Despite significant investments in micronutrient programs targeting pregnant women, the nutrition of pregnant women and their children continues to be a substantial concern in many developing countries. In Bangladesh, for example, there has been significant health infrastructure investment and a widespread iron and folic acid (IFA) supplementation program in place since 1988. Yet, the rate of anemia among pregnant women remains at nearly fifty percent, contributing to the relatively high prevalence of poor nutrition and health among mothers and children (DFID 2018; WHO 2017).
The science clearly suggests that the IFA supplements can work: if consumed regularly during pregnancy, the supplements can reduce anemia and improve the nutrition of mother and newborn child, reducing the risks of stunting and other indicators of poor nutrition among children (Peña-Rosas, De-Regil, Garcia-Casal & Dowswell, 2015; Rasmussen & Stoltzfus, 2003).
If the science is sound, then why are these programs not more effective? Why does the rate of anemia, stunting, and other indicators of poor nutrition among women and children remain so high despite the widespread distribution of IFA supplements?
Using data collected by Nutrition International in Bangladesh, a recent academic study (Kurzawa et al., 2020) based on Limestone Analytics’ evaluation provides insight into these questions.
Our study shows that even when such programs successfully deliver supplements into the hands of local healthcare workers, consumption of the supplements among pregnant women may still be low.
In some instances, this is because the healthcare workers fail to pass the supplements on to women, and in other cases, women who receive the supplements do not consume them because they do not understand their benefits or they believe the supplements are likely to have adverse effects. Such insights are consistent with other evidence from Bangladesh, where women often believe the IFA supplements are unnecessary (Rashid et al., 2010), or they worry that by increasing fetus size, the supplements could lead to birth complications (Alam et al., 2015).
The frontline healthcare workers themselves also do not always understand the importance of the supplements, the need to adhere to a daily regime, or the likely impacts on child health (Alam et al., 2015). This is consistent with there being high variance in the knowledge and training of frontline healthcare workers, particularly in developing countries (Vaughan et al., 2015).
These insights suggest that simply delivering IFA supplements to frontline healthcare workers or pregnant women is not enough to guarantee that pregnant women will consume them. The delivery of supplements is only a necessary, not a sufficient, part of the solution. Effective interventions or programs must also ensure that pregnant women consume the supplements when they are provided.
Training healthcare workers on the importance and use of IFA supplements could help. Healthcare workers who understand the benefits of IFA supplementation are more likely to distribute the supplements and will be better positioned to convey the benefits of the supplements to pregnant women. This idea is consistent with evidence that improved healthcare worker training can improve knowledge and behavior among patients (Omer et al., 2008; Ballard & Montgomery, 2017).
Using data from a healthcare worker IFA training program implemented by Nutrition International and the Government of Bangladesh, Kurzawa et al. (2020) shows how training healthcare workers on the benefits and uses of IFA supplements significantly increased knowledge of IFA supplement benefits among both healthcare workers and women. It also led to a significant increase in IFA consumption among pregnant women.
The impact is sizable. Training healthcare workers on the benefits of IFA supplements led to an additional month and a half of IFA consumption (45 supplements) reported by women who had recently given birth in the program locations, on average, relative to women who had recently given birth in locations where healthcare workers did not receive training. Put another way, the healthcare worker training increased by 40 percentage points the likelihood that mothers reported adhering to a three-month regimen of supplements, consuming at least 90 supplements, during their most-recent pregnancy.
Of course, training healthcare workers adds to the cost of any IFA program. However, in Kurzawa et al. (2020), we conduct a cost-effectiveness analysis showing that these added costs are worthwhile.
Comparing the benefits with the costs of the program, we find that the cost of the training program was $47.11 USD per disability-adjusted life year (DALY) averted. According to common cost-effectiveness thresholds used by the WHO and others, this means the program is highly cost-effective (Leech et al., 2018; Woods et al., 2016).
The evidence from Bangladesh we present in Kurzawa et al. (2020) suggests the importance of making frontline healthcare worker training an important piece of an IFA supplementation program. It is a highly cost-effective means of improving IFA program effectiveness to improve health and nutrition outcomes for mothers and children.
Christopher Cotton is the Jarislowsky-Deutsch Chair of Economic & Financial Policy at Queen’s University, the Director of the John Deutsch Institute for the Study of Economic Policy, and the Director of Research at Limestone Analytics. Zuzanna Kurzawa is the Lead Associate at Limestone Analytics.
