This document is a literature review analyzing the nutritional status of women aged 15-44 in Bihar, India from 1998-2014. It finds that 45% of women in Bihar are malnourished based on their body mass index. Anemia prevalence is severe at 60-75% and maternal mortality is high at 261 deaths per 100,000 live births. The literature review explores factors contributing to poor nutrition such as gender discrimination, poverty, and lack of education. It recommends accelerating nutrition programs, improving social conditions, and enforcing laws against gender discrimination to help achieve nutrition-related Millennium Development Goals.

1. TERM PAPER
A literature review of nutritional status of women in reproductive age group in Bihar:1998 to 2014
Manasvini Vimal Kumar
Student ID-1637545
25 July 2014
MADS 6643
COMMUNITY NEEDS ASSESSMENT and QUALITY ANALYSIS
Prof. ASHRAF MOHAMMED, Ph. D
FAIRLEIGH DICKINSON UNIVERSITY
VANCOUVER, BC

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Table of Contents
Topic Page Number
Abstract 3
Introduction 4
Aim, Objective and Purpose 5
Method/ Document Review/ Literature Review 5-9
Results 9
Limitations 10
Discussion 11
Conclusion 11
Recommendations 12
References 13-16
Acknowledgements 17

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Title: A literature review of nutritional status of women in reproductive age group in
Bihar:1998 to 2014
Abstract: The focus of this literature review is to find out the nutritional status of women in
reproductive age group, 15-44 years, in Bihar over the past 15 years. The status is reviewed on
the basis of Body Mass Index, Maternal Mortality Rate, Number of cases of Intrauterine Growth
Retardation, data on micronutrient deficiencies, Female literacy rate and the burden of disease
due to malnutrition in the state. The literature review was done by exploring information in
articles, government publications, journals, and reliable websites. In the results and discussion it
is mentioned how poorly the state of Bihar has been performing in terms of women's nutritional
status over the years and recommendations within the scope of literature review have been listed
that are bi-fold. It is important to address the issue from a medical and a social point of view,
especially with the need for education underpinning everything else. The major limitation of this
study is that consolidated data for comparison of nutritional status over the years is not available
so the amount of progress could not been determined.
Keywords: Malnutrition, Bihar, Women, Maternal Mortality Rate, Micronutrients, Millennium
Development Goals, Reproductive age

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Introduction:
Malnutrition in Indian women has been a growing health concern in the past few years and
although a lot is being done in the field, we are nowhere near reaching the fifth Millennium
Development Goal yet (Central Statistical Organization, 2009, page 61). Malnutrition for women
is defined as ''The condition that occurs when your body does not get enough nutrients (Medline
Plus, 2014).'' For women, it is given as a measurement of body mass index (Blossner & Onis,
2014). The nutritional status of women in the reproductive age group is important because it is
an attributable factor towards Maternal Mortality Rate, Intra Uterine Growth Retardation and
poor pregnancy outcomes (King , 2003). Lower than required levels of iron and folate lead to
preterm deliveries and poor pregnancy outcome (King, 2003). It is estimated that in africa and
Asia , 27-51% of women in the reproductive age group are underweight and 130 million children
were being estimated to be underweight in 2005 due to maternal malnutrition (Onis et.al, 2004 in
Blossner & Onis, 2014). According to a WHO report, 12.42% of neonatal deaths are attributed to
poor maternal nutrition where maternal BMI is less than/equal to 20kg/m 2
in the age group of
15-29 years and 12.13% in the age group of 30-44 years (age of the mother) (Blossner & Onis,
2005. page 31).
However, despite the availability of the knowledge and statistics about nutritional status
of women, Bihar is still lagging behind in reaching the MDG of 2015.The MMR, for the state,
given in 2007-09 was 261/100,000 (most recent available) and to fulfill the MDG (for whole
country), it should be 109/100, 000 live births in 2015 (Office of the Registrar General , 2011).
This is the gap in the process and since maternal nutrition is so vital, that good nutrition can save
thousands of lives and result in much better outcomes of pregnancy, hence, it is imperative to fill
in this gap. Since this is just a literature review, not much can be written about the approach to

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address the gap here. Nevertheless, it is felt that educating the masses and rigorous interventions
to address poor maternal nutrition in Bihar would go a long way in solving this problem.
Literature review: Since this paper is basically just a review of the available research, with no
actual empirical study being done, hence, this section will be covered under Methods below.
Aim: To assess the nutritional status and estimate the burden of disease caused by malnutrition,
in women and of reproductive age group in Bihar from 2009-13.
Objectives:
1. To estimate the average Body Mass Index of women in Bihar
2. To estimate the Maternal Mortality Rates of women in Bihar
3. To estimate the numbers of children born premature due to maternal malnutrition
4. To estimate the numbers of children with Intrauterine Growth Retardation due to maternal
malnutrition
5. To estimate the burden of disease in terms of Disability Adjusted Life Years of women in
Bihar.
Purpose: To understand the gap and necessary steps that must be taken in order to reach the
Millennium Development Goal of 2015, which is To reduce the MMR to 109/100,000 live births
by 2015 (Office of Registrar General of India, 2011).
Method/Literature review/Data Review:
This is an exploratory analysis of a substantial portion of a wide database of research available
online, done previously in the form of journal articles, reports by state and central governments,

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reliable websites like that of The WHO and so on. Data primarily pertaining to the objectives
stated above will be explored. This data has mostly been obtained through empirical research and
systematic randomization has been done in the studies chosen.
Social determinants of Malnutrition in Bihar
1. Gender discrimination -females are not fed well enough (Ramani & D' Souza, 2006).
2. Caste system-prevalence is higher in scheduled castes and scheduled tribes (Ramani & D'
Souza, 2006)
3. Poverty- malnourished people cannot work well, leading to lesser income and hence poorer
health (Ramani & D' Souza, 2006)
4. Illiteracy and early marriages- The girl child is not wanted and therefore still considered a
liability. So, not much is spent on her education and she is married away as soon as possible. A
young teenager, is often seen a mother already- speaking for her poor nutritional status
(UNICEF, 2014).
5. Lack of contraceptive use- 24.6 million couples in India do not use contraception, despite thet
fact that they do not require more children (Coonrod, 1998).
Other causes-
1. Environmental- crop failure, floods, access cut from cities, highways causing lack of transport
of food (Giri, 2007).
2. Repeated unwanted pregnancies and unsafe abortions- cause chronic malnutrition due to loss
of blood and consequent iron deficiency anemia (Velkoff & Adlakha, 1998).
3. Few institutional deliveries, poor antenatal and paranatal care (Velkoff & Adlakha, 1998).
4. Dietary habits- people used to having more rice suffer from thiamine deficiency
(WHO, 1999).

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5. Micronutrient deficiencies in soil -Calcareous soil in Bihar is severely lacking in zinc and
Boron (Singh, 2004).
6. Poor water supply, leading to diarrhea and infections and therefore dehydration
7. Parasitic diseases causing anemia and micronutrient deficiency
Indices used to measure nutritional status:
1.Anthropometric indicator of malnutrition-
A. Body Mass Index- is body weight in kilograms divided by the square of the body height in
meters (National Institute of Health, 2014).
According to National Family Health Survey, for women:
BMI = 18.5 is the lower limit of normal range and
BMI =25 is the upper limit.
< 18.5 considered as undernourished
> 25 is considered as over nourished
17.0-18.4 is mildly thin
<17.0 is moderately/severely thin. (NFHS, 2005-06).
Definition of malnutrition-
Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it
also refers to overnutrition. People are malnourished if their diet does not provide adequate calories
and protein for growth and maintenance or they are unable to fully utilize the food they eat due
to illness (undernutrition). They are also malnourished if they consume too many calories
(overnutrition)(UNICEF, 2006).
Finding- Malnutrition among women of Bihar: 45% of women in Bihar (NFHS, 2005-06)
2.Biochemical indicator of malnutrition:
A. Anemia definition by WHO:- "Anemia is a condition in which the number of red blood cells
or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age,
sex, altitude, smoking, and pregnancy status (WHO, 2014)."
1.Finding-60-75% women in Bihar suffer with anemia -i.e. severe prevalence (NFHS, 2005-06)

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3.Clinical Indicators of Malnutrition:
Prevalence of micronutrient deficiency (diseases like) Thiamine, Niacin, Riboflavin, deficiency,
Scurvy, Rickets, Nightblindness, Xerophthalmia (Unite for Sight, 2013).
4.Maternal Mortality Ratio:
Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy,
irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the
pregnancy or its management but not from accidental or incidental causes (WHO, 2014).
Bihar statistics=261/100,000 live births in 2007 (Office of Registrar General, 2011).
No of children born premature due to maternal malnutrition
1.158,000 children below the age of 1year perish in Bihar per year mainly due to maternal
malnutrition (UNICEF, 2006)
2. 400 children die daily in Bihar , on any given day (UNICEF, 2006).
5. IUGR Cases due to malnutrition
Data from a study conducted on morbidity and mortality patterns of neonates in Neonatal
Intensive Care Unit, in Rohtas district in Bihar (Kumar, Thakur & Singh, 1994)
a) Intra Uterine Growth Retardation was seen in 33 cases out of a total of 236, i.e 14% (Kumar,
Thakur & Singh, 1994)
b) 4 OF these neonates died due to IUGR (12.1%) Relative risk of death was 0.87,(CI= 0.3-2.3),
12.5% of total (Kumar, Thakur & Singh, 1994).
6. Burden of disease due to maternal malnutrition
India is categorized as SEAR D country and the combined burden for all SEAR countries
together is,
Mortality count = 1,187,000 (Blossener & Onis, 2005)
DALYs lost due Malnutrition = 44,063 (Blossener & Onis, 2005)

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DALYs lost due to Iodine deficiency (in pregnant women leading to cretinism in children) in
India :0.2 million (Stein & Qaim, 2013)
DALYs lost due to Iron Deficiency Anemia (IDA)=4.0 million (Stein & Qaim, 2013)
DALYs lost due to Vitamin A deficiency=2.3 million (Stein & Qaim, 2013)
DALYs lost due to Zinc deficiency=1.74 million (Stein & Qaim, 2013)
Although these are not estimates for Bihar particularly or women in specific, but these do give us
an idea about the estimate of the burden of malnutrition in females given the soci0-economic
conditions prevailing there.
7. Female Literacy Rate-
Female is the percentage of females age 15 and above who can, with understanding, read and write a short,
simple statement on their everyday life. This indicator is calculated by dividing the number of female literates
aged 15 years and over by the corresponding age group population and multiplying the result by 100 (The
World Bank,2014 ).
Only 33.57 %Bihar women in 2001, were literate (Census Statistics, 2003) and this shows the
amount of knowledge they can be expected to have about nutrition.
Results:
1. Malnutrition among women of Bihar: 45% of women in Bihar (NFHS, 2005-06)
2. Finding-60-75% women in Bihar suffer with anemia -i.e. severe prevalence (NFHS, 2005-06)
3. 158,000 children below the age of 1year perish in Bihar per year mainly due to maternal
malnutrition (UNICEF, 2006)
2. 400 children die daily in Bihar , on any given day mainly due to maternal
malnutrition (UNICEF, 2006)
3. Intra Uterine Growth Retardation was seen in 33 cases out of a total of 236, i.e 14% (Kumar,
Thakur & Singh, 1994)

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4. 4 of these neonates died due to IUGR (12.1%) Relative risk of death was 0.87,(CI= 0.3-2.3),
12.5% of total (Kumar, Thakur & Singh, 1994).
5. Bihar statistics on MMR=261/100,000 live births in 2007 (Office of Registrar General, 2011).
6. DALYs Lost:
Malnutrition- 44,063 (Blossener & Onis, 2005)
Iodine deficiency-0.2 million (Stein & Qaim, 2013)
Iron deficiency anemia-4.0 million (Stein & Qaim, 2013)
Vitamin A deficiency-2.3 million (Stein & Qaim, 2013)
Zinc deficiency-1.74 million (Stein & Qaim, 2013)
7. Anemia is the second leading cause of death in Bihar with respect to Years of Life Lost
(Indrayan et.al, 2002).
8. Only 33.57 %Bihar women were literate in 2001(Census Statistics, 2003)
Steps being taken to reduce burden:
1.Malnutrition Intensive Care Unit inaugurated in Bihar (MSF, 2014).
2. Integrated Child Development System IV has been launched in Bihar-UNICEF's Dular
strategy is being adopted (Fifth objective enhances the capability of the mothers to look after
normal health and nutritional needs of the child through proper nutrition and health education
(Khanna, 2008).
3. Setting up of nutrition rehabilitation centers (Giri, 2007).
4. Yukti scheme for total care during and after abortions , has been introduced by the state
government (TNN, 2011).
Limitations:
1.The data available is not recent so it does not appraise the present situation in Bihar, in 2014.

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2. The data has only been considered for Bihar, does not show a picture of other states.
3. Comparative data over the years in Bihar could not be found, so we have little knowledge
about the progress made.
4. Comparative data with other states has not been included so position of Bihar is not clear.
5. Data set and randomization methods have not been defined , so extrapolation of results may
not give a true picture.
6. We do not have information on systematic errors, instrumental errors and biases, so validity
cannot be taken 100%
Discussion: Overall, it is clear from the literature review that nutritional status of women is quite
poor in Bihar, but it seems that results have been more or less similar over the years. Although
direct comparison of the status over the years is not available, yet the picture looks rather grey.
However, it is important to note that the problem is solvable and the burden of malnutrition in
Bihar is likely to be addressed easily if the efforts and resources could be managed better.
A large component of the burden can be reduced with proper education against gender
discrimination, delaying marital age, sex education, nutritional education and more awareness,
rest of it by planned and organized infrastructure and warning system establishment for floods
etcetera.
Conclusion:
The nutritional status of women in Bihar is worrisome. There is a need to accelerate the
efficiency and reach of the reformative programs if we are planning to reach Millennium
Development Goal by at least 2020, if not 2015. This requires battle at two fronts- social and
medical with many times over manpower committed to the cause of malnutrition and strict law
enforcement against gender discrimination, dowry deaths and corruption. We need to incessantly

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work towards improving the parameters of Body Mass Index, Maternal Mortality Rate,
Micronutrient deficiencies, Disability Adjusted Life Years and IUGR cases to address the larger
picture of Burden of Disease due to Malnutrition in Bihar
Recommendations:
1. More rigorous follow ups of nutritional statuses of women should be done and reported
2. Incentives need to be given to ladies coming in for regular checkups and attendance at
maternity centers, ICDS centers and for immunization of kids
3. Supplemental nutrition should be given to all females in the reproductive age groups.
4. Other causes such as parasitic infections should be dealt with by mass- antihelminthic
treatment and education about sanitation and hygiene.
5. Volunteers from high schools and medical colleges should be recruited for dissemination of
education and monitoring.
6. Carry out and implement Needs Assessment based on the above data in specific areas of the
community in Bihar to progress towards MDG

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ACKNOWLEDGEMENT
I wish to express my sincere gratitude towards Professor Ashraf Mohammed, Ph. D, a scholar of
Epidemiology and Microbiology for having guided me throughout the course of Community
Needs Assessment and also giving me every piece of information required in order to complete
this paper. Sir, I will always be grateful to you for having given me another perspective into the
field of Health and Epidemiology
Manasvini Vimal Kumar
25 July 2014