Drushti Shirsekar

M2024BEDMED009
PHECB14 - Social Epidemiology of Nutrition

NUTRITIONAL STATUS OF PREGNANT

AND LACTATING WOMEN IN INDIA

Introduction
Maintaining a balanced diet is crucial for pregnant and lactating women as it affects their
physiological, psychological and behavioural health. Poor maternal nutrition can lead to serious
issues like maternal morbidities, underweight babies, and preterm deliveries. It can also make the
child vulnerable to cardiometabolic diseases later in life. The nutritional status of pregnant
women and breastfeeding mothers in India is characterized by undernutrition. Anemia due to
iron and folate deficiency is the most common cause of nutritional deficiencies among pregnant
women. It is estimated that about 19% of maternal deaths in India occur due to anemia. More
than half of pregnant women (52%) were found to have anemia, according to the National
Family Health Survey (NFHS-5) conducted in 2019-21. This number increased by 2 percent
from 50% in 2015-16.

Factors causing poor maternal nutrition

● Poverty
Women living below the poverty line often find it difficult to consume nutritious food during
pregnancy and after childbirth because of the inadequate resources available to them. Most of
them are daily wage earners and have to work even during their pregnancy to support their
families and feed themselves. Therefore, they spend more energy but do not have access to
enough good quality food.

● Caste-based discrimination
Caste continues to play a major role in rural areas of India, where those belonging to the lower
castes remain marginalized. It is often observed that caste and class are intertwined, which means
that those from the lower caste face extreme poverty. Therefore, pregnant and breastfeeding
women from lower castes are unable to meet their daily nutritional needs.

● Early and multiple pregnancies

In India, many girls, mostly in rural areas, get married at an early age, leading to early
pregnancies. It is found that women who get pregnant during adolescence tend to suffer more
from undernutrition as compared to adult women (Marshall et al., 2022). Also, women who have
undergone multiple pregnancies require more nutrition to compensate for the cumulative
depletion of nutrients from previous pregnancies. Thus, both early and multiple pregnancies can
make it difficult for women to achieve their recommended daily nutritional intake.

● Gender inequality
In most Indian households, it is a customary practice for women to eat after everyone else in the
family has eaten. Hence, they usually end up eating leftover food, which might not be sufficient
for their energy needs. Lactating women usually bear the brunt of it as they are expected to
resume their daily chores, which were not expected of them during the later stages of pregnancy.

● Influence of sociocultural factors

Every society has traditional beliefs about what kinds of foods must be consumed by pregnant
and lactating women. In India, a clear distinction is made between 'hot' and 'cold' foods. 'Hot'
foods are believed to be unsafe during pregnancy and 'cold' foods are considered favourable.
Most people in India believe that animal products like fish, meat, or eggs are 'hot' foods, whereas
milk, yogurt, and buttermilk are seen as 'cold' products in some communities. There is no
consensus regarding the hotness or coldness of foods. For instance, vegetables, including radish,
eggplant, and bottle gourd, are considered 'cold' in Tamil Nadu but 'hot' in Andhra Pradesh.
Sometimes, perceptions about the same food items might vary even within the same state or
community.
Also, in some states like Uttar Pradesh and Karnataka, pregnant women are advised to consume
less food because of various beliefs like overeating will result in obese babies. Therefore, these
beliefs are not backed by biomedical science, which also leads to poor nutritional status among
pregnant and lactating women in India.

Importance of nutrition for pregnant and lactating women

A study conducted by Marshall et al. (2022) in the United States claimed that body size,
nutritional status, and dietary practices of women before and during pregnancy are crucial factors
in determining the health of the fetus. Both undernutrition and overnutrition, as well as weight,
can cause difficulties related to both maternal and paternal fertility, conception, development of
the placenta, embryo, and fetus, fetal size, and perinatal complications, resulting in suboptimal
pregnancy outcomes for both the mother and the infant (Marshall et al., 2022). Thus, pregnant
women need to eat nutritious meals in order to ensure the proper health and weight of the
newborn baby. Women who report 'health-conscious' eating patterns before and during
pregnancy tend to experience fewer complications during pregnancy and adverse child health
outcomes (Marshall et al., 2022). Moreover, adequate nutritional supplementation (protein and
micronutrients) among pregnant women has been linked to improved birth rates and reduced low
birth weights (Marshall et al., 2022).
Malnutrition during the early stages of pregnancy is further aggravated by ignoring
supplementation to meet the nutritional needs of pregnant women. This leads to weight loss
during the pregnancy and increases rates of low birth weight. The fetus requires ready-made
nutrients for rapid growth, including blood production, bone formation, brain formation, and
building muscles, as well as other tissues.

Additionally, breastfeeding mothers are also vulnerable to nutritional deficiencies since it is

observed that after delivery, the focus of nutrition shifts from the mother to the child. Many
studies have found a strong link between the dietary intake of fatty acids during pregnancy and
breastfeeding and the fatty acid composition in human milk (Carretero-Krug et al., 2024). During
pregnancy and lactation, tissue fatty acid levels depend on the mother's diet, the body's capacity
to store it, and their metabolic use. Therefore, the transfer of these nutrients to the baby, first
through the placenta and then through breastfeeding, determines the availability of long-chain
fatty acids in the newborn. Hence, it is critical for the mother to meet the nutritional requirements
during pregnancy and lactation since it determines the baby's health.

Current nutritional status of pregnant and lactating women

The National Nutrition Monitoring Bureau (NNMB) conducted surveys in 10 Indian states to
study the diet patterns of the Indian population. It revealed that millet and cereals form a major
portion of the rural diets, but only half of the pregnant population consumes adequate protein and
energy. Moreover, NNMB disclosed that pregnant women's intake of essential nutrients like
vitamin A, vitamin C, folic acid, and iron was below 50% of the recommended levels. In
addition, the median energy intake among pregnant women was found to be 1736 kcal instead of
the recommended 2010 kcal. The median protein intake for sedentary pregnant women was 45g
as compared to the estimated average requirement of 54g (NFHS-5). Nutritional deficiencies
were also observed in lactating women, including inadequate consumption of vitamins like
vitamin B12, vitamin A, vitamin D, and folic acid, as well as minerals like iron, calcium, and
iodine and polyunsaturated omega-3 fatty acid deficiencies like eicosapentaenoic acid and
docosahexaenoic acid.

According to a study, 30% of breastfeeding mothers do not even meet half the recommended
daily energy requirement (Sharma et al., 2021). Around 51% of pregnant women and 40% of
lactating women meet less than 50% of their daily recommended protein intake. The intake of
calcium, iron, and folic acid among the majority of the pregnant women (77%, 81%, and 96%,
respectively) was also found to be less than 50% of the recommended levels. This research also
found a higher intake of fat among both pregnant and lactating women, which was attributed to
the high prevalence of cereals in the Indian diet. It is necessary to note that high fat intake makes
pregnant women susceptible to preeclampsia and may also lead to congenital heart defects in the
newborn infant.
Additionally, educated women, working women, and those who were economically well off had
higher intakes of carbohydrates, fats, proteins, calcium, iron, and folic acid. However, women
from urban slums reported less intake of nutrients due to inadequate access to healthcare
resources. The study also states that women belonging to ST and SC communities suffer
disproportionately from anemia and CED as compared to their privileged counterparts. It is
observed that the incidence of malnutrition declines with a rise in socioeconomic status
(Navnatham & Jose, 2008). This study compared the nutritional status of women across all age
groups in India. Surprisingly, it was found that women of all age groups suffered from nutritional
deficiencies. Also, despite having high nutritional requirements, the nutrient intake of pregnant
and lactating mothers was similar to that of women who were not pregnant and lactating.

Government Interventions
The various programmes to ensure better nutrition for pregnant and lactating women in India
include –

1. National Health Mission (NHM) - It was launched in 2013 and also consists of sub-
missions, including the National Rural Health Mission (NRHM) and the National Urban
Health Mission (NUHM). It is included in the reproductive, maternal, newborn, child and
adolescent health (RMNCH+A). These programmes aim to provide quality healthcare
services to all citizens who access public health institutions.

2. Anemia Mukt Bharat (AMB) - It was launched in 2018 and is executed under the NHM
platform. It focuses on providing Oral Iron Folic Acid (IFA) supplementation to pregnant
women. IFA tablets, containing about 30 to 60 gms of iron and 0.4 mg of folic acid, are
 recommended to prevent iron deficiency anemia, preterm birth, low birth weight and
puerperal sepsis. According to guidelines, a woman should take at least 100 IFA tablets.
However, according to the NFHS-5, only about one-fourth of pregnant women availed
these services. Over the years, there has been a minimal increase in the percentage of
women consuming these tablets for 180 days or more, from 12% in 2005-06 to 14% in
2015-16 and later to 26% in 2019-21. Additionally, the number of pregnant women
consuming the IFA tablets for 100 days or more increased from 15% in 2005-06 to 30%
in 2015-16 and further increased to 44% in 2019-21. A rural-urban divide was also
noticed during this period. The percentage of women who took the IFA tablets for 100
days or more in urban areas was 54%, while in rural areas, it was 40%. It can thus be
inferred that the prevalence of iron deficiency anemia among pregnant women can be
attributed to the lower consumption of IFA tablets (Mehta et al., 2023).

3. Integrated Child Development Services (ICDS) - It is one of India’s flagship programmes

which aims to supplement protein and energy intake among pregnant and lactating
women. Under the ICDS, the Supplementary Nutrition Programme (SNP) is aimed at
providing pregnant women and lactating mothers a ration of about 600 kcal, including
18-20 gms of protein for Rs. 5 during the period of pregnancy and 6 months after
childbirth. The ICDS staff also offers health education and counselling services to these
women through Anganwadi centers (AWCs). It is found that frequent visits to these
centers have had a positive impact on the nutritional status of women and their offspring.
However, lack of awareness among communities, limited funding, inequitable use of
services and poor implementation of the programme makes the programme ineffective.

4. Pradhan Mantri Matru Vandana Yojana (PMMVY) - It was launched in 2017 to provide
cash transfers of Rs. 5000 to pregnant and lactating women as wage compensation to
enable them to rest and improve their nutritional status. The scheme saw an increase in
the registration of pregnancies, ANC visits, and institutional deliveries. However, it has
had little to no impact on the anemia status and weight of mothers (Jagannath &
Chakravarthy, 2025).
 5. POSHAN Abhiyaan - The National Nutrition Mission, POSHAN Abhiyaan, was
launched in 2017 and aims to improve maternal diets through community mobilization,
capacity building, behavioural change mechanisms and cross-sectoral interventions. The
existing strategies to combat maternal malnutrition include subsidized staples, free
rations, nutrition-sensitive agriculture, cash transfers to poor women, food fortification,
nutritional supplements, diet education, awareness-building and counselling. The
government had allocated Rs. 9046 crores for this programme. However, as per the 4th
report of Niti Aayog titled, Preserving Progress on Nutrition in India: Poshan Abhiyan in
Pandemic Times, published in 2021, the utilization of funds by states/union territories
was less than 50%. States like Nagaland (87%), Meghalaya (78%), and Sikkim (71%)
had the highest utilization of funds. In contrast, Odisha (8%), Arunachal Pradesh (9%)
and Tripura (16%) were among the states which utilized the least amount of funds. In
states like Odisha, Maharashtra, Kerala, Meghalaya, Tripura, and Jharkhand, Take-Home
Ration (THR) distribution to pregnant and lactating women was 100%. Meanwhile, the
delivery of THR to pregnant and lactating women was found to be the lowest in Jammu
and Kashmir, Bihar, and Sikkim. Thus, even though the government has allocated money
for the scheme, the failure of states and union territories to utilize the funds adequately
hinders the implementation of this programme, preventing numerous people from getting
its benefits.

All the above-mentioned interventions are aimed at helping pregnant and lactating women,
especially those from urban slums and rural areas, to achieve their nutritional needs. However,
various factors like logistical constraints, weak public health distribution systems, scarce
resources, and unequal access to food and health resources hinder the reach and impact of
Anganwadi services.

The government can enhance the implementation of these schemes by strengthening the public
distribution system and addressing institutional barriers that limit the impact of these schemes.
Furthermore, most of the rural population is unaware of the schemes or does not know how to
utilize them. Thus, the government must introduce campaigns to provide nutritional education to
families and increase community awareness regarding various schemes. The government should
also promote dietary diversification among the masses to enhance nutritional outcomes. The
Poshan Vatika (kitchen garden) scheme, which aims to achieve nutritional security by
encouraging people to grow their own fruits and vegetables, must be implemented properly.
Families with pregnant and lactating mothers should be encouraged to grow iron and vitamin-
rich crops to address their nutritional needs. Thus, the government must work in tandem with the
states, union territories, NGOs, and public health institutions to ensure that all its programmes
run smoothly and expand their reach to beneficiaries.
Conclusion
The nutritional status of pregnant and lactating women in India is marginal. They suffer from
several micronutrient deficiencies, which has an adverse effect on their own as well as their
child's health. Anemia is one of the biggest issues faced by these women. Its prevalence has only
increased over the years despite the implementation of several programmes to combat the
problem. If India wants to achieve its Sustainable Development Goal-3 (SDG 3) targets, it will
be necessary for the central government, states, union territories, NGOs, and several stakeholders
to work together. The center should ensure timely disbursement of funds, reduce paperwork, and
run awareness campaigns to inform the general public about the nutritional needs of pregnant
and lactating women. It should also invest in making health education a part of the education
ecosystem. The government must also encourage dietary diversity by promoting the kitchen
garden scheme. States and union territories must utilize the allocated funds prudently and ensure
policies are adequately implemented at the grassroots level. A comprehensive strategy will help
in alleviating issues related to pregnant and lactating women.
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