Special Article

COVID-19 pandemic and mitigation strategies: implications for

maternal and child health and nutrition
Nadia Akseer,1 Goutham Kandru,2 Emily C Keats,1 and Zulfiqar A Bhutta1,3

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1 Centre
for Global Child Health, Hospital for Sick Children, Toronto, Canada; 2 Gates Ventures, Seattle, WA, USA; and 3 Center of Excellence in Women and
Child Health, Aga Khan University, Karachi, Pakistan

ABSTRACT Introduction
Coronavirus disease 2019 (COVID-19) continues to ravage health As a highly communicable disease, coronavirus disease 2019
and economic metrics globally, including progress in maternal
(COVID-19) continues to ravage the state of the world’s health
and child nutrition. Although there has been focus on rising
and economy (1). Its impact also underscores the limited
rates of childhood wasting in the short term, maternal and child
progress we have made against noncommunicable diseases
undernutrition rates are also likely to increase as a consequence
(NCDs). Children and adults with underlying comorbidities,
of COVID-19 and its impacts on poverty, coverage of essential
particularly NCDs such as diabetes, hypertension, undernutrition,
interventions, and access to appropriate nutritious foods. Key sectors
and overweight/obesity, are strikingly vulnerable to serious
at particular risk of collapse or reduced efficiency in the wake of
illness and death from COVID-19 (2). Yet, COVID-19 response
COVID-19 include food systems, incomes, and social protection,
health care services for women and children, and services and
measures such as self-isolation, social distancing, and lockdowns
access to clean water and sanitation. This review highlights key of communities can lead to poor management of key risk
areas of concern for maternal and child nutrition during and in factors such as unhealthy diets and physical activity (2), and
the aftermath of COVID-19 while providing strategic guidance for limited access to preventive care in primary care settings.
countries in their efforts to reduce maternal and child undernutrition. Additionally, insecure economic conditions, restricted travel and
Rooted in learnings from the exemplars in Global Health’s Stunting access to health care services, delayed vaccination schedules, and
Reduction Exemplars project, we provide a set of recommendations shuttering of educational facilities further compound poor health
that span investments in sectors that have sustained direct and indirect conditions for young children, especially in low- and middle-
impact on nutrition. These include interventions to strengthen the income countries (LMICs) (3). There is significant concern
food-supply chain and reducing food insecurity to assist those at that COVID-19 responses have had a negative impact on the
immediate risk of food shortages. Other strategies could include nutritional status of women and children, and that these could
targeted social safety net programs, payment deferrals, or tax breaks worsen over time. A recent modelling exercise of various
as well as suitable cash-support programs for the most vulnerable. estimates of the potential impact of COVID-19–related economic
Targeting the most marginalized households in rural populations deterioration, food insecurity, and interruption of programs of
and urban slums could be achieved through deploying community community-based detection and management of malnutrition
health workers and supporting women and community members.
Community-led sanitation programs could be key to ensuring healthy The authors reported no funding received for this study.
household environments and reducing undernutrition. Additionally, Data described in the manuscript, code book, and analytic code will not be
several COVID-19 response measures such as contact tracing and made available because this is a review article and did not have primary data
self-isolation could also be exploited for nutrition protection. Global analysis.
health and improvements in undernutrition will require governments, Address correspondence to ZAB (e-mail: zulfiqar.bhutta@sickkids.ca).
donors, and development partners to restrategize and reprioritize Abbreviations used: CHW, community health worker; CLTS, community
led total sanitation; COVID-19, coronavirus disease 2019; FCHV, female
investments for the COVID-19 era, and will necessitate data-driven
community health volunteer; FSC, food supply chain; HEW, health extension
decision making, political will and commitment, and international
worker; LMIC, low- and middle-income country; NCD, noncommunicable
unity. Am J Clin Nutr 2020;112:251–256. disease; WASH, water, sanitation, and hygiene.
Received May 27, 2020. Accepted for publication June 8, 2020.
Keywords: COVID-19, stunting, nutrition, interventions, children, First published online June 19, 2020; doi: https://doi.org/10.1093/ajcn/
women nqaa171.

Am J Clin Nutr 2020;112:251–256. Printed in USA. Copyright © The Author(s) on behalf of the American Society for Nutrition 2020. This is an Open Access
article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted
reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 251
252 Akseer et al.

suggests that the prevalence of wasting could increase by 10–50% for women, is a challenge in many LMICs struggling
with an excess of ∼40,000–2,000,000 child deaths (4). with COVID-19 as funds are diverted to immediate needs
We believe that these projected nutrition effects of the global compounded by limited mobility and access to services.
pandemic could well be underestimates, as they fail to take into • Limited care and restricted health services
account the potential effect on maternal nutrition, micronutrient ◦ Given overburdened health systems, restricted travel, and
deficiencies, and intrauterine growth as well as downstream changing priorities at the primary care level, access
impacts on maternal and child health programs that can impact to routine health services for women and children has
linear growth and childhood stunting. This is unfortunate since suffered tremendously. While quality of care was an
the world has made some, albeit slow, progress in reducing ongoing challenge prior to COVID-19 (14), in its current
childhood stunting over the last decade. Current estimates state and onward for years targeted efforts for high-
indicate that 149 million children under 5 y are stunted, a quality health care for those in the most need will likely
reduction from 166 million in 2012 but still far from the required take a backseat. Consequently, the health and risk of
global targets for progress (5). COVID-19 now threatens to halt undernutrition in mothers and their children may increase
or reverse gains even further. If unaddressed, the effects on linear dramatically, especially if current conditions persist long
growth in children and consequent stunting could be much more term. In Pakistan, available data from district health

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consequential than short-term effects of undernutrition. systems indicate a dramatic drop in access for and
provision of antenatal care services (ZA Bhutta, personal
communication, 2020), and others have highlighted the
Risk Factors for Undernutrition in the Context of importance of the unmet need for mental health services
COVID-19 and interventions (15). As has been indicated by United
Sectors critical to reducing childhood undernutrition at Nations Population Fund (UNFPA) (15), reduced access
particular risk of collapse or reduced efficiency due to widespread to family-planning services and enforced confinement of
impact of COVID-19 are summarized below and in Figure 1. families is projected to lead to 7 million unintended births
in some of the poorest countries of the world. Persistent
• Food insecurity and poor-quality diets disruptions to routine and requisite maternal care and
◦ Building resilient food systems during COVID-19 requires nutrition could lead to adverse fetal outcomes including
innovative context-specific demand and supply-side initia- preterm birth, low birth weight, and small-for-gestational-
tives. Food supply chains (FSCs) are of particular interest, age newborns.
since 80% of all foods consumed in Africa and Asia • Interrupted education for children and adults
are now dependent on these markets (6). Despite being ◦ Educational facilities, including primary, secondary, post-
nominally “exempt” from lockdowns, COVID can have secondary, and specialized training institutions, have been
direct and indirect impacts on FSC function in LMICs, shuttered almost completely worldwide in the wake of
especially the informal sectors. While direct impacts, COVID-19 (16, 17). One of the major effects of COVID-
through closures of restaurants and restrictions on vendors, 19 has been on exacerbating inequities in education.
represent a small share of the total food economy in urban Much has been made of alternative forms of learning,
settings, the impact on rural markets could be much greater such as online classrooms, web-based courses, and home-
Additionally, indirect impacts due to unemployment and schooling, but these are inaccessible to most children
falling incomes of daily wage laborers and industry in LMICs. Women and girls, who often experience
workers have taken a heavy toll on people in LMIC the highest rates of illiteracy and school drop-outs in
settings (7). Further compounding this is the issue of LMICs, are yet further debilitated and disadvantaged. The
food pricing. Restrictions on mechanisms for production benefits of general and specialized health and nutrition
and delivery may drive up cost, while fear of shortages education to improve maternal nutrition and reducing
could drive speculative hoarding (8). Loss of household intergenerational childhood stunting are indisputable,
income exposes vulnerable families to price spikes and having been shown consistently in stunting case studies
food shortages, while low agricultural productivity and (18–20). An additional setback has been the interruption
breaks in the food import–export system disrupt local food of school nutrition programs, the mainstay of addressing
markets and small businesses (9). food insecurity in some of the poorest sections of the
◦ Additionally, given limited access to fresh produce, chil- population.
dren and families may be more likely to resort to cheaper • Unhealthy household environment
and more accessible processed and prepackaged, high- ◦ Given diverted funds and priorities, building safe and
sodium, and less-nutritious foods (10), with deleterious healthy household and community environments, partic-
health consequences. ularly as related to clean water, appropriate sanitation, and
• Reduced income and limited financial resources hygiene (WASH), may fall behind on country agendas.
◦ COVID-19 has pushed millions of households into eco- Yet now more than ever, WASH interventions are essential
nomic despair and has been described as more lethal than to protecting human health and preventing undernutrition
the 2008 global financial crisis (11). Oxfam predicts that (21). For instance, in urban slums (some of the most
half a billion people could be pushed into poverty (12), vulnerable communities), lockdowns and limited mobility
while the World Bank contends that an additional 40–60 have impacted access to clean water and safe sanitation
million people could be pushed into extreme poverty (13). services. Given the nature of COVID-19 transmission, this
The interruption of existing social safety nets, especially could result in lethal outbreaks of infectious diseases.
 COVID-19 and nutrition response 253

BASIC RISK DRIVERS UNDERLYING RISK DRIVERS IMMEDIATE RISK DRIVERS

COMPROMISED MATERNAL & CHILD NUTRITION

DEPRIORITIZED CONTEXT & REDUCED INCOME & LIMITED POOR FEEDING PRACTICES & FOOD
STUNTING
COMPROMISED ENABLERS RESOURCES INSECURITY POOR DIETARY INTAKE
• Policy diversion to urgent • Increased poverty and • Limited or interrupted food supply
care reduced spending power chain, driving food insecurity

• Reduced social sector • Limited / interrupted • Interrupted school & community

spending or diversion to nutrition programming /
social safety nets
counseling WASTING
COVID response
• Interrupted / discontinued
• Increased inequity education LIMITED CARE & RESTRICTED
HEALTH SERVICES
HIGHER DISEASE
• Reduced care seeking INCIDENCE WITH UNDERWEIGHT
LONGER DURATIONS
• Limited access to modern
contraceptives and family
planning – driving high-risk
pregnancies

SMALL FOR GESTATIONAL AGE

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• Reduced coverage of antenatal
care services

• Limited service and supplies for

regular maternal and childcare
HIGHER RISK OF
delivery e.g. immunizations
INTERGENERATIONAL
TRANSFER
MATERNAL & CHILD
(COMPROMISED MATERNAL MICRONUTRIENT DEFICIENCIES
UNHEALTHY HOUSEHOLD HEALTH)

ENVIRONMENT
• Limited access / proximity to
available services (e.g., clean
water, safe sanitation)

FIGURE 1 COVID-19 direct effects on basic, underlying, and immediate drivers of acute and chronic malnutrition. COVID-19, coronavirus disease 2019.

We believe that countries can address these extraordinary nu- • Food insecurity interventions
trition risks across the continuum of mothers, newborns, children, ◦ Given the diversity of food environment and security
and adolescents by addressing determinants and implementing challenges experienced by LMICs during COVID-19,
evidence-informed strategies for action. solutions must be context specific. Lessons from many
This narrative is aimed at reviewing key areas of concern for stunting-reduction exemplar countries could be useful.
supporting maternal and child nutrition progress during and in the In the Kyrgyz Republic, for instance, the unprecedented
aftermath of COVID-19, while providing strategic guidance for economic collapse after the dissolution of the Soviet
countries to continue making headway in reducing maternal and Union created new opportunities for mobilizing the
child undernutrition while battling COVID-19. As our research agricultural sector to drive economic recovery. A range
into stunting reduction exemplars has demonstrated, stunting of radical agrarian reforms focused on revitalizing in-
progress in LMICs has been driven by a multifactorial set of stitutions for land, livestock, capital, and labor, while
investments in sectors that have direct and indirect impacts on concurrently, shifting land ownership from the state
nutrition (Figure 2), most of which are extremely relevant in the to private households was considered among the most
current COVID-19 crisis and must be continued. pivotal driving factors of stunting reduction in Kyrgyz
Republic between 1990 and 2014 (23). While agrarian
land reforms focused on shifting land ownership and
Way Forward adopting innovative/efficient agricultural practices may
Our exemplars underscore multiple examples of high-impact yield dividends on undernutrition in the long term,
strategies both within and outside a country’s traditional health immediate solutions also have value. One of Ethiopia’s
system. These examples were data-driven and enabled by strong, solutions to food insecurity (i.e., the Productive Safety
focused country leadership, efficient financing, and effective Net Program) was aimed at providing emergency food
partnerships (22). We believe that the same approach is needed aid to 15 million individuals vulnerable to food insecurity
within LMICs to address the nutritional consequences of COVID- and was considered important to the country’s stunting-
19 mitigation strategies. reduction narrative (18). Such long- and short-term solu-
The state of the world and our collective response to COVID- tions addressing both supply and demand-side challenges
19 is continually evolving as new information is received. could be considered for nutrition protection in COVID-
Nevertheless, initial observations across different countries and 19–affected countries.
contexts, along with key lessons from countries managing • Social protection programs
through other crises in the past, suggest that we prioritize ◦ The prioritization of efforts to provide economic security
the following approaches to address and prevent exacerbating by governments to their at-risk populations (e.g., through
maternal and child undernutrition: innovative and targeted social safety net programs,
254 Akseer et al.

Political will 1 STAKEHOLDER CONSULTATION / BUY-IN

FOCUSED INVESTMENTS IN MNCH SERVICES
Political will 2 ROBUST SITUATIONAL ANALYSIS THROUGH EXISTING HEALTH SYSTEMS AND
EXTENSION SERVICES
Non-health
3 ADDRESS FOOD INSECURITY – ESPECIALLY FOR MARGINALIZED POPULATIONS
sector

Non-health
4 INVEST IN EDUCATION, ESPECIALLY FOR GIRLS
sector

Non-health 5 ADDRESS GENDER DISPARITIES AND EMPOWER WOMEN

sector
LEVERAGING COMMUNITY-BASED SYSTEMS TO
Non-health PROVIDE SERVICES AND MANAGE HEALTH AND
6 IMPROVE LIVING CONDITIONS, ESP. WASH
sector NUTRITION OUTREACH

Indirect,
health sector 7 ACCESS TO FAMILY PLANNING

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Direct, health
8 ACCESS TO MATERNAL AND NEWBORN HEALTH CARE
sector

Direct, health
9 PROMOTION OF EARLY AND EXCLUSIVE BREASTFEEDING
sector PROVIDING TARGETED PROGRAMATIC SUPPORT
TO ENSURE THE MOST VULNERABLE ARE
Direct, health 10 IMPROVING COMPLEMENTARY FEEDING AND DIETARY DIVERSIFICATION PROTECTED
sector

FIGURE 2 Investments to prioritize both within and beyond the health sector to mitigate COVID-19 consequences on nutrition. COVID-19, coronavirus
disease 2019; MNCH, maternal and child health. Adapted from reference 22 with permission.

payment deferrals, or tax breaks) is essential to prevent- community health volunteers (FCHVs) (19) showcase suc-
ing financial collapse of vulnerable households. Social- cessful models of mobilizing community health workers
protection programs are increasingly taking center stage (CHWs; who receive basic training and commodities)
in policy dialogues for tackling poverty, vulnerability, and to deliver vaccines, nutritional supplements, health and
social exclusion. Several exemplar countries, notably Peru nutrition education, and even reproductive, maternal,
(20) and the Kyrgyz Republic (23), employed successful and newborn care. The current recommendations are
financial-incentive based models as a means for providing to remunerate such CHWs rather than rely on pure
social safety nets for reaching marginalized and vulnerable volunteerism. Amidst the COVID-19 crises, while the
populations. In Peru, for instance, the Juntos conditional primary health care system may not be fully functional
cash transfer program provided households with a fixed and supplies short, governments could consider calling
monthly cash transfer (∼$30 USD) to comply with basic on existing CHW cadres to reprioritize their tasks and
education, health, and nutrition services for children. cater to emerging maternal, child health, and nutrition
This was paired with strong data-management systems screening in communities. These CHWs are also key to re-
that allowed for identification of vulnerable populations establishing programs for community-based management
and effective targeting to ensure that resources were of malnutrition. Governments could also invest in deploy-
disbursed effectively. The Kyrgyz Republic’s Monthly ing additional health workers and incentivizing current
Benefit for Poor Families with Children Program is an workers to continue delivering high-quality essential
analogous essential social-protection scheme that was interventions to families (e.g., vaccines, antenatal care,
found to be notably important to stunting reduction in referrals) and provide essential communication related to
the country. In today’s COVID-19 environment, such COVID-19 preparedness and triage. Where community
systems in Peru, Kyrgyz Republic, and many other health extension programs currently do not exist, countries
countries can be leveraged to build on and enhance social may want to consider piloting or adopting such a program
and economic protection for vulnerable families, and to supplement primary health care, as a short- or long-term
consequently prevent ill health and chronic undernutrition solution.
in children. • Educational programs
• Access to health care ◦ In the wake of closed formal education systems, countries
◦ As has been shown in several stunting-reduction exemplar could mobilize informal institutions such as CHWs
countries, access to health care for even the most and women’s and community support groups to de-
remote and hard-to-reach populations can happen with an liver health and general education. These systems are
effective community health extension system. Ethiopia’s already in place in many LMICs and could be revital-
health extension workers (HEWs) (18) and Nepal’s female ized and repurposed for continuing education. Several
 COVID-19 and nutrition response 255
stunting-reduction exemplar countries have shown the also overall protection of global health and improvements in
potential utility and impact of these mechanisms on undernutrition.
stunting reduction. Having learned from their experience
with Ebola, Senegal’s CHW program (24) has proven We thank Drs. Oliver Rothschild and Niranjan Bose from Gates Ventures
to be an effective mechanism for communicating health for funding support and overall technical/research support this perspective.
best practices to the community. Nepal’s FCHV (19) The authors’ responsibilities were as follows—NA, GK, and ZAB:
conceived the perspective outline; NA and GK: conducted research and
and Ethiopia’s HEW (18) programs have also had highly
prepared the first draft of the manuscript; ZAB and ECK: provided critical
successful health and nutrition counseling components. review and feedback; ZAB: is overall guarantor of the content; and all authors:
The Kyrgyz Republic used women’s support groups in read and approved the final manuscript. The authors report no conflicts of
communities as a means to keep updated on the evolving interest.
health situation and share knowledge (23), a model that
could continue to be expanded upon.
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