Antenatal Care Service Utilization Among Adolescent Pregnant Women- Evidence from Swabhimaan Programme in India
Prakash H. Fulpagare, Abhishek Saraswat, Konsam Dinachandra, Nikita Surani, Rabi N. Parhi, Sourav Bhattacharjee, Somya S, Apollo Purty, Babita Mohapatra, Nita Kejrewal, Neeraj Agrawal, Vikas Bhatia, Manisha Ruikar, Raj Kumar Gope, Zivai Murira, Arjan De Wagt and Vani Sethi
Purpose: Pregnant adolescent girls (15–19 years) are more vulnerable to poor health and nutrition than adult pregnant women because of marginalization and lack of knowledge about the antenatal care (ANC) services. The present study aims to test this hypothesis and assess determinants of ANC service utilization among currently adolescent pregnant women.
Methods: Data were drawn from the baseline survey of SWABHIMAAN project, which had been conducted in three states of India: Bihar, Chhattisgarh, and Odisha. Out of a total 2,573 pregnant women (15–49 years) included in the sample, about 10% (N = 278) were adolescent girls (15–19 years) at the time of the survey, and the rest were adults. Sample was selected from the population using simple random sampling, and information was collected using pretested questionnaires.
Results: For all indicators of ANC service utilization, performance of adolescent pregnant women was better than adult pregnant women. However, significant variations were reported in the level of services received by adult pregnant women for different indicators. Religion, wealth, food insecurity, Village Health Sanitation and Nutrition Day meeting, Public Distribution System and Integrated Child Development Services entitlements, and knowledge of family planning methods had a significant effect on the ANC service utilization.
Conclusion: Adolescent pregnant women have shown better utilization of selected indicators than their adult counterparts. Utilization of full ANC services starting from first trimester itself for adolescent pregnant women is an urgent need in present context. Intervention program must pay attention to such
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Mid-upper arm circumference cut-offs for screening thinness and severe thinness in Indian adolescent girls aged 10–19 years in field settings
Vani Sethi, Neha Gupta, Sarang Pedgaonkar, Abhishek Saraswat, Konsam Dinachandra Singh, Hifz Ur Rahman, Arjan de Wagt and Sayeed Unisa
Objective: (i) To assess diagnostic accuracy of mid-upper arm circumference (MUAC) for screening thinness and severe thinness in Indian adolescent girls aged 10–14 and 15–19 years compared with BMI-for-age Z-score (BAZ) <−2 and <−3 as the gold standard and (ii) to identify appropriate MUAC cut-offs for screening thinness and severe thinness in Indian girls aged 10–14 and 15–19 years.
Design: Cross-sectional, conducted October 2016–April 2017. Setting: Four tribal blocks of two eastern India states, Chhattisgarh and Odisha. Participants: Girls (n 4628) aged 10–19 years. Measurements included height, weight and MUAC to calculate BAZ. Standard diagnostic accuracy tests, receiver–operating characteristic curves and Youden index helped arrive at MUAC cut-offs at BAZ < −2 and <−3, as gold standard.
Results: Mean MUAC and BMI correlation was positive (0·78, P = 0·001 and r2 = 0·61). Among 10–14 years, MUAC cut-off corresponding to BAZ < −2 and BAZ < −3 was ≤19·4 and ≤18·9 cm. Among 15–19 years, corresponding values were ≤21·6 and ≤20·7 cm. For both BAZ < −2 and BAZ < −3, specificity was higher in 15–19 v. 10–14 years. State-wise variations existed. MUAC cut-offs ranged from 17·7 cm (10 years) to 22·5 cm (19 years) for BAZ < −2, and from 17·0 cm (10 years) to 21·5 cm (19 years) for BAZ < −3. Single-age area under the curve range was 0·82–0·97.
Conclusions: Study provides a case for use of year-wise and sex-wise contextspecific MUAC-cut-offs for screening thinness/severe thinness in adolescents, rather than one MUAC cut-off across 10–19 years, depending on purpose and logistic constraints.
Predictors of the diets consumed by adolescent girls, pregnant women and mothers with children under age two years in rural eastern India
Sayeed Unisa, Abhishek Saraswat, Arti Bhanot, Abdul Jaleel, Rabi N. Parhi, Sourav Bhattacharjee, Apollo Purty, Sudhira Rath, Babita Mohapatra, Avinash Lumba, Sonali Sinha, Nita Kejrewal, Neeraj Agrawal, Vikas Bhatia, Manisha Ruikar and Vani Sethi
Adolescents, pregnant women and mothers of children under 2 years of age are in stages of life characterized by higher nutritional demands. The study measured the dietary diversity of 17,680 adolescent girls, pregnant women and mothers of children under age 2 years in the eastern Indian states of Bihar, Chhattisgarh and Odisha using data from the Swabhimaan baseline survey conducted in 2016. The association of women’s mean Dietary Diversity Scores with socioeconomic, health and nutrition service indicators was assessed. The sampled population was socioeconomically more vulnerable than the average Indian population. There was not much variation in the types of foods consumed daily across target groups, with diet being predominantly cereal (98%) and vegetable (83%) based. Nearly 30% of the mothers had low Dietary Diversity Scores, compared with 25% of pregnant women and 24% of adolescent girls. In each target group, more than half of the respondents were unable to meet the Minimum Dietary Diversity score of at least five of ten food groups consumed daily. Irrespective of their background characteristics, mean Dietary Diversity Scores were significantly lower in Bihar than in Chhattisgarh and Odisha for all target groups. Having at least 6 years of education, belonging to a relatively rich household and possessing a ration card predicted mean dietary diversity. Project interventions of participatory women’s group meetings improved mean Dietary Diversity Scores for mothers and adolescent girls. Considering the association between poverty and dietary diversity, the linkage between girls and women and nutrition-focused livelihoods and supplementary nutrition programmes needs to be tested.
Assessment of nutritional status of pregnant women based on mid-upper arm circumference (MUAC) and associated factors in poverty of Eastern India
Abhishek Saraswat, Sayeed Unisa, R.S. Reshmi, Laxmi Kant Dwivedi, Sarang Padgoanker, Vani Sethi
Mid-upper arm circumference (MUAC) is an appropriate measure for screening undernutrition during pregnancy. This study examines the nutritional status of pregnant women in India using MUAC and assesses nutrition- specific and nutrition-sensitive predictors of low MUAC (<23 cm), using baseline data of a prospective sectional study conducted in rural areas of Chhattisgarh and Odisha, India. Data was collected from 1,637 pregnant women (ages 15 – 49 years). Detailed background characteristics, diets, food security, heights and MUAC, and utilization of support services were collected. Undernutrition in pregnancy expressed as the proportion of pregnant women having low MUAC was high in the study area. The prevalence of low (<23 cm) and severely low MUAC (<21cm) was 38% and 7% respectively. Low MUAC was more prevalent in Chhattisgarh (39%) than Odisha (36%). The prevalence of low and severely low MUAC was higher among adolescents and socioeconomically underprivileged respondents. Working status (OR 1.30, CI 1.03-1.64, p<0.05), food insecurity (OR 1.23, CI 0.99 - 1.44, p<0.05) and not consuming IFA (OR 1.42, CI 1.08-1.87, p<0.001) increased the risk of low MUAC. High diet diversity (OR 0.76, CI 0.62- 0.94, p<0.001) and attending village health sanitation and nutrition day (VHSND) meeting (OR 0.81, CI 0.65-1.01, p<0.10) were associated with reduced likelihood of low MUAC. The findings justify the importance of a multi-sectoral and integrated approach, including nutrition- specific and nutrition-sensitive interventions and services in improving nutrition of pregnant women and pregnancy outcomes.
An Adaptation of the Food Insecurity Experience Scale (FIES) for Measuring Food Insecurity Among Women in SociallyBackward Communities
Federica Onori, Preeti Dhillon, Konsam Dinachandra, Abdul Jaleel, Abhishek Saraswat, Reshmi R. S., Sayeed Unisa, and Vani Sethi
Recent reviews on the use of experience-based food insecurity scales in the Indian context suggested the addition of "how often" related items to food insecurity modules to avoid overestimation of food insecurity, especially in underprivileged communities. Following this recommendation, we adapted the 8-item Food Insecurity Experience Scale (FIES), an official tool for measuring access to food within the Sustainable Development Goals (target 2.1), and assessed its validity and reliability in socially-backward communities in the Indian context. The polytomous Rasch model was successfully applied and soundly integrated within the probabilistic methodology already in use for the FIES, allowing the computation of comparable prevalence of food insecurity at different levels of severity and related measures of uncertainty. Data from the SWABHIMAAN programme survey, which collected information on food insecurity from mothers of children under two years of age in three Indian states (Bihar, Odisha, and Chhattisgarh), was used for analysis. Results suggest that the proposed adapted version of the FIES can be considered as a proper tool for measuring food insecurity in underprivileged communities, since it satisfies requirements of internal and external validity and reliability. Individual determinants and protective factors of food insecurity were also investigated within this methodological framework and results suggest that education, economic wealth, and homestead kitchen garden can act as a buffer against food insecurity, while the number of pregnancies seems to exacerbate a situation of food insecurity
Early lessons from Swabhimaan, a multi-sector integrated health and nutrition programme for women and girls in India
Monica Shrivastav, Abhishek Saraswat, Neha Abraham, R.S. Reshmi, Sarita Anand, Apolenarius Purty, Rika Shalima Xaxa, Jagjit Minj, Babita Mohapatra and Vani Sethi
What we know: Poor nutrition status before and during pregnancy is a serious problem in India and a key driver of low birth weight and child undernutrition.
What this article adds: Swabhimaan is a five-year initiative (2016-2021) integrated within the Government of India’s flagship poverty alleviation programme, Deendayal Antyodaya Yojana-National Rural Livelihoods Mission (DAY-NRLM), across three states in India, carried out in partnership with UNICEF. The programme aims to mobilise women via village-level women’s collectives to develop and implement integrated nutrition microplans and strengthen local government services in order to improve the nutrition outcomes of women and adolescent girls. The results are presented of a midline evaluation carried out in 2018-2019 covering villages in five different sites across the three states (including 3,171 adolescent girls, 1,856 pregnant women and 3,277 mothers of children under two years of age). The results reveal strong progress in implementation with 336 village-level microplans developed, 77,000 females screened and 15,122 identified as being at nutritional risk and referred for nutrition, agriculture and social protection support. Midline results show a reduction in thinness in adolescent girls (13.8% versus 18.5% at baseline) and mothers with children under two years of age (44.6% versus 48.4% at baseline) and an increase in the average mid-upper arm circumference of pregnant women (24.0cm versus 23.5cm at baseline). Evidence also shows improved household food security and improved uptake of government health, water, sanitation and hygiene and social protection services. Results suggest that utilising and funding women’s collectives to respond to nutrition needs in their communities with integrated responses are feasible. The results of the endline evaluation and an impact evaluation will be forthcoming.
Integrated multisectoral strategy to improve girls and womens nutrition before conception,during pregnancy and after birth in India (Swabhimaan) - protocol for a prospective,non-randomised controlled evaluation
Vani Sethi, Arti Bhanot, Sourav Bhattacharjee, Rajkumar Gope, Debjeet Sarangi, Vikash Nath, Nirmala Nair, Usha Singh, Abner Daniel, Rabi N Parhi, Sonali Sinha, Avinash Loomba, Somya S, Apollo Purty, Naushad Ali, Babita Mohapatra, Neeraj Agarwal, Vikas Bhatia, Manisha Ruikar, Bharati Sahu, Reshmi R S, Sarang Pedgaonkar, Laxmi Kant Dwivedi, Farhat Saiyed, Mahendra Prajapati, Preetu Mishra, Audrey Prost, Nita Kejrewal, Arjan De Wagt, Harshpal Sachdev, Sayeed Unisa
Swabhimaan is a community-based programme to improve adolescent girls’ and women’s nutrition in the rural areas of three Indian statesBihar, Chhattisgarh and Odisha with high prevalence of undernutrition.
In India, despite provisions for tribal development, 32% of tribal women are chronically undernourished, as opposed to 23% among those not belonging to tribal households. Large-scale surveys and routine monitoring are currently deficient in measuring the nutrition status of women, especially tribal women. This study was undertaken to analyse the reach of various health-related schemes for tribal women in Chhattisgarh, Jharkhand, and Odisha. In the light of its findings, it is recommended that all national schemes should be reviewed through a tribal lens, as tribes remain outside the ambit of most nutrition safety nets. Proven measures like strengthening tribal development nodal agencies, motivational incentives to fieldworkers and organised community involvement, need to be scaled up.
Maternal undernutrition is highly prevalent in underprivileged populations of India, especially in rural, tribal and urban poor settings. These mothers are at an increased risk of experiencing adverse pregnancy outcomes including maternal morbidities and mortality, increased foetal loss, and low birth weight, small for gestational age and prematurity, which contribute to increased infant mortality and morbidity
Water, Sanitation, and Hygiene (WASH) practices may affect the growth and nutritional status among adolescents. Therefore, this paper assesses WASH practices and its association with nutritional status among adolescent girls.
We examined the feasibility of engaging women collectives in delivering a package of women’s nutrition messages/services as a funded stakeholder in three tribal-dominated districts of Odisha, Jharkhand and Chhattisgarh States, in eastern India. These districts have high prevalence of child stunting and poor government service outreach.
Context for layering women’s nutrition interventions on a large scale poverty alleviation program: Evidence from three eastern Indian states
Reshmi R. S., Konsam Dinachandra, Arti Bhanot, Sayeed Unisa, Gopinath T. Menon,Neeraj Agrawal, Vikas Bhatia, Manisha Ruikar, Abner Daniel, Sourav Bhattacharjee,Rabi N. Parhi, H. P. S. Sachdev, Raj Kumar Gope, Arjan De Wagt, Vani Sethi
Over 70 million women of reproductive age are undernourished in India. Most poverty alleviation programs have not been systematically evaluated to assess the impact on women’s empowerment and nutrition outcomes. National Rural Livelihoods Mission’s poverty alleviation and livelihoods generation initiative is an opportune platform to layer women’s nutrition interventions being tapped by project Swabhimaan in three eastern Indian states—Bihar, Chhattisgarh and Odisha. A cross-sectional baseline survey covering 8755 mothers of children under two years of age, one of the three primary target groups of the program are presented. Standardized questionnaire was administered and anthropometric measurements were undertaken from October 2016 to January 2017. 21 indicators on women’s empowerment, Body Mass Index and Mid-upper Arm Circumference for nutrition status, food insecurity indicators as per the Food Insecurity Experience Scale and selected indicators for assessing women’s access to basic health services were included. National Rural Livelihoods Mission operates in contexts with stark social and gender inequalities. Self-help group members exhibited better control over financial resources and participation in community activities than non-members
Using Body Mass Index, at least 45% mothers were undernourished irrespective of their enrolment in self-help groups. Higher proportion of self- help group members (77%-87%) belonged to food-insecure households than non-members (66%-83%). Proportion of mothers reporting receipt of various components of antenatal care service package varied from over 90% for tetanus toxoid vaccination to less than 10% for height measurement. Current use of family planning methods was excruciatingly low (8.2%-32.4%) in all states but positively skewed towards self-help group members. Participation in monthly fixed day health camps was a concern in Bihar. Layering women’s nutrition interventions as stipulated under Swabhimaan may yield better results for women’s empowerment and nutrition status under National Rural Livelihoods Mission. While this opportunity exists in all three states, Bihar with a higher proportion of matured self-help groups offers more readiness for Swabhimaan implementation.