Improving Nutrition and Health for Pregnant and Lactating Women
Nutrition for women in pre-pregnancy, pregnancy, and over the first two years of the child’s life is of utmost importance for the survival, health and development of mothers and their children. In pregnancy, requirements of energy, protein, and essential micronutrients (vitamins and minerals) are increased not only to maintain the mother’s own health, but to also support optimal physical and brain development in the foetus. Furthermore, nutrition reserves are built over pregnancy to produce breastmilk for the post-child birth phase. Deficiencies of energy, protein, iron, calcium, iodine, vitamin A and folic acid during pregnancy predispose mothers to maternal complications and even mortality. These also contribute to foetal birth defects, low birth weight, restricted physical and mental potential, and foetal or newborn mortality.
Exclusive breastfeeding is recommended for infants 0-6 months of age to meet all their nutrition needs for optimal growth, and to protect them from infection. This should be followed by continued breastfeeding alongside appropriate complementary feeding until the child reaches 2 years of age. To sustain the production of adequate quantity and nutritional quality of breastmilk, lactating women have higher requirements of energy, protein, and other micronutrients. Poor maternal nutrition over this period risks depletion of the mother’s own nutrient stores and health, and harms the nutrition and health of the growing child . Addressing nutritional needs of pregnant and lactating women is now entrenched within the Sustainable Development Goals. By scaling up efforts to achieve this target, progress will also be accelerated on the targets on maternal and child mortality and health.
Scale of the Problem
Maternal nutrition and health
The impact of poor nutrition on maternal health and survival is indisputable. Anaemia, which results from deficiencies of nutrients such as iron and folic acid is an important risk factor for haemorrhage; a leading cause of maternal mortality. Calcium deficiency during pregnancy also increases the risk of pre-eclampsia, another cause of maternal mortality . Improving nutrition alongside good antenatal care can reduce these numbers significantly. Globally 52% of maternal deaths are attributable to haemorrhage, sepsis, and hypertensive disorders; 28% to non-obstetric causes; 8% to unsafe abortion . Infection during pregnancy can deteriorate a mother’s nutritional and health status, and impact foetal development. Maternal infections before or during childbirth are known to be associated with around 1 million new-born deaths each year, and contribute to about 10% of the global burden of maternal mortality. Malnutrition, is one of the main factors increasing the risk of such life-threatening infections through its role in decreasing immunity and delaying recovery .
Integrated Efforts in Pakistan
Maternal nutrition and health in Pakistan
Maternal and child undernutrition contributes greatly to mortality and morbidity of women and children in Pakistan, and is also one of the most important contributing factors to inter-generational poverty. Around 51% of Pakistani women of reproductive age are anaemic. A recent health survey acknowledges deficiencies of iron and vitamin A among pregnant and lactating women as a common public health challenge. Despite this, only 22% of women are found to be taking the full 90-day course of iron supplements in pregnancy whilst around 55% took none. The proportion of pregnant women receiving antenatal care from a skilled health provider has increased from 26% in 1990 to 73% in 2012-13. However, 3 in 5 pregnant women in Pakistan still do not receive 4 or more antenatal care visits as recommended by the World Health Organisation. These visits are extremely important to prevent and detect health complications, and to reduce the risk of adverse pregnancy outcomes for both the mother and child. In addition, 2 out of 5 pregnant women in Pakistan do not receive the two recommended doses of tetanus toxoid vaccination which protect against maternal and neonatal tetanus. Furthermore, huge disparities in health and nutrition outcomes exist based on maternal age, education, economic status, and location.
Political will and commitment to improve nutrition Nutrition within Pakistan’s Vision for 2025
The 2025 Vision for Pakistan emphasises food and nutrition security within one of the pillars to support human development in the country. Recognising the contribution of nutritional inadequacy to hindering intellectual capacity and worsening inequalities in income and opportunities, the 2025 vision seeks to reduce food insecurity from 60% to 30% in the population. It also outlines innovative and cost-effective strategies to improve nutrition and food insecurity for the population. These include initiatives such as the Hunger Free Pakistan programme, the provision of ready to use fortified food for pregnant and lactating women, livelihood initiatives to improve food access, fortified food supplementation and biofortification, and programmes to improve infant and young child feeding practices. A new National Nutrition Policy is also now being developed to harmonise efforts across the devolved structure to improve nutrition for vulnerable groups.
Scaling up domestic investments for improving nutrition and health
At the launch of the Global Strategy for Women’s Children’s and Adolescents’ health in 2015, the Government of Pakistan announced that it would enhance its health sector spending to 3% of its Gross Domestic Product (GDP) from the existing 0.6%, with a specific focus on improving the health of these vulnerable groups; reinforced within its National Health Vision (2016-2025). Since then, at the 2016 World Bank Human Capital Summit on Investing in the Early Years for Growth and Productivity, the Finance Secretary for Pakistan also committed to allocating 1.06% of Pakistan’s GDP to nutrition specific and nutrition sensitive interventions.
Bi-annual Mother and Child Health Weeks
These were launched to accelerate efforts to prevent maternal and child mortality, and expand essential health services particularly in rural and remote areas. Conducted twice every year, they are implemented under the national programme for family planning and primary health care, with the support of non-government organisations. Health and nutrition services for pregnant and lactating women cover iron and folic acid supplementation, tetanus toxoid vaccination, deworming, and treating infections such as malaria and dengue. Additionally, awareness on good dietary and hygiene practices for the mother and her child, breastfeeding and complementary feeding, and family planning is also promoted. Lady Health Workers (a cadre of community health workers) also play an important role in mobilising communities, providing services, and counselling on nutrition and health.
National and Provincial Fortification Alliances
With financial and technical support from donors and international development agencies, Pakistan has launched a country-wide food fortification programme to reduce micronutrient deficiencies in women and children. This programme is implemented through a multi-stakeholder partnership involving the National Food Fortification Alliance, Ministry of National Health Services Regulation and Coordination, Provincial Fortification alliances, the Pakistan Flour Mills Association, Pakistan Vanaspati Manufacturers Association and Pakistan Standards and Quality Control Authority. All flour and edible oil or ghee are fortified with essential micronutrients with the objective to reduce iron deficiency anaemia by one-third, and vitamin A deficiency by one-quarter in women and children. Efforts are also underway on wheat bio-fortification, and to develop policy and a regulatory framework to strengthen large scale fortification.
Commitment to the SUN Movement and strengthening multi-stakeholder partnerships
Since having joined the SUN movement in 2013, the Government of Pakistan has been working with multiple stakeholders in strengthening integrated financing, policy, and programmes for health and nutrition. The donor network has been playing a role in improved harmonisation of donor efforts and expanding nutrition specific and sensitive interventions, whilst the UN network supports the government in the planning and coordination of policy and programmes. The SUN civil society alliance has been supporting national and provincial authorities in planning cross-sectoral strategies and budgetary allocations for nutrition, as well as advocating for greater accountability for nutrition efforts. As a result of coordinated efforts, provincial authorities are now in the process of developing integrated health and nutrition reform plans.
It is critical that we continue and expand our response and momentum around nutrition….Health related nutrition interventions are being rolled out in all 4 provinces (of Pakistan)….Pakistan plans to strengthen its political commitment, institutional arrangements and implement priority nutrition interventions through multiple key sectors on large scale.”
Dr. Waqar Masood Khan, Finance Secretary, Ministry of Finance, Government of Pakistan At the World Bank Human Capital Summit (2016)
Recommendations for further improvement
Develop the capacities of provincial and district level authorities on policy plans with clear nutrition and health objectives and necessary budgetary allocations As health services were devolved to the provinces in 2011, provincial authorities must be sensitized on important maternal nutrition and health issues within their administrative areas, and supported in developing specific, measurable, achievable, realistic and time-bound plans. These plans must include clear objectives and end-targets for improving nutrition and health of women, for example, on maternal anaemia reduction, and must also be adequately financed through provincial budgetary allocations to achieve the set objectives.
Increase the accountability of provincial health and nutrition authorities for nutrition and health efforts and outcomes There is a need to strengthen district information systems on health and nutrition indicators for pregnant women and breastfeeding mothers, such as anaemia rates, food and micronutrient supplementation, deworming, and dietary practices for example, consumption of fortified food and diverse food groups. In addition, Provincial Fortification Alliances must play their part in quality control for fortification initiatives, to ensure wider outreach and accessibility of fortified food amongst communities. This is imperative to be able to track and report progress against nutrition and health objectives set within provincial health and nutrition plans, and strengthen accountability for the outcomes achieved.
Improve nutrition and reproductive health among adolescent girls Nutrition and health of adolescent girls contributes significantly to their development, and to the health of future pregnant and lactating women. In addition, preventing adolescent pregnancy is also critical to prevent the detrimental impact on maternal health outcomes. In Pakistan, 8% percent of adolescent girls 15-19 years are already mothers or pregnant with their first child18, which compromises the survival and health and nutrition of the adolescent, as well as the mother and child. It is thus necessary to scale up nutrition and health interventions targeted towards adolescent girls in Pakistan to prevent adolescents entering pregnancy in a malnourished state.