Maternal nutrition in India: Insights from National Family Health Surveys Rasmi Avula, Phuong Nguyen, Purnima Menon, International Food Policy Research Institute December 5, 2017 Maternal nutrition

Maternal nutrition and child outcomes Here is a conceptual framework by Ramakrishanan and colleagues of factors associated with maternal nutrition and their influence on pregnancy outcomes. Source: Ramakrishnan et al. 2012

Maternal nutrition a key challenge in India: Women enter pregnancy with a nutritional disadvantage and remain so during pregnancy 42.2% pre-pregnant women are underweight 50% pregnant women are anemic 7 kg weight gain during pregnancy -Pre-pregnancy nutritional status and nutrition during pregnancy are useful measures of maternal nutrition. These factors interact to determine birth weight. On average, women with lower prepregnancy body mass need to gain more weight during pregnancy to deliver infants of the same birth weight as women who start off pregnancy with a higher body mass index. Source: National Family Health Survey rounds 3 and 4; Coffey 2014

Multiple determinants of women’s nutrition in India Immediate determinants Underlying determinants Mothers’ low intrahousehold rank  restricted access to food ; intense physical work  lowering of BMI  poor birth outcomes – Coffey 2015 Source: National Family Health Survey rounds 3 and 4

Global guidance on improving maternal nutrition and health during pregnancy addresses the immediate determinants Balanced protein-energy supplements reduced risk of low-birth weight among undernourished women (Imdad & Bhutta, 2012) Iron folate supplementation (Bhutta et al. 2008) Prevention and management of diabetes and hypertension (Lassi et al. 2013) Management of infections and vaccination (Lassi et al. 2013) Antenatal Care plays an important role in promoting healthycare needs (Lassi et al. 2013) Optimum antenatal care (World Health Organization, 2016) 8 or more contacts Counseling on nutrition Routine health check-ups Micronutrient supplementation (IFA and Calcium) Tetanus toxoid Deworming

Interventions in place for maternal nutrition and health during pregnancy in India follow global guidance Integrated Child Development Services (ICDS) Platform Health/ANC Platform Pre- conception Folic acid supplementation   Pregnancy 4 ANC check-ups (weighing, BP check, urine test, abdomen check) Early pregnancy registration Food supplementation IFA supplementation Calcium supplementation Advice on nutrition Maternity benefits: Early pregnancy registration (1000 INR) and at least one ANC after 6 mo (2000 INR) Deworming after the first trimester Malaria prevention & treatment

Coverage of the existing interventions improved between 2006 and 2016 but is not optimal Strengthen ANC platform to ensure delivery of all interventions with quality Source: NFHS-3 and NFHS-4; RSOC (food supplementation data)

Percent who consumed ≥5 food groups Integrated approaches improve compliance and diet quality – an example from Bangladesh Percent who consumed ≥5 food groups Source: Nguyen et al. 2017

Limited implementation evidence on efficacy of diet-based interventions on pregnancy outcomes Randomized-controlled efficacy trial: Improving women’s dietary micronutrient quality pre-and during pregnancy did not have any overall effect on birth weight (Potdar et al. 2014) Larger effect on newborn size observed in women with higher pre- conceptional BMI Cluster-randomized controlled effectiveness trial: Consumption of small-quantity lipid-based nutrient supplement increased mean birth weight, birth length and head circumference in Bangladesh (Mridha et al. 2016) LNS (20 g/d, 118 kcal/d) consumed mixed with any food Need to build rigorous evidence on new interventions like one-full meal scheme on its impact, cost-effectiveness along with process documentation Examine unintended consequences of food-based programs, especially in the emerging overweight population Food transfer in the Progresa program in Mexico led to excess weight gain among already overweight women during the two years of intervention (Leroy et al. 2013) -Based on several trials, it was assessed that undernourished women benefitted from balanced protein-energy supplementation and had -RCT – Potdar – intent to improve micronutrient supplementation -Focus on tackling immediate determinants only; Call for a comprehensive approach -Ingredients: included soybean oil, powdered milk, peanut paste, sugar, and MMNs.

Closing thoughts Women in India face multiple challenges including poor food, health, and care environments along with early marriage, early conception, multiple pregnancies and low social status Critical to ensure pre-pregnancy well-being for good maternal and child outcomes Policies and interventions in the Indian context exist to improve food and health of pregnant women Implementation variability need to be addressed Strengthen existing delivery systems for interventions – e.g. ANC Build evidence for new intervention modalities Social and structural issues need special attention Emerging platforms (e.g. SHGs, Women’s collectives) have potential to tackle the social issues Overall, strategies that combine nutrition-based interventions with approaches that improve women's status and reproductive health are essential to improve birth outcomes.

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