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Objective To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. Methods We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. Findings Only 15% of 231 113 mother-child pairs received all eight health interventions (weighted percentage). The percentage of mother-child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. Conclusion Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms. Objectif Examen des inegalites et des ecarts de perspectives dans la couverture commune des interventions en matiere de sante et de nutrition dans sept pays. Methodes Nous avons utilise les donnees des enquetes demographiques et sanitaires les plus recentes (2015-2018) aupres de meres ayant des enfants de moins de 5 ans en Afghanistan (n = 19 632), au Bangladesh (n = 5051), en Inde (n = 184 641), aux Maldives (n = 2368), au Nepal (n = 3998), au Pakistan (n = 8285) et au Sri Lanka (n = 7138). Nous avons estime la couverture commune pour un ensemble de huit interventions dans le domaine de la sante et huit autres liees a la nutrition et nous avons evalue les inegalites au sein des pays en matiere de couverture commune en fonction de la richesse et de la geographie. Nous avons examine les ecarts de perspectives en comparant la couverture des interventions en matiere de nutrition avec celle des plateformes de prestation de soins correspondantes. Resultats Seuls 15 % des 231 113 couples mere-enfant ont beneficie des huit interventions sanitaires (pourcentage pondere). Le taux de couples mere-enfant n'ayant beneficie d'aucune intervention en matiere de nutrition etait le plus eleve au Pakistan (25 %). Les ecarts de richesse (les plus riches par rapport aux plus pauvres) pour la couverture commune des interventions sanitaires etaient les plus importants au Pakistan (indice de pente des inegalites : 62 points de pourcentage) et en Afghanistan (38 points de pourcentage). Les ecarts de richesse pour la couverture commune des interventions en nutrition etaient les plus eleves en Inde (32 points de pourcentage) et au Bangladesh (20 points de pourcentage). La couverture des interventions en matiere de nutrition etait plus faible que celle des interventions sanitaires associees, avec des ecarts de perspectives s'etalant de 4 a 54 points de pourcentage. Conclusion La couverture commune des interventions en matiere de sante et de nutrition est loin d'etre optimale et affecte de maniere disproportionnee les menages pauvres d'Asie du Sud. Les efforts en matiere de politique et de programmation devraient viser a combler les ecarts en matiere de couverture, dequite et de perspective et a ameliorer la fourniture d'interventions de nutrition au travers de soins de sante et d'autres plateformes de prestation. Objetivo Analizar las desigualdades y la falta de oportunidades en la cobertura conjunta de las intervenciones sanitarias y de nutricion en siete paises. Metodos Se utilizaron los datos de las encuestas demograficas y sanitarias mas recientes (entre 2015 y 2018) de madres con hijos menores de 5 anos en Afganistan (n= 19 632), Bangladesh (n= 5051), India (n= 184 641), Maldivas (n= 2368), Nepal (n= 3998), Pakistan (n= 8285) y Sri Lanka (n= 7138). Se calculo la cobertura conjunta de un grupo de ocho intervenciones sanitarias y ocho de nutricion y se evaluaron las desigualdades en la cobertura conjunta dentro del pais segun la riqueza y la geografia. Se analizaron las diferencias de oportunidad al comparar la cobertura de las intervenciones de nutricion con la cobertura de sus correspondientes plataformas de prestacion de servicios sanitarios. Resultados Solo el 15 % de 231 113 parejas madre e hijo recibieron las ocho intervenciones sanitarias (porcentaje ponderado). El porcentaje de parejas madre e hijo que no recibieron ninguna intervencion de nutricion fue mayor en Pakistan (25 %). Las diferencias de riqueza (los mas ricos frente a los mas pobres) para la cobertura conjunta de las intervenciones sanitarias fueron mayores en Pakistan (indice de desigualdad de la pendiente: 62 puntos porcentuales) y en Afganistan (38 puntos porcentuales). Las diferencias de riqueza para la cobertura conjunta de las intervenciones de nutricion fueron mayores en India (32 puntos porcentuales) y en Bangladesh (20 puntos porcentuales). La cobertura de las intervenciones de nutricion fue menor que la de las intervenciones sanitarias asociadas, con diferencias de oportunidad que iban de 4 a 54 puntos porcentuales. Conclusion La cobertura conjunta de las intervenciones sanitarias y de nutricion esta lejos de ser optima y afecta de manera desproporcionada a los hogares pobres de Asia Meridional. Los esfuerzos en materia de politica y programacion deben prestar atencion a la reduccion de las diferencias de cobertura, equidad y oportunidad, y a la mejora de la prestacion de servicios de nutricion a traves de la atencion sanitaria y demas plataformas de prestacion. [phrase omitted], Introduction Universal health coverage (UHC) is fundamental to achieving the sustainable development goals (SDGs), reducing inequalities and ensuring that no one is left behind. (1) Timely delivery of a complete [...]

Poor diet quality (diet diversity and animal‐source food [ASF] consumption) during childhood negatively affects growth, development, behaviour and physiologic function in later life. Relatively less is known about the impact of poor diet on the growth of school‐age children compared to children <5 years of age, especially in low/middle‐income countries. A better understanding of delivery strategies for effective interventions to improve diet and hence growth in school‐age children is needed. A 36‐month longitudinal controlled impact evaluation in rural Nepal assessed the nutrition and growth of children <5 years of age in families assigned via community clusters to full package intervention (community development, training in nutrition [during pregnancy and for children <5 years] and livestock husbandry), partial package (training only) or control (no inputs). Concurrent data were collected prospectively (baseline plus additional four rounds) on school‐age children (5–8 years at baseline) in these households; the present study analysed findings in the cohort of school‐age children seen at all five study visits (n = 341). Diet quality improved more in the full package school‐age children compared to those in partial package or control households. full package children consumed more ASF (β +0.40 [CI 0.07,0.73], p < 0.05), more diverse diets (β +0.93 [CI 0.55,1.31], p < 0.001) and had better head circumference z‐scores (β +0.21 [CI 0.07,0.35], p < 0.01) than control children. In conclusion, a multi‐sectoral community development intervention was associated with improvements in diet and growth of school‐age children in rural Nepal even though the intervention focused on the diet of children <5 years of age. The diet and growth of school‐age children can be favourably influenced by community‐level interventions, even indirectly. Key messages: Relatively less is known about the factors that influence diet quality and growth in school‐age children compared to younger children, especially in low‐ and middle‐income countries.Better diet quality and growth were found among school‐age children whose families participated in an impact study multi‐sectoral intervention compared to children in control families or those whose families only received nutrition training.Diet and growth of school‐age children can be favourably influenced by community‐level interventions. [ABSTRACT FROM AUTHOR]

Progress to improve nutrition among women, infants and children in South Asia has fallen behind the pace needed to meet established global targets. Renewed political commitment and monitoring of nutrition interventions are required to improve coverage and quality of care. Our study aimed to assess the availability of national nutrition policies, programmes, and coverage data of nutrition interventions for women, children, and adolescents in eight countries in South Asia. We reviewed relevant policy and programme documents, examined questionnaires used in the most recent rounds of 20 nationally representative surveys, and generated an evidence gap map on the availability of policies, programmes, and survey data to track progress on coverage of globally recommended nutrition interventions. Current policies and programmes in South Asian countries addressed almost all the recommended nutrition interventions targeted at women, children, and adolescents. There was a strong policy focus in all countries, except Maldives, on health system platforms such as antenatal and postnatal care and child growth and development. Survey data on nutrition intervention coverage was most available in India and Nepal, while Bangladesh and Bhutan had the least. Though countries in South Asia have committed to national nutrition policies and strategies, national surveys had substantial data gaps, precluding progress tracking of nutrition intervention coverage. Greater attention and effort are needed for multisectoral collaboration to promote and strengthen nutrition data systems. Key messages: Most South Asian countries had several policies and programmes in place which considered or addressed nutrition interventions across the life course.Nationally representative surveys provide coverage data for evidence‐based recommendations to improve policy and programme actions.Significant coverage data gaps remain in nationally representative surveys around counselling during pregnancy, interventions targeted for newborns, infant, and young child feeding, and counselling on and identification and treatment of severe and moderate acute malnutrition.Mobilising political commitment and increasing multisectoral collaboration are required for an enabling environment in support of nutrition data systems in South Asia. [ABSTRACT FROM AUTHOR]

Background: Children, especially disadvantaged children in poor countries, were expected to be among the "biggest victims" of the Covid pandemic. Economic burdens, decreased nutritious foods, reduced medical care, school closures, and ill‐health or death of family members were predicted to increase child undernutrition and developmental delays, and diminish home child‐rearing quality. Methods: A planned nutrition intervention could not be implemented due to Covid restrictions. However, three surveys (pre‐Covid [December 2019], July 2021, and September 2021) in 280 Nepali households (309 parent‐dyads, 368 children, 6–66 months old) collected demographics, child anthropometry and development (Ages and Stages Questionnaire‐3 [ASQ‐3]), and home child‐rearing quality (caregiver engagement, learning resources, adult supervision [UNICEF's Multiple Indicator Cluster Survey]). Mixed‐effect regression models adjusted for household (wealth, maternal education) and child factors (age, gender) and survey round. Results: Height, mid‐upper‐arm circumference, and head circumference measurements improved over time. The total ASQ‐3 score did not change: Communication scores increased while fine motor and personal‐social scores declined. Girls' growth and development worsened more than boys. Caregiver engagement (especially mothers') generally declined, but learning resource availability increased. More children were left unsupervised at Round 2 than Round 1 or 3. Conclusions: In this sample, some aspects of child growth, development, and home child‐rearing quality improved while others declined. Better understanding of these changes in child well‐being and the family environment during the pandemic could provide insight on how to protect children during future crises. [ABSTRACT FROM AUTHOR]

The economic and health crises related to the COVID-19 pandemic raised considerable concern about child and family diet, especially among small-holder farming households in low- and middle-income countries (LMIC). In rural Nepal, 309 families (including 368 children aged 6–66 months) were enrolled pre-COVID-19 in a prospective study of a nutrition education intervention and family milk consumption. The intervention could not be implemented due to COVID-19; however, child and family diet was assessed in three household surveys (one before and two during the pandemic). Over time, after adjusting for child and household factors, child and family diet quality declined (reduced diet diversity, consumption of milk and animal-source-foods (ASF)). However, in dairy-animal-owning (vs. non-dairy-animal-owning) households, both children and family were more likely to consume milk (aOR respectively 2.88× (p < 0.05), 5.81× (p < 0.001)). Similarly, in households producing >3.5 L/d milk (vs. ≤3.5 L/d), children and family members were more likely to consume milk (respectively 7.45× and 11.88× (both p < 0.001)). Thus, the overall decline in child and family diet quality, especially related to milk consumption, was buffered independently by household ownership of ≥1 dairy animals (cow or buffalo) and by milk production >3.5 L/day. A better understanding of these protective factors might facilitate the development of interventions to promote resilience in future crises. [ABSTRACT FROM AUTHOR]

Maternal depression has been associated with adverse child growth and development; less is known about its relation to children's diet. In a cross‐sectional study embedded at endline of a longitudinal community development intervention, mothers of 629 children (age 23–66 months) in rural Nepal responded to household and children's diet questionnaires and were screened for depression. Child anthropometry and development (Ages and Stages Questionnaire) were assessed. Regression models examined children's diet, growth and development, adjusting for household, child and maternal characteristics. The prevalence of maternal depression was 21%. Maternal depression was associated with 11% lower likelihood that the child consumed one additional food group [Poisson regression, adjusted relative risk (aRR) 0.89, 95% confidence intervals (95% CI 0.81, 0.99), p = 0.024] and 13% lower likelihood that the child consumed one additional animal source food (ASF) [aRR 0.87, (95% CI 0.76, 1.01), p = 0.061] compared with children of nondepressed mothers. However, maternal depression was not associated with either child anthropometry or development: these outcomes were strongly associated with better home child‐rearing quality. Stunting also related to child age and intervention group; child development related to mother's education and household wealth. This study suggests a correlation between maternal depression and child dietary diversity. This association could be due to unmeasured confounders, and therefore, further research is warranted. Understanding the relationship of depression to child outcomes—and the role of other potentially compensatory household factors—could help address some of the earliest, modifiable influences in a child's life and contribute to innovative approaches to improve child well‐being. [ABSTRACT FROM AUTHOR]

Early marriage (EM) and early childbearing (ECB) have far‐reaching consequences. This study describes the prevalence, trends, inequalities, and drivers of EM and ECB in South Asia using eight rounds of Demographic and Health Survey data across 13 years. We report the percentage of ever‐married women aged 20–24 years (n = 105,150) married before 18 years (EM) and with a live birth before 20 years (ECB). Relative trends were examined using average annual rate of reduction (AARR). Inequalities were examined by geography, marital household wealth, residence, and education. Sociodemographic drivers of changes for EM were assessed using regression decomposition analyses. We find that EM/ECB are still common in Bangladesh (69%/69%), Nepal (52%/51%), India (41%/39%), and Pakistan (37%/38%), with large subnational variation in most countries. EM has declined fastest in India (AARR of –3.8%/year), Pakistan (–2.8%/year), and Bangladesh (–1.5%/year), but EM elimination by 2030 will not occur at these rates. Equity analyses show that poor, uneducated women in rural areas are disproportionately burdened. Regression decomposition analysis shows that improvements in wealth and education explained 44% (India) to 96% (Nepal) of the actual EM reduction. Investments across multiple sectors are required to understand and address EM and ECB, which are pervasive social determinants of maternal and child wellbeing. [ABSTRACT FROM AUTHOR]

The "second 1000 days" is a period of rapid brain growth which consolidates developmental foundations and establishes school readiness. Understanding the relation between household characteristics, child diet, and child development remains incomplete, especially in resource-poor settings where >250 million children risk not achieving their full developmental potential. Child developmental performance was assessed (Ages & Stages Questionnaire [ASQ]) at ages 2 and 5 years in a cohort of Nepali children (n = 207) whose families participated in a nutrition/livestock management+community development intervention trial. Relationships between child developmental performance and mother's education, family wealth, child diet (animal source food [ASF] consumption, dietary diversity score [DDS]), school attendance, and intervention group were examined by adjusted linear regressions. These relationships varied at the 2 ages. At age 2 years, ASQ scores related positively to "Full Package Intervention" and negatively to "Partial Package Intervention" membership. At age 5 years, intervention group did not relate to ASQ scores. Mother's education did not relate to developmental findings for 2-year-olds. Mother's education, wealth, and school attendance positively predicted ASQ scores for these same children as 5-year-olds. Animal source food consumption was related to child development more strongly at age 5 than at 2 years. DDS had a less pronounced relationship to development than ASF consumption at both ages. Over this time span bracketing the second 1000 days, household characteristics and child diet related differentially to developmental performance depending on child age. Better understanding of the timing and mechanisms of these relationships is needed to effectively design interventions targeting improved child development in resource-poor settings. [ABSTRACT FROM AUTHOR]

Child undernutrition afflicts >150 million children worldwide, contributing to poor child growth, increased risk of infections, and loss of developmental potential. Animal-source foods (ASF) can ameliorate these problems by providing high-quality, high-density, and bioavailable protein and micronutrients. However, many children in developing countries lack ASF in their diet, although generally milk is the ASF most often consumed. Nevertheless, the relation of ASF—and that of specific ASF—to child growth in these contexts has been difficult to define, as has the association between diet and child and household factors in influencing growth outcomes. To better understand these relationships, we evaluated child growth by age groups (6–23 mo, 24–60 mo, and >60 mo) in relation to ASF consumption in rural Nepal. We used an observational study design that leveraged a data set generated through a 3-yr longitudinal controlled impact evaluation of a communitydevelopment intervention. Child anthropometry and 24-h diet recall were obtained at 5 household visits. At baseline, children were generally undernourished: 47% were stunted, 46% underweight, 17% wasted, and 24% microcephalic. Patterns of undernutrition varied with age but improved somewhat over time. Over the 3-yr period of study (9,283 observations), ASF were consumed infrequently: milk in 28% of assessments, meat in 27%, and eggs in 15%. Consumption patterns differed by age group, with younger children (6–23 mo) consuming more milk and less meat than children 24 to 60 or >60 mo. Consumption of even a single ASF at any of the 5 surveys was associated with greater growth in bivariate analysis. After adjustment for household (group assignment, survey round and its interaction, wealth, income, livestock and land ownership, maternal education) and child factors (age, sex, baseline anthropometry), mixed-effect linear regression analysis showed that milk consumption related to higher height for age and weight for age z-scores for children >60 mo of age and to higher head circumference z-score for children age 24 to 60 mo. For children >60 mo, egg consumption also related to higher weight z-scores. Household and child factors also influenced these outcomes. Of the ASF, milk had the strongest and most consistent relationship to child growth. Better measures of diet intake could reveal stronger associations between diet consumption patterns and child growth. Regardless, milk may be a key ASF to target for growth promotion among undernourished rural Nepali children. [ABSTRACT FROM AUTHOR]

Developmental delays affect between 150 and 200 million children <5 years of age worldwide. Outside of diet supplement studies, relatively little is known about the relationships between diet quality and developmental status in resource‐poor settings. We examined associations between different aspects of dietary quality (dietary diversity score [DDS] and animal‐source food [ASF] consumption) and child development (assessed using the Ages and Stages Questionnaire‐3 [ASQ‐3]) among children whose families were enrolled in a community development intervention trial (implemented by Heifer Nepal) in western Nepal. Two sets of analyses were performed: (a) cross‐sectional Sample (N = 629) seen at the endline survey and (b) longitudinal sample (N = 269) with complete dietary records (six surveys over 48 months). In both samples, child development was significantly related to household wealth, maternal education, and especially home environmental quality. In the cross‐sectional sample, greater consumption of eggs (adjusted odds ratio [aOR] 0.80, p =.04) or dairy products (aOR 0.95, p =.05) over the previous 7 days significantly reduced odds of low total ASQ score, by logistic regression analysis. In the longitudinal sample, only egg consumption and cumulative DDS and ASF scores were associated with significantly reduced odds of low total ASQ score (aORs 0.59–0.89). In adjusted linear regression analysis, both cumulative DDS (β [CI]: 1.92 [0.4, 3.5]) and ASF scores (2.46 [0.3, 4.7]) were significantly associated with greater continuous total child development. Programmes targeting child development must address home environmental quality as well as long‐term diet quality. [ABSTRACT FROM AUTHOR]

Optimal child growth requires a combination of nutrition‐specific and sensitive interventions in the first 1,000 days. There is limited guidance on how to measure the population‐level coverage of nutrition‐sensitive social protection (NSSP), which is designed with explicit nutrition goals and often provides food or cash transfers and co‐coverage with nutrition and health intervention. In this study in India, we designed a questionnaire that captures seven core NSSP program elements (transfer type, size, modality, population, timing, provider, conditionalities), then used cognitive testing to refine the questionnaire, and then implemented the questions as part of a telephone survey. Cognitive testing indicated variability in understanding the terms used to specify NSSP programs, including the need to use regional program names. Respondents also had difficulty recalling the timing of the benefit receipt. We included the refined NSSP coverage questions in a phone‐based survey with 6,627 mothers with children <2 years across six states. Coverage of subsidized food was 73% across all households. Women were more likely to report receiving food than cash transfers during pregnancy (89% vs. 60%) and during lactation (75% vs. 13%). Co‐coverage of NSSP with nutrition and health interventions during pregnancy (16%) and early childhood (3%) was low. It was feasible to measure coverage of NSSP investments in these populations; however, further research is needed to comprehensively assess all the dimensions of the NSSP benefits, including benefit adequacy and the validity of these questions when administered in person and by phone. [ABSTRACT FROM AUTHOR]

Background: The 2015 earthquake in Nepal caused massive damages and triggered relief activities to minimize human suffering. The post-earthquake nutrition and food security situation in the hardest hit areas remains uncertain. Methods: Two national cross-sectional surveys were conducted in 2014 and 2016 among households (HH) with pre-school aged children or newly married women. Of the 21 village development committees (VDCs) included in this sample, 7 fell within “earthquake-affected” areas. This paper presents data from 982 HH, 1015 women, and 883 children from 2014 and 1056 HH, 1083 women, and 998 children from 2016 living in these areas, with longitudinal overlap of about 55%. Prevalence estimates and 95% confidence intervals were calculated, and logistic regression was used to calculate p-values, both using robust estimates of standard errors to account for clustering. Results: From 2014 to 2016, child wasting (weight-for-height z score <-2) fell from 4.5% (95% CI 3.3%– 6.1%) to 2.1% (1.4%– 3.1%) and food insecurity (assessed using the household food insecurity access scale) dropped from 17.6% (11.7%– 25.6%) to 12.4% (6.9%– 21.2%). Child stunting prevalence remained similar at both time-points. Improvements were also evident in dietary diversity and breastfeeding indicators. Conclusions: Nutrition and food security conditions remained comparable or improved one year after the earthquake despite evidence of structural and other damage. Livelihood resilience to shocks and/or effective nutrition, food or health interventions may have helped buffer the impact on nutrition, although this hypothesis requires further exploration. [ABSTRACT FROM AUTHOR]

Objective To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries. Methods We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms. Findings Only 15% of 231 113 mother--child pairs received all eight health interventions (weighted percentage). The percentage of mother--child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for cocoverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points. Conclusion Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms. [ABSTRACT FROM AUTHOR]

Antenatal care (ANC) is an opportunity to receive interventions that can prevent low birth weight (LBW). We sought to 1) estimate LBW prevalence and burden in South Asia, 2) describe the number of ANC visits (quantity) and interventions received (quality), and 3) explore associations between ANC quantity, quality and LBW. We used Demographic and Health Survey (DHS) data from Afghanistan (2015), Bangladesh (2018), India (2016), Nepal (2016), Pakistan (2018) and Sri Lanka (2016) (n = 146,284 children <5y). Women were categorized as follows: 1) low quantity (<4 ANC visits) and low quality (<5 of 10 interventions received during ANC), 2) low quantity and high quality (≥5 of 10 interventions), 3) high quantity (≥4 visits) and low quality, 4) high quantity and high quality. We used fixed effect logistic regressions to examine associations between ANC quality/quantity and LBW (<2500 grams). LBW prevalence was highest in Pakistan (23%) and India (18%), with India accounting for two-thirds of the regional burden. Only 8% of women in Afghanistan received high quantity and high quality ANC, compared to 42-46% in Bangladesh, India, and Pakistan, 65% in Nepal and 92% in Sri Lanka. Compared to the low quantity/quality reference group, children of women with high quantity/quality ANC had lower odds of LBW in India (Adjusted Odds Ratio 0.84, 95% CI 0.78-0.89), Nepal (0.57, 0.35-0.94), Pakistan (0.45, 0.23-0.86), and Sri Lanka (0.73, 0.57-0.92). Low quantity but high quality ANC was protective in India (0.90, 0.84-0.96), Afghanistan (0.53, 0.27-1.05) and Pakistan (0.49, 0.23-1.05). High quantity but low quality ANC was protective in Sri Lanka (0.76, 0.61-0.93). Neither frequent ANC without appropriate interventions nor infrequent ANC with appropriate interventions are sufficient to prevent LBW in most South Asian countries, though quality may be more important than quantity. Consistent measurement of interventions during ANC is needed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Neupane et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Adolescent pregnancy and child undernutrition are major social and public health concerns. We aimed to examine associations between adolescent pregnancy and child undernutrition in India, where one in five adolescents live, and one in three of the world's stunted children., Methods: Data were from India's fourth National Family Health Survey, 2015-16. Primiparous women aged 15-49 years who gave birth between 2010 and 2016 were classified on the basis of age at first birth: 10-19 years (adolescence), 20-24 years (young adulthood), and 25 years or older (adulthood). Primary outcomes were anthropometric measures of offspring undernutrition. Multivariable regression and structural equation models were used to understand the extent to which these measures were linked to adolescent pregnancy and the potential social, biological, and programmatic pathways., Findings: Of the 60 096 women in the sample, 14 107 (25%) first gave birth during adolescence. Children born to adolescent mothers had lower Z scores for length or height-for-age (mean difference -0·53 SD), weight-for-age (-0·40 SD), and weight-for-length or height (-0·16 SD) than children born to adult mothers. Compared with adult mothers, adolescent mothers were shorter (-1·21 cm, 95% CI -1·78 to -0·65), more likely to be underweight (18 percentage points, 15-21) and anaemic (8 percentage points, 6-11), less likely to access health services (-4 to -15 percentage points), and had poorer complementary feeding practices (-3 to -9 percentage points). Adolescent mothers also had less education (-3·30 years, 95% CI -3·68 to -2·91), less bargaining power (-7 to -15 percentage points), and lived in poorer households (-0·66 SD, 96% CI -0·82 to -0·50) with poorer sanitation (-28 percentage points, -32 to -24). In the path analysis, these intermediate factors predicted child anthropometry, with the strongest links being mother's education (18%), socioeconomic status (13%), and weight (15%)., Interpretation: Children born to adolescent mothers are at risk of being undernourished. Adolescent pregnancy is related to child undernutrition through poor maternal nutritional status, lower education, less health service access, poor complementary feeding practices, and poor living conditions. Policies and programmes to delay pregnancy and promote women's rights could help break the intergenerational cycle of undernutrition through many routes., Funding: Bill & Melinda Gates Foundation through Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India, led by the International Food Policy Research Institute., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)