Malnutrition is a serious problem in the state of Madhya Pradesh, which has the highest levels of childhood malnutrition in the country (60% of children under the age of 5 years, according to NFHS-3).
In children, malnutrition is commonly caused by faulty feeding practices such as inadequate breastfeeding, delayed or insufficient complementary feeding (after 6 months of age) and inadequate nutrition of older children. Repeated or continuous episodes of common infections like diarrhoea, pneumonia and worm infestations, vaccine preventable diseases like whooping cough and measles (due to poor immunization coverage) as well as chronic infections (eg malaria, tuberculosis) also give rise to malnutrition.
The ICDS programme, started nationally in 1975, aims to tackle the problem of childhood malnutrition through a network of anganwadis. However, the programme has had a limited impact, if any, on the malnutrition situation.
Several NGOs and networks in Madhya Pradesh have also been involved in the area of nutrition and malnutrition, and have approached the issue in different ways. While some have been active in educating the community, others have been more directly involved in monitoring the growth of children in communities in their field areas.
At CPHE in Bhopal, we have been concerned with the problem of childhood malnutrition for the past two years. Several of our Fellows have reported high levels of this problem in their field areas, during and after their Fellowship. Some of them have attempted to monitor the growth of children in anganwadis (of the Govt. ICDS programme). Others have reported on the functioning of the anganwadis and have tried to mobilize the community to improve their functioning. CPHE has decided to work on strengthening the functioning of anganwadis along with working with the communities as strategy to tackle malnutrition. As a part of this, CPHE is working in three slums of Bhopal.
1. Getting acquainted with the community – several visits were made to the slum community to meet mothers, anganwadi staff, ANMs and USHA workers.2. Regular visits to anganwadis during routine days, weighing sessions and Village Health and Nutrition Days (VHND) - when immunization sessions are conducted for children and pregnant women.
3. Review of anganwadi registers and records, including growth charts and cards, along with the anganwadi workers.
4. Health education sessions with mothers of under-five children – covering such subjects as breast feeding, complementary feeding, feeding of older children, immunization. We have also explained the importance of weighing children and the use of growth charts and cards.
These health education sessions are usually conducted in the anganwadis, but we have also visited the homes of children, particularly those who are severely malnourished.
5. Training of MUSKAAN (partner NGO) staff in nutrition, malnutrition, growth monitoring and other related subjects. The training was well received, but we found that it had to be followed up regularly in the field.
SOME PRELIMINARY FINDINGS:
Malnutrition levels in children under the age of five years were found to be 61.4% (n=105) in all three slums put together (n=171) with the value ranging between 51.6% (n=49) and 78.9% (n=30) as per the WHO growth chart. Of the children who were malnourished 26.7% (n=28) were severely malnourished with 4.1% (n=2) to 50% (n=13) of the children as such in individual slums and the rest were moderately malnourished (n=77). The malnutrition occurs most commonly after six months of age, indicating that complementary feeding is probably delayed and inadequate. Breast feeding in almost all cases is adequate.
Along with malnutrition, there is a high level of anaemia in children. This is manifested by pallor of the tongue and nails, and also by the symptom of eating mud or earth (known as pica or geophagy). The latter symptom is common in our slums and is also seen in pregnant women. It is almost universally wrongly associated by local doctors and health workers as being due to calcium deficiency. We have used every opportunity to educate anganwadi workers, USHA workers and ANMs about this, and also the local chemists and medicine stores, which are often directly approached by mothers of children.
An important associated factor which is probably related to malnutrition in these children is the widespread consumption of packaged snack food such as potato chips, biscuits, “kurkure” and mixtures (“namkeen”). These packaged snack foods are widely and easily available at all shops in the slums, in small packets costing Rs. 1 and 2. They are nutritionally poor, and also tend to suppress the appetite of children consuming them. We are making efforts to discourage their consumption, and suggesting healthy natural nutritious alternatives such as roasted peanuts, chana and puffed rice.
It is hoped that the work on malnutrition in children will be extended to all the slums covered by Muskaan in Bhopal city, in a gradual phased manner. These slums have some of the poorest and most disadvantaged people in the city, and we hope to make an impact in this population by our work.
We also plan to take up similar work with our partner NGOs and ex-Fellows in different districts of the state, particularly where malnutrition is common.