Opportunities and challenges for introduction of balanced energy protein supplementation through routine antenatal care

Background The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation during pregnancy in contexts where prevalence of maternal underweight, defined as body mass index (BMI) < 18.5 kg/m2, is ≥ 20%. Evidence shows that BEP supplementation in underweight pregnant women reduces the risk of low birthweight, small for gestational age, and preterm birth. Yet little is known about how to introduce BEP through routine antenatal care (ANC). This paper explores challenges, opportunities, and recommendations for successful introduction of BEP supplementation through ANC service delivery. Methods From August – December 2023, a mixed-methods landscape analysis was carried out, which comprised of a review of country antenatal care guidelines, as well as key informant interviews (KIIs) with thirteen global and country stakeholders. KIIs were recorded, transcribed, and analyzed by themes and subthemes using Dedoose qualitative software 10.0. Results Findings revealed confusion around the definition of BEP, coupled with low awareness of the WHO ANC guideline on BEP supplementation among country stakeholders. Provider capacity for BEP provision is weak. Sharing, selling, and stockouts of BEP supplies are common. Data on the feasibility and cost-effectiveness of the introduction of BEP at country level is critical to inform implementation. Conclusion Successful introduction of BEP as part of ANC service delivery requires country program implementers to consider government commitments, health provider training, demand generation, compliance, supplies and logistics, local production, and routine monitoring of BEP indicators. Globally, standardized BEP guidance, indicators, and definitions are critical to support quality country implementation. For sustainability, emerging concerns around reductions in global health funding should be addressed in future program design and implementation.