I recently came across Rani, nine-months-old, at a district malnutrition treatment centre. Barely 3kg, she was suffering from acute malnutrition. Her distraught parents cried, not understanding why their daughter had reached this state. The answer was not obvious. Did Rani experience a draining illness? Was she not breastfed properly? Was the complementary feeding inadequate? Was Rani born at a low-birth weight, and if so why?

Why exactly do children die? Why are so many malnourished, like Rani? These are critical questions to ask given India’s sorry public health outcomes. Here, it is useful to think in terms of the “Golden 1,000 Days Period"—roughly the number of days between conception and age two, when so much child mortality and sickness happens.

The 1,000 days can be thought of in distinct segments. The nine months of pregnancy are the antenatal period; there is the intranatal period of the birth passage; the four weeks following birth, called the neonatal period; the 11 months that follow—the infant stage; and the period beyond until two years when the child is weaned from the breast, and starts to crawl, eat solids, talk and walk! Some Mint readers might liken these to upstream and downstream phases of a manufacturing process!

Upstream, two factors are key for a pregnant woman—regular antenatal check-ups (ANC) to monitor nutrition, and iron and folic acid (IFA) tablets to control anaemia. Anaemia during pregnancy increases chances of low-birth weight babies. IFA tablets are often in short supply; where distributed, women are often reluctant to have them.

According to government data, almost half the pregnant women in India miss the required four antenatal check-ups. More than half are anaemic.

At the time of birth, the quality of health facilities and presence of skilled birth attendants are critical. A 2016 study in the WHO South-East Asia Journal of Public Health estimated India has 6.4 qualified doctors, nurses, and midwives for every 10,000 people. The World Health Organization benchmark is 22.8. Ill-equipped labour rooms without protocols for infection prevention are common. An example is radiant warmers—simple equipment to provide immediate warmth to newborns, that are mandatory in labour rooms. I have found them missing or broken in facilities in several northern states.

The first few weeks after birth require utmost attention. Breastfeeding within one hour of birth has immense benefits. Unfortunately, this happens for less than half the babies in India, according to government data. Pre-term births and infections are the largest causes of neonatal deaths. Both can be tackled with basic care. Kangaroo Mother Care (KMC), where the mother maximizes skin-to-skin contact with her baby, is a simple and cost-effective intervention to increase survival of low-birth weight babies.

There are several excellent programmes that focus on different segments of the 1,000 days. For example, ensuring adequate facilities for safe child birth is being addressed by Johns Hopkins University affiliate Jhpiego, and others. Society for Education, Action and Research in Community Health (SEARCH) has demonstrated how newborn lives can be saved through the protocol of home-based newborn care (HBNC) at the village itself. The Ekjut programme showed how participatory learning and action with women’s groups reduced newborn deaths. There are programmes that focus exclusively on nutrition, and within that, some that look at food fortification alone.

While each makes a critical contribution, none of them alone will address the overall issue of childhood mortality and sickness. They all must be taken together.

Problems upstream flow downstream. If a child needs acute neonatal care because it is born with low-birth weight, it could well be that the mother was underweight and anaemic. That may well have been avoided if she had the four simple ANCs. Why she didn’t have these four check-ups may have been because the frontline workers didn’t share data, and get to her in time, an issue dealt with earlier in these columns.

The medium-term answer lies in designing programmes that manage right across the 1,000 days, with the greatest emphasis as far upstream as possible. This is ultimately a management approach rather than a technical solution. In other words, it makes for both sound public health and business sense. Maybe we need a new thousand rupee note carrying the picture of a newborn baby!

Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok.

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