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Using flow charts and health systems strengthening to improve antenatal nutrition services in India

Vani Sethi is a Nutrition Specialist at UNICEF Regional Office of South Asia.

Archana Mishra is a Deputy Director at the Maternal Health Division, Government of Madhya Pradesh.

Akhand Pratap Singh is the Chief Medical Health Officer, Vidisha district.

Sameer Pawar is a Nutrition Specialist at the UNICEF Field Office for Madhya Pradesh.

Pushpa Awasthy is a Nutrition Officer at the UNICEF Field Office for Madhya Pradesh.

Arjan de Wagt is Chief of Nutrition at UNICEF India.

The authors would like to thank the contribution of J.P. Kapoor (Lal Bahadur Shastri Hospital, New Delhi), Manju Puri (Lady Hardinge Medical College, New Delhi), Neena Bhatia (Niti Aayog), Praveen Kumar (Kalawati Saran Children’s Hospital, New Delhi) and Dinesh Baswal (PATH India, New Delhi) for the development of the flow charts and training materials. The review and data support from Tashi Choedan, Narendra Patel, William Joe, Abhishek Kumar and Avi Saini is acknowledged. The contributions of Mansi Chopra, Akanksha Sharma and Naman Kaur in the training of master trainers and Mansi Shekhar (Nutrition International, Madya Pradesh Field Office) are duly acknowledged.

Key messages:

  • This article outlines the integration of flow charts and a health systems strengthening approach to improve the delivery of government antenatal nutrition services in Madhya Pradesh, India.
  • Most Indian women enter pregnancy with one or more nutrition risks. However, simple flow charts to screen, classify, counsel accordingly and manage nutrition risks were missing.
  • The combined approach was programmatically feasible and led to considerable improvements in the uptake of routine antenatal nutrition services.
  • As a next step, the authors are exploring the evaluation of management protocols, integrating the management of anxiety/depression into the flow charts and nesting evaluations to assess impact through longitudinal studies.


Many Indian women enter pregnancy with poor nutrition – 19% of women of reproductive age are thin for their height (body mass index (BMI) less than 18.5 kg/m2), 24% are obese (BMI greater than 25 kg/m2) and 57% are anaemic (haemoglobin (Hb) levels < 12.0 g/dL).  Additionally, 15% of pregnant women are adolescent mothers (IIPS, 2021).

An estimated 30 million pregnant women in India are eligible to receive antenatal nutrition services, delivered through two national centrally sponsored schemes – the Integrated Child Development Services (Ministry of Women and Child Development) and the National Health Mission (Ministry of Health and Family Welfare). These services delivered are detailed in Box 1.

Box 1: Antenatal nutrition services offered by the Government of India

Nutrition assessment: height, weight, haemoglobin level, monitoring of gestational weight gain

Micronutrient supplementation:

iron and folic acid: 60 mg iron and 500 mcg folic acid

calcium supplements: 500 mg elemental calcium and 250 I.U. of vitamin D

peri-conception folic acid: 400 mcg

Deworming: 400 mg of albendazole

Nutrition counselling: includes topics such as diet, breastfeeding, family planning and receipt of food security and maternity entitlements

Unconditional cash transfers: USD85 per pregnancy

Insecticide treated bed nets in malaria prone areas

Screening and nutrition and/or medical management for: fluorosis, anaemia, tuberculosis, gestational diabetes mellitus and malaria

Balanced energy protein supplementation in the form of take-home rations or hot cooked meals, comprising 600 kcal and 18-20 g protein, provided for 25 days per person per month

Although state governments may have additional state-funded schemes to improve maternal nutrition services,1 the coverage of antenatal nutrition services in India remains constrained by programmatic challenges. To address these challenges, in 2017 a national-level task force developed simplified flow charts that were designed to guide healthcare providers to systematically deliver nutrition services to pregnant women. In 2018, the state government of Madhya Pradesh decided to adopt and test the use of these flow charts as a frontrunner state, starting with Vidisha district and then expanding to seven other districts in the state. A health systems strengthening (HSS) approach was also adopted to strengthen the delivery of nutrition services through the six HSS building blocks – service delivery, health workforce, supplies, information systems, financing and leadership/governance.

In this paper, we describe the processes to develop and test the use of these flow charts alongside the HSS approach. We also analyse the changes that took place in the Vidisha district between 2016 (prior to the initiative) and 2021 (after the initiative).

Arriving at flow charts

In 2017, after the release of the World Health Organization (WHO) 2016 guidelines for positive pregnancy experience (WHO, 2016) and of the results of the fourth National Family Health Survey (IIPS, 2017), the Government of India’s maternal health task force hosted a series of expert consultations to review the evidence on strengthening nutrition services in antenatal care. An expert sub-committee within this taskforce developed two sets of flow charts to assess, classify and manage nutrition risk during pregnancy. The first flowchart is for use during antenatal care at the facility level (Figure 1) and the second is for community health workers at the community level (Figure 2). These flowcharts were accompanied by two sets of counselling cards: gestational month specific counselling2 and nutrition risk specific counselling.3 These were field tested and refined to account for contextual differences between states.

Figure 1: Outpatient department/clinic maternal nutrition services flowchart

Figure 2: Community based maternal nutrition services flowchart

Applying a health system strengthening approach to improve delivery of maternal nutrition services

In April 2018, the Madhya Pradesh government officials convened local partners (UNICEF and Nutrition International) to conduct a gap assessment of health systems to adequately deliver nutrition interventions that focused on the six HSS building blocks. Based on this, a rollout plan to address the gaps identified was developed. This included the development of state operational guidelines, the local translation of existing training packages, the prepositioning of supplies, preparation for capacity building and the development of a reporting and rapid assessment checklist with indicators for review.

The pilot and expansion phases

In the pilot test, conducted between January and December 2019, we assessed the feasibility of implementing both interventions in Vidisha; i.e., flow charts and health systems strengthening. Vidisha is one of the eight aspirational districts of the state of Madhya Pradesh in central India4. Services were provided to an estimated 54,100 pregnant women, through 31 antenatal clinics and 206 village health and nutrition day outreach centres, by 206 auxiliary nurse midwives and 35 staff nurses.

With this intervention, the auxiliary nurse midwife/staff nurse who registers and conducts antenatal care also records a nutrition assessment (height, mid-upper arm circumference (MUAC) and BMI), dispenses micronutrient supplements (iron folic acid (IFA) and calcium) and deworming services and provides gestational month-specific counselling. Then, as per the flow chart, the auxiliary nurse midwife classifies those who are at nutritional risk (short, thin, young, anaemic, obese) and provides nutrition-risk specific counselling using the cards accordingly. Community level workers – such as accredited social health activists and/or Anganwadi workers (healthcare assistants) – then conduct a monthly follow up visit and provide individual nutritional risk-based counselling and motivation to comply with micronutrient supplement regimes. If there are medical or nutrition risks that require treatment, the pregnant woman is then referred to a medical officer at the nearest health facility.

To ensure the efficiency of this workflow, each health system building block was strengthened. First, six master trainers and 226 health personnel were taught through cascade training on the flow chart and gap assessment. Routine communication efforts were used to spread awareness to improve the uptake of antenatal services. Mothers who were at nutrition risk were provided with monthly counselling by health workers in their homes or on their doorsteps dependent on the local COVID restrictions. In the first year, UNICEF funded the additional cost of USD 29,518 (on top of routine government funds5) for this intervention which included flow chart printing, the training of workers and payments to field monitor to monitor the quality of the integration. Most supplies were available through government resources and newly introduced components (training and counselling materials) were arranged in collaboration with development partners such as the TATA Trust6 and UNICEF. MUAC tapes were supplied by the Government of Madhya Pradesh. For reporting, monitoring and review, the routine health systems reporting mechanism was used and additional support was provided for backlog data and biannual reviews. Five indicators were added to the programme register, i.e., weight, MUAC, pre-pregnancy BMI (if available), age < 19 years and inappropriate gestational weight gain, to support nutrition risk classification in addition to the indicator on Hb < 11 g/dL. For data fields that were not covered in the routine reporting system, manual reports were handed to health supervisors together with health management information system (HMIS) compiled reports.

From January 2020 to December 2021, this programme was expanded to the remaining seven aspirational districts (the expansion phase). In 2022, the initiative continues in a total of eight districts (pilot and expansion phases) covering a work force of 2,163 health workers. In the expansion phase, the cascade training down to district level was conducted by master trainers through an online format due to the COVID-19 pandemic. From 2020 onwards, the additional financial requirement was included as part of the government budget and received sanction under maternal health, research and innovation (USD88,671).

Methods used to assess change

To assess the changes in how the health systems performed, we compared how the components of the six HSS pillars had evolved, comparing the presence or absence of each recommended component before (2016) and after (2021) the project was in operation. Interviews were also conducted with auxiliary nurse midwives in order to assess the uptake of flow chart use and their perceived feasibility.

To assess the uptake of nutrition services within antenatal care services, we looked at several output and outcome indicators using the last two rounds of the National Family Health Survey (NFHS) (2016, 2022) which covered representative data on nutrition (IIPS, 2021) (Table 1).

For the process indicators, data consolidated from the government district HMIS for September 2018 to August 2019, September 2019 to August 2020 and September 2021 to August 2022 was used to show how the delivery of maternal services had evolved before and after the programme started. Changes that happened in the expansion districts were also assessed but are not reported in this paper.

Table 1: Indicators used to assess changes



Source of data

Process indicators




Districts that submitted their programme reports in the previous month (%)


Receipt of services

Pregnant women who were given the recommended dose of IFA in the previous month by a health worker at any platform (community/facility) (%)



Pregnant women who were given the recommended dose of calcium in the previous month by a health worker at any platform (community/facility) (%)


Nutrition risks (programme)

Of the pregnant women who were measured for nutrition risks during their antenatal visit, pregnant women who had

  • Weight < 35 kg
  • Pre-pregnancy BMI < 18.5 kg/m 2 or BMI > 23 kg/m 2 in the first visit if in the first trimester
  • Inappropriate gestational weight gain flag-sign (< 1 kg, 0 kg, > 3 kg)
  • Hb < 11g/dL
  • MUAC < 23 cms
  • Age < 19 years

Programme reproductive child health registers

Output indicators



Antenatal care in the first trimester

Women who had an antenatal check-up in the first trimester of their last pregnancy (%)

NFHS surveys

Four+ antenatal care

Women who had at least four antenatal care visits during their last pregnancy (%)

NFHS surveys

IFA 180+

Women who consumed IFA for 180 days or more during their last pregnancy (%)

NFHS surveys

Outcome indicators



Anaemia (survey)

Pregnant women 15-49 years who had anaemia – Hb < 11 g/dL (%)

NFHS surveys

Maternal nutrition status (survey)

Women who were thin (BMI < 18.5 kg/m2) (%)

NFHS surveys


Women who were overweight or obese (BMI ≥ 25.0 kg/m2) (%)



Changes in health systems to deliver maternal nutrition services

Table 2 shows the various elements that were put in place through this programme, comparing the level of implementation prior to the intervention (2016-2018) and after the intervention (2021). Several items that had been missing during 2016 to 2018 such as key indicators and budget items (MUAC tapes and nutrition counselling materials) were integrated to become part of the government antenatal services both from an intervention and systems perspective. The overall state maternal nutrition budget also increased from USD8.5 million to USD17.8 million between 2018 and 2021.

After one year of programme implementation, interviews with 52 auxiliary nurse midwives from Vidisha district showed that 95% of them used the flow chart and 77% reported it had not increased but instead streamlined their workflow. However, only 45% of auxiliary nurse midwives could provide the correct description of all the steps of the algorithm, while 55% reported measuring and recording MUAC of the pregnant women.

Table 2: Applying HSS to assess the preparedness of Vidisha district to deliver maternal nutrition services

Health systems pillar



Leadership and governance

  • Operational guidelines in place for strengthening maternal nutrition
  • Nutrition risk assessment (thinness and overweight), classification and counselling included as part of antenatal care
  • MUAC and BMI as part of nutrition assessment
  • IFA supplements formulation (sugar coated, 60 mg iron and 500 mcg folic acid)
  • State level thematic technical working group/committee for maternal nutrition
  • Joint planning, monitoring, review and feedback to government



















Capacity building

  • State-specific comprehensive ANC*
  • Training of field staff**








  • Availability of digital haemoglobinometers
  • Availability of MUAC tapes
  • Supply managers supported in planning and monitoring stock outs









Financing (USD)

  • Maternal nutrition training
  • Maternal nutrition counselling materials
  • Overall maternal nutrition budget
  • Nutrition services monitoring and handholding support




8.53 million







Information systems – Indicators tracked

  • Pregnant women “at nutrition risk/medical risk”
  • Pregnant women with any nutritional risk counselled
  • Pregnant women with MUAC < 23 cm
  • Pregnant women with BMI < 18.5 kg/m2 (up to 20 weeks)
  • Pregnant women with night blindness/fluorosis/goitre













* Including maternal nutrition training module and counselling material gestational month-wise and nutrition risk specific cards, recipe book for maternal severe thinness and obesity

** Face-to-face in 2019 and online in 2020-2021

Changes in the delivery of maternal nutrition services (process)

Although the data was incorporated into reproductive child health registers, the reporting efficiency was sub-optimal (Table 3). Data from HMIS showed that during the intervention there were no stock outs of micronutrients (IFA and calcium tablets) or albendazole in the district drug store between the period 2018 to 2022. Vidisha district showed improvement in the receipt of IFA and calcium tablets between the years 2018 and 2020. However, a decline in the coverage of both micronutrient supplements was observed in 2021. The decline in reporting efficiency and coverage has been attributed to the COVID-19 pandemic and associated service restrictions (Table 3).

Table 3: Process indicators: maternal services delivered in Vidisha district (source HMIS)





Reporting (%)




Receipt of IFA (%)




Receipt of calcium tablets (%)




Uptake of antenatal maternal nutrition services (outputs)

Baseline and end line comparisons for Vidisha district show considerable improvement for the receipt of antenatal care in the first trimester (29.5% to 84.9%) and the receipt of four antenatal visits (16.9% to 54.4%). Compliance in the consumption of IFA tablets for 180 days or more during pregnancy considerably improved during the programme in both the intervention (4.0% to 24.9%) and district areas (Table 4).

Table 4: Output indicators: uptake of maternal services in Vidisha district



(NFHS, 2016)

Endline (NFHS, 2021)

Women who had an antenatal check-up in the first trimester (%)



Women who had at least four antenatal care visits (%)



Consumption of IFA for 180 days or more in pregnancy (%)



The prevalence of mothers who registered for antenatal check-ups in their first trimester of pregnancy increased by 42% between baseline and endline. 

Changes in maternal nutrition status (outcomes)

The percentage of women who were thin declined in both the intervention and control districts during programme implementation (Table 5). The prevalence of anaemia decreased from 44.5% to 38.5% in Vidisha.

Women in Vidisha district continued to enter pregnancy with various nutrition risks: too thin (23.1%), obese (19.8%) and anaemic (38.5%).

Table 5: Outcome indicators: anaemia and maternal nutrition status in Vidisha District



(NFHS, 2016)


(NFHS, 2021)

Women of reproductive age who are thin (BMI < 18.5 kg/m2) (%)



Women of reproductive age who are overweight or obese (BMI ≥ 25.0 kg/m2) (%)



Women who are anaemic (%)



Lessons learned

The intervention enabled state teams to add important maternal nutrition indicators to routine monitoring, ensure funding for the previously missing but necessary supply items and initiate training in a systematic way while expanding the programme to other districts.

Nevertheless, challenges were also observed. When auxiliary nurse midwives were transferred from a facility, they often took the counselling materials away with them thus limiting availability. Other challenges included the high caseload at facilities, limited human resources and a frequent turnover of staff, gaps in the routine reporting system, a lack of motivation leading to poor adherence to directives as well as a weak district and block review system. The frequent changes in staff duties, particularly to respond to the pandemic requirements, necessitated that all the staff nurses be trained not only auxiliary nurse midwives.

Also, previously missed indicators – such as weight < 35kg, MUAC, BMI and gestational weight gain – were included in reproductive child health registers but there was a large discrepancy between the reproductive child health registers and the HMIS reported data. This shows that investments in reporting efficiency require strengthening. Moreover, to realise financial resources consistently, district and state level planning and the utilisation of allocations for maternal nutrition need to be ensured within every budget cycle. Although state level disaggregated financial data on planning, allocation and disbursement is in the public domain, tracking such information on expenditure at district level remains a challenge as the latter data is not publicly available.

In terms of output, strengthening health systems for nutrition service delivery also considerably improved the uptake of maternal services in Vidisha district. The fact that women in Vidisha district continued to enter pregnancy with various nutrition risks shows that such a comprehensive antenatal care package in Vidisha remains integral to improving maternal nutrition outcomes. Our findings are in line with other similar studies (Rajpal et al, 2021) which confirm a positive impact of HSS activities on the utilisation of health and nutrition services. However, further improvements in suboptimal service delivery require repeated training and the ongoing close supervision of the relevant staff. Even within Vidisha district, not all blocks in Vidisha benefitted which calls for a deeper exploration into the causes of this as well as strengthening the programme expansion.


The study offers an important contribution to the understanding of the effectiveness of strengthening the provision of nutrition services integrated within antenatal care services. The flowchart-based protocol combined with HSS was programmatically feasible. It led to considerable improvements in the uptake of maternal health and nutrition services and a more streamlined workload for auxiliary nurse midwives which ensured the targeted delivery of services and counselling. This programme brought a renewed focus on the importance of routine antenatal care as well as the necessity of a functioning supply chain, adequate financing, an information system and systematic training to result in improved service delivery and monitoring systems. Such real time intervention and analysis will be helpful in providing answers to working at scale to address all forms of maternal malnutrition in Indian states.

There are a few caveats to this study. Firstly, only the pregnant women attending the government antenatal care programme received these interventions. Also, a lack of unit level NFHS data prevented us from establishing the association between service utilisation and the changes in outcomes. Although in this study we did not evaluate direct impact, previous studies indicate that counselling based services are associated with improvement in maternal and child health outcomes (Nguyen et al, 2019). The missing piece at present is whether the provision of additional nutrition support to at-nutrition risk pregnant women and integrating the management of anxiety/depression into the flow charts will lead to better outcomes. Given that this is an ongoing intervention, these components will be strengthened and evaluated in due course in discussion with the government.

For more information, please contact Vani Sethi at


IIPS (2017) National Family and Health Survey-4 (NFHS-4) 2015-16. International Institute of Population Sciences, Ministry of Health and Family Welfare, India: Government of India.

IIPS (2021) National, State and Union Territory, and District Fact Sheets 2019-21 National Family Health Survey NFHS-5. International Institute of Population Sciences, Ministry of Health and Family Welfare, India: Government of India

Nguyen P, Kachwaha S, Avula R et al (2019) Maternal nutrition practices in Uttar Pradesh, India: role of key influential demand and supply factors. Matern Child Nutr 2019;15:e12839

Rajpal S, Kumar A, Alambusha R et al (2021) Maternal dietary diversity during lactation and associated factors in Palghar district, Maharashtra, India. PloS one16(12), e0261700.

WHO (2016) WHO recommendations on antenatal care for a positive pregnancy experience. WHO


1 Examples of such schemes include maternal spot feeding programmes, engagement with women self-help groups for screening and support for nutrition risks and conditional cash transfer schemes; a financial contribution worth USD213 is, for example, provided to pregnant women when they deliver at a health facility in the state of Madhya Pradesh.

2 month cards.pdf

3 at (

4 ‘Aspirational districts’ are defined by poor socio-economic development and poorer health indicators and are recipients of additional support.

5 The routine government funds provided by the health ministry include micronutrient supplements (IFA, folic acid and calcium), deworming (albendazole tablets), drugs and supplies for the screening and management of anaemia (iron sucrose, digital haemoglobinometers and consumables), incentives to community volunteers, the cost of the distribution of insecticide treated bed nets in malaria endemic areas and some routine demand generation activities.

6 Tata Trust is a non-government organisation that works across several Indian states including Madhya Pradesh and has programmes on nutrition, particularly fortification.

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Reference this page

Vani Sethi, Archana Mishra, Akhand Pratap Singh, Sameer Pawar, Pushpa Awasthy and Arjan de Wagt (). Using flow charts and health systems strengthening to improve antenatal nutrition services in India. Field Exchange 68 , November 2022.



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