As the burden of nutrition-related death and disability is concentrated among women of reproductive age and their children, and in recognition of the critical role women play in determining the nutritional status of populations, national nutrition strategies should focus on improving the nutritional status of women of reproductive age and on strengthening their capacity to provide nutritious diets for themselves, their children and their extended families. Accordingly, countries should set targets for halving underweight and anemia among women 15-49 years by 2020 and for eliminating both by 2030.
To achieve these goals, all nutrition stakeholders should work together to simultaneously increase the supply of foods and supplements designed to meet the special nutritional needs of women, especially during pregnancy, and encourage their use by educating women, by providing cash transfers conditional on their use, by offering nutritious foods and supplements as incentives for healthy behaviors (e.g. childhood vaccination, prenatal care visits), and by making foods and supplements available at the places women frequent daily (e.g. schools, workplaces and shops).
Urgent action on the consumption of iron-folic acid supplements and iron-fortified staple foods is required, alongside protein-energy foods and supplements especially for adolescent girls and pregnant women in the countries where iron-deficiency prevalence and deaths are highest. Women should be encouraged to use these products through a mix of education and cash and non-cash incentives, which the World Bank concludes can improve nutrition, especially when delivered directly to women. Incentives can include cash directly to mothers or rewards such as mobile phone minutes, energy subsidies, access to job information, educational supplies for children, or other rewards valued by specific populations. Another model is to link food rewards to compliance with other health and related programs. For example, the Poverty Action Lab in India found that when women were offered a food reward (lentils) upon completion of their child’s vaccination schedule, full vaccine coverage went up substantially.
Given the gender dynamics within families, care needs to be taken to ensure that special foods meant for women actually reach them, via special labelling, custom formulations that cannot be taken by children, and/or consumption on site at schools or workplaces. Programs that incentivize fathers to prioritize the nutritional status of their wives and daughters should also be explored. For example, analysis by Rohini Pande and Seema Jayachandran suggests that the lower nutritional status of women in India starts very early in life. Their study revealed that first born children in India are actually taller than firstborn African children and that stunting emerges within Indian families only after the arrival of the first son. This suggests that India will never end child malnutrition without broader shifts in parental attitudes towards daughters.
Incentives should also be provided to enable women to breastfeed in hospital, at home and at work and to transition to cooking methods that do not create the high levels of indoor air pollution that are contributing to a massive burden of death and disability (household air pollution is the third leading risk factor for disease burden globally). WHO acknowledges that early and exclusive breastfeeding has the single largest impact on newborn and child mortality of any preventive intervention, and most of the countries that have reduced child deaths by two-thirds since 1990 have exclusive breastfeeding rates above 50%, including Bangladesh, Bolivia, Cambodia, Egypt, Eritrea, Ethiopia, Madagascar, Malawi, Mongolia, Nepal, Peru, Rwanda, and Uruguay. The University of Sheffield is conducting trials to test whether cash payments for breastfeeding can lift rates well above the currently low levels and there needs to be much more experimentation with new approaches to enable breastfeeding (e.g. low cost breast pumps, paid leave, human milk banks, employer rewards). Incentives are also being tested to encourage the use of clean energy including by enticing husbands and fathers to purchase new cookstoves by including phone rechargers and the like.
It is important that nutritional foods and supplements are accessible to women in the course of their daily lives and do not add any further inconvenience. The recent work by GAIN and Alive & Thrive to encourage large employers of young women in Bangladesh and Viet Nam to educate women about nutrition and provide nutritious foods and breastfeeding support at work is one example of how to reach women without asking them to incur additional costs. Another way is to deliver foods and supplements alongside other services (e.g. polio campaigns, prenatal visits and medicine distribution). For example, the Clinton Health Access Initiative, the Children’s Investment Fund Foundation, Nutriset, the Government of Nigeria and UNICEF recently collaborated on a campaign in Nigeria where children received nutritional supplements alongside their malaria medicines, protecting them against the double scourge of malaria and malnutrition at a particularly vulnerable time of the year.
All of these investments in improving the nutritional status of women of reproductive age will bear fruit for children’s nutritional status. The Global Nutrition Report estimates that 70% of the recent reduction in childhood stunting in Bangladesh is due to advances in education, incomes, sanitation and contraception, most of it targeted to women 15 to 49 years.