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Maternal undernutrition is a critical public health problem in India with almost one in four women in the reproductive age reported to be underweight. Maternal undernutrition leads to low birth weight (LBW) and LBW children grow as undernourished stunted children. Additionally, poor Infant and Young Child Feeding practices and repeated infections due to an unhygienic environment contribute to childhood stunting, micronutrient deficiencies and anaemia. As per the National Family Health Survey (2015-16), about 38% of children below five years were reported to be stunted.
The ongoing Covid-19 pandemic poses an increased threat to maternal and child undernutrition, and compels us to reflect on the causes of maternal and child nutrition, and reaffirm the focus to improve the status.
Nutrition in the First 1000 Days: The Obvious and not so Obvious Determinants
The initial 1000 days of a child’s life are critical for the long-term physical and cognitive development of the child. Nutrition supplementation programmes are an obvious strategy and help in bridging the gap between the nutrition requirements and the habitual dietary intakes of the vulnerable groups. However, there is increasing recognition that dietary interventions, although necessary, are not sufficient to achieve the intended improvement in the nutrition outcomes as the antecedents of nutritional problems are often multidimensional and need comprehensive strategies. Therefore, it is pertinent to focus even on the not so obvious, underlying reasons for nutritional challenges.
Evidence shows that malnutrition is high in areas where people defecate in the open or use unhygienic toilet facilities. In such conditions, children are constantly exposed to pathogens which make them vulnerable to chronic intestinal diseases impairing the absorption of nutrients from food. Lack of sanitation and access to clean drinking water are important reasons underlying the persistent nutritional problems in India despite improved food availability.
Integrated approach for improving Maternal and Child Nutrition
The POSHAN Abhiyan launched by the Government of India emphasizes inter-sectoral convergence as a key strategy along with Jan Andolan (people’s movement). An integrated approach to combat malnutrition is the key to approach the nutrition challenge holistically and sustainably. The underlying causes of undernutrition arise from unsuitable/insufficient food intake, poor care practices and disease – these are directly or indirectly related to inadequate access to water, sanitation and hygiene.
Given this context, the Government of India’s new scheme “Nal se Jal” to provide piped drinking water to every household by 2024 is a welcome step and the improved access to clean drinking water in the implementing states may also result in some nutritional benefits.
The Covid-19 pandemic: Challenges and some Opportunities
With the onset of the Covid- 19 pandemic, India’s path towards achieving nutritional security has encountered unforeseen hurdles. During the first wave of Covid-19, there were transient disruptions in economic activities and access to perishable nutritious foods with potential impact on nutrition insecurity. Moreover, disruptions in the routine preventive maternal and child health care services due to the unprecedented challenges faced by the healthcare systems posed additional risks to maternal and child nutrition.
The current pandemic, despite its challenges, has also opened opportunities through increased resources for health promotion activities. It has also led to positive behaviour change as people, irrespective of their socio-economic status, now understand the importance of frequent hand washing for preventing disease transmission. Reduced burden of these infections can in turn help with significant improvements in the health and nutritional status of vulnerable groups.
Convergence of nutrition determinants at household and individual level
The recent Mission POSHAN 2.0 and ‘Saksham Anganwadi’ envision strengthening the content, delivery, and outreach of the interventions, thereby improving nutrition indicators. Alongside the efforts of inter-sectoral convergence at National and State levels, it is important to study the convergence of different determinants of child nutrition at household and individual levels as well as the dynamic interactions between different factors that may impact nutritional indicators.
More so, in the current situation as we need a better understanding of the changes in behaviours, dietary practices, and health-seeking habits in response to the Covid-19 pandemic and how these changes may have impacted maternal and child nutrition outcomes. We need to know if these changes stay on for a longer duration and what impact they would have in the coming days. Better understanding is also needed on whether improved health behaviours like hand washing have become the ‘new normal’ or if people have discontinued these practices after the recession of the pandemic.
At this precise juncture, ICMR-National Institute of Nutrition, as a part of a recently initiated interdisciplinary study, Action Against Stunting Hub, will be conducting an assessment of hygiene practices, water and sanitation, intestinal parasites, and microbiome along with infant and child feeding practices and maternal diets to advance understanding on the role of the social, nutritional, and biological components that affect childhood stunting.
More initiatives that seek to understand and subsequently address critical nutrition challenges in India through integrated multifaced approaches are required. Hence, the convergence of thematic areas and all stakeholders is needed to improve the growth and development of young children and achieve the goals of the POSHAN Abhiyaan.
