(P24-002-24) Achieving Sustainability and Scalability of a Large-Scale Prenatal Cash and Food Transfer Intervention in Bangladesh

Objectives: The WHO (2016) antenatal care guidelines recommend research on alternatives to prenatal energy and protein supplements – such as cash or food distribution. The Bangladesh government is currently implementing the Mother and Child Benefit Programme (MCBP) to improve prenatal nutrition and child health. We conducted implementation research that aimed to understand how the MCBP, and augmented versions of it, 1) stimulated behavior changes, 2) enabled or prevented participants to sustain behavior changes, and 3) achieved conditions required for program scale-up.

Methods: A three-arm, cluster-randomized trial was designed to assess the impact on pregnancy and birth outcomes of the following intervention packages: 1) MCBP (cash transfers and nutrition education), 2) MCBP + top-up cash (during pregnancy), or 3) MCBP + fortified foods (idem). Three of six sub-districts included in the main trial were selected for the implementation research. Semi-structured, in-depth interviews were conducted with beneficiary (n=45) and non-beneficiary (n=15) pregnant women, beneficiary postnatal mothers (n=18), and program implementers (n=18). Data analysis used deduction, induction, and verification techniques.

Results: Beneficiaries of all interventions reported following dietary advice and a positive shift in mental health, self-confidence, and self-worth following delivery of the intervention. Women's dietary habits were often dictated by their husbands, who were the decision makers around cash utilization and food allocation. Termination of top-up cash and food interventions at birth led mothers to reduce nutritious food intake and occasionally explore new earning avenues. Implementation challenges included delayed distribution of food and cash, religious and cultural barriers to community awareness activities, and coordination challenges between government and non-government institutions.

Conclusions: The program stimulated healthy behaviors and mental wellbeing of pregnant women in the short term, but adjustments are needed for sustainable and scalable behavior changes. Possible adjustments include raising pre- and postnatal cash transfers beyond the standard MCBP amount, collaboration with religious leaders, and expanding government health workforce for program implementation.

Funding Sources: Bill & Melinda Gates Foundation