Nutrition and the Continuum of Care: Pre-Conception to the Post-Natal Period
When Dr. Ranu Dhillon stumbled upon baby Reena during a routine visit to a clinic in India, she was almost comatose and unable to get the care she needed. Dhillon traveled with Reena and her mother from hospital to hospital, but left again and again without finding treatment.
Reena’s story, which Dhillon told at the Wilson Center alongside a panel of health and nutrition experts on July 28, is not one of infectious disease or an incurable illness, but of maternal malnutrition and its lasting effects across generations. Globally, malnourished mothers give birth to as many as 17 million underweight infants a year, according to the World Food Program. These children often face health and development challenges throughout their lives as a result.
Ending structural malnutrition is a matter of addressing not only shortfalls in food security, Dhillon said, but also empowering women and improving health care systems.
From Mother to Child
To understand why Reena was so sick, one has to look at the health of her mother, especially her nutrition, said Dhillon, a global health expert from Columbia University and Harvard Medical School who has worked on strengthening health care systems in India and other developing countries for more than a decade.
Reena’s mother was undernourished well before her pregnancy and consequently suffered from iron-deficiency anemia, a condition that can be remedied relatively easily through diet changes but otherwise increases risks for low body-mass index levels, health complications, and even death during and after pregnancy. Worldwide, approximately 468 million women between 15 and 49, or 30 percent of all women, are believed to be anemic, at least half because of iron deficiency.
Besides these risks to their own health, anemic mothers are also more likely to give birth to a child that suffers from stunted physical and cognitive development and low birth weight. Maternal malnutrition accounts for 20 percent of child stunting globally, said World Food Program Senior Policy Advisor Tanuja Rastogi.
Combatting the effects of malnutrition requires a “continuum of care” approach, said Frederika Meijer, UNFPA country representative for India and country director for Bhutan, in which mothers and children are targeted with specialized treatment in each stage of pregnancy and development. There is a 1000-day window, stretching from the start of pregnancy through a child’s second birthday, that is particularly important for the nourishment of mothers and children, said Rastogi.
Left unaddressed, deficiencies in iron – as well as zinc, iodine, and vitamin A – in young girls can catalyze an intergenerational cycle of malnutrition, said Meijer. “Undernourished girls become undernourished mothers who give birth to the next generation of undernourished children.”
This cycle also reinforces another – that of poverty. Children who don’t receive adequate nutrition at a young age often lag behind in school and suffer worse health outcomes, limiting their ability to support themselves later in life, she said.
“These People, This Is How They Die”
Reena, a seven-month-old born to low-caste parents, was in the midst of both these cycles. But she and her mother also faced a stacked deck because of their gender. Reena’s father passed away sometime after her birth, sending her and her mother’s social standing and purchasing power – already low – plummeting even further.
“In India, there’s a program to have a nutritional supplementation feeding center in every village,” explained Dhillon. But for Reena’s mother, going to the public center “was not even an option.”
“I’m a low-caste woman,” she explained to Dhillon, “the staff at the feeding center are high-caste; they’re not going to accept me.’”
When her mother, with Dhillon’s help, brought Reena to a private clinic instead, many kilometers away, the staff also refused them entry, saying “this is a girl child from a low-caste family with no menfolk.”
Another team of doctors, also unwilling to treat Reena’s malnutrition, explained to Dhillon, “these people, this is how they die.” It was only through Dhillon’s lobbying on her behalf that Reena was eventually admitted to a private hospital, where she recovered.
The rights to complete an education and make reproductive and sexual health decisions are not recognized for many women and girls in India. Forty-seven percent of girls get married and 30 percent give birth before they turn 18, said Meijer.
Mothers are also often unable to make decisions about pregnancy care and how finances are allotted towards food and health care for their children. “Just because you have access to food, for example, doesn’t necessarily mean that you have the decision-making authority within your household or within your family to distribute the food,” said Corinne Mazzeo, a health and nutrition advisor at Childfund International.
There are some facilities that poor, low-caste women like Reena’s mother are able to access, explained Dhillon, but these facilities have very limited capacity, are regularly flooded with patients, and as a result, generally provide poor care. He explained a litany of mistakes he observed during his time with Reena: antenatal care physicians at a community clinic failed to supply Reena’s mother with enough iron and folic acid supplements during her pregnancy; the primary health center several miles away did not test Reena for malnutrition; and staff at the larger public hospital in a neighboring town admitted Reena to the malnutrition ward but were not properly trained to treat her.
India boasts nearly one third of the global low-weight birth cases and 38 percent of the global stunting burden, said Meijer. An astounding 22 percent of newborns have low birth weights.
“After hearing stories like [Reena’s],” said Dhillon, “the question we should ask is not, ‘why is health coverage so low?’ but, ‘why is it not lower?’”
“Girls Have Their Own Aspirations”
Policymakers have long tried to meet the Millennium Development Goals on child mortality and maternal health by working towards universal health coverage, said Dhillon. But to ensure wider delivery of much-needed services for mothers and children, he suggested focusing more specifically on women’s empowerment and nutrition.
“The issues of nutrition and health…sometimes get separated out when we talk at a policy level,” said Dhillon, but given that “half of child deaths are driven by undernourishment,” policymakers cannot “aggressively close the gap on child mortality without making nutrition a part of that discussion.”
Drawing from their work in India, Egypt, and Senegal, among other places, the panelists offered different strategies to adapt health systems to meet the unique nutritional needs of women before, during, and after pregnancy and accommodate the challenges they face in their homes and communities.
Justine Kavle, a senior program officer for nutrition with USAID and PATH’s Maternal and Child Health Integrated Program, stressed the importance of counseling and information services to help women incorporate the right foods into their diets. Meijer called on governments and development donors to boost the capacity of community health workers. Mazzeo pointed out the need to engage male partners. And Rastogi highlighted the usefulness of nutrition-sensitive programs in schools and employment programs, as well as cross-sector partnerships (for example, recent research has cast light on the value of addressing nutrition alongside water, sanitation, and hygiene in urban India, since poor sanitation and malnutrition reinforce each other).
The panelists also cautioned policymakers to look closely for “gender gaps” within existing approaches. For example, providing nutritious lunches in schools is a popular approach to reaching adolescent girls, said Kavle, but if girls – particularly those from the lowest rungs of society – are dropping out of school, then they won’t benefit.
Similarly, mobile phone technology is widely touted as a way to reach women who are unable to travel to clinics or leave their homes without male supervision, but women often lack the privacy necessary to use cell-based health services, said Mazzeo.
Ultimately, policymakers should prioritize the empowerment of women and girls in all aspects of their health and development agendas, said Meijer. “We tend to forget that these are also girls in their own right. We always think girls want to become mothers but also, girls have their own aspirations, and we have to see…that they can really work [towards] building their own futures.”
Sources: World Food Program, World Health Organization.
Drafted by Sarah Meyerhoff and edited by Schuyler Null
Senior Health Advisor,Earth Institute at Columbia University; Faculty, Division of Global Health Equity, Brigham and Women’s Hospital/ Harvard Medical School
Senior Program Officer for Nutrition, USAID's Maternal and Child Health Integrated Program (MCHIP)/PATH
Health and Nutrition Advisor, ChildFund International
Representative for India and Country Director for Bhutan, United Nations Population Fund
Sandeep Bathala // Senior Program Associate, Environmental Change and Security Program, Maternal Health Initiative
Senior Policy Advisor, United Nations World Food Program