EMS 2014: Programme Notes

For more than a century, visionary leaders of countries and corporations have known that long- term investment in maternal and child health is a condition of human capital formation. Some have emphasized healthcare as a human right. Some, with an eye on productivity, creativity and innovation, have focused on links between physical, intellectual and emotional health and the capacity to learn. Some have emphasized links between birth weights, life spans and long-term health. Some have drawn attention to low birth weights attributable to poor maternal health and nutrition (or in utero defi ciencies) and low birth weights attributable to premature birth. Some have concentrated on relationships between the psychological status of pregnant women and fetal development. Some have investigated the consequences of post-partum psychosis. Some have stressed relationships between health and nutrition in the 1000 days from conception to age two and longevity, freedom from disease and adult capabilities. The symposium described in this note was designed to allow participants to contribute to a robust framework that would take account of complementary and competing perspectives

Maternal and Child Health and Nutrition

In an ideal world, all women everywhere would enjoy good health and nutrition before, during and after pregnancy. In practice, even in high-income economies, there are huge contrasts between social and economic groups. In Brazil, China, India, Indonesia, Mexico, Russia, South Africa, Turkey and other emerging markets three decades of rapid economic growth and rising incomes have brought many improvements in health and nutrition. Some emerging markets have made more progress than others. Some have changed at remarkable speeds. Yet good health and optimal nutrition remain abstract ideas for millions of women and children in most of them.

Policy makers sometimes cite declining Maternal Mortality Ratios and Child Mortality Rates as evidence of improving maternal and child health. But these are blunt instruments compared with the more subtle measure of birth weight for gestational age and ignore the fact that for every female death attributable to pregnancy, labour or delivery, fifty other women may suffer serious long-term consequences of childbirth. Policy makers also tend to overlook the reality that the intellectual and physical potential of nutritionally disadvantaged children is poorer than that of nutritionally advantaged children.

The implications are profound because what is at stake is the future human potential of emerging markets. These economies have grown faster than high-income economies since 1980. They have powered the world through recession since 2008. And with 50% of the world’s people and nearly 40% of its economy they expect – and are expected - to be increasingly powerful actors on the world stage. Their future growth, cohesion and stability is however clouded by eroding competitive advantages, by environmental degradation, by weaknesses in national, local and corporate governance and by unresolved problems of human welfare - including problems of maternal and child health and nutrition.

The Symposium

This symposium set out to examine: (i) The causes and consequences of impaired maternal, fetal and child health and nutrition in emerging markets; (ii) What has been learned as emerging markets and other countries have tried to address the issues; (iii) Whether new science offers grounded solutions to those problems; and (iv) Strategies for adapting  solutions to the distinctive financial, economic and cultural realities of countries that share important economic attributes but are in many ways diverse.

(i) Problems, Causes and Consequences
The first task for the symposium was to consider the causes and consequences of problems associated with maternal and child health and nutrition in emerging markets including:

• The impact of intergenerational attributes; the availability and quality of primary, secondary and adult education; the organisational, institutional, managerial and fiscal capacities of governments to design, implement and evaluate maternal and child health and nutrition initiatives; government spending priorities; and the quality and effectiveness of leadership in government, the public and private sectors and civil society.

• Patterns of economic growth that have been generally associated with substantial - in some cases dramatic - reductions in poverty and improvements in human welfare and human security but have also been associated with regressive trends in income distribution, growing contrasts between the well-nourished and the poorly-nourished, and the co-existence of endemic under-nutrition and epidemic obesity*.

• Rapid and massive urbanisation that has been positively associated with improved access to education, health and other services but negatively associated with co-existing infectious and chronic diseases and hostile environments for the physical, mental and emotional health of mothers and children including:

• Economic environments of poverty, deprivation, economic uncertainty, poor job security, poor workplace conditions and arduous journeys to work.
• Living environments featuring inadequate housing, overcrowding, noise, lack of privacy, poor sanitation and public services and poor air and water quality.
• Social environments that feature social inequality, fragmented nuclear families, social isolation, domestic violence and sexual predation.

(ii) What Has Been Learned?

The second task was to consider lessons learned from public, private and voluntary sector initiatives, policies, programmes, practises and projects to improve maternal and child health and nutrition in emerging markets and elsewhere.

(iii) Are There New Solutions?
Having considered the nature, causes and consequences of problems of maternal and child health and nutrition in emerging markets, and what could be learned from past experience the thirdtask for the symposium was to consider possible solutions taking account of the implications of recent research in intergenerational factors and other fields but focussing on the results of the INTERGROWTH-21st Project+ which has recently generated new 'prescriptive' standards describing optimal fetal and newborn growth in eight geographically diverse populations++. These standards define how fetuses and infants should grow if their mothers’ nutritional and healthcare needs are met and are linked to neonatal health risks and to physical growth and cognitive development through the age of two. Given the nature and magnitude of the economic, political, cultural and other differences between emerging markets, the global fetal and newborn growth standards cannot offer a ‘one size fits all’ solution.  The INTERGROWTH-21st findings would assist nations identifying what needs to be done to prevent poor growth in early life, providing a new benchmark for early life growth against which progress could be measured.

(iv) Strategies
Policy makers are generally reluctant to devote scarce resources, including political capital, to initiatives that combine short-term costs and delayed benefits. Accordingly, the fourth task for the symposium was to consider how new science could improve the nutrition and physical, intellectual and emotional health of mothers and children, particularly in disadvantaged communities and if reluctance could be overcome by:

• Showing that improvements in maternal and child health (including mental and emotional health) and nutrition offer extraordinary opportunities to enhance the physical and intellectual potential of future generations and the human capital required to sustain economic growth and promote social cohesion.
• Suggesting how science-based health and nutrition interventions could be tailored to the needs and conditions of individual emerging market countries taking account of the likely costs and benefits of those interventions.
• Identifying specific initiatives, including pilot initiatives, that could be respectively or collaboratively executed by scientists, governments and the public, private and voluntary sectors to implement the findings of scientific research on maternal and child health and nutrition, the enabling conditions for those initiatives and (in light of explicit criteria) their relative priorities.
• Identifying potential links with other initiatives (e.g. education initiatives) that could be coordinated with health and nutrition initiatives bearing in mind that health outcomes are strongly influenced by policies and programmes in non-health sectors.
• Persuading leaders in governments, civil society and multilateral institutions that maternal and child health and nutrition policies cannot succeed without strong, coherent and consistent vision, commitment and high level leadership, and that the main issue is not the cost of action but the price of inaction.

Potential Impact

The themes of this symposium were fundamentally important to the future of all emerging markets. Like previous EMS symposia this symposium addressed complex issues and potentially 'wicked' problems that evade straightforward solutions. The central challenge was to suggest how the outcomes of scientific research could be adapted to benefit all women and children in all emerging markets. It is not hard to envisage that optimised solutions could be delivered to relatively well-off mothers and children in relatively benign environments. It is much harder to envisage how optimised solutions could be realistically and reliably modified to deliver at least partial solutions to very poor mothers and children in hostile economic, social, physical and emotional environments. The symposium was driven by the belief that it could be done and that science, government, business and civil society must collaborate to make it happen.

*In Brazil, 53% of adults are overweight; in China, the figure is 25% with higher rates among city-dwellers. See Special Report on Obesity, Economist, December 15th 2012

+The INTERGROWTH-21st Project, funded by the Bill and Melinda Gates Foundation, is based at the Oxford Maternal & Perinatal Health Institute, Green Templeton College (http://www.intergrowth21.org.uk)

++Brazil, China, India, Italy, Kenya, Oman, UK and USA