0
Child Malnutrition inChild Malnutrition in
Maharashtra (India)Maharashtra (India)
August 2013August 2013-- January 2014Jan...
PPT1/6PPT1/6
2006
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 conte...
Background and contextBackground and context
There is discussion of 40-50% Child
malnutrition in India
Similar issues are ...
We should discuss facts and causes.. RatherWe should discuss facts and causes.. Rather
than images..than images..
25
30
35...
The pyramidThe pyramid
of Causesof Causes Some Child
Deaths
Vicious Cycle of Malnutrition
and
Child deaths, 20-30%
Malnutr...
CNSM Survey Statistics (2012)CNSM Survey Statistics (2012)
The CNSM Survey by IIPS
Mumbai (2012) shows
reduction in child ...
Comparison of 3 surveys: 2006 to 2012Comparison of 3 surveys: 2006 to 2012
Children 0-23
months
NFHS3
(U+R)
2005-6
IIPS CN...
Statewise Malnutrition NNMB 2012-Survey
State Underweight Stunting Wasting
Kerala 20.8 23.4 16.4
TN 28.6 21.7 26.4
Maharas...
Comparison of states on ChildComparison of states on Child
Malnutrition NNMB 2012Malnutrition NNMB 2012--
30
40
50
60
Maln...
Comparison of CNSM &Comparison of CNSM & NNMB SurveysNNMB Surveys
NNMB Survey is limited to rural areas.
Here we compared ...
The CNSM Survey is more reliableThe CNSM Survey is more reliable
IIPS conducted the NFHS Survey 1-2-3
in India
The sample ...
CNSMCNSM --ObservationObservation & Comments& Comments
Child Malnutrition in Maharashtra has dropped in
comparison to 2005...
CNSM:BoysCNSM:Boys & Girls& Girls
Nutrition indices for girls look better than those of
boys
Girls and boys show a MN prop...
CNSMCNSM--Neonatal CareNeonatal Care
The proportion of newborn
babies that received breast
feeding in the first hour rosef...
CNSMCNSM--Care of the young child (0Care of the young child (0--2Y)2Y)
Semi solid or solid feeds were given
between 6-8 mo...
CNSMCNSM --Care after 6Care after 6
monthsmonths
Feeding and care after 6 months is a weak area.
Only about 77 % of babies...
Immunization & micronutrientsImmunization & micronutrients
In the last 6 months 48% babies got
a Dose of vitamin A, this i...
Health and Nutrition of MothersHealth and Nutrition of Mothers
Maternal Health care has improved.
AN Care, IFA supplement ...
CNSMCNSM --Women’s BMI is lowWomen’s BMI is low
The proportion of wasting women
(BMI less than 18.5) has dropped
by just 1...
CNSMCNSM --Low Birth WeightLow Birth Weight
The proportion of low birth weight babies has
somewhat reduced. But these figu...
Known facts: Maharashtra’s Map ofKnown facts: Maharashtra’s Map of
MalnutritionMalnutrition
Malnutrition in maharashtra-A ...
ICDS data: Blocks/Projects with highICDS data: Blocks/Projects with high
burden of Malnutrition (July 2013burden of Malnut...
Social context ofSocial context of Malnutrition (1)Malnutrition (1)
There is more Malnutrition is some tribal districts
es...
Social context of Malnutrition (2)Social context of Malnutrition (2)
Some tribes may be more malnourished than
others but ...
Malnutrition and Age groupMalnutrition and Age group
About 20-30% babies in Maharashtra are born with less
weight (2.5Kg o...
Malnutrition in 2Malnutrition in 2--5 age group5 age group
The children attending AW are in age group of 36 to 60/72
month...
Other context of malnutrition
Migration for employment is a major
challenge, despite MNREGA.
In some blocks communication ...
Food Security and Child MalnutritionFood Security and Child Malnutrition
It is difficult to connect child Malnutrition
to ...
Lack of Proteins, Vitamins & MineralsLack of Proteins, Vitamins & Minerals
But the lack of
proteins, vitamins and
minerals...
(B) MAHARASHTRA’S(B) MAHARASHTRA’S
EFFORTSEFFORTSEFFORTSEFFORTS
Malnutrition in maharashtra-A Review Jan
2014 31
Focus on theFocus on the
AnganwadiAnganwadi CenterCenter
(AWC)(AWC)
The State of Maharashtra1.07 lakh AWCs, including
mini...
Improving the AWCImproving the AWC
Supplementary feeding is only one of the tasks of AWC
AWC should provide 25 to 30% of f...
Improving AWC: MIS to GISImproving AWC: MIS to GIS
The survey statistics of nutrition of AWC and
growth was not very relia...
The MN statistics of AWCsThe MN statistics of AWCs
The ICDS website (http://www.icds.gov.in/# ) offers
the monthly progres...
Monthly Progress ReportMonthly Progress Report –– A sampleA sample
Malnutrition in maharashtra-A Review Jan
2014 36
The Geographic Information SystemThe Geographic Information System
RJMCHN has now established
a GIS system for the entire
...
ICDS and Rajmata Jijau MissionICDS and Rajmata Jijau Mission
ICDS and RJMCHM together are working on
reducing malnutrition...
Dr Arole Committee ReportDr Arole Committee Report
The Non Governmental Members
Committee under Dr. Rajanikant Arole
appoi...
The important 1000 days’ window for theThe important 1000 days’ window for the
childchild..
About 270 days of pregnancy an...
Ten rules for preventingTen rules for preventing
malnutritionmalnutritionInstitutional
birth and
Breastfeeding
6 m Exclusi...
Chief Minister’s 5 pointChief Minister’s 5 point ProgramProgram
1. Ensuring health & nutrition of adolescent girls.
2. Eff...
Child deaths due to MalnutritionChild deaths due to Malnutrition
Malnutrition triggers child deaths.
About 20-25% child de...
TThe challengehe challenge
The CNSM study reports decline in
malnutrition in Maharashtra.
But there are tough challenges a...
Best Wishes for More EffortsBest Wishes for More Efforts
Dr Shyam Ashtekar (MD, Community
Medicine)
21 Cherry Hills Societ...
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Child Malnutrition Decline in Maharashtra-1 An Overview

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Malnutrition dropped-esp UW and stunting- in U2 children in Maharashtra as per CNSM surveys 2012. It is only a beginning. But there are challenges ahead, including cultural,socio-economic, women-health, nutrition and child care.

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  1. 1. Child Malnutrition inChild Malnutrition in Maharashtra (India)Maharashtra (India) August 2013August 2013-- January 2014January 2014 Situation, Efforts, Decline and ChallengesSituation, Efforts, Decline and Challenges A ReviewA ReviewA ReviewA 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) shyamashtekar@yahoo.com
  2. 2. PPT1/6PPT1/6 2006 PPT1/6PPT1/6 AN OVERVIEWAN OVERVIEW 200 to 2013
  3. 3. (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
  4. 4. 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 ? Malnutrition in maharashtra-A Review Jan 2014 4
  5. 5. We should discuss facts and causes.. RatherWe 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 Malnutrition in maharashtra-A Review Jan 2014 5
  6. 6. The pyramidThe 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. Malnutrition in maharashtra-A Review Jan 2014 6 Low BMI inWomen 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.
  7. 7. 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. Malnutrition in maharashtra-A Review Jan 2014 7 0 5 10 15 Under Wt by age(- 2SD) Stunting (- 2SD) Wasting (- 2SD)
  8. 8. 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 Malnutrition in maharashtra-A Review Jan 2014 8 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
  9. 9. Statewise Malnutrition NNMB 2012-Survey State Underweight Stunting Wasting Kerala 20.8 23.4 16.4 TN 28.6 21.7 26.4 Maharashtra 31.5 43.9 15 AP 31.7 42.9 14.1 Malnutrition in maharashtra-A Review Jan 2014 9 AP 31.7 42.9 14.1 Karnataka 35.6 36.7 20.7 WB 35.6 40.6 21.4 Pooled 37.7 41.3 22.3 Orissa 40.3 47.3 18.2 UP 47.8 44.9 31.7 Gujarat 48.4 54.9 27.7 MP 51.4 48.7 33
  10. 10. Comparison of states on ChildComparison of states on Child Malnutrition NNMB 2012Malnutrition NNMB 2012-- 30 40 50 60 Malnutrition in maharashtra-A Review Jan 2014 10 0 10 20 30 UnderWeight Stunting Wasting
  11. 11. 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 Malnutrition in maharashtra-A Review Jan 2014 11
  12. 12. 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 1322The 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
  13. 13. CNSMCNSM --ObservationObservation & 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) Malnutrition in maharashtra-A Review Jan 2014 13
  14. 14. 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. Malnutrition in maharashtra-A Review Jan 2014 14
  15. 15. CNSMCNSM--Neonatal CareNeonatal Care The proportion of newborn babies that received breast feeding in the first hour rosefeeding in the first hour rose from 52% to 60%. Conversely 40% newborns don't get early breast feeding. Malnutrition in maharashtra-A Review Jan 2014 15
  16. 16. 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.. Malnutrition in maharashtra-A Review Jan 2014 16
  17. 17. CNSMCNSM --Care after 6Care 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. Malnutrition in maharashtra-A Review Jan 2014 17
  18. 18. 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% Malnutrition in maharashtra-A Review Jan 2014 18
  19. 19. 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. Malnutrition in maharashtra-A Review Jan 2014 19
  20. 20. CNSMCNSM --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) Malnutrition in maharashtra-A Review Jan 2014 20
  21. 21. CNSMCNSM --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. Malnutrition in maharashtra-A Review Jan 2014 21
  22. 22. Known facts: Maharashtra’s Map ofKnown facts: Maharashtra’s Map of MalnutritionMalnutrition Malnutrition in maharashtra-A Review Jan 2014 22
  23. 23. ICDS data: Blocks/Projects with highICDS data: Blocks/Projects with high burden of Malnutrition (July 2013burden of Malnutrition (July 2013)) Malnutrition in maharashtra-A Review Jan 2014 23
  24. 24. Social context ofSocial 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. Malnutrition in maharashtra-A Review Jan 2014 24
  25. 25. 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 ScheduledPossibly 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 in maharashtra-A Review Jan 2014 25
  26. 26. 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 maharashtra-A Review Jan 2014 26
  27. 27. 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. Malnutrition in maharashtra-A Review Jan 2014 27
  28. 28. 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 . Foodserious 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. Malnutrition in maharashtra-A Review Jan 2014 28
  29. 29. 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 inMaharashtra state of today, except in some tribal parts. Employment, PDS, and local agro produce usually ensure food grain availability even in difficult areas. Malnutrition in maharashtra-A Review Jan 2014 29
  30. 30. 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. Malnutrition in maharashtra-A Review Jan 2014 30
  31. 31. (B) MAHARASHTRA’S(B) MAHARASHTRA’S EFFORTSEFFORTSEFFORTSEFFORTS Malnutrition in maharashtra-A Review Jan 2014 31
  32. 32. Focus on theFocus on the AnganwadiAnganwadi CenterCenter (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. Malnutrition in maharashtra-A Review Jan 2014 32
  33. 33. Improving the AWCImproving 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 Malnutrition in maharashtra-A Review Jan 2014 33
  34. 34. 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 levelslevels 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 Malnutrition in maharashtra-A Review Jan 2014 34
  35. 35. 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. Malnutrition in maharashtra-A Review Jan 2014 35
  36. 36. Monthly Progress ReportMonthly Progress Report –– A sampleA sample Malnutrition in maharashtra-A Review Jan 2014 36
  37. 37. 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 bothboxes 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 Sangram software 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 Malnutrition in maharashtra-A Review Jan 2014 37
  38. 38. ICDS and Rajmata Jijau MissionICDS and Rajmata Jijau Mission ICDS and RJMCHM together are working on reducing malnutrition The RJMCHM offers technical assistance and isThe 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
  39. 39. Dr Arole Committee ReportDr Arole Committee Report The Non Governmental Members Committee under Dr. Rajanikant Arole appointed by Dr the Hon High Courtappointed by Dr the Hon High Court worked on this issue from 2008 to 2011. The Report has been submitted to the Govt. in 2013 Malnutrition in maharashtra-A Review Jan 2014 39
  40. 40. The important 1000 days’ window for theThe 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. Malnutrition in maharashtra-A Review Jan 2014 40
  41. 41. Ten rules for preventingTen rules for preventing malnutritionmalnutritionInstitutional birth and Breastfeeding 6 m Exclusive Breastfeeding Complimentar y 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, immuniz ation Handwash, water safety, Sanitation Growth monitoring- wt/ht//MUAC 3/16/2014 महारा ातले कु पोषण नमूलनाचे व वध य न--डॉ शाम अ टेकर- 41
  42. 42. 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 Malnutrition in maharashtra-A Review Jan 2014 42
  43. 43. 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 orimportant 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. Malnutrition in maharashtra-A Review Jan 2014 43
  44. 44. 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. Malnutrition in maharashtra-A Review Jan 2014 44
  45. 45. Best Wishes for More EffortsBest Wishes for More Efforts Dr Shyam Ashtekar (MD, Community Medicine) 21 Cherry Hills Society, Anandwalli, Nashik 422013 shyamashtekar@yahoo.com 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 Malnutrition in maharashtra-A Review Jan 2014 45
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