This document analyzes how COVID-19 impacted the delivery of maternal and child nutrition services in India. Using district-level health management data from January 2018 to May 2021, it finds substantial declines in key services during the pandemic, especially in the initial months, including centers conducting health/nutrition activities, children receiving iron supplements, and pregnant women receiving tests and supplements. These declines do not appear to be fully explained by data reporting disruptions. The study aims to help assess actual declines in service provision versus reporting issues and inform policies to address nutrition service gaps during pandemics.

1. Delivery of Maternal and Child Nutritional
Services in India During the COVID-19 Pandemic
Averi Chakrabarti, Elizabeth Bair, Harsha Thirumurthy
University of Pennsylvania

2. • Nutrition outcomes in India likely to have suffered during COVID-19
• Service disruptions
• Loss of livelihoods, income declines
• Food supply chain interruptions/Price increases
• Evidence from select studies and reports
• Decline in women’s diet diversity in select districts (Gupta et al, 2021)
• Disruption in health/nutrition services in Uttar Pradesh (Nguyen et al, 2021)
• “According to the Women and Child Development Ministry, as of October 14 this year,
there were 17,76,902 severely acute malnourished children and 15,46,420 moderately
acute malnourished children”, a 91% increase in severe acute child malnourishment
since November 2020 (National Herald, 2021)
Introduction/Rationale

3. • Goals
• Assess how COVID-19 impacted the delivery of health/nutrition services across India
• Distinguish between actual declines in service provision and data reporting disruptions
• Data
• District-month level: Health Management Information System, Jan 2018 – May 2021
• Methods
• Interrupted time series analysis
• To identify average district-level change in services in COVID-19 months (Mar 2020 –
May 2021) relative to pre-COVID-19 months (Jan 2018 – Feb 2020)
• Controls: district fixed effects, month indicators and district clustering of standard errors
• Additional analysis to compare districts with and without high drops in ‘total births’
reporting during early pandemic (proxy for data reporting disruptions)
Study aims, Data and Methods

4. • Outcomes pertaining to maternal and child health
• Number of anganwadis/urban primary health centers reported to have conducted health
and nutrition days (HNDs)/outreach activities
• Number of children (6-59 months) provided 8-10 doses (1ml) of iron and folic acid (IFA)
syrup (bi-weekly)
• Number of pregnant women (PW) tested for haemoglobin (Hb) ≥ 4 times
• Number of PW given full course (180) IFA tablets
Outcomes

5. Results – trends in services during COVID-19
-600
-400
-200
0
200
Change
relative
to
Jan
18-Feb
20
Mar20 Apr20 May20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20 Jan21 Feb21 Mar21 Apr21 May21
Centers conducting HNDs
-20000
-10000
0
Change
relative
to
Jan
18-Feb
20
Mar20 Apr20 May20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20 Jan21 Feb21 Mar21 Apr21 May21
Each circle is a point estimates. Spikes represent 95% confidence intervals
Child IFA
Change in district-level #s
during COVID-19 months
compared to monthly average
pre-COVID-19 (Jan 18 - Feb 20)
Sample: 690 districts, ~28,000
district-month observations

6. Results – trends in services during COVID-19
-1500
-1000
-500
0
Change
relative
to
Jan
18-Feb
20
Mar20 Apr20 May20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20 Jan21 Feb21 Mar21 Apr21 May21
Pregnant women Hb tests
-1500
-1000
-500
0
Change
relative
to
Jan
18-Feb
20
Mar20 Apr20 May20 Jun20 Jul20 Aug20 Sep20 Oct20 Nov20 Dec20 Jan21 Feb21 Mar21 Apr21 May21
Each circle is a point estimates. Spikes represent 95% confidence intervals
Pregnant women IFA
Change in district-level #s
during COVID-19 months
compared to monthly average
pre-COVID-19 (Jan 18 - Feb 20)
Sample: 690 districts, ~28,000
district-month observations

7. Results – interpreting service declines
53
64
55
48
0
20
40
60
80
Percent
Centers conducting HNDs Child IFA PW Hb tests PW IFA
DECLINES in April 2020 as % of services in April 2019

8. Results – data quality check
40
60
49
74
32
66
27
57
0
20
40
60
80
April
2020
declines
as
%
of
services
in
April
2019
Centers conducting HNDs Child IFA PW Hb tests PW IFA
Flagged districts reported >=15% lower births in initial COVID months (Mar-May 20) compared to the same time in the previous year
Data quality
Observed declines in services are larger in districts that likely have HMIS reporting disruptions
Districts not flagged for reporting disruptions Districts flagged for reporting disruptions

9. • Takeaway: Substantial declines in nutrition services, especially in initial months of
the pandemic. Do not appear to be entirely driven by reporting disruptions
• Future analyses: Heterogeneity by
• Lockdown severity and pre-COVID-19 institutional capacity
• Limitations
• Data quality – reporting issues during COVID-19
• Cannot fully examine trends during the second wave of COVID-19 in India (data until May 2021)
• Policy implications
• Need corrective action to reverse service gaps
• Essential to implement nutrition programming targeted at mothers and children in the early
phase of pandemics or other disasters
Discussion

10. Thank you