save the children state of the worlds mothers report 2012 final

7/31/2019 Save the Children State of the Worlds Mothers Report 2012 Final

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NUtritioN iN the FirSt 1,000 DaSIn commemoration of Mothers Day, Save the Children is publishingits thirteenth annual State of the Worlds Mothersreport. Te focus ison the 171 million children globally who do not have the opportunityto reach their full potential due to the physical and mental eects of

poor nutrition in the earliest months of life. Tis report shows whichcountries are doing the best and which are doing the worst atproviding nutrition during the critical window of development thatstarts during a mothers pregnancy and goes through her childs secondbirthday. It looks at six key nutrition solutions, including breastfeeding,that have the greatest potential to save lives, and shows that thesesolutions are aordable, even in the worlds poorest countries.

Te Infant and Toddler FeedingScorecardranks 73 developingcountries on measures of early child nutrition. Te Breastfeeding PolicyScorecardexamines maternity leave laws, the right to nursing breaks

at work and other indicators to rank 36 developed countries on thedegree to which their policies support women who want to breastfeed.And the annualMothers Indexevaluates the status of womens health,nutrition, education, economic well-being and political participation torank 165 countries both in the industrialized and developing world to show where mothers and children fare best and where they face thegreatest hardships.


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2

ForeWorD

Its hard to believe, but a childs future

can be determined years before theyeven reach their fth birthday. As afather of three, I see unlimited poten-tial when I look at my kids. But formany children, this is not the case.

In some countries, half of all chil-dren are chronically undernourishedor stunted. Despite signicant prog-ress against hunger and poverty inthe last decade, undernutrition is anunderlying killer of more than 2.6 mil-lion children and more than 100,000

mothers every year. Sustained poornutrition weakens immune systems, making children andadults more likely to die of diarrhea or pneumonia. And itimpairs the eectiveness of lifesaving medications, includ-ing those needed by people living with HIV and AIDS.

Te devastating impact of undernutrition spans genera-tions, as poorly nourished women are more likely to suerdicult pregnancies and give birth to undernourished chil-dren themselves. Lost productivity in the 36 countries withthe highest levels of undernutrition can cost those econo-mies between 2 and 3 percent of gross domestic product.Tats billions of dollars each year that could go towardseducating more children, treating more patients at healthclinics and fueling the global economy.

We know that investments in nutrition are some of themost powerful and cost-eective in global development.Good nutrition during the critical 1,000-day window frompregnancy to a childs second birthday is crucial to devel-oping a childs cognitive capacity and physical growth.Ensuring a child receives adequate nutrition during thiswindow can yield dividends for a lifetime, as a well-nour-ished child will perform better in school, more eectivelyght o disease and even earn more as an adult.

Te United States continues to be a leader in ghtingundernutrition. Trough Feed the Future and the GlobalHealth Initiative were responding to the varying causes andconsequences of, and solutions to, undernutrition. Ournutrition programs are integrated in both initiatives, as weseek to ensure mothers and young children have access tonutritious food and quality health services.

In both initiatives, the focus for change is on women.Women comprise nearly half of the agricultural workforcein Africa, they are often responsible for bringing home

water and food and preparing family meals, they are theprimary family caregivers and they often eat last and least.

Given any small amount of resources, they often spendthem on the health and well-being of their families, and it

has been proven that their own health

and practices determine the healthand prospects of the next generation.

o help address this challenge,our programs support country-ledefforts to ensure the availability ofaordable, quality foods, the promo-tion of breastfeeding and improvedfeeding practices, micronutrient sup-plementation and community-basedmanagement of acute malnutrition.Since we know rising incomes do notnecessarily translate into a reduction

in undernutrition, we are support-ing specic eorts geared towards better child nutritionoutcomes including broader nutrition education target-ing not only mothers, but fathers, grandmothers andother caregivers.

Te United States is not acting alone; many develop-ing countries are taking the lead on tackling this issue.In 2009, G8 leaders met in LAquila, Italy and pledgedto increase funding and coordination for investment inagriculture and food security, reversing years of decliningpublic investment. And since 2010, some 27 developingcountries have joined the Scaling Up Nutrition (SUN)Movement, pledging to focus on reducing undernutrition.

Tat same year, the United States and several inter-national partners launched the 1,000 Days Partnership. TePartnership was designed to raise awareness of and focuspolitical will on nutrition during the critical 1,000 daysfrom pregnancy to a childs second birthday. 1,000 Daysalso supports the SUN Movement, and I am proud to bea member of the SUN Lead Group until the end of 2013.

Preventing undernutrition means more than just pro-viding food to the hungry. It is a long-term investment inour future, with generational payos. Tis report docu-

ments the extent of the problem and the ways we can solveit. All we must do is act.

D. R SAdministrator of the United States Agency forInternational Development (USAID)


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S ae th e c h ilD re N S tate oF th e W orlD S Moth e rS 2 0 1 2 3

Every year, our State of the Worlds

Mothersreport reminds us of the inex-tricable link between the well-being ofmothers and their children. More than90 years of experience on the groundhave shown us that when mothershave health care, education and eco-nomic opportunity, both they andtheir children have the best chance tosurvive and thrive.

But many are not so fortunate.Alarming numbers of mothers andchildren in developing countries are

not getting the nutrition they need.For mothers, this means less strength and energy for thevitally important activities of daily life. It also meansincreased risk of death or giving birth to a pre-term, under-weight or malnourished infant. For young children, poornutrition in the early years often means irreversible dam-age to bodies and minds during the time when both aredeveloping rapidly. And for 2.6 million children each year,hunger kills, with malnutrition leading to death.

Tis report looks at the critical 1,000-day window oftime from the start of a womans pregnancy to her childssecond birthday. It highlights proven, low-cost nutri-tion solutions like exclusive breastfeeding for the rst 6months that can make the dierence between life anddeath for children in developing countries. It shows howmillions of lives can be saved and whole countries canbe bolstered economically if governments and privatedonors invest in these basic solutions. As AdministratorShah states persuasively in the Foreword to this report, theeconomic argument for early nutrition is very strong thecost to a nation's GDP is signicant when kids go hungryearly in life.

Save the Children is working to ght malnutrition on

three fronts as part of our global newborn and child sur-vival campaign:

First, Save the Children is increasing awareness of theglobal malnutrition crisis and its disastrous eects onmothers, children, families and communities. As part ofour campaign, this report calls attention to areas wheregreater investments are needed and shows that eec-tive strategies are working, even in some of the poorestplaces on earth.

Second, Save the Children is encouraging action bymobilizing citizens around the world to support qual-

ity programs to reduce maternal, newborn and childmortality, and to advocate for increased leadership,

commitment and funding for pro-

grams we know work.

Tird, we are making a major dier-ence on the ground. Save the Childrenrigorously tests strategies that leadto breakthroughs for children. We

work in partnerships across sec-tors with national ministries, localorganizations and others to supporthigh quality health, nutrition andagriculture programming through-out the developing world. As part of

this, we train and support frontlinehealth workers who promote breast-feeding, counsel families to improve diets, distributevitamins and other micronutrients, and treat childhooddiseases. We also manage large food security programswith a focus on child nutrition in 10 countries. Workingtogether, we have saved millions of childrens lives. Tetragedy is that so many more could be helped, if onlymore resources were available to ensure these lifesavingprograms reach all those who need them.

Tis report contains our annual ranking of the best and

worst places in the world for mothers and children. Wecount on the worlds leaders to take stock of how mothersand children are faring in every country and to respondto the urgent needs described in this report. Investing inthis most basic partnership of all between a mother andher child is the rst and best step in ensuring healthychildren, prosperous families and strong communities.

Every one of us has a role to play. As a mother myself, Iurge you to do your part. Please read the ake Action sec-tion of this report, and visit our website on a regular basisto nd out what you can do to make a dierence.

C MPresident and CEOSave the Children USA(Follow @carolynsave on witter)

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eecUtie SUMMar:Ke FiNDiNgS aND recoMMeNDatioNS

Malnutrition is an underlying cause of death for 2.6 million children each year,

and it leaves millions more with lifelong physical and mental impairments.Worldwide, more than 170 million children do not have the opportunity toreach their full potential because of poor nutrition in the earliest months of life.

Much of a childs future and in fact much of a nations future is deter-mined by the quality of nutrition in the rst 1,000 days. Te period from thestart of a mothers pregnancy through her childs second birthday is a criticalwindow when a childs brain and body are developing rapidly and good nutri-tion is essential to lay the foundation for a healthy and productive future. Ifchildren do not get the right nutrients during this period, the damage is oftenirreversible.

Tis years State of the Worlds Mothersreport shows which countries are suc-ceeding and which are failing to provide good nutrition during the critical

1,000-day window. It examines how investments in nutrition solutions makea dierence for mothers, children, communities, and society as a whole. It alsopoints to proven, low-cost solutions that could save millions of lives and helplift millions more out of ill-health and poverty.

Ky Fdgs

1. Children in an alarming number o countries are not getting adequatenutrition during their frst 1,000 days. Out of developing countries which together account for percent of child deaths only four score verygood on measures of young child nutrition. Our Infant and Toddler FeedingScorecardidenties Malawi, Madagascar, Peru and Solomon Islands as the top

four countries where the majority of children under age are being fed accord-ing to recommended standards. More than two thirds of the countries on theScorecardreceive grades of fair or poor on these measures overall, indicatingvast numbers of children are not getting a healthy start in life. Te bottom fourcountries on the Scorecard Somalia, Cte d'Ivoire, Botswana and EquatorialGuinea have staggeringly poor performance on indicators of early child feed-ing and have made little to no progress since in saving childrens lives. (Toread more, turn to pages 26-3.)

2. Child malnutrition is widespread and it is limiting the uture success omillions o children and their countries. Stunting, or stunted growth, occurswhen children do not receive the right type of nutrients, especially in utero or

during the rst two years of life. Children whose bodies and minds are limitedby stunting are at greater risk for disease and death, poor performance in school,and a lifetime of poverty. More than 80 countries in the developing world havechild stunting rates of 20 percent or more. Tirty of these countries have whatis considered to be very high stunting rates of 40 percent or more. Whilemany countries are making progress in reducing child malnutrition, stuntingprevalence is on the rise in at least 14 countries, most of them in sub-SaharanAfrica. If current trends continue, Africa may overtake Asia as the region mostheavily burdened by child malnutrition. (To read more, turn to pages -2.)

3. Economic growth is not enough to fght malnutrition. Political will andeective strategies are needed to reduce malnutrition and prevent stunting.

A number of relatively poor countries are doing an admirable job of tacklingthis problem, while other countries with greater resources are not doing so

Vital statiticVital statitic

Malnutrition is the underlying causeMalnutrition is the underlying causeo more than .6 million child deathso more than .6 million child deathseach year.each year.

171 million children 7 percent o all chil171 million children 7 percent o all chil--dren globally are stunted, meaning theirdren globally are stunted, meaning theirbodies and minds have suered permanent,bodies and minds have suered permanent,irreversible damage due to malnutrition.irreversible damage due to malnutrition.

In developing countries, breasted childrenIn developing countries, breasted childrenare at least 6 times more likely to survive inare at least 6 times more likely to survive inthe early months o lie than non-breastedthe early months o lie than non-breastedchildren.children.

I all children in the developing worldI all children in the developing worldreceived adequate nutrition and eedingreceived adequate nutrition and eedingo solid oods with breasteeding,o solid oods with breasteeding,stunting rates at 1 months could be cutstunting rates at 1 months could be cutby 0 percent.by 0 percent.

Breasteeding is the single most eectiveBreasteeding is the single most eectivenutrition intervention or saving lives.nutrition intervention or saving lives.I practiced optimally, it could preventI practiced optimally, it could prevent1 million child deaths each year.1 million child deaths each year.

Adults who were malnourished as childrenAdults who were malnourished as children

can earn an estimated 0 percent less oncan earn an estimated 0 percent less onaverage than those who werent.average than those who werent.

Te eects o malnutrition in developingTe eects o malnutrition in developingcountries can translate into losses in GDPcountries can translate into losses in GDPo up to -3 percent annually.o up to -3 percent annually.

Globally, the direct cost o malnutrition isGlobally, the direct cost o malnutrition isestimated at $0 to $30 billion per year.estimated at $0 to $30 billion per year.


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Community health workers and midwives meet critical needs in these com-munities by screening children for malnutrition, treating diarrhea, promotingbreastfeeding, distributing vitamins and other micronutrients, and counsel-ing mothers about balanced diet, hygiene and sanitation. Te lifesaving sixinterventions highlighted in this report can all be delivered in remote, impov-erished places by well-trained and well-equipped community health workers.In a number of countries including Cambodia, Malawi and Nepal thesehealth workers have contributed to broad-scale success in ghting malnutritionand saving lives. (To read more, turn to pages 32-37.)

6. In the industrialized world, the United States has the least favorable envi-ronment or mothers who want to breasteed. Save the Children examinedmaternity leave laws, the right to nursing breaks at work, and several otherindicators to create a ranking of 36 industrialized countries measuring whichones have the most and the least supportive policies for women who want tobreastfeed. Norway tops the Breastfeeding Policy Scorecardranking. Te UnitedStates comes in last. (To read more, turn to pages 3-43.)

RCds

1. Invest in proven, low-cost solutions to save childrens lives and prevent

stunting. Malnutrition and child mortality can be fought with relatively simpleand inexpensive solutions. Iron supplements strengthen childrens resistanceto disease, lower womens risk of dying in childbirth and may help preventpremature births and low birthweight. Six months of exclusive breastfeedingincreases a childs chance of survival at least six-fold. imely and appropriatecomplementary feeding is the best way to prevent a lifetime of lost potentialdue to stunting. Vitamin A helps prevent blindness and lowers a childs riskof death from common diseases. Zinc and good hygiene can save a child fromdying of diarrhea. Tese solutions are not expensive, and it is a tragedy thatmillions of mothers and children do not get them.

2. Invest in health workers especially those serving on the ront lines to

reach the most vulnerable mothers and children. Te world is short more than3 million health workers of all types, and there is an acute shortage of frontline

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8 executive summary

workers, including community health workers, who are critical to deliveringthe nutrition solutions that can save lives and prevent stunting. Governmentsand donors should work together to ll this health worker gap by recruiting,training and supporting new and existing health workers, and deploying themwhere they are needed most.

3. Help more girls go to school and stay in school. One of the most eective

ways to ght child malnutrition is to focus on girls education. Educated womentend to have fewer, healthier and better-nourished children. Increased investmentsare needed to help more girls go to school and stay in school, and to encouragefamilies and communities to value the education of girls. Both formal educationand non-formal training give girls knowledge, self-condence, practical skills andhope for a bright future. Tese are powerful tools that can help delay marriageand child-bearing to a time that is healthier for them and their babies.

4. Increase government support or proven solutions to fght malnutritionand save lives. In order to meet internationally agreed upon development goalsto reduce child deaths and improve mothers health, lifesaving services mustbe increased for the women and children who need help most. All countries

must make ghting malnutrition and stunting a priority. Developing countriesshould commit to and fund national nutrition plans that are integrated withplans for maternal and child health. Donor countries should support thesegoals by keeping their funding commitments to achieving the MillenniumDevelopment Goals and countries should endorse and support the Scaling UpNutrition (SUN) movement. Resources for malnutrition programs should notcome at the expense of other programs critical to the survival and well-beingof children.(To read more, turn to page 5.)

5. Increase private sector partnerships to improve nutrition or mothers andchildren. Many local diets fail to meet the nutritional requirements of children 6-24months old. Te private sector can help by producing and marketing aordablefortied products. Partnerships should be established with multiple manufactur-ers, distributors and government ministries to increase product choice, access andaordability, improve compliance with codes and standards, and promote publiceducation on good feeding practices and use of local foods and commercial prod-ucts. Te food industry can also invest more in nutrition programs and research,contribute social marketing expertise to promote healthy behaviors such as breast-feeding, and advocate for greater government investments in nutrition.

. Improve laws, policies and actions that support amilies and encouragebreasteeding. Governments in all countries can do more to help parents andcreate a supportive environment for breastfeeding. Governments and part-ners should adopt policies that are child-friendly and support breastfeedingmothers. Such policies would give families access to maternal and paternal

leave, ensure that workplaces and public facilities oer women a suitableplace to feed their babies outside of the home, and ensure working womenare guaranteed breastfeeding breaks while on the job. In an increasingly urban

world, a further example is that public transportation can oer special seatsfor breastfeeding mothers.

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Save the Childrens thirteenth annualSave the Childrens thirteenth annualMothers IndexMothers Index

compares the well-being o mothers and children in 165compares the well-being o mothers and children in 165countries more than in any previous year. Tecountries more than in any previous year. TeMothers IndexMothers Indexalso provides inormation on an addialso provides inormation on an addi--tional 8 countries, 7 o which report sucient datational 8 countries, 7 o which report sucient datato present fndings on womens or childrens indicato present fndings on womens or childrens indica--tors. When these are included, the total comes totors. When these are included, the total comes to173 countries.173 countries.

Norway, Iceland and Sweden top the rankings thisNorway, Iceland and Sweden top the rankings thisyear. Te top 10 countries, in general, attain very highyear. Te top 10 countries, in general, attain very highscores or mothers and childrens health, educationalscores or mothers and childrens health, educationaland economic status. Niger ranks last among the 165and economic status. Niger ranks last among the 165countries surveyed. Te 10 bottom-ranked countriescountries surveyed. Te 10 bottom-ranked countries eight rom sub-Saharan Arica are a reverse image eight rom sub-Saharan Arica are a reverse image

o the top 10, perorming poorly on all indicators. Teo the top 10, perorming poorly on all indicators. TeUnited States places 5th this year up six spots romUnited States places 5th this year up six spots romlast year.last year.

Conditions or mothers and their children in theConditions or mothers and their children in thebottom countries are grim. On average, 1 in 30 womenbottom countries are grim. On average, 1 in 30 womenwill die rom pregnancy-related causes. One child inwill die rom pregnancy-related causes. One child in7 dies beore his or her fth birthday, and more than7 dies beore his or her fth birthday, and more than1 child in 3 suers rom malnutrition. Nearly hal the1 child in 3 suers rom malnutrition. Nearly hal thepopulation lacks access to sae water and ewer than 4population lacks access to sae water and ewer than 4girls or every 5 boys are enrolled in primary school.girls or every 5 boys are enrolled in primary school.

Te gap in availability o maternal and child healthTe gap in availability o maternal and child healthservices is especially dramatic when comparing Norwayservices is especially dramatic when comparing Norwayand Niger. Skilled health personnel are present at virtuand Niger. Skilled health personnel are present at virtu--ally every birth in Norway, while only a third o birthsally every birth in Norway, while only a third o births

are attended in Niger. A typical Norwegian girl canare attended in Niger. A typical Norwegian girl can

Nee 2012 Mothers Index2012 Mothers Index: orwa op Lit, ier Rank Lat,: orwa op Lit, ier Rank Lat,Unite state Rank 25tUnite state Rank 25t

expect to receive 18 years o ormal education and to liveexpect to receive 18 years o ormal education and to liveto be over 83 years old. Eighty-two percent o womento be over 83 years old. Eighty-two percent o womenare using some modern method o contraception, andare using some modern method o contraception, andonly 1 in 175 is likely to lose a child beore his or heronly 1 in 175 is likely to lose a child beore his or herfth birthday. At the opposite end o the spectrum, infth birthday. At the opposite end o the spectrum, inNiger, a typical girl receives only 4 years o educationNiger, a typical girl receives only 4 years o educationand lives to be only 56. Only 5 percent o women areand lives to be only 56. Only 5 percent o women areusing modern contraception, and 1 child in 7 dies beoreusing modern contraception, and 1 child in 7 dies beorehis or her fth birthday. At this rate, every mother inhis or her fth birthday. At this rate, every mother inNiger is likely to suer the loss o a child.Niger is likely to suer the loss o a child.

Zeroing in on the childrens well-being portion oZeroing in on the childrens well-being portion othetheMothers IndexMothers Index, Iceland fnishes frst and Somalia is, Iceland fnishes frst and Somalia islast out o 171 countries. While nearly every Icelandiclast out o 171 countries. While nearly every Icelandicchild girl and boy alike enjoys good health and educhild girl and boy alike enjoys good health and edu--

cation, children in Somalia ace the highest risk o deathcation, children in Somalia ace the highest risk o deathin the world. More than 1 child in 6 dies beore age 5.in the world. More than 1 child in 6 dies beore age 5.Nearly one-third o Somali children are malnourishedNearly one-third o Somali children are malnourishedand 70 percent lack access to sae water. Fewer than 1 inand 70 percent lack access to sae water. Fewer than 1 in3 children in Somalia are enrolled in school, and within3 children in Somalia are enrolled in school, and withinthat meager enrollment, boys outnumber girls almostthat meager enrollment, boys outnumber girls almost to 1. to 1.

Tese statistics go ar beyond mere numbers. TeTese statistics go ar beyond mere numbers. Tehuman despair and lost opportunities represented inhuman despair and lost opportunities represented inthese numbers demand mothers everywhere be giventhese numbers demand mothers everywhere be giventhe basic tools they need to break the cycle o povertythe basic tools they need to break the cycle o povertyand improve the quality o lie or themselves, theirand improve the quality o lie or themselves, theirchildren, and or generations to come.children, and or generations to come.

See the Appendix for the Complete Mothers IndexSee the Appendix for the Complete Mothers Indexand Country Rankings.and Country Rankings.


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Sae the chilDre N State oF the WorlDS MotherS 2012 11

Good nutrition during the 1,000-day period between the start of a womans

pregnancy and her childs second birthday is critical to the future health, well-being and success of her child. Te right nutrition during this window can havea profound impact on a childs ability to grow, learn and rise out of poverty.It also benets society, by boosting productivity and improving economicprospects for families and communities.

Malnutrition is an underlying cause of 2.6 million child deaths each year.Millions more children survive, but suer lifelong physical and cognitiveimpairments because they did not get the nutrients they needed early in theirlives when their growing bodies and minds were most vulnerable. When chil-dren start their lives malnourished, the negative eects are largely irreversible.

Pregnancy and infancy are the most important periods for brain develop-ment. Mothers and babies need good nutrition to lay the foundation for the

childs future cognitive, motor and social skills, school success and productiv-ity. Children with restricted brain development in early life are at risk for laterneurological problems, poor school achievement, early school drop out, low-skilled employment and poor care of their own children, thus contributing tothe intergenerational transmission of poverty.

Millions of mothers in poor countries struggle to give their children a healthystart in life. Complex social and cultural beliefs in many developing countriesput females at a disadvantage and, starting from a very young age, many girlsdo not get enough to eat. In communities where early marriage is common,teenagers often leave school and become pregnant before their bodies have fullymatured. With compromised health, small bodies and inadequate resources andsupport, these mothers often fail to gain sucient weight during pregnancyand are susceptible to a host of complications that put themselves and theirbabies at risk.

Worldwide, 20 million babies are born with low birthweight each year.Many of these babies are born too early before the full nine months of preg-nancy. Others are full-term but they are small because of poor growth in themothers womb. Even babies who are born at a normal weight may still havebeen malnourished in the womb if the mothers diet was poor. Others becomemalnourished in infancy due to disease, inadequate breastfeeding or lack ofnutritious food. Malnutrition weakens young childrens immune systems andleaves them vulnerable to death from common illnesses such as pneumonia,diarrhea and malaria.

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12 W y F cu s N t e Fi rs t 1, 00 0 Days?

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Investments in improving nutrition for mothers and children in the rst1,000 days will yield real payos both in lives saved and in healthier, morestable and productive populations. In addition to its negative, often fatal, healthconsequences, malnutrition means children achieve less at school and theirproductivity and health in adult life is aected, which has dire nancial con-

sequences for entire countries.Children whose physical and mental development are stunted by malnutri-

tion will earn less on average as adults. One study suggested the loss of humanpotential resulting from stunting was associated with 20 percent less adultincome on average. Malnutrition costs many developing nations an estimated2-3 percent of their GDP each year, extends the cycle of poverty, and impedesglobal economic growth. Globally, the direct cost of child malnutrition isestimated at $20 to $30 billion per year.

In contrast, well-nourished children perform better in school and grow upto earn considerably more on average than those who were malnourished aschildren. Recent evidence suggests nutritional interventions can increase adultearnings by as much as 46 percent.

An estimated 450 million children will be aected by stunting in the next15 years if current trends continue. Tis is bad news for the economies ofdeveloping nations, and for a global economy that is increasingly dependenton new markets to drive economic growth.

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Sobia grew up in a large amily thatSobia grew up in a large amily thatstruggled to get by, and like many girls, shestruggled to get by, and like many girls, shedid not get enough to eat. We were fvedid not get enough to eat. We were fvebrothers and sisters and lived a very hardbrothers and sisters and lived a very hardlie, she said. My mother looked ater uslie, she said. My mother looked ater usby doing tailoring work at home and ed usby doing tailoring work at home and ed uson this meager income.on this meager income.

When Sobia was 18 and pregnant withWhen Sobia was 18 and pregnant withher frst child, she elt tired, achy, everishher frst child, she elt tired, achy, everishand nauseous. Her mother-in-law toldand nauseous. Her mother-in-law toldher this was normal, so she did not seekher this was normal, so she did not seekmedical care. She knows now that she wasmedical care. She knows now that she was

anemic, and she is lucky she and her babyanemic, and she is lucky she and her babyare still alive. With no prenatal care, sheare still alive. With no prenatal care, shewas unprepared or childbirth. When herwas unprepared or childbirth. When herlabor pains started, her amily waited threelabor pains started, her amily waited threedays, as they were expecting her to deliverdays, as they were expecting her to deliverat home. Finally, when her pain becameat home. Finally, when her pain becameextreme, they took her to the hospital.extreme, they took her to the hospital.She had a dicult delivery with extensiveShe had a dicult delivery with extensivebleeding. Her baby boy, Abdullah, was bornbleeding. Her baby boy, Abdullah, was bornsmall and weak. Sobia was exhausted, and itsmall and weak. Sobia was exhausted, and it

was dicult or her to care or her inant.was dicult or her to care or her inant.Sobia ollowed local customs that saySobia ollowed local customs that say

a woman should not breasteed her babya woman should not breasteed her babyor the frst three days. Over the nextor the frst three days. Over the next

ew months, Abdullah suered bouts oew months, Abdullah suered bouts o

diarrhea and pneumonia, but he manageddiarrhea and pneumonia, but he managedto survive. When Abdullah was 8 monthsto survive. When Abdullah was 8 monthsold, Sobia discovered she was pregnantold, Sobia discovered she was pregnantagain. Ater she miscarried, she soughtagain. Ater she miscarried, she soughthelp rom a nearby clinic established byhelp rom a nearby clinic established bySave the Children. Tat was when sheSave the Children. Tat was when shelearned she was severely anemic.learned she was severely anemic.

Te sta at the clinic gave Sobia ironTe sta at the clinic gave Sobia ironsupplements and showed her ways tosupplements and showed her ways toimprove her diet. Tey advised her to useimprove her diet. Tey advised her to usecontraceptives to give hersel time to restcontraceptives to give hersel time to restand get stronger beore having her nextand get stronger beore having her next

baby. She discussed this with her husbandbaby. She discussed this with her husbandand they agreed they would wait two years.and they agreed they would wait two years.Sobia was anemic again during her thirdSobia was anemic again during her third

pregnancy, but this time she was gettingpregnancy, but this time she was gettingregular prenatal care, so the doctors gaveregular prenatal care, so the doctors gaveher iron injections and more advice abouther iron injections and more advice aboutimproving her diet. Sobia ollowed theimproving her diet. Sobia ollowed theadvice and gave birth to her second baby, aadvice and gave birth to her second baby, ahealthy girl named Arooj, in July 011. Shehealthy girl named Arooj, in July 011. Shebreasted Arooj within 30 minutes aterbreasted Arooj within 30 minutes atershe was born, and continued breasteedingshe was born, and continued breasteedingexclusively or 6 months. My Arooj is soexclusively or 6 months. My Arooj is somuch healthier than Abdullah was, Sobiamuch healthier than Abdullah was, Sobiasays. She doesnt get sick all the time likesays. She doesnt get sick all the time like

he did.he did.

nin a Famil Leac of alnutritionnin a Famil Leac of alnutrition

Wnv i s nn wmn nw, i s ssns ind, s y wn v suff k i dd, sys Sb, 23. Sb, 8-mn-d du aj, nd 3-y-d snabdu, v n hu, pksn. Photo by Daulat Baig

pksn


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One in four of the worlds children are chronically malnourished, also known

as stunted. Tese are children who have not gotten the essential nutrients theyneed, and their bodies and brains have not developed properly.

Te damage often begins before a child is born, when a poorly nourishedmother cannot pass along adequate nutrition to the baby in her womb. Shethen gives birth to an underweight infant. If she is impoverished, overworked,poorly educated or in poor health, she may be at greater risk of not being ableto feed her baby adequately. Te child may endure more frequent infections,

which will also deprive the growing body of essential nutrients. Children underage 2 are especially vulnerable, and the negative eects of malnutrition at thisage are largely irreversible.

Te issue of chronic malnutrition, as opposed to acute malnutrition (as inthe Horn of Africa in the last year) seldom grabs the headlines, yet it is slowly

destroying the potential of millions of children. Globally, 171 million childrenare experiencing chronic malnutrition, which leaves a large portion of the

worlds children not only shorter than they otherwise would be, but also facingcognitive impairment that lasts a lifetime.

More than 80 countries in the developing world have child stunting ratesof 20 percent or more. Tirty of these countries have what are considered to be

very high stunting rates of 40 percent or more. Four countries Afghanistan,Burundi, imor-Leste and Yemen have stunting rates close to 60 percent. Asmuch as a third of children in Asia are stunted (100 million of the global total).In Africa, almost 2 in 5 children are stunted a total of 60 million children. Tislargely unnoticed child malnutrition crisis is robbing the health of tomorrowsadults, eroding the foundations of the global economy, and threatening globalstability.

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16 the gloBal MalNUtritioN criS iS

LUR d ChLd RLy

Every year, 7.6 million children die before they reach the age of 5, mostfrom preventable or treatable illnesses and almost all in developing countries.Malnutrition is an underlying cause of more than a third (35 percent) of thesedeaths.

A malnourished child is up to 10 times as likely to die from an easily pre-

ventable or treatable disease as a well-nourished child. And a chronicallymalnourished child is more vulnerable to acute malnutrition during food short-ages, economic crises and other emergencies.

Unfortunately, many countries have not made addressing malnutrition andchild survival a high-level priority. For instance, a recent analysis by the WorldHealth Organization found that only 67 percent of 121 mostly low- and mid-dle-income countries had policies to promote breastfeeding. Complementaryfeeding and iron and folic acid supplements were included in little over half ofall national policy documents (55 and 51 percent, respectively). And vitamin Aand zinc supplementation for children (for the treatment of diarrhea) were partof national policies in only 37 percent and 22 percent of countries respectively.

While nutrition is getting more high-level commitment than ever before, there

is still a lot of progress to be made.Persistent and worsening malnutrition in developing countries is perhaps

the single biggest obstacle to achieving many of the Millennium DevelopmentGoals (MDGs). Tese goals agreed to by all United Nations member states in2000 set specic targets for ending poverty and improving human rights andsecurity. MDG includes halving the proportion of people living in hunger.MDG is to ensure all children complete primary school. MDG aims toreduce the worlds 1990 under-5 mortality rate by two thirds. MDG aims toreduce the 1990 maternal mortality ratio by three quarters. And MDG is tohalt and begin to reverse the spread of HIV/AIDS and the incidence of malariaand other major diseases. Improving nutrition helps fuel progress toward allof these MDGs.

With just a few years left until the 2015 deadline, less than a third (22)of 75 priority countries are on track to achieve the poverty and hunger goal(MDG ). Only half of developing countries are on target to achieve univer-sal primary education (MDG ). Just 23 of the 75 countries are on track toachieve the child survival goal (MDG ). And just 13 of the 75 countries areon target to achieve the maternal mortality goal (MDG ). While new HIVinfections are declining in some regions, trends are worrisome in others. Also,treatment for HIV and AIDS has expanded quickly, but not fast enough tomeet the 2010 target for universal access (MDG 6).

RL LUR

Many children are born undernourished because their mothers are under-nourished. As much as half of all child stunting occurs in utero, underscoringthe critical importance of better nutrition for women and girls.

In most developing countries, the nutritional status of women and girls iscompromised by the cumulative and synergistic eects of many risk factors.Tese include: limited access to food, lack of power at the household level, tra-ditions and customs that limit womens consumption of certain nutrient-richfoods, the energy demands of heavy physical labor, the nutritional demandsof frequent pregnancies and breastfeeding, and the toll of frequent infections

with limited access to health care.Anemia is the most widespread nutritional problem aecting girls and wom-

en in developing countries. It is a signicant cause of maternal mortality andcan cause premature birth and low birthweight. In the developing world, 40

Four pe of alnutritionFour pe of alnutrition

Stunting A child is too short or their age. A child is too short or their age.Tis is caused by poor diet and requentTis is caused by poor diet and requentinections. Stunting generally occurs beoreinections. Stunting generally occurs beoreage , and the eects are largely irreversible.age , and the eects are largely irreversible.Tese include delayed motor development,Tese include delayed motor development,impaired cognitive unction and poorimpaired cognitive unction and poorschool perormance. In total, 171 millionschool perormance. In total, 171 millionchildren 7 percent o all children globallychildren 7 percent o all children globally are stunted. are stunted.

Wasting A childs weight is too low A childs weight is too lowor their height. Tis is caused by acuteor their height. Tis is caused by acutemalnutrition. Wasting is a strong predicmalnutrition. Wasting is a strong predic--

tor o mortality among children under 5.tor o mortality among children under 5.It is usually caused by severe ood shortIt is usually caused by severe ood short--age or disease. In total, over 60 millionage or disease. In total, over 60 millionchildren 10 percent o all children globallychildren 10 percent o all children globally are wasted. are wasted.

Underweight A childs weight is too low A childs weight is too lowor their age. A child can be underweightor their age. A child can be underweightbecause she is stunted, wasted or both.because she is stunted, wasted or both.Weight is a sensitive indicator o short-termWeight is a sensitive indicator o short-term(i.e., acute) undernutrition. Whereas a(i.e., acute) undernutrition. Whereas adefcit in height (stunting) is dicult todefcit in height (stunting) is dicult tocorrect, a defcit in weight (underweight)correct, a defcit in weight (underweight)can be recouped i nutrition and healthcan be recouped i nutrition and healthimprove later in childhood. Worldwide,improve later in childhood. Worldwide,more than 100 million children are undermore than 100 million children are under--weight.weight. Being underweight is associatedBeing underweight is associatedwith 19 percent o child deaths.with 19 percent o child deaths.

Micronutrient deciency A child A childlacks essential vitamins or minerals.lacks essential vitamins or minerals.Tese include vitamin A, iron and zinc.Tese include vitamin A, iron and zinc.Micronutrient defciencies are caused byMicronutrient defciencies are caused bya long-term lack o nutritious ood or bya long-term lack o nutritious ood or byinections such as worms. Micronutrientinections such as worms. Micronutrientdefciencies are associated with 10 percentdefciencies are associated with 10 percento all childrens deaths, or about one-thirdo all childrens deaths, or about one-third

o all child deaths due to malnutrition.o all child deaths due to malnutrition.


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percent of non-pregnant women and half (49 percent) of pregnant women areanemic. Anemia is caused by poor diet and can be exacerbated by infectiousdiseases, particularly malaria and intestinal parasites. Pregnant adolescents aremore prone to anemia than older women, and are at additional risk becausethey are often less likely to receive health care. Anemia prevalence is especiallyhigh in Asia and Africa, but even in Latin America and the Caribbean, onequarter of women are anemic.

Many women in the developing world are short in stature and/or under-weight. Tese conditions are usually caused by malnutrition during childhoodand adolescence. A woman who is less than 145 cm or 4'7" is considered to bestunted. Stunting among women is particularly severe in South Asia, wherein some countries for example, Bangladesh, India and Nepal more than 10percent of women aged 15-49 are stunted. Rates are similarly high in Boliviaand Peru. And in Guatemala, an alarming 29 percent of women are stunted.Tese women face higher risks of complications during childbirth and of hav-

ing small babies. Maternal underweight means a body-mass index of less than18.5 kg/m and indicates chronic energy deciency. en to 20 percent of thewomen in sub-Saharan Africa and 25-35 percent of the women in South Asiaare classied as excessively thin. Te risk of having a small baby is even greaterfor mothers who are underweight (as compared to stunted).

In many developing countries, it is common for girls to marry and beginhaving babies while still in their teens before their bodies have fully matured.

Younger mothers tend to have fewer economic resources, less education, lesshealth care, and they are more likely to be malnourished when they becomepregnant, multiplying the risks to themselves and their children. eenagers

who give birth when their own bodies have yet to nish growing are at greaterrisk of having undernourished babies. Te younger a girl is when she becomes

pregnant, the greater the risks to her health and the more likely she is to havea low-birthweight baby.

determinant of Cil utrition an xample of how to re emdeterminant of Cil utrition an xample of how to re em

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Experts recommend that children be breastfed within one hour of birth,exclusively breastfed for the rst 6 months, and then breastfed until age 2

with age-appropriate, nutritionally adequate and safe complementary foods.Optimal feeding according to these standards can prevent an estimated 19 per-cent of all under-5 deaths, more than any other child survival intervention.

Yet worldwide, the vast majority of children are not breastfed optimally.What are some of the reasons for this? Cultural beliefs, lack of knowledge

and misinformation play major roles. Many women and family members areunaware of the benets of exclusive breastfeeding. New mothers may be toldthey should wait several hours or days after their baby is born to begin breast-feeding. Aggressive marketing of infant formula often gives the impression thathuman milk is less modern and thus less healthy for infants than commercialformula. Or mothers may be told their breast milk is bad or does not containsucient nutrients, so they introduce other liquids and solid food too early.

Most breastfeeding problems occur in the rst two weeks of a childs life. Ifa mother experiences pain or the baby does not latch, an inexperienced mothermay give up. Support from fathers, mothers-in-law, peer groups and health

workers can help a mother to gain condence, overcome obstacles and prolongexclusive breastfeeding.

Women often stop breastfeeding because they return to work. Many arentprovided with paid maternity leave or time and a private place to breastfeedor express their breast milk. Legislation around maternity leave and policiesthat provide time, space, and support for breastfeeding in the workplace couldreduce this barrier. For mothers who work in farming or the informal sector,family and community support can help them to continue breastfeeding, evenafter returning to work. Also many countries need better laws and enforcementto protect women from persecution or harassment for breastfeeding in public.

Riin Foo Price CanRiin Foo Price Canhurt oter an Cilrenhurt oter an Cilren

As global ood prices remain high andAs global ood prices remain high andvolatile, poor mothers and children involatile, poor mothers and children indeveloping countries can have little choicedeveloping countries can have little choicebut to cut back on the quantity and qualbut to cut back on the quantity and qual--ity o the ood they eat. Te World Bankity o the ood they eat. Te World Bankestimates that rising ood prices pushed anestimates that rising ood prices pushed anadditional 44 million people into povertyadditional 44 million people into povertybetween June 010 and February 011.between June 010 and February 011.Staple ood prices hit record highs inStaple ood prices hit record highs inFebruary 011 and may have put the lives oFebruary 011 and may have put the lives omore than 400,000 more children at risk.more than 400,000 more children at risk.

Poor amilies in developing countriesPoor amilies in developing countriestypically spend between 50 to 70 percenttypically spend between 50 to 70 percento their income on ood.o their income on ood. When meat,When meat,fsh, eggs, ruit and vegetables become toofsh, eggs, ruit and vegetables become tooexpensive, amilies oten turn to cheaperexpensive, amilies oten turn to cheaper

cereals and grains, which oer ewercereals and grains, which oer ewernutrients. Studies show that women tendnutrients. Studies show that women tendto cut their ood consumption frst, and asto cut their ood consumption frst, and asa crisis deepens, other adults and eventuallya crisis deepens, other adults and eventuallychildren cut back.children cut back.

When pregnant mothers and youngWhen pregnant mothers and youngchildren are deprived o essential nutrientschildren are deprived o essential nutrientsduring a critical period in their developduring a critical period in their develop--ment, the results are oten devastating.ment, the results are oten devastating.Mothers experience higher rates o anemiaMothers experience higher rates o anemiaand chronic energy defciency. Childbirthand chronic energy defciency. Childbirthbecomes more risky, and babies are morebecomes more risky, and babies are morelikely to be born at low birthweight.likely to be born at low birthweight.

Children ace increased risk o stunting,Children ace increased risk o stunting,acute malnutrition and death.acute malnutrition and death. Countrie akin te Fatet an slowet gain aintCountrie akin te Fatet an slowet gain aintCil alnutrition, ~1990-2010Cil alnutrition, ~1990-2010

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sUFFC PRgRss

Globally, there have been modest improvements in child malnutrition ratesin the past two decades; however, the pace of progress has varied considerablyacross regions and countries. Between 1990 and 2010, child stunting rates fellglobally by one third, from 40 to 27 percent. Asia, as a region, reduced stuntingdramatically during this period, from 49 to 28 percent. Te Africa region, incontrast, shows little evidence of improvement, and not much is anticipatedover the next decade. In Latin America and the Caribbean, overall stuntingprevalence is falling; however, stunting levels remain high in many countries(for example: Guatemala, Haiti and Honduras).

Angola and Uzbekistan are the two priority countries that have made thefastest progress in reducing child malnutrition both cut stunting rates in half

in about 10 years. Brazil, China and Vietnam have also made impressive gains,each cutting stunting rates by over 60 percent in the past 20 years.Stunting rates have declined signicantly in a number of the poorest coun-

tries in the world including Bangladesh, Cambodia, Eritrea, Kyrgyzstan andNepal underscoring that marked improvements can be achieved even inresource-constrained settings.

Stunting rates have gotten worse in 14 countries, most of them in sub-Saharan Africa. Somalia has shown the worst regression stunting rates in thatcountry increased from 29 to 42 percent from 2000-2006, the only years for

which data are available. Afghanistan the most populous of the 14 countries has seen stunting increase by 11 percent. In both Somalia and Afghanistan,war and conict have likely played a signicant role in stunting rate increases.

frica i xpecte to vertake ia a te Reion ot heavil Burene b alnutritionfrica i xpecte to vertake ia a te Reion ot heavil Burene b alnutrition

Su: Mds d ons, Mnk Bssn nd en B, pvn nd tnds f Sunn amn p-S cdn,1990-2020, Public Health Nutrition, .15, N.1, Juy 14, 2011, .142-148

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While children who live in impoverished countries are at higher risk formalnutrition and stunting, poverty alone does not explain high malnutritionrates for children. A number of relatively poor countries are doing an admirable

job of tackling this problem, while other countries with greater resources arenot doing so well.

Political commitment, supportive policies and eective strategies have a lotto do with success in ghting child malnutrition. Tis is demonstrated by ananalysis of stunting rates and gross domestic product (GDP) in 127 developedand developing countries. For example: India has a GDP per capita of $1,500and 48 percent of its children are stunted. Compare this to Vietnam where theGDP per capita is $1,200 and the child stunting rate is 23 percent. Nigeria andGhana both have a GDP per capita around $1,250, but Nigerias child stuntingrate is 41 percent, while Ghanas is 29 percent.

Countries that are performing better on child nutrition than their nationalwealth might suggest include: Brazil, Chile, Costa Rica, Kyrgyzstan, Mongolia,Senegal and unisia. Countries that are underperforming relative to their GDPinclude: Botswana, Equatorial Guinea, Guatemala, Indonesia, Mexico, Panama,

Peru, South Africa and Venezuela.

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LUR g h PR

Most malnourished children tend to be poor. Generally speaking, chil-dren in the poorest households are more than twice as likely to be stunted orunderweight as children in the richest households. For many of these families,social protection programs and income-generating opportunities can play animportant role in contributing to better nutrition. However, in many countries,stunting can be relatively high even among the better-o families, showingthat knowledge, behavior and other factors also play a part.

Across all developing regions, malnutrition is highest in the poorest house-holds. In South Asia, the poorest children are almost three times as likely to beunderweight as their wealthiest peers. Latin America has some of the largestinequities. Te poorest children in Guatemala and Nicaragua are more thansix times as likely to be underweight as their wealthy peers. In Honduras, theyare eight times as likely, and in El Salvador and Peru, they are 13 and 16 timesas likely to be underweight.

Te relationship between stunting and wealth varies across countries. Incountries such as Bolivia, India, Nigeria and Peru, children in the richest house-holds are at a distinct advantage compared to children in other households.Tis contrasts with Ethiopia, where stunting is widespread. Even among chil-dren living in the wealthiest Ethiopian households, the prevalence of stuntingis high, at 30 percent. Similarly, in Bangladesh, stunting in children less than

5 years of age is found in one-fourth of the richest households. And in Egypt,stunting prevalence is remarkably similar across income groups (30 percent and27 percent among the poorest and richest households, respectively).

Te poorest children also tend to have the poorest dietary quality. In Ethiopia,Kenya and Nigeria, for example, the wealthiest children are twice as likely toconsume animal source foods as the poorest. In South Africa, they're almostthree times as likely.

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Here is a look at six key nutrition solutions that have the greatest potential

to save lives in a childs rst 1,000 days and beyond. Using a new evidence-based tool, Save the Children has calculated that nearly 1.3 million childrenslives could be saved each year if these six interventions are fully implementedat scale in the 12 countries most heavily burdened by child malnutrition andunder-5 mortality.

Implementing these solutions globally could save more than 2 million lives,and would not require massive investments in health infrastructure. In fact,

with the help of frontline health workers, all six of these interventions can bedelivered fairly rapidly using health systems that are already in place in mostdeveloping countries. What is lacking is the political will and relatively smallamount of money needed to take these proven solutions to the women andchildren who need them most.

Tree of the six solutions iron, vitamin A and zinc are typically packagedas capsules costing pennies per dose, or about $1 to $2 per person, per year. Teother three solutions breastfeeding, complementary feeding and good hygiene are behavior-change solutions, which are implemented through outreach,education and community support. Te World Bank estimates these latter threesolutions could be delivered through community nutrition programs at a costof $15 per household or $7.50 per child. All combined, the entire lifesavingpackage costs less than $20 per child for the rst 1,000 days.

Breastfeeding, when practiced optimally, is one of the most eective childsurvival interventions available today. Optimal feeding from birth to age 2can prevent an estimated 19 percent of all under-5 deaths, more than any otherintervention. However there are also other feeding practices and interventionsthat are needed to ensure good nutrition in developing countries (see sidebaron this page and graphic on page ).

Given the close link between malnutrition and infections, key interventionsto prevent and treat infections will contribute to better nutrition as well asreduced mortality. Tese interventions include good hygiene practices and hand

washing, sanitation and access to safe drinking water (which reduce diarrheaand other parasitic diseases to which undernourished children are particularlyvulnerable) and oral rehydration salts and therapeutic zinc to treat diarrhea.

h s LFsVg sLUs R:

Iron olate supplements Iron deciency anemia, the most common

nutritional disorder in the world, is a signicant cause of maternal mortality,increasing the risk of hemorrhage and infection during childbirth. It may alsocause premature birth and low birthweight. At least 25 percent or 1.6 billionpeople are estimated to be anemic, and millions more are iron decient, thevast majority of them women. A range of factors cause iron deciency ane-mia, including inadequate diet, blood loss associated with menstruation, andparasitic infections such as hookworm. Anemia also aects children, lower-ing resistance to disease and weakening a childs learning ability and physicalstamina. Recent studies suggest that pregnant women who take iron folatesupplements not only lower their risk of dying in childbirth, they also enhancethe intellectual development of their babies. Iron supplements for pregnant

women cost just $2 per pregnancy. It is estimated that 19 percent of maternaldeaths could be prevented if all women took iron supplements while pregnant.

SaiNg lieS aND BUilDiNg a Better FUtUre:loW-coSt SolUtioNS that WorK

at le eee toat le eee to

Fit alnutrition anFit alnutrition ansave Live?save Live?

In 008, world nutrition experts workedIn 008, world nutrition experts workedtogether to identiy a group o 13 cost-together to identiy a group o 13 cost-eective direct nutrition interventions,eective direct nutrition interventions,which were published in thewhich were published in the LancetLancetmedicalmedicaljournal. It was estimated that i thesejournal. It was estimated that i theseinterventions were scaled up to reach everyinterventions were scaled up to reach everymother and child in the 36 countries thatmother and child in the 36 countries thatare home to 90 percent o malnourishedare home to 90 percent o malnourishedchildren, approximately 5 percent o childchildren, approximately 5 percent o childdeaths could be prevented. Tere woulddeaths could be prevented. Tere would

also be substantial reductions in childhoodalso be substantial reductions in childhoodillnesses and stunting.illnesses and stunting.Experts also agreed that to make an evenExperts also agreed that to make an even

greater impact on reducing chronic malnugreater impact on reducing chronic malnu--trition, short- and long-term approaches aretrition, short- and long-term approaches arerequired across multiple sectors involvrequired across multiple sectors involv--ing health, social protection, agriculture,ing health, social protection, agriculture,economic growth, education and womenseconomic growth, education and womensempowerment.empowerment.

In 010, experts rom the Scaling UpIn 010, experts rom the Scaling UpNutrition (SUN) movement recommendedNutrition (SUN) movement recommendeda slightly revised group o 13 program-a slightly revised group o 13 program-matically easible, evidence-based directmatically easible, evidence-based directnutrition interventions. Te liesavingnutrition interventions. Te liesaving

six solutions profled in this report aresix solutions profled in this report area subset o both the 13 Lancet and the 13a subset o both the 13 Lancet and the 13SUN interventions. Te other seven SUNSUN interventions. Te other seven SUNinterventions are:interventions are:

Multiple micronutrient powdersMultiple micronutrient powders

Deworming drugs or children (to reduceDeworming drugs or children (to reduceloss o nutrients)loss o nutrients)

Salt iodizationSalt iodization

Iodized oil capsules where iodized salt isIodized oil capsules where iodized salt is

unavailableunavailable

Iron ortifcation o staple oodsIron ortifcation o staple oods

Supplemental eeding or moderately malSupplemental eeding or moderately mal--nourished children with special oodsnourished children with special oods

reatment o severe malnutrition withreatment o severe malnutrition withready-to-use therapeutic oods (RUF)ready-to-use therapeutic oods (RUF)


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24 SaiNg lieS aND BUilDiNg a Better FUtUre : loW-coSt SolUt ioNS that WorK

Breasteeding Human breast milk provides all the nutrients newborns

need for healthy development and also provides important antibodies againstcommon childhood illnesses. Exclusive breastfeeding prevents babies fromingesting contaminated water that could be mixed with infant formula. Teprotective benets of breastfeeding have been shown to be most signicant with6 months of exclusive breastfeeding and with continuation after 6 months, incombination with nutritious complementary foods (solids), up to age 2. Inconditions that normally exist in developing countries, breastfed children areat least 6 times more likely to survive in the early months than non-breastfedchildren.

Complementary eeding When breast milk alone is no longer sucientto meet a childs nutritional needs, other foods and liquids must be addedto a childs diet in addition to breast milk. Optimal complementary feed-

ing involves factors such as the quantity and quality of food, frequency andtimeliness of feeding, food hygiene, and feeding during/after illnesses. Tetarget range for complementary feeding is 6-23 months. WHO notes thatbreastfeeding should not be decreased when starting complementary feeding;complementary foods should be given with a spoon or a cup, not in a bottle;foods should be clean, safe and locally available; and ample time should be givenfor young children to learn to eat solid foods. Rates of malnutrition amongchildren usually peak during the time of complementary feeding. Growthfaltering is most evident between 6-12 months, when foods of low nutrientdensity begin to replace breast milk and rates of diarrheal illness due to foodcontamination are at their highest. During the past decade, there has beenconsiderable improvement in breastfeeding practices in many countries; how-ever, similar progress has not been made in the area of complementary feeding.Complementary feeding is a proven intervention that can signicantly reducestunting during the rst two years of life. If all children in the developing

world received adequate complementary feeding, stunting rates at 12 monthscould be cut by 20 percent.

Vitamin A supplements Roughly a third of all preschool-age children(190 million) and 15 percent of pregnant women (19 million) do not haveenough vitamin A in their daily diet. Vitamin A deciency is a contributingfactor in the 1.3 million deaths each year from diarrhea among children and thenearly 118,000 deaths from measles. Severe deciency can also cause irrevers-ible corneal damage, leading to partial or total blindness. Vitamin A capsules

given to children twice a year can prevent blindness and lower a childs risk ofdeath from common childhood diseases at a cost of only 2 cents per capsule.It is estimated that at least 2 percent of child deaths could be prevented if allchildren under age 5 received two doses of vitamin A each year.

Zinc for diarrhea Diarrhea causes the death of 1.3 million children eachyear, most of them between the ages of 6 months and 2 years. Young childrenare especially vulnerable because a smaller amount of uid loss causes sig-nicant dehydration, because they have fewer internal resources, and becausetheir energy requirements are higher. Children in developing nations suer anaverage of three cases of diarrhea a year. Diarrhea robs a childs body of vitalnutrients, causing malnutrition. Malnutrition, in turn, decreases the abilityof the immune system to ght further infections, making diarrheal episodes

more frequent. Repeated bouts of diarrhea stunt childrens growth and keepthem out of school, which further limits their chances for a successful future.

Promotin an supportinPromotin an supportin

arl nitiation ofarl nitiation ofBreatfeeinBreatfeein

Despite its benefts, many women delayDespite its benefts, many women delayinitiation o breasteeding. Only 43 percentinitiation o breasteeding. Only 43 percento newborns in developing countries areo newborns in developing countries areput to the breast within one hour o birth.put to the breast within one hour o birth.Establishing good breasteeding practicesEstablishing good breasteeding practicesin the frst days is critical to the health oin the frst days is critical to the health othe inant and to breasteeding success.the inant and to breasteeding success.Initiating breasteeding is easiest and mostInitiating breasteeding is easiest and mostsuccessul when a mother is physicallysuccessul when a mother is physicallyand psychologically prepared or birth andand psychologically prepared or birth and

breasteeding and when she is inormed,breasteeding and when she is inormed,supported, and confdent o her ability tosupported, and confdent o her ability tocare or her newborn. Te ollowing actionscare or her newborn. Te ollowing actionscan increase rates o early initiation ocan increase rates o early initiation obreasteeding:breasteeding:

Identiy the practices, belies, concernsIdentiy the practices, belies, concernsand constraints to early and exclusiveand constraints to early and exclusivebreasteeding and address them throughbreasteeding and address them throughappropriate messages and changes inappropriate messages and changes indelivery and postnatal proceduresdelivery and postnatal procedures

Counsel women during prenatal care onCounsel women during prenatal care onearly initiation and exclusive breasteedingearly initiation and exclusive breasteeding

Upgrade the skills o birth attendants toUpgrade the skills o birth attendants tosupport early and exclusive breasteedingsupport early and exclusive breasteeding

Make skin-to-skin contact and initiationMake skin-to-skin contact and initiationo breasteeding the frst routine atero breasteeding the frst routine aterdeliverydelivery

Praise the mother or giving colostrumPraise the mother or giving colostrum(the frst milk), provide ongoing(the frst milk), provide ongoingencouragement, and assist with positionencouragement, and assist with position--ing and attachmenting and attachment


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N

* D f Sudn ssn f rub f Su S udn n Juy 2011.

Te annual estimated number o under-5 lives saved represents the potential combinedTe annual estimated number o under-5 lives saved represents the potential combinedeect o scaling up the ollowing liesaving six interventions to universal coverage (seteect o scaling up the ollowing liesaving six interventions to universal coverage (setat 99%) by 00: iron olate supplementation during pregnancy, breasteeding (includingat 99%) by 00: iron olate supplementation during pregnancy, breasteeding (including

exclusive breasteeding or the frst six months and any breasteeding until 4 months),exclusive breasteeding or the frst six months and any breasteeding until 4 months),counseling on complementary eeding, vitamin A supplementation, zinc or treatment ocounseling on complementary eeding, vitamin A supplementation, zinc or treatment odiarrhea and improved hygiene practices (i.e. access to sae drinking water, use o improveddiarrhea and improved hygiene practices (i.e. access to sae drinking water, use o improvedsanitation acilities, sae disposal o children's stool, handwashing with soap). In the ewsanitation acilities, sae disposal o children's stool, handwashing with soap). In the ewinstances where intervention coverage data was missing, developing world averages wereinstances where intervention coverage data was missing, developing world averages wereused. LiS analysis was done by Save the Children, with support rom Johns Hopkinsused. LiS analysis was done by Save the Children, with support rom Johns HopkinsUniversity Bloomberg School o Public Health. Estimates or the number o stunted chilUniversity Bloomberg School o Public Health. Estimates or the number o stunted chil--dren in country were calculated by Save the Children.dren in country were calculated by Save the Children.

D sus: My nd und-5 un, UNice F. The State of the Worlds Children 2012 . tbs 1 nd 6; Sunn, Whogb Dbs n cd gw nd Mnun (us.n/nuwb /.), UNiceF gb Dbs s (dnf.) ndn DhS nd MicS suvys (s f a 2012)

When children with diarrhea are given zinc tablets along with oral rehydration

solution, they recover more quickly from diarrhea and they are protected fromrecurrences. At 2 cents a tablet, a full lifesaving course of zinc treatment fordiarrhea costs less than 30 cents. It is estimated that 4 percent of child deathscould be prevented if all young children with diarrhea were treated with zinc.

Water, sanitation and hygiene Poor access to safe water and sanitationservices, coupled with poor hygiene practices, kills and sickens millions ofchildren each year. Hand washing with soap is one of the most eective andinexpensive ways to prevent diarrheal disease and pneumonia, which togetherare responsible for approximately 2.9 million child deaths every year. It isestimated that 3 percent of child deaths could be prevented with access tosafe drinking water, improved sanitation facilities and good hygiene practices,especially hand washing.

e Can save 1.3 illion Live in ee 12 Countriee Can save 1.3 illion Live in ee 12 Countrie

UNDer-5 DeathS chilD StUNtiNg lieS SaeD

# (1,000s) rnk cuny % # (1,000s) rnk # (1,000s)

1,696 1 ind 48% 61,300 1 326

861 2 N 41% 10,900 2 308

465 3 Dr cn 43% 5,100 8 145

423 4 pksn 42% 8,900 3 100

315 5 cn 9% 7,700 5 22

271 6 e 44% 5,300 7 73

191 7 afnsn 59% 3,300 11 125

151 8 indns 40% 8,700 4 36

143 9 Sudn nd Su Sudn* 35% 2,200 16 31

141 10 Und 39% 2,500 13 51

140 11 Bnds 41% 6,100 6 22

133 12 tnzn 43% 3,400 10 45

otal live ave: 1.3 million


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26 SaiNg lieS aND BUilDiNg a Better FUtUre : loW-coSt SolUt ioNS that WorK

F d ddLR Fdg sCRCRd

Save the Children presents the Infant and Toddler Feeding Scorecardshowingwhere young children have the best nutrition, and where they have the worst.Tis analysis reveals that the developing world has a lot of room for improve-ment in early child feeding. Only 4 countries out of 73 score very good overall

on measures of young child nutrition. More than two-thirds perform in thefair or poor category.Te Scorecardanalyzes the status of child nutrition in 73 priority countries

where children are at the greatest risk of dying before they reach the age of 5or where they are dying in the greatest numbers. For each country, it measuresthe percentage of children who are:

Put to the breast within one hour of birth Exclusively breastfed for the rst 6 months Breastfed with complementary food from ages 6-9 months Breastfed at age 2Countries are ranked using a scoring system that assigns numeric values to

very good, good, fair and poor levels of achievement on these four indicators.

Te performance thresholds are consistent with those established by the WHOand USAIDs Linkages Project in 2003.

ver half te orl Cilren do ot have cce to te Lifeavin sixver half te orl Cilren do ot have cce to te Lifeavin six

in f sumnn

dun nny

Bsfdn

cmmny fdn

mn a sumnn

Zn f mn f d

W,1 snn2 nd yn3

timate eat preventewit univeral coverae

19% = 68,000 (mn)

13% = 990,000 (d)

6% = 460,000 (d)

2% = 150,000+ (d)

4% = 300,000 (d)

3% = 230,000 (d)

av v v n dvn uns

ouny sv vs w fu s-u

inuds xusv f s 6 mns nd ny b sfdn 6-11 mns

+ Sumnn nns n a s ud bn u 7%

0% 20% 40% 60% 80% 100%

3 2 1

Te number o deaths that could be prevented with universal coverage o the liesaving six interventions is calculated by applyingTe number o deaths that could be prevented with universal coverage o the liesaving six interventions is calculated by applying LancetLancetestimates o intervention eectiveness (Bhutta et al., 008 or iron olate, all others Jones et al., 003) to 010 child and 008 maternalestimates o intervention eectiveness (Bhutta et al., 008 or iron olate, all others Jones et al., 003) to 010 child and 008 maternalmortality. Coverage data are or the ollowing indicators: % mothers who took iron during pregnancy (90+ days); % children exclusivelymortality. Coverage data are or the ollowing indicators: % mothers who took iron during pregnancy (90+ days); % children exclusivelybreasted (frst 6 months); % children (6-8 months) introduced to sot, semi-sot or solid oods; % children (6-59 months) reached with twobreasted (frst 6 months); % children (6-8 months) introduced to sot, semi-sot or solid oods; % children (6-59 months) reached with twodoses o vitamin A; % children (6-59 months) with diarrhea receiving zinc; % population with access to sae drinking water (1); % populadoses o vitamin A; % children (6-59 months) with diarrhea receiving zinc; % population with access to sae drinking water (1); % popula--

tion using improved sanitation acilities (); % o mothers washing their hands with soap appropriately (i.e. ater handling stool and beoretion using improved sanitation acilities (); % o mothers washing their hands with soap appropriately (i.e. ater handling stool and beorepreparing ood) (3).preparing ood) (3).

D sus: UNiceF. The State of the Worlds Children 2012 . (Nw k: 2012), tb 2; Who/U NiceF Jn Mnn pmm f W Suy nd S nn. Progress on DrinkingWater and Sanitation - 2012 Ud. (UNiceF nd Who : Nw k: 2012); Susn hn, M Sk, csn MDnd, ajy M nd Jn Kysn Bks, Scaling Up Nutrition: WhatWill it Cost?(Wd Bnk: Wsnn Dc : 2010); n DhS suvys nd cus, ls D nqu nd rb aun, pnnd, Mvd nd hbu hyn Bvu:an evn cun y rvw, Health Education Research 2009, 24(4):655-673.


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Complementary feeding is the area where improvement is needed most.Countries score the most poor marks on this indicator, indicating widespreadnutritional shortfalls during the vulnerable period from 6 to 9 months of age.Tis is the time in many childrens lives when malnutrition is most likely to

begin, and when greater attention is clearly needed to prevent stunting.Te Scorecardalso looks at each countrys progress towards MillenniumDevelopment Goal 4 and at the degree to which countries have implementedthe International Code of Marketingof Breast-milk Substitutes. MDG chal-lenges the world community to reduce child mortality by two-thirds by 2015.Te marketing of breast-milk substitutes Code stipulates that there should beno promotion of breast-milk substitutes, bottles and teats to the general public;that neither health facilities nor health professionals should have a role in pro-moting breast-milk substitutes; and that free samples should not be providedto pregnant women, new mothers or families. Tese last two indicators arepresented to give a fuller picture of each countrys eorts to promote nutritionand save lives they were not included in the calculations for country rankings.

It is important to note that even in countries that have taken action to imple-ment the Code, monitoring and enforcement is often lacking. Only eective

Malnutrition can be greatly reduced through the delivery o simple interventions at key stages o the liecycle or the mother during pregMalnutrition can be greatly reduced through the delivery o simple interventions at key stages o the liecycle or the mother during preg--nancy and while breasteeding; or the child, in inancy and early childhood. I eectively scaled up, these key interventions will improvenancy and while breasteeding; or the child, in inancy and early childhood. I eectively scaled up, these key interventions will improvematernal and child nutrition and reduce the severity o childhood illness and under-5 mortality. Good nutrition is also important or chilmaternal and child nutrition and reduce the severity o childhood illness and under-5 mortality. Good nutrition is also important or chil--dren ater the frst 1,000 days, and interventions such as vitamin A supplementation, zinc treatment or diarrhea, and management o acutedren ater the frst 1,000 days, and interventions such as vitamin A supplementation, zinc treatment or diarrhea, and management o acutemalnutrition are also critical or these young children.malnutrition are also critical or these young children.

add fm: Mnsmn Nun inv, 2006; Zuq Bu, tmd amd, rb e. Bk, Smn cusns , Kyn Dwy, es gun, B hd, By Kkwd, SuMs, hpS Sdv nd M S k, W Wks? invnns f Mn nd cd Undnun nd Su vv, Lancet 2008 nd hn, . Scaling Up Nutrition: What Will it Cost?(Wd Bnk: Wsnn Dc: 2010)

save the children state of the worlds mothers report 2012 final

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