child malnutrition decline in maharashtra-1 an overview

Child Malnutrition in Child Malnutrition in

Maharashtra (India) Maharashtra (India) August 2013August 2013-- January 2014January 2014

Situation, Efforts, Decline and ChallengesSituation, Efforts, Decline and Challenges

A Review A Review A Review A Review For the State Nutrition MissionFor the State Nutrition Mission

P o w e r P o i n t 1 / 6P o w e r P o i n t 1 / 6

Dr Shyam Ashtekar, MD (Community Med)

[email protected]

PPT1/6PPT1/62006

PPT1/6PPT1/6

AN OVERVIEWAN OVERVIEW

200

to

2013

(A) The context and the MN (A) The context and the MN

problemproblem

� Child malnutrition is a complex

problem, and the context too is important

for action

Malnutrition in maharashtra-A Review Jan 2014 3

Background and contextBackground and context

� There is discussion of 40-50% Child

malnutrition in India

� Similar issues are raised in media and

Legislative Assembly in MaharashtraLegislative Assembly in Maharashtra

� Melghat, Satpuda and Jawhar-Mokhada

often hit newspapers for malnutrition

� What is the real situation ?


We should discuss facts and causes.. Rather We should discuss facts and causes.. Rather

than images..than images..

25

30

35

40

� CNSM Survey 2012

0

5

10

15

20

Under Wt by age(-2SD)

Stunting (-2SD)

Wasting (-2SD)

2005-6

2012-13


The pyramid The pyramid

of Causesof Causes Some Child

Deaths

Vicious Cycle of Malnutrition and

Child deaths, 20-30% Malnutrition

in 0-5 age group. about 4% children

severely wasted.


Low BMI in Women and adolescence girls, malnutrition and anemia. Multiple causes for this– early marriage and child bearing, poor

AN care and high rate of low birth weight. Neglect of proper breast feeding and

complementary feeding

Lack of hygiene Poor food culture, weak health care, blind faith and wrong concepts low status of

women, migration, terrain, jobs and incomes, inflation, gaps in PDS etc.

CNSM Survey Statistics (2012)CNSM Survey Statistics (2012)

� The CNSM Survey by IIPS

Mumbai (2012) shows

reduction in child malnutrition

in Maharashtra.

20

25

30

35

40

2005-6

in Maharashtra.

� The survey included 2600

children.


0

5

10

15

Under Wt by age(-2SD)

Stunting (-2SD)

Wasting (-2SD)

Comparison of 3 surveys: 2006 to 2012Comparison of 3 surveys: 2006 to 2012

Children 0-23

months

NFHS3

(U+R)

2005-6

IIPS CNSM

2012 (U+R)

IIPS CNSM

only rural

NNMB2012

(Rur)0-36m

Number

surveyed

2654 1332 571

Stunting (-2SD) 39 23.9 27.8 43.9


Stunting (-2SD) 39 23.9 27.8 43.9

Wasting (-2SD) 19.9 15.9 16.9 15

Under Wt by

age(-2SD)

29.6 22.1 25.9 31.5

%MUAC<11.5cm 3.5 4.3

% of low birth

weight

20.3 21.6

Statewise Malnutrition NNMB 2012-Survey

State Underweight Stunting Wasting Kerala 20.8 23.4 16.4TN 28.6 21.7 26.4

Maharashtra 31.5 43.9 15AP 31.7 42.9 14.1


AP 31.7 42.9 14.1Karnataka 35.6 36.7 20.7

WB 35.6 40.6 21.4Pooled 37.7 41.3 22.3Orissa 40.3 47.3 18.2UP 47.8 44.9 31.7

Gujarat 48.4 54.9 27.7MP 51.4 48.7 33

Comparison of states on Child Comparison of states on Child

Malnutrition NNMB 2012Malnutrition NNMB 2012--

30

40

50

60


0

10

20

30

UnderWeight

Stunting

Wasting

Comparison of CNSM &Comparison of CNSM & NNMB SurveysNNMB Surveys

� NNMB Survey is limited to rural areas.

� Here we compared NNMB with the rural Column of CNSM

Survey.

� CNSM Survey age group is 0-23 months while that of

NNMB is 0-36 months.NNMB is 0-36 months.

� Both Surveys are in done in 2012.

� The NNMB Survey shows more malnutrition probably

because of age group and sample size. � But the NNMB survey also is important for the fight

against malnutrition


The CNSM Survey is more reliableThe CNSM Survey is more reliable

� IIPS conducted the NFHS Survey 1-2-3

in India

� The sample size in CNSM is 1322

� The sample size in CNSM is 1322

(rural) while in NNMB it was 571 � All Govt. Agencies use the NFHS

Statistics done by IIPS

� Hence CNSM Survey is more reliable. Malnutrition in maharashtra-A Review Jan 2014 12

CNSM CNSM --Observation Observation & Comments& Comments

� Child Malnutrition in Maharashtra has dropped in

comparison to 2005-06 figures. � Underweight (Weight for age) proportion has dropped

from 29 to 22%

� Stunting has dropped from 39-29%� Stunting has dropped from 39-29%

� Wasting has also dropped from 20 to 16

� Percentage of children with MUAC (Mid Upper Arm

Circumference) less than 11.5cm. is about 3.5%

� Proportion of low birth weight babies is 21% (from birth

records)


CNSM:BoysCNSM:Boys & Girls & Girls

� Nutrition indices for girls look better than those of

boys

� Girls and boys show a MN proportions as follows : � Girls and boys show a MN proportions as follows :

stunting 20.7 and 26.5, underweight 19.2 and

24.4, wasting 13.9 and 17.4, severely low MUAC

3.9 and 3.2 respectively.

� This suggests that there is no particular

discrimination against girls in this age group.


CNSMCNSM--Neonatal CareNeonatal Care

� The proportion of newborn

babies that received breast

feeding in the first hour rose feeding in the first hour rose

from 52% to 60%.

� Conversely 40% newborns don't

get early breast feeding.


CNSMCNSM--Care of the young child (0Care of the young child (0--2Y)2Y)

� Semi solid or solid feeds were given

between 6-8 months to 63% babies, from

the earlier level of 48.the earlier level of 48.

� Safe disposal of excreta of the child was

satisfactory only about 41% children..


CNSM CNSM --Care after 6 Care after 6

monthsmonths

� Feeding and care after 6 months is a weak area.

� Only about 77 % of babies in >6 months group got at least 6 feeds a

day. which needs to be better.day. which needs to be better.

� Only 10-34% young infants getting age appropriate feeds, diverse

feeds, feeds with iron and vitamin A content

� This implies that the family is failing to take care.

� About 85% U 2Y children get complementary food packets from the

Anganwadi in the rural area.


Immunization & micronutrientsImmunization & micronutrients

� In the last 6 months 48% babies got

a Dose of vitamin A, this is better

than previous level of 32%

� Iodinated salt is consumed in the

families of 75% babies.

� The percentage of immunization

has risen from 59 to 69%


Health and Nutrition of MothersHealth and Nutrition of Mothers

� Maternal Health care has improved. � AN Care, IFA supplement and institutional

delivery have improved. � The 102 ambulance is available commonly.� The 102 ambulance is available commonly.


CNSM CNSM --Women’s BMI is lowWomen’s BMI is low

� The proportion of wasting women

(BMI less than 18.5) has dropped

by just 1 from 32.6 to 31.6%

� The low BMI Proportion in rural

women is 42%.

� About 20% of urban women suffer

from overweight (BMI>25)


CNSM CNSM --Low Birth WeightLow Birth Weight

� The proportion of low birth weight babies has

somewhat reduced. But these figures are from

recorded data rather than direct observations. We

can not very much bank on this decline.can not very much bank on this decline.

� A study of about 3000 recent births in the

Aurangabad Medical College suggests LBW >30%

� The causes of LBW include both inter-generational

and some current causes.


Known facts: Maharashtra’s Map of Known facts: Maharashtra’s Map of

MalnutritionMalnutrition


ICDS data: Blocks/Projects with high ICDS data: Blocks/Projects with high

burden of Malnutrition (July 2013burden of Malnutrition (July 2013))


Social context of Social context of Malnutrition (1)Malnutrition (1)

�There is more Malnutrition is some tribal districts

especially some development blocks in those districts.

�The blocks of Jawhar Mokhada (Thane) Dhadgaon and

Akkalkuwa (Nandurbar) Chikhaldara-Dharni Known as

Melghat. (Amravati) are most malnourished blocks.

�Some blocks in Gadchiroli, Nashik and Chandrapur

districts also have more malnutrition.


Social context of Malnutrition (2)Social context of Malnutrition (2)

� Some tribes may be more malnourished than

others but we do not have comparative

statistics.

� Possibly more malnutrition in some Scheduled � Possibly more malnutrition in some Scheduled

castes.

� It is possible that VJNT (nomadic tribes)

categories also suffer from Malnutrition but we

need more information on this.


Malnutrition and Age groupMalnutrition and Age group

� About 20-30% babies in Maharashtra are born with less

weight (2.5Kg or less)

� There is less malnutrition in first 6 months, because of

protective role of breast feeding .protective role of breast feeding .

� The breast milk is not enough between 6 months to 2

years; however because of lack of proper

complementary feeds malnutrition figures start rising

after 6 months.


Malnutrition in 2Malnutrition in 2--5 age group5 age group

� The children attending AW are in age group of 36 to 60/72

months .

� These children can not improve enough if they are already

malnourished before they reach AWC.malnourished before they reach AWC.

� But even this age group does need good nutrition support.


Other context of malnutrition

� Migration for employment is a major

challenge, despite MNREGA.

� In some blocks communication gaps are

serious because of hills and forests . Food serious because of hills and forests . Food

supply suffers esp. in rainy seasons.

� The neglect of family planning-spacing is

also a major problem in many blocks.


Food Security and Child MalnutritionFood Security and Child Malnutrition

� It is difficult to connect child Malnutrition

to lack of food grains in homes in

Maharashtra state of today, except in Maharashtra state of today, except in

some tribal parts.

� Employment, PDS, and local agro produce

usually ensure food grain availability even

in difficult areas.


Lack of Proteins, Vitamins & MineralsLack of Proteins, Vitamins & Minerals

� But the lack of

proteins, vitamins and

minerals is an important

factor. factor.

� Hence we need a new

perspective on this

aspect of food security.


(B) MAHARASHTRA’S (B) MAHARASHTRA’S

EFFORTSEFFORTSEFFORTSEFFORTS


Focus on the Focus on the

AnganwadiAnganwadi Center Center

(AWC)(AWC)

� The State of Maharashtra1.07 lakh AWCs, including

mini AWCs. mini AWCs.

� 70% AWCs are in villages.

� About 80,00,000 children U6 are associated with

Anganwadis

� AWCs are important for rural areas as nurseries for

towns.


Improving the AWC Improving the AWC

� Supplementary feeding is only one of the tasks of AWC

� AWC should provide 25 to 30% of food need in 3-6Y age group.

� The remaining 70% must come from home, hence home feeding is

more crucial for the child and control of malnutrition.more crucial for the child and control of malnutrition.

� Pre primary education is an equally important task of AWC.

� Other tasks include immunization, medical check

up, micronutrients, monitoring weight and height


Improving AWC: MIS to GISImproving AWC: MIS to GIS

� The survey statistics of nutrition of AWC and

growth was not very reliable before 2010.

� In those days the abstract of categories of

malnutrition was communicated to higher

levels levels

� The system of sending abstract report remains

the same even now.

� However there is less tendency to hide

malnutrition in reports.

� The AWC statistics is more reliable than before.

� GIS is now available for all AWCs


The MN statistics of AWCsThe MN statistics of AWCs

� The ICDS website (http://www.icds.gov.in/# ) offers

the monthly progress report (MPR) of various

levels.

� The MPR includes district wise and block wise

information of services and malnutrition.information of services and malnutrition.

� We also get line listing of malnourished children

in tribal blocks, but these are rather dated for

current action.


Monthly Progress Report Monthly Progress Report –– A sampleA sample


The Geographic Information SystemThe Geographic Information System

RJMCHN has now established a GIS system for the entire state.

� This GIS is available on www//:mhnss.ind.in

� Basically it has all the 1206 boxes of the monthly

This can help to

� Generate MIS from AWC to state level and update within 48 hrs

� Generate info for action on every level.

� It can generate both boxes of the monthly progress Report-MP

� The AW sevika can get it done in 30 Rs provision and within 30 min.

� She can Upload the AWC abstract info (5-7 KB file)on the site thru the Sangramsoftware at village level.

� It can generate both process and outcome indicators

� We can generate about 1500 reports from this data

� It also provides camera sites for physical verification at each AWC


ICDS and Rajmata Jijau MissionICDS and Rajmata Jijau Mission

� ICDS and RJMCHM together are working on

reducing malnutrition

� The RJMCHM offers technical assistance and is � The RJMCHM offers technical assistance and is

supported by Unicef.

� The important window of 1000 days before

entering AWC is more important, and both

agencies are focused on this window.Malnutrition in maharashtra-A Review Jan 2014 38

Dr Arole Committee ReportDr Arole Committee Report

� The Non Governmental Members

Committee under Dr. Rajanikant Arole

appointed by Dr the Hon High Court appointed by Dr the Hon High Court

worked on this issue from 2008 to 2011.

The Report has been submitted to the

Govt. in 2013


The important 1000 days’ window for the The important 1000 days’ window for the

childchild..

� About 270 days of pregnancy and 730 days of year

1 and 2 together make 1000 days. This window of

1000 days is important for growth and nutrition.

� If growth suffers in this period, there is less

progress in the future.

� RJMCHM and ICDS have introduced various

programs for this period.


Ten rules for preventing Ten rules for preventing

malnutritionmalnutritionInstitutional birth and

Breastfeeding

6 m Exclusive Breastfeeding

Complimentary feeding at 6m, 6m BD

Vit A doses

Complete Immunization

Focus on 6m-3y child-

nutrition ed of the mother

Micronutrients Sachet

De-worming,

illness treatment when

necessary, immunization

Handwash,

water safety,

Sanitation

Growth monitoring-wt/ht//MUAC

3/16/2014

महाराातले कुपोषण �नमू�लनाच े�व�वध �य�न--डॉ शाम अटेकर- 41

Chief Minister’s 5 pointChief Minister’s 5 point ProgramProgram

1. Ensuring health & nutrition of adolescent girls.

2. Effort to improve birth weights, including better

ANC services.

3. Early and exclusive breast feeding till 6 months.

4. Proper complementary feeding after 6 months.

5. Management of SAM (Severe Acute

malnutrition) children


Child deaths due to MalnutritionChild deaths due to Malnutrition

� Malnutrition triggers child deaths.

� About 20-25% child deaths are linked to severe

Malnutrition.

� For this context, rather than underweight or stunting more

important parameters are wasting, severely low MUAC or important parameters are wasting, severely low MUAC or

edema on feet

� Infectious illnesses like diarrhea and pneumonia can also

push the baby into Malnutrition.

� Child deaths will decline with decline in Malnutrition. The

current IMR is 25 while U5 MR is 33.


TThe challengehe challenge

� The CNSM study reports decline in

malnutrition in Maharashtra.

� But there are tough challenges ahead..Low birth weight Poor breast feeding practices,

Poor breast feeding practices, Gaps in proper complementary feeds for U2 children Lack of proteins and micronutrients in meals Infections and insanitation Low Body mass index of women.

� The AWC can not meet this challenge alone

� We need efforts by society and family.


Best Wishes for More EffortsBest Wishes for More Efforts

Dr Shyam Ashtekar (MD, Community

Medicine)

21 Cherry Hills Society, Anandwalli, Nashik 422013

[email protected]

Cell +919422271544

Website:

arogyavidya.org,

bharatswasthya.net

A study of Anganwadis and campaign against malnutrition in Maharashtra

For and with support of

Rajmata Jijau State Nutrition Mission (RJMCHN),

August to Dec 2013


child malnutrition decline in maharashtra-1 an overview

Health & Medicine