| |  | | | State nutrition cell (SNC):
State nutrition cell is the state level unit for planning, management and monitoring of nutrition programs in the state. All programs namely MAMTA Abhiyan, Anemia control, Vit A supplementation, IDDCP, Fluorosis control and NNMB cell are under the nutrition cell. This unit is a focal point for intersectoral co ordination of nutrition programs. The cell is functional under FW department and is staffed as Nodal officer, Nutrition officers with management and nutrition qualification, and other support faculties.
Tertiary nutrition rehabilitation units:
TNRC tertiary care level nutrition rehabilitation centers are developed in six regions in six medical colleges under the pediatric department. A postgraduate nutritionist is posted at these centers who work at pediatric wards, pediatric and obstetrics OPD and postnatal ward for individual and group nutrition counseling. These centers manage the very severe as well as referred severely malnourished cases
District nutrition units:
At district level District nutrition extenders units are developed. A nutritionist with post graduate qualification is posted at District Project Management Units and their role is to support and monitor Nutrition activities of MAMTA Abhiyan and participation in nutrition training programs.
Block nutrition unit CDNC:
Child Development and Nutrition Centers (CDNC) are short term nutrition rehabilitation centers attached to CHCs at the block level. The centers are managed by a graduate nutritionist, a medical officer and a staff nurse. Severely malnourished child are referred to this center where mother and child are provided stay and the children are treated for infection if any and are provided nutritious dietary supplementation. Mothers participate in this care and child is discharged as he/she starts gaining weight. We have established 14 CDNCs in the year 2008-09. In the Year 2009-10, the total CDNCs are in the process of scaling up to 52.
Mamta Abhiyan:
The base of the Nutrition service is MAMTA Abhiyan at Village Level. As described in the outreach services MAMTA Abhiyan is an integrated health and nutrition primary Care intervention.
Preventive promotive health and Nutrition services at village level are provided through MAMTA Abhiyan which is operationalised in convergence with health and ICDS department. The objectives of health service components of health and ICDS department are common and the beneficiary group is overlapping. Nutrition intervention remained a domain of ICDS for last decade and health department was focusing on micronutrients components. To accelerate the reach and access and converge health and nutrition intervention through collaborative efforts of health and ICDS MAMTA Abhiyan is implemented.
• Goal: To enhance reach, access and utilization of the integrated health and Nutrition services
• Current status:
 | The coverage of ICDS services as per NFHS III indicates a boost up towards achieving goals of reduction of child mortality and enhancing the health and nutrition profile of children.
The components like growth monitoring, health check ups and immunization can be better handled through convergence of health and nutrition services at outreach. Mamta Abhiyan is an outreach activity for health and nutrition evidence based service delivery by joint efforts of health and ICDS department. |
| The nutrition components of Mamta Abhiyan are:
| | Growth monitoring of children (0-3 years) and counseling on IYCF |
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| | Community Growth Monitoring |
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| | IFA, Calcium and Iodised salt supplementation to Antenatal women, Postnatal Women |
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| | IFA supplementation to under five children |
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| | Vitamin A Supplementation |
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| | Diet and nutrition counseling |
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| | Referral services for severely malnourished |
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Strategy:
Mamta Abhiyan is a comprehensive strategy amalgamating key health and nutrition interventions to be delivered under one roof. Components under this Abhiyan include MAMTA Divas (Health and Nutrition day), MAMTA Mulakat (Post natal home visits), MAMTA sandarbh (Referral services) and MAMTA Nondh (Mother and child card)
1. Mamta Diwas (Village health and Nutrition day)
Mamta divas is a fix day, fix site, preventive, promotive health care service offered to pregnant /lactating mothers and under 5 child every month. One MAMTA divas is organized per average 1000 population. The services are provided by a team of health workers, ICDS workers, Kishori Shakti Yojana, girls, Mahila Swasthya Sangh representative and FNGO / MNGO representative. Mamata Divas provide an opportunity for integrated Management of Antenatal, Postnatal, Neonatal Child Health and nutrition Services. Monthly Growth monitoring is done and plotted on MAMTA card as a record and counseling tool of parents. Mamta day is a day of counseling for institutional delivery; diet, IFA and Calcium supplement compliance, child feeding and care, vaccination, FP and early detection and timely treatment.
2. Mamta Mulakat (Post natal care home visit)
Mamta Mulakat is a home visit on 1st, 3rd and 7th day after delivery for preventive and promotive health care of mother and child and offer opportunities for timely referral in order to prevent neonatal and maternal mortality. Post natal counseling for maternal nutrition, supplement of IFA, Calcium, Vit. A and breast feeding, hypothermia and infection prevention among newborn is an integral activity of these visits.
3.. Mamta Sandarbh (Referral and Services)
Mamta Sandarbh Service is the fix day, fix site, referral services at block level by consulting pediatricians and obstetrician through public private partnership for ANC, PNC, ENBC, severe malnutrition and RTI – STI.
4. Mamta Nondh (Record and Reports)
A comprehensive individual recording of health and nutrition status and health and nutrition services with antenatal registration tracked up to 3 years age of the child is done through MAMTA card for beneficiaries and in register 4 – 5 for the record of the service providers.
Programmes under Nutrition Cell: Anemia Prevention & Control Programme:
Iron deficiency Anemia is the most common form of anaemia affecting mainly women in their reproductive years, infants, and children. In both rural and urban areas this type of anaemia is extremely common.
Goals:
At least 20% reduction in number of women suffering with any anemia.
At least 20% reduction in the prevalence of anemia among adolescent girls.
Interventions:
Anemia among ever married and pregnant women is 55.3% and 60.8% respectively. Prevalence rate of anemia among ever married women increased from 46% to 55% and that of pregnant women increased from 47% to 60% between NFHS II and NFHS III.
| | Gujarat is a pioneer in the Adolescent anemia control intervention and the program is in place since 2002. 92% School going Adolescent girls (Std. 8th to 12th) are given one tablet of IFA every Wednesday in Schools. Almost 10 lac girls have been benefited by “Adolescent Girl’s Anemia Control Programme” in Gujarat in secondary and higher secondary schools. |
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| | An integrated approach of IFA supplementation, food fortification and Sickle cell anemia control is under implementation. |
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| | A lifecycle approach has been put in place to reduce the prevalence rate of anemia in the state. |
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| | IFA tablets procurement and logistics is strengthened. |
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| | IFA supplementation of pregnant women and children as per the national program guideline is monitored along with state specific additionalities |
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| | Out of school going girls are being supplemented with IFA on Mamta Diwas under the Kishori Shakti Yojana (through ICDS). |
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| | Fortification of ICDS supplementation by IFA and other micronutrients (Bal bhog). |
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| | Wheat flour fortification by Iron have been implemented in the state since last two years by civil supply department |
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| | Plantation of drumstick trees by forest departments and development of kitchen and community gardens by panchayat departments are the initiatives under Nirogi Bal Varsh aiming at improving supplementation towards anemia prevention |
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Vitamin A Supplementation Programme:
Vitamin A is important for healthy eyes and skin, prevention of infection and growth of children. TA supplementation at six months interval up to three years age was introduced as an intervention to prevent blindness due to Vit.A deficiency in children. Scope of this supplementation has been widened towards better growth and immunity under this national program.Scientific studies have shown benefit of Vit.A supplementation to mothesr during the early postnatal phase in terms of reduction of risk of puerperal sepsis and improving Vit.A content of breast milk.
Goals:
At least 80% of children from 6 m- 5 yrs to receive Vit A supplementation twice yearly.
At least 20% increase in routine Vit A supplementation along with measles vaccine
At least 80% postnatal mothers receive Vit.A capsule (200,000 IU) in first week
As per the National program guidelines, Vitamin A supplementation is done at six months interval as a bi annual round in August and February in the state and the the first dose of Vit.A is supplemented with Measles vaccination.As per DLHSII Vitamin A Supplementation in last six months was 31.7% , this coverage rate has almost doubled at 61% as per DLHS III 07-08.
Interventions:
| | Under five children supplemented as per National program guideline |
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| | Postnatal Mothers are supplemented 2 Lakh IU capsule within 3 days after delivery. |
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| | School health check up and therapeutic dose to students with signs and symptoms of Vitamin A deficiency |
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| | Fortification of ICDS supplement with Vit.A and other micronutrients (Bal bhog) |
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| | Plantation of drumstick trees by forest departments and development of kitchen and community gardens by panchayat departments are the initiatives under Nirogibalvarsh aiming at improving supplementation towards Vit.A deficiency prevention |
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Iodine Deficiency Disorder Control Programme:
Gujarat is an endemic state for Iodine Deficiency Disorder. North Eastern regions with Hilly terrain and tribal population are most affected. IDD affects the survival and growth development of the fetus and subsequently of the child.The irreversible deaf mutism,cretinism and physical and mental growth retardation resulting due to iodine deficiency is a public health challenge.
Goals:
HH consumption of adequately iodised salt is scaled up to 80%
As on Sept 08 67.37 % samples were found to have > 15PPM iodine content (Adequately Iodised salt)
16 districts are reported IDD endemic districts in Gujarat.
Adequately Iodised salt use rate as per NFHS III in Gujarat is 56% and non iodised salt use rate is 28%.
Strategy to ensure availability and use of iodised salt by families and
Intensive drive to ensure the same for tribal families and families with pregnant lady and breast feeding lady is important in view of irreversible damage to growth and development of the children.
Interventions:
| | Iodised salt promotion campaigns |
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| | 1.5 kg iodized salt distribution to all pregnant and lactating women through Mamta Diwas |
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| | Salt testing is being done at grass root level by Female Health worker |
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| | Six regional IDD monitoring laboratories established in six government Medical College |
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| | Regular IDD surveys by Government Medical Colleges |
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| | Advocacy and sensitization of salt producers for adequate iodization. |
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| | Partnership strengthening with Dept of Foods & Civil Supplies to make subsidized iodized salt available in PDS |
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| | Awareness Programme in schools |
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Fluorosis Control Programme:
Gujarat is high endemic fluorosis state. Fluoride is not a nutrient but its cumulative toxicity affects iron absorption and is one of the contributing factors for anemia. Fluoride toxicity is severe in presence of calcium deficiency. Pregnancy and breast feeding aggravates the calcium deficiency and can facilitate sudden severe irreversible crippling in a lady. Calcium and anti oxidants are used as a prevention of such severity.Gujarat is the first state to introduce fluorosis diagnostic facilities in medical college and district hospitals. In order to prevent and control Fluorosis, 32 units have been established for fluorine testing in water, urine and serum.
Goal: Mitigation of human fluorosis
Current Situation
| | Development of Diagnostic Facilities: 32 Ion meters supplied to estimate fluoride level in water, urine and serum. |
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| | Trainings: Laboratory technicians, faculties of medical colleges and doctors of district hospitals are trained for early detection, laboratory testing and management of cases |
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| | Calcium tablets are supplemented to pregnant and postnatal women |
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| | NNMB: National Nutrition Monitoring Bureau, Hyderabad has established a unit with Government of Gujarat which is under the State Nutrition Cell. This unit is working for diet survey once a year. |
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New interventions proposed: 1. IFA DOTS:-
In order to address poor consumption rate of IFA tablets the state is going to initiate IFA DOTS strategy. It will be first introduced as a pilot in tribal districts with.
| | DOTs treatment -IFA tablets given to pregnant women under direct supervision ASHA\CBV shall be the DOTs provider for pregnant women |
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| | DOT shall be twice in a week from 4th month or the registration (if the registration is in second /third trimester) till first month of PNC |
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| | DOTs card of each pregnant women will be prepared and signed by the ANM\HV\MO |
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| | 18 strips (180 IFA tablets) with previously stapled marked stickers contain ANC number, code of ASHA and signature of ANM\Supervisor, to be given to the pregnant women |
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| | DOTs card – To be retained by ASHA and regularly filled up after every bi-weekly home visit (48 tablets to be given under direct observation of provider and consumption of rest of tablets should be ensured) |
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| | After completion of treatment regime, DOTs card and signed empty strips to be returned back to the ANM |
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| | ANM is to verify both the strips and card and, pay the remuneration to ASHA (200 Rs per pregnant woman) |
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2. Hb. Screening with colour scales:
Hb. Estimation is important to decide the anemia management of an individual case. Hb. Estimation at outreach by FHW needs to be simple but useful for decision making about IFA supplementation and referral.
| | A colour scale method of Hb. Estimation shall be introduced as a pilot on the tribal districts where IFA DOT shall be introduced |
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| | Hb. Testing of a woman with the help of colour scale shall be done at least thrice, at 4th month, 7th month, 9th month and end of 1st month of PNC. |
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| | As per the National program guideline IFA shall be given to ANC according to Hb. Status |
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| | A referral system for severely anemic ANC for further investigation and management shall be designed |
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| | IFA DOT shall be synchronized with this screening |
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3. Management of severe Anemia cases:
A pilot project to develop institutional referral service network and protocol shall be developed in three tribal districts with three medical colleges.
| | The referral service network shall be designed |
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| | The referral case investigation, management and follow up protocols shall be worked out. |
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| | Documentation of the process and impact shall be done |
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| | The experience shall be replicated in other districts in subsequent year |
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4. Management of Severe Acute Malnutrition (SAM):
The pilot CDNC centers at Block level and TNRC centers at Medical college level shall be developed as centers for management of SAM.
| | Training of the teams of CDNC and TNRC for SAM based on WHO modules shall be done |
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| | CDNC and TNRC shall be equipped to manage SAM cases as per the protocol |
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| | Logistics requirements for SAM management shall be systemized |
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| | The follow-up system of SAM treated and discharged cases shall be developed |
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| | The documentation of Pilot of Management of SAM shall be done |
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5. Nutrition support units:
The ongoing and proposed nutrition interventions in the state needs mentoring and technical support. Colleges with developed Foods and Nutrition department shall be involved in these activities as Nutrition support units.
| | There are four colleges with the Foods and Nutrition departments developed up to Postgraduate and post doctoral programs. |
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| | As a pilot a Nutrition support unit shall be developed in these four colleges with UNICEF support |
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| | Colleges shall take-up one district in the region as a pilot for technical support for Nutrition programs |
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| | NSU shall also provide hand holding to District nutrition Extension. Centers |
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| | NSU shall be involved in the trainings |
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| | NSU shall be part of state nutrition taskforce. |
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