Factors influencing quality nutrition service provision at antenatal care contacts: Findings from a public health facility-based observational study in 21 districts of Bangladesh.

Malnutrition during pregnancy is associated with increased maternal morbidity and mortality and has a long-term negative impact on child growth and development. Antenatal care (ANC) is the formal point of contact for pregnant women to receive preventive health and nutrition services. We assessed the quality of nutrition service delivery during ANC and examined its influencing factors related to the health facility, health care provider (HCP) and client characteristics. We conducted a cross-sectional assessment in 179 facilities, including 1,242 ANC observations and exit interviews of pregnant women from 21 districts in Bangladesh. We considered four essential nutrition services at each ANC contact including maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplement provision. We defined a composite 'quality nutrition service' outcome by counting the number of services (out of four) provided at each ANC from observation data. We explored both the supply-side and the client-level factors of quality nutrition service using multilevel Poisson regression. Overall, only 15% of clients received all four nutrition services. Performance of weight measurement (79%) was higher than IFA provision (56%), anaemia assessment (52%) and nutrition counselling (52%). The multivariable analysis showed that quality nutrition service delivery is positively associated with good logistical readiness of the facilities (aIRR: 1.23, 95% CI: 1.08-1.39), consultation by paramedics (aIRR 1.23, 95% CI: 1.06-1.42) and community health care providers (aIRR 1.32, 95% CI: 1.12-1.57), HCPs' knowledge on maternal nutrition (aIRR 1.04; 95% CI: 1.01-1.08), better HCP-client communication (aIRR 1.14; 95% CI: 1.04-1.26) and use visual aids or ANC card (aIRR 1.18; 95% CI: 1.11-1.27). We found limited associations between HCP training and external supervision with the quality of nutrition services. In conclusion, the quality of nutrition service provision during ANC is suboptimal. Public health nutrition programmers should ensure the facilities' logistical readiness, and revisit and reinforce the content and modality of training and supportive supervision of the HCPs. They should also emphasize positive HCP-client communication and the use of job aids to improve the quality of nutrition service provision during ANC.