Advancing nutrition measurement: Developing quantitative measures of nutrition service quality for pregnant women and children in low‐ and middle‐income country health systems

Abstract The health sector plays an important role in the delivery of high‐quality nutrition interventions to women and children in low‐ and middle‐income countries (LMICs). However, there are no standardized approaches to defining and measuring nutrition service quality in these contexts. This study aims to systematically develop quality of care indices for direct health systems nutrition interventions using a five‐step process: (1) identify recommended interventions for inclusion in indices, (2) extract service readiness, provision of care, and experience of care items from intervention‐specific clinical guidelines, (3) map items to data available in global health facility surveys, (4) conduct an expert survey to prioritize interventions and items, and (5) use findings from previous steps to propose quality of care metrics. Thirty‐two recommended interventions were identified, for which the guidelines review yielded 763 unique items that were reviewed by experts. The proposed nutrition quality of care indices for pregnant women reflects eight interventions and the indices for children under 5 reflects six interventions. The indices provide a standardized measure for nutrition intervention quality and can be operationalized using existing health facility assessment data, facilitating their use by LMIC decision makers for planning and resource allocation.

Where anemia prevalence among pregnant women is less than 20% , intermittent oral supplementation of 120mg elemental iron and 2.8mg folic acid once weekly can be implemented in lieu of daily supplements to improve maternal and perinatal outcomes. Pregnant women who are intolerant to sideeffects of daily iron supplementation may use the same intermittent dosing regimen. In areas where the baseline prevalence of hookworm and/or T. trichiura infection among pregnancy women is 20% or more, and where anaemia prevalence among pregnant women is 40% or higher, women should receive preventive chemotherapy (deworming), using single-dose albendazole (400 mg) or mebendazole (500 mg) after the first trimester in order to prevent infection and malnutrition. Delayed cord clamping by more than one minute after the birth will allow blood flow to continue between the placenta and neonate, which can improve iron status in the infant for up to six months after birth. Increase potassium intake from food to control blood pressure (in children and adults at risk of CVD)

Recommended (WHO)
Increasing potassium intake from food to control blood pressure in children aged 2-15 years with a recommended intake adjusted based on child's energy requirement using adults intake of at least 90 mmol/day as a upper reference.

Child (2-15 years)
Reducing sodium intake to control blood pressure Reducing sodium intake to control blood pressure in children aged 2-15 years with a recommended intake adjusted based on child's energy requirement using adult intake of less than 2g/day as a upper reference. (1) knowledge on recognizing the milk ejection reflex (or let-down) effective feedings and understanding feeding patterns and growth spurts.

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(2) anticipate and address important challenges and contexts for BF (3) knowledge on benefits of BF such as protection and comfort as well as food (4) support mothers to make informed choices about other feeding choices, if mother does not breastfeed (5) mothers and their families to start a nurturing, caring and responsive relationship with their infant and aim to enable a positive and loving environment. (6) support and boosting mother's confidence, (7) address concerns about maintaining breastfeeding during (1) receive a total of 5 BFC sessions postnatally: during and immediately after birth; at 1-2 weeks after birth; in the first 3-4 months; at 6 months; and after 6 months (1) not a "topdown" intervention of "telling women what to do".
(2) focus on empowering women to breastfeed (3) respecting their personal situations and wishes and never be forced upon any women. (4) positive feedback and emotional support are especially needed to support the mothers' confidence and self-efficacy in breastfeeding (5) BFC should be provided as a continuum of care, (6) face-to-face counselling preferably [30] 36 (1) assess general condition (i.e. alertness, restless, irritable, lethargy) (2) assess eyes (normal or sunken) (3) assess ability to tolerate fluids (4) assess skin turgor (5) assess presence of blood in stool (6) assess duration of diarrhoea (7) assess number of watery stools per day (8) assess number of episodes of vomiting (9) assess presence of fever, cough or other important problems (10) type and amount of fluids and food taken during illness (11) drugs or other remedies taken (12)