Maternal Anemia within Child Survival Grants Program: Lessons Learned and a Way Forward? - A Selected Review

Maternal Anemia within Child Survival Grants Program: Lessons Learned and a Way Forward? - A Selected Review - SilvanaFaillace, A2Z Project April 26, 2010 Baltimore, United States

Overview
Child Survival Grants Program (CSGP) selected review
Part I:
Maternal Anemia programs and effectiveness at scale
Part II:
Findings and lessons learned from CSGP programs review
Recommendations

Child Survival Grants Program (CSGP) selected review
Objective
Critically review a sample of CSGP programs to i dentify maternal anemia program components and barriers to implementation and/or scale-up
Methods
Program selection
CSGP information system and portfolio mapping (Macro International)
Search done for programs with iron folate and maternal anemia that ended in 2009 or planned to end in 2010 and 2011
Identified “inputs”, “outputs”, “outcomes” and “impacts” specific to maternal anemia reduction activities, as well as self-reported barriers to implementation and scale up
Assessed identified maternal anemia program components against commonly accepted benchmarks from “Anemia-What Works”, systematic reviews of effective large-scale maternal anemia programs

Child Survival Grants Program (CSGP)
Programs reviewed
PVO Country Program Project end date Finished Projects HKI Niger YALLANDO KLEYA Child Survival Project 9/30/2009 HKI Mali Synergy and Action for Nutrition 9/30/2009 CPI India Jeevan Daan Maternal and Child Survival Cost Extension program 9/30/2009 On-going Projects Hope Worldwide India Chotton Ki Asha Child Survival Program 9/29/2010 Goal Ethiopia Sidama Child Survival Program 9/29/2011 INMED Peru Healthy Babies Project 9/30/2010 MIHV Tanzania Tanzania Child Survival Project 9/29/2011 Plan International Nepal Local Innovation for Better Outcomes for Neonates Project 9/29/2011 Relief International Niger Healthy Start Child Survival Program 9/30/2011 The Salvation Army World Service Office (SAWSO) Zambia Chikankata Child Survival Project 9/29/2010

Maternal anemia programs and effectiveness at scale

Key Program Components for Anemia Control
Increasing iron intake
Iron/folate supplementation
Food fortification
Dietary diversity
Malaria control (where relevant)
Reducing parasitic worm loads

Maternal Anemia Integrated Intervention Package
Effectiveness IFA Supplement supply Delivery system Compliance Supplements taken Iron status improves Anemia and other iron-related health outcomes improve Efficacy Adapted from Ekstrom 2002 Malaria Control: Bednets, IPTl Deworming Motivation

Characteristics of Effective Maternal Anemia Programs
Comprehensive approaches addressed major preventable causes (iron deficiency, malaria, parasitic worms)
Addressed known barriers
Commitment to action
Awareness of benefits by both clients & providers
Logistics (supply, tablets & packaging)
Access to quality ANC (motivation, training & supervision)
Communication materials & counseling (e.g. memory prompts, anticipate & cope with side-effects)
Tailored to country context

Nicaragua: Prevalence of anemia in mothers/caregivers 1993, 2000 & 2003
Percentage Hb<12 g/dL Source: SIVIN 2004
ANC increased from 62% to 70% from ’97-’01
80% women reported taking 90+ IFA tablets in ‘01
CB programs and pharmacies possible sources of IFA also

Thailand: Trend in anemia in pregnant women in Thailand
Source: Routine MOH data based on women receiving ANC at health facilities
National program linked health facilities with community-based workers
De-worming, sanitation and hygiene, dietary diversification also major emphases
Economic development accompanied decline in anemia

Evidence on effective large scale programs
Nicaragua : ANC increased from 62% to 70% from ’97-’01. Brigadistas (community health worker) follow-up and counsel. Supply is acceptable; no major side effects. 80% women reported taking 90+ IFA tablets in ’01. Fortification also in effect.
Thailand : National program linked health facilities with community-based workers. Emphasis on reducing stockouts through district health fund. Deworming, sanitation and hygiene, dietary diversification, birth spacing also. Economic development accompanied decline in anemia but later continued.
Source: Sanghvi T, P. Harvey, E. Wainwright. “Maternal Iron-Folic Acid Supplementation Programs: Evidence of Implementation and Impact. Beijing May 2009

Elements of program are in place, but implementation?
Most countries have MMR reduction goals: IFA given priority?
ANC guidelines include preventive IFA: monitoring?
Varied causes recognized, e.g. IDA, worms, malaria: package?
Essential Drugs Lists have IFA, deworming, malaria drugs: stock outs
Basic health worker training covers anemia: counseling and follow up for IFA?

Iron/Folate Supplement Program Framework
MOST, USAID Micronutrient Program. 2004. A Strategic Approach to Anemia Control Programs. Arlington, Virginia, USA KPC Baselines, BEHAVE Framework, Focus Groups, Key Informants Target groups Health services and providers focus of trainings and program activities Areas where capacity building, health systems strengthening and program monitoring , can be tailored and strengthened to ensure maternal nutrition and anemia objectives are being achieved. CSGP

Key Findings
Program Components - Good Practices and Benchmarks Number of Programs Programs conducted initial formative research, qualitative research on attitudes and behaviors related to anemia and iron-folic acid (IFA) supplementation, e.g KPCs, BEHAVE, etc. 10 Programs with communications strategy designed to develop and deliver effective messages to overcome consumer resistance and ensure compliance in taking IFA supplements 7 Programs with increase in ANC attendance as an outcome 7 Programs reviewed with reduction of maternal anemia as an outcome 3 Programs reviewed with integrated anemia reduction approach ANC, IPT, IFA, De-worming, nutrition counseling 5 Programs explicitly working on improving supply and logistics systems for IFA, IPT or anti-helminths, e.g. stock outs 3 Programs with IFA receipt as outcome 6 Programs training health workers at all levels 10 Programs collaborating with community, district and national level decision makers 10

Low IFA coverage even where ANC is high

Lessons Learned
Variation between DIP plans and results at MTE and EOP (where available), due to variety of contextual, management and implementation issues
Quality of ANC services not being systematically monitored
Supplies
Receipt of IFA does not equate intake
Missed opportunity to reduce maternal anemia
All programs focusing on ANC attendance and quality of service
All programs focusing on health systems improvement
All programs have strong IEC/BCC components at household, community and health system level

Recommendations and Next Steps
- Given that CSHGP projects already program and invest in activities to improve maternal nutrition, such as IFA, de-worming, ANC service provision/counseling, nutrition counseling, would be beneficial to improve in the design, implementation and monitoring of these activities e.g. - Measure receipt and compliance of IFA tablets by pregnant women - Assess quality of ANC services and HW knowledge on anemia and its prevention activities offered - Use RHFA to report of health service content and quality Discussion - What is do-able within the Child Survival Grants Program? - What are the overall limitations that PVO see in having more integrated anemia control programs?

Acknowledgements
NazoKureshy, Stacey Maslowsky and Emily Wainwright - USAID Leo Ryan and David Cantor - Macro International Rolf Klemm - A2Z Project and Johns Hopkins University Jennifer Burns - Johns Hopkins University Elizabeth Deal - A2Z Project

THANK YOU
This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. GHS-A-00-05-00012-00 . The contents are the responsibility of the Academy for Educational Development and do not necessarily reflect the view of USAID or the United States Government.

Maternal Anemia within Child Survival Grants Program: Lessons Learned and a Way Forward? - A Selected Review

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