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!

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. THE EFFORTS TO REDUCE MALNUTRITION
IN MAHARASHTRA
The Important 1000 days window

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. 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. AWARENESS CAMPAIGN
Malnutrition in Maharashtra Review
Maharashtra-A
2014
5

6. DASHAPADI OR THE TEN IMPORTANT RULES.
Malnutrition in Maharashtra Review
Maharashtra-A
2014
6

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. A PAGE
Malnutrition in Maharashtra Review
Maharashtra-A
2014
FROM
HEIGHTWEIGHT
TABLE
28

29. THE USUAL METHOD OF MALNUTRITION DETECTION.
Malnutrition in Maharashtra Review
Maharashtra-A
2014
29

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. 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. 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. 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. 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. 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. CO-OPERATION OF VARIOUS
SECTORS/DEPARTMENTS
ICDS/AWC
Health Department
RJMCHMN
and Unicef
Malnutrition in Maharashtra Review
Maharashtra-A
2014
Tribal Development
36

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. 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