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Nutrition Exchange (NEX) South Asia: Maternal nutrition

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In its first-ever regional issue, Nutrition Exchange has partnered with the United Nations Children’s Fund (UNICEF) Regional Office of South Asia (ROSA) to build on the momentum from the ‘Stop Stunting: the Power of Maternal Nutrition’ conference held in Nepal in 2018. Nutrition is high on the political agenda in South Asia, with many countries having developed and resourced multi-sector nutrition plans to meet global targets on child stunting, wasting and overweight. However, there is a danger that women will be left behind in the regional momentum to improve nutrition unless greater attention is given to their nutritional care. 
The nutritional status of women is improving in South Asia, but progress is uneven and slow. One in five women is underweight (body mass index <18.5 kg/m²); one in 10 are of short stature (height <145 cm); and anaemia is a severe or moderate public health problem in seven out of eight countries (UNICEF-WHO, 2019). Meanwhile, the prevalence of overweight is increasing at an alarming rate in women and now exceeds underweight in all countries in the region, except Bangladesh and India.  

The focus of the issue was to share the experiences and lessons learned from national government stakeholders and their development partners on how they are improving maternal nutrition at country and sub-national level, and what challenges remain. NEX South Asia contains nine articles from seven countries (Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka), providing a range of different contexts. Each country 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. 

One of the predominant themes to emerge from the articles was the emphasis placed on nutrition counselling; particularly as delivered via community-based actors and platforms. This is very much in line with World Health Organization (WHO) global guidance (WHO, 2016). In Afghanistan, the creation of a new cadre of nutrition counsellors at health-facility level is resulting in increased interaction with pregnant woman and new mothers, despite the ongoing security challenges (Maroof et al, 2019). 

Two articles from Nepal explored the role of the country’s large workforce of female community health volunteers (FCHVs). This role was seen as crucial to the country’s success story in reducing the prevalence of maternal anaemia through the work of the FCHVs in promoting iron and folic acid uptake (Bichha et al, 2019). 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. The focus was on social and behaviour-change communication strategies and capacity-building of the FCHVs to deliver these activities (Pun et al, 2019). 

The Indian states of Bihar and Uttar Pradesh have addressed building the technical capacity of health practitioners at all levels, including medical training for doctors and midwives, to improve the quality of maternal nutrition-counselling services (Ghosh et al, 2019). Having showcased the importance of this training, there are plans to scale up to other states in the country.

Lack of data and information on the coverage and quality of services is another theme that features in a number of 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 (Rahman  et al, 2019). However, in Pakistan, there are ongoing constraints due to the lack of quality data (Ahmed et al, 2019). 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 (Dzed et al, 2019). 

Public-sector services such as health are decentralised in a number of the featured countries, which can offer opportunities to both integrate with other sectors and add new activities within sectors. In Punjab province, Pakistan, overlapping programmes and interventions for maternal and child health have been combined under one umbrella programme for an integrated health-sector response (Ahmed et al, 2019). Challenges remain, however, to involve 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 deliver a hot mid-day meal as part of the health-service provision for pregnant women, with the aim of increasing their calorie intake and uptake of services such as counselling and antenatal care (Mahadevan et al, 2109).   

Finally, Sri Lanka is one of the few countries in the region with maternal nutrition policy and programming that is attempting to address the new reality of double burden among women (Nilaweera et al, 2019). It is doing this through the counselling of pregnant women to promote healthy eating and physical activity to prevent excessive weight gain. However, challenges remain; in particular, with a blanket supplementation distributed to all pregnant and lactating women. This programme was originally introduced to address undernutrition, but now needs to adopt a targeted approach in light of increasing obesity and overweight.

The second NEX South Asia issue is due out in June 2020. This issue will focus on country articles on complementary feeding, following the ‘Stop Stunting: Improving Young Children’s Diets in South Asia’ conference in Nepal, 2019.

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Nutrition Exchange (NEX) South Asia: Maternal nutrition. Field Exchange 61, November 2019. p9. www.ennonline.net/fex/61/maternalnutrition

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