Photo: EDUARDO SOTERAS/AFP via Getty Images
More than one billion adolescent girls and women suffer from undernutrition.
On March 7, the United Nations Children’s Fund (UNICEF) released its long-awaited and first-of-its-kind report, Undernourished and Overlooked, on the state of nutrition for adolescent girls and women, highlighting the dire condition of maternal nutrition worldwide. Despite the critical role nutrition plays in maternal and child health, the state of maternal nutrition has not progressed significantly since 2000. With few developments and a grim outlook, critical questions remain: Why is nutrition vital for maternal and child health, what is the global state of maternal nutrition, and what is needed to fight the maternal nutrition crisis?
Q1: What role does nutrition play in maternal and fetal health?
A1: Nutrition is critical in all four stages of the maternal timeline—adolescence, prepregnancy, pregnancy, and postpartum.
Maternal health starts well before pregnancy. In adolescence, girls need nutritious diets with sufficient amounts of protein, iron, and other micronutrients. During this period girls are particularly vulnerable to malnutrition due to the high nutritional and caloric requirements of proper growth and development. Women in prepregnancy need access to nutritious foods to establish the nutrient and caloric reserves necessary for pregnancy. After becoming pregnant, a woman’s caloric needs increase by an average of 300 kcal per day. During the first six months of the postpartum period and while breastfeeding women need an average of 640 kcal per day more than women in prepregnancy and non-lactating women.
The key nutrients necessary for a healthy, full-term pregnancy include iodine, iron, folate, calcium, and zinc. Without sufficient intake, women can suffer from increased risk of pregnancy complications, including anemia, preeclampsia, hemorrhage, and, in some cases, maternal death. Infants can suffer low birthweight, wasting, developmental delays, and stunting; maternal malnutrition also increases the risk of stillbirth.
The first 1,000 days of life—starting at pregnancy and ending around the child’s second birthday—are the window of opportunity to reduce the risk of nutrition-related diseases in infancy and through adulthood. This period is a critical time for a child’s development; negative impacts on cognitive and physical development are often irreversible, leading to lifelong impacts on a child’s health, development, education, and future earnings.
In their latest report, UNICEF highlights the first 500 days between pregnancy and until the child reaches six months of age. Emily Mates, a maternal nutrition specialist for UNICEF and author of UNICEF’s report recently emphasized the lack of attention paid to these first 500 days. “In that 1,000-day window, more attention has gone on once the baby is born and the first six months and up to 24 months of its life. There has not been as much focus on a critical period of that 1,000 days, which is the first 280 days of pregnancy and, of course, the first six months of the child’s life,” Mates said at a CSIS event.
UNICEF estimates that over half of all children under two who experience stunting do so within this first 500-day window. Specifically, 26 percent of children who suffer from stunting are stunted at birth or become stunted within the first week of life, and 34 percent become stunted between eight days and six months. Adequate nutrition before, during, and after pregnancy is essential for providing a healthy foundation for the child’s long-term health and development.
Q2: What is the current state of global maternal nutrition?
A2: Maternal nutrition is a global concern. According to UNICEF, over one billion adolescent girls and women are experiencing undernutrition (lacking sufficient energy and nutrient consumption), micronutrient deficiencies, or anemia. Since 2000, the prevalence of underweight among adolescent girls has stayed constant, with only a two percent decline in the number of underweight women. Additionally, between 2020 and 2022, the number of acutely malnourished pregnant and breastfeeding women increased by 25 percent across the 12 countries hardest hit by the current nutrition and food crises spanning the Horn of Africa, West Africa, and the Middle East.
The future of maternal nutrition is, unsurprisingly, grim. Globally, no region is currently on track to meet the 2030 targets of halving the prevalence of anemia in girls and women and reducing the incidence of underweight in women by 30 percent. While data is limited, an estimated 69 percent of women and girls are reportedly suffering from micronutrient deficiencies and 30 percent are suffering from anemia.
The Covid-19 pandemic and Russia’s war in Ukraine disrupted global supply chains. Rising food prices made nutritious foods increasingly inaccessible and unaffordable to many. The pandemic placed a disproportionate burden on women and girls, affecting their employment, income, and livelihoods, further reducing their access to nutritious foods. Russia’s war in Ukraine further strained global food systems, pushing global food prices to an all-time high, putting nutritious foods out of reach for millions more, and deepening the global malnutrition crisis.
Worldwide, more women than men suffer from food insecurity, as quantified in the food insecurity gender gap. In 2019, 49 million more women than men were food insecure, a gap that more than doubled to 126 million in 2021.
Q3: How will investing in maternal nutrition impact future generations?
A3: Malnutrition affects not only the health and development of children—it also affects future generations. A child who suffers from malnutrition is more likely to suffer poor health in adulthood, achieve lower educational levels, experience developmental delays, and ultimately reach a lower socioeconomic status. Their children are more likely to experience malnutrition, poverty, and nutrition-related disease. Maternal underweight, maternal short stature, and low birthweights are predictors that a child could become stunted or wasted.
Stunting (low height for one’s age), underweight (low weight for one’s age), and wasting (low weight for one’s height) are the most commonly used indicators of malnutrition. In 2020, over 149 million children under five years of age suffered from stunting, over 45 million children experienced wasting, and nearly 39 million were overweight. The prevalence of maternal and child malnutrition is concentrated in Eastern and Southern Africa, West and Central Africa, and South Asia. Together, these regions account for 65 percent of the global prevalence of underweight in women, 73 percent of infants suffering from low birthweight, and 74 percent of children experiencing stunting.
Investments in nutrition are relatively inexpensive and therefore yield some of the highest economic returns. For example, each U.S. dollar invested in breastfeeding programs and promotion has a 35-dollar return. On an individual level, children who experience long-term nutrition, growth, and development challenges are at risk of decreased learning and earning outcomes, and children who do not experience stunting are 33 percent more likely to not experience poverty as an adult. On a national level, UNICEF reports the prevalence of stunting can decrease a country’s GDP by as much as three percent. For women and girls, specifically, malnutrition, anemia, and micronutrient deficiencies widen gender inequalities by decreasing learning potentials, wages, and life opportunities.
Q4: What is needed to improve the current state of maternal nutrition?
A4: First and foremost, investing in research is a crucial step in improving the current state of global maternal nutrition. Across the board, women’s health is overlooked and underfinanced. Glaring research gaps exist and little information is available on the state of micronutrient deficiencies in women and girls more generally. Investments in research would enable global policymakers to design and implement programs that are data-driven and specifically target maternal malnutrition.
Today, only 43 percent of women globally benefit from iron and folic acid (IFA) supplementation, which is the current World Health Organization (WHO) recommendation for pregnant women worldwide. The WHO reports that one of the possible reasons for the limited use of IFA is the varying levels of availability of supplements on a community level. Investments must be made to ensure global access to low-cost nutrition interventions, including IFA.
Multiple micronutrient supplements (MMS) are another nutritional intervention that UNICEF refers to as an “untapped opportunity.” MMS, often referred to in the United States as prenatal vitamins, provide 15 essential micronutrients to pregnant women, including iron, folic acid, zinc, and several other crucial vitamins and minerals. The WHO has recommended the use of MMS in humanitarian settings since 2007 but has not recommended it for use in low- and middle-income countries generally. MMS confer numerous benefits: Medical providers report greater compliance with MMS than IFA because MMS do not cause nausea, constipation, or other side effects associated with IFA. Furthermore, MMS have been found to be more effective in reducing low birthweight, maternal mortality, anemia, and stillbirth.
Today, only 29 percent of low and middle-income countries provide access to MMS. Martin Mwangi, the program lead for the Healthy Mothers, Healthy Babies Consortium, recently emphasized the importance of equitable access to MMS: “Ensuring that women and mothers have access to the right nutrition and right prenatal vitamins, such as multiple micronutrient supplements, no matter where they live, is actually an equity issue globally.”
Additional investments to support accessibility to and availability of nutritious foods are critical. Worldwide, almost 3.1 billion people could not afford the least expensive version of a healthy diet in 2020, which had an average cost of just 3.54 USD per person per day. Supporting value chains for nutritious foods—which are more perishable than staple foods—is an important step in this regard.
Maternal health requires access to supplements—whether IFA or MMS—in addition to nutritious diets, and regular prenatal care. Improving nutrition for adolescent girls likewise requires action at multiple levels, including increasing the availability of nutritious food and healthcare, and challenging discriminatory social norms. Improved research will provide the basis for more effective nutrition interventions. The results of these interventions are clear: healthier children and women are more empowered to make positive contributions to both their communities and their countries.
Anita Kirschenbaum is a program coordinator with the Global Food Security Program at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Zane Swanson is an associate fellow with the CSIS Global Food Security Program. Caitlin Welsh is the director of the CSIS Global Food Security Program.
