Public health interventions, barriers, and opportunities for improving maternal nutrition in India
Usha Ramakrishnan, Alyssa Lowe, Sheila Vir, Shuba Kumar, Rani Mohanraj, Anuraag Chaturvedi, Elizabeth A. Noznesky, Reynaldo Martorell, and John B. Mason Abstract Background. Inadequate nutrient intake, early and multiple pregnancies, poverty, caste discrimination, and gender inequality contribute to poor maternal nutrition in India. While malnutrition is seen throughout the life cycle, it is most acute during childhood, adolescence, pregnancy, and lactation. Although nutrition policies are on the books and interventions are in place, child malnutrition and maternal undernutrition persist as severe public health problems. Objective. To evaluate the implementation of maternal nutrition programs in India. Methods. The research was conducted in two phases. Phase 1 consisted of a desk review of national and state policies pertinent to maternal nutrition and nationallevel key informant interviews with respondents who have a working knowledge of relevant organizations and interventions. Phase 2 utilized in-depth interviews and focus group discussions at the state, district, and community levels in eight districts of two states: Tamil Nadu and Uttar Pradesh. All data were analyzed thematically. Results. India has a rich portfolio of programs and policies that address maternal health and nutrition; however, systematic weaknesses, logistical gaps, resource scarcity, and poor utilization continue to hamper progress. Conclusions. Elevating the priority given to maternal nutrition in government health programs and Usha Ramakrishnan, Alyssa Lowe, Elizabeth A. Noznesky, and Reynaldo Martorell are affiliated with the Rollins School of Public Health, Emory University, Atlanta, Georgia, USA; Sheila Vir is affiliated with the Public Health Nutrition and Development Center, New Delhi, India; Shuba Kumar and Rani Mohanraj are affiliated with Samarth, Chennai, Tamil Nadu, India; Anuraag Chaturvedi is affiliated with the Public Health Foundation of India, New Delhi, India; John B. Mason is affiliated with the School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA. Please direct queries to the corresponding author: Usha Ramakrishnan, Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1519 Clifton Rd., Atlanta, GA 30322, USA; e-mail:
[email protected].
implementing strategies to improve women’s status will help to address many of the challenges facing India’s nutrition programs. Programs can be strengthened by promoting integration of services, ensuring effective procurement mechanisms for micronutrient and food supplements, establishing regional training facilities for improved program implementation, and strengthening program monitoring and evaluation.
Key words: Tamil Nadu, Uttar Pradesh, maternal and child health, maternal nutrition, nutritional interventions, women’s health
Background Hunger in India has been referred to as “the silent emergency” [1]. India is currently ranked 66 out of 88 in the International Food Policy Research Institute (IFPRI) Hunger Index, which “captures three interlinked dimensions of hunger—inadequate food consumption, child underweight, and child mortality” [2]. India’s rank puts it in IFPRI’s “alarming” category. Malnutrition* in India is caused by a combination of factors, including lack of access to adequate and nutritious food, poor hygienic practices, and infections such as diarrhea and helminths, as well as gender and class disparities [4]. Malnutrition is seen throughout the life cycle and is most acute during childhood, adolescence, pregnancy, and lactation. The Indian government recognizes undernutrition as a health priority and addresses nutrition in its health policies and programs. India’s National Nutrition Policy (1993) provides guidelines for improving health and nutrition and calls for fortification of essential food, an * For the purpose of this paper, UNICEF’s definition of malnutrition is used. People are classified as malnourished if “their diet does not provide adequate calories and protein for growth an maintenance or they are unable to fully utilize the food they eat due to illness” [3] (for example, because of anemia or helminth infection).
Food and Nutrition Bulletin, vol. 33, no. 2 (supplement) © 2012, The United Nations University. Delivered by Publishing Technology to: Guest User IP: 162.218.208.135 on: Wed, 08 Oct 2014 11:29:45 Copyright (c) Nevin Scrimshaw International Nutrition Foundation. All rights reserved.
S71
S72
U. Ramakrishnan et al.
increase in the per capita availability of nutrient-rich foods, and improved nutrition awareness and education [5]. The National Population Policy (2002) and India’s 10th and 11th Five Year Plans also focus on nutrition as a crucial component of maternal and child health [2, 6]. The policies convey a strong understanding that education and empowerment, especially for women, are important catalysts for improved maternal and child health. Therefore all health and nutrition policies in India also promote women’s literacy and improved status. The Indian government has a number of nutrition-based interventions in place to improve pregnancy and birth outcomes, including educational campaigns, monitoring weight gain during pregnancy, prenatal iron–folic acid (IFA) supplementation, supplementary food programs, and fortified food programs. Although nutrition policies are on the books and interventions are in place, child malnutrition and maternal undernutrition persist as severe public health problems (table 1). Inadequate nutrient intake, early and multiple pregnancies, poverty, caste discrimination, and gender inequality all contribute to poor maternal nutrition [13]. Children born of undernourished mothers are more likely to be undernourished themselves and less likely to reach their potential as productive adults [14]. This study is part of a larger effort to assess the role of maternal interventions to improve maternal, neonatal, and child health (MNCH). The overall goal of this study was to evaluate the status of implementation and bottlenecks in maternal nutrition programs in three countries with high burdens of maternal mortality and undernutrition: India, Ethiopia, and Nigeria. The specific objectives were to identify existing platforms for maternal nutrition interventions, to explore the gaps and barriers to maternal nutrition interventions, to identify new and innovative platforms for nutrition programs, and to recommend strategies for improving the delivery of efficacious interventions for reducing maternal undernutrition. This paper focuses on findings for India in which two states, Tamil Nadu and Uttar Pradesh, were originally selected for in-depth data collection to help illustrate the maternal nutrition landscape in India and provide policy makers and health providers relevant information on barriers to and opportunities for improved service delivery and increased utilization. The findings from a third state, Bihar, which was added subsequently, are presented separately in this Supplement [15].
Methods Study setting
Data collection was conducted at the national level and at the state level in Uttar Pradesh and Tamil Nadu, two
states with different health and development indicators (table 1). The northern state of Uttar Pradesh, India’s most populous state (~200 million) and its fifth largest in area, was selected because of its high rate of undernutrition and poor MNCH outcomes, combined with a weak health infrastructure. The total fertility rate in Uttar Pradesh is 3.8 per woman, compared with the national rate of 2.7 per woman [16], and over half (52%) of the population is undernourished [17]. In contrast, the southern state of Tamil Nadu, India’s 11th largest in area and 7th most populous state, has relatively strong health and nutrition infrastructure and has demonstrated recent success in improving the health status of its residents. Four districts were purposively selected for in-depth data collection in each state (table 2). The districts were selected to provide diversity of context, based on health and development indicators and recommendations from state-level officials. Data collection Phase 1: Desk review
National and state policies were reviewed for relevance to maternal nutrition. Results from recent census data, three National Family Health Surveys, the 2009 Coverage Evaluation Survey, the 2011 Annual Health Survey 120 district level surveys from the Hungama Study, and the National Sample Surveys were reviewed for relevant statistics and information on the current state of maternal nutrition and health [7, 9–12, 16–19]. Evaluations of national nutrition programs were reviewed where available. Key informant interviews
Key informant interviews with national- and state-level policy and decision makers were conducted to discuss issues related to maternal nutrition. The interviews lasted between 30 minutes to an hour. Key informants were purposively selected to ensure that the opinions of all key informants could adequately address the research questions, aims, and objectives. Key informants were identified with the help of gatekeepers. The informants were individuals who had a working knowledge of the way various organizations and units operate and are organized. Respondents represented the National State Ministries of Health, the National Rural Health Mission (NRHM), Integrated Child Development Services Scheme (ICDS), the UK Department for International Development (DFID), the United Nations Children Fund (UNICEF), the World Health Organization (WHO), CARE India, the International Clinical Epidemiology Network (INCLEN), Save the Children, and the All India Institute of Medical Sciences (AIIMS). Phase 2: District- and community-level qualitative research
The study utilized a variety of qualitative methods: key
Delivered by Publishing Technology to: Guest User IP: 162.218.208.135 on: Wed, 08 Oct 2014 11:29:45 Copyright (c) Nevin Scrimshaw International Nutrition Foundation. All rights reserved.
S73
Health interventions, barriers, and opportunities for maternal nutrition in India
TABLE 1. Key indicators of women’s health and nutrition Indicator Maternal health and nutrition Total fertility rate (/woman) Maternal mortality rate (/100,000) Median age at marriage for women (yr) Women aged 20–24 yr married before age 18 yr (%) Median age at 1st birth for women aged 25–49 yr (yr) Anemia (%)a Adolescent girls aged 15–19 yr Pregnant women Breastfeeding women Undernutrition (%)b 15–19 yr 20–29 yr 30–39 yr 40–49 yr Child health and nutrition (%) LBWc Newborn smaller than averaged Stunting (under 3 yr) Wasting (under 3 yr) Underweight (under 3 yr) Anemia (6–35 mo)e Maternal utilization of services (%) ≥ 3 antenatal care visits Full antenatal caref Consumed ≥ 100 IFA tablets or syrup during last pregnancy Institutional birth Visited PHC within 2 days after delivery Took deworming medicine during pregnancy ICDS services during pregnancyg Supplementary food Health checkups Nutrition and health education None JSY services Any assistance during delivery Assistance among those who delivered in a government institution
Source
Year
India
Uttar Pradesh
Tamil Nadu
Census Office of Registrar DHS DHS
2001 2009
2.7 212
3.8 359
1.8 97
2006 2006
17 46
16 59
19 22
DHS
2006
20
19.4
21
DHS DHS DHS
2006 2006 2006
56 59 63
49 52 58
50 58 59
DHS DHS DHS DHS
2006 2006 2006 2006
NA NA NA NA
42 36 34 30
48 32 23 10
DHS DHS DHS DHS DHS DHS
2006 2006 2006 2006 2006 2006
21 21 38 19 46 79
25 21 52 20 42 85
17 28 31 23 26 73
DHS CES CES
2006 2009 2009
51 26.5 27.6
26 12.4 20
96 44.1 48
DHS DHS DHS
2006 2006 2006
41 37 4
22 14 2
90 90 7
DHS DHS DHS DHS
2006 2006 2006 2006
20.5 12.3 10.9 77.5
9.6 1.8 1.3 89.8
50.4 35.6 36.3 48.1
CES CES
2009 2009
32.5 59.3
35.1 86.5
33.1 37.0
CES, Coverage Evaluation Survey; DHS, Demographic and Health Survey; ICDS, Integrated Child Development Services; IFA, iron–folic acid; JSY, Janani Suraksha Yojana; LBW, low birthweight; NA, not available; PHC, Primary Health Centre Source: references [7–12]. a. Hemoglobin level < 12 g/dL for all groups except pregnant women where
