Despite spending billions of rupees on health issues under different schemes by the state and the central governments, Madhya Pradesh, it seems, has miserably failed to end the scourge of malnutrition deaths. During past five months, 116 children lost their lives due to malnutrition in villages under Badauda, Karahal and Vijaypur blocks of Sheopur district in Madhya Pradesh alone. Madhya Pradesh, with the highest number of malnutrition deaths, anaemic and underweight children, worst early neo-natal mortality rate (ENMR) and neo-natal mortality rate (NMR) and declining fertility rate, tops the list of Indian states fighting malnutrition, according to the Sample Registration System and the Rapid Survey on Children reports.
On this issue, Congress Member of Parliament Jyotiraditya Scindia said “such incidents taking place in the state in 21st century was a shame for everyone and it needs to be properly investigated to where funds amounting to crores being spent on eradication of malnutrition were actually going.” Taking the on the off chance to corner the Shivraj Singh Chouhan led BJP government in the state, the opposition Congress leaders have stepped up their offensive against the government for its failure to tackle malnutrition in the state. According to sources in the Congress Party, more than one lakh children have died due to malnutrition in Madhya Pradesh during the past 12 years, despite the BJP government spending over Rs 22 billion on health issues under different schemes. A statement issued by the party claimed that over 9,000 children died in the state because of malnutrition this year.

Madhya Pradesh

  • 116 children die of malnutrition during past five months in Sheopur district alone
  • MP has highest number of 74.1 per cent malnourished children
  • 60 per cent under-five children suffering from anaemia
  • Malnourishment among boys – stunting over 58 per cent and underweight 49 per cent
  • Tops with worst ENMR of 26 per 1,000 live births
  • NMR 35 per 1,000 live births
  • 23 per cent low birth-weight babies
  • Under-5 mortality rate 70
  • Girl child U-5 mortality rate 79
  • Total fertility rate (TFR) declines by 23.7 per cent

However, after the Sample Registration System (SRS) report, released in July last, shamed the state government for its utter failure in improving early neonatal mortality rate (ENMR) and neonatal mortality rate (NMR) in the state, chief minister Chouhan now wants to do an impromptu damage control. Chouhan constituted a high-level panel and reportedly asked it to prepare a “white paper on malnutrition in the state” which would showcase how his flagship scheme for girls “Ladli Laxmi” had succeeded in improving mortality rate of girls across the state.
Sources said that the committee comprising ministers Archana Chitnis and Rustom Singh and top bureaucrats Deepak Khandekar, JN Kansotiya and Gauri Singh was directed that the document must highlight the government’s successes in improving the ENMR and NMR indices while also efforts made towards alleviating malnutrition and undernourishment. According to the SRS report, Madhya Pradesh has the highest number of malnourished children in the country with 74.1 per cent of those under the age of five suffering from anaemia and 60 per cent from malnutrition. The state still has high percentage (51) of stunted children. The percentage of underweight children is 40. However, malnourishment among boys is very high in the state. The stunting is as high as over 58 per cent and underweight is 49 per cent. While Jharkand has the second highest number of malnourished children (56.5 per cent) followed by Bihar (55.9 per cent), Chhattisgarh has second highest number of anaemic children with Andhra Pradesh ranking third.

SRS-2014 report
The first part of the SRS-2014 report revealed that Madhya Pradesh tops the list with the worst ENMR of 26 per 1,000 live births. In terms of NMR, the state reported 35 per 1,000 live births in a year, the second highest after Odisha with an NMR of 36. The 2013 SRS report showed 36.4 NMR in MP. The report also reveals that rural Madhya Pradesh ranks the worst in terms of under-5 mortality, as the state tops the list with the highest U-5 mortality of 70. The situation of girl child in the state is worst with the highest U-5 mortality of 79, as reported in SRS. The state is worst in infant mortality rate (IMR) this year also, consecutively for the 12th year in the country.
Similarly, birth rate in Madhya Pradesh has shown a decline from 27.7 in 2009 to 25.7 per cent in 2014, whereas the death rate has dropped from 8.5 in 2009 to 7.8 per cent in 2014. Infant mortality has rate has declined from 67 in 2009 to 52 in 2014. The total fertility rate of the state has dropped from 3.3 per cent to 2.8. However, sex ratio at birth has shown a slight improvement from 921 in 2009 to 927 in 2014. General Fertility Rate (GFR) at the national level shows that 77.6 children were born to every thousand women aged 15-49 years. This number varies from 61.7 in urban areas to 85.4 in rural areas. Among the bigger States, GFR varies from 53.5 in Kerala to 103.2 in Bihar. In Madhya Pradesh the GFR is 98.2 in 2014.
At national level, a decline of 18.8 per cent in GFR has been registered during the decade. It was 97.0 in 2002-04 and 78.8 in 2012-14 (declined by 8.8%), whereas in Madhya Pradesh it was 124.5 and 99.7 respectively (declined by 19.9%). The data reveals that the decline in fertility rates is more in rural areas compared to urban areas except in the age groups 20-24. The total fertility rate (TFR) has declined by 23.3 per cent at the national level, whereas it was 23.7 per cent in Madhya Pradesh. The average level of Total Marital Fertility Rate (TMFR) at national level has been declined by 8.7 per cent, while Madhya Pradesh has registered a decline of 5.9 per cent).

Rapid Survey on Children
In 2013 and 2014 the UN agency for children, Unicef, and the government of India conducted a new combined study called the Rapid Survey on Children (RSOC).  According to the study report released recently, despite India’s 50% increase in GDP since 1991, more than one third of the world’s malnourished children live in India. Among these, half of them under 3 are underweight and a third of wealthiest children are over-nutrient.
The study points to some striking national trends. The proportion of underweight children has fallen from 42.5% a decade ago, to just under 30% now. There have been similar improvements on stunting, wasting and other measures of malnutrition. However, the national immunisation rate has risen and the rate of open defecation is down from 55% of households to 45%. By and large social and health indicators across India follow predictable patterns. In states with higher incomes, those nearer the coast and farther south, most health indicators are better. Typical high achievers are Kerala and Tamil Nadu.
In landlocked states, poorer ones and in the north, social and health results are usually worse. Notorious backward states include Bihar and Uttar Pradesh. North-eastern states are often outliers, both poor and landlocked but often with high rates of literacy and better health. Results from the RSOC mostly bear out these trends. Everywhere has seen a reduction in the share of underweight children and in stunting. But it is striking that on occasion higher incomes do not correlate with the biggest health gains. Two crucial factors are worth looking at. Lower rates of open defecation correlate well with reduced malnutrition. When children live and play in clean environments they are less likely to be infected with parasites that make it hard to absorb nutrients. And states that focus on helping girls and young mothers probably do better at breaking long-term cycles of malnutrition. Where teenage girls have a low body-mass index there seems a greater likelihood mothers will give birth to undernourished children. Proper nutrition for girls and women should be a priority.

Underweight U-5 children
The proportion of U-5 children who are underweight ranges from 20 per cent in Sikkim and Mizoram to 60 per cent in Madhya Pradesh. Besides Madhya Pradesh, more than half of young children are underweight in Jharkhand and Bihar. Other states where more than 40 per cent U-5 children are Meghalaya, Chhattisgarh, Gujarat, Uttar Pradesh and Orissa. In Meghalaya, Madhya Pradesh, and Jharkhand, more than one in every four children is severely underweight.
Although the prevalence of underweight is relatively low in Mizoram, Sikkim, and Manipur, even in those states more than one-third of children are stunted. Wasting is most common in Madhya Pradesh (35 per cent), Jharkhand (32 percent), and Meghalaya (31 per cent).

Low birth-weight babies

The incidence of low birth-weight babies varied across the states, from the lowest two per cent in Mizoram to 23 per cent in Madhya Pradesh, Rajasthan and Uttar Pradesh. In four other states from the North-east region—Manipur (7%), Sikkim and Meghalaya (10%) and Arunachal Pradesh (12%)—incidence of low birth-weight was at lower side. In most of the states, incidence of low birth weight was lower in urban than rural areas.

Infant and Young Children Feeding (IYCF) practices
Indian children have the same growth and development potential as of all children worldwide. Optimal nutrition in the first two years of life-including good breastfeeding, complementary feeding and care and hygiene practices-are critical to prevent stunting in infancy and early childhood and break the intergenerational cycle of under nutrition. The correct or good breastfeeding practices include initiation of breastfeeding within the first hour of life, exclusive breastfeeding for the first six months and continued breastfeeding for at least two years. After the completion of six months, children need to be fed the right foods both in quantity and quality along with mother’s milk. The IYCF, using the indicators recommended by WHO and UNICEF, has included the following care practices:
a) Early initiation of breastfeeding; immediately after birth, preferably within one hour.
b) Exclusive breastfeeding for the first six months; no other foods or fluids, not even water; but allows infant to receive ORS, drops, syrups of vitamins, minerals and medicines when required.
c) Timely introduction of complementary foods (solid, semi-solid or soft foods) after the age of six months.
d) Continued breastfeeding for two years or beyond
e) Age appropriate complementary feeding for children 6-23 months, while continuing breastfeeding. Children should receive food from four or more food groups: (1) grains, roots and tubers, legumes and nuts; (2) dairy products ; (3) flesh foods (meat fish, poultry); (4) eggs, (5) vitamin A rich fruits and vegetables; (6) other fruits and vegetables and fed for a minimum number of times (two times for breastfed infants, 6- 8 months; three times for breastfed children, 9-23 months; four times for non-breastfed children, 6-23 months)
f) Active feeding for children during and after illness.

Under-nutrition among pre-school children
Under-nutrition among the pre-school children is one of the major public health concerns in India. Malnutrition limits development and the capacity to learn. It also costs lives: about 50 per cent of all childhood deaths are attributed to malnutrition. Malnutrition in early childhood has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults, at greater risk of disease and early death.

Micro-nutrient supplementation
Micro-nutrients are essential vitamins and minerals required in small quantity for healthy body. Regular intake of vitamins and nutrients such as vitamin A, iron and iodine is essential to ensure good growth and development in infants, and optimal cognitive development among the pre-school children. In addition, supplementation and de-worming improves health and nutrition. Vitamin A deficiency is a leading cause of preventable blindness, morbidity and mortality among pre-school children.
According to RSOC data, children who consume meat and organ meats, fish, eggs, pumpkin, carrots, sweet potatoes that are yellow or orange inside, dark green leafy vegetables, ripe mango, papaya, cantaloupe and jackfruit are considered as given vitamin A rich food.

Nutritional status among rural children
There are no gender differentials in the nutritional status of Indian children. Children from rural areas are more likely to be stunted (42 per cent rural vs 32 per cent urban) and underweight (32 per cent rural vs 24 per cent urban) in comparison to their urban counterparts. However, children from both the areas are equally likely to be wasted. Considering the levels of all the three indicators of nutrition, among children from all the different religion groups, those from the Sikh and Jain religion are least likely to be undernourished and those from Hindu and Islam are more likely to be undernourished. The proportion of children who are stunted, wasted as well as underweight is the highest among ST (42 per cent, 19 per cent and 37 per cent respectively) children and the lowest among those belonging to other castes (34 per cent, 14 per cent and 24 per cent respectively).  In the meanwhile, the World Bank data indicates that India has one of the world’s highest demographics of children suffering from malnutrition said to be double that of Sub-Saharan Africa with dire consequences. In the Global Hunger Index, India was ranked 67th of the 80 nations with the worst hunger situation, even below North Korea or Sudan. The 2015 Global Hunger Index (GHI) Report ranked India 20th amongst leading countries with a serious hunger situation. Amongst South Asian nations, it ranks third behind only Afghanistan and Pakistan with a GHI score of 29.0. One of the major causes for malnutrition in India is gender inequality. Due to the low social status of Indian women, their diet often lacks in both quality and quantity. Women who suffer malnutrition are less likely to have healthy babies. In India, mothers generally lack proper knowledge in feeding children. Consequently, new born infants are unable to get adequate amount of nutrition from their mothers.

Sex ratio drops
According to SRS 2014, nationally, the number of girls born per 1,000 boys has dropped from 909 during 2011-13 to 906 in 2012-14. Internationally, the figure is 950 girls per 1000 boys.
*Samuel Mathai is a editorial advisor of Mitaan Express & Founder of  Inquest Bhopal
Views expressed in the Article are his personal.