John Hoddinott

Introduction: Micronutrient deficiencies during pregnancy have serious consequences for both mother and child; thus the longstanding standard of care in low- and low-middle income countries (LMICs) has been daily prenatal iron–folic acid (IFA) supplementation. While prenatal multiple micronutrient supplements (MMSs) provide additional significant benefits in comparison to IFA supplements, the view that MMS is too expensive has hindered national MMS adoption. However, increased competition, volume procurement and the use of advanced purchase commitments have significantly reduced the cost of MMS. Methods: Using new cost data, we estimate the benefits of replacing IFA with MMS in both health (averted low birth weights (LBWs), stillbirths and female neonatal mortality) and monetary (costs of averted LBW and death; total economic value; benefit–cost ratios) terms in 25 LMICs with the greatest burden of LBW. A number of scenarios describing different coverage and procurement cost scenarios are explored. Results: Replacing preventive antenatal IFA with MMS would avert 3 514 594 LBW births, 186 369 stillbirths and 218 914 female neonatal deaths over 5 years in these countries. Providing MMS to all pregnant women receiving at least one antenatal care visit averts 7 272 320 LBW, 473 471 stillbirths and 541 591 female neonatal deaths. The total cost of replacing IFA with MMS ranges from US$201.8 million to US$1.326 billion, equivalent to between 0.5% and 3.0% of current spending on efforts to reduce undernutrition. Using the most conservative estimate, this would generate US$7.19 billion in economic returns and a benefit–cost ratio greater than 10. The cost of averting a stillbirth or neonatal death ranges from US$497 to US$1306. Conclusion: Replacing prenatal IFA with MMS cost-effectively generates large health benefits.

We investigate whether traditional poverty alleviation policies, typically designed for immediate poverty reduction, also enhance households' resilience to future unexpected shocks. We revisit a randomized control trial in Bangladesh which undertook a two year intervention across two rural regions of Bangladesh. Using an improved resilience metric and machine learning methods, we present new findings of the impact of the different poverty alleviation strategies, both at the endline and four years post intervention. Our study reveals that poverty alleviation interventions, such as unconditional cash transfers, and cash or food transfers combined with intensive group-based behavior change communication (BCC), significantly improve resilience compared to pure in-kind transfers. However, these policies are primarily effective in strengthening resilience to extreme poverty. Four years after the intervention, we find some evidence of cash transfers enhancing resilience to extreme poverty. We explain our findings through both short-term coping strategies and long-term adaptive mechanisms.\

This study aims to examine intra‐household gender dynamics in response to a nutrition intervention (maternal Behaviour Change Communication (BCC), paternal BCC, and food vouchers) aimed at improving IYCF practices using qualitative methods. Participants were drawn from a subset of households enrolled in a larger cluster – randomized controlled trial (RCT) conducted in rural Ethiopia. A total of 40 participants (20 mother–father pairs) from intervention and control households were interviewed separately to explore intra‐dyadic beliefs and household decision‐making. Furthermore, this study explores plausible mechanisms behind the main RCT finding that greater father involvement, while increasing knowledge, did not consistently improve infant and young child feeding (IYCF) outcomes. We find that BCC mothers had the tendency to adopt more gender‐equal beliefs, particularly regarding men's roles in childcare and household chores, whereas fathers were slower to shift their views. This may have led to increased discordance in gender norms within BCC households. By contrast, control couples often retained traditional views, but showed more intra‐couple alignment. Unexpectedly, control fathers were sometimes more progressive than control mothers, potentially due to higher education levels. We also find increased paternal engagement occasionally introduced conflicting priorities, as fathers asserted authority over household spending – sometimes at the expense of child‐focused nutrition. These findings underscore the complexity of engaging fathers in nutrition interventions and point to the need for strategies that address underlying gender norms and decision‐making dynamics within households.

A key element of women’s empowerment is the ability to participate in household decision-making. This study presents the qualitative results from the Shonjibon Cash and Counselling Trial baseline process evaluation with the aim of exploring the status of women’s decision-making at the trial’s outset and to facilitate the exploration of any changes in women’s empowerment over the course of the trial. Between January and March 2021, we conducted forty-one in-depth interviews with pregnant women in rural Bangladesh. The research team translated, transcribed, coded, and discussed the interviews. We used thematic analysis to examine women’s experience and perceptions on household decision-making. The key findings that emerged; women jointly participated in financial decision-making with their husbands; men made the final decision regarding seeking healthcare, and women solely made choices regarding infant and young child feeding. Our findings revealed that women felt that they needed to discuss their plans to go outside the house with their husbands, many perceived a lack of importance in the community towards women’s participation in decision-making. This study documents current contextual information on the status of women’s involvement in household decision-making and intrahousehold power dynamics at the start of the Shonjibon Cash and Counselling Trial.

This paper reports the results of two 2-year randomized control trials in two poor rural areas of Bangladesh. Treatment arms included monthly cash transfers, monthly food rations of equivalent value to the cash transfers, and mixed monthly cash and food transfers, and treatment arms—one with food and one with cash—that combined transfers with nutrition-behavior communication change (BCC). This design enables a comparison of transfer modalities within the same experiment. Intent-to-treat estimators show that cash transfers and nutrition BCC had a large impact on nutritional status, a 0.25 standard deviation increase in height-for-age z-scores and a 7.8 percentage point decrease in stunting prevalence. No other treatment arm affected anthropometric outcomes. Mechanisms underlying these impacts are explored. Improved diets—particularly increased intake of animal source foods in the cash plus BCC arm—are consistent with the improvements observed in this paper.

An important cause of stunting is limited consumption of complementary foods, in terms of both quantities and nutrients. Although existing studies show a positive association between fathers' engagement and children's diet, programmes designed to improve complementary feeding practices often only target mothers. In response to this, maternal behaviour change communication (BCC), paternal BCC and food voucher programmes were designed and implemented in Ethiopia using a clustered randomized controlled trial design. The paternal BCC programme included gender‐equal messages to increase fathers' participation in childcare, household labour and decision making. The research reported in this paper is an examination of the BCC programmes, characterizing the behavioural, normative and control beliefs of both mothers and fathers in BCC households compared to those in control households. In this study, a total of 40 participants were included, with 13 mother–father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately. We found that BCC mothers showed more gender‐equal tendencies than the control mothers despite being more rural in location. By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender‐equal BCC. More work is needed to develop and test effective methods for changing fathers' beliefs and practices.