Improving prenatal nutrition in developing countries: strategies,
prospects, and challenges13
Jose O Mora and Penelope S Nestel
ABSTRACT In developing countries, the health and nutrition
of females throughout their entire life is affected by complex and
highly interrelated biological, social, cultural, and health
servicerelated factors. Rather than focusing exclusively on the
prenatal period, we describe a life cycle approach to improving
maternal nutrition, which goes beyond the traditional provision of
nutrition services during pregnancy, by addressing risk factors that
are present well before pregnancy, even before childbearing age.
This approach involves specific policy initiatives and a minimum
package program that is targeted at females. Policy actions and the
components for effective implementation of the program are
described. The prospects and challenges to be overcomewhich
include translating scientific knowledge into action, removing con-
ceptual and implementational constraints, identifying biologically
meaningful indicators for problem identification, and improving
understanding of physiologic and social adaptation mechanisms
are discussed, as are persistent problems with health care delivery
systems. Am J Clin Nutr 2000;71(suppl):1353S63S.
KEY WORDS Prenatal nutrition, developing countries,
nutrition strategies, women, adolescent girls, nutritional
programs, malnutrition
INTRODUCTION
Good maternal nutrition is important for the health and repro-
ductive performance of women and the health, survival, and devel-
opment of their children. Malnutrition in women, including preg-
nant women, is not conspicuous and remains, to a large extent,
uncounted and unreported; thus, insufficient attention has been
given to the extent, causes, and consequences of malnutrition in
women (1). As a result, inadequate resources and efforts have been
allocated to improving womens nutrition compared with other
nutritional and public health actions (2). The limited available data
and the few experiences with programs that do exist come mostly
from small-scale efforts to improve nutrition during pregnancy,
often through nutritional supplementation to enhance fetal growth
and birth weight (3). It was suggested that highly publicized ini-
tiatives such as child survival and safe motherhood have not
had the expected effect because too little attention has been given
to the nutritional status of women, including mothers (4). This
lack of emphasis on womens nutrition is unacceptable given the
importance of nutrition to womens health, pregnancy outcome,
and child survival; the availability of effective nutrition-related
Am J Clin Nutr 2000;71(suppl):1353S63S. Printed in USA. 2000 American Society for Clinical Nutrition
programs; and the increased opportunities for policies and pro-
grams that can be implemented through existing health systems,
which are expanding and providing better coverage, particularly in
prenatal care, in most developing countries.
The situation is not dire, however. By translating and integrat-
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ing existing biological and socioeconomic knowledge into practi-
cal action, a solid basis for policy and program decisions can be
developed. The purposes of this article are 1) to review the ration-
ale for improving prenatal nutrition and strategy, policy, and pro-
gram options and 2) to identify the prospects for and challenges
to improving prenatal nutrition in developing countries.
RATIONALE
Some 200 million women become pregnant each year, most of
them in developing countries (5). Many of these women suffer
from both ongoing nutritional deficiencies and the long-term
cumulative consequences of undernutrition during childhood.
Pregnancy-related health and nutritional problems affect a
womans quality of life, that of her newborn infant well beyond
delivery, and that of her family and community.
The effect of womens prenatal health and nutritional status
on child growth, health, survival, and development occurs both
through reproductive performance and survival and through fetal
growth and development. McGuire and Popkins (6) review of
studies on the nutritional status of pregnant and lactating women
showed that women in developing countries consumed only
about two-thirds of the recommended daily intake of energy and
that their average weight for height was, in most cases, well
below the 50th percentile for small-framed women in developed
countries. Moreover, the energy and nutrient intakes of pregnant
and lactating women tended to be only slightly higher than those
of nonpregnant women, although the nutritional requirements of
pregnant and lactating women were significantly greater. Other
studies, for example the study by Black et al (7), showed that
1
From the International Science and Technology Institute, Arlington,
VA, and the Department of International Health, Johns Hopkins University,
Baltimore.
2
Presented at the symposium Maternal Nutrition: New Developments and
Implications, held in Paris, June 1112, 1998.
3
Reprints not available. Address correspondence to JO Mora, 1820 North
Fort Myer Drive, Suite 600, Arlington, VA 22209. E-mail: jmora@istiinc.com.
1353S
1354S MORA AND NESTEL

micronutrient deficiencies, particularly deficiencies of iron and
vitamin B-12, were frequent in pregnant women in Mexico. Poor
health and nutrition are associated with repeated, closely spaced
pregnancies that progressively reduce womens nutritional
reserves to the point of nutritional depletion, known as the
maternal depletion syndrome (810).
The definitive negative outcome of poor prenatal health and
nutrition, as well as inadequate care during pregnancy and delivery,
is reflected in the high prevalence of maternal mortality in devel-
oping countries; nearly 600 000 women die each year from preg-
nancy-related causes (11). As shown in Table 1, the global mater-
nal mortality rate is 460/100 000 live births; the rate for developing
countries is 500/100 000 live births, and the rate for developed
countries is 10/100 000 live births. Within the developing world,
however, there are huge regional variationsfrom 140/100 000 live
births in Central America to 1080/100 000 live births in eastern
Africa (12). Adolescent girls have a 25 times greater risk of mor-
tality than do other women of reproductive age (1). Indeed, of all
the human-development indicators, the greatest disparity between
developed and developing countries is in the risk of maternal mor-
Maternal mortality, however, is not the only adverse or most
frequent outcome of pregnancy. More than 40% of pregnancies
in developing countries result in complications, illness, or per-
manent disability for the mother or child (1). Because of a
womans childbearing and nurturing roles, her pre- and postnatal
health and nutritional status is an important determinant of the
survival and development of her fetus and newborn child. More
than 7 million newborn deaths are associated with maternal
health- and nutrition-related problems resulting from poorly
managed pregnancies and deliveries or inadequate care of the
neonate soon after birth (5).
An intergenerational cycle of ill health and growth failure in
which undernutrition in childhood leads to small body size in
adulthood has been described (16, 17). Malnourished women (ie,
women who are short, are underweight, do not gain sufficient
weight during pregnancy, or are anemic) are more likely to have
miscarriages or stillbirths or to deliver babies with intrauterine
growth retardation (IUGR) or low birth weight (LBW; 1820),
which are linked, in turn, to increased risk of perinatal and infant
mortality (2123). Globally, 15.3% of all babies are born with

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tality (11). Although poor prenatal nutrition contributes directly
and indirectly to this large mortality rate, the extent of its contribu-
tion has not been measured because the main reported causes of
maternal mortality (hemorrhage, obstructed delivery, eclampsia,
sepsis, and unsafe abortion) greatly overshadow the role of nutri-
tion itself. It is well established, however, that stunted women are
at higher risk of obstructed labor as a result of cephalopelvic dis-
proportion (13). Nationally representative data collected in the
Demographic and Health Surveys show that significant proportions
of nonpregnant women were at risk of adverse pregnancy outcomes
by virtue of their short stature (<145 cm), low body weight (<45 kg),
or both (Table 2) (S Rutstein, personal communication, 1998).
Between 1% and 20% of these women were chronically energy
deficient (14), although there is no consensus about the value of
body mass index as an indicator (15).
LBW, > 2.5 times more so in developing (16.4%) than in devel-
oped (6.2%) countries (24). Severe anemia in pregnancy is
believed to increase the risk of maternal mortality in childbirth
(23) and about half of the infants whose mothers have died do
not survive to celebrate their fifth birthday (25). There is also
evidence to suggest that severe maternal iron deficiency causes
reduced iron storage in the fetus and the newborn infant, which
predisposes the infant to iron deficiency anemia (18). In addi-
tion, malnourished women do not have adequate capacity to sus-
tain prolonged lactation (19, 20).
Newborns with IUGR and babies with LBW have the greatest
risk of infection because of reduced immune competence. Poor
nutrition in early childhood not only increases the risk of perina-
tal, infant, and child morbidity and mortality but also affects
long-term physical growth (26, 27), cognitive development and

TABLE 1
Selected maternal health and nutritional indicators, 19981
Women aged Total Contraceptive Prenatal Delivery Maternal
Region All women 1549 y fertility rate use care care mortality
million million per 1000 live births % % % per 100 000 live births
Asia 1753 929 2.9 54 65 61 410
Western 88 44 4.2 61 71 350
South central 701 354 3.8 35 52 36 570
Southeast 253 135 3.2 43 79 53 460
East 711 396 1.8 78 80 87 90
Africa 390 182 5.6 18 63 43 880
Sub-Saharan 321 146 6 12 40 980
Northern 83 42 4 38 56 61 330
Western 115 100 6.2 6 60 34 1020
Eastern 121 108 6.2 12 66 33 1080
Middle 46 41 6.5 58 950
Southern 25 20 3.4 48 89 80 270
Latin America and Caribbean 252 134 3 57 73 75 180
Central 66 34 3.5 52 70 67 140
Caribbean 18 10 2.7 49 88 79 350
South 167 90 2.8 61 73 77 190
World 2941 1514 3 50 68 65 460
Developed 606 297 1.6 61 97 99 10
Developing 2334 1216 3.4 48 65 58 500
1
From references 5 and 12.
 PRENATAL NUTRITION IN DEVELOPING COUNTRIES 1355S

TABLE 2
Maternal nutritional status1
Obstetric risk
Short stature Low body wt Both risk Total Neither risk BMI
(<145 cm) (<45 kg) factors at risk factor <18.5 30
%
Africa
Benin (n = 2566) 1.3 11.9 0.8 14.0 86.0 NA NA
Burkina Faso (n = 4233) 0.8 6.7 0.3 7.8 92.2 14.7 1
CAR (n = 2408) 1.6 10.4 1.6 13.7 86.3 NA NA
Comoros (n = 899) 2.4 12.2 1.6 16.1 83.9 NA NA
Cte d Ivoire (n = 3520) 0.7 7.0 0.3 8.0 92.0 NA NA
Ghana (n = 1927) 0.6 9.0 0.5 10.1 89.9 12.2 3.5
Kenya (n = 3822) 0.5 7.9 0.6 9.0 91.1 9.9 2.5
Malawi (n = 2776) 1.3 11.3 1.5 14.2 85.8 9.7 1.1
Mali (n = 5064) 0.5 7.4 0.4 8.3 91.7 NA NA
Namibia (n = 2581) 1.2 8.9 0.4 10.5 89.5 13.9 7.6
Niger (n = 4104) 0.2 12.3 0.3 12.7 87.3 19.6 1.4
Senegal (n = 3483) 0.7 6.6 0.1 7.4 92.6 15.1 3.8
Tanzania (n = 4364) 1.8 10.2 1.7 13.7 86.3 9.8 2
Uganda (n = 4120) 1.4 8.3 0.9 10.6 89.4 NA NA

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Zambia (n = 4525) 0.8 7.6 0.8 9.2 90.8 11.4 2.5
Zimbabwe (n = 2103) 0.4 3.6 0.5 4.6 95.4 5.2 5.9
North Africa
Egypt (n = 7539) 1.4 1.7 0.3 3.3 96.7 1.6 23.9
Morocco (n = 3354) 1.6 4.5 0.5 6.6 93.4 3.8 10.9
Turkey (n = 2650) 2.2 3.3 0.3 5.8 94.2 2.6 18.4
Latin America and Carribean
Bolivia (n = 2670) 10.6 5.0 2.2 17.8 82.2 2.5 8
Brazil (n = 3302) 2.3 6.5 1.5 10.3 89.7 NA NA
Colombia (n = 3817) 4.3 5.1 1.3 10.8 89.2 3.9 9.2
Dominica (n = 2358) 1.8 10.3 1.1 13.1 86.9 9 7.4
Guatemala (n = 5413) 20.1 6.8 12.8 39.8 60.2 3.8 8.2
Haiti (n = 2271) 1.7 13.9 1.2 16.8 83.3 NA NA
Peru (n = 10711) 12.4 3.2 3.1 18.6 81.4 1.3 9.2
Asia
Bangladesh (n = 4497) 2.2 53.7 15.9 71.8 28.2 NA NA
Nepal (n = 3745) 2.8 39.1 12.0 53.9 46.1 NA NA
Newly Independent States
Kazakstan (n = 3707) 0.6 5.4 0.4 6.4 93.7 NA NA
Uzbekistan (n = 4388) 0.7 5.6 0.4 6.7 93.3 NA NA
1
Source: S Rutsetin, personal communication, 1998.

future learning capacity (28), school performance (28, 29) and
educational outcomes, and work performance (30). Girls often
experience discriminatory child-care, feeding, and health care
compared with boys that can result in protein-energy malnutrition
(PEM) and micronutrient deficiencies. The increased nutritional
demands for adolescent growth, coupled with chronic PEM and
micronutrient deficiencies and often early childbearing, preclude
many teenage girls from fully realizing their growth potential (31,
32). Moreover, Bruner et al (33) found that treating anemic US
adolescent girls improved the girls cognitive abilities, which may
have important implications for the many adolescent mothers in
developing countries. During their reproductive years, particu-
larly during pregnancy and lactation, many women continue to
experience PEM and micronutrient deficiencies, although some
are affected by the consequences of overnutrition. In the postre-
productive years, undernutrition, anemia, osteoporosis, and other
nutrition-related problems are observed frequently in women (4).
There is also growing concern that poor fetal and infant health
and nutrition determine health risks, such as coronary heart dis-
ease, in adulthood (34, 35). Clearly, the lack of attention to
womens nutrition has enormous implications for social, eco-
nomic, and national development.
It is difficult to estimate the extent of womens malnutrition,
even in pregnant women, in developing countries because few
nationally representative studies have been done. This is com-
pounded by the lack of consensus on the appropriate indicators and
reference standards for women. In 1985, Leslie (2) conservatively
estimated that of the 1130 million women aged > 15 y living in
developing countries, almost 500 million were stunted as a result of
PEM, <250 million were at risk of iodine deficiency disorders, and
almost 2 million were blind because of vitamin A deficiency. Vita-
min A deficiency is more frequent in Asia and Africa than in other
countries (36), and in endemic areas night blindness has been
observed to be 525 times more frequent in pregnant women than
in preschool children (37, 38), indicating womens increased vul-
nerability to vitamin A deficiency during times of increased vita-
min A requirements. On the basis of data collected in 1998 and on
the assumption that 59% of pregnant women and 47% of all
1356S MORA AND NESTEL
women (39) are anemic, > 745 million of the > 1514 million women
of childbearing age (1549 y) are anemic. Prevalence rates of ane-
mia in pregnant and nonpregnant women are greater in Asia
(<60% and 55%, respectively) and in Africa (51% and 42%,
respectively) (40) than in Latin America (35% and 20%, respec-
tively) (41). PEM, iodine deficiency disorders, and iron deficiency
are known to disproportionately affect females throughout infancy
and childhood as well as before and during pregnancy.
The magnitude of female undernutrition and the enormous
social, economic, health, and developmental implications of
poor prenatal nutrition of women and children provide a com-
pelling rationale for systematic stronger action. Because of the
reproductive consequences and the long-term effects of child-
hood malnutrition on adult physical and intellectual productivity,
as well as of the widespread effect of womens health and nutri-
tion on child survival, womens productivity, family welfare, and
poverty reduction in the community as a whole, securing ade-
quate nutrition of women, particularly before and during preg-
nancy, is a socially and economically important goal for devel-
oping countries.
CONCEPTUAL FRAMEWORK
Throughout womens entire life cycle, their health and nutrition
is affected by complex social, cultural, psychologic, biological, and
health servicerelated factors that are highly interrelated. A con-
ceptual framework, adapted from Tinker et al (4), that identifies the
critical points for action is outlined in Figure 1. Social, economic,
and cultural factors include social status, female discrimination,
fertility patterns (eg, pregnancy intervals, teenage pregnancy, and
unplanned pregnancies), and disease exposure. Individual behavior
and psychologic factors include dietary practices, reproductive pat-
FIGURE 1. Determinants of womens health and nutritional status.
terns, health-seeking behavior, and use of health and nutritional
services. Biological factors include age of menarche, menstruation,
pregnancy, and increased risk of infections.
To have an effect on womens health and nutritional status,
programs that are socially, economically, culturally, and biolog-
ically appropriate are needed throughout the female life cycle,
beginning as early as possible. In other words, womens health
and nutrition have to be considered as part of an intergenera-
tional continuum under the rubric of reproductive and child
health (ie, pre- and postnatal care, including family planning,
child survival, child development, school health, and adolescent
health). This framework highlights the important role for public
and private health services and 2 practical conclusions need to be
emphasized. First, the consequences of womens undernutrition
on child survival and development are at least as important as is
the direct biological effect of undernutrition on the fetus during
pregnancy and the infant during lactation. Second, a focus on
prenatal nutrition ignores the more fundamental problem of a
womans nutrition throughout her entire life, of which prenatal
nutrition is only a small, albeit important, contributory factor.
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This is significant because nutritional status, unlike disease, is
cumulative over time and not an isolated incident (16).
STRATEGIES
Strategies to improve prenatal nutrition need to go beyond the
conventional approach of providing services to pregnant women
through the traditional maternal and child health care programs.
Instead, a more comprehensive life cycle approach is needed that
addresses the risk factors present well before pregnancy, ideally
beginning in early childhood or, at the very least, before preg-
nancy or before girls reach reproductive age.
 PRENATAL NUTRITION IN DEVELOPING COUNTRIES
The promotion of optimal nutrition in girls during childhood
is a sound strategy for affecting female nutrition because it can
result in a build up of the nutritional reserves needed during peri-
ods of increased nutritional demand, including the adolescent
growth spurt, pregnancy, and lactation. Such action should be
complemented by specific programs during critical periods, eg,
adolescence, childbearing age, pregnancy, and lactation.
Research in Guatemala, for instance, showed that improved
nutrition during early childhood had longer-term payoffs than
was previously thought in terms of greater stature and fat-free
mass, especially in females; improved work capacity in males;
and enhanced intellectual performance in both sexes (17).
Although primary health care nutritional programs are often
targeted at women, particularly pregnant women, in practice
most are designed primarily to reduce malnutrition in children.
Leslie (2) made an important distinction between being the tar-
get and being the beneficiary of a program. Women have been
the targets of health and nutritional programs aimed at improv-
ing fetal growth (birth weight) or childrens growth but paying
little attention to the health and nutritional needs of the women
themselves. There is currently a move toward getting consensus
that health and nutritional programs implemented well before
women become pregnant, and within a life cycle perspective,
will have a long-term effect on both the mother and the child,
although data to support this are still lacking. It is also probable
that women are more likely to be motivated to participate in pro-
gram activities that have a clear benefit for themselves as well as
for their children.
POLICY AND PROGRAM OPTIONS
In an ideal world, policy and program options are based on a
generally accepted, research-proven, conceptual framework that
has been tested in an appropriate environment. Unfortunately,
this has rarely been the case for prenatal nutrition in developing
countries. There is an urgent need to identify the conditions and
circumstances under which prenatal undernutrition (eg, PEM or
specific micronutrient deficiencies) can be prevented throughout
a womans reproductive cycle or improved during pregnancy,
after which the appropriate strategy can be carefully shaped to
the particular situation in each country or setting.
On the basis of the documents reviewed and of personal expe-
riences, the text that follows identifies some general and specific
policy (4) and program options that have either been shown to be
effective or are likely to be effective, although there may be no
data to support the latter. More data are needed to show the
effectiveness of programs under the specific conditions that are
present in most developing countries.
Policy options
Broaden policy support for enhanced investments in female
education
Given the strong evidence associating higher levels of mater-
nal education with improved child survival and nutritional status
(42) and very likely with better nutritional status of women
themselves, investment in the education of females is expected to
have enormous payoffs in health, nutrition, and development
(43, 44). These effects are likely to be mediated through more-
efficient purchasing and intrahousehold distribution of food (45),
1357S
a greater propensity and more- efficient use of health services
(42), fewer pregnancies, and increased employment opportuni-
ties for women (46). It is therefore an important component of
any policy to enhance the status of women.
Strengthen legislative and other support for womens nutrition
Improvements in legislative and other support for womens
nutrition would help provide universal food fortification; provide
consumer price subsidies and targeted food distribution; provide
labor-saving devices for women; improve womens access to
agricultural extension services and credit for small-scale busi-
ness; reduce discrimination against women in employment prac-
tices; encourage womens control over family resources; remove
credit restrictions against women; enact fair marriage legislation;
abolish practices harmful to womens health (eg, violence
against women); remove legal impediments to the effective
delivery of health services for females (eg, impediments to con-
traception and barriers to service based on age, sex, or marital
status); support appropriate training and delegation of responsi-
bility, particularly for nonphysician health care in rural areas;
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and encourage private sector participation in the delivery of
health services for women.
Improve equity and efficiency in financing health and
nutritional services for women
Improved equity and efficiency in financing health and nutri-
tional services for women could be achieved by selecting a pack-
age of highly cost-effective nutritional programs to be publicly
financed; establishing cost-recovery schemes that target public
expenditures at the poor; and protecting poor women and remov-
ing legal impediments to the effective delivery of health services.
Increase womens access to health and nutrition services
Womens access to health and nutritional services could be
improved by designing delivery strategies to meet womens
needs; strengthening the health care delivery infrastructure;
improving the quality of services for women; increasing the
number of health care providers for women; and delegating
responsibilities to nonphysicians.
Other policy initiatives
Other policy initiatives include integrating women into
healthcare and nutrition planning via local health committees
and womens groups; strengthening collaboration with the pri-
vate sector through nongovernment organizations and for-profit
providers; intensifying public education to promote the use of
health services and healthy behaviors; advocating both policy
changes and behavior modification; meeting informational
needs on indicators of health status; designing programs based
on culture-specific health needs, formative research, and pro-
gram-based operations research; and monitoring and evaluating
programs.
Program options
Womens nutrition is expected to be equally or more strongly
influenced by policies and actions intended to improve nutrition
in the entire household (eg, increased crop yields, higher
income, food price subsidies, better nutrition knowledge, and
food fortification) than by those targeted solely at women. The
components that need to be considered in designing effective
community- and household-level programs that the health care
1358S MORA AND NESTEL
system can target toward women, with the emphasis on prenatal
nutrition, are presented below.
A comprehensive health and nutritional program
The provision of regular health and nutritional services for
women requires a comprehensive program rather than single,
isolated programs. Although framed in the context of a life cycle
approach, such a program focuses on specific female life peri-
ods: prepregnancy, pregnancy, delivery and lactation, early
childhood, adolescence, and childbearing age. An important
aspect is that appropriate information, education, and communi-
cation (IEC) aimed at key behavioral modifications for that life
period is given. The essential health and nutritional care program
includes the components that follow.
One important component is the prevention and management
of unwanted pregnancies and management of abortion services
by improving access to birth-spacing information and services,
including counseling, education, and family planning. Signifi-
cant efforts are being made and substantial progress has been
achieved in several developing countries to reduce fertility and
increase birth spacing (47). Family planning services still need
to be fully integrated with other health and nutritional services
for women of childbearing age. IEC family planning strategies
need to incorporate womens health and nutritional concerns.
Existing service-delivery channels for contraceptive products
can be used effectively for the provision of iron supplements and
other nutritional services for women.
Another important component is expanded health and nutri-
tional services for nonpregnant women, including adolescents.
This has been a highly neglected area. Both the availability of
and the access to health services by women are often restricted
to prenatal and delivery services, often involving limited contact
with health personnel, usually a few times during pregnancy and
a few hours during delivery. Womens visits to health services,
for either curative or preventive child health care, are excellent
opportunities for health workers to tap and provide health and
nutritional preventive services (education, counseling, and
micronutrient supplements) to women. The delivery of micronu-
trient and possibly even food supplements to female adolescents
through the school system can also be considered.
A third essential component of a health and nutritional care
program is enhanced maternity care that is effective, affordable,
accessible, and acceptable and that includes prenatal health and
nutritional services, safe delivery, and postpartum care. The
well-documented increase in the coverage of prenatal services,
currently > 50% in most developing countries (5), offers a unique
opportunity to reach women during pregnancy with a package of
health and nutritional services, including education and counsel-
ing and micronutrient supplements. About a third of women in
these countries, however, still do not have access to good-quality
health services during pregnancy (Table 1) and childbirth, espe-
cially poor and uneducated women who live in rural areas.
Finally, a health and nutritional care program must include
extended nutritional assistance to vulnerable female groups to
improve overall nutritional status, including supplementary feed-
ing, micronutrient supplements, and food fortification. Nutri-
tional assistance has usually been restricted to limited supple-
mentary feeding and the distribution of iron supplements to
pregnant women rather than to all women because of resource
constraints. Providing a program of nutritional services to all
women of childbearing age may be a more effective way to
improve prenatal nutrition than are limited prenatal programs,
which are unlikely to begin early enough in pregnancy to have a
significant biological effect. For example, providing long-term
preventive weekly iron or multivitamin and mineral supplements
to nonpregnant women, ideally beginning during adolescence, or
implementing a widespread iron-fortification program may
improve the iron reserves of these women to the extent that the
need for preventive daily supplementation during pregnancy
could be reduced significantly.
Behavioral change programs
Behavioral change programs include expanded promotion of
positive health and nutritional practices for females, including
behavioral changes to improve maternal, infant, and early child-
hood feeding and to eliminate self-inflicted female discrimina-
tion. Most health and nutrition educational activities currently
targeted toward women focus almost exclusively on child feed-
ing, particularly breast-feeding. There is a need to redirect some
of the IEC efforts toward women themselves. Concrete efforts
are needed to improve womens eating practices, which is impor-
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tant for the health of the women themselves and for that of their
children, particularly in rural areas where women endure the
dual burden of moderate-to-high levels of physical work and fre-
quent pregnancies without noticeable increases in energy and
nutrient intakes. Studies showed that female discrimination in
developing countries may to a large extent be self-inflicted (48)
as a result of a self-sacrificing role through which they meet
their own needs last. For example, increased female wages were
associated with improved nutrient intakes of most household
members except the women themselves (49). IEC activities tar-
geted toward women could be specifically designed to reduce
and ultimately remove these attitudes.
It is also important to delay childbearing among adolescents.
First births can be delayed by postponing the age of marriage
and the onset of sexual activity and by using effective methods
of family planning. This requires culturally sensitive IEC pro-
grams for changing individual and societal motivations for early
childbearing and enhanced opportunities for formal education
of girls.
Another crucial behavioral change is the removal of sex dis-
crimination. Enhancing the social status of women will require
specific policies and intensive IEC efforts addressed at the pop-
ulation as a whole and at women in the community, at schools,
and in the workplace.
The implementation of a comprehensive health and nutritional
program may not be feasible because of financial and resource
limitations. Although a comprehensive approach would be
expected to lead to significant and sustainable improvements in
womens nutrition, and hence prenatal nutrition, a minimal pro-
gram can be tailored to the local situation in accordance with the
resources available. It should be emphasized, however, that
nutritional programs that are restricted to the limited provision
of health and nutritional services during pregnancy may not
make a significant difference to the health and nutritional status
of the mother and the child.
A minimum health and nutritional program
Given that financial and resource constraints frequently limit
the number and scope of programs, the minimum package of
key nutritional programs identified by Baker et al (50) was mod-
ified and expanded to specify the programs required to improve
 PRENATAL NUTRITION IN DEVELOPING COUNTRIES
the nutrition of adolescent girls and pregnant and lactating
women. The purposes of this minimum package are to delay first
pregnancy, improve knowledge and practices related to repro-
ductive health and nutrition, and improve access to quality pre-
natal and postpartum services.
For adolescent girls, the following minimal programs are
recommended:
1) improve access to family planning and reproductive health
services;
2) provide nutritional education through schools, religious
organizations, and marketplaces or workplaces and health
promotion based on research that has identified cultural
and institutional constraints and detrimental attitudes and
practices;
3) prevent and treat sexually transmitted diseases, parasites, and
micronutrient deficiencies; and
4) provide supplementary food through school meals to induce
growth catchup and maximize the pubertal growth spurt,
increase school attendance, and serve as an excellent oppor-
tunity for health and nutrition education (51).
For pregnant and postpartum women, the recommended min-
imal programs can be categorized as service-delivery and health-
promotion programs. The service-delivery programs 1) provide
iron and folate supplements during pregnancy; 2) monitor preg-
nancy weight gain; 3) provide antimalarials, antihelminths, and
other micronutrient supplements, when appropriate, including
postpartum vitamin A in vitamin Adeficient areas; 4) provide
prompt diagnosis and treatment of illness; and 5) provide and
target supplementary food to at-risk and undernourished women
by using appropriate indicators for screening, beginning as early
as possible during pregnancy.
A review of randomized, controlled trials on the effectiveness of
nutritional programs in pregnancy to reduce IUGR found that only
balanced protein-energy supplementation was effective (3). The
authors raised concern about the dearth of data to support recom-
mended nutritional programs during pregnancy, some of which are
used widely, even in women with no evidence of nutritional defi-
ciencies. Although this review was limited to the effects of pro-
grams on IUGR, it highlights the need for better monitoring and
evaluation of prenatal programs and for further operations
research on how to improve the nutrition of women in general.
Health-promotion programs for pregnant and postpartum women
1) provide nutritional, breast-feeding, family planning, and HIV
counseling and disease prevention education, and 2) involve
men and other family members in behavior-modification activi-
ties so that they increase the demand for health services for girls
and women.
Ten actions are critical to effectively implement a package of
health and nutritional programs for women:
1) Existing programs within health services should be inte-
grated. By integrating nutritional programs within the health
service, complementary health care activities can be clus-
tered at the same place and time, which will reduce service-
delivery costs for both the providers and the clients. There
are opportunities for better integration of all mother and
child health activities, child survival programs, supplemen-
tary feeding programs, safe motherhood, and family plan-
ning and other reproductive health activities.
1359S
2) Community- and facility-based health and nutritional care
should be combined. The provision of health services alone
is not enough to improve womens nutrition. Community-
based programs can complement regular health services by
focusing on nutritional monitoring and supplementation,
family planning, hygiene practices, infection prevention and
control, and identification and referral of complicated ill-
ness. Community health care providers, including commu-
nity health committees, health workers, traditional birth
attendants and practitioners, and mobile outreach teams
from health services, need to be trained, supervised, and
supported by health service staff. Government policies and
programs, however, are more likely to influence the cover-
age and effectiveness of formal health and nutritional ser-
vices than is the community-based care provided by
untrained community members and traditional practitioners
who are often the major source of advice and counseling on
nutrition and health care for women in developing countries.
3) Public- and private-sector health and nutritional service-
delivery systems should be combined. Despite the substan-
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tial improvement in health care coverage in recent decades,
the public health sector in most developing countries still
lacks the material and human resources required for provid-
ing sufficient health care coverage to most of the population,
let alone to those at greatest risk of ill health and malnutri-
tion, who are often not easily accessible geographically and
economically. Compounding the limited number of service-
delivery points is the fact that health and nutrition services
in developing countries, particularly preventive services for
women, are largely underused. This has been attributed to
womens preference for seeking care from traditional health
care providers, poor accessibility to services, poor quality of
care, lack of information, relatively high costs, lack of
womens decision-making power and control of family
income, and the opportunity cost of womens time (52).
Although the removal of these constraints to increase the use
of health services by women is a clear priority, delivery
channels outside the regular health care system need to be
identified and tapped (eg, traditional health care providers,
secondary schools, womens groups and cooperatives, and
factories).
4) Risk assessment should be used for targeting high-risk preg-
nancies so that appropriate referrals can be made. Risk
assessment is seen as a logical tool for rationalizing service
delivery to ensure special care of those in need. Experience
has shown, however, that a formal risk approach can be
problematic and can divert scarce resources away from most
women with poor pregnancy outcomes. The World Health
Organization (53) proposed that, because of the absence of
data indicating the effectiveness of screening for high-risk
pregnancies, risk assessment should not be relied on as the
sole basis for matching the requirements for and provision
of maternity services. Because there are often several objec-
tives of risk assessments, it is difficult to develop a simple
tool as a panacea. It was shown, for example, that the effec-
tiveness of supplementary feeding to improve fetal growth
(birth weight) is greater when targeted at undernourished
pregnant women identified through anthropometric indica-
tors (54). Thus, anthropometric indicators can be useful if
birth weight is the outcome but will not be useful for identi-
fying women at risk of preeclampsia.
1360S MORA AND NESTEL
5) Health services should be organized by levels of care. Such
a strategy is cost-efficient and improves the quality of care
because the responsibilities at each level are thus more
clearly defined and it allows for a functional bidirectional
referral system (eg, severely anemic patients can receive
specialized care and be referred to less-specialized care
when appropriate).
6) Health personnel should be trained and motivated to deliver
nutrition services. Good quality services indicate that health
care providers have adequate clinical and counseling skills
and are sensitive to womens needs. This requires appropri-
ate initial training and periodic retraining and updating, as
well as a quality-based system that ensures that health care
providers and their supervisors are sufficiently motivated to
do a good job.
7) IEC should be provided systematically. IEC is essential to
any nutritional program and has 2 major purposes. The first
is to disseminate information, sensitize the populace, and
mobilize both the providers and the recipients to support
policies and programs aimed at enhancing the social status
of women and the provision of health, nutritional, and edu-
cational services to them. The second purpose is to promote
individual behavioral changes to increase the use of and
demand for available health services for women and to
improve womens and childrens eating and health practices.
Changing womens eating habits appears to be one of the
most difficult things to do and there is no evidence that
efforts to do so have been effective in the long term.
8) The cost-effectiveness of different programs and delivery
systems should be analyzed. Cost-effectiveness analysis is
an important tool for identifying the appropriate mix of pro-
grams and service-delivery mechanisms that will achieve
specific nutrition objectives. For example, the generally
accepted view that prenatal care was strongly associated
with improved pregnancy outcomes in the early 1980s led to
the question of whether prenatal care was cost-effective. The
ensuing US Institute of Medicines review showed that for
every dollar spent on prenatal care, $3.38 was saved in direct
medical care expenditures (55).
9) Opportunities for promoting the nutritional status of adoles-
cent girls should be identified. This is a relatively new, chal-
lenging (but promising) area for which there are some small-
scale but highly relevant experiences (56). As womens
education improves, increased opportunities for programs
targeted at adolescents through the school system will
become available.
10) Basic supplies required for prenatal and delivery care should
be improved. Good-quality care also requires that service
facilities have the necessary equipment and supplies, includ-
ing iron and folate supplements (57, 58). This is a frequently
neglected area in developing countries that urgently needs
systematic attention.
PROSPECTS AND CHALLENGES
The prospects for improving maternal nutrition are contingent
on there being political commitment and national capacity to
develop and implement sound policies and programs. Policy
decisions and program implementation will be affected by the
context of nutritionally relevant global trends that are character-
ized, on the positive side, by increased womens education,
delayed age of marriage, declining fertility rates, smaller fami-
lies, longer life expectancy, greater health-system coverage, and
increased womens participation in the labor force. On the nega-
tive side, these global trends are characterized by severe resource
constraints, slow economic growth, poor use of available health
and nutritional services by females, and slow progress in
improving the social status of women in many countries.
From a program perspective, possibly the most important fac-
tor favoring the implementation of enhanced health and nutri-
tional services for women is the ongoing trend toward increased
coverage of maternal services. A recent analysis of demographic
and health surveys conducted in 12 countries between 1986 and
1996 showed that, overall, the countries experienced a steady
increase in prenatal and delivery care coverage ranging from 2%
to 34% for prenatal care, 2% to 39% for tetanus immunization,
and 3% to 79% for delivery care (59). However, prenatal care
coverage fell in 1 country and delivery care coverage declined in
3 countries. Quality of care was not assessed, which is important
because it may not have improved significantly.
The challenges ahead are not insignificant. There is little doc-
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umentation on program experiences to improve prenatal nutri-
tion, womens food intake, and weight gain during pregnancy in
developing countries. It is disappointing to note that, despite the
research-based evidence that iron supplementation is efficacious,
this relatively simple program was not effective in reducing the
prevalence of anemia in women and children (58, 60). Most iron
and folate supplementation programs for pregnant women and
young children have serious operational constraints related to
supply and distribution systems, access to health care services,
motivation and behavior of health care providers, and compli-
ance by the target population. Unresolved problems that affect
the acceptability of and compliance with supplements continue
to persist and include the lack of good-quality, low-cost generic
supplements; suitable compounds and dispensing mechanisms
(tablets, pills, syrups, liquid forms, and powder); appropriate
regimens (daily or intermittent) for different environments (areas
of endemic malaria and helminth infection); and potential
adverse effects (real or overestimated).
Although there is little evidence that an iron-supplementation
program works, it remains one of the few options available for
improving the iron status of the population and appears to be the
only program likely to meet the high iron requirements during
pregnancy and early childhood (23). Operations research is mov-
ing toward testing systematic, intermittent supplementation of
adolescent girls in schools and of nonpregnant women in the
workplace to reduce the need for aggressive high-dose supple-
mentation, with its associated potential adverse effects and low
compliance, during pregnancy. This approach, however, assumes
that the most at-risk adolescent girls attend school and that
women work in organized work settings, which is not yet the
case in most developing countries.
Regrettably, conceptual and implementational constraints
have minimized the effect of efforts to improve womens nutri-
tion, largely because the focus has been almost exclusively on
the prenatal period (50). Many programs were conducted as
small-scale research activities or vertical interventions or relied
heavily on manipulating only the biological factors that influ-
ence womens nutrition. Such approaches are difficult to expand
because of the lack of broad-based support and demand for the
services. Although, as emphasized above, efforts to improve
womens nutrition in a sustainable way must involve a life cycle
 PRENATAL NUTRITION IN DEVELOPING COUNTRIES
perspective, the reality in most developing countries is that
financial and resource constraints often reduce action to a few
programs that tend to focus on pregnancy and, to a lesser extent,
lactation. A stronger political commitment is needed to support
womens health and nutritional programs and to create the
demand for a minimum package of services.
Major challenges
Translating current knowledge into practice
It will be a major challenge to translate current knowledge
into practical application in the context of resource constraints in
developing countries, ie, to move from theory to practice in a
resource-limited setting. Baker et al (50) identified conceptual
and implementational constraints to improvements in female
nutrition that will need to be addressed if womens nutrition is to
improve. The conceptual constraints include a consistent lack of
political support for womens nutrition, nutritional programs
narrowly focused on pregnant women, nutritional programs usu-
ally designed as pilot projects or small-scale research activities,
lack of a consensus on the most appropriate and practical indi-
cators of womens nutrition, and lack of information on the cost-
effectiveness of programs. The implementational constraints,
which are common to health programs, include limited service-
delivery capacity and low use of existing services, poor program
management, limited focuses on behavioral factors and behav-
ioral change, and inadequate training of health personnel.
Determining definitions of prenatal nutrition and undernutrition
in women
Another major challenge will be to develop acceptable, bio-
logically meaningful and programmatically relevant definitions
of prenatal nutrition and undernutrition in women by using
anthropometric, dietary, and biochemical indicators. This is criti-
cal for problem definition, risk identification, program targeting,
and monitoring and evaluation. Current indicators include anemia
rates (based on hemoglobin concentration) and womens height,
weight and weight gain, body mass index, and midupper arm cir-
cumference (61, 62). There is no general consensus, however, on
the use and interpretation of anthropometric indicators in preg-
nant and nonpregnant women (15, 63, 64). Guidelines on the
application of anthropometric indicators emphasize the use of
these indicators as screening tools rather than for surveillance,
and instruments designed for the latter purpose are pending satis-
factory validation. A related question that needs to be addressed
is the identification and interpretation of maternal undernutrition
in poor communities in which a relatively large proportion of
women are short but overweight (eg, in parts of Latin America),
yet indicators of pregnancy outcomes also are not optimal.
Allaying womens concerns about weight gain and delivery
complications
A review of research from 18 developing countries on changes
in dietary practices during pregnancy found that food intake is
consciously restricted during pregnancy because of the fear of
delivery complications associated with having a large newborn
(65). Although this concern is rational, there are no data to sup-
port it. Restricted food intake by pregnant women can compro-
mise their nutritional status and needs to be addressed through
behavioral change programs, when appropriate.
1361S
Understanding the physiologic and social adaptation
mechanisms during pregnancy
Evidence from several studies suggests that pregnant women
subsisting on limited energy intakes adapt to this situation
through a physiologic reduction in their basal metabolic rate or a
reduction in activity to conserve energy for fetal growth (66).
These mechanisms affect the use and interpretation of nutritional
indicators during pregnancy and the guidelines on energy intakes
to sustain adequate weight gain. Irrespective of the physiologic
adaptations of the body, Naeye (67) showed that a womans nutri-
tional store as she enters pregnancy is a more important determi-
nant of perinatal mortality than is pregnancy weight gain per se.
Reducing persistent problems with health service development
and access to quality prenatal care services
Prospects for steady increases in the availability of and access
to quality health services for women in developing countries are
uncertain given current financial constraints. However, great
efforts have been made toward improving the efficiency of health
care expenditures, enhancing coverage within existing resource
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constraints and, to a much lesser extent, improving access for
poor, uneducated women, especially those in rural areas.
Problems with access to and quality of prenatal care services,
however, are not exclusive to developing countries. In an attempt
to understand the poor standing of the United States in the inter-
national rankings of infant mortality rates, a recent situation
analysis identified the need for increasing access to prenatal care,
redirecting the content of prenatal care, understanding the behav-
iors of pregnant and lactating women, and facilitating changes in
the delivery of nutritional care (68). The new guidelines for the
delivery of nutritional care issued by the US Institute of Medicine
(69) address the predisposing factors that inhibit health profes-
sionals from including nutritional care in their practices, empha-
size a more culturally sensitive approach to care, and recommend
new tools for screening and targeting prenatal programs.
Womens nutrition remains a global issue with common prob-
lems and constraints that will be resolved only if womens health
and nutrition are put in the context of the life cycle rather than
into discrete compartments. This approach includes addressing
the underlying social and cultural determinants of behaviors con-
nected to womens nutrition at all stages of the life cycle.
We thank Leslie Elder and Ritu Nalubola for their comments and sugges-
tions on an earlier draft of the article.
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