By Sunit Bagree (Senior Policy Advocacy Officer at Results UK and Research Associate in International Development at the University of Sussex)
A recent article in Health Policy and Planning by Jain et al laid bare the enormous costs of inaction on undernutrition. Nevertheless, there is no doubt that the overall state of global nutrition is abysmal. Sustainable Development Goal 2, ‘zero hunger’, is among the Global Goals that are most off-track. Meanwhile, the World Health Assembly’s main global nutrition targets are almost certainly not going to be met in large part. Yet, amidst this sea of despair, there are shining beacons of hope.
Two highly cost-effective interventions for reducing childhood deaths and illnesses due to malnutrition are prenatal vitamins and minerals (known as multiple micronutrient supplementation or MMS) and breastfeeding support. As a new briefing paper demonstrates, Ethiopia and Sierra Leone provide real-life examples of how these proven nutrition interventions can be successfully promoted. These positive examples should galvanise political leaders across the world, including those in the UK, into supporting these interventions with far greater vigour.
Prenatal multiple micronutrient supplementation in Ethiopia
In the Global South, deficiencies of micronutrients are especially common during pregnancy, due to increased nutrient requirements by mothers. Such deficiencies negatively impact the health of the mother, foetus and newborn baby. Prenatal MMS consists of a single daily tablet containing 15 vitamins and minerals that can contribute to addressing micronutrient deficiencies. In 2021, the World Health Organization added a formulation of prenatal MMS to its Model List of Essential Medicines.
In Ethiopia, UNICEF is supporting the Government to introduce the use of MMS among pregnant women and girls attending antenatal services across five of the country’s regions. This programme aims to reach 400,000 pregnant women and girls by the end of 2025, and inform the equitable and sustainable scale-up of prenatal MMS in the country. While the focus of the programme is prenatal MMS, it aims to generate demand for, and to improve the quality of, antenatal services more broadly. In addition, the programme has benefited from strong national and international academic partnerships, including for collecting and managing micronutrient data.
Breastfeeding support in Sierra Leone
Breastmilk contains antibodies which help protect babies from infections and diseases, and breastfed children perform better on intelligence tests. Women who breastfeed also have a reduced risk of cancer and other diseases. The United Nations recommends that babies are exclusively breastfed for the first 6 months of their lives. The global targets for exclusive breastfeeding rates are 50% by 2025 and 70% by 2030.
Sierra Leone is one of only six Global South countries projected to achieve a 70% exclusive breastfeeding rate by 2030. Exclusive breastfeeding messages are communicated across the country via radio, awareness drives, mother-to-mother support groups and religious leaders. It is particularly important to address misconceptions on the part of mothers, fathers and influential community members, e.g. that it is necessary to give babies under 6 months old water because they are ‘thirsty’ (breastmilk alone is sufficient). Moreover, training hospital staff in line with the UN’s ‘10 Steps to Successful Breastfeeding’ has enabled maternity facilities in Sierra Leone to become more trusted centres of breastfeeding.
Challenges remain
Despite the genuine progress in Ethiopia and Sierra Leone, there are still some significant challenges. These challenges apply to other Global South countries as well. Four are worth highlighting.
First, while sound laws, policies and guidelines exist in both countries, more action is required. In the case of Ethiopia, the country’s prenatal MMS strategy needs to be married to ambitious strategies to tackle food insecurity and unhealthy diets across the population. In Sierra Leone, there is a clear need to ensure greater workplace support for good breastfeeding practices, particularly for women in the farming sector.
Second, although both countries have rightly eschewed a narrow outlook and adopted approaches centred on strengthening wider health systems, they have a long way to go. In particular, considerably more skilled health workers need to be trained, recruited and retained in Ethiopia and Sierra Leone. It is also necessary for prenatal MMS and breastfeeding support to be explicitly linked to broader health (and other social) services.
Third, both countries need to do more to reach teenagers. This is because teenagers are particularly at risk of not benefiting from prenatal MMS (and other maternal nutrition services), and they are more likely to not exclusively breastfeed. Therefore it is necessary to promote and tailor prenatal MMS and breastfeeding support to those who become pregnant as teenagers. This includes addressing misconceptions on the part of some teenagers, as well as tackling the stigmatisation faced by some unmarried teenagers who become pregnant.
Fourth, it is critical that both countries adequately regulate the private sector in line with their human rights obligations. For example, there is increasing interest in local production of prenatal MMS in Ethiopia. While the private sector can have a role to play in the prenatal MMS sector, government action to involve non-state actors in this sector should prioritise social enterprises and other non-profit entities, and robust regulation is necessary to ensure fair pricing and quality. Moreover, free public distribution of prenatal MMS will continue to be critical to ensure that marginalised women and girls benefit.
Similarly, in line with the International Code of Marketing of Breast-milk Substitutes, the Parliament of Sierra Leone passed a law to regulate the marketing of breastmilk substitutes in 2021. It is vital that Sierra Leone fully implements this law, as the aggressive marketing and promotion of breastmilk substitutes in the country has been a major factor in the early introduction of additional foods for babies.
The UK’s funding for nutrition programmes overseas fell off a cliff following the then Government’s decision to cut official development assistance (ODA) in 2020. The new Government should immediately return to spending 0.7% of Gross National Income on ODA, substantially increase spending on nutrition, and prioritise cost-effective interventions such as prenatal MMS and breastfeeding support. The UK should also support Global South countries to comprehensively regulate micronutrient supplements and breastmilk substitutes. In this way, the UK can help to turn the tide against malnutrition and create more shining beacons.
Image credit: © UNICEF Ethiopia/2023/Ayene
