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doi: 10.1111/j.1365-3016.2012.01279.x 315

Global Policy and Programme Guidance on Maternal Nutrition:

What Exists, the Mechanisms for Providing It, and
How to Improve Them? ppe_1279 315..325

Roger Shrimpton
Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New
Orleans, LA, USA

Abstract
Undernutrition in one form or another affects the majority of women of reproductive age in most developing
countries. However, there are few or no effective programmes trying to solve maternal undernutrition problems.
The purpose of the paper is to examine global policy and programme guidance mechanisms for nutrition, what
their content is with regard to maternal nutrition in particular, as well as how these might be improved. Almost all
countries have committed themselves politically to ensuring the right of pregnant and lactating women to good
nutrition through the Convention on the Elimination of all Forms of Discrimination Against Women. Despite this,
the World Health Organization (WHO) has not endorsed any policy commitments with regard to maternal nutri-
tion. The only policy guidance coming from the various technical departments of WHO relates to the control
of maternal anaemia. There is no policy or programme guidance concerning issues of maternal thinness, weight
gain during pregnancy and/or low birthweight prevention. Few if any countries have maternal nutrition pro-
grammes beyond those for maternal anaemia, and most of those are not effective. The lack of importance given to
maternal nutrition is related in part to a weakness of evidence, related to the difficulty of getting ethical clearance,
as well as a generalised tendency to downplay the importance of those interventions found to be efficacious. No
priority has been given to implementing existing policy and programme guidance for the control of maternal
anaemia largely because of a lack of any dedicated funding, linked to a lack of Millennium Development Goals
indicator status. This is partly due to the poor evidence base, as well as to the common belief that maternal
anaemia programmes were not effective, even if efficacious. The process of providing evidence-based policy and
programme guidance to member states is currently being revamped and strengthened by the Department of
Nutrition for Health and Development of WHO through the Nutrition Guidance Expert Advisory Group pro-
cesses. How and if programme guidance, as well as policy commitment for improved maternal nutrition, will
be strengthened through the Nutrition Guidance Expert Advisory Group process is as yet unclear. The global
movement to increase investment in programmes aimed at maternal and child undernutrition called Scaling Up
Nutrition offers an opportunity to build developing country experience with efforts to improve nutrition during
pregnancy and lactation. All member states are being encouraged by the World Health Assembly to scale-up
efforts to improve maternal infant and young child nutrition. Hopefully Ministries of Health in countries most
affected by maternal and child undernutrition will take leadership in the development of such plans, and ensure
that the control of anaemia during pregnancy is given a great priority among these actions, as well as building
programme experience with improved nutrition during pregnancy and lactation. For this to happen it is essential
that donor support is assured, even if only to spearhead a few flagship countries.

Keywords: maternal nutrition, policy and programme guidance.

Maternal undernutrition is a serious global problem.
Anaemia affects about a half of the pregnant women
in the world, with little or no reduction in the last two
Correspondence: Roger Shrimpton, PhD, Urbanização Zona Alta,
Lote 1, Apt 3D, 8700-270 Olhão, Portugal.
E-mail: roger.shrimpton@sapo.pt
decades.1 Low birthweight (LBW) rates affect about
15% of the babies born each year globally, with the
highest concentration in South Asia where 27% are so
affected. Excessive thinness, that is, a body mass index
of <18.5 kg/m2, affects >20% of women of reproduc-
tive age in countries of South Asia. Despite this, in

© 2012 Blackwell Publishing Ltd

Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
316 R. Shrimpton
most developing countries the only maternal nutrition
programmes are for maternal anaemia2 and even these
are recognised to be of poor effectiveness, especially
because maternal anaemia rates have not improved.
Maternal nutrition is an important determinant of
young child growth failure. It is well accepted that the
process of child length growth faltering in children
from developing countries occurs in a critical 1000
day ‘window of vulnerability’ from conception to
2 years of age.3 Comparison with the new World
Health Organization (WHO) growth standards reveals
that such children are already born with weights
and lengths below normal,4 confirming the need for
greater efforts to improve nutritional status of preg-
nant women and women in childbearing age. The tra-
jectory of length growth after birth seems to be largely
set in uterus,5,6 even though it can falter from birth to
2 years, such that poor maternal nutrition may be
as important as inadequate infant and young child
feeding practices in determining height at 2 years of
age, depending on the country setting.7,8 After the
second year of life the length growth of children is
essentially the same on average for all children. Those
born with LBW are about 5 cm shorter than those not
born LBW at age 17–19 years, be it in developed or
developing countries.9 Because the adequacy of height
at 2 years of age seems to be a good proxy for the
quality of the future human capital of a nation,10 there
is increasing concern with the process of becoming
stunted. The concern being that restricted growth
during pregnancy which limits length growth poten-
tial, also impacts negatively on brain and immune
system development.
The Lancet Nutrition Series (LNS) described a
package of interventions, which could reduce stunting
at 36 months by a third and early child mortality by
a quarter if implemented at scale in the 36 countries
most affected by maternal and child undernutrition
(MCU) and that retain 90% of the global burden of
stunting.11 Few if any countries have implemented
this package of interventions at scale however. The
LNS also considered the processes for producing nor-
mative nutrition guidance to be laborious and dupli-
cative, and the international nutrition system to be
largely dysfunctional.12 However, the authors did not
describe the processes for providing normative policy
guidance, or suggest how this could be simplified
and/or improved.
Undernutrition in one form or another therefore
affects the majority of women of reproductive age in
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
developing countries and is an important cause
of young child growth failure, yet few if any pro-
grammes address the problem. The purpose of this
paper is to describe the global policy and programme
guidance mechanisms for nutrition, what their con-
tent is with regard to maternal nutrition, as well as to
suggest ways that this situation might be improved.
Methods
Information was collected both through direct inter-
views as well as email exchanges with those involved
in and responsible for policy and programme work,
in or linked to the field of nutrition, within the WHO
during the month of July 2010. Interviews were
conducted with seven members of the Department
of Nutrition for Health and Development (NHD), as
well as three concerned members of the Departments
of Child and Adolescent Health, one from the Depart-
ment for Making Pregnancy Safer, and two from
the Department of Reproductive Health Research,
in addition to the six Regional Nutrition Officers.
Searches were also carried out in PubMed and with
Google using the search terms ‘maternal nutrition’,
‘nutrition policy’ and ‘nutrition programme guid-
ance’, for recommendations and guidance coming
from intergovernmental sources on how to deal
with maternal nutrition problems. The results of these
various interviews, searches, reports and feedback
form the basis for this article which was finalised after
a further review of the literature and feedback on pre-
liminary drafts, in April 2011. To facilitate understand-
ing of a broader audience, the many abbreviations that
abound in this literature are listed together with their
extensive form in Table 1.
Results
The global mechanisms that regulate and/or provide
guidance for national nutrition efforts are all inter-
governmental, with commitments ranging from broad
political ones to those that are more policy related.
Political commitments are for a nation as a whole
while policy commitments relate to a national govern-
ment commitment for a programmatic area or sector.
These mechanisms are summarised in Table 2 in accor-
dance with the nature of the strength of commitment
and scope of orientation. Mechanisms related to emer-
gency or humanitarian aid situations are not consid-
ered in this analysis.
© 2012 Blackwell Publishing Ltd
 Policy and programme guidance on maternal nutrition
Table 1. A list of acronyms found in the literature searched con-
cerning maternal and child nutrition
BMI = body mass index
CAH = Department of Child and Adolescent Health of WHO
CEDAW = Convention on the Elimination of all Forms of
Discrimination Against Women
CFS = Committee on World Food Security of FAO
CHERG = Child Health Epidemiological Research Group
CMBS = The Code of Marketing of Breastmilk Substitutes
CODEX = Codex Alimentarius Commission
ENA = Essential Nutrition Actions
FAO = Food and Agriculture Organization
HIV/AIDS = Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome
ICESCR = International Covenant Economic, Social and
Cultural Rights
IDD = iodine deficiency disorders
IMCI = Integrated Management of Childhood Illness
IMPAC = Integrated Management of Pregnancy and
Childbirth
IYCF = Infant and Young Child Feeding
IYCN = Infant and Young Child Nutrition
LBW = low birth weight
LiST = Lives Saved Tool
LNS = Lancet Nutrition Series
MCU = maternal and child undernutrition
MIYCN = Maternal Infant and Young Child Nutrition
NGOs = non-government organisations
NHD = Department of Nutrition for Health and Development
of WHO
NUGAG = Nutrition Guidance Expert Advisory Group
RHL = Reproductive Health Library
RHR = Department of Reproductive Health Research of WHO
SUN = Scaling Up Nutrition
UDHR = Universal Declaration of Human Rights
UN = United Nations
UNICEF = The United Nations Children’s Fund
US = United States of America
WFC = World Fit for Children
WFP = World Food Programme
WSC = World Summit for Children
WHA = World Health Assembly
WHO = World Health Organization
Intergovernmental political commitments
Political commitments are formed when states agree
to work together to achieve development outcomes,
that usually include certain minimum standards or
goals which may be nutrition related. The strength of
commitment of these political agreements varies from
international covenants and treaties with potential
legal implications to far less binding ones to work
together in favour of certain improved development
© 2012 Blackwell Publishing Ltd
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
317
outcomes. These contrasting ‘rights based’ and ‘needs
based’ approaches to development can be complimen-
tary, even if of differing orientation.13
Most nations are politically committed to freeing
their citizens from the scourge of hunger and malnu-
trition, be it through the Universal Declaration of
Human Rights of 1948, or the International Covenant
Economic, Social and Cultural Rights of 1966. For
maternal nutrition specifically, further instruments
include the 1979 Convention on the Elimination of All
Forms of Discrimination Against Women (CEDAW),
which in article 12 says that all states shall ensure to
women appropriate services in connection with preg-
nancy, confinement and the postnatal period, granting
free services where necessary, as well as adequate
nutrition during pregnancy and lactation. Currently
158 states are parties to the legally binding Interna-
tional Covenant on Economic, Social and Cultural
Rights, and although around 30 United Nations
member states have not yet signed the Covenant, only
five signatories have not yet ratified it, and only six
have not yet ratified the CEDAW.14
In 2000 the United Nations General Assembly
endorsed The Millennium Development Declaration,15
committing all state parties to work together to
achieve eight international development goals, called
the Millennium Development Goals (MDGs). The first
MDG on poverty reduction (MDG 1) includes a target
to halve the proportion who suffers from hunger
by 2015. There are no MDGs that are specifically
related to maternal nutrition, although there is one for
maternal health (MDG 5). In 2010 progress towards
the MDGs was considered insufficient to meet the
targets.16
In 2002 the General Assembly also adopted the
resolution for a World Fit for Children which built on
the progress and achievements of the 1990 World
Summit for Children (WSC) and agreed to achieve the
unmet WSC goals and to achieving other goals and
objectives, in particular the MDGs, by 2015. The
World Fit for Children objectives included the reduc-
tion of child malnutrition among children under 5
years of age by at least one-third, with special atten-
tion to children under 2 years of age, and reduction in
the LBW rate by at least one-third of the current rate.17
It was further agreed these goals would be achieved
by strategies and actions which among others, aim
to: improve the nutrition of mothers and children,
including adolescents, through household food secu-
rity, through dietary diversification, food fortification
 318
Table 2. Intergovernmental mechanisms for providing nutrition-related recommendations

Scope and orientation of recommendations

Type of mechanisms and strength Rights-based, normative and Needs-based, target-goal driven,
R. Shrimpton

of commitments/who for standard setting efficacy and effectiveness Where/who by

Political commitments UDHR – freedom from hunger MDGs especially MDG 1 Poverty Reduction with Rights: Human Rights Council
– Rights based: potentially legally binding CSECR – right to food hunger reduced by half of 1990 level by 2015 MDGs: United Nations General
for each nation state CRC – right to develop (mental and physical) (energy adequacy and child underweight) Assembly
– Goal based: a collective political promise CEDAW – right to adequate nutrition during
– Most nations pregnancy
Policy commitments – Global Strategy on Infant and Young Child – Iodine deficiency disorders and universal salt WHA (CODEX and CFS not
– Global Strategies are about minimum Feeding including Code of Marketing of iodization (MDG 2) included)
standards of health for all the population Breastmilk Substitutes – Vitamin A supplementation (MDG 4)
that WHA urges member states to adopt – Global Strategy on Diet and Physical Activity – Exclusive breast feeding (MDG 4)
– Goals-based interventions are about – Global Strategy on the Prevention and Control – Adequate complementary feeding (MDG 1)
reaching targets (i.e. 50% reduction) that of Non-Communicable Diseases – Lancet Nutrition Series package (all MDGs)
all nations agreed to work towards
– All member states
Policy guidance – Development of Child Growth Standards – Development of guidelines for food fortification WHO/FAO/UNICEF/
Technical recommendations on ‘what to do’ – Development of Recommended Dietary Intakes – Development of guidelines for micronutrient WFP/NGOs
for any party (national governments, supplementation
NGOs, private sector) to use in – Development of guidelines for adequate infant
developing programmes and young child feeding
– Maternal iron folic acid supplementation, MPS/RHL
calcium supplementation, energy/protein
supplementation
Programme guidance – Promotion of adequate infant and young child feeding NHD/CAH/UNICEF
Technical orientation on ‘how to’ for any – Promotion of infant and young child growth and development
party (national governments, NGOs, – Control of iodine deficiency NHD/UNICEF/WFP/NGOs
private sector) to use in developing – Control of vitamin A deficiency
programmes – Control of anaemia
– Promotion of Essential Nutrition Actions Basics/WHO/UNICEF

CAH, Department of Child and Adolescent Health of WHO; CEDAW, Convention on the Elimination of all Forms of Discrimination Against Women; CFS, Committee on World Food
Security of FAO; Codex Alimentarius Commission; CODEX; FAO, Food and Agriculture Organization; CRC, Convention on the Rights of the Child; CSECR, Covenant on Economic,
Social and Cultural Rights; MDGs, Millennium Development Goals; MPS, Department for Making Pregnancy Safer; NGOs, non-government organisations; NHD, Department of
Nutrition for Health and Development of WHO; RHL, Reproductive Health Library; UDHR, Universal Declaration of Human Rights; UNICEF, The United Nations Children’s Fund;
WFP, World Food Programme; WHA, World Health Assembly; WHO, World Health Organization.

Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325

© 2012 Blackwell Publishing Ltd
 Policy and programme guidance on maternal nutrition
and supplementation, access to basic social services
and adequate caring practices.
Intergovernmental policy commitments
Policy commitments are formed when recommenda-
tions and guidance are agreed to and endorsed by the
international bodies that oversee the relevant techni-
cal area for a policy. As described in Table 2, the prin-
cipal authority for international policy guidance in the
area of nutrition lies with WHO through its govern-
ing body the World Health Assembly (WHA). Other
technical bodies that generate nutrition-related inter-
governmental agreements include the Committee
on World Food Security of the Food and Agriculture
Organization (FAO), as well as the Codex Alimenta-
rius Commission. The Committee on World Food
Security of the FAO policy recommendations are
mostly limited to food security, while The Codex
Alimentarius Commission is concerned with food
safety,18 both of which are essential but alone insuffi-
cient requirements for nutrition security. For the
purpose of this review the mechanisms for generating
policy recommendations focuses on those generated
by the WHA, the principal policy making body for
nutrition globally.
The WHA has endorsed three Global Strategies
that are nutrition related, and that are essentially nor-
mative, that is, they make recommendations setting
standards to be achieved for the whole population.
Among these is WHA55.25 on Infant and Young
Child Nutrition (IYCN) adopted in 2002 which urged
member states to adopt and implement the Global
Strategy for Infant and Young Child Feeding (IYCF)
in order to ensure optimal feeding for all infants
and young children, and to reduce the risks associated
with obesity and other forms of malnutrition.19 In
addition there are the Global Strategy on the Control
of Non-Communicable Diseases adopted in 2000,20
and the Global Strategy on Diet and Physical Activity
adopted in 2004,21 both of which make recommenda-
tions concerning how populations should eat and take
exercise in order to reduce the risk of obesity, diabetes
and other non-communicable diseases.
The NHD is the principal unit within WHO respon-
sible for supporting the development of global norma-
tive guidance in nutrition. The NHD website lists the
36 WHA resolutions on nutrition, of which 50% are on
IYCN, 25% on micronutrients, and 25% on other more
policy-related nutrition issues. The IYCN resolutions
© 2012 Blackwell Publishing Ltd
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
319
are especially concerned with the International Code
of Marketing of Breastmilk Substitutes (CMBS), which
was adopted by the WHA in 1981 as a ‘minimum
requirement’ to be enacted ‘in its entirety’ in ‘all coun-
tries’. The resolution also request the Director General
of WHO to report every 2 years on progress with the
implementation of the CMBS. Since then a further 16
WHA resolutions on IYCN have been adopted, almost
one every 2 years, all of which must be considered
together with the CMBS in their interpretation and
translation into national measures.
Since the WSC in 1990, WHA resolutions on
IYCN have increasingly included endorsements for
the targets of needs based approaches including WSC
goals for exclusive breast feeding, adequate comple-
mentary feeding, and vitamin A supplementation. A
select few WSC goals were made mid-decade goals,
to be achieved by 1995 and in consequence received
extra priority and resources from The United Nations
Children’s Fund.22 The control of iodine deficiency
disorders was the only nutrition mid-decade goal, and
seven of the nine WHA resolutions on micronutrients
are specifically on the elimination of iodine deficiency
disorders, as stand-alone endorsements.
There are no WHA resolutions on maternal nutri-
tion as a stand-alone issue, and in none of the other
nutrition related resolutions is maternal nutrition
indicated to be a problem. In none of the many WHA
resolutions on IYCN which promote exclusive breast
feeding for the first 6 months of life and continued
breast feeding through to at least 2 years of age is the
nutritional status of the mother questioned or consid-
ered. The 2002 Global Strategy on IYCF recommends
that the effect of improving maternal nutritional status
on pregnancy outcomes be considered as an ‘impor-
tant research topic’, suggesting that nothing is proven
in this regard. The lack of importance given to mater-
nal nutrition in the normative guidance on IYCF is
unfortunately compounded by the lack of importance
given to maternal nutrition by normative guidance
on maternal health. The WHO Reproductive Health
Strategy, endorsed by the WHA in 2004, only men-
tions the word ‘nutrition’ twice in its 65 pages and has
no mention at all of maternal anaemia, for example, as
being a problem for reproductive health.23
Intergovernmental policy and programme guidance
Providing normative guidance on minimum standards
and effective interventions is considered to be an
320 R. Shrimpton
important component of the stewardship function
of the international nutrition system.12 As shown in
Table 2, there are two dimensions to this function: one
is policy guidance, which is technical recommenda-
tions on ‘what to do’; the other is programme guid-
ance, which is more about explaining ‘how to do it’.
Both policy and programme guidance are listed
together on the NHD website, organised under the
four functional areas of NHD namely: (1) Growth
Assessment and Surveillance, (2) Reduction of Micro-
nutrient Malnutrition, (3) Nutrition in the Lifecourse,
and (4) Nutrition Policy and Scientific Advice. Each of
these substantive areas has two categories of guidance,
namely ‘nutrition topics’ and ‘publications’, with each
being hyperlinked to their relevant source for down-
loading the relevant documents. The list of ‘nutrition
topics’ tends to be concerned with policy guidance
and the list of ‘nutrition publications’ is more con-
cerned with programme guidance.
Policy guidance from NHD can be divided into
those more rights-based and normative in orientation
and those more needs-based and target driven. The
normative policy guidance includes the develop-
ment of child growth standards and of recommended
dietary intakes for example, which provide the scien-
tific underpinning for the normative aspects of the
right to food and the right to development. Such nor-
mative policy guidance is developed through techni-
cal expert meetings often in collaboration with FAO
if they concern dietary intakes for example. Needs-
based goal-driven policy guidance is more on specific
topics like micronutrient supplementation and food
fortification, aimed at controlling a deficiency state in
order to achieve a specific target. Maternal anaemia
reduction is included within the anaemia policy guid-
ance. Such guidance is usually developed by experts
with support from the various agencies and non-
government organisations that are active in that par-
ticular field.
The only NHD policy guidance related to maternal
nutrition as a stand-alone issue is in the area of
‘foetal/maternal nutrition’. The report of the 2003
technical consultation on ‘Promoting Optimal Foetal
Development’ concluded among other things that
many of the required components of a strategy for
promoting optimal foetal development already exist
as single packages, and proposed that by embedding
these components in a broader framework, other
approaches and programmes (Integrated Management
of Childhood Illness, Making Pregnancy Safer, Roll
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
Back Malaria and HIV/AIDS) can become part of
an overall package of measures which collectively
work together to secure the strategy objectives, that is,
optimal foetal development.24 Two regional meetings
were held in follow up and largely arrived at the same
conclusions, but how this broader framework would
be articulated and who would champion this were not
articulated.
Policy guidance for maternal nutrition is also
provided through the Reproductive Health Library
(RHL) in collaboration with the Department of
Reproductive Health Research.25 The RHL provides
summaries of the findings of Cochrane Reviews, and
provides evidence-based nutrition policy guidance
for ‘pregnancy and lactation’ which includes: calcium
supplementation; iron supplementation; multiple
micronutrient supplementation; energy and protein
intake, periconceptional supplementation with folate
and/or multivitamins for preventing neural tube
defects, and vitamin A supplementation. For energy
and protein intake during pregnancy the guidance
is that ‘dietary advice is unlikely to yield any major
benefits for either the infant or the mother. The
best way of improving the dietary status of pregnant
women may be to supplement their diets with energy-
rich foods through community-based sustainable pro-
grammes. The best long-term solution is to raise the
social and economic status of women’.26 The guidance
for supplementary iron or iron + folic acid (provided
either daily or weekly) is that it is considered ‘effective
in preventing anaemia and iron deficiency at term,
although there is no significant effect of supplementa-
tion on the incidence of substantive maternal and neo-
natal adverse clinical outcomes such as LBW, delayed
development, preterm birth, infection, and postpar-
tum haemorrhage’.27
Programme guidance on how to develop and
implement nutrition programmes brings together the
rights-based and evidence-based guidance modalities.
Such guidance includes the ‘what to do’, the ‘why
to do’ and the ‘how to do’. Most of the NHD publica-
tions explaining ‘how to implement programmes’ are
related to goal-driven programmes. These are deve-
loped in collaboration with Department of Child
and Adolescent Health in particular for IYCN
programmes, as well as with other agencies that have
funding to promote those particular nutrition pro-
grammes, such as The United Nations Children’s
Fund and the US funded non-government organisa-
tions that support food and nutrition programmes
© 2012 Blackwell Publishing Ltd
 Policy and programme guidance on maternal nutrition
such as Basics for example. One of these publications
produced by Basics, brings together all of the various
nutrition protocols, including a chapter on maternal
nutrition, and explains how a district health officer
could manage the implementation of these in an inte-
grated manner.28
The main source of maternal nutrition programme
guidance from WHO is provided through the Depart-
ment for Making Pregnancy Safer and its publications
on the ‘Integrated Management of Pregnancy And
Childbirth’ (IMPAC).29 This includes key interventions
to be delivered through health services, family and
the community in order to improve maternal and
newborn health and survival. The print versions of
IMPAC available in mid-2010 did not reflect the latest
policy guidance on nutrition in pregnancy as on the
RHL website however, largely due to lack of funds to
update and reprint IMPAC since it was last published
in 2007.
Future directions in nutrition policy and
programme guidance
The NHD is currently strengthening its role in provid-
ing evidence-based policy and programme guidance
to member states. Guided by the new WHO Guide-
lines Development process,30 NHD is implementing
the development and update of some 30 nutrition
guidelines in 2010–2011 through four subgroups
of the Nutrition Guidance Expert Advisory Group
(NUGAG). Only five of the guidelines are specifically
on women during pregnancy and lactation and they
are in the micronutrient subgroup. In the nutrition in
the life course subgroup, which is where maternal
nutrition is to be dealt with, none of the nine topics
covers maternal nutrition specifically. How NUGAG
can learn from the experience gained from ‘Essential
Nutrition Actions’ initiative28 promoting the inte-
grated delivery of a package of such nutrition inter-
ventions is perhaps one of the most important of these
future directions.
Comments
It seems remarkable that while there is broad political
commitment to ensuring adequate maternal nutrition
as a human right, there are no policy commitments for
this emanating from the WHA. Difficulty in creating
a strong evidence base would seem to be one of the
reasons why there is no policy commitment for mater-
© 2012 Blackwell Publishing Ltd
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
321
nal nutrition, as well as the lack of a champion. But
these are probably related because if there was a
strong evidence base there would more likely be a
champion.
The lack of evidence that maternal iron supplemen-
tation improves maternal and child survival and deve-
lopment is in part because the global policy existed
before an evidence base was created. Iron supplemen-
tation as the treatment of maternal anaemia during
pregnancy was made policy in the US in 1968,31 and
global policy guidance from WHO followed in 1972.32
Experience gained with implementing iron supple-
mentation programmes during the seventies and
eighties led to the development of WHO programme
guidance on how to deliver programmes to control
anaemia in 1989.33 In consequence it became very
difficult on ethical grounds to carry out trials of iron
supplementation during pregnancy with a placebo
control anywhere in the world. While observational
studies strongly suggest that iron deficiency anaemia
contributes substantially to death and disability, espe-
cially among women and children in Asia and Africa,
it is also recognised that the need for definitive evi-
dence continues to be a barrier for action.34 Evidence
for the importance of iron supplementation during
pregnancy on birthweight has now emerged from
trials in non-anaemic mothers in developed country
settings.35
It would also seem that the importance of maternal
nutrition has been minimised by a variety of compet-
ing development actors. The pro-breast-feeding move-
ment claims there is very little difference in the milk
of healthy mothers and mothers who are severely
malnourished36 largely in order to counter any claims
by formula companies of the superiority of their pro-
duct.37 Those involved in promoting maternal health
have also asserted that there is no evidence that nutri-
tion makes a major difference in maternal mortality,38
or to support the implementation of specific nutrition
public health interventions to prevent impaired foetal
growth,39 and even that maternal supplementation can
be dangerous.40 The very conservative interpretations
of the evidence of the importance of maternal nutri-
tion interventions can also be seen in the guidance
found in the RHL, the over-arching message seems to
be to wait for socio-economic development.
The competing interests of breast feeding, and
maternal health causes, make the politics of maternal
nutrition quite complicated, especially when competi-
tion for funding is so critical for any intervention to be
322 R. Shrimpton
prioritised. Funding of WHO for the development of
policy guidance largely depends on extra budgetary
funding by the donors who largely choose what they
want to support.41 The apparent lack of evidence for
the importance of maternal nutrition interventions
either for maternal mortality or for child growth
and survival outcomes meant that no MDG-linked
maternal nutrition targets were adopted. In turn this
has meant no earmarked donor funding for maternal
nutrition programmes during the last two decades
that goal driven approaches have become more domi-
nant. This lack of evidence linking maternal nutrition
to either MDG 5 in particular has therefore contrib-
uted to the lack of interest in maternal nutrition and to
the lack of a champion that would raise these issues in
the WHA for example, and donor funding has gone
elsewhere.
In 2010 the WHA endorsed Resolution WHA63.23
on IYCN42 which urged member states to scale
up interventions to improve IYCN in an integrated
manner with the protection, promotion and support
of breast feeding and timely, safe and appropriate
complementary feeding as core interventions; the
implementation of interventions for the prevention
and management of severe malnutrition; and the
targeted control of vitamin and mineral deficiencies.
WHA63.23 further more requested the Director
General to develop a comprehensive implementation
plan on IYCN as a critical component of a global mul-
tisectoral nutrition framework for preliminary discus-
sion at the 64th WHA (2011) and for final delivery at
the 65th WHA (2012), through the Executive Board
and after broad consultation with member states. The
Secretariat Report prepared for discussion at the 64th
WHA in May 2011 stated that the Executive Board
recommended changing the name of the plan to cover
maternal nutrition, that is, to become Maternal IYCN
(MIYCN), as well as to deal more clearly with the
double burden of undernutrition and overweight.43
The increasing global momentum for investing in
nutrition programmes provides an opportunity to
strengthen the development of maternal nutrition
programmes. The global movement to fund national
nutrition programmes called Scaling Up Nutrition
(SUN), recognises that development funding for MCU
has been far too small, and that increased investments
in nutrition would help to achieve all MDGs.44 Under
the SUN umbrella an estimate of the costs for taking
the LNS package of interventions11 to scale in the
68 countries most affected by stunting has been
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
developed.45 Because of the lack of policy and pro-
gramme guidance, these estimates did not include the
costs of scaling up maternal nutrition interventions
other than iron supplementation. The LNS package
included balanced energy protein supplementation in
pregnancy, with an estimated 32% reduction in intrau-
terine growth retardation in populations where >10%
of mothers were excessively thin (body max index
<18.5). Now would seem to be an opportune time
for countries with problem to develop policy and
programme guidance for nutrition during pregnancy
and lactation, which could build on the implementa-
tion guide developed for the US,46 with suitable adap-
tion to take into consideration local contextual issues.
The reinvigoration of maternal anaemia reduction
efforts should be seen as the ‘low hanging fruit’ in
scaling up MIYCN programmes. The ‘what’ and the
‘how’ of controlling maternal anaemia are well known
and the policy for the provision of iron and folic acid
tablets during pregnancy already exists in most coun-
tries.47 A wealth of programme experience shows that
the reasons for such programmes not working is
not related to problems of acceptance of the tablets.48–50
The problem lies with maintaining the supply of
tablets and ensuring regular delivery51 together with
infection control.52 It means ensuring that iron folic
acid tablets are included in the continuum of care
being delivered by health services from conception to
2 years of age,53 especially through the community
based outreach mechanisms with community facilita-
tors and mobilisers encouraging adherence.54 Mea-
surement of anaemia should be an essential part of
re-establishing this programmatic area of work, and a
relatively accessible tool has been developed for this.55
In most developing countries the norm is blanket pro-
vision of iron tablets without the need for a diagnostic
test for anaemia. In consequence the problem is rarely
measured and the patient is never aware what their
anaemia status is, let alone has the problem explained
to them. Anaemia is not one of the Countdown indi-
cators56 for example, and so does not get included in
health system management information systems and
is not on the radar of district health management
teams. What is not measured is not important. For all
of this to happen, it is essential that a donor decides to
fund these activities and provide technical assistance,
even if only in a few ‘flagship countries’ to begin with
and help build programme experience.
The renewed efforts of NHD to improve the nutri-
tion policy guidance mechanisms through NUGAG
© 2012 Blackwell Publishing Ltd
 Policy and programme guidance on maternal nutrition
are certainly to be applauded. However, whether
these mechanisms will prove capable of delivering
policy and programme guidance within a time frame
capable of influencing the development of the com-
prehensive implementation plan on MIYCN is less
sure, as any new policy guidance will take up 2 to 3
years to be developed, let alone to be disseminated.
Maternal nutrition issues will certainly have to wait
for the next biennium in 2012 to be included in new
guideline development. In the mean time the global
nutrition and health research community continues to
produce evidence on the importance of a multitude of
nutrition and non-nutritional inputs for various birth
outcomes, and especially maternal newborn and child
survival. One such group is the Child Health Epide-
miological Research Group,57 and most recently the
Lives Saved Tool modality of Child Health Epidemio-
logical Research Group has just produced some
35 new reviews, including nine reviews of nutrition
interventions, which are published and available
online.58 How the NUGAG groups can best coordinate
and/or draw on and/or even be ‘up-to-speed’ with
the development of these various disparate research
efforts, including the results of this maternal nutrition
review group, is obviously a challenge.
The whole issue of accountability for maternal
nutrition is one that is obviously still left begging.
Most states are committed to ensuring mothers nutri-
tion during pregnancy as a right, but it is hard to find
any evidence of citizens claiming that right. FAO has
helped develop normative clarification of the right to
food through General Comment 12.59 Country led
efforts to implement this right are also supported by
dissemination of the Right to Food Guidelines,60 as
well as a ‘Tool-box’ on different aspects of the right to
food.61 The latter includes a paper on ‘Women and the
Right to Food’ that looks at aspects of international
law and state practice in this regard.62 It would be
interesting to see if the experience with realising the
right to food could be used and extended to promot-
ing the right to maternal nutrition as proscribed in
CEDAW.
Conclusions
We can conclude that almost all countries are political
committed to ensuring that the right of mothers
to good nutrition during pregnancy and lactation is
realised. Despite this commitment the majority of
mothers in countries most affected by MCU suffer
© 2012 Blackwell Publishing Ltd
Paediatric and Perinatal Epidemiology, 2012, 26 (Suppl. 1), 315–325
323
from at least one form of undernutrition. Furthermore
few if any countries that are among those most
affected by MCU have any programmes dealing with
maternal undernutrition beyond maternal anaemia,
and even the anaemia programmes are not working
in most countries. There are no global policy commit-
ments in relation to maternal undernutrition coming
from the WHA. Policy and programme guidance
from WHO is provided with regard to the treatment
and prevention of maternal anaemia in particular, but
there is little or no policy or programme guidance on
how to deal with issues of maternal thinness, weight
gain during pregnancy and/or LBW prevention for
example.
The lack of importance given to maternal nutrition
programmes is in part related to a lack of evidence,
as well as a systematic tendency to down play the
importance of the evidence that exists by other actors,
such as those interested in promoting maternal health
and breast feeding. This minimising of the impor-
tance of maternal nutrition has resulted in a lack of
linkage of maternal nutrition indicators to MDG goals
and targets, and in consequence very little donor
funding, that is so essential for interventions to get
implemented.
The process of providing evidence-based policy and
programme guidance to member states is currently
being revamped and strengthened by NHD through
the NUGAG processes. How and if programme guid-
ance as well as policy commitment for improved
maternal nutrition will be strengthened although the
NUGAG process, is as yet unclear.
The global movement to increase investment in
MIYCN programmes called SUN offers an opportu-
nity to build developing country experience with
efforts to improve nutrition during pregnancy and
lactation. All member states are being encouraged by
the WHA to scale up such plans. Hopefully Ministries
of Health will assume the leadership in the scaling
up the MIYCN interventions, and among these the
control of anaemia during pregnancy will be given a
great priority, as well as building programme experi-
ence for improved nutrition during pregnancy and
lactation. For this to happen it is essentially that a
donor decide to take up the cause and help establish
such efforts.
Conflicts of interest
The author has no conflicts of interest to declare.
324 R. Shrimpton
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