Delivering balanced energy and protein (BEP) supplements to pregnant and breastfeeding women in low- and middle-income countries: A scoping review

In settings where more than 20% of women of reproductive age are classified as underweight, the World Health Organization recommends balanced energy and protein (BEP) supplementation during pregnancy to reduce adverse birth outcomes. However, guidance on contextually acceptable and feasible supplement delivery platforms remains limited, posing critical challenges for implementation. We synthesized literature on acceptable and feasible delivery platforms for BEP supplementation (direct evidence), as well as iron and folic acid (IFA) or multiple micronutrient supplements (MMS; indirect evidence) to pregnant and breastfeeding women (PBW) to broaden the search scope. A systematic search was conducted across five databases and grey literature to identify studies that addressed the acceptability and feasibility of BEP supplement delivery platforms in low- and middle-income countries (LMICs), at facility and community levels. We identified 48 studies conducted in LMICs: 22 specifically evaluated BEP supplement delivery, while 26 evaluated IFA or MMS. In the direct evidence, home delivery (11/22) was the most frequently mentioned delivery platforms of BEP supplements followed by community-level feeding centers (provided cooked meals or take-home rations) anchored by frontline community health workers (8/22 studies) and antenatal care (ANC) at health facilities (6/22; some studies assessed multiple delivery platforms). Only four studies assessed preferred BEP delivery platforms, and PBW favored home over facility-based delivery. Authors attributed this preference to the comprehensive nutrition education and behavior change communication (BCC) provided during home delivery. Indirect evidence showed that enhancing delivery of IFA or MMS at health facilities (not specific) through strategies such as BCC and home visits may improve supplement compliance. Overall, limited evidence exists regarding market-based approaches for delivering any of these interventions. Based on existing evidence, scale-up delivery of BEP supplementation through ANC at health centers, enhanced by community health workers may be feasible in reaching PBW, especially when combined with BCC.