CHILD MALNUTRITION IN
MAHARASHTRA (INDIA)
AUGUST 2013- JANUARY 2014
Malnutrition in Maharashtra Review
Maharashtra-A
2014
...
THE EFFORTS TO REDUCE MALNUTRITION
IN MAHARASHTRA

The Important 1000 days window
THE IMPORTANT 1000 DAYS’ WINDOW

7 to 12
months, 145

Only Breast
feeding, 180

Malnutrition in Maharashtra Review
Maharas...
IMPROVING

THE AWC

improve it’s attendance.. And then extend the
services to the U2 group also.
This calls for improvemen...
AWARENESS CAMPAIGN

Malnutrition in Maharashtra Review
Maharashtra-A
2014

5
DASHAPADI OR THE TEN IMPORTANT RULES.

Malnutrition in Maharashtra Review
Maharashtra-A
2014

6
TEN RULES FOR
PREVENTING
MALNUTRITION

Institutional
birth and
Breastfeeding
Complete
Immunization

6 m Exclusive
Breastfe...
HEALTH AND NUTRITION OF
ADOLESCENT GIRLS
Malnutrition in Maharashtra Review
Maharashtra-A
2014

Health of adolescent girls...
ANTE NATAL CARE
Early diagnosis of pregnancy, at least 3 medical check ups and

IFA provision for 90 days.

Malnutrition i...
INSTITUTIONAL
CHILDBIRTH
There is an effort to ensure institutional delivery for all cases.

102 ambulance is available in...
THE EFFORT TO IMPROVE BIRTH
WEIGHT
Low Birth Weight was and is a major issue.

districts.
These babies tend to remain unde...
PROMOTING NEONATAL
CARE UNITS-JSSK
PROGRAM

illnesses call for neonatal care units.
The ambulance ensures door to door ser...
EARLY BREAST FEEDING
Need to start breast feeding within the 1st hour of birth.

Mothers need to learn a proper technique ...
EXCLUSIVE BREAST FEEDING
TILL 6 MONTHS.

harmful.
But many families give water, honey, gripe water, extra
milk, baby food ...
HIRKANI KAXA FOR
PROMOTING BREAST
FEEDING .

feeding in all public hospitals and 250 bus
stands
This helped both breast-fe...
BETTER MANAGEMENT OF HOME FEEDING

Malnutrition in Maharashtra Review
Maharashtra-A
2014

More than improving the SNP (sup...
SEMI SOLID FEEDS AFTER 6
MONTHS.
It is time to give semi solid substances like porridge.
The CNSM (Comprehensive Nutrition...
FREQUENT, PROPER FEEDS & FOOD VARIETY.
The baby should get at least 6-8 feeds every day besides breast
feeding. (6 months ...
HYGIENE AND
SANITATION

with open defecation.
This causes infections and triggers malnutrition.

Malnutrition in Maharasht...
MICRO NUTRIENTS
Our meals lack iron, Zinc, Calcium, vitamins.
To ensure this a sachet of Micro Nutrients is

These Micro N...
TAKE HOME RATION (THR)
Younger babies can not attend and sit in the AWC.

3 packets of 1 KG THR are provided for children....
SOME WAYS OF USING THR
In some districts THR is used to prepare popular food

Frying in oil or ghee makes it more energy d...
CRÈCHE
Crèches have been started in some Tribal blocks.

Space is rented ensuring that it has a toilet.
2 women assistants...
CRÈCHE
Malnutrition in Maharashtra-A
Malnutrition in Maharashtra Review 2014

Crèche is a valuable social facility.

A Crè...
RBSK (RASHTRIYA BAL
SWASTHYA KARYAKRAM)
Each block has a RBSK mobile team since 2013.

Has a rented vehicle.
RBSK offers c...
RBSK..
Malnutrition in Maharashtra Review
Maharashtra-A
2014

But the work load implies that it is at least
4-6 months bef...
IMMUNIZATION
AWC has monthly immunization day.

against 6 infections.
Hence immunization is important for prevention of
ma...
A PAGE

Malnutrition in Maharashtra Review
Maharashtra-A
2014

FROM
HEIGHTWEIGHT
TABLE

28
THE USUAL METHOD OF MALNUTRITION DETECTION.

Malnutrition in Maharashtra Review
Maharashtra-A
2014

29
SCREENING FOR MALNUTRITION
Every U 6 Child’s weight is recorded in the AWC every

The weight is plotted on growth charts a...
MALNUTRITION- SUW, SAM, MAM, MUAC ETC.
THE LINE LISTING OF MALNOURISHED CHILDREN IN A PHC AREA

Malnutrition in Maharashtr...
IF THE CHILD IS ALREADY MALNOURISHED..
Malnutrition in Maharashtra Review 2014
Maharashtra-A

We must ensure timely
diagno...
SCREENING OF MALNUTRITION

the 3 methods
Severe wasting ( weight for height )
MUAC less than 11.5 cm.
Foot edema

Malnutri...
NUTRITION REHABILITATION
If the Child is severely malnourished it is
this we have rehab centers at the village or the
heal...
BETTER MONITORING- GEOGRAPHIC INFO SYSTEM
RJMCHN has now has a GIS
system for the entire state.
This GIS is available on
w...
CO-OPERATION OF VARIOUS
SECTORS/DEPARTMENTS
ICDS/AWC

Health Department
RJMCHMN
and Unicef

Malnutrition in Maharashtra Re...
MY ESTIMATION OF MALNUTRITION PREVENTION EFFORTS
201

2020

1 Ante natal care
Safe/Institutional
2 births
Better birth3 we...
BEST WISHES
Dr Shyam Ashtekar (MD, Community Medicine)
21 Cherry Hills Society, Anandwalli,
Nashik 422013
shyamashtekar@ya...
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Declining Child malnutrition in Maharashtra India 2-The Effort

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The ICDS and the nutrition mission focused on a 1000 days window approach, about improving ANC and child care till 2 years much before the child comes to the Anganwadis. This has given dividends!

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Declining Child malnutrition in Maharashtra India 2-The Effort

  1. 1. CHILD MALNUTRITION IN MAHARASHTRA (INDIA) AUGUST 2013- JANUARY 2014 Malnutrition in Maharashtra Review Maharashtra-A 2014 SITUATION, EFFORTS, DECLINE AND CHALLENGES A REVIEW FOR THE STATE NUTRITION MISSION POWERPOINT 2 /6 THE EFFORTS Dr Shyam Ashtekar, MD (Community Med) shyamashtekar@yahoo.com 1
  2. 2. THE EFFORTS TO REDUCE MALNUTRITION IN MAHARASHTRA The Important 1000 days window
  3. 3. THE IMPORTANT 1000 DAYS’ WINDOW 7 to 12 months, 145 Only Breast feeding, 180 Malnutrition in Maharashtra Review Maharashtra-A 2014 2nd Year 365 Pregnancy 300 3
  4. 4. IMPROVING THE AWC improve it’s attendance.. And then extend the services to the U2 group also. This calls for improvement of building, equipment and services. This was the effort. Malnutrition in Maharashtra Review Maharashtra-A 2014 First of all AWC (Anganwadi center) must retain and 4
  5. 5. AWARENESS CAMPAIGN Malnutrition in Maharashtra Review Maharashtra-A 2014 5
  6. 6. DASHAPADI OR THE TEN IMPORTANT RULES. Malnutrition in Maharashtra Review Maharashtra-A 2014 6
  7. 7. TEN RULES FOR PREVENTING MALNUTRITION Institutional birth and Breastfeeding Complete Immunization 6 m Exclusive Breastfeeding Growth monitoringwt/ht/muac Focus on 6m-3y child-nutrition edn of the mother Malnutrition in Maharashtra Review Maharashtra-A 2014 Vit A doses Compliment ary feeding at 6m, 6m Birthday Hand-wash, Micronutrie nts Sachet water safety, Sanitation De-worming, Illness treatment, immunization 7
  8. 8. HEALTH AND NUTRITION OF ADOLESCENT GIRLS Malnutrition in Maharashtra Review Maharashtra-A 2014 Health of adolescent girls is crucial for prevention of future child malnutrition, ALSO her own well being is no less important. Includes health and nutrition education, growth promotion and personality development. a weekly tablet of iron folic acid is given to girls outside school from the AWC At least 3 girls get THR for home use – the utility is not known. 8
  9. 9. ANTE NATAL CARE Early diagnosis of pregnancy, at least 3 medical check ups and IFA provision for 90 days. Malnutrition in Maharashtra Review Maharashtra-A 2014 treatment contacts. Take Home ration provision every month. to improve meals at home. Detecting and action for smaller abdominal size foot-edema or hyper tension, proteins in urine etc. These pregnancies lead to smaller babies. Need to protect and promote health of mother and baby But only 75% pregnant women got the 3 essential visits. 9
  10. 10. INSTITUTIONAL CHILDBIRTH There is an effort to ensure institutional delivery for all cases. 102 ambulance is available in every district. All care medicines for mother and children are free. Mothers also get some incentives for attending institutional delivery. Malnutrition in Maharashtra Review Maharashtra-A 2014 We have JSY program under NRHM for this. Some districts registered 90% institutional delivery rate. ASHA activists help this program. 10
  11. 11. THE EFFORT TO IMPROVE BIRTH WEIGHT Low Birth Weight was and is a major issue. districts. These babies tend to remain underweight. A limited but possible solution is to improve ANC Malnutrition in Maharashtra Review Maharashtra-A 2014 20%-50% babies have low birth weight in various care. (But the LBW is a long term issue) 11
  12. 12. PROMOTING NEONATAL CARE UNITS-JSSK PROGRAM illnesses call for neonatal care units. The ambulance ensures door to door service NICUs have been started in each districts by Health dept..with all free care Follow up services are available Malnutrition in Maharashtra Review Maharashtra-A 2014 Low Birth Weight , prematurity and other neonatal 12
  13. 13. EARLY BREAST FEEDING Need to start breast feeding within the 1st hour of birth. Mothers need to learn a proper technique of breast feeding Need counseling for dispelling wrong concepts about breast feeding. There are special rooms for breast feeding mothers in all hospitals. Malnutrition in Maharashtra Review Maharashtra-A 2014 ASHA & AWC workers offer counseling for this from early stage. However despite all this only 60% babies get timely initiation of breast feeding. 13
  14. 14. EXCLUSIVE BREAST FEEDING TILL 6 MONTHS. harmful. But many families give water, honey, gripe water, extra milk, baby food etc in the state of Maharashtra. This causes infections and triggers malnutrition. Malnutrition in Maharashtra Review Maharashtra-A 2014 No need to give any other feed till 6 months-actually The CNSM survey reports only 58% of exclusive breast feeding. 14
  15. 15. HIRKANI KAXA FOR PROMOTING BREAST FEEDING . feeding in all public hospitals and 250 bus stands This helped both breast-feeding mothers and send the right message to community Malnutrition in Maharashtra Review Maharashtra-A 2014 Promoted separate rooms for breast 15
  16. 16. BETTER MANAGEMENT OF HOME FEEDING Malnutrition in Maharashtra Review Maharashtra-A 2014 More than improving the SNP (supplementary Nutrition Program) in the AWC, It was necessary to Early and Exclusive Breast feeding AND Improve home feeding from 6 months to 6 years. 16
  17. 17. SEMI SOLID FEEDS AFTER 6 MONTHS. It is time to give semi solid substances like porridge. The CNSM (Comprehensive Nutrition Survey of Maharashtra 2012 by IIPS) reports this at 63% --too low. Many children get liquids, milk etc. as supplements; this triggers malnutrition. Malnutrition in Maharashtra Review Maharashtra-A 2014 After 6 months breast feeding is not enough for the baby. 17
  18. 18. FREQUENT, PROPER FEEDS & FOOD VARIETY. The baby should get at least 6-8 feeds every day besides breast feeding. (6 months to 2 years age group.) The CNSM survey reports low compliance on this (10-34%). Malnutrition in Maharashtra Review Maharashtra-A 2014 The feed should include energy dense & proteins , iron and vitamins. Nutrition will not improve unless home feeding improves considerably. The AWC tried to promote this factor through mother education 18
  19. 19. HYGIENE AND SANITATION with open defecation. This causes infections and triggers malnutrition. Malnutrition in Maharashtra Review Maharashtra-A 2014 Use of toilets must improve. But countless villages continue AWC is promoting a hand-wash before feeding the baby and encourage children to do the same. 19
  20. 20. MICRO NUTRIENTS Our meals lack iron, Zinc, Calcium, vitamins. To ensure this a sachet of Micro Nutrients is These Micro Nutrients reduce illnesses and promote growth. However the change of taste has made Micro Nutrients less popular in some districts. Malnutrition in Maharashtra Review Maharashtra-A 2014 added in the daily meals in the AWC 20
  21. 21. TAKE HOME RATION (THR) Younger babies can not attend and sit in the AWC. 3 packets of 1 KG THR are provided for children. At home it is expected that some portion of THR is mixed in hot water or cooked and the child given a feed. But there are complaints about the quality of THR and hence it is discarded or fed to cattle or chicken. Malnutrition in Maharashtra Review Maharashtra-A 2014 THR is meant for this younger group. Other families cook the entire packet and serve it to the entire family. Therefore THR utilization is unsatisfactory. 21
  22. 22. SOME WAYS OF USING THR In some districts THR is used to prepare popular food Frying in oil or ghee makes it more energy dense. Some families have liked this option. But many families have no time for these niceties. Malnutrition in Maharashtra Review Maharashtra-A 2014 items like laddus and sweets. That perpetuates the question mark on THR 22
  23. 23. CRÈCHE Crèches have been started in some Tribal blocks. Space is rented ensuring that it has a toilet. 2 women assistants work on monthly honorarium of Rs. 1600/- each About 10-15 children are served with 4 meals a day in the crèche. The meals are made from THR and some other food-stuff Malnutrition in Maharashtra Review Maharashtra-A 2014 Crèche operates from 9 to 5 in the day time. The AWC Sevika checks Height and weight. The RBSK medical team attends the crèche once in 4 to 6 months. 23
  24. 24. CRÈCHE Malnutrition in Maharashtra-A Malnutrition in Maharashtra Review 2014 Crèche is a valuable social facility. A Crèche ensures a safe baby–sitting with trained workers. This frees the mother for work and leisure. The Crèche service is free. But non tribal areas do not have this facility. We need a larger movement and system management for Crèches everywhere. 24
  25. 25. RBSK (RASHTRIYA BAL SWASTHYA KARYAKRAM) Each block has a RBSK mobile team since 2013. Has a rented vehicle. RBSK offers checkup from infants to adolescence. Malnutrition in Maharashtra Review Maharashtra-A 2014 RBSK has 2 doctors, a nurse & pharmacist RBSK offers treatment/referral for childhood 25 illnesses
  26. 26. RBSK.. Malnutrition in Maharashtra Review Maharashtra-A 2014 But the work load implies that it is at least 4-6 months before the next visit. The RBSK generates lot of useful data but this must be put online for better research. 26
  27. 27. IMMUNIZATION AWC has monthly immunization day. against 6 infections. Hence immunization is important for prevention of malnutrition. Malnutrition in Maharashtra Review Maharashtra-A 2014 Complete immunization protection of the child Measles was especially linked to malnutrition 27
  28. 28. A PAGE Malnutrition in Maharashtra Review Maharashtra-A 2014 FROM HEIGHTWEIGHT TABLE 28
  29. 29. THE USUAL METHOD OF MALNUTRITION DETECTION. Malnutrition in Maharashtra Review Maharashtra-A 2014 29
  30. 30. SCREENING FOR MALNUTRITION Every U 6 Child’s weight is recorded in the AWC every The weight is plotted on growth charts against the age in months. This helps in grading of nutrition. About 8-10% children are malnourished in the state. Severely underweight child is rare in non tribal areas. Height is measured every three months to check Malnutrition in Maharashtra Review Maharashtra-A 2014 month. wasting with wt-height table 30
  31. 31. MALNUTRITION- SUW, SAM, MAM, MUAC ETC. THE LINE LISTING OF MALNOURISHED CHILDREN IN A PHC AREA Malnutrition in Maharashtra Review Maharashtra-A 2014 31
  32. 32. IF THE CHILD IS ALREADY MALNOURISHED.. Malnutrition in Maharashtra Review 2014 Maharashtra-A We must ensure timely diagnosis and timely treatment. The AWC and RBSK do this by screening every baby Children with MN are referred for rehab. 32
  33. 33. SCREENING OF MALNUTRITION the 3 methods Severe wasting ( weight for height ) MUAC less than 11.5 cm. Foot edema Malnutrition in Maharashtra Review 2014 Maharashtra-A Severe Malnutrition is decided by one of 33
  34. 34. NUTRITION REHABILITATION If the Child is severely malnourished it is this we have rehab centers at the village or the health center or the block or District hospital. Malnutrition in Maharashtra Review 2014 Maharashtra-A necessary to start the management early. For 34
  35. 35. BETTER MONITORING- GEOGRAPHIC INFO SYSTEM RJMCHN has now has 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 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. Malnutrition in Maharashtra-A Review 2014 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 process and outcome indicators We can generate about 1500 reports from this data It also provides camera sites for physical verification at each AWC 35
  36. 36. CO-OPERATION OF VARIOUS SECTORS/DEPARTMENTS ICDS/AWC Health Department RJMCHMN and Unicef Malnutrition in Maharashtra Review Maharashtra-A 2014 Tribal Development 36
  37. 37. MY ESTIMATION OF MALNUTRITION PREVENTION EFFORTS 201 2020 1 Ante natal care Safe/Institutional 2 births Better birth3 weight Early 4 Breastfeeding Exclusive breastfeeding till 5 6m Complimentary 6 feeding after 6m 80 95 63 95 7 Immunization 69 95 8 Micronutrients Treatment of 9 illnesses 50 95 60 90 10 Hygiene 50 90 87 1 0 95 70 1 80 9 60 90 59 100 90 80 70 60 50 40 30 20 10 0 2 3 90 8 4 7 Malnutrition in Maharashtra Review Maharashtra-A 2014 Necessary efforts 5 6 37 Necessary efforts 2012 2020
  38. 38. BEST WISHES 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 Mission, August to Dec 2013 38 Malnutrition in Maharashtra-A Review 2014

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