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Maternal and Infant Nutrition and Growth

Figure 1: Life stages from newborn to pregnancy
Source: Exemplars in Global Health
Globally, more than a billion women are malnourished and a quarter of children under five are experiencing stunting and/or wasting.1,2 Improving maternal nutrition can help disrupt an intergenerational cycle malnourishment by promoting healthy fetal development and reducing risk of growth faltering from the start. This, in turn, can reduce the risk of undernourishment amongst girls, who are often likely to become undernourished mothers who then give birth to small and vulnerable newborns.

Quick facts on maternal and infant nutrition and growth

Stunting is the failure of children to reach their full growth potential and is defined as a child’s height being too low for their age.

Wasting, or acute malnutrition, is the most life-threatening form of malnutrition and indicates that a child’s weight is too low for their height.

45 million

Wasting—generally considered a more acute form of malnutrition than stunting—threatened the lives of an estimated 7% or 45 million children under five globally in 2022.2 Evidence points to low maternal body mass index as the leading factor associated with wasting in older children 12 to 59 months of age.3

20%

Stunting affected an estimated 22% or 148 million children under five globally in 2022.2 An estimated 20% of stunting begins in utero.4

2.9 times

Children 12 to 59 months of age who were born with low birth weight in low- and middle-income countries are approximately 2.9 times more likely to develop stunting and are at a 2.7 times higher risk of wasting compared with those born with normal birth weight.5

A mother’s nutritional status underpins critical outcomes for both her and her baby, and can have lasting intergenerational effects.

Globally, a billion women and girls, mostly in low- and middle-income countries, suffer from various forms of undernutrition, including underweight and micronutrient deficiencies. 6 Women bear a greater burden of malnutrition, with 150 million more women than men suffering from food insecurity.7 The gender gap in food insecurity has worsened in recent years due to compounding global crises, such as the COVID-19 pandemic, climate change, and conflict; however, even under normal circumstances in some societies, women often eat the least and eat last.8 Women have increased nutritional needs during pregnancy and lactation, so food insecurity has an even greater impact on women during these stages.

Preventing malnutrition is essential for both a woman’s well-being and her child’s, as a child’s nutritional status is closely tied to the mother’s nutrition before, during, and after pregnancy. Poor maternal nutrition impairs fetal development, which leads to negative birth outcomes and various forms of undernutrition. This perpetuates an intergenerational cycle of undernourished girls who are more likely to become undernourished mothers who then give birth to small and vulnerable newborns.

The role of maternal nutrition on birth outcomes begins before pregnancy. Factors such as low body mass index (BMI) compounded with other factors during pregnancy (e.g., inadequate dietary intake or quality), can result in harmful effects for both the mother and her child. Diets that lack sufficient energy, macro-, and micronutrients—and/or a body’s inability to absorb nutrients—can lead to poor pregnancy outcomes, such as maternal anemia and preeclampsia. These can also have negative effects on the child, such as intrauterine growth restriction, stillbirth, or low birth weight and growth faltering (i.e., stunting and wasting) among infants who survive.

The Exemplars in Global Health work in Maternal and Infant Nutrition and Growth aims to identify countries that have made progress across several key nutrition indicators and to understand how these Exemplar countries have driven progress to disrupt the intergenerational cycle of malnutrition. Figure 2 is the Maternal and Infant Nutrition and Growth conceptual framework, which has been modified from the United Nations Children’s Fund (UNICEF) framework for undernutrition.9 The conceptual framework presents the underlying, intermediate, and direct causes of poor maternal nutrition and infant and child growth along with the relevant relationships between them.

Figure 2: Exemplars in Global Health conceptual framework for Maternal and Infant Nutrition and Growth

Figure 2: Exemplars in Global Health conceptual framework for Maternal and Infant Nutrition and Growth
Adapted from UNICEF Conceptual Framework

Evidence shows that maternal height and BMI, key indicators of maternal nutritional status, impact birth outcomes and growth faltering in children.

It is hypothesized that the consistent association between low maternal BMI and child growth faltering may be attributed to fetal intrauterine growth restriction, which increases the risk of a child having low birth weight and being small for their gestational age—all of which can form the fetal origins of childhood undernutrition. 10

Poor maternal nutrition continues to impact child health outcomes beyond infancy, leading to developmental delays during childhood and reduced productivity in adulthood. The nutritional status of children beyond the first six months of life (i.e., the exclusive breastfeeding period) is increasingly impacted by factors beyond maternal nutrition, such as dietary intake, disease, and household environment.

Maternal nutrition and birth outcomes

Women who are underweight, defined as BMI less than 18.5 kg/mg2, or who have short stature, defined as height less than 150 cm, are more likely to give birth to small and vulnerable newborns (i.e., those who are small for their gestational age, have low birth weight, and/or are born preterm). 11 It is estimated that, annually, 6.5 million small-for-gestational-age or preterm births are associated with short maternal stature.11 Small and vulnerable newborns are at higher risk of stillbirth, and those who survive have an increased risk for multiple morbidities with adverse consequences, including undernutrition, metabolic disorders, and developmental delays, all of which can result in loss of health and human capital.

Maternal nutrition and early growth faltering

The highest prevalence of wasting and highest incidence of stunting occur at birth or during the exclusive breastfeeding period when maternal nutrition is directly linked to child health outcomes.12,13 Periods of early growth faltering continue to impact children beyond the first six months of life. For example, children who were wasted at birth and then recover have higher cumulative incidences of wasting after six months compared with those who do not experience wasting.12

Evidence shows that maternal nutrition plays a strong role in stunting and wasting in infants and young children. A cohort analysis across 20 studies in low- and middle-income countries found that children born to mothers with low maternal height had a lower length-for-age z score (LAZ) across the time period and were therefore more likely to experience stunting (Figure 3, top, left side).12 Children born to mothers with low maternal height had a lower weight-for-length z score (WLZ) from 3 to 24 months and were therefore more likely to experience wasting (Figure 3, top, right side). The differences in WLZ and LAZ from 0 to 24 months based on maternal BMI are pronounced, indicating that children born to mothers with low BMI are more likely to experience stunting and wasting in the first two years of life (Figure 3, bottom).

Figure 3: Child LAZ and WLZ trajectories stratified by maternal height and BMI

Figure 3: Child LAZ and WLZ trajectories stratified by maternal height and BMI
Adapted from Mertens A, Benjamin-Chung J, Colford JM Jr, et al.

Abbreviations: BMI, body mass index; LAZ, length-for-age z score; WAZ, weight-for-length z score.

Maternal nutrition and growth faltering in older children

Evidence continues to point to maternal height and BMI as leading factors associated with growth faltering for older children 12 to 59 months of age. A study in low- and middle-income countries confirmed that short maternal height was the strongest factor associated with child stunting, closely followed by low BMI (Figure 4).10 Low maternal BMI was the strongest factor associated with child wasting.

 

Figure 4: Relative ranking of factors associated with child stunting and wasting

Figure 4: Relative ranking of factors associated with child stunting and wasting
Adapted from Li et al.

Abbreviations: ANC, antenatal care; BMI, body mass index; HH, household; ORT, oral rehydration therapy; SBA, skilled birth attendant.

After the first six months of life, factors beyond maternal nutrition become increasingly important in preventing child malnutrition, including high-quality dietary intake and complementary feeding practices, exposure to disease, and access to health care services, education, and water, sanitation, and hygiene. 14 Multiple interventions will be important for reducing undernutrition in early childhood, which will subsequently decrease risk of mortality, disability, reduced learning potential, and life-course complications.

Maternal nutrition and wasting

More than 1 million deaths annually are attributed to wasting, or acute malnutrition, which affects 45 million children globally.12 Progress in the reduction of wasting has stagnated or even reversed in recent years.15 As of 2022, approximately 45.4 million children under five were affected by wasting, and about 13.6 million were affected by severe wasting.16

South Asia has a significantly higher prevalence of wasting at birth and in children under five compared with other regions (Figure 5), which can be correlated with the burden of low birth weight in the region (Figure 6). This underscores the impact of maternal malnutrition, maternal morbidities, and maternal small stature on poor fetal growth and their potential as key regional drivers of wasting.

Figure 5: Number (millions) of children under five affected by wasting by United Nations sub-region, 2022

Figure 5: Number (millions) of children under five affected by wasting by United Nations sub-region, 2022
United Nations Children’s Fund (UNICEF) et al.

The South Asia region also experiences longer wasting episodes, which is strongly associated with a higher risk of stunting. These two growth faltering outcomes have a negative reinforcing relationship (i.e., wasting increases the risk of future stunting and vice versa), with the strength of the relationship increasing with longer durations of wasting episodes.12

In recent years, compounding crises have stagnated progress made in many nutrition indicators.

Globally, over a billion adolescent girls and women suffer from undernutrition, micronutrient deficiencies, and/or anemia.17 Undernourished women who become pregnant face the greatest risks to their health and survival and have a higher likelihood of giving birth to small infants with low body nutrient reserves who suffer from wasting and stunting during the crucial early years of life. In 2022, globally, 22% of children under five years of age were stunted and 7% were wasted, with most of the burden occurring in low- and middle-income countries.18 Recent Global Burden of Disease estimates based on outcomes from 1990 to 2019 attribute more than 164,000 deaths annually to stunting and about 900,000 deaths annually to wasting.19 In recent years, contextual factors—including the COVID-19 pandemic, effects of climate change, and conflict—have eroded some of the progress made in many nutrition indicators and have led to an increase in wasting.

Maternal nutrition and birth outcomes

More than two-thirds of adolescent girls and women around the world suffer from micronutrient deficiencies (69%) and the prevalence of anemia remains high and unchanged since 2000 at approximately 30%.17,20 Across low- and middle-income countries, short stature (i.e., height less than 150 cm) in women of reproductive age (WRA) declined from 9.3% in 2000 to 7.0% in 2015, and low BMI in WRA declined from 27.2% in 2000 to 14.2% in 2015.21 According to the most recent Lancet series on maternal and child undernutrition in 2021,22 however, the burden of low BMI among women in west, east, and central Africa and in Asia remains elevated, particularly in South Asia at 24%. In 2014, India ranked first globally in low BMI prevalence (42%), with over 100 million women being underweight. In South and Southeast Asia, short maternal stature affects as many as 40% to 70% of all women.

Undernourished women, reflected in low BMI and short stature, are more likely to give birth to infants who are born too early (preterm) or born too small (having low birth weight or being small for their gestational age). In 2020, 35.3 million births were small and vulnerable newborns, reflecting more than one in four of all live births.23 This translates to 26% of the world’s newborns.

Children born too soon and born too small account for a significant proportion of stillbirths and approximately 55% of all neonatal mortality in the world, which in turn accounts for almost half of all under-five mortality in the world. As a proportion of global live births:

  • 1.1% were preterm and small for gestational age, accounting for 1.5 million births and 0.19 million (12.7%) attributable neonatal deaths
  • 8.8% were preterm and not small for gestational age, accounting for 11.9 million births and 0.82 million (6.9%) attributable neonatal deaths
  • 16.3% were full-term and small for gestational age, accounting for 21.9 million births and 0.37 million (1.7%) attributable neonatal deaths23

The majority of small and vulnerable newborns are born in sub-Saharan Africa and southern Asia, as shown by the significant burden of low birth weight in these regions (Figure 6).

Figure 6: Prevalence and number of low birth weight by United Nations sub-region, 2020

Figure 6: Prevalence and number of low birth weight by United Nations sub-region, 2020
World Health Organization

Stunting

More than 250,000 deaths per year are attributed to stunting, or chronic malnutrition, which affects about 148 million children under five globally.24 Global prevalence has improved, from 33% to 22% from 2000 to 2022; however, like other nutrition indicators, progress has slowed due to climate shocks, the COVID-19 pandemic, and other contextual factors.18 Regional variations in stunting incidence exist, with substantially higher stunting at birth in South Asia and Africa compared with other regions (Figure 7).

Figure 7: Number of children under five affected by stunting by United Nations sub-region, 2012 and 2022

Figure 7: Number of children under five affected by stunting by United Nations sub-region, 2012 and 2022
United Nations Children’s Fund (UNICEF) et al.

Concurrent stunting and wasting

Stunting and wasting, two manifestations of undernutrition, have common causes. A 2019 study showed that when body weight falters, linear growth is also slowed, which increases the risk of stunting and wasting occurring in the same individual, a situation defined as concurrence.25

Globally, approximately 8% of children under five may be both wasted and stunted at the same time.26 The impact of these coexisting forms of malnutrition—specifically for children under six months—increases the risk of child mortality by 4.8 times compared with those who are impacted by a singular outcome.26

Ending malnutrition has long been a priority of the international health community, with the United Nations (UN) Sustainable Development Goal (SDG) 2 focused on achieving zero hunger by 2030. Reducing malnutrition improves overall health, thereby increasing human capital and boosting economic productivity. Global goals have been set to reduce undernourishment and improve women’s nutritional status, improve birth outcomes, and decrease child stunting and wasting.

The global community has set multiple goals to improve the nutritional status of women. Broadly, SDG 2.1 aims to end hunger and ensure access by all people to safe, nutritious, and sufficient food all year round by 2030. In 2022, an estimated 2.4 billion individuals, or about 30% of the world’s population, experienced moderate to severe food insecurity.27 This burden was disproportionally borne by women. The gender gap in food insecurity, which quantifies how many more women experience food insecurity compared with men, more than doubled between 2019 (49 million) and 2021 (126 million) as girls and women across the world were disproportionately impacted by compounding crises.28

To achieve the SDGs by 2030, the global community recognizes that significant effort is required to close the gender nutrition gap. In July 2023, a group of over 40 organizations across the UN, international and national nonprofits, philanthropies, national medical societies, and research institutes co-created an action agenda to close the gender nutrition gap.29 The agenda provides eight action domains to bridge the gap across sectors, 10 principles to guide all actions, and four action areas with policy and program recommendations.

SDG 2.1 also includes a goal to reduce anemia among women of reproductive age by 50% by 2030, from approximately 30% in 2012 to 15% in 2030. Progress in reducing anemia has largely stagnated, and no region in the world is on course to meet the 2030 SDG target. Despite the global shortfall in meeting the 2030 SDG target, some countries have made significant strides in reducing anemia among women of reproductive age.

Learn more about global goals to reduce anemia among women of reproductive age.

Birth outcomes

As a part of its nutrition targets, the World Health Assembly set a goal to achieve a 30% reduction in low birth weight by 2030 from a baseline of 15% in 2012. In 2020, 14.7% of infants had low birth weight and only 15 countries were on course to meet the low birth weight target.30 The estimated average annual rate of reduction (AARR) was 0.3% per year between 2012 and 2020 worldwide, which is much lower than required to achieve the 2030 target.31 Achieving the low birth weight target could also support progress toward the SDGs, including those relating to neonatal mortality and SDG 2.

Growth faltering

SDG 2.2 commits countries to “end all forms of malnutrition,” with child stunting and wasting as explicit targets. SDG 2.2.1 aims to reduce stunting from 33% in 2000 to 13.5% in 2030. Currently, the world is not on track to achieve the 2030 target and the rate of reduction needed to achieve this target is four times higher than what has been achieved over the past decade (Figure 8). Despite this, some countries have made significant progress, demonstrating that with concerted effort and effective policies, substantial improvements are possible.

Learn more about global goals to reduce stunting.

Figure 8: Percentage of children with stunting from 2000 to 2022 and projections to 2030

Figure 8: Percentage of children with stunting from 2000 to 2022 and projections to 2030
Adapted from United Nations Children’s Fund (UNICEF) et al.

Abbreviation: AARR, annual average rate of reduction.

SDG 2.2.2 aims to reduce the prevalence of child wasting to less than 3% by 2030. In 2022, 6.8% of children under five globally were affected by wasting and over half of all children lived in countries that were not on track to achieve the 2030 target (Figure 9).

Figure 9: Progress toward malnutrition SDG targets

Figure 9: Progress toward malnutrition SDG targets
United Nations Children’s Fund (UNICEF) et al.

Abbreviation: SDG, Sustainable Development Goal.

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Maternal and Infant Nutrition and Growth Exemplars

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