Maternal Anemia within Child Survival Grants Program:  Lessons Learned and a

Way Forward?- A Selected Review -

SilvanaFaillace, A2Z ProjectApril 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 identify 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 ProgramProject end

dateFinished Projects      

HKI Niger YALLANDO KLEYA Child Survival Project 9/30/2009

HKI Mali Synergy and Action for Nutrition 9/30/2009

CPI IndiaJeevan Daan Maternal and Child Survival Cost Extension program 9/30/2009

On-going Projects      

Hope Worldwide India Chotton Ki Asha Child Survival Program 9/29/2010Goal Ethiopia Sidama Child Survival Program 9/29/2011INMED Peru Healthy Babies Project 9/30/2010

MIHV Tanzania Tanzania Child Survival Project 9/29/2011

Plan International NepalLocal Innovation for Better Outcomes for Neonates Project 9/29/2011

Relief International Niger Healthy Start Child Survival Program 9/30/2011The 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

Effectivenes

s

IFA Supplementsupply

Delivery system

Compliance

Supplementstaken

Iron statusimproves

Anemia and other iron-related health outcomes

improve

Efficacy

Adapted from Ekstrom 2002

MalariaControl:

Bednets, IPTlDeworming

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

16.1

33.6

23.7

0

5

10

15

20

25

30

35

40

1993 2000 2003

Per

cent

age

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

Trend in Anaemia prevalence in Pregnant Women in Thailand (%)

0

5

10

15

20

25

30

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

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?

Source: Sanghvi T, P. Harvey, E. Wainwright. “Maternal Iron-Folic Acid Supplementation Programs: Evidence of Implementation and Impact. Beijing May 2009

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

Child Survival Grants Program (CSGP)Key Findings

Program Components - Good Practices and BenchmarksNumber 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. 10Programs with communications strategy designed to develop and deliver effective messages to overcome consumer resistance and ensure compliance in taking IFA supplements 7Programs with increase in ANC attendance as an outcome 7Programs reviewed with reduction of maternal anemia as an outcome 3Programs reviewed with integrated anemia reduction approach ANC, IPT, IFA, De-worming, nutrition counseling 5Programs explicitly working on improving supply and logistics systems for IFA, IPT or anti-helminths, e.g. stock outs 3Programs with IFA receipt as outcome 6Programs training health workers at all levels 10Programs collaborating with community, district and national level decision makers 10

Source: Sanghvi T, P. Harvey, E. Wainwright. “Maternal Iron-Folic Acid Supplementation Programs: Evidence of Implementation and Impact. Beijing May 2009

Low IFA coverage even where ANC is high

Child Survival Grants Program (CSGP)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 improvementAll programs have strong IEC/BCC components at household, community and health system level

Child Survival Grants Program (CSGP)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 activitiese.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.