Earlier this month, I attended a meeting organised jointly by the South Asian Association for Regional Cooperation (SAARC) and the UNICEF Regional Office for South Asia (ROSA) together with Nutrition International to discuss and identify actions to accelerate the nutritional care of women during pregnancy and postpartum in South Asia. The meeting was attended by representatives from all 8 SAARC countries with all countries sending high level officials from Governments perhaps indicative of the importance of the issue in the region. 

Adequate maternal nutrition is important in its own right to ensure the wellbeing of mothers and the first 1000 days of life is also a critical window for improving a child’s health and nutrition outcome. Maternal undernutrition is a significant determinant of undernutrition of children as an estimated 20-30% of wasting and stunting originates in utero.

Maternal nutrition has not received the attention it deserves and is with this background that this meeting, which is in the series of meetings under the STOP STUNTING agenda was timed to bring attention to this critical issue in South Asia.

What is the status of women in South Asia?  

1. Half of the world’s adolescent mothers live here – a staggering number of more than 17 million
2. It is home to 37% of the world’s anaemic women a staggering number of 227 million anaemic women making anaemia a serious public health and development problem in the region
3. One quarter of South Asian women are too thin and one in ten women in the region are shorter than 145 cms which is often an indication of immature physical development during pregnancy and hence impacting the health of both mother and the child
4. Overweight and obesity in women are on the rise in every country with more than 30% of women in 5 of 8 countries being either overweight or obese.

The 3-day meeting was a good mix of technical updates on maternal nutrition, sharing of country experiences and concluded with each country team coming up with a Plan of Action to improve maternal nutrition in their respective countries.

The challenges related to maternal nutrition however rang true across the room and below, I summarise the common threads of the discussions:

1. An analysis of existing policies in all the countries revealed that in most countries whilst, policies mention all 8 recommendations in the WHO recommendations on antenatal care for a positive pregnancy experience a detailed look revealed that coverage was varied, and was far from universal even for  Iron- Folic Acid (IFA) supplementation with  gaps also in adherence to necessary dosage in IFA and calcium.
2. The importance of approaching Maternal Nutrition multi-sectorally often arose with examples from many countries making use of more than one platform to deliver services and messages. There was emphasis on actively identifying platforms and innovative delivery mechanisms for simple but vital inputs for example, IFA to reach every girl and woman even if she is unable to reach the health centre. The challenge of translating policies and strategies at the subnational level was common to all countries with bottlenecks being identified clearly downstream. This is an issue which has been recently looked at in detail by ENN in Nepal in Asia and in Senegal and Kenya.
3. Participants emphasised the importance of contextualisation of all recommendations – as much as this is important to ensure compliance and increase coverage, it must be borne in mind not to alter the core of the recommendation which are evidence based.
4. The importance of dietary diversity was recognised as key towards improving nutrition. The importance of preserving indigenous knowledge on locally available foods came up frequently. A challenge mentioned by the Government representative from Afghanistan was that there are no funds available to promote dietary diversity at the household level- all funds are directed towards food fortification. An interesting initiative from one of the states of India needs mention in this context- the southern state of Karnataka has put in place a hot cooked meal programme for all pregnant and lactating women through the Integrated Child Development Services (ICDS) centres. The meal is designed to suit the local palate and provide 40% of her daily nutritional needs. This programme which is fully Government funded is yet to evaluated for impact but positive changes are being noted at the community level. This and such initiatives at scale need to be followed up closely to derive lessons for others to replicate.
5. The importance of appropriate data came up for discussion. It was seen that besides IFA supplementation, there were few other indicators related to maternal nutrition that were captured in national surveys at regular intervals. In countries like India which has abundant data on health and nutrition disaggregated to the level of the district, the issue of data stewardship was raised – numerous platforms all using the same source data is duplication. How can this be rationalised to avoid duplication to make it simple for implementers?

In my view there were 2 issues which deserved more attention in this meeting:

• First, Adolescent Nutrition- in a region where early marriage and teenage pregnancy is common, adolescent girls needs to be prioritised as much as the pregnant woman and the child if we are to prevent stunting (and for that matter wasting). Most interventions on Nutrition have focussed on the 1000-day critical period which excludes an adolescent unless she becomes pregnant. A life cycle approach which includes the adolescent; not taking away the focus from the 1000 days is a useful approach. The National Policy on Maternal and Child Health, 2012 of Sri Lanka clearly articulates such an approach.
• Second, the high workload of women and its impact on their nutrition and health deserved more discussion. Even as we lament the poor and underpaid participation of women in the workforce, we must recognise that most women’s work in poorer sections of society is unpaid and at the cost of her own health and if pregnant, to the detriment of the unborn child. To be addressed, this issue requires a multisectoral gendered approach. As was mentioned in one of the sessions, the importance of an enabling environment for improved maternal nutrition cannot be over emphasised but what is critical, is an environment enabled to support women and children and which brings them centre stage as active participants and not solely as the objectives of development

The meeting was well timed as it was seen that most countries in the region are in the process of rolling out recently approved plans and policies for nutrition – South Asia will not achieve the SDGs if maternal nutrition is not prioritised.

In conclusion, it is beyond doubt that nutrition is clearly viewed as a multisectoral agenda and that the need to draw more attention to maternal nutrition was amply emphasised. The organisers would also do well to consider a meeting focussed on Adolescent Nutrition as the next in the series on STOP STUNTING. This being one of ENN’s interest areas, it recently organized a meeting to identify synergies, opportunities, priorities and next steps to help develop the evidence base in adolescent nutrition which can be found on this link. Watch this space.