UNICEF SOUTH ASIA TARGET
10 million fewer children with stunted growth and development by 2021
40 per cent reduction in child stunting by 2025
After that, it is very difficult to get back what the child has lost. This time cannot be replaced.”
UNICEF Regional Ambassador for Nutrition in South Asia
In South Asia, 36 per cent of under-five children are stunted. The three main causes of child stunting are
poor diets in the first two years of life, poor nutrition of women before and during pregnancy, and poor sanitation.
10 million fewer children with stunted growth and development by 2021
40 per cent reduction in child stunting by 2025
Stunting in infancy and early childhood causes damage that lasts a lifetime. It increases the risk of dying from childhood illnesses, impairs cognitive development, lowers educational performance and reduces the likelihood in adulthood of earning a decent wage. When accompanied by excessive weight gain in later life, it also increases the risk of nutrition-related chronic diabetes.
In close alignment with Sustainable Development Goal (SDG) 2, UNICEF South Asia supports the scale-up of evidence-based programmes to prevent stunting and other forms of malnutrition in children, adolescents and women. This requires a multi-sector approach involving health, nutrition, WASH (water, sanitation and hygiene), social policy and education.
In early childhood, our priority is to prevent malnutrition throughout the 1,000-day window of opportunity between conception and a child's second birthday. This includes actions to improve nutrition during pregnancy and lactation, and to optimize child feeding and care practices in the first two years of life. It also involves micronutrient nutrition and anaemia control in young children. When children suffer severe acute malnutrition they must be detected quickly and treated in line with World Health Organization (WHO) recommendations.
UNICEF also works to prevent anaemia and other forms of malnutrition in school-aged children, adolescents and women, to improve both their own nutrition and that of future generations.
Global estimates indicate that about 22 per cent of under-five children (151 million) had stunted growth in 2017. Stunting levels in South Asia (35 per cent) are the highest in the world and the region bears 40 per cent (59 million) of the global burden of stunted children. The regional average masks wide disparities in national stunting levels - stunting in Pakistan is twice as prevalent as the global average, for instance.
Data source: National surveys (Demographic and Health Surveys and National Nutrition Survey, various years) and UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates, 2018
Improvements are slow
The prevalence of stunting in South Asia declined from about 51 per cent (89 million children) in 2000 to 35 per cent (59 million children) in 2017, with all countries seeing some improvement (see figure below). While this progress is impressive compared to most other regions, it is too slow reach the SDG target of reducing the number of stunted children by 40 per cent. In fact, only Bangladesh has is on course to meet this target.
Data Source: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates, 2000-2017
There are large disparities
Regional and national averages hide important disparities. In six of the eight South Asian countries, the percentage of stunted children in the poorest wealth quintile is more than double the percentage in the richest wealth quintile.
Data source: National surveys (Demographic and Health Surveys and National Nutrition Survey), various years
Between 2000 and 2017, the number of stunted children in South Asia declined by about 30 million from 89.2 million to 59.4 million (see figure below). But the reduction over the past three years (2014-2017) was roughly 7-8 million between, which fell short of UNICEF's target of 12 million during this period.
Much greater efforts are clearly needed to ensure that women, children and their families receive the services and support they need to prevent stunting. This includes information for caregivers on how best to feed their children in early life, and access to affordable nutritious foods. Children need prompt treatment if they become severely acutely malnourished, and adolescent girls and women must receive services for the prevention of anaemia and other forms of malnutrition.
1 - AFGHANISTAN
UNICEF supported the Afghanistan government to become the 60th country to join the global Scaling Up Nutrition (SUN) movement - a global partnership that brings actors together to tackle nutrition challenges - in 2017. UNICEF also supported the government to launch its Food Security and Nutrition Agenda (AFSeN), a multi-sectoral, multi-stakeholder framework to ensure that all Afghans, especially children, have adequate physical and economic access to nutritious food. These milestones mark a substantive expansion from treatment to a greater emphasis on preventing all forms of malnutrition. The coverage of essential nutrition interventions has been significantly increased: over 200,000 children with severe acute malnutrition are now treated annually. And almost a million adolescent girls receive iron-folate supplements, together with twice-yearly deworming and education on good nutrition.
2 - BANGLADESH
Following the development of Bangladesh's National Nutrition Policy in 2015, UNICEF supported Bangladesh to develop a National Plan of Action on Nutrition (NPAN) and revitalize the Bangladesh National Nutrition Council (BNNC, the highest policy and coordinating body for nutrition). With the establishment of District Nutrition Support Officers - which the government has agreed to finance throughout the country - UNICEF support has significantly enhanced the capacity for decentralized decision-making and multi-sectoral engagement. UNICEF also introduced and supported the roll-out of competency-based training for frontline workers, and a real-time monitoring platform on nutrition service delivery has been institutionalized through the country. Eighty per cent of health facilities now provide counselling to caregivers on infant and young child feeding, and 76 per cent are equipped with essential supplies (compared to just 5 per cent at the outset). An innovative Mothers@Work initiative is demonstrating how garment factories can support their female employees to continue breastfeeding when they return to work, and how this benefits both the companies and the mothers themselves.
3 - BHUTAN
Stunting in young children decreased significantly - from 33 to 21 per cent - between 2010 and 2015 in Bhutan, but it remains a public health problem. UNICEF contributed to the development of a multi-sectoral National Food and Nutrition Security Strategy and Accelerated Plan for Nutrition. UNICEF also supported the design and implementation of the National Nutrition Survey, which generated disaggregated data that has been used to identify key drivers of malnutrition. The analysis has been used to refocus efforts on the low diversity of children's diets, beginning with the development of National Guidelines on Complementary Feeding.
4 - INDIA
Following sustained advocacy and support by UNICEF, India's National Nutrition Strategy was launched and the National Nutrition Mission received cabinet approval in 2017. UNICEF has also supported the formation of seven State Nutrition Missions to bring key sectors such as health and WASH to work together to enhance maternal and child nutrition. UNICEF assisted the government to further expand and improve its nutrition programmes to prevent under-nutrition in early life, to care for severely wasted children and to improve the nutritional status of adolescent girls and women. The focus is on the most economically disadvantaged populations and children of socially excluded groups. UNICEF partnered with State Rural Livelihood Missions to implement the Swabhimaan demonstration programme to improve women's nutrition in three states. The Weekly Iron Folic Acid Supplementation programme now covers 14 states and reaches 36 million adolescents. The Comprehensive National Nutrition Survey (CNNS) will provide national and state-level data on the nutritional status of preschoolers, school-age children and adolescents.
5 - MALDIVES
UNICEF is supporting the implementation of the national standards and programme on infant and young child feeding. UNICEF is also helping to build the capacity of health staff to counsel mothers on feeding their babies, particularly on atolls with a high prevalence of under-nutrition. And it is supporting the development of a behaviour-change communication strategy on maternal and child nutrition that focuses on the first 1,000 days of life. UNICEF has also supported the update of growth monitoring tools and procedures to include the issue of encouraging early stimulation and growth development. Finally, UNICEF is working with the Ministry of Education to develop a School Nutrition Policy to protect school-age children and adolescents from both under-nutrition and over-eating.
6 - NEPAL
UNICEF supported the implementation of the Nepal's Multi Sector Nutrition Plan (MSNP) I, scaling up the coverage to 28 districts by the end of 2017 and cumulatively reaching over 700,000 children. UNICEF was also instrumental in supporting the design of MNSP II (2018-2021), which will further expand access to nutrition services for children and women. Crucially, the government has committed its own funds to cover approximately 60 per cent of the US$ 500 million MSNP II budget. UNICEF has also been working with the National Planning Commission and key line ministries in developing systematic tools for financial tracking of nutrition investments, including a budget code for nutrition. With UNICEF's continuous lobbying and advocacy, Nutrition and Food Security Steering Committees have been formed and are functioning in 55 districts, providing coordination and managerial support for nutrition-specific and -sensitive interventions.
7 - PAKISTAN
UNICEF supported all provincial and regional governments to roll out multi-sectoral nutrition strategies. Scaling Up Nutrition (SUN) Secretariats are now active in all provinces. UNICEF also supported the development of the National Infant and Young Child Feeding Strategy, together with a plan and budget to guide implementation at province and regional level. Assisted by UNICEF, the government is conducting a national assessment of complementary feeding, and UNICEF has initiated an integrated Nutrition-WASH programme to reduce stunting in Sindh province. Finally, UNICEF has established an online Nutrition Management Information System at provincial and regional levels.
8 - SRI LANKA
Whilst the children of Sri Lanka are generally better fed than the regional average, the decline in malnutrition has stagnated. To address this, UNICEF supported the Presidential Secretariat to develop the new Multi-sectoral Action Plan for Nutrition (MsAPN) for 2017-2021, which elaborates sectoral objectives to improve nutrition. UNICEF also supported the review of the National Nutrition Policy and Micronutrient Strategy and the costing of the health-sector component of the National Nutrition programme. UNICEF has strengthened the data management and monitoring system in all 25 districts, and tested a real-time monitoring system in three districts.
Many nutrition services are inadequately monitored. For example, few health systems monitor whether caregivers receive information on how to feed their children. But, given the persistent disparities in minimum dietary diversity (MDD, a measure of whether the diet of a child aged 6-23 months contains sufficient food groups), it is clear that the most vulnerable families need far more information and support. There are:
- Huge inequities between countries: MDD ranges from 15 per cent in Bhutan to 73 per cent in Sri Lanka.1
- Wealth disparities: In Nepal, the MDD among children in the wealthiest households (76 per cent) is double that of the poorest households (38 per cent).2
- Education disparities: In Bangladesh MDD is almost four times higher if the child's mother had secondary education (40 per cent), than if the mother had no education (10 per cent).3
The challenge laid down by world leaders when they adopted SDG Target 2.2 was to end all forms of malnutrition by 2030, including a 40 per cent reduction in the number of stunted children.
Good nutrition is not just an outcome of sustainable development - it is also a driver of sustainable development. Addressing nutrition reduces the burden on the health system, while good nutrition fuels brain development, which can lift families out of poverty and is essential for economic development.
Continued progress will be needed in South Asia for the global nutrition targets to be met. Evidence shows that the three 'make-or-break' areas to reduce child stunting in South Asia are
- Child feeding: Improving the quality of complementary foods for children aged 6-23 months, with emphasis on nutrient density and dietary diversity, while breastfeeding continues.
- Women’s nutrition: Improving women's food intake (in both quantity and quality) along the lifecycle and dealing with the underlying gender determinants of women's nutrition and social status.
- Household sanitation: Improving family and community hygiene practices, especially washing hands with soap after defecation and before feeding a child.
In pursuit of these aims, the South Asia Regional Action Framework on Nutrition - adopted by the South Asian Association for Regional Cooperation (SAARC) in 2014 - encourages the eight member-countries to apply a four-pillar approach:
- High-level political commitment to improve nutrition governance and programmes.
- Evidence-based, nutrition-specific and nutrition-sensitive interventions delivered at scale.
- Stronger institutional and human capacity to manage nutrition programmes.
- Coherent monitoring frameworks and knowledge-management systems.
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Campbell, R. K., et al., Infant and young child feeding practices and nutritional status in Bhutan, Maternal & Child Nutrition, 21 December 2017.
Chandrasekhar, S., et al., Household food insecurity and children's dietary diversity and nutrition in India. Evidence from the comprehensive nutrition survey in Maharashtra, Maternal & Child Nutrition, vol. 13, suppl. 2, 2017.
Harding, K. L., V. M. Aguayo and P. Webb, Hidden hunger in South Asia: a review of recent trends and persistent challenges, Public Health Nutrition, 2017 pp.1-11.
Harding, K.L., et al., Determinants of anemia among women and children in Nepal and Pakistan: An analysis of recent national survey data, Maternal & Child Nutrition, 2017.
Kim, R., et al., Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan, Social Science & Medicine, vol. 187, 2017, pp. 144-154.
Krishna, A., et al., Trends in inequalities in child stunting in South Asia, Maternal & Child Nutrition, 19 October 2017.
McGovern, M.E., et al., A review of the evidence linking child stunting to economic outcomes, International Journal of Epidemiology, vol. 46, no. 4, 2017 pp. 1171-1191.
Na, M., et al., Risk factors of poor complementary feeding practices in Pakistani children aged 6-23 months: A multilevel analysis of the Demographic and Health Survey 2012-2013, Maternal & Child Nutrition, vol. 13, suppl. 2, 2017.
Na, M., et al., Trends and predictors of appropriate complementary feeding practices in Nepal: An analysis of national household survey data collected between 2001 and 2014, Maternal & Child Nutrition, 17 November 2017.
Nisar, Y. B., M. J. Dibley and V. M. Aguayo, Iron-folic acid supplementation during pregnancy reduces the risk of stunting in children less than 2 years of age: a retrospective cohort study from Nepal, Nutrients, 2016.
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Improving maternal and child nutrition, Kurigram, Bangladesh
Chini Rani and Kamal Roy were delighted when Chini became pregnant in mid-2017. But they knew that expectant mothers should have proper antenatal care, so Chini (22) made the 12 km journey to the Ulipur Upazila Health Complex in Kurigram.
"The counsellors advised me to eat additional nutritious food, such as vegetables, egg, meat, fish lentil, fruits and milk," she said, sitting in the hospital's antenatal and postnatal care corner. Chini Rani, who studied in school up to Class VIII, said she had also been advised her to take one iron tablet and one calcium tablet every day and to rest adequately.
"My husband bought me varied food and the tablets. My mother-in-law too encouraged me to eat whenever I was hungry," she said, with her healthy, 12-day-old son sleeping on her lap. The baby weighed more that 2.5 kg at birth.
"I am very happy," Chini said, adding that she was breastfeeding her son and would do so until he was six months old. From then on, she would add complementary food while continuing to breastfeed so that her child will grow properly.
Chini Rani is just one example of how pregnant and lactating mothers in Kurigram are benefiting from a programme to promote breastfeeding that started in October 2016. Two counsellors on antenatal and postnatal care were recruited in each of the five sub-district hospitals of Kurigram, one of the country's poorest districts. Two receptionists have also been appointed at each of the five hospitals to help patients and keep records.
Before the programme started, only one pregnant woman out of 177 in Kurigram had benefited from antenatal visits and received information on the importance of breastfeeding. Most did not seek antenatal care until the third trimester of pregnancy. An assessment by UNICEF and BRAC in 2016 also found less than 10 per cent of mothers had received information on feeding duration and correct position while breastfeeding infants.
"The counsellors advise pregnant mothers on how to improve their nutrition, help them with breastfeeding techniques and refer them to doctors if complications arise," said Shahidul Hassan, Nutrition Officer of UNICEF for Rangpur and Rajshahi divisions. There are 30 trained health workers who promote breastfeeding and provide antenatal and postnatal counselling in the 15 unions of Ulipur upazila.
"These efforts are contributing significantly to the improvement of child and mother health," said Dr. Borhan-ul Islam Siddiki, Health and Family Welfare Officer in Ulipur Upazila. Nationally, exclusive breastfeeding is practised by just 56 per cent of mothers, but in Ulipur in the last quarter of 2017 it was 97 per cent for all infants and 77 per cent for children up to six months, he said.
While indicators of better nutrition for the mother and child are improving in Kurigram, ensuring exclusive breastfeeding for the women undergoing caesarian section in private clinics remains a difficult job.
"Sometimes it is challenging to convince parents about the need for exclusive breastfeeding. Initially, if the newborn does not get breast milk, they are often pushed for infant formula," said Dr. Siddiki.
Reaching remote and hard-to-access areas - such as the river islands - is also a challenge.
Not all reap benefits equally
Not all pregnant mothers get the care they need. Many don't know where to get counselling, while others cannot afford to visit trained health personnel or buy adequate nutritious food (which can lead to malnutrition of the mother and stunting of the child).
According to the Bangladesh Demographic and Health Survey 2014, 33 per cent of under-five children in Bangladesh are stunted (low height for age), which is linked to low brain development.
Sultana Begum (30), of Kurigram sadar, said she visited the local community clinic four or five times during her pregnancy and received counselling on breastfeeding, and on maternal and child nutrition. However, during her pregnancy, she could not eat properly because of sores in her mouth. She thinks that nutritional deficit might be one reason why her baby weighed only 2.4 kg at birth (minimum standard birth-weight is 2.5 kg). As Shahidul Hassan of UNICEF points out, "Sultana's child has some risk of stunting, but if the mother continues exclusive breastfeeding for six months and then provides adequate complementary food alongside breast milk for up to two years, the risks can be overcome."