Effectiveness of Health Systems Strengthening Implementation Model to Improve Health of Pregnant and Lactating Women by Increasing Compliance with IFA and Calcium Tablets: A Quasi-Experimental Study

Anemia affects nearly half of all pregnant and lactating women in India. Suboptimal compliance is often due to lack of awareness on effective management of perceived side effects, issues in ensuring regular last mile availability for distribution to beneficiaries owing to challenges in timely and adequate procurement supply chain management issues, family and household dynamics, lack of support for maternal nutrition. Implementation research was conducted in two states of India to deliver a package of interventions with the objective of preventing and managing anemia and improving health by increasing compliance with IFA and calcium supplements among pregnant and lactating women. Method: A quasi-experimental approach with a non-equivalent control group was adopted to assess the effectiveness of the model in a pragmatic setup across two blocks in each of the two states, divided into intervention and control arms (2007 pregnant and 2117 lactating women). Both arms continued with the standard government programs. Health systems interventions like supply chain strengthening, capacity building, behavior change were designed and delivered to ensure availability, accessibility and utilization of IFA and calcium by the beneficiaries in the intervention arm. The primary outcome was compliance with IFA among pregnant women. Secondary outcomes were compliance with calcium among pregnant women and IFA and calcium among lactating women. Difference-in-difference (DID) analysis was conducted, and logistic regression identified contributing factors. Results: The intervention package resulted in 26% improved compliance (DID: 8.1% vs. 1.5%) with IFA among pregnant women in the intervention arm compared to baseline. Similarly, compliance with IFA in lactating women increased by 49.2%. The attributable fraction was greatest (24.4%) for ‘proper instructions’ given. Compliance with calcium increased by 59% among pregnant women in one state, where the baseline parameters were lagging and interventions were initiated early within the stipulated time. Standardized ANC services and provision of proper instructions were consistently found to be associated with improved compliance. Interventions led to improved supply chain management, distribution of IFA and calcium in adequate quantities, increased awareness in the community, and better access to services. Conclusions: The intervention model was found to be effective in improving compliance with IFA in pregnant and lactating women. It is concluded that provision of proper instructions while distributing supplements seemed to have the greatest impact in improving compliance. State-specific variations highlight the need for tailored approaches. Scaling up such models, with emphasis on systemic and behavioral enablers, could strengthen India’s anemia control efforts.