Unequal coverage of nutrition and health interventions for women and children in seven countries.

OBJECTIVE: To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. METHODS: We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. FINDINGS: Only 15% of 231 113 mother-child pairs received all eight health interventions (weighted percentage). The percentage of mother-child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. CONCLUSION: Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

Assessment of regional networks on nutrition in South Asia: a multi-methods study.

BACKGROUND: Many national and international organizations are working to improve maternal and child nutrition in countries with high malnutrition prevalence and burdens. While there has been progress in strengthening multi-organizational networks on nutrition at country and global levels, the regional level has received much less attention. We conducted a study to 1) determine the existing relationships and levels of engagement between international organizations working to improve nutrition at the regional level or in at least two countries in South Asia; and 2) examine the experiences and perspectives of international organizations on regional-level communication, coordination or collaboration on nutrition in South Asia. METHODS: A mixed methods approach involving organizational network analysis (ONA) and semi-structured interviews was used to develop an understanding of the existing network and relationships between international organizations working on nutrition in South Asia. ONA data from 43 international organizations was analysed using a social network analysis software (UCINET) to systematically quantify and visualize the patterns of relationships between organizations. RESULTS: We found a high degree of connectivity between most of the international organizations in South Asia, but there were gaps between the many organizations that knew each other and the work they did together regionally on nutrition. Most organizations worked together only 'rarely' or 'sometimes' on nutrition at the regional level and high-intensity (collaborative) working relationships were uncommon. Organizations of the same type tended to cluster together, and a small number of UN agencies and multilateral organizations were central brokers in the nutrition working relationships. Perceived constraints to the nutrition working relationships included organizations' agenda and mandate, threats to visibility and branding, human and financial resources, history, trust and power relations with other organizations, absence of a regional network for cooperation, and donor expectations. There was high demand to remedy this situation and to put network mechanisms in place to strengthen communication, coordination and collaboration on nutrition. CONCLUSIONS: Opportunities are being missed for organizations to work together on nutrition at the regional level in South Asia. The effectiveness of regional nutrition networks in influencing policy or programme decisions and resources for nutrition at country level should be explored.

Micronutrient gaps during the complementary feeding period in South Asia: A Comprehensive Nutrient Gap Assessment.

Micronutrient malnutrition is a key driver of morbidity and mortality for millions of children in South Asia. Understanding the specific micronutrients lacking in the diet during the complementary feeding period is essential for addressing undernutrition caused by inadequate diets. A Comprehensive Nutrient Gap Assessment was used to synthesize diverse evidence and estimate the public health significance of complementary-feeding micronutrient gaps and identify evidence gaps in 8 countries in South Asia. There were important gaps across the region in iron, zinc, vitamin A, folate, vitamin B12, and, to a lesser extent, calcium and vitamin C. The most nutrient-dense, whole-food sources of these micronutrients include liver, small fish, eggs, ruminant meat, and dark leafy greens. Investment is needed in some countries to collect data on micronutrient biomarkers and dietary intakes. A food systems approach is essential for improving child diets and reducing malnutrition, which affects millions of children, their futures, and society at large across South Asia and beyond.

Affordability of nutritious foods for complementary feeding in South Asia.

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.

Aiming higher for maternal and child nutrition in South Asia.

The sustainable development of nations relies on children developing to their full potential and leading healthy, productive, and prosperous lives. Poor nutrition in early life threatens the growth and development of children, especially so in South Asia, which has the highest burdens of stunting, wasting, and anaemia in the world. Targeted actions to reduce stunting and other forms of child malnutrition in South Asia should be informed by an understanding of what drives poor nutrition in children, who is most affected, and effective programme approaches. To this end, 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 maternal and child nutrition in South Asia, including analyses of: (a) the links between anthropometric failure in children and child development; (b) the time trends, current distribution, disparities and inequities of child stunting, wasting and anaemia, and their direct and underlying causes, including maternal anaemia, low birth weight, breastfeeding, and complementary feeding; (c) policy and programme actions to increase the coverage of nutrition interventions during pregnancy, improve breastfeeding practices, and care for severely wasted children. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy, and programme actions to improve maternal and child nutrition in South Asia.

Trends and predictors of optimal breastfeeding among children 0-23 months, South Asia: Analysis of national survey data.

Optimal breastfeeding practices, including early initiation of breastfeeding (EIBF) within 1 hr of birth, exclusive breastfeeding (EBF) for the first 6 months of age, and continued breastfeeding (CBF) for 2 years of age or beyond with appropriate complementary foods, are essential for child survival, growth, and development. Breastfeeding norms differ within and between countries in South Asia, and evidence is needed to inform actions to protect, promote, and support optimal practices. This study examines time trends and predictors of EIBF, avoidance of prelacteal feeding (APF), EBF, and CBF to 2 years using survey data from Afghanistan, Bangladesh, India, Nepal, and Pakistan since 1990. EIBF, APF, and EBF increased in Bangladesh, India, and Nepal from 1990 to 2016. EIBF and EBF increased in Pakistan from 1990 to 2013, but both EIBF and APF decreased in recent years. In Afghanistan, EIBF, APF, and EBF decreased from 2010 to 2015. CBF remained fairly constant across the region although prevalence varied by country. Significant (p < 0.05) predictors of suboptimal practices included caesarian delivery (4-25%), home delivery, small size at birth, and low women's empowerment. Wealth, ethnic group, and caste had varied associations with breastfeeding. Progress towards optimal breastfeeding practices is uneven across the region and is of particular concern in Afghanistan and Pakistan. There are some common predictors of breastfeeding practices across the region, however country-specific predictors also exist. Policies, programs, and research should focus on improving breastfeeding in the context of women's low empowerment and strategies to support breastfeeding of infants born small or by caesarian section, in addition to country-specific actions.

Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia.

The nutritional status of women before pregnancy, during pregnancy, and after delivery has far reaching consequences for maternal health and child survival, growth, and development. In South Asia, the high prevalence of short stature, thinness, and anaemia among women of reproductive age underlie the high prevalence of child undernutrition in the region, whereas overweight and obesity are rising concerns. A systematic review of evidence (2000-2017) was conducted to identify barriers and programme approaches to improving the coverage of maternal nutrition interventions in the region. The search strategy used 13 electronic bibliographic databases and 14 websites of development and technical agencies and identified 2,247 citations. Nine studies conducted in Bangladesh (n = 2), India (n = 5), Nepal (n = 1), and Pakistan (n = 1) were selected for the review, and outcomes included the receipt and consumption of iron and folic acid and calcium supplements and the receipt of information on dietary intake during pregnancy. The studies indicate that a range of barriers acting at the individual (maternal), household, and health service delivery levels affects intervention coverage during pregnancy. Programme approaches that were effective in improving intervention coverage addressed barriers at multiple levels and had several common features: use of formative research and client assessments to inform the design of programme approaches and actions; community-based delivery platforms to increase access to services; engagement of family members, as well as pregnant women, in influencing behavioural change; actions to improve the capacity, supervision, monitoring, and motivation of front-line service providers to provide information and counselling; and access to free supplements.

Association of household rice expenditure with child nutritional status indicates a role for macroeconomic food policy in combating malnutrition.

Macroeconomic food policies have the potential to reduce malnutrition by improving access to food, a determinant of nutritional status. However, very little is understood about the mechanisms and the magnitude of the effects of macroeconomic food policies such as food price policies on nutritional status. Data collected by the Nutritional Surveillance Project on a total of 81,337 children aged 6-59 mo in rural Bangladesh between 1992 and 2000 were used to examine how changes in rice price affect child underweight. Rice consumption per capita declined only slightly during the period but rice expenditure per capita varied widely due to fluctuations in rice price. Rice expenditure was positively correlated with the percentage of underweight children (r = 0.91, P = 0.001). Households were found to spend more on nonrice foods as their rice expenditure declined, and nonrice expenditure per capita was negatively correlated with the percentage of underweight children (r = -0.91, P = 0.001). Expenditure on nonrice foods per capita increased with the frequency with which nonrice foods were consumed (P < 0.05) and with the diversity of the diet (P < 0.001). The findings suggest that the percentage of underweight children declined when rice expenditure fell because households were able to spend more on nonrice foods and thereby increase the quantity and quality of their diet. We hypothesize that macroeconomic food policies that keep the price of food staples low can contribute toward reducing child underweight.