Hosnia Abdul, a pregnant and lactating mother with a 1-year-old son, is screened for malnutrition during an antenatal care visit at UNICEF-supported village health center in North Delta, Kassala state, Sudan.
Children's Health

Inside Look: How UNICEF is Tackling the Global Nutrition Crisis for Women and Girls

A groundbreaking report reveals alarming rates of malnutrition among adolescent girls and women. UNICEF USA spoke with UNICEF Nutrition Specialist and co-author Harriet Torlesse to learn more about what’s at stake and how UNICEF is advancing solutions in Afghanistan, Ethiopia, Nepal and elsewhere. "Unless we improve the nutrition of adolescent girls and women," Torlesse says, "we are unlikely to end child undernutrition."


Behind every severely malnourished child: a mother who is herself undernourished

Q: UNICEF’s report — Undernourished and Overlooked: A Global Nutrition Crisis in Adolescent Girls and Women — is a first-of-its-kind analysis for UNICEF. Why did you do such a deep dive, and why now?

HARRIET TORLESSE: Back in early 2022, we were concerned about the lack of global progress on this issue. At the time, we were putting together the first global database on women's nutrition and saw that there had been barely any reduction in underweight or anemia over the last two decades.

We were also extremely concerned about the impact of COVID-19 on women's access to nutritious diets and health and nutrition services. 

Then the war in Ukraine broke out, and the context for women’s nutrition changed considerably for the worse. Prices went zooming up — food, fuel, fertilizers — and this had knock-on effects on the cost of nutrition supplies.

But what did this global food and nutrition crisis — which looks set to be largest in modern history — mean for adolescent girls and women? We already had evidence that a child becomes severely wasted every minute in the 15 countries most affected by the global food and nutrition crisis. Behind every severely malnourished child, there is a mother whose nutritional status is linked to her child’s.

We needed to dig deeper into all of these trends and contributing factors and uncover what it all means for the well-being of mothers and their children.

Q: The report refers to a ‘cycle of malnutrition.’ Please explain. 

HARRIET TORLESSE: The cycle of malnutrition is intergenerational. It starts with mothers entering pregnancy with poor nutritional status. These mothers are often too young, too short, too thin and anemic. Malnutrition affects their own well-being and dignity, and also affects the unborn child.

If a mother is undernourished, her child is more likely to be born with a low birth weight, and to then suffer poor growth and development in early childhood. If they are girls, they are more likely to become short and thin adolescent girls, who become malnourished mothers, and so the cycle continues from one generation to the next. This is the cycle we are trying to break.

Q: And so how do you break the cycle?

HARRIET TORLESSE: Malnutrition has many interacting factors that vary between and within countries. In simple terms, we need to address the challenges that adolescent girls and women face in accessing nutritious diets, utilizing essential nutrition services and benefiting from positive nutrition and care practices.

We also need to eliminate harmful social and gender norms that often underpin malnutrition in adolescent girls and women.

Q: Such as child marriage?

Yes. We know that one of our best ways to prevent malnutrition in girls and women is to prevent adolescent girls from marrying and having a pregnancy before their own growth has completed. Child marriage has severe consequences for the nutrition and well-being of adolescent girls and their children. 

In many countries where we're working, there are other social and gender norms that disempower girls and women. Unequal power relations between adolescent girls or women and other household members mean they may not be able to move freely outside the home and choose what food is bought. Some are not permitted to make decisions about what food they eat or to decide when they access nutrition services, especially younger and less experienced mothers. And some countries still have laws and legislation that block women’s equal access to employment, so they have less opportunities to earn income, which is crucial for their social and economic empowerment.

Girls and women living in countries affected by conflict, climate disasters or the socioeconomic effects of the COVID-19 pandemic are particularly vulnerable. They struggle most to pull themselves out of food and nutrition crises because they lack resources, social capital and bargaining power. 

Gender discrimination against women affects all children.

Gender discrimination has a huge impact. When a woman is discriminated against in terms of her access to income, to nutritious diets and to nutrition services, she's more likely to be undernourished. If she becomes pregnant, her children — both boys and girls — are at higher risk of undernutrition. So gender discrimination against women affects all children. And this is what we need to tackle — the unequal rights of women and men to own land and access resources, and the imbalance in decision-making power within the family. This is a major factor driving the high prevalence of undernutrition in women and children in South Asia and sub-Saharan Africa.

Q: It would be great to shift that narrative. The idea that everyone has a mother, so your mother needs to be treated well or you won't be treated well.


Q: That’s a good tee up to this next question: when you improve nutrition for individuals, which is in itself a good goal, how does that benefit society at large? 

HARRIET TORLESSE: It is crucial to appreciate how poor maternal nutrition contributes to child undernutrition. Our analysis found that half of all stunting in children under 2 years originates during pregnancy or in the first six months, when the child is dependent on the mother for nutrition — either during pregnancy or the period of exclusive breastfeeding. This tells us that unless we improve the nutrition of adolescent girls and women, we are unlikely to end child undernutrition.

Unless we improve the nutrition of adolescent girls and women, we are unlikely to end child undernutrition.

If children are not getting the nutrients they need to grow well, it is a sign that they’re not getting the nutrients they need for good brain development. They do less well at school, and are less able to earn a good income in later life. The estimated economic costs to a country range anywhere from 2 to 3 percent of GDP. In some countries, the losses are as high as 16 percent. A 2022 study that looked at the costs to the private sector — the implications of malnutrition in childhood for lower productivity and lower wages — and found it to be in the order of $135 billion in sales in low- and middle-income countries.

Q: Can you share some success stories? Examples of how UNICEF interventions are helping to improve maternal and child nutrition?

HARRIET TORLESSE: We know what works. We know the nutrition interventions that adolescent girls and women need before and during pregnancy and while breastfeeding. The challenge is making sure these interventions reach all who need them, especially the most vulnerable. 

In Afghanistan, prior to August 2021, UNICEF was supporting a nationwide program to deliver iron and folic acid supplements to adolescent girls to prevent anemia, together with nutrition education. This program was reaching 1.6 million adolescent girls every year through secondary schools.

Somaya, a UNICEF-supported Community Health Worker, educates Freshta about the importance of good nutrition in Kitijik, Daikundi Province, central Afghanistan.
Somaya, left, a UNICEF-supported Community Health Worker in Kitijik, Daikundi Province, central Afghanistan, educates Freshta, holding 15-month-old Yasmine, about the importance of good nutrition. Yasmine weighed just over 2 pounds at birth because, Freshta explains, "I was malnourished." UNICEF works with partners to make iron and folic acid supplements available to pregnant women in rural areas to help prevent low birth weight. © UNICEF/UN0733579/Naftalin

When the Taliban took over the government, girls were barred from secondary schools, and so the program came to an immediate stop. We were extremely concerned because these girls were more vulnerable than ever due to the economic crisis that followed. We had to figure out a new way to deliver the supplements to adolescent girls in order to protect them from anemia. 

We worked with partners to transform the school-based program to a community-based program that brought the supplements directly to adolescent girls in their homes. This was a huge undertaking, considering the challenges in the country. But by the end of 2022 we were able to reach 700,000 girls. 

This was a huge undertaking ... but by the end of 2022 we were able to reach 700,000 girls.

Community health workers are playing a vital role in going house to house to distribute the supplements to girls four times a year. Coverage is still lower than it was, however, there are plans to cover all provinces in 2023 and to get it back to where it was.

Q: Sounds like another case of UNICEF being nimble and adjusting and adapting to conditions on the ground — how country teams work with local partners to find a way to keep delivering, even in complex crisis situations.

HARRIET TORLESSE: Yes. Our teams are positioned in a country long before a crisis, building systems, relationships and plans. And when a crisis strike, these teams are immediately available to use their local knowledge, resources, networks and skills to make an impact wherever it matters most.

Shalu, 15, a student at Sarvodaya School in Saptari Shalu Kumari Sah, Nepal, holds a packet of iron and folic acid supplements she received through a UNICEF-supported government nutrition program for adolescent girls.
Shalu, 15, a student at Sarvodaya School in Saptari Shalu Kumari Sah, Nepal, holds a packet of iron and folic acid supplements she received through a UNICEF-supported government nutrition program for adolescent girls. With UNICEF's help, use of the supplements among pregnant women has jumped from a rate of 6 percent to 71 percent between 2000 and 2016, making Nepal's coverage rate among the highest in the world. © UNICEF/UN0721247/Upadhayay

Q: Other country examples?

HARRIET TORLESSE: Nepal is another example of a country where UNICEF and partners have had huge success with its nutrition program — specifically with reaching pregnant women with iron and folic acid supplements to stay healthy and ensure healthy growth and development of their infants.

Globally, we estimate that only 43 percent of women take iron and folic acid supplements for at least 90 days during pregnancy, which is really low considering this is one of the longest running interventions for pregnant women.

Back in 2000, just 6 percent of pregnant women in Nepal were taking the supplements for at least 90 days, but by 2016 this increased to 71 percent — which is one of the highest coverage rates in the world.

Q: How did you pull that off?

HARRIET TORLESSE: Pregnant women used to get supplements only if they attended antenatal care at health facilities. But in 2000, two-thirds of Nepalese women lived more than an hour away from these facilities, and some lived two or three hours away, especially those in remote rural and mountainous areas. This was a major deterrent to accessing services. And few women were aware of the dangers of anemia during pregnancy or the benefits of taking the supplements. 

UNICEF worked with the government to enlist the help of community health volunteers to distribute the supplements to pregnant women in their communities, close to where they lived. As trusted and respected members of the community, these volunteers counseled pregnant women to consume the supplements and to attend antenatal check-ups. They also involved other family members, such as husbands and mothers-in-law, to encourage and remind pregnant women to take supplements.

Q: Are the iron and folic acid supplements the same thing as multiple micronutrient supplements (MMS) — an intervention UNICEF seems very keen to expand worldwide?

HARRIET TORLESSE: Multiple micronutrient supplements — what we call MMS or “multis” for short — contain 15 vitamins and minerals, including iron and folic acid. This is important because we know that when women’s diets are lacking in iron and folic acid, they are also likely to be lacking in other essential vitamins and minerals, such as vitamin A, vitamin C, calcium and zinc. Foods that are rich sources of iron and folic acid are also rich sources of these other micronutrients. 

We are working to ensure that [multiple micronutrient supplements] are freely available to all pregnant women in countries experiencing emergencies. ... This is a huge priority.

All these micronutrients have vital roles in the body, building strong immune, nervous, skeletal, muscular, and cardiovascular systems. Studies have shown that the multis are more effective than iron and folic acid supplements in preventing preterm birth, stillbirths and low birth weight. And we have heard from pregnant women that they prefer MMS because they have fewer side effects than iron and folic acid supplements, such as nausea or black stool. With less side effects, women are more likely to take the supplements.

We are working to ensure that MMS are freely available to all pregnant women in countries experiencing emergencies because these women face great difficulties in accessing nutritious diets. This is a huge priority, given the mounting global food and nutrition crisis.

But we also want to make sure that all pregnant women can benefit from the added benefits of MMS, regardless of where they live. MMS are already a standard of care in high-income countries, and yet are currently only available to pregnant women in 29 low- and middle-income countries. 

We are partnering with the Bill and Melinda Gates Foundation to generate the evidence on the added benefits of MMS and how to integrate them into nutrition services for pregnant women, so more countries can make informed decisions on why and how to switch from iron and folic acid supplements to MMS.

UNICEF and partners are finding ways to leverage cash assistance programs to support women's nutrition.
UNICEF and partners are finding ways to leverage cash assistance programs in rural Ethiopia and elsewhere to support women's nutrition. "Cash is likely cheaper and faster to distribute than alternatives such as restocking, seed distribution and food distribution,” Eyob Getachew, a UNICEF planning and monitoring specialist, points out. “It also maintains people’s dignity, as beneficiaries have the right to choose what to buy.” © UNICEF/UN0723429/Pouget

Q: The report mentions a social protection program in Ethiopia that is helping to make nutritious food more affordable for women. Can you tell us more about that?

HARRIET TORLESSE: Sure. In Ethiopia, we’ve worked with the government to improve nutrition outcomes for women enrolled in what we call the Rural Productive Safety Net program, which reaches 8 million extremely poor households with cash or food in exchange for labor — such as building roads and bridges, things like that. The assistance enables families to buy nutritious foods that they would otherwise not be able to afford. 

What we have been able to do is make some changes to the program to better support women’s and children’s nutrition. First, we made sure that if women enrollees become pregnant, they are excused from work but continue to receive the benefit until their child’s first birthday. This way they can stay nourished during pregnancy but also get plenty of rest, and once their baby is born, they can focus on breastfeeding and caring for the baby. 

Another great thing about this program is that we’ve established childcare centers at many of the work sites, so when the women return to work they can bring their young children with them, and the children are safe and looked after. The centers are staffed by other mothers — which counts as their contribution to the public works. At the center the children receive a nutritious meal every day and early childhood education. 

Q: Awesome. Is there more?

HARRIET TORLESSE: Oh, and through this program we have found a way to empower women too — giving them the information and support they need to become nutrition champions, providing nutrition advice and support to their fellow community members.

Q: The report ends with a quite lengthy description of "the route out" of this nutrition crisis. What are UNICEF’s priorities, at the global level?

HARRIET TORLESSE: So we continue to work with governments around the world to increase access to essential nutrition interventions before pregnancy, during pregnancy and while breastfeeding — women need a package of nutrition interventions, which includes the MMS we were talking about. One of our current priorities is to develop operational guidance to help countries identify and treat pregnant women who are underweight. 

In addition, we need to ensure that adolescent girls have access to affordable nutritious foods, including fortified foods. Greater investments in social protection programs are needed so that more vulnerable women have access to cash transfers or vouchers that they can exchange for nutritious foods. 

We’ve identified three “flagship” results, global targets that we want to meet by 2025: every year, we want to reach at least 300 million children and women with programs that prevent malnutrition; at least 200 million children with programs that detect and treat severe wasting; and at least 100 million adolescent girls and boys with programs that prevent anemia. We are committed to meeting these targets.

Q: Ambitious! Is this a big increase in how many you were already reaching?

We actually reached 335 million children with programs to prevent malnutrition in 2021, despite the disruptions caused by COVID-19. And we reached more than 150 million children with programs that detect and treat severe wasting and more than 67 million adolescent girls and boys with programs to prevent anemia that same year. So overall our new targets do raise the level of ambition, yes.

Q: What makes you confident that UNICEF can meet these targets?

We have nutrition teams in over 120 countries, which gives us deep insights on the causes of malnutrition, as well as the reach to take effective solutions to more children and women in need — in times of stability and in times of crisis.

Learn more about UNICEF's strategies for addressing the global nutrition crisis for girls and women.

UNICEF's No Time to Waste Acceleration Plan aims to reach 9.3 million pregnant mothers in 15 countries with a core package of services — including nutrition counseling and support and micronutrient supplements to prevent anemia and low birth weight in newborns. That appeal remains significantly underfunded. Your contribution can help fund these and other programs. Donate today.


TOP PHOTO: Hosnia, a 20-year-old pregnant and lactating mother with a 1-year-old son, is screened for malnutrition at Al Biritani Health Center in Wager village, North Delta locality, Kassala state, Sudan. "I didn't know I was sick," she says. "I thought I was normal." Now enrolled in UNICEF's supplementary feeding program, Hosnia receives nutrition counseling and is learning how to cook readily available nutritious foods at home. She is also a beneficiary of UNICEF's Mother and Child Cash Transfer program, which provides cash assistance, which she has used to buy fruits, vegetables, meat and eggs. © UNICEF/UN0791857/Mojtba Moawia Mahmoud Video edited by Tong Su for UNICEF USA.