Knowledge Brief 1 Determinants of Nutrition in Nagaland, India Maternal, Infant, Young Child Feeding (MIYCF) Practices Knowledge and application of appropriate maternal, infant, and young child feeding practices are lacking in Nagaland. The practice of exclusive breastfeeding for a duration of six months was not prevalent among most respondent mothers. There is an urgent need to disseminate context-specific knowledge through existing platforms such as the monthly Village Health and Nutrition Days and home-based visits by frontline workers for providing counselling to pregnant and lactating women. Introduction Overall, MIYCF practices in Nagaland need to be improved in order to address a major proximate Inadequate feeding practices are often a critical determinant of malnutrition. The 2015-16 National driver of poor nutritional outcomes in children. Family Health Survey found that in Nagaland WHO recommends exclusive breastfeeding up 53 percent of children were breastfed in the first hour to six months of age, after which infants should of life as recommended (compared to the national start receiving complementary foods in addition average of 42 percent), and only 44 percent of to breastmilk. The transition from exclusive children under six months were exclusively breastfed breastfeeding to complementary feeding is a (compared to the national average of 55 percent). very vulnerable period and is often the time that Further, 19 percent of children aged 6-23 months malnutrition starts in many infants.1 Similarly, there were fed an adequate diet at appropriate frequency is substantial evidence that maternal iron deficiency and from an appropriate number of food groups anemia increases the risk of pre-term delivery and (compared to the national average of 10 percent).4 subsequent low birthweight, and may also affect At the same time, a third of all pregnant women in the iron status of infants postpartum.2 In addition to Nagaland were anaemic and about 12 percent of all micronutrient supplementation, WHO recommends women were too thin. Within the state of Nagaland, a diet containing adequate amounts of bioavailable there is significant variation in nutritional status iron, especially during pregnancy, for prevention between districts.5 and control of anemia.3 July 2019  |  Page 1 Methods decision to be theirs alone, with no influence from health providers. In some cases, cultural norms and The mixed-method study included focus group practices also suggested food items to be avoided discussions with mothers and fathers of young during pregnancy. children (0-5 years), conducted in selected villages in two pilot districts of the Nagaland Health Project Women’s Diet Diversity (Tuensang and Peren), followed by a quantitative survey across all districts in the state. The survey was Over 90 percent of the surveyed women reported to done in 55 villages, which were purposively selected have consumed food made from grains, vitamin A from among those participating in the Nagaland rich fruits and vegetables, any type of meat or poultry Health Project, and covered 728 households with a and any dark green leafy vegetable at least once in woman who had had a pregnancy in the past two the past week of the survey. The average number of years.6 From each sampled household, women who days these foods were consumed varies from daily had a pregnancy in the past two years (n=676) and in the case of grains, to 4.5 days for leafy vegetables, the household head (n=728) were interviewed.7 4 days for white roots and tubers like potatoes, and 3 days for meat and pulses. 27 percent of women reported to have consumed tobacco for at least one Findings day in the past week of the survey, with an average consumption of 4.4 days in the past week. This brief describes findings on MIYCF practices commonly followed in Nagaland. Infant Feeding It is recommended that infants be exclusively Diet During Pregnancy breastfed for their first six months, after which Both the qualitative study and quantitative survey they should receive appropriate complementary found that, in general, women do not follow any foods along with continued breastfeeding up to at special diet during pregnancy (61 percent of the least two years. In Nagaland, the study found that sampled women (n=676)), with a majority stating only 36 percent of mothers initiated breastfeeding lack of awareness while a small proportion reporting immediately after birth and 45.5 percent started within financial constraints as the main reason. Among 2 hours of birth, with 84 percent feeding colostrum those who did follow a special diet (39 percent of to the child. However, 33 percent of mothers stated sampled women), most reported eating more fresh that they also fed the child something other than vegetables and fruits and meat, and having either breastmilk immediately after birth, namely plain a greater quantity of food or more frequent meals. water, other milk and gripe water. Indeed, it was Among these women, about half stated that a family commonplace for mothers to start feeding water member or relative had advised them to follow a to their child early on (within 2-3 months of birth), special diet, as compared to medical professionals and providing semi-solid food within 4-6 months of (under 20 percent) and frontline health workers birth. More specifically, over 75 percent of mothers (under 9 percent). About 17 percent of respondents reported giving water to the child at an average age said that they avoided certain food items during their of three months. Additionally, more than half of the pregnancy, including yellow or red coloured fruits, mothers reported that they started giving semi-solid red meat, and tobacco and alcohol. Most stated this foods like soft rice, mashed potato, non-breast milk Page 2  |  July 2019 liquids such as tea, juice to the child under 6 months sample (either pregnant or lactating) are consuming of age. (Meat, eggs and pulses were started to be carbohydrate-based food items frequently as given at seven months, as were instant noodles and compared to protein and nutrient-rich food. More other salty fried snacks). During the focus group alarmingly, the practice of exclusive breastfeeding discussions, it was evident that there was both a for a duration of six months was not prevalent among gap in knowledge about exclusive breastfeeding a majority of respondents. There is an urgent need (water was given to “quench the thirst”), as well as to disseminate context-specific knowledge through financial constraints where mothers had to resume existing platforms such as the monthly Village Health work (predominantly farming) soon after giving birth, and Nutrition Days and home-based visits made and therefore the infant was fed water and other milk by frontline workers for providing counselling to when the mother was away. pregnant and lactating women. Given the importance of familial bonds and cultural norms in Nagaland, information and counselling should be provided to Conclusion entire families rather than only pregnant women and mothers. The findings of this study should inform Knowledge and application of appropriate the areas of focus and content of behaviour change MIYCF practices is critically lacking among Naga communication and counselling interventions. communities. For example, women in the study Footnotes 1 Pan American Health Organization and World Health Organisation. 2005. Guiding principles for complementary feeding of the breastfed child. Washington, DC. 2 Allen, LH. 2000. Anemia and iron deficiency: effects on pregnancy outcomes. Am J Clin Nutr. 2000 May; 71(5 Suppl):1280S-4S. doi: 10.1093/ajcn/71.5.1280s. 3 World Health Organization. 2014. WHA Global Nutrition Targets 2025: Anemia Policy Brief. Geneva, Switzerland. 4 International Institute for Population Sciences and ICF. (2018). National Family Health Survey - 4 (NFHS 4) India 2015-16: Nagaland. 5 Kohli, N., Nguyen, P., Avula, R., & Menon, P. 2017. Improving nutrition in Nagaland: Insights from examining trends in outcomes, determinants and interventions between 2006 and 2016. POSHAN Policy Note #28. New Delhi: International Food Policy Research Institute. 6 To detect a population proportion of children under two years of age who received an adequate diet (based on NFHS-4 for Nagaland), with a margin of error of 4.5%, confidence level of 95%, and design effect of 2, the survey would require a sample size of 540 households. 7 A total of 676 women were interviewed as 52 women were not present or available for the interview at the time of the survey. Page 3 © 2019 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some Rights Reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution Please cite the work as follows: “World Bank. 2019. India: Nutrition Determinants and Strategies in Nagaland, Knowledge Brief - Determinants of Nutrition in Nagaland, India – Maternal, Infant, Young Child Feeding (MIYCF) Practices. © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Acknowledgements This work was led by Patrick Mullen and Aarushi Bhatnagar, with contributions from Young Eun Kim, Mohini Kak, Bathula Amith Nagaraj, Neesha Harnam, Avril Kaplan and Mamata Baruah, under the oversight of Rekha Menon. The World Bank team would like to thank the Directorate of Health and Family Welfare and Department of Social Welfare, Government of Nagaland, the Nagaland Health Project team, Oxford Policy Management Ltd., the Kohima Institute and all study participants for their contributions. This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. Page 4  |  July 2019