Undernutrition during pregnancy and lactation is a critical determinant of maternal, neonatal, and child health outcomes. Maternal undernutrition is associated with an increased risk of maternal mortality (Christian et al., 2008), and both maternal stunting and wasting are associated with term and preterm births of children small for gestational age (SGA) (Black et al., 2013) and low birth weight (ACC/SCN, 2001, among others). Children born SGA are more likely to become stunted children and adults, which, for women, can place them at increased risk for delivery complications, morbidity, and mortality over time (Bhutta, 2013; Mason et al., 2012). Low birth weight has been shown to cost society in increased infant mortality (Katz et al 2013), lost wages and productivity in adulthood, increased stunting and related illness, and increased rates of noncommunicable disease (NCDs) in adulthood (Alderman and Behrman, 2006).
Maternal anemia is associated with an increased risk of maternal death, and there is a strong causal link between iron deficiency anemia and both low birthweight (LBW) and perinatal mortality (Rasmussan and Stolzfus, 2003). Maternal vitamin A deficiency is associated with visual impairment among women (Black et al., 2013) as well as increased risk of infants being LBW (Tielsh et al., 2008) and infant mortality (Christian et al., 2001). Deficiencies of zinc, iodine, folate, and calcium are also implicated in adverse maternal and child health outcomes.
Improving dietary adequacy during pregnancy and lactation is critical to helping women accommodate their nutritional requirements as well as their children’s requirements during intrauterine development and while breastfeeding (Haileslassie, et al., 2013).
There is limited evidence regarding the effectiveness of protein and energy-related interventions to address maternal wasting and SGA. The strongest evidence comes from a Cochrane Review which concluded that balanced energy protein supplementation reduced the incidence of SGA by 32%. A subsequent meta-analysis found that balanced energy protein supplementation increased birth weight by 73g and reduced the risk of SGA by 34% (Bhutta et al., 2013).
Evidence supporting the benefits of maternal micronutrient supplementation and fortification is more robust. Iron folic acid supplementation during pregnancy is associated with improved mean birth weight and a 79% reduction in megaloblastic anemia (Lassi et al., 2013). Multiple micronutrient supplementation in pregnant women is associated with a 10% reduction in SGA and 11% reduction in LBW babies (Haider and Bhutta, 2012). The consumption of micronutrient and iron-rich foods can also contribute to improved maternal nutritional status. Increasing the consumption of certain plant-based foods (such as green leafy vegetables) or meat and fish can have a considerable impact on an individual’s iron status (Allen et al., 2001).
This chapter focuses on the effectiveness of Social and Behavior Change Communication (SBCC) approaches to increase the quantity and quality of women’s dietary intake during pregnancy and lactation.
Table 3.1.1: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses),
by recommended practice and study design
|Increased energy and protein|
intake during pregnancy and
|1 (1)||0||1 (0)||3 (2)||0||5 (3)|
| Enhanced quality of diet during|
pregnancy and lactation
|1 (0)||1 (1)||0||4 (3)||0||6 (4)|
| Micronutrient supplementation|
|0||3 (2)||0||3 (1)||0||6 (3)|
| Increased rest and decreased|
work during pregnancy
|0||0||0||1 (0)||1 (1)||2 (1)|
* Note that columns do not sum to the “total” since some articles reported on multiple practices.
Fifteen peer-reviewed studies on women’s dietary practices met the review’s inclusion criteria.5 A complete list of the studies reviewed, including a summary of the SBCC approach(es) utilized, the study design, practices measured, and levels of significance is presented in Table 3.1.4.
Ten studies reported a statistically significant change in at least one of the priority practices. Each of those articles is described in greater detail below. Studies reporting a statistically significant change in more than one of the prioritized practices and/or utilizing more than one SBCC approach are cited and discussed multiple times. Where this occurs, we have provided a detailed description of the study in the first reference, and only discuss results in subsequent references.
The findings are organized by practices targeted, SBCC approach(es) utilized, and study design. This organization enables the reader to derive an independent judgment regarding findings from each study. In addition, implementation processes followed are also discussed.
Of the 15 studies reviewed for this chapter, one was a literature review including a meta-analysis, four were randomized controlled trials (RCT), one was a longitudinal study (including a control group), eight were repeated crosssectional studies (five of which included control groups and three that did not) and was a cross-sectional study implemented only at one point in time. See Table 3.1.1.
Table 3.1.4: Studies reporting on maternal dietary practices during pregnancy and lactation
|Title||Approaches Used||Scale/Scope||Evaluation Design||Outcomes Measured||Results||P-values/CIs|
|Adhikari et al (2009); Nepal||Counseling in facilities by providers, Small media||1 hospital||RCT – pregnant women receiving prenatal care: 71 in education group, 70 in pill count group, 73 education + pill count group, 70 in control group|
Iron supplementation compliance
Education + Pill count vs. Pill count alone: 88% vs. 73%
p < 0.001
|Ahrari et al. (2006); Egypt||Group education in facilities by providers, Support group in facilities by providers and/or lay volunteers, Counseling in homes by lay volunteers||2 large communities||Repeated cross-sectional – 519 women (344 intervention, 175 control)|
% of women who reported an increase in daytime rest during pregnancy
% of women who reported consumption of more food during pregnancy
% of pregnant women who reported taking IFA
% of pregnant women who reported taking 7 or more IFA tablets per week
% of women who reported consumption of more meat during pregnancy
% of women who reported consumption of more vegetables during pregnancy
64.1% vs. 11.7%
54.9% vs. 10.6%
97.5% vs. 80.6%
86.2% vs. 0.0%
57.1% vs. 4.2%
66.9% vs. 5.3%
Not clear in article
Not clear in article
Not clear in article
Not clear in article
|Akter et al. (2012); Bangladesh||Counseling in facilities by providers, Group education in facilities by providers||1 hospital||Longitudinal – 115 women (57 intervention, 58 control)|
% of pregnant women who increased frequency of meals from three to five times a day
|Baqui et al. (2008b); India||Counseling in homes by lay volunteers, Counseling in homes by providers||2 districts||Repeated cross-sectional – baseline: 14,952 recently delivered women (8,756 intervention, 6,196 control); endline: 13,826 recently delivered women (7,812 intervention, 6,014 control)|
% of women who consumed equal to or more than 100 IFA tablets during pregnancy
Endline vs. baseline: Intervention group: 21.3% vs. 5% Control group: 8.3% vs. 6.7%
|Bortolini and Vitolo (2012); Brazil||Counseling in homes by providers||1 hospital||RCT – 397 (163 intervention, 234 control)|
% of women who consume dietary iron that is highly bioavailable
% of women with daily iron intake ≥ 3 mg/day
Based on a 24 hour dietary recall among children 12-16 months old, mean intake of meat (g), iron (mg), and heme iron (mg)
% of women who use fortified flour
18.1% vs. 9.8%
83.2% vs. 82.8%
54.3 vs. 47.3, 5.1 vs. 5.4, and 1.5 vs. 1.2 (respectively)
45.2% vs. 44.2%
p=0.024, NS, and p=0.003
|Casey et al. (2010); Vietnam||Mobilization of issue groups, Counseling in homes by peers||2 districts||Repeated cross-sectional – baseline (Nov 2005): 389 women of reproductive age (WRA); 1st follow-up (July 2006): 253 WRA; 2nd follow-up (Sept 2007): 276 WRA; 3rd follow-up (Apr 2009): 322 WRA|
% of women who took at least 75% of tablets received during pregnancy
3rd follow-up vs. 2nd follow-up vs. 1st follow-up: 87% vs. 90% vs. 51%
95% CIs: (80% - 93%) vs. (84% - 95%) vs. (37% vs. 65%)
|Garg and Kashyap (2006); India||Counseling in facilities by providers, Group education in communities by providers, Counseling in homes by providers||1 village||Repeated cross-sectional – 100 women (50 intervention, 50 control)|
Mean daily intake of green leafy vegetables (g) during pregnancy
Energy (kcal) intake during pregnancy
Protein (g) intake during pregnancy
49.3 vs. 13.9
1521.23 vs. 835.14
48.05 vs. 25.00
|Guyon et al. (2009); Madagascar||Mobilization of issue groups, Mobilization of campaign, event, or special 'days', Mass media||2 highland provinces; targeted population varied throughout project from 1.4 million in 6 districts to 6 million in 23 districts||Repeated cross-sectional – baseline (2000): 1,200 children under two years old; endline (2005): 1,760 children under two years old|
% of mothers of infants < 6 months who reported increased food intake during pregnancy
Endline vs. baseline: 55% vs. 51%
|Ndiaye et al. (2009); Senegal||Mid-sized media, Counseling in homes by peers, Group education in communities by lay volunteers||2 communities||Repeated cross-sectional – baseline: 171 pregnant women (89 intervention, 82 control); endline: 200 (100 intervention, 100 control)|
% of pregnant women who reported eating meat or fish at least once a week
Endline vs. baseline: Intervention: 70.7% vs. 49.4%; Control: 32.0% vs. 41.5%
p ≤ 0.003; p ≤ 0.019 (difference in differences: p=0.0001)
|Omer et al. (2008); Pakistan||Traditional media, Counseling in homes by peers||10 communities from three districts (5 intervention and 5 control)||Cross-sectional study – 1,070 women were pregnant or had delivered during the preceding three years (529 intervention, 541 control; 310 women advised by an LHW , 799 women advised by others or no-one)|
% of women who reported a reduction in routine heavy work during pregnancy
Women in intervention group advised by LHW vs. women advised by others or no one(11): 77.1% vs. 58.9%; OR= 1.48
(95% CI: 1.01–2.16)
|Ota et al. (2012); various||Individual counseling, Group education||Varied||Literature review – 15 RCTs reviewed, four related to dietary advice to increase energy and protein intake|
Protein intake (g/day) during pregnancy
Energy intake during pregnancy
Pooled mean differences: 6.99g/day
Pooled mean differences: 105.61 kcal/day
p = 0.00057
|Risonar et al. (2008); Philippines||Counseling in communities by lay volunteers, Small media, Counseling in homes by lay volunteers||6 municipalities / villages from two provinces||RCT – 1,180 pregnant women (596 intervention, 584 control)|
Likelihood of taking Fe tablets in the intervention areas - baseline
Likelihood of taking Fe tablets in the intervention areas - endline
Likelihood of taking Fe tablets in the intervention areas
8.5% vs. 74.3%
79.2% vs. 57.4%
p=0.001 (95% CI: 2.22- 6.49)
|Senanayake et al. (2010); Sri Lanka||Group education in facilities by providers||1 hospital||Repeated cross-sectional – 218 women between 16-20 weeks of gestation (107 intervention, 111 control)|
% of pregnant women who took iron tablets correctly at 34 weeks gestation
86.9% vs. 32.4%
|Sun et al. (2007); China||Mass media, Mid-sized media, Small media, Group education in communities||2 urban districts and 2 rural villages||RCT – 373 women 19 to 70 years old (113 rural intervention, 80 rural control, 97urban intervention, 83 urban control)|
% of women who reported buying FeSS - Rural areas
% of women who reported buying FeSS - Urban areas
% of women who bought FeSS who reported eating FeSS - Rural areas
% of women who bought FeSS who reported eating FeSS - Urban areas
53.6% vs. 19%
43.3% vs. 11%
85.7% vs. 65%
49.5% vs. 11.0%
|Wang et al. (2009); China||Community/social mobilization, Small media, Group education in communities, Social media marketing, Meetings targeting policy makers and regulators||3 counties (one urban and two rural)||Repeated cross-sectional – baseline: 801 adult non-pregnant women older than 20 years of age; endline: 716; survey 3: 787|
% of women who have ever purchased (FeSS)
endline vs. baseline: 36.6% vs. 8.9%
Overview of the Evidence, by Practice
The evidence focuses on four key maternal nutrition practices: increased energy and protein intake during pregnancy, enhanced quality of diet during pregnancy and lactation, consumption of micronutrient supplements, and reduced work during pregnancy and lactation. While health status is also an important determinant of women’s nutritional status, practices associated with improved health status were not explored in this review.
Of the studies reviewed, five explored energy and protein intake among pregnant and lactating women, six assessed enhanced quality of diet among pregnant and lactating women, six reported on the intake of micronutrient supplements, and two looked at increased rest and reduced work during pregnancy. See Table 3.1.1.
Increased energy and protein intake during pregnancy and lactation
Of the five studies that discussed increased energy and protein intake, two measured the proportion of women consuming more food during pregnancy, one measured the proportion of women consuming more food during lactation, two measured caloric intake and two measured protein intake. Three of the five studies reported statistically significant results.
Literature Reviews with meta-analysis
Ota et al. (2012) conducted a meta-analysis of four RCTs looking at energy and protein intake among pregnant women. The authors included three studies in each of the analyses comparing intake among women who received nutritional advice during pregnancy and those who did not. Following a pooled analysis, the authors concluded that “advice to increase protein intake seems to be successful in achieving its goal [mean difference of +6.99 g/day], but there was no significant increase in energy intake.”
Garg and Kashyap (2006) conducted a repeated crosssectional study looking at mean daily energy and protein intake among pregnant women in one village in India. The nutrition education intervention included facility-based counseling, weekly home visits to pregnant women, and six group meetings for pregnant women over a period of two to four months. Following baseline data collection, the intervention was delivered to 50 pregnant women having completed 5-7 months of gestation. Another 50 women in month 8-9 of pregnancy were considered to be the control group. By the time women in the intervention group had reached 8-9 months of gestation they consumed 686 kcal more per day than those in the control group.
Guyon et al. (2009) looked at dietary intake during lactation in two highland provinces in Madagascar. The intervention included training of health workers, interpersonal communication including small and large group activities, one-to-one counseling in homes and at local health facilities, community/social mobilization events such as festivals celebrating breastfeeding and child health days, and the use of mass media to air breastfeeding promotion songs. The authors found that women in intervention communities were 12% more likely to report increased food intake during lactation than women in control communities.
Enhanced quality of diet during pregnancy and lactation
Of the six studies explored the effectiveness of SBCC interventions on the consumption of specific nutrient-rich foods, including fortified foods, during pregnancy, four reported statistically significant results.
Randomized controlled trials
Sun et al. (2007) conducted an RCT exploring the “effectiveness of social marketing (SM) on the improvement of women’s knowledge, attitudes, and behaviors” regarding consumption of iron fortified soy sauce (FeSS) in Guidzhou Province, China. The intervention included the use of mass media and “social marketing strategies using an integrated 6 Ps approach (product, price, place, promotion, policy, and partnership).” The SM strategy included physician-led counseling of patients on the benefits of consuming FeSS, as well as the distribution of FeSS samples and calendars with FeSS information at the community level. The authors reported an increase in eating and purchasing behaviors in rural and urban intervention site as well as in control sites. In rural sites there was a net increase in FeSS purchase in intervention sites of 35 percentage points compared with rural control sites. Likewise, the net increase in was 29.5 percentage points in urban intervention sites compared with urban control sites. With regard to the consumption of FeSS, the authors reported a net increase of 21.1 percentage points in rural intervention sites compared with rural control sites and a net increase of 25.6 percentage points in the proportion of urban women consuming FeSS.
Repeated cross-sectional studies
Garg and Kashyap (2006) conducted a repeated crosssectional study looking at mean daily intake of green leafy vegetables. By the time women in the intervention group had reached 8-9 months of gestation they consumed 49.3g of green leafy vegetables daily compared with only 12.9g among women in the control group.
Ndiaye et al. (2009) looked at the intake of animal products among pregnant women in rural Senegal. The study compared two intervention packages within the Micronutrient and Health Program (MICAH). Control communities received the standard MICAH intervention package which included basic nutrition education and a supply of iron supplements and other products through health centers. Intervention communities received the standard MICAH package along with a positive deviance (PD)/Hearth6 intervention, exposure to mid-sized media (such as community radio/ video, local billboards), home counseling by peers, and group education. After eight months, the percent of pregnant women consuming meat or fish increased from 49.4% to 70.7% in PD/Hearth intervention communities while it had declined from 41.5% to 32.0% in control communities.
Finally, Wang et al. (2009) conducted a study to look at “the effectiveness of social mobilization and social marketing in improving knowledge, attitudes and practices (KAP) and Fe status in an Fe-deficient population.” The intervention included a kick-off meeting with key stakeholders as well as the training of community health workers, community heads and store owners/market managers. In addition, “schoolchildren were mobilized to distribute information, education and communication (IEC) materials to the whole family after they learned the relevant knowledge through specially designed classes” and “trained volunteers were recruited to disseminate IEC materials in public areas like hospitals, culture and sports centres.” After one year, the percentage of women in the intervention area who had ever purchased FeSS increased from 8.9% to 36.6%.
Table 3.1.2: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses),
by SBCC approach and study design
|SBCC approach|| Reviews|
|Interpersonal Communication||1 (1)||4 (3)||1 (0)||8 (5)||1 (1)||15 (10)|
|One-on-One Counseling||1 (1)||3 (2)||1 (0)||6 (4)||1 (1)||12 (8)|
|Counseling in facilities||0||1 (1)||1 (0)||1 (1)||0||3 (2)|
|Counseling in communities||0||1 (1)||0||0||0||1 (1)|
|Counseling in homes (home visits)||0||2 (1)||0||5 (3)||1 (1)||8 (5)|
|Counseling in other settings||1 (1)||0||0||1 (1)||0||2 (2)|
|Group Education||1 (1)||1 (1)||1 (0)||6 (2)||0||9 (4)|
|Education in facilities||0||0||1 (0)||2 (1)||0||3 (1)|
|Education in communities||0||1 (1)||0||3 (0)||0||4 (1)|
|Education in other settings||1 (1)||0||0||1 (0)||0||2 (1)|
|Support Group||0||0||0||2 (1)||0||2 (1)|
|Support group in facilities||0||0||0||1 (0)||0||1|
|Support group in communities||0||0||0||0||0||0|
|Support group in other settings||0||0||0||1 (0)||0||1|
|Media||0||3 (3)||0||3 (3)||1 (1)||7 (7)|
|Mass media||0||1 (1)||0||1 (1)||0||2 (2)|
| Mid-sized media (community radio /|
video, local billboards)
|0||1 (1)||0||1 (0)||0||2 (1)|
| Small media (posters, flyers, calendars,|
|0||3 (3)||0||1 (0)||0||4 (3)|
|Traditional media (songs, drama)||0||0||0||0||1 (1)||1 (1)|
|Social media (Twitter, Facebook, etc.)||0||0||0||1 (0)||0||1|
|Community/Social Mobilization||0||0||0||3 (2)||0||3 (2)|
|Campaign, event, special "days"||0||0||0||1 (1)||0||1 (1)|
|Issue groups||0||0||0||2 (1)||0||1 (1)|
|Other||0||0||0||1 (1)||0||1 (1)|
Micronutrient supplementation or fortification
Although many studies reported on micronutrient supplementation or fortification among pregnant and lactating women, just six presented results in a way that allowed for examination of the distinct effect of SBCC approaches on uptake, and all of these were associated with iron supplementation. Three of these reported statistically significant results.
Randomized controlled trials
Adhikari et al. (2009) assessed the effect of an “education program and/or pill count on the change in hemoglobin levels and the prevalence of anemia in pregnant women” among 320 pregnant women receiving prenatal care at the Tribhuvan University Teaching Hospital in Nepal. Women were randomly assigned to one of four groups (education, pill count, education with pill count, and control). By the end of the intervention, women in the education with pill count group were significantly more likely to comply with iron supplementation recommendations than women in the pill count alone group (88% and 73%, respectively).
Risonar et al. (2008) assessed a “redesigned Fe supplementation delivery system” on the island of Negros in the Southern Philippines. The project included providing iron tablets to all pregnant women in two provinces (one intervention and one control). In the intervention group, village health workers and traditional birth attendants also identified and registered pregnant women for antenatal care, and used IEC materials such as posters and flyers to promote iron supplementation. After six months, the percentage of women in the intervention group taking iron tablets had increased from 57.4% to 79.2%, an increase nearly four times greater than in the control group (OR=3.79).
Repeated cross-sectional studies
Baqui et al. (2008b) conducted a repeated cross-sectional study focused on iron folic acid (IFA) supplementation for pregnant women in two districts in India. Both intervention and control groups received counseling on preventive care, nutrition, preparedness for child birth, and health-care utilization for complications during home visits by health care providers. In intervention communities, community health workers recruited additional community volunteers (“change agents”) to further the reach of the program through additional counseling. The authors report a net increase of 14.7 percentage points in the number of women consuming ≥100 IFA tablets during pregnancy in intervention sites compared with control sites.
Increased rest and decreased work during pregnancy
Two studies reported on rest and work during pregnancy. One of those two reported statistically significant results. Omer et al. (2008) conducted a cross-sectional study focused on reducing heavy workload during pregnancy (such as lifting), attending prenatal check-ups, and feeding colostrum to newborns in the Sindh province of Pakistan. The intervention trained lady health workers (LHW) to present and discuss an embroidered cloth panel portraying key messages during routine home visits with pregnant women. Following the intervention, the authors found no difference in overall workload practices between the intervention and control groups, but did find that women in the intervention group were 50% more likely to reduce routine heavy work compared with those in the control group (OR=1.48). No baseline data were collected.
Summary of the Evidence
SBCC approaches utilized
SBCC approaches are organized SBCC activities into three primary categories or approaches: interpersonal communication, media, and community/social mobilization. These approaches and the specific activities associated with each are described in further detail in the introductory chapter.
The studies reviewed in this chapter included a broad range of approaches to promote optimal dietary intake among pregnant and lactating women. Most included more than one specific SBCC activity and many utilized more than one approach.
The review conducted by Ota et al. (2012) included several studies involving interpersonal communication (IPC) approaches – specifically individual counseling and group education for the promotion of women’s energy and protein intake.
Among the nine other studies reporting statistically significant results, all included IPC approaches, seven included some form of media, and two included community/social mobilization. One-on-one counseling (in the home) was the most commonly used IPC approach, and small media (such as posters, flyers, stickers) was the most commonly used media approach. See Table 3.1.2.
The breadth of evidence regarding the effectiveness of SBCC in changing dietary practices during pregnancy and lactation varies greatly by type approach. Table 3.1.3 provides a summary of these findings.
There is some evidence of the effectiveness of IPC approaches in increasing protein/energy intake, enhancing the quality of diet, and increasing intake of micronutrient supplements.
The meta-analysis conducted by Ota et al. (2012) found a statistically significant increase in women’s protein intake as a result of individual counseling and group education (pooled mean difference of 6.99g per day), but no increase in energy intake.
In addition to the meta-analysis, two other studies reported significant outcomes related to the effect of IPC approaches on protein/energy consumption, four reported significant outcomes related to enhanced quality of diet, three report significant outcomes with respect to iron intake, and one reported a significant effect on workload during pregnancy.
Among these studies, two reported on the effectiveness of IPC, even after controlling for other SBCC approaches. In a repeated cross-sectional study, Baqui et al. (2008b) documented an increase from 5% to 21.3% in the percentage of women consuming <100 IFA tables as a result of an IPC intervention, while Garg and Kashyap (2006) reported an increase from 13.9g to 49.3g in the daily intake of green leafy vegetables as a result of an IPC intervention.
We found no evidence to support the effectiveness of IPC approaches on the intake of other micronutrients during pregnancy and lactation, or related to decreasing work load or increasing rest during pregnancy.
Table 3.1.3: Number of studies reviewed (with number of studies reporting statistically significant results
in parentheses), by SBCC approach, practice, and study design
|SBCC approach||Increased energy and|
protein intake during
pregnancy and lactation
|Enhanced quality of diet|
during pregnancy and
| Increased rest and|
5, 3 reporting statistical
6, 4 reporting statistical
6, 3 reporting statistical
2, 1 reporting statistical
1, 1 reporting statistical
3, 3 reporting statistical
2, 2 reporting statistical
1, 1 reporting statistical
1, 1 reporting statistical
1, 1 reporting statistical
|1, none reporting|
We identified six primary research studies that reported positive outcomes associated with interventions that included media-based SBCC approaches. One study reported positive outcomes related to protein/energy consumption, three reported positive outcomes related to enhanced quality of diet, two reported positive outcomes related to iron intake, and one reported a positive effect on workload during pregnancy.
None of these media-based interventions was delivered in isolation. All included some form of IPC, one included both IPC and community/social mobilization approaches, and the independent effect of media-based approaches was not assessed. It is therefore difficult to derive conclusions regarding the independent, net effective of these mediabased approaches. We identified no evidence related to intake of micronutrients other than iron.
We identified two primary research studies looking at the effect of community/social mobilization approaches on the uptake of optimal dietary practices during pregnancy and lactation. Both studies, however, included IPC and media approaches in addition to community/social mobilization, and the independent effect of community/social mobilization approaches on maternal dietary practices was not assessed.
Multiple SBCC approaches
We identified nine primary research studies that assessed the effectiveness of multiple SBCC approaches to improve maternal dietary practices, and seven of the nine reported statistically significant results. Guyon et al. (2009) reported a difference of 12 percentage points between intervention and control communities, while Ndiaye et al. (2009) reported a difference of 21 percentage points in the intake of animal products. Sun et al. (2007) reported a difference of 21-26 percentage points in intake of iron fortified soy sauce between intervention and control communities in rural and urban areas, and Adhikari et al. (2009) and Risonar et al. (2008), both RCTs, reported differences in micronutrient intake of 15 and 22 percentage points respectively. Finally, Omer et al. (2008) reported a positive, statistically significant effect with respect to reduction in workload during pregnancy (OR=1.48); however, no baseline data were collected, making attribution to the intervention difficult.
Just one study, Adhikari et al. (2009), compared the effect of more than one SBCC approach to a single SBCC approach. The authors found higher compliance rates with iron supplementation recommendations in an intervention that combined education with pill counting (88% compliance) compared with an intervention that included pill counting alone (73% compliance). Iron supplementation compliance was not reported for the control group.
Implementation processes followed
None of the studies reviewed in this chapter specifically assessed the effect of implementation processes (e.g. intensity and timing of communications; type and training of person communicating messages, or target audience) on the effectiveness of the SBCC approach on women’s dietary practices during pregnancy or lactation, nor did they consistently report all aspects of the implementation processes.
The intensity of communications ranged between one and four visits/sessions or weekly to monthly visits/sessions for various lengths of time. None of the studies compared the effect of timing or frequency.
In terms of target audiences, the studies reviewed primarily targeted the potential or actual breastfeeding woman. The literature review by Ota et al. (2012) conducted a metaanalysis of studies of interventions targeting the woman alone, and among nine primary research studies reporting at least one statistically significant difference, eight targeted the woman herself, three targeted direct influencers, four targeted local community actors, and two targeted actors of the enabling environment. Six targeted more than one target audience or behavioral influencer, but none compared the effect of targeting one vs. multiple audiences or of targeting different audiences.
The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is small, but indicates that SBCC approaches can and do succeed in improving uptake of those practices. While the literature may reflect a bias to publish positive results, it also underscores the important role of SBCC approaches to improve nutrition practices – practices which have been shown to have an impact on nutritional status of women, infants, and children.
What stands out from this review is the lack of evidence (or attention) that has been given to improving women’s dietary practices during pregnancy and lactation. The greatest gap was in evidence of effectiveness of SBCC approaches in improving rest and workload during pregnancy.
In addition, there is considerable variation in the description of SBCC interventions, interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context.
There is also variation in how nutrition practices are defined and measured. Of the five studies that discussed energy and protein intake during pregnancy and lactation, four different indicators were measured and no one indicator was measured more than twice. Of the six studies that looked at the quality of diet during pregnancy and lactation, four reported statistically significant results related to distinct indicators. Each of the three studies reporting on micronutrient supplementation or fortification measured a slightly different indicator. This underscores the importance of developing indicators related to women’s dietary practices during pregnancy and lactation that are globally recognized, accepted, and used by the research and program communities alike.
The SBCC approach most used, and the only one used without other communication interventions, was IPC. While media and community/social mobilization were used, they were always used with at least one other communication approach. Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, but this is not tested in the literature. It is difficult and expensive to disaggregate the contribution of single channels within a multi-channel intervention, and an important question for SBCC practitioners and researchers is whether that line of research is useful.
All but one of the studies reviewed targeted the pregnant or lactating woman herself. More than half targeted other audiences or influencers as well.
The majority of the studies were implemented on a relatively small scale (e.g., in one hospital or community) and typically with between 50 and 350 people per group. The small scale of research on this topic constrains the generalizability of findings and raises important questions about the scalability and sustainability of approaches used.
Differences in local context (including social norms, culture, and environmental factors) as well as differences in the implementation and scale of implementation affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.
Because of the relatively limited body of evidence on this topic and due to the lack of standardization in the way research related to SBCC is designed and described, it is challenging to make conclusions beyond the fact that projects with SBCC result in uptake of promoted practices. While there is much to be learned from this body of literature to aid us in developing future programs, there are also many questions generated from reviewing this literature that can and hopefully will guide future evaluations and operations research. These include questions related to:
- globally recognized indicators related to women’s dietary practices during pregnancy and lactation;
- the generalizability of research in this area;
- the positive (or negative) effect of using multiple SBCC approaches compared with focusing on only one;
- the positive (or negative) effect of targeting multiple audiences or influencers of the behaviors being promoted, rather than focusing on just one target population;
- the role of context, in other words, the effect of the same SBCC intervention implemented in different contexts;
- the effectiveness of different approaches (including intensity and targeting) for different behaviors;
- the cost and cost effectiveness of various SBCC approaches (particularly as it relates to scalability); and
- the effectiveness and sustainability of these approaches when implemented at scale.