Maternal and Child Undernutrition 1
Maternal and child undernutrition: global and regional
exposures and health consequences
Robert E Black, Lindsay H Allen, Zulfiqar A Bhutta, Laura E Caulfield, Mercedes de Onis, Majid Ezzati, Colin Mathers, Juan Rivera, for the Maternal
and Child Undernutrition Study Group*
Maternal and child undernutrition is highly prevalent in low-income and middle-income countries, resulting in
substantial increases in mortality and overall disease burden. In this paper, we present new analyses to estimate the
effects of the risks related to measures of undernutrition, as well as to suboptimum breastfeeding practices on
mortality and disease. We estimated that stunting, severe wasting, and intrauterine growth restriction together were
responsible for 2·2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years.
Deficiencies of vitamin A and zinc were estimated to be responsible for 0·6 million and 0·4 million deaths,
respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths,
and combined were responsible for about 0·2% of global childhood DALYs. Iron deficiency as a risk factor for maternal
mortality added 115 000 deaths and 0·4% of global total DALYs. Suboptimum breastfeeding was estimated to be
responsible for 1·4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years). In an
analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35%
of child deaths and 11% of the total global disease burden. The high mortality and disease burden resulting from
these nutrition-related factors make a compelling case for the urgent implementation of interventions to reduce their
occurrence or ameliorate their consequences.
Maternal and child undernutrition remain pervasive and
damaging conditions in low-income and middle-income
countries. A framework developed by UNICEF recognises
the basic and underlying causes of undernutrition,
including the environmental,
sociopolitical contextual factors, with poverty having a
central role (figure 1). Although addressing general
deprivation and inequity would result in substantial
reductions in undernutrition1 and should be a global
priority, major reductions in undernutrition can also be
made through programmatic health and nutrition
interventions. This paper is the first in a Series of five
papers that focus on the disease burden attributable to
undernutrition and the interventions affecting household
food availability and use, maternal and child care, and
control of infectious diseases. The first two papers
quantify the prevalence of maternal and child
undernutrition and consider the short-term consequences
in terms of deaths and disease burden, as measured by
disability-adjusted life-years (DALYs). They also discuss
the long-term educational and economic effects and
associations with adult chronic diseases, particularly as
countries go through the demographic, epidemiological,
and nutritional transitions.2–6 The third paper estimates
the potential benefits of implementing health and
nutrition interventions that current evidence indicates
are effective and applicable in low-income and
middle-income countries. The final two papers consider
the current state of such interventions and how they
could be implemented fully through actions at national
and global levels.
Undernutrition encompasses stunting, wasting, and
deficiencies of essential vitamins and minerals (col-
lectively referred to as micronutrients) as one form of the
condition known as malnutrition, with obesity or
over-consumption of specific nutrients as another form.
The term hunger, which literally describes a feeling of
discomfort from not eating, has also been used to describe
January 17, 2008
This is the first in a Series of five
papers about maternal and child
*Members listed at end of paper
Johns Hopkins Bloomberg
School of Public Health,
Baltimore, MD, USA
(Prof R E Black MD,
Prof L E Caulfield PhD); USDA,
ARS Western Human Nutrition
Research Center, Davis, CA, USA
(Prof L H Allen PhD);
Aga Khan University, Karachi,
Pakistan (Prof Z A Bhutta, MD);
World Health Organization,
(M de Onis MD, C Mathers PhD);
Harvard School of Public
Health, Boston, MA, USA
(M Ezzati PhD); and Mexico
National Institute of Public
Health, Cuernavaca, Mexico
(Prof J Rivera PhD)
Robert Black, Johns Hopkins
Bloomberg School of Public
Health, Baltimore, MD, USA
• Maternal and child undernutrition is the underlying cause
of 3·5 million deaths, 35% of the disease burden in
children younger than 5 years and 11% of total global
• The number of global deaths and DALYs in children less
than 5 years old attributed to stunting, severe wasting,
and intrauterine growth restriction constitutes the largest
percentage of any risk factor in this age group
• Vitamin A and zinc deficiencies have by far the largest
remaining disease burden among the micronutrients
• Iodine and iron deficiencies have small disease burdens,
partly because of intervention programmes, but sustained
effort is needed to further reduce their burden
• Suboptimum breastfeeding, especially non-exclusive
breastfeeding in the first 6 months of life, results in
1·4 million deaths and 10% of disease burden in children
younger than 5 years
• Maternal short stature and iron deficiency anaemia
increase the risk of death of the mother at delivery,
accounting for at least 20% of maternal mortality
undernutrition, especially in reference to food insecurity,
wherein people do not have “physical and economic
access to sufficient, safe, nutritious, and culturally
acceptable food to meet their dietary needs”.7,8
Undernutrition is an important determinant of maternal
and child health.9–12
The Millennium Development Goals (MDGs) state as
the first goal “to halve between 1990 and 2015 the proportion
of people who suffer from hunger.”7 One indicator to
monitor progress for this target is the proportion of
children who are underweight—ie, low weight compared
with that expected for a well-nourished child of that age
and sex. This anthropometric indicator can indicate
wasting (ie, low weight-for-height, indicating acute weight
loss), or much more commonly, stunting (ie, low
height-for-age, indicating chronic restriction of a child’s
potential growth). Those two conditions can have different
determinants and respond to different interventions.13
Therefore, consideration of wasting and stunting is more
useful than consideration of underweight. This series
primarily uses these two indicators, but also presents
information on underweight because weight-for-age has
been used in previous analyses.9–11 Reduction of fetal
growth restriction and micronutrient deficiencies is also
essential to achieving the MDGs and deserves high priority,
even though there are no MDG indicators for these
conditions. This Series also examines the consequences of
low body-mass index and short stature in women.
This paper consists mainly of new analyses of the
prevalence of nutritional conditions, risk factors, and
consequent disease burden; if this was not possible or
necessary, previously published results are presented.
The burden of disease attributable to maternal and child
undernutrition is presented for three world regions—
Africa, Asia, and Latin America—that include primarily
low-income and middle-income countries; only 1% of
deaths in children younger than 5 years occur outside
these regions. UN regions and subregions (webtable 1)
Prevalence and consequences
Maternal short stature and low body-mass index in
pregnancy and lactation
Maternal undernutrition, including chronic energy and
micronutrient deficiencies, is prevalent in many regions,
especially in south-central Asia, where in some countries
more than 10% of women aged 15–49 years are shorter
than 145 cm (webtable 2). Maternal undernutrition—ie,
body-mass index of less than 18·5 kg/m²—ranges
from 10% to 19% in most countries. A serious problem of
maternal undernutrition is evident in most countries in
sub-Saharan Africa, south-central and southeastern Asia,
and in Yemen, where more than 20% of women have a
body-mass index of less than 18·5 kg/m². With a
prevalence of low body-mass index around 40% in
women, the situation can be considered critical in India,
Bangladesh, and Eritrea. Maternal short stature and low
body-mass index have independent adverse effects on
The nutritional status of a woman before and during
pregnancy is important for a healthy pregnancy
outcome.14,15 Maternal short stature is a risk factor for
caesarean delivery, largely related to cephalopelvic
disproportion. A meta-analysis of epidemiological studies
found a 60% (95% CI 50–70) increased need for assisted
delivery among women in the lowest quartile of stature
(146 cm to 157 cm, depending on the region) compared
with women in the highest quartile.16 If operative delivery
to ensure a healthy birth is not available to women who
need it, both mother and baby are at risk.17 Even if
operative delivery is accessible, affordable, and safe,
anaesthesia and laparotomy increase the risk of maternal
morbidity.18 Low maternal body-mass index does not
seem to increase the risk of pregnancy complications and
assisted delivery.16 Rather, there seems to be a synergistic
positive effect of short stature and higher maternal
body-mass index on increasing these complications.19,20
Low maternal body-mass index is associated with
intrauterine growth restriction.11 Previous analyses
estimated the disease burden of low maternal body-mass
index as a risk factor for perinatal conditions,11 whereas
the estimates presented in this paper consider intrauterine
Adult size, intellectual ability,
metabolic and cardiovascular disease
Mortality, morbidity, disability
dwelling, assets, remittances,
pensions, transfers etc
Lack of capital: financial, human,
physical, social, and natural
and political context
environment and lack
of health services
Inadequate dietary intakeDisease
Maternal and child
Figure 1: Framework of the relations between poverty, food insecurity, and other underlying and immediate
causes to maternal and child undernutrition and its short-term and long-term consequences
See Online for webtable 1
See Online for webtable 2
growth restriction to be the risk factor for neonatal
conditions. Additional work is needed to quantify the
relative effects of low maternal body-mass index, extent
of weight gain in pregnancy, and maternal micronutrient
deficiencies on the occurrence and severity of intrauterine
Maternal undernutrition has little effect on the
volume or composition of breast milk unless
malnutrition is severe. The concentration of some
micronutrients (vitamin A, iodine, thiamin, riboflavin,
pyridoxine, and cobalamin) in breast milk is dependent
on maternal status and intake, so the risk of infant
depletion is increased by maternal deficiency.21 This
factor is most evident in the case of vitamin A, where
the content in breast milk is the main determinant of
infant status because stores are low at birth. Maternal
supplementation with these micronutrients increases
the amount secreted in breast milk, which can improve
Childhood underweight, stunting, and wasting
The prevalences of underweight, stunting, and wasting
worldwide and for UN regions are based on analysis
of 388 national surveys from 139 countries, applying
comparable methods, including use of the new WHO
Child Growth Standards.22–26 In 2005, 20% of children
younger than 5 years in low-income and middle-income
countries had a weight-for-age Z score of less than –2
(table 1). The prevalences were highest in south-central
Asia and eastern Africa where 33% and 28%, respectively,
For all developing countries, an estimated 32%
(178 million) of children younger than 5 years had a
height-for-age Z score of less than –2 in 2005 (table 1).22,23
Eastern and middle Africa have the highest prevalence
estimates in UN subregions with 50% and 42%,
respectively; the largest number of children affected by
stunting, 74 million, live in south-central Asia.
Of the 40 countries with a child stunting prevalence
of 40% or more, 23 are in Africa, 16 in Asia, and one in
Latin America; and of the 52 countries with prevalence of
less than 20%, 17 are in Latin America and the Caribbean,
16 in Asia, 11 in Europe, and four each in Africa and
<5 years in
stunted (95% CI)
Number stunted in
millions (95% CI)
wasted in millions
millions (95% CI)
Stunting=height-for-age less than –2 SD. Severe wasting=weight-for-length or weight-for-height less than –3 SD. Underweight=weight-for-age less than –2 SD.
Table 1: Childhood stunting, severe wasting, and underweight estimates and numbers affected in 2005 based on the WHO Child Growth Standards by
UN regions and subregions
Figure 2: Prevalence of stunting in children under 5 years
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