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Maternal and Child Health & Nutrition Survey in Kurigram District, Bangladesh Supported by December, 2014
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Page 1: Maternal and Child Health & Nutrition Survey in Kurigram District, … · 2020. 4. 30. · Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 5 3. Methodology 3.1

Maternal and Child Health & Nutrition Survey

in

Kurigram District, Bangladesh

Supported by

December, 2014

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 2

Contents

1. Introduction ......................................................................................................................................... 4

2. Survey Objectives:................................................................................................................................ 4

3. Methodology ........................................................................................................................................ 5

3.1 Study design ....................................................................................................................................... 5

3.2 Sampling Procedure ........................................................................................................................... 5

4. Case definitions and inclusion criteria .................................................................................................. 6

4.1 Household: ......................................................................................................................................... 6

4.2 Anthropometry: ................................................................................................................................. 6

4.3 Acute Malnutrition: ............................................................................................................................ 6

4.4 Water Sanitation and Hygiene: ........................................................................................................... 6

5. Data collection ..................................................................................................................................... 7

5.1 Questionnaire: ................................................................................................................................... 7

5.2 Survey teams and supervision: ........................................................................................................... 7

5.3 Training & data collection: .................................................................................................................. 7

5.4 Ethical considerations: ....................................................................................................................... 8

5.5 Challenges: ......................................................................................................................................... 8

6. Data analysis ........................................................................................................................................ 8

7. Anthropometric results (based on WHO standards 2006) ................................................................... 9

7.1 Distribution of age and sex of children: .............................................................................................. 9

7.2 Prevalence of Acute malnutrition based on Weight for Height Z scores (WHZ): .................................. 9

7.3 Prevalence of Acute Malnutrition based on MUAC cut off: ............................................................... 11

7.4 Prevalence of underweight based on WAZ scores: ............................................................................ 11

7.5 Prevalence of stunting based of HAZ scores: ..................................................................................... 12

8. Child morbidity .................................................................................................................................. 12

8.1 Proportion of children receives Vitamin -A and Measles immunization: ............................................ 13

8.2 Health care seeking behaviour for child illness: ................................................................................ 13

9. Infant and young child feeding practice ............................................................................................... 13

9.1 Early initiation of breastfeeding: ....................................................................................................... 13

9.2 Exclusive breastfeeding under six months: ....................................................................................... 13

9.3 Continued breastfeeding at one year (12 - 15 months): .................................................................... 14

9.4 Introduction of solid, semi-solid and soft food: ................................................................................. 14

9.5 Minimum dietary diversity: .............................................................................................................. 14

9.6 Minimum meal frequency: ............................................................................................................... 14

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 3

9.7 Minimum acceptable diet:.................................................................................................................14

10. Water sanitation and hygiene ..........................................................................................................15

10.1 Source of drinking water: ................................................................................................................15

10.2 Time to collect water:......................................................................................................................15

10.3 Water purification: ..........................................................................................................................16

10.4 Sanitation: .......................................................................................................................................16

10.5 Hand washing practice: ...................................................................................................................16

11. Maternal health and other related factors .......................................................................................17

11.1 Age at marriage: ..............................................................................................................................17

11.2 Nutritional status of pregnant and lactating women: .......................................................................17

11.3 Proportion of woman who consumed at least 100 IFA (Iron Folic Acid) tablets during last pregnancy:

...............................................................................................................................................................17

11.4 ANC check-up and Vitamin-A capsule consumption: ........................................................................17

11.5 Proportions of households consume iodine salt: .............................................................................17

11.6 Last delivery: ...................................................................................................................................18

12. Discussion .......................................................................................................................................18

13. Acknowledgements .........................................................................................................................19

14. References ......................................................................................................................................19

15. Annex .............................................................................................................................................20

Annex 1: Map of the survey areas: ..........................................................................................................20

Annex 2: Plausibility check for Anthro data all areas Kurigram District.....................................................21

Annex 3: Selected Clusters ......................................................................................................................22

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 4

1. Introduction

Terre des hommes-Lausanne Foundation (Tdh) an International Non-Government organisation has been

working in Kurigram since 1974. In 2012, Tdh began implementation of the Integrated Mother and Child

Nutrition (IMCN) project supported by World Food Programme (WFP), Humanitarian Aid and Civil

Protection Department of the European Commission (ECHO) and Swiss Solidarity (CdB) in three Upazilas

(Kurigram, Chilmari and Ulipur) of Kurigram district situated in Northern Bangladesh. The main objective

of the project was to contribute to reduction of global acute malnutrition defined by MUAC among

children aged less than five years and pregnant and lactating women. As needs persisted even after 3 years

of work Terre des hommes Because of remaining needs, as well as an encouraging collaboration with health

authorities, a new strategic phase was introduced to increase the impact of ongoing work, expand

coverage, and transfer skills to government health service providers. The Ministry of Health and Family

Welfare (MoHFW) Community Clinics (CC) provide primary health care services, albeit very often with

limited human resources capacities and medical supplies. Through this programme Tdh aims to fully cover

three Upazilas (Kurigram Sadar, Ulipur, Chilmari), where it will significantly strengthen the capacities of

CCs, as well as encourage the population to demand quality health care. Knowledge and correct practices

on health, nutrition and WASH will be diligently promoted at community level.

Kurigram District is situated in North West Bangladesh (Rangpur Division). Three major rivers

Brahmaputra, Dharla, and Teesta flow through or border these areas creating several chars or riverine

islands. Weather of the Kurigram District is little different from the other parts of Bangladesh. During

summer, temperature is higher and during winter lower compared to central or southern Bangladesh.

Heavy rainfall is usually observed during the rainy season (June – September) like in other parts of

Bangladesh and the average annual rainfall is about 3000 mm.

Total population of Kurigram district is approximately 2,069,273 (2011 BBS data). The population is mostly

stable with few pockets of internally displaced persons owing to flooding within the district. Agriculture is

the main occupation with most residents being agricultural day labourers.

The district is subdivided into nine Upazilas or Sub-districts. Each of these Sub-districts is further divided

into several Unions. The survey covered all 9 Upazilas of Kurigram though Terre des hommes will in this

phase work only in 3 Upazilas. This survey was a response to a demand made by local health authorities

and UNICEF to assess the nutrition status of below 5 children and (Pregnant and Lactating Women) PLWs

in the entire district.

2. Survey Objectives:

The survey focussed on U5 children and Pregnant and Lactating women with the following specific

objectives

- To estimate the prevalence of acute malnutrition in children aged 6-59 months

- To assess appropriate IYCF practices in children between 0-23 months of age

- To assess morbidity prevalence in children U5 and health care seeking practices

- To assess the prevalence of malnutrition among pregnant and lactating women and the coverage of

health interventions for this population

- To assess the Water, Sanitation and Hygiene Practices at the household level

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3. Methodology 3.1 Study design

The survey was cross sectional in design. Quantitative tools like structured questionnaires were used to

collect information on anthropometry, IYCF practices, maternal health and WASH.

3.2 Sampling Procedure

The sampling procedure of the survey was implemented according to the Standardized Monitoring and

Assessment of Relief and Transition (SMART) methodology (SMART Methodology, 2006).

A two stage cluster sampling methodology was applied. In the first stage, the primary sampling unit was the

Para- smallest geographical units within the unions with 200 households on an average in each Para. 151

Paras were randomly selected using Probability Proportional to Size from 22 unions covering all 9 Upazilas

of the entire district.

In the second stage, 16 households were selected from each para following a household list prepared by

the survey team with the help of elders in the respective communities. Desired numbers of households

then were selected systematically at an interval. Data was collected from 2,074 households by administering

structured questionnaires on IYCF, Child health, PLW and WASH. Anthropometric measurements of

1,200 children aged 6 – 59 months were taken from the same households. For infant and young child

feeding practice appropriate information was collected from households with children aged less than 24

months. In households without children less than five years, the respondents were women, either wives or

mothers of the household head. During the survey data collection, if any household was found empty or

children aged less than five years were unavailable, the survey team re-visited those HHs later on the same

day or recorded it as a non-response.

Sample size calculation was done using the formula

n = t2 x (p) x (1-p) x DEFF d2

Table1: Estimates for Sample size calculation

Indicator Estimates

Estimated prevalence (p) 15%

Desired precision (d) 3

Design effect (DEFF) 1.5

Average Household size 5

Percentage of under five in

population

11.2%

Percentage of non-respondent 15%

Children to be included 889

Household to be included 2,074

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4. Case definitions and inclusion criteria

4.1 Household:

A household consists of a person or group of persons, related or unrelated, in the same dwelling unit who

usually live together and eat together.

4.2 Anthropometry:

Anthropometry refers to measurement of children’s age, height, weight and mid upper arm circumferences

(MUAC). For the baseline survey, children aged 6-59 months were targeted and all children in the

household were measured to collect the following information.

- Age: Vaccination Card was used as the reference document to verify age. In absence of vaccination

card, birth certificates were used and verified with a local event calendar.

- Weight: Children were measured using digital baby weighing machine. In keeping with Tdh’s child

protection policy no children were measured unclothed. Appropriate adjustments were made for the

weight of the clothes after measurement.

- Height: A height scale was used to measure children. Children with linear measurement less than 85 cm

or less than 2 years old were measured lying down while taller and older children were measured

standing up.

- MUAC: MUAC was measured on the left arm, using MUAC tapes, at the middle point between the

elbow and the shoulder, while the arm was relaxed and hanging by the body’s side. MUAC was

measured to the nearest mm.

- Bilateral Oedema: This was assessed by the application of moderate thumb pressure for at least 3

seconds to both feet. Only children with bilateral oedema were recorded as having nutritional oedema.

4.3 Acute Malnutrition:

Weight-for-Height Index: The acute wasting was estimated from the weight-for-height index values

combined with the presence of oedema. This index was compared with the World Health Organization’s

(WHO) standard expressed in z-scores or WHZ. Guidelines for the results expressed in z-scores are given

below.

- Severe malnutrition is defined by WHZ <-3 SD and/or existing bilateral oedema

- Moderate malnutrition is defined by WHZ <-2 SD and >=-3 SD and no oedema

- The Global acute malnutrition (GAM) in this report is therefore expressed as the proportion of

children presenting with a WHZ index less than -2 Z scores with/without oedema.

- No measurements were excluded based on Z scores.

MUAC: MUAC is a rapid assessment tool of malnutrition. It also acts as a good predictor of mortality. The

guideline for MUAC cut off point is as given below.

- Severe acute malnutrition with high risk of mortality is defined by MUAC < 115mm and/or bilateral

oedema.

- Moderate acute malnutrition with risk of mortality is defined by MUAC >=115mm and MUAC <

125mm.

4.4 Water Sanitation and Hygiene:

Hand washing at critical/key times: Government of Bangladesh defined times mentioned in the “National

hygiene promotion strategy 2012”

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- Hand-washing with soap and clean water before food handling and after defecation

- Hand-washing with soap and clean water after cleaning baby's bottom and defecation

Safe water: Meeting any of the following criteria (water quality in terms of testing for arsenic, bacteria, etc.

was not considered here): (a) shallow/deep tube well with concrete platform (b) supply water (c) rain

water (d) protected well (e) PSF water

Hygienic latrine: Meeting any of the following criteria: (a) pit latrine with slab & water seal (b) pucca latrine

with septic tank (c) ventilated improved pit latrine (d) ECOSAN latrine

Water fetching time: Time required to walk to the water point from home, to waiting, to collect collection

and to come back home

5. Data collection

5.1 Questionnaire:

The questionnaire was adapted from the Health and Nutrition Surveys conducted by Tdh in Kurigram and

adjusted with district nutrition indicators (DNI). The questionnaire had four sections i.e. anthropometry,

IYCF, Maternal health and WASH. The anthropometry section included in addition to Age, Sex, Height,

Weight and MUAC, vaccination and morbidity related questions. The IYCF questionnaire was developed

according to the WHO guideline (World Health Organization, 2010).

5.2 Survey teams and supervision:

For the purpose of the survey, a survey team was formed. The survey team consisted of M&E team

leaders and Monitoring Assistants. From the government side Health Inspectors (HI) and Assistant Health

Inspectors (AHI) also participated. Total 41 surveyors were trained for the survey and out of them 36

participated in the data collection. Most surveyors had previous experience of surveys and screening of

children or measurement of weight, height and MUAC in Kurigram.

The team also included two senior staff members from the Tdh Monitoring & Evaluation team who

supervised the day to day data collection, ensured that survey protocols were maintained, entered survey

data in ENA for SMART and Statistical Package for Social Science (SPSS Version-13), and provided feedback

to the interviewers and measurers. The supervisors accompanied the survey teams during few initial few

days, later conducted spot checks randomly and re-visited some households if needed. At the end of each

day the anthropometric data was entered into the software ‘ENA for SMART’ and team leaders were

provided feedback based on plausibility checks and observation during the day. These standardised

procedures ensured data quality to the highest extent.

5.3 Training & data collection:

The survey team received five days training. The training materials were adapted based on SMART

(SMART, 2012) guidelines. The training covered general survey objectives, overview of survey design,

household selection procedures, anthropometric measurements, data collection and basic interview skills

on questionnaires (IFCY, WASH and Maternal health). The training was facilitated by the “District

Nutrition Support Officer” (DNSO), UNICEF and National Coordinator, Monitoring and Evaluation

Department of Tdh.

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On the fourth and fifth day of training, participants were divided into 18 groups. Each group led by a team

leader tested and administered the questionnaire at household level and selected according to the selection

procedure. Following the field test, each participant measured two children and results were compared

with other participants who measured the same child using ENA-“Evaluation of Enumerators”. The results

were also compared with supervisors, who observed the procedure of measurement. Based on the findings

of field test and measurement, 24 participants were designated as measurers, 12 were designated as

Interviewers.

Following the training, the survey team was divided into twelve small groups consists of a team leader, two

measurers and one interviewer. The groups were then assigned different clusters to collect data.

5.4 Ethical considerations:

Consent for the interview was taken before starting the interview from each participant who in most cases

was the mother of an U5 child or pregnant or lactating woman. The participants i.e. women had the right

to refuse or withdraw any time during the Interview. Participant information was treated highly

confidentially. It was ensured during survey that there was no action or behaviour by which a child could

be abused in any form- physically, sexually, physiologically or even neglected. Before taking anthropometric

measurements, the process was explained to the mothers so that they could assist in the procedure. Any

child who refused measurement was not compelled. The participants did not receive any compensation but

children identified with acute malnutrition were referred to either Tdh’s community nutrition centres or

Govt. health facilities within the area.

5.5 Challenges:

As the survey covered whole Kurigram District survey team had to move into different chars (riverine

islands) hard-to-reach areas. Some of the areas were as far as four or five hours on a boat journey.

Informed local government authorities were not always available. It was not always easy to find the sampled

para in a complete new area. And in char areas selected paras were sometimes at distances of one to five

kilometres from each other with no form of transportation. Walking was the only resort.

Additionally, many caregivers around 6% were busy during daytime and hence were not available during the

time of data collection. In such cases survey team was instructed to visit the same household later in the

day. Even then, it was not always possible to meet the caregiver later in the day due to distance among

clusters. As the sample size was calculated taking into account 15% non-response this did not affect the

overall sample size.

6. Data analysis

The survey data was entered either on the same evening or the following morning by the data entry staff.

Anthropometric data was entered in ENA for SMART while IYCF, Maternal health and WASH data were

entered in Excel. The M&E Officer responsible for survey coordination conducted random checks on 10%

of entered records. He also prepared frequency distribution of responses for each question and verified

irrelevant data. Due to these initiatives the data quality as mentioned in the summary plausibility checks

performed by the software for anthropometric measurement was reported as 6% which is good. Plausibility

test report is annexed (Annex 2).

Basic descriptive analysis like frequency distribution, percentage and cross–tabulation were also performed

using SPSS to analyse the data as well as to calculate the indicators mentioned in the objective.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 9

7. Anthropometric results (based on WHO standards 2006)

7.1 Distribution of age and sex of children:

As part of the baseline survey 1,012 children aged between 6 and 59 months were assessed. Among them

53.3% (539) were boys and 46.7% (473) were girls. The ratio of boy to girl rather equal, demonstrating that

there was no selection bias in the sample. Age distribution was also similar across the groups.

Table 2: Distribution of age and sex of sample

Boys Girls Total Ratio

Age (month) no. % no. % no. % Boy: Girl

6-17 112 48.9 117 51.1 229 22.6 1.0

18-29 116 52.5 105 47.5 221 21.8 1.1

30-41 133 52.2 122 47.8 255 25.2 1.1

42-53 121 58.2 87 41.8 208 20.6 1.4

54-59 57 57.6 42 42.4 99 9.8 1.4

Total 539 53.3 473 46.7 1012 100.0 1.1

7.2 Prevalence of Acute malnutrition based on Weight for Height Z scores (WHZ):

Prevalence of global acute malnutrition (GAM) is 14.0% (95% C.I., 11.9 – 16.4) Prevalence of severe acute

malnutrition (SAM) is 2.8% (2.0 - 3.8 95% C.I.)There was no significant difference in GAM prevalence across

sexes. There was no oedema. According to age distribution, GAM is highest (13%) among the children of

42-53 months.

Table 3: Prevalence of acute malnutrition based on WHZ scores (and/or oedema) and by sex

All (n = 1012) Boys (n = 539) Girls (n = 473)

Prevalence of global

malnutrition

(<-2 z-score and/or oedema)

(142) 14.0 %

(11.9 - 16.4 95% C.I.)

(77) 14.3 %

(11.5 - 17.6 95% C.I.)

(65) 13.7 %

(11.0 - 17.1 95% C.I.)

Prevalence of moderate

malnutrition

(<-2 z-score and >=-3 z-score,

no oedema)

(114) 11.3 %

(9.3 - 13.6 95% C.I.)

(61) 11.3 %

(8.7 - 14.5 95% C.I.)

(53) 11.2 %

(8.6 - 14.4 95% C.I.)

Prevalence of severe

malnutrition

(<-3 z-score and/or oedema)

(28) 2.8 %

(2.0 - 3.8 95% C.I.)

(16) 3.0 %

(1.8 - 4.8 95% C.I.)

(12) 2.5 %

(1.5 - 4.2 95% C.I.)

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 10

WFH z-score distribution curve of the surveyed

sample is relative to the WHO-Growth

Standards curve. The findings indicate a shift to

the left of the sample curve, with a mean score

of -0.88 and a standard deviation of 1.11, which

indicates that overall, the population surveyed

exhibits a poor nutritional status compared with

the WHO reference population.

Figure 1: Comparison of WHZ curve (red

line) with WHO standard (green line)

Table 4: Prevalence of acute malnutrition by age, based on WHZ scores and/or oedema

Severe wasting

(<-3 z-score)

Moderate wasting

(>= -3 and <-2 z-score)

Normal

(> = -2 z score)

Oedema

Age (mo) Total No. % No. % Age (mo) Total No. %

6-17 229 8 3.5 18 7.9 6-17 229 8 3.5

18-29 221 8 3.6 31 14.0 18-29 221 8 3.6

30-41 255 8 3.1 29 11.4 30-41 255 8 3.1

42-53 208 0 0.0 27 13.0 42-53 208 0 0.0

54-59 99 4 4.0 9 9.1 54-59 99 4 4.0

Total 1012 28 2.8 114 11.3 Total 1012 28 2.8

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7.3 Prevalence of Acute Malnutrition based on MUAC cut off:

The prevalence of GAM was 3.9% (95%, C.I., 2.7 – 5.5) with a SAM prevalence of 0.2%.

Table 5: Prevalence of acute malnutrition based on MUAC (and/or oedema) and by sex

All (n = 1012) Boys (n = 539) Girls (n = 473)

Prevalence of global malnutrition

(< 125 mm and/or oedema)

(39) 3.9 %

(2.7 - 5.5 95% C.I.)

(17) 3.2 %

(1.9 - 5.2 95% C.I.)

(22) 4.7 %

(3.0 - 7.2 95% C.I.)

Prevalence of moderate malnutrition

(< 125 mm and >= 115 mm, no oedema)

(37) 3.7 %

(2.6 - 5.2 95% C.I.)

(17) 3.2 %

(1.9 - 5.2 95% C.I.)

(20) 4.2 %

(2.7 - 6.5 95% C.I.)

Prevalence of severe malnutrition

(< 115 mm and/or oedema)

(2) 0.2 %

(0.0 - 0.8 95% C.I.)

(0) 0.0 %

(0.0 - 0.0 95% C.I.)

(2) 0.4 %

(0.1 - 1.7 95% C.I.)

The prevalence of GAM among boys was 3.2% while it was measured 4.7% among girls. The prevalence of

GAM by age group represented in table 6 shows that the % of GAM is high among children less 30 months

(13.7%) compared to children aged between 30-59 months (3.0%).

Table 6: Prevalence of acute malnutrition by age, based on MUAC and/or oedema

Severe wasting

(< 115 mm)

Moderate wasting

(>= 115 mm and < 125 mm)

Normal

(> = 125 mm)

Age (mo) Total No. % No. % Age (mo) Total

6-17 229 0 0.0 17 7.4 6-17 229

18-29 221 0 0.0 14 6.3 18-29 221

30-41 255 1 0.4 5 2.0 30-41 255

42-53 208 0 0.0 0 0.0 42-53 208

54-59 99 1 1.0 1 1.0 54-59 99

Total 1012 2 0.2 37 3.7 Total 1012

7.4 Prevalence of underweight based on WAZ scores:

The prevalence of underweight among the children assessed was 30.8% (95% C.I. 27.6% - 34.3%). The

following table represents the prevalence of underweight by sex and by age of the children.

Table 7: Prevalence of underweight based on weight-for-age z-scores by sex

All

n = 1012

Boys

n = 539

Girls

n = 473

Prevalence of underweight

(<-2 z-score)

(312) 30.8 %

(27.6 - 34.3 95% C.I.)

(156) 28.9 %

(24.7 - 33.6 95% C.I.)

(156) 33.0 %

(29.1 - 37.1 95% C.I.)

Prevalence of moderate underweight

(<-2 z-score and >=-3 z-score)

(249) 24.6 %

(21.7 - 27.7 95% C.I.)

(120) 22.3 %

(18.8 - 26.1 95% C.I.)

(129) 27.3 %

(23.4 - 31.5 95% C.I.)

Prevalence of severe underweight

(<-3 z-score)

(63) 6.2 %

(5.0 - 7.8 95% C.I.)

(36) 6.7 %

(4.9 - 9.1 95% C.I.)

(27) 5.7 %

(4.2 - 7.7 95% C.I.)

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 12

7.5 Prevalence of stunting based of HAZ scores:

The prevalence of stunting based on HAZ scores was 35.6% (95% C.I., 31.9 - 39.4) among the children

assessed. There was no significant difference between sexes.

Table 8: Prevalence of stunting based on height-for-age z-scores and by sex

All (n = 1012) Boys (n = 539) Girls (n = 473)

Prevalence of stunting

(<-2 z-score)

(360) 35.6 %

(31.9 - 39.4 95% C.I.)

(180) 33.4 %

(29.2 - 37.8 95% C.I.)

(180) 38.1 %

(33.3 - 43.0 95%

C.I.)

Prevalence of moderate

stunting

(<-2 z-score and >=-3 z-score)

(278) 27.5 %

(24.2 - 31.0 95% C.I.)

(129) 23.9 %

(20.0 - 28.4 95% C.I.)

(149) 31.5 %

(27.4 - 35.9 95%

C.I.)

Prevalence of severe stunting

(<-3 z-score)

(82) 8.1 %

(6.5 - 10.1 95% C.I.)

(51) 9.5 %

(7.4 - 12.1 95% C.I.)

(31) 6.6 %

(4.4 - 9.6 95% C.I.)

Figure 2: Nutrition status of under five children

2.8% 0.2%6.2% 8.1%

11.3%3.9%

24.6%27.5%

0.0%

10.0%

20.0%

30.0%

40.0%

WHZ MUAC WAZ HAZ

Moderate

Severe

In summary it can be said that the nutritional status of the children in the district is poorer in all 3

indicators compared to the WHO reference population. With a GAM prevalence (14.1 %) based on WHZ

scores close to the emergency threshold of 15% and a stunting prevalence of 35.6 the need for continuing

interventions to address under nutrition in children is reiterated.

8. Child morbidity

Along with anthropometric data information on coverage of vitamin A and measles, morbidity among under

five children and treatment seeking behaviour for reported illness was collected during the survey. A two

weeks recall period was used for morbidity while six months recall period was used for vitamin A coverage.

1,935 caregivers were asked about their children’s illnesses. 38.8% of caregivers reported illness in their

children in the past 2 weeks with Fever being the most common illness reported. 74% of those reporting

illness reported fever as an isolated symptom and 39% reported fever with cough and cold. Cough and cold

without fever was reported by 49% of care givers and diarrhoea prevalence was relatively low at 6.9%.

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8.1 Proportion of children receives Vitamin -A and Measles immunization:

The “Vitamin A” coverage was 59% within a recall period of six months. The coverage of measles

vaccination was 80.4%

Table 9: Coverage: Vitamin A for 6-59 months and measles for 9-59 months

Vitamin A

(N=1,935), %

Measles (with card)

(N=1,935) , %

Measles (without card)

(N=1,935) , %

YES 59.4% 80.4% 8.5%

8.2 Health care seeking behaviour for child illness:

Among 750 children who were suffering from illness within the recall period of six months, only 84.8%

(n=636) of caregivers seeking healthcare for child’s illness. Those who sought help only 23% (n=144) went

to qualified service providers e.g. hospital, union/upazila health complex, satellite clinic, doctor’s chamber

etc. and others 77% (n=492) sought care from unqualified service providers quack, traditional healer, village

doctors etc.

Table 10: Health care seeking behaviour

n %

Sought care for child’s illness 636 84.8

From qualified service providers 144 22.6

From unqualified service providers 492 77.4

9. Infant and young child feeding practice

Infant and Young child feeding practices for the children 0 – 23 months were also collected. Data was

collected from 826 children. The information is then was analysed according to WHO 2010 IYCF manual

(World Health Organization, 2010).

9.1 Early initiation of breastfeeding:

In the survey area, 75.5% of the mothers of children aged less than 24 months informed that the children

were put to breast immediately (within one hour) after birth, 11.9% after one hour but within 24 hours and

12.6% after one day but within 48 hours. This rate is higher compared to the results from the Multiple

Indicator Cluster Survey (MICS) which was 59.1% for Rangpur division in 2012-13. The rate of early

initiation of breastfeeding was further calculated for two age categories i.e. 0 – 12 months and 12 – 24

months and the percentages were 78% and 74% respectively.

Table 11: Initiation of breast feeding

Time of initiation n %

Immediately after birth 624 75.5

1 - 24 hours 98 11.9

24 - 48 hours 104 12.6

Total 826 100.0

9.2 Exclusive breastfeeding under six months:

Among the 826 children aged less than 24 months only 246 were less than six months of age. The rate of

exclusive breast feeding based on 24 hours recall question among the 246 children was 78.9%. According to

MICS (2012-13) the rate is 67.7% for Rangpur division.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 14

9.3 Continued breastfeeding at one year (12 - 15 months):

Continuation of breastfeeding was calculated as 30.0% as 45 children were found still breast feeding out of

150 children aged between 12 to 15 months. This is lower than the result reported in the MICS for

Rangpur division.

9.4 Introduction of solid, semi-solid and soft food:

At the age of 6 – 8 months 52 (57%) out of 92 children were introduced to solid, semi – solid and soft

food.

9.5 Minimum dietary diversity:

Among the 826 children, 580 were age between six and 23 months. Among these 580 children, only 100

had at least four groups of food among WHO recommended seven groups. The information is further

divided among different age groups and presented in the table below.

Table 12: Minimum Dietary Diversity by Age group

Age Group Total Less than 4 groups At least 4 groups n %

6 – 23 months 580 480 100 100 17.2

6 – 8 months 70 64 6 70 8.6

9 – 23 months 510 416 94 94 18.4

9.6 Minimum meal frequency:

The proportion of children aged 6 – 23 months fed in line with WHO recommended minimum meal

frequency was 53.9% among 564 children. The information is further disaggregated by age group presented

in table.

Table 13: Minimum meal frequency by age group

Age Group n= no. of children fed minimum

acceptable times in a day

%

6 – 23 months 304 53.9

6 – 8 months 46 50.0

9 – 23 months 258 54.7

9.7 Minimum acceptable diet:

The proportion of children 6 – 23 months with minimum acceptable diet was 14.5%.

Table 14: Minimum acceptable diet by age groups

Age Group n= no. of children fed minimum

acceptable times in a day

%

6 – 23 months 82 14.5

6 – 8 months 5 5.4

9 – 23 months 77 16.3

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 15

Figure 3: Infant and Young Child Feeding Practices

10. Water sanitation and hygiene

Water Sanitation and Hygiene is one of the key determinants of acute malnutrition. Hand washing at critical

times defined by Government of Bangladesh in “National hygiene promotion strategy 2012” as hand-

washing with soap and clean water before food handling and after defecation; hand-washing with soap and

clean water after cleaning baby's bottom and defecation.

10.1 Source of drinking water:

The households in the survey area access drinking water mainly through tube wells. Considering the safety

features, tube wells with platform was considered as safe and around 37% people use this type of tube well

as source of drinking water and the remaining 63% collect drinking water from tube wells without platform.

Findings represent the scenario in the season when the survey was conducted.

Table 15: Source of Drinking Water

Source of drinking water n %

Tube well with platform 822 36.9

Tube will without platform 1397 62.6

Others (well, supply water) 11 0.5

10.2 Time to collect water:

In order to understand accessibility, caregivers were also asked about the time required to collect water

including travel to and from water point and waiting time at the point. 99% of the caregivers reported that

it took < 30 minutes to collect water.

Table 16: Time required collecting Water

Time required n %

Less than 30 minutes 2202 98.7

30 minutes to 1 hour 27 1.3

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 16

10.3 Water purification:

97% of the caregivers do not purify the water before drinking.

Table 17: Water purification

Purification system n %

None 2152 96.5

Boiling 15 0.7

Filter with cloth 63 2.8

10.4 Sanitation:

Facilities for sanitation is very poor only 35% households have hygienic latrine (latrine with water sealed

pan) while 59% have latrine but not water sealed. 5% use hole with some cover and 1% use undesignated

open spaces.

Table 18: Sanitation

Type of sanitation facilities n %

Hygiene latrine 777 34.8

Unhygienic latrine 1324 59.4

In a hole 102 4.6

Undesignated open space 27 1.2

10.5 Hand washing practice:

In order to understand hygiene practices, caregivers were asked about key events before and after which

they should usually wash their hands. The following table represents that hand washing practices with

soap/ash after defecation 99% and before eating food 94%. Other key events like hand washing before food

preparation 56% and after cleaning child defecation 87% were mentioned by the caregivers.

Table 19: Hand washing practices

Hand washing at key times with soap/ash % of cases

Hand washing: After defecation 99.0

Hand washing: After child defecation/cleaning child stool 86.6

Hand washing: Before cooking/food preparation 56.1

Hand washing: Before eating 94.1

Hand washing: Before feeding children 20.0

Hand washing: Before breast feeding 10.8

Practice of washing hands with soap at five critical times was found to be only 13.0% considering five key

times as after defecation, after child defecation, before cooking, before eating and before feeding children.

To understand hand washing practices with soap at different level for breastfed and non breastfed children

data was further segregated and it is lower for breastfed children at 7.3%.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 17

11. Maternal health and other related factors

Data on Maternal health came from a sample of 851 Pregnant or lactating women.

11.1 Age at marriage:

88% (n=791) women reported were married before they were 18 years old and half of these women

became pregnant within a year of their marriage.

11.2 Nutritional status of pregnant and lactating women:

MUAC was measured of 895 pregnant and lactating women. 6.4% (n=57) women had a MUAC less than

21cm which is the cut off as defined by WFP. Among these PLWs 98% were lactating women and only 2%

were pregnant.

11.3 Proportion of woman consumed at least 100 IFA (Iron Folic Acid) tablets during

last pregnancy:

Lactating mothers were asked about iron folic acid tablet consumption during their last pregnancy. Among

851 lactating mothers only 82% reported consuming IFA tablets during their last pregnancy. Only 17%

(n=142) women reported consuming at least 100 IFA tablets.

Table 20: Iron Folic Acid tablet consumption during last pregnancy

n %

Consumed IFA tablet during last pregnancy 700 82.3

Consumed at least 100 IFA tablets 142 16.7

Consumed less than 100 IFA tablets 558 65.6

11.4 ANC check-up and Vitamin-A capsule consumption:

86% (n=774) women had at least one ANC check-up as indicated in the PLW check-up card provided by

Government, BRAC or Tdh and 55% (n=489) completed at least 4 ANC check-ups. Among 851 lactating

women, 487 (57%) mother consumed Vitamin-A capsule within 14 days of delivery.

11.5 Proportions of households consume iodine salt:

Only 51% of PLW households reported consumption of iodised salt which is an essential nutrient.

Information is justified by observing salt packets using daily basis in household cooking.

Table 21: Iodine consumption

n %

Households are consuming iodized salt 457 51.1

Households are consuming salt without iodine 416 46.5

Households are consuming iodine salt sometimes 22 2.5

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 18

11.6 Last delivery:

895 women were asked about the location of their last childbirth. 72% (n=648) reported delivering at

home. Among these 648 women who delivered at home only 23% were assisted by a skilled birth

attendant. Majority 77% of deliveries at home were in the absence of skilled attendants. In their last

delivery 21% (n=133 child among 628 children birth weights taken from EPI cards) of children were born

with low birth weight.

Table 22: Place of last birth

n %

Delivered at: govt. hospital (district hospital or

Upazila health complex) 143 16.0

Delivered at: clinic (private or other NGO clinic) 99 11.1

Delivered at: home 648 72.4

Delivered at: other places 5 0.6

12. Discussion

The prevalence of acute malnutrition defined by WHZ found in the survey was 14.0% with severe wasting

at 2.8%. The prevalence of acute wasting defied by Mid Upper Arm Circumference was found to be 4.1%.

The proportion of children fed in line with WHO recommended practices are found poor in the survey in

comparison to the National figures of FSNSP, Round 10. Only 17.2% children were fed on a diet which had

Minimum dietary diversity and the overall minimum acceptable diet score was achieved only in 14.5% of

children between 6-23 months.

6.4% pregnant and lactating women (PLW) were found to be malnourished with a mid-upper arm

circumference less than 21 cm. 55% women only completed at least four ANC check-ups. Iron and iodine

supplementation is important for PLWs. Only 17% women reported consumed at least 100 Iron Folic Acid

tablets recommended by Bangladesh government and 51% households were found consuming iodized salt.

Most households in the area have access to tube-wells within the neighbourhood for drinking water but

sanitation situation was poor. The biggest concern was lack of water purification in majority of households.

Most of the people use unhygienic latrines or hole/open/designated place for defecation. This was exposing

the community as well as the children to the risk of water borne diseases. Prevalence of diarrhoea in the

2 weeks prior to the survey in children under 5 was 6.8%. Hand washing was practiced mainly after

defecation and before eating but other key times were ignored. Hand washing with soap at five key times

was found to be as low as 13%.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 19

13. Acknowledgements

Terre des hommes would like to take this opportunity to acknowledge the support provided by various

persons and stakeholders without which the survey would not have met its objective. These includes

1. Government Departments

a) Civil Surgeon, Kurigram district

b) Upazila Health & Family Planning Officer

2. ECHO and WFP for financial assistance

3. District Nutrition Support Officer (DNSO), UNICEF, Kurigram M&E team and Government Health

Inspectors for their supervision to ensure data quality

4. Tdh’s Kurigram team for their logistic support during training and data collection

5. The data collection team

6. The caregivers and community leaders to allow the enumerator to collect data from the respective

household

14. References

1. BDHS (2011). Bangladesh on the move to better health: Baseline measurement of health, population and

nutrition sector development programme. Bangladesh Bureau of Statistics.

2. FSNSP (2013). The Food Security and Nutrition Surveillance Project: Results from Round 10: February to April,

2013. BRAC University, HKI & Bangladesh Bureau of Statistics.

3. FSNSP (2012). The Food Security and Nutrition Surveillance Project: Results from Round 9: October to

December, 2012. BRAC University, HKI & Bangladesh Bureau of Statistics.

4. World Health Organization (2010). Indicators for assessing Infant and Young Child Feeding Practices: Part 2

Measurement. Geneva, CH.

5. Multiple Indicator Cluster Survey MICS (2012-2013). Progotir Pathay. Bangladesh Bureau of Statistics (BBS),

United Nations Children’s Fund (UNICEF).

6. Baseline Situation Analysis (2014). Water, Sanitation and Hygiene, Internal Document. Swiss Water &

Sanitation Consortium, Terre Des Hommes Foundation Lausanne.

7. A mixed method approach to identify potential risk factors of acute malnutrition in areas affected by flood of

northern Bangladesh (2014). Internal Document. Terre des hommes Foundation Lausanne.

8. Michel Golden, J. S. (2013, July). ENA for SMART. Retrieved August 2013, from

http://www.nutrisurvey.net/ena/ena.html

9. SMART (2012). Standardized training package. Retrieved from : http://www.smartmethodology.org/

10. SMART Methodology (2006). Measuring Mortality, Nutritional Status and Food Security in Crisis situation.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 20

15. Annex

Annex 1: Map of the survey areas:

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 21

Annex 2: Plausibility check for Anthro data all areas Kurigram District

Standard/Reference used for z-score calculation: WHO standards 2006

(Flagged data also included in the evaluation. Some parts of this plausibility report are more for advanced

users and skipped for a standard evaluation)

Overall data quality (generated from ENA software)

Criteria Flags* Unit Excel. Good Accept Problematic Score

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-7.5 >7.5

(% of in-range subjects) 0 5 10 20 0 (1.9 %)

Overall Sex ratio Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 4 (p=0.038)

Overall Age distrib Incl p >0.1 >0.05 >0.001 <=0.001

(Significant chi square) 0 2 4 10 0 (p=0.158)

Dig pref score - weight Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (4)

Dig pref score - height Incl # 0-7 8-12 13-20 > 20

0 2 4 10 2 (12)

Dig pref score - MUAC Incl # 0-7 8-12 13-20 > 20

0 2 4 10 0 (7)

Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >=1.20

. and and and or

. Excl SD >0.9 >0.85 >0.80 <=0.80

0 2 6 20 0 (1.01)

Skewness WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 0 (-0.02)

Kurtosis WHZ Excl # <±0.2 <±0.4 <±0.6 >=±0.6

0 1 3 5 0 (-0.06)

Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <=0.001

0 1 3 5 0 (p=0.790)

Timing Excl Not determined yet

0 1 3 5

OVERALL SCORE WHZ = 0-9 10-14 15-24 >25 6 %

The overall score of this survey is 6 %, this is excellent.

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 22

Annex 3: Selected Clusters

Upazila Union Para Population

Bhurungamari Andhari Jhar Union Andhari Jhar 2014

Bhurungamari Andhari Jhar Union Khamar Andhari Bari 4267 Bhurungamari Andhari Jhar Union Bir Baruitari 2186 Bhurungamari Andhari Jhar Union Char Dhaurar Kuthi 3570 Bhurungamari Bhurungamari Union Jhukia 1860

Bhurungamari Bhurungamari Union Bagbhandar 4243 Bhurungamari Bhurungamari Union Madhya Bhothat 1720 Bhurungamari Bhurungamari Union Paschim Dewaner Khamar 4131

Bhurungamari Bhurungamari Union Dakshin Kamat Angaria 5815 Bhurungamari Bhurungamari Union Kayem Naleya 1505 Bhurungamari Joymanirhat Union Bara Khatamari 4648

Bhurungamari Joymanirhat Union Chhota Khatamari 6635 Char Rajibpur Char Rajibpur Union Badarpur 1223 Char Rajibpur Char Rajibpur Union Baliamari Naya Para 950

Char Rajibpur Char Rajibpur Union Bazar Para 588 Char Rajibpur Char Rajibpur Union Paschim Bepari Para 645 Char Rajibpur Char Rajibpur Union Uttar Maricha Kandi 1205

Char Rajibpur Char Rajibpur Union Madhya Maricha Kandi 414 Char Rajibpur Char Rajibpur Union Sabujbag 886 Char Rajibpur Char Rajibpur Union Karagar Para 833

Char Rajibpur Char Rajibpur Union Kechomary 894 Char Rajibpur Char Rajibpur Union Jalchira Para 1073 Char Rajibpur Char Rajibpur Union Mia Para 995

Char Rajibpur Char Rajibpur Union Dhublia Para 835 Char Rajibpur Char Rajibpur Union Lamba Para 637 Char Rajibpur Char Rajibpur Union Dhula Uri 1415 Char Rajibpur Char Rajibpur Union Asgar Dewani Para 457

Char Rajibpur Char Rajibpur Union Karati Para 1597 Char Rajibpur Char Rajibpur Union Kachari Para 1771 Char Rajibpur Char Rajibpur Union Shiberdangi 2340

Char Rajibpur Char Rajibpur Union Tangalia Para 2223 Char Rajibpur Char Rajibpur Union Madrasa Para 418 Char Rajibpur Char Rajibpur Union Sadek Dewani Para 640

Char Rajibpur Char Rajibpur Union Nama Para 1441 Chilmari Ramna Pachim Kharkharia 1431 Chilmari Ramna Dalali Para 652

Chilmari Ramna Bharatgram 860 Chilmari Ramna Jargachh Natun Bazar 874 Chilmari Ramna Satghari Para 692

Chilmari Ramna Sarkarer Para 3001 Chilmari Ramna Gafulbeparirgram 532 Chilmari Ramna Rahaman Hajir Para 1346

Chilmari Ramna Manir Beparirgram 473 Chilmari Ramna Bepari Para 376 Chilmari Ramna Mistree Para 1358

Chilmari Ramna Gurati Para 662 Chilmari Thanahat Kismat Banu Khamargram 794 Chilmari Thanahat Nalarpar 863

Chilmari Thanahat Abul Moulvirgram 957 Chilmari Thanahat Sardar Para Doctorgram 1008 Chilmari Thanahat Baharer Bhita 1403 Chilmari Thanahat Fakir Bhitagram 471

Chilmari Thanahat Chhota Kushturi 2449 Chilmari Thanahat Balabari Rail Station Para 1333 Chilmari Thanahat Bazar Majhi Para 1383

Chilmari Thanahat Demnarpar 710 Chilmari Thanahat Khalil Membarergram 1331 Kurigram sodor Kurigram Paurashava Sawdagar Para 1429

Kurigram sodor Kurigram Paurashava Guati Para 309

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 23

Upazila Union Para Population

Kurigram sodor Kurigram Paurashava Gorasthan Para 1850 Kurigram sodor Kurigram Paurashava Chowkidar Para 768 Kurigram sodor Kurigram Paurashava Tapo Velakopa 3027

Kurigram sodor Kurigram Paurashava Hospital Para 2262 Kurigram sodor Kurigram Paurashava Chorua Para 2182 Kurigram sodor Kurigram Paurashava Uttar Dakua Para 647 Kurigram sodor Belgachha Dakshin Dhananjoy 1422

Kurigram sodor Belgachha Bhogaram 1014 Kurigram sodor Belgachha Palashbari (Part) 5575 Kurigram sodor Bhogdanga Dalal Para 727

Kurigram sodor Bhogdanga Char Nanda Dalal 1048 Kurigram sodor Bhogdanga Umarer Bhita 890 Kurigram sodor Bhogdanga Nanda Dulalar Bhita 1767

Kurigram sodor Bhogdanga Nagar Khamar 871 Kurigram sodor Bhogdanga Bramayur 471 Kurigram sodor Bhogdanga Sardar Para 534

Kurigram sodor Ghogadaha Sardar Para 495 Kurigram sodor Ghogadaha Jumarkuti 626 Kurigram sodor Ghogadaha Duba Char 507

Kurigram sodor Ghogadaha Banchharam 2347 Kurigram sodor Mogalbachha Char Sitai Jhar 3744 Kurigram sodor Mogalbachha Krishnapur (Part) 4206

Nageshwari Nageshwari Paurashava Bakshir Khamar 2136 Nageshwari Nageshwari Paurashava Madhur Halla (Part) 1533 Nageshwari Nageshwari Paurashava Madhur Hilla (Part) 660

Nageshwari Nageshwari Paurashava College Para 769 Nageshwari Nageshwari Paurashava Badizamapur 3508 Nageshwari Nageshwari Paurashava Kachari Pairadanga 1117

Nageshwari Nageshwari Paurashava Arazi Kumarpur 835 Nageshwari Nageshwari Paurashava Panchat Para 343 Nageshwari Nageshwari Paurashava Jola Para 706 Nageshwari Santoshpur Union Heerarkuti 1244

Nageshwari Santoshpur Union Nilur Khamar 3550 Nageshwari Santoshpur Union Singrirpar 458 Phulbari Bara Bhita Union Hitarkuti 993

Phulbari Bara Bhita Union Balatari 759 Phulbari Bara Bhita Union Kayatari 731 Phulbari Bara Bhita Union Maguatari 1340

Phulbari Bara Bhita Union Satakuti 1363 Phulbari Bara Bhita Union Taluk Mekhli 1206 Phulbari Phulbari Union Balatari 2394

Phulbari Phulbari Union Kabir Mamud 3342 Phulbari Phulbari Union Kuthi Chandrakhana 4608 Phulbari Shimulbari Union Char Jot Indranarayan 2155

Phulbari Shimulbari Union Rowsantari 733 Phulbari Shimulbari Union Fakir Para 1451 Rajarhat Chakirpashar Union Chakir Pasarpathak Para 5078

Rajarhat Chakirpashar Union Achingachh 1269 Rajarhat Chakirpashar Union Uttarpara 757 Rajarhat Chakirpashar Union Taluk Nakkati 1176

Rajarhat Chhinai Union Chhatrajit 1901 Rajarhat Chhinai Union Joykumar 1657 Rajarhat Chhinai Union Mahidhar Khandakshetra 2998 Rajarhat Chhinai Union Nilai 868

Rajarhat Rajarhat Union Chandamari 3276 Rajarhat Rajarhat Union Dina 601 Rajarhat Rajarhat Union Kismat Punkar 1935

Rajarhat Rajarhat Union Natua Mahal 1581 Rowmari Bandaber Union Khas Para & Baguar Char 1118 Rowmari Bandaber Union Pakhiura 2018

Rowmari Bandaber Union Purba Char Sailmari 1031 Rowmari Bandaber Union Jantirkanda 1761

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Maternal/Child Health & Nutrition Survey - Kurigram - December 2014 24

Upazila Union Para Population

Rowmari Bandaber Union Char Bandaber 2608 Rowmari Bandaber Union Dakshin Khanjanmara 1268 Rowmari Bandaber Union Char Gandaragla 978

Rowmari Bandaber Union Faluar Char 428 Rowmari Bandaber Union Bhaguar Char 2786 Rowmari Bandaber Union Nalbari 470 Rowmari Bandaber Union Purar Char 1746

Rowmari Raumari Union Kanda Para 1104 Rowmari Raumari Union Bara Madhartila 913 Rowmari Raumari Union Bawirgram 1683

Rowmari Raumari Union Kalabari / Katalbari 802 Rowmari Raumari Union Natun Para 2342 Rowmari Raumari Union Raumari Bazar 1425

Rowmari Raumari Union Khatiamari 849 Rowmari Raumari Union Char Natun Bandar 687 Rowmari Raumari Union Dakshin Fulbari 1203

Rowmari Raumari Union Paschim Khanjanmara 1023 Rowmari Raumari Union Islamari 1666 Rowmari Raumari Union Raumarigram 2768

Ulipur Hatia Anantapur 2918 Ulipur Hatia Chirakhoya 1821 Ulipur Hatia Beparigram 1714

Ulipur Hatia Bakshi Para 1398 Ulipur Hatia Balar Char 1039 Ulipur Hatia Jola Para 916

Ulipur Hatia Sarkar Para 866 Ulipur Hatia Hijli 2019 Ulipur Hatia Hijli Goppara 2720

Ulipur Hatia Ramkhana 341 Ulipur Hatia Shyampur 906


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