Improving IYCF Practices
among deprived and
integration to CMAM
Programme
Raj Kumar Pokharel Chief, Nutrition Section
Child Health Division,
DoHS
Ministry of Health and Population/GoN
South Asia Regional Knowledge
Forum
Kathmandu, Nepal
12 – 13 June 2012
Status of Child Mortality
and Nutrition
NEPAL IS ON TRACK TO REACH MDG4 : REDUCING CHILD MORTALITY
153
118
91
6154 54
102
7964
48 4634
45.9 5039 33 33
150
40
80
120
160
200
1991 1996 2001 2006 2011 2015
MDG
U5MR IMR NMR
Status of Undernutrition of
Children in Nepal
Status of Undernutrition in U5 Nepal
Source: NDHS 2011
57
49
41
28
43
39
29
27
11 13
11
5
0
10
20
30
40
50
60
NDHS 2001 NDHS 2006 NDHS 2011 MDG Target 2015
Pe
rce
nt
Stunting Underweight Wasting
Regional Inequity: Stunting by Sub-region
Percent of children under
age 5 who are too short
for their age (based on
WHO standards)
Nepal
41% Eastern terai
31%
Central terai
41%
Western mountain
60%
Mid-western terai
44%
Far-western
hill 58%
Eastern hill 46%
Central
hill 31%
Western hill
36%
Mid-western hill
52% Far-western terai
32%
Western terai
40%
Central mountain
46%
Eastern mountain
45%
Fig 24: Stunting (-2SD) Trend for children between 6-23 months,
by Wealth Index
0%
10%
20%
30%
40%
50%
60%
1996 2001 2006
Poorest
Poorer
M iddle
Richer
Richest
Total
Ref: DHS 2001 and 2006. Adapted from Ramu Bishwakarma. Social Inequalities in Child Nutrition in Nepal. August 2009
(Background paper for Nepal Nutrition Assessment and Gap Analysis, November 2009)
65% reduction in
richest quintile!
12% increase in
poorest quintile!
14% reduction
overall
Trend in stunting prevalence by wealth index
High Inequity
•Overview of Community based Management
National Scale Up Plan
UNICEF
2012 - 2017
Status of wasting (by eco-regions)
Source: NDHS 2011
Infant and Young Child
Feeding Practices in
Nepal
Status of Breastfeeding
• 45% of newborns are breastfed within the first hour of life, and 85% within the first day.
• 28% of newborns given food or liquid other than breast milk (prelacteal feed), although this is not recommended.
• 98% of infants are ever breastfed.
(NDHS 2011)
Exclusive Breastfeeding by Age
Age in months
Percent of children exclusively breastfed,
NDHS 2011
IYCF Practices Percent of children 6-23 months, NDHS 2011
Status of Micronutrient
Deficiencies among
Children in Nepal
Status of Micronutrients Deficiency in
Nepal
Indicators Achievement Target
1996 2001 2006 2011 2015
Iron Deficiency Anemia among
<5 years 78 - 48 46 43
Iron Deficiency Anemia among
<2 years 82 - 74 70 43
HH consumption of adequate
Iodized Salt 55 - 58 80 90
VA coverage among 6-59
months - - 90 92 >95
% of low birth weight (or small)
babies - 43 39 27 <25
Anemia Situation in Children age 6-59 Months
Source: NDHS 2011
Anemia Prevalence in Children Percent of children age 6-59 months with anemia –
NDHS 2011
78
74 72
57
44 38
25
46
0
10
20
30
40
50
60
70
80
90
6-8 9-11 12-17 18-23 24-35 36-47 48-59 Total
Age in months
Ways adopted to address inequity and reach to
deprived
• Improve dietary intake and care and feeding
practices up to grass root level through scaling-up
IYCF counseling.
• Frontline workers such as CHWs, female volunteers
and mobilization of mother’s group to improve IYCF.
• CMAM linked with IYCF promotion.
• Also, multiple micronutrient powders distribution
linked with IYCF promotion
• Improvement in IYC and maternal nutrition through
multi-sectoral nutrition plan
Overview of CMAM integrated
with IYCF
Situation of malnutrition in 2007/08
• GAM rate nationally was 11% in 2001, 13% in 2006
and 11% in 2011 – stagnant trend
• Global Acute malnutrition was in critical threshold -
13% nationwide and <15% in mid and far western
regions
• SAM rate around 3% nationwide
• Droughts in hills and mountains especially in mid and
far-western regions
• Severe food insecurity in 45 districts (Out of total 75
districts of Nepal)
• Disease epidemics – diarrhea/cholera Source: DHS 2006
Situation of Emergencies in Mid and Far-western
Regions in 2007/08 (2)
• Impact of the ten-year lasting armed conflict
with high migration, displacement – disruption
of basic social services
• Concentrated epidemic of HIV and AIDS
• Floods in terai regions
Severity of Nutrition Crisis ( WHO Benchmarks)
Severity Prevalence of
Global Acute
malnutrition
(GAM)
Action required Status of Nepal
Acceptable < 5 % No any district fall in this box
Poor 5 – 9 % No need for population interventions
Attention to malnourished individuals through
regular community services[
Approx. 25 districts fall in this status
Even in the poor nutrition situation,
attention should be given to the acutely
malnourished children
Critical 10 – 14 % or 5-9%
with aggravating
factors*
No general rations, but supplementary
feeding targeted to individuals identified as
Malnutrition among vulnerable groups
Therapeutic feeding for severely acute
malnourished individuals
Most of the districts (more than 40) fall in
critical threshold
Nepal has 11% GAM and 2.6% SAM.
Therefore, national wide, acute
malnutrition crosses the critical threshold
Serious > = 15 % or 10-
14% with
aggravating
factors*
General rations (unless situation is limited to
vulnerable groups); plus
Supplementary feeding for all members of
vulnerable groups.
Therapeutic feeding for severely acutely
malnourished individuals
Many districts (10) especially mid and far
western hills and mountainous, some
districts of central and western Terai fall in
the serious situation
* The aggravating factors include: general food ration below the mean energy requirement, epidemic of measles of whooping cough
(pertussis), high incidence of respiratory or diarrheal diseases, epidemic of HIV and AIDS, prevalence of malaria, natural disasters
such as floods, earthquakes, droughts, heavy snow/hail falling, climate change and destroying humankinds or foods or livelihood, High
prevalence of pre-existing malnutrition, e.g., stunting, Tsunami etc.; complex humanitarian situation such as arm conflict, Household
food insecurity, Crude mortality rate greater than 1/10,000/day; Under-five crude mortality rate greater than 2/10,000/day etc;
Emergency
Threshold
Source: WHO, Management of Malnutrition in Major Emergencies, 2000
Steps towards CMAM Pilot Dec 2007: Feasibility Study
October 2007: Orientation workshop with potential partners
March 2008: Child Health Sub-committee meeting on protocol & implementation framework
June 2008: Approval of Emergency Nutrition Policy, including CMAM piloting
2008: CMAM baseline survey in five districts
January 2009: National Pilot Planning Meeting
February 2009: Master TOT training – technical part
March 2009: Started district implementation in three districts
Sept. 2010: Implemented in next two districts
2010/2011: CMAM is Recommended for national scale up from SUN initiative and health sector nutrition evidence review
July-Dec. 2011: CMAM pilot evaluation
The Objective of CMAM pilot
• To evaluate the feasibility of the CMAM
approach in districts with different agro-
ecological characteristics.
• To recommend on potential approach for
scaling-up CMAM program including
monitoring and evaluation framework.
Wasting Rate in Remote Pilot Districts
District Mugu Kanchan
pur
Bardiya Achha
m
Jajark
ot
Years May/Jun2
008
May/Jun
2008
May/Jun,
2008
Sept,
2008
Dec,
2008
GAM 26.6 % 17 % 16.2 % 18.0 % 10.5 %
SAM 7.1 % 3.3 % 2.8 % 3.6 % 2.4 %
JHAPA MORANG
SAPTARI SUNSARI
•Rajbiraj
•Biratnagar
•Chandragadi
FAR-WESTERN
REGION
DOLPA
MUGU
JUMLA
KAILALI
BARDIYA
HUMLA
DOTI
SURKHET
NAWALPARASI KAPILBASTU
RUPANDEHI
DANG
BANKE
ACHHAM KALIKOT
SIRAHA
DARCHULA
BAJHANG
BAITADI
DADEL- DHURA
KANCHAN- PUR
BAJURA
PARSA
BARA RAUTA-
DHANUSA MAHO- TARI
SARLAHI
DHADING
MAKAWANPUR
CHITWAN
KASKI
TANAHU
PALPA
SYANGJA
PARBAT
ARGHAKHACHI
GULMI
UDAYAPUR
SINDHULI
ILAM
BHOJ- PUR
DHANKUTA
TAPLEJUNG
OKHAL-
DHUNGA
TERHA-
THUM
KHOTANG
Patan
B
KTM SOLUK- HUMBU
DOLAKHA
SANKHUWA- SABA
NUWAKOT SINDHU- PALCHOK
KAVRE
RASUWA
LAMJUNG
GORKHA
PYUTHAN
ROLPA SALYAN
MYAGDI
DAILEKH JAJARKOT
RUKUM
MUSTANG
MANANG
•Simikot •Darchula
•Baitadi
•Dadeldhura
•Mahendranagar
•Dhangadi
•Dipayal
•Chainpur •Martadi
•Magalsen
•Gularia
•Birendranagar
•Dailekh
•Manma
•Jumla
•Gamgadi
•Jajarkot
•Dunai
•Jumlikhalanda
•Salyan
•Nepalgunj
•Ghorahi
•Liwang
•Jomosom
•Beni
•Baglung
BAGLUNG
•Kusma
•Pyuthan
•Taulihawa
•Sandhikharka
•Tamghas
•Sidharthanagar
•Tansen
•Syangja
•Pokhara
•Chame
•Besisahar
•Damauli
•Parasi
•Bharatpur
•Gorkha
•Dhadingbesi
•Dhunche
•Bidur
•Hetauda
•Birgunj
•Kalaiya
•Gaur
HAT
•Dhulikhel
•Chautara
•Charikot
•Ramechhap
•Sindhulimadi
•Malangwa
Jaleshwor •Janakpur
•Siraha •Ineruwa
•Gaighat
•Diktel
•Salleri
•Okhaldhunga
•Bhojpur
•Khandbari •Taplejung
•Phidim
•Ilam
•Dhankuta
•Terhathum
EASTERN
REGION
CENTRAL
REGION
WESTERN
REGION
MID-WESTERN
REGION
CMAM Pilot
Legend
CMAM Pilot Districts
CMAM Components Included
UNICEF
4. IYCF, Care,
Health and WASH
Counselling
2. Out-patient
treatment
(OTPs)
3. In-patient
treatment (SCs)
1. Community
outreach/social
mobilization/
screening
5. Strengthen and improve WASH
facilities in OTPs/ SCs
Hygiene promotion
CMAM Performance in Five Districts (as of Nov. 2011)
Districts/
OTP
started
dates
SAM as
per
baselin
e
Admi
ssion
Disch
arge
Recov
ered
Deaths Defaulte
r
Under
treatme
nt
Relapse Not
recover
ed
No
of
OTP
Bardiya/M
ay 2009
2.8 3149 2799 2327 8 445 350 70 19 15
88.89 83.14 0.29 15.90 11.11 2.22 0.68
Achham/J
an 2010
3.6 2132 1887 1763 8 102 245 15 14 26
88.51 93.43 0.42 5.41 11.49 0.70 0.74
Mugu/
July 2009
7.1 1225 1141 1053 19 62 84 21 7 7
93.14 92.29 1.67 5.43 6.86 1.71 0.61
Kanchanp
ur/Sep
2010
3.3 2867 2684 2537 2 143 183 23 2 17
93.62 94.52 0.07 5.33 6.38 0.80 0.07
Jajarkot/S
ep 2010
2.4 776 676 583 5 86 100 34 2 11
87.11 86.24 0.74 12.72 12.89 4.38 0.30
Number 10149 9187 8263 42 838 962 163 44 76
Per cent 90.52 89.94 0.46 9.12 9.48 1.61 0.48
SPHERE Standard >75% <10% <15%
Rationale for Including IYCF into CMAM
• Infection and inappropriate infant and young child
feeding practices.
• For appropriate IYCF, community and family resilience is
essential to prevent under nutrition
• Only treatment of SAM is not enough. Therefore,
preventive measures should be integrated with CMAM
programme
• For the prevention of under nutrition, IYCF and care is
the most appropriate action with CMAM for complete
package
• Health workers and FCHVs are essential to make
resilience community/families for IYCF
Practicalities of Integrating
IYCF into CMAM
Key Components of IYCF in CMAM • Capacity building of health workers and FCHVs
• Community based assessment through MUAC by FCHVs
and community health workers
• Promotion, protection and support of Breast feeding and
Infant and Young Child Feeding (IYCF)
• Management of moderate malnutrition (MAM) through
counseling services for behavior change on IYCF, care,
health seeking, WASH and ECD
• Management of severe acute malnutrition (SAM) through
RUTF and essential medications and behavior change
communication through counseling to continue enhanced
nutrition status
• Community based monitoring and reporting
Training/Capacity Building
• Developed cascade type training curriculum and
monitoring checklists integrating IYCF into CMAM
• Orientation to district and VDC level multi-stakeholders
• Training to district, community health workers and FCHVs.
• Orientation to mother groups on CMAM including IYCF
• Organized integrated monitoring training of CMAM and
IYCF
Community based Assessment through
MUAC
• Community based nutrition assessment of 6-59 months
children through MUAC is done through FCHVs during
mothers group meeting and discuss about the nutrition
status of children.
• Children SAM or MAM with medical complications are
referred nearest OTPs/stabilization center for nutrition
rehabilitation through RUTF and essential medications.
• IYCF counseling services to improve their nutrition
status.
Promotion, Protection and Support for IYCF
• FCHVs and community health workers acted as Key
counselors for promotion, protection and support for
IYCF.
• Mode of message dissemination is mother group’s
monthly meeting, PHC/ORC, OTPs and MUAC
assessment
• Promotion, protection and support for IYCF counseling is
ongoing in OTP, SCs, communities and PHC/ORCs
• Local available diversified foods are promoted by FCHVs
and community health workers such as; Khichadi and
porridge of blended flour for complementary feeding.
• Focusing to early initiation and exclusive breast feeding
and on time and appropriate complementary feeding
Promotion, Protection and Support for IYCF
Major messages on IYCF are discussed during CMAM
training:
• Importance of Breastfeeding for Infant, Mother, Family and
Community
• Recommended breastfeeding practices
• Recommended complementary feeding practices based on the
available food varieties/diversifications
• Good and Poor Attachment for breast feeding
• Listening and learning counselling skills
• IYCF Assessment with mother
• Common breastfeeding difficulties
• Insufficient breastmilk
• Care of children and women for successful breast feeding and
infant and young child feeding
Outcomes of IYCF integrating in CMAM
• The case load of SAM has been reduced dramatically.
• IYCF integration into CMAM has supported to maintain
enhanced nutrition status of SAM children
• MAM children have improved their nutrition status and
supported for reduction of wasting
• Families and communities have improved their behaviors
dramatically which is shown through the CMAM impact
evaluation
• IYCF incorporated into CMAM training and tools
• Government has top priority to scale up IYCF and it has been
already included into CMAM
• Currently conducted formative evaluation has also
recommended to strengthen IYCF into CMAM
Challenges
• Improve quality of counseling
• Regular and adequate monitoring.
• Enough preparedness for IYCF in Emergency
• Coordination mechanism still need to be strengthened
Recommendations
• Develop comprehensive IMAM package with IYCF and WASH practices.
• Incorporate key IYCF and CMAM messages in education curricula.
• Strengthen coordination among the duty bearers
• Strengthen support services (clean and safe water, and nutrition for women, support on BF)
• Develop integrated communication package for IMAM.
• Capacitate and mobilize community support group for IYCF and CMAM lead by FCHVs.
Thank You
