Maternal and child undernutrition: an urgent opportunity.

Nutrition is a desperately neglected aspect of maternal, newborn, and child health. The reasons for this neglect are understandable but not justifiable. When one considers specific actions to improve maternal and child survival, one is drawn to particular interventions— vaccination, oral rehydration therapy, and the treatment of infection and haemorrhage. In recent years, this portfolio of responses has broadened to embrace the health system—human resources, financing, and stewardship. Somehow, nutrition has slipped through the gap. And yet we know that nutrition is a major risk factor for disease. What public-health experts and policymakers have not done is to gather the evidence about the importance of maternal and child nutrition, catalogue the long-term effects of undernutrition on development and health, identify proven interventions to reduce undernutrition, and call for national and international action to improve nutrition for mothers and children. The five-part Series on maternal and child undernutrition, launched this week by The Lancet, aims to fill this gap in global public health and policy action. The key messages of the Series, which has been written by an independent team of public-health scientists led by Robert Black, Zulfiqar Bhutta, Jennifer Bryce, Saul Morris, and Cesar Victora, are critically important for all those concerned with the health and wellbeing of women and children. Undernutrition is the largely preventable cause of over a third—3·5 million—of all child deaths. Stunting, severe wasting, and intrauterine growth restriction are among the most important problems. There is a golden interval for intervention: from pregnancy to 2 years of age. After age 2 years, undernutrition will have caused irreversible damage for future development towards adulthood. Incredibly, four-fifths of undernourished children live in just 20 countries across four regions—Africa, Asia, western Pacific, and the middle East. These are the priority nations for action. In terms of under-5 mortality rates, the most immediate needs are for Afghanistan, Democratic Republic of Congo, Nigeria, Ethiopia, Uganda, Tanzania, Madagascar, Kenya, Yemen, and Burma. In order of population size, and excluding the countries with highest mortality rates, the ranking is different: India, Indonesia, Pakistan, Bangladesh, Vietnam, Philippines, Egypt, South Africa, Sudan, and Nepal. As this Series shows so clearly, there are proven effective interventions to reduce stunting and micronutrient deficiencies. According to strict criteria around admissible evidence, breastfeeding counselling, vitamin A supplementation, and zinc fortification have the greatest benefits. Attention to maternal nutrition through adequate dietary intake in pregnancy and supplementation with iron, folic acid, and possibly other micronutrients and calcium are likely to provide value. But these interventions need additional programmatic experience about how to achieve full coverage. There is no magic technological bullet to solve the problem of undernutrition. Long-term investments in the role of women as full and equal citizens—through education, economic, social, and political empowerment—will be the only way to deliver sustainable improvements in maternal and child nutrition, and in the health of women and children more generally. The compelling logic of this scientific evidence is that governments need national plans to scale-up nutrition interventions, systems to monitor and evaluate those plans, and laws and policies to enhance the rights and status of women and children. Although complex and fraught with political disagreement, none of these solutions are separable from global treaties and negotiations over trade, agriculture, and poverty reduction. This latest Lancet Series concludes, not surprisingly perhaps, that the international nutrition system is broken. Leadership is absent, resources are too few, capacity is fragile, and emergency response systems are fragmentary. New governance arrangements are urgently needed. An agency, donor, or political leader needs to step up to this challenge. There is a fabulous opportunity right now for someone to do so. But who?