Evidence Based Interventions for Improving Maternal and
Child Nutrition:
What Can be Done and at What Cost?
Zulfiqar A Bhutta1,2, Jai K Das1, Arjumand Rizvi1, Michelle Gaffey2, Neff Walker3, Sue Horton4, Patrick
Webb5, Anna Lartey6, Robert E Black for Lancet Maternal and Child Nutrition & Interventions Review
Groups
1
The Aga Khan University and Medical Center, Karachi, Pakistan
Hospital for Sick Children (Sick Kids), Toronto , Canada
3 Johns Hopkins University, Baltimore, USA
4 University of Waterloo, Canada
5 Tufts University, Boston, USA
6 University of Ghana, Ghana
2
Nutrition-Specific Interventions and Programs:
How can they Help Accelerate Progress in Improving
Maternal and Child Nutrition?
2
Furthering the Evidence Base to Improve
Maternal and Child Nutrition
 Since 2008 Lancet Series, many nutrition interventions
have been successfully implemented at scale, and the
evidence base for effective interventions and delivery
strategies has grown; coverage rates for other
interventions are either poor or non-existent
 The evidence base for nutrition specific and sensitive
interventions was updated & enhanced
 Ten nutrition-specific interventions across the life cycle
to address undernutrition and micronutrient
deficiencies in women and children were modelled to
assess impact and cost of scaling up
3
Interventions Across the Lifecycle
4
Nutrition Interventions Reviewed
Women of
reproductive age
and pregnancy
Neonates
• Folic acid
supplementation
• Delayed cord
clamping
• Iron and iron-folate
supplementation
• Neonatal vitamin K
administration
• MMN
supplementation
• Vitamin A
supplementation
• Calcium
supplementation
• Kangaroo mother
care and promotion
of breastfeeding
• Iodine through
iodisation of salt
• Maternal
supplementation with
balanced energy
protein
Infants and children
Disease prevention
and management
• Complementary
feeding promotion (624 months)
• WASH interventions
• Preventive vitamin A
supplementation (6
months – 5 years)
• Deworming in
children
• Maternal deworming
• Iron supplementation
• Feeding practices in
diarrhoea
• MMN
supplementation
• Zinc therapy for
diarrhoea
• Zinc supplementation
• IPTp/ITN for malaria
in pregnancy
• Malaria prophylaxis in
children
5
Delivery Platforms Reviewed
Community delivery platforms
for nutrition education and
promotion
• Improve rates of facility births by
28%
• Doubling of initiation of
breastfeeding within 1 h and EBF
• Substantial potential to improve
the uptake of child health and
nutrition outcomes among
difficult to reach populations
Reduction of financial barriers
Integrated Management of
Childhood Illness (IMCI)
• Policy strategies to ameliorate
poverty, reduce financial barriers,
and improve population health
• Includes both curative and
preventive interventions at
health facilities and at home
• Promote increased coverage of
child health interventions
• Various benefits in health
services, quality, mortality
reduction, and health-care cost
savings
• Pronounced effects achieved by
those that directly removed user
fees for access to health services
• Significant increase in EBF and
comparatively faster reduction in
the prevalence of stunting
6
Delivery Platforms Reviewed
Fortification strategies
• MMN: Increase in haemoglobin
concentrations and reduced risk
of anaemia by 57%
• Iron fortification - 41%
reduction in anaemia and 52%
reduction in iron deficiency
• Vitamin D fortification increased
serum 25-OH D concentration
Child health days
• Introduced in weak health
systems to rapidly enhance
coverage of essential child
survival interventions
• Promote increased coverage
than stand alone campaigns
• Overall equity effect of these
approaches are uncertain and
further studies are needed
School-based delivery
platforms
• Two tier- Improve attendance
and health
• Improve school attendance by
4-6 days annually and weight
gains 0.39 kg over 11 months
and 0.71 kg over 19 months
• Evidence scarce- Enormous
opportunity
• Zinc fortification- higher serum
and erythrocyte zinc
concentration and lower serum
copper
7
Breast Feeding Promotion-Effects on breast feeding
rates
Effects on exclusive breastfeeding rates
Outcome
Estimates
EBF at Day 1
43% RR: 1.43 (1.09-1.87) increase
EBF at 4-6 weeks
30% (RR: 1.30, 95% CI: 1.19-1.42) increase
EBF at 6 month
90% (RR: 1.90, 95% CI: 1.54-2.34) increase
Effects on NOT breastfeeding
Outcome
Estimates
Not breast feeding at Day 1
32% (RR: 0.68, 95% CI: 0.54-0.87) decrease
Not Breast feeding at 1 month
30% (RR: 0.70, 95% CI: 0.62-0.80) decrease
Not breast feeding at 6 months
18% (RR: 0.82, 95% CI: 0.77-0.89) decrease
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
WAZ
SMD: 0·26 (95% CI 0·12, 0·41)
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
WAZ
SMD: 0·26 (95% CI 0·12, 0·41)
Complementary food provision with education in food insecure populations
HAZ
SMD: 0.39 (95% CI: 0.05, 0.73)
WAZ
SMD: 0·26 (95% CI 0·04–0·48)
underweight
RR: 0.35 (95% CI: 0.16, 0.77)
Micronutrient interventions in childhood
•
Vitamin A Supplementation: Reduces all-cause mortality (RR 0·76, 95% CI 0·69–0·83),
diarrhoea-related mortality (RR 0·72, 95% CI 0·57–0·91), incidence of diarrhoea (RR
0·85, 95% CI 0·82–0·87) and incidence of measles (RR 0·50, 95% CI 0·37–0·67)
•
Preventive Zinc Supplementation: Reduces incidence of diarrhoea RR: 0.87 (95% CI
81–94) and pneumonia RR: 0.81 (95% CI 0.73–0.90) and improves mean height gain by
0·37 cm (SD 0·25)
•
Iron Supplementation: Reduces anaemia (RR 0·51, 95% CI 0·37–0·72), increases
haemoglobin concentration (MD 5·20 g/L, 95% CI 2·51–7·88) and ferritin concentration
(MD 14·17 mcg/L, 95% CI 3·53–24·81). Developmental benefits mainly in school age
children.
•
Micronutrient Powders: Reduce anaemia (RR 0·66, 95% CI 0·57–0·77), retinol
deficiency (RR 0·79, 95% CI 0·64–0·98) and improve haemoglobin concentrations (SMD
0·98, 95% CI 0·55–1·40). Further evaluation of safety needed when used at scale
LiST modeling effects on mortality for
34 high burden countries: revised model
13
80
60
40
0
Main outcomes (mortality and
stunting impact) reported across the
under 5 period as opposed to point
impact at 36 months of age
20
% of birth cohort
Major component remains a cohort
model, following children from birth
to 36 months, with stunting and death
as outcomes. Wasting is also included
in the model
100
Modeling the Impact of Interventions: What’s New?
0
12
24
36
Age in months
Died
Not stunted
Stunted
Target coverage 90% (compared to
99% in 2008) in 34 countries with
maximum burden
14
Countries With High Burden of Malnutrition
These 34 countries account for 90% of the global burden
of malnutrition
15
Effect of Scale-up Interventions on
Cause-specific Deaths
16
Impacts
Mortality in children younger than 5 years could be reduced by 15%
(range 9-19%)
• 35% (19-43) reduction in diarrhoea-specific mortality
• 29% (16-37) reduction in pneumonia-specific mortality
• 39% (23-47) reduction in measles-specific mortality
• Reduced deaths due to asphyxia and congenital anomalies
• Little effect on maternal mortality
Stunting overall reduced by at least 20.3% (range 11.1-28.9%)
Severe wasting reduced overall by 61.4% (range 35.7-72%)
17
Effect of Scale-up Interventions on Deaths in Children
Younger than 5 Years
18
Packages of Nutrition Interventions
Optimal maternal nutrition during pregnancy
•
•
•
•
Maternal multiple micronutrient supplements to all
Calcium supplementation to mothers at-risk of low intake3
Maternal balanced energy protein supplements as needed
Universal salt iodization
Infant and young child feeding
• Promotion of early, exclusive breastfeeding for 6 months; continued breastfeeding until 24 months
• Appropriate complementary feeding education in food secure populations and additional
complementary food supplements in food insecure populations
Micronutrient supplementation in children at risk
• Vitamin A supplementation between 6-59 months age
• Preventive zinc supplements between 12-59 months of age
Management of acute malnutrition
• Supplementary feeding for moderate acute malnutrition
• Management of severe acute malnutrition
19
Effect of Packages of Nutrition Interventions
at 90% Coverage
Number of lives
saved
Cost per life-year
saved
Optimum maternal nutrition during pregnancy
102,000
(49,000-146,000)
$571
(398-1,191)
Infant and young child feeding
221,000
(135,000-293,000)
$175
(132-286)
Micronutrient supplementation in children at risk
145,000
(30,000-216,000)
$159
(106-766)
Management of acute malnutrition
435,000
(285,000-482,000)
$125
(119-152)
Nutrition interventions
20
Can community based nutrition programs reach the poor?
All Community Platforms
•
•
•
•
•
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)
All Community Platforms
•
•
•
•
•
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)
•
•
•
•
Facility births (RR 1.28; 95% CI 1.04 to 1.59)
Breastfeeding rates 125% (RR 2.25; 95% CI 1.70 to 2.97)
Skilled care births (RR 1.59; 95% CI 0.64 to 3.95)
Iron/folate supplementation (RR 1.47; 95% CI 0.99 to 2.17).
Community based Interventions Modeled
1.
2.
3.
4.
5.
6.
7.
Multiple micronutrient supplementation in pregnancy
Promotion of breastfeeding
Promotion of appropriate complementary feeding
Vitamin A supplementation
Preventive zinc supplementation
Treatment of diarrhoea with zinc
Recognition and management of severe acute malnutrition
Equity Analysis of Effect of Scale Up Nutrition
Interventions
25
Potential Impact of Scaling Up
10 Proven Interventions
Continued investment in nutrition-specific interventions and
delivery strategies to reach poor segments of the population
at greatest risk can make a significant difference
If these 10 proven nutrition-specific interventions were
scaled-up from current population coverage to 90%, we could:
• Save an estimated 900,000 lives in 34 high burden
countries (where 90% of the world’s stunted children
live)
• Reduce the number of children with stunted growth
and development by 33 million
On top of existing trends, the WHA targets for 2025 are
reachable
26
Total Additional Annual Cost of Achieving 90% Coverage
with Nutrition Interventions
Nutrition interventions
Cost
Salt iodisation
$68
Multiple micronutrient supplementation in pregnancy (includes iron-folate)
Calcium supplementation in pregnancy
$472
$1914
Energy-protein supplementation in pregnancy
$972
Vitamin A supplementation in childhood
$106
Zinc supplementation in childhood
$1182
Breastfeeding promotion
$653
Complementary feeding education
$269
Complementary feeding supplementation
$1359
SAM management
$2563
Total
$9559
Data are 2010 international dollars, millions.
27
Paper 2 Key Messages
Promising interventions exist to improve maternal nutrition and reduce fetal growth
restriction and small-for-gestational age (SGA) births in appropriate settings in
developing countries, if scaled up
A set of 10 evidence-based interventions if implemented at scale can save at least
15% of under 5 child deaths (i.e. 1 million lives saved) and avert a fifth of all stunting
Delivery strategies exist to especially target undernutrition and impact child mortality
among the poorest
The costs for scaling up these nutrition specific interventions globally is $9.6 billion,
affordable given the gains
A clear need and opportunity exists to introduce promising evidence-based
interventions in the preconception period and adolescents and also address the
impact on long-term neurodevelopmental outcomes
28