Menu ENN Search

Higher heights: a greater ambition for maternal and child nutrition in South Asia

Research Summary 1

Poor nutrition in early life threatens the growth and development of children, which has a knock-on effect on the sustainable development of nations. This is particularly so in South Asia, where 40% of the world’s stunted children (59 million children) and 53% of the world’s wasted children (27 million children) live (UNICEF et al, 2018). Although the prevalence of child stunting is falling in the region, the pace of progress is too slow and most countries with available data are not on track to meet stunting reduction targets. The UNICEF Regional Office for South Asia commissioned a series of papers in 2016-2017 to fill knowledge gaps in the current body of evidence on stunting drivers, who is most affected and effective programme approaches. This overview paper summarises the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions. 

Child growth and development 

Analysis of pooled national survey data from Bangladesh, India, Nepal and Pakistan shows that stunted is concentrated among children of households experiencing multiple forms of deprivation, including poor child diets, low levels of maternal education and household poverty (Kirshna et al, 2018). Large inter?country differences were found in average rates of stunting reduction, from 0.6 percentage points (pp) per year in Pakistan, 1.3 pp in India, 2.9 pp in Bangladesh and 4.1 pp in Nepal. Stunting has declined across all wealth quintiles in all countries, but inequalities among wealth quintiles have persisted and widened in Nepal and Pakistan. 

A retrospective case series analysis (Aguyao et al, 2018) examining the effectiveness of Pakistan’s community-based management of acute malnutrition (CMAM) programme for severely wasted children (most of whom were aged 6-23 months) found that the programme was effective in achieving high survival (99.6%) and recovery (87.8%) rates. Severely wasted or stunted children had higher death and lower recovery rates compared to other children, suggesting that targeting children age 6-23 months old with multiple anthropometric failure will increase impact. 

As child survival improves in South Asia, the developmental consequences of poor nutrition in early life become a more pressing concern than mortality, particularly given the high number of children with low cognitive and socio-emotional test scores in the region (McCoy et al, 2016). Pooled data from multiple indicator cluster surveys (MICS) in Bangladesh, Bhutan, Nepal and Pakistan found that stunted children were at increased risk of sub-optimal learning/cognition development at three to four years old, but found no association between wasting and learning/cognition development (Kang et al, 2018), suggesting that interventions effective in improving linear growth in the first years of life may improve early childhood development. 

Childhood anaemia is also associated with impaired cognitive development and possibly motor development. Studies from Nepal and Pakistan (Harding et al, 2018) and Bhutan (Campbell et al, 2018) show that anaemia is more likely in children with an anaemic mother and in infants (suggesting that mother’s anaemia status may affect that of her child), in stunted children in all three countries and children with thin mothers in Pakistan (reflecting the contribution of dietary inadequacy before and during pregnancy and in childhood). 

Maternal nutrition and low birth weight (LBW)

South Asia has the highest prevalence of LBW (26%) in the world (Lee et al, 2013), reflecting the poor status of women’s nutrition in the region. Goudet et al (2018) estimate that one in 10 South Asian women of reproductive age have low stature (<145 cm), one in five have low body mass index (BMI) (<18.5 kg/m2) and overweight is rising rapidly, all of which are risk factors for child stunting. Pooled national survey data from six South Asian countries (Harding et al, 2018) show that children with reported LBW are significantly more likely to be wasted and severely wasted than non?LBW children and LBW is a predictor of concurrent wasting and stunting. Anaemia in women of reproductive age in Nepal and Pakistan is associated with thinness (BMI <18.5 kg/m2) and children under five years old are more likely to be anaemic if their mother is anaemic. This and the Campbell et al (2018) study in Bhutan show that anaemia is concentrated in the most disadvantaged women, including those from the poorest households in Pakistan, women without schooling in Bhutan, and women lacking sanitation facilities in Bhutan and Nepal. The prevalence of anaemia in pregnant women in Bhutan is lower than non?pregnant, an atypical finding suggesting that iron folic acid (IFA) supplementation during antenatal care is effectively protecting pregnant women from anaemia.

A combination of nutrition-specific and nutrition-sensitive actions are needed to address women’s low-quality diets, poor access to health, and nutrition services and their causes. A systematic review by Goudet et al (2018) identifies barriers to pregnant women receiving and consuming IFA and calcium supplements at maternal-level (low women’s education level and knowledge), household-level (low husband’s education level, support from husband and household wealth) and health-facility level (late timing of first antenatal visit and low number of visits). Programme delivery platforms reaching pregnant women with supplements in their homes and communities, combined with information and counselling, can improve access to services and consumption of supplements. 


Using pooled data from six South Asian countries, Harding et al (2018) find that children were less likely to be wasted if they were breastfed within the first hour of birth, were not given any pre-lacteal foods, and were exclusively breastfed. The rapid fall in the prevalence of wasting during the first few months of life in several South Asian countries suggests that early and exclusive breastfeeding may help infants recover from LBW. Focusing on Bhutan, Campbell et al (2018b) report that children under two years old are less likely to be overweight if they are currently breastfed. 

Benedict et al (2018a) identify a steady increase in early initiation of breastfeeding, avoidance of pre-lacteal feeding and exclusive breastfeeding in Bangladesh, India and Nepal over the last 25 years. Despite this, only about half of children in these countries benefit from early initiation of breastfeeding and exclusive breastfeeding, and rates of continued breastfeeding at two years have remained stagnant at ~70%. Progress in Afghanistan and Pakistan has lagged behind other countries, with recent declines in breastfeeding practices in Afghanistan and in the early initiation of breastfeeding and avoidance of pre-lacteal feeding in Pakistan.

Using data from national surveys, Nguyen et al (2018) report that socio?economic inequalities in the early initiation of breastfeeding and exclusive breastfeeding in India narrowed between 2006 and 2016, a significant achievement given the rising economic equalities in the country. Improvements in breastfeeding in lower socioeconomic quintiles appear to have been driven by improved access to and use of health and nutrition services by mothers and children.

Multivariate analysis of national survey datasets from South Asia’s five largest countries (Benedict et al 2018a and 2018b) reveals that common predictors of delayed initiation of breastfeeding, pre-lacteal feeding and not being exclusively breastfed include infant being born by caesarean section, small size at birth and home delivery (suggesting that these women and infants need more breastfeeding support) and low women’s empowerment. A review of 31 studies by Benedict et al (2018b) reports that programmes to support breastfeeding are more likely to be effective if they include multiple interventions (education and counselling, community mobilisation, mass media and newborn health initiatives) in multiple intervention environments (home, community and health facility). Other important factors appear to be intervention coverage, timing relative to the age of the child, frequency, duration and targeting.

Complementary foods and feeding practices 

Poor complementary feeding practices are highly prevalent in South Asia (UNICEF, 2016) and often predict stunting and wasting in the first two years of life. The likelihood of stunting is higher in South Asia in infants aged 6-8 months who are not fed any complementary foods and in children aged 6-23 months whose diets do not meet minimum dietary diversity (MDD) (Kim et al, 2017). Likelihood of wasting in children age 6-23 months is higher if their diets do not meet MDD and of severe wasting if their diets do not meet minimum meal frequency (MMF) (Harding, Aguayo, and Webb, 2018).  In India, not meeting MDD is also associated with concurrent wasting and stunting. 

A review of South Asia national survey data (2006-2013) found that only 57% of infants aged 6-8 months are fed any complementary foods and, of the diets of children aged 6-23 months, only 48% meet MMF, 33% meet MDD and 21% meet minimum adequacy (sufficient number of meals, food groups, and breastmilk or milk feeds) (Aguayo, 2017). Across all countries, MDD is consistently lower than MMF, indicating that MDD is a greater problem. Considerable variation in feeding practices exists between countries and only Sri Lanka and the Maldives have rates that exceed 50% for all these practices. 

Three multivariate analyses of national survey data in Afghanistan, Bangladesh and Nepal (Na et al 2018a, 2018b and 2018c) show that complementary feeding practices are more likely to be sub-optimal among infants (6-11 months), first-born children, children whose mothers are younger or less educated, and in communities with poor access to health and nutrition services. Cultural beliefs continue to be a barrier to recommended feeding practices in Nepal, where the Dalit and minority ethnic and religious castes have poorer complementary feeding practices than other population groups. Wealth quintile is associated with dietary diversity (DD) in Afghanistan, Bangladesh and Bhutan, suggesting availability of affordable nutritious foods is a common barrier to diverse diets in South Asia (Cambell et al, 2018b). Nguyen et al (2018) show that the equity gaps in complementary feeding practices between socio?economic status quintiles in India narrowed between 2006 and 2016, but practices remain poor across all groups. Paintal and Aguayo (2016) show that harmful feeding practices during childhood illness are a widespread concern in South Asia, in part driven by inadequate and sometimes harmful advice from health workers. Information, education and counselling delivered by a range of well?trained primary healthcare workers and community resource persons can improve the timeliness, frequency, diversity and/or adequacy of complementary feeding, although impact may be limited by lack of availability or affordability of nutritious foods (Aguayo, 2017). 

Implications for future advocacy, policy and programme actions 

1. The concurrence of child stunting with wasting and anaemia in South Asia requires governments to address all forms of malnutrition in an integrated manner across the life cycle. 

In the past there has been a tendency to address different forms of malnutrition in isolation and with varying levels of intensity. However, they often affect the same children and share common risk factors (Khara & Dolan, 2014). Policies and programmes should move away from siloed approaches and realign to address child malnutrition in all its forms. 

2.  Improving women’s and children’s diets is central to breaking the inter-generational    cycle of malnutrition in South Asia.

Complementary foods and feeding practices in South Asia remain unacceptably poor due to weaker policy on complementary feeding compared to breastfeeding and a lack of clarity in interventions, approaches and coordination between sectors on this issue. Children’s diets need much greater attention by all stakeholders concerned and strategies are needed to improve access to nutritious and affordable foods, coupled with communication interventions for behaviour and social change. This series reaffirms the close connection between the nutritional status of a mother and her children and the need to tackle dietary drivers of poor women’s nutrition before and during pregnancy. 

3. A coordinated, multi-system approach is needed to ensure families have all the inputs they need for children’s healthy growth. 

Coordination between the food, health, social protection, water, sanitation and hygiene (WASH) and education systems is needed and between different levels of government to combine actions to improve the nutrition status of women and young children. 

4. Deliberate actions are needed to address the disparities and inequalities in child growth and early life. 

Targeted efforts are needed to reach children, mothers and communities at greatest risk of malnutrition. Interventions should focus on children born small; children under two years of age; younger, less experienced mothers; and poorer households. At community level the focus should be on communities with higher levels of anthropometric failure and lower access to maternal and child health and nutrition services, using trained healthcare workers and community volunteers. 

5. Continued attention is needed in all countries to gather, analyse and use data to assess progress and inform decisions.

This includes the use of routine information systems and periodic surveys to gather data on anthropometric indicators, feeding practices and service coverage. Studies and implementation research are also needed to better understand the context-specific barriers, enablers and pathways to improving access to services and adoption of recommended nutrition behaviours and practices.  


The South Asia region bears a disproportionate burden of stunted children who experience worse health, cognition and learning outcomes. These children are concentrated in the most economically disadvantaged households and often experience multiple concurrent forms of nutrition deprivation. More attention is needed to improve the nutritional status of women before and during pregnancy and the diets of infant and young children in the first two years of life, while addressing underlying drivers. A coordinated, multi-system approach and actions to tackle inequalities are needed. 


1Torlesse H, Aguayo VM. Aiming higher for maternal and child nutrition in South Asia. MaternChild Nutr. 2018;14(S4):e12739. within: Hall Moran V and Pérez-Escamilla R (eds) and Aguayo VM and Torlesse H (guest eds). Higher heights: a greater ambition for maternal and child nutrition in South Asia. Maternal and Child Nutrition, November 2018, Volume 14, Supplement 4.


Aguayo VM, Badgaiyan N, Qadir SS, Bugti AN, Alam MM, Nishtar N & Galvin M. (2018). Community management of acute malnutrition (CMAM) programme in Pakistan effectively treats children with uncomplicated severe wasting. Maternal & Child Nutrition, 14(Suppl 4), e12623.

Aguayo VM. (2017). Complementary feeding practices for infants and young children in South Asia. A review of evidence for action post?2015. Maternal & Child Nutrition, 13(Suppl 2), e12439. https://doi. org/10.1111/mcn.12439

Benedict RK, Craig HC, Torlesse H & Stoltzfus RJ. (2018a). Trends and predictors of optimal breastfeeding among children 0-23 months, South Asia: Analysis of national survey data. Maternal & Child Nutrition, 14(Suppl 4), e12698.

Benedict RK, Craig HC, Torlesse H & Stoltzfus RJ. (2018b). Effectiveness of programmes and interventions to support optimal breastfeeding among children 0-23 months, South Asia: A scoping review. Maternal & Child Nutrition, 14(Suppl 4), e12697.

Campbell RK, Aguayo VM, Kang Y, Dzed L, Joshi V, Waid JL, …West Jr KP. (2018a). Epidemiology of anemia in children, adolescent girls and women age in Bhutan. Maternal & Child Nutrition, 14(Suppl 4), e12740.

Campbell RK, Aguayo VM, Kang Y, Dzed L, Joshi V, Waid J, …West Jr KP. (2018b). Infant and young child feeding practices and nutritional status in Bhutan. Maternal & Child Nutrition, 14(Suppl 4), e12762.

Goudet S, Murira Z, Torlesse H, Hatchard J & Busch?Hallen J. (2018). Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia. Maternal & Child Nutrition, 14(Suppl 4), e12699.

Harding KL, Aguayo VM, Namirembe G & Webb P. (2018). Determinants of anemia among women and children in Nepal and Pakistan: An analysis of recent national survey data. Maternal & Child Nutrition, 14(Suppl 4), e12478.

Harding KL, Aguayo VM & Webb P. (2018). Birthweight and feeding practices are associated with child growth outcomes in South Asia. Maternal & Child Nutrition, 14(Suppl 4), e12650. 

Kang Y, Aguayo VM, Campbell RK, Dzed L, Joshi V, Waid JL, …West Jr KP. (2018). Nutritional status and risk factors for stunting in preschool children in Bhutan. Maternal & Child Nutrition, 14(Suppl 4), e12653.

Khara T & Dolan C. (2014). Technical briefing paper: Associations between wasting and stunting. Policy, programming, and research implications. Emergency Nutrition Network (ENN). Available at

Kim R, Mejia?Guevara I, Corsi DJ, Aguayo VM & Subramanian SV. (2017). Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan. Social Science & Medicine, 187, 144–154.

Krishna A, Mejía?Guevara I, McGovern M, Aguayo VM & Subramanian SV. (2018). Trends in inequalities in child stunting in South Asia. Maternal & Child Nutrition, 2017.

Lee AC, Katz J, Blencowe H, Cousens S, Kozuki N, Vogel JP, … CHERG SGA?Preterm Birth Working Group (2013). National and regional estimates of term and preterm babies born small for gestational age in 138 low?income and middle?income countries in 2010.

McCoy DC, Peet ED, Ezzati M, Danaei G, Black MM, Sudfeld CR … Fink G. (2016). Early childhood developmental status in low and middle?income countries: National, regional, and global prevalence estimates using predictive modeling. PLoS Medicine, 13, e1002034.

Na M, Aguayo VM, Arimond M, Dahal P, Lamichhane B, Pokharel R.… Stewart CP. (2018). Trends and predictors of appropriate complementary feeding practices in Nepal: An analysis of national household survey data collected between 2001 and 2004. Maternal & Child Nutrition, 14(Suppl 4), e12564.

Na M, Aguayo VM Arimond M, Narayan A & Stewart CP. (2018). Stagnating trends in complementary feeding practices in Bangladesh: An analysis of national surveys from 2004?2014. Maternal & Child Nutrition, 14(Suppl 4), e12624.

Na M, Aguayo VM, Arimond M & Stewart CP. (2017). Risk factors of poor complementary feeding practices in Pakistani children aged 6?23 months: A multilevel analysis of the Demographic and Health Survey 2012?2013. Maternal & Child Nutrition, 13(Suppl 2), e12463.

Nguyen PH, Avula R, Headey D, Tran LM, Ruel MT & Menon P. (2018). Progress and inequalities in infant and young child feeding practices in India between 2006 and 2016. Maternal & Child Nutrition, 14(Suppl 4), e12663.

Paintal K & Aguayo VM. (2016). Feeding practices for infants and young children during and after common illness. Evidence from South Asia. Maternal & Child Nutrition, 12(1), 39–71.

UNICEF (2018). Child stunting, hidden hunger and human Capital in South Asia: Implications for sustainable development post 2015. UNICEF: Kathmandu, Nepal.

More like this


Global guidance WHO (2016) WHO recommendations on antenatal care for a positive pregnancy...

Leveraging the power of multiple systems to improve diets and feeding practices in early life in South Asia

View this article as a pdf Zivai Murira is the Nutrition Specialist at UNICEF Regional Office for South Asia, based in Kathmandu, Nepal. Harriet Torlesse is the Regional...

FEX: Nutrition Exchange (NEX) South Asia: Maternal nutrition

View this article as a pdf In its first-ever regional issue, Nutrition Exchange has partnered with the United Nations Children's Fund (UNICEF) Regional Office of South Asia...

FEX: Outcomes and risk factors for infants under six months old with severe acute malnutrition in Bangladesh

Research snapshot 1 Severe acute malnutrition (SAM) affects around four million infants under six months of age (u6m) worldwide, but evidence underpinning their care is...

FEX: Individualised breastfeeding support for acutely ill, malnourished infants under six months of age

View this article as a pdf Research snapshot1 Re-establishing exclusive breastfeeding (EBF) is the cornerstone of the 2013 World Health Organization (WHO) treatment...

FEX: Management of severe acute malnutrition by community health workers: Early results of Action Against Hunger research

View this article as a pdf By Pilar Charle-Cuellar, Noemi Lopez-Ejeda, Magloire Bunkembo, Abdias Ogobara Dougnon and Hassane Toukou Souleymane Pilar Charle Cuellar is a...

Unlocking the power of maternal nutrition to improve nutritional care of women in South Asia

Unlocking the power of maternal nutrition to improve nutritional care of women in South Asia View this article as a pdf Zivai Murira is the Nutrition Specialist at...

The double burden of malnutrition among young children in South Asia: Policy and programme options

View this article as a pdf Dr Angela de Silva is the Regional Adviser, Nutrition and Health for Development, WHO Regional Office for South-East Asia. Dr Ayoub Al Jawalhdeh...

en-net: IYCF practices

As part of a master's work, I focused my research on the analysis of the relationship between IYCF practices and wasting in children aged 6 to 23 years. I would be...

Creating an enabling environment for delivering maternal nutrition interventions in Bhutan

Creating an enabling environment for delivering maternal nutrition interventions in Bhutan View this article as a pdf Laigden Dzed is a Senior Programme Officer in the...

FEX: Continuum of care for children with wasting in India: Opportunities for an integrated approach

View this article as a pdf By Arjan de Wagt, Eleanor Rogers, Praveen Kumar, Abner Daniel, Harriet Torlesse and Saul Guerrero Arjan de Wagt is Chief of the Nutrition section,...


View this article as a pdf Welcome to the second issue of Nutrition Exchange (NEX) South Asia. The South Asia region continues to bear the highest burden of child malnutrition...

FEX: Food aid for nutrition: A landscape review of current research and implications for future studies

View this article as a pdf By Maria Wrabel, Kristine Caiafa, Beatrice Lorge Rogers and Patrick Webb All authors are affiliated with the Food Aid Quality Review (FAQR) project...

FEX: Management of At-risk Mothers and Infants under six months (MAMI): Update and direction

View this article as a pdf Summary of meeting report1 A two-day meeting of the MAMI Special Interest Group (SIG)2 was held on 12-13 December 2019, organised by Emergency...

FEX: Severe acute malnutrition management in India’s children: the riddle

By Anne-Dominique Israel de Monval and Yara Sfeir Anne-Dominique Israel is a senior nutrition and health advisor with ACF France. She holds a nursing degree and a Master's in...

FEX: Role of nutrition in integrated early child development

Research Location: Global What we know already: Early child development (ECD) is a key predictor of future social capital and national productivity. Worldwide, 250 million...

Integration of maternal nutrition into Nepal’s health service platforms: What’s happening?

View this article as a pdf Bhim Kumari Pun is the Senior Integrated Nutrition Programme Manager in the Suaahara II programme. Khim Khadka is Provincial Health Director,...

FEX: Improving minimum dietary diversity for children aged 6-23 months when household affordability is a major constraint in northeast Bangladesh.

View this article as a pdf By Md Masud Rana, Sheikh Shahed Rahman, Md Al-Amin Shovan, Bazlul Kabir Joarder and Mohammad Raisul Haque Md Masud Rana is a nutrition advisor for...

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...

FEX: A series of three related published papers share findings regarding quality of care, treatment outcomes and cost-effectiveness of uncomplicated SAM treatment delivered by community health workers (CHWs) in rural Mali.

By Eleanor Rogers, Karen Martínez, Jose Luis Alvarez Morán, Franck G. B. Alé, Pilar Charle, Saul Guerrero, Natalie Sessions and Chloe Puett Quality of...


Reference this page

Higher heights: a greater ambition for maternal and child nutrition in South Asia. Field Exchange 59, January 2019. p37.



Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.