Association of Trends in Child Undernutrition and Implementation of the National Rural Health Mission in India: A Nationally Representative Serial Cross-sectional Study on Data from 1992 to 2015

Overview

Journal PLoS Med

Specialty General Medicine

Date 2022 Apr 8

PMID 35395023

Authors

Apurv Soni

Nisha Fahey

Zulfiqar Bhutta

Wenjun Li

Tiffany Moore Simas

Somashekhar Nimbalkar

Jeroan Allison

Affiliations

Soon will be listed here.

Abstract

Background: India launched the National Rural Health Mission (NRHM) in 2005 to strengthen its primary healthcare system in high-focus and northeast-focus states. One of the NRHM objectives was to reduce child undernutrition in India.

Methods And Findings: We used data from 1992, 1998, 2005, and 2015 National Family Health Survey (NFHS) of India to evaluate trends in child undernutrition prevalence before and after NRHM and across different categories of focus states. Stunting, Wasting, and Comprehensive Index of Anthropometric Failure (CIAF) were assessed using the World Health Organization (WHO) growth curves to assess chronic, acute, and overall undernutrition. The study included 187,452 children aged 3 years or under. Survey-weighted and confounder-adjusted average annualized reduction rates (AARRs) and predicted probability ratios were used to assess trends and socioeconomic disparities for child undernutrition, respectively. Nationwide, the prevalence of all types of undernutrition decreased from 1992 to 2015. However, the trends varied before and after NRHM implementation and differentially by focus states. After NRHM, acute undernutrition declined more rapidly among high-focus states (AARR 1.0%) but increased in normal-focus states (AARR -1.9% per year; p-value for the difference <0.001). In contrast, the prevalence of chronic undernutrition declined more rapidly (AARR 1.6%) in the normal-focus states in comparison to high-focus states (0.3%; p-value for the difference = 0.01). Income and caste-based disparities in acute undernutrition decreased but did not disappear after the implementation of the NRHM. However, similar disparities in prevalence of chronic undernutrition appear to be exacerbated after the implementation of the NRHM. Major limitations of this study include the observational and cross-sectional design, which preclude our ability to draw causal inferences.

Conclusions: Our results suggests that NRHM implementation might be associated with improvement in wasting (acute) rather than stunting (chronic) forms of undernutrition. Strategies to combat undernutrition equitably, especially in high-focus states, are needed.

Citing Articles

Socioeconomic inequality in child health outcomes in India: analyzing trends between 1993 and 2021.

Jain A, Kim R, Swaminathan S, Subramanian S Int J Equity Health. 2024; 23(1):149.

PMID: 39085858 PMC: 11290299. DOI: 10.1186/s12939-024-02218-z.

Nutritional status of infants and young children in India across three decades: Analysis of five national family health surveys.

Kundu R, Gautam R, Chatterjee A, Bharati P, Liczbinska G, Malina R Eur J Clin Nutr. 2024; 78(7):591-606.

PMID: 38467858 DOI: 10.1038/s41430-024-01427-7.

References

Dhingra B, Dutta A . National rural health mission. Indian J Pediatr. 2011; 78(12):1520-6. DOI: 10.1007/s12098-011-0536-4. View

. Eight million women have unmet need for family planning in Uttar Pradesh. Natl Fam Health Surv Bull. 1995; (1):1-4. View

Paul V, Sachdev H, Mavalankar D, Ramachandran P, Sankar M, Bhandari N . Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet. 2011; 377(9762):332-49. PMC: 3341742. DOI: 10.1016/S0140-6736(10)61492-4. View

. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995; 854:1-452. View

de Onis M, Garza C, Victora C, Onyango A, Frongillo E, Martines J . The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food Nutr Bull. 2004; 25(1 Suppl):S15-26. DOI: 10.1177/15648265040251S103. View

Nagarajan S, Paul V, Yadav N, Gupta S . The National Rural Health Mission in India: its impact on maternal, neonatal, and infant mortality. Semin Fetal Neonatal Med. 2015; 20(5):315-20. DOI: 10.1016/j.siny.2015.06.003. View

Vellakkal S, Gupta A, Khan Z, Stuckler D, Reeves A, Ebrahim S . Has India's national rural health mission reduced inequities in maternal health services? A pre-post repeated cross-sectional study. Health Policy Plan. 2016; 32(1):79-90. PMC: 5886191. DOI: 10.1093/heapol/czw100. View

Subramanyam M, Kawachi I, Berkman L, Subramanian S . Socioeconomic inequalities in childhood undernutrition in India: analyzing trends between 1992 and 2005. PLoS One. 2010; 5(6):e11392. PMC: 2894973. DOI: 10.1371/journal.pone.0011392. View

Mudur G . India launches national rural health mission. BMJ. 2005; 330(7497):920. PMC: 556363. DOI: 10.1136/bmj.330.7497.920-a. View

10.

de Onis M, Woynarowska B . [WHO child growth standards for children 0-5 years and the possibility of their implementation in Poland]. Med Wieku Rozwoj. 2010; 14(2):87-94. View

11.

Kim R, Mejia-Guevara I, Corsi D, Aguayo V, Subramanian S . Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan. Soc Sci Med. 2017; 187:144-154. DOI: 10.1016/j.socscimed.2017.06.017. View

12.

Krishna A, Mejia-Guevara I, McGovern M, Aguayo V, Subramanian S . Trends in inequalities in child stunting in South Asia. Matern Child Nutr. 2017; 14 Suppl 4:e12517. PMC: 6519254. DOI: 10.1111/mcn.12517. View

13.

Nandy S, Miranda J . Overlooking undernutrition? Using a composite index of anthropometric failure to assess how underweight misses and misleads the assessment of undernutrition in young children. Soc Sci Med. 2008; 66(9):1963-6. PMC: 2685640. DOI: 10.1016/j.socscimed.2008.01.021. View

14.

Nandy S, Irving M, Gordon D, Subramanian S, Davey Smith G . Poverty, child undernutrition and morbidity: new evidence from India. Bull World Health Organ. 2005; 83(3):210-6. PMC: 2624218. DOI: /S0042-96862005000300014. View

15.

Filmer D, Pritchett L . Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography. 2001; 38(1):115-32. DOI: 10.1353/dem.2001.0003. View

16.

Kumar C, Singh P, Rai R . Coverage gap in maternal and child health services in India: assessing trends and regional deprivation during 1992-2006. J Public Health (Oxf). 2013; 35(4):598-606. DOI: 10.1093/pubmed/fds108. View

17.

Sanneving L, Trygg N, Saxena D, Mavalankar D, Thomsen S . Inequity in India: the case of maternal and reproductive health. Glob Health Action. 2013; 6:19145. PMC: 3617912. DOI: 10.3402/gha.v6i0.19145. View

18.

. National Rural Health Mission (2005-2012)--Mission document. Indian J Public Health. 2006; 49(3):175-83. View