Monitoring and Evaluation:Maternal and Child Nutrition

Session Objectives

By the end of this session participants will be able to:

• Apply basic M&E concepts to maternal and child nutrition interventions

• Design and use M&E frameworks for nutrition programs

• Identify nutrition interventions and common indicators for assessing their results

• Describe M&E challenges of nutrition programs

Session Overview

• The problem of malnutrition

• Interventions and strategies

• M&E frameworks for nutrition programs

• Common indicators & data sources

• M&E challenges

The Problem

• Malnutrition contributes to over half of all child deaths, (60%)

• Malnutrition is largely hidden, (mild, moderate, ?)

Importance of malnutrition as an underlying factor in under-five mortality in Ethiopian Children.

Malnutrition

58%

Others

Perinatal Complications

Diarrheal Diseases

AcuteRespiratoryInfections

MeaslesMalaria WHO ’98

Micronutrient deficiencies

Micronutrient deficiencies have severe consequences;• Iodine deficiency damages intellectual development,

• 50% of pregnant women and 40-50% of children < 5 in developing countries are iron deficient, • VAD affects > 100 million children, and is

responsible for as many as one out of every four child deaths in places with Vitamin A deficiency,

•How maternal and child nutrition are linked

Causes of Malnutrition: conceptual framework

Nutrition and Development

• Nutritional status is a key indicator of progress in attaining MDGs;

• Eradicate extreme poverty and hunger (Goal 1),

• Achieve universal primary education (Goal 2),

• Promote gender equality and empower women (Goal 3),

• Reduce child mortality (Goal 4),

• Improve maternal health (Goal 5),

• Combat HIV/AIDS, malaria and other diseases (Goal 6),

• Ensure environmental sustainability (Goal 7),

• Develop a global partnership for development (Goal 8)

Nutrition is Critical in Achieving MDGs

#1. Poverty alleviation - an indicator is % children underweight

#2. Primary education - benefits can accrue when nutrition and cognition are adequate

#3. Gender equality- better nourished girls likely to stay in school longer

#4. Child mortality - 60% associated with malnutrition

#5. Maternal health - anemia, iodine deficiency, low BMI associated with health indicators

#6. Infectious diseases and HIV AIDS- malnutrition worsens and makes them more susceptible to adverse outcomes

World Fit for Children Goals

• Reduction of child malnutrition among children under five years of age by at least one third, with special attention to children under two years of age.

• Achieve the sustainable elimination of iodine deficiency disorders by 2005

• Achieve the sustainable elimination of vitamin A deficiency by 2010

• Reduce the prevalence of anemia (including iron deficiency) by one third by 2010

Interventions and Strategies

Interventions Proven to Reduce Malnutrition When Linked with Health Services

(Essential Nutrition Actions)

Vitamin A and iron

Iodized salt

BreastfeedingMother’s nutrition

Complementaryfeeding

Sick/severe cases

Monitoring and Evaluation Frameworks forNutrition Programs

Results Framework

SO: Vulnerable families achieve sustainable improvement in the nutrition and health status of seven million women and children by 2008

IR1 Service providers improve quality & coverage of maternal and child health & nutrition services & key systems

IR1.1 Coordinate/converge services provided by the Dept. of social services (ICDS) and MOH, e.g. through Nutrition and Health Days, and Block planning

IR1.2 Build capacity of service providers, supervisors and managers in the dept. of social services (ICDS) and MOH

IR2 Communities sustain activities for improved maternal and child survival and nutrition

IR2.3 Stronger links between health systems and communities

IR2.2 Increase ownership and participation of community leaders and groups in monitoring health and nutrition services and behaviors

IR2.1 Increase awareness of households & other key audiences about desirable nutrition and health behaviors through multiple channels, e.g. ‘change agents’

Source: Adapted from CARE/India INHP II,

DAP II 2001-2006

Logical Framework

ASSUMPTIONS

 

- Stable political situation, sustained political commitment and financing

- Sufficient numbers of competent health care personnel and supplies in the government sector

- No natural disaster or disease epidemic

MEANS OF

VERIFICATION

1.Annual reports from MCH services, special surveys

2.Annual reports, special surveys

3.National / local tracking reports (surveillance) of high risk areas/ populations

PERFORMANCEINDICATORS  

1.Proportion of children 6-35 months who are malnourished

2. Coverage of essential nutrition actions: exclusive BF, appropriate CF, vitamin A, iron supplements /fortified foods, iodized salt use, coverage of sick and malnourished in special programs

3. Proportion of households at risk of or vulnerable to food insecurity

PURPOSE

 

Sustainable improvement in the nutrition and health status of women and children through improved services provision and community participation

NOTE: A logic model would allow a program to select indicators that monitor all stages (inputs, process, outputs) of their activities e.g. funds and staff available (inputs), training sessions completed (process), number of skilled workers or villages with trained volunteers (outputs).

Common Indicatorsand Data Sources

Categories of Nutrition Indicators

• Nutritional status• Breastfeeding practices• Complementary feeding practices• Micronutrient supplements/fortified foods• Household food security; vulnerability to

food and nutrition insecurity

Most Common Indicators

• Nutritional status– Weight-for-age and/or height-for-age– Body Mass Index in women– Anemia prevalence– Vitamin A deficiency

• Infant and young child feeding practices– Timely initiation of breastfeeding– Exclusive breastfeeding rate– Complementary feeding rate– Extra feeding for malnourished/recently sick

children

Most Common Indicators

• Micronutrient Interventions– Vitamin A supplementation– Iron supplementation– Coverage with iodized salt, other fortified foods

• Household Food Security/Vulnerability– Daily meal frequency of family/individuals– Perceived inadequacy of food reserves in the

home/community

Data Collection Systems

Routine• Sentinel food and nutrition surveillance• Institutional health records- clinics, schools• Feeding & cash or food transfer programs records-

daily/weekly/monthly attendance

Non-routine• Population-based surveys• Emergency appraisals, rapid assessments• Experimental and operational research

Anthropometric Measures (1)

Children:

• Weight-for-age (underweight)– Reflects chronic or acute malnutrition or both

• Height-for-age (stunting)– Reflect chronic (prolonged, cumulative) malnutrition

• Weight-for-height (wasting)– Reflects acute and recent malnutrition

Anthropometric Measurements (2)Adults:

• Body Mass Index (BMI)– Low weight-for-height ( kg/m2) reflects chronic &/or

acute

• Mid-upper arm circumference (MUAC)– Thin reflects chronic &/or acute

Data Sources for Anthropometry

• MCH programs/clinic records

• School feeding- school heights.

• Food and nutrition, epidemiological surveillance

• Poverty mapping/school height census - heights for chronic, weights for current

• Reports from emergency/refugee programs

Detecting Low Weight-for-age

Option B

Table of weight-for-age cut-off points

Option A

Growth Chart

Low wt/agebelow this line

Cut-Off PointsLow Weight-for-Age

Girls Boys

Age mths

Age mths

Low wt for age below this line

Statistical Presentation of Anthropometric Indicators

• Prevalence

– Percent below a cut-off, such as <-2SD or < -3 SD

• Mean Z-score values (in SD units)

– Z score refers to how far and in what direction the measure deviates from the median of the NCHS/WHO international reference standard

Exercise: Interpreting Standard DHS Nutrition Status Tables

• If low HFA is 50%, WFA is 30%, WFH is 15%, which is the worst problem? Why?

• Which child is more vulnerable to die: a -sd wasted or a -3sd stunted child? Why? In which age group?

• Which characteristics are more important for program targeting: rural/urban, region, sex, age, or birth order?

Feeding Practices: M&E Considerations

• Proportion of infants aged 0-5 months who were exclusively breastfed in the last 24 hours,

• Proportion of infants less than 12 months of age who were put to the breast within one hour of delivery,

• Proportion of infants aged 6-9 months receiving breastmilk & complementary foods,

• Mean number of food groups eaten in the last 24 hours by children 6-23 months of age,

Appropriate Complementary Feeding

• Percentage of infants and young children 6 -23 months of age who receive appropriate complementary feeding

• 6 to 8 months of age : Breastmilk + other food at least 2-3 times per day + variety of food groups

• 9 to 11 months of age : Breastmilk + other food at least 3-4 times per day + variety of food groups

• 12 to 23 months of age : Breastmilk + other food at least 3-4 times per day + variety of food groups

Coverage Indicators for Micronutrient Programs

• Proportion of children aged 6-59 months who received a high dose of vitamin A in the last 6 months,

• Proportion of households consuming adequately iodized (i.e. 15+ ppm of iodine) salt,

• Proportion of pregnant women who received the recommended number of iron/folate supplements during pregnancy,

Choices in Program M&E Design

• Which age groups to measure • Anthropometry, infant and young child feeding,

• How to obtain valid measurements• Anthropometry; micronutrients; infant and young child

feeding

• Timing• Trends; seasonality

• Evaluation design

Examples of Flaws in Nutrition Evaluations• No comparison groups

• No pretest or baseline

• No control for age, e.g. < 6 mo.,< 2 and 3+ yrs

• Not accounting for confounding factors

• Seasons not comparable

• Not controlling for mortality reduction

• Non-representative samples, small samples

• Pilot projects, not replicable

Economic Analysis in Nutrition M&E

• Cost-effectiveness analysis – compares two or more alternatives for achieving coverage

or scale or behavior change, or a process outcome such as training to build capacity

– Answers the question ‘which is the more efficient option?’– Used more in evaluations

• Cost-benefit– compares the resources required to achieve impact and

the monetary value of that impact– Answers the question ‘is the investment worthwhile?’– Based on many assumptions with limited empirical

evidence

ENA Indicators

4635 41 42 47 52

65 59 58 53 4854

0

10

20

30

40

50

60

70

80

90

100

EBF in children<5 months

Weight/age -2SD in children

0-35 months

Vit A supp. forchildren 6-59months (one

dose)

Pregnantwomen whoreceived iron

tablets

Amount of foodis maintainedor increased

during dirrahea

Iodized saltconsuption(>15ppm)

Unmetneed

Currentcoverage

Example: Use of Data to Assess Program Gaps

Monitoring and Evaluation Challenges

Challenges of M&E

• Multisectoral programs (attributing outcome?)

• Clinical Indicators– May need large samples (e.g. xerophthalmia)– May be sensitive to enumerator training (e.g. goiter)– Measurement of iron deficiency (lack of specificity)– Selection bias (institution based sample)

Challenges: Comparisons & Trends

• Sample design

• Sample size

• Cutoff points & standards

• Seasonality

References• Arimond, Mary and Marie T. Ruel. 2003. Generating Indicators of

Appropriate Feeding of Children 6 through 23 Months from the KPC 2000+. Washington, D.C.: Food and Nutrition Technical Assistance Project, Academy for Educational Development.

• Cogill, Bruce. 2003. Anthropometric Indicators Measurement Guide. Washington, D.C.: Food and Nutrition Technical Assistance Project, Academy for Educational Development.

• Wasantwisut, Emorn. 2002. Recommendations for monitoring and evaluating vitamin A programs: outcome indicators. Journal of Nutrition, 132: 2940S-2942S.

• Ruel, M.T., K.H. Brown, and L.E. Caulfield. 2003. Moving Forward with Complementary Feeding: Indicators and Research Priorities. Food Consumption and Nutrition Division Discussion Paper #146. Washington, D.C.: International Food Policy Research Institute.

• WHO. 2001a. Assessment of Iodine Deficiency Disorders and Monitoring their Elimination: A Guide for Programme Managers. Second Edition. WHO/NHD/01.1. Geneva: World Health Organization.

• WHO. 2001b. Iron Deficiency Anaemia: Assessment, Prevention and Control - A Guide for Programme Managers. WHO/NHD/01.3. Geneva: World Health Organization.

• Wellstart International’s Tool Kit for Monitoring and Evaluating Breastfeeding Practices and Programs.

Madagascar Nutrition Case StudyDuring 1996-2002, Madagascar followed a comprehensive model, the “essential nutrition actions” (ENA) framework, which coordinated efforts from the community level through national policy making, and included both government and non-government entities. The model was first implemented in two districts in the Antananarivo and Fianarantsoa provinces. It focused on a set of proven interventions covering micronutrients and dietary practices for mother and young children. From 1995 to 1998, the overall focus was placed on designing mechanisms that linked nutrition interventions more directly with other child health and RH services, and national- and community-level actions. Further instructions are provided in the handout.