No. 9 | SEPTEMBER 2018

Coverage of Nutrition and Health Interventions in Insights from the National Family Health Survey-4

ABOUT THIS DATA NOTE Nutrition-specific interventions are aimed at improving the proximal food, health, and care environment for women and children during the first 1000 days. They can help improve maternal and child health, improve diets and other nutrition practices, and reduce infections. These interventions span pregnancy, postnatal, and early childhood periods and include food and micronutrient supplementation, nutrition education and/or counselling, growth monitoring and promotion, as well as routine immunization, deworming, and care during illness. At 90% coverage, these interventions can contribute to 20% reduction in stunting and 61% reduction in severe wasting1.

India’s policy framework for health and nutrition is robust and includes most evidence-based nutrition and health interventions. Two large-scale national program platforms – the Integrated Child Development Services and the National Health Mission together provide the public sector delivery platforms with the mandate to deliver these interventions across the country. ’s efforts at scaling up nutrition interventions are now also supported by the National Nutrition Mission.

This Data Note describes the coverage of a set of key nutrition and health interventions. The findings here are based on data from the National Family Health Survey 2015-2016. Indicators to capture the coverage of the interventions here are all calculated for women (15-49 years) with a child under five years of age. All analyses are based on the last-born child for each woman and indicator definitions are provided in Annex 1 of this Note. For some indicators, age categories may vary.

FIGURE 1 Coverage of interventions across the continuum of care, in 2016

100 90 80 70 60

% 50 40 30 20 10 0 ≥ 4ANC Weighing Weighing Vitamin A Vitamin Deworming Iodized salt Deworming Pediatric IFA Any ANC visits Tetanus injection Institutional birthInstitutional Full immunization Received MCP card MCP Received Zinc during diarrhea Care seeking for ARI for seeking Care ORS during diarrhea Skilled birth attendant Skilled birth Received IFA tab/syrup Food supplementation Food supplementation Food supplementation Demand for FPDemand for satisfied Postnatal care for babies Postnatal care for Consumed IFA 100+Consumed days Breastfeeding counselling Postnatal care for mothers Postnatal care for Counselling on child growth Health & nutrition education Health & nutrition education

Pre- Pregnancy Delivery and postnatal Early childhood pregnancy Note: ANC = Antenatal care; ARI = Acute respiratory infection; FP = Family planning; IFA = Iron and folic acid; MCP = Mother and child protection; ORS = Oral rehydration salts; The bars represent state average, the dots represent India average. Source: NFHS-4. 1Bhutta, Z.A., J.K. Das, A. Rizvi, M.F. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey, R.E. Black, Lancet Nutrition Interventions Review G, et al. 2013. “Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?” The Lancet 382(9890):452-477. MAP 1 Percentage of women who received 4 or more ANC visits, by district, 2016

Top 5 districts, %

Dhamtari 76.3 76.2 Uttar Bastar Kanker 72.1 Raigarh 67.6 Rajnandgaon 64.2

Bottom 5 districts, %

Jashpur 34.6 Narayanpur 40.9 Surguja 41.7 Kabirdham 43.8 Janjgir Champa 44.3 Source: NFHS-4. MAP 2 Percentage of women who were weighed during pregnancy, by district, 2016

Top 5 districts, %

Dhamtari 99.6 Mahasamund 99.4 Rajnandgaon 99.3 Bijapur 99.0 Bilaspur 98.4

Bottom 5 districts, %

Surguja 79.7 Kabirdham 86.1 Jashpur 87.3 Koriya 88.4 Janjgir Champa 89.2 Source: NFHS-4. MAP 3 Percentage of women who received or bought any IFA during pregnancy, by district, 2016

Top 5 districts, %

Korba 93.8 Dhamtari 93.7 Rajnandgaon 93.5 Bilaspur 93.3 Raigarh 93.3

Bottom 5 districts, %

Narayanpur 78.9 Dakshin Bastar Dantewada 85.8 Bijapur 86.3 Janjgir Champa 86.5 Surguja 86.9 Source: NFHS-4. MAP 4 Percentage of women who consumed IFA for 100+ days during pregnancy, by district, 2016

Top 5 districts, %

Dhamtari 43.0 Rajnandgaon 40.0 Koriya 39.6 Bilaspur 39.4 Uttar Bastar Kanker 38.5

Bottom 5 districts, %

Surguja 18.5 Janjgir Champa 18.5 Kabirdham 19.1 Bijapur 21.3 Raigarh 21.3 Source: NFHS-4. MAP 5 Percentage of women who received breastfeeding counselling during pregnancy, by district, 2016

Top 5 districts, %

Bilaspur 85.2 Dhamtari 79.6 Rajnandgaon 78.4 Korba 75.2 73.6

Bottom 5 districts, %

Jashpur 52.6 Raigarh 58.2 Surguja 59.1 Janjgir Champa 59.9 Kabirdham 62.0 Source: NFHS-4. MAP 6 Percentage of women who received food supplements during pregnancy, by district, 2016

Top 5 districts, %

Dhamtari 94.3 Mahasamund 94.2 Bastar 93.3 Kabirdham 93.1 Rajnandgaon 91.9

Bottom 5 districts, %

Durg 82.0 Raipur 83.0 Korba 83.2 Janjgir Champa 84.2

Source: NFHS-4. Koriya 84.3 MAP 7 Percentage of women who gave birth in a health facility, by district, 2016

Top 5 districts, %

Rajnandgaon 86.7 Dhamtari 83.4 Bilaspur 80.8 Uttar Bastar Kanker 79.9 Bijapur 78.4

Bottom 5 districts, %

Kabirdham 49.3 Janjgir Champa 62.6 Jashpur 62.9 Dakshin Bastar Dantewada 63.9 Narayanpur 66.2 Source: NFHS-4. MAP 8 Percentage of women who received food supplements during lactation, by district, 2016

Top 5 districts, %

Kabirdham 90.9 Dhamtari 90.1 Bastar 89.4 Mahasamund 88.2 Uttar Bastar Kanker 87.9

Bottom 5 districts, %

Koriya 78.6 Raipur 80.8 Durg 81.2 Korba 81.3

Source: NFHS-4. Narayanpur 81.4 MAP 9 Percentage of mothers who received postnatal care within two days of childbirth, by district, 2016

Top 5 districts, %

Rajnandgaon 86.8 Bilaspur 81.6 Dhamtari 76.9 Raigarh 68.6 Raipur 67.6

Bottom 5 districts, %

Jashpur 41.7 Surguja 45.5 Dakshin Bastar Dantewada 46.2 Kabirdham 49.4

Source: NFHS-4. Janjgir Champa 49.6

MAP 10 Percentage of children (0-59 months) who received postnatal care within two days of their birth, by district, 2016

Top 5 districts, %

Dhamtari 55.5 Rajnandgaon 54.5 Raipur 47.6 Narayanpur 42.5 Bilaspur 42.5

Bottom 5 districts. %

Surguja 13.1 Jashpur 15.5 Korba 20.0 Durg 21.3 Janjgir Champa 24.5 Source: NFHS-4. MAP 11 Percentage of children (12-23 months) who were fully immunized, by district, 2016

Top 5 districts, %

Durg 91.1 Dhamtari 89.1 Rajnandgaon 86.5 Bijapur 85.7 Korba 81.0

Bottom 5 districts, %

Jashpur 52.3 Narayanpur 61.5 Kabirdham 61.7 Surguja 65.7 Dakshin Bastar Dantewada 67.0 Source: NFHS-4.

MAP 12 Percentage of children (6-35 months) who received food supplements, by district, 2016

Top 5 districts, %

Kabirdham 93.7 Uttar Bastar Kanker 93.2 Janjgir Champa 93.1 Rajnandgaon 92.5 Bilaspur 92.5

Bottom 5 districts, %

Durg 81.5 Raipur 82.2 Korba 83.1 Koriya 83.8 Dakshin Bastar Source: NFHS-4. Dantewada 84.0 MAP 13 Percentage of children (6-59 months) who received vitamin A supplements, by district, 2016

Top 5 districts, %

Raigarh 77.7 Bijapur 77.6 Bilaspur 77.5 Rajnandgaon 76.9 Kabirdham 72.9

Bottom 5 districts, %

Surguja 59.1 Mahasamund 60.4 Dhamtari 61.5 Korba 62.1 Jashpur 63.2 Source: NFHS-4. MAP 14 Percentage of children (0-59 months) with diarrhea who received ORS, by district, 2016

Top 5 districts, %

Bijapur 100.0 Dhamtari 81.4 Koriya 76.0 Kabirdham 75.0 Bilaspur 74.4

Bottom 5 districts, %

Jashpur 46.5 Raipur 46.6 Surguja 53.3 Durg 59.1 Uttar Bastar Source: NFHS-4. Kanker 59.2 MAP 15 Percentage of children (0-59 months) who were weighed in the last 12 months, by district, 2016

Top 5 districts, %

Rajnandgaon 85.7 Uttar Bastar Kanker 85.1 Bilaspur 84.8 Bijapur 84.2 Bastar 83.3

Bottom 5 districts, %

Janjgir Champa 72.4 Koriya 73.4 Narayanpur 73.9 Raipur 74.6

Source: NFHS-4. Durg 75.3

MAP 16 Percentage of mothers with children (0-59 months) who were counselled about child growth after their child was weighed, by district, 2016

Top 5 districts, % Uttar Bastar Kanker 75.6 Dhamtari 71.1 Bilaspur 66.5 Bastar 66.2 Mahasamund 65.8

Bottom 5 districts, % Dakshin Bastar Dantewada 44.0 Surguja 48.9 Jashpur 49.3 Korba 49.4

Source: NFHS-4. Koriya 51.4 DASHBOARD: Coverage of nutrition-specific interventions, by district, 2016

<25% 25-<50% 50-<75% ≥75% Durg Korba Bastar Koriya Raipur Bijapur Surguja Raigarh Jashpur Bilaspur Dhamtari Kabirdham Narayanpur Mahasamund Rajnandgaon State/District JanjgirChampa CHHATTISGARH UttarBastar Kanker DakshinBastar Dantew

Demand for FP satisfied 79.6 75.4 84.3 84.3 60.6 90.2 82.4 80.9 70.0 83.3 76.3 76.2 85.6 74.1 76.0 80.7 86.9 70.9 80.4 Pre- Iodized salt 98.8 98.5 99.3 99.0 99.6 99.6 99.2 98.6 99.1 96.6 98.9 98.6 98.7 99.4 98.2 99.0 98.7 98.6 99.0 pregnancy

Any ANC visits 96.2 98.3 99.3 99.1 95.1 100 98.9 94 .4 89.4 92.2 95.4 91.1 99.8 91.1 96.0 97.9 99.3 85.1 96.1

≥4ANC 59.1 55.7 4 9.1 60.7 60.5 76.3 59.9 44.3 34.6 43.8 52.9 45.1 60.8 40.9 67.6 76.2 64 .2 41.7 72.1

Received MCP card 86.0 86.0 95.5 94 .9 82.0 91.5 91.8 81.0 75.8 77.4 84.1 89.5 94 .9 79.4 79.2 81.2 98.1 68.5 92.9

Received IFA tab/syrup 91.4 90.4 86.3 93.3 85.8 93.7 92.4 86.5 89.3 92.8 93.8 90.8 92.8 78.9 93.3 92.0 93.5 86.9 92.7

Consumed IFA 100+ days 30.6 29.2 21.3 39.4 26.2 43.0 37.6 18.5 26.1 19.1 24 .3 39.6 23.8 23.7 21.3 31.6 40.0 18.5 38.5

Deworming 23.9 17.8 28.7 39.1 13.7 18.7 22.5 15.5 13.8 17.0 24 .4 27.8 24 .9 23.4 15.3 17.9 35.2 24 .7 17.2 Pregnancy Weighing 93.9 97.3 99.0 98.4 93.3 99.6 98.2 89.2 87.3 86.1 93.3 88.4 99.4 90.4 91.6 94 .4 99.3 79.7 94 .3

Breastfeeding counselling 70.0 67.3 69.4 85.2 64 .6 79.6 73.6 59.9 52.6 62.0 75.2 64 .0 70.0 62.8 58.2 67.9 78.4 59.1 71.8

Food supplementation 87.2 93.3 89.7 88.7 88.0 94 .3 82.0 84.2 89.0 93.1 83.2 84.3 94 .2 84.8 87.2 83.0 91.9 86.2 90.8

Health & nutrition education 78.4 85.0 87.4by81.5 district,81.1 90.7 77.6 70.1201671.3 82.4 72.2 66.9 86.2 77.6 74.4 76.9 85.3 70.5 87.8

Tetanus injection 92.9 95.9 94 .4 96.5 93.5 98.9 95.0 91.2 90.8 91.9 91.1 93.3 95.4 84.7 92.2 91.7 95.8 83.4 91.9

Institutional birth 72.8 68.5 78.4 80.8 63.9 83.4 73.8 62.6 62.9 4 9.3 69.3 70.3 78.3 66.2 70.4 72.7 86.7 66.4 79.9

Skill birth attendant 80.2 77.1 82.9 87.7 70.8 91.4 84.1 69.2 68.3 59.3 75.2 76.8 85.9 75.2 79.6 81.1 93.2 69.4 85.8

Postnatal care for mothers 63.7 53.0 63.9 81.6 4 6.2 76.9 61.5 4 9.6 41.7 4 9.4 54.9 64 .4 57.4 63.0 68.6 67.6 86.8 45.5 60.8

Postnatal care for babies 34.2 39.0 31.0 4 2.5 31.6 55.5 21.3 24 .5 15.5 33.0 20.0 30.5 28.0 4 2.5 34.6 47.6 54.5 13.1 32.4

Delivery & postnatal & Delivery Food supplementation 84.7 89.4 82.8 87.0 87.7 90.1 81.2 85.5 84.5 90.9 81.3 78.6 88.2 81.4 81.5 80.8 87.4 85.6 87.9

Health & nutrition education 71.1 78.5 76.9 77.7 77.5 83.2 75.8 71.0 68.8 68.1 69.4 62.0 77.0 66.3 55.7 63.1 75.6 64 .5 75.5

Full immunization 76.4 70.9 85.7 80.9 67.0 89.1 91.1 71.1 52.3 61.7 81.0 73.9 74.1 61.5 67.1 80.2 86.5 65.7 81.0

Vitamin A 68.9 70.1 77.6 77.5 66.6 61.5 66.9 63.9 63.2 72.9 62.1 72.9 60.4 70.5 77.7 70.8 76.9 59.1 68.2

Paediatric IFA 35.5 32.2 41.2 47.8 31.1 34.9 29.0 19.1 31.9 36.1 31.0 45.2 26.2 4 2.1 36.4 39.5 4 2.5 33.9 33.6

Deworming 39.9 35.5 61.1 64 .1 36.5 35.8 41.4 24 .3 23.4 31.1 38.9 45.8 34.8 55.9 35.2 32.8 60.2 31.6 38.6

Care seeking for ARI 71.4 68.6 77.8 80.8 81.3 76.5 68.9 63.7 54.7 67.6 58.8 77.5 66.8 64 .5 70.1 77.5 86.2 62.5 73.4

ORS during diarrhea 66.2 72.5 100 74.4 69.7 81.4 59.1 60.6 4 6.5 75.0 68.8 76.0 64 .8 72.5 66.4 4 6.6 74.3 53.3 59.2 Early childhood Early Zinc during diarrhea 29.5 24 .9 50.4 43.1 13.0 27.4 32.1 13.7 10.1 37.1 22.0 4 2.8 27.4 25.5 23.0 7.3 41.2 22.6 11.3

Food supplementation 88.0 89.8 86.1 92.5 84.0 92.3 81.5 93.1 89.6 93.7 83.1 83.8 88.3 85.2 89.8 82.2 92.5 91.8 93.2

Weighing 79.0 83.3 84.2 84.8 77.6 81.3 75.3 72.4 79.1 79.3 76.2 73.4 78.9 73.9 78.9 74.6 85.7 78.7 85.1

Counselling on child growth 57.7 66.2 65.6 66.5 44.0 71.1 52.5 51.6 4 9.3 55.3 4 9.4 51.4 65.8 57.0 57.3 53.7 64 .9 48.9 75.6

Source: NFHS-4 Summary of findings

• High coverage (≥75%): Sustained efforts are required to maintain the high coverage for the following interventions: • Before & during pregnancy: demand for family planning, iodized salt, any ANC visits, MCP cards, IFA supplementation, weighing, food supplementation, health & nutrition education, tetanus toxoid injection. • Delivery & postnatal: skilled birth attendant, food supplementation. • Early childhood: full immunization, food supplementation, weighing.

• Low coverage (<50%): The state should focus efforts on increasing coverage of the following interventions: • Before & during pregnancy: consuming 100+ IFA, deworming. • Delivery & postnatal: postnatal care for babies. • Early childhood: IFA supplementation, deworming, zinc during diarrhea.

• Missed opportunities: Coverage of postnatal care is higher for mothers than for babies. Many women receive some IFA but fewer are consuming IFA for at least 100 days during pregnancy. Deworming during pregnancy is lower than during childhood. Though ORS is provided during childhood diarrhea in most cases, zinc is provided less frequently.

ANNEX 1 Definition of indicators used in the analyses

Indicators Definition Pre-pregnancy Demand for FP satisfied Percentage of women (15-49 years) who have their need for family planning satisfied with modern methods. Iodized salt Percentage of households with children under 5 years of age using iodized salt. Pregnancy Any ANC visits Percentage of women (15-49 years) with children under 5 years of age who were attended by any trained provider ever or at least once, when they were pregnant with their youngest child. ≥ 4ANC Percentage of women (15-49 years) with children under 5 years of age who were attended by any trained provider 4 or more times, when they were pregnant with their youngest child. Received MCP card Percentage of women (15-49 years) with children under 5 years of age who received the Mother and Child Protection card after pregnancy registration, whenby they district, were pregnant with their2016 youngest child. Received IFA Percentage of women (15-49 years) with children under 5 years of age who received or bought any IFA tablets/syrup, when they were pregnant with their youngest child. Consumed IFA for 100+ Percentage of women (15-49 years) with children under 5 years of age who consumed IFA tablets/syrup for 100 days or more, days when they were pregnant with their youngest child. Deworming Percentage of women (15-49 years) with children under 5 years of age who received any deworming drug, when they were pregnant with their youngest child. Weighing Percentage of women (15-49 years) with children under 5 years of age who were weighed when they were pregnant with their youngest child. Breastfeeding counselling Percentage of women (15-49 years) with children under 5 years of age who received advice on breastfeeding from any provider, when they were pregnant with their youngest child. Food supplementation Percentage of women (15-49 years) with children under 5 years of age who received food supplements from the anganwadi center (AWC), when they were pregnant with their youngest child. Health & nutrition Percentage of women (15-49 years) with children under 5 years of age who received health and nutrition education from the AWC, education when they were pregnant with their youngest child. Tetanus injection Percentage of women (15-49 years) with children under 5 years of age who received at least 2 TT injections when they were pregnant with their youngest child. Delivery and postnatal care Institutional birth Percentage of women (15-49 years) with children under 5 years of age who delivered their youngest child in a health facility. Skilled birth attendant Percentage of women (15-49 years) with children under 5 years of age who were attended by skilled health personnel when they delivered their youngest child. Postnatal care for mothers Percentage of women (15-49 years) with children under 5 years of age who received postnatal care, while in facility or at home, two days after they delivered their youngest child. Postnatal care for babies Percentage of last-born children (0-59 months) in the last 5 years, who received postnatal care within two days after they were born. Food supplementation Percentage of women (15-49 years) with children under 5 years of age who received food supplements from the AWC, when they were breastfeeding their youngest child. Health & nutrition Percentage of women (15-49 years) with children under 5 years of age who received health and nutrition education from the AWC, education when they were breastfeeding their youngest child. Early childhood Full immunization Percentage of last-born children (12-23 months) in the last 5 years who received one dose of BCG vaccine, three doses of polio vaccine, three doses of DTP3 vaccine, and one dose of measles vaccine. Vitamin A Percentage of last-born children (6-59 months) in the last 5 years, who received vitamin A supplements in the six months preceding the survey. Pediatric IFA Percentage of last-born children (6-59 months) in the last 5 years, who received iron supplements in the last 7 days prior to the survey. Deworming Percentage of last-born children (12-59 months) in the last 5 years, who received albendazole or any other deworming drug in the last 6 months prior to the survey. Care seeking for ARI Percentage of last-born children (0-59 months) in the last 5 years, with suspected ARI symptoms in the last two weeks, who were taken to a health care provider. ORS during diarrhea Percentage of last-born children (0-59 months) in the last 5 years, with diarrhea in the last two weeks, who received ORS. Zinc during diarrhea Percentage of last-born children (2-59 months) in the last 5 years, with diarrhea in the last two weeks who received zinc. Food supplementation Percentage of last-born children (6-35 months) in the last 5 years, who received food supplements from the AWC in the last 12 months prior to the survey. Weighing Percentage of last-born children (0-59 months) in the last 5 years, who were ever weighed in the last 12 months. Counselling on child Percentage of women (15-49 years) with children under 5 years of age, who were counselled about their youngest child’s growth growth after they were weighed in the last 12 months prior to the survey. ABOUT POSHAN Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India (POSHAN) is a multi-year initiative that aims to AUTHORS support the use of data and evidence in decision-making for nutrition in Anjali Pant, Research Analyst, IFPRI India. It is supported by the Bill & Melinda Gates Foundation and led by Rasmi Avula, Research Fellow, IFPRI IFPRI in India. Phuong Hong Nguyen, Research Fellow, IFPRI ABOUT DATA NOTES Lan Mai Tran, Independent Researcher POSHAN Data Notes focus on data Samuel Scott, Associate Research Fellow, IFPRI visualization to highlight geographic and/or thematic issues related to Purnima Menon, Senior Research Fellow, IFPRI nutrition in India. They draw on multiple sources of publically available data.

SUGGESTED CITATION CONTACT US Pant, A., R. Avula, P.H. Nguyen, L.M. Tran, S. Scott, and Email: IFPRI [email protected] P. Menon. 2018. Coverage of Nutrition and Health Interventions in Chhattisgarh: Insights from the National Family Health Survey-4. POSHAN Data Note 9. , IFPRI-NEW DELHI India: International Food Policy Research Institute. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE NASC Complex, CG Block, Dev Prakash Shastri Road, Pusa, New Delhi 110012, India T+91.11.66166565 F+91.11.66781699

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This publication has been prepared by POSHAN. It has not been peer reviewed. Any opinions stated herein are those of the author(s) and do not necessarily reflect the policies of the International Food Policy Research Institute.

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