Background: a. Burden: Maternal nutrition profoundly affects foetal growth, development, and
subsequent infant birth weight. Babies with low birth weight (LBW) have an elevated risk of
death in infancy. Furthermore, these babies have a higher risk of stunting or linear growth
failure and slower mental development in childhood. b. Knowledge gap: A recent systematic
review revealed that multiple micronutrient supplementations (MMS) could reduce the risk of
LBW by 13% in comparison with iron and folic acid (IFA). Based on this newer evidence, the
World Health Organization (WHO) has updated the antenatal nutrition recommendations. Now, MMS
is recommended during a pregnancy instead of IFA, with consideration of the country
context-specific research. However, little progress is being achieved in ensuring adequate
MMS coverage to improve pregnancy outcomes. Furthermore, the MMS tablets are expensive
compared to the IFA, which might hinder the uptake of the MMS by the people. c. Relevance:
Based on the WHO recommendation, CIFF awarded the Social Marketing Company (SMC) to set up a
sustainable business model with affordable and quality MMS to pregnant women in Bangladesh
over a period of 5 years through SMC's pharmacy networks. The investigators propose to
develop an evaluation design including both process and outcome evaluation to evaluate the
implementation and effect of the MMS by the SMC in Bangladesh.
Hypothesis: The prevalence of LBW will be reduced by 5% point in the intervention group
compared to the control group by the end of the 5-year program.
Objectives: Outcome evaluation- To evaluate the effectiveness of market-based distribution of
MMS intervention on the prevalence of low birth weight (less than 2500 g) in the infants born
to women in the intervention area who received the intervention compared to control areas
Process evaluation- To measure the fidelity, reach and mechanism of impact of the
intervention
Methods: The evaluation study will comprise both process and outcome evaluation,
complementing each other. The design will be a quasi-experimental cluster-based open cohort,
two-arm, mixed-methods design. The evaluation would take place in 5 divisions of Bangladesh:
Barishal, Chattogram, Dhaka, Rajshahi, and Sylhet. For outcome evaluation: Eligible pregnant
women will be approached for recruitment with proper consent. Right after recruitment, a
baseline data collection will be conducted using a structured questionnaire along with
anthropometric measurements. The recruited participants will be followed up until the end of
their pregnancy. After successful delivery of a baby, an endpoint data collection will be
done along with birth weight measurement of the baby. Data from the control areas will be
collected following the same guideline to maintain consistency. The process evaluation will
be carried out concurrently to monitor the program activities. This will follow a
mixed-method design, including both quantitative and qualitative components. The participants
will be recruited from the same area where activity for outcome evaluation will be ongoing.
The investigators will focus on the fundamental aspects of process evaluation that includes-
(a) understanding the health promotion program and how it is supposed to work, (b) defining
the purposes for the process evaluation, and (c) considering program characteristics and
context and how these may affect implementation.
Outcome measures/variables: The key variable for outcome evaluation is the measurement of
birth weight. Key variables for process evaluation are fidelity, reach, and mechanism of
impact of the intervention (MMS).