Maternal malnutrition is a global problem and is more prevalent in low- and middle-income-countries (LMICs). In Kenya, many pregnant women have poor nutritional status, with 42% suffering from anaemia [1] and 12.3% of women of reproductive age having a BMI of less than 18.5 [2]. Low birth weight (<2500g), one of the best composite indicators of short- and long-term undernutrition in women affects one in ten new-borns in Kenya [2]. Anaemia in pregnancy contributes to high rates of intrauterine growth retardation (IGR) and premature birth, increased complications of post-partum bleeding and greater risk of maternal mortality [3–7].
Malnutrition is a complex problem which is caused by a wide range of direct and indirect factors including inadequate nutritional intake as a result of household food insecurity or an infection which can increase nutritional requirements and prevent the body from absorbing those consumed [8]. For women in sub-Saharan Africa, the environmental and economic conditions place an extra burden on their nutritional status. Pervasive poverty affects the quality of their diet, their heavy workload increases their nutritional requirements, frequent and short reproductive cycles often leave them moving from one pregnancy to the next without adequately replenishing the body’s nutrient stores, and lack of nutritional knowledge makes them consume inappropriate nutrition [9].
The Government of Kenya has acknowledged the problem of malnutrition and is committed to reducing hunger and to achieve adequate nutrition for the optimum health of all Kenyans as a fundamental human right [10]. Kenya has also providing special nutrition interventions for certain vulnerable groups such as children and pregnant women through its National Food and Nutrition Security Policy [11].
Since 2001, maternal nutrition interventions in Kenya were implemented within the framework of the Kenya Reproductive Health strategy (1997-2010) using the World Health Organization (WHO) Focused Antenatal Care (FANC) strategy. FANC put in place a National Reproductive Health Programme that sought to expand on the achievements of the Maternal Child Health/Family Planning (MCH/FP) programme that had been functioning since 1967. The goal of the programme was to provide a comprehensive and integrated system of reproductive health care that offers a full range of services by the Government, Non-Governmental organizations (NGOs) and the Private Sector. In the FANC care package, nutrition education and counselling are the main strategy to improve the nutritional status of women during pregnancy. The counselling is focuses on a healthy diet by increasing the diversity and amount of food consumed, keeping physically active during pregnancy to stay healthy and to prevent excessive weight gain during pregnancy, health promotion and disease prevention and nutrition supplementation, healthy lifestyles and diet, support and care in the home.
In 2013, the Maternal Infant and Young Child Nutrition (MIYCN) policy for health workers was introduced [12]. This is anchored in WHO’s the Essential Nutrition Actions: Improving maternal, new-born, infant and young health and nutrition [13]. In the MIYCN Programme, nutrition education and counselling still remain the main strategy to improve the nutritional status of women during pregnancy. The strategy focuses primarily on promoting a healthy diet by increasing the diversity and amount of food consumed, promoting adequate weight gain through sufficient and balanced protein and energy intake and promoting consistent and continued use of micronutrient supplements (IFAs), food supplements or fortified foods.
IFAs intervention is implemented through MIYCN programme and is offered free of charge in all Kenyan government hospitals as part of routine ANC services. Studies have confirmed that with effective implementation and compliance to these intervention packages, maternal nutrition is improved. Available evidence further suggests that nutrition education and counselling may support optimal gestational weight gain (i.e. neither insufficient nor excessive), reduce the risk of anaemia in late pregnancy, increase birth weight and lower the risk of preterm delivery, reduced mortality, micronutrient deficiency, low birth weight, neural tube defects and obesity [14]. This will consequently reduce infant and child mortality, improve physical and mental growth and development, and improve maternal health and pregnancy outcome [15–20].
Despite the proven efficacy of maternal nutrition education, counselling and supplementation, the outcome in addressing maternal malnutrition and associated health indicators has been less successful than anticipated. Currently, Kenya is among the 10 countries that experience the most neonatal deaths globally and 42% of Kenyan pregnant women are estimated to be anaemic [2]. Besides, high levels of under-nutrition, particularly stunting, have persisted in Kenya for decades. The levels of wasting and stunting have remained unaltered for about 20 years at between 6% and 7% for wasting and 30% and 35% for stunting. Although Kenya has made significant strides in reducing neonatal, infant, child, and under-5 mortality, one in every 26 Kenyan children will die before reaching 1 year of age and one in every 19 will not survive to their fifth birthday [1,2,21]. This undoubtedly questions the implementation fidelity of IFAs policy guidelines. There is therefore a pressing need to examine IFAs implementation processes in Kenya and to understand whether the policy is being implemented as intended.
The major reason for programme failure even among well-designed programmes is the failure to implement with fidelity. Studies have shown that effective interventions typically yields diminishing returns, regardless of their success during a demonstration period, due to failure to implement with fidelity [22–24]. A meta-analysis of 500 studies from various fields showed that programmes with better implementation had mean effect sizes two to three times larger than those with poor implementation [24].
Therefore, this study aims to acquire insight into the degree to which the IFAs policy guidelines during pregnancy have been implemented as intended and which factors have constrained implementation fidelity. Implementation research is one of the most important and at the same time most neglected aspects of programme evaluation research. Rather, outcome/impact evaluations have become the norm for most researchers, especially those studying maternal nutrition intervention programmes in Kenya [25–27]. Such results provide information on what happened as a result of the programme without a clear picture of how it happened, and without sufficiently illuminating the reasons behind the success or failure of interventions. Obtaining a clear picture of how a programme was implemented not only allows programmers to more confidently link programmes to observed outcomes, but also provides important information on how programmes should be designed and implemented in future to produce positive results [28,29]. Implementation research also improves the ability to identify and disseminate best programme practices. The few studies that have focused on implementation fidelity of nutritional programmes, particularly in LMICs, mainly assessed participant responsiveness to the programme and left out other elements of fidelity (see below) [30–35].
Programme context
This study assesses implementation fidelity of IFAs policy in Kenya using Uasin Gishu County as a case study. IFAs in Kenya is implemented under Kenya’s National Maternal, Infant and Young Child Nutrition (MIYCN) policy for health workers [12]. The MIYCN policy’s main goal is to improve the nutritional status, health, growth and development, and the survival of infants and young children in Kenya, through optimal feeding practices and improved maternal nutrition. The MIYCN document operationalizes the IFAs policy objectives by providing guidelines for service providers on day-to-day implementation of the national and global recommendations on maternal and child nutrition care and support at all levels of operation for optimal health of the target populations in Kenya. It provides nutrition interventions for women at different stages (pre-natal, antenatal, postpartum and continued care) and infants and children from conception to five years of age. Specific objectives for IFAs policy as outlined in MIYCN document are to:
- Strengthen maternal nutrition assessment and counselling within the healthcare system
- Strengthen and advocate for the uptake and utilization of iron and folate supplements among women of reproductive age and postpartum Vitamin A supplementation
Below we elaborate on the policy implementation guidelines for these two objectives:
Policy guideline 1: To achieve objective one, all pregnant women should have access to and should be knowledgeable about the need for an adequate and nutritious diet through nutritional training and counselling. They should be encouraged and supported on how to cope with the food-related problems during pregnancy, including morning sickness, constipation and heartburn.
Policy guideline 2: This policy guideline aims at achieving objective two of MYICN programme. Under this policy, programme implementers should provide and promote intake of Iron and Folic Acid supplements (IFAs) through antenatal care services, and support other strategies to address maternal anaemia. Recommendations and key messages for this policy guideline include:
- Encourage pregnant women to take 60mg of Iron tablets daily for the duration of pregnancy irrespective of their haemoglobin levels to prevent anaemia.
- Encourage mothers to continue to take 400 μg of folic acid daily around the time of conception to significantly reduce the incidence of neural tube defects Folic acid supplementation should be started in the first trimester of pregnancy to prevent birth defects.
- Provide information on possible side effects and how to avoid them when taking IFA supplements
- Provide nutritional counselling practices that promote iron-rich diet and absorption during pregnancy.