Maternal & child nutrition: the Sri Lankan perspective.
Most improvements gained during the past two decades in maternal
and child nutrition can be attributed to the successful, countrywide
maternal and child health programme of the Ministry of Health, Sri
Lanka. Other supporting programmes to combat deficiencies of individual
micronutrients have also contributed significantly. As the latest
Demographic and Health Survey (DHS) data have shown regional disparities
in nutrition status, it indicates that more effort is needed to improve
nutrition status of marginalized populations. A National Nutrition
Policy and strategic plan of Sri Lanka is being formulated and new
evidence based nutrition strategies are being promoted or planned in
keeping with national policies on nutrition. More emphasis is being
placed on inter-sectoral co-operation, essential for poverty alleviation
and food security which would improve nutrition status of marginalized
groups. A newly established nutrition surveillance system is an example
where inter-sectoral co-operation has been successful. Feedback data
from surveillance will be used to monitor and evaluate the progress of
nutrition interventions. With the greater emphasis on poverty
alleviation and food production, sensitization of non health sectors and
better strategic interventions for nutritionally vulnerable populations,
Sri Lanka is hopeful of achieving further improvements in nutritional
status of its population.
Key words Child--intervention--mother--nutrition--Sri Lanka
Pregnant women (Food and nutrition)
de Silva, Angela
|Publication:||Name: Indian Journal of Medical Research Publisher: Indian Council of Medical Research Audience: Academic Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2009 Indian Council of Medical Research ISSN: 0971-5916|
|Issue:||Date: Nov, 2009 Source Volume: 130 Source Issue: 5|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Sri Lanka Geographic Code: 9SRIL Sri Lanka|
As a result of the social welfare oriented government policy for over five decades, Sri Lanka has a well established, extensive network of free healthcare facilities accessible to all citizens across the country. Extensive manpower for health, well trained public health personnel with an orientation towards community health and nutrition have resulted in improvement in nutrition of communities in during the past three decades. The well established preventive care system, which has withstood many years of civil conflict and the high literacy rate of the population (male; 97 %, female; 95 %) may be regarded as key factors behind the impressive health and social indicators (1). Most basic health indicators are better than in other countries with a comparable GDP (gross domestic product); infant mortality: 13 per 1,000 live births, maternal mortality rate: 44.3 per 100,000 live births, life expectancy; 71.7 years (males), 77 years (females) (2). A recent report concluded that Sri Lanka was on track to achieve several of the health millenuim development goals (MDGs) (3). Education has also led to empowerment of women and improvement in nutrition status of the population.
The problems of poor nutrition status are yet prevalent in some areas. The nutritional status of vulnerable populations is not in keeping with other outstanding health and social indicators (4). Though a remarkable improvement in nutrition indicators occurred between 1993 and 2000, advances in nutrition status of women and children between the years 2000 to 2007 have been slower (4-6). The prevalence of low birth weight has improved to 16. (6) per cent (4) from the last Demographic and Health Survey (DHS) in 2000 (6). The current prevalence of underweight among children under five is 22 per cent, with 18 per cent being stunted and 15 per cent being acutely malnourished/wasted (4). The recent DHS survey also reports that the highest prevalence of stunting was in the 18-23 month age group (4). The most striking feature of these prevalence figures are the regional disparities. Though improvement in malnutrition has occurred in urban areas (Western Province), high levels of malnutrition are reported from the estate sector with isolated and remote regions and some rural areas (4).
Three micronutrient deficiencies are identified as public health problems, namely iron, vitamin A and iodine. Iodine deficiency has been addressed by salt iodization with > 90 per cent of households having access to iodised salt by 20057. The prevalence of vitamin A deficiency among children is 29 per cent, and a similar proportion is affected by iron deficiency (8,9). Approximately 30 per cent of pregnant mothers are anaemic, leading to an increased risk of low birthweight babies and other pregnancy related complications8. While undernutrition is a problem in rural and estate areas, paradoxically, urbanization has resulted in nutrition transition, challenging the healthcare system to meet new demands. Change in food habits, a stressful lifestyle and lack of physical activity at all stages of life have led to the emerging problems of overweight and obesity (10). The paradigm shift is seen particularly among children in urban areas, causing a risk of increase in lifestyle related diseases such as diabetes mellitus. The Ministry of Healthcare and Nutrition has created a Directorate for Non Communicable Diseases which aims to promote a national behaviour change, including promotion of nutritionally healthy foods and lifestyle modification.
Nutrition related interventions
The disparity between other health indicators and nutrition status has highlighted the need for targeted, high impact nutrition interventions for different regions. The main strategy implemented to improve nutrition is the comprehensive maternal and child healthcare (MCH) package which focuses on pregnant and lactating mothers and young children.
Nutritional care for pregnant and lactating women includes supplementation of iron, folic acid and calcium, and food supplementation in the form of a pre-cooked ready to eat food, Thriposha. Thriposha is a locally manufactured food supplement of maize and soya with minerals and vitamins. The target groups for Thriposha include all pregnant women and lactating mothers up to six months after delivery, infants and preschoolers identified with growth faltering and hospitalized children with growth faltering.
Promotion of breastfeeding, complementary feeding, growth monitoring and promotion
The breastfeeding code, which was brought into effect in 1983, ensures that maternity and breastfeeding benefits are offered to mothers in all sectors of life (11). The code has also been effective in regulating the sale of breast milk substitutes. Some hospitals are designated as "Baby Friendly Hospitals" and promote a culture of exclusive breastfeeding. Promotion of exclusive breastfeeding, advice on complementary feeding and growth monitoring of children under five years and promotion and supplementary feeding and referral of children with growth faltering are the activities directed at improving nutrition of young children.
The anaemia control programme includes weekly distribution of iron and vitamin C tablets to school girls over 10 yr of age, nutrition education promoting consumption of iron rich foods, provision of iron folate and vitamin C supplements during pregnancy and post partum are the main activities.
The vitamin A deficiency control programme includes a combination of promoting consumption of vitamin A containing foods and a high dose vitamin A supplementation schedule. However, the coverage data from the field indicate that coverage is relatively low (57%), leading to persistent vitamin A deficiency.
With the salt iodisation programme Sri Lanka has achieved > 90 per cent coverage of salt iodization (since 2001), a remarkable achievement in a short period of time leading to reduction in the prevalence of goiter (12).
These programs target children with glass of milk and school meal programs target children from low income families and have been initiated in some areas. It is hoped that increased school attendance would lead to breaking the cycle of malnutrition and poverty.
Under the Poshana Malla programme initiated in 2006, a basket of food consisting of essential items is distributed to the most needy pregnant mothers. The coverage of areas in this programme is increasing yearly and aims to target the most food insecure groups.
Several new nutrition intervention strategies and scaling up of existing strategies are being planned with more emphasis on targeting specific populations and sectors. Increased coverage and better targeting with nutrition education programmes for sustainable improvements in nutrition, nutritional supplements, food supplementation programmes such as Thriposha, an adolescent nutrition programme aimed at pre pregnant age group, are some of the planned strategies aiming to target vulnerable groups in the population. Another strategy is the implementation of an integrated nutrition package to improve nutritional status throughout the life cycle.
The Ministry of Healthcare and Nutrition is formulating a National Nutrition Policy which will function as the basis upon which strategies and action plans will be developed. The Nutrition policy has focused attention on optimum nutrition throughout the lifecycle, enhancing capacity to develop effective and appropriate interventions, effective delivery of adequate nutrition interventions to vulnerable populations, food and nutrition security to all citizens, strengthening of advocacy, partnerships and networking, strengthening of research capacity and monitoring and evaluation. These policy decisions would be implemented through national, provincial and district level committees where there would be participation from other sectors such as planning, education, agriculture, livestock, poverty alleviation, child development, trade and commerce sectors and communities. An integrated nutrition package has been launched in March 2009 in five of the most vunerable districts of Sri Lanka, targeting pregnant women, children under five, school children and adolescents. This comprehensive package includes behaviour change communication training, multiple micronutrient fortification for young children and growth monitoring and promotion.
Establishment and implementation of National Nutrition Surveillance System is another strategy that will enhance quality of service provision since the information base will provide data on timely and appropriate targeting of nutrition interventions. The surveillance system will provide data on a regular basis on nutritional status and its determinants at divisional, district, provincial and central levels. In future, policymakers and planners at different levels of the health system would be able to use these data to plan and manage their programmes.
With the newly revamped food production drive, sensitization of non health sectors, better strategic interventions for nutritionally vulnerable populations, Sri Lanka is hopeful to achieve improved nutritional status in the near future. Sustained commitment and adequate investment in terms of technology and implementation of evidence based strategies and comprehensive evaluation of programmes by the government and development partners will no doubt achieve improvements in nutrition of mother and child.
Received April 24, 2009
(1.) National Literacy Policies, Sri Lanka, UNESCO Institute for Statistics 2000. Available at http://www.accu.or.jp/litdbase/ policy/lka/index.htm, accessed on September 11, 2008.
(2.) Annual Health Bulletin 2005, Ministry of Health, Sri Lanka.
(3.) Malnutrition in Sri Lanka. Scale, Scope, Causes and Potential Response. Health Nutrition and Population, Human Development Network, Human Development Unit, South Asia Region, Washington DC, USA: The World Bank; September 2007.
(4.) Department of Census and Statistics. Sri Lanka Demographic and Health Survey 2006 Colombo, Sri Lanka. Department of Census and Statistics in collaboration with Ministry of Health, Sri Lanka; (2007).
(5.) Department of Census and Statistics. Sri Lanka Demographic and Health Survey 1993 Colombo, Sri Lanka. Department of Census and Statistics in collaboration with Ministry of Health, Sri Lanka; 1996.
(6.) Department of Census and Statistics. Sri Lanka Demographic and Health Survey 2000 Colombo, Sri Lanka. Department of Census and Statistics in collaboration with Ministry of Health, Sri Lanka; 2002.
(7.) Medical Research Institute 2005, Ministry of Health, Colombo Sri Lanka.
(8.) vitamin A deficiency status of children in Sri Lanka 1995/96. Colombo, Sri Lanka; Medical Research Institute, Ministry of Health and Indigenous Medicine; 1996.
(9.) Piyasena C, Mahamithawa AMASB. Assessment of anaemic status in Sri Lanka. Colombo, Sri Lanka; Medical research Institute, Department of Health Services; 2003.
(10.) Wickremasinghe vP, Lamabadusuriya SP, Atapattu N, Sathyadas G, Kuruparanatha S, Karunarathne P. Nutritional status of children in an urban area of Sri Lanka. Ceylon Med J 2004; 49 : 114-8.
(11.) Code for the promotion of breastfeeding and marketing of breast milk substitutes and related products Sri Lanka; 1983.
(12.) National Iodine Deficiency Disorder Survey, MRI, Colombo: Ministry of Health, Sri Lanka, 2005.
Reprint requests: Dr Chandrani Piyasena, Head, Nutrition Department Medical Research Institution, Ministry of Healthcare Nutrition and Uva Mellassa Development, 385, Suvasiripaya Colombo 10, Sri Lanka e-mail: email@example.com
Angela de Silva, A.M.A.S.B. Mahamithawa * & Chandrani Piyasena **
Faculty of Medicine, University of Colombo, Sri Lanka and Nutrition Society of Sri Lanka, * Nutrition Coordination Division, Ministry of Health and Nutrition Society of Sri Lanka & ** Nutrition Unit Medical Research Institute, Ministry of Health and Nutrition Society of Sri Lanka
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