Global Policy and Programme Guidance on Maternal Nutrition: What Exists, the Mechanisms for Providing It, and How to Improve Them?
Roger Shrimpton, PhD, Urbanização Zona Alta, Lote 1, Apt 3D, 8700-270 Olhão, Portugal. E-mail: firstname.lastname@example.org
Undernutrition in one form or another affects the majority of women of reproductive age in most developing countries. However, there are few or no effective programmes trying to solve maternal undernutrition problems. The purpose of the paper is to examine global policy and programme guidance mechanisms for nutrition, what their content is with regard to maternal nutrition in particular, as well as how these might be improved. Almost all countries have committed themselves politically to ensuring the right of pregnant and lactating women to good nutrition through the Convention on the Elimination of all Forms of Discrimination Against Women. Despite this, the World Health Organization (WHO) has not endorsed any policy commitments with regard to maternal nutrition. The only policy guidance coming from the various technical departments of WHO relates to the control of maternal anaemia. There is no policy or programme guidance concerning issues of maternal thinness, weight gain during pregnancy and/or low birthweight prevention. Few if any countries have maternal nutrition programmes beyond those for maternal anaemia, and most of those are not effective. The lack of importance given to maternal nutrition is related in part to a weakness of evidence, related to the difficulty of getting ethical clearance, as well as a generalised tendency to downplay the importance of those interventions found to be efficacious. No priority has been given to implementing existing policy and programme guidance for the control of maternal anaemia largely because of a lack of any dedicated funding, linked to a lack of Millennium Development Goals indicator status. This is partly due to the poor evidence base, as well as to the common belief that maternal anaemia programmes were not effective, even if efficacious. The process of providing evidence-based policy and programme guidance to member states is currently being revamped and strengthened by the Department of Nutrition for Health and Development of WHO through the Nutrition Guidance Expert Advisory Group processes. How and if programme guidance, as well as policy commitment for improved maternal nutrition, will be strengthened through the Nutrition Guidance Expert Advisory Group process is as yet unclear. The global movement to increase investment in programmes aimed at maternal and child undernutrition called Scaling Up Nutrition offers an opportunity to build developing country experience with efforts to improve nutrition during pregnancy and lactation. All member states are being encouraged by the World Health Assembly to scale-up efforts to improve maternal infant and young child nutrition. Hopefully Ministries of Health in countries most affected by maternal and child undernutrition will take leadership in the development of such plans, and ensure that the control of anaemia during pregnancy is given a great priority among these actions, as well as building programme experience with improved nutrition during pregnancy and lactation. For this to happen it is essential that donor support is assured, even if only to spearhead a few flagship countries.
Maternal undernutrition is a serious global problem. Anaemia affects about a half of the pregnant women in the world, with little or no reduction in the last two decades.1 Low birthweight (LBW) rates affect about 15% of the babies born each year globally, with the highest concentration in South Asia where 27% are so affected. Excessive thinness, that is, a body mass index of <18.5 kg/m2, affects >20% of women of reproductive age in countries of South Asia. Despite this, in most developing countries the only maternal nutrition programmes are for maternal anaemia2 and even these are recognised to be of poor effectiveness, especially because maternal anaemia rates have not improved.
Maternal nutrition is an important determinant of young child growth failure. It is well accepted that the process of child length growth faltering in children from developing countries occurs in a critical 1000 day ‘window of vulnerability’ from conception to 2 years of age.3 Comparison with the new World Health Organization (WHO) growth standards reveals that such children are already born with weights and lengths below normal,4 confirming the need for greater efforts to improve nutritional status of pregnant women and women in childbearing age. The trajectory of length growth after birth seems to be largely set in uterus,5,6 even though it can falter from birth to 2 years, such that poor maternal nutrition may be as important as inadequate infant and young child feeding practices in determining height at 2 years of age, depending on the country setting.7,8 After the second year of life the length growth of children is essentially the same on average for all children. Those born with LBW are about 5 cm shorter than those not born LBW at age 17–19 years, be it in developed or developing countries.9 Because the adequacy of height at 2 years of age seems to be a good proxy for the quality of the future human capital of a nation,10 there is increasing concern with the process of becoming stunted. The concern being that restricted growth during pregnancy which limits length growth potential, also impacts negatively on brain and immune system development.
The Lancet Nutrition Series (LNS) described a package of interventions, which could reduce stunting at 36 months by a third and early child mortality by a quarter if implemented at scale in the 36 countries most affected by maternal and child undernutrition (MCU) and that retain 90% of the global burden of stunting.11 Few if any countries have implemented this package of interventions at scale however. The LNS also considered the processes for producing normative nutrition guidance to be laborious and duplicative, and the international nutrition system to be largely dysfunctional.12 However, the authors did not describe the processes for providing normative policy guidance, or suggest how this could be simplified and/or improved.
Undernutrition in one form or another therefore affects the majority of women of reproductive age in developing countries and is an important cause of young child growth failure, yet few if any programmes address the problem. The purpose of this paper is to describe the global policy and programme guidance mechanisms for nutrition, what their content is with regard to maternal nutrition, as well as to suggest ways that this situation might be improved.
Information was collected both through direct interviews as well as email exchanges with those involved in and responsible for policy and programme work, in or linked to the field of nutrition, within the WHO during the month of July 2010. Interviews were conducted with seven members of the Department of Nutrition for Health and Development (NHD), as well as three concerned members of the Departments of Child and Adolescent Health, one from the Department for Making Pregnancy Safer, and two from the Department of Reproductive Health Research, in addition to the six Regional Nutrition Officers. Searches were also carried out in PubMed and with Google using the search terms ‘maternal nutrition’, ‘nutrition policy’ and ‘nutrition programme guidance’, for recommendations and guidance coming from intergovernmental sources on how to deal with maternal nutrition problems. The results of these various interviews, searches, reports and feedback form the basis for this article which was finalised after a further review of the literature and feedback on preliminary drafts, in April 2011. To facilitate understanding of a broader audience, the many abbreviations that abound in this literature are listed together with their extensive form in Table 1.
Table 1. A list of acronyms found in the literature searched concerning maternal and child nutrition
|BMI = body mass index|
|CAH = Department of Child and Adolescent Health of WHO|
|CEDAW = Convention on the Elimination of all Forms of Discrimination Against Women|
|CFS = Committee on World Food Security of FAO|
|CHERG = Child Health Epidemiological Research Group|
|CMBS = The Code of Marketing of Breastmilk Substitutes|
|CODEX = Codex Alimentarius Commission|
|ENA = Essential Nutrition Actions|
|FAO = Food and Agriculture Organization|
|HIV/AIDS = Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome|
|ICESCR = International Covenant Economic, Social and Cultural Rights|
|IDD = iodine deficiency disorders|
|IMCI = Integrated Management of Childhood Illness|
|IMPAC = Integrated Management of Pregnancy and Childbirth|
|IYCF = Infant and Young Child Feeding|
|IYCN = Infant and Young Child Nutrition|
|LBW = low birth weight|
|LiST = Lives Saved Tool|
|LNS = Lancet Nutrition Series|
|MCU = maternal and child undernutrition|
|MIYCN = Maternal Infant and Young Child Nutrition|
|NGOs = non-government organisations|
|NHD = Department of Nutrition for Health and Development of WHO|
|NUGAG = Nutrition Guidance Expert Advisory Group|
|RHL = Reproductive Health Library|
|RHR = Department of Reproductive Health Research of WHO|
|SUN = Scaling Up Nutrition|
|UDHR = Universal Declaration of Human Rights|
|UN = United Nations|
|UNICEF = The United Nations Children's Fund|
|US = United States of America|
|WFC = World Fit for Children|
|WFP = World Food Programme|
|WSC = World Summit for Children|
|WHA = World Health Assembly|
|WHO = World Health Organization|
The global mechanisms that regulate and/or provide guidance for national nutrition efforts are all intergovernmental, with commitments ranging from broad political ones to those that are more policy related. Political commitments are for a nation as a whole while policy commitments relate to a national government commitment for a programmatic area or sector. These mechanisms are summarised in Table 2 in accordance with the nature of the strength of commitment and scope of orientation. Mechanisms related to emergency or humanitarian aid situations are not considered in this analysis.
Table 2. Intergovernmental mechanisms for providing nutrition-related recommendations
|Political commitments||UDHR – freedom from hunger||MDGs especially MDG 1 Poverty Reduction with hunger reduced by half of 1990 level by 2015 (energy adequacy and child underweight)||Rights: Human Rights Council|
|– Rights based: potentially legally binding for each nation state||CSECR – right to food||MDGs: United Nations General Assembly|
|– Goal based: a collective political promise||CRC – right to develop (mental and physical)|
|– Most nations||CEDAW – right to adequate nutrition during pregnancy|
|Policy commitments||– Global Strategy on Infant and Young Child Feeding including Code of Marketing of Breastmilk Substitutes||– Iodine deficiency disorders and universal salt iodization (MDG 2)||WHA (CODEX and CFS not included)|
|– Global Strategies are about minimum standards of health for all the population that WHA urges member states to adopt||– Global Strategy on Diet and Physical Activity||– Vitamin A supplementation (MDG 4)|
|– Goals-based interventions are about reaching targets (i.e. 50% reduction) that all nations agreed to work towards||– Global Strategy on the Prevention and Control of Non-Communicable Diseases||– Exclusive breast feeding (MDG 4)|
|– Adequate complementary feeding (MDG 1)|
|– All member states|| ||– Lancet Nutrition Series package (all MDGs)|
|Policy guidance||– Development of Child Growth Standards||– Development of guidelines for food fortification||WHO/FAO/UNICEF/WFP/NGOs|
|Technical recommendations on ‘what to do’ for any party (national governments, NGOs, private sector) to use in developing programmes||– Development of Recommended Dietary Intakes||– Development of guidelines for micronutrient supplementation|
|– Development of guidelines for adequate infant and young child feeding|
|– Maternal iron folic acid supplementation, calcium supplementation, energy/protein supplementation||MPS/RHL|
|Programme guidance||– Promotion of adequate infant and young child feeding||NHD/CAH/UNICEF|
|Technical orientation on ‘how to’ for any party (national governments, NGOs, private sector) to use in developing programmes||– Promotion of infant and young child growth and development|
|– Control of iodine deficiency||NHD/UNICEF/WFP/NGOs|
|– Control of vitamin A deficiency|
|– Control of anaemia|
|– Promotion of Essential Nutrition Actions||Basics/WHO/UNICEF|
Intergovernmental political commitments
Political commitments are formed when states agree to work together to achieve development outcomes, that usually include certain minimum standards or goals which may be nutrition related. The strength of commitment of these political agreements varies from international covenants and treaties with potential legal implications to far less binding ones to work together in favour of certain improved development outcomes. These contrasting ‘rights based’ and ‘needs based’ approaches to development can be complimentary, even if of differing orientation.13
Most nations are politically committed to freeing their citizens from the scourge of hunger and malnutrition, be it through the Universal Declaration of Human Rights of 1948, or the International Covenant Economic, Social and Cultural Rights of 1966. For maternal nutrition specifically, further instruments include the 1979 Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), which in article 12 says that all states shall ensure to women appropriate services in connection with pregnancy, confinement and the postnatal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation. Currently 158 states are parties to the legally binding International Covenant on Economic, Social and Cultural Rights, and although around 30 United Nations member states have not yet signed the Covenant, only five signatories have not yet ratified it, and only six have not yet ratified the CEDAW.14
In 2000 the United Nations General Assembly endorsed The Millennium Development Declaration,15 committing all state parties to work together to achieve eight international development goals, called the Millennium Development Goals (MDGs). The first MDG on poverty reduction (MDG 1) includes a target to halve the proportion who suffers from hunger by 2015. There are no MDGs that are specifically related to maternal nutrition, although there is one for maternal health (MDG 5). In 2010 progress towards the MDGs was considered insufficient to meet the targets.16
In 2002 the General Assembly also adopted the resolution for a World Fit for Children which built on the progress and achievements of the 1990 World Summit for Children (WSC) and agreed to achieve the unmet WSC goals and to achieving other goals and objectives, in particular the MDGs, by 2015. The World Fit for Children objectives included the reduction of child malnutrition among children under 5 years of age by at least one-third, with special attention to children under 2 years of age, and reduction in the LBW rate by at least one-third of the current rate.17 It was further agreed these goals would be achieved by strategies and actions which among others, aim to: improve the nutrition of mothers and children, including adolescents, through household food security, through dietary diversification, food fortification and supplementation, access to basic social services and adequate caring practices.
Intergovernmental policy commitments
Policy commitments are formed when recommendations and guidance are agreed to and endorsed by the international bodies that oversee the relevant technical area for a policy. As described in Table 2, the principal authority for international policy guidance in the area of nutrition lies with WHO through its governing body the World Health Assembly (WHA). Other technical bodies that generate nutrition-related intergovernmental agreements include the Committee on World Food Security of the Food and Agriculture Organization (FAO), as well as the Codex Alimentarius Commission. The Committee on World Food Security of the FAO policy recommendations are mostly limited to food security, while The Codex Alimentarius Commission is concerned with food safety,18 both of which are essential but alone insufficient requirements for nutrition security. For the purpose of this review the mechanisms for generating policy recommendations focuses on those generated by the WHA, the principal policy making body for nutrition globally.
The WHA has endorsed three Global Strategies that are nutrition related, and that are essentially normative, that is, they make recommendations setting standards to be achieved for the whole population. Among these is WHA55.25 on Infant and Young Child Nutrition (IYCN) adopted in 2002 which urged member states to adopt and implement the Global Strategy for Infant and Young Child Feeding (IYCF) in order to ensure optimal feeding for all infants and young children, and to reduce the risks associated with obesity and other forms of malnutrition.19 In addition there are the Global Strategy on the Control of Non-Communicable Diseases adopted in 2000,20 and the Global Strategy on Diet and Physical Activity adopted in 2004,21 both of which make recommendations concerning how populations should eat and take exercise in order to reduce the risk of obesity, diabetes and other non-communicable diseases.
The NHD is the principal unit within WHO responsible for supporting the development of global normative guidance in nutrition. The NHD website lists the 36 WHA resolutions on nutrition, of which 50% are on IYCN, 25% on micronutrients, and 25% on other more policy-related nutrition issues. The IYCN resolutions are especially concerned with the International Code of Marketing of Breastmilk Substitutes (CMBS), which was adopted by the WHA in 1981 as a ‘minimum requirement’ to be enacted ‘in its entirety’ in ‘all countries’. The resolution also request the Director General of WHO to report every 2 years on progress with the implementation of the CMBS. Since then a further 16 WHA resolutions on IYCN have been adopted, almost one every 2 years, all of which must be considered together with the CMBS in their interpretation and translation into national measures.
Since the WSC in 1990, WHA resolutions on IYCN have increasingly included endorsements for the targets of needs based approaches including WSC goals for exclusive breast feeding, adequate complementary feeding, and vitamin A supplementation. A select few WSC goals were made mid-decade goals, to be achieved by 1995 and in consequence received extra priority and resources from The United Nations Children's Fund.22 The control of iodine deficiency disorders was the only nutrition mid-decade goal, and seven of the nine WHA resolutions on micronutrients are specifically on the elimination of iodine deficiency disorders, as stand-alone endorsements.
There are no WHA resolutions on maternal nutrition as a stand-alone issue, and in none of the other nutrition related resolutions is maternal nutrition indicated to be a problem. In none of the many WHA resolutions on IYCN which promote exclusive breast feeding for the first 6 months of life and continued breast feeding through to at least 2 years of age is the nutritional status of the mother questioned or considered. The 2002 Global Strategy on IYCF recommends that the effect of improving maternal nutritional status on pregnancy outcomes be considered as an ‘important research topic’, suggesting that nothing is proven in this regard. The lack of importance given to maternal nutrition in the normative guidance on IYCF is unfortunately compounded by the lack of importance given to maternal nutrition by normative guidance on maternal health. The WHO Reproductive Health Strategy, endorsed by the WHA in 2004, only mentions the word ‘nutrition’ twice in its 65 pages and has no mention at all of maternal anaemia, for example, as being a problem for reproductive health.23
Intergovernmental policy and programme guidance
Providing normative guidance on minimum standards and effective interventions is considered to be an important component of the stewardship function of the international nutrition system.12 As shown in Table 2, there are two dimensions to this function: one is policy guidance, which is technical recommendations on ‘what to do’; the other is programme guidance, which is more about explaining ‘how to do it’. Both policy and programme guidance are listed together on the NHD website, organised under the four functional areas of NHD namely: (1) Growth Assessment and Surveillance, (2) Reduction of Micronutrient Malnutrition, (3) Nutrition in the Lifecourse, and (4) Nutrition Policy and Scientific Advice. Each of these substantive areas has two categories of guidance, namely ‘nutrition topics’ and ‘publications’, with each being hyperlinked to their relevant source for downloading the relevant documents. The list of ‘nutrition topics’ tends to be concerned with policy guidance and the list of ‘nutrition publications’ is more concerned with programme guidance.
Policy guidance from NHD can be divided into those more rights-based and normative in orientation and those more needs-based and target driven. The normative policy guidance includes the development of child growth standards and of recommended dietary intakes for example, which provide the scientific underpinning for the normative aspects of the right to food and the right to development. Such normative policy guidance is developed through technical expert meetings often in collaboration with FAO if they concern dietary intakes for example. Needs-based goal-driven policy guidance is more on specific topics like micronutrient supplementation and food fortification, aimed at controlling a deficiency state in order to achieve a specific target. Maternal anaemia reduction is included within the anaemia policy guidance. Such guidance is usually developed by experts with support from the various agencies and non-government organisations that are active in that particular field.
The only NHD policy guidance related to maternal nutrition as a stand-alone issue is in the area of ‘foetal/maternal nutrition’. The report of the 2003 technical consultation on ‘Promoting Optimal Foetal Development’ concluded among other things that many of the required components of a strategy for promoting optimal foetal development already exist as single packages, and proposed that by embedding these components in a broader framework, other approaches and programmes (Integrated Management of Childhood Illness, Making Pregnancy Safer, Roll Back Malaria and HIV/AIDS) can become part of an overall package of measures which collectively work together to secure the strategy objectives, that is, optimal foetal development.24 Two regional meetings were held in follow up and largely arrived at the same conclusions, but how this broader framework would be articulated and who would champion this were not articulated.
Policy guidance for maternal nutrition is also provided through the Reproductive Health Library (RHL) in collaboration with the Department of Reproductive Health Research.25 The RHL provides summaries of the findings of Cochrane Reviews, and provides evidence-based nutrition policy guidance for ‘pregnancy and lactation’ which includes: calcium supplementation; iron supplementation; multiple micronutrient supplementation; energy and protein intake, periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects, and vitamin A supplementation. For energy and protein intake during pregnancy the guidance is that ‘dietary advice is unlikely to yield any major benefits for either the infant or the mother. The best way of improving the dietary status of pregnant women may be to supplement their diets with energy-rich foods through community-based sustainable programmes. The best long-term solution is to raise the social and economic status of women’.26 The guidance for supplementary iron or iron + folic acid (provided either daily or weekly) is that it is considered ‘effective in preventing anaemia and iron deficiency at term, although there is no significant effect of supplementation on the incidence of substantive maternal and neonatal adverse clinical outcomes such as LBW, delayed development, preterm birth, infection, and postpartum haemorrhage’.27
Programme guidance on how to develop and implement nutrition programmes brings together the rights-based and evidence-based guidance modalities. Such guidance includes the ‘what to do’, the ‘why to do’ and the ‘how to do’. Most of the NHD publications explaining ‘how to implement programmes’ are related to goal-driven programmes. These are developed in collaboration with Department of Child and Adolescent Health in particular for IYCN programmes, as well as with other agencies that have funding to promote those particular nutrition programmes, such as The United Nations Children's Fund and the US funded non-government organisations that support food and nutrition programmes such as Basics for example. One of these publications produced by Basics, brings together all of the various nutrition protocols, including a chapter on maternal nutrition, and explains how a district health officer could manage the implementation of these in an integrated manner.28
The main source of maternal nutrition programme guidance from WHO is provided through the Department for Making Pregnancy Safer and its publications on the ‘Integrated Management of Pregnancy And Childbirth’ (IMPAC).29 This includes key interventions to be delivered through health services, family and the community in order to improve maternal and newborn health and survival. The print versions of IMPAC available in mid-2010 did not reflect the latest policy guidance on nutrition in pregnancy as on the RHL website however, largely due to lack of funds to update and reprint IMPAC since it was last published in 2007.
Future directions in nutrition policy and programme guidance
The NHD is currently strengthening its role in providing evidence-based policy and programme guidance to member states. Guided by the new WHO Guidelines Development process,30 NHD is implementing the development and update of some 30 nutrition guidelines in 2010–2011 through four subgroups of the Nutrition Guidance Expert Advisory Group (NUGAG). Only five of the guidelines are specifically on women during pregnancy and lactation and they are in the micronutrient subgroup. In the nutrition in the life course subgroup, which is where maternal nutrition is to be dealt with, none of the nine topics covers maternal nutrition specifically. How NUGAG can learn from the experience gained from ‘Essential Nutrition Actions’ initiative28 promoting the integrated delivery of a package of such nutrition interventions is perhaps one of the most important of these future directions.
It seems remarkable that while there is broad political commitment to ensuring adequate maternal nutrition as a human right, there are no policy commitments for this emanating from the WHA. Difficulty in creating a strong evidence base would seem to be one of the reasons why there is no policy commitment for maternal nutrition, as well as the lack of a champion. But these are probably related because if there was a strong evidence base there would more likely be a champion.
The lack of evidence that maternal iron supplementation improves maternal and child survival and development is in part because the global policy existed before an evidence base was created. Iron supplementation as the treatment of maternal anaemia during pregnancy was made policy in the US in 1968,31 and global policy guidance from WHO followed in 1972.32 Experience gained with implementing iron supplementation programmes during the seventies and eighties led to the development of WHO programme guidance on how to deliver programmes to control anaemia in 1989.33 In consequence it became very difficult on ethical grounds to carry out trials of iron supplementation during pregnancy with a placebo control anywhere in the world. While observational studies strongly suggest that iron deficiency anaemia contributes substantially to death and disability, especially among women and children in Asia and Africa, it is also recognised that the need for definitive evidence continues to be a barrier for action.34 Evidence for the importance of iron supplementation during pregnancy on birthweight has now emerged from trials in non-anaemic mothers in developed country settings.35
It would also seem that the importance of maternal nutrition has been minimised by a variety of competing development actors. The pro-breast-feeding movement claims there is very little difference in the milk of healthy mothers and mothers who are severely malnourished36 largely in order to counter any claims by formula companies of the superiority of their product.37 Those involved in promoting maternal health have also asserted that there is no evidence that nutrition makes a major difference in maternal mortality,38 or to support the implementation of specific nutrition public health interventions to prevent impaired foetal growth,39 and even that maternal supplementation can be dangerous.40 The very conservative interpretations of the evidence of the importance of maternal nutrition interventions can also be seen in the guidance found in the RHL, the over-arching message seems to be to wait for socio-economic development.
The competing interests of breast feeding, and maternal health causes, make the politics of maternal nutrition quite complicated, especially when competition for funding is so critical for any intervention to be prioritised. Funding of WHO for the development of policy guidance largely depends on extra budgetary funding by the donors who largely choose what they want to support.41 The apparent lack of evidence for the importance of maternal nutrition interventions either for maternal mortality or for child growth and survival outcomes meant that no MDG-linked maternal nutrition targets were adopted. In turn this has meant no earmarked donor funding for maternal nutrition programmes during the last two decades that goal driven approaches have become more dominant. This lack of evidence linking maternal nutrition to either MDG 5 in particular has therefore contributed to the lack of interest in maternal nutrition and to the lack of a champion that would raise these issues in the WHA for example, and donor funding has gone elsewhere.
In 2010 the WHA endorsed Resolution WHA63.23 on IYCN42 which urged member states to scale up interventions to improve IYCN in an integrated manner with the protection, promotion and support of breast feeding and timely, safe and appropriate complementary feeding as core interventions; the implementation of interventions for the prevention and management of severe malnutrition; and the targeted control of vitamin and mineral deficiencies. WHA63.23 further more requested the Director General to develop a comprehensive implementation plan on IYCN as a critical component of a global multisectoral nutrition framework for preliminary discussion at the 64th WHA (2011) and for final delivery at the 65th WHA (2012), through the Executive Board and after broad consultation with member states. The Secretariat Report prepared for discussion at the 64th WHA in May 2011 stated that the Executive Board recommended changing the name of the plan to cover maternal nutrition, that is, to become Maternal IYCN (MIYCN), as well as to deal more clearly with the double burden of undernutrition and overweight.43
The increasing global momentum for investing in nutrition programmes provides an opportunity to strengthen the development of maternal nutrition programmes. The global movement to fund national nutrition programmes called Scaling Up Nutrition (SUN), recognises that development funding for MCU has been far too small, and that increased investments in nutrition would help to achieve all MDGs.44 Under the SUN umbrella an estimate of the costs for taking the LNS package of interventions11 to scale in the 68 countries most affected by stunting has been developed.45 Because of the lack of policy and programme guidance, these estimates did not include the costs of scaling up maternal nutrition interventions other than iron supplementation. The LNS package included balanced energy protein supplementation in pregnancy, with an estimated 32% reduction in intrauterine growth retardation in populations where >10% of mothers were excessively thin (body max index <18.5). Now would seem to be an opportune time for countries with problem to develop policy and programme guidance for nutrition during pregnancy and lactation, which could build on the implementation guide developed for the US,46 with suitable adaption to take into consideration local contextual issues.
The reinvigoration of maternal anaemia reduction efforts should be seen as the ‘low hanging fruit’ in scaling up MIYCN programmes. The ‘what’ and the ‘how’ of controlling maternal anaemia are well known and the policy for the provision of iron and folic acid tablets during pregnancy already exists in most countries.47 A wealth of programme experience shows that the reasons for such programmes not working is not related to problems of acceptance of the tablets.48–50 The problem lies with maintaining the supply of tablets and ensuring regular delivery51 together with infection control.52 It means ensuring that iron folic acid tablets are included in the continuum of care being delivered by health services from conception to 2 years of age,53 especially through the community based outreach mechanisms with community facilitators and mobilisers encouraging adherence.54 Measurement of anaemia should be an essential part of re-establishing this programmatic area of work, and a relatively accessible tool has been developed for this.55 In most developing countries the norm is blanket provision of iron tablets without the need for a diagnostic test for anaemia. In consequence the problem is rarely measured and the patient is never aware what their anaemia status is, let alone has the problem explained to them. Anaemia is not one of the Countdown indicators56 for example, and so does not get included in health system management information systems and is not on the radar of district health management teams. What is not measured is not important. For all of this to happen, it is essential that a donor decides to fund these activities and provide technical assistance, even if only in a few ‘flagship countries’ to begin with and help build programme experience.
The renewed efforts of NHD to improve the nutrition policy guidance mechanisms through NUGAG are certainly to be applauded. However, whether these mechanisms will prove capable of delivering policy and programme guidance within a time frame capable of influencing the development of the comprehensive implementation plan on MIYCN is less sure, as any new policy guidance will take up 2 to 3 years to be developed, let alone to be disseminated. Maternal nutrition issues will certainly have to wait for the next biennium in 2012 to be included in new guideline development. In the mean time the global nutrition and health research community continues to produce evidence on the importance of a multitude of nutrition and non-nutritional inputs for various birth outcomes, and especially maternal newborn and child survival. One such group is the Child Health Epidemiological Research Group,57 and most recently the Lives Saved Tool modality of Child Health Epidemiological Research Group has just produced some 35 new reviews, including nine reviews of nutrition interventions, which are published and available online.58 How the NUGAG groups can best coordinate and/or draw on and/or even be ‘up-to-speed’ with the development of these various disparate research efforts, including the results of this maternal nutrition review group, is obviously a challenge.
The whole issue of accountability for maternal nutrition is one that is obviously still left begging. Most states are committed to ensuring mothers nutrition during pregnancy as a right, but it is hard to find any evidence of citizens claiming that right. FAO has helped develop normative clarification of the right to food through General Comment 12.59 Country led efforts to implement this right are also supported by dissemination of the Right to Food Guidelines,60 as well as a ‘Tool-box’ on different aspects of the right to food.61 The latter includes a paper on ‘Women and the Right to Food’ that looks at aspects of international law and state practice in this regard.62 It would be interesting to see if the experience with realising the right to food could be used and extended to promoting the right to maternal nutrition as proscribed in CEDAW.
We can conclude that almost all countries are political committed to ensuring that the right of mothers to good nutrition during pregnancy and lactation is realised. Despite this commitment the majority of mothers in countries most affected by MCU suffer from at least one form of undernutrition. Furthermore few if any countries that are among those most affected by MCU have any programmes dealing with maternal undernutrition beyond maternal anaemia, and even the anaemia programmes are not working in most countries. There are no global policy commitments in relation to maternal undernutrition coming from the WHA. Policy and programme guidance from WHO is provided with regard to the treatment and prevention of maternal anaemia in particular, but there is little or no policy or programme guidance on how to deal with issues of maternal thinness, weight gain during pregnancy and/or LBW prevention for example.
The lack of importance given to maternal nutrition programmes is in part related to a lack of evidence, as well as a systematic tendency to down play the importance of the evidence that exists by other actors, such as those interested in promoting maternal health and breast feeding. This minimising of the importance of maternal nutrition has resulted in a lack of linkage of maternal nutrition indicators to MDG goals and targets, and in consequence very little donor funding, that is so essential for interventions to get implemented.
The process of providing evidence-based policy and programme guidance to member states is currently being revamped and strengthened by NHD through the NUGAG processes. How and if programme guidance as well as policy commitment for improved maternal nutrition will be strengthened although the NUGAG process, is as yet unclear.
The global movement to increase investment in MIYCN programmes called SUN offers an opportunity to build developing country experience with efforts to improve nutrition during pregnancy and lactation. All member states are being encouraged by the WHA to scale up such plans. Hopefully Ministries of Health will assume the leadership in the scaling up the MIYCN interventions, and among these the control of anaemia during pregnancy will be given a great priority, as well as building programme experience for improved nutrition during pregnancy and lactation. For this to happen it is essentially that a donor decide to take up the cause and help establish such efforts.
Conflicts of interest
The author has no conflicts of interest to declare.