Intervention Trough LCA

8/9/2019 Intervention Trough LCA

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Int ervention Through Life Cycle Approach-

A Possible Solut ion To The Low Birth W eight Problem In Rural And Tribal Ind ia

Shyamal Santra*

ABSTRACT

Nearly 7 -8 out of 10 deaths15

during the neonatal period occur in LBW babies. In developing countries the

prevalence of LBW is 17% (IUGR predominant) as compared to 5-7% (pre-term predominant) in developedcountries. In India, the estimates are somewhat between 10 percent and 56 percent, more than one-third in

rural and tribal areas. Experiences from around the world exhibits that nutrition and health care in

combination can very well take care of the problem; provided the programmes are community based. In a

resource constraint environment like those of South-East Asia, a programme designed to deliver nutritional

supplementation would be an extremely costly venture; especially when there is no guarantee that the impact

of such intervention would be reflected over generations to come. The three-pronged strategy of Case

Management, Behaviour Change Communication and Linkage Convergence& Partnership based on Life

Cycle Approach might be a more cost-effective alternative for the rural and tribal dominated areas. The

appropriateness is more suitable when it caters to three stages of human life namely infant/children,

adolescent and women during pregnancy and lactation.

Introduction

The intrauterine life of an unborn essentially decides in a big way the future course he or she is destined to.

The maternal environment is the most important determinant of birth weight; a deprived environment in

utero enhances its chance of facing a vulnerable life cycle prone to life threatening consequences. Factors

that prevent normal circulation across the placenta cause poor nutrient and oxygen supply to the foetus,

thereby restricting growth. Duration of gestation is another principal factor that decides the fate of the

foetus. Longer gestation period gives more time to the foetus to develop and mature. Fortunately, low birth

weight (< 2,500 g) due to pre-term is not a major threat in South-East Asia.

It would be worthwhile at this juncture to elucidate the term low birth weight (LBW) and intrauterine

growth retardation (IUGR). IUGR refers to foetal growth that has been constrained by an inadequate

nutritional environment in utero. In most circumstances in developing countries, it is not possible todetermine the gestational age of an infant. Therefore, low birth weight is often used as a proxy for IUGR.

In developing countries major determinants of growth retardation in utero are inadequate maternal

nutritional status before conception, short maternal stature (principally due to under nutrition and infection

during childhood), and poor maternal nutrition during pregnancy (low gestational weight gain, primarily due

to inadequate dietary intake). Pre-pregnancy maternal weight is the strongest predictor of infant weight10

and

reflects nutritional stores potentially available to the growing foetus. In women with a pre-pregnancy weight

less than 49.5 kg there is 84% increase in risk of IUGR and a 25% increase in risk of pre-term birth11

.

Maternal energy intake and nutritional stores are the sole source for foetal energy requirements; therefore

weight gain during pregnancy has been shown to affect IUGR. There is a 98% increase11

in risk of IUGR in

women with low gestational weight gain (less than 7 kg), further, in populations with a high prevalence of

short stature (like those in India), low maternal height accounts for about 18.5%3.

Approximately one third of all deaths occurring in the first year of life can be attributed to low birth weight

(based on 17% prevalence and 4.0 relative risk)12

i.e. a third of all infant deaths can be averted with the

prevention of LBW and with preventive interventions against the sequelae of LBW during early childhood12

.

*Shyamal Santra: Project Coordinator, Child In Need InstituteIUGR is measured as birth weight less than 10

thpercentile for gestational age or less than 2500 g and gestational age = 37

weeks or birth weight < birth weight for gestational age - 2 SD


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Low birth weight is associated with impaired immune function, poor cognitive development, and high risks

of developing acute diarrhoea or pneumonia.

For Bangladesh (which is adjacent to West Bengal) it was estimated that almost half of infant deaths from

these diseases could be prevented if low birth weight were eliminated (Podja & Kelley, ibid.). Those low

birth weight infants who do survive have significantly diminished chances of reaching their growth potential

- they have lower body weights, heights and head circumferences (Bavdekar 1994; Bhargava, 1995). While

there is some tendency for catch-up growth, low birth weight infants suffer growth retardation in later life

(an earlier onset of menarche, which halts physical growth has been documented in a longitudinal study;

Bhargava, 1995). The effects of intra-uterine growth retardation cannot be entirely reversed by even ideal

environment and nutritional inputs in post-natal life (Gopalan, 1994).

As compared to their appropriate birth weight counterparts, on average IUGR infants are 5 cm shorter and 5

kg lighter as adults (Proos, 1992). According to the fetal origins of disease hypothesis, under-nutrition at

critical periods of development in the intra-uterine environment and during infancy leads to permanent

changes in body structures and metabolism. This results in adult susceptibility to chronic diseases including

high blood pressure, coronary heart disease and non-insulin dependent diabetes mellitus (Barker, 1995). An

investment in preventing foetal under-nutrition is a highly effective investment because it not only improves

maternal and infant nutrition, but may also slow down or prevent the onset of chronic diseases in later life.

Global and regional prevalence

Of the approximately 10.4 million infant deaths each year in developing countries, 33 40% (population

attributable risk) can be attributed to LBW, i.e. 3.5 to 4 million infant deaths each year12

. The high burden of

perinatal and neonatal ill health in 2000 consisted of 7 million perinatal deaths (4 million stillbirths and 3

million early neonatal deaths) and 4 million neonatal deaths (3 million early neonatal deaths and 1 million

late neonatal deaths)12

. Perinatal mortality rate was 56/ 1000 live births, while neonatal mortality rate was

34/ 1000 live births. The global burden of low birth weight infants was 16% of all births. In the less

developed countries, the LBW incidence was 17% i.e. three times the incidence in less developed countries

(5 - 7%)15

.

In the South-East Asian region the stagnating Neo-natal Mortality Rate, despite steady decline in IMR

during the last two decades caused a lot of hue and cry among the national and global partners. The regionexperiences 25 30% of babies to be low birth weight. Unfortunately no direct estimates of GBD are

available. However, indirect estimates states that LBW accounts for 17% of all births globally, of which

90%12

(approximately 22 million) births are in developing countries.

The Indian scenario exhibits considerable regional variation in LBW prevalence from 10% among high

socio-economic class to 56% in the rural & tribal poor and urban slums13

. The reliable institution based NNF

data for the year 1985 on 37082 live births observed LBW prevalence of 32.8%. In 1994, WHO conducted a

multi-centric study on LBW in three South-Asian countries namely India, Sri Lanka and Nepal. The study

reported LBW prevalence in India at 28.1% with a mean birth weight of 2627 grams14

. Available data on

LBW prevalence in different region of India is illustrated in Figure 1. Kerala and Tamil Nadu register

highest mean birth weight and LBW incidence is lowest in these two states (figure 1). A meagre 28 percent

of the babies got weighed within 48 hours after birth. Of these, 15 percent could not report, as the motherscould not recall the birth weight of their baby. In Punjab, the incidence of LBW is estimated approximately

25% despite better diet during pregnancy, showing that health care services needs to be improved along with

maternal nutrition for the reduction of LBW.


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Figure 1: LBW prevalence in selected states in India5

Problem statement

In India percentage of women who had full antenatal check-up

is 31.85

percent, in rural areasthe figure goes down to 28.3 percent while it is slightly high for urban areas, 45.9 percent. 44.2

percent of women had three or more ANC visits amongst them only 34.5 percent had their

weight measured. Almost one-third of pregnant women (35%)5

do not receive any prenatal care,which is an important determinant of LBW. Low gestational weight gain, which may account

for more than 14 percent of growth retardation in utero poses the greatest threat in these regions.

When only a third of all pregnant women get their weight checked, monthly weight monitoring

to measure the gestational weight gain is far from reality.

Early marriage is in rampant practice especially in the rural belts of the country. Mean age at

marriage for girls is though 19.2 years, yet, 37 percent of the girls marry before the legal age i.e.

18 years.560 percent of women first cohabit below 18 years of age even before their physical

and physiological maturity is potentially in a position to support the phenomenon of

reproduction. The early occurrence of childbirth increases the susceptibility that will eventually

boil down to the consequence of low birth weight. To compliment the process short inter-

pregnancy interval further empties their nutritional store before they can actually replenish it.

According to World Health Organisation (WHO), in developing countries the prevalence of

anaemia among pregnant women averages 56%, ranging between 35 to 100% among different

regions of the world8. A cross-sectional study conducted by Maulana Azad Medical College,

New Delhi projected very high prevalence of anaemia in pregnant women. The study marked the

Full ANC is defined as at least 3 AN visits plus IFA given plus one TT injection given

35.1

95.1

12.4

33

55.4

7.9

42.5

28

76.5

16.4

28.9

13

5.3

30.8

16.6

8.6

45.7

7.6

14.9

6.7

34.7

27.9

22.114.8 21.9

19.4

18.9 17.3

17

16.9

10.8

16.5

15.3

0

10

20

30

40

50

60

70

80

90

100

Percentage

Percentage oflivebirths weighedat birth

Percentage ofbabies with

unknown birthweight


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prevalence at 96.5 percent (Hb


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2. Behaviour Change Communication to increase awareness and knowledge regarding

various health care practices categorically pregnancy and childcare. Women in the project

area are also informed about the locally available low cost nutritious food and the

importance of balanced nutrition, especially during pregnancy. Behaviour Change

Communication (BCC) strategies are used within the context of case management at the

individual, family and community level. It aims at inculcating healthier behaviours orhealth related skills by increasing individual, family and community awareness and

knowledge through health education. It also aims at bringing about greater interpersonal

communication within the family and community. The behavioural messages stress the

importance of appropriate nutrition during pregnancy and lactation, the importance of

reducing workload, increasing rest and the importance of birth spacing. Women of higher

pregnancy orders are urged to undertake sterilisation. The effective use of TBAs is an

example of how CINI uses indigenous human resources to facilitate programme activities.

Peer educators also reinforce the same messages at the community level.

A very important component of the BCC strategy is the emphasis on husband and mother-

in-law involvement. Often it becomes imperative to target the husband and/ or mother-in-

law in lieu of the women alone to achieve the desired changes at the family level.

3. Linkage Convergence and Partnership to strengthen existing health care facilities and

improve linkages within the community through partnership with other stakeholders

Convergence of all basic services at the household level is another major task of this

strategy.

Since LBW is associated primarily with young maternal age, repeated pregnancies in quick

succession, poor access to antenatal care, absence of food security and other socio-economic

factors hence, the three pronged strategy was adapted to address these issues more holistically.

These strategies interacting on the life cycle framework makes the programme more

comprehensive and impact oriented.

In an operational research study carried out in ten villages

in Punjab, India (1968 1973)

perinatal mortality was reduced almost 40%1. This was achieved with combined efforts of

nutritional and medical care. Interventions, which were a part of the study were1:

1. Growth monitoring for pregnant women and infants

2. Prolonged breast feeding

3. Twice daily food supplementation for all (especially for those children with under

nutrition or inadequate growth). Supplementation was in the form of calorie-enriched

milk in the morning and porridge like gruel of crushed wheat, raw sugar, oil and milk

powder in the afternoon. Standard servings provided 400 kcal and 11g of protein.

4. Prenatal nutrition care in the form of iron folate tablets for all mothers.

5. Immunisation and/ or medical care as required.

The study concluded, Prenatal nutrition care to pregnant women was the most cost-effective

in preventing perinatal deaths.

Villages were selected as clusters and provided one of the following patterns of services: a) nutrition care, b)medical care, c) combination of nutrition and medical care, and d) control villages (minimal symptomatic treatment

and emergency care)


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TheBangladesh Integrated Nutrition Programme has its nutrition component as the largest and

the important one. The Community-Based Nutrition Component (CNBC), has taken the shape of

one of the most promising example of large-scale community based projects in the world. It

aims at reducing childhood and maternal under nutrition thereby affecting the incidence of low

birth weight by half, which is presently at its notorious high in Bangladesh. Though it is

premature to make any comment on the impact on low birth weight prevalence; however, the

findings of a study performed under the ICDDRB BINP Operations Research project indicatethat improvement in birth weight is achieved, but only when supplementation is initiated in early

pregnancy and continued for at least 120 150 days up to delivery4.

In a period of two and half years the programme has successfully decreased severe stunting in

children between 6 23 months of age from 36% to 21%, severe wasting from 12% to 2% and

underweight from 30% to 18%. 2.3% reduction in low BMI was recorded in women in

childbearing age (15 49years).

The current programme that is taking the shape ofNational Nutrition Programme will carry a

large array of community-based services aiming towards reducing low birth weight as a key

mandate. The programme will provide:

1. Energy supplements of 600 kcal/day plus micronutrients.

2. Packages of nutrition education messages

3. Utilisation of nutrition negotiation process whereby women will decide their own

health.

4. Immunisation, birth spacing and post-partum conception.

The Indonesian experience on the effect of energy supplementation on birth weight is another

glowing example of success. The supplementation trailconducted in a rural community in

East Java states that woman with pre-pregnancy weight less than 41kg or a weight of less than

45kg in the second half of pregnancy are more at risk of delivering low birth weight babies16

.

In the trail food supplementation was given to women in the last trimester and impact was noted

in relation to low birth weight. Two types of supplementation were administered; high (465

kcal) and low (52 kcal). Increase in birth weight and simultaneous decrease of low birth weight

was noted from 12.2 % to 9.5% in either groups17

. Results elucidate:

1. Increase in birth weight by 50 g for every 10,000-addition kcal consumed.

2. Targeting supplementation to women with low pre-pregnancy weight may be the most

cost effective strategy to prevent LBW.

Discussion

As mentioned earlier the stagnating Neo-natal Mortality Rate is the biggest cause of concern for

the stakeholders. The stagnation has been largely owing to the more or less steady rate of deathsin the early days of life, majority of which is sequelae to low birth weight. Low birth weight

increases manifold the risk of dying (infants weighing between 2000 2500g at birth are four

times at risk of death than those weighing between 2500 3000g and ten times higher than their

3000 3500g counterparts) due to other direct causes and therefore addressing these such as

diarrhoeal disease, malnutrition, and acute respiratory infections can prevent a sizeable portion

of the attributable deaths. Investment into programmes directed towards reduction of low birth

weight carries not only the potential to reduce the perinatal and early neonatal mortality but it

has the inherent strength to manifest effects evident in due course of time. Since, low birth


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weight is an established risk factor for adult chronic diseases any means to curb low birth weight

will obviously reflect through reduction in diseases in the adult life, thereby reducing DALY and

increasing productivity.

Moreover, experiences cited above from various countries in South-East Asia illustrate that

nutritional supplementation (macronutrient and micronutrient) during pregnancy especially

during the latter part warrants reduction of low birth weight (considering other factors to bestable). In a country of more than a billion population and CBR - 26.7 are such strategies

financially feasible enough keeping in view their short-term impact? How long can we ensure

nutritional supplementation to those who are pregnant to prevent low birth weight? Even if such

supplementations are arranged for one generation is it a guarantee that the impact will be carried

over to the subsequent generations, especially when there is a chronic prevalence of food

insecurity?

CINIs three pronged mutually reinforcing strategy based on the life cycle approach can be a

relevant solution to these pertinent questions. Any solution to the low birth weight problem has

to be designed keeping in mind the continuous resource constraint environment, to make it

feasible and optimally impact oriented. The strategy is not to provide any additional nutritional

supplementation to the target group to orient result rather it advocates usage of locally availablenutritious vegetables and cereals, scientifically proven to have high nutritious value, to improve

the nutritional status of women and children. Regularly organised nutrition camps demonstrate

the preparation of these foods and health workers explain the nutritional value to the participants

(pregnant women/ mothers) in such settings. Since these foods are locally available and cheap it

is easy for them to procure, moreover compliance with nutritional recommendations is more

expected in such situation. Often it is observed that families start producing them of their own in

settings like kitchen garden. Our effort is to inculcate appropriate food habit in the family

because once that is achieved we can expect it to continue over time to come (considering that

there is reasonable food security). Food habits or patterns in a family or a region do not change

quite regularly, so once the appropriate practices are ingrained they are expected to continue

over generations without considerable alterations. Nutritional status being closely inter-twined

with food habits any improvement in food habits enhances the nutritional status of children,

adolescent and women of childbearing age. Cost-effectiveness of such a programme makes it

more practical while there is no compromise with result; rather once the practices are modified

impact will be more sustainable and reflective over time.

Moreover the Life Cycle Approach gives the programme a comprehensive outlook by

addressing different stages in a womans life necessary to terminate the vicious cycles of

malnutrition more so, when the nutritional status of women in these regions carry the highest

attributable risk to LBW. An effective solution always asked for an approach that addressed both

immediate risk factors, i.e. health during the pregnancy, and latent risk factors, i.e. neonate and

infant health and female adolescent health. The entire process culminated into the creation of

Life Cycle Approach that works very well in under served areas dominated by populationsbelow poverty line.

The approach targets three decisive stages of life infants/ children (0-2 years), adolescents

(10 19 years) and women (during her childbearing years). It was so designed to address the

needs within and outside the cohort of pregnant women that could be mobilised to dare the

challenge of low birth weight. Since low birth weight is influenced by many extrinsic factors in

addition to gestational ones hence, the strategy to reduce its incidence also encompass programs

that specifically caters to the needs of infant and adolescent health. The other groups are very


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important because malnourished children are frequently born to mothers who themselves have

suffered from some degree of chronic malnutrition since their childhood and/or were themselves

undernourished during their childhood. These conditions are essentially propagated through

generations and addressing all relevant primary and secondary risk factors of the target

population can only stop the self-perpetuating cycle. CINI has attempted to stop this by

monitoring health and nutrition status of adolescent, health of the women during pregnancy and

lactation as well as infant health.

The necessary interventions at each of these stages have helped ensure a declining trend in the

rate of low birth weight incidence in CINI target areas. These interventions can be broadly

categorised into three headings Case Management, Behaviour Change Communication and

Linkage Convergence and Partnership. The United Nations Administrative Committee on

Coordination Sub-Committee on Nutrition has also highlighted it in their report published in

September 20002. The workshop recommended the CINI strategy for LBW intervention

programs at the meeting held at Dhaka, Bangladesh (14th -17th, June 1999). Early identification

of the pregnant women and marking out the risk factors (if any) gives enough opportunity to act

upon in the best possible way, specific to the needs of the individual e.g. additional nutritional

care for those with BMI < 18.5 or early treatment for RTI/ STI or anti-malarial prophylaxis in

malaria endemic zone etc. Since anaemia is a predisposing condition for LBW and exhibits highprevalence in SEA region, iron tablet distribution curves out an important place for itself in the

programme. Regular ANC check-up in a government, private or NGO facility has a

synchronising effect on the reduction of low birth weight. Monitoring the weight gain by the

pregnant women (every month) also gives a fair idea of the foetal growth situation especially

when it is towards the latter half of the third trimester. The entire process gives a fair bit of room

for corrective action well in advance. To ensure continuity of service CINI encourages women

to go for at least three post-natal check-ups and render childcare advices include counselling on

topics that pertain to exclusive breast feeding, weaning, immunization, appropriate care of the

infant and birth spacing/ limiting.

Perhaps the backbone of the programme lays on the two pillars of behaviour change

communication and linkage convergence & partnership between community and the ultimate

service providers i.e. government health functionaries. In order to ensure that low birth weight

gradually reduce to a minimum and never take an upward trend, CINI tries to modify behaviour

of those who matters through effective communication. CINIs effort is to make them feel,

realise and then internalise what is good for them and why it is good. To facilitate the

process of behaviour change CINI workers carry out activities like regular home visits, periodic

group meetings, nutrition demonstration camps, issue based discussions and institute based

counselling.

CINI uses indigenous human resources like Traditional Birth Attendants (TBAs) and Multi-

Purpose Health Workers (MPHWs) to facilitate its programme activities like identification of

pregnant women or motivating someone to take up child spacing etc. Involving the husbandsand mothers-in-law is an imperative part of BCC strategy. More often than not their ratification

becomes necessary for the pregnant women to take a decision. CINI has male health workers

who work hand in hand with female health workers to target the husbands of the pregnant

women while their female counterparts deal with the mothers-in-law. By appealing the parental

2United Nations Administrative Committee on Coordination Sub Committee on Nutrition, Nutrition Policy Paper No. 18, September 2000.


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instincts of these groups greater compliance with advices are achieved, which would otherwise

have been difficult.

The programme has reached a stage where from today community have started owning the

service and demand for it. The gram-panchayat members have developed such rapport with the

health functionaries that enables them to demand greater accountability for the services they

receive. The phenomenon of community based monitoring of health services have improved thequality of service to a greater extent.

Being a non-government organisation, CINI always bears in mind that it has a role that is

complementary (in nature) to the various health services provided by the government and other

NGOs in the state. CINI ensures that the services are not redundant, but viable, effective,

sustainable and acceptable to the community.

Conclusion

CINI has reduced the low birth weight prevalence by one-fifth in its project area in a period of

five years. Though the figure might look meagre but we are sure that the scenario will never take

an upsurge, rather our efforts are on the way to permanently seal the fate of LBW from allperspectives with the help of life cycle approach and the supporting strategies.

It would be brave, though, to acknowledge that poor start to human life in the countries of the

South-East Asian region is attributable to low female literacy; insufficient empowerment of

women; low income; intergenerational vicious cycle of under nutrition; unsatisfactory fertility

regulation; poor access to and unsatisfactory utilisation of health care during pregnancy and

deliveries taking place under unhygienic conditions at home even without the presence of a

trained birth attendant and many other factors.

Hence, a programme more comprehensive in nature catering to all the above-mentioned issues

will be obviously better equipped, and might bring about changes in the low birth weight

scenario at a faster rate than ever before. The programmatic impacts through LCA are

sustainable, cost-effective and replicable in areas dominated by poorer communities where

regular healthcare services are bare minimum. Therefore, it calls for further experimentations in

those under-served areas of rural and tribal India.


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References

1. ACC/SCN (1999). Low Birth Weight. Report based on the International LBW Symposium

at ICDDR,B Dhaka, Nutrition policy paper no. 18

2. CINI (2000). http://www.cini-india.org/

3. Fourth report on the World Nutrition Situation. United Nations System Standing Committee

on Nutrition.4. Shaheen R, Arifeen SE, de Francisco A (2000). The optimal duration of nutritional

supplementation for malnourished pregnant women. In: Findings of studies performed

under the BINP Operations Research Project (ORP). Vol 2. ed. Osendarp SMJ. Roy Sk,

Fuchs GJ. Dhaka: ICDDR,B, 8 - 9

5. RCH Rapid Household Survey, (1998 1999)

6. Chaudahri, S. CINIs approach to intervention: An innovative strategy to combat

malnutrition in India (unpublished)

7. Sachdeva, H.P.S. (1997), Nutritional status of women and children in India. Recent

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8. World Health Organisation. The prevalence of anaemia in women: a tabulation of available

information, 2nd

Ed., Geneva: WHO, 1992.

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Community Medicine. Vol. XXVII, NO.4

10. Osrin, D. and de L. Costello, A. M. (2000). Maternal nutrition and foetal growth: practical

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11. Bull, J., Mulvihill, C., Quigley, R., Prevention of low birth weight: assessing the

effectiveness of smoking cessation and nutritional interventions, Evidence briefing, Health

Development Agency, Ist Ed July 2003

12. Fuchs, G.J., Low Birth Weight, Global Forum for Health Research, ICDDRB: Centre for

Health and Population Research

13. Bhargava, SK., Kumari, S., and Choudhary, P. (1984). Outcome of low birth weight infants.

Acta Pediatric Scand. 73: 406 7

14. WHO (1994). Multi-centre study on Low birth weight and Infant mortality in India, Nepal

and Sri Lanka. New Delhi, World Health Organisation (Regional Health Paper, SEARO,

No. 25)

15. WHO (2002). Improving Neonatal Health in South-East Asia Region. (Report of the

regional Consultation, New Delhi, India, SEARO)

16. Kusin JA. Kardjati S, de with C (1989) Infant mortality in Madura, Indonesia. Implications

for action. Journal of Tropical Padiatrics 35: 129 132.

17. Kardjati S, Kusin JA, de with C (1998) Energy supplementation in the last trimester of

pregnancy in East Java: I. Effect on birth weight. British Journal of Obstetrics and

Gynaecology 95: 783 794.

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