Participatory Women's Groups with Cash Transfers Can Increase Dietary Diversity and Micronutrient Adequacy during Pregnancy, whereas Women's Groups with Food Transfers Can Increase Equity in Intrahousehold Energy Allocation

Random allocation

The interventions were community based, so were allocated by cluster. Each cluster was defined as 1 Village Development Committee, a geopolitical unit that contains 9 wards. Clusters were excluded if they had been allocated to a women's group intervention in an earlier trial. To reduce the heterogeneity of the sample, clusters were also excluded if they were small (population <4000), large (population >9200), near to the East-West Highway, hilly, forested, non–Maithili-speaking, or large towns or municipalities. In a public “bingo” event involving local stakeholders, the remaining 80 clusters were allocated to 1 of 4 trial arms, giving 20 clusters per arm. We used stratified block randomization. Strata were based on cluster size and accessibility: small inaccessible, small accessible, large inaccessible, and large accessible. Due to the nature of the interventions, masking of the cluster allocations was not possible. Statisticians were not masked to the allocation; analyses followed a prespecified plan.

Participants

All pregnant women living in selected clusters were eligible to participate in the trial, but this study evaluated the effects of the interventions on diets and intrahousehold food allocation in joint, male-headed households. This was to reduce the heterogeneity of the sample and because these households were hypothesized to be the least equitable and least likely to change their behaviors (14). Criteria for enrolled women and their households to be interviewed for this study were as follows: women in their third trimester who were living with their mother-in-law in male-headed households. Sampled individuals from these households were pregnant women, their mothers-in-law, and male household heads. Male household heads were hypothesized to be the most favored in terms of food allocation, and mothers-in-law typically controlled food allocation (13). We initially planned to collect data over 1 y but were delayed due to severe political conflict, major earthquakes, and lack of funds.

Interventions

The full protocol is reported in Saville et al. (23). The 3 interventions were a behavior-change strategy of monthly women's groups practicing PLA, PLA women's groups with a monthly unconditional food transfer, and PLA women's groups with a monthly unconditional cash transfer.

The groups followed a PLA cycle of 4 phases: identify problems, plan strategies, act together, and evaluate impact (as shown in Figure 1).

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FIGURE 1

Women's group meeting plan using a Participatory Learning and Action cycle.

In the first phase, groups used participatory methods such as picture cards, games, and stories to discuss nutrition problems and local barriers to achieving good health during pregnancy. In the second phase, groups prioritized and voted on the issues they wanted to focus on, designed strategies to address these problems, and engaged the wider local community for support and feedback. In the third phase, the groups implemented these strategies while continually discussing new topics related to pregnancy and infant health. Finally, in the fourth phase, the groups reviewed what went well and discussed what to do next after the implementing organization (MIRA) withdrew from the community.

The women's groups were held at the ward level and, with 9 wards per Village Development Committee, 539 women's groups were facilitated in all 60 intervention clusters (one small ward was merged with a neighboring ward). Government-incentivized female community health volunteers (FCHVs) facilitated the PLA women's groups, with support from MIRA-recruited “nutrition mobilizers.” FCHVs and nutrition mobilizers received training on group facilitation and maternal and infant nutrition.

The PLA groups served as a mechanism to deliver the food and cash transfers. The food consisted of 10 kg of fortified wheat and soya blend with sugar (“Super Cereal”)—a product developed and tested by the World Food Programme—and the cash was NPR 750 (23). The nutritional composition and safety of Super Cereal is reported in the trial protocol (23). Women were advised to eat 150 g Super Cereal/d, which would provide 570 kcal/d and meet most micronutrient requirements for pregnant women. The monthly 10-kg transfer allowed for women to share another 179 g/d with other household members. The cash transfer was calculated to be the equivalent cost of the Super Cereal transfer. The cost of an adequate diet in 2012 was estimated at NPR 1767/mo per person, so the cash transfer would provide 43% of this cost. In the PLA plus food arm, PLA groups discussed how much Super Cereal should be consumed (150 g/d) and recipes for using the Super Cereal. In the PLA plus cash arm, groups discussed how the cash should be spent on nutritious foods such as milk and fruit. In both transfer arms, groups discussed why the transfers should be selectively consumed by pregnant women.

As a benefit to all participants (including controls), training on maternal, newborn, and child health was provided to 189 health workers in both districts. When the final measurements were taken after delivery, women in the control and PLA-only arms received NPR 1000 to thank them for participating.

Outcomes

The outcomes are summarized in Table 1.

We report intervention effects on food and nutrient intakes of pregnant women and intrahousehold allocation. To describe both intakes and allocation, we selected nutrients (energy, protein, and dietary iron) and food groups (“flesh foods”, i.e., meat, fish, or shellfish; dairy foods; and green leafy vegetables) that were promoted in the PLA groups. Other foods were also promoted, but we chose flesh foods because they are culturally high status, dairy foods because they are high-status foods that are cheaper and more regularly consumed than flesh foods, and green leafy vegetables because they are micronutrient-rich yet considered “inferior.” We report on intakes of dietary iron (excluding iron-folate supplements) and consumption of supplements, and on intrahousehold allocation of dietary and total iron (dietary iron plus iron from supplements). Midupper arm circumference (MUAC) is reported as an indicator of nutritional status.

We also report summary measures that were added to the initial analysis plan to describe overall nutritional and dietary adequacy: mean probability of adequacy (MPA), the average adequacy of 11 nutrients, and the Minimum Dietary Diversity Score for Women (29), the number of food groups consumed out of 10 food groups.

The primary outcomes for this study were mean Relative Dietary Energy Adequacy Ratio (RDEAR) between pregnant women and the male household heads and mean RDEARs between pregnant women and their mothers-in-law, as defined in the following equation:

(1)

where a denotes the pregnant woman and b denotes another household member (the male household head or mother-in-law). Estimated Average Requirements (EARs) were individually calculated, on the basis of their age, sex, body weight, pregnancy/lactating status, and self-reported physical activity levels (30). Total energy expenditure was calculated as basal metabolic rate × physical activity levels. Basal metabolic rates were based on Indian-specific values (31). Self-reported activity levels were assessed by asking each respondent whether they spent most of the previous day 1) sitting down or standing still, such as doing office or shop work (“sedentary”); 2) moving around, such as walking, carrying light loads, or doing domestic work (“moderate”); or 3) doing strenuous work like carrying heavy loads, working in the field, or pulling a rickshaw (“strenuous”). Based on Indian Council of Medical Research's guidelines, Physical activity levels were taken as 1.5 for sedentary activity, 1.8 for moderate work, and 2.3 for strenuous, heavy activity levels (31). The additional cost of pregnancy was taken to be 390 kcal/d (31).

We calculated the ratios of the MPA between pairs of household members. MPA was calculated by using the Probability approach (32), as follows. We first transformed nutrient intake distributions to normality using Box-Cox transformations (33) and obtained the best linear unbiased predictors derived from separate linear mixed-effects regression models for each household member, treating clusters and individuals (repeat measurements) as random effects and strata and study arm as fixed effects. We then calculated the probability of adequacy (PA) for each individual and each nutrient by comparing the individual's back-transformed usual intake to the population distribution of requirements, which are normal distributions with known means (i.e., EARs) and SDs (34–37). For mothers-in-law and male household heads, iron PAs were calculated by using a table of probabilities for different intervals of usual intakes (36). We assumed low bioavailability of iron (5%), apart from pregnant women who have higher iron absorption (23%) (36), and low bioavailability of zinc (25% for women, 18% for men) (37).

We also report, but did not formally test, the percentage of women with a probability of iron adequacy of >0.7 based on total iron including supplements.

Field procedures

Enrollment of pregnant women into the main trial ran from December 2013 to February 2015, and the interventions ran from February 2014 to October 2015. The last enrolled woman gave birth in October 2015. Between 10 June and 26 September 2015, all eligible households were visited for a series of three 24-h dietary recall interviews. Dietary intakes of pregnant women, male household heads, and mothers-in-law were assessed up to 3 times each on nonconsecutive days. The 5-stage “multi-pass” dietary assessment method has been described in detail elsewhere (38–40). Portion sizes were estimated by using an atlas of life-sized photographs that was developed locally and validated before use (41).

Individual nutritional intakes were estimated with the use of a local food-composition table compiled from multiple published sources (42–45). We also added the nutritional content of cooked, mixed dishes to this table using recipes that we collected before data collection and analyzed using the published values of raw foods. We did not apply nutrient retention factors due to the lack of locally appropriate estimates.

MUAC and body weight were measured with the use of Seca 212 circumference tapes and Tanita solar weighing scales accurate to 100 g. Socioeconomic and demographic data were collected by the main trial surveillance (23, 46). Data on exposure to the interventions were collected during the third dietary recall.

Before data collection, interviewers received standardization exercises for MUAC measurement and 1 wk of training on dietary assessment. To ensure data quality, supervisors and project coordinators conducted spot checks, revisited interviewed households, and checked plausibility of values, frequency of outliers, digit preference, and Global Positioning System points every week.

Ethics

Research ethics approval was obtained from the Nepal Health Research Council (108/2012) and the University College London Ethical Review Committee (4198/001). Women gave consent by signature or thumbprint. A data-monitoring committee was formed, and harms were tracked in the form of stillbirths and deaths, but there was no intent to ask the committee to apply any stopping rules, and no reason to believe the interventions would cause harm (23). For each 24-h recall interview, respondents gave verbal consent and were free to stop the interviews at any point.

Exposure to interventions

Group attendance was much higher in the transfer arms (86% and 96% attendance in the food and cash arms, respectively) than in the PLA-only arm (25%) (Table 3). Groups were most commonly attended by pregnant women and their mothers-in-law. Most women in the transfer arms had received ≥4 transfers of either cash or food by their third dietary recall.

In the food arm, more than half (54%) of pregnant women consumed some Super Cereal, but only 3% consumed the recommended 150 g. Of those who consumed any, the median intake was 43 g. Most (55%) of the households used their Super Cereal to prepare haluwa, a stiff porridge prepared with oil and sugar (215 kcal/100 g); one-third (35%) prepared roti, unleavened flatbread (263 kcal/100 g); and 5% prepared litho, a watery Super Cereal mixture (82 kcal/100 g; estimates of nutritional values are based on typical average recipes). The median Super Cereal consumption of 43 g would give 165 kcal (or 42% of 390 kcal, the energy costs of pregnancy). Pregnant women in the PLA plus food arm consumed 2147 kcal/d; to meet EARs, pregnant women would need to consume an additional 256 kcal, which is 119 g haluwa, 97 g roti (around 2 small roti), or 312 g litho (around 1 medium-sized bowl). Six percent of household heads consumed some Super Cereal, as did 19% of mothers-in-law.

Trial effects on dietary intakes of pregnant women

Table 4 shows effects of the interventions on pregnant women's intakes of key nutrients and nutritional status (MUAC), and Table 5 shows effects on food item consumption. Supplemental Table 1 reports arm-wise intakes of energy, protein, and 11 micronutrients, MPA, dietary diversity, and MUAC. Supplemental Table 2 reports the percentage of pregnant women consuming any of the 10 food groups or iron-folate supplements in each arm.

Compared with the control, participants consumed, on average, 86 kcal more in the PLA plus food arm and 118 kcal less in the PLA-only arm, but neither these nor the slight differences in kilocalorie adequacy ratios were significant. Dietary iron adequacy was higher in both transfer interventions than in the control arm (PLA plus cash = coefficient of 0.06; 95% CI: 0.01, 0.11; P = 0.015; PLA plus food: 0.07; 95% CI: 0.01, 0.12; P = 0.012). Notably, in the PLA plus cash arm, odds of consuming iron-folate supplements were 4.6 times higher, the odds of consuming dairy were 1.8 times higher, and the mean dietary diversity and PA were higher than in the control arm. For all interventions, the pregnant women's mean MUAC and the odds of consuming iron-folate supplements were significantly higher than in the control arm.

Trial effects on intrahousehold food allocation

The trial effects on intrahousehold nutrient allocation are given in Table 6 (with the nutrient allocation ratios in each arm shown in Supplemental Table 3), and effects on intrahousehold food item allocation are reported in Table 7 (with food allocation ratios in each arm given in Supplemental Table 4). Effect sizes are reported as log-transformed outcomes in the tables, but their exponents are reported in the text for ease of interpretation.

In the PLA plus food arm, RDEARs between pregnant women and their mothers-in-law were significantly higher (12% higher; P = 0.014) than in the control arm, and RDEARs between pregnant women and their household heads were slightly but not significantly higher (8% higher; P = 0.078). On the contrary, in the PLA-only arm, RDEARs between pregnant women and the male household heads were 10% lower (P = 0.020), but MPA ratios (after adjusting for RDEARs) were 27% higher (P = 0.038) compared with the control arm. In the PLA plus cash arm, there was no difference in RDEARs or MPA ratios between pregnant women and household heads or their mothers-in-law relative to control.

For total iron (including supplements), compared with the control arm, all intervention arms had higher allocation ratios between pregnant women and male household heads [51% higher for PLA plus cash (P < 0.001); 24% higher for PLA only (P = 0.032) and PLA plus food (P = 0.022)]. A similar trend was observed between pregnant women and their mothers-in-law. There were no trial effects on intrahousehold dietary iron allocation.

In all of the intervention arms, the odds of pregnant women consuming more animal-source foods (flesh foods and dairy) than the household head were higher than in the control arm, with the largest effect in the PLA-only arm (flesh food OR: 2.4; 95% CI: 1.09, 5.10; P = 0.028). There were no differences between trial arms in the odds of pregnant women consuming more flesh foods, dairy, or green leafy vegetables compared with their mothers-in-law.

We thank Sarah Style, Jayne Harthan, and Lu Gram from University College London and thank Ritesh Shrestha, Bidur Thapa, Rishi Neupane, and Bishnu Bhandari for their valuable inputs and support with logistics, planning, and intervention implementation. Lalbabu Kushuwa and Dhruba Devkota of Save the Children helped us to implement the food and cash transfer system. Pramila Ghimire, Srijana Nakermi, Marco Cavalcante, and Allison Prather of the World Food Programme Nepal provided the Super Cereal for the study and advice on managing its distribution. We thank Saskia DePee from World Food Programme and Andrew Hall from Save the Children for providing technical advice. We thank Elaine Ferguson and Sarah Kehoe who provided comments on an earlier draft. Special thanks to the supervisors, Devlal Bishwakarma, Shankar Kaphle, Suresh Mandal, and Dharambir Pasman. The authors’ responsibilities were as follows—HAH-F: wrote the manuscript and had primary responsibility for final content; HAH-F, NMS, AMdLC, and DSM: designed the research; HAH-F, PP, SJ, NS, and BPS: conducted the research; BJB, NS, and TH: provided essential materials; HAH-F, NMS, AC, and MC-B: analyzed data; and all authors: read and approved the final manuscript.