Specificity matters: Unpacking impact pathways of individual interventions within bundled packages helps interpret the limited impacts of a maternal nutrition intervention in India

Background: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive (I-ANC) to standard (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight gain monitoring. Objectives: This study examined intervention-specific program impact pathways (PIP) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. Methods: We used mixed methods: frontline workers surveys (FLWs, n∼500); counseling observations (n = 407); and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed seven PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. Results: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC versus S-ANC (90 vs.70%), but gaps remained for training content and refresher trainings. FLW's knowledge improvement was higher in I-ANC than S-ANC (22–36 percentage points), but knowledge on micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30–50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52 vs. 36%), but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight gain monitoring were low (30–40%). Conclusions: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.