Special Feature

doi:10.1038/nindia.2018.51 Published online 30 April 2018

In search of a good start for our mothers and babies

Adverse birth outcomes still too common, with a legacy of growth issues that last a lifetime.

[Nature India Special Issue: Grand Challenges]

Maharaj Kishan Bhan, Shirshendu Mukherjee

A baby born in India today has twice the life expectancy of one born 70 years ago, but there is much still to be done to improve health measures.
© Dinodia Photos/Alamy
The Grand Challenges project aims to command the attention of world-class researchers and to focus funding and research on solutions to the biggest public health and development problems we face. Grand Challenges India has the same mandate on a domestic scale — directing Indian innovation to solve our specific challenges, which can be taken to the rest of the world.

A child born in India today has a life expectancy of 68 years, more than twice that of a child born in 1947. More mothers survive birth today than they did even a decade ago. These are markers of slow, yet steady progress in improving the lives of our mothers and children.

This is where the good news ends. The stillbirth rate and neonatal mortality are still high in India and other low and middle-income countries (LMICs). Around 20% of our babies come into the world with low birth weight as a result of prematurity, fetal growth restriction alone or in combination. A high proportion of Indian newborns experience wasting and become stunted by their second birthday. This increased risk of linear growth retardation occurs both in low birth weight and those weighing 2.5kg at birth, but the risk is many fold higher in the former category. We therefore have the challenge and the opportunity to improve both child survival rates and growth, and prevent this exceptionally high rate of stunting in Indian children.

There are gaps in our knowledge of what causes these adverse outcomes, as much as the unaddressed concern of relatively lower coverage and quality of current interventions. Research is important for both.

The factors associated with adverse birth outcomes, such as prematurity and low birth weight explains about a third to a half of the variation in these outcomes. These include under nutri­tion and specific nutrient deficiency, hypertensive and thyroid disorders, anemia, infections and inflammation particularly of the reproductive tract, complications related to pregnancy involving mother and fetus. Sanitation, hygiene, water supply increase risk of infection and inflammation. Psycho social factors may have direct and indi­rect effects on gestation and growth, but there are knowledge gaps. Many of these and other factors also affects placental function which is related to fetal growth and development.

On the implementation side, there is inequitable and inadequate interven­tion, and only low to moderate compli­ance by mothers and families.

How do we engage and initiate the research community, working alone, and through interdisciplinary teams to generate applicable knowledge, inno­vative tools for measuring gestation, fetal growth, pregnancy complications, placental function, postnatal growth and development? On the nutrition front, there is uncertainty about which are the most critical nutrients for mother and child. And how do we mea­sure and address sub-clinical infection and inflammation that impairs linear growth in the fetus and the child. On the basis of new knowledge we can improve existing measures and add new interventions.

Research is needed on how to improve intervention delivery to achieve high coverage and quality on a wide scale.

Investments in promoting research and innovation on these issues is a high priority, given the link between adverse birth outcome, stunting at two years of age and eventual education attainment, income, and health (partic­ularly risk of chronic diseases such as coronary artery disease and diabetes).

This is where the value of pro­grammes such as Grand Challenges India lies. It encourages innovation to address some of these challenges through two mechanisms, open calls for solutions and through the policy think tank KnIT.

The ‘Achieving Healthy Growth through Agriculture and Nutrition’ (AGN) and the ‘All Children Thriving’ (ACT) threw open the challenge to researchers from across the country. The AGN call targeted the interrela­tionship between nutrition and agri­cultural practices to reduce the high incidence of low birth weight, early stunting and wasting among Indian infants and mothers. The ACT call was envisaged to investigate measure­ment tools and mechanisms to tackle unhealthy birth, growth and develop­ment in infants and children.

“There are markers of slow, yet steady progress in improving the lives of our mothers and children."

The linear growth study, under the ACT grant, is being carried out by the Society for Applied Studies to understand the causes of stunting in India, and to develop mecha­nisms to address them. There are many possible explanations as to why stunting rates haven’t improved in India, despite significant socio-eco­nomic progress, and this study intends to investigate many.

Specifically the study evaluates the impact of a package of interventions targeted at known risk factors on prematurity, fetal growth restriction and stunting and wasting at two years of age. The study will assess the role of intergenerational factors, such as maternal height, play in modulating the effectiveness of intervention pack­ages. The study is designed as a ran­domized control intervention trial in low-income areas in New Delhi and will deliver the intervention package from pre-pregnancy, through pregnancy and the first two years of life.

It comprises of host of interventions addressing nutrition, medical disor­ders, infection and inflammation, psy­cho social support and timely detection and care of pregnancy complications. Postnatally, it provides evidence-based intervention for the mother and infant during the first two years. We will learn how much reduction in childhood stunting is feasible with evidence based intervention.

Another ACT project, implemented by THSTI in collaboration with Regional Centre for Biotechnology (RCB) and National Institute for Bio­medical Genomics (NIBMG) is creating and using a biobank generated from a large pregnancy cohort to find new ways of predicting, detecting and addressing premature birth. The study uses omics technologies and imaging in search of new tools and ideas.

Another programme working in nutrition and maternal and child health is the Knowledge Integration and Translation Platform or KnIT. This is a policy thinktank which collates, analyses and synthesize secondary data and evidence on child survival and thriving to inform policy-makers on various aspects of health policy that are relevant and targeted to the Indian context. It works to synthesize and disseminate Indian evidence derived from routine surveillance, periodic health and nutrition surveys, interven­tion trials and programme evaluation. The output is helpful in reshaping policy and strategies in maternal child health and in assisting state govern­ments in programme redesign and systems improvement. This platform is designed to ask the right questions and rigorously evaluate evidence supporting different interventions. It will provide state policy-makers with a holistic view of the challenge in their states with tailored interventions that may help mitigate the problems.

Today, KnIT is working on important questions in the area of nutrition and maternal and child health such as pos­sible interventions for low birth weight babies, interventions to reduce anemia rates, and understand the facility level demands and supply for the care of sick and small newborns at the district level in the country. KnIT is assessing equity and impact of existing nutritional and health programmes for women and children at national and state level.

The agri-nutrition linkage pro­gramme supports innovative ideas in agriculture and food sector that could improve the nutrition of the very same communities that produce food.

Many interesting projects are testing innovation to reduce postharvest losses, preserve nutrition quality of seasonal vegetables and fruits, and reengineer distribution to ensure access to sustenance for the poorest communities.

Grand Challenges for healthy growth and birth is identifying a new genera­tion of young investigators and pro­viding an opportunity to support and nurture them. The programme, it is hoped will gen­erate as many solutions and tools as there are insightful and creative young researchers.

Maharaj Kishan Bhan is National Science Professor, Indian Institute of Technology, Delhi, and the Former Secretary, Department of Biotechnology. Shirshendu Mukherjee is mission director, Grand Chal­lenges India, BIRAC, New Delhi.