OverviewIn September 2012 Shiree and scale fund partners began the roll-out of a direct nutrition intervention designed in line with the latest WHO/GoB guidance and based on the Lancet series on Maternal and Child Nutrition. By the end of 2016 the intervention reached approximately 217,000 households living in extreme poverty across Bangladesh. The aim of the DNI was to compliment existing interventions and add a further dimension to break the intergenerational cycle of extreme poverty.
Why was a nutrition component included?
Undernutrition is a major public health issue in Bangladesh, as illustrated in the 2011 Bangladesh Demographic Health Survey. Shiree’s change monitoring system (CMS) demonstrates that amongst the extreme poor the situation is even worse.
- Wasting (low weight for height) had a prevalence of 17.2% amongst under 5 year old children, compared with a national figure of 16% (which still exceeds the WHO emergency threshold of 15%).
- 48.3% of all children under 5 were stunted (short for their age), compared with 41% nationally.
- 44.8% of children under 5 and 57.7% of women were anaemic, compared with national figures of 51% and 42% respectively.
- 50.7% of women had Chronic Energy Deficiency (CED, defined as a BMI < 18.5), compared with a national figure of 24%.
The impact of poor nutrition starts in utero and its adverse consequences become apparent in early postnatal life and track through adolescence into adulthood: underweight and stunted children grow up to become underweight and stunted adolescents; stunted and wasted mothers are more likely to have low birth weight babies, leading to a vicious cycle. The DNI aimed to help break the intergenerational cycle of poverty and malnutrition, and reduce the risk of households slipping back into extreme poverty.
What did the Shiree nutrition component include?
1. Individual Counselling and Behavioural Change Communication
Counselling to pregnant and breastfeeding mothers: EEP used a cadre of trained community health workers to provide mothers with information on Infant and Young Child Feeding (IYCF) practices. This included explaining the importance of (a) the early initiation of breastfeeding and exclusive breastfeeding for the first 6 months and (b) complimentary feeding from 6 months onwards. Additional messaging covered food hygiene, hand-washing, sanitary practices, family planning, dietary advice, basic health advice and gender related issues such as child marriage, household division of labour. Materials can be found under “Nutrition Publications”.
2. Iron and Folate Supplementation
Iron and folic acid deficiencies result in anaemia in children and women, and neural tube defects in new-borns. Poor intake of foods rich in iron and folic acid and multiple infections have resulted in high rates of anaemia among women. To address this, pregnant and breastfeeding mothers were provided with Iron and Folate Tablets (IFA) daily throughout pregnancy and for 6 months post-partum. Adolescent girls received 2 IFA per week from the age of 10 years old until either the end of the project, or the age of 16 (whichever occurred first).
3. Micronutrient Powder Supplementation
To overcome chronic under-nutrition, children between 6-23 months of age were put on a repeated 6 month regimen, and received a daily micronutrient sachet (MNS) containing iron, folate, zinc and others for 2 months (60 days), followed by a 4 month non-supplementation period (following World Health Organisation (WHO) guidelines published in 2011).
4. Provision of Deworming Medication
Deworming has been proven to have significant health gains amongst children and adults. All family members (except pregnant women) were dewormed at the beginning of the intervention, and at 6 monthly intervals. Women were not dewormed whilst pregnant; breastfeeding mothers were dewormed for the first time 42 days after delivery; adolescent girls were dewormed at 6 monthly intervals, and children were dewormed at 6 monthly intervals starting at 12 months of age up to 5 years of age.
What did the intervention achieve?
The indicators were revised in 2015, following an investigation which identified that the logframe’s independent means of verification could not provide all the required information. Results of the interventions were measured through an IYCF survey that was conducted alongside CMS 3, and through additional studies that EEP conducted. Alongside greater knowledge and awareness, key results include:
Under 2 year old children
- 7.5% reduction in stunting (against a 3% target)
- 0.5% reduction in anaemia (against a 5% target).
Other groups (target for all was a 5% reduction)
- 27.3% reduction in anaemia in pregnant women
- 12.1% point reduction in anaemia in breastfeeding women
- 25.8% point reduction in adolescent girls
- 1.2% point reduction in thinness in adolescent girls
The results are further discussed in the Nutrition Lesson Learning Report (2016), alongside a detailed commentary on intervention design.
What information can I see?
This report describes the baseline nutritional status of mothers, pregnant women, adolescent girls and under 5 year old children in 2013 before the intervention commenced.
The IYCF endline surveys (2015 and 2016)
This was one of the studies commissioned to provide evidence for one component of an Outcome indicator that was not being studied as part of the IFPRI independent review, or CMS 3. It shows that highly significant results can be achieved from IFA supplementation to pregnant women.
This report examines the relationship between adult nutritional status and socio-economic and demographic variables over the five annual surveys (2010 to 2014) based on the data gathered in the CMS 3 surveys. It is useful for researchers looking to understand the importance of nutrition in multi-dimensional extreme poverty, and seeking areas for further research.