Maternal underweight and anemia are highly prevalent in Bihar, especially among adolescent girls aged 15 to 19 years. Although numerous programs and platforms exist for delivering efficacious interventions for improving maternal nutrition, the coverage and quality of these interventions are low.
Objective
To examine existing interventions for reducing maternal undernutrition in Bihar and identify barriers to and opportunities for expanding their coverage and quality.
Methods
The research was conducted in New Delhi and Bihar between May and August 2010. Forty-eight key informant interviews were conducted with policy makers, program managers, and service providers at multiple levels. Secondary data were collected from survey reports and program documents. All data were analyzed thematically.
Results
Barriers to the delivery and uptake of interventions to improve maternal nutrition include the shortage of essential inputs, low prioritization of maternal undernutrition, sterilization bias within the family planning program, weak management systems, poverty, gender inequality, caste discrimination, and flooding. In order to overcome barriers and improve service delivery, the current government and its partners have introduced structural reforms within the public health system, launched new programs for underserved groups, developed innovative approaches, and experimented with new technologies.
Conclusions
Since coming to power, the Government of Bihar has achieved impressive increases in the coverage of prioritized health services, such as institutional deliveries and immunization. This success presents it with an excellent opportunity to further reduce maternal and infant mortality by turning its attention to the serious problem of maternal undernutrition and low birthweight.
International Institute for Population Sciences (IIPS). District Level Household and Facility Survey (DLHS-3), 2007–08: Bihar. Mumbai, India: IIPS, 2010. Available at: http://www.rchiips.org/pdf/rch3/report/BH.pdf. Accessed 21 March 2012.
2.
International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-2) India, 1998–99: Bihar. Mumbai, India, and Calverton, Md, USA: IIPS, MEASURE DHS+, and ORC Macro, 2001. Available at: http://www.nfhsindia.org/bihar.shtml. Accessed 21 March 2012.
3.
International Institute for Population Sciences (IIPS) and Macro International (MI). National Family Health Survey (NFHS-3), India, 2005–06: Bihar. Mumbai, India, IIPS and MI, 2008. Available at: http://www.nfhsindia.org/NFHS-3%20Data/Bihar_report.pdf. Accessed 21 March 2012.
4.
VictoraCGAdairLFallCHallalPCMartorellRRichterLSachdevHS. Maternal and child undernutrition: consequences for adult health and human capital. Lancet2008;371:340–57.
5.
BryceJCoitinhoDDarnton-HillIPelletierDPinstrup-AndersenP. Maternal and child undernutrition: effective action at national level. Lancet2008;371:510–26.
6.
CetinIBertiCCalabreseS. Role of micronutrients in the periconceptional period. Hum Reprod Update2010;16:80–95.
7.
ShrimptonRThorne-LymanATrippKTomkinsA. Trends in low birthweight among the Bhutanese refugee population in Nepal. Food Nutr Bull2009;30(2 suppl):S197–206.
8.
FishmanSMCaulfieldLEde OnisMBlössnerMHyderAAMullanyLBlackRE. Childhood and maternal underweight. In: EzzatiM, ed. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization, 2004:39–135.
9.
KramerMS. Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ1987;65:663–737.
10.
KramerMSKakumaR. Energy and protein intake in pregnancy. Cochrane Database Syst Rev2003;(4):CD000032. DOI: 10.1002/14651858.CD000032.
11.
VillarJBelizanJM. The relative contribution of prematurity and fetal growth retardation to low birth weight in developing and developed societies. Am J Obstet Gynecol1982;143:793–8.
12.
McIntireDDBloomSLCaseyBMLevenoKJ. Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med1999;340:1234–8.
13.
MartorellRRamakrishnanUSchroederDGMelgarPNeufeldL. Intrauterine growth retardation, body size, body composition and physical performance in adolescence. Eur J Clin Nutr1998;52(suppl 1):S43–52.
14.
BarkerDJ. Adult consequences of fetal growth restriction. Clin Obstet Gynecol2006;49:270–83.
15.
GodfreyKMBarkerDJ. Maternal nutrition in relation to fetal and placental growth. Eur J Obstet Gynecol Reprod Biol1995;61:15–22.
16.
Rich-EdwardsJWStampferMJMansonJERosnerBHankinsonSEColditzGAWillettWCHennekensCH. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. BMJ1997;315:396–400.
17.
SaiyedFAyoyaMAguayoV. School-based weekly iron and folic acid supplementation reduce anemia in adolescent girls in Bihar, India … but much remains to be done. Poster presentation at the Micronutrient Forum, 12–15 May 2009 in Beijing, China. UNICEF, Patna—Bihar, India. Patna. Available at: http://www.micronutrientforum.org/meeting2009/PDFs/MN%20Forum_2009_Abstracts_Book.pdf. Accessed 21 March 2012.
18.
UNICEF. Strategy for improved nutrition of children and women in developing countries: a UNICEF policy review. New York: UNICEF, 1990.
19.
BhuttaZAAhmedTBlackRECousensSDeweyKGiuglianiEHaiderBAKirkwoodBMorrisSSSachdevHPShekarM. What works? Interventions for maternal and child undernutrition and survival. Lancet2008;371:417–40.
20.
ChristianP. Micronutrients, birth weight, and survival. Annu Rev Nutr2010;30:83–104.
21.
ChristianPKhatrySKWestKPJr. Antenatal anthelmintic treatment, birthweight, and infant survival in rural Nepal. Lancet2004;364:981–3.
22.
TorlesseHHodgesM. Anthelminthic treatment and haemoglobin concentrations during pregnancy. Lancet2000;356:1083.
23.
MasonJBSaldanhaLSMartorellR. The importance of maternal undernutrition for maternal, neonatal and child health outcomes: an editorial. Food Nutr Bull2012;33:S3–S5.
World Food Programme. Food security atlas of rural Bihar. New Delhi: WFP and Institute of Human Development, 2009. Available at: http://www.wfp.org.in/FSARB.pdf. Accessed 21 March 2012.
UNICEF. Coverage Evaluation Survey Report 2009: Bihar State Fact Sheet. New Delhi: UNICEF and Ministry of Health and Family Welfare, 2009. Available at: http://www.unicef.org/india/Bihar_Fact_Sheet.pdf. Accessed 21 March 2012.
29.
Bihar State Health Society. National Rural Health Mission Programme Implementation Plan 2010–2011. Patna, Bihar: State Health Society, Department of Health, Government of Bihar, 2010.
Ministry of Health and Family Welfare (MOHFW). Bulletin of Rural Health Statistics in India, 2008. New Delhi, India: MOHFW, Government of India, 2009.
32.
CasanuevaERosello-SoberonMEDe-RegilLMArguellesMCCespedesMI. Adolescents with adequate birth weight newborns diminish energy expenditure and cease growth. J Nutr2006;136:2498–501.
33.
RahJHChristianPShamimAAArjuUTLabriqueABRashidM. Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh. J Nutr2008;138:1505–11.
RogalyBRafiqueA. Struggling to save cash: seasonal migration and vulnerability in West Bengal, India. Dev Change2003;34:659–81.
36.
Bihar State Health Society. National Rural Health Mission Programme Implementation Plan 2011–2012. Patna, Bihar: State Health Society, Department of Health, Government of Bihar, 2011.
