Intervention details

Micronutrient supplementation: women will receive daily micronutrient supplement tablets from recruitment preconceptionally, throughout pregnancy and during breast feeding. Given the high likelihood of multiple deficiencies, the composition will be based on the WHO/UNICEF/UNU international multiple micronutrient preparation.

Lifestyle behaviour change support: women will receive support from CHWs trained in Healthy Conversation Skills (HCS), in group settings. The details of the group work are in online supplemental appendix 1. HCS is a communication technique developed at the University of Southampton by our wider team for use by health workers to support behaviour change in socioeconomically disadvantaged women.²⁵ This technique has been translated to LMIC settings; in a recent feasibility study involving our group in South Africa, CHWs have been successfully trained in HCS to support young women to improve their diets and lifestyles. The group work emphasises the role of increasing self-efficacy in promoting behaviour change. It is based on the understanding that providing participants with knowledge alone is not sufficient to change their behaviour unless they are also motivated and empowered to change. The aim will be to promote a diverse diet, achieve a normal body weight, and achieve an adequate intake of micronutrients before and during pregnancy, and while breast feeding. CHWs will provide support postnatally to encourage exclusive breast feeding for the first 6 months and the timely introduction of diverse and nutritious infant weaning foods. Women will be educated about the importance of using safe water for feeding their infants after 6 months, and advised to use boiled and cooled water. They will receive support to ensure that their infants are fully vaccinated, and that they adopt appropriate hygiene measures, particularly hand washing after using the toilet, changing ‘nappies’ and before preparing food, eating and feeding their infants. During the preconception stage, the group work will be held at approximately monthly intervals. There will be six modules, with the first module serving as an introductory and general health module. This will be delivered first to all women in the arm. The other five modules will be delivered cyclically and address diet, physical activity and sleep, environmental exposure and hygiene, mental health and preparing for pregnancy.

bmjopen-2020-045862supp001.pdf

Group parenting and cognitive behaviour intervention (Learning Through Play Plus (LTP Plus)): LTP Plus is a group parenting programme, integrated with a cognitive–behavioural therapy intervention (Thinking Healthy Programme) designed to address perinatal depression and improve child development in LMIC settings.^{26 27} It is a manual assisted, low-literacy, potentially sustainable programme whose activities enhance children’s development. It simultaneously promotes attachment security through building parents’ ability to be sensitive to their children’s cues, and be actively involved in their children’s development. These sessions will be delivered in phases which will not only match the woman’s pace, but also the gestational period antenatally and the infant’s developmental stages postnatally. This two-pronged psychosocial participatory group intervention will help mothers to cope with stress, reduce depression and provide information and strategies that they need to nurture their children’s health and development. This will consist of a total of 10 sessions, 3 during pregnancy and 7 postnatally. LTP Plus uses a standardised manual and the material will be delivered by CHWs.

Avoiding environmental pollution: we will provide advice and information on avoidance of environmental pollutants particularly indoor smoke (cooking and smoking). We will facilitate liquefied petroleum gas (LPG) connections actively through a recently introduced government scheme which provides subsidised stoves and fuel. We will also address exposure to, and safe handling of pesticides.

Women in this group will receive the same package of interventions described above, but starting only after they become pregnant, which, in practice, will mean late in the first trimester. Last menstrual period dates will be monitored monthly and women will be offered a urine pregnancy test when they report missing two consecutive periods.

Women in this group will receive an enhanced standard of care. In addition to encouraging vaccinations (two doses of tetanus toxoid) during pregnancy, provision of 100 tablets of iron and folate, and promoting institutional delivery, they will have a similar number of contact sessions with CHWs untrained in our behaviour change and parenting interventions. They will receive standard advice on healthy lifestyle during pregnancy and postnatally, supported by information leaflets (mainly pictorial and using simple language); these will include advice on breast feeding, immunisations and infant weaning foods.