“Do you know why we eat gutka so much?” a woman from one of the low-income neighbourhoods where the Aga Khan University Hospital (AKUH) has established antenatal clinics (ANC) asked the doctor.

“So we don’t feel hunger.”

This is not a rare occurrence. Over the last several weeks, my interactions with health practitioners and field staff at the antenatal clinic (ANC) at Rehri Goth — a low-income fishing neighbourhood on the outskirts of Karachi — I have come to realise how common malnourishment is in a resource-constrained and food-insecure country like ours.

Antenatal | Related to medical care given to pregnant women before their babies are born.

In Pakistan, 18 per cent of married women of reproductive age are nutrient-deficient, as a result of which 44pc of children have stunted growth.

According to Dr Shaikh Tanveer Ahmed, the chief executive officer of HANDS Pakistan, a non-profit organisation working in rural areas across Sindh and Punjab, nearly “50pc [of women] are malnourished” to some extent.

“If we screen hundreds of thousands of women, 12 to 15pc [of them] are severely malnourished while some 20 to 22pc moderately malnourished and nearly 40 to 45pc are healthy,” he told Dawn.com.

Globally, maternal undernutrition poses a significant health burden, accounting for 7pc morbidity plus 70pc neonatal and 20pc maternal mortality rates.

Neonatal | Related to newborn children.

Morbidity | The state of being ill or having a disease.

The trouble starts with the very definition of terms like ‘malnourishment’ and ‘underweight’, which are not universally understood in the same manner. This is something that dawned on me following my conversations with pregnant women at the ANC — what someone from a similar socio-economic class as mine would understand by these terms can be fundamentally different from women belonging to another background and vice versa.

How can you know you are eating less when you don’t know what is ‘enough’? You can only know what less is when you know the normative standard. If you eat less, your body will get used to it, making that ‘your normal’.

This was reflected in the answers of every other woman I asked whether they ate ‘enough’. No matter how many symptoms of anaemia or other forms of malnourishment they would show, they would respond with an optimistic ‘yes’ almost every time.

When I asked them if their previous babies were healthy, they would again reply with a resounding ‘yes’. However, on further probing, one such woman revealed that by healthy she meant that her newborn babies completed the nine-month term.

Kiran, 24, is pregnant with her sixth child after losing two sons. She was at the clinic with excruciating pain in the left side of her womb. The doctors, perplexed, were trying to ascertain the cause of the pains, which occurred during her final trimester.

Speaking about her deceased sons, she said that they became sick and passed away. The parents still don’t know the reason for their death.

“By the grace of God, they were all healthy and their weight was okay,” she added. When asked about the weight of her babies, however, Kiran said she was not sure.

“Bohot takleef hai [It’s very painful],” she kept repeating in a whimpering voice.

Health practitioners have advised the 24-year-old to consume meat, fruits, vegetables and milk. But for Kiran, whose family is run by a single bread earner, this is very difficult.

“Bus chai paratha kha lete hain kabhi [We only eat chai and paratha sometimes],” she said. “Na fruit naseeb ho raha hai, na doodh naseeb ho raha hai [We neither get fruit nor milk].

“Bus guzara karna hai [We only have to survive],” she said with a sigh.

The discomfort visible on her face, Kiran told Dawn.com that she has had enough now and won’t have another child. However, for her fallopian tubes to be tied — permanently preventing pregnancy — she would need her husband’s consent.

Seated in the same clinic was Bushra, who was about to give birth to her eighth child. Like Kiran, her family is also dependent on a single earner. “Whatever Allah gives, we just eat that,” she said in a subdued voice.

For her to even travel to the clinic was a task on its own. Bushra’s husband had to take a day off from work to drop her off at the centre on his motorcycle.

This was a problem faced by several women at the clinic. They would earlier commute to and from the centre via free-of-cost transportation, provided by the ANC. But since the number of women coming in has increased, the centre only provides transport in emergency cases.

Despite the distance, they persist in travelling from distant areas of the city to access the clinic’s free healthcare services, highlighting the scarcity of such accessible options for the majority of the population.

Pregnant for the third time, 18-year-old Shazia has to commute a total of “four hours” from Dawood Goth, near Seaview, each time she comes to the clinic.

“We have to wait for so long for the bus and that too costs Rs200,” she said. Shazia also faces difficulties finding a ride home.

Like most women at the centre, her husband is a fisherman. “The only time we eat any kind of meat is when he catches a good amount of fish,” she said. “Otherwise, we cannot afford to buy it from the market.”

“On one hand, he faces trouble finding good fish. On the other, when he does, he finds it hard to sell them,” she lamented.

Other forms of nutritious food are also out of reach for her. “If we buy potatoes then we can’t buy tomatoes. If we buy tomatoes, we can’t buy potatoes,” she said. “I have a two-year-old and a four-year-old at home. We have to make sacrifices.”

She also complained that in addition to gas and electricity shortages, there is a dire lack of potable water in her area. “We only get water once a week,” she said. To collect water, she has to walk to a common spot and do it all by herself during her fourth month of pregnancy. Without this arduous task, her family won’t have water for a week.

Save the mothers

“The killer, the major stream underlying all of the deaths that happen among babies as well as mothers, is malnutrition,” said Dr Fyezah Jehan, chairperson of the Department of Paediatrics and Child Health at the AKUH.

Her work focuses on maternal newborn and child health and nutrition.

“One in four babies in Pakistan are born smaller for their age,” she told Dawn.com. This is a huge issue because when these babies grow, they are at risk of not developing properly. In the first five years of life, they do not reach their growth or mental potential, she added.

“They are cognitively challenged, they may catch up with their weight if there’s the additional nutrition, but because they are programmed to be small, they end up becoming fat,” the doctor explained.

“This is known as the Barker’s hypothesis,” she explained.

Barker’s hypothesis posits that if a woman is undernourished during pregnancy, the foetus growing inside the womb genetically programmes itself for survival with limited nutrition. If the deficiency is significant, the foetus may die. However, if the baby is born alive and receives some nutrition, it can sustain itself. Yet, excess nutrition beyond what the baby is programmed for can lead to obesity.

“This is one of the reasons why obesity is so common in our population because we are genetically programmed to be small,” she said, explaining the “increased risk of hypertension, obesity, diabetes, and ischemic heart diseases” in Pakistan.

Dr Imran Nisar, Vice Chair of Research at the Department of Paediatrics and Child Health at AKUH, stressed that there’s an urgent need to improve nutrition among children under five years of age and lactating women in Pakistan.

His work mainly focuses on women, children and the global disease burden.

“Around 42 pc of our children are stunted and wasted. They don’t grow neurodevelopmentally, for example at different age points, two years, three years, and five years, they have cognitive delays, they have motor delays, they have language delays, and they have social behavioural delays, resulting in a low IQ population.”

The initial “nutritional insults” during the first 1,000 days of life hold immense significance. This period encompasses approximately 280 days spent by the foetus inside the mother, in addition to the first two years of life.

Insufficient nutrition during these 1,000 days is detrimental to the long-term growth and development of a child and thus places them at a disadvantaged position right from the start, depriving them of a fair opportunity at optimal development.

However, it is key to understand that one “cannot help the baby without fixing the mother”, said Dr Jehan.

“About one in three moms is malnourished and around half of them have anaemia. One of the reasons why the babies are small is because the moms are actually not well nourished.

“Having enough food to eat does not mean that your food is of good quality,” she said, adding that what was prevalent here was “hidden hunger”, whereby “there are adequate calories but not enough vitamins and minerals in our diet”.

This is because of “low dietary diversity”. Most women depend on cereal and wheat-based foods as well as chai that “fills the stomach but doesn’t provide the required nutrition to the body, especially during pregnancy when this requirement is much higher.

For instance, Kiran who said she eats chai and paratha sometimes is “missing out on the essential vitamins such as vitamin A, D, B and folic acid — which are needed particularly during pregnancy.

“Even the fats that are coming from the paratha, they lack the essential fats,” the doctor explained.

There has been so much emphasis on breastfeeding during the first six months of a baby’s life. The problem here arises that if the mother is severely malnourished then how can she properly breastfeed her child?

“Through my work with the community, I have seen mothers weighing 40kgs having three or four kids, trying to breastfeed their newborn but they are dry, their children are dry.

“If they have anything [enough nutrients], only then they can give them [to their babies],” Dr Jehan stressed.

That’s why it is paramount to focus on the nutrition of pregnant women. “We have to address the issue at the point of origin.”

Dr Jehan has been working in this area for over a decade. Initially, her work focused on child health, specifically examining infectious diseases and noting that adverse outcomes and treatment failures were prevalent among small children.

This observation prompted them to initiate The Alliance for Maternal and Newborn Health Improvement (AMANHI) study, revealing that infants born small tended to remain small and malnourished. This realisation raised questions about the necessity of intervening during pregnancy.

Subsequently, they observed that malnourished pregnant women were more likely to give birth to small babies, either due to prematurity or low birth weight.

They began interventions targeting anaemia, starting with iron supplementation. Their efforts included door-to-door surveillance for anaemia in pregnancy and providing iron supplementation, including IV iron for severe cases — a novel approach for these communities, where such treatments were typically inaccessible outside tertiary care centres.

Therefore, the focus of health stakeholders has shifted from children under five, to newborn health to now the mother, she said.

Supplements — one solution for all?

“Supplements are ideally for severely malnourished individuals in emergency cases. For example, if someone has a vitamin D deficiency, they can fulfil that requirement by taking a capsule,” said Dr Ahmed.

“Ideally, you should be getting that from food or sunlight.“However, for most, that is not the reality in Pakistan therefore, they must resort to supplements.

To address the urgent needs of malnourished pregnant women, micronutrients in the forms of Multiple Micronutrient Supplements (MMS) and Balanced Energy Protein (BEP) Supplements called ‘Maamta’ are commonly provided by government facilities across Pakistan.

Multiple Micronutrient Supplements (MMS) | MMS is a supplement that includes minerals, iron and vitamins.

Balanced Energy Protein (BEP) | In undernourished populations, balanced energy and protein dietary supplementation is recommended by the World Health Organisation (WHO) to improve pregnancy outcomes.

Dr Ahmed pointed out that the private sector does not offer these supplements. “No one offers preventive services because it’s not profitable,” he explained. This creates difficulties for populations in urban slums to access these supplements, particularly since the public sector’s management is more effective in rural areas than in urban centres, he said.

In Rehri Goth, the “majority work, in community management, is to [first] classify the children based on criteria whether they are moderately malnourished or severely malnourished. Similarly, the mother gets classified as malnourished on either the BMI (body mass index) or the mid-arm upper circumference,” stated Dr Nisar.

“Then they get any of the two kinds of supplements — either ready-to-use therapeutic food (RU2F) or ready-to-use supplementary food (RUSF) — based on the criteria. Those who are more malnourished would get RU2F and the less malnourished would get RUSF,” Dr Nisar explained.

RU2F | A life-saving essential supply that treats severe wasting in children under 5 years old.

RUSF | A food supplement for the dietary management of children 6 months and older with moderate acute malnutrition.  

Commercial entities manufacture these supplements which are then procured by international organisations, the likes of WHO and Unicef, to supply as part of different programmes. For disadvantaged women who don’t have access to nutritious food like meat and chicken, supplements act like a “stopgap” solution.

“At least give them adequate nourishment during pregnancy. It’s the least that we can do,” Dr Jehan said.

The government of Pakistan can buy them if they receive funding for a nutrition programme. “If it is in flood and emergency settings, they will buy it and distribute it. The process usually requires 3-6 months,” said Dr Nisar.

“It is a form of a paste that is either chickpea-based or oil-based,” he elaborated. “This is the standard of care that we [health practitioners] have to provide.”

BEP or Maamta supplements are available at designated Benazir Nashaunoma Program (BNP) facilities across Sindh. They require registration and an antenatal checkup at a government faculty. “Even though MMS is not easily available, there is a clear plan to introduce it soon,” Dr Jehan added.

No One-Stop shop

But are supplements enough? The simple answer is no.

“If nutrition could solve the issue, it would be really easy. But there are many other vulnerabilities in these women. For example, we live in an area where, mostly in low and middle-income countries like Pakistan, the environment is not clean. Right?” Dr Jehan asked rhetorically.

There’s a lot of exposure to pathogens.

Pathogens | A pathogen is defined as an organism causing disease to its host.

Populations that are “chronically exposed” to pathogens develop a “mechanism” where they don’t get sick but experience “a low level of illness”.

“What happens is that these bacteria go in our colon and start increasing [in number] and become colonised in our guts, causing inflammation,” the doctor explained.

“Inflammation means, for example, if you have a pimple, there’s redness, heat, and pain. That’s a low level of inflammation which affects every system of your body,” she said. Therefore, when a woman gets pregnant and has inflammation in her body, she is more likely to have other pregnancy-related problems.

“The most commonly used food supplement, BEP, has shown mixed results — some women respond to it, some don’t,” Dr Jehan said.

One of the reasons for the non-response is inflammation. “Even if you provide these women with supplements, you don’t have the bacteria that helps them process the food. “Just giving supplements is also problematic because we don’t want to give them only empty calories,” she stated. “This is what we call the hidden malnutrition where the person appears to be of good weight but is malnourished.”

“The cause of death in most infectious diseases is malnutrition. It’s not the infection that kills, but the underlying vulnerability,” the doctor added.

Another concerning issue is that children under five relapse after being provided with nutrients. A study by The Childhood Acute Illness and Nutrition (CHAIN) Network has shown that about 40pc of children discharged from the hospital after treatment for malnourishment die in the next two years in Pakistan.

The magic bullet

Earlier, stakeholders in the healthcare sector prioritised lowering the mortality rate of newborn babies globally, Dr Nisar said. The focus then shifted to improving nutrition.

Now, improved neurodevelopment of children — how many of them go to schools, how many get jobs as adults, and what is their potential for economic development — has become the centre of concern.

Dr Jehan and Dr Nisar have conducted trials where they introduced additional elements to supplements and assessed their impact. These trials primarily focus on outcomes relevant to children. For instance, when administering to pregnant mothers, the baby’s weight becomes a crucial factor. Similarly, when providing it to lactating mothers, it’s essential to monitor the baby’s growth over six months.

Dr Nisar explained that malnourished women were enrolled in the trial setting, as per certain criteria, where they were given supplements as “standard of care”, along with other elements.

“One of them is azithromycin, an antibiotic. The full biological mechanism of how it works is not completely understood but it has some beneficial effects for immunity,” he added.

Azithromycin | It is from a group of medicines called macrolide antibiotics that work by killing the bacteria that cause the infection.

It improves one’s microbiome by killing harmful bacteria in the gut. “It defies logic somewhat. You give two doses of azithromycin [to the mother] and the baby’s weight at the time of birth is somehow better,” he said.

Microbiome | The body is home to trillions of microorganisms known as the microbiome.

However, there is “huge opposition” to the use of the drug.

Antimicrobial resistance groups have expressed concern about the widespread usage of antibiotics. They particularly emphasise the importance of preserving azithromycin as “one of the last resort drugs” effective against extensively drug-resistant (XDR) typhoid. They argue that implementing it on a large scale might lead to overuse and further resistance to development, according to Dr Nisar.

In response, he acknowledged that antibiotics, including azithromycin, are already widely prescribed “day and night”. However, he stressed that targeting specific populations such as pregnant women and malnourished individuals, could significantly improve newborn outcomes with minimal impact on overall resistance levels. He noted that this intervention involves only two doses, mitigating the risk of widespread resistance.

Despite this, concerns remain due to the strong influence of the antibiotic lobby.

The current WHO recommendation is that if a country’s neonatal mortality rate is very high, one dose of azithromycin to children can be given annually. It works like a “magic bullet”, Dr Nisar described.

The supporting character: MMS plus

Since azithromycin is still considered somewhat of a “taboo”, they are going for BEP, MMS, and MMS plus, said Dr Nisar.

“MMS plus is also something which has not been used anywhere. They have been in trials for 20 years, but their recommendations have not been adopted by anyone. They are beneficial, but till now, it is not a universal adoption.

“What we are saying is that instead of MMS, MMS plus which contains nicotinamide and other things [choline] that have an additional beneficial effect, should be given,” he added.

Even though RUSF and RU2F are nutritious, he continued, better results are seen when they are accompanied by azithromycin and MMS.

“This means they are working through some other pathway. So one of the postulated pathways is through the microbiome. Because you eat food and pass it to the baby but if your microbiome is not optimal, it will not necessarily get absorbed.

“You have to have a healthy gut environment as well. The gut of mothers and children in low and middle-income countries like ours is in a state called dysbiosis,” Dr Nisar stated.

Dysbiosis | An imbalance in the microbiome of an individual, often leading to disease.

What they are striving to achieve through various interventions is the restoration of the gut microbiome’s healthy state. This enables nutritional interventions and other measures to function more effectively.

The clinic at Rehri Goth, AKUH’s oldest and most well-established site, is also the most socioeconomically disadvantaged.

“We have implemented some recent projects in collaboration with other partners, where we have seen a significant decline in mortality there,” the doctor highlighted.

“We started with children under the age of five years. Their mortality rate was around 100 per 1,000 live births, which means that for every 10 children, one died before their fifth birthday. And we have brought it down to around 50. We also decreased the neonatal mortality rate from approximately 40 to 20.”

The question of hunger remains

Despite the substantial interest and investment from global stakeholders, the true measure of these interventions lies in whether average malnourished women like Kiran, Bushra, and Shazia can lead healthy lives and give birth to healthy babies.

“Nutrition is not a health issue, it is a multi-sectoral issue,” said Dr Ahmed. “The government needs to take the lead — the private and industrial sectors can only fill the gaps. “

The role of the community and its women becomes paramount since their lives are ultimately at stake. Even if supplements enable them to have healthy pregnancies, the issue of hunger remains, as noted by Dr Jehan.

The goal is not only to provide adequate nourishment but also to alleviate hunger. Can a pill or supplement ever replace a good hearty meal shared with family?

There is an urgent need for all relevant stakeholders, including state-level bodies, private and government sectors, and community members, to intervene and halt the perpetuation of socioeconomic inequality in society.

“We need to fix the economic problems. If we don’t improve poverty and help alleviate [people’s situations], how will they [afford] to eat?” said the NGO head.

Why should Shazia make “sacrifices” while feeding her two- and four-year-old children? Why can’t she have a balanced meal of potatoes, tomatoes as well as meat?

Even after receiving much-needed supplements, what about the constant stress Shazia endures daily due to her inability to adequately feed her children?

It’s easy to blame individual women from disadvantaged backgrounds for having multiple children, suggesting they brought their struggles upon themselves.

“Why did they have multiple children if they lack resources?”

But is it fair that those with more resources can have as many children as they want while individuals like Shazia face societal judgment regarding their reproductive choices?

This isn’t to disregard the need for family planning in our country, but to put the onus of the abysmal healthcare system on individual women’s reproductive choices is not fair. It is about time that the narrative shifts from blaming women from disadvantaged classes for giving birth to multiple children to understanding how societal structures can move towards a more egalitarian way of living.

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