Mainstreaming interventions in the health sector to address maternal and child undernutrition

Malnutrition is a contradiction of sorts – a multi‐sectoral problem that needs to be addressed sector by sector. The health, education, water and sanitation, agriculture, trade and several other sectors have a role to play in addressing malnutrition. Cognizant of this need for ‘thinking multi‐sectorally and acting sectorally’ (World Bank 2006), the World Bank awarded a grant under its Development Grant Facility to the International Center for Diarrheal Disease Research, Bangladesh to host a partnership to mainstream nutrition through the health sector. The plan is to learn from this experience and to follow this up with an expanded partnership that would bring under its umbrella similar efforts through other critical sectors. One of the key objectives of the Development Grant Facility grant is to support the documentation of the evidence, lessons and experiences from strengthening the nutrition component in Maternal and Child Health (MCH) initiatives. This global review of nutrition interventions, coordinated by the Mainstreaming Nutrition Initiative in collaboration with the Aga Khan University, is a part of this larger attempt.

Undernutrition represents the non‐income face of poverty and is embodied within Target 2 of Millenium Development Goal 1 (MDG 1). Addressing maternal and child undernutrition is, therefore, in itself a major MDG target and also a critical input factor for achieving MDG 4 and 5. As highlighted by the World Bank (2006), while most of the world is on track vis‐à‐vis the income poverty goal of MDG 1, only 24% of the countries are on‐track vis‐à‐vis non‐income poverty, 18% are improving but do not show sufficient progress, another 18% show a deterioration in progress, and, for a large number of countries (40%) there are no trend data available to monitor progress. Although there is some indication of improvement in global trends for stunting (de Onis 2000), the effect is not uniform. An estimation of these trends indicated that the prevalence of stunting fell in developing countries from 47% in 1980 to 33% in 2000 (i.e. by 40 million). Although this analysis indicated that stunting had reduced in South‐Eastern Asia, a subsequent analysis of the data indicates that the trends were largely driven by China and that stunting rates in south Asia have largely remained static (Svedberg 2006). The same is the case for trends in underweight (World Bank 2006).

It has been shown that undernutrition in childhood has a multiplicative effect on mortality and that even mild to moderate malnutrition was associated with increased risk of death (Pelletier et al. 1994). A recent analysis of changes in general malnutrition and mortality trends in 59 developing countries between 1966 and 1996, as measured by child weight‐for‐age (WA) and, on changes in child survival, indicates a significant relationship between improvements in WA and changes in child mortality, independent of socioeconomic and policy changes represented by the secular trend (Pelletier & Frongillo 2003). This evidence of the impact of undernutrition on morbidity and mortality is also accompanied by emerging evidence of the link of maternal and child undernutrition with impaired cognitive development, reproduction, physical work capacity and risks for several adult‐onset chronic diseases. The World Bank (2006) has underscored the critical link of improving nutrition at population level as a fundamental pre‐requisite for health, human development, human capital formation and economic growth.

While poverty alleviation strategies are important for improving nutrition outcomes, income growth alone is insufficient to promote a rapid rate of decline in undernutrition, and the shorter route to improving nutrition is through integrated evidence‐based interventions. The recent reviews of interventions that can affect newborn and child mortality (Jones et al. 2003; Darmstadt et al. 2005) suggest that almost one‐third of child deaths are potentially avertable through nutrition interventions. However, many of these interventions are not available to the very populations in need and inequitable distribution of key interventions, especially multiple related interventions, is a major challenge in health systems (Bryce et al. 2006). Data also show that the poor are most undernourished, and that without focusing on equity, the net gains of interventions on population health and nutrition may not be realized (Ergo et al. 2008).

The results from the current review have formed the basis for a comprehensive analysis of the evidence base and impact of these interventions on maternal and child's disability adjusted life years and have appeared as part of the Lancet series on maternal and child undernutrition in January 2008 (Bhutta et al. 2008). The current supplement of Maternal and Child Nutrition summarizes some of the additional commissioned reviews that have helped inform the evidence base of nutrition interventions.

The review on strategies for scaling includes an extensive review of the evidence base for interventions to scale up exclusive breastfeeding by Nita Bhandari and Iqbal Kabir (p. 5). Given the critical importance given to exclusive breastfeeding for newborn and child growth and survival, the low rates of exclusive breastfeeding in many countries are cause for concern. The review highlights the importance of political will and consistency in health systems approaches to breastfeeding promotion strategies. Although not highlighted in the current review, future strategies must also include early initiation of breastfeeding which has been shown to improve significantly newborn survival (Edmond et al. 2006).

Katherine Dewey and Seth Adu‐Afarwuah (p. 24) undertake a systematic review of strategies to address complementary feeding among children between 6 and 24 months of age, a period when growth faltering, micronutrient deficiencies and infectious illnesses generally peak in developing countries and a period that has been identified as the ‘window of opportunity’ for addressing undernutrition (World Bank 2006). Although cultural and religious taboos and lack of knowledge of the importance of responsive feeding are important factors, this is also the period where nutrient intake can be significantly compromised in poor food‐insecure populations. Household food insecurity and lack of dietary diversity can be addressed by a variety of interventions including well‐targeted food and micronutrient supplements and the review summarizes the evidence for selecting from a panel of potential interventions in various settings.

Growth monitoring and promotion (GMP) has long been the mainstay of child nutrition programmes in primary care settings. However, there is considerable disparity of views on its effectiveness and as the review by Ann Ashworth (p. 86) indicates, in most programmatic settings there has been much more emphasis on growth monitoring than on promotion. The review also indicates the pre‐requisites which may make GMP work and a few examples of success. This review needs to be considered in conjunction with a recent consensus statement (UNICEF 2007) on GMP from a consultation hosted by UNICEF that states:

Growth monitoring (GM) is the process of following the growth rate of a child in comparison to a standard by periodic anthropometric measurements in order to assess growth adequacy and identify faltering at early stages. Assessing growth allows capturing growth faltering before the child reaches the status of malnutrition. Growth monitoring and promotion (GMP) is a prevention activity that uses growth monitoring (GM), i.e. measuring and interpreting growth, to facilitate communication and interaction with caregiver and to generate adequate action to promote child growth through: a) increased caregiver's awareness about child growth, b) improved caring practices and c) increased demand for other services, as needed. ‘. . .’ Child anthropometric measurements for assessing nutritional status are not GM or GMP. GM and GMP thus should not be used for surveillance purposes, or to determine levels of under‐nutrition, or to decide on eligibility for the correction of poor nutritional status (e.g. food supplementation, therapeutic feeding, etc). When GM information is not used to inform the education and promotion element of an intervention then it is not GMP; both the monitoring of growth and using that growth information in counseling are essential to GMP.

The emerging evidence suggests that future strategies could include GMP as a platform for nutrition education and promotion for breastfeeding promotion, appropriate complementary feeding, dietary diversification and disease prevention strategies, provide some of the conditions for success are met and the focus is on promotion, rather than on monitoring.

There is insufficient recognition of the undernutrition and micronutrient deficiencies associated with intercurrent infections such as malaria, tuberculosis, diarrhoeal disorders, respiratory infections and intestinal helminthiasis. Hall et al. (p. 118) review the evidence to date from antihelminthic strategies targeting young children. Infestation with geohelminths may affect more than half of the world's population, and a proportion may have heavy infestation associated with significant nutritional deficits (Awasthi et al. 2003). The review suggests that in addition to deworming, adequate attention must be paid to nutritional rehabilitation and that in line with the earlier recommendations on the ‘window of opportunity’ to address undernutrition, intervention programmes may need to focus on a younger age group than the current target of school children.

Finally, despite the evidence available on effective interventions, why is their uptake by communities and availability so limited? Streatfield et al. review the evidence related to barriers for care seeking within MCH programmes (p. 237). Lack of availability and variable quality of services indicate that much of care seeking by poor families is from the private or non‐formal sector. Their review highlights the importance of systematic discrimination on the basis of poverty, gender, socio‐cultural factors and geography. These barriers to uptake of health and nutrition services are of equal importance in the context of MCH outcomes (Green & Gerein 2005; Victora et al. 2006) and nutrition. Recognition of these factors is an essential first step in addressing these at grass root levels.

Together, the five reviews suggest that even when evidence‐based interventions exist for improving nutrition, as is the case in the health sector, mainstreaming these within the sector needs critical attention to operational issues of integration within the health systems approach, to build political commitment for scaling up these interventions, while still maintaining the quality of implementation. Without this, impact may be hard to come by.