Tracking progress in achieving the global nutrition targets May 2014

Transcription

1 Tracking progress in achieving the global nutrition targets May 2014 Setting targets is a way to galvanize attention and mobilize financial resources around priorities in maternal and child nutrition. Leaders in government and actors in civil society who are aware of the pressing problems and care for people can transform targets into concrete action. WHO and partners are set to enable this process. In 2012 WHO Member States endorsed six global nutrition targets for 2025, selected because they illustrate the key outcome indicators that are related to the one-thousand-days critical window of opportunity from conception through the second year of life. Given the global baselines 1 for each indicator, the corresponding global targets for 2025 are: 1 years are different from 2012 for anaemia (2011), low birth weight ( ) and exclusive breastfeeding ( ). 1

2 More on the targets story: national vs. global National adaptations of the global targets will be needed when for example a country has already achieved or surpassed one or several global targets. Where a country has achieved a global target and there is potential to surpass it, the aim should be to continue and progress towards improving the nutritional status of still more children. For example, if exclusive breastfeeding to six months is already 50%, work should continue towards ensuring that additional infants will benefit by setting a target above the global one. Similarly, some countries might be very close to achieving one or more targets, and they should aim to continue progressing so that they achieve and possibly surpass the target. Targets are interlinked, and some interventions have an impact on multiple targets. Improving exclusive breastfeeding for example is likely to reduce stunting and possibly prevent overweight at the same time. Reducing anaemia in women of reproductive age will most likely decrease low birth weight and wasting as well as stunting in the young child. As Dr Chan, the Director General of WHO, has said on other occasions: What is measured gets done. So let s get on with it! Data are not only important for advocacy purposes; they also trigger decision-making, which in turn helps to attract resources and sustain momentum. Countries will need to translate these global targets into action suitable to their own contexts. The WHO Department of Nutrition together with experts is developing an interactive tracking tool for this purpose. This online tool illustrates the current status for each of the target indicators and allows developing different progress scenarios until It also can visualize the status and trends of regional and global targets, and furthermore map them. The mapping feature is particularly useful for depicting patterns of severity and showing where most of the people live as defined by each of the outcome indicators. The tool s country, regional and global target profiles and accompanying maps will be updated with new indicator estimates as they become available. A data harmonization process was initiated in 2010 for the three child growth indicators, stunting, overweight and wasting, and over the last couple of years UNICEF, WHO and the World Bank jointly derived global and regional estimates using an agreed data set and method (the next joint data set will be available in September 2014). Due to the scarcity of survey data, estimates for anaemia in women of reproductive age (pregnant and nonpregnant) were derived using a modelling approach. For the rate of exclusive breastfeeding in the first six months, data are currently being harmonized among relevant UN agencies, and will become available soon. UNICEF and WHO and a number of academic institutions are conducting a thorough review of national information on low birth weight, and this information will be made available in a subsequent update. 2

3 The following pages summarize available global target indicator data, which will eventually be fed into the first Global Nutrition Report to be published later in They start with the global targets for 2025 and what they mean, and then focus on regional and country level situations. The table at the end provides an overview of the current target indicator status for each country. With time and greater data availability, this table will be revised in future reports. Data sources Most of the indicator estimates are commonly derived from nationally representative household surveys. Additional data collections should be planned carefully and aligned with existing information systems or survey projects. Representative data in many countries are gathered through population-based surveys (ideally every 3-5 years), and this will most likely continue to be a main source of information. On the other hand, many countries are looking at ways to reinforce their information systems and ensure that nutrition indicators are properly integrated in systems that are relevant to nutrition. Some countries are enhancing or building surveillance systems to generate more detailed subnational data. These systems are usually linked to programme implementation and provide data for evaluating progress. The WHO Department of Nutrition and partners are currently strengthening surveillance systems in 11 sub- Saharan countries. This project, which seeks to accelerate improved nutrition, will yield additional data and lessons for the tracking exercise of the six global nutrition targets. In all instances the objective is to have timely relevant data of sufficient quality to inform policy-makers and programme planners in their efforts to improve their populations health status. For a final assessment of the six target indicators it will be important to have data from that will allow assessment of the achievements made by the target year

4 The global situation based on latest analyses The following section gives an overview of status and recent trends for each of the global indicators. The graphs below visualize the trends with the corresponding rate or number for 2025 if the target would be achieved. Red bars refer to the population, with dark red highlighting the baseline and faded red forecasts. The blue dots, in turn, with upper and lower levels of uncertainty refer to the prevalence estimates, and the 2025 target is marked in green. Rates of progress are given as annual average rates of reduction ( 2 ) or average annual rates of increase (AARI) depending on the target. Stunting in children 0-5 years of age Globally the prevalence and numbers of stunted children are decreasing. Stunting refers to children who are too short for their age. Nevertheless, if the current rate of decline continues, and considering projected population dynamics, the 2025 target of about 100 million stunted children worldwide will not be achieved. In other words, extra efforts will be required to reach this goal. Given that the stunting target focusses on numbers, countries have an additional pathway to trigger improvements, which is to invest in programmes that slow population growth such as family planning. Focusing only on interventions to reduce stunting, to achieve this target countries on average would need to reach an of 3.9 per year. A recent analysis has shown that countries are able to reduce stunting at this rate. 3 million % UNICEF Division of Policy and Practice, Statistics and Monitoring Section. Technical Note: How to calculate Average Annual Rate of Reduction () of Underweight Prevalence. UNICEF: New York, 2007; 3 de Onis et al. The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions. Maternal and Child Nutrition 2013;9 Suppl 2:

5 Anaemia in women of reproductive age Global levels of anaemia in women of reproductive age decreased little over the last 2 decades, from 38% to 29%. Anaemia refers to haemoglobin levels below 12 g/dl for women in reproductive age and 11 g/dl for pregnant women. Because this period saw a growing population of women, the numbers, in turn, increased from 503 to 529 million. The drop in numbers between 1990 and 1995 is due to the fact that the improvement happened simultaneously to slow population growth, while the subsequent stagnation of anaemia improvements coincided with faster population growth. The global target of a 50% reduction focusses on prevalence only. Although it is an ambitious target, it was chosen knowing that there are interventions which have shown great impact. Encouraging countries to take action is the objective of this somewhat aspiring target. million % Target 0 Low birth weight Globally, an estimated 15% of neonates suffer from low birth weight (2012) 4. This prevalence estimate was derived using average country estimates weighted by corresponding population. To achieve a decline of 30% by 2025 will require an of 2.74 to attain an end-line prevalence of 10% (see graph below). While it is presently not possible to undertake global trend analyses for this indicator, the majority of countries with comparable data show that there has been little progress over the last 15 years. This suggests that unless a radical shift in programming occurs to address this early form of 4 Note that the baseline for low birth weight of 15% includes an estimate for China; however given methodological concerns related to the estimate for China, the global figure without China is noted as 18% for which the target in 2025 would be 13% requiring an of

6 malnutrition, the target is unlikely to be met. It should be noted that there are approximately 50% of neonates with unknown birth weight in developing countries (excluding China), which is further challenging the ability to generate reliable estimates. Consequently, a team of interested partners including WHO, John s Hopkins University, London School of Medicine and Tropical Hygiene and UNICEF are leading an in depth review of data and methods to improve low birth weight estimates which may result in a new baseline for the next year. Global low birth weight: status and target (%) Notes: "2012" data are most recent from , with the exception of India which is 2005/06 and Indonesia which is The 2012 globale estimate of 15% includes China (2008) for which methodolgical concerns exist. Therefore, an alternate scenario for the global avergae without China wascalculated, indicating a baseline of 18% and target of 13%. Overweight in children 0-5 years of age Global child overweight has been steadily increasing in prevalence and numbers in and this trend appears to accelerate since Overweight refers to children that are heavy for their height. Therefore it was intentional to set the global target to halt any further increase in prevalence. Countries with low levels of child overweight can contribute towards this target by stabilizing their rates, while other with high rates (>10%) should aim to decrease towards the global baseline level of 7%. 5 United Nations Children s Fund, World Health Organization, The World Bank. UNICEF-WHO-The World Bank: 2012 Joint child malnutrition estimates - Levels and trends. UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC;

7 million % Target 0 Exclusive breastfeeding for the first six months At present, an estimated 38% of infants aged 0-5 months are exclusively breastfed globally. This prevalence estimate was derived using average country estimates weighted by corresponding population. To reach the global target of 50% by 2025, the required annual average rate of increase (AARI) is A number of countries have surpassed AARIs of 10, while some even have AARIs in excess of 20. On the other end of the spectrum, there are some countries showing a decrease over the last 5-10 years, as indicated by negative AARIs. As many countries have already surpassed the global target for this indicator, and given that rates of progress for this indicator can change suddenly, it is particularly important that all countries, even those that are currently above 50%, maintain the progress achieved and whenever possible strive towards further improvements. 7

8 Global exclusive breastfeeding : status and target (%) "2012" data are most recent from , with the exception of India which is 2005/06. Wasting in children 0-5 years of age The presentation of the wasting target is slightly different because trends for this condition are not meaningful. Wasting refers to children that are too thin for their height. Wasting rates can change rapidly following sudden impacts such as natural or man-made disasters. The presented global estimate thus refers only to 2012 and is based on recent data to limit the potential bias. The global wasting target is to reach or maintain levels below 5%. Weighted quartiles (by population of under-5 year olds) based on 119 countries with data between 2005 and 2012 show that 9 countries with wasting rates 15.7% (3 rd quartile) total more than 55% of the global estimated number of wasted children (Bangladesh, Chad, Djibouti, India, Niger, Papua New Guinea, South Sudan, Sudan and Timor Leste). Given that wasting rates can change rapidly, the composition of the list countries with very high wasting levels is also extremely variable. 8

9 % rd quartile Target Tracking tool To assist countries in deriving individual targets WHO and partners currently develop an online tracking tool. This tool will enable countries to explore scenarios taking into account different progress rates for the six targets and the time left to It is meant to complement existing tools related to nutrition intervention, impact and costing. In summary this target tracking tool will: allow countries to develop scenarios for the global targets given their current situation explore alternative reduction rates wherever a complete achievement seems unrealistic enable visualizing of different scenarios and how much can be done in what time allow users to picture target information for the different countries provide new data as they become available and encourage contributions to update the database The tool will be able to produce outputs in form of target and country profiles, maps and charts, and data tables. Examples of output maps from the tool are shown below. The tool will be maintained by the WHO Department of Nutrition and posted on the department s website 9

10 Global maps Geographic patterns of severity for each target indicator show at a glance where interventions are most needed. The following global maps depict these patterns for each of the target indicators using most recent national estimates. For wasting, exclusive breastfeeding and low birth weight data are currently lacking to produce such a map. Global distribution of numbers of stunted children (in thousands) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Copyright - WHO All rights reserved. Global patterns of percent child overweight (%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Copyright - WHO All rights reserved. 10

11 Global patterns of percent child wasting (%) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Copyright - WHO All rights reserved. Maps on patterns of anaemia in women of reproductive age, exclusive breastfeeding and low birth weight are still in development. 11

12 Country indicator status (May 2014) The table below summaries country target status listing countries in alphabetical order and the target indicators tracking status in subsequent columns. Data are currently available for stunting, wasting overweight and exclusive breastfeeding. The other indicators are being currently prepared. To focus on recent trend histories in countries and based on the assumption that these are most likely to direct future trend lines, we truncated the available data and included in the calculations country estimates from 1999 to the present. Whenever a country has only one or no survey estimate in that time period, no calculation on trends was possible and in the table appears a blank. For countries with only two survey estimates the trend analysis is unstable and the new data can dramatically change the trend. For both type of country estimates we added respective footnotes. The suggested rules for defining on and off track are as follows: Indicator On track Off track Stunting required < required Anaemia required < required Overweight or or >7% Exclusive breastfeeding >50% or suggested minimum AARI < 2.11 <50% or suggested minimum AARI>2.11 Wasting < 5% 5% 12

13 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required Afghanistan EMR (a) (a) (b) (a) (a) (a) (a) (a) (b) Suggested minimum AARI (% per Albania EUR Algeria AFR Andorra EUR Angola AFR (b) (a) (a) (b) (a) Antigua and Barbuda AMR Argentina AMR (b) (b) (d) Armenia EUR Australia WPR Austria EUR Azerbaijan EUR Bahamas AMR Bahrain EMR (a) (a) (b) (a) (a) (a) (a) (a) (b) Bangladesh SEAR (d) Barbados AMR Belarus EUR (b) (b) Belgium EUR Belize AMR (c) (c) Benin AFR (c) (c) Bhutan SEAR (d) Bolivia (Plurinational State of) AMR (c) (c) (d) Bosnia and Herzegovina EUR Botswana AFR (c) (c) Brazil AMR (b) (b) Brunei Darussalam WPR Bulgaria EUR (a) (a) (b) (a) (a) (a) (a) (a) (b) Burkina Faso AFR

14 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required Suggested minimum AARI (% per Burundi AFR (c) (d) Cambodia WPR (d) Cameroon AFR Canada AMR Cape Verde AFR (a) (a) (b) (a) (a) (a) (b) (d) Central African Republic AFR Chad AFR Chile AMR (a) China WPR Colombia AMR (d) Comoros AFR (c) (c) (a) Congo AFR (c) (c) Cook Islands Costa Rica AMR (b) (b) Côte d'ivoire AFR Croatia EUR Cuba AMR (a) (a) (b) (a) (a) (a) (a) (a) (b) (d) Cyprus EUR Czech Republic EUR (a) (a) (b) (a) (a) (a) (a) (a) (b) Democratic People's Republic of Korea SEAR (c) (a) Democratic Republic of the Congo AFR Denmark EUR Djibouti EMR Dominica AMR Dominican Republic AMR Ecuador AMR (a) (a) (b) (a) (a) (a) (a) (a) (b) (a) Egypt EMR (d) 14

15 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required El Salvador AMR (c) (c) Equatorial Guinea AFR (a) (a) 4.8 (c) (a) (a) (a) (a) (a) 12.3 (c) (a) Eritrea AFR (a) (a) (b) (a) (a) (a) (a) (a) (b) (a) Estonia EUR Suggested minimum AARI (% per Ethiopia AFR (d) Fiji WPR (a) (a) (b) (a) (a) (a) (a) (a) (b) (a) Finland EUR France EUR Gabon AFR (c) (c) Gambia AFR Georgia EUR (d) Germany EUR (b) (b) Ghana AFR (d) Greece EUR Grenada AMR Guatemala AMR (d) Guinea AFR (d) Guinea-Bissau AFR Guyana AMR (c) Haiti AMR Honduras AMR (c) (c) Hungary EUR Iceland EUR India SEAR (c) (c) (d) Indonesia SEAR (d) Iran (Islamic Republic of) EMR (c) (a) (a) (b) Iraq EMR

16 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Ireland EUR Israel EUR Required Suggested minimum AARI (% per Italy EUR Jamaica AMR Japan WPR Jordan EMR Kazakhstan EUR Kenya AFR Kiribati WPR (a) (a) (b) (a) (a) (a) (a) (a) (b) (d) Kuwait EMR Kyrgyzstan EUR Lao People's Democratic Republic WPR (c) (c) Latvia EUR Lebanon EMR (a) (a) (b) (a) (a) (a) (a) (a) (b) Lesotho AFR (d) Liberia AFR (c) Libya EMR (b) (b) Lithuania EUR Luxembourg EUR Madagascar AFR (c) 5.8 (a) (a) (a) (a) (b) (d) Malawi AFR (d) Malaysia WPR (c) 4.6 (a) (a) (a) (a) (b) Maldives SEAR (c) (c) (d) Mali AFR (c) Malta EUR Marshall Islands WPR Mauritania AFR (d) 16

17 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required Suggested minimum AARI (% per Mauritius AFR (a) (a) (b) (a) (a) (a) (a) (a) (b) (a) Mexico AMR (c) (c) Micronesia (Federated States of) WPR Monaco EUR Mongolia WPR (d) Montenegro EUR (b) (b) Morocco EMR (c) (c) (a) Mozambique AFR (d) Myanmar SEAR Namibia AFR (c) (c) Nauru WPR (d) Nepal SEAR (d) Netherlands EUR New Zealand WPR Nicaragua AMR Niger AFR Nigeria AFR Niue WPR Norway EUR Oman EMR (c) (c) Pakistan EMR (c) Palau WPR Panama AMR (c) (a) (a) (b) Papua New Guinea WPR (c) (b) (d) Paraguay AMR (b) (b) Peru AMR (d) Philippines WPR

18 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Poland EUR Portugal EUR Required Qatar EMR (a) (a) (b) (a) (a) (a) (a) (a) (b) Republic of Korea WPR Suggested minimum AARI (% per Republic of Moldova EUR (b) (b) (d) Romania EUR (a) (a) 4.4 (a) (a) (a) (a) (a) 5.5 (a) Russian Federation EUR Rwanda AFR (d) Saint Kitts and Nevis AMR Saint Lucia AMR Saint Vincent and the Grenadines AMR Samoa WPR (a) (a) (b) (a) (a) (a) (a) (a) (b) (d) San Marino EUR Sao Tome and Principe AFR (d) Saudi Arabia EMR (b) (b) Senegal AFR Serbia EUR (c) (c) Seychelles AFR (a) (a) (b) (a) (a) (a) (a) (a) (b) Sierra Leone AFR Singapore WPR (a) (a) (b) (a) (a) (a) (a) (a) (b) Slovakia EUR Slovenia EUR Solomon Islands WPR (b) (b) (d) Somalia EMR (c) (b) South Africa AFR (a) (a) (c) (a) South Sudan AFR (c) (c) (d) Spain EUR 18

19 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required Suggested minimum AARI (% per Sri Lanka SEAR (d) Sudan EMR (c) (b) Suriname AMR Swaziland AFR (d) Sweden EUR Switzerland EUR Syrian Arab Republic EMR (d) Tajikistan EUR Thailand SEAR (b) (b) The former Yugoslav Republic of Macedonia EUR Timor-Leste SEAR (d) Togo AFR (d) Tonga WPR (a) (a) (b) (a) (a) (a) (a) (a) (b) Trinidad and Tobago AMR (a) (a) (b) (a) (a) (a) (a) (a) (b) Tunisia EMR Turkey EUR (c) (a) (a) (b) (d) Turkmenistan EUR (a) (a) (b) (a) (a) (a) (a) (a) (b) Tuvalu WPR Uganda AFR Ukraine EUR (a) (a) 59.8 (c) (a) (a) (a) (a) (a) (b) United Arab Emirates EMR United Kingdom EUR United Republic of Tanzania AFR (d) United States of America AMR (a) (a) (c) (a) (a) (a) (a) (a) Uruguay AMR (d) Uzbekistan EUR (c) Vanuatu WPR (b) (b)

20 Stunting Wasting Overweight Exclusive breastfeeding Country WHO region Required Suggested minimum AARI (% per Venezuela (Bolivarian Republic of) AMR Viet Nam WPR West Bank and Gaza (b) Yemen EMR (c) (a) (a) (b) (a) Zambia AFR (d) Zimbabwe AFR (a) latest survey before no baseline; (b) number of surveys from 1999 smaller than 2 - no current trend; (c) number of surveys from 1999 equals to 2 - current to be interpreted with caution as it will potentially change dramatically when new data become available; (d) actual required AARI <1.5; therefore a minimum AARI of 1.5 suggested; whenever suggested led to a rate above 90% by 2025, smaller AARI to reach 90% by 2025 suggested 20

21 Indicator summaries Stunting From the 143 countries with stunting data, 120 have a recent estimate between 2005 and These latest estimates are used as baseline for deriving the 2025 target and thus 74 countries currently have no baseline. A total of 108 (75%) countries have two survey estimates or more since 1999 which allows an analysis of current trends. Out of those 108 countries, 45% are in Africa, 30% in Asia and 18 in Latin America and the Caribbean. Comparing current average annual reduction rates () with required from baseline to reach the stunting target, out of 104 countries, 81 (43 in Africa, 24 in Asia, 10 in Latin America and the Caribbean) indicate the need to accelerate progress on reducing the number of stunted children; and 24 out of the 81 start from a baseline stunting rate >40%. Looking at the 81 countries from the angle of a different country grouping, 60% of them are of low or middle income. The remaining 23 (mostly in Asia and in Latin America and the Caribbean) are on track or are likely to surpass the 2025 target. Overweight ly there are 139 countries with data on child overweight, out of which 112 have a latest estimate between 2005 and Out of those 112, there are only 8 European countries that hence have a baseline. Considering these recent data, 50 of these 112 countries have levels of child overweight above the global baseline of 7%, one fifth above 10%. Those countries with rates above 10% translate into 8.5 million children overweight, which are concentrated in the lower and upper middle income groups. Exclusive breastfeeding For exclusive breastfeeding, 113 countries presently have a baseline (latest national estimates between 2005 and 2012). Out of those, 27 countries show breastfeeding rates equal or above 50% and 21 are close to the target with rates equal or above 40%. The remaining 65 countries require average annual rate of increase (AARI) within a range of 1.8 and 28.1, about a quarter of those have to increase their rates at more than 9 relative per cent per year. Wasting The target for wasting is to at least keep the level to below 5%. Wasting information is available for 141 countries, out of which 118 have been collected recently (between 2005 and 2012). ly, there are 60 countries with wasting levels above the threshold of 5%. Out of those, the majority (50 countries), belong to the low or lower middle income groups. 21

22 Combining indicators Stunting & exclusive breastfeeding 41 countries who need to accelerate stunting reduction have an exclusive breastfeeding rate of less than 40% 8 out of the 41 require an AARI for breastfeeding of more than 9% per year Stunting & overweight 30 countries need to accelerate in stunting reduction and have an overweight baseline above 7%. Out of those, 29 have recent trend information, and in 17 cases show increasing recent trends in overweight Stunting & wasting 51 countries that need to accelerate on stunting reduction and simultaneously have recent wasting levels above 5%. 27 countries 6 have to increase efforts on various fronts: Accelerate stunting reduction Latest wasting above 5% for exclusive breastfeeding below 40% When adding overweight > 7% as an additional problem, there are only six countries 7. 6 Azerbaijan, Benin, Botswana, Burkina Faso, Cameroon, Central African Republic (The), Chad, Congo (The), Democratic Rep. of the Congo (The), Djibouti, Gambia (The), Guinea-Bissau, Guyana, Haiti, Iraq, Kenya, Mali, Myanmar, Namibia, Niger (The), Nigeria, Pakistan, Philippines (The), Senegal, Sierra Leone, Somalia and Tajikistan 7 Azerbaijan, Benin, Botswana, Djibouti, Iraq and Sierra Leone 22

23 Acknowledgements These pages were drafted by UNICEF and WHO staff who will also prepare the data for the global nutrition report. The global target tracking tool was initiated by the European Union who funded a pilot product developed by the French Institute of Research for Development (IRD). Technical input was provided by WHO throughout this process. The subsequent further development of the on-line tool is led by WHO in collaboration with UNICEF, the World Bank and the IRD. Data sources by indicators Stunting, overweight and wasting United Nations Children s Fund, World Health Organization, The World Bank. UNICEF-WHO-The World Bank: 2012 Joint child malnutrition estimates - Levels and trends. UNICEF, New York; WHO, Geneva; The World Bank, Washington, DC; Anaemia Exclusive breastfeeding Low birth weight Stevens GA et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for : a systematic analysis of population-representative data. The Lancet Global Health 2013;1:e16-e25. UNICEF global databases, 2014, based on Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys (DHS) and other nationally representative surveys, , with the exception of India (2005/06). UNICEF global databases, 2014, based on Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys (DHS), other nationally representative surveys, and administrative data, , with the excep on of India (2005/06) and Indonesia. Given methodological concerns for the China (2008) estimate, the global average is presented with (15%) and without (18%) China. 23