{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T15:55:50Z","timestamp":1785426950938,"version":"3.56.0"},"reference-count":40,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:00:00Z","timestamp":1777939200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Gates Foundation","doi-asserted-by":"publisher","award":["INV-055523"],"award-info":[{"award-number":["INV-055523"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"award":["INV-055523"],"award-info":[{"award-number":["INV-055523"]}],"id":[{"id":"https:\/\/ror.org\/0456r8d26","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>The World Health Organization recommends the use of balanced energy protein (BEP) supplements during pregnancy in settings with a \u2265\u200920% prevalence of underweight women of reproductive age to reduce the risk of adverse health outcomes. Several countries are implementing BEP supplementation in varied formats. However, the implementation and monitoring of outcomes remain poor across countries. This qualitative study explores the experiences, opportunities, and challenges related to implementing national and sub-national BEP supplementation programs in nine countries (12 countries originally invited) to inform best practices. Methods: Semi-structured interviews were conducted with 15 personnel involved in its implementation in Haiti, India, Malawi, Mexico, Nigeria, Pakistan, Rwanda, Senegal, and Sri Lanka between October 2024 and March 2025. The interviewees in each country were predominantly implementation experts but also government officials involved in the provision of BEP supplementation. The transcripts were analyzed thematically, focusing on acceptability, adoption, appropriateness, cost, feasibility, and sustainability of outcomes. Results: In non-humanitarian settings (five countries), BEP supplementation was commonly integrated into the governmental health system or social protection programs. However, humanitarian contexts (four countries) often relied on partner-led (e.g., UN organizations) implementation. Clear operational protocols, including behavioral change communication strategies, facilitated the implementation. Community-based organization partnerships strengthened adherence; however, implementation costs, stock shortages, and geographic inequities in coverage varied and were limiting factors in scale-up, primarily in humanitarian contexts. Conclusion: In sum, two distinct implementation pathways emerged: government-led models characterized by policy integration, national ownership, and more stable systems, and humanitarian or donor-led models shaped by crisis response, external dependency, and non-committal challenges. Successful implementation of BEP supplements depends on the presence of effective policies, context-adapted design, integration into health systems, consistent funding, and effective monitoring. There is a need for implementation research to generate evidence on best practices when implementing BEP supplementation programs.<\/jats:p>","DOI":"10.3390\/nu18091471","type":"journal-article","created":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T10:01:30Z","timestamp":1777975290000},"page":"1471","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["National and Sub-National Delivery of Balanced Energy and Protein (BEP) Supplements to Pregnant and Lactating Women in LMICs: Lessons from Multi-Country Implementation Case Studies"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7016-9616","authenticated-orcid":false,"given":"Mihaela C.","family":"Kissell","sequence":"first","affiliation":[{"name":"Healthy Mothers Healthy Babies Initiative, Micronutrient Forum, Washington, DC 20005, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaosar","family":"Afsana","sequence":"additional","affiliation":[{"name":"James P. Grant School of Public Health, BRAC University, Dhaka 1212, Bangladesh"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sufia","family":"Askari","sequence":"additional","affiliation":[{"name":"Sight and Life Foundation, 4303 Kaiseraugst, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rimu","family":"Byadya","sequence":"additional","affiliation":[{"name":"Nutrition and Food Safety, World Health Organization, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0055-6653","authenticated-orcid":false,"given":"Ranadip","family":"Chowdhury","sequence":"additional","affiliation":[{"name":"Society for Applied Studies, New Delhi 110016, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Parul","family":"Christian","sequence":"additional","affiliation":[{"name":"International Health and Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saskia","family":"de Pee","sequence":"additional","affiliation":[{"name":"Nutrition Division, World Food Programme, 00148 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lieven","family":"Huybregts","sequence":"additional","affiliation":[{"name":"Nutrition, Diets, and Health Unit, International Food Policy Research Institute, Washington, DC 20005, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fyezah","family":"Jehan","sequence":"additional","affiliation":[{"name":"Department of Paediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6054-4075","authenticated-orcid":false,"given":"Tsering P.","family":"Lama","sequence":"additional","affiliation":[{"name":"Nepal Nutrition Intervention Project Sarlahi, Kathmandu 355, Nepal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne C.","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Paediatrics, Warren Alpert Medical School, Brown University, Providence, RI 02912, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-2601-2660","authenticated-orcid":false,"given":"Elisabeth T.","family":"Mukendi","sequence":"additional","affiliation":[{"name":"Healthy Mothers Healthy Babies Initiative, Micronutrient Forum, Washington, DC 20005, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5832-1630","authenticated-orcid":false,"given":"Nafissa","family":"Osman","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynochology, Eduardo Mondlane University, Maputo 1100, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3494-534X","authenticated-orcid":false,"given":"Isabel","family":"Potani","sequence":"additional","affiliation":[{"name":"Global Health Research Department, Ripple Global Health, London W1W 5PF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisa","family":"Rogers","sequence":"additional","affiliation":[{"name":"Nutrition and Food Safety, World Health Organization, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vani","family":"Sethi","sequence":"additional","affiliation":[{"name":"Global Practice for Child Nutrition and Development\u2014Center of Excellence, UNICEF, Bangkok 10200, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8358-4448","authenticated-orcid":false,"given":"Martin N.","family":"Mwangi","sequence":"additional","affiliation":[{"name":"Healthy Mothers Healthy Babies Initiative, Micronutrient Forum, Washington, DC 20005, USA"},{"name":"Division of Human Nutrition and Health, Wageningen University & Research, 6700 Wageningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/S0140-6736(07)61690-0","article-title":"Maternal and Child Undernutrition Study Group. 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Health"}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/9\/1471\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T10:13:20Z","timestamp":1777976000000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/18\/9\/1471"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,5]]},"references-count":40,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["nu18091471"],"URL":"https:\/\/doi.org\/10.3390\/nu18091471","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,5]]}}}