Elsevier

The Lancet

Volume 382, Issue 9890, 3–9 August 2013, Pages 452-477
The Lancet

Series
Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

https://doi.org/10.1016/S0140-6736(13)60996-4Get rights and content

Summary

Maternal undernutrition contributes to 800 000 neonatal deaths annually through small for gestational age births; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3·1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008. We did a comprehensive update of interventions to address undernutrition and micronutrient deficiencies in women and children and used standard methods to assess emerging new evidence for delivery platforms. We modelled the effect on lives saved and cost of these interventions in the 34 countries that have 90% of the world’s children with stunted growth. We also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behaviour change, access and uptake of interventions. Our analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage. Additionally, access to and uptake of iodised salt can alleviate iodine deficiency and improve health outcomes. Accelerated gains are possible and about a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way. The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 focus countries is Int$9·6 billion per year. Continued investments in nutrition-specific interventions to avert maternal and child undernutrition and micronutrient deficiencies through community engagement and delivery strategies that can reach poor segments of the population at greatest risk can make a great difference. If this improved access is linked to nutrition-sensitive approaches—ie, women’s empowerment, agriculture, food systems, education, employment, social protection, and safety nets—they can greatly accelerate progress in countries with the highest burden of maternal and child undernutrition and mortality.

Introduction

Stunting prevalence has been decreasing slowly and 165 million children were stunted in 2011.1 Undernutrition, consisting of fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc, along with suboptimum breastfeeding, underlies nearly 3·1 million deaths of children younger than 5 years annually worldwide, representing about 45% of all deaths in this group.2 Maternal and child obesity have also increased in many low-income and middle-income countries.3

In a comprehensive review of nutrition interventions, we previously assessed 43 nutrition-related interventions in detail and reported estimates of efficacy and effect for 11 core interventions.4 Much progress has been made since with many interventions implemented at scale, assessments of promising new interventions, and new delivery strategies. We used standard methods to do a comprehensive review of potential nutrition-specific interventions to address undernutrition and micronutrient deficiencies in women and children. We modelled the potential effect of delivery of these interventions on lives saved in the 34 countries with 90% of the global burden of stunted children, and estimated the effect of various delivery platforms that could enhance equitable scaling up of nutrition-specific interventions.

Section snippets

Selection of interventions for review

We selected several nutrition-specific interventions across the lifecycle for assessment of evidence of benefit (figure 1); these interventions included those affecting adolescents, women of reproductive age, pregnant women, newborn babies, infants, and children. We also reviewed the evidence for delivery platforms for nutrition interventions and other emerging interventions of interest for nutrition of women and children.

We identified and relied on the most recent reviews with good quality

Interventions to address adolescent health and nutrition

There is growing interest in adolescent health as an entry point to improve the health of women and children, especially because an estimated 10 million girls younger than 18 years are married each year.6 A range of interventions exist in relation to adolescent health and nutrition, which could also affect the period before first pregnancy or between pregnancies. Evidence supporting reproductive health and family planning interventions in this age group suggests that it might be possible to

Folic acid supplementation

Neural tube defects can be effectively prevented with periconceptional folic acid supplementation. A review19 of five trials of periconceptional folic acid supplementation suggested a 72% reduction in risk of development of neural tube defects and a 68% reduction in risk of recurrence compared with either no intervention, placebo, or micronutrient intake without folic acid (table 119, 20, 21, 22, 23, 24, 25, 26). A review20 of folic acid supplementation during pregnancy showed that folic acid

Delayed cord clamping

Early clamping of the umbilical cord after birth is a common practice and permits immediate transfer of the baby for care as required, whereas delaying of clamping allows continued blood flow between the placenta and the baby for a longer duration. A Cochrane review39 suggested that delayed cord clamping in term neonates led to significant increase in newborn haemoglobin and higher serum ferritin concentration at 6 months of age (table 239, 40, 41, 42, 43, 44, 45). Another review40 of studies

Promotion of breastfeeding and supportive strategies

WHO recommends initiation of breastfeeding within 1 h of birth, exclusive breastfeeding of infants till 6 months of age, and continued breastfeeding until 2 years of age or older.47 However, global progress on this intervention is both uneven and suboptimum.48 The exact scientific basis for the absolute early time window of feeding within the first hour after birth is weak.49, 50 A systematic review51 suggests that breastfeeding initiation within 24 h of birth is associated with a 44–45%

Disease prevention and management

Several interventions have the potential to affect health and nutrition outcomes through reduction in the burden of infectious diseases. Table 477, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88 summarises the evidence for interventions for disease prevention and management.

Prevention and treatment of severe acute malnutrition

A substantial global burden of wasting exists, especially severe acute malnutrition (SAM; weight-for-height Z score [WHZ] <–3), which coexists with moderate acute malnutrition (MAM; WHZ <–2). In stable non-emergency situations with endemic malnutrition, MAM can often present in combination with stunting. Most of the interventions previously discussed should be implemented to prevent the development of SAM in food insecure populations. Several approaches for prevention and treatment are in use.

Interventions for prevention and management of obesity

Obesity is increasing in many populations and is one of the most important challenges of the 21st century. Obese women are at an increased risk of adverse pregnancy outcomes. A Cochrane review100 assessed the effectiveness of interventions (eating, exercise, behaviour modification, or counselling) that reduce weight in obese pregnant women and identified no evaluable trials. Some studies assessed the effect of diet, exercise, or both for weight reduction in women after childbirth, and showed

Delivery platforms and strategies for implementation of nutrition-specific interventions

Delivery strategies are crucial to achieve coverage with nutrition-specific interventions and to reach populations in need. A range of channels can provide opportunities for scaling up and reaching large segments of the population.

Delivery of nutrition interventions in humanitarian emergency settings

Delivery strategies for nutrition interventions in humanitarian emergencies necessitate a different approach to what might be deemed optimum in stable circumstances. In view of variability in the characteristics of emergencies and protracted population displacement, humanitarian emergencies might closely mirror situations of endemic malnutrition in food insecure settings. Hence prevention and health promotion strategies, such as breastfeeding and complementary feeding education and support,

Emerging interventions that need further evidence

We also reviewed interventions that are not currently recommended but that have potential and future prospects for inclusion in regular programmes. These interventions, which have possible effects on nutritional outcomes in women and children, include strategies to reduce household air pollution, maternal vitamin D supplementation, maternal zinc supplementation, omega 3 fatty acids supplementation in pregnancy, antenatal psychosocial assessment and cognitive behaviour therapy for depression,

Modelling the effect of scaling up coverage of nutrition interventions in countries with the highest burden

We used the Lives Saved Tool (LiST) to model the potential effect on child health and mortality in 2012 of scaling up a set of ten nutrition-specific interventions that could affect stunting and severe wasting183 (panel 6,4, 122, 145, 184, 185, 186, 187, 188 figure 2). Although included in costing, we did not model the promotion and use of iodised salt. For modelling, we selected 34 countries with more than 90% of the burden of stunting (figure 3; appendix pp 8–12) and took 2011 as the base

Implementation of nutrition-specific packages of care

We also assessed the potential effect of nutrition-specific packages of care by scaling up these interventions to 90% coverage. Four packages were assessed for effect on child survival: optimum maternal nutrition during pregnancy (maternal multiple micronutrients, use of iodised salt, calcium, and balanced energy protein supplementation), an infant and young child nutrition package (breastfeeding promotion and appropriate complementary feeding education or provision), micronutrient

Can these interventions promote equitable access?

To assess the potential benefit of community-based delivery strategies on reaching and engaging poor and marginalised populations, we assessed the effect of community-based promotion and delivery of seven nutrition-specific interventions (multiple micronutrient supplementation in pregnancy, promotion of breastfeeding, appropriate complementary feeding, management of SAM, vitamin A supplementaton, preventive zinc supplementation, and treatment of diarrhoea with zinc) across various wealth

Cost analysis

We used a so-called ingredients approach to work out the cost of nutrition interventions, based on the UN One Health Tool,193 which allows for regional variation due to personnel costs. We constructed cost estimates as add-ons to existing antenatal, postnatal, and standard infant visits as part of WHO’s Expanded Program on Immunisation, plus five stand-alone nutrition visits between 6 and 35 months of age. The few interventions targeted at children between 36 and 59 months of age were assumed

Discussion

This update of nutrition interventions differs from past exercises in several ways. First, we included a wider range of nutrition-specific interventions and applied more stringent assessment criteria, using the Grades of Recommendation Assessment, Development and Evaluation system and Child Health Epidemiology Reference Group criteria for most inverventions.5 Second, in view of emerging evidence of the importance of maternal nutrition, SGA, and early stunting,1 we specifically focused on

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