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.
PPT1/6PPT1/6
2006
PPT1/6PPT1/6
AN OVERVIEWAN OVERVIEW
200
to
2013

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Known facts: Maharashtra’s Map ofKnown facts: Maharashtra’s Map of
MalnutritionMalnutrition
Malnutrition in maharashtra-A Review Jan
2014 22

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.
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.
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.
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.
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.
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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.
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.
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.
(B) MAHARASHTRA’S(B) MAHARASHTRA’S
EFFORTSEFFORTSEFFORTSEFFORTS
Malnutrition in maharashtra-A Review Jan
2014 31

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.
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.
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.
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.
Monthly Progress ReportMonthly Progress Report –– A sampleA sample
Malnutrition in maharashtra-A Review Jan
2014 36

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
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2014 37

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.
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
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2014 39

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.
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.
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
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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.
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.
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