Maternal Nutrition in Emergencies: technical review and round table discussion

By Emily Mates and Tanya Khara

Emily Mates is a Technical Director with the ENN. Tanya Khara worked as an ENN consultant on the project.

Through the INSPIRE consortium, the European Commission (ECHO) commissioned the ENN to conduct a technical review of maternal nutrition in emergencies1. The ENN undertook this review recognising it as a critical technical gap area.

Location: Global

What we know: The nutritional status of a woman is crucial for her wellbeing and that of her children. There is a gap in policy and guidance on maternal nutrition in emergencies.

What this article adds: There are gaps in evidence to inform nutrition specific interventions (acute malnutrition management and micronutrient supplementation) and in particular, nutrition sensitive interventions (such as food assistance, health, agricultural, protection or education sectors). The nutritional needs of mothers in their own right, not just in terms of their infant’s health, and of adolescent mothers are neglected. Specific gaps include how to integrate maternal nutrition into assessment and response analysis and how to target interventions. Recommendations for practice include that programmes provide an optimal diet based on maternal nutrition requirements, that maternal nutrition interventions link to obstetric care, and that childcare implications of interventions must be considered.

Current evidence underlines the importance of the nutritional status of women as a crucial factor in the survival, healthy growth and development of her children. Although it is the subject of less global attention, maternal nutrition is also crucial for women’s own ability to live a healthy life.

The DG ECHO was concerned that there are a number of gaps at policy and practice levels and limited guidance available to efficiently and effectively address the needs of maternal nutrition in emergencies. ECHO thus commissioned a review of maternal nutrition in emergencies which comprised preparation of a technical background paper by the ENN and organisation of a technical round table meeting by the INSPIRE Consortium in Brussels in November 2014. The background paper prepared by the ENN formed the basis for the roundtable discussions..

Summary of technical background paper

The technical background paper identified a number of gaps in the area of maternal nutrition in emergencies. An extensive literature review was conducted (using search engines google, bing and pubmed), summarising the available literature relating to: women’s particular nutritional vulnerabilities, what the implications of these are for women and their infants, current international guidance on maternal nutrition and what is currently being done in emergency programming.

Women are particularly vulnerable to undernutrition from a physiological point of view due to their increased nutrient requirements, both during their lifecycle and when considering their reproductive role. A recent review of evidence indicates that maternal nutrition is of great concern in many countries, many of which experience the most frequent humanitarian emergencies. Underweight, stunting, anaemia and vitamin A deficiency rates are extremely high; with iodine deficiency also creating considerable problems both for the mother and for the healthy development of her infant. Substantial gaps have been reported between micronutrient intakes and requirements for women of reproductive age in diverse resource poor settings, which are not currently well addressed through supplementation programmes. Evidence is growing of the critical role that essential fatty acids have in the development of a healthy foetus and for maternal mental health and wellbeing. Early marriage and pregnancy during adolescence is particularly worrying as it occurs while the girls are still growing themselves, interfering with growth patterns and increasing the risk of obstetric complications.

Women’s vulnerabilities in the humanitarian context are increased for a host of reasons, for example: the likelihood that during crises they might eat less; increased activities outside of the home environment as coping strategies are employed; increased risk of psychological problems due to stress or conflict situations; heightened risk of gender based violence; disruption of ‘normal’ services such as antenatal or reproductive health; disruption of breastfeeding; etc. The implications of these heightened vulnerabilities are many and varied. For women, increases in micronutrient deficiencies can have major impacts on mortality risks, while reduced immunity (due to pregnancy) can increase risks of contracting infectious diseases such as malaria. Maternal acute undernutrition predisposes the foetus and infant to greater risk of many problems, e.g. poor macro or micronutrient intake by the mother can lead to more low birth weight (LBW) or small for gestational age (SGA) births. This leads not only to much higher risks of neonatal mortality, but also higher risk that surviving infants develop non-communicable disease, such as diabetes, later in life. Undernourished infants who do survive are more likely to grow into shorter adults, have lower educational achievements and for girls, more likely to give birth to smaller infants themselves, thus perpetuating the intergenerational cycle of undernutrition.

Current international guidance on maternal nutrition has been very limited until recently, with the submission to the World Health Assembly of a 2012 WHO report ‘Nutrition of women during pregnancy’. The Scaling Up Nutrition (SUN) framework includes a number of direct interventions for maternal nutrition, although the emergency context is not specifically dealt with in any of these recent reports or compilations. The Sphere project 2011 also gives some key actions and guidance notes for direct interventions to support maternal nutrition; however most are linked to infant feeding and the welfare of the child, while the Global Nutrition Cluster (GNC) 2013 handbook does suggest the inclusion of women in supplementary feeding.

For macronutrient supplementation, provision of nutritional advice and balanced energy and protein supplements to undernourished pregnant women is strongly recommended. Additionally, evidence is growing, that improving the diets during the early stages of pregnancy can have as much effect on improving birth weights as supplementing during later pregnancy. More evidence is required of the effect of essential fatty acid supplementation, although early indications are that it could have a beneficial effect on both maternal wellbeing and breastmilk composition. During emergencies, the latest guidance from the GNC in 2012 is that all pregnant and lactating women (PLW) with moderate acute malnutrition should be included in targeted Supplementary Feeding Programmes (SFPs), regardless of their age or pregnancy status. The evidence base for the benefits of blanket SFP needs to be strengthened before clear guidance can be given. Some cultural perceptions that supplementary feeding can increase the incidence of obstructed labour (due to larger size of the foetus) was reported, however no published evidence of this could be located during the literature search.

In terms of micronutrient supplementation, strong evidence supports the provision of iron and folic acid for pregnant women. Additional prevention, diagnostics and treatment of malaria in endemic areas is important to prevent any negative effects of this supplementation. Evidence is growing, but consensus has not yet been reached to recommend the provision of multiple micronutrient (MMN) tablets instead of iron/folate. Iodine supplementation for PLW is also recommended in areas where universal salt iodisation is not fully implemented. Calcium supplementation for pregnant women in areas of low calcium intake is strongly recommended, along with vitamin A supplementation; especially in areas where deficiency is a severe public health problem. During emergencies, MMN tablets are recommended for pregnant women due to the likelihood of increased deficiency in populations at risk, iodised salt should be used for all general food distributions and vitamin A supplementation is strongly recommended for all PLW (for lactating women, within 6 weeks of delivery).

For the care and support aspect of maternal and infant health and wellbeing, breastfeeding care and support is strongly recommended, which includes; assessment of breastfeeding challenges, provision of a package of support services, support for safe and appropriate alternative feeding where required, and promotion of international codes, resolutions and national laws regarding the marketing of breast milk substitutes. Caring for the caregivers is also a vital aspect, particularly during emergency situations where conflict and stress have been encountered.

The provision of insecticide treated bed nets is recommended for all pregnant women, as is prophylactic malarial treatment in endemic areas. Prophylactic treatment for intestinal parasites is also recommended for women in the 2nd and 3rd trimester of pregnancy. Provision of a minimum package of reproductive health services is strongly recommended, to ensure appropriate antenatal care (ANC), safe delivery and availability of post-partum services. A focus on adolescents is highlighted as critical for efforts to reduce the incidence of LBW.

Nutrition sensitive interventions have yet to produce the evidence linking particular interventions in food assistance, health, agricultural protection or education sectors to nutritional outcomes for women or children; although this may in part be due to the weaknesses of measuring nutrition outcomes in programming to date. More evidence is clearly required before any associations or cause and effect relationships can be adequately described. Some studies have demonstrated a relationship between women’s empowerment and nutrition and also of a relationship between women’s disempowerment and adverse nutritional impacts. More work is however required, for concrete guidance to be given. While cash transfers/voucher programmes are becoming more common, there is little evidence yet for any improvement of nutrition outcomes during emergency programming. Again, more work is required to establish associations and effects (positive or negative). Furthermore, food assistance programmes must be developed using a nutrition sensitive lens, in order to reduce the risk of inadvertently undermining efforts to improve maternal nutrition, for example by increasing their physical workloads.

There is limited guidance on effective assessment and the appropriate response, with the targeting of PLWs in emergency situations usually being conducted through mid upper arm circumference (MUAC) measurements. It has been suggested that it would be more appropriate to use population level targeting for all women (including adolescents), although current practice sees interventions usually only targeting PLWs through SFPs and some micronutrient supplementation. Mapping of the most common emergency interventions was conducted in 2012 which has helped identify where, and how many, women have been included in SFPs. Performance data from the programmes targeting women were, however, insufficient for analysis; a recurring theme for studies looking at outcomes of emergency interventions for women, including those using nutrition education and counselling (NEC) techniques (despite the frequency of these strategies being deployed). Use of Lipid-based Nutritional Supplements (LNS) for women is a relatively new area where research is currently being conducted. Routine monitoring data of these programmes were almost completely lacking and no financial information specifically related to maternal nutrition in emergencies was found during the literature search.

The review concluded with a summary of specific knowledge and guidance gaps, including:

• How should maternal nutrition be reflected at assessment and response analysis stage?
• Who to target? Which maternal anthropometric and demographic characteristics should be used, if any, for inclusion into nutrition interventions, and for discharge?
• What to do?
• How to do it?
• What to use?
• How to monitor?

Technical round table meeting; Brussels November 12th 2014

A one-day technical roundtable on “Maternal Nutrition in Emergencies” was convened by DG ECHO, organised by the INSPIRE Consortium and facilitated by the ENN. The meeting brought together key DG ECHO technical staff and partners, agency nutrition focal points, donors and technical experts. The aim of the round table was to discuss the evidence, current practice and issues related to maternal nutrition in emergencies and to suggest priority actions and initiatives required to address the gaps and challenges highlighted in the technical background paper. The meeting was structured into three topic sessions:

• Nutrition specific interventions – micronutrient supplementation
• Nutrition specific interventions – acute undernutrition
• Nutrition sensitive interventions to support maternal nutrition

Each session consisted of one or two presentations from key experts in the field to provide insights into the above topics. This was followed by discussion among the participants. For the nutrition sensitive interventions, the group was split into two: one group covering food security and water, sanitation and hygiene (WASH) and the second dealing with health, women’s empowerment and mental/psychosocial support. A number of key questions based on the gaps identified in the technical background paper were used as triggers for the discussion. During each session four areas were drawn out from the discussion by the facilitators: recommendations for practice, research gaps, areas for wider discussion (other sectors/groups) and policy gaps.

A final session brought together all the outputs from the above four areas and a prioritisation exercise was carried out to identify the major recommendations of the group, outlined in Table 1.

Main recommendations for policy gaps

Policy recommendations occupied a ‘cross cutting’ space in the discussions, and were:

• The nutritional needs of adolescents and adolescent mothers in particular, are not currently on the radar in either policy or guidance for emergencies.
• Recognition that the nutritional needs of lactating women themselves, rather than their needs to produce a healthy infant, are being neglected.
• The aims and outcomes for maternal nutrition interventions in emergencies need to be clearly defined.
• There is a need for agreed definitions of maternal nutrition, maternal malnutrition and what this means in the emergency situation.

For more information, contact: Emily Mates, email: Emily@ennonline.net

1Maternal Nutrition In Emergencies. Summary of the state of play and key gaps. Background Technical Paper for the round table. DG ECHO. Brussels, 12 November 2013. Prepared by the ENN. ENN, Inspire Consortium, ECHO. Available at: http://www.ennonline.net/