Can Sub–Sahara African Countries be able to benefit much from the 1000–Days ‘Window of Opportunity’ For Maternal and Infant Health?

The publication of the Lancet Series on Maternal and Child Undernutrition [1] in 2008 has provided sufficient scientific evidence on the consequences of maternal and child undernutrition. The articles identified a critical window of time between the start of a woman’s pregnancy and her child’s second birthday in which nutrition lays the foundation for a person’s lifelong health, cognitive development and future potential. This critical period, later termed the 1,000 days window, has revolutionized the way the world approaches the persisting problems of undernutrition. The authors of the Series have made it clear that by focusing investments on improving nutrition for women and children, from pregnancy to age two, much of the serious, often irreversible, damage caused by malnutrition can be prevented – and that doing so is also extremely cost–effective. Economists [2] have argued that improving nutrition is one of the best investments that can be made to achieve lasting progress in global health and development, estimating that every $1 spent on improving nutrition can have as much as a $138 return on investment.

It is argued in this editorial that populations in sub–Saharan countries may not benefit much from this important window of opportunity if their governments will not fulfil three conditions that are considered necessary. The three conditions are outlined here below.

Presence of well functioning Antenatal Care system

The potential of antenatal care services for reducing maternal morbidity and improving newborn survival and health has been widely acknowledged [3]. In 2001 the World Health Organization (WHO) issued guidance on a new model of antenatal care (ANC) called goal–oriented or focused antenatal care (FANC) for implementation in developing countries [4]. The new model reduced the number of required antenatal visits to four, and provides focused services shown to improve maternal outcomes. FANC emphasizes on helping women to maintain normal pregnancies by identifying existing health conditions, detecting emerging complications, promoting health, preparing for a healthy birth, and educating clients on postpartum care including nutrition, breastfeeding, and family planning. Trials conducted in other countries proved that FANC was safe and was a more sustainable, comprehensive, and effective ANC model [5]. However, a systematic review in a number of sub–Saharan countries [6] indicates that compliance with the FANC services is lacking whereby health workers don’t perform all procedures stipulated in the FANC guideline, and that some necessary services are not provided because the reagents for laboratory tests and drugs are often out of stock.

Political commitment to eliminating hunger and undernutrition

Lack of political will or political prioritization has been blamed for insufficient progress in reducing hunger and undernutrition [7]. Political commitment to reduce hunger and undernutrition is shown by purposeful and decisive public action; through public policies and programmes, public spending and legislation that are designed to tackle these twin problems. Attempts have been made by different researchers to design ways of assessing political commitment to reduce hunger and undernutrition by governments in the world. One of such recent attempt is the Hunger and Nutrition Commitment Index (HANCI) [8]. Other previous attempts include food security metrics and scorecards such as the Global Hunger Index [9], the Global Food Security Index [10]; SUN country analyses [11] and WHO’s Global Landscape Analyses [12].

While the international initiatives such as Scaling up Nutrition (SUN) have helped to put pressure on governments to show more commitment on nutrition, there is still a lot to be done. According to the 2012 HANCI Report, only 11 governments in the sub–Saharan Africa have been ranked among the top 20 countries out of 45 globally surveyed countries considered to be mostly affected by hunger and undernutrition.

Inclusion of maternal and infant health (and nutrition) considerations in other related development policies and strategies

Maternal and infant health is a multifaceted issue that requires integration of various sectors in addressing the problem. Traditionally, health sector has been considered as the most important sector for addressing the problem probably due to its direct link to health outcomes. However, according to FAO [13], integration of food and nutrition policy issues into overall and sectoral national development policies and strategies of a country is very effective in tackling the food and nutrition problems including those of maternal and infant health. Contrarily, a recent review of public policies in Tanzania [14], a typical country in sub–Saharan Africa, revealed that most of the development policies and strategies in the country have not included nutrition issues. Only few policies related to health, food and nutrition, agriculture, child and community development have somehow incorporated food insecurity and diseases; and under–nutrition was frequently addressed than over–nutrition or emerging diet–related chronic diseases. The situation is likely to be the same in much of the sub–Saharan countries.

Conclusion

Globally there is now sufficient scientific evidence for benefits of incorporating nutrition sensitive interventions within the first 1000 days, from pregnancy to second birthday of a child, in improving maternal and child nutrition. However, it is still doubtful whether most of sub–Sahara African countries will be able to enjoy the same. Governments and other stakeholders in these countries need to strive for more commitment to eliminating hunger and undernutrition. This will allow for presence of well functioning antenatal care systems, as well as inclusion of nutrition considerations in all development policies and strategies. Short of that, this window of opportunity islikely to remain a distant dream for these countries.

References

1. Richard Horton. The Lancet Series on Maternal and Child Undernutrition. The Lancet. 2008; 371.
2. John Hoddinott, Mark Rosegrant, Maximo Torero. Hunger and Malnutrition, 2012 Global Copenhagen Consensus, 2012; Copenhagen Consensus Challenge: published on-line. 2012.
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4. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizán J, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001; 357: 1551-1564.
5. WHO. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. World Health Organization, Geneva.2001.
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7. FAO.The State of Food Insecurity in the World 2012, Rome.Food and Agriculture Organisation of the UN.2012.
8. Dolf te Lintelo, Lawrence Haddad, Rajith Lakshman and Karine Gatellier. The Hunger And Nutrition Commitment Index (HANCI 2012) - Measuring the Political Commitment to Reduce Hunger and Undernutrition in Developing Countries. Institute of Development Studies (IDS). 2013. Can be accessed from: www.hancindex.org
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14. Save the Children Tanzania. Nutrition Policy Mapping for Tanzania. Report of a study conducted to enhance Partnership for Nutrition in Tanzania (PANITA). Save the Children Tanzania, Dar es Salaam.2012.