NEX South Asia Editorial
Nutrition Exchange (NEX) is a long-standing ENN publication that captures the different experiences of countries in preventing and treating malnutrition. The focus of NEX has been global, but ENN is aware of a growing appetite for sharing lessons learned between countries from the same region. This edition is the first opportunity for NEX to ‘go regional’. It arose from a desire to build on the momentum from the ‘Stop Stunting: the Power of Maternal Nutrition’ conference held in Nepal in 2018. Through a partnership with the UNICEF Regional Office for South Asia, NEX editors have worked closely with national governments and their development partners to develop articles that explore how they are improving maternal nutrition.
We feature nine articles from seven countries – Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka. Each country is a unique context in its own right, is at a different stage of development in terms of maternal nutrition policies and programmes, and has adopted varying approaches to strengthening its maternal nutrition services. The countries provide a rich insight into what’s being done to improve maternal nutrition, the obstacles confronting them in achieving this, and what more needs to be done.
An overview, written by our UNICEF colleagues, highlights the alarming levels of maternal malnutrition in South Asia; one in five women is underweight, one in 10 is of short stature and anaemia is a significant public health problem. Rightly, they point out that the solutions to these problems require policies and programmes that integrate actions from multiple sectors, with the health sector having a pivotal role.
What is striking in this NEX regional issue is that five of the seven countries featured are addressing their maternal nutrition problems in widely varying contexts of conflict/fragility, with disrupted services and hard-to-reach populations adding to the challenges of programming. The Afghanistan article, for example, illustrates how the creation of a new cadre of nutrition counsellors at health-facility level can help increase interaction with pregnant woman and new mothers, despite the ongoing security challenges.
Another strong theme to emerge is the emphasis placed (based on WHO Global Guidance) on nutrition counselling, particularly delivered via community-based actors and platforms. In Nepal the role of the country’s large workforce of female community health volunteers (FCHVs) in promoting iron and folic acid uptake was crucial in reducing the prevalence of maternal anaemia. A second article from Nepal highlights efforts to strengthen the integration of maternal nutrition activities into the health system with support from a development partner, again with a focus on social and behaviour change communication strategies and capacity-building of the FCHVs. Pakistan’s lady health workers are also a vital part of its health sector response to improving maternal nutrition, bridging the divide between health facilities and women at community and household level.
In Bihar and Uttar Pradesh in India, concerted efforts have also focused on building the capacity of health practitioner at all levels, including medical training for doctors and midwives, to improve the quality of maternal nutrition counselling services. Having showcased the importance of this training, there are plans to scale up to other states in the country.
The double burden of malnutrition is of increasing concern in the South Asia region, with the prevalence of overweight among women being greater than underweight in all but two countries (India and Bangladesh). Sri Lanka is one of the few countries whose maternal nutrition policy and programming is attempting to address this new reality through the counselling of pregnant women to promote healthy eating and physical activity to prevent excessive weight gain.
Lack of data and information about the coverage and the quality of services is a theme running through a number of the articles. In Bangladesh a deliberate focus on prioritising indicators for maternal nutrition and strengthening the country’s nutrition information system has led to an increase in the resources available for scaling up services for pregnant women. In Pakistan there are ongoing constraints due to the lack of quality data, and even in countries with a strong enabling environment for maternal nutrition, such as Bhutan, the article emphasises that work is still needed to improve programme coverage and quality.
In a number of countries services are decentralised, which can offer opportunities to both integrate with other sectors and add new activities within sectors. For example, in Punjab province, Pakistan, overlapping programmes and interventions for maternal and child health have been combined under one umbrella programme for a health sector response, although challenges remain in involving other sectors, despite the existence of multi-sector mechanisms at provincial level. In Karnataka state, India, state-level resources under the Anganwadi services scheme are being used to include a hot mid-day meal in the health service provision for pregnant women, with the aim of increasing their calorie intake and uptake of services.
All the articles in this issue provide powerful stories of diverse country agendas for improving maternal nutrition. Yet, for all of these countries, maternal nutrition is very much unfinished business and, as countries themselves acknowledge, much more must be done to enable women to avoid the perils of undernutrition – and, indeed, the growing risk of overweight/obesity. It is evident from these stories that some of the pieces are starting to be put into place, and we look forward to capturing the region’s progress towards improving the nutrition status of women in future editions of NEX.
Carmel Dolan, NEX co-editor
Judith Hodge, NEX co-editor