Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts

This is a summary of a Field Exchange ‘views’ article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Zivai Murira and Harriet Torlesse.

Zivai Murira is Nutrition Specialist at UNICEF Regional Office for South Asia (ROSA), Kathmandu, Nepal.

Harriet Torlesse is Regional Advisor Nutrition at UNICEF ROSA, Kathmandu, Nepal.

Background

The South Asia region has made remarkable gains in child survival in the last two decades. In comparison, the rate of decline in child malnutrition has been slow. The region remains home to over half of the world’s wasted children (25.1 million). These children are at an increased risk of infectious disease and death as well as of stunting and its long-term consequences. Risk accumulates with the frequency, duration and severity of wasting episodes and is greater for children who are wasted at birth or in early infancy. However, this period of life has so far received little attention in prevention and treatment efforts.

The South Asia region has the highest prevalence of low birth weight (LBW) in the world (27%). This vulnerability in early life may help to explain the widespread child wasting rates in South Asia. The risk of LBW is influenced by the nutrition and health status of women before and during pregnancy which suggests that maternal nutrition has an important role in the prevention of child wasting.  

Why maternal nutrition matters in child wasting prevention in South Asia

In South Asia, the majority of children born with a LBW are ‘small for gestational age’,¹ with some being born preterm. Early growth failure increases the risk of infections, poor linear growth and delayed development. It also makes infants more vulnerable to persistent growth failure as they age and increases their risk of early childhood mortality.

While the proportion of undernourished women in South Asia has declined in recent years, thinness (body mass index <18.5 kg/m²) still affects one in five women and one in 10 have a short stature (height <145 cm). Overweight and obesity rates are rising rapidly across the region and micronutrient deficiencies (e.g., of iron, zinc, iodine and vitamin A) persist. A large body of evidence links poor maternal nutrition and LBW to child wasting in South Asian countries.

Other maternal factors also impact birth weight and child nutrition, including maternal infections (e.g., malaria, rubella, syphilis), low maternal education, adolescent pregnancy and short birth spacing. Several of these factors reflect the low status of women in South Asian settings due to deeply entrenched patriarchal values and social norms. Thus, increasing women’s status may have substantial benefits for child nutrition in the region. Additionally, adolescent pregnancy – which is linked with child marriage – remains prevalent in some South Asian countries such as Afghanistan (20%) and Bangladesh (24%) and must be addressed.

Response to maternal nutrition in South Asia

The impact of poor nutrition during the first 1,000 days of life² on national development is increasingly being recognised by South Asian governments. This has led to the development and implementation of multi-sector strategies to scale up nutrition interventions. However, more attention is needed to protect nutrition during the first six months of life when infants are entirely dependent for their nutrition on their mothers.

A recent review examined policy and programme action on maternal nutrition in the South Asia region relative to the World Health Organization’s (WHO) “Recommendations on Antenatal Care for a Positive Pregnancy Experience”. Between one and six of the eight recommendations for improving maternal nutrition were included in national policies or programme guidance across South Asian countries. Only daily iron and folic acid (IFA) supplementation was included in all countries. With the exception of the Maldives and Pakistan, all countries had policies and programme guidance in place for the two interventions specific to undernourished populations (nutrition education on increasing energy and protein intake and balanced energy and protein supplementation).

Access to and utilisation of maternal nutrition interventions vary by intervention and country. This is influenced by a range of barriers and enablers at individual, household and health system levels. Individual-level factors include a woman’s education, decision making capacity, self-efficacy to follow recommended practices, tolerance to the side-effects of micronutrient supplements and cultural beliefs. Household level factors include family support networks, the husband’s education level and household wealth.

In general, health system barriers to delivering maternal nutrition programmes relate to the demand for, supply of and quality of interventions. These include health workforce constraints, supply chain breaks (especially for IFA and calcium supplements), service delivery and utilisation issues and information management (availability of routine data on coverage). Because of these bottlenecks, coverage of maternal nutrition interventions in the region continues to lag behind that of antenatal care (ANC) services.

A recent systematic review exploring coverage of micronutrient supplement interventions in the South Asia region found that combining actions to reach pregnant women in their homes and communities with information and counselling improves access to, and consumption of, supplements. These effects are greatest when programmes are based on formative research, engage influential family members, increase the capacities, supervision and motivation of frontline workers and provide an uninterrupted supply of services and supplements free of charge.

Despite a lack of global normative guidance on balanced protein energy supplementation during ANC, several countries have dietary supplementation programmes targeting pregnant and breastfeeding women through health or social safety mechanisms. However, there is no data on the coverage of these programmes or their effectiveness in improving maternal nutrition and birth weight.

It is important to note that these analyses predate the COVID-19 pandemic. Across the region, lockdowns and public health measures to halt the spread of the virus severely restricted the availability of, access to and utilisation of ANC and maternal nutrition services. However, by May and June 2020, most countries reprioritised and reintroduced these services with a range of programmatic adaptations. These included collection of supplements for pregnant women by their relatives (Sri Lanka), inclusion of nutrition counsellors in mobile health teams (Afghanistan) and the remote delivery of counselling services (India). This demonstrates the resilience of the primary healthcare system in South Asia and may offer long-term opportunities to increase access to services. However, as further lockdowns are potentially introduced and the economic downturn impacts government budgets, protecting essential maternal nutrition services is a priority.

Implications for child wasting prevention efforts

Efforts to manage child wasting in the South Asia region have focused on access to therapeutic care for the management of severe wasting. Inadequate attention has been given to prenatal factors which contribute to high burdens of LBW, small for gestational age infants and preterm deliveries. Greater focus must therefore be given to improving women’s nutritional status before pregnancy. This should be underpinned by efforts to improve adolescent nutrition, prevent adolescent pregnancies and address gender inequities.

While the health sector cannot solve all the underlying causes of poor maternal nutrition, it must ensure that, at a minimum, women have access to quality maternal health and nutrition interventions during ANC. WHO recommends a minimum of eight ANC contacts during which women should receive the full package of nutritional assessments, nutrition counselling support and micronutrient supplementation, as well as dietary supplementation in food insecure population groups. Community-based platforms can increase access to ANC in early pregnancy, the number of contacts and the coverage of maternal nutrition interventions.

ANC providers must give special attention to adolescent girls, women experiencing their first pregnancy and women at nutritional risk (those with low stature, thinness and anaemia). Early identification, referral and management of these adolescents and women should be part of routine ANC to optimise fetal growth and prevent adverse birth outcomes. Criteria for women at nutritional risk should also be included in the definitions of high-risk pregnancies in appropriate maternal health and nutrition guidelines. In addition, pregnant women in undernourished populations would benefit from balanced energy and protein dietary supplementation to reduce small for gestational age neonates.

There is a need to address care gaps in early infancy for infants who are born small. Better data is needed on LBW to track progress and high-risk babies must be identified for timely care and support at health facility and community levels. In countries such as Bangladesh, where over half of infants are born at home, innovative approaches are needed to ensure that all newborns are weighed. The provision of newborn care and support for nutritionally vulnerable infants and their mothers is fundamental to improving neonatal and infant survival and to prevent wasting in South Asia.

Actions beyond the health system are also needed, particularly to improve women’s diets. Food, health and social protection systems should combine actions to increase the availability, affordability and acceptability of nutritious foods. The education system plays an important role in increasing girls’ access to primary and secondary education and there is need for policy and societal actions to raise the age of marriage and first pregnancy.

Conclusions

In South Asia, high rates of LBW, child wasting and stunting are driven by poor maternal nutrition and intervention coverage is insufficient to transform the care of women before and during pregnancy. Social and gender norms also continue to constrain girls’ and women’s access to available resources and the COVID-19 pandemic threatens to unravel the progress made to date.  

Reducing the high burden of wasting (and stunting) in South Asia depends on greater attention to (1) the nutritional care of adolescent girls and women before and during pregnancy, (2) the identification of infants born small and (3) the provision of nutritional care to infants born small or those who become nutritionally vulnerable in early life and their mothers. This requires a continuum of care that is responsive to the underlying social, economic and gender inequities in access to healthcare in the region. Maternal nutrition services should be fully integrated into primary healthcare and governments must continue to prioritise these services to mitigate the impacts of the COVID-19 pandemic. An evidence base is also needed on the effectiveness of maternal nutrition intervention packages to prevent small for gestational age and LBW, as well as on approaches to improve the care of infants who are born small, in South Asian countries.

For more information, please contact Zivai Murira.