary literature and carry out qualitative interviews with key informants.
To gather the qualitative data a series of key informant interviews will be held through telephone or skype calls lasting approximately 30-45 minutes. These interviews will be facilitated by the lead researcher, supported by my supervisor. The interviews will be recorded, if consent is given by the participants, using a tape recorder and the data stored on a password protected computer/laptop. To preserve the anonymity of participants, names will not be used or identifying characteristics states in the interviews. Participants are able to leave the study at any time. Feedback will also be given to all participants.
If you agree to take part in this study, you will be asked to sign a participant consent form. If requested, participants will receive a copy of the participants consent form and information sheet.

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ANNEX 5: RESEARCH QUESTIONS

QUESTIONS FOR KEY INFORMANT
1. What do you think influences good maternal nutrition?
2. Which maternal nutrition interventions have proven to work in low income countries?
3. What other interventions help improve maternal nutrition outcomes?
4. Are these different in emergency situations? If so why?
5. Which three LIC/MIC countries have made the best progress in improving maternal nutrition?

6. Which three LIC/MIC countries have made the least progress in improving maternal nutrition?

7. What interventions have led to the good outcome countries?

8. What are the barriers to good maternal nutrition in low income countries?

9. What challenges have led to poor maternal nutrition outcomes in selected countries?

10. Are there specific non-nutrition factors which affect nutrition outcomes the most?

11. Data collection comes out as a major factor that hinders the progress of maternal nutrition, why is there no data on this?

12. What needs to change to improve maternal nutrition data?