1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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 )
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.

10. 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.

11. Thank you