Table 2 Programmatic implications for intervention

Perception of birth weight

• No desired minimum or maximum birth weight and size for their unborn baby.

Women desire a ‘normal’ and ‘healthy’ baby.

Training SS and SKs to:

• Discussions about the condition of an unborn child are perceived to be harmful.

• convey messages about the importance of normal birth weight and role of IFA and

• discuss the risks associated with low birth weight and how anaemia is linked to low birth weight.

Perception of size of the baby

Concerns that a large baby would create delivery complications.

Promote awareness that a big baby does not necessarily create birth complications if the mother remains healthy during pregnancy and appropriate antenatal care is received.

Perception of antenatal iron-folic acid intake

• Perceived to increase the size of the foetus resulting in increased birth complications and potential surgery.

• IFA is perceived to increase volume and quality of blood, which helps women recover from blood loss during childbirth, and retain their physical strength.

Training SS and SKs to enable them to:

• Higher parity women are less positive about iron-folic acid intake.

• Younger and first-time pregnant women tend to follow advice of health workers sincerely.

• take available opportunities such as community events to improve awareness of antenatal IFA intake in community.

Negative impression among few older females.

• counsel pregnant women about impact of IFA on the growth of foetus in greater detail.

• use existing favourable cultural reasoning in the promotion of antenatal IFA supplementation.

• target older and multiparous pregnant women for counselling

• include older women in the household in the counselling sessions.

Experience IFA intake

• Side effects are experienced by pregnant women.

• Many women do not consider these side effects very serious.

• Use a formulation of iron-folic acid with minimal smell

• Smell of IFA supplements is difficult to stand for many pregnant women.

• No concern about colour of the supplement.

• Train SS and SKs to provide better counselling about possible side effects and management of side effects

Sources of information on iron-folic acid

• In rare cases, pregnant women receive negative and discouraging information about IFA from their social network.

• Many currently pregnant women heard about IFA at younger age and before they were pregnant from the pregnant women in the family and neighbourhood.

• SS and SK of BRAC should be used to distribute and counsel about IFAs.

• SS and SK are the main sources of information on antenatal IFA intake.

• The SS and SKs should be trained to deal with negative information from outside the trial zone.

Influence of family members on decision-making

Husbands have little concern about their wife taking IFA and consider it a female domain.

Mothers-in-law have the strongest influence in decision-making.

Mothers-in-law should be counselled in the few initial home visits after IFA supplements are supplied.

Concerns of IFA early in pregnancy

• SS/SK: Concerns that the community might hold the overall BRAC health programme responsible for any miscarriage/abortion that happens to a women who was taking iron-folic acid supplements early in pregnancy on their advice.

• Widespread opinion exists among pregnant women in favour of starting IFA intake as early as a BRAC SS/SK advises.

• Distribute iron-folic acid supplement and provide instructions to use through BRAC SSs/SKs who have already established their trustworthiness in the community.

• BRAC Managers at Upazila level are confident about the ability of SS/SKs to motivate their clients to start IFA according to the Programme’s decision.

• Address the community concerns about IFA supplementation in the CHW training.

Medical pluralism

Multiple sources of IFA supplements and information exists

Pregnant women usually visit private practitioners only when they are sick.

Maintain cordial relationship and organise periodical stakeholders meetings with providers outside BRAC Health Program to align messages about early IFA supplementation

Costs

Women wanted to have access to free IFA supplements.

The Shonjibon project has resources for free provision of IFA supplements.

Provide IFA supplements free of cost to reduce economic burden on the family.