Introduction

As a result of the social welfare orientedgovernment policy for over five decades, Sri Lanka has awellestablished,extensivenetworkoffreehealthcarefacilities accessible to all citizens across the country.Extensivemanpowerforhealth,welltrainedpublichealthpersonnelwithanorientationtowardscommunityhealthandnutritionhaveresultedinimprovementinnutritionofcommunitiesinduringthepastthreedecades.Thewellestablishedpreventivecaresystem,whichhaswithstoodmany years of civil conflict and the high literacy rate

Maternal&childnutrition:theSriLankanperspective

AngeladeSilva,A.M.A.S.B.Mahamithawa*&ChandraniPiyasena**

Faculty of Medicine, University of Colombo, Sri Lanka and Nutrition Society of Sri Lanka, *Nutrition Coordination Division, Ministry of Health and Nutrition Society of Sri Lanka & **Nutrition Unit Medical Research Institute, Ministry of Health and Nutrition Society of Sri Lanka

ReceivedApril24,2009

Most improvements gained during the past two decades in maternal and child nutrition can be attributed to the successful, countrywide maternal and child health programme of the Ministry of Health, Sri Lanka. Other supporting programmes to combat deficiencies of individual micronutrients have also contributed significantly. As the latest Demographic and Health Survey (DHS) data have shown regional disparities in nutrition status, it indicates that more effort is needed to improve nutrition status of marginalized populations. A National Nutrition Policy and strategic plan of Sri Lanka is being formulated and new evidence based nutrition strategies are being promoted or planned in keeping with national policies on nutrition. More emphasis is being placed on inter-sectoral co-operation, essential for poverty alleviation and food security which would improve nutrition status of marginalized groups. A newly established nutrition surveillance system is an example where inter-sectoral co-operation has been successful. Feedback data from surveillance will be used to monitor and evaluate the progress of nutrition interventions. With the greater emphasis on poverty alleviation and food production, sensitization of non health sectors and better strategic interventions for nutritionally vulnerable populations, Sri Lanka is hopeful of achieving further improvements in nutritional status of its population.

Key wordsChild-intervention-mother-nutrition-SriLanka

of thepopulation(male;97%,female;95%)mayberegarded as key factors behind the impressive healthandsocialindicators1.Mostbasichealthindicatorsarebetter than inothercountrieswithacomparableGDP(grossdomesticproduct);infantmortality:13per1,000live births, maternal mortality rate: 44.3 per 100,000livebirths,lifeexpectancy;71.7years(males),77years(females)2. A recent report concluded that Sri Lankawasontracktoachieveseveralofthehealthmillenuimdevelopmentgoals(MDGs)3.Educationhasalsoledtoempowermentofwomenandimprovementinnutritionstatusofthepopulation.

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Nutritional status

Theproblemsofpoornutritionstatusareyetprevalentin some areas. The nutritional status of vulnerablepopulations is not in keeping with other outstandinghealth and social indicators4. Though a remarkableimprovement in nutrition indicators occurred between1993and2000,advancesinnutritionstatusofwomenand children between the years 2000 to 2007 havebeenslower4-6.Theprevalenceoflowbirthweighthasimprovedto16.6percent4fromthelastDemographicandHealthSurvey(DHS)in20006.Thecurrentprevalenceof underweight among children under five is 22 per cent, with 18 per cent being stunted and 15 per cent beingacutelymalnourished/wasted4.TherecentDHSsurveyalso reports that the highest prevalence of stuntingwasinthe18-23monthagegroup4.Themoststrikingfeature of these prevalence figures are the regional disparities. Though improvement in malnutrition hasoccurred in urban areas (Western Province), high levels ofmalnutritionarereportedfromtheestatesectorwithisolatedandremoteregionsandsomeruralareas4.

Three micronutrient deficiencies are identified as public health problems, namely iron, vitamin A andiodine. Iodine deficiency has been addressed by salt iodization with > 90 per cent of households havingaccess to iodised salt by 20057. The prevalence ofvitamin A deficiency among children is 29 per cent, and a similar proportion is affected by iron deficiency8,9.Approximately 30 per cent of pregnant mothers areanaemic,leadingtoanincreasedriskoflowbirthweightbabiesandotherpregnancyrelatedcomplications8. While undernutrition is a problem in rural and estate areas,paradoxically, urbanization has resulted in nutritiontransition, challenging the healthcare system to meetnewdemands.Changeinfoodhabits,astressfullifestyleandlackofphysicalactivityatallstagesoflifehaveledtotheemergingproblemsofoverweightandobesity10.Theparadigmshiftisseenparticularlyamongchildrenin urban areas, causing a risk of increase in lifestylerelateddiseasessuchasdiabetesmellitus.TheMinistryofHealthcareandNutritionhascreatedaDirectorateforNon Communicable Diseases which aims to promotea national behaviour change, including promotion ofnutritionally healthy foods and lifestyle modification.

Nutrition related interventions

Thedisparitybetweenotherhealthindicatorsandnutritionstatushashighlighted theneed for targeted,high impact nutrition interventions for differentregions. The main strategy implemented to improvenutrition is the comprehensive maternal and child

healthcare(MCH)packagewhichfocusesonpregnantandlactatingmothersandyoungchildren.

Supplementation

Nutritionalcareforpregnantandlactatingwomenincludes supplementation of iron, folic acid andcalcium, and food supplementation in the form of apre-cookedreadytoeatfood,Thriposha.Thriposhaisalocallymanufacturedfoodsupplementofmaizeandsoyawithmineralsandvitamins.ThetargetgroupsforThriposha include all pregnant women and lactatingmothers up to six months after delivery, infants andpreschoolers identified with growth faltering and hospitalizedchildrenwithgrowthfaltering.

Promotion of breastfeeding, complementary feeding, growth monitoring and promotion

The breastfeeding code, which was brought intoeffectin1983,ensuresthatmaternityandbreastfeedingbenefits are offered to mothers in all sectors of life11.Thecodehasalsobeeneffectiveinregulatingthesaleofbreastmilksubstitutes.Somehospitalsaredesignatedas “Baby Friendly Hospitals” and promote a cultureof exclusive breastfeeding. Promotion of exclusivebreastfeeding, advice on complementary feeding andgrowth monitoring of children under five years and promotionandsupplementaryfeedingandreferralofchildrenwithgrowthfalteringaretheactivitiesdirectedatimprovingnutritionofyoungchildren.

Theanaemiacontrolprogrammeincludesweeklydistribution of iron and vitamin C tablets to schoolgirlsover10yrofage,nutritioneducationpromotingconsumptionofironrichfoods,provisionofironfolateandvitaminCsupplementsduringpregnancyandpostpartumarethemainactivities.

The vitamin A deficiency control programme includes a combination of promoting consumption ofvitaminAcontainingfoodsandahighdosevitaminAsupplementationschedule.However,thecoveragedatafrom the field indicate that coverage is relatively low (57%), leading to persistent vitamin A deficiency.

With the salt iodisation programme Sri Lanka has achieved>90percentcoverageofsaltiodization(since2001),aremarkableachievementinashortperiodoftimeleadingtoreductionintheprevalenceofgoiter12.

Theseprogramstargetchildrenwithglassofmilkand school meal programs target children from lowincomefamiliesandhavebeeninitiatedinsomeareas.Itishopedthatincreasedschoolattendancewouldleadtobreakingthecycleofmalnutritionandpoverty.

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Reprint requests:DrChandraniPiyasena,Head,NutritionDepartmentMedicalResearchInstitution,MinistryofHealthcareNutritionandUvaMellassaDevelopment,385,SuvasiripayaColombo10,SriLanka

e-mail: chandrani4@hotmail.com

Under thePoshanaMallaprogramme initiated in2006,abasketoffoodconsistingofessentialitemsisdistributed to the most needy pregnant mothers.Thecoverageofareasinthisprogrammeisincreasingyearlyandaimstotargetthemostfoodinsecuregroups.Current/new approaches Several new nutrition intervention strategies andscalingupofexistingstrategiesarebeingplannedwithmore emphasis on targeting specific populations and sectors. Increased coverage and better targetingwith nutrition education programmes for sustainableimprovementsinnutrition,nutritionalsupplements,foodsupplementation programmes such as Thriposha, anadolescentnutritionprogrammeaimedatprepregnantagegroup,aresomeoftheplannedstrategiesaimingtotargetvulnerablegroupsinthepopulation.Anotherstrategyistheimplementationofanintegratednutritionpackagetoimprovenutritionalstatusthroughoutthelifecycle.Future responses The Ministry of Healthcare and Nutrition isformulating a National Nutrition Policy which willfunctionas thebasisuponwhichstrategiesandactionplans will be developed. The Nutrition policy hasfocusedattentiononoptimumnutritionthroughoutthelifecycle, enhancing capacity to develop effective andappropriateinterventions,effectivedeliveryofadequatenutrition interventions to vulnerable populations, foodand nutrition security to all citizens, strengthening ofadvocacy, partnerships and networking, strengtheningof research capacity and monitoring and evaluation.Thesepolicydecisionswouldbeimplementedthroughnational,provincialanddistrictlevelcommitteeswherethere would be participation from other sectors suchas planning, education, agriculture, livestock, povertyalleviation, child development, trade and commercesectors and communities. An integrated nutritionpackage has been launched in March 2009 in five of the most vunerable districts of Sri Lanka, targetingpregnant women, children under five, school children andadolescents.Thiscomprehensivepackageincludesbehaviour change communication training, multiplemicronutrient fortification for young children and growthmonitoringandpromotion. Establishment and implementation of NationalNutritionSurveillanceSystemisanotherstrategythatwillenhancequalityofserviceprovisionsincetheinformationbasewillprovidedataontimelyandappropriatetargetingofnutritioninterventions.Thesurveillancesystemwill

providedataonaregularbasisonnutritionalstatusandits determinants at divisional, district, provincial andcentral levels. In future,policymakers andplanners atdifferentlevelsofthehealthsystemwouldbeabletousethesedatatoplanandmanagetheirprogrammes.

Conclusion With the newly revamped food production drive, sensitization of non health sectors, better strategicinterventionsfornutritionallyvulnerablepopulations,SriLankaishopefultoachieveimprovednutritionalstatusinthenearfuture.Sustainedcommitmentandadequateinvestmentintermsoftechnologyandimplementationofevidencebasedstrategiesandcomprehensiveevaluationof programmes by the government and developmentpartnerswillnodoubtachieveimprovementsinnutritionofmotherandchild.

References1. NationalLiteracyPolicies,SriLanka,UNESCoInstitutefor

Statistics 2000. Available at http://www.accu.or.jp/litdbase/policy/lka/index.htm,accessedonSeptember11,2008.

2. AnnualHealthBulletin2005,MinistryofHealth,SriLanka.3. Malnutrition in Sri Lanka. Scale, Scope, Causes and Potential

Response.HealthNutritionandPopulation,HumanDevelopmentNetwork, Human Development Unit, South Asia Region,Washington DC, USA: The World Bank; September 2007.

4. DepartmentofCensusandStatistics.SriLankaDemographicandHealthSurvey2006Colombo,SriLanka.DepartmentofCensusandStatisticsincollaborationwithMinistryofHealth,SriLanka;(2007).

5. DepartmentofCensusandStatistics.SriLankaDemographicandHealthSurvey1993Colombo,SriLanka.DepartmentofCensusandStatisticsincollaborationwithMinistryofHealth,SriLanka;1996.

6. DepartmentofCensusandStatistics.SriLankaDemographicandHealthSurvey2000Colombo,SriLanka.DepartmentofCensusandStatisticsincollaborationwithMinistryofHealth,SriLanka;2002.

7. MedicalResearchInstitute2005,MinistryofHealth,ColomboSriLanka.

8. vitamin A deficiency status of children in Sri Lanka 1995/96. Colombo,SriLanka;MedicalResearchInstitute,MinistryofHealthandIndigenousMedicine;1996.

9. PiyasenaC,MahamithawaAMASB.Assessmentofanaemicstatus in Sri Lanka. Colombo, Sri Lanka; Medical researchInstitute,DepartmentofHealthServices;2003.

10. Wickremasinghe vP, Lamabadusuriya SP, Atapattu N, Sathyadas G, Kuruparanatha S, Karunarathne P. NutritionalstatusofchildreninanurbanareaofSriLanka.Ceylon Med J 2004;49 :114-8.

11. Code for the promotion of breastfeeding and marketing ofbreastmilksubstitutesandrelatedproductsSriLanka;1983.

12. National Iodine Deficiency Disorder Survey, MRI, Colombo: MinistryofHealth,SriLanka,2005.

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