Clutching their hungry babies, a group of mothers stir a semolina dish under the guidance of a teacher, part of an effort to combat malnutrition that affects nearly half of children in southern Pakistan.

Though Sindh province is home to Karachi, the country’s sprawling financial hub along the Arabian coastline, children in rural areas just hours away face alarming rates of wasting and stunting.

In the sun-scorched village of Sujawal, lethargic children with visible bones struggle in the heat as social workers teach mothers about nutrient-rich ingredients and debunk harmful food myths.

"Before, we only fed our children potatoes because they were always available at home,” said Shahnaz, 25, who has transformed the diet of her six children – once weak and frequently ill – after a year of classes.

Now, convinced that children should eat a varied diet, she has introduced affordable ingredients such as lentils and semolina into her cooking, lifting her daughter out of malnutrition.

In impoverished rural Sindh province, 48% of children under 5 suffer from malnutrition, and 20% from its most severe form, wasting, according to the latest national survey on the issue, conducted in 2018.

In this class, Azma, a social worker, shows mothers how to cook with semolina, which is easily available in the market.

"Semolina is cheap. For 50 rupees, it can last a week if you're feeding one to two spoonfuls daily to a six-month-old child,” she explained to Agence France-Presse (AFP).

In Sindh, a province of 55 million people where contraception remains taboo and large families are the norm, 3,500 mothers have benefited from cooking classes developed by UNICEF.

Like many mothers in the area, Kulsoom, 23, who is pregnant with her sixth child, all born prematurely and underweight, once only fed her children pieces of fried flatbread.

"One of my children died, and my youngest is extremely weak, so I was advised to take these classes,” said Kulsoom, who goes by only one name, like most women in her district.

No spices

Parents are recommended to feed babies solid foods starting at about six months, but in rural Sindh, this often means adult leftovers, which are too spicy for young stomachs.

"The main problem is the lack of dietary diversity,” said Mazhar Iqbal, a nutritionist for UNICEF.

In Pakistan, 38% of children eat only two or fewer of the eight food categories recommended by UNICEF.

Meat is saved for special occasions, yet inexpensive protein alternatives exist, such as chicken offal, boiled bones, lentils, and beans.

As for fruit and vegetables, they are usually fried, losing their nutrients.

Bakhtawar Kareem joined the program after her child died of anemia.

"I have no money. Sometimes we eat, sometimes we don't,” she lamented, scanning the swollen belly of her one-year-old daughter, who has only sparse clumps of hair.

Like 72% of children in the village, her daughter has stunting, well above Pakistan’s average of 42% – one of the highest rates in the world.

Stunting is most closely associated with brain development and physical growth and can have long-term physical and mental impacts.

Vulnerable to a lack of clean water and sanitation, which contributes to malnutrition, children often also suffer from dengue fever or malaria, vomiting, diarrhea, or difficulty urinating, and may have abnormally swollen bellies.

Women eat leftovers

But the vicious cycle of malnutrition begins with the mothers.

"With early marriages and repeated pregnancies, more than 45% of women in Sindh are anemic,” said Iqbal.

"This increases the risk of having low-birth-weight babies, who are more likely to suffer from malnutrition.”

In Sujawal, where only a quarter of the population can read and write, myths about food also deprive women of vital nutrients.

Farrah Naz, head of the Global Alliance for Improved Nutrition in Pakistan, regularly has to remind women that eggs and dried fruits do not cause heavier menstrual bleeding.

Cultural norms requiring women to serve meals to men first and eat the leftovers – despite the physical work they carry out in the fields – also contribute to poor health.

"And when food runs out, it's their rations that are cut first,” she said.