Nutrition and maternal, newborn and child health: joining the dots and looking beyond the Millennium Development Goals

A news bulletin sent around earlier this year by Dr Carole Presern, Executive Director of The Partnership for Maternal, Newborn and Child Health, threw down the gauntlet for the world community. At the time of the G8 summit – which I covered here in relation to the Enough Food For Everyone IF… campaign – the PMNCH highlighted the importance of nutrition. Since then I have found the work and the general approach of the PMNCH to be invaluable in joining the dots between various global health and development issues now that world leaders and development workers are considering a framework for initiatives extending beyond 2015.

The result of this summer’s discussions and presentations was the signing, by numerous international players, of the Global Nutrition forGrowth Compact, with up to $4.15 billion committed on this initiative up to 2020. Those who contributed to this strong pledge for a reduction in under-nutrition included the Bill and Melinda Gates Foundation, World Vision and Save the Children.

As Dr Presern writes,

Leaders should be especially motivated to see pledges result in measurable action. Bringing commitments to invest in nutrition under the umbrella of the Every Woman Every Child movement led by UN Secretary-General Ban Ki-moon would provide a useful framework for tracking their progress. We look forward to supporting efforts in this direction.

All of these issues are already very high on the international agenda. At the 66^th meeting of the World Health Assembly in Geneva in May this year, global delegates passed a resolution to implement the recommendations of the United Nations Commission on Life-Saving Commodities for Women and Children and also discussed a first-ever action plan pertaining to newborn health to end preventable deaths, which will be realised at the 2014 World Health Assembly.

At the Nutrition for Growth event in June, Justine Greening MP from the Department for International Development spoke about the importance of nutrition as a major development issue. She also outlined the financial pledges made by the international community of leaders in politics, social enterprise and business. She added,

Under-nutrition is stopping children and countries from reaching their full potential, accounting for the loss of billions of dollars in productivity. A strong and healthy workforce is vital if a country’s economy is to prosper. This means business and science taking a lead in fighting for good nutrition because we understand that better nutrition is the smart way to tackle extreme poverty, child mortality and economic underachievement.

What has to happen next is an integration of understanding between the issues – and, I would argue, an analysis of how gender inequality and sexist social values underpin many of the disadvantages, risks and problems covered.

The PMNCH’s own research provides a nuanced analysis of the relationship between nutrition, sustainable development and women’s and children’s health. Their findings were developed for the Open Working Group of the UN General Assembly in preparation for the formation of post-2015 development plans. They make a strong case for the importance of investment in nutrition for women and children as a major factor in ensuring sustainable development and its four pillars of economic development, environmental sustainability, social inclusion and peace and security; these criteria having been delineated by the UN System Taskforce on Sustainable Development.

This is about more than being hungry or not getting the right vitamins or minerals. Malnutrition and under-nutrition, rooted in long term poverty, inequality and disadvantage, have wideranging and interconnected health, social and economic consequences which do not affect just individuals but entire families, communities and generations. Their finding – spelled out in greater detail here, with references to specific studies – demonstrate myriad risks of malnutrition.

The report states,

Malnutrition contributes to disease and early deaths, especially for women and children. Malnourished women have lower birth weight babies resulting in children born into unhealthy, poorer families… and a lifetime of nutrition-related morbidity and mortality, which affects a woman’s own health and productivity and that of her offspring.

What is particularly interesting about the report is that it doesn’t just chronicle a problem, it also points to the benefits of action, stating that improved nutrition and greater health result in higher productivity. The findings are that women who are healthy, fed and working participate in the economy from a stronger position, both saving and investing. Healthy, well-nourished children have better mental development and learning skills and are more likely to stay in education and therefore to have a greater chance of earning more. The report points out that those who did not receive adequate nutrition in utero and in their earliest years “has been associated with reduced labor supply” and consequently lower adult incomes and therefore lower productivity at a mass level, across countries, where under-nutrition is widespread.

Whether or not you agree with this approach – that we should nourish human beings because they’ll then nourish capitalism more heartily instead of lying there like non labour producing duds - rather than seeing this as a human rights issue – it’s an interesting insight into the dramatic difference something as basic as nutrition can make.

There is also the cost of treating malnutrition:

• In some  low-income countries, the direct costs of iron deficiency (disease and death) are as high as 0.57% of  GDP, while indirect costs (related to physical and cognitive losses) can reach 4% of GDP.8

As a final thing to think about, the PMNCH also considers the risks and consequences to the health and the economy of too much food (and of the wrong time), not just too little food. In environments where the issue is not lack of food but over-consumption of food which is not nutritional and involves many risky factors (processed and refined food, food containing many additives and few nutrients, food high in salt, sugar and trans fats) there is an ever-rising figure, currently up to 8% of healthcare spending, associated with obesity. In China, right now, the cost of dealing with obesity is actually more than the economic costs associated with under-nutrition.

Related articles:

• The power of simplicity: reducing maternal mortality in Sierra Leone and Burundi
• Help the mother, help the child, secure the future: maternal and child health in India
• World hunger: time is running out

 Bidisha is a 2013 International Reporting Project Fellow reporting on global health and development.

Help the mother, help the child, secure the future: maternal and child health in India

Photo (c) Children In Need India

Like many people ‘of colour’, I am occasionally subject to a random dousing of imprecise and pejorative cultural clichés by ignorant people with a superiority complex, just like a delicate lotus blossom caught in a balmy, allegorical, toxic monsoon shower.

Woman in publishing, at literary festival: “What do you do?”
Me: “At the moment I’m working with the Gates Foundation and Johns Hopkins University, reporting on international development? No, before you ask, I haven’t met the Gates’s. The next thing I’m doing is on maternal health, I think. It’s really interesting.”
Woman in publishing: “Oh! That’s so interesting because the other day I was thinking to myself, I had trouble with my two pregnancies and if I’d been having my babies in the developing world, I wouldn’t have survived. Do you know [random British Asian woman in publishing PR]? Because you look like her and you remind me of her.”
Me: ???

I have no doubt that I in no way resemble the one other Asian person Publishing Woman has met in her working life. Poor PW, we met for 10 minutes out of nowhere and she couldn’t stop talking about race, refugees, poverty and the pathetic ills of the ‘developing world’ – it’s like she had racial Tourettes. And had I been able to recover from the speechlessness that afflicted me at the crucial moment, despite the fact that I talk for a living, I would have asked her which country exactly in ‘the developing world’ (which bigots usually take to mean everywhere or possibly anywhere from Senegal, across Libya, Somalia, Congo, down to Mozambique, then up through Iraq, Iran, Afghanistan, Uzbekistan, definitely India, Pakistan, Bangladesh, Sri Lanka and then possibly through to rural China perhaps… and maybe Burma, or rural Indonesia…and maybe also acrossways to some countries in South and Latin America, oh and the Caribbean islands maybe too, and gosh even some parts of Greece?) she meant, and then which region in which country.

The whole thing – or rather, her gloating and ignorance – made me think of an article I wrote a long while back, about Children in Need India. I described ‘two Indias’: that of the extremely numerous privileged middle class, who have the finest education, prospects, family support, influence, connections and healthcare; and that of the poorest, who despite the general dynamism, ambition and industry of today’s India still suffer due to lack of access to healthcare, education, influence, rights and justice. So often, it is only the second India that the wider world sees. It pains me, as a British Indian, that the rest of the world is blind to the incredible humour, energy, intelligence, broadness and enlightenment I see everywhere in India. In many ways, as a woman I find Indian culture much more sisterly and infinitely less misogynistic, judgemental, brittle, sleazy, objectifying, ageist-sexist and dollybirdish than British culture – but that’s a subject for another article.

Still, when it comes to society’s least advantaged, there are certain issues which cannot be ignored. India has a population of around 1 billion people and poverty, hunger, illness, gender and class injustice, lack of access, lack of rights, abuse, exploitation and geographical isolation from sources of both power and assistance (such as healthcare) are disproportionately weighted against those with the least. In short, despite India’s great achievements and many distinguished citizens, there are still an awful lot of poor, disempowered, ill and hungry people.

Looking back through Children in Need India’s work since I wrote that first 'two Indias' article, it is clear that solving the most fundamental problems must start from birth. I was intrigued by CINI because it started up with just two clinics for deprived children in Kolkata, where my mother’s family are from, and has since grown into a much larger organisation operating in West Bengal.

They present some sobering statistics, from Unicef studies:

• Infant mortality is highest in India than anywhere else in the world. According to Unicef’s 2010 figures, the majority of the 6,000 children who die in India every day, the majority are from preventable causes.
• Almost a half of all children under the age of five in India are clinically malnourished (Unicef study, January 2012)
• According to Unicef’s 2005 figures women in India are 80 times more likely to die during childbirth than in the UK due to lack of access to basic healthcare and monitoring during pregnancy for poorer women, as well as malnutrition and anaemia, which are linked.

There are further statistics – all, sadly, predictable – relating to rates of child labour, the possible consequence of exploitation and abuse of children who labour, the young age of girls’ marriage in rural areas, relatively low rates of child education (education in India is now free for all but uniforms and books can be expensive) and the knock-on effect in terms of adult literacy and, of course, gender equality.

This month the Wilson Centre in America held an extremely wide-ranging conference on Maternal Health in India: Emerging Priorities. There is a brilliant sum-up and full footage of the conference here. Taking place across New Delhi, Boston and Washington, the speakers argued strongly for the issue of maternal health to be seen in the context of multiple underlying social, health and economic factors, pointing out the importance of various key factors. First, more attention must be paid to women's health after giving birth - focusing on morbidity, not just mortality - and ensuring that all of a woman's health needs, from family planning to sexual health, are met in the same (geographical) place by the same people or organisation. Second, there must be an understanding of he importance of family planning: fewer pregnancies, with longer gaps in between, are better for women's physical and mental health and the health of their babies. And third, the importance of post-partum health care and sustained treatment cannot be underestimated.

Underlying all of this are the effects of gender inequality on women's health: early marriages leading to early and numerous births; violence against women; the underprivileging of female family members when it comes to feeding/serving, leaving women with the worst and least food (leading to malnutrition and anaemia) and the most and hardest labour within the house and beyond it. Class is also a powerful influence on Indian women's access to healthcare: disenfranchisement due to caste or other low class status is serious and widespread.

When it comes to healthcare, the best work is done through direct outreach, local engagement and the creation of long term relationships and structures: in one film, CINI describes visiting people door to door, inviting local people to meetings, the setting up of ‘panchayat’ council meeting where citizens speak up about what they need and are also educated and informed of their rights. In this way, the fundamentals – health, education, nutrition – are slowly strengthened. One intriguing project, which kills two birds with one stone (so to speak… actually it gives life to two birds with one stone…) is the ‘Nutrimix’ nutritional project: this is a pre-mixed nutritional food supplement which benefits Under-5s, which is sold by women to their local communities at a low price, but with a  small profit. It incentivises the women to sell and benefits them financially, while also aiding child health.

Other solutions are more traditional, like drop-in clinics giving advice on prenatal care, nutrition, vaccinations (one doctor talks positively about the success of the polio vaccination project at her clinic – once mothers see how simple it is, they are bringing as many local children as they can), reproductive health and more. Still, the strong theme of gender inequality, sexual exploitation and hypocrisy cuts through all of these issues. The clinic deals with STI’s, among other things, and it is left tactfully open as to where the STIs come from (hint: it’s not the women). Many of the women having babies are under-nourished because, even in a generally poor family, the men and boys will be privileged and the mother will eat last. In the film, one doctor at a baby clinic gestures to a patient and points out that the woman (and by consequence her baby) is under-nourished and in frail health because, due to a lack of contraception and consideration from her husband, she has too many children, who she can’t feed and is visibly too exhausted to look after.

Still, it is these same women who are finding a voice. From the seemingly small act of seeking and receiving healthcare treatment they are empowered to take a stand not only in their local area – one example is of women going door-to-door and educating their neighbours about the importance of environmental health and sanitary local conditions, which help to prevent the spread of germs – but also speaking out against the marrying-off of girls at a young age and insisting on the right for all children, whether they are boys or girls, to be educated. They are also empowered to demand safe and adequate healthcare. As one woman says: “We also want all mothers to be able to give birth in a hospital, without the risks of a home birth.”

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development.