Emphasis on nutrition: A must for quality maternal care

Karin Lapping, Director, Alive & Thrive Program and Dr Shalini Singh, Deputy Director General, Division of Reproductive Biology and Maternal Health, ICMR, advocate multi-sectoral alignment on maternal nutrition specific initiatives as a measure for India to achieve its maternal health goals

Despite significant global political attention on maternal health and the increased adoption of maternity services, the MDGs for maternal health have not been achieved, and many women continue to remain at risk.

The gaps in progress in maternal care are particularly significant where maternal nutrition is concerned, largely due to undernutrition and its associated causes such as early marriage and child birth, gender norms and misinformed health practices associated with social beliefs. The loss of health and productivity is multiplied manifold as the impact of poor nutrition is inter-generational, affecting future cohorts of men and women in a vicious cycle. Given the extensive and growing reach of Maternal Newborn Child Health (MNCH) programmes, it makes sense to place and prioritise proven maternal nutrition interventions at the core of public maternal care services.

For instance, calcium and iron folic acid (IFA) supplementation are two key nutrition interventions that help address high blood pressure disorders and post-partum hemorrhage – the two leading causes of maternal deaths. International evidence shows that prenatal and antenatal iron and folic acid supplementation not only reduces the risk of postpartum haemorrhage but also preterm labour and infection post-delivery. Indian studies have also indicated that Calcium supplementation reduces the occurrence of high blood pressure related conditions like pre-eclampsia and preterm delivery in first time pregnant women with low daily dietary calcium intake.

Another key nutrition intervention is improving sub-optimal diets, which is an underlying cause of poor pregnancy outcomes. It is critical for communities to be sensitised about the importance of life-saving early breastfeeding practices and MNCH programmes must include this in the counselling given to pregnant women. Optimal breastfeeding, in addition to being the leading intervention for child survival, also has additional benefits for women in helping prevent maternal cancer deaths and short birth intervals.

Global maternal nutrition guidelines have been issued by WHO and many countries including India have pro-breastfeeding and maternal nutrition policies in place due to the large and growing evidence of its significant health impacts. Over the past few years, India has also developed programme guidelines for addressing some of the emerging maternal nutrition concerns such as a revised strategy for IFA supplementation, calcium supplementation and deworming during pregnancy.

However, coverage of these nutrition interventions, which are critical in bridging the access gap and addressing the slow progress in maternal health, remains low. Although improvement in antenatal care has been seen in states like Bihar, where Tetanus Toxoid during pregnancy is almost 90 per cent, IFA coverage however remains less than 15 per cent. High coverage of interventions like Tetanus Toxoid suggests it is possible to reach these women with adequate nutrition interventions as well.

The gaps in connect between health workers and pregnant women is a big missed opportunity for delivering nutrition. The same MNCH system, which is effective in delivering critical health-focused interventions, can also deliver a small package of proven nutrition interventions for maximising health outcomes for mothers and newborns. Nutrition can be delivered even where the availability or use of formal health services is weak, as no highly qualified specialists or diagnostics or cold chain and drugs are needed and counselling can be delivered at home or in the community.

The National Family Health Survey 4 (2014) shows that timely initiation of breastfeeding was only 34.5 per cent in Madhya Pradesh, 34.9 per cent in Bihar and 40 per cent in Andhra Pradesh, whereas the institutional delivery rates were 81 per cent, 63.8 per cent and 96.5 per cent respectively. The challenge clearly lies in setting nutrition priorities within MNCH services with the assistance of nutrition scientists and practitioners to plan for adequate nutrition coverage and quality. Additionally, monitoring indicators need to prioritise coverage for select critical nutrition interventions like initiation of early and exclusive breastfeeding.

For India, a focus on maternal nutrition aligns well with shifts in patterns of overall maternal health outcomes – from maternal mortality alone to mortality, morbidity and disability, and the rise in nutrition related conditions such as diabetes, heart disease, hypertension and other chronic illnesses linked to maternal health outcomes. The delivery of even one set of nutrition interventions can positively affect a diversity of poor outcomes. With almost 30 million women becoming pregnant in India annually and the delivery of 27 million babies each year, placing greater emphasis on nutrition interventions during pregnancy care in MNCH programmes deserves greater attention.

Multi-sectoral alignment on maternal nutrition-specific initiatives is important for India to achieve its maternal health goals. For instance, ensuring coordinated action among the public, decision makers and programme managers across relevant ministries like the Ministry of Health & Family Welfare and Ministries of Women & Child Development and Drinking Water & Sanitation in addressing maternal undernutrition will go a long way in achieving India’s overall health and nutrition outcomes, including its SDG goals in maternal health.

Government and community interventions across India and South East Asia have already yielded positive results in this regard. Vietnam, for example, has shown an improvement in exclusive breastfeeding levels from 19 per cent to 58 per cent through a primary healthcare-based Ministry of Health (MoH) programme. Bangladesh recently demonstrated a rapid increase in the consumption of iron folic acid and calcium tablets among pregnant women, and the adoption of a more diversified diet through intensified monitoring and working with family and community influentials. In India, recent formative research in Bihar and UP also shows that husbands and mothers-in-law can be engaged by frontline workers to ensure the procurement and consumption of nutrient supplements and locally available nutritious foods for pregnant women.

We have already seen that our health system can deliver services by improving antenatal care (ANC), institutional delivery and routine immunisation coverage. There is no reason why maternal nutrition interventions should continue to be left behind.