Santosh Jain Passi and Akanksha Jain
Malnutrition among populations – particularly the children, is an interplay of multiple factors like illiteracy, ignorance, poverty, large families, lack of resources including food/nutrition insecurity and poor access to health care services. Since long, our government’s endeavour has been to reduce morbidity/mortality rates by implementing multipronged strategies for breaking the intergenerational cycle of under-nutrition. Events leading to malnutrition often predate child-birth; maternal under-nutrition, teenage pregnancies, closely spaced child-births and high parity are the major contributors to pre-term/low birth weight deliveries. Escalating malnutrition among children aged below 2 years is indicative of poor infant feeding practices. Therefore, appropriate infant feeding practices coupled with adequate maternal nutrition are crucial for healthy growth/development of the child; and for this a life cycle approach is imperative.
Appropriate/optimal Infant and Young Child Feeding (IYCF) practices emphasise on early initiation of breastfeeding (within the 1st hour of child-birth) without giving any pre-lacteals, exclusive breastfeeding for the first six months of life (not even water, only prescribed medicines/tonics, if any); and after 6 months, age-appropriate complementary foods with continued breastfeeding up to two years and beyond. In the light of this, theme for this year’s National Nutrition Week is ‘Optimal IYCF Practices: Better child health’.
Every year, National Nutrition Week is celebrated from 1st to 7th September for intensifying nutrition/health related awareness among the masses. Launched by the Food & Nutrition Board in 1982, it is envisaged that the nutrition education/training programmes carried out by the governmental/non-governmental organizations will have far reaching implications on productivity, economic growth and ultimately the nation’s development.
Optimum nutrition coupled with regular physical activity is the cornerstone of good health/well-being. Importance of proper nutrition in survival, health and development of the current as well as the succeeding generations cannot be undermined. Healthy children learn better and adequately nourished individuals are more productive. On the other hand, poor nutrition can result in lowered immunity, impaired physical growth/mental development, increased morbidity and thereby, reduced productivity.
WHO/UNICEF have designated the first 1000 days of life (270 days in-utero + 2 years post-birth) as the critical window for infant/young child nutrition interventions. This period being vital for brain growth/development, any malnutrition can cause stunting and suboptimal mental development. Breastfeeding – the gold standard feeding option for babies needs to be promoted; therefore, mothers as well as the other caregivers need to be made cognizant of its benefits, both for the baby and the mother. During pregnancy itself, effective counselling (inter-personal/small groups) should be carried out to highlight the advantages of breastfeeding vs. the dangers of artificial feeding; and thus, prepare the expectant mothers for successful breastfeeding.
When a child – particularly the girl child – is not provided enough nourishment, an inter-generational cycle of malnutrition may set in. Both the individual level and intergenerational (from one generation to the next) cycles of under-nutrition and ill health operate simultaneously posing grave consequences. A low-birth-weight baby-girl borne by a malnourished mother becomes a stunted/malnourished girl child à stunted/ malnourished adolescent à malnourished woman; and in turn, gives birth to a second-generation low-birth-weight baby. This clearly illustrates how poor in-utero nutrition from an under-nourished mother (both during & prior to pregnancy/lactation) extends through the life-course affecting nutrition/health status of generation-by-generation. This is further heightened by teenage pregnancies where the adolescent girls have to bear the dual-burden of their own growth and that of the developing foetuses leading to still poorer pregnancy outcome. Further, closely spaced high parity pregnancies often exacerbate nutritional deficits which get passed on to their offspring/s too. Micro-nutrient (iron, zinc, iodine & vitamin A) deficiencies in young girls too can catalyze the intergenerational malnutrition cycle. This can mar the nation’s development due to physically/mentally affected workforce with reduced work capacity.
In the light of these adversaries, nutrition has become an integral component of all the maternal and child health programmes such as:
· Integrated Child Development Services (ICDS), launched on 2nd Oct 1975 has been universalized in the country. The target group comprises children (<6 years), pregnant/nursing mothers & women in reproductive ages (15-44 years) as well as adolescent girls for improving their nutrition/health status by providing a package of services right at the grass-roots level.
· Reproductive, Maternal, Newborn, Child and Adolescent Health Programme (RMCH+A, launched in 2013) addresses the major causes of mortality among women, children & adolescents along with the reasons for delayed access/utilization of health care services. This strategic approach highlights the importance of ‘continuum of care’ during various stages of life.
· Janani Shishu Suraksha Karyakaram (JSSK) – launched on 1st June, 2011 aims to provide better women/child health services such as cost-free/cashless facilities for pregnant women (normal deliveries/caesarean section operations) and sick new-borns (<30 days post-partum) through government health institutions in rural/urban areas.
· Pradhan Mantri Matritva Vandana Yojana (PMMVY) is a maternity benefit program implemented by Ministry of Women & Child Development, Government of India. It is a conditional cash transfer scheme for pregnant/nursing mothers (aged >19 years) for first two live births to partially compensate the childbirth/childcare linked wage-loss. In addition, it provides adequate facilities for safe delivery and breastfeeding/infant feeding.
· Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) aims to reduce maternal and infant mortality rates in the country through safe pregnancies and safe deliveries. It provides quality comprehensive antenatal care to pregnant women on a designated day – 9th of every month.
· The Mother and Child Tracking System – Monitors the health care system to ensure all mothers & their children to have an easy access to various health-care services like care during pregnancy/child-birth and complete maternal & child immunization.
· MAA (Mothers’ Absolute Affection) – an intensified flagship programme of the MoHFW was launched in 2016. It aims to enhance optimal breastfeeding practices in the country through a set of comprehensive activities for protecting, promoting and supporting breastfeeding/child feeding, both at community & the facility level. The programme emphasises on generating community awareness, strengthening inter-personal communication skills of the functionaries and providing necessary support for breastfeeding at delivery points/public health facilities along with the need for adequate family support to the nursing mother.
· Recent amendment of the Maternity Benefit Act (April 2017) enshrines paid maternity leave for 26 weeks even in private sector; however, for the pregnant women already having 2 living children, it remains unchanged (12 weeks) and the same is for adoptive/commissioning mothers too. Crèche facility and the option for work from home are other features of this amended Act.
· India Newborn Action Plan (INAP), launched in September 2014, aims to end preventable new-born deaths and stillbirths so as to achieve single digit neonatal mortality/stillbirth rates by 2030.
· Adolescent Reproductive and Sexual Health (ARSH) programme comprises the package of preventive, promotive, curative and counselling services for addressing their reproductive and sexual issues.
Other programmes/schemes targeting adolescent girls include Kishori Shakti Yojana, Balika Samridhi Yojana, Scheme for Adolescent Girls (SABLA), Weekly Iron and Folic Acid Supplementation (WIFS) programme, Menstural Hygiene Scheme and many more. These programmes aim at empowering the adolescents with improved nutrition/health related awareness as well as better nutritional status so that they enter matrimony and motherhood with better nutrient stores.
Under UIP, Mission Indradhanush is cost-free expanded immunization coverage for children against 7 vaccine preventable diseases (Diphtheria, Pertussis, Tetanus, Childhood-Tuberculosis, Polio, Hepatitis B and Measles) by 2020. Further, Swachh Bharat, ‘Beti Bachao Beti Padao’ abhiyan, adolescent friendly clinics also address critical nutrition-sensitive issues.
It is thus, possible that through concerted efforts, the intergenerational cycle of malnutrition can be turned virtuous and improvements in maternal nutritional status and pregnancy outcome can be achieved. Better diet quantity/quality, micronutrient supplementation and improved health services can be the catalytic strategies for bringing about the desired change. As per the continuum of care approach, focusing on girl child to women along the lifecycle is imperative for achieving the Sustainable Development Goals (SDGs) and overcoming poverty, malnutrition and ill-health.
“Optimum IYCF practices coupled with good nutrition along lifecycle can retain the individuals’ health…..break the inter-generational cycle of malnutrition….and eventually make India a healthy & productive nation”!! (Dr Santosh Jain Passi – Public Health Nutrition Consultant; Former Director, Institute of Home Economics, University of Delhi
and Akanksha Jain – Ph D Scholar, Amity University, Noida, Uttar Pradesh; Research Officer – Public Health Nutrition Division, LSTech Ventures Ltd, Gurgaon, Haryana, India) (Views expressed in the article are author’s personal)