Food insecurity and child malnutrition in North Bangladesh

By Kimon Schneider, Pranab K. Roy and Dr. Hasan

Kimon Schneider is a development practitioner and Country Delegate with Tdh Foundation. He has a M.A. in Anthropology and a postgraduate degree in Development Cooperation.

Pranab K. Roy is a development practitioner with 27 years experience on MCH/N project management.

Dr. Hasan is a Public Health Physician with special interests in MCH, Nutrition, and Emergency Medicine

The authors would like to acknowledge Tdh Foundation's beneficiaries in Kurigram District, Geoffrey Cordell, Tdh Foundation Regional Advisor Protection, Jean-Pierre Papart, Tdh Foundation Resource Person on MCH/N, and Dr. C. Banerjee, Programme Manager Tdh Foundation India.

This article describes the experiences of a Swiss-based NGO, Tdh Fondation, on maternal and child nutrition programming in Bangladesh, and their observations around the impact of the food price crisis.

According to a survey released by WFP, UNICEF and the Institute of Public Health Nutrition¹, one in four households in Bangladesh are food insecure while two million children aged six months to five years are affected by acute wasting (13.5%). Out of those two million, half a million children (3.4%) are suffering from severe wasting². The survey, which was carried out during the harvest season when levels of wasting were likely to be at their lowest, was undertaken throughout the whole country from November 2008 to January 2009 with representative samples collected from the six divisions by area. A total of 10,378 households were surveyed and 4,175 children under five were assessed for their health and nutrition status.

A main reason for undertaking the survey was to assess the impact of the food price increases in Bangladesh in 2008. In Bangladesh the price of rice, the main staple, together with pulses, edible oil and other food commodities, nearly doubled between 2007 and 2008, and the average price of basic commodities is still 20% higher than the level before the price escalation.

The survey found that 58% of households claimed they had insufficient food during the last twelve months. Real household income dropped by 12% between 2005 and 2008. At the end of 2008, food expenditure represented 62% of total household expenditure, 10% higher than the national average of 2005. In order to cope with higher food prices, people have got themselves into a deeper spiral of debt. The survey showed a clear link between malnutrition and household food insecurity. Food insecure households had higher percentages of malnourished children.

Almost half of the surveyed children aged 6- 59 months were stunted (48.6%), while 37.4% were underweight. Rural areas presented higher rates of all three types of malnutrition.

Growth monitoring in a programme 'target area'

Among the causes of malnutrition, the survey identified lack of dietary diversity as a key problem. Almost half of children between 6-24 months did not receive the minimum meal frequency, while two thirds of the same age group did not meet the minimum dietary diversity of four food groups per day.

Poor infant and young child feeding practices are major factors contributing to poor nutrition in Bangladesh. For example, complementary foods are introduced inappropriately and with insufficient dietary diversity.

Recommendations by the survey team underlined the need to strengthen and expand ongoing efforts to promote exclusive breastfeeding for the first six months of life and to educate families about optimal infant and young child feeding practices. Other key recommendations included expanding the social safety net intervention and better targeting of it towards areas where malnutrition and food insecurity are most prevalent. Food assistance interventions should emphasise micronutrient-enriched foods and improved dietary diversity. Furthermore, there should be provision of micronutrients in the worst affected geographic areas to specific age groups, such as adolescent girls, pregnant women and 6-24 month old children. The survey also recommended expansion of therapeutic and supplementary food interventions for the management of acute malnutrition at both facility and community levels, to take care of the large numbers of acutely malnourished children.

Tdh Foundation programmatic experiences

The programmatic experiences in Bangladesh of Terre des hommes Foundation (Tdh Foundation), a Swiss based child focused organisation, support findings of a "causal relationship" between escalating food prices and the rise in malnutrition, in the children it has been working with in Bangladesh. Furthermore, there are indications that in the areas where Tdh Foundation has been operating with its comprehensive community based approach to Maternal and Child Health and Nutrition (MCH/N), the prevalence of malnutrition is considerably lower than in areas where Tdh Foundation has not been working.

Street yard drama in a programme 'target area'

Decline in child nutritional status during period of food price inflation

Tdh Foundation has delivered a MCH/N project for several years in the north of Bangladesh. In 2008, Tdh Foundation started to witness the impact of the food crisis in terms of unusually high numbers of malnourished children. In order to grasp the extent of child malnutrition and its link to the rise in food prices, several quantitative and qualitative assessments were commissioned in Tdh Foundation's working areas.

Working areas consist of target areas and catchment areas. Target areas are identified by baseline data and defined as having particularly poor health related activities and behaviours. The aim in target areas is to focus energies on addressing these needs and to measure the impact of the agency's work in order to be able to improve the interventions. In target areas, work is community focused and covers all households. In the geographically defined catchment areas from which people would normally travel to a particular service, work is primarily facility based, including two Mother and Child Health Centres (MCHC) and Bangladesh's only Specialised Nutrition Unit (SNU). The SNU is a permanent indoor facility where children are discharged at -2SD weight for height and individually followed up at household level.

Tdh Foundation conducted an assessment in several poverty pockets within its catchment area. Here, 921 children aged 1-5 years were measured using mid-upper arm circumference (MUAC) only. Of these, 625 cases were found to be malnourished - 31.5% were moderately malnourished (MUAC>=12.5 and <13.5cm) and 36.4% were severely malnourished (MUAC <12.5cm)³. These malnourished children were then measured using weight/height Z-scores (WHO growth standards). Of these, one-third (33.3%) were moderately malnourished and 11.4% severely malnourished. Acknowledging the methodological limitation of switching over from assessing MUAC to measuring weight/ height, the findings show that of the original sample of 921 children aged 1.5 years, 22.6% were moderately wasted and 7.7% were severely wasted.

This severely malnourished rate (7.7%) is high compared with data from between 2006 and early 2008 in Tdh Foundation's MCHC, where the rate of severe wasting amongst children attending the centres was 5%, on average. However, it is recognised that the former population are an in situ population while the latter are a clinic based population so that findings may not be directly comparable. The fact that the national average is 3.4% SAM (WHO growth standards) makes these findings even more alarming.

Another assessment was conducted in one of Tdh Foundation's MCHC. Data over the year were collected and analysed on wasting prevalence of under-5 year old children who visited the centre between January 2006 and January 2009. The assessment was based on the following samples: the first 500 children (newly presenting and already attending) who visited the centre in January and August 2006, 2007 and 2008, respectively, and in January 2009. For each period, wasting (weight/height Z-scores), using WHO growth standards, was assessed. Data for wasting are given in Table 1.

We find that the situation deteriorated sharply between August 2008 and January 2009. In order to improve the power of statistical analysis (reducing degrees of freedom), the sample was divided into two periods - a 'non crisis' period from January 2006 to January 2008, and a 'crisis' period from August 2008 to January 2009. The result indicates that despite the peak of malnutrition observed in August 2006 (for which there is no explanation) the likelihood that the food crisis had an impact on wasting prevalence in under-5 children is very high. The observed difference in wasting prevalence is statistically significant (p<0.001). The risk (odds ratio) of wasting is multiplied by 2 (CI 95%: 1.7-2.3), from 19.5% to 32.3%.

Effective management of child malnutrition

Despite recent improvements, the government of Bangladesh does not provide an appropriate health care infrastructure for its rural population. There is no integrated health service, and until recent years, there has been no centrally driven strategy for ensuring an adequate coverage of appropriate services. This being the case, different development agencies, including Tdh Foundation, do what they can to fill the gap.

Tdh Foundation's MCH/N strategy is based on extensive field experience. It takes three approaches, each designed to supplement and support the other:

• Service provision - leading to improved access to health care.
• Health promotion/community awareness - leading to positive changes in the behaviour of the community and an improved health and nutritional status.
• Securing the support of formal and informal power structures within the community.

The approaches complement each other at both facility and community level. At the facility level, MCHCs diagnose, treat and refer patients. Medicines are dispensed and children are screened and monitored. Children are also immunised, while carers are given advice and provided with health care information. The SNU manages severely malnourished children according to the WHO protocols. Special emphasis is given to the community level where problems are systematically addressed via a wide range of activities including, for example:

• tackling social issues such as early marriage, dowry, illegal divorce, abandonment and the consequences for women headed house holds in society.
• promoting exclusive breastfeeding and complementary feeding, women's nutrition through supplementary feeding, the importance of safe motherhood, immunisation and neonatal care.
• monthly growth monitoring of children under-2 years of age and six-monthly nutrition screening (weight/height) of children aged 25-60 months, including counselling on health and nutrition behaviours, providing de-worming tablets and referring severely malnourished cases to our SNU
• delivering messages using a variety of means, such as folk song, street yard drama, pictures and practical demonstration (e.g. cooking of complementary food, oral rehydration salts (ORS) preparation, and hand washing), individual counselling of women, men, adolescents and children, home visits and follow-up visits
• curative services from satellite and static clinics, including treatment of minor ailments and ante-natal and post-natal care. Complicated cases are referred to government institutions and/or to the MCHC and SNU.
• promoting the take up and use of tube wells and latrines, reflecting the centrality of a water, sanitation and hygiene (WASH) programme approach.

Community based role in dealing with increased food prices

When Tdh Foundation launched its work in the target areas, there were many complex MCH/N related issues to tackle. Taking just three examples, mothers did not know about the importance of exclusive breast feeding, most households did not practice optimal food distribution, and families were not optimising their daily food intake.

Exclusive breastfeeding: Many mothers used to interrupt exclusive breastfeeding by early complementary feeding. Gradually, they learnt about the importance of exclusive breastfeeding, especially the nutritious value of breastmilk and the risks early complementary feeding exposed their infants to. Accordingly, by the time the price hike set in, most mothers were already used to exclusive breastfeeding. Therefore, their children were less vulnerable to a wide range of diseases, and in this respect less prone to the increased risk of malnutrition. In addition, the practice of exclusive breastfeeding allowed mothers to save their money by not spending it on expensive complementary foods.

Optimal food distribution: Tdh Foundation has been tackling social issues (gender) and taboos for many years. This helped many families to learn about the importance of optimal food distribution among their household members. Therefore, especially pregnant and lactating mothers and children were better protected from reduced access to food due to the price hike.

Optimising daily food intake: In order to add value to household members' daily food intake, families gradually learnt how to assess locally available food items in terms of their affordability and nutritious value. Households were therefore able to optimize their food intake during the food price increase.

Impact on malnutrition prevalence

Tdh Foundation's experience indicates that its comprehensive MCH/N programmes and the integrated community based work, in particular, have had a positive impact on the prevalence of malnutrition in the face of rising food prices in the communities. This conclusion is partly based on an assessment comparing the prevalence of wasting for two different groups of under-5 year old children. The first group is from a target area (one Union) where Tdh Foundation has been providing community based preventive services since 2004. The second group is from a neighbouring target area (one Union) where Tdh Foundation launched its operations only recently (2008). The data analysed for both groups were collected from 5% of households in all villages in the Unions at the end of 2008 (see Table 2). Wasting prevalence was 6.5% (5.8% moderate + 0.7% severe) (WHO Growth Standards) in the target area where Tdh Foundation has been working since 2004, whereas the figures for the new target area are 23.4% (17.2% + 6.2%). Although the comparison is not statistically valid, i.e. they are not based on cluster surveys and there are no confidence intervals, the marked difference between the two areas does suggest a positive impact of the Tdh Foundation programme on child nutritional status. The populations in the two neighboring target areas have been exposed to very similar social, economic and environmental conditions. Hence, the Tdh Foundation's community based preventive work may have contributed to a reduced risk for children becoming malnourished (odds ratio) by a factor of 3 (CI 95%: 2.2-4.0).

Another indication of Tdh Foundation's programme impact is provided through monthly monitoring of severe malnutrition in its target areas. In three target areas, 362 children under two years of age were monitored on a monthly basis over a period of six months when food prices were increasing sharply, i.e. between December 2007 and June 2008. Data on their nutritional status (weight/age) were collected and analyzed according to WHO growth standards. The findings indicate that in spite of the considerable price hike, the nutritional status of the under two population improved. In fact, prevalence of severe malnutrition decreased from 9.7% to 6.9% during the corresponding period. This may be due to improved health and nutrition related knowledge and behaviour change due to Tdh Foundation programming, as well as to seasonal factors.

Conclusion

Community health educatiion in a programme 'target area'

At a time when the international community is preoccupied with the crisis in financial markets, the world's poor are still trying to tackle the effects of the food crisis. In Bangladesh, for example, there is a strong indication that malnutrition increased due to the sharp price hike the country experienced between 2007 and 2008. Impact on severe malnutrition is particularly striking. Tdh Foundation's experience indicates that its community based programmes may have had a positive impact on the prevalence of malnutrition in the face of rising food prices and corresponding lack of food in the communities.

For more information, contact Kimon Schneider, Tdh Bangladesh, Dhaka, email: ksc@tdh.ch, mobile: 0088 (0) 1714134147

¹Household Food Security and Nutrition Assessment in Bangladesh, November 2008-January 2009, (WFP, UNICEF, IPHN), March 2009.

²Weight-for-height <-3 z score

³These differ to the WHO recommended cut-off points, MUAC<11.5cm for severe malnutrition (recently updated from MUAC<11cm), and MUAC >=11.5 and <12.5cm for moderate malnutrition.