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SAVE THE CHILDREN · STATE OF THE WO R L D ’ S M OT H E R S 2 0 1 2 3
Every year, our State of the World’s
Mothers report reminds us of the inex-
tricable link between the well-being of
mothers and their children. More than
 years of experience on the ground
have shown us that when mothers
have health care, education and eco-
nomic opportunity, both they and
their children have the best chance to
survive and thrive.
But many are not so fortunate.
Alarming numbers of mothers and
children in developing countries are
not getting the nutrition they need.
For mothers, this means less strength and energy for the
vitally important activities of daily life. It also means
increased risk of death or giving birth to a pre-term, under-
weight or malnourished infant. For young children, poor
nutrition in the early years often means irreversible dam-
age to bodies and minds during the time when both are
developing rapidly. And for . million children each year,
hunger kills, with malnutrition leading to death.
is report looks at the critical ,-day window of
time from the start of a woman’s pregnancy to her child’s
second birthday. It highlights proven, low-cost nutri-
tion solutions – like exclusive breastfeeding for the rst 
months – that can make the dierence between life and
death for children in developing countries. It shows how
millions of lives can be saved – and whole countries can
be bolstered economically – if governments and private
donors invest in these basic solutions. As Administrator
Shah states persuasively in the Foreword to this report, the
economic argument for early nutrition is very strong – the
cost to a nation's GDP is signicant when kids go hungry
early in life.
SavetheChildren is working to ght malnutrition on
three fronts as part of our global newborn and child sur-
vival campaign:
•
First, SavetheChildren is increasing awareness of the
global malnutrition crisis and its disastrous eects on
mothers, children, families and communities. As part of
our campaign, this report calls attention to areas where
greater investments are needed and shows that eec-
tive strategies are working, even in some of the poorest
places on earth.
•
Second, SavetheChildren is encouraging action by
mobilizing citizens around the world to support qual-
ity programs to reduce maternal, newborn and child
mortality, and to advocate for increased leadership,
commitment and funding for pro-
grams we knowwork.
• ird, we are making a major dier-
ence on the ground. SavetheChildren
rigorously tests strategies that lead
to breakthroughs for children. We
work in partnerships across sec-
tors with national ministries, local
organizations and others to support
high quality health, nutrition and
agriculture programming through-
out the developing world. As part of
this, we train and support frontline
health workers who promote breast-
feeding, counsel families to improve diets, distribute
vitamins and other micronutrients, and treat childhood
diseases. We also manage large food security programs
with a focus on child nutrition in  countries. Working
together, we have saved millions of children’s lives. e
tragedy is that so many more could be helped, if only
more resources were available to ensure these lifesaving
programs reach all those who need them.
is report contains our annual ranking of the best and
worst places in the world for mothers and children. We
count on the world’s leaders to take stock of how mothers
and children are faring in every country and to respond
to the urgent needs described in this report. Investing in
this most basic partnership of all – between a mother and
her child – is the rst and best step in ensuring healthy
children, prosperous families and strong communities.
Every one of us has a role to play. As a mother myself, I
urge you to do your part. Please read the Take Action sec-
tion of this report, and visit our website on a regular basis
to nd out what you can do to make a dierence.
C M
President and CEO
SavetheChildren USA
(Follow @carolynsave on Twitter)
INTRODUCTION
4 CHAPTER TITLE GOES HERE
Somalia
SAVE THE CHILDREN · STATE OF THE WO R L D ’ S M OT H E R S 2 0 1 2 5
EXECUTIVE SUMMARY:
KEY FINDINGS AND RECOMMENDATIONS
Malnutrition is an underlying cause of death for . million children each year,
and it leaves millions more with lifelong physical and mental impairments.
Worldwide, more than  million children do not have the opportunity to
reach their full potential because of poor nutrition in the earliest months of life.
Much of a child’s future – and in fact much of a nation’s future – is deter-
mined by the quality of nutrition in the rst , days. e period from the
start of a mother’s pregnancy through her child’s second birthday is a critical
window when a child’s brain and body are developing rapidly and good nutri-
tion is essential to lay the foundation for a healthy and productive future. If
children do not get the right nutrients during this period, the damage is often
irreversible.
is year’s State of the World’s Mothers report shows which countries are suc-
ceeding – and which are failing – to provide good nutrition during the critical
,-day window. It examines how investments in nutrition solutions make
a dierence for mothers, children, communities, and society as a whole. It also
points to proven, low-cost solutions that could save millions of lives and help
lift millions more out of ill-health and poverty.
KEY FINDINGS
. Children in an alarming number of countries are not getting adequate
nutrition during their first , days. Out of  developing countries –
which together account for  percent of child deaths – only four score “very
good” on measures of young child nutrition. Our Infant and Toddler Feeding
Scorecard identies Malawi, Madagascar, Peru and Solomon Islands as the top
four countries where the majority of children under age  are being fed accord-
ing to recommended standards. More than two thirds of the countries on the
Scorecard receive grades of “fair” or “poor” on these measures overall, indicating
vast numbers of children are not getting a healthy start in life. e bottom four
countries on the Scorecard – Somalia, Côte d'Ivoire, Botswana and Equatorial
Guinea – have staggeringly poor performance on indicators of early child feed-
ing and have made little to no progress since  in saving children’s lives. (To
read more, turn to pages -.)
. Child malnutrition is widespread and it is limiting the future success of
millions of children and their countries. Stunting, or stunted growth, occurs
when children do not receive the right type of nutrients, especially in utero or
during the rst two years of life. Children whose bodies and minds are limited
by stunting are at greater risk for disease and death, poor performance in school,
and a lifetime of poverty. More than  countries in the developing world have
child stunting rates of  percent or more. irty of these countries have what
is considered to be “very high” stunting rates of  percent or more. While
many countries are making progress in reducing child malnutrition, stunting
prevalence is on the rise in at least  countries, most of them in sub-Saharan
Africa. If current trends continue, Africa may overtake Asia as the region most
heavily burdened by child malnutrition. (To read more, turn to pages -.)
. Economic growth is not enough to fight malnutrition. Political will and
eective strategies are needed to reduce malnutrition and prevent stunting.
A number of relatively poor countries are doing an admirable job of tackling
this problem, while other countries with greater resources are not doing so
Vital StatisticsVital Statistics
Malnutrition is the underlying cause Malnutrition is the underlying cause
of more than . million child deaths of more than . million child deaths
each year.each year.
 million children –  percent of all chil million children –  percent of all chil
dren globally – are stunted, meaning their dren globally – are stunted, meaning their
bodies and minds have suffered permanent, bodies and minds have suffered permanent,
irreversible damage due to malnutrition. irreversible damage due to malnutrition.
In developing countries, breastfed children In developing countries, breastfed children
are at least  times more likely to survive in are at least  times more likely to survive in
the early months of life than non-breastfed the early months of life than non-breastfed
children.children.
If all children in the developing world If all children in the developing world
received adequate nutrition and feeding received adequate nutrition and feeding
of solid foods with breastfeeding, of solid foods with breastfeeding,
stunting rates at  months could be cut stunting rates at  months could be cut
by  percent.by  percent.
Breastfeeding is the single most effective Breastfeeding is the single most effective
nutrition intervention for saving lives.nutrition intervention for saving lives.
If practiced optimally, it could prevent If practiced optimally, it could prevent
 million child deaths each year. million child deaths each year.
Adults who were malnourished as children Adults who were malnourished as children
can earn an estimated  percent less on can earn an estimated  percent less on
average than those who weren’t.average than those who weren’t.
e effects of malnutrition in developing e effects of malnutrition in developing
countries can translate into losses in GDP countries can translate into losses in GDP
of up to - percent annually.of up to - percent annually.
Globally, the direct cost of malnutrition is Globally, the direct cost of malnutrition is
estimated at  to  billion per year.estimated at  to  billion per year.
6 EX EC UT IVE SUM MA RY
well. For example: India has a GDP per capita of , and  percent of
its children are stunted. Compare this to Vietnam where the GDP per capita
is , and the child stunting rate is  percent. Others countries that are
performing better on child nutrition than their national wealth might suggest
include: Brazil, Chile, Costa Rica, Kyrgyzstan, Mongolia, Senegal and Tunisia.
Countries that are underperforming relative to their national wealth include:
Botswana, Equatorial Guinea, Guatemala, Indonesia, Mexico, Panama, Peru,
South Africa and Venezuela. (To read more, turn to pages -.)
. We know how to save millions of children. SavetheChildren has high-
lighted six low-cost nutrition interventions with the greatest potential to save
lives in children’s rst , days and beyond. Universal coverage of these
“lifesaving six” solutions globally could prevent more than  million mother
and child deaths each year. e lifesaving six are: iron folate, breastfeeding,
complementary feeding, vitamin A, zinc and hygiene. Nearly  million lives
could be saved by breastfeeding alone. is entire lifesaving package can be
delivered at a cost of less than  per child for the rst , days. Tragically,
more than half of the world’s children do not have access to the lifesaving six.
(To read more, turn to pages -.)
. Health workers are key to success. Frontline health workers have a vital role
to play in promoting good nutrition in the rst , days. In impoverished
communities in the developing world where malnutrition is most common,
doctors and hospitals are often unavailable, too far away, or too expensive.
Vietnam
SAVE THE CHILDREN · STATE OF THE WO R L D ’ S M OT H E R S 2 0 1 2 7
Community health workers and midwives meet critical needs in these com-
munities by screening children for malnutrition, treating diarrhea, promoting
breastfeeding, distributing vitamins and other micronutrients, and counsel-
ing mothers about balanced diet, hygiene and sanitation. e “lifesaving six”
interventions highlighted in this report can all be delivered in remote, impov-
erished places by well-trained and well-equipped community health workers.
In a number of countries – including Cambodia, Malawi and Nepal – these
health workers have contributed to broad-scale success in ghting malnutrition
and saving lives. (To read more, turn to pages -.)
. In the industrialized world, the United States has the least favorable envi-
ronment for mothers who want to breastfeed. SavetheChildren examined
maternity leave laws, the right to nursing breaks at work, and several other
indicators to create a ranking of  industrialized countries measuring which
ones have the most – and the least – supportive policies for women who want to
breastfeed. Norway tops the Breastfeeding Policy Scorecard ranking. e United
States comes in last. (To read more, turn to pages -.)
RECOMMENDATIONS
. Invest in proven, low-cost solutions to save children’s lives and prevent
stunting. Malnutrition and child mortality can be fought with relatively simple
and inexpensive solutions. Iron supplements strengthen children’s resistance
to disease, lower women’s risk of dying in childbirth and may help prevent
premature births and low birthweight. Six months of exclusive breastfeeding
increases a child’s chance of survival at least six-fold. Timely and appropriate
complementary feeding is the best way to prevent a lifetime of lost potential
due to stunting. Vitamin A helps prevent blindness and lowers a child’s risk
of death from common diseases. Zinc and good hygiene can save a child from
dying of diarrhea. ese solutions are not expensive, and it is a tragedy that
millions of mothers and children do not get them.
. Invest in health workers – especially those serving on the front lines – to
reach the most vulnerable mothers and children. e world is short more than
 million health workers of all types, and there is an acute shortage of frontline
Kyrgyzstan
8 EX EC UT IVE SUM MA RY
workers, including community health workers, who are critical to delivering
the nutrition solutions that can save lives and prevent stunting. Governments
and donors should work together to ll this health worker gap by recruiting,
training and supporting new and existing health workers, and deploying them
where they are needed most.
. Help more girls go to school and stay in school. One of the most eective
ways to ght child malnutrition is to focus on girls’ education. Educated women
tend to have fewer, healthier and better-nourished children. Increased investments
are needed to help more girls go to school and stay in school, and to encourage
families and communities to value the education of girls. Both formal education
and non-formal training give girls knowledge, self-condence, practical skills and
hope for a bright future. ese are powerful tools that can help delay marriage
and child-bearing to a time that is healthier for them and their babies.
. Increase government support for proven solutions to fight malnutrition
and save lives. In order to meet internationally agreed upon development goals
to reduce child deaths and improve mothers’ health, lifesaving services must
be increased for the women and children who need help most. All countries
must make ghting malnutrition and stunting a priority. Developing countries
should commit to and fund national nutrition plans that are integrated with
plans for maternal and child health. Donor countries should support these
goals by keeping their funding commitments to achieving the Millennium
Development Goals and countries should endorse and support the Scaling Up
Nutrition (SUN) movement. Resources for malnutrition programs should not
come at the expense of other programs critical to the survival and well-being
of children.(Toread more, turn to page .)
. Increase private sector partnerships to improve nutrition for mothers and
children. Many local diets fail to meet the nutritional requirements of children -
months old. e private sector can help by producing and marketing aordable
fortied products. Partnerships should be established with multiple manufactur-
ers, distributors and government ministries to increase product choice, access and
aordability, improve compliance with codes and standards, and promote public
education on good feeding practices and use of local foods and commercial prod-
ucts. e food industry can also invest more in nutrition programs and research,
contribute social marketing expertise to promote healthy behaviors such as breast-
feeding, and advocate for greater government investments in nutrition.
. Improve laws, policies and actions that support families and encourage
breastfeeding. Governments in all countries can do more to help parents and
create a supportive environment for breastfeeding. Governments and part-
ners should adopt policies that are child-friendly and support breastfeeding
mothers. Such policies would give families access to maternal and paternal
leave, ensure that workplaces and public facilities oer women a suitable
place to feed their babies outside of the home, and ensure working women
are guaranteed breastfeeding breaks while on the job. In an increasingly urban
world, a further example is that public transportation can oer special seats
for breastfeedingmothers.
Afghanistan
SAVE THE CHILDREN · STATE OF THE WO R L D ’ S M OT H E R S 2 0 1 2 9
Save the Children’s thirteenth annual Save the Children’s thirteenth annual Mothers’ IndexMothers’ Index
compares the well-being of mothers and children in  compares the well-being of mothers and children in 
countries – more than in any previous year. e countries – more than in any previous year. e
Mothers’ IndexMothers’ Index also provides information on an addialso provides information on an addi
tional  countries,  of which report sufficient data tional  countries,  of which report sufficient data
to present findings on women’s or children’s indicato present findings on women’s or children’s indica
tors. When these are included, the total comes to tors. When these are included, the total comes to
 countries. countries.
Norway, Iceland and Sweden top the rankings this Norway, Iceland and Sweden top the rankings this
year. e top  countries, in general, attain very high year. e top  countries, in general, attain very high
scores for mothers’ and children’s health, educational scores for mothers’ and children’s health, educational
and economic status. Niger ranks last among the  and economic status. Niger ranks last among the 
countries surveyed. e  bottom-ranked countries countries surveyed. e  bottom-ranked countries
– eight from sub-Saharan Africa – are a reverse image – eight from sub-Saharan Africa – are a reverse image
of the top , performing poorly on all indicators. e of the top , performing poorly on all indicators. e
United States places th this year – up six spots from United States places th this year – up six spots from
last year.last year.
Conditions for mothers and their children in the Conditions for mothers and their children in the
bottom countries are grim. On average,  in  women bottom countries are grim. On average,  in  women
will die from pregnancy-related causes. One child in will die from pregnancy-related causes. One child in
 dies before his or her fifth birthday, and more than  dies before his or her fifth birthday, and more than
 child in  suffers from malnutrition. Nearly half the  child in  suffers from malnutrition. Nearly half the
population lacks access to safe water and fewer than  population lacks access to safe water and fewer than 
girls for every  boys are enrolled in primary school.girls for every  boys are enrolled in primary school.
e gap in availability of maternal and child health e gap in availability of maternal and child health
services is especially dramatic when comparing Norway services is especially dramatic when comparing Norway
and Niger. Skilled health personnel are present at virtuand Niger. Skilled health personnel are present at virtu
ally every birth in Norway, while only a third of births ally every birth in Norway, while only a third of births
are attended in Niger. A typical Norwegian girl can are attended in Niger. A typical Norwegian girl can
Niger
The The 2012 Mothers’ Index2012 Mothers’ Index: Norway Tops List, Niger Ranks Last, : Norway Tops List, Niger Ranks Last,
United States Ranks 25thUnited States Ranks 25th
expect to receive  years of formal education and to live expect to receive  years of formal education and to live
to be over  years old. Eighty-two percent of women to be over  years old. Eighty-two percent of women
are using some modern method of contraception, and are using some modern method of contraception, and
only  in  is likely to lose a child before his or her only  in  is likely to lose a child before his or her
fifth birthday. At the opposite end of the spectrum, in fifth birthday. At the opposite end of the spectrum, in
Niger, a typical girl receives only  years of education Niger, a typical girl receives only  years of education
and lives to be only . Only  percent of women are and lives to be only . Only  percent of women are
using modern contraception, and  child in  dies before using modern contraception, and  child in  dies before
his or her fifth birthday. At this rate, every mother in his or her fifth birthday. At this rate, every mother in
Niger is likely to suffer the loss of a child. Niger is likely to suffer the loss of a child.
Zeroing in on the children’s well-being portion of Zeroing in on the children’s well-being portion of
the the Mothers’ IndexMothers’ Index, Iceland finishes first and Somalia is , Iceland finishes first and Somalia is
last out of  countries. While nearly every Icelandic last out of  countries. While nearly every Icelandic
child – girl and boy alike – enjoys good health and educhild – girl and boy alike – enjoys good health and edu
cation, children in Somalia face the highest risk of death cation, children in Somalia face the highest risk of death
in the world. More than  child in  dies before age . in the world. More than  child in  dies before age .
Nearly one-third of Somali children are malnourished Nearly one-third of Somali children are malnourished
and  percent lack access to safe water. Fewer than  in and  percent lack access to safe water. Fewer than  in
 children in Somalia are enrolled in school, and within  children in Somalia are enrolled in school, and within
that meager enrollment, boys outnumber girls almost that meager enrollment, boys outnumber girls almost
 to .  to .
ese statistics go far beyond mere numbers. e ese statistics go far beyond mere numbers. e
human despair and lost opportunities represented in human despair and lost opportunities represented in
these numbers demand mothers everywhere be given these numbers demand mothers everywhere be given
the basic tools they need to break the cycle of poverty the basic tools they need to break the cycle of poverty
and improve the quality of life for themselves, their and improve the quality of life for themselves, their
children, and for generations to come. children, and for generations to come.
See the Appendix for the Complete Mothers’ Index See the Appendix for the Complete Mothers’ Index
and Country Rankings.and Country Rankings.
10 CHAPTER TITLE GOES HERE
Bangladesh
SAVE THE CHILDREN · STATE OF THE WO R L D ’ S M OT H E R S 2 0 1 2 11
Good nutrition during the ,-day period between the start of a woman’s
pregnancy and her child’s second birthday is critical to the future health, well-
being and success of her child. e right nutrition during this window can have
a profound impact on a child’s ability to grow, learn and rise out of poverty.
It also benets society, by boosting productivity and improving economic
prospects for families and communities.
Malnutrition is an underlying cause of . million child deaths each year.¹
Millions more children survive, but suer lifelong physical and cognitive
impairments because they did not get the nutrients they needed early in their
lives when their growing bodies and minds were most vulnerable. When chil-
dren start their lives malnourished, the negative eects are largely irreversible.
Pregnancy and infancy are the most important periods for brain develop-
ment. Mothers and babies need good nutrition to lay the foundation for the
child’s future cognitive, motor and social skills, school success and productiv-
ity. Children with restricted brain development in early life are at risk for later
neurological problems, poor school achievement, early school drop out, low-
skilled employment and poor care of their own children, thus contributing to
the intergenerational transmission of poverty.²
Millions of mothers in poor countries struggle to give their children a healthy
start in life. Complex social and cultural beliefs in many developing countries
put females at a disadvantage and, starting from a very young age, many girls
do not get enough to eat. In communities where early marriage is common,
teenagers often leave school and become pregnant before their bodies have fully
matured. With compromised health, small bodies and inadequate resources and
support, these mothers often fail to gain sucient weight during pregnancy
and are susceptible to a host of complications that put themselves and their
babies at risk.
Worldwide,  million babies are born with low birthweight each year.³
Many of these babies are born too early – before the full nine months of preg-
nancy. Others are full-term but they are small because of poor growth in the
mother’s womb. Even babies who are born at a normal weight may still have
been malnourished in the womb if the mother’s diet was poor. Others become
malnourished in infancy due to disease, inadequate breastfeeding or lack of
nutritious food. Malnutrition weakens young children’s immune systems and
leaves them vulnerable to death from common illnesses such as pneumonia,
diarrhea and malaria.
WHY FOCUS ON THE FIRST 1,000 DAYS?
South Sudan
12 WH Y FO CUS ON TH E FIRST 1 ,0 00 DAYS?
ECONOMIC GROWTH AND FUTURE SUCCESS
Investments in improving nutrition for mothers and children in the rst
, days will yield real payos both in lives saved and in healthier, more
stable and productive populations. In addition to its negative, often fatal, health
consequences, malnutrition means children achieve less at school and their
productivity and health in adult life is aected, which has dire nancial con-
sequences for entire countries.
Children whose physical and mental development are stunted by malnutri-
tion will earn less on average as adults. One study suggested the loss of human
potential resulting from stunting was associated with  percent less adult
income on average. Malnutrition costs many developing nations an estimated
- percent of their GDP each year, extends the cycle of poverty, and impedes
global economic growth. Globally, the direct cost of child malnutrition is
estimated at  to  billion per year.
In contrast, well-nourished children perform better in school and grow up
to earn considerably more on average than those who were malnourished as
children. Recent evidence suggests nutritional interventions can increase adult
earnings by as much as  percent.
An estimated  million children will be aected by stunting in the next
 years if current trends continue. is is bad news for the economies of
developing nations, and for a global economy that is increasingly dependent
on new markets to drive economic growth.
Malawi