Child Malnutrition in Child Malnutrition in Maharashtra (India) Maharashtra (India)

Child Malnutrition in
Maharashtra (India)
August 2013-
2013- January 2014
Situation, Efforts, Decline and Challenges
A Review
For the State Nutrition Mission
PowerPoint 1/6
Dr Shyam Ashtekar,
MD (Community Med)
shyamashtekar@yahoo.com
200
2006
PPT1/6 to
2013
AN OVERVIEW
(A) The context and the MN
problem
Child malnutrition is a complex
problem, and the context too is important
for action
Malnutrition in maharashtra-A Review Jan

2014 3
Background and context
There is discussion of 40-50% Child
malnutrition in India
Similar issues are raised in media and
Legislative Assembly in Maharashtra
Melghat, Satpuda and Jawhar-Mokhada
often hit newspapers for malnutrition
What is the real situation ?

2014 4
We should discuss facts and causes.. Rather
than images.. CNSM Survey 2012
40
35
30
25
20
2005-6
2012-13
15
10
0
Under Wt Stunting (- Wasting (-
by age(- 2SD) 2SD)
2SD)

2014 5
The pyramid
of Causes Some Child
Deaths
Vicious Cycle of Malnutrition

and
Child deaths, 20-30%
Malnutrition
in 0-5 age group. about 4%
children
severely wasted.
Low BMI in Women 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.

2014 6
CNSM Survey Statistics (2012)
40 The CNSM Survey by IIPS
2005-6
35
30 Mumbai (2012) shows

25
reduction in child malnutrition
20
15 in Maharashtra.
10
5 The survey included 2600

0
Under Wt Stunting (- Wasting (-
by age(- 2SD) 2SD)
children.
2SD)

2014 7
Comparison of 3 surveys: 2006 to 2012
Children 0-23 NFHS3 IIPS CNSM IIPS CNSM NNMB2012

months (U+R) 2012 (U+R) only rural (Rur)0-36m
2005-6
Number 2654 1332 571
surveyed
Stunting (-2SD) 39 23.9 27.8 43.9
Wasting (-2SD) 19.9 15.9 16.9 15
Under Wt by 29.6 22.1 25.9 31.5
age(-2SD)
%MUAC<11.5cm 3.5 4.3
% of low birth 20.3 21.6
weight

2014 8
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
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
2014 9
Comparison of states on Child
Malnutrition NNMB 2012-
2012-
60
50
40
30
UnderWeight
Stunting
20
Wasting
10

2014 10
Comparison of CNSM & NNMB 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.
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

2014 11
The CNSM Survey is more reliable
IIPS conducted the NFHS Survey 1-2-3

in India
The 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.
2014 12
CNSM -Observation & 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%
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)

2014 13
CNSM:Boys & Girls
Nutrition indices for girls look better than those of

boys
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.
2014 14
CNSM--Neonatal Care
CNSM
The proportion of newborn

babies that received breast
feeding in the first hour rose
from 52% to 60%.
Conversely 40% newborns don't
get early breast feeding.

2014 15
CNSM--Care of the young child (0
CNSM (0--2Y)
Semi solid or solid feeds were given

between 6-8 months to 63% babies, from
the earlier level of 48.
Safe disposal of excreta of the child was
satisfactory only about 41% children..

2014 16
CNSM -Care after 6
months
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.
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.

2014 17
Immunization & 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%
2014 18
Health and Nutrition of Mothers
Maternal Health care has improved.
AN Care, IFA supplement and institutional
delivery have improved.
The 102 ambulance is available commonly.

2014 19
CNSM -Womens 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)
2014 20
CNSM -Low 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.
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.
2014 21
Known facts: Maharashtras Map of
Malnutrition

2014 22
ICDS data: Blocks/Projects with high
2013)
burden of Malnutrition (July 2013)

2014 23
Social context of 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.

2014 24
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 Scheduled
castes.
It is possible that VJNT (nomadic tribes)
categories also suffer from Malnutrition but we
need more information on this.

2014 25
Malnutrition 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 .
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.

2014 26
Malnutrition in 2-
2-5 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.
But even this age group does need good nutrition support.

2014 27
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 . Food
supply suffers esp. in rainy seasons.
The neglect of family planning-spacing is
also a major problem in many blocks.

2014 28
Food Security and Child Malnutrition
It is difficult to connect child Malnutrition
to lack of food grains in homes in
Maharashtra state of today, except in
some tribal parts.
Employment, PDS, and local agro produce
usually ensure food grain availability even
in difficult areas.
2014 29
Lack of Proteins, Vitamins & Minerals
But the lack of

proteins, vitamins and
minerals is an important
factor.
Hence we need a new
perspective on this
aspect of food security.

2014 30
(B) MAHARASHTRAS
EFFORTS

2014 31
Focus on the
Anganwadi Center
(AWC)
The State of Maharashtra1.07 lakh AWCs, including
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.
2014 32
Improving 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.
Pre primary education is an equally important task of AWC.
Other tasks include immunization, medical check
up, micronutrients, monitoring weight and height

2014 33
Improving 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
levels
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

2014 34
The 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.
We also get line listing of malnourished children
in tribal blocks, but these are rather dated for
current action.

2014 35
Monthly Progress Report A sample

2014 36
The Geographic Information System
RJMCHN has now established This can help to
a GIS system for the entire Generate MIS from AWC to
state. state level and update
This GIS is available on within 48 hrs
www//:mhnss.ind.in Generate info for action on
Basically it has all the 1206 every level.
boxes of the monthly It can generate both
progress Report-MP process and outcome
The AW sevika can get it indicators
done in 30 Rs provision and We can generate about
within 30 min. 1500 reports from this data
She can Upload the AWC It also provides camera sites
abstract info (5-7 KB file)on for physical verification at
the site thru the Sangram each AWC
software at village level.

2014 37
ICDS and Rajmata Jijau Mission
ICDS and RJMCHM together are working on
reducing malnutrition
The 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.
2014 38
Dr Arole Committee Report
The Non Governmental Members
Committee under Dr. Rajanikant Arole
appointed by Dr the Hon High Court
worked on this issue from 2008 to 2011.
The Report has been submitted to the
Govt. in 2013

2014 39
The important 1000 days window for the
child.
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.

2014 40
Ten rules for preventing
malnutrition
Institutional
birth and
Breastfeeding
Complete 6 m Exclusive
Immunization Breastfeeding
Complimentar
Vit A doses y feeding at
6m, 6m BD
Focus on 6m-
Growth
3y child-
monitoring-
nutrition ed of
wt/ht//MUAC
the mother
Handwash,
Micronutrients
water safety,
Sachet
Sanitation De-worming,
illness treatment
when
necessary, immuniz
ation

3/16/2014 -- - 41
Chief Ministers 5 point Program
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

2014 42
Child 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 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.

2014 43
The challenge
The CNSM study reports decline in
malnutrition in Maharashtra.
But there are tough challenges ahead..
Low birth weight
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.
2014 44
Best 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

2014 45

Child Malnutrition in Child Malnutrition in Maharashtra (India) Maharashtra (India)

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Child Malnutrition in

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Vicious Cycle of Malnutrition

Low BMI in Women and adolescence

Malnutrition in maharashtra-A Review Jan

30 Mumbai (2012) shows

5 The survey included 2600

Malnutrition in maharashtra-A Review Jan

Children 0-23 NFHS3 IIPS CNSM IIPS CNSM NNMB2012

Malnutrition in maharashtra-A Review Jan

State Underweight Stunting Wasting

Malnutrition in maharashtra-A Review Jan

NNMB Survey is limited to rural areas.

Malnutrition in maharashtra-A Review Jan

IIPS conducted the NFHS Survey 1-2-3

Malnutrition in maharashtra-A Review Jan

Nutrition indices for girls look better than those of

The proportion of newborn

Malnutrition in maharashtra-A Review Jan

Semi solid or solid feeds were given

Malnutrition in maharashtra-A Review Jan

Only about 77 % of babies in >6 months group got at least 6 feeds a

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.

In the last 6 months 48% babies got

Malnutrition in maharashtra-A Review Jan

The proportion of wasting women

The proportion of low birth weight babies has

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

especially some development blocks in those districts.

The blocks of Jawhar Mokhada (Thane) Dhadgaon and

Akkalkuwa (Nandurbar) Chikhaldara-Dharni Known as

Some blocks in Gadchiroli, Nashik and Chandrapur

districts also have more malnutrition.

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

It is difficult to connect child Malnutrition

to lack of food grains in homes in

Maharashtra state of today, except in

some tribal parts.

Employment, PDS, and local agro produce

usually ensure food grain availability even

But the lack of

Malnutrition in maharashtra-A Review Jan

Malnutrition in maharashtra-A Review Jan

Supplementary feeding is only one of the tasks of AWC

Malnutrition in maharashtra-A Review Jan

In those days the abstract of categories of

The system of sending abstract report remains

However there is less tendency to hide

The AWC statistics is more reliable than before.

GIS is now available for all AWCs

Malnutrition in maharashtra-A Review Jan