Knowledge Brief 3 Determinants of Nutrition in Nagaland, India Maternal and Child Health and Nutrition Services Utilization of key maternal and child health and nutrition services remains weak in Nagaland, suggesting an adverse impact on health and nutrition outcomes. Improvements in antenatal care, child vaccinations and growth monitoring can be brought about by strengthening the platform of the Village Health and Nutrition Day and enhancing the capacity of frontline workers to act as agents of behavior change. Introduction responsibility of Anganwadi Workers through the Integrated Child Development Services. In 2013-14, While coverage of key maternal and child health and only 14 percent of children aged 36-71 months received nutrition services in Nagaland has improved marginally supplementary food from Anganwadi Centres.5 over the last decade, most indicators continue to be low and worse than the national average. According to the National Family Health Surveys (NFHS), the Methods proportion of women who had four or more antenatal The mixed-method study included focus group care visits increased from 12 to 15 percent between discussions with mothers and fathers of young 2005-06 and 2015-16, with the national average at children (0-5 years), conducted in selected villages 51 percent in the latter period.1 Moreover, there is in two pilot districts of the Nagaland Health Project significant variation across districts; with coverage (Tuensang and Peren), followed by a quantitative ranging from 1.5 percent in Longleng to 36 percent survey across all districts in the state. The survey6 was in Mokokchung.2 With 33 percent of all births taking done in 55 villages, which were purposively selected place in health facilities, coverage of institutional from among those participating in the Nagaland delivery remains low in the state (despite an increase Health Project, and covered 728 households with a from 12 percent in 2005-06), as compared to a national woman who had had a pregnancy in the past two average of 78.9 percent in 2015-16.1 years. From each sampled household, the woman The proportion of children aged 12-23 months who who had had a pregnancy in the past two years have received all basic vaccinations3 has improved (n=676) and the household head (n=728) were from 21 in 2005-06 to 36 percent in 2015-16, but interviewed.7 is substantially lower than the national average of 62 percent. Moreover, in 2015-16, only four percent of children under five years of age were weighed and Findings eight percent of women received nutrition counselling This brief describes findings on utilization of key at an Anganwadi Centre.1 Provision of supplementary maternal and child health and nutrition services in nutrition to women and children4 is largely the selected parts of Nagaland. July 2019  |  Page 1 Antenatal Care a family member (42 percent) followed by a nurse/ auxiliary nurse-midwife (39 percent) and Accredited Among the sampled respondents, 88 percent Social Health Activist (ASHA) (30 percent). Among of mothers (n=501) and 81 percent of currently those who received this counselling, 70 percent pregnant women (n=175) reported to have consulted of the mothers reported that they were advised on a provider for antenatal care, typically at Primary exclusively breastfeeding for six months. Health Centres (34 percent) and Community Health Centres (29 percent) with only about 3 percent using Supplementary Nutrition antenatal care services provided at the Village Health and Nutrition Day. Over 80 percent women reported 77 percent of the respondent mothers reported to to have received, on average, three antenatal care receive supplementary food from the Anganwadi consultations. However, only 66 percent of mothers Centre or Anganwadi Workers, mostly in the form visited a provider for antenatal care within the first of biscuits (91 percent) and pre-mixed food packets trimester of their pregnancy. (61 percent). Similarly, 58 percent reported to have received Take Home Ration during their last Delivery pregnancy, comprising of rice (48 percent) and pre- mixed food packets (35 percent). On an average, About 55 percent of mothers reported to have women received such rations four times during their delivered in a health facility, with about 5 percent last pregnancy. A substantial proportion (93 percent) among them delivering at private clinics. The of mothers reported that they did not consume the remaining 45 percent preferred to deliver at home. ration by themselves but shared it with their children Findings from qualitative interviews also confirm or other family members. a strong preference for home delivery due to geographic access and apprehensions about quality Nutrition counselling from frontline of care at facilities, particularly fear of surgical workers9 malpractices during a delivery, along with the comfort of delivering within the community in the presence Of the sampled mothers who reported to receive of family members. Over half of all home deliveries services from Accredited Social Health Activists (41 are observed among the two poorest quintiles, percent) and Anganwadi Workers (62 percent) in while private facilities are chosen predominantly by the past month of the survey, nutrition counselling the richest quintile. Only 54 percent of the mothers constituted only 26 and 10 percent of these services reported to have received the Janani Suraksha respectively. However, the survey of frontline Yojana conditional cash transfer that is designed to workers from the same villages showed that over 90 encourage institutional deliveries.8 percent reported to provide counselling services for maternal, infant and young child feeding practices. Postnatal and Newborn Care This discrepancy in the reports of mothers and those of frontline workers suggests a critical gap in quality Of the mothers who delivered at a health facility, all of the counselling provided. reported that their baby was weighed immediately after birth. While 41 percent of respondent Child vaccination mothers reported to have received a postnatal care consultation, they stated that they were, on For children aged 12-23 months included in the an average, checked only once during the first survey (n=164), information on immunization two months. 37 percent reported to have received status was obtained from vaccination cards for 76 counselling on breastfeeding after the delivery, percent while the remaining were based on their with most mothers receiving this counselling from mother’s recall.10 Using data from either source, Page 2  |  July 2019 the survey found that only 16 percent have been fully vaccinated,11 and 8 percent have not received Conclusion a single vaccination. In the case of three-part Utilization of key maternal and child health and nutrition vaccinations, such as DPT and Polio, there was a services remains weak in Nagaland, suggesting an stark difference between the proportion receiving adverse impact on health and nutrition outcomes. The the first dose (42 and 60 respectively) and those state needs to make concerted efforts for improving completing all three doses (31 and 48 percent antenatal care to at least four visits through the length respectively). About half the respondents reported of the pregnancy, with a special focus on increasing to have received vaccination for their children at the antenatal during the first trimester. Strengthening Village Health and Nutrition Day. delivery and quality of antenatal care, along with improving the implementation of the Janani Suraksha Child Growth Monitoring Yojana, is likely to increase institutional delivery rates. Vaccination and growth monitoring services 39 percent of mothers reported that their child’s for children, at all levels of service delivery, require growth (only weight) was monitored in the past six urgent attention in the state, with a special emphasis months, with the service being used predominantly on strengthening the platform of Village Health and at a government health facility, Anganwadi Centre, Nutrition Day for providing these services. Similarly, Village Health and Nutrition Day, and during a home enhancing the capacity of frontline workers, through visit. This is further corroborated by the survey of competency-based trainings, use of job aides, and frontline workers, which found that only 25 percent better performance incentives, could help to improve of ASHAs and 40 percent of Anganwadi Workers the quantity and quality of counselling provided reported measuring the height and weight of a and enable them to act more efficiently as agents newborn during home visits. Similarly, qualitative of behavior change at the frontline. Through its interviews also suggested that they did not consider interventions at the community level, the Nagaland weighing the children regularly or referring cases Health Project is well placed to support improvements of severely malnourished children as a primary in these areas. responsibility. Footnotes 1 International Institute for Population Sciences and ICF. (2018). National Family Health Survey - 4 (NFHS 4) India 2015-16: Nagaland. 2 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. 3 All basic vaccinations refer to BCG, measles, and three doses each of DPT and polio vaccine (excluding polio vaccine given at birth). 4 Women receive supplementary food in the form of dry packets of take-home ration during pregnancy leading up to first six months of breastfeeding while children receive it in the form of take-home ration from six months to three years of age, and in the form of cooked food at the Anganwadi Centre every day from three to six years of age. 5 Ministry of Health and Family Welfare and UNICEF. Rapid Survey on Children. India 2013-14. 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. 8 Janani Surakha Yojana is an intervention under the National Health Mission, which provides cash incentives to eligible (below poverty line and those belonging to the Scheduled Tribe social group) pregnant women for delivering in a government or accredited private facility. 9 Accredited Social Health Activists and Anganwadi Workers are the main frontline agents of the National Health Mission and the Integrated Child Development Services respectively, and are responsible for outreach services including nutrition counselling. 10 Don’t know is counted as not received, and not applicable is counted as missing; only 8 vaccines (BCG, DPT, Polio (excluding polio at age 0) and measles are considered for no vaccination. 11 Implying that they have received their BCG vaccination, 3 injections of DPT, three doses of polio (excluding polio zero) immunization and measles vaccination. 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 and Child Health and Nutrition Services. © 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