Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India.

BACKGROUND: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring. OBJECTIVES: This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. METHODS: We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. RESULTS: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%). CONCLUSIONS: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.

Violations of International Code of Breast-milk Substitutes (BMS) in commercial settings and media in Bangladesh.

The International Code of Marketing of Breast-milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national 'Breast-milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013' of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross-sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ2 tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among "other milk" for children aged 0 to <36 months compared to formulas and growing-up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations.

Gaps in the implementation and uptake of maternal nutrition interventions in antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India.

Antenatal care (ANC) is the largest health platform globally for delivering maternal nutrition interventions (MNIs) to pregnant women. Yet, large missed opportunities remain in nutrition service delivery. This paper examines how well evidence-based MNIs were incorporated in national policies and programs in Bangladesh, Burkina Faso, Ethiopia and India. We compared the nutrition content of ANC protocols against global recommendations. We used survey data to elucidate the coverage of micronutrient supplementation, weight gain monitoring, dietary and breastfeeding counselling. We reviewed literature, formative research and program assessments to identify barriers and enabling factors of service provision and maternal nutrition practices. Nutrition information in national policies and protocols was often fragmented, incomplete and did not consistently follow global recommendations. Nationally representative data on MNIs in ANC was inadequate, except for iron and folic acid supplementation. Coverage data from subnational surveys showed similar patterns of strengths and weaknesses. MNI coverage was consistently lower than ANC coverage with the lowest coverage of weight gain monitoring and variable coverage of dietary and breastfeeding counselling. Key common factors associated with coverage were micronutrient supply disruptions; suboptimal counselling on maternal diet, weight gain, and breastfeeding; and limited or no record keeping. Adherence of women to micronutrient supplementation and dietary recommendations was low and associated with late and too few ANC contacts, poor maternal knowledge and self-efficacy, and insufficient family and community support. Models of comprehensive nutrition protocols and health systems that deliver maternal nutrition services in ANC are urgently needed along with national data systems to track progress.

Process of developing models of maternal nutrition interventions integrated into antenatal care services in Bangladesh, Burkina Faso, Ethiopia and India.

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country-specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community-level activities were essential for complementing facility-based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts.

COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights from Service Providers, Household Phone Surveys, and Administrative Data.

BACKGROUND: The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. OBJECTIVES: This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic. METHODS: We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. RESULTS: Compared with prepandemic, service provision reduced substantially during lockdown (83-98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%-90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%-90%), social distancing (80%), and using PPE (40%-50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40-80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). CONCLUSIONS: COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

Strengthening Nutrition Interventions in Antenatal Care Services Affects Dietary Intake, Micronutrient Intake, Gestational Weight Gain, and Breastfeeding in Uttar Pradesh, India: Results of a Cluster-Randomized Program Evaluation.

BACKGROUND: Maternal nutrition interventions are inadequately integrated into antenatal care (ANC). Alive & Thrive aimed to strengthen delivery of micronutrient supplements and intensify interpersonal counseling and community mobilization through government ANC services. OBJECTIVES: We compared nutrition-intensified ANC (I-ANC) with standard ANC (S-ANC) on coverage of nutrition interventions and maternal nutrition practices. METHODS: We used a cluster-randomized design with cross-sectional baseline (2017) and endline (2019) surveys (n ∼660 pregnant and 1800 recently delivered women per survey) and a repeated-measures longitudinal study in 2018-2019 (n = 400). We derived difference-in-difference effect estimates (DIDs) for diet diversity, consumption of micronutrient supplements, weight monitoring, and early breastfeeding practices. RESULTS: Despite substantial secular improvements in service coverage from India's national nutrition program, women in the I-ANC arm received more home visits [DID: 7-14 percentage points (pp)] and counseling on core nutrition messages (DID: 10-23 pp) than in the S-ANC arm. One-third of women got ≥3 home visits and one-fourth received ≥4 ANC check-ups in the I-ANC arm. Improvements were greater in the I-ANC arm than in the S-ANC arm for any receipt and consumption of iron-folic acid (DID: 7.5 pp and 9.5 pp, respectively) and calcium supplements (DID: 14.1 pp and 11.5 pp, respectively). Exclusive breastfeeding improved (DID: 7.5 pp) but early initiation of breastfeeding did not. Maternal food group consumption (∼4 food groups) and probability of adequacy of micronutrients (∼20%) remained low in both arms. Repeated-measures longitudinal analyses showed similar results, with additional impact on consumption of vitamin A-rich foods (10 pp, 11 g/d), other vegetables and fruits (22-29 g/d), and gestational weight gain (0.4 kg). CONCLUSIONS: Intensifying nutrition in government ANC services improved maternal nutrition practices even with strong secular trends in service coverage. Dietary diversity, supplement consumption, and breastfeeding practices remained suboptimal. Achieving greater behavior changes will require strengthening the delivery and use of maternal nutrition services integrated into ANC services in the health system. This trial was registered at clinicaltrials.gov as NCT03378141.

Provision and utilisation of health and nutrition services during COVID-19 pandemic in urban Bangladesh.

The COVID-19 pandemic is expected to have profound effects on healthcare systems, but little evidence exists on service provision, utilisation, or adaptations. This study aimed to (1) examine the changes to health and nutrition service delivery and utilisation in urban Bangladesh during and after enforcement of COVID-19 restrictions and (2) identify adaptations and potential solutions to strengthen delivery and uptake. We conducted longitudinal surveys with health care providers (n = 45), pregnant women (n = 40), and mothers of children <2 years (n = 387) in February 2020 (in-person) and September 2020 (by phone). We used Wilcoxon matched-pairs signed-rank tests to compare the changes before and during the pandemic. Services delivery for women and children which require proximity were severely affected; weight and height measurements fell by 20-29 percentage points (pp) for pregnant women and 37-57 pp for children, and child immunisations fell by 38 pp. Declines in service utilisation were large, including drops in facility visitations (35 pp among pregnant women and 67 pp among mothers), health and nutrition counselling (up to 73 pp), child weight measurements (50 pp), and immunisations (61 pp). The primary method of adaptation was provision of services over phone (37% for antenatal care services, 44%-49% for counselling). Despite adaptations to service provision, continued availability of routine maternal and child health services did not translate into service utilisation. Further investments are needed to provide timely and accurate information on COVID-19 to the general public, improve COVID-19 training and provide incentives for health care providers and ensure availability of personal protective equipment for providers and beneficiaries.

Global mid-upper arm circumference cut-offs for adults: a call to action.

Since 2009, mid-upper arm circumference (MUAC) has become an accepted measure for screening children for acute malnutrition and determining eligibility for services to manage acute malnutrition. Use of MUAC has increased the reach and enhanced the quality of community-based management of acute malnutrition services. Increasingly, MUAC is also used to assess nutritional status and eligibility for nutrition support among adolescents and adults, including pregnant and lactating women and HIV and TB clients. However, globally recognised cut-offs have not been established to classify malnutrition among adults using MUAC. Therefore, different countries and programmes use different MUAC cut-offs to determine eligibility for programme services. Patient monitoring guidelines provided by WHO for country adaptation to support the integrated management of adult illness do not include MUAC, in part because guidance does not exist about what MUAC cut-off should trigger further action.

It takes a village: An empirical analysis of how husbands, mothers-in-law, health workers, and mothers influence breastfeeding practices in Uttar Pradesh, India.

Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a programme evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential programme influence on improving breastfeeding. A cross-sectional survey was conducted among 1,838 recently delivered women, 1,194 husbands, and 1,353 mothers/mothers-in-law. We used bivariate and multivariable logistic regression models to examine the association between key determinants (maternal, household, community, and health services) and breastfeeding outcomes [early initiation of breastfeeding (EIBF)], prelacteal feed, and exclusive breastfeeding (EBF). We used population attributable risk analysis to estimate potential improvement in breastfeeding practices. Breastfeeding practices were suboptimal: EIBF (26.3%), EBF (54%), and prelacteal feeding (33%). EIBF was positively associated with maternal knowledge, counselling during pregnancy/delivery, and vaginal delivery at a health facility. Prelacteal feeds were less likely to be given when mothers had higher knowledge, beliefs and self-efficacy, delivered at health facility, and mothers/mothers-in-law had attended school. EBF was positively associated with maternal knowledge, beliefs and self-efficacy, parity, and socio-economic status. High maternal stress and domestic violence contributed to lower EBF. Under optimal programme implementation, we estimate EIBF can be improved by 25%, prelacteal feeding can be reduced by 25%, and EBF can be increased by 23%. A multifactorial approach, including maternal-, health service-, family-, and community-level interventions has the potential to lead to significant improvements in breastfeeding practices in Uttar Pradesh.

Concordance and Discordance of the Knowledge, Understanding, and Description of Children's Experience of Food Insecurity Among Hispanic Adults and Children.

Food insecurity is highly detrimental for children, who experience food insecurity differently than do adults. We aimed to understand concordance and discordance of adults' and children's knowledge, understanding, and description of children's experience of food insecurity. In-depth interviews were conducted with the primary caregiver, another caregiver, and a child 9 to 16 years of age in 16 Hispanic families at risk of food insecurity in South Carolina. Adults often lacked knowledge of the food insecurity experiences of their children, which presents challenges for adults with roles as caregivers, educators, or policy makers to recognize and address these experiences.

Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors.

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self-efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization-recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.

Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study.

BACKGROUND: Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020. METHODS: We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2. RESULTS: In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges. CONCLUSIONS: Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Advancing Use of Nutrition Knowledge to Improve Practice by Policy and Program Communities in India During a Political Transition.

Models are needed for how to advance use of knowledge by programs and policy officials to make evidence-based decisions about nutrition. How to advance use of nutrition knowledge in India from 2011 to 2015 during a political transition was investigated through studying a knowledge initiative led by the International Food Policy Research Institute. Semistructured interviews were conducted with 37 diverse participants, and 1091 news articles, 318 Twitter and 175 Facebook posts, 12 YouTube events, 65 knowledge products, and 130 engaging events were assessed. Open-axial coding, content and themes analysis, triangulation, and process tracing were used. The knowledge initiative analyzed the landscape, made knowledge available, mobilized it, and engendered its use. After political transition, knowledge was readied for the reassembled nutrition technical community, including timely responses to governmental information needs. Making nutrition knowledge available, mobilizing it, and engendering its use can be advanced through knowledge initiatives in large, complex countries during political transitions.

Impact of COVID-19 on household food insecurity and interlinkages with child feeding practices and coping strategies in Uttar Pradesh, India: a longitudinal community-based study.

OBJECTIVES: The COVID-19 pandemic has profound negative impacts on people's lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies. DESIGN: A longitudinal survey in December 2019 (in-person) and August 2020 (by phone). SETTING: Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India. PARTICIPANTS: Mothers with children <2 years (n=569). MAIN OUTCOMES AND ANALYSES: We measured HFI by using the HFI Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models. RESULTS: HFI increased sharply from 21% in December 2019 to 80% in August 2020, with 62% households changing the status from food secure to insecure over this period. Children in newly or consistently food-insecure households were less likely to consume a diverse diet (adjusted OR, AOR 0.57, 95% CI 0.34 to 0.95 and AOR 0.51, 95% CI 0.23 to 1.12, respectively) compared with those in food-secure households. Households with consistent food insecurity were more likely to engage in coping strategies such as reducing other essential non-food expenditures (AOR 2.2, 95% CI 1.09 to 4.24), borrowing money to buy food (AOR 4.3, 95% CI 2.31 to 7.95) or selling jewellery (AOR 5.0, 95% CI 1.74 to 14.27) to obtain foods. Similar findings were observed for newly food-insecure households. CONCLUSIONS: The COVID-19 pandemic and its lockdown measures posed a significant risk to HFI which in turn had implications for child feeding practices and coping strategies. Our findings highlight the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and after COVID-19.

Terminal Logic Behavior and Strategic Defection of Governmental Officials during Presidential Transitions in Guatemala: Implications for the Sustainability of Food and Nutrition Security Policy.

BACKGROUND: Presidents with no possibility of re-election overvalue far-future rewards and succumb to terminal logic behavior (TLB), responding to end-of-tenure legacy concerns despite political context. Government authorities perceiving the outgoing government is losing power at the end of term behave under the logic of strategic defection (SD), dissociating from the outgoing government once it is perceived powerless. In countries where re-election is impossible and government turnover and inconstant political parties are concerns, governmental officials at all levels may show TLB and SD during transitions that affect policy sustainability. OBJECTIVES: This study aimed to understand the context during presidential transitions that makes TLB and SD relevant, whether TLB and SD affect sustainability of food and nutrition security policy (FNSP), and the tactics for navigating transitions that favor sustainability. METHODS: A case-study design was used with semi-structured qualitative interviews and document review of news articles in Guatemala. Purposeful criteria and snowball sampling were used to recruit 52 policy actors implementing an FNSP across 2 transitions; 252 news articles from the referenced period covering topics on policy programmatic areas were purposefully sampled. Interviews were analyzed using coding and thematic analyses. News articles were analyzed using a priori thematic coding for verifying themes in interviews and data triangulation. RESULTS: Governmental officials were replaced by others during transitions; political parties were perceived as inconstant. TLB and SD occurred at all levels and had consequences for sustainability of FNSP: implementation slow-down, dysfunctional collaboration, inefficient use of resources, benefits not reaching targeted groups, and loss of momentum. These occurred through individual, institutional, and political mechanisms. Civil society, international organizations, and government adopted tactics for maximizing sustainability. CONCLUSIONS: Understanding governmental officials' experiences and the extent to which TLB and SD occur and affect sustainability could be advantageous to develop compensatory actions for reaching long-term FNSP goals.

Nutrient Adequacy Is Low among Both Self-Declared Lacto-Vegetarian and Non-Vegetarian Pregnant Women in Uttar Pradesh.

Poor dietary intake during pregnancy remains a significant public health concern, affecting the health of the mother and fetus. This study examines the adequacy of energy, macronutrient, and micronutrient intakes among self-declared lacto-vegetarian and non-vegetarian pregnant women. We analyzed dietary data from 627 pregnant women in Uttar Pradesh, India, using a multiple-pass 24 h diet recall. Compared to non-vegetarians, lacto-vegetarians (~46%) were less likely to report excessive carbohydrate (78% vs. 63%) and inadequate fat intakes (70% vs. 52%). In unadjusted analyses, lacto-vegetarians had a slightly higher mean PA for micronutrients (20% vs. 17%), but these differences were no longer significant after controlling for caste, education, and other demographic characteristics. In both groups, the median intake of 9 out of 11 micronutrients was below the Estimated Average Requirement. In conclusion, the energy and micronutrient intakes were inadequate, and the macronutrient intakes were imbalanced, regardless of stated dietary preferences. Since diets are poor across the board, a range of policies and interventions that address the household food environment, nutrition counseling, behavior change, and supplementation are needed in order to achieve adequate nutrient intake for pregnant women in this population.