While India as a whole has seen considerable reduction in child malnutrition rates in recent decades, this progress still varies widely by state. Ensuring that nutrition interventions reach all vulnerable populations and that progress in nutrition outcomes is comprehensive and equitable requires understanding these state-level differences. To help provide this understanding, IFPRI’s Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India (POSHAN) program has undertaken a series of policy notes examining the trends in nutrition outcomes, drivers, and interventions at the state level. This blog post discusses the latest note focusing on Maharashtra.
The analysis spans 2006-2016 and utilizes data from India’s National Family Health Surveys for 2005-2006 and 2015-2016 and the 2013-2015 Rapid Survey on Children, as well as a comprehensive review of national and state-level policies and programs aimed at improving women’s and children’s nutrition outcomes. The study also utilizes summary data reported in the NFHS-4 district-level fact sheets to examine inter-district variability.
The study focuses on a set of global nutrition targets for maternal, infant, and young child nutrition: stunting, wasting, low birth weight, exclusive breastfeeding, child overweight, and anemia status among women of reproductive age. Levels and changes in several immediate, underlying, and basic determinants of nutrition were also examined.
The Indian state of Maharashtra is the third largest state in the country, accounting for around 110 million people. The report finds that the state has experienced overall improvements in nutrition and health outcomes during the study period. The prevalence of stunting among children under five years of age declined from 46.3 percent to 34.4 percent, which is below the national average. Similarly, low birthweight rates fell from 22.1 percent to 20.6 percent and the rate of exclusive breastfeeding increased from 53 percent to 56.6 percent.
Other indicators did not see such progress, however. Anemia among women of reproductive age remains a particular challenge, with anemia rates stagnating at 48 percent during the study period. Even more concerning are the rates of wasting among children under the age of five – that number increased during the study period from 16.5 percent to 25.6 percent, with severe wasting increasing from 5.2 percent to 9.4 percent. The report emphasizes the need for further research into the drivers of this increase in child wasting.
Nutrition trends vary within the state as well. Within Maharashtra’s 36 districts, child stunting rates range from 21.3 percent to 47.6 percent. In nearly one-third of the state’s districts, 40 percent of children under the age of five suffer from stunting. Anemia rates among women of reproductive age range from 35.5 percent to 60.2 percent, but most districts see anemia rates of almost 40 percent. Every district in Maharashtra has very high child wasting rates – above 15 percent. Levels of severe wasting range from 2.9 percent to 22.2 percent.
The study also examines the determinants of these nutrition outcomes, both immediate and underlying. Immediate determinants are defined as including early initiation of breastfeeding, timely introduction of complementary feeding for infants and young children, and disease burden. The rates of early initiation of breastfeeding improved over the study period, from 51.8 percent to 57.5 percent. However, appropriate introduction of complementary foods for children between six and eight months of age declined from 45.5 percent to 43.3 percent, and only 6.5 percent of children between the ages of six months and two years receive an adequate diet. In addition, diarrhea rates increased slightly during the study period, from 8.1 percent to 8.5 percent.
Underlying determinants include women’s literacy and education levels, household access to electricity and safe drinking water, and access to improved sanitation facilities. The proportions of literate women and women with more than 10 years of education have both increased over the past decade, and over 90 percent of households in Maharashtra now have access to electricity and safe drinking water. However, the study finds that more than half of the state’s population still does not have access to proper sanitation facilities.
Improving these trends will require increased investment and attention to nutrition interventions. During the study period, the report finds that interventions focused on pregnant women generally improved; the proportion of women receiving four or more prenatal care appointments rose from 59.8 percent to 72.7 percent. The proportion of pregnant women who got vaccinated against tetanus also increased from 25.8 percent to 47.4 percent. The proportion of women who delivered their babies in health facilities attended by skilled attendants grew impressively, reaching above 90 percent in 2016. On the other hand, while pregnant women’s consumption of iron and folic acid supplements increased, it remains low; further improving the reach of interventions to supply these supplements could be an important channel through which to reduce anemia rates.
The coverage of many interventions focused on children also increased during the study period. The proportion of children receiving vitamin A supplements grew from 23.3 percent to 70.5 percent, and receipt of supplementary foods from India’s Integrated Child Development Services rose from 30.5 percent to 51.4 percent. However, immunization coverage for children declined over the past decade, falling from 58.8 percent to 56.3 percent.
The report concludes with several recommendations for Maharashtra to continue and accelerate its progress on important nutrition outcomes. More research is needed into the factors contributing to the continued high rates of anemia in women and child wasting. In addition, continued and increased investment should be made in interventions to provide iron and folic acid supplements for both pregnant women and young children, as well as supplementary foods for young children. Attention also needs to be paid to reversing the trend of declining immunization among children and to the provision of improved sanitation facilities.
Finally, almost one-quarter of the adult men and women in Maharashtra are overweight or obese, with the related challenges of heart disease and high blood sugar developing rapidly. This highlights the double burden of malnutrition faced by the state and the need to balance interventions for early childhood nutrition with interventions to battle these growing non-communicable diseases.
By: Sara Gustafson