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DISCUSSION

Nutriwards did not differ from nutrihuts with respect to admission, discharge, and follow-up weights, weight gain during confinement and after discharge. Patients in nutrihuts, however, stayed longer and had a lower mortality rate during confinement than patients in nutriwards. Nutriwards, tended to attract patients from the municipalities where they are located, whereas nutrihuts attracted more patients from the rest of the province. The availability of lodging facilities in nutrihuts for mothers and other siblings may be the reason for the difference in geographical coverage. The large proportion (24 per cent) of patients who were discharged against medical advice is disturbing, and it probably means that a significant number of mothers cannot afford to leave home for the duration of the rehabilitation process.

The weights-for-age on admission, discharge, and follow-up - 57.1 per cent, 64.3 per cent, and 68.3 per cent respectively - are comparatively lower than Webb's findings in Haiti (12). He recorded weights-for-age of 65.3 per cent on admission, 69.4 per cent on discharge, and 72.2 per cent 21 months after discharge. But the gain in weight of 7.2 per cent of normal weight in our study is higher than the 4.1 per cent reported by Webb (12), 3.4 per cent found by King et al. (13), 4.4 per cent reported by Latham et al. (10), and 4.4 per cent observed by Berggren (14).

Webb also reported a further gain of 2.8 per cent from discharge weight at 21 months after discharge. Our figure of 4.0 per cent at 8.7 months after discharge does indicate that, on average, children were maintaining their improved nutritional status and not regressing towards their admission weight level. The relapse rate of 23 per cent can be further reduced by an improved follow-up programme.

The overall mortality rate of 6.8 per cent during confinement is probably an under-estimate, since cases with complications are first admitted to the paediatric wards of the hospital and transferred to the nutriward or nutrihut when they improve. The higher mortality rate during confinement in nutriwards compared to nutrihuts agrees with Cook's finding that hospitalized malnourished children have a higher mortality rate (9). Spalding et al. (15) reported a mortality rate of 23 per cent of cases with PEM during hospital stay in the Gambia, and Lamptey (16) found a mortality rate of 20 per cent in malnourished children admitted to the Princess Marie Louise Hospital in Ghana. The mortality rate of 12.4 per cent among all children after discharge refers to deaths in children previously admitted with PEM, and does not necessarily represent deaths from malnutrition. This rate is 13 times the estimated national 1-to-4-year mortality rate (even though only 80 per cent of the patients were from one to four years old; the rest were over five years old).

Immediate younger and older siblings of patients were better nourished than the rehabilitated children. This may be due to the fact that most of the younger siblings had not yet reached the nutritionally critical weaning period, while the older siblings were past it,

During the course of the three-month study in the Philippines, I was amazed and impressed by the keen interest of local government officials in nutrition rehabilitation, and most of the nutrihuts appear to have been built due to the efforts of such people. However, the locations of these nutrition rehabilitation units are unevenly distributed in the region. Of the seven provinces in the region, only two have nutrihuts - Surigao del Norte has 22 (only half were functioning) and Agusan del Sur has a nutrivillage. The rest of the provinces have none, despite the fact that the prevalence of PEM is about evenly distributed in all of the provinces. There is therefore a need for more central planning in the sitting of nutrihuts based on need and geographical coverage.

Five of the nutrihuts that we visited were not functioning; the major reason given was that there were no patients coming in. Of the nutrihuts that were functioning, almost all were full at the time of our study, whereas most of the nutriwards were partially empty. There is no doubt that there are a lot of patients with severe PEM who need nutrition rehabilitation who are not being reached by the present system. In 1978, of the estimated 3 million cases of second and third degree PEM in the country, only 4,000 (0.1 per cent) were treated in nutrition rehabilitation institutions. It is obvious, therefore, that nutriwards and nutrihuts cannot cater to all the clinical cases of PEM in the country. A mobile nutrition rehabilitation programme would help to improve coverage, especially of moderately severe cases of PEM, as well as of other children with severe PEM whose parents cannot afford, or are reluctant, to leave home for a variety of economic and social reasons.

The rural health network and the barangay nutrition scholar programme can help coverage through an improved referral system and better follow-up services to reduce the high mortality among discharged children.

The lodging facilities for the care-taker of the patients was generally satisfactory in nutrihuts, but inadequate in nutriwards. Malnutrition is as much a problem of the mother as of the child, and provisions should therefore be made to accommodate both mother and child. A mother who spends most of her nights in the hospital on an uncomfortable bench and the rest of the time caring for her child in a strange environment, while also worrying about the family at home, is not likely to be in a mood to listen to or participate in nutrition education.

Record-keeping was generally inadequate, especially in some of the nutrihuts. This may be the result of inadequate training or lack of supervision. The nutrihuts are being run by a number of dedicated, hard-working individuals who really care about their patients. It is imperative that they be given adequate support in terms of regular, continuing education and supervision as well as encouragement and reward for their services. Internal and external evaluation is necessary to maintain and improve the quality of the rehabilitation process.

SUMMARY

Patients admitted to nutrihuts stayed longer and had a lower mortality rate during confinement than those admitted to nutriwards. There was a significant improvement in nutritional status during confinement in both nutriwards and nutrihuts and after discharge. The relapse rate was 23 per cent. The mortality rate after discharge in all institutions was 12.4 per cent, with patients of nutriwards having a mortality 12 times higher than that of patients discharged from nutrihuts.

ACKNOWLEDGEMENTS

We are grateful for the support and help of Dr. Rodolfo Florentino, Mrs. Salome Dominguez, Dr. and Mrs. Florenino Solon, and the staff of the NCP-UNU office of the Nutrition Center of the Philippines and the assistance of Mrs. Tes Rosete and Miss Emily de Leon of the NCP. The cooperation and help of the following people is also greatly appreciated: Mrs. Minda Aceron (Surigao del Norte); Miss Iris de Lara (Misamis Oriental); Miss Clarita Montilla (Agusan del Norte); and Mr. Plaza (Agusan del Sur); and several other people who contributed to the success of the study.

REFERENCES

1. Disease Intelligence Center, The Philippines Health Statistics, 1974 (Department of Health, Manila, Philippines, 1976).

2. The Philippine Nutrition Program, 1978-1982 (published by the National Nutrition Council in conjunction with the National Economic Development Authority [NEDA], Manila, Philippines, 1977).

3. R. Florentino, C. Adorna, and F. Solon, in Interface Problems between Nutrition Policy and Its Implementation (United Nations University, Tokyo, in preparation).

4. J. M. Bengoa, "Nutritional Rehabilitation Programmes," J. Trop. Pediat. African Child Hlth., 10 (3): 63-64 (1964).

5. I. D. Beghin and F. E. Viteri, "Nutritional Rehabilitation Centres: An Evaluation of Their Performance," J. Trop. Pediat. Environ. Child Hlth., 19 (4): 404-416 (1973).

6. D. C. Robinson, "The Nutrition Rehabilitation Unit at Mulago Hospital, Kampala: Further Development and Evaluation 1967-1969," J. Trop. Pediat. Environ. Child Hlth., 17 (Monogr. 13): 35-43 (1971).

7. M. Sadre, G. Donoso, and H. Hedayat, The Fate of the Hospitalized Malnourished Child in Iran," J. Trop. Pediat. Environ, Child Hlth., 19: 28-32 (1973).

8. D. B. Jelliffe, The Assessment of Nutritional Status in the Community, WHO Monograph No. 53 (WHO, Geneva, 1966).

9. R. Cook, "Is Hospital the Place for the Treatment of Malnourished Children?" J. Trop. Pediat. Environ. Child Hlth. 17: 15-25 (1971).

10. M. C. Latham and M. Beaudry-Darisme, "Nutrition Rehabilitation Centres - An Evaluation of Their Performance," J. Trop. Pediat. Environ. Child Hlth., 19: 299-332 (1973).

11. "World Health Organization Reference Standards of Weight for Age" (WHO, Geneva).

12. R. E. Webb, W. Fougere, and Y. Papillon, "An Evaluation Of the Educational Benefits of Nutritional Rehabilitation Centres as Measured by the Nutritional Status of Siblings," J. Trop. Pediat Environ, Child Hlth., 21 (1): 7-10 (1975).

13. K. W. King, I. D. Beghin, W. Fougere, G. Dominque, R. Grinker, and J. Foucould, "Two-Year Evaluation of a Nutritional Rehabilitation Centre," Arch. Venezol. Nut., 18: 245-261 (1968).

14. W. L. Berggren, in Proceedings of the Western Hemisphere Nutrition Congress III - 1971 (Mount Kisco, N. Y., USA: Futura Publishing Co., Inc., 1972), p.84.

15. E. Spalding, J. McCrea, I. H. Rutishauser, and J. M. Parkin, "A Study of the Severely Malnourished Children in the Gambia," J. Trop. Pediat Environ. Child Hlth" 23 (5): 215-219 (1977).

16. P. R. Lamptey, "Study Of Malnourished Children Admitted to the Princess Marie Louise Hospital in Ghana" (unpublished).

Malnutrition, wealth, and development

Peter L. Pellett

Department of Food Science and Nutrition, Chenoweth Laboratory, University of Massachusetts, Amherst, Massachusetts, USA

While poverty remains the most important single cause of malnutrition, and strategies to alleviate malnutrition among the poor are central to nutrition planning activities throughout the world, it is well recognized that removal of poverty does not, by itself, guarantee good nutritional status. As wealth increases within a developing country, sections of the population become prone to the diseases of the affluent. Obesity, atherosclerosis, diabetes, and other diseases are increasingly significant in oil-rich nations and also among the rich sections of some of the poor nations so that public health and nutrition consultants may be faced simultaneously with nutritional problems related to poverty and affluence. This is obvious and is an expected consequence of development.

What is less obvious, however, are recent reports that demonstrate poor growth in children and malnutrition in its extreme form, nutritional marasmus, in newly rich nations such as Libya and Saudi Arabia (1-3). Personal observation in both Iraq and Libya has revealed this disease to be occurring much more frequently than it should, and also at an extremely early age. In the West Indies (4), a similar phenomenon has also been reported, Here it was emphasized that, while a major prerequisite for improving nutritional status is enhanced economic well-being, the length of time of breast-feeding and the total number of persons in the family are also important factors in the pathogenesis of malnutrition.

In an initial report in 1976 concerning Libya (1), it was hypothesized that nutritional marasmus will probably continue to be a major nutritional problem in the world for two contrasting reasons. Increasing trends toward urbanization will mean more children at risk as the result of poverty and poor hygiene. Simultaneously, increasing affluence will produce a more numerous urban middle class in terms of wealth, but education and health services will remain inadequate. This will lead to the emergence of a class of the "urban, uneducated relatively well-to-do" (1) whose problems will be different from those they experienced in the past.

Because of governmental investment in housing, their accomodations will often be adequate, allowing them to be able to afford baby-food products for their children. The danger here is that poorly educated mothers will not know how to prepare and use such products correctly. Three recent studies support this hypothesis and will be briefly discussed here.

TABLE 1. Some Major Positive Factors Relating to Nutritional Marasmus in Libya

Source: Ref. 2.; The factors are arranged in priority according to decreasing values of chi square. It should be noted that many of the factors are not mutually exclusive; e.g., high birth rank will also usually imply large numbers of children and thus low per capita family income. Similarly, illiterate parents will be unlikely to have newspapers in the household. (* At the time of the survey, one Libyan diner was equal to US$3.60)

In a recent study in Libya (2), fifty families with marasmic infants (mean weight for age 58.4 per cent of US standards) were questioned and compared with fifty families whose infants of the same age were being brought to the OPD of the same hospital in Tripoli for check-ups and for minor ailments. Table 1 shows some of the major positive factors that relate to nutritional marasmus in Libya. As can be seen, the marasmic infant in Libya is frequently the most recent baby in a large family where the parents are first cousins. The family receives an average total income, but because of the large family size, per capita income is low. Housing conditions, while crowded, are nevertheless extremely good by developing country standards.

The mother is often illiterate, tends to breast-feed her baby for only a short period, and uses supplementary foods early. The child subsequently develops severe diarrhoea for an extended period while still very young, but is only brought to the hospital when critically ill despite wide availability of medical facilities in the country. Because of the large number of hospital admissions and the consequent need for beds, especially in the summer months, the child is usually discharged within two weeks after admission, as soon as he or she is rehydrated and begins to gain weight. Little is known about the subsequent fate of these children; many must relapse and return to hospital.

While per capita income was a very significant factor, total family income was much less so. In fact, in this study, if allowance is made for the rather skewed distribution of income in the comparison group where there were several high-income families, the mean family income is almost identical. Also, total numbers of the poorest families (income less than about US$350 per month) were similar in both groups. Additional factors of high predictive significance were more than six family members, more than four children, a poorly educated mother, and a short period of breast-feeding. It should be noted that neither group in this population was living in the poverty generally found in developing countries. All families had adequate housing with separate kitchens and bathrooms, and in addition, radios, televisions, and even automobiles were widely present in both groups.

In the Caribbean study, the period of breast-feeding and the age at which it ceased (leverage) were also important factors in St. Vincent (4) despite the population's being in general poorer than the families observed in the Middle East. Using multiple regression analysis on a sample of 189 children, Greiner and Latham (4) showed that the four major Actors affecting nutritional status (Table 2), as measured by percentage weight for age, were the age of leverage (defined as the complete cessation of breast-feeding), whether the child had previously been in the hospital for malnutrition, general living conditions, and the number of siblings, both alive and dead. Although income is a major factor in causation of malnutrition, general living conditions, and the number of siblings, both alive and dead. Although income is a major factor in causation of malnutrition, a comparison of these two surveys from widely differing, communities shows general agreement that the duration of breast-feeding and number of children in the family are also factors of considerable significance.

Another study in Saudi Arabia (3), which was more concerned with anthropometric and haematological measurements relative to nutritional status than with sociological criteria, also shows some basically similar features. A cross-sectional study was performed on 198 children whose ages ranged from one month to five years. Family income ran from US$468 to US$1,723 per month, but despite this seemingly high income, 36 per cent of the children were mildly to moderately malnourished by the Gomez classification. In this study, duration of breast-feeding was not as significant a predictive factor of malnutrition, possibly because breast-feeding was the traditional way of feeding infants and the average length of feeding for the children surveyed was about one year.

TABLE 2. Significance and Magnitude of Effect of Variables Associated with Weight for Age (Nutritional Status) in St. Vincent, West Indies

Adapted from Greiner and Latham (4).
* Average magnitude of effect is multiple of the mean value of each independent variable and the regression coefficient. Number in brackets indicates relative importance of the effect

When families were divided into two groups on the basis of income (above or below US$1,000 per month), there was a high correlation with the number of infant deaths. Seventeen per cent of the lower income group had had a deceased child compared to less than half that number in the other group.

Sibling deaths have been shown to be of predictive value in several other studies (5-8), as well as those (2,4) discussed here. In the Libyan study the usefulness of infant deaths for predictive purposes was limited by the fact that deaths were high in both groups, perhaps reflecting the fact that improvements in wealth and living conditions have been quite recent. Unfortunately, in the Saudi Arabian study the total number of children and family members was not reported; thus the predictive value of number in the families could not be compared with data from the other studies.

Estimates of the prevalence of malnutrition on a world basis fully recognize the relationship of poverty to malnutrition (9), and even improved procedures (10) that include estimates of interpersonal variations treated in a probabilistic manner are dependent on income distribution data. Income and energy intake estimates, however, must be supported by clinical and/or biological evidence before statements concerning the prevalence of malnutrition can be justified. While fully realizing that income is basic to these considerations, it is the purpose here to emphasize additional factors that may indicate the profile of a family where malnutrition is likely to be present. Income alone, while a strong indicator, is not the only one; family size is a most important characteristic, and thus per capita income, if correctly reported by including all family members, is a considerably improved indicator because it reveals within family "stress factors" as well as wealth. A further important feature when young children are present is the duration of breast-feeding before leverage, a factor of high significance in both Libya (2) and St. Vincent (4).

Finally, it is now widely recognized that malnutrition in mothers and children reflects underlying socio-economic problems, and thus the target groups for both nutritional and social development planning will often be identical. Nevertheless, within the same overall income level, some families have malnourished children and some do not. Furthermore, even with very significantly improved social conditions, malnutrition may persist within some populations. In my view, education has a fundamental role despite its lack of success in some countries. I believe that insufficient attention has been paid to the need for simultaneous improvements: adequate income, adequate housing, and adequate education are necessary together before malnutrition can be eliminated. Thus, while socioeconomic improvements themselves are fundamental, unless health and nutrition education are continued and adapted to the new conditions, overall success will be limited.

REFERENCES

1. P. L. Pellett, "Marasmus in a Newly Rich, Urbanized Society," Ecol. Food Nut, 6: 53-56 (1977).

2. D. Mamarbachi, P. L. Pellett, M. M. Basha, and F. Djani, "Observations on Nutritional Marasmus in Newly Rich Nations," Ecol. Food Nutr., 9: 43-54 (1980).

3. M. Abaheseen, G. G. Harrison, and P. B. Pearson, "Nutritional Status of Saudi Arab Preschool Children in the Eastern Province," Ecol. Food Nutr. (in press)

4. T. Greiner and M. C. Latham, "Factos Associated with Nutritional Status among Young Children in St. Vincent," Ecol. Food Nutr. (in press).

5. D. Morley, J. Bickwell, and M. Woodland, "Factors Influencing the Growth and Nutritional Status of Infants and Young Children in a Nigerian Village," Trans. Roy. Soc. Trop. Med. Hyg., 62: 164-195 (1968).

6. J. D. Wray and A. Aguirre, "Protein-Calorie Malnutrition in Candelaria, Colombia. I. Prevalence: Social and Demographic Causal Factors," J. Trop. Pediat., 15: 76-98 (1969).

7. A. C. K. Antrobus, "Child Growth and Related Factors in a Rural Community in St. Vincent," J. Trop. Pediat., 17: 187-209 (1971).

8. A. A. Kanwati and D. S. McLaren, "Failure to Thrive in Lebanon II. An investigation of the causes," Acta Paediat. Scand., 62: 571-576 (1973).

9. S. Reutlinger and M. Selowsky, "Malnutrition and Poverty: Magnitude and Policy Options," World Bank Staff Occasional Papers No. 23 (Johns Hopkins University Press, Baltimore and London, 1973).

10. S. Reutlinger and M. Alderman, "The Prevalence of Calorie Deficient Diets in Developing Countries," World Bank Staff Working Paper No. 374 (World Bank, Washington, D. C. 1980).

Report of the third meeting of the ACC/SCN consultative group on maternal and young child nutrition

The third session of the Consultative Group on Maternal and Young Child Nutrition, held in Geneva, 1 - 4 September 1980, was conducted as a scientific meeting primarily to examine the question of the appropriate time for beginning complementary feeding of the breast fed infant, and also to consider further the question of maternal nutrition. What follows is an abridged version of its report.

APPROPRIATE TIMING FOR COMPLEMENTARY FEEDING OF THE BREAST-FED INFANT

Conclusions and Recommendations for Inclusion in the Report "Dietary Management of Young Infants Who Are Not Adequately Breast-fed"

The purpose of this study is to review the age at which infants who are exclusively breast-fed should be given additional food. This process, defined as complementary feeding, is not intended to replace, interrupt, or interfere with the mother's breast-feeding capacity. In fact, the intention is to promote the breast-feeding of the infant for as long as possible, and to recommend that complementary feeding be initiated only when the mother's milk production is inadequate to meet the energy and nutrient needs of the child for normal growth and development.

Current patterns of infant feeding

The age at which complementary foods are introduced depends on many biological, cultural, social, and economic factors. In communities where breast-feeding for the first months of a child's life is the rule, complementary foods may be introduced from as early as the first week of life. In others, the interval may be as long as one year. However, accumulated evidence suggests that in most cases the practice is begun when mothers themselves think the child is receiving insufficient milk from the breast.

Need for complementary feeding

If mother's milk fails to provide the energy and nutrient needs of an infant, adequate growth and development will not be maintained. This will have adverse consequences on the health and survival of the child. Adequacy has been assessed in a number of studies by investigating growth patterns and identifying the age at which the rate of growth starts to deviate from the reference pattern. The cause of this growth faltering is complex, and may include infection as well as dietary insufficiency.

Age at which complementary feeding should be started

Available evidence and experience indicate that, among healthy well-nourished populations, exclusive breast-feeding should be sufficient for most infants to support adequate growth for four to six months. In general, children who are not receiving complementary feeding after six months do not maintain adequate growth. In conditions where undernutrition and social deprivation are common, the growth of exclusively breast-fed children may begin to show signs of faltering before four months. However, early complementary feeding has definite hazards for the infant - especially in poor and deprived environments where the risk of contamination is high. It poses a definite threat of gastroenteritis with all its consequences, which are more serious in the younger child. Complementary foods do not provide the benefits of breast milk, e.g. anti-infective factors. Early complementary feeding has economic and social costs that may be critical to marginal families. Unless carefully conducted, it may also have a negative effect on the successful maintenance of lactation.

Recommendations regarding complementary feeding

- In general, it should not be necessary, and indeed may be hazardous, to introduce complementary foods to exlusively breast-fed infants before four months. However, complementary feeding should not be delayed beyond the age of six months.

- An infant's growth faltering may be due to inadequacy of energy and nutrient intake, to infection, to other causes, or to a combination of these. Despite limitations, a sustained reduction in growth rate is the best available indicator to alert health workers that complementary foods may be necessary. Growth faltering is best identified by weighing the child at regular intervals, preferably starting at birth. Where only a single weight measurement is available, complementary feeding should only be considered when there is obvious malnutrition, gross weight deficit, or when the child is nearing six months of age. Otherwise a second weighing should be awaited.

- Breast milk inadequacy may be due to a complex of interrelated nutritional, health, and psycho-social factors. If a mother is concerned that her milk production is insufficient, the first priority of the health workers is to make every effort to improve milk yield before recommending the initiation of complementary feeding

- Health personnel, particularly at the primary health level, should guide mothers in the correct preparation and administration of locally available complementary foods. Complementary foods should be given immediately after the child has completed a breast-feed, using a cup and spoon and not a feeding bottle.

- The above recommendations should be viewed as part of an integrated health programme promoting successful breast-feeding.

Research Needed

As far as possible, all studies in relation to "the appropriate time for complementary feeding" should be replicated in different countries with comparable methods. Many of the studies recommended are overlapping and many require sequential and longitudinal observations.

Adequacy of lactation and related topics

- Studies of the average length of time for which breast-feeding alone will satisfy babies' needs, and the range of variation in this length of time.

- Studies of what is meant by "satisfying a baby's needs." This will require research into functional, immunological, and other criteria besides growth faltering.

- Examination of the validity of existing reference growth standards, particularly during the first six months of life.

- Further work on the development of practical methods of measuring breast milk production.

- Further studies on the cost to mothers of lactation, and of the effect of supplementation during pregnancy and lactation on lactation performance and infant development. This work should include long-term studies over successive pregnancies, as existing evidence on this subject is considered inadequate.

- A review of the use and effectiveness of galactagogues.

Factors affecting the timing of complementary feeding

- Investigation of the big-availability of energy and nutrients in complementary foods (including vegetable mixtures) and in breast milk at different stages of infant life.

- Development of methods for improving availability and safety of complementary foods, prevention of bacterial growth, effects of fermentation, etc.

- Studies of infant feeding practices in relation to the time and resources available to the mother. This should include the cost/benefit aspects of early complementary feeding and the mother's work/income relative to the development of better foods by village technology.

- Examination of the psycho-social factors influencing breast and complementary feeding. How are the mother's perceptions of the need for complementary foods formed, and how do these perceptions compare to biological needs in terms of quantity and timing?

Functional studies

- Measurement of the energy intake and expenditures of infants and of their mothers. (This is indicated because of the very large gap recorded in many cases between intake and requirement.) As part of such studies, methods need to be developed for assessing the physical activity of young infants.

- Studies on the biology of the gastro-intestinal tract and its development in young infants.

Further work on the timing and curse of development of immune function.

Studies on infection in relation to complementary feeding

- The natural history of gastro-enteritis in infants from very early in life. (It is important to distinguish between acute and chronic diarrhoea: Are there differences in aetiology and pathophysiology?)

- The effect of diarrhoea on absorptive capacity, mucosal structure and function, enzyme activity, etc.

- The effect of nutritional state on the frequency, severity, and duration of diarrhoeal episodes.

- The role, if any, of absorption of macro-molecules, such as breast-milk immunoglobulins.

- The relative importance of contamination of the environment and of food in increasing the infectious load, including infections of the respiratory tract.

MATERNAL NUTRITION IN DEPRIVED POPULATIONS

Much of the physiological research on maternal nutrition has been undertaken in relatively well-fed populations. Uncertainty remains as to what extent these observations can be adapted and applied to mothers in deprived circumstances where under-nutrition and malnutrition are common. Thus, there is a clear need for well-designed research to elucidate the physiological and social consequences of marginal nutrition. However, already there is clear evidence from developing countries of a need for practical action even in the absence of full theoretical understanding.

The Maternal Situation in Developing

Quantitative and qualitative variations occur in different circumstances, but for many women the situation is as follows:

- Women arrive at conception with depleted nutrient stores resulting from the intergenerational nutritional effect, inadequate food intake, and the drain of infections, parasites, physical labour, or closely spaced pregnancies.

- During pregnancy their food intake does not rise, energy output does not diminish, and exposure to infections and infestations persists.

- Weight gains during pregnancy are much below those in well-fed women; iron and folate deficiency anaemia is common, maternal mortality rates are elevated, foetal losses are high, and babies of lower birth weight are produced who have a higher risk of perinatal morbidity and mortality.

- Although the foetus receives considerable protection at the expense of the mother, she is less able to pass on nutrients for foetal needs, nor is she able to build up her own reserves to ensure prolonged and successful lactation.

- Finally, many mothers may go on to their next pregnancy without opportunity to achieve full nutritional recovery, and thus the downward spiral is continued.

Remedial measures have been tried in most countries of the world, although only rarely on a scale commensurate with the extent of the problem. Unfortunately, only a few studies have been conducted under controlled conditions, but these have been sufficient to draw some general conclusions:

- Undernourished women who consume a supplement to their deficient diets showed increased maternal weight gain, a small improvement in birth weights, and reduced perinatal morbidity and mortality. The supply of energy appears to be more crucial than that of protein.

- Supplementation with iron in anaemic women can raise the haemoglobin of most to acceptable levels. In women without iron stores when beginning pregnancy, the requirement for iron can only be met by supplementation.

- Although evidence of need or benefit is less clear, and there is considerable geographic variation, the consensus of experts appears to be that a daily dietary supplement of folate (0.4 mg) should be provided throughout pregnancy.

- The situation with regard to other vitamins and minerals, especially trace elements, is less clear, with wide differences among localities.

In general, recommended allowances are raised in proportion to the required increase in energy intake. Supplementation of mothers only appears to be effective where there is demonstrable deficiency, and often it is the foetus or infant who seems to be the most obvious beneficiary, e.g., thiamine in rice areas, niacin for maize eaters, vitamin D in countries where exposure to sunlight is limited, vitamin A in arid lands lacking carotene or a retinal source, iodine before conception in endemic goitre areas.

Knowledge That Needs to Be Acquired to Render Remedial Actions More Effective

Scientific knowledge of nutritional physiology during human pregnancy and the sociological influences and outcomes is far from complete and has been mostly gathered from well-nourished women in developed countries. There is a great need for information on the whole spectrum of physiological and anthropological adaptation in pregnancy in women living in restricted circumstances in developing countries.

Some of the questions that need to be answered are:

- Do present recommended dietary allowances provide an appropriate tool for designing remedial programmer, particularly as they relate to energy requirements?

- What are the limits of tolerance or adaptation that a pregnant woman may attain without seriously compromising her own health or that of her offspring?

- What are the systems, either physiological or behavioural, that such a woman USES to make the adaptation, and what is their relative importance?

- What are the long-term effects of deprivation or supplementation on subsequent pregnancies?

- What are the most important environmental influences: disease, behavioural beliefs, physical work, constraints on the mother's time, the social structured

- In field or more sophisticated circumstances, what are the most feasible indicators for detecting the women at risk, and what is their reliability? E.g., weight increments in pregnancy, weight loss in lactation, urinary or serum metabolites, etc.

- Given very limited resources, what are the most cost effective interventions and the appropriate evaluation techniques? E.g., inputs such as iron plus folate, supplementing the whole family, educational campaigns, birth spacing, etc.; delivered singly or in combination.

- In different environments, what are the most cost effective service systems for identifying the women at risk and delivering the necessary care?

Possible Remedial Measures

In essence, the need is to improve the intake of the mother prior to conception, during pregnancy, and to lighten her workload. Improvement in socio-economic conditions of the family, and especially the social status of women, is the only real long-term solution. Particularly important are programmes and policies that increase the availability of food to the poorest segment of the community. While the principle is simple, usually fundamental and far-reaching decisions on economic policies and distribution systems are required, and implementation of these on a sufficient scale takes time to achieve. But in the shorter term, there are several measures that governments should undertake:

- Integration of information on nutritional needs in pregnancy and lactation into formal and informal education programmes utilizing schools, social groups, adult education programmer, mass media, maternal and child health services, etc.

- Expanded training on the subject for all staff in contact with the population, teachers, health workers, social and agricultural workers, community and religious leaders.

- Provision of a primary health care system of good coverage in which each village worker has the ability to monitor a mother's progress during pregnancy and lactation; has a supply of oral iron and folate; has the knowledge to advise on diet and family planning; has access to a centre to which mothers making poor progress can be referred for checking and supplementation.

None of the above measures are new or innovative. All imply improved contact between the at-risk population and services, which inevitably means increased expense. Hence, the emphasis on integration with broader services, such as primary health care, or social programmes - for instance, maternity benefits. The particular mix of interventions that will be employed will vary with local circumstances. But in every case the chances of impact will be enhanced if they can be accompanied by economic measures that improve the poorest families' ability to become self-reliant.

SUPPORTING DOCUMENTS

"Effects of Maternal Nutrition on Infant Health: Implications for Action," Archivos Latinoamericanos de Nutrición, vol. XXIX, suppl. 1 (1979 - issued 1 April 1980).

"Prenatal and Perinatal Nutrition," Archivos Latinoamericanos de Nutrición, vol. XXVII, no. 2, suppl. 1 (second part), (June 1977 - issued 10 March 1980).

H. Aebi and R. Whitehead, eds., "Maternal Nutrition during Pregnancy and Lactation," Nestlé Foundation Workshop 1979 (Hans Huber, Publishers, Bern).

H. L. Vis and P. H. Hennart, "Decline in Breast Feeding," Acta Paediat. Belg. 31: 195-206 (l978).

H. L. Vis, "Human Milk Production (Influences of Sucking Behaviour and Nutritional Status of the Mother)" (mimeographed).

H. L. Vis, P. Hennart, and M. Carael, "The Health of Mother and Child in Rural Central Africa," Studies in Family Planning, 6: 437-441 (1975).

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