Many nutrition-sensitive approaches were delivered in broader community-based settings and more equitably reached women across the life course. Non-facilities-based settings more equitably delivered nutrition interventions to women who were not pregnant or lactating, and who were less engaged with health clinics and schools. For instance, food fortification, which was often delivered through markets, home visits, and community centers, seemed to be more effective at reaching women of reproductive age than health center–based delivery platforms. Community-level interventions are often reported as more equitable than platforms that require access to “fixed and well-equipped health facilities” (212). This aligns with our findings, where we found that community-based platforms such as home visits, community centers, homes of community leaders, work, mass media, mobile phones, and commercial settings were effective at reaching women across the life course (Table 1). Other delivery platforms such as marketplaces, water points, tailoring shops, and agricultural points for seeds or inputs were also effective. These locations need to be context-specific in order to capture where women spend their time. For instance, in countries where many adolescent girls do not attend school, school-based delivery platforms might be less effective. Delivery platforms also need to be sensitive to the sociodemographic differences that influence where women spend their time, such as differences for women in rural and urban areas, and of different socioeconomic statuses. Additional research needs to identify and report where women and adolescent girls are, and how best to reach them.
Nutrition interventions that target mothers alone inadequately address women's needs across their lives: during adolescence, preconception, and in later years of life. They also fail to capture nulliparous women. The extent to which nutrition interventions effectively reach women throughout the life course is not well documented. In this comprehensive narrative review, we summarized the impact and delivery platforms of nutrition-specific and nutrition-sensitive interventions targeting adolescent girls, women of reproductive age (nonpregnant, nonlactating), pregnant and lactating women, women with young children <5 y, and older women, with a focus on nutrition interventions delivered in low- and middle-income countries. We found that although there were many effective interventions that targeted women's nutrition, they largely targeted women who were pregnant and lactating or with young children. There were major gaps in the targeting of interventions to older women. For the delivery platforms, community-based settings, compared with facility-based settings, more equitably reached women across the life course, including adolescents, women of reproductive age, and older women. Nutrition-sensitive approaches were more often delivered in community-based settings; however, the evidence of their impact on women's nutritional outcomes was less clear. We also found major research and programming gaps relative to targeting overweight, obesity, and noncommunicable disease. We conclude that focused efforts on women during pregnancy and in the first couple of years postpartum fail to address the interrelation and compounding nature of nutritional disadvantages that are perpetuated across many women's lives. In order for policies and interventions to more effectively address inequities faced by women, and not only women as mothers, it is essential that they reflect on how, when, and where to engage with women across the life course.
In our review, we found that fortification interventions that provided fortified foods reached women of all life stages through home visits, community distribution centers, local markets, and retail stores. Delivery of fortified foods in school-based programs, at work, and in maternal–child health centers were also used to target school-age children, women of reproductive age, and pregnant and lactating women that were engaged with those facilities (37, 72–74, 84). There was mixed evidence that consumption of fortified foods reached all socioeconomic groups. Some studies showed differences in consumption between nonpoor and extremely poor, and between urban and rural stakeholders (33, 64, 85). Women who have restricted access to markets, depend largely on locally grown foods, are in areas with underdeveloped distribution channels, or have limited purchasing power, might have limited access to fortified foods (64). Additional research is needed to address implementation gaps and to determine the best platforms for reaching high-risk populations.
In 2000, the United Nations created Millennium Development Goal (MDG) 5 to improve maternal health. Target 5A sought to reduce maternal mortality by three quarters from 1990 to 2015, using two indicators, 5.1 the MMR and 5.2 the proportion of deliveries attended by skilled health personnel (physician, nurse or midwife). Early reports indicated MDG 5 had made the least progress of all MDGs. By the target date of 2015 the MMR had only declined by 45%, from 380 to 210, most of which occurred after 2000. However this improvement occurred across all regions, but the highest MMRs were still in Africa and Asia, although South Asia witnessed the largest fall, from 530 to 190 (64%). The smallest decline was seen in the developed countries, from 26 to 16 (37%). In terms of assisted births, this proportion had risen globally from 59 to 71%. Although the numbers were similar for both developed and developing regions, there were wide variations in the latter from 52% in South Asia to 100% in East Asia. The risks of dying in pregnancy in developing countries remains fourteen times higher than in developed countries, but in Sub-Saharan Africa, where the MMR is highest, the risk is 175 times higher. In setting the MDG targets, skilled assisted birth was considered a key strategy, but also an indicator of access to care and closely reflect mortality rates. There are also marked differences within regions with a 31% lower rate in rural areas of developing countries (56 vs. 87%), yet there is no difference in East Asia but a 52% difference in Central Africa (32 vs. 84%). With the completion of the MDG campaign in 2015, new targets are being set for 2030 under the Sustainable Development Goals campaign. Maternal health is placed under Goal 3, Health, with the target being to reduce the global maternal mortality ratio to less than 70. Amongst tools being developed to meet these targets is the WHO Safe Childbirth Checklist.
Equally challenging for women are the physiological and emotional changes associated with the cessation of menses (menopause or climacteric). While typically occurring gradually towards the end of the fifth decade in life marked by irregular bleeding the cessation of ovulation and menstruation is accompanied by marked changes in hormonal activity, both by the ovary itself (oestrogen and progesterone) and the pituitary gland (follicle stimulating hormone or FSH and luteinizing hormone or LH). These hormonal changes may be associated with both systemic sensations such as hot flashes and local changes to the reproductive tract such as reduced vaginal secretions and lubrication. While menopause may bring relief from symptoms of menstruation and fear of pregnancy it may also be accompanied by emotional and psychological changes associated with the symbolism of the loss of fertility and a reminder of aging and possible loss of desirability. While menopause generally occurs naturally as a physiological process it may occur earlier (premature menopause) as a result of disease or from medical or surgical intervention. When menopause occurs prematurely the adverse consequences may be more severe.
Protein should provide about 15% of a healthy person's daily calories. As a rule of thumb, people of both sexes and any size will do fine with about 60 grams of protein a day. Athletes who have large muscles and work out hard may need 20% more. But even that's not very much; 8 ounces of chicken or 6 ounces of canned tuna, for example, will fit the bill.
Energy and protein supplementation was most often associated with weight gain of women, and often targeted pregnant women with suboptimal weight. For pregnant women, energy and protein supplementation modestly increased maternal weight (86–90). Other maternal outcomes were not frequently reported, and were often secondary objectives of protein-energy supplementation interventions (33, 88). Many studies reported on infant health outcomes, including reductions in low birth weight and preterm births (19, 89–91). Adequate energy and protein intake was also relevant for interventions targeting the prevention of excessive gestational weight gain of overweight and obese pregnant women. These interventions restricted dietary energy intake of overweight women during pregnancy and resulted in reduced excess weight gain during pregnancy but had no impact on pregnancy-related hypertension and pre-eclampsia (19, 88).
Schools (“condition” and delivery platform) ↑ food expenditures, ↑/NC food share, ↑ HH food consumption, ↑ dietary diversity, ↑ HH intake of fruits, vegetables, and ASF, ↑/NC intake of fats and sweets ↑ knowledge about health and nutrition, ↑ food expenditures, ↑/NC food share, ↑ HH food consumption, ↑ dietary diversity, ↑ HH intake of fruits, vegetables, and ASF, ↑/NC intake of fats and sweets, ↑ participation in social networks, ↑ self-confidence, ↑ control HH resources ↑ knowledge about health and nutrition, ↑ HH food security, ↑ food expenditures, ↑/NC food share, ↑ HH food consumption, ↑ dietary diversity, ↑ HH intake of fruits, vegetables, and ASF, ↑/NC intake of fats and sweets, ↑ participation in social networks, ↑ self-confidence, ↑ control over resources ↑ knowledge about health, NC hypertension, ↓ missed meals, ↑ health care utilization