Experiences in the villages of Gujarat

Shree Chhotubhai A. Patel Hospital and Community Health Center

Mota Fofalia, Gujarat, India Reena Patel

Topics to Cover
General statistics Nutrition statistics Structure of malnutrition management Current changes in management Shakti Krupa Charitable Trust and Hospital My project Future management of malnutrition Our future involvement

Indias General Statistics

Currently (2013) there are 1,270,272,105 people in India = 17.3% of worlds population ~13% are children 0-6 years (158.8million) Projected to be the most populous country by 2030 The WHO, World Health Report for mortality rates per 100,000 population (2008): non-communicable diseases: 685 communicable diseases: 363 injuries: 99 Indiaonlinepages.com

Breakdown of India and Our Site

State Level (29) Gujarat District Level (33) Vadodara aka Baroda Taluka Level (13) Sinor Village Level (43) Mota Fofalia

Government of India
(GOI)

Nutrition Statistics

Ministry of Family Health and Welfare

(MoFHW)

National Rural Health Ministry

NRHM

International Institute for Population Science IIPS

District Level Health Survey

(2007-08)

National Family Health Survey-3 (2005-06)

National Family Health Survey - 3

Surveyed 109,041 households from 2005-2006 29 states in India = 99 percent of Indias population Two national-level fact sheets and 29 state fact sheets that provide estimates of more than 50 key indicators of population, health, family welfare, and nutrition

District Level Health Survey (DLHS) and facility survey

Surveyed 720,320 households from 28 States at the district level It was used to assess the utilization of services provided by government health care facilities and peoples perceptions about the quality of services Facility Survey: Sub-Centres, Primary Health Center, Community Health Center, and District Hospital www.rchiips.org

Anthropometric Measures
Underweight Weight for Age Acute and Chronic malnutrition Height for Age Linear growth retardation, past growth failure Recurrent or chronic illness Weight for Height Acute malnutrition Measure of muscle wasting Acute malnutrition

Stunting-

Wasting-

Mid-Upper Arm Circumference-

Indias Nutrition Statistics

Percent of children < 5years: underweight
Tamil Nadu Maharashtra Uttranchal Rajasthan Orrissa Uttar Pradesh INDIA Gujarat Meghalaya Bihar Jharkhand Madhya Pradesh

30
37 38 40 41 42 43

45
48 56 57 60
DLHS-3 (2007-08)

NFHS-3, 2005-06

Gujarat

DLHS-2, 2002-04

Gujarats Child Nutrition Statistics

Weight for Age criteria Weight for Height criteria

55.4 %

Normal % [Green]

55.4 %
25.9 % 12.9 %
5.8%
Wasting (%)

Normal %

28.3 %
44.6%

Moderate Under Weight % [Yellow] Severe Under Weight % (Red)

SUW/ MUW Moderate Acute Malnutrition (MAM) % Severe Acute Malnutrition (SAM) %

16.3 %
Underweight (%)

18.7%

NFHS-3, 2005-06

Indias Nutrition Statistics

rural areas 50% of young children are stunted ~1/2 are underweight 20% are wasted urban areas 40 % of young children are stunted 1/3 are underweight 17% are wasted

There is a strong inverse relationship between undernutrition in children and the level of wealth of the households that they live in. However, even in the wealthiest households (households in the highest wealth quintile), one-quarter of children are stunted and one-fifth are underweight.

DLHS 3, 2007-08

Breastfeeding Statistics
100

1. Initiation of Breastfeeding within 1 hour of birth 2. Exclusive Breastfeeding upto 6 months of life

50

48

48

3. Children 6-9 months fed Complementary foods 1+ 2+3

19

28

Most mothers (57 percent) gave their babies something other than breast milk to drink in the first three days after birth.
Source: DLHS-3 (2007-08)

Indicator: Child Mortality

Infant mortality is steadily declining Still, > than 1:18 children die within the first year of life, and >1:13 die before age five Mortality rates are 50% higher in rural than urban areas Scheduled Class/Tribe (23.5% of population) are at greater risk

Poor nutrition as a contributing factor to child mortality

NFHS-3, 2005-06

So whats been/being done?

ICDS: Government Stewardship

Integrated Child Development Services was first launched in 1975 Developed by the GOI to combat malnutrition and health problems in children below 6 years of age and their mothers They started the concept of an Anganwadi Centre (AWC) located in the villages The following services are sponsored by UNICEF and the World Bank Immunization, Supplementary nutrition, Health checkup, Referral services, Pre-school non formal education, Nutrition and Health information ICDS provides $10-22 per year per child As of Jan 1, 2013 there are 1,300,000 AWCs and mini-AWCs in India

Anganwadi Centre: AWC

Angan: is where people get together to discuss, greet, socialize, even cook and sleep. In the home it is the heart and considered sacred.

Courtyard shelter

Anganwadi Worker (AWW)

Role: health worker chosen from the community 4 months training in health, nutrition and child-care Importance: link to rural and healthcare needs, builds community trust, good advocate, affordable/accessible Each AWC covers 1,000 population, Each AWW covers 150-200 children Supervised and trained by ICDS government officials/agents

AWW & AW helper

AWC services
Growth Monitoring* Supplementary Nutrition Program in the AWC for 6 month to 6 yrs old: a) Energy dense Bal Bhog (3.5kg)/ month to 6mos to 3 yrs b) Hot cooked food to 3 yrs to 6 yrs c) Energy dense Take Home Ration (THR) for severe underweight children Milk to children 3-6 yrs, twice a week. Fruits to children 3- 6 yrs, twice a week Nutri-Candy with micronutrients (Iron, Folic acid, Vitamin A and Vitamin C) for age group of 3 to 6 years Mobile Anganwadi scheme for NREGA/Migrants population. Conditional Cash Transfer Scheme- cash incentive for pregnant mothers to have institutional births

AWC services
To create awareness about nutrition in the community. To counsel on Infant and Young Child Feeding (IYCF) practices. To mobilize the community to access health and nutrition services. To escort mothers with malnourished children to nearest care centers & to motivate mothers to stay during the intervention To ensure that children are followed up at care centers

Bal Bhog = supplementary foods

*Growth Monitoring
In 2008, ICDS adopted the new WHO Child Growth Standards (launched April 27, 2006).
Weight-for-age Height-for-age Weight-for-height

Measure physical growth and nutritional status of children from birth to 5 years age using anthropometric measures Using a Mamta Card to keep record

Despite >80% of children under age six years lived in enumeration areas covered by an anganwadi centre in the 12 months prior to the NFHS-3

Current Referral Scheme

District Hospital/Medical College District Nutrition Units

Care centers Nutrition centers

Community Health Center (CHC) Primary Health Center (PHC) Child Development and Nutrition Centers (CDNC)

Sub-Centres/AWCs (village level) Mamta Abihyan Initiative,routine care

Recent Changes

 In 2009, the WHO came out with updated growth standards with new cut-off values, and with anthropometric measures The Government of Gujarat is now adopting this model to propose a new measure of growth monitoring and management guidelines for malnutrition referral and intervention

MUAC as a measure of growth monitoring

Benefit of MUAC
Same specificity as W/H Cheap Easy to do Does not factor in age Indicator of acute issue

WHO Growth Standards, 2009

Moderate Under Weight (MUW) if : Weight for Age < -2SD to -3SD
Moderate (MAM) if : Acute Malnutrition

Severe Under Weight (SUW) if : Weight for Age < -3SD

Severe Acute Malnutrition (SAM) if : W/H < -3SD &/or MUAC <11.5cm &/or Bilateral pitting oedema

W/H between -2 and -3 SD &/or MUAC between 11.5 to <12.5 cm

Mission Balam Sukham happy child

Government sponsored nutrition program
Previously known as Gujarat Nutrition Mission Statement September 12, 2012

Mission Balam Sukham

Gujarat govt Budget 60 million rupees ($1,500,000) 2,000 rupees ($400) to each 18,000 villages in Gujarat

Mission
To strengthen growth monitoring and evaluation system and bringing in subject specialist. Ensuring growth monitoring and promotion by improving
Survey efficiency Weighing efficiency Plotting of weights on growth charts, and Identification of undernourished children and detection of growth faltering and stagnation and focusing on the most vulnerable- SAM, MAM, SUW and MUW

Amongst other mission statements not shown

Developing and Integrating appropriate Referral and Practice Guidelines as outlined in the WHO child growth standards and the identification of severe acute malnutrition in infants and children.

Operational Structure: Three tier approach

Children admitted with defined SAM criteria with severe Medical Complications/ Oedema

Children admitted with defined SAM criteria with Medical Complications Children admitted with defined SAM & MAM criteria without Medical Complications* *Medical complication: infection, edema, failure of appetite test

District Hospital/Medical College (Baroda)Nutrition Rehabilitation Centers (NRCs) Who qualifies: SAM criteria with severe Medical Complications/ Failed Appetite test/Oedema Duration: 25 days. Costs approx Rs 250/ child/ day Daily visit by a Trained Doctor Mother/guardian with child and compensated Rs 100/day for wage loss.

Community (CDNCs) Child Malnutrition Treatment Centres (CMTCs) Who qualifies: SAM criteria with medical complications Duration: 21 days Costs approx Rs 200/ child/ day Daily visit by a Trained Doctor Mother/guardian accompany onsite, compensated Rs 100/d for wage loss.

Village (Sub-centres) Village Child Nutrition Centres (VCNCs) at AWCs Who qualifies: SAM & MAM criteria without Medical Complications Duration : 30 days Cost approx Rs 40/child/day managed by AWW, AWH & ASHA.

WHO Standard for therapeutic feeding programs

NRC

CMTC

For children admitted at -3 SD weight-for-height defined by the WHO standards, a discharge at -2 SD and at -1 SD corresponds on average to a weight gain of 9% and 19% respectively.

Shakti Krupa Charitable Trust

Empowering Citizens to Strengthen the Roots of the Nation

www.shaktikrupa.org

Private K-12 School 50-bed adult hospital Community Health Center 3 Ambulances Helipad Farm for agricultural empowerment Government recognized

Shree Chhotubhai A. Patel Hospital

The Staff

Dr. Singh (OBGyn) and Dr. Nilesh (internist) with nursing staff. Also pictured: Meghna and Dr. Maloney

Dr. Pradeep (Internist)

Swaddle technique

Avg birthweight ~2.5kg

Post-partum room & Well baby Nursery

Community Health Centre

Second tier care center: Child Development and Nutrition Center (CDNC) In 2011, the AWWs in the surrounding Taluka of Sinor referred their children to Mota Fofalia for a pilot program using new WHO standard of care They referred 144 children who were classified as SAM for treatment

10 day hospital based refeeding program

Based on WHO treatment standards for SAM children 10 -21 day stay, until child reaches target weight Components:
Initial management of the child:
Management of comorbidities: hypoglycemia, diarrhea, vomiting Administering electrolyte solution: ReSoMal

10 day hospital based refeeding program

Feeding:
F-75 formula: 75kcal and 0.9g protein/100ml
Amounts per reference card Refeeding without laboratory monitoring

F-100 formula: 100 kcal and 2.9g protein/kg/100ml Monitoring of vital signs and

Involving mothers in the care 10 day teaching program for families:

Hygiene Food choices and preparation Danger signs

SAM program Gujarat Pilot Mota Fofalia

144 children treated in 2011 Discharged when they reached target weight
Should be about 15% weight gain to go up 1SD

Long term outcomes ???

Established Follow-up
There hasnt been any.hadnt

My Project

 The Plan: To follow up on the 144 children treated at the CDNC at Shree Chhotubhai Hospital for 10 days in 2011 The Follow-up: weight, MUAC, dietary history, recent illnesses The Team: 1 driver, 1 sister (nurse), 1 wardboy, myself The Equipment: 1 electronic weight scale, MUAC tape, 1 heavy duty vehicle, and a lot of patience The Route: 7 day adventure to 28 of 36 villages in the Sinor Taluka

Hashmuk (not shown ), primary driver

Parul, Nurse

Bhagu, Driver
(hes usually more happy than depicted here)

Ashok, Ward Boy

Anganwadi Centers
step one

Village-to-Village
step two

House-to-House
step three

Visited 28/36 villages in Sinor Taluka

 Were able to find 85 of 144 children = 59% Children not accounted for:
12 children in those 8 villages we did not go to 2 children passed away* Children were out of town for Holi celebration Children were with their parents in the farm

Results
Of the 85 children found and measured by MUAC: 63 were green (74.6%) 15 were yellow = moderate acute malnutrition (17.4%) 7 were red = severe acute malnutrition (8%)
No child had edema on exam One child with a mild skin infection

*2 children expired, cause unknown, unrecorded - 1 was taken to a nearby hospital the other was not hospitalized. - From word of mouth, they both had an infection
Reported Illness in past 2 weeks: ARI: 36/85, (42%) Diarrhea: 20/85, (23.5%) Fever: 22/85 (26%)

Successes and Attributes

Majority of children were green! Parents seemed educated appropriate nutrition Intra-village and inter-village awareness of community members Respect for Mota Fofalias hospital

Shortcomings, Improvement needs

- Efficiency of growth monitoring records and interpretation - Efficient referral systems and communication - Follow-up structure and plans

Future Malnutrition Management

At the Local Level

Growth Monitoring:
Using MUAC as a marker for acute wasting and a criteria for referral Making appropriate referrals

Education
Workshops for teaching new VCNC guidelines at to the village workers Improve approach of teaching feeding practices to families

Training Day

At a Taluka Level
Electronic Data Collection as a means for:
Efficient and simple ways to record anthropometric measures Quick reference Ease of follow-up Database for research

Current idea is using a mobile data entry system

To allow quick transfer of communication for appropriate referral

At a District Level
Building NRCs in more accessible locations while providing adequate treatment, with appropriate resources and management Advantages: closer outreach to the rural population, decreased transportation cost, ease of navigation, trust in a community stronghold

New Pediatric Center

Equipped w/ a: NICU, PICU, an operating room, 4 general wards and 4 special rooms

Main entrance

Connection to Adult Hospital

2nd floor: Nursing area

2nd floor: Pediatric OR

Nutrition Rehabilitation Center

The Shree Chhotubhai A. Patel Hospital will soon provide a new NRC for the district of Vadodara

Our Involvement

U of U Pediatrics Department and the SKCT partnership?

For residents
Opportunity to learn how to build from the ground up Clinical experience rotation for residents Public health project development

For the university program

potential global health fellowship site

Potential Project Ideas

Developing and researching public health interventions
Anemia, Vitamin A follow-up research Smoke exposure in homes Diarrheal disease Genetic syndromes Malaria research

Defining outcomes and accountability

QI projects

Developing appropriate care process models and overseeing integration

References
International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 200506: India: Volume I. Mumbai: IIPS. WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization, United Nations Children's Fund. Publication 2009. District Level Health Survey 3 (DLHS) website: rchiips.org World Health Statistics 2012. Global Health Indicators. www.who.int/healthinfo Guidelines on Facility Based Management of Malnourished Children. Commission of Health, Government of Gujarat, Gandhinagar. 2012.

Questions?

Every revolution has to originate from villages; only then can it be successful. Mahatma Gandhi

Thank You!