India's child malnutrition conundrum
It is puzzling that at a time when the Indian economy is growing at an unprecedented 9 percent plus per year and poverty levels are declining according to official data, child malnutrition is stubbornly persistent. According to recent estimates of the National Family Health Survey-3 for 2005-06, 46 percent of India’s children under three years of age are underweight — as compared to 47 percent reported in 1992-93. In contrast, less than 30 percent of children are malnourished in Sub-Saharan Africa and less than 10 percent in China. Many myths surround debates on the causative factors of child malnutrition. Low incomes, unequal income distribution and income poverty don’t offer sufficient explanation for the persistence of child malnutrition in developing countries. Cursory examination indicates that almost all Sub-Saharan Africa countries report lower per capita income, more skewed income distribution and higher levels of income poverty than India.
Therefore some development experts believe that child malnutrition has much to do with food self-sufficiency. But this argument is contradicted by India’s impressive record in expanding food produc-tion. Yet others argue that more than aggregate food availability within a country, children are malnourished because families are too poor to feed their children. This is not true as even the poorest families have access to the minimal quantity of food needed to feed an infant — half a chapatti, half a banana, a boiled potato or a bowl of dal.
Against this backdrop of rising per capita income and food production and declining poverty, what’s the explanation for persistent high levels of child malnutrition in India? The first clue is found in the proportion of low birth weight babies. Estimates for India reveal that 20-30 percent of infants weigh less than 2,500 grams at birth — an indicator of inter-generational malnutrition passed from the mother to child. The cause of this phenomenon is the poor health and nutritional status of women. Indeed close to one-third of Indian women suffer from chronic energy deficiency. And implicit in this statistic is societal neglect of pregnant women in particular who rarely receive proper care, nutrition and sufficient rest during pregnancy.
The second clue is the very limited reach of acceptable quality public health services for women and children. For instance in 2005-06, a mere 44 percent of children aged 12-23 months were fully immunised. And only 26 percent of children with diarrhoea were given oral rehydration salt. Similarly, barely half (51 percent) of mothers across the country had received at least three ante-natal care visits during pregnancy.
A third explanation for widespread child malnutrition is poor child care practices in India. A child typically becomes malnourished between six and 18 months of age, and remains so thereafter because nutritional rehabilitation is difficult. Breastmilk provides vital nutrients during the first stage of a child’s life; but beyond four to six months, infants must be given solid foods to supplement breastmilk. Despite this, national surveys reveal that almost half of new born babies (46 percent) age 0-5 months, are exclusively breastfed. And only 56 percent of infants aged 6-9 months receive solid or semi-solid food and breast milk.
This is where child care practices become an important factor. Infants cannot eat by themselves; they need to be fed small amounts of food frequently. Feeding a six-month old infant is time-consuming and most women in low income groups simply don’t have the time to feed infants. The task is often entrusted to an elder sibling who understandably may not have the required patience to feed an infant.
The last explanation is limited opportunities available to women. Access to education, for instance, makes a big difference. According to NFHS-3, the incidence of malnutrition among Indian children below three years of age born to illiterate mothers (55 percent) is more than twice the level (26 percent) reported among mothers who have completed more than ten years of school. The significance of these four factors becomes evident when we compare levels of under-nourishment across Indian states. Punjab, Kerala and Tamil Nadu report among the lowest proportions of underweight children (27-33 percent); whereas Chattisgarh, Bihar, Jharkhand and Madhya Pradesh report high proportions of under-weight children (52-60 percent). Analysis of this data indicates that in the states with the lowest percentage of under-weight children, provision of health services, child care services especially to newborns and the nutritional status of women is better than in the four high malnutrition states.
Quite obviously high levels of child malnutrition which contradict and cast a shadow over the fast-track Indian economy are unacceptable. Therefore there’s urgent need to expeditiously expand the reach of maternal health and child care services to mothers and their new born children as also to all children below three. Investing in newborns should become a national priority if India wants to cash in its demographic advantage and ride to prosperity on the strength of its 450 million child population.
(Dr. A. K. Shiva Kumar is a Delhi-based advisor to Unicef and visiting professor at Harvard University)