TOWARDS A C OMPREHENSIVE COMMUNITY-BASED MODEL

AGAINST MALNUTRITION

R ESULTS OF THE BASELINE SURVEY

(D ATA COLLECTED IN 2012)

February 2013

VIKAS SAMVAD (BHOPAL)

In coordination with
SPANDAN SAMAJ SAMITI (KHANDWA)
COMMUNITY DEVELOPMENT CENTRE (BALAGHAT) &
[SUPPORTED BY SIR DORABJI TATA TRUST]

Contact: E-7/226, First Floor, Opp. Dhanvantri Complex, Arera Colony, Shahpura, Bhopal, MP /
vikassamvad@gmail.com / www.mediaforrights.org
SECTION I BACKGROUND AND INTRODUCTION
It is widely recognised that in spite of high economic growth and progress in many other fronts, the
malnutrition level in India is very high. The existing programmes for addressing malnutrition have
obviously failed and although there has been a lot of focus on the issue in the recent years, there is
still a dearth of interventions that show a workable solution.

Madhya Pradesh is a state with the highest child malnutrition level in India. The results of NFHS-3
show that, among children under age three, 60% are underweight and 40% are stunted. Further, the
percent of children underweight actually increased in Madhya Pradesh between NFHS-2 (1998-99)
and NFHS-3 (2005-06) from 54% to 60%. Madhya Pradesh is also the only state in India that falls
in the extremely alarming category of the India State Hunger Index developed by IFPRI.
According to the recently conducted HangaMa Survey the percent of children under 5 years of age
in MP who are severely underweight is 16%; severely stunted is 31%; and severely wasted is 4%.
Another survey conducted by NIN recently (2010) shows that the malnutrition rates in MP have
improved but still high. According to the NIN survey 51.9% of children under 5 years of age in MP
are underweight and 48.9% are stunted. Both these surveys therefore show that the prevalence of
moderate and severe malnutrition among young children in MP is still very high.

The last few years have seen heightened focus on malnutrition in Madhya Pradesh by both
government and non-government organisations. The media has reported on numerous cases of
malnutrition-related deaths, public hearings and commissions of inquiry have been held, public
protests have been organised and the government has also tried to make some innovations.

In December 2010 the Government of Madhya Pradesh launched an ambitious project for
prevention and management of Malnutrition i.e., Atal Bal Arogya avm Poshan Mission (ABM).
The formation of this Mission provides an opportunity for significant policy reforms to reduce
malnutrition in the State. The Mission has the political backing from the highest levels and also
promises to usher in major reforms and invest large sums of money.

It is now well accepted that interventions for addressing malnutrition must primarily focus on
children under the age of 2 years, along with pregnant and lactating mothers and adolescent girls.
Preventing malnutrition among these target groups can break the inter-generational cycle of
malnutrition. Currently, the only programme that is designed to address the nutrition needs of these
groups is the Integrated Child Development Services (ICDS) Scheme. ICDS is a centrally
sponsored scheme that functions through anganwadi centres with the objective of providing health,
nutrition and preschool education services. Many reviews of ICDS have shown that it has failed in
meeting these objectives. A number of reasons including inadequate resources and infrastructure,
design failures, lack of community participation, absence of convergence with other departments
especially health etc. have been cited for the failure of the ICDS. The ABM aims to resolve many
of these issues. However, it is still not clear how the ABM proposes to do this.

The ICDS primarily aims at reducing malnutrition through growth monitoring, nutrition
counselling and supplementary nutrition. However it has been seen that growth monitoring is not
conducted regularly, there is no clear strategy on what needs to be done when there is growth
faltering or if a child is identified as being severely malnourished and there is no system of using
data collected from growth monitoring for further activities. Similarly, nutrition counselling has
failed as the already overburdened anganwadi workers do not have the time for home visits to meet
families and conduct counselling sessions. Supplementary nutrition has been of poor quality with
irregular supplies. All these issues need to be addressed through the ABM.
In this context in the state, it was felt that there is an opportunity for intervention in the state, with
the involvement of NGOs and CBOs, to create a model of intervention for prevention and
treatment of malnutrition not only for the State but the country as a whole.
Some organisations in Madhya Pradesh therefore got together and decided to work towards setting
up a pilot for a model of comprehensive community based management of malnutrition. In order to
help design such a model and also to have some baseline data, a survey was conducted in three
districts in the state. The NGOs involved in the survey were Vikas Samvad, Spandan and
Community Development Centre (CDC). This report presents the findings of this survey.

OBJECTIVES

One of the objectives of the baseline exercise was to understand the local situation in the four
blocks where the intervention is planned, with regard to food and nutrition. Therefore the study
attempted to get information on the following:

a. Assess the level and spread of malnutrition

b. Assess local food consumption and production practices
c. Understand nutrition, and child care practices
d. Assess the local situation of poverty and access to livelihood
e. Assess the status of implementation of the ICDS and other related government
programmes
f. Assess current practices for treatment of common childhood illnesses, malnutrition

A further objective of this study was to have baseline data which can be used at a later stage to
compare and evaluate any change in the malnutrition situation in the blocks. This could be seen as a
way of assessing impact of the project.

Moreover, the study also aimed to understand the local production and consumption patterns so that
this information could be used to design menus for supplementary nutrition in the ICDS and
possibly any day care centres that might be set up.

METHODS

A mix of quantitative and qualitative techniques was used. A pre-coded structured questionnaire
was used for households with a child under 3 years of age, Anganwadi Centres (AWCs) and village
level information.

Sample households which had at least one child under three years of age were visited and the
mother of the under-three year old child, and in the case of her unavailability any other responsible
adult member of the family, was interviewed. In the case of Anganwadi centres, the questionnaire
was filled up on the basis of interview with the Anganwadi worker, observation by the investigator
and examination of records. For the village questionnaire, a group interview was held with 4 or 5
informed persons, usually including gram panchayat members, of the village.

For qualitative information Focus Group Discussions and case studies were relied upon. In every
village one group discussion was held on issues related to food and nutrition. Further case studies
of malnourished children were also collected.

Finalising Tools

The broad design of the study was discussed in a preliminary advisory group meeting. Based on the
discussions the tools were prepared. All the tools were tested by the partner organisations in their
respective districts. In a follow up meeting for the advisory group, each questionnaire and tool was
discussed in detail and feedback from the field testing was also shared. Based on the comments
received the tools were then finalised.

On the basis of the area of operation of the partner organisations it was decided that the
intervention would be planned in Khandwa and Balaghat districts. The intervention is proposed to
be carried out in two blocks each in these two districts. One of the blocks is where the partner
organisation is already involved in some programmes, whereas the second is a new block. It was
further decided that the survey would be conducted in one block in Chhindwara district, so that it
could serve as a comparison block for later evaluation. It is predicted that since the intervention on
community based management of malnutrition is planned only in two blocks each of Khandwa and
Balaghat, these blocks will see a greater fall in malnutrition compared to an area where this
intervention is not undertaken. To capture this, the survey was also conducted in Tamia Block in
Chhindwara district. This is not a control block in the sense that there is no proactive effort to
stop any intervention from taking place in this area. It is only that the present programme is not
planned here. In case some other NGO or government starts another intervention in Tamia block,
then the extent to which it can be used as a comparative block will be decided at the time of the
mid-line and end-line surveys.

Training of investigators

A three day training of all the investigators was held in Khandwa. The team consisted of 6
investigators, 1 supervisors for each block. The training included an introduction to malnutrition
and related issues, going over the methodology and the tools for the survey, conducting mock
interviews and a one day field practice session.

AREA PROFILE

All the three districts where the survey was conducted have a high population of STs. In Balaghat
too, while the district average of ST population is 22.8%; the percent of tribals in the blocks where
the survey was conducted is higher than 50%. Baiga, Gondi and Korku are the adivasi tribes living
in these areas.

All the three districts are also highly rural with 86% of the population in Balaghat and 80% of
population in Khandwa living in rural areas. The literacy rate in Khandwa is lower than in the other
two districts. The gender gap in literacy rate in all three districts is high. The female literacy rate in
Khandwa is only about 50%. In Balaghat about two thirds of females are literate.

In terms of percent of children under six in the total population, Khandwa has the highest with
about 16% of the population being under six years. This is also reflected in the higher birth rate in
Khandwa amongst the three districts.

All three districts have a child sex ratio that is skewed towards boys point towards a gender bias.

A very low percent of the population in all the districts have access to toilets or easily accessible
sources of drinking water.

The three districts also have high infant and child mortality rates. The under five mortality rate in
Khandwa is the highest at 108. In Balaghat and Chhindwara, the female child and infant mortality
rates is higher than for male. While it is the other way round in Khandwa, the child sex ratio at birth
and in the 0-6 age group is the worst in Khandwa.
Rural Balaghat Chhindwara Khandwa
Total Population 14,56,435 15,85,177 10,50,067
% Rural 85.6% 75.8% 80.2%
Sex Ratio 1025 968 943
Child Sex Ratio (0-6) 967 951 934
Child Percentage (0-6) 12.4% 13.5% 16.3%
Average Literacy 76.8% 67.5% 63.0%
Male Literacy 86.2% 77.0% 74.7%
Female Literacy 67.8% 57.7% 50.6%
% SC population (2001) 7.4% 10.6% 11.4%
% ST population (2001) 22.8% 42.5% 39.1%
% Rural 87.1% 75.5% 73.2%
% population without toilets 88.3% 87.7% 82.6%
% with drinking water source within premises 17.8% 14.4% 16%
% getting tap water from treated source 2.3% 9.5% 12.4%
Source: Census 2011

HEALTH SURVEY - RURAL BALAGHAT CHHINDWARA KHANDWA

CBR 23.8 24.1 25.4
IMR 67 76 66
IMR M 61 75 70
IMR F 72 76 61
U5MR 80 90 108
U5MR M 73 87 113
U5MR F 87 93 103
SEX RATIO BIRTH 980 925 880
SEX RATIO 0-4 987 914 933
SEX RATIO ALL 1007 956 920

As seen in this broad overview of the districts where the survey was carried out, the districts are
poor with low access to health, water and sanitation facilities. They have a low literacy rates,
skewed sex ratios and high child mortality rates. The districts are also predominantly rural and have
a high tribal population.

SAMPLING

The survey was conducted in five blocks: 2 in Khandwa, 2 in Balaghat and 1 in Chhindwara. The
blocks were chosen purposively based on the plan for intervention. These blocks represent the more
backward blocks in the district and are those that have a high tribal population. The intervention is
planned to be carried out in 50 gram panchayats in each block. In each block, of the 50 gram
panchayats where the intervention is planned, 10 were chosen randomly. In this manner, 50 gram
panchayats were covered in the survey.
Every village in the chosen gram panchayat was covered in the survey. The village questionnaire
was filled in every village, thereby covering 86 villages in all. One FGD per village was conducted.
Every Anganwadi in the panchayat was covered in the survey, thereby bringing the sample of
Anganwadi centres to 166.

In each panchayat 50 households were sampled for the household interview. For this, the list of
children under three years from the Anganwadi survey (not enrolment) was first collected from
every Anganwadi centre in the panchayat. Then all the lists from one panchayat were collated and
from this list 50 children were randomly chosen. The households of these children were then
visited. The interview was in relation to the sample child, even if there were other children under
three years present in the household. If the survey was not able to reach any household or if the
respondent was not available then the next child on the list was visited.

In all, the survey covered 2491 households with children under three years.

Table gives details of the sample.

Balaghat Khandwa Chhindwara Total

No. of blocks 2 2 1 5
No. of Panchayats 20 20 10 50
No. of villages 34 29 23 86
No. of AWCs 77 62 27 166
No. of households 991 1000 500 2491
SECTION II SOCIO-ECONOMIC INDICATORS OF SAMPLE
HOUSEHOLDS
We now present the main findings from the survey. On each issue the results of the household
survey are presented and this is complemented with information from the FGDs wherever possible.

BACKGROUND CHARACTERISTICS

For the survey an attempt was made to ensure that the mother of the child was present during the
interview. In 60% of the cases, the mother was the main respondent while in another 31%, it was
the father of the child. In almost all the remaining cases the response was given by a grandparent
who was responsible for taking care of the child while the parents were away. In about 2% of the
cases the main respondents were other adult relatives of the child.

Caste

Almost 60% of the respondents were adivasis. About 12% of the respondents were SCs. Only
about 3% of the respondents belonged to upper castes, while the rest were OBCs. While all the
blocks had a high percent of respondents who were STs, in Khalwa about 90% of the respondents
were STs. The sample households were therefore predominantly from adivasi and dalit
communities. While this might not be representative of the population, it reflects the situation of
the communities with whom the project proposes to work.

78% respondents
are Hindu, caste
composition
skewed in favour
of Scheduled
Tribes.

Education and Occupation

About 50% of mothers and 30% of fathers of the children in the sample are illiterate. Even amongst
those who were literate, most were educated only up to primary or middle school. Less than 10% of
the mothers of the children in the sample were educated up to high school or higher levels. Even
amongst the fathers, only about 15% were educated up to high school or more. Mothers education
is an important underlying factor causing child malnutrition. While this cannot be directly
addressed by the intervention being planned, it is an important aspect that needs to be kept in mind.

In relation to parents occupation, about two thirds of the women said that they were housewives.
Among those who stated other occupations, most were involved in wage labour or cultivation. Few
were engaged in any business or regular employment. Amongst the fathers almost two thirds said
they worked as wage labour, about 30% in cultivation. A small percent were in government or
other regular jobs.

Education Mothers Fathers Occupation Mothers Fathers

Illiterate 47.9% 29.5% Culltivation 6.5% 29.4%
Literate 9.1% 10.0% Labour 27.3% 64.2%
Up to 19.5% 22.4% Government 0.6% 2.0%
primary job
Middle 15.6% 22.2% Private job 0.2% 0.7%
High school 6.4% 13.0% Business 0.2% 1.7%
Graduate 1.5% 2.9% Artisan 0.4% 1.7%
and above
At 64.8% 0.2%
Home/Nothing

Apart from asking what the main occupation of the mother and father is, the respondents were also
asked whether any member of the household participated in each of the main occupations. In
response to this, it was found that 86% of the households were engaged in some kind of wage
labour and about 60% of the households are engaged in cultivation. 2% households had members
who were engaged in some kind of business, 2% in service and about 1% were artisan households.
Most households were engaged in a mix of occupations.

Land Ownership

Almost 50% of the respondents do not own any agricultural land. There is some variation in the
percent of landless across the various blocks. The blocks in Khandwa and Chhindwara districts
have more than 50% of the respondent households being landless whereas in Balaghat about one
third of the respondent households are landless. Balaghat in general has a more hilly terrain while
the other blocks are mostly plains.

It is seen that even among those who own some land, the amount of land owned is very small in all
the blocks. About 90% of the respondents in all the blocks own less than 5 acres of land. There are
very few households that own more than 5 acres of land.
 68% land is not
irrigated at all;
another 15% is
partially irrigated

Further even among those who own any land, the percent of respondents who own irrigated land is
very low. 68% of those who own any land, have no irrigation at all. Another 15% said that there
land was partially irrigated. Therefore, only about 15% among the land owners had fully irrigated
land.

Household Income

The respondents were asked to state their average monthly income. It is well known that in a
sample where most of the respondents are in the informal sector with unpredictable wages, it is
difficult to estimate incomes. Therefore it is common to estimate consumption expenditures as a
proxy to income. However, consumption expenditure surveys and long and tedious and not
required for the objectives of the present survey. While questions related to land and asset
ownership and food consumption were asked to get a general sense of the economic status of the
respondents, we also asked them to state their average income. While this might not be accurate, it
still gives some indication of the level of income.

About 50%
households fall
in low income
group; another
33% in low-
middle income
group

Two thirds of all the respondent households placed themselves in the band of Rs. 1000 to Rs. 3000
a month. This translates into minimum wage for about 8 to 25 days of minimum wages for person
in a month (assuming minimum wage = Rs. 120 per day). Birsa in Balaghat and Pandhana in
Khandwa had a higher percent of respondents in the category of more than Rs. 3000 in a month.

Investigators Ranking Freq. Percent The investigators were also asked to rank the
low 1,272 51.1 households that they visited based on their
low middle 832 33.4 perception of the economic status of the household.
middle 326 13.1 The investigators ranked each household as low,
high middle 46 1.9
Low-middle, middle, middle-high or high.
high 15 0.6
2,491 100 Based on the investigators ranking most of the
households fall in the bottom two categories with
about 50% being in the low group and another 33% being in the low-middle group.

Comparing the investigators ranking it is seen that amongst those who said their monthly income
is less than Rs.750 a month, almost all were ranked as being in the low or low-middle groups. In
fact, about 85% were ranked as being in the low group. About 90% of those who said they were
in the income groups of Rs. 750 to Rs. 3000 a month were ranked by the investigators as being in
the low or low-middle groups, with a higher percent being in the low group. About two-thirds
of those who said their monthly income is between Rs. 3000 to Rs. 5000 were also placed by the
investigators in the low or low-middle groups, with about 30% in the low group. Among those
who said their monthly income is above Rs.5000 a month, very few were placed in the low group.
Most (45%) were in the middle group and about 25% were ranked in the high-middle or high
groups. Therefore while there is no perfect correlation between the investigators ranking and the
respondents reporting of their income, it can be seen that these two broadly match with the
investigators perceiving most in the lower income groups (less than Rs. 3000 a month) as being
amongst the lower groups and those in the highest group of more than Rs. 5000 a month as being
the better off. What is seen is that amongst the different groups below Rs. 3000 a month the
investigators did not find much difference, except for the poorest group of those below Rs. 750 a
month.

Availability of Work

To get a sense of livelihood security people were asked how many days in a year they usually have
to spend without getting any work. Only a quarter of the respondents said that such a situation did
not usually arise where they need work and are not getting work. 17% said that such a situation
arose for less than one month in a year. 21% of the respondents said that they do not get work for 2
to 3 months in a year and another 26% said that they did not get work for about 3 to 4 months in a
year. This reflects the shortage of employment opportunities in the areas where the survey was
conducted, with such a large percentage of the respondents reporting that they usually do not get
work for a substantial part of the year. In terms of availability of work, Birsa block seems to be the
best off with almost half the respondents saying that they did not face the problem of unavailability
of work.
 When asked what
work government
should provide,
more than half the
respondents said
mazdoori/labour

Other Socio-Economic Indicators

It is seen that 77% respondents live in kachcha houses. Most of the respondents in the Birsa and
Baihar blocks of Balaghat live in kachcha houses. In Khalwa about 66% of the respondents and
about 43% of the respondents in Pandhana live in kachcha houses.
About 60% households have some livestock. 38% of the respondents own an ox; 33% own a cow
and about 15% own a hen.
About one fourth of the families saw one member or more migrating for work over the last one
year. One fifth of all the households said that they are in debt.
98% of the respondents use wood/cow-dung cake as fuel for cooking. This is the same in all the
blocks. Very few had access to cooking gas. Use of kerosene for cooking is not seen in the survey
area.
Most of the households had access to electricity. Overall about 83% of the households had access
to electricity with the blocks in Khandwa district having a better access to electricity than the
blocks in Balaghat district. Although there is access to electricity, the number of hours that there is
power supply is limited. Households that do not have access to electricity use kerosene for the
purpose of lighting.

Hand pump is the most common source of water in the survey area with 44% using hand pump for
drinking water, 35% and 19% using well and tap respectively. In Birsa only 21.5% of the
respondents said that the source of drinking water for them was a handpump, and about 43.9%
access drinking water from a well. In Baihar too, the percent of households accessing drinking
water from a well is high. In Birsa and Tamia about 30% - 35% of the households also had access
to tap water.
In some villages in Pandhana, people reported paying Rs 100 per month to owner of the water
source. Respondents in Baihar and Khalwa reported that the area surrounding the water source is
not clean. According to the investigators perception based on examining the main source of
drinking water in the village, in about half the villages (45 out of 86) the source of drinking water is
not clean. In 55 out of 86 villages there is some water stagnation around the source of water, and
in 71 out of 86 villages animals also use the same water source.

In 68.4% of the households the respondents said that they took any steps to purify the water. About
31% of the respondents said that they sieve drinking water with a cloth before drinking. A couple
of respondents said that they use a filter or boil the water before drinking.

As seen in the Census data for the district, a very small percent of the respondents have access to a
toilet facility. Among the different blocks in the survey, the blocks of Balaghat are slightly better
off in this regard compared to Khandwa and Chhindwara.

Toilet Availability Baihar Birsa Khalwa Pandhana Tamia Total

Yes 14.8% 10.3% 6.8% 9.0% 5.4% 9.2%
No 85.2% 89.7% 93.2% 91.0% 94.6% 90.8%
SECTION III: HOUSEHOLD FOOD CONSUMPTION
Respondents were asked how much of each of the main food items they consumed in a month.
Based on the number of members in the household, the monthly mean per capita consumption has
been calculated. Recommended Dietary Allowance (RDA) for different food items is based on the
sex, age and work profile of individuals. It is difficult to comment on the adequacy of the diets in
relation to RDA because our data is not individual-based. However, some comparisons are made to
get an idea of whether the consumption is close to the RDA or not. Further for the major food
items, the last column of the table also provides the per capita average consumption as estimated by
the NSS from the Consumption Expenditure Survey of 2009-10.

On average it is seen that, the average per capita consumption of cereals is 9.35kgs a month. This is
lower than the average for rural Madhya Pradesh from NSS data. In terms of pulses the average per
capita consumption among the sample was 0.9kgs. While this is slightly higher than the average
given by the NSS for rural Madhya Pradesh, this is very low when we consider the RDA for pulses.
The RDA for pulses for a 1-3 year old child is 30gms a day which translates into 0.9kgs a month.
The RDA for pulses for a moderate working woman is 75gms a day i.e. 2.25kgs monthly.
Therefore the current pulses consumption which is at the level that is adequate only for children
under three years is grossly inadequate.

The per capita oil consumption is 0.57kg per month. This is lower in Baihar and Pandhana. The
RDA for adults and children comes to about 0.75kgs a month. The oil requirement of children in
the age group of 10 to 18 years is even higher. The consumption of vegetables, leafy vegetables,
fruits is very low, on an average about 1kg a month. The consumption of milk was negligible and
this was seen in the NSS data as well.

Mean Monthly Per capita Consumption of Food Items

Food Item Baihar Birsa Khalwa Pandhana Tamia Total MP

Rural
(NSS)
cereals (kg) 9.61 9.91 10.13 9.36 7.78 9.35 11.3
pulses 0.52 0.67 0.64 0.96 1.69 0.90 0.71
oil 0.40 0.61 0.42 0.77 0.65 0.57 0.59
sugar 0.30 0.49 0.55 1.21 0.58 0.63 0.7
egg 0.90 0.89 0.76 0.77 0.95 0.85 0.67
meat 0.14 0.15 0.25 0.21 0.17 0.18 0.06
fish 0.14 0.15 0.08 0.10 0.13 0.12 0.09
leafy vegetables 0.59 1.84 0.42 0.36 1.30 0.90 0.43
groundnut 0.02 0.01 0.02 0.12 0.02 0.04 0.05
vegetables 2.27 1.93 1.15 1.07 0.34 1.35
mango 0.14 0.30 0.13 0.39 0.05 0.20
fruit 0.09 0.11 0.21 0.16 0.04 0.12
tea 0.13 0.04 0.03 0.08 0.04 0.07
jaggery 0.04 0.09 0.02 0.05 0.12 0.06
The consumption of foods such as eggs, fish and meat is also very low and does not really
contribute to the nutrition of members of the sample households.

In Khalwa, people are used to eating twice a day while in Birsa and Baihar, thrice a day is the
norm. So nearly two thirds eat at least twice a day. Among the sample households about 38% said
that they normally eat twice and day and another 61% said that they eat about three times a day.

In Birsa and Baihar, in the morning people are used to taking pej of rice, wheat or maize.

When asked about their normal diet consists of all the respondents mentioned cereal. About 80%
mentioned pulses, but most said that they did not consume pulses everyday but about two to three
times a week. About 90% mentioned that vegetables are regular part of their diets. Soya bean is
consumed as oil in Baihar while in Pandhana and Khalwa, it is consumed as boiled or roasted
beans. Fruits, eggs, meat, milk were reported to be part of routine diet by a mere 2 to 5 people in
the entire sample.

Source of Food PDS Market Own Production

Items:
Cereals 32.4 67.1 83.2
Pulses (1.7 no response) 94.2 5.2
Oil 98.3 2
Note: Totals do not add up to 100% as people access food items from multiple sources

It is only in the case of cereals, that for majority of the people at least some amount comes from
their own production. For pulses, oil and all other items people are mainly dependent on the market
for their consumption.

This information on household food consumption is reinforced in later sections where it is seen that
childrens food consumption is also largely cereal based. Due to the small quantities that children
eat and the fact that childrens requirement for this variety of food items is proportionally greater
Peoples diets are largely cereal based with the amount of pulses, oil consumed not being sufficient
to meet the nutritional requirements of people. Further the consumption of nutrient-rich foods such
as fruits, milk, eggs and other animal products is extremely low.
SECTION IV: MATERNAL HEALTH
At least three ante natal check-ups are recommended during pregnancy. Amongst the sample
respondents, 90% of the mothers had at least one ante Natal check up during last pregnancy, but
only about one-third got a check-up three or more times. In terms of ANC, Baihar is one of the
better off blocks where about 68% of the women received ANC three or more times. In relation to
the other components of ANC it is seen that 86% mothers took some Iron & Folic Acid
supplements during their pregnancy. Tetanus Toxoid vaccine was given to 97%.

Baihar Birsa Khalwa Pandhana Tamia Total

TT administered 99.2% 99.0% 93.0% 97.6% 97.6% 97.3%
IFA consumed 82.6% 93.8% 83.4% 78.6% 93.6% 86.4%

In the discussions with the women in the community, women mentioned leucorrhoea, back ache
and anaemia as common ailments among women in general.

In all the blocks, in the group discussions people reported that in general pregnant women eat the
same amount and the same food that they eat normally. Some food restrictions during pregnancy
and lactation were mentioned by the respondents during group discussions. Foods that are seen to
be hot foods or cold foods are generally restricted. Items that were commonly restricted include
Jaggery, Urad dal, Potato, Lemon, Banana, Mango, Brinjal, Drumsticks, Suran, Papaya, Curd and
Eggs. In Baihar Vegetable Kultha was mentioned as an essential component of the diet of pregnant
women.

During the lactating period also, there are cultural norms on what is good and what is restricted in
the mothers diet. "Halwa", "Ghata" and "Dalia" were common items that were mentioned as what
a new mother should include in her diet. However, people also mentioned that they were not able to
ensure such a diet due to poverty. In Khalwa, people also reported that soup of head and leg of goat
is nutritious during lactation. Women are also given a pejof Kutki or Samariya in the blocks of
Khandwa during lactation.

In most places, especially in Birsa and Baihar, it was reported that the mother should not eat much
in the lactating period because they believe that this will lead to the childs stomach bloating or
other kinds of problems for the child such as diarrhoea and indigestion. Therefore it is seen that
women are not given enough to eat immediately after delivery. In some places in Birsa mothers are
not given proper food to eat for up to six days after the delivery.

The respondents mentioned one maternal death each in Khalwa, Birsa and Baihar. There was no
mention of a maternal death in Pandhana.

Place of Delivery

In spite of improvements in the percent of institutional deliveries due to the NRHM and JSY, it is
found that almost half of the deliveries are still taking place at home. Birsa is the worst block with
about two thirds of the deliveries taking place at home, whereas in Pandhana only about a quarter
of the deliveries take place at home. In some villages in Birsa, women mentioned that they did not
prefer institutional delivery because the ANM beats the women during delivery.

Home Delivery
70.0% 66.0%
59.6%
60.0%
54.7%
49.8%
50.0%
42.6%
40.0%

30.0% 26.4%

20.0%

10.0%

.0%

baihar birsa khanlwa pandhana tamia

BLOCK Total

Most of the institutional deliveries are in government facilities PHC/CHC, SC and district
hospitals

Among those who had institutional deliveries it was seen that most of the women delivered in
government facilities such as the PHC or CHC. A small percent of the deliveries also take place in
the sub-centre or district hospitals. Only about 1% of the deliveries took place in a private facility.
On the other hand, as seen below, in case of illness people usually access private health facilities.
This shows that while there is an improvement in the public health system, it is only for deliveries
and not so for other aspects. Even in the case of deliveries while there is an increase in the number
of women going to institutions, in the discussions many issues related to quality of care were raised
in terms of facilities available, the kind of treatment received from health personnel, absence of
clean toilet facilities etc.
SECTION V: CHILD ANTHROPOMETRIC INDICATORS

To get an idea of the birth weight of children, respondents were

Percent of Children Whose
first asked whether the children were weighed after birth. If the
Birth Weight was Measured
child was weighed, within one week after birth, then it was Block Number Percent
considered. It is seen that a high percent of children in the blocks Baihar 345 69.8%
of Balaghat are weighed within first week of birth. In Birsa Birsa 461 92.8%
block, although home deliveries are high, it is seen that the Khalwa 134 26.8%
weight of the baby was taken within the first week in almost Pandhana 235 47.0%
93% of the cases. On the other hand in Khalwa, only about 27% Tamia 226 45.2%
of the respondents said that birth weight was taken. In Pandhana Total 1401 56.2%
about 47% of the children were weighed. Overall, in case of 56.2% of the children in the sample
the respondents reported that birth weight had been recorded. The birth weight of those children
who said that it had been recorded was asked. Where records were available these were also
checked. Of the 1401 children in whose cases the respondents said that birth weight was taken, they
were able to recall the birth weight in 1339 cases.

The figures given here are based on the reporting of the respondents. It is well known that there is a
recall error in reporting of birth weights and therefore one cannot be sure of its accuracy. On the
whole in about 14.1% of the cases it was reported that the birth weight was less than 2.5kg.
Another 36.9% of the cases it was reported that the birth weight was 2.5kg.

In all blocks, such a trend of a high number of respondents reporting birth weight as exactly 2.5kg
is seen. Such bunching indicates that there might be recall error or the birth weight was not taken
properly. In spite of these errors, there about 15% cases where low birth weight has been reported.

Anthropometry
Heights/lengths and weights of all children was measured. The Salter scale was used for measuring
weight. The Mid-Upper Arm Circumference of children was also measured. For height/length a
locally made infantometer was used. MUAC tapes got from Government of Madhya Pradesh were
used. The data on heights and weights were entered in Stata along with data on date of birth, date of
interview and sex of the children and the WHO Anthro software was used to calculate the z-scores
for weight-for-age; weight-for-height and height-for-weight. Based on these z-scores the
prevalence of severe and moderate underweight, stunting and wasting has been estimated using
standard WHO definitions.

A high percent of the children included in the sample were found to be underweight. Overall, half
the children were found to be underweight. The percent of underweight children in Khandwa was
the highest with 62.3% children under three years underweight.

Around 20% of all children are severely underweight. In this also, there is a block-wise variation
with more than one third of the children in Khalwa being severely underweight whereas in Tamia
about 13.6% of the children are severely underweight.

The survey also found very high prevalence of stunting amongst the sample children. For instance
severe stunting in Khalwa is as high as 46.4%. In the sample, overall 57% of the children were
found to be stunted. Such high rates of severe stunting across the blocks highlight the situation of
chronic hunger and deprivation among the sample population in these blocks. It is also noted that
the sample included in the survey is biased towards the poor and tribal communities among whom
malnutrition prevalence is expected to be higher.

District Underweight Stunted Wasted

Khandwa 62.3 64.9 27
(56.9) (45.1) (29.8)
Balaghat 44.5 52.1 26.7
(48.1) (40.7) (23.6)
Chhindwara 40.3 54 21.2
(48.8) (44.3) (27.3)
Total 50.7 56.7 25.9
Figures in bracket are from the NIN survey (2010)

A half of the
children in the 5
blocks were
found to be
underweight, the
problem being
most acute in
Khalwa (72%
underweight).
 57% children
are stunted - the
least prevalence
is in Baihar
(46%) and the
most is in
Khalwa (69%).

Severe wasting or SAM is also high compared to international standards. Overall about 10% of
children in the age group of 0-3 years are SAM affected by the weight for height criteria.

Of the children included in the sample, 1879 were in the age group of 6 months to 3 years. Of
these, 8.9% have a WHZ < -3. On the other hand only 4.9% were with MUAC 115mm. Therefore
the overlap between SAM as identified by WHZ <-3 nd MUAC 115mm is low. This has
implications to the Government of Madhya Pradeshs decision to use MUAC to identify SAM only
by MUAC through anganwadi centres. Although there are advantages to MUAC such as ease of
measurement and identification, the costs of excluding children in need of referral care needs to be
taken into account (Refer to IP papers).

One fourth of
the children
show wasting
in these blocks,
Khalwa is
again worse off
with one third
of the children
being wasted.
SECTION VI: CHILD FEEDING
Immediate causes of child malnutrition are related to appropriate child feeding practices and illness
among children. The recommended breastfeeding practices include early initiation (starting
breastfeeding within one hour of birth), exclusive breastfeeding (for six months) and continued
breastfeeding (up to two years).

Timing of Initiation of
Baihar Birsa Khalwa Pandhana Tamia Total
Breastfeeding
within 1 hour 62.1% 92.2% 72.8% 63.8% 92.6% 76.7%
within 2 hour 23.5% 3.6% 10.6% 11.6% 3.4% 10.5%
2 to 24 hour 7.7% .6% 6.4% 7.2% 3.4% 5.1%
next day 2.4% 1.6% 5.4% 4.2% .4% 2.8%
third day 3.6% 1.2% 3.2% 10.2% .2% 3.7%
more than 3 days .6% .8% 1.6% 3.0% .0% 1.2%

Based on the survey, it is found that 76.7% of the respondents started breastfeeding within one hour
of birth. The early initiation practice is lower in Baihar and Pandhana districts where around 63%
of the respondents said that breastfeeding was initiated in the first hour. With regard to pre-lacteals,
the respondents reported in 90% of the cases that the babies were given breastmilk as the first feed.
About 35% reported that colostrum is squeezed out. The NIN (2010) survey reports that colostrum
feeding in the state is 91%.

In the remaining 9% of the cases, sugar water, jaggery and honey were some of the things that
babies were given. During the group discussions in Pandhana and Khalwa, in majority of places
participants reported that before initiation of breastfeeding they usually give jaggery water to the
newborn. In some places, they informed that breastfeeding to newborns is initiated even after two
days. A few groups said that they discard few drops of colostrum before feeding the newborn. In
Birsa and Baihar, on the other hand, in most group discussions participants reported that
breastfeeding is initiated within one hour. It was only in some places that they said that a few drops
of colostrum were squeezed out before beginning breastfeeding or that any pre-lacteals were given.

Around 75%
start feeding the
child, within
one hour of
birth. In many
places, honey or
jaggery water
are given as pre
lacteal drink.
The WHO recommends exclusive breastfeeding up to the age of 6 months and continued
breastfeeding for two years or beyond. Exclusive breastfeeding means that the child is not given
anything else, including water for the first six months of life. In line with other large scale surveys,
it was found that while the practice of breastfeeding is quite widespread; the same is not true with
exclusive breastfeeding. Since it is difficult to ask about exclusive breastfeeding, the respondents
were asked the age at which the child was first given water. 35% of the respondents said that they
gave their children water to drink before they completed six months. In some places water was
given within the first 2-3 months. In all the group discussions as well, there was a general response
that water could be given to children from 2 to 3 months onwards, sometimes even earlier.

In relation to continued breastfeeding the situation is better. 84.3% of respondents are still
breastfeeding. Among those who are not still breastfeeding 31% stopped before one year, 25% at
one year, 28% between one and two years, and 10% at 2 years. On an average breastfeeding is
given 5 times a day.

Baihar Birsa Khalwa Pandhana Tamia Total

Still Breastfeeding 91.3% 91.1% 78.2% 74.0% 87.2% 84.3%
Age at which water was given for the first time:
Before 6 months 12% 8% 64% 80% 13% 36%
After 6 months 68% 77% 31% 16% 69% 52%
Not Yet 18% 14% 5% 1% 14% 10%
Dont Know 2% 1% 0% 3% 4% 2%

Complementary Feeding

The IYCF guidelines recommend introduction of complementary feeding at completion of 6

Initiated months of age. It is further recommended that up to
complementary Number Percent the age of 2 years children are fed 4-5 times a day.
feeding Along with this breastfeeding must also be continued.
Before 6 months 2 0.1 The survey found that among the respondents where
3 to 6 months 63 3.1 the children more than 6 months of age; about 15%
6 to 9 months 1,388 68.41 had started complementary feeding after the age of 9
9 to 12 months 168 8.28 months and another 12% have not yet started
After 12 months 139 6.85 complementary feeding. Timely onset of
Don't know 30 1.48 complementary feeding is therefore a problem. Even
Not started yet 239 11.78 during the group discussions it came out that there
Total was no particular age at which complementary
(children > 6 feeding was started, it more depended on the child.
months) 2029 100
Further, initially feeding is not done separately for the
child, rather the child eats along with the adults without being served in a separate plate/bowl.
 21.5% of
children above
6 months
started
complementary
feeding after the
age of 9 months

Further, even amongst those for whom complementary feeding had been started; it is found that
children were not being fed regularly enough. While it is recommended that children are fed four to
five times a day; according to the respondents more than 50% fed the children generally three times
a day and another 30% even less than three times a day. Less than 10% of the respondents said that
they fed their young children 5 or more times a day.

To get a better idea, the respondents were asked to list everything the child ate a day before the
survey. In response to this, it was found that almost 80% of the children ate 3 meals the previous
day. Only in 4.5% of the cases, it is seen that the child ate more than 3 times on the previous day.
About 15% ate only twice.

On the day
preceding the
survey - 10.8%
children had
one meal,
84.7% had two
meals.

When asked whether children ate separately and were given their own plate or bowl, only about
34.6% of the respondents (amongst those whose children had started eating solid food) said that
this was indeed the case. The percent of children eating separately is slightly higher in the
Khandwa blocks compared to the blocks in Balaghat.
What do children eat?

Along with quantity and frequency, it is also important to Items that Children Percent of
see what the children are eating. While doing a proper diet Had to Drink Children
survey is beyond the scope of this study, some idea can be Breast milk 79.9
got from the respondents reporting of everything the Cow/Goat Milk 11.9
child ate in the 24 hours before the survey. Formula/Powdered 1.9
Milk
All the food the children ate and everything they had to Pej 48.7
drink in the previous 24 hours was recorded verbatim. The Kheer 4.6
food was then classified into different food categories. Rabadi 2
Based on such a 24 hours recall it is found that almost all children ate some cereal. About 75% of
the child ate cereal three times the previous day. Another 18% ate only twice and about 4% ate
once. It is found cereal is consumed in almost every meal that the child has.

The survey found that almost 20% of the children ate no pulses on the previous day. Dal/pulses is
the main source of protein for these young children. 31% of the children consumed pulses only
once on the previous day and about 26% consumed pulses twice. 24% of the children had pulses in
three meals during the previous day.
The consumption of all other food items was very low. Only about 10% of the children ate any
vegetables. About 3% of the children had any root vegetables, and only around 1% had any fruits
on the previous day.

A negligible number of children (1%) ate any egg, meat, fish or chicken on the previous day.
Among these children, almost 80% were also breastfed. About 12% had some milk the previous
day. Almost half the children were given pej (gruel) on the previous day.
Based on the data on food consumption by the children on the previous day it is seen that children
are not eating frequently enough and are not getting adequate variety in their diet. The quantity that
children eat cannot be assessed in this survey. It is also difficult because most children were not
given food separately but just ate along with adults or other children. So in many cases the mothers
also did not have an idea of how much the child ate.

Further, there is clearly a deficit in the variety of foods consumed by children, with most children
not getting any fruits, vegetables, eggs, meat or fish.

SECTION VII: CHILDRENS ILLNESS AND HEALTH STATUS

The respondents were first asked whether felt that there was any problem with the childs health
(kya bachche ko koyi pareshaani hai). This was a probing question. In response to this question,
579 (23.2%) respondents answered that their child had one or two problems. Among these 579
respondents, the most common problems mentioned were that the child fell ill frequently with
cold and cough (61%); fever (47%) and/or diarrheoa (36%). About 28% of these respondents said
that the child had lost weight, about 20% each mentioned the child getting tired easily, having no
appetite or being irritable. 17.4% of the respondents who said that the child had any problem,
mentioned crying too much as the problem.

Note: Sum is higher than 100% because of multiple responses

In response to a general question on how they would rate the health status of the children, 80% of
all the respondents said that the child was healthy; about 18% said that the child was weak
(kamzor) and the remaining 2% said that they cannot say how the child was.

The investigators were also asked to note if they felt the child had certain visible symptoms of
malnutrition such as child having wrinkled skin, being so thin that the ribs could be seen, having
dry and thin hair, being lethargic/not responding, being pot bellied and having swollen feet. In 324
cases (13% of the sample), the investigators felt that there was one or more such symptom in the
child. Of the symptoms recorded by the investigators, about 45% of the children were lethargic and
not responding, 34% children were very thin, 28% of the children had light coloured dry hair, 17%
of the children had a pot belly, 5.9% children had swollen feet and 7.1% children had dry and
wrinkled skin.

Note: Sum is higher than 100% because of multiple responses

Pneumonia, itching, fever, diarrhoea, vomiting, cough and cold, boils and malaria were the
illnesses mentioned as common ailments among children in the various group discussions held in
the villages.

The respondents were asked about whether children had any illness in the previous two weeks. To
this, 577 (23.2%) responded in the positive. Most of the children had more than one illness. Of the
total sample of children, 11.3% had diarrhoea and 18.3% had fever. 1% of the sample children had
suffered from malaria in the previous two weeks.

Of those who said that the child had been ill in the previous two weeks; diarrhoea, cough and fever
were the common illnesses.
Of the 577 cases where children were ill in the preceding two weeks, 539 had sought treatment for
the child. Some of them sought treatment from multiple sources. In almost 70% of the cases where
treatment was sought, a private doctor was consulted. In 18.6% of the cases, the family went to a
government doctor and in about 10% of the cases a traditional healer was approached. About 5% of
the children were taken to the anganwadi worker and 2% each to the ANM and the male health
worker. Only about 1.5% of the respondents consulted the ASHA regarding the childs illness.

Only about 20% of those who sought treatment said that other than the medicine they had received
any advice on how to care for the child. Of those who got any advice (N=106); most were given
advice related to feeding more liquids, giving ORS and/or feeding nutritious food. Some were also
told about keeping the surrounding clean, given the child a bath regularly and ensuring that there
was no water stagnation.

In the discussions with the community in Pandhana, most mentioned malaria as a major health
problem. Further, they reported that for any health problems they usually first visit the ojha/padiyar
and then go to a doctor if needed. Even in emergencies they said that they preferred going to a
private doctor. One of the reasons mentioned was that in government facilities they were only given
tablets where as the private doctor also gave injections which were more effective. In Khalwa
people mentioned that in case of physical health problems people are take treatment from private
doctors and in case of other problems like, Bhoot, Pret and Upari Hawa they visit Ojha, Padiyar or
Patajan. The health centres are located at a distance of 3 to 15 Kms. In Birsa, people did not report
going to the Ojha/Padiyars so much. In all the blocks, it was mentioned that the private doctors
were their most preferred source of treatment. In Baihar some mentioned that in case of prolonged
illness they went to the government hospital.

Immunisation

In the group discussions, all groups said that they have faith in immunization and thus children and
pregnant women get immunized regularly. Among the sample children who are over one year old,
76.2% of children have been fully immunized. Almost 80% of the children above year of age have
been given the measles vaccination. The coverage of the measles vaccination is greater in the
blocks of Balaghat district and then in the blocks in Khandwa district.

Almost 84% of the respondents who had children more than a year old said that the child had been
given Vitamin A drops at least once and about 39% of them had been given deworming
medication.

Use of Soap

Respondents
are not used to
washing their
hand before
cooking or
eating.
As a specific indicator related to hygiene, questions were asked regarding hand washing with soap.
It was seen that while almost all use soap while bathing, the practice of using soap during other
times is less prevalent. For instance less than 15% said that they used soap to wash their hands
before eating. Only around 30% said that they used soap after using the toilet and only a quarter
said they washed their hands with soap after cleaning a childs faeces.
SECTION VIII: ACCESS TO GOVERNMENT SCHEMES
1. ICDS

To understand the functioning of the ICDS, respondents were asked some questions on their access
to ICDS and also the investigators visited the Anganwadi centre and interviewed the Anganwadi
worker.

Every survey village (except one) has an Anganwadi Centre (AWC) in it. However, blocks like
Pandhana reported that tribal beneficiaries were being excluded in some AWCs.

Taken child to AWC Baihar Birsa Khalwa Pandhana Tamia Total

Daily 25.3% 14.7% 23.6% 28.6% 25.6% 23.6%
At least once a week 47.2% 72.2% 57.8% 27.8% 55.6% 52.1%
At least once a month 23.3% 11.5% 8.6% 30.8% 7.2% 16.3%
Less Frequently 1.8% 1.0% 1.6% 3.2% 3.2% 2.2%
Never 2.4% 0.6% 8.4% 9.6% 8.4% 5.9%

Most of the respondents said that children are taken to the Anganwadi centre at least once a week
(75.7%). Considering that the children under three years of age only go to the AWC to collect the
take home rations that are distributed once a week and for growth monitoring, this is quite
encouraging. However about 8% of the children still do not access the AWC regularly.

Growth Monitoring

In a positive finding, 88% of the respondents said that their children were weighed at the AWC at
least once in the last three months. However, while the practice of growth monitoring seems to be
widespread this is not very meaningful because only 26% respondents were aware of the provision
of childs growth chart in AWC, with the figure falling to 5-6% in Khandwa blocks.

26% respondents have attended a meeting in an AWC, but this masks substantial variation of the
statistic between the blocks.

Baihar Birsa Khalwa Pandhana Tamia Total

Home visit by AWW 85.8% 86.3% 66.4% 48.8% 76.0% 72.6%
Attended AWC meeting 20.4% 21.9% 14.2% 4.0% 69.8% 26.1%
Aware of growth chart of child at 35.4% 31.2% 5.0% 6.0% 55.4% 26.6%
AWC
Other family members also 82.8% 55.5% 82.2% 79.2% 84.8% 76.9%
consume SNP

Supplementary Nutrition Program (SNP)

Based on the reporting by the respondents, in about 95% of cases either the child or mother or both
are getting SNP from ICDS. Most received 4 packets during the last month; which is the norm.
Therefore this survey shows that there has been a great improvement in the regularity and coverage
of SNP with most households reporting that they do receive the take how rations and in the
frequency that is mandated by the Government. However there are still issues with the quality of
SNP that remain. In Pandhana, in the group discussions dissatisfaction was expressed regarding the
quality of SNP.

Packets of SNP received last

Baihar Birsa Khalwa Pandhana Tamia Total
month
None 2.4% 1.0% 0.8% 0.4% 0.0% 0.9%
One 11.7% 7.0% 16.0% 0.8% 29.0% 12.9%
Two 20.2% 1.8% 18.2% 1.8% 6.4% 9.7%
Three 4.5% 0.0% 9.4% 3.6% 0.2% 3.5%
Four 57.5% 89.7% 46.0% 81.8% 59.6% 66.9%
Don't remember/ Don't know 0.8% 0.4% 2.4% 1.8% 1.4% 1.4%
Not applicable 2.8% 0.0% 7.2% 9.8% 3.4% 4.7%

Further, it was also seen that three-fourth of the respondents said that other members of the family
also share the SNP. Therefore the take home rations are not actually providing as many calories to
the under three child as they are supposed to. On the other hand, given the situation of food
insecurity in the area, it can only be expected that the take home rations will be shared amongst
other family members.

Anganwadi Centre (AWC)

60% AWCs surveyed were found in the centre of village, 27.7% in one corner and 12.3% outside
the village. Around 75% AWCs were in or around a tribal location. Average number of children
present in the AWC was 15. Other characteristics that were recorded based on observation by the
investigators is presented in the table below.

Observation by Investigators Observation by Investigators

AWC open during unannounced visit 99.4% AWW stays in the same village 84.3%
AWW present 96.4% AWC accessible to all children 76.5%
Investigator saw signs of cooking or
Weighing machine available 96.4% 76.5%
feeding
RTE was available at the centre during
93.4% Supervisor visited in the last month 72.9%
visit
Growth register updated in the last 2
Growth Register Available 92.2% 72.3%
months
Weighing machine in working
92.2% AWC building pakka 67.5%
condition
Date of birth recorded 91.6% Working water facility available 50.0%
Hot cooked meals served on day of
91.6% Medicine Kit 25.9%
visit
AWH present 90.4% Working toilet available 14.5%
While there were many positive findings in relation to the Anganwadi centres such as centres being
open, weighing machines being available and hot cooked meals being served at the centre there
were also many gaps. For instance, about one third of the Anganwadi centres were not in a pakka
building, only 50% had working water facility available and a very small percentage of the
Anganwadi centres had a medicine kit available to a working toilet facility in them. About 25% of
the Anganwadi centres were so located that they are not accessible to all children that they are
supposed to cater to, and in a similar percent of Anganwadi centres the growth registers have not
been updated in the last two months. Therefore the survey presents a mixed picture of the
anganwadi centres where compared to earlier studies AWCs exist and seem to be functioning on a
regularly basis; but they still have very poor infrastructure and the quality of services need to be
greatly improved.

A huge majority of the groups were aware of Ladli Laxmi Yojana. The practice of celebrating
Mangal Diwas is fairly widespread in Birsa but not in Khalwa and Baihar.

Responses of AWW

The AWWs were also asked some questions regarding the functioning of the ICDS. The survey
was conducted in mid-May/early-June. About 57% of the AWWs had received their last salary in
March or earlier. On an average, they had spent 16 years in service. A fifth of the AWWs had
received no training in the last two years.

Average number of children registered in the 0 to 3 year group was 48 and in the 3 to 6 year group
was 56. The latter group was fed for about 24 days in the previous month, according to the records
of the AWW. Average number of home visits reported in the previous month was 56. Almost 90%
received SNP supply either in the survey month or the previous month.

Anganwadi Workers Understanding of Malnutrition

The anganwadi workers were asked to say whatever they understood by kuposhan. Most of them
associated malnutrition with breastfeeding and sufficient food or nutritious food. Fewer talked
about the linkages with safe drinking water or illness/infection/health care.

Instead of labelling malnutrition as Kuposhan, the names that are used by the community are
based on symptoms. In Birsa and Baihar, a majority was not aware of NRCs. In Khalwa where
many groups were aware, people dislike taking children to NRC because they have other children
at home to take care of.
 As shown in the
graph, most of
AWWs associated
malnutrition with
breastfeeding and
sufficient food.

The Anganwadi workers were then asked to report on what they would do to prevent malnutrition.
Early initiation of breastfeeding and full immunization seemed to be the two most prevalent
interventions to prevent malnutrition that the AWWs are aware of.

Intervention Percent Intervention Percent

Early initiation breastfeeding 63.0% Keeping house clean 30.0%
Full immunization 58.0% Balanced diet 28.0%
Timely complementary feeding 53.0% Clean drinking water 20.0%
Exclusive breastfeeding 52.0% Vitamin sampoorn 19.0%
Sufficient food 48.0% Hand washing with soap 14.0%
Hygienic food 37.0% Spend more on money 2.0%
Keep children clean 36.0% Dont know 7.0%
Immediate medical attention during
34.0%
illness

PDS AND NREGA

A little less than half of the households have a BPL card, a similar proportion received ration in the
previous month.

85% of the households have an NREGA job card, about 60% worked under the Act over the last
one year. Delay in wage payment by 2 to 3 months was reported in the group discussions.
More than two thirds of the households have an account in bank or post office. A negligible number
of households had health insurance or life insurance.
SECTION IX: VILLAGE CHARACTERISTICS
Along with the household survey, some data was also collected at the village level. This data was
collected on the basis of interview of a group of key informants in each village. The respondents
were usually members of the gram panchayat, Anganwadi workers, village Secretary, school
teachers, MPW and so on.

Facilities in village

Number of Villages Baihar Birsa Khalwa Pandhana Tamia Total

with:
Sample Villages 24 10 17 12 23 86
Anganwadi 24 10 17 12 22 85
Asha 20 10 17 12 21 80
Primary school 24 10 16 12 22 84
Middle school 11 5 7 8 13 44
Sub-centre 4 4 5 5 7 25
PHC 0 2 0 1 2 5
Private doctor 4 6 4 4 4 22
Ojha 20 6 16 4 11 57
Post office 5 2 2 4 6 19
Bank 0 2 0 2 2 6
Ration shop 10 7 8 7 4 36
Kirana shop 18 10 14 11 11 64
Medical shop 2 2 1 2 1 8

All the villages, except for one in Tamia block, had an Anganwadi centre in the village. All but 6
villages had an ASHA appointed for the village. Except for one village in Tamia and one in Birsa,
all other sample villages had a primary school. About half the sample villages had a middle school
in them. 5 of the sample villages and 25 of the sample villages were PHC and sub-centre villages
respectively. Ration shops were present in only 36 of the 86 villages. 64 of the 86 villages had a
kirana shop. In 57 of the 86 villages, there was an ojha (traditional healer) in the village.

Physical amenities
Baihar Birsa Khalwa Pandhana Tamia Total
(% of Villages)
Electricity 22 9 14 22 22 79
Coal Tar approach road 14 8 11 10 12 55
Easily approachable in rain 20 9 11 10 14 64
Public transport: bus 14 7 6 7 6 40

In terms of other amenities, it is seen that 79 of the 86 villages have access to electricity. 3 villages
in Khlawa, 2 in Baihar and one each in Birsa and Tamia have no electricity. The mean duration of
availability of electricity in a day is 8.5 hours.
The most common source of water in the sample villages was a public well. However, there is a lot
of district-wise variation in this. While the public well is common in Baihar, Birsa and Tamia, the
common sources of water in Khalwa and Pandhana are public tap and public tubewell. According
to the observations of the investigators, the most used source of water was in clean surroundings in
only less than half the villages (41 out of 86).

Source of water Baihar Birsa Khalwa Pandhana Tamia Total

Public well 15 7 3 3 1 9
Public tap 8 3 9 3 4 27
Public tube well 1 0 4 4 5 14
Stream 0 0 0 0 2 2
Others 0 0 1 4 3 8

Cropping Pattern

The most commonly grown crops in the Rabi season are Wheat and Chana, with these being grown
in a large majority of the villages all the villages in Khalwa and Pandhana. The crops that are also
found in about 20-30% of the villages each are Sarson, Matar and Moong. The other crops that are
grown during the Rabi season but were mentioned only in a few villages are Alsi, Onion, Arbi,
Rice, Jagani, Urad, Arhar, Dhania, Lakhori, Mirch, Moong and Tivada.

Rice, Soyabean and Maize are the main crops grown during the Kharif season. Rice is grown in all
the villages in the blocks of Balaghat whereas Soya is grown in all the villages in the blocks of
Khandwa district. Kodo and Kutki are also widely grown, especially in the villages of Baihar and
Khalwa. Jwar is grown in more than half the villages in Khalwa. Pulses such as urad, Arhar and
Moong are grown in about 20% of the villages. A few villages also grow cotton. The other crops
that were mentioned by very few villages as being grown in the Kharif season include Bhadli,
Jagni, Kurathi, Sarson, Savaria, Sem, Sugarcane, Kultha, Madia, Tilli, Jagani And Sama.

All villages use multiple sources of irrigation the agriculture in the sample blocks are
predominantly dependent on the monsoon and other natural sources (pond, river). In 11 out of 86
villages, tubewells and in 15 out of 86 villages, canals are used for irrigation. In 63 out of the 86
villages well are also used for irrigation.

Livestock

Cows, oxen, goats and hen are livestock available in all the villages. Almost all the villages also
have some buffaloes.

SHGs

In 76 of the 86 villages in the sample, there is at least one SHG. In all the villages where there is an
SHG, SHGs are involved in supplying MDM to the schools. The other activities that the SHGs are
involved in include saving, and a few in grain procurement.

Migration

In 83 out of the 86 villages, the people said that there are some people in the village who migrate
out for work. In 39 of the 83 villages where they said that people migrate out for work, they said
that they mostly migrate to other states, in 28 villages they said that the common destination is
within the state, in 15 villages the migration was within the same district and in one village they
said that the migration was to nearby villages. In 76 of the 83 villages, people mainly migrated out
as unskilled labour in non-farm work. The other work that people find in the destination included
agriculture labour, government jobs, in mills etc. In 39 of the 83 villages, the common practice was
only for the male member to migrate. In rest of the villages, people reported that the whole family
migrates.

Food Availability and Consumption

The survey also attempted to document all the food items that people consume in the villages and
how many of these are also grown in the villages. This was just a preliminary exercise at the village
level quantities and sufficiency were not looked at. What is presented is only whether the item is
consumed and whether this item is bought from the market or own produce or both.

Cereals

As can be seen in the table, the main cereals consumed in the blocks covered under the survey are
maize, rice, wheat, kutki and kodo. In all the villages that were survey people consumed maize and
in almost all rice and wheat was also consumed. Maize is also grown in almost all the villages in
the sample, whereas Wheat is grown in two-thirds of the villages in the sample and Rice in three-
fourths of the villages. In half the villages maize is also purchased from the market1. In 81% of the
villages wheat is purchased from the market too and in almost 90% of the villages Rice is also
accessed from the market. While Kutki and Kodo are also consumed and produced widely, these
cereals are mainly consumed from the market
with respondents only in a few villages saying Percentage of Villages With:
that even buy Kutki and Kodo from the market Cereals Consumption Production Purchase
for consumption. Jowar and Sawan are also Maize 100.0 97.7 51.2
eaten by many, mainly from their own produce. Wheat 98.8 67.4 81.4
Rice 95.3 75.6 89.5
Kutki 81.4 77.9 16.3
Kodo 77.9 75.6 16.3
Jowar 51.2 40.7 23.3
Sawan
/Sawariya 39.5 38.4 0.0
Bajra 9.3 0.0 9.3
Ragi 3.5 1.2 1.2
Jo 1.2 1.2 0.0
Jayi 0.0 0.0 0.0

1
Market is basically outside the village. This is only village level data and within each village there would be people
who eat from own consumption, others who purchase and others who consume different proportions from own
production and consumption. As mentioned above, what this section is mainly looking at is the different food items
people consume, which of these are also grown locally (whether they meet the local requirement or not) and which
of these have a market locally (whether they are purchased at all from the market or consumption is mainly from own
production)
Pulses

With regard to pulses, we find that Arha, Chana and Urad are consumed in most of the villages.
While these three pulses are also produced in a large number of villages, in most of the villages
people also have to depend on the market for consumption. The other commonly consumed pulses
are moong, matar and masoor. While these are grown in about 35-40% of the sample villages, in
two thirds of the villages people also
purchase these pulses from the market. Percentage of Villages With:
Chanwla is eat in almost half the villages. Pulses Consumption Production Purchase
This is also produced in almost all the Toor/Arhar 100.0 69.8 80.2
villages where it is consumed, but people Chana 98.8 81.4 69.8
also buy it from the market. Gulabi chana Urad 97.7 79.1 72.1
and Tivsa are also consumed by people Moong 84.9 38.4 66.3
but is grown in very few villages. In one Matar 76.7 38.4 62.8
village there was a response that rajma is Masoor 73.3 36.0 68.6
consumed, but rajma is not grown in this chanwla 48.8 40.7 31.4
area and is bought from the market only. Gulabi chana 19.8 5.8 17.4
Tivda 14.0 4.7 12.8
From the household survey it is seen that Rajma 1.2 0.0 1.2
while pulses are produced in most of the
villages, only 5.2% of the households said that their pulse consumption was wholly or partly from
their own production. On the other hand, 83.2% of the respondents depended at least to some extent
on their own production of cereals for consumption.

Oil

The commonly consumed cooking oil in the

Percentage of Villages With:
sample villages are til and groundnut
Item Consumption Production Purchase
followed by mustard and Soyabean. All of
Til 69.8 50.0 52.3
these are also grown in the area. People
Groundnut 61.6 32.6 48.8
largely also depend on the market for
Mustard 45.3 37.2 40.7
oilseeds/oil. In about a quarter of the villages
Soyabean 43.0 52.3 51.2
people said that they also consume Alsi oil. Alsi 25.6 16.3 19.8
While a few villages now have sunflower Kardi 1.2 0.0 2.3
seeds production, locally in none of the Sunflower 0.0 2.3 1.2
villages is sunflower oil consumed.

The Annexure gives tables of food items block wise and also details for vegetables and fruits that
consumed and produced in the local area.

In all the villages of Khalwa and Pandhana, it was reported that soyabean is grown but not locally
consumed but only sold in the market.
QUESTIONS FOR FURTHER RESEARCH
Following are some more issues that can be analysed with the data available:

Possible link between household food security and childhood stunting can be explored. For e.g. it is
seen that the difference in per capita consumption of food items, between households where
children are stunted and those where they are not, comes out to be statistically significant for eggs,
vegetables and oil.

Though MUAC is an internationally accepted practice to identify Severely Acute Malnutrition; this
data shows otherwise. Whether there is a problem with MUAC measurement done for this survey
or there is something different with Indians, can be possibly verified by a smaller survey.
Preliminary findings based on this survey have already been published in the journal Indian
Pediatrics (http://www.indianpediatrics.net/jan2013/154.pdf).

Variables pertaining to household and children can be used to assess the determinants of
malnutrition through a multivariate analysis.
CONCLUSION AND RECOMMENDATIONS
The survey was conducted in five blocks in Khandwa, Balaghat and Chhindwara districts of
Madhya Pradesh, in four of which an intervention on community based management of
malnutrition is planned. The survey focussed on households with children under three years of age.
It was found that the level of malnutrition among children under three years is very high with 57%
of the sample children being stunted and 51% of the children being underweight based on WHO
standards.

The survey areas have a high concentration of tribal population. The sample population largely
belonged to vulnerable and deprived communities with poor living standards. Almost 60% of the
sample belonged to adivasi communities. 47.9% of mothers and 29.5% of fathers of the sample
children are illiterate. While 64.8% of the mothers were engaged in household work, the rest were
working outside the home. 27.4% of the mothers work as wage labour. Almost 50% of the
households said they did not own any agricultural land and 85% of the households estimated that
monthly household income is less than Rs. 3000 a month. Low levels of income is also reflected in
other socio-economic indicators of the household with a large number of households living in
kachcha houses and having no access to sanitation/toilets and clean drinking water.

The poor living conditions of people are also brought out when we look at the food consumption of
the household. Based on data on peoples reporting on how much of main food items that they
consume in a month, it is seen that peoples diets are largely cereal based. While pulses and oil do
form a part of their diet, the quantities consumed are not enough to meet nutritional requirements.
Nutrient rich foods such as milk, fruits, eggs and meat are conspicuous by their almost complete
absence in peoples diets. Household food security therefore is one of the important contributing
factors to the extent of child malnutrition, especially chronic forms (stunting) seen in the sample
children.

Along with poverty and household food insecurity, it is found that there are also problems in
childcare feeding and care practices that contribute to malnutrition. These problems are associated
with lack of health and nutrition services, lack of knowledge on appropriate feeding practices and
difficulty in accessing age-appropriate foods (calorie-dense with greater concentration of oil etc.)
foods.

Most women accessed ante natal care during pregnancy, however only 68% of the women had at
least three checkups. During the discussions in the village it also came out that there were many
food restrictions on pregnant and lactating women. Further, women usually ate the same amount
during pregnancy as otherwise. Almost half of the children under three years in the sample were
born at home. Only about 50% of the deliveries were institutional. Among the institutional
deliveries, most were in government facilities.

While early initiation and colostrum feeding (although about 35% said they said they squeezed out
some milk before beginning breastfeeding) were quite prevalent, 35% of the respondents said that
the children were given to drink water before they turned six months of age. This indicates that
many children are not exclusively breastfed for six months. On the other hand, there is a delay in
starting of complementary feeding in the form of solid/semi-solid foods. 21% of the children begin
complementary feeding after nine months of age. Further, while it is recommended that young
children are fed five times a day 80% of the respondents said that children normally eat three times
a day. Moreover on the day preceding the survey 85% children had only two meals and another
10% had only one meal. Two-thirds of children are also not given their food in a separate
plate/bowl but eat along with adults or other children.

On enquiring about the composition of childrens diets it was found that even the food that children
ate was largely cereal based. While all the children (among those who had started eating) had some
cereal on the day preceding the survey; 20% had no pulses. Almost none had eggs, fruit, fish or
meat. Almost one fourth of the respondents felt that their childs health was not satisfactory with
the child being weak or repeatedly falling ill. 11% and 18% of the sample children had diarrhoea
and fever in the last two weeks, respectively. In response to illness most sought care from a private
doctor. About 80% of the children above one year of age had received the measles vaccination.

Hygiene and sanitation levels are poor hand washing with soap is not a prevalent practice, most
drinking water sources are not clean, water is not boiled or filtered before drinking. Very few
respondents said that used soap at times other than bathing (before eating, after toilet etc).

In terms of access to services, the survey shows that the condition of ICDS has fairly improved
when compared to previous surveys of a similar kind. While coverage and regularity seem to have
increased, the quality of services is still a big problem. Except one, all the sample villages had an
Anganwadi centre. About 75% of the sample respondents said that the child visited the Anganwadi
at least once a week. This is a positive development considering that the ICDS has largely failed to
reach out to the children under three years of age effectively. However, even though children are
now regularly accessing the ICDS, are being weighed regularly and are being given take home
rations the survey also provides some clues into why this is not having the desired effect on
malnutrition. 88% of the children were weighed but only 26% of the parents were aware of a
growth chart or malnutrition status of the child. About 95% of the respondents said that the mother
or the child was receiving the SNP from the Anganwadi, however three fourths said that the THR
was shared by all members of the family.

The infrastructure facilities in Anganwadi centres are poor with many centres not having their own
building, proper water or toilet facilities. A little less than half of the households have a BPL card, a
similar proportion received ration in the previous month. 85% of the households have an NREGA
job card, about 60% worked under the Act over the last one year. Delay in wage payment by 2 to 3
months was reported in the group discussions.

The survey therefore showed that prevalence of malnutrition in the sample villages is very high and
there is a lot of scope for improvement and expansion in government programmes to address
malnutrition, health, drinking water and sanitation all of which are related. Further, there is a need
to also increase awareness on child feeding and care practices and create an enabling environment
and supportive services (such as maternity benefits and crches) to ensure that appropriate IYCF
practices are followed. Moreover, from the discussions it is seen that malnutrition is still not
recognised as a widespread problem, especially one that is related with childrens food
consumption. For this there is a need for massive community mobilisation involving all groups.

The following section gives some suggestions for the intervention.

Questions and Suggestions for Next Phase

How should child - care practices be improved, especially those related to complementary feeding
and hygiene?

Community groups can possibly be created, nutrition counselling can be provided through home
visits, group meetings and public awareness campaigns. But even if these measures are adopted,
diets can improve only when household food security improves. This entails not just improving
PDS access but also access to pulses, eggs, meat, milk, fruits etc. A linked aspect is to strengthen
the functioning of NREGA through social audits and sahayta kendras, strengthening systems of
demand for work, ensuring wage payments through work at the panchayat, block, district and state
levels. A potential plan is needed to enhance the levels of food production for local use and for
market.

ICDS has more design issues than implementation at the AWC level What can be done about
this?

Interventions such as setting up of crches and Anganwadi cum crches must be thought of so that
young children whose mothers are working have access to proper care and supervised feeding can
be ensured. The quality of SNP needs to be improved with the introduction of new recipes, more
allocation and diverse foods. Growth monitoring has to be made more meaningful for both the
community and planning within ICDS (set up a MIS from AWC to state, training of cadre at all
levels). Further, there are no proper protocols in place for the Anganwadi worker to follow in case
she identified malnourished children, children whose growth is faltering etc. While NRCs are
available, not all children need to nor can be admitted in an NRC. A community based arrangement
for managing all kinds of malnutrition needs to be put in place. The anganwadi worker along with
ASHA should also be able to addressing infections/illnesses (training of AWWs, convergence with
health).

Health Services need to be improved

While most women accessed government facilities, it was found that in case of childhood illnesses
people depended on private facilities. All institutions related to provision of health services such as
VHSNCs, need to be strengthened. Convergence mechanisms with ASHA, ANM and at higher
levels need to be set up. The referral and follow up to and from NRCs needs to be strengthened as
well.

Water, Sanitation and Hygiene

There were serious lacunae in terms of access to safe drinking water, hygiene and sanitation
facilities. Panchayats need to be involved in this.

Awareness campaigns on all the above issues need to be conducted.

 Data Sheet - Community based Management of Malnutrition and CMAM Program

SPANDAN PARHIT CDC

Name of District Khandwa Shivpuri Balaghat
Name of Blocks Khalwa Pohri Birsa
Number of GPs to be covered in each
block 60 34 27
Number of villages 100 100 100
Total Population to be covered 104588 56321 77000
Name of tribes to be reached Korku and Gond Sahariya Gond, Baiga and Oraon
Jaatav Mahar, Chamar,
Name of SC communities to be reached Balai (Charamkaar)
Goli (Yadav), Dhakad, Yadav, Pawar, Marar, Teli,
Banjara, Muslim Gurjar Kushwaha Sunar, Ahir, Panika,
Name of OBC communities to be reached Muslim
Number of crches proposed 10 10 10
Number of children to be reached
through crches (at a time) 150 150 150
Number of villages to covered under
mobilisation minus crches (if any) 90 90 90
Number of crche workers proposed 20 20 20
Number of community mobilisers
proposed 25 25 25
Number of crche coordinators proposed 0 0 0
Number of block coordinators 1 1 1
Number of cluster coordinators 5 5 5
Crude Birth Rate (annual health survey -
2011) (Rural) 25.4 32 23.8
Estimated number of children under
three in intervention area 7969.6056 5406.816 5497.8
Estimated number of malnourished
children (50%) 3984.8028 2703.408 2748.9
Estimated number of pregnant and
lactating women 2656.5352 1802.272 1832.6
Underweight (District level) in %age (NIN
2010) 56.9 55 48.1
Stunting (District level) in %age (NIN
2010) 45.1 62 40.7
Wasting (District level) in %age (NIN
2010) 29.8 25.7 23.6