Strengthening maternal and child nutrition - what's working?

Nearly two-third of women of reproductive age in Ethiopia are affected by at least one micronutrient deficiency. Despite the proven benefits of prenatal micronutrient supplementation, adherence remains critically low, with only 17% of women consuming the recommended 90 Iron and Folic Acid Supplement (IFAS) pills. We conducted implementation research to develop interventions that optimize adherence to micronutrient supplements among pregnant women. The study identified determinants of adherence to micronutrient supplementation among pregnant women in Ethiopia through a cross-sectional survey of 2,402 participants. Results indicated pill count adherence rates of 49% for multiple micronutrient supplementation (MMS) and 22% for IFAS. Key factors significantly positively influencing adherence included thoughtful discussion with healthcare providers, supportive partner communication, knowledge of supplementations, perceived benefits of taking supplements, and normative beliefs about ANC, all P< 0.05. Conversely, barriers such as illness and forgetfulness were significant hurdles, particularly for women in their last trimester. The findings underscore the need for targeted educational interventions, improved counseling with health care provider, and communication with partner; and enhanced access to antenatal care to foster better adherence. A multifaceted approach that addresses different level barriers including individual level perceptions and beliefs about nutrition supplements, family support to pregnant women as well as quality healthcare are essential for improving maternal and fetal health outcomes. CCP used the evidence to inform a Human-Centered-Framework to develop tailored interventions. The lessons can be applied to other similar contexts. 

Zambia continues to face high rates of maternal anemia, low birthweight, and poor birth outcomes despite long-standing iron and folic acid (IFA) supplementation. With evidence demonstrating the superiority of the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMAPP) multiple micronutrient supplements (MMS) over IFA, the Ministry of Health (MoH), with partners, is piloting MMS integration into antenatal care (ANC). To guide this transition, formative research was conducted jointly by MoH through the Tropical Diseases Research Centre (TDRC), World Vision Zambia, World Vision USA, and Vitamin Angels.
Findings of a cross sectional, mixed-methods showed strong motivation among women to attend ANC, but cultural norms delaying pregnancy disclosure, gendered decision-making, and distance to facilities hindered timely and consistent practice. Health system barriers included counseling gaps, frequent IFA stock-outs, and limited social and behavior change communication (SBCC) materials, weakening trust in supplementation. At the community level, CBVs and Safe Motherhood Action Groups (SMAGs) were trusted messengers, though sustainability was threatened by high attrition and limited incentives. Critically, adherence was driven more by interpersonal trust and respectful provider interactions than by technical information alone.
The research highlights the importance of community knowledge and lived experience in shaping service delivery. Elevating these perspectives as evidence ensures that Zambia's MMS rollout is positioned not only as a clinical innovation, but as a trusted, community-owned intervention.

Nepal has made progress in reducing malnutrition, yet significant challenges persist, with one in four children under five stunted and one in five wasted. Social norms and gendered expectations strongly influence maternal and child nutrition, shaping food allocation, dietary practices, and women's decision-making power. Harmful traditions-such as food taboos, and Chhaupadi-continue to restrict women's diets and agency, while child marriage perpetuates cycles of malnutrition. To measure and trace existing norms, a nutrition project implemented the Social Norms Analysis Plot (SNAP) framework consisting of four measurement stages- formative research, baseline, monitoring, and endline assessments. Data were collected from 25 municipalities through surveys of 1,750 mothers, focus group discussions, and key informant interviews. Analysis revealed widespread restrictive practices, including avoidance of certain foods during pregnancy, postpartum diets limited to salt and rice, and newborns given honey or water. Normative expectations, such as women eating last and limited control over food purchases, were prevalent; only 56% of women reported active participation in household decisions, and 40% were married before 18. Findings informed a multi-year Social and Behavior Change Communication strategy targeting households and communities, engaging men and leaders to challenge harmful norms. Participatory tools like vignettes have been planned to support monitoring, ensuring culturally responsive interventions that promote equitable nutrition practices and mitigate backlash. SNAP framework has enabled the project to identify strength of norms and trace how it has changed over time which will eventually inform adaptation of interventions for sustaining positive nutrition outcomes across mothers and children.

In Pakistan's remote districts of Balochistan and Khyber Pakhtunkhwa, where weak infrastructure and socio-cultural barriers limit access to essential health services, Nutrition International (NI) and the Pakistan Poverty Alleviation Fund (PPAF) implemented a community-based health and nutrition integration project from January 2024 to February 2025. The initiative aimed to reduce preventable child morbidity and mortality by improving diarrhoea management, maternal and child health, and nutrition practices. It addressed key gaps such as the low use of zinc and low-osmolarity oral rehydration salts (LO-ORS) for childhood diarrhoea, limited provider knowledge, and low caregiver awareness, integrating diarrhoea management with broader MNCH, nutrition, WASH, and Early Childhood Development (ECD) services to promote sustainability and continuity of care as interventions are delivered in isolation rather than reinforced through coordinated counseling, referrals, and messaging.



To strengthen local delivery systems, the project established Family Health Outlets (FHOs) managed by trained female community resource persons and formed Nutrition Clubs led by local influencers. Beyond improving service delivery, FHOs empowered women by creating sustainable income opportunities. These platforms provided diarrhoea treatment, promoted breastfeeding, immunization, hygiene, and birth spacing, and enhanced referral linkages with government facilities. In Zhob, Sherani, and D.I. Khan districts, the project trained 164 providers, treated 45,000 children with Zinc/LO-ORS, and reached nearly 48,000 people through awareness sessions. 



The project demonstrated how locally-led, community-centered SBCC models can complement fragile and uncoordinated health systems by fostering shared accountability and culturally grounded engagement to improve service uptake, equity, and sustained behavioral change.