declining child malnutrition in maharashtra india 2-the effort
TRANSCRIPT
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CHILD MALNUTRITION IN
MAHARASHTRA (INDIA) AUGUST 2013- JANUARY 2014
SITUATION, EFFORTS, DECLINE AND CHALLENGES
A REVIEW
Malnutritio
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A REVIEWFOR THE STATE NUTRITION MISSION
P O W E R P O I N T 2 / 6
T H E E F F O R T S
Dr Shyam Ashtekar, MD (Community Med)
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THE EFFORTS TO REDUCE MALNUTRITION
IN MAHARASHTRA
The Important 1000 days window
THE IMPORTANT 1000 DAYS’ WINDOW
Pregnancy 300
2nd Year 365
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Only Breast feeding, 180 7 to 12
months, 145
2nd Year 365
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IMPROVING THE AWC
� First of all AWC (Anganwadi center) must retain and
improve it’s attendance.. And then extend the
services to the U2 group also.
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services to the U2 group also.
� This calls for improvement of building, equipment and
services. This was the effort.
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AWARENESS CAMPAIGNMalnutritio
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DASHAPADI OR THE TEN IMPORTANT RULES.
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TEN RULES FOR
PREVENTING
MALNUTRITIONInstitutional birth and
Breastfeeding
6 m Exclusive Breastfeeding
Complimentary feeding at 6m, 6m Birthday
Vit A doses
Complete Immunization
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Focus on 6m-3y child-nutrition
edn of the mother
Micronutrients Sachet
De-worming,
Illness treatment,
immunization
Hand-wash,
water safety,
Sanitation
Growth monitoring-wt/ht/muac
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HEALTH AND NUTRITION OF
ADOLESCENT GIRLS
�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
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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.
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ANTE NATAL CARE
� Early diagnosis of pregnancy, at least 3 medical check ups and
treatment contacts.
� IFA provision for 90 days.
� Take Home ration provision every month. to improve meals at home.
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� 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.
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INSTITUTIONAL
CHILDBIRTH
� There is an effort to ensure institutional delivery for all cases.
� We have JSY program under NRHM for this.
� 102 ambulance is available in every district.
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� All care medicines for mother and children are free.
� Mothers also get some incentives for attending institutional
delivery.
� Some districts registered 90% institutional delivery rate.
� ASHA activists help this program.
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THE EFFORT TO IMPROVE BIRTH
WEIGHT
� Low Birth Weight was and is a major issue.
� 20%-50% babies have low birth weight in various
districts.
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districts.
� These babies tend to remain underweight.
� A limited but possible solution is to improve ANC
care. (But the LBW is a long term issue)
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PROMOTING NEONATAL
CARE UNITS-JSSK PROGRAM
� Low Birth Weight , prematurity and other neonatal
illnesses call for neonatal care units.
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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
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EARLY BREAST FEEDING
� Need to start breast feeding within the 1st hour of birth.
� ASHA & AWC workers offer counseling for this from early stage.
� Mothers need to learn a proper technique of breast feeding
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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.
� However despite all this only 60% babies get timely initiation of breast
feeding.
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EXCLUSIVE BREAST FEEDING
TILL 6 MONTHS.
� No need to give any other feed till 6 months-actually
harmful.
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� But many families give water, honey, gripe water, extra
milk, baby food etc in the state of Maharashtra.
� This causes infections and triggers malnutrition.
� The CNSM survey reports only 58% of exclusive breast
feeding.
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HIRKANI KAXA FOR
PROMOTING BREAST
FEEDING ..
�Promoted separate rooms for breast
feeding in all public hospitals and 250 bus
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feeding in all public hospitals and 250 bus
stands
�This helped both breast-feeding mothers
and send the right message to community
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BETTER MANAGEMENT OF HOME FEEDING
More than improving the SNP (supplementaryNutrition Program) in the AWC, It was necessary to
� Early and Exclusive Breast feeding AND
Improve home feeding from 6 months to 6
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� Improve home feeding from 6 months to 6 years.
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SEMI SOLID FEEDS AFTER 6 MONTHS.
� After 6 months breast feeding is not enough for the baby.
� It is time to give semi solid substances like porridge.
� The CNSM (Comprehensive Nutrition Survey of
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� 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.
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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 feed should include energy dense & proteins , iron and vitamins.
� The CNSM survey reports low compliance on this (10-34%).
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� Nutrition will not improve unless home feeding improves considerably.
� The AWC tried to promote this factor through mother education
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HYGIENE AND
SANITATION
� Use of toilets must improve. But countless villages continue
with open defecation.
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� This causes infections and triggers malnutrition.
� AWC is promoting a hand-wash before feeding the baby and
encourage children to do the same.
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MICRO NUTRIENTS
� Our meals lack iron, Zinc, Calcium, vitamins.
� To ensure this a sachet of Micro Nutrients is
added in the daily meals in the AWC
� These Micro Nutrients reduce illnesses and
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� These Micro Nutrients reduce illnesses and
promote growth.
� However the change of taste has made Micro
Nutrients less popular in some districts.
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TAKE HOME RATION (THR)
� Younger babies can not attend and sit in the AWC.
� THR is meant for this younger group.
� 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
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� 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.
� Other families cook the entire packet and serve it to the entire family.
� Therefore THR utilization is unsatisfactory.
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SOME WAYS OF USING THR
� In some districts THR is used to prepare popular food
items like laddus and sweets.
� Frying in oil or ghee makes it more energy dense.
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� 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.
� That perpetuates the question mark on THR
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CRÈCHE
� Crèches have been started in some Tribal blocks.
� Crèche operates from 9 to 5 in the day time.
� Space is rented ensuring that it has a toilet.
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� 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
� The AWC Sevika checks Height and weight.
� The RBSK medical team attends the crèche once in 4 to 6 months.
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CCRÈCHERÈCHE
� Crèche is a valuable social facility.
� A Crèche ensures a safe baby–sitting with trained workers.
� This frees the mother for work and leisure.
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� 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.
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RBSK (RASHTRIYA BAL
SWASTHYA KARYAKRAM)
� Each block has a RBSK mobile team since 2013.
� RBSK has 2 doctors, a nurse & pharmacist
� Has a rented vehicle.
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� Has a rented vehicle.
� RBSK offers checkup from infants to
adolescence.
� RBSK offers treatment/referral for childhood
illnesses
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RBSK..RBSK..
�But the work load implies that it is at least 4-6 months before the next visit.
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4-6 months before the next visit.
�The RBSK generates lot of useful data but this must be put online for better research.
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IMMUNIZATION
� AWC has monthly immunization day.
� Complete immunization protection of the child
against 6 infections.
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against 6 infections.
� Hence immunization is important for prevention of
malnutrition.
� Measles was especially linked to malnutrition
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A PAGE
FROM
HEIGHT-WEIGHT
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WEIGHT
TABLE
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THE USUAL METHOD OF MALNUTRITION DETECTION.
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SCREENING FOR MALNUTRITION
� Every U 6 Child’s weight is recorded in the AWC every
month.
� The weight is plotted on growth charts against the age
in months. This helps in grading of nutrition.
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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
wasting with wt-height table
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MMALNUTRITIONALNUTRITION-- SUW, SAM, MAM, MUAC SUW, SAM, MAM, MUAC ETCETC..THE LINE LISTING OF MALNOURISHED CHILDREN IN A PHC AREA
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IF THE CHILD IS ALREADY MALNOURISHED..
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� We must ensure timely diagnosis and timely treatment.
� The AWC and RBSK do this by screening every baby
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The AWC and RBSK do this by screening every baby
� Children with MN are referred for rehab.
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SSCREENINGCREENING OFOF MMALNUTRITIONALNUTRITION
Severe Malnutrition is decided by one of
the 3 methods
� Severe wasting ( weight for height )
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� Severe wasting ( weight for height )
� MUAC less than 11.5 cm.
� Foot edema
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NUTRITION REHABILITATION
� If the Child is severely malnourished it is
necessary to start the management early. For
this we have rehab centers at the village or the
health center or the block or District hospital.
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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
This can help to
� Generate MIS from AWC to state level and update within 48 hrs
� Generate info for action on every level.
Malnutrition in Maharashtra-A Review 2014
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 Sangramsoftware at village level.
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
CO-OPERATION OF VARIOUS
SECTORS/DEPARTMENTS
� ICDS/AWC
� Tribal Development
� Health Department
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� Health Department
� RJMCHMN
� and Unicef
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MY ESTIMATION OF MALNUTRITION PREVENTION EFFORTS
20
30
40
50
60
70
80
90
100
1
2
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1
0 Malnutritio
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Necessary efforts 201 2020
1 Ante natal care 80 95
2Safe/Institutional births 87 95
3Better birth-weight 70 80
4Early Breastfeeding 60 90
0
10
20
4
5
6
7
8
Necessary efforts 2012 2020
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4 Breastfeeding 60 90
5
Exclusive breastfeeding till 6m 59 90
6Complimentary feeding after 6m 63 95
7 Immunization 69 95
8 Micronutrients 50 95
9Treatment of illnesses 60 90
10 Hygiene 50 9037
BEST WISHES
Dr Shyam Ashtekar (MD, Community Medicine)
21 Cherry Hills Society, Anandwalli,
Nashik 422013
Cell +919422271544
Website: 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
Malnutrition in Maharashtra-A Review
2014
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