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Business News/ Opinion / Views/  Poshan Abhiyaan: It’s time for national self-reflection
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Poshan Abhiyaan: It’s time for national self-reflection

India’s deficit in nutrition care can be bridged with systemic reforms for better maternal and child care

Only one in 10 children above 6 months receives an adequate diet in line with the recommended frequency of semi-solids fed 3-4 times a day at 6-8 months made of items from at least four food groupsPremium
Only one in 10 children above 6 months receives an adequate diet in line with the recommended frequency of semi-solids fed 3-4 times a day at 6-8 months made of items from at least four food groups

The National Family Health Survey (NFHS-5), released in November, indicates slow improvement in India’s malnutrition situation. The problem remains persistent, pervasive and grave, with every third child under five and a fifth of women undernourished, and overweight women increasing to a quarter. More than every second child, adolescent and woman is anaemic. This is despite a substantial positive trend in maternal-child health services, including antenatal care (ANC) services, child immunizations and diarrhoea management, which besides nutrient-intake are immediate determinants of the maternal and child nutrition situation. Interestingly, there has also been significant improvement in fixing the underlying causes of undernutrition, such as improved sanitation services, and on proxy indicators of women’s empowerment: a lower total fertility rate, 10 years of schooling, ownership of mobile phones and own bank accounts, access to clean cooking fuel, marriages after 18 and reduced spousal violence. These positive outcomes were achieved through greater political commitment, with a systematic push given to the Jandhan Yojana and initiatives like Mission Indradhanush and Janani Suraksha Yojana under the National Health Mission, Swachh Bharat Abhiyan, Ujjawala Scheme, Beti Bachao Beti Padhao and women’s self-help groups.

So, where are we failing? Unfortunately, these positive trends are not accompanied by other doable and essential nutrition interventions during the first 1,000 days of life (270 days of pregnancy and 730 days 0-24 months), the ‘window of opportunity’. We have no maternal nutrition policy, but there has been an Infant and Young Child Feeding (IYCF) policy since 2000. The promotion of IYCF practices, like ensuring exclusive breastfeeding and ‘effective’ nursing for the first six months, followed by the introduction of appropriate semi-solids to complement breastfeeding, remains weak. Rupal Dalal of CTARA at IIT-Bombay conducted a study in Gujarat’s Banaskantha district which showed that mothers trained in latching and breast-emptying skills by healthcare workers during ANC and post-natal care (PNC) reaped significant benefits. Only 9.8% of the children of such trained mothers were underweight at six months, compared to 18.1% of the children of untrained mothers. NFHS-5 data suggests complementary feeding of semi-solids also needs attention. Only one in 10 children above 6 months receives an adequate diet in line with the recommended frequency of semi-solids fed 3-4 times a day at 6-8 months made of items from at least four food groups.

In other Asian countries, the situation is almost five times better. The main reason for our poor showing is an information deficit. We cannot ignore that 20% of undernourished children are from communities with the highest wealth index. Additionally, families with overweight mothers often have undernourished children. Caregivers are not well informed about what, when and how often to feed a child over six months, and that breastfeeding must also be continued. Poor IYCF practices also contribute to obesity, micronutrient deficiencies and increased chances of adult-onset noncommunicable diseases. Often, parents unaware of the damage done by inappropriate feeding, take pride in spending 25-30 daily on feeding packaged snacks to their babies, instead of family-cooked pulses, curd, vegetables, ghee, eggs. The belief that 6–8-month-olds can’t swallow semi-solids often results in watery pulses being fed instead of khichdi. NFHS-5 findings confirm that we have failed to make the behavioural changes needed to improve nutrition care during the critical first 1,000 days of life—a basic strategy of the National Nutrition Mission.

Frequent interpersonal counselling by health workers/medical teams at the right time is imperative. The Integrated Child Development Services (ICDS) scheme is our lead programme for this, but is not adequately reaching caregivers/mothers. In contrast, the public health system that is in charge of ANC, child delivery, PNC, home-based newborn and young child care and immunization services has the advantage of a minimum of 15 contact occasions with mothers, from the start of pregnancy until the child is 16 months old, and can influence nutrition practices. Under government rules, however, this public health system is not the lead agency accountable for preventive nutrition interventions such as promoting child-feeding in India, though it is in charge of managing anaemia, obesity and the institution-based care of children suffering from acute malnutrition.

Nutrition care is divided into prevention and care between our health system and ICDS. Between the two, problems of prevention being resolved at the community level is a convenient assumption, but in actual practice, it’s highly impractical and time-consuming, as nutrition experts have said.

To make a real difference in nutrition care behaviour practices and service delivery, it is time for the government to explore an alternative nutrition delivery mechanism. Policymakers must examine whether the mandate to spearhead interventions should be given to the regular health system, rather than ICDS. Merging the human resources of ICDS with our primary healthcare system would strengthen maternal-child nutrition and healthcare workforce and team work. This could cost-effectively lower child mortality, as 68% of India’s under-5 mortality is associated with undernutrition.

Sheila C. Vir is senior nutrition specialist and founder director, Public Health Nutrition and Development Centre, Delhi

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Published: 04 Jan 2022, 10:07 PM IST
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